Staging Strategies for the Infected,Deformed Foot

The treatment of complex foot and ankle pathology in high-risk populations, particularly those with Charcot neuroarthropathy, infection, and compromised soft tissues, remains a challenging problem. The study by Fischer et al, ¹ “Two-Stage vs Single-Stage Ilizarov Application in High-Risk Patients: Impact on Early Complications and Resource Utilization,” offers an encouraging and clinically meaningful perspective. Its central finding is that a 2-stage approach is associated with lower rates of impaired wound healing and fewer wound revisions, particularly in Charcot and infected cases, without increasing hospital stay or overall costs.

The Ilizarov method remains a cornerstone of limb salvage, especially for complex deformities, infections, compromised soft tissues, and to enable gradual corrections. However, the question of whether to proceed with a single-stage or a staged approach is debatable. Single-stage surgery may be more efficient and reduce need for multiple anesthetics. Staging can allow improved soft tissue management and infection control. The present study contributes meaningfully to this discussion by demonstrating that, in carefully selected high-risk patients, staging may confer a protective effect against a consequential complication in this population: wound breakdown.

Equally noteworthy is the study’s observation that these improved wound outcomes do not come at the expense of increased hospital stay or cost. Optimizing surgical strategy for complication avoidance may be as important, if not more so, than minimizing the number of operative events.

By separating debridement, infection control, and definitive fixation into distinct phases, the 2-stage approach allows the soft tissue envelope to recover, inflammation to subside, infected bone to be resected, and local conditions to optimize before definitive reconstruction. In patients with Charcot deformity or active infection—where vascularity, tissue integrity, and immune response are often compromised—this interval may be helpful. Prior literature has also demonstrated successful staged reconstructions of infected ulcerated Charcot deformities treated with internal fixation. ²

Equally noteworthy is the study’s observation that these improved wound outcomes do not come at the expense of increased hospital stay or cost. This challenges a common perception that staging inherently imposes greater resource utilization. Optimizing surgical strategy for complication avoidance may be as important, if not more so, than minimizing the number of operative events.

Our previous experience has included success with both approaches for various clinical situations: single-stage reconstruction with both internal and ring external fixation for infected ankle and hindfoot deformity. ³ In a trauma setting, we have used a staged approach for the management of severe tibia pilon fractures with primary ankle arthrodesis, also using both internal and ring external fixation methods. ⁴

From a clinical standpoint, these results underscore the importance of patient selection and individualized care planning. High-risk patients are not a homogeneous group, and the factors that predispose to wound complications—such as infection, ulcerations, neuropathy, vascular insufficiency, and poor glycemic control—vary widely. The demonstrated benefit of staging in Charcot and infected cohorts suggests that these subgroups, in particular, may derive the greatest advantage from a deliberate, phased reconstructive strategy.

The findings also highlight the continued importance of multidisciplinary care. ² Even with an optimal surgical strategy, outcomes are influenced by factors such as glycemic control, vascular status, nutritional support, social support system, and adherence to postoperative protocols. A staged approach may provide additional opportunities to address these variables between procedures, further enhancing the likelihood of successful healing.

In interpreting these results, it is important to recognize that no single approach will be universally applicable. Single-stage reconstruction remains an effective and appropriate option in selected patients, particularly those with stable soft tissues and lower infection risk. However, the present study provides compelling evidence that, in higher-risk scenarios, a 2-stage strategy may offer meaningful advantages.

It is also important to point out that Ilizarov frames in this study were static holding frames and not used for gradual correction of deformity. Acute correction of more severe deformities is often associated with wound healing issues. Gradual correction of more advanced deformities is another established means of decreasing the incidence of wound problems. Further investigation of the 2-stage concept will, we hope, include an evaluation of deformity parameters and guidelines for which are best treated in 2 stages vs one.

In conclusion, this study reinforces the value of thoughtful, patient-centered surgical planning in complex foot and ankle reconstruction. By demonstrating lower rates of impaired wound healing and fewer wound revisions with a 2-stage Ilizarov approach—without increased hospital stay or cost—it supports the role of staging as a deliberate and effective strategy in high-risk patients.

Supplemental Material

sj-pdf-1-fai-10.1177_10711007261457417 – Supplemental material for Staging Strategies for the Infected, Deformed Foot

Supplemental material, sj-pdf-1-fai-10.1177_10711007261457417 for Staging Strategies for the Infected, Deformed Foot by Doug Beaman and Paul T. Fortin in Foot & Ankle International

Doug Beaman, MDAdventist Health Columbia Gorge Orthopaedic Surgery, The Dalles, OR, USA Paul T. Fortin, MDMichigan Orthopedic Surgeons, Royal Oak, MI, USA