The management of acute Charcot fracture-dislocations with the Taylor's spatial external fixation system

The surgical repair of acute diabetic neuropathic osteoarthropathy of the midfoot remains a challenge with little guidance available in the medical literature. The authors present a review of the diabetic Charcot neuropathic osteoarthropathy process and proposed surgical intervention techniques with a special emphasis on the available data regarding the use of external fixation. A detailed, step-by-step, guide through the foot-specific Taylor spatial external fixation system is provided. Finally, the authors' preferred technique for these difficult limb salvage cases is presented in detail.     

Charcot salvage of the foot and ankle using external fixation

This article details the advantages of external fixation for salvage of the Charcot foot and ankle. Preoperative evaluation, postoperative care, and surgical technique for external fixation are described. The literature on the effectiveness of this technique in the Charcot foot and ankle is reviewed.     

Charcot of the calcaneus

Charcot of the calcaneus, although not as prolific as midfoot deformation, still results in significant morbidity. Current treatment centers on methods proven effective for other joints in the foot. Most neuropathic conditions of the calcaneus can be managed reasonably nonoperatively. In cases of severe deformity or ulceration, surgical management may be the more conservative approach. The surgical principles of proper soft tissue balancing and handling are critical. As the diabetic population continues to increase, the incidence of Charcot of the calcaneus will concomitantly increase. Further research into methods of arthrodesis and osteotomy with external fixation seem to be the direction of the future.     

Compression arthrodesis of the ankle by triangular external fixation: an improved technique

In this preliminary report, the authors present a new application of an external tubular fixation system for compression arthrodesis of the ankle. A triangular ankle fusion frame was designed that provides rigid immobilization of the tibiotalar joint, with midfoot control provided by a metatarsal pin. Over the past 3 years, the authors have used this device to achieve solid tibiotalar arthrodesis in 12 of 14 patients. The surgical method, including step-by-step construction and application of the triangular ankle fusion frame, is presented. Early results suggest a nearly 90% union rate, including reoperative cases for failed primary fusion.     

微型外固定支架结合有限内固定治疗跗横关节骨折脱位

目的 分析微型外固定支架结合有限内固定治疗跗横关节骨折脱位的临床疗效.方法 自2006年5月至2008年1月应用微型外固定支架结合有限内同定治疗跗横关节骨折脱位15例,骨折脱佗按Main分型:Ⅰ型8例,Ⅱ型2例,Ⅳ型1例,Ⅴ型4例.对骨折脱位行切开复位内同定,使用微型外固定支架恢复维持足内外侧柱的长度.术后指导功能锻炼,术后3个月拆除内、外固定,采用美国足踝外科协会(AOFAS)中足评分系统评估临床疗效. 结果 本组12例患者获得11～24个月(平均15个月)随访,3例失访.术后3个月AOFAS评分为(68.6±3.9)分,术后6个月为(72.9±2.6)分,术后1年为(77.5±4.6)分,所有患者均能自丰行走,无需进一步治疗. 结论 微型外固定支架结合有限内固定治疗跗横关节骨折脱位可获得满意的临床疗效,治疗时除了使骨折脱位解剖复位外,更应注意恢复足内外侧柱的长度.     

Charcot foot and ankle reconstruction: current thinking and surgical approaches

The surgical repair of unstable diabetic neuropathic osteoarthropathy of the midfoot or the hindfoot and ankle remains a challenge with little guidance available in the medical literature. The authors present their proposed surgical intervention techniques regarding the use of external fixation with or without combined internal fixation. A step-by-step guide through the authors' preferred technique for these difficult limb salvage cases is presented in detail.     

Powered metaphyseal stapler: an effective and simplified internal fixation system used in multiple types of podiatric surgery.

The multiplicity of types of usage of the powered stapler system in podiatric surgery were explored. The stapler system reduces surgical time and trauma, especially with complex reconstructive and repair procedures. The expedited surgical procedures along with minimized surgical trauma and comfortably implanted staples improved healing rate and less postoperative pain. The important criteria and indications for the usage of powered stapler fixation were reviewed. This relatively new system offers an effective alternative for internal fixation in the foot and ankle.     

External fixation of Charcot arthropathy

Deformity, instability, and ulceration are present in a high percentage of patients who have Charcot arthropathy. Traditional treatment of these conditions has consisted of debridement, antibiotics, and immobilization with limited weight bearing. These measures are followed by long-term use of various foot and ankle bracing devices, such as the CROW walker, double metal upright, and the lined clam shell AFO with accommodative footwear either incorporated or attached. Sometimes these conservative measures fail and surgery is indicated for foot and ankle deformities with: (1) unbraceable deformity; (2) recurrent ulceration secondary to deformity, instability, or both; and (3) Charcot arthropathy with pain that is unresponsive to conservative measures. Certain acute traumatic situations with impending deformity also may benefit from early surgical stabilization. High deep infection rates (25%) have been reported in surgical reconstruction of feet that have a history of ulceration. The high rates of infection with internal fixation techniques and improved external fixation devices have led surgeons to consider external fixation as a viable alternative for: (1) singlestage correction of a limb with recent or current ulceration; (2) revision or salvage of previously reconstructed limbs; and (3) acute treatment of insufficiency type fractures (impending Charcot arthropathy) in the diabetic who has severe peripheral neuropathy with or without adjuvant internal fixation.     

外固定支架结合有限内固定治疗Pilon骨折

目的探讨外固定支架结合有限内固定治疗Pilon骨折的疗效。方法采用外固定支架结合有限内固定治疗24例Pilon骨折。结果 24例均获得随访,时间10~20个月。无骨不连、皮肤坏死发生。踝关节功能Mazur评分：优14例,良7例,可3例。结论外固定支架结合有限内固定可以获得术后骨折稳定,取得良好踝关节功能,是治疗Pilon骨折有效的手术方案。     

Incidence of postoperative infection in a free-standing ambulatory surgery center

A 1-year study was undertaken at the Hugar Surgery Center, a freestanding ambulatory surgery center, to determine the infection rate for outpatient podiatric surgery. One hundred and forty-eight patients underwent foot surgery that included digital, soft tissue, metatarsal, simple bunionectomies, complex hallux abducto valgus correction with osteotomy and internal fixation, first metatarsophalangeal joint implant arthroplasty, midfoot, and rearfoot procedures. An infection rate of 1.35% was identified. The study indicates all types of podiatric surgery may be performed at ambulatory surgery centers without increased risk of postoperative infection. Infection rate of 1.35% is quite acceptable for clean foot surgery and compares rather favorably with hospital infection rates.     

External fixation for the foot and ankle in children

During the last decade, external fixation for the pediatric foot and ankle has evolved as a result of advances in technology (eg, Taylor spatial frame, hydroxyapatite-coated external fixator pins) and preoperative deformity planning. Although complications are common, most are minor and can be addressed nonoperatively while treatment continues. This article reviews the indications and applications of external fixation for soft tissue contractures, idiopathic and teratologic clubfoot, osteotomies, metatarsal lengthening, tibial lengthening, and foot and ankle trauma.     

External fixation use in arthrodesis of the foot and ankle

The use of external fixation in foot and ankle arthrodesis can be beneficial. Its advantages, disadvantages, and indications were reviewed in this article. External fixation offers the surgeon an opportunity to treat complex foot and ankle deformities, trauma, chronic infections, pseudoarthroses, soft tissue contractures, and limb length discrepancies in ways that were unavailable before its advent. The Ilizarov technique requires considerable experience and patient compliance for the best postoperative outcome. An understanding of musculoskeletal physiology and the biomechanics of bone and soft tissue are essential for the competent application of external fixators in general and Ilizarov frames in particular. The surgeon should be aware of all the surgical options before the application of an external complex apparatus.     

Percutaneous reduction and external fixation for foot and ankle fractures

Percutaneous reduction with external fixation is an advanced technique for surgical management in foot and ankle trauma. In the high-risk patient, closed or percutaneous reduction followed by external fixation for reduction and stabilization is a unique alternative to achieve anatomic stabilization without increased physical strain to the patient. The significant advantages of this approach include minimizing damage to the vascular supply, maintaining and preserving a stable soft tissue envelope, and allowing for correction to be performed acutely or adjusted gradually over time. This article provides an overview of closed or percutaneous reduction with limited soft tissue dissection and external fixation stabilization techniques, and their role in foot and ankle trauma for the high-risk patient.     

Closed wound suction drainage

Closed wound suction drainage may have application to certain podiatric surgical procedures. It can be used to reduce postoperative edema and hematoma formation, decrease the possibility of infection, and minimize the chance of external contamination of the surgical site. Certain conditions that may occur after podiatric surgical procedures and that are detrimental to the healing and rehabilitation of the patient but can be obviated by the use of closed suction drainage are illustrated. Drains should be considered in any podiatric surgical procedure that results in the creation of large voids or causes substantial bleeding as occurs in large resections of bone. Included in this would be any plastic surgical procedures or amputations of the foot.     

Arthroscopic-assisted reduction and percutaneous external fixation of a displaced intra-articular glenoid fracture.

Arthroscopic reduction and percutaneous external fixation is a well-known technique for treating selected fractures. This is the first report of a method of treating intra-articular glenoid rim fracture using shoulder arthroscopy and percutaneous external fixation. The surgical trauma associated with open operative treatment of these fractures can be minimized using minimally invasive techniques under arthroscopic control. This technique not only allows for anatomic reduction with minimal surgical trauma but provides a valid diagnostic and treatment alternative for associated injuries. Arthroscopic reduction and percutaneous external fixation yielded excellent results with no complications. The authors describe the principles of the procedure and discuss its advantages compared with traditional surgery.     

Intramedullary foot fixation for midfoot Charcot neuroarthropathy

Midfoot Charcot collapse commonly occurs through the tarsometatarsal and/or midtarsal joints, which creates the characteristic "rocker bottom" deformity. Intramedullary metatarsal fixation spanning the tarsus into the talus and/or calcaneus is a recently developed method for addressing unstable midfoot Charcot deformity. The intramedullary foot fixation technique has various advantages when addressing midfoot Charcot deformity in the neuropathic patient. These advantages include anatomical realignment, minimally invasive fixation technique, formal multiple joint fusion, adjacent joint fixation beyond the level of Charcot collapse, rigid interosseus fixation, and preservation of foot length. The goals of the intramedullary foot fixation procedure are to create a stable, plantigrade, and ulcer-free foot, which allows the patient to ambulate with custom-molded orthotics and shoes.     

Tailor's bunion: clinical evaluation and correction by distal metaphyseal osteotomy with cortical screw fixation

Fifth metatarsal distal metaphyseal osteotomy represents a very common surgical procedure performed for tailor's bunion deformity. The authors advocate using a cortical bone screw for fixation device offers many advantages over conventional devices (i.e., Kirschner wire). The purpose of this paper is to offer a means to thoroughly evaluate tailor's bunion deformity clinically, biomechanically, and radiographically. This will allow the podiatric surgeon to choose a procedure of choice to correct the deformity. The technique of fifth metatarsal distal metaphyseal osteotomy with cortical bone screw fixation using AO4 principles is fully described.     

Temporary bridge plating of the medial column in severe midfoot injuries

Severe crush injuries to the midfoot often involve comminuted cuneiform or tarsal navicular fractures. Treatment principles for the bony injury of the crushed midfoot include maintenance of the medial column length and alignment, as well as appropriate stable fixation after open or closed fracture reductions. This is especially important because outcomes after midfoot injuries are related to the stability of the medial longitudinal arch of the foot. Treatment options include closed reduction and isolated K-wire fixation, limited open reduction and internal fixation with K-wires, screw fixation directed from the navicular to the cuneiforms, spanning external fixation between the talus and the first metatarsal, or combinations of these techniques. Limited internal fixation combined with external fixation may be difficult or impossible in comminuted fractures secondary to the small size and large number of bony fragments. Also, the external fixator is a potential source of pin tract infections. We propose a temporary internal bridge plating technique of the medial column of the foot using an 8- to 10-hole, 2.7-mm reconstruction plate between the talar neck and the first metatarsal, which may provide adequate temporary internal stabilization until bony healing occurs.     

External fixation techniques for plastic and reconstructive surgery of the diabetic foot

Wound healing in high-risk patients with diabetes is often lengthy and fraught with complications. Techniques in plastic and reconstructive surgery of the diabetic foot continue to develop as a result of advances in external fixation. This article highlights the surgical aspect of the diabetic foot with an emphasis on the indications, advantages, technical pearls, and complications with use of external fixation as an adjunct to plastic and reconstructive surgery of the diabetic foot.     

Mini external fixation in the hand

External fixation is an effective means of addressing several pathologies of the hand. The advantages of its use include the ability to achieve stable fixation, minimize soft tissue trauma at the site of injury, and allow wound care and mobilization of adjacent joints. External fixators can be constructed from material readily available in the operating room or obtained from a commercial source. Sufficient rigidity can be achieved by any of these means. Improper placement, although achieving rigid fixation, may compromise motion and overall function if basic principles of external fixation are not followed or if the anatomy of the hand is not taken into consideration. The objective of this article is to describe the technique of application of mini external fixation, emphasizing the basic principles of external fixation as they relate to the specific anatomy of the hand. In addition to fracture fixation, various other uses are described including distraction lengthening, arthrodesis, treatment of nonunion, and infection.