SLR - January 2020 - Andres L. Caneva
Reference: K. Yammine, C. Assi. Intramedullary Nail versus External Fixator for Ankle Arthrodesis in Charcot Neuroarthropathy: A Meta-analysis of Comparative Studies. Journal of Orthopaedic Surgery. 2019 March 20; 27(2), 1-7.Scientific Literature Review
Reviewed By: Andres L. Caneva, DPM
Residency Program: AMITA Health, St. Joseph Hospital – Chicago, IL
Podiatric Relevance: An often serious condition seen and treated by foot and ankle specialists is Charcot neuroarthropathy. If not caught at an early stage and conservative treatment is not implanted, it can lead to a quickly progressive and destructive architecture of the foot involving the bones, joints and soft tissues. A rocker-bottom deformity may be the result, with greater predisposition to ulcerations, and leading to higher risk of amputation. Our goal as podiatric surgeons when treating the later stages of Charcot is to establish a plantigrade foot with osseous stability. When the hindfoot and ankle become involved, arthrodesis is usually the surgical treatment indicated to realign and stabilize the deformity. The goals of this study were to systematically review evidence from comparative studies to look for significant differences between fusion rate, salvage rate and complications using external fixation or intramedullary nail techniques for tibiotalocalcaneal (TTC) arthrodesis.
Methods: This paper is a meta-analysis of four comparative studies including 117 patients. The authors searched different databases initially obtaining 257 articles from inception to June 2018. After review of the initial search, one quasi-randomized clinical trial and three retrospective comparative studies were included. The inclusion criteria were comparatively designed studies which reported the primary outcome of radiological fusion healing rate. Cohort studies, review articles and case reports were excluded. Secondary outcome measures included time to heal, revision surgery, hardware infection, wound infection and amputation rate. Proportion meta-analysis was used to look for weighted frequencies of outcomes in each study.
Results: Within the four comparative studies obtained through the search, 117 patients or interventions were obtained. Of the 117 patients, 98 were found to have a diabetic Charcot neuropathy. Seventy patients were included in the Intramedullary nail (IMN) group and 47 in the external fixator (EF) group, with no previous surgeries. All deformities were classified as stage II/II Eichenholz. The average follow-up period was 2.84 +/- 0.55 years. IMN was found to yield double fusion rate than ED with five weeks less time to heal. There was no significant difference noted in revision surgery and amputation, although ED yielded higher rates of hardware infection and wound infection.
Conclusions: Overall, the IMN technique seemed to offer quicker and better fusion rate when compared to EF with lower post-operative infection rates. Limitations of this study were the small pooled sample size and the study design of the included studies. When trying to decide which procedure is better, it is important to remember that there are a multitude of factors to be considered and the method chosen should be tailored on an individual patient basis. The authors of this study found that for patients without ulcerations or only medial/lateral ankle ulcerations, IMN is preferable. Those patients with plantar ulcers, it may be better to pursue EF so as to avoid the plantar approach required for IM nail insertion. Future higher level studies are the next step to better evaluate outcomes associated with each method.