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.

Anatomy and Biomechanics of Charcot Ankle

The ankle joint is a modified synovial hinge joint that is formed by the articulations of the talus, tibia and fibula (Figure 1)³. The congruency of the bone and ligaments of the ankle creates a high level of stability.³ This is important as the ankle joint bears about five times the body weight in the stance phase during normal gait, which increases to 13 times the body weight during activities such as running³. In contrast to midfoot deformities, Charcot neuroarthropathy at the hindfoot and ankle level is often multiplanar and can be more challenging to treat³. Alteration of the biomechanics and proprioception of the involved ankle often results in gait changes, whereas, malalignment of the Charcot limb makes it more prone to ulceration due to altered pressure distribution and limited soft tissue coverage³. These changes are often associated with limb shortening due to bone collapse caused by avascular necrosis or fractures³.

Source: https://www.csog.net/the-basics-of-ankle-anatomy-and-foot-anatomy/

Tibiotalocalcaneal Arthrodesis

Surgical reconstruction of the Charcot hindfoot and ankle is preferred over conservative techniques, since malalignment and bony prominences often make the limb not suitable for bracing⁴. Tibiotalocalcaneal arthrodesis aims to inhibit the ankle joint motion and is frequently performed to address Charcot in the hindfoot or ankle, but also in cases of severe osteoarthritis, avascular necrosis of the talus, or in the revision of failed arthroplasty⁵. The combination of poor structural bone quality in Charcot patients and the biomechanical challenge of a long moment arm applied during stance phase make stable and secure fixation a challenge⁶.

Intramedullary Nailing

In patients with Charcot neuroarthropathy, retrograde locked intramedullary nailing is considered one of the best options for tibiotalocalcaneal arthrodesis (Figure 2), especially in patients at high risk for postoperative complications^2,6, as the nail can be inserted via small incisions with minimal soft tissue dissection². The load-sharing properties of tibiotalocalcaneal nails provide compression across the ankle and talocalcaneal joints and thus allow early weightbearing². In general, intramedullary nails were shown to provide higher stability for axial compression and torsion when compared to external fixators³. However, in more complex deformities hybrid fixation should be considered as it is associated with a higher rate of limb salvage and low soft tissue irritation rates³.

The most common complications of tibiotalocalcaneal arthrodesis are local deep infection, perioperative fracture and subsidence of the components, neurologic affection, delayed union or complete nonunion⁵. Reoperations are more frequent as well when a talectomy has been performed⁶.

Lisa Grant-McDonald (DPM, Doctors Grant Foot & Ankle, Virginia Beach) explains her approach for tibiotalocalcaneal arthrodesis: “I try to salvage the talus whenever it’s possible. However, when the talus is necrotic, all dead bone must be removed. In this situation, a talus implant should be considered to hold the hindfoot nail appropriately and avoid windshield wiper effect.”

As an alternative to talus implants, Stephanie Oexeman (DPM, Oexeman Foot & Ankle, Chicago) recommends: “Tibiocalcaneal arthrodesis with distal lengthening is my preferred technique when the talus isn’t salvageable. The benefit of distal lengthening is that it can enhance the vascularity of the arthrodesis site.”

Daniel Scott (Medical University of South Carolina (MUSC) Orthopaedics, Charleston) offers another possible solution: “Consider the fibula as an autograft when salvage of the talus is not feasible. Some shortening can be accepted in these cases.”

Alternatives to nailing for tibiotalocalcaneal arthrodesis are internal fixation with screws and plates, external fixation alone, or the combination of internal and external fixation⁵. However, screw fixation and external fixation alone are associated with low union rates⁵.

Circular Fixation and Hybrid Constructs

Tibiotalocalcaneal arthrodesis with a circular fixator has the benefit of being less invasive, preserving the blood supply, and allowing axial micromotion of bone fragments during weightbearing³. In addition, adaptations in the frame components can be used for staged deformity corrections without soft tissue tensioning³. Therefore, circular fixators are often considered in patients presenting with late deformity, soft tissue compromise and infection, which are contraindications to primary internal fixation⁷. The possibility for gradual corrections makes them an optimal solution to address severe Charcot deformities in single or two-stage approaches⁷. At least two fixation points per ring are recommended and stability can be increased by adding additional fixation elements per ring⁷.

The use of hybrid constructs with a circular fixator and a form of internal fixation is frequently cited and is associated with high rates of limb salvage and bone union^3,8. The added stability by circular fixation can be beneficial in patients who are at high risk for complications or require extended arthrodesis⁸. It is important that the wires and pins of the circular fixator have no contact with the internal fixation to avoid deep infections⁷.

Plates

Although less frequently used than intramedullary nails or external fixators, arthrodesis with a plate via the posterior approach is an alternative reconstruction option for Charcot ankle⁹. Of course, the plate insertion requires a more invasive approach via a longitudinal incision on the lateral border of the Achilles’ tendon, posterior capsular resection, removal of the cartilage and fibrous tissues, and resection or restoration of the talus⁹. Locking plates are frequently used because they significantly enhance the structural stability of plates and screws, are highly resistant to shear and pull out force, and preserve the periosteal blood supply since they have no direct pressure to the bone¹⁰. In certain patients, tibiotalocalcaneal arthrodesis with a locking plate is a safe method with relatively short operative and fluoroscopy time¹⁰.

Conclusion

Despite being a technically demanding procedure, tibiotalocalcaneal arthrodesis is considered safe and effective to surgically manage Charcot neuropathy in the hindfoot and ankle⁵. However, major complications might occur in diabetic patients, even in the presence of bone union⁵. Therefore, achieving successful clinical outcomes also depends on thorough preoperative planning and the collaboration of a multidisciplinary team⁷.

8. DeVries JG, Berlet GC, Hyer CF. A retrospective comparative analysis of Charcot ankle stabilization using an intramedullary rod with or without application of circular external fixator–utilization of the Retrograde Arthrodesis Intramedullary Nail database. J Foot Ankle Surg. Jul-Aug 2012;51(4):420-5. doi:10.1053/j.jfas.2012.03.005

9. Cinar M, Derincek A, Akpinar S. Tibiocalcaneal arthrodesis with posterior blade plate in diabetic neuroarthropthy. Foot Ankle Int. Jun 2010;31(6):511-6. doi:10.3113/fai.2010.0511 10. Zhang C, Shi Z, Mei G. Locking plate versus retrograde intramedullary nail fixation for tibiotalocalcaneal arthrodesis: A retrospective analysis. Indian J Orthop. Mar-Apr 2015;49(2):227-32. doi:10.4103/0019-5413.152492

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.

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.

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