External fixation (frames) for Charcot foot and limb salvage

What external fixation is

In external fixation, fine wires and thicker half-pins pass through the skin into the bones of the leg and foot and are clamped to metal rings that circle the leg. For Charcot surgery the frame is often “static”: it is assembled and locked to keep the corrected foot still while bone and soft tissue heal.⁠^[8,3,2] Because the support sits outside the leg, no permanent implant has to be left inside infected bone, and the correction can be done in stages if needed. Some reconstructions combine a frame with plates, screws or a rod inside the bone.⁠^[1]

When a frame is the right tool

Wound care and offloading are the foundation for every foot wound. A frame comes in when the foot must be rebuilt or protected and plates, screws or a cast are a poor fit:

• A Charcot foot with infection or an open wound. In Charcot foot, the bones of a numb foot weaken and collapse.⁠^[1] When an ulcer over the collapse lets infection reach the bone (osteomyelitis), a frame can hold the corrected foot once the infected bone is removed.⁠^[3]
• Severe deformity or fragile skin. Frames are also favored when the deformity is severe or the soft tissue is in poor condition.⁠^[1]
• Protecting a repair after surgery. After infected bone is removed and the wound closed with a flap or skin graft, a frame can hold the foot so nothing presses on the repair, as reported after midfoot surgery and after removing infected heel bone.⁠^[4,9] See skin grafts and flaps and heel ulcers.

Dr. Efe Ozturk, a Foot and Ankle Surgeon, uses external fixation in limb salvage surgery for the feet that need it. A frame is typically one part of a larger operation, such as Charcot reconstruction or surgery to remove infected bone.

How the surgery works

In one surgical team’s published Charcot series, frame surgery combined several steps:⁠^[3,10]

• removing infected bone when present
• lengthening a tight Achilles tendon through small incisions
• taking out a wedge of bone at the peak of the deformity so the foot can rest flat on the ground
• applying a static frame with three levels of rings to hold the new shape
• for an infected foot, antibiotics given by vein and chosen from the culture results

Before frame surgery, we check your circulation with noninvasive testing at our practice and involve a vascular specialist when blood flow needs attention (see circulation tests for foot wounds). In the Italian midfoot study, people with severely reduced blood flow had at least one artery below the knee reopened.⁠^[4]

It is a hospital operation; in one series, people with a ring frame went home after 4.6 days on average.⁠^[6] To get ready, see preparing for limb salvage surgery and the Center for Lower Extremity Surgery’s guide to smoking, diabetes and foot surgery healing (external site).

What the results show

These single-center studies, two of them from the same surgical team and one a small nonrandomized comparison, show what is possible in selected patients, not what everyone can expect.⁠^[3,10,9,4]

A review of 1,116 reconstructed Charcot feet, 31% of them held with frames, found no clear advantage for any fixation method, and the evidence was of low quality.⁠^[7] A 2026 review pooled 30 studies (957 people) of Charcot surgery in the hindfoot and ankle. Feet held with frames fused less often than feet held with internal fixation (68.2% versus 84.9%). They also had more amputations (8.1% versus 4.5%), though that gap could have been chance. Return to walking was similar. Frames had more skin and pin problems, while plates and rods had more hardware failures and repeat operations. Frames were usually chosen for infected or more complex feet, so the authors caution that these figures describe the groups rather than compare the methods.⁠^[1]

Living with a frame

How long. The frame stays on until the correction is stable. In a German series of 292 Charcot feet, the external fixator came off after six to eight weeks, followed by a custom brace for another 11 months; in a US series of Charcot ankle and hindfoot fusions, ring frames came off after about 13 weeks on average.⁠^[5,6] We check the bones with X-rays at the practice.

Day to day. One review notes that frames can be uncomfortable and that months in one are hard for some people.⁠^[1] Plan for a walker or wheelchair (we will tell you what is safe with your frame), a clear path at home, and help with bathing and errands.

Pin care. In 283 people with diabetes who had ring frames after Charcot surgery, 20.8% had signs of infection at one or more pins; the redness and drainage settled with local pin care and antibiotic pills in every case, and no wires had to come out early.⁠^[2] Pin infections were more common with higher A1c levels, so blood sugar control matters while the frame is on.⁠^[2] Trials of pin care in orthopedic patients, generally of poor quality, have not clearly shown that any one pin cleaning or dressing routine prevents infection better than others,⁠^[11] so follow the routine you are given. We teach you and your family pin care before you go home and check the pins at each visit.

After the frame comes off

The foot still needs protection while it finishes healing. We fit a knee-high device for that stage, then move you into therapeutic shoes. In both Pinzur studies, success meant walking in ready-made therapeutic shoes.⁠^[3,10] We add custom inserts when your foot needs them. See offloading boots and footwear and recovery after limb salvage surgery. Our parent practice’s diabetic foot care (external site) page covers therapeutic shoes and inserts.

Risks and limits

Problems are common but mostly minor. In 238 ring frames at one center, 44% had a minor problem, mostly wire irritation and redness, and 73% of those settled without extra treatment; 9% had a major complication that meant early removal of the frame or a return to the operating room.⁠^[8] Other risks include bones that do not fuse, new ulcers, infection and, for some people, an amputation even after a careful reconstruction.⁠^[1,10,5] In one team’s 12-year series of 214 people, 7 died within a year of surgery and 15 had part or all of the foot amputated.⁠^[10] This is major surgery, and these numbers are worth weighing with your surgeon.

A frame is not the only route: internal fixation, a frame combined with internal hardware, long-term bracing or a carefully planned partial foot amputation can each be right for a given foot. If you have been told amputation is the only option, a limb salvage second opinion can help you weigh them.

Questions to ask

• Why a frame for my foot, rather than plates, screws or a rod, or a frame combined with internal hardware?
• How long will it stay on, and how much weight can the leg take?
• Who checks my pins, and what should I do if one becomes red or drains?
• What brace or shoes will I need once it comes off?

When to seek care

See us within a day or two for any foot wound that isn’t healing, especially if you have diabetes. If you have diabetes or poor circulation, call us at 908-215-5953 the same day for a red, hot, swollen foot, other signs of infection, or new foot pain at rest.