Charcot neuroarthropathy is a rare, but devastating complication of diabetes¹. Progressive destruction of the bones and joints of the foot cause deformities and thus alter foot biomechanics¹. If not recognized nor treated properly, the disease can result in ulcer formation, infection, and progression of the disease with joint instability and bone destruction^2,3. In the worst case, limb amputation is required^4,5.

In this article, we will focus on the foot biomechanics, challenges of Charcot foot surgery and briefly describe different surgical approaches.

Foot Biomechanics

The most common foot bone anatomies involved in the Charcot neuroarthropathy are⁶:

The Lisfranc joint: articulation between the midfoot and forefoot; affected in about 60% of cases.
The Chopart joint: transverse/midtarsal joint (talus and calcaneus proximally, navicular and cuboid bone distally); affected in about 30% of cases.
The ankle joint: affected in about 10% of cases.

In patients with advanced stages of the disease, the involved joints collapse, and the foot takes on an abnormal shape, such as the rocker bottom appearance shown in Figure 1.

Figure 1 – Differences in appearance between normal foot and Charcot foot⁶

The altered joint morphology – a result of osteopenia and lack of proprioceptive feedback – increases mechanical forces, leading to further joint deterioration in a negative feedback loop.

Indications for Charcot Foot Fixation

The main goal of Charcot foot treatment, independent of the approach, is to achieve a stable plantigrade foot resistant to ulceration, prevent amputation, and improve the patient’s quality of life⁷. Untreated deformities may cause ulcers with the risk for deep infection and subsequent amputation. Lower limb amputation, in turn, significantly impacts patients’ lives⁸. Partial foot amputation was reported to result in mortality rates of 22% after 1 year, whereas transtibial or more proximal amputations can reach mortality rates as high as 52% after 1 year⁸.

Therefore, surgical reconstruction should be considered in the presence of the following⁶:

Severe instability of the foot or ankle
Varus or valgus deformity of the foot or ankle
Acute dislocation of the foot or ankle
Infected, long standing and recalcitrant ulcers
Failure of previous conservative treatment.

Patients with an unstable ankle in the coronal and sagittal plane are very prone to ulceration and require rapid surgical reconstruction. Daniel Scott (MD, Medical University of South Carolina (MUSC) Orthopaedics, Charleston) confirms: “Every time I see a patient with Charcot of the ankle, I’m a lot more worried. These patients are prone to ulceration and require rapid surgery when the coronal and sagittal plane show an unstable ankle.”

The most common methods of Charcot foot fixation are internal fixation, external fixation, or a combination of both⁹. The success of Charcot foot surgery, however, can be compromised by various factors, including:

Delayed wound healing and infection
- impacted by immune dysfunction, hyperglycemia, and nutritional and biologic deficiencies
Delayed bone healing due to neurovascular and autonomic dysfunctions
- along with inflammation and trophic alterations to bone⁹.

Therefore, the combination of altered bone healing, decreased bone density, poor soft tissue envelope, and recurrent progressive fracture patterns create significant challenges for surgical fixation methods⁹.

Internal Fixation

Charcot-specific fixation systems have evolved to address the mechanical demands on internal fixation constructs due to bone resorption, fragmentation, and osteoporosis^9,10. Internal fixation methods include plating with locking screws, axial beaming with solid bolts and screws, and retrograde hindfoot intramedullary nailing¹⁰.

As standard plating is usually insufficient for Charcot foot reconstruction, the principle of superconstructs was first described by Sammarco et al. (2009). It is defined by 4 factors⁷:

Fusion is extended to non-affected joints for better fixation.
Bone resection to shorten the extremity is performed to allow adequate reduction without undue tension on the soft tissue envelope.
The strongest implant, as tolerated by the soft tissue envelope, is selected.
- In particular, biomechanical studies of Charcot-specific implants showed higher stiffness, force to failure, and pullout strength for stainless steel than for titanium¹¹.
Implants are positioned in a way to maximize mechanical function.

Midfoot beaming allows for restoring the medial and lateral columns with minimal soft tissue dissection¹⁰. Beaming can be performed with screws or bolts and resists axial loading forces across the midtarsal joints¹⁰. However, the risk of hardware failure after beaming should be considered. Hardware failure rates reported in scientific literature vary from 4% to 67%^12-14.

Mohammad Sharif (DPM, Village Podiatry, Atlanta) explains his beaming approach: “My surgical approach always includes beaming. Beaming of the medial and lateral column is usually considered for midfoot pathologies, whereas the subtalar joint is included when the rear foot is also involved.”

Intramedullary nail fixation is used for hindfoot and ankle reconstruction, with tibiotalocalcaneal (TTC) arthrodesis being the most common technique¹⁰. Retrograde intramedullary nailing offers a stable load-sharing fixation that resists torsional forces¹⁰.

External Fixation

External fixation is especially useful in the presence of poor bone quality, ulceration, compromised soft tissue, active infection, or osteomyelitis, where the use of internal fixation is limited or contraindicated¹⁰. Circular external fixation is the most described external fixation method as it allows deformity correction while providing stability and compression when arthrodesis is required⁹. Compared to monolateral external fixators, circular external fixators do not rely on the cortical fixation of half pins but gain stability through transosseous wires⁹. They are suitable for midfoot, rearfoot, and ankle deformities⁹. An overview of different concepts of circular external fixation is shown in Table 1.

Table 1 Characteristics of circular external fixation concepts⁹

Circular External Fixation Concept	Characteristics
Static circular external fixation	Provide primary stability or can augment fixation Can be prebuilt and are thus easy to use Example: combination of 2 tibia circular rings and a foot plate
Stabilization off-loading	Different designs, including hybrid constructs with circular rings and a bar-to-clamp apparatus Suitable to off-load wounds and for soft tissue reconstruction Off-loading constructs can be converted to a static or dynamic external fixation construct Example: tibia and forefoot ring connected with threaded rods
ADynamic external fixation	For severe long-standing deformities requiring staged correction Examples: Ilizarov technique or hexapod systems Allows continuous postoperative adjustment and thus prevents over- or undercorrection

The most common complications associated with external fixation are pin site infections, pin/wire fixation failure, deep infection, malunion or nonunion⁹. Besides surgical experience, the outcome also highly depends on appropriate patient selection, continuous patient education, family support, and regular follow-up by a multidisciplinary team⁹.

Combined Internal and External Fixation

Severe obesity, a need for increased mechanical stability and/or soft tissue protection, control of adjacent joint mobility, and a high risk for hardware failure are the main indications for a combined internal and external fixation approach⁹. Internal fixation for midfoot correction combined with external fixation can be used to address an equinus contracture. In the presence of unstable rearfoot or ankle deformities, the combination of plate fixation or intramedullary nailing with external fixation can provide proper alignment while providing compression and limited motion for better bone healing⁹.

Best Practice Tips and Pitfalls

Patients with diabetic neuropathy have difficulties in adhering to long periods of non-weightbearing. Therefore, robust and durable constructs are even more important than in non-diabetic and non-neuropathic patients¹⁵.
In patients with midfoot pathologies, the placement of both a medial and lateral beam can prevent recurrent midfoot deformity¹⁶. Additional beams can be considered to improve postoperative outcomes¹⁶. You can find more information about beaming of midfoot pathologies here.
In patients with combined midfoot and hindfoot pathologies, a combination of a hindfoot nail, midfoot beams and locking plates is used in modern approaches¹⁷. When using this combination, make sure that the hindfoot nail is inserted outside of the medial third of the talus as this area is reserved for medial column beam¹⁷.

14. Butt DA, Hester T, Bilal A, Edmonds M, Kavarthapu V. The medial column Synthes Midfoot Fusion Bolt is associated with unacceptable rates of failure in corrective fusion for Charcot deformity: Results from a consecutive case series. Bone Joint J. Jun 2015;97-b(6):809-13. doi:10.1302/0301-620x.97b6.34844

15. Kummen I, Phyo N, Kavarthapu V. Charcot foot reconstruction—how do hardware failure and non-union affect the clinical outcomes? Annals of Joint. 2020;5

16. Grant W, Grant-McDonald L. Beaming the Charcot Foot. Clin Podiatr Med Surg. Oct 2022;39(4):605-627. doi:10.1016/j.cpm.2022.05.007

17. Kavarthapu V, Guduri V, Hester T. Combined Charcot hindfoot and midfoot reconstruction using internal fixation method—surgical technique and single surgeon series. Annals of Joint. 2023;8

Link to the Charcot article about internal fixation.

Link to Charcot article “Charcot Foot Reconstruction Using Internal Fixation”

Link to the downloadable premium material: “Neuropathic (Charcot) Foot surgical cases”.

Surgical Management of the Charcot Ankle2024-01-17

Charcot neuroarthropathy of the ankle is an especially challenging condition that often leads to instability and destruction of the joint with significant morbidity requiring an amputation in many instances^1-3. According to Brodsky et al., the ankle is affected in 9% of patients with Charcot neuroarthropathy, whereas the hindfoot is involved in 30-35%³. The overall goal of Charcot ankle reconstruction is to achieve a painless, plantigrade and stable foot, and thus avoid ulceration with subsequent infection^1,2. However, this procedure is also associated with a high complication rate^1,2.

Postoperative Management in Charcot Foot Reconstruction2024-01-10

The successful treatment of Charcot foot does not end with a completed surgery; success also requires a diligent postoperative care regime. This devastating condition mainly affects patients with diabetes and peripheral neuropathy, resulting in bone destruction and joint deformation¹. During the initial, inflammatory stage, the recommended treatment consists of off-loading with total contact casts or custom orthotics to prevent further damage, although surgical management is indicated in cases of severe instability or soft tissue compromise². After the acute stage, the focus of treatment is on deformity correction and foot reconstruction to prevent further damage and improve the patients’ quality of life².

Foot and Ankle Charcot Reconstruction with External Fixation2023-12-20

Surgical reconstruction of foot and ankle Charcot with external fixation is especially useful in the presence of poor bone quality, ulceration, compromised soft tissue, active infection, or osteomyelitis – cases in which the use of internal fixation is limited or contraindicated¹.

Charcot Foot Reconstruction Using Internal Fixation2023-12-12

Appropriate timing for surgical intervention is a matter of controversy among specialists¹. While in the past Charcot foot surgical reconstruction was mainly reserved to salvage the limb, today surgeons also perform operative corrections to ensure patients can use commercially available footwear instead of cumbersome orthoses¹. Regardless, the main goal of Charcot foot surgery, independent of the fixation method, is to create a stable and plantigrade foot. This article will discuss different approaches for Charcot foot surgery with internal fixation, focusing on midfoot reconstruction.

Expert Tips on How to Medically Diagnose Charcot Arthropathy2023-11-30

The diagnosis of Charcot neuroarthropathy of the foot and ankle can be challenging due to a lack of information in the patient's history, clinical assessment, imaging, and laboratory findings¹. It is assumed that one in four cases of acute foot and ankle Charcot are undiagnosed or misdiagnosed¹. However, correct diagnosis and effective treatment are crucial to avoid ulceration, worsening deformity, infection, or amputation¹.

Charcot Arthropathy Symptoms and Initial Stage2023-11-21

Charcot arthropathy occurs in the presence of peripheral neuropathy and metabolic abnormalities. Today it is seen more commonly in patients with long-standing diabetes^1,2. Its pathogenesis, although still largely unknown, involves several pro-inflammatory pathways, which stimulate osteoclastic activity³.

Medical Resources for Charcot Foot & Ankle Specialists2023-11-14

There is an overwhelming wealth of scientific literature available on Charcot foot. In this article, we gather and summarize some of the most interesting sources, including Charcot neuroarthropathy of the foot and ankle reviews, diabetic foot reviews, and diabetic foot care articles.

The Experts’ Definition of Diabetic Charcot Foot2023-11-14

Charcot foot is a progressive, devastating pathology defined by bone and joint changes that occur as a result of loss of sensation. Also called Charcot joint or neuropathic arthropathy, this condition is almost always associated with the vascular and neurological changes caused by poorly controlled diabetes¹.

Charcot Surgical Reconstruction2023-11-14

Charcot foot, also called Charcot neuropathy, is a condition caused by a combination of peripheral neuropathy and vascular disorders that results in progressive joint damage and eventually foot instability¹. If left untreated, the consequences for patients are devastating, with reduced quality of life, inability to weight-bear, and an increased risk of amputation².

Tips for Timely Diagnosis of Charcot Foot and Ankle2022-01-17

It is known that around 9 per cent of patients with diabetic neuropathy and foot ulcers develop a Charcot foot and ankle. This pathology often goes unrecognized, particularly during the acute phase, until severe complications occur, such as an abnormal pressure distribution on the plantar fascia with bones weakened enough to fracture, followed by a marked foot and ankle deformation and, in the worst cases, by amputation. Thus, today, one of the most crucial questions is how to timely diagnose this condition.

Magnetic Resonance for Charcot Foot and Ankle Diagnosis2021-12-21

Charcot Foot and Ankle is a significant problem caused by peripheral neuropathy, with an estimated incidence of 0.3 to 7.5% in the diabetic population. This condition, which is also known as Charcot arthropathy, Charcot joint, or neuropathic arthropathy, affects the soft tissues, joints, and bones in the foot and ankle. If left untreated, it may lead to progressive foot deformity, ulceration, or osteomyelitis. In the most advanced stages, it may be necessary to resort to limb amputation.

Tips for the Prevention of Charcot Foot and Ankle2021-12-17

Charcot Foot and Ankle is a severe condition that, if left untreated, may lead to deformity, permanent disability, amputation or ultimately to the patient’s death. People with diabetic neuropathy are at high risk of developing Charcot Foot and Ankle, because of the decreased sensation and diminished ability to feel temperature, pain or trauma.

Computerized Tomography for Charcot Foot and Ankle Diagnosis2021-12-14

Charcot Foot and Ankle, also known as Charcot arthropathy or Charcot joint, is a condition caused by peripheral neuropathy, leading to the progressive degeneration and destruction of the soft tissue, joint, and bone. In modern society, the most common cause for this neuropathic neuropathy is diabetes mellitus, with long-term diabetic patients having an increased risk of developing the condition.

Radionuclide for Charcot Foot and Ankle Diagnosis2021-12-09

Early Charcot Foot Diagnosis is essential to a proper management, but this can be challenging. There are some factors that should increase clinical suspicion for acute Charcot arthropathy, namely if the patient presents with:

Radiography for Charcot Foot and Ankle Diagnosis2021-12-07

Charcot Foot and Ankle, also known as Charcot arthropathy, neuropathic arthropathy or Charcot joint, is a progressive condition that affects the bones, joints and soft tissue of the foot and ankle. It is caused by peripheral neuropathy. Today, diabetes is the most common cause for developing Charcot Foot and Ankle.

Charcot Foot and Ankle Diagnosis: The Multidisciplinary Approach2021-12-02

Patients with Charcot neuroarthropathy, a condition that affects the bones, joints, and soft tissues of the foot and ankle, greatly benefit from a timely diagnosis and appropriate treatment. However, Charcot Foot and Ankle diagnosis can be quite challenging, especially in an early stage, where acute symptoms can be similar to other conditions.

Charcot Foot and Ankle: Patient Questions and Doctor Answers2021-11-30

Linked to peripheral neuropathy, Charcot Foot and Ankle is one of the serious foot complications affecting people with diabetes. Foot injuries that go unnoticed due to the reduced pain sensation accumulate, and, over time, there is bone deformation, ulceration, and infection. In a worst-case scenario, amputation may be necessary.

Charcot Foot and Ankle Causes: Where the Pathology Starts2021-11-25

Charcot Foot and Ankle, also known as Charcot arthropathy, is a progressive, inflammatory condition that affects the bones, joints, and soft tissues in the feet of people with peripheral neuropathy. If left untreated, Charcot of the foot and ankle leads to severe deformity, ulceration, and – worst-case scenario – to limb amputation.

The Stages of Charcot Foot and Ankle Disease and The Importance of a Quick Diagnosis2021-11-23

When dealing with Charcot Foot Disease, a swift diagnosis is crucial to improve patient outcomes and avoid complications such as foot deformity, ulceration, and in a worst-case scenario, limb amputation. However, not all physicians are able to recognize the initial signs of a Charcot Foot and Ankle in their diabetic patients.

Emergency in Diabetic Foot and Ankle2021-11-16

Diabetic foot is one of the most important sources of morbidity in patients with diabetes, affecting 6.4% of patients worldwide. It is the most common cause of lower extremity amputation.

Charcot Foot and Ankle: Definition and Classification2021-11-12

Charcot Neuroarthropathy, also called Charcot Foot and Ankle, is a progressive and inflammatory condition that weakens the soft tissues, bones, and joints of the foot and ankle. This complex and challenging type of neuropathic arthropathy is commonly linked to diabetes. If left untreated, it can lead to devastating consequences, such as deformity, ulceration, and infection. In the worst-case scenario, it may result in limb amputation.

The Surgical Approach to the Charcot Foot and Ankle Treatment2021-05-24

Charcot Foot and Ankle is a complex, challenging and sometimes devastating inflammatory foot disease which causes loss of sensation, weakening of the bones and collapse of the weight bearing joints. Most often due to diabetes and underlying neuropathic arthropathy, it needs a multidisciplinary team approach in order to treat it properly and prevent amputation.

What Is Arthrodesis (Joint Fusion)?2021-05-06

Arthrodesis may be defined as the surgical immobilization of a joint by fusion of the bones. It is commonly referred to as joint fusion, also known as artificial ankylosis or syndesis. It can be performed in several parts of the body, and it is indicated in the presence of painful joints, often due to arthritis or osteoarthritis, with highly compromised mobility.

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