Case 59: Charcot Reconstruction with

External Fixation

Bradley M. Lamm

Contents Abstract
1 Brief Clinical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Many patients with Charcot neuropathy develop a
malaligned foot position. Deformity of the foot,
2 Preoperative Clinical Photos and Radiographs . . . . . . . . . . 422
instability, osteomyelitis, and ulceration are all common
3 Preoperative Problem List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 indications for Charcot reconstruction surgery. External
4 Treatment Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 422 fixation should always be considered when osteomyelitis
has been previously diagnosed. Presented is a case of a
5 Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
52 year old diabetic male with an unstable Lisfranc and
6 Images During Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 Charcot midtarsal joint of the right foot who underwent
7 Technical Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 external fixation correction. A two-stage gradual
8 Outcome Clinical Photos and Radiographs . . . . . . . . . . . . . . . 426 technique was utilized. First gradual distraction of the
forefoot on a fixated hindfoot provides anatomical
9 Avoiding and Managing Problems . . . . . . . . . . . . . . . . . . . . . . . . . 426
realignment of the foot. The second stage is a formal
10 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426 minimally invasive fusion of the Charcot joints with
References and Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 427 either intramedullary foot fixation or external fixation
compression. This two-stage gradual technique creates a
stable plantigrade foot.

1 Brief Clinical History

The patient has diabetes, Charcot neuroarthropathy, and

status post partial fourth and fifth ray amputation. A
hyperkeratotic lesion or preulcerative lesion along the
plantar medial column of the foot was present for months
without relief from débridement and off-loading with insert/
shoe gear changes. Equinus is noted with dorsiflexion of the
ankle only to neutral. The Lisfranc/midtarsal Charcot is
unstable upon loading of the forefoot. The patient has
significant adduction and rocker bottom deformity of the
foot, which could not be fully corrected upon physical
examination.

B.M. Lamm (*)

International Center for Limb Lengthening, Rubin Institute for
Advanced Orthopedics, Sinai Hospital, Baltimore, MD, USA
e-mail: bradankle@yahoo.com; blamm@lifebridgehealth.org

# Springer International Publishing Switzerland (outside the USA) 2015 421

S.R. Rozbruch, R.C. Hamdy (eds.), Trauma/Foot and Ankle,
DOI 10.1007/978-3-319-18026-7_118
422
Fig. 1 A midfoot Charcot neuroarthropathy deformity (Eichenholtz
stage II, unstable, with superficial plantar medial ulceration and
previous resection of the fourth and fifth metatarsals). Anteroposterior
view radiograph shows midfoot adduction deformity
2 Preoperative Clinical Photos
and Radiographs
See Figs. 1 and 2.
3 Preoperative Problem List
1. Diabetes mellitus
2. Peripheral neuropathy
3. Charcot neuroarthropathy of the Lisfranc and midtarsal
joints
4. Superficial plantar medial ulceration
5. Equinus
4 Treatment Strategy
The chronic Charcot foot (i.e., Eichenholtz stage 2 or 3) can
be stable or unstable. The unstable Charcot foot is difficult to
shoe or brace and typically results in ulceration. The stable
B.M. Lamm
Fig. 2 Lateral view radiograph shows rocker bottom and equinus
deformities. Note the dorsal displacement of the forefoot and the
break in Meary’s angle
Charcot foot is easier to shoe or brace but is still prone to
ulceration if deformity is present. The goal of surgical
treatment in cases of chronic Charcot neuroarthropathy
(i.e., Eichenholtz stage 2 or 3) is to establish a plantigrade
foot. Achilles tendon lengthening, ostectomy, débridement,
osteotomy, arthrodesis, and open reduction with internal
fixation are well-known surgical reconstructive procedures
aimed to reestablish the normal foot position. Acute
correction via open reduction with rigid internal fixation
or plantar plating is frequently used for reconstruction
(Cooper 2002). Also, acute correction via open reduction
with application of static external fixation has been
reported (Jolly et al. 2003). Recently, a new, minimally
invasive method of gradual distraction with external
fixation that provides both realignment and stabilization
has been presented (Lamm and Paley 2006; Lamm
et al. 2010). By applying an external fixator (Taylor Spatial
Frame (TSF)), dynamic gradual deformity correction and
distraction can be performed, and then once the foot is in
the corrected position, a minimally invasive formal fusion
of the Charcot joint is performed. The surgeon then has the
option of compressing through the external fixation or
removing the external fixator and implanting internal
fixation (intramedullary foot fixation). In this case the
distraction of the forefoot on the hindfoot took 3 weeks
utilizing a butt frame (TSF) external fixation device.
A second stage surgery was then performed to create a
formal midtarsal and Lisfranc fusion through a medial
longitudinal incision with insertion of the intramedullary
foot fixation screws. A non-weight-bearing short-leg cast
was applied for 10 weeks.
Case 59: Charcot Reconstruction with External Fixation 423

Fig. 3 The lateral view still image, obtained by using

Fig. 4 The lateral view still image, obtained by using
videofluoroscopy, confirms the instability of the midfoot Charcot
videofluoroscopy, confirms the instability of the midfoot Charcot
demonstrating significant forefoot dorsiflexion
demonstrating significant forefoot plantar flexion

5 Basic Principles

A common factor is equinus which is typically present with a

Charcot deformity and is important to be evaluated and
treated when present.
Midfoot Charcot collapse commonly occurs through the
tarsometatarsal and/or midtarsal joints, which creates the
characteristic “rocker bottom” deformity. The indications
for Charcot reconstruction via intramedullary foot fixation
are an unstable Charcot midfoot or a stable but deformed
Charcot midfoot without a history of osteomyelitis.

6 Images During Treatment

See Figs. 3, 4, 5, 6, 7, 8, and 9.

7 Technical Pearls

The first stage consists of osseous realignment achieved by

performing ligamentotaxis. The TSF forefoot 6  6 butt
frame construct is applied and provides gradual relocation
of the forefoot on the hindfoot. The distal tibia, talus, and
Fig. 5 Immediate post-operative anteroposterior view radiograph
calcaneus are fixed with two U-plates joined and first shows midfoot adduction. The stirrup wires (90 bent wires that are
mounted orthogonal to the tibia in both the anteroposterior not tensioned) are placed adjacent to the region of distraction and
and lateral planes. The U-plate is affixed to the tibia with realignment (midfoot in this case)
424 B.M. Lamm

one lateromedial 1.8-mm wire and two to three other points

Fig. 6 Immediate post-operative lateral view radiograph shows plantar
flexion of the forefoot. The stirrup wires (90 bent wires that are not
tensioned) are placed adjacent to the region of distraction and
realignment (midfoot in this case)
of fixation (combination of smooth wires or half-pins).
For additional stability, a second distal tibial ring can be
added to create a distal tibial fixation block. It is essential
to fix the hindfoot in a neutral position; an Achilles tendon
lengthening typically is required to achieve a neutral
hindfoot position. With the hindfoot manually held in a
neutral position, the U-plate is fixed to the calcaneus
with two crossing 1.8-mm wires. A 1.8-mm medial-lateral
talar neck wire also is inserted and fixed to the U-plate.
Next, two 1.8-mm stirrup wires are inserted through the
osseous segment just proximal and distal to the Charcot
joint(s). Stirrup wires are bent 90 just outside the skin to
extend and attach but are not tensioned to their respective
external fixation rings distant from the point of fixation.
These stirrup wires capture osseous segments that are far
from an external fixation ring, thereby providing accurate
and precise Charcot joint distraction. A full external
fixation ring is then mounted to the forefoot with two
1.8-mm crossing metatarsal wires and the aforementioned
distal stirrup wire. Digital pinning often is required
whereby the digital wires (1.5 or 1.8 mm) are attached to
the forefoot ring. The six TSF struts are placed and
final radiographs obtained (anteroposterior and lateral
views of the foot to include the tibia). Superimposition
of the reference ring on the final films is critical for
accurate post-operative computer deformity planning
(www.spatialframe.com). The surgeon enters the deformity
and mounting parameters into an Internet-based software
program that produces a daily schedule for the patient to

Fig. 7 Clinical photograph

shows the Taylor spatial frame
(forefoot 6  6 butt frame)
applied. Note the delta
configuration of the tibial half-
pins and the build out off the
distal foot ring in order to allow
for soft tissue clearance
Case 59: Charcot Reconstruction with External Fixation 425

Fig. 8 A clinical lateral

photograph shows the Taylor
spatial frame (forefoot 6  6 butt
frame) applied. Note the stirrup
wires adjacent to the distraction
region

perform adjustments on each of the six struts. The patient is

Fig. 9 Lateral view post gradual Taylor spatial frame correction
showing a normal or zero Meary’s angle. Now the plantar foot ulcer
has healed and the foot is correctly positioned
clinically and radiographically followed in the office weekly
or biweekly.
After gradual distraction with the TSF has realigned the
anatomy of the foot, the second stage of correction is
performed. In the second stage, the external fixator is
removed while simultaneously performing minimally
invasive arthrodesis of the affected joints with percutaneous
insertion of internal fixation. After frame removal and
re-prepping and trapping, incisions overlying the appropriate
joint(s) are made to perform joint preparation for
arthrodesis. Minimally invasive arthrodesis is easily
performed because the Charcot joints are already distracted.
Under fluoroscopic guidance, the guidewires for the large-
diameter cannulated screws are inserted percutaneously
through the plantar skin incision into the first, second, and
either the third or fourth metatarsal head by dorsiflexing the
digit. After the lateral and medial column guidewires are
inserted to maintain the corrected foot position, three large-
diameter cannulated intramedullary metatarsal screws are
inserted: medial and lateral column partial-threaded screws
for compression of the arthrodesis site and one central fully
threaded screw for additional stabilization. These screws
span the entire length of the metatarsals to the calcaneus
and talus, provide compression across the minimally
invasive arthrodesis site, and stabilize adjacent joints. The
intramedullary metatarsal screws cross an unaffected joint,
the Lisfranc joint, thereby protecting the Lisfranc joint from
experiencing a future Charcot event. A non-weight-bearing
short-leg cast is maintained for 2–3 months, and then gradual
426
Fig. 10 After removal of the external fixation, a minimally invasive
fusion of the midtarsal joint was performed to prevent future Charcot
foot collapse. A weight-bearing anteroposterior view radiograph shows
three percutaneous intramedullary metatarsal screws that were inserted
for stabilization of the fusion of the midtarsal joint. Note the accurate
anatomic reduction
progression to weight bearing is achieved in a walking boot.
Thus, the entire treatment is completed in 4–5 months.
8 Outcome Clinical Photos
and Radiographs
See Figs. 10 and 11.
9 Avoiding and Managing Problems
Utilizing this two-stage method of gradual distraction of the
Charcot joint dislocation followed by internal fixation is
indicated for large Charcot deformity.
Success of this treatment is to achieve efficient Charcot
joint reduction (gradual distraction over a 2-week period)
followed by a rigid internal fixation construct
(intramedullary foot fixation) and 8–12 weeks of non-
weight-bearing in a cast.
B.M. Lamm
Fig. 11 Lateral view post-operative photograph of the patient during
weight-bearing shows a plantigrade foot with intramedullary metatarsal
screws
Charcot patients take a greater amount of time for osseous
consolidation; therefore, multiple host factors have to be
addressed in combination with accurate well-planned
surgical technique.
Creative and stable frame construction is required
because of the small pedal anatomy, which renders it
difficult to apply external fixation. When applying the
forefoot 6  6 butt frame, it is important to mount the
U-plate on the hindfoot and the full ring on the forefoot as
posterior and anterior as possible, respectively. The greatest
distance between the forefoot and hindfoot ring is critical to
accommodate the TSF struts.
Bone segment fixation is important, at least two points of
fixation per segment; otherwise, failure of osteotomy
separation or incomplete anatomic reduction occurs.
Small wire fixation is preferred in the foot because of the
size and consistency of the bones.
When treating a patient with neuropathy, building
extremely stable constructs is of great importance.
This two-stage gradual external fixation correction with
Intramedullary Foot Fixation (IMFF) method has been
reported to have positive short-term results as a primary or
salvage procedure.
10 Cross-References
▶ Case 60: Charcot Reconstruction with Intramedullary
Foot Fixation
Case 59: Charcot Reconstruction with External Fixation 427

References and Suggested Reading and reconstruction surgery. Informa Healthcare, New York,
pp 221–231
Lamm BM, Gottlieb HD, Paley D (2010) A two-stage percutaneous
Cooper PS (2002) Application of external fixators for management of
approach to charcot diabetic foot reconstruction. J Foot Ankle Surg
Charcot deformities of the foot and ankle. Foot Ankle Clin
49(6):517–522
7(1):207–254
Lamm BM, Siddiqui NA, Nair AK, LaPorta G (2012) Intramedullary
Jolly GP, Zgonis T, Polyzois V (2003) External fixation in the
foot fixation for midfoot Charcot neuroarthropathy. J Foot Ankle
management of Charcot neuroarthropathy. Clin Podiatr Med Surg
Surg 51(4):531–536
20(4):741–756
Lamm BM, Paley D (2006) Charcot neuroarthropathy of the foot
and ankle. In: Rozbruch RS, Ilizarov S (eds) Limb lengthening