Current Trends in the Surgical Management of Diabetic Neuroarthropathy of the Foot and the Ankle

Abstract

The management of CN patients of the foot and ankle ischallenging. Education of patients about prevention,early recognition of arthropathy, and promptinstitution of protective treatment are clearly themost effective means available to diminish theimpact of this problem . Occasionally, however, there are patients who,when they are first seen, have a disabling deformityor severe instability for which treatment witha brace or a plaster cast alone is destined to failure. For those patients, reconstruction of thefoot and ankle is a valuable technique. The goals ofoperative treatment are to allow the patient to weara shoe or a brace and to prevent amputation.Stability and appropriate alignment are moreimportant than union for achieving a successfulresult. Diabetic foot and ankle trauma and Charcot reconstruction require a clear understanding of the pathogenesis of the disease process. The surgeon must consider patient factors,specifically peripheral neuropathy,and also factors specific to the injury or reconstruction. Appropriate preoperative planning is necessary for optimal outcome and to prevent postoperative complications. The surgeon should choose a fixation construct before embarking on a surgical procedure and understand its advantages and disadvantages for the selected procedure. The choice of fixation,whether internal,external,or a combination of the two,should be applied to provide osseous stability and account for anticipated problems commonly seen in this patient population. The surgeon should also consider the potential problems that may arise in these difficult cases. Open reduction with internal fixation for Charcot osteoarthropathy is associated with a high rate of complications and failure because of infection, bone softening, resorption, fragmentation and breakage of the implant . Complex reconstructive procedures with arthrodesis are more frequently reserved for realignment and stabilization of severely deformed feet and ankles in an effort to avoid amputation. The choice of internal or external fixation depends on the quality of the bone. Generally in Charcot disease, the bone stock is poor and external fixation provides better compression with fewer fixation failures and soft tissue complications. Due to its ability to correct multiplanar deformities in osteopenic bone even in the presence of open wounds, the circular (Ilizarov) external fixation is preferred for most of Charcot foot and ankle reconstructions .