SLR - July 2020 - John R. Constantino

Midterm Walking Ability after Charcot Foot Reconstruction Using the Ilizarov Ring Fixator

Reference: Wirth SH, Viehöfer AF, Tondelli T, Hartmann R, Berli MC, Boni T, Waibel FW. Midterm Walking Ability after Charcot Foot Reconstruction Using the Ilizarov Ring Fixator. Archives of Orthopedic and Trauma Surgery. 2020 Mar 13.

Scientific Literature Review

Reviewed By: John R. Constantino, DPM
Residency Program: Mount Auburn Hospital – Cambridge, MA

Podiatric Relevance: Podiatric surgeons frequently utilize external ring fixators for reconstruction following Charcot neuroarthropathy. The use of external ring fixators provides stability, deformity correction and allows resection of necrotic bone. Previous studies have reported successful limb salvage, amputation rates and various complications following reconstruction with external fixators. This study aims to investigate whether reconstruction using external ring fixation can lead to increased walking ability.

Methods: Twenty-nine patients that underwent a single stage correction for their Charcot deformity using external fixation were retrospectively analyzed. Information collected included demographic data, need for amputation and amputation level, walking ability, presence of osteomyelitis at the time of reconstruction, fusion, complications and comorbidities. Walking ability was grouped into three categories: ability to walk more than six blocks with or without an assistive device, and wheelchair bound. Fisher’s exact test was applied to calculate an association between presence of osteomyelitis and walking ability and between fusion and walking ability. 

Results: Mean follow up for patients was 35.1 months. Mean time of Ilizarov ring fixator treatment was 112.9 days followed by a removable total contact cast for 113.2 days. Two patients underwent major amputations and required a lower leg prosthesis. Of the 27 patients who had successful limb salvage, 26 of these patients were able to walk six blocks at final follow up. Twenty-three patients (85.2 percent) walked independently while three patients required an assistive device; one patient was wheelchair dependent but could use the foot for reliably for transfers. Nineteen patients suffered with osteomyelitis and a total of 16 (84.2 percent) of these patients were able to walk more than six blocks after treatment. The fusion rate at final follow up was estimated to be 17.9-54.3 percent. In the fusion group, all patients ambulated without a wheelchair, while one patient in the non-fusion group required a wheelchair. There was no significant association between fusion status and walking ability.

Conclusions: The authors conclude that single stage Charcot reconstruction utilizing Ilizarov external fixation may lead to an increased walking ability despite the presence of osteomyelitis preoperatively, or failure to achieve radiographic fusion. This is demonstrated in their study as 26/29 patients being ambulatory without major amputation. Development of ulcers and osteomyelitis after reconstruction were associated with secondary amputation. The findings encourage the choice for limb preserving surgery even in settings of osteomyelitis. Limitations of this study include its retrospective design as well as the limited sample size. 

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