Charles Green was leaving an office on the South Side early last year when he suffered a life-changing injury.

Annie O'Neill, Post-Gazette Katie Green helps her husband, Charles, adjust a frame attached to his ankle. The frame, in place to help heal a fracture, must be adjusted daily using settings generated by a computer. Click photo for larger image. Diabetes Facts Nearly 21 million children and adults in the United States have diabetes, up from an estimated 18.2 million in 2003. In Pennsylvania, about 1.1 million people have the disease. The cost of diabetes in the United States in 2002 was at least $132 billion. In Pennsylvania, diabetes accounts for about $6.7 billion in health care costs annually. In Pennsylvania, diabetes is the leading cause of new blindness, end-stage renal disease and non-traumatic amputations. More than 11,000 Pennsylvanians die each year from diabetes. Sources: American Diabetes Association; University of Pittsburgh Diabetes Institute

Trying to get around a group of people gathered on the steps outside, he jumped a short distance to the sidewalk and severely fractured his right ankle.

Mr. Green, 52, of Carrick, had two surgeries early on to repair the break, then developed an infection and switched doctors. Last month, his current surgeon, Dr. Dane Wukich, chief of orthopedic foot and ankle surgery at the University of Pittsburgh Medical Center, performed another operation and also installed an external frame attached to the ankle with an array of pins and wires.

Dr. Wukich and other proponents of using the frames believe they offer a better alternative for repairing some severe foot and ankle injuries than more conventional surgery using plates and screws.

"We are starting to develop evidence that this offers huge hope," said Dr. Michael Pinzur, professor of orthopedic surgery and rehabilitation at Loyola University Medical Center in Chicago.

Dr. Pinzur, a former board member of the American Orthopaedic Foot and Ankle Society, said he has used the frames in about 50 to 60 cases over the past several years and has had good results, even in patients at risk for amputation. Surgical repairs of deformities can be held in place by the frames even when bone quality is poor, he said.

Dr. Wukich, who reported promising results in about 45 cases, said the frames also can be used to correct deformities before surgery, resulting in operations that are less invasive.

The external frames can be especially useful in foot or ankle cases involving infection, tumors, trauma or diabetes, said Dr. Paul Kupcha, an orthopedic surgeon in Wilmington, Del.

Others caution that evidence is lacking to demonstrate that the frames can improve outcomes compared to standard surgery.

"You'd think it would be less invasive and offer the opportunity for better healing and less infection. But we don't know that yet," said Dr. Peter Sheehan, director of the diabetes center at New York's Cabrini Medical Center and a board member of the American Diabetes Association.

Proponents cite the rising tide of diabetes as a compelling reason for identifying ways to head off potential complications.

Diabetes is the nation's leading cause of lower extremity amputations, Dr. Wukich noted. Diabetics who lose one leg are at higher risk of losing the other leg or of dying within a few years.

"If we can do things to keep people ambulatory," said Dr. Pinzur, "they will probably live longer and be more productive."

Diabetics who develop a foot ulcer or a condition known as Charcot foot are especially at risk for amputation, he said.

Many people with diabetes have neuropathy that results in impaired sensation. They may not notice abnormal pressure or injuries to the foot, which can lead to ulcers.

Diabetics with Charcot foot also may have increased circulation that can leave the foot warm, red and swollen and contribute to bone softening. People with the condition may suffer injuries to the foot but continue to walk until the foot's bony structure collapses.

John Eberlein broke his left foot when he fell off a ladder in January, but was unaware of the fracture and didn't go to the hospital until the following month, when the foot swelled and he was unable to go to church.

Tests then indicated multiple fractures, said Mr. Eberlein, 54, of the West End.

Mr. Eberlein, who has diabetes, said Dr. Wukich placed his foot in an external frame for three months and later inserted two screws.

While he wears a special shoe and has some stiffness, he is able to ride an exercise bike and has returned to work as a construction foreman for the city of Pittsburgh.

If Charcot foot is caught early, wearing a cast and keeping weight off the limb can prevent severe injury, said Dr. Jim Christina, director of scientific affairs for the American Podiatric Medical Association.

But the condition is "very commonly mistaken for an infection or cellulitis," he said.

"Often, we're presented with foot and ankle problems we shouldn't be presented with because patients come to us so late and with significant deformities," said Dr. Stephen Conti, director of foot and ankle surgery at Allegheny General Hospital.

He said patients with neuropathy should wear protective shoes -- generally covered by Medicare -- and should consider any unusual sore or warm, swollen foot as a potentially serious problem requiring immediate evaluation from a medical professional familiar with diabetic foot and ankle problems.

If deformities have occurred, a variety of surgical approaches may help, he said, some of which involve external frames.

Doctors said the frames have their roots in an approach originated in the 1950s by a Soviet physician, Dr. Gavrill Ilizarov. He found that tension applied to the ends of bones cut during surgery could regenerate bone and lengthen limbs.

More recently, the approach has been adopted for foot and ankle surgeries, said Dr. Kupcha, who utilizes both an Ilizarov frame and a similar device, the Taylor Spatial Frame, developed in the 1990s. That frame allows patients to make their own daily adjustments to the device, guided by a printout generated by a computer.

Using the devices in foot and ankle surgery "has not caught on like wildfire," in part because the learning curve is high, Dr. Kupcha said.

It also can be time-consuming for surgeons and frustrating for patients, said Dr. Wukich, noting that patients can develop superficial infections or other problems.

"I tell patients it won't be easy, but it's better than the alternative," Dr. Wukich said.

He said Mr. Green faced the possibility of amputation after his injury and complications from an infection left him with an unstable ankle and shortened his leg by about an inch.

His latest surgery was aimed at fusing the ankle and using the spatial frame to lengthen his shin bone, a process expected to take several months.

Mr. Green, a dental technician who is married and the father of a 6-year-old son, said he gets around pretty well on crutches and noted that dealing with the frame is not all that difficult.

"It probably looks more painful than it is," he said, pointing out that he already can put some weight on his foot.

"I have a lot of hope that everything is going to work out and that someday, I may be able to stand on two feet again."