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diabetic peritalar neuropathy. Foot Ankle Int. 1995;16:332-338.

6. Papa J, Myerson M, Girard P. Salvage, with arthrodesis, inintractable diabetic neuropathic arthropathy of the footand ankle. J Bone Joint Surg. 1993;75-A:1056-1066.

7. Stuart MJ, Morrey BF. Arthrodesis of the diabetic neuro-pathic ankle joint. Clin Orthop Relat Res. 1990;253:209-211.

8. Jude EB, Selby PL, Burgess J, et al. Bisphosphonates in thetreatment of Charcot neuroarthropathy: a double-blindrandomised controlled trial. Diabetologia. 2001;44:2032-2037.

9. Sayner LR, Rosenblum BI, Giurini JM. Elective surgery ofthe diabetic foot. Clin Podiatr Med Surg. 2003;20:783-792.

0. Sticha RS, Frascone ST, Wertheimer SJ. Major arthrode-sis in patients with neuropathic arthropathy. J Foot AnkleSurg. 1996;35:560-566.

1. Wang JC. Use of external fixation in the reconstruction ofthe Charcot foot and ankle. Clin Podiatr Med Surg. 2003;20(1):97-117.

2. Paul GW. The history of external fixation. Clin PodiatrMed Surg. 2003;20(1):1-8.

3. LaBianco GJ, Vito GR, Rush SM. External fixation. In:McGlamry’s comprehensive textbook of foot and anklesurgery, Vol. 1. 3rd ed. Philadelphia, PA: Lippincott, Wil-liams & Wilkins; 2001:107-108.

4. Charnley J. Compression arthrodesis of the ankle andshoulder. J Bone Joint Surg. 1951;33B:180-191.

5. Baker MJ, Offutt SM. External fixation indications andpatient selection. Clin Podiatr Med Surg. 2003;20(1):9-26.

6. Fox IM, Shapero C. The use of the hybrid external fixatorsystem in the foot and ankle. Clin Podiatr Med Surg. 2002;17:131-145.

7. De Bastini G, Apley AG, Goldberg A. Orthofix ExternalFixation in Trauma and Orthopedics. New York: Springer-Verlag; 2000.

8. Wang JC, Le AW, Tsukuda RK. A new technique forCharcot’s foot reconstruction. J Am Podiatric Med Assoc.2002;92:429-436.

9. Cooper PS. Application of external fixators for manage-ment of Charcot deformities of the foot and ankle. FootAnkle Clin N Am. 2002;7(1):207-254.

0. Talarico LM, Vito GR. Triple arthrodesis using external

ring fixation and arched-wire compression; an evaluation t

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of 87 patients. J Am Podiatric Med Assoc.2004;94(1):12-21.

1. Grady JF, O’Connor KJ, Axe TM, et al. Use of electro-stimulation in the treatment of diabetic neuropathy. J AmPodiatr Med Assoc. 2000;6:287-294.

2. Myerson MS, Henderson MR, Saxby T, et al. Manage-ment of the midfoot diabetic neuroarthropathy. Foot An-kle Int. 1994;15:233-241.

3. Farber DC, Juliano PJ, Cavanagh PR, Ulbrecht J, CaputoG. Single stage correction with external fixation of theulcerated foot in individuals with Charcot neuroarthropa-thy. Foot Ankle Int. 2002;23:130-134.

ommentary: These of Externalixation forreatment ofomplex Lowerxtremityeuropathicrthropathy

ichard Alvarez, MD, and Brent L. Norris, MD

epartment of Orthopedic Surgery, University ofennessee College of Medicine, Chattanooga,ennesseee would like to commend the authors on their review of a

ifficult problem—diabetic and/or neuropathic arthropathy.aving said that, we have some strong opinions regarding their

osition and treatment of this difficult problem. First, weould like to point out that the article is a review of only 8 cases

hat the authors have performed with this treatment. The 8ases had a 36% nonambulation rate and a 12% reulcerationate. In addition, the follow-up was only 2 months on at least 1atient and a maximum of 32 months on the remaining pa-ients. With a condition such as neuropathic arthropathy,here the illness runs at least 8 months to 1 year, this time frame

s woefully inadequate. Additionally, the authors try to convey

hat external fixation is routine for treatment of charcot joint

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roblems. They quote several authors, one of whom is Dr. Paulooper in the Baltimore/DC area. Dr. Cooper has publishedumerous articles on neuropathic problems of the foot and haseen trained in the use of Ilizarov external fixation. Dr. Coopereals with complex arthropathy patterns and problems. Theroblems Dr. Cooper sees cannot be solved using standard fix-tion techniques and often requires salvage procedures withlizarov external fixation. Even in his hands, these proceduresre not without complications and they can include significantin loosening, pin infection, and persistent deformity and com-licated wounds. Having said this, the authors wish to sell aore simple form of external fixation for the treatment of neu-

opathic anthropathy as the up-and-coming procedure ofhoice when really it should be reserved for the rare case requir-ng a salvage procedure.

A review of the literature and treatment of this problemhows that in 1993, ankle and hindfoot arthrodesis was foughtith nonunion and persistent deformity. Complications such

s below-the-knee and, in rare instances, above-the-knee ampu-ations were common. In 1993, Dr. Alvarez published the firstrticle on blade plate fixation for the treatment of neuropathicrthropathy and deformities related to this disease process. Itas shown that the deformities and ulcerations associated witheuropathic arthropathy could be corrected without a signifi-ant complication rate. Open reduction and internal fixationas used in the face of ulcerations and in many cases changed

he biomechanics of the foot, lessening the pressure on the site

f ulceration and allowed them to heal. Additionally, placement p

24 CURRENT

f internal fixation allowed for less cumbersome follow-up. Byaving the correction at the time of surgery, the aftercare wasimplified. With external fixation, the follow-up is laboriousnd usually requires once-a-week or once-every-two-week visitso ensure that the problems of pin infection and loosening arereated quickly and appropriately. Neuropathic bone has a ten-ency for pins to become loose (secondary to resorption ofone), especially in the areas of compression.In closing, in our mind, external fixation serves a limited role

n the treatment of neuropathic arthropathy usually in the sal-age of difficult complicated deformities in which no otherlternatives are available. We agree that external fixation may behe treatment of choice in these most severe neuropathic defor-ities that require correction and have complicated wounds

hat prohibit internal fixation. Furthermore, there is no ques-ion that a place exists for both external and internal fixation forhe treatment of this condition. Having said this, any well-rained orthopedic surgeon with the knowledge of sound prin-iples of internal fixation can salvage most hindfoot/midfooteformities. On occasion, neuropathic arthropathy will requirexternal fixation.

The authors certainly have experience with external fixationalthough few in number), and in their hands, it seems to workdequately for them. However, it should not be construedhrough the publication of this article that this is the standard ofare. We feel that the readers should know that there are mul-iple alternatives, several of which are probably more commonly

reformed and predicated on better research and outcomes.

SURGERY • Volume 62/Number 6 • November/December 2005