Comparison of Complications for Internal and External Fixation for Charcot Reconstruction: A Systematic Review


      The surgical reconstruction of Charcot deformity can be a challenge for foot and ankle surgeons. Consensus is lacking among surgeons regarding the best method of surgical fixation to be used in reconstruction, and clear strong evidence is also lacking in published studies. We undertook a systematic review of electronic databases and other relevant sources in an attempt to better understand the complications and outcomes associated with internal and external fixation for Charcot foot and ankle reconstruction. A total of 23 level 4 studies with 616 procedures were identified. Of these, 12 studies with 275 procedures used internal fixation, and 11 studies with 341 procedures used external fixation. The odds of a successful outcome with internal fixation was 6.86. The odds of a successful outcome with external fixation was 13.20 (odds ratio 0.52, 95% confidence interval 0.30 to 0.90). The odds of success for internal fixation was 0.52 times as likely as the odds of success with external fixation. Because the odds ratio did not include 1, this difference was statistically significant at the p < .05 level. An identified trend was that external fixation was used more often in cases deemed to be difficult by the surgeon preoperatively. These findings could prove helpful to foot and ankle surgeons when making decisions regarding fixation for Charcot reconstruction.

      Level of Clinical Evidence


      To read this article in full you will need to make a payment


        • Trepman E.
        • Nihal A.
        • Pinzur M.S.
        Current topics review: Charcot neuroarthropathy of the foot and ankle.
        Foot Ankle Int. 2005; 26: 46-63
        • Zgonis T.
        • Roukis T.S.
        • Lamm B.M.
        Charcot foot and ankle reconstruction: current thinking and surgical approaches.
        Clin Podiatr Med Surg. 2007; 24: 505-517
        • Stroup D.F.
        • Berlin J.A.
        • Morton S.C.
        • Olkin I.
        • Williamson G.D.
        • Rennie D.
        • Moher D.
        • Becker B.J.
        • Sipe T.A.
        • Thacker S.B.
        Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of observational studies in epidemiology (MOOSE) group.
        JAMA. 2000; 283: 2008-2012
        • Sammarco V.J.
        • Sammarco G.J.
        • Walker Jr., E.W.
        • Guiao R.P.
        Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy.
        J Bone Joint Surg Am. 2009; 91: 80-91
        • Dalla Paola L.
        • Volpe A.
        • Varotto D.
        • Postorino A.
        • Brocco E.
        • Senesi A.
        • Merico M.
        • De Vido D.
        • Da Ros R.
        • Assaloni R.
        Use of a retrograde nail for ankle arthrodesis in Charcot neuroarthropathy: a limb salvage procedure.
        Foot Ankle Int. 2007; 28: 967-970
        • Garchar D.
        • DiDomenico L.A.
        • Klaue K.
        Reconstruction of Lisfranc joint dislocations secondary to Charcot neuroarthropathy using a plantar plate.
        J Foot Ankle Surg. 2013; 52: 295-297
        • DeVries J.G.
        • Berlet G.C.
        • Hyer C.F.
        A retrospective comparative analysis of Charcot ankle stabilization using an intramedullary rod with or without application of circular external fixator—utilization of the retrograde arthrodesis intramedullary nail database.
        J Foot Ankle Surg. 2012; 51: 420-425
        • Grant W.P.
        • Garcia-Lavin S.
        • Sabo R.
        Beaming the columns for Charcot diabetic foot reconstruction: a retrospective analysis.
        J Foot Ankle Surg. 2011; 50: 182-189
        • Pinzur M.S.
        • Gil J.
        • Belmares J.
        Treatment of osteomyelitis in Charcot foot with single-stage resection of infection, correction of deformity, and maintenance with ring fixation.
        Foot Ankle Int. 2012; 33: 1069-1074
        • Lamm B.M.
        • Gottlieb H.D.
        • Paley D.
        A two-stage percutaneous approach to Charcot diabetic foot reconstruction.
        J Foot Ankle Surg. 2010; 49: 517-522
        • Karapinar H.
        • Sener M.
        • Kazimoglu C.
        • Akgun U.
        Arthrodesis of neuropathic ankle joint by Ilizarov fixator in diabetic patients.
        J Am Podiatr Med Assoc. 2009; 99: 42-48
        • Conway J.D.
        Charcot salvage of the foot and ankle using external fixation.
        Foot Ankle Clin. 2008; 13: 157-173
        • Wang J.C.
        • Le A.W.
        • Tsukuda R.K.
        A new technique for Charcot's foot reconstruction.
        J Am Podiatr Med Assoc. 2002; 92: 429-436
        • Papa J.
        • Myerson M.
        • Girard P.
        Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle.
        J Bone Joint Surg Am. 1993; 75: 1056-1066
        • Early J.S.
        • Hansen S.T.
        Surgical reconstruction of the diabetic foot: a salvage approach for midfoot collapse.
        Foot Ankle Int. 1996; 17: 325-330
        • Pinzur M.S.
        • Kelikian A.
        Charcot ankle fusion with a retrograde locked intramedullary nail.
        Foot Ankle Int. 1997; 18: 699-704
        • Simon S.R.
        • Tejwani S.G.
        • Wilson D.L.
        • Santner T.J.
        • Denniston N.L.
        Arthrodesis as an early alternative to nonoperative management of Charcot arthropathy of the diabetic foot.
        J Bone Joint Surg Am. 2000; 82-A: 939-950
        • Stone N.C.
        • Daniels T.R.
        Midfoot and hindfoot arthrodeses in diabetic Charcot arthropathy.
        Can J Surg. 2000; 43: 449-455
        • Caravaggi C.
        • Cimmino M.
        • Caruso S.
        • Dalla Noce S.
        Intramedullary compressive nail fixation for the treatment of severe Charcot deformity of the ankle and rear foot.
        J Foot Ankle Surg. 2006; 45: 20-24
        • Assal M.
        • Ray A.
        • Stern R.
        Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy: surgical technique.
        J Bone Joint Surg Am. 2010; 92: 20-31
        • Caravaggi C.M.
        • Sganzaroli A.B.
        • Galenda P.
        • Balaudo M.
        • Gherardi P.
        • Simonetti D.
        • Ferraresi R.
        • Farnetti A.
        • Morandi A.
        Long-term follow-up of tibiocalcaneal arthrodesis in diabetic patients with early chronic Charcot osteoarthropathy.
        J Foot Ankle Surg. 2012; 51: 408-411
        • Farber D.C.
        • Juliano P.J.
        • Cavanagh P.R.
        • Ulbrecht J.
        • Caputo G.
        Single stage correction with external fixation of the ulcerated foot in individuals with Charcot neuroarthropathy.
        Foot Ankle Int. 2002; 23: 130-134
        • Zarutsky E.
        • Rush S.M.
        • Schuberth J.M.
        The use of circular wire external fixation in the treatment of salvage ankle arthrodesis.
        J Foot Ankle Surg. 2005; 44: 22-31
        • Fabrin J.
        • Larsen K.
        • Holstein P.E.
        Arthrodesis with external fixation in the unstable or misaligned Charcot ankle in patients with diabetes mellitus.
        Int J Low Extrem Wounds. 2007; 6: 102-107
        • Pinzur M.S.
        Neutral ring fixation for high-risk nonplantigrade Charcot midfoot deformity.
        Foot Ankle Int. 2007; 28: 961-966
        • Dalla Paola L.
        • Brocco E.
        • Ceccacci T.
        • Ninkovic S.
        • Sorgentone S.
        • Marinescu M.G.
        • Volpe A.
        Limb salvage in Charcot foot and ankle osteomyelitis: combined use single stage/double stage of arthrodesis and external fixation.
        Foot Ankle Int. 2009; 30: 1065-1070
        • El-Gafary K.A.
        • Mostafa K.M.
        • Al-Adly W.Y.
        The management of Charcot joint disease affecting the ankle and foot by arthrodesis controlled by an Ilizarov frame: early results.
        J Bone Joint Surg Br. 2009; 91: 1322-1325
        • Grant W.P.
        • Garcia-Lavin S.E.
        • Sabo R.T.
        • Tam H.S.
        • Jerlin E.
        A retrospective analysis of 50 consecutive Charcot diabetic salvage reconstructions.
        J Foot Ankle Surg. 2009; 48: 30-38