Charcot neuroarthropathy occurs in patients with peripheral neuropathy , most commonly due to diabetes. It is a destructive process with potentially devastating results that can lead to significant deformity, ulceration, infection, and even amputation [1]. Charcot is often confused with an infection, but one must realize that an underlying infection is relatively uncommon in a patient without an ulcer or a history of an ulcer [2]. If concomitant osteomyelitis is suspected, a MRI with contrast is indicated. The MRI will most likely show marrow edema, especially in the acute phase, but the findings are only consistent with osteomyelitis if there is an ulcer in communication with the bone marrow edema.

Immobilization and offloading are the mainstays of treatment in the early stages [1]. This is usually achieved with a total contact cast or a pneumatic CAM boot [3]. Significant activity modification should be recommended, and a period of nonweightbearing can be considered depending on the acuity [4]. The goal of the immobilization is to provide support so that the patient will advance from the acute fragmentation phase to the consolidation phase.

If the patient progresses to the consolidation phase without significant deformity, then a custom brace or orthosis is recommended [3]. If they are consolidated and have a minor deformity with a prominence that leads to ulceration, then an irrigation, debridement, or partial ostectomy is recommended [4]. A course of culture-specific antibiotics should also be administered postoperatively. If the ulceration is located on the plantar surface, then the patient should be examined for an equinus contracture and an Achilles lengthening should be performed in addition to the ostectomy [1].

Patients who develop significant deformities require corrective fusions. If there is an infection or ulceration, then external fixation should be utilized. In all other cases, internal fixation is the best option since it is biomechanically stronger. A standard tibiotalar fusion is usually not possible due to extensive bony destruction with avascularity or necrosis common, particularly of the talus. As a result, the surgeon must be ready to extend the fusion to the calcaneus. Extending the fusion across the subtalar joint may also allow for stronger fixation and lessen the chance of failure. If the talus is completely necrotic, then a talectomy is indicated, and a tibiocalcaneal fusion would be performed [5]. Moreover, the degree of deformity may require extending to a tibiotalocalcaneal or even a pantalar fusion. The fixation can be performed using plates, cannulated screws, or an intramedullary nail. A combination of these fixation methods can also be utilized and is at the discretion of the surgeon. Regardless of the choice of fixation, more fixation than usual is recommended due to the poor quality of bone and possibility of hardware failure.