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.

Challenges of Midfoot Pathologies

For many surgeons, Charcot reconstruction of the midfoot is more challenging than hindfoot pathologies.

This is also confirmed by Lisa Grant-McDonald (DPM, Doctors Grant Foot & Ankle, Virginia Beach): “Getting a dislocated Lisfranc joint back in the right direction with olives [using external fixation] can be really challenging. In addition, achieving an almost perfect stabilization is much more important than for the hindfoot. Hindfoot pathologies are more straightforward and usually achieve good results.”

Midfoot Reconstruction with Beams

Beaming is an increasingly used intramedullary reconstruction method for midfoot pathologies, as it realigns the anatomy and reinforces the corrected foot at the same time². Large-diameter cannulated screws or bolts are placed in the medullary canal of one or more midfoot columns². Drs. William Grant and Lisa Grant-McDonald describe the following beaming approach²:

Achilles tendon lengthening: Contracture of the Achilles tendon can worsen midfoot collapse and increases forefoot stress due to negative calcaneal inclination angles. Achilles tendon lengthening is therefore recommended to reduce the risk of hardware failure. The main approaches for Achilles tendon lengthening are the open approach (incision at the medial border of the mid-substance of the tendon) or the percutaneous approach using a “Z” cut for lengthening.
Hindfoot pinning: Hindfoot stabilization with a Steinmann pin is recommended to place the ankle in a neutral position and the calcaneus in a positive inclination angle.
Midfoot osteotomy:
- Any dislocated bone and articular cartilage should be removed.
- Bony structures involved in the collapse can now be prepared for fusion. The Lisfranc and talonavicular joint are frequently involved in the medial aspect. A lateral incision is usually required to reduce the cuboid, which is often dislocated at the calcaneocuboid joint and the cuboid metatarsal articulation.
- Once the midfoot is de-rotated against a stable hindfoot block, the midfoot can then be fixated.
Hardware application:
- Placement of both a medial and lateral beam can prevent recurrent midfoot deformity.
Supplemental beams should be considered to achieve better postoperative outcomes. A beaming “Truss” creates a functional triangle by crossing the base of one metatarsal of the medial column and the body of the calcaneus.

Lisa Grant-McDonald (DPM, Doctors Grant Foot & Ankle, Virginia Beach) provides insights into her beaming approach: “My beaming approach usually starts with Achilles tendon lengthening and extra articular pinning of the hindfoot into neutrality. A medial Beam wire is placed first from the 1st metatarsal head back to the body of the talus. At this time the foot is derotated and the cuboid is lifted from its typically dislocated position. The lateral column is pinned and a beam wire is placed from between the 4th and 5th metatarsal into the central aspect of the CC joint. Next the subtalar joint wire is applied followed by a final “Truss” beam locking the 2nd metatarsal base to the anterior process of the calcaneus. Once ‘weight bearing’ alignment is confirmed with radiographs each beam is applied in the same order.”

There are challenging situations for beaming, especially in patients with soft tissue contractures of the midfoot, as Stephanie Oexeman (DPM, Oexeman Foot & Ankle, Chicago) explains: “Proper alignment of the midfoot can be difficult. It is important to take enough time and be patient. Inadequate intraoperative alignment won’t get better later on!”

Beam failure can occur due to weak implant material, insufficient sizing, or inappropriate screw configuration². Stainless steel is the preferred material for Charcot foot surgery² due to the superior biomechanical properties of stainless steel, including higher stiffness, force to failure, and pullout strength³. The main benefits of beaming the midfoot are that it preserves soft tissue and provides a superconstruct without extensive soft tissue dissection². However, reported hardware failure rates vary significantly from 4% to 67%^4-6. Surgeons should also be aware of the risk for deep infection in the presence of full-thickness plantar ulcers⁴.

Figure 1 shows an example case where beaming of the medial column, lateral column, and subtalar joint were performed along with an Achilles tendon lengthening. In addition, a trussing technique was used where a “truss” beam was placed between the medial and lateral columns in the midfoot.

Midfoot Reconstruction with Medial Column Plates

The reduction and fixation of the medial column are key elements in treating midfoot deformities⁷. Medial column fusion has become a common technique that can also be considered for earlier stages of Charcot arthropathy⁸. However, standard implants and reconstruction techniques for midfoot arthrodesis in severe deformities can frequently lead to high complication rates due to loss of fixation^8,9. Modern fixation techniques, including superconstructs, maximize stability as they fuse beyond the zone of injury⁹. Superconstructs utilize two or more devices for fixation and enhanced stability such as a medial column plate positioned over a beam.

The principle of superconstructs was first described by Sammarco et al. (2009) and is defined by four factors⁸:

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
Implants are positioned in a way to maximize mechanical integrity.

Superconstruct techniques have evolved for several reasons. Charcot foot surgery is complicated by sensory neuropathy and the inability to avoid weightbearing and the dissolution of bone, including resorption and fragmentation⁹. Therefore, the poor quality of the bone can make fixation in this area almost impossible⁹. Superconstructs bypass this problem by using non-affected bone for fixation⁹.

Locking plates are frequently used devices for medial column plating as they create a strong fixed-angle device and provide the ability to include multiple bone fragments into the fusion mass⁹. Plates with high strength are recommended to resist cycle loading as soon as patients start weightbearing⁹.

Considerations for Postoperative Care

The best postoperative care is discussed controversially, especially regarding immobilization. Experts consider long-term bracing or casting from 3 to 7 months as a key to achieving successful outcomes¹⁰. Alrashidi et al. also recommended keeping the affected limb elevated for the first days to reduce edema, prescribing deep vein thrombosis prophylaxis, and regularly checking the vascular status⁷. Physiotherapy can be started after removal of the stitches with regular stretching of the Achilles tendon to prevent recurrent contracture⁷. Routine radiographs should be considered at 6 weeks, 3 months, and every 6 months until bone union is clearly evident⁷.

6. 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

7. Alrashidi Y, Hügle T, Wiewiorski M, Herrera-Perez M, Valderrabano V. Surgical Treatment Options for the Diabetic Charcot Midfoot Deformity. Clin Podiatr Med Surg. Jan 2017;34(1):43-51. doi:10.1016/j.cpm.2016.07.006

8. Sammarco VJ. Superconstructs in the treatment of charcot foot deformity: plantar plating, locked plating, and axial screw fixation. Foot Ankle Clin. Sep 2009;14(3):393-407. doi:10.1016/j.fcl.2009.04.004

9. Sammarco VJ, Chevillet J. The role of internal fixation in surgery of the Charcot foot and the evolution of “super- construct” techniques. Current Orthopaedic Practice. 2010;21(3)

10. Salvaterra P. The Surgical Management of Neuropathic (Charcot) Foot – A Practical Guideline. 2017;

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.

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.

Surgical Approaches for Charcot Foot2023-11-14

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.

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.

REQUEST MORE INFORMATION

Please read our Privacy Policy before submitting this form

I have read and understood the Privacy Policy above and, therefore, I hereby consent to the processing of my personal data by Orthofix S.r.l.:

A) to allow Orthofix to carry out marketing initiatives described in point 3 (d) of the Privacy Policy, including for sending you marketing and promotional communications regarding Orthofix-branded products or services, or new initiatives and events. *

I consent

I do not consent

B) for transmitting your personal data to third parties (namely to other Orthofix Group’s legal entities and to distributors engaged by them and Orthofix directly), in order to enable them to provide you with their own marketing and promotional communication. *