Episode Overview

Podcast: Foot & Ankle International
Episode: Painful Nonunion in Patients With Clinically Plantigrade Diabetes-Associated Charcot Foot Arthropathy
Release Date: September 17, 2024
Host: Dr. Charlie Saltzman
Guest: Dr. Michael Pinzur, Professor of Orthopedic Surgery, Loyola University Health System

Main Theme:
This episode provides a deep dive into Dr. Pinzur’s highly impactful study on the occurrence and management of painful nonunion in clinically plantigrade patients with diabetes-associated Charcot foot arthropathy. Dr. Pinzur shares both the scientific basis and practical pearls from his decades of pioneering work, challenging traditional beliefs and emphasizing an evidence-driven, patient-centered approach to surgical care in this vulnerable population.

Key Discussion Points & Insights

1. Redefining Painful Charcot Nonunions

• Pain as a Key Symptom: Classical teaching suggests pain is absent in Charcot foot due to neuropathy. Dr. Pinzur’s series found a subset of patients who, despite appearing healed and plantigrade on radiographs, reported significant pain, which corresponded to unhealed, nonunited fractures.
  • “When you have somebody that appears to be well controlled but they're complaining of pain, you need to be a little more vigilant...their pain is from the non union and then it's a relatively simple thing to solve.” (Dr. Pinzur, [02:28])
• Clinical Implication: Surgeons must not dismiss pain in diabetic neuropathic foot; it deserves further investigation, often with CT scanning.

2. Study Design: Patient Selection & Historical Context

• Inclusion Criteria: Patients were plantigrade, both clinically and radiographically, and had been managed conservatively but continued to experience life-altering pain.
• Exclusion Criteria: No surgery if pain was mild or absent, or if function was acceptable with accommodation footwear.
• Historical Reflection: Earlier studies that formed the bedrock of Charcot knowledge (e.g., Eichenholtz) were based on small, limited samples.
  • “All of our thinking is based on this. 50 patients...A lot of the things that we were taught turned out to be wrong. We have to look at this population differently.” (Dr. Pinzur, [07:54])

3. Revisiting Classic Theories of Charcot Foot Pathogenesis

• Dr. Pinzur posits the neurovascular and neurotraumatic theories are not mutually exclusive, but both contribute to disease:
  • Diabetic patients with neuropathy are likely to have systemic osteopenia and fragility fractures that may fail to heal, particularly in higher BMI patients who load their feet more.
  • “We've asked for years, do we believe in the neurotraumatic or the neurovascular theories of Charcot foot?...I think both theories are correct.” (Dr. Pinzur, [05:15])

4. Preoperative Medical Optimization

• Four "Hard Stops" for Elective Surgery:
  • Hemoglobin A1C < 8.0
  • Control of hypertension
  • Adequate hemoglobin (no anemia)
  • Cardiac optimization
• Patient Safety Emphasis:
  • Always aim for patients to be in best possible health pre-op.
  • Prefer regional anesthesia to reduce complications and costs.
  • “We care for these patients at half the projected cost...it's because we don't have medical complications...” (Dr. Pinzur, [10:48])

5. Surgical Techniques & Pearls

• Circular External Fixation Preference:
  • Allows minimally invasive approaches and preservation of motion segments.
  • Enables controlled compression and enhances primary bone healing.
  • “We can use the modern approach of MIS surgery...my incision might be a centimeter...the reason I like to use frames...I lose no more motion segments.” (Dr. Pinzur, [13:04])
• Bone Grafting:
  • Rarely uses bone grafts/biologics unless autologous; data does not show marked added benefit.
• Technical Tips:
  • Closed rings always (never two-thirds).
  • Olive wires in heel and forefoot at 30° angles; tensioned for compression.
  • Tension always to 120 mm (never with squeeze tensioner due to inadequate force).
  • “Always use closed rings. Never ever use a two thirds or an open ring...” (Dr. Pinzur, [23:20])
• Post-Op Management:
  • Patients seen at 3 and 12 weeks.
  • Non-weight bearing except as needed for transfers, with creative use of modified cast shoes and elastic bands to avoid shearing pin wires.
  • Showering allowed after 72 hours.
  • Pin tract infections managed with oral antibiotics and local care; usually resolve after frame removal.
  • “We published...283 consecutive circular frames on diabetics where 20%...get pin tract infections...not one...had persistent infection after the pins were removed at 12 weeks.” (Dr. Pinzur, [18:12])

6. Defining Success & Outcome Measures

• True Goal:
  • Patients should be able to walk in the community using a standard diabetic shoe; use of AFOs or CROW boots equals a poor outcome.
  • “A good result is somebody who can wear a commercially available shoe in a custom orthosis. If they need even a short ankle foot orthosis, they're called a fair result and a crow boot...That's a failure.” (Dr. Pinzur, [21:35])
• Pain as a “Red Flag”:
  • Due to neuropathy, pain should not be present; if it is, a thorough workup for nonunion and other causes is necessary, not dismissal.

7. Major Clinical Implications

• Take Patient Complaints Seriously:
  • Pain in diabetic Charcot patients is never “just in their head”—seek the organic cause.
  • Avoid amputation whenever possible; these patients do poorly with prosthetics due to fluctuating limb volume from systemic disease.
  • “Avoiding amputation allows these people to walk...If you fail, if these people end up as a BK, they're in a chair the rest of their life.” (Dr. Pinzur, [24:32])

Notable Quotes & Memorable Moments

• On Challenging Old Dogma:
  • "A lot of the things that we were taught turned out to be wrong. We have to look at this population differently." (Dr. Pinzur, [07:54])
• On Defining “Success”:
  • "If they need even a short ankle foot orthosis, they're called a fair result and a crow boot...That's a failure." (Dr. Pinzur, [21:35])
• On Painful Nonunion:
  • “When you have somebody that appears to be well controlled but they're complaining of pain, you need to be a little more vigilant...their pain is from the non union and then it's a relatively simple thing to solve.” (Dr. Pinzur, [02:28])
• On Patient Gratitude:
  • “These people are so grateful when you take care of them...Avoiding amputation allows these people to walk...If you fail...they're in a chair the rest of their life.” (Dr. Pinzur, [24:32])
• On Medical Optimization:
  • "By starting up front, getting these people as good as they can be, minimize the risk when you do the surgery, and then we have a better chance of taking care of them without complications." (Dr. Pinzur, [11:24])

Important Timestamps

• 00:00–01:30: Introduction to study and Dr. Pinzur’s background
• 01:30–03:15: Summary of main findings—painful nonunion is overlooked in plantigrade Charcot foot
• 03:15–07:14: Detailed criteria for patient inclusion/exclusion and pathophysiology theories
• 09:08–11:48: Preoperative optimization, patient safety, anesthesia choices
• 11:48–17:46: Technical surgical discussion—frames, bone grafts, intra-op tricks, post-op care
• 19:04–20:45: Weight bearing, patient compliance, management of hardware
• 20:45–22:47: Defining clinical success, the critical importance of pain
• 23:20–24:22: Wire tensioning strategy and ring selection
• 24:32–25:37: Final pearls—never block diabetic patients, amputation as failure

Conclusion

Dr. Pinzur’s conversation with Dr. Saltzman offers both a challenge to outdated paradigms and a highly practical roadmap for foot & ankle surgeons dealing with diabetic Charcot arthropathy. Recognizing and managing painful nonunion in these patients prevents misdiagnosis, avoids unnecessary amputations, and improves their quality of life. Dr. Pinzur emphasizes rigorous preoperative optimization, evidence-based surgical approaches, and truly patient-centered outcome measures—defining not radiographic, but functional and community-based success.