Department of Orthopaedic Surgery, Loyola University Health System, Maywood, IL 60153, USA.
Foot Ankle Int. 2012 Dec;33(12):1069-74. doi: 10.3113/FAI.2012.1069.
There is both increased interest and awareness in diabetes-associated Charcot foot arthropathy. The number of affected patients will likely increase as the incidence of both diabetes and morbid obesity increases. Many experts now favor surgical correction of the deformity rather than longitudinal management with accommodative bracing. In patients with open wounds and exposed bone and/or chronic osteomyelitis, it is controversial whether resolution of the bony infection should be achieved before attempting surgical correction of the acquired deformity.
During a 78-month period, 178 patients underwent surgical correction of deformity with diabetes-associated Charcot foot or ankle arthropathy by a single surgeon. Seventy-three had evidence of osteomyelitis at the time of surgery. There were 41 males and 32 females. Their average age was 57.9 (range, 31 to 76) years, and body mass index was 36.9 (range, 21.8 to 60.9). The clinical diagnosis of osteomyelitis was made by (a) an open wound overlying the deformity with exposed bone and chronic drainage; (b) a history of biopsy-diagnosed osteomyelitis that was not currently draining, but had clinical and pathologic evidence of abnormal bone in the region of the previous infection; or (c) a history of previous wound overlying bony deformity with abnormal bone observed at the time of surgery. Surgery involved radical resection of the clinically infected bone, combined with acute correction of the deformity to a plantigrade foot. Parenteral culture-specific antibiotic therapy was administered and monitored by an infectious disease comanagement service. A three-level preconstructed static circular external fixator was applied to maintain the surgically obtained correction.
Sixty-eight of 71 patients (95.7%) achieved limb salvage and were able to ambulate with commercially available therapeutic footwear. One patient died shortly after removal of the external fixator from unrelated causes. Three patients required amputation. Resolution of infection and wound closure was achieved in five patients following a second surgical debridement. Two noninfected wounds were resolved with local soft tissue flaps. Two patients have persistent noninfected wounds that have been resistant to wound care therapy.
A plantigrade noninfected foot can be achieved in patients with infected diabetic Charcot foot deformity with single-stage radical resection of osteomyelitis, correction of the deformity, maintenance of the correction with static external fixation, and culture-specific antibiotic therapy.
糖尿病相关夏科氏足关节病的关注度和认识度都有所提高。随着糖尿病和病态肥胖发病率的增加，受影响的患者数量可能会增加。许多专家现在赞成通过手术矫正畸形，而不是通过适应性支具进行长期管理。对于有开放性伤口、暴露骨和/或慢性骨髓炎的患者，是否应该在尝试矫正获得性畸形之前，先解决骨感染，这一点存在争议。
在 78 个月的时间里，一位外科医生为 178 例糖尿病相关夏科氏足或踝关节关节病患者进行了手术矫正畸形。73 例患者在手术时存在骨髓炎的证据。其中男 41 例，女 32 例。平均年龄为 57.9 岁（范围 31 至 76 岁），体重指数为 36.9（范围 21.8 至 60.9）。骨髓炎的临床诊断依据为：（a）畸形处有开放性伤口，伴有暴露骨和慢性引流；（b）有活检诊断为骨髓炎的病史，但目前无引流，且该区域有临床和病理异常骨；（c）先前有覆盖骨畸形的伤口，手术时发现异常骨。手术包括对临床感染的骨进行彻底切除，结合急性矫正畸形至足底承重位。给予针对特定病原体的抗生素治疗，并由传染病联合管理服务进行监测。应用三级预构建的静态环形外固定架以维持手术获得的矫正效果。
71 例患者中的 68 例（95.7%）实现了肢体挽救，并能够使用商业上可获得的治疗性鞋具行走。1 例患者因与手术无关的原因在拆除外固定器后不久死亡。3 例患者需要截肢。5 例患者在第二次清创术后感染和伤口愈合得到了治愈。2 例非感染性伤口通过局部软组织皮瓣得到解决。2 例患者有持续的非感染性伤口，对伤口护理治疗有抵抗力。
对于患有感染性糖尿病夏科氏足畸形的患者，可以通过一期彻底切除骨髓炎、矫正畸形、使用静态外固定架维持矫正效果以及针对特定病原体的抗生素治疗，获得足底承重且无感染的足部。
