Collaborative efforts by multidisciplinary diabetic foot teams have significantly reduced morbidity and mortality from the risks associated with diabetic foot disease.¹,²,³,⁴,⁵,⁶,⁷,⁸,⁹,¹⁰,¹¹,¹²,¹³ High-pressure areas secondary to foot deformity results in recurrent ulceration in patients with Charcot neuroarthropathy (CN). Repeated skin breakdown has a negative impact on their quality of life due to multiple hospital visits to treat or prevent sepsis and amputation.¹⁴,¹⁵,¹⁶ Reconstructive surgery has been shown to improve patient-reported outcomes by reducing amputation rates.³,⁴,¹²,¹⁷,¹⁸

Orthopedic foot and ankle surgeons are better equipped to address these complex cases.¹⁹ “Superconstruct” internal fixation and extended arthrodesis, with Charcot-specific reconstruction systems, facilitates earlier surgical intervention preventing significant, difficult-to-manage deformities.²⁰ With percutaneous skin incisions, minimally invasive surgery (MIS) corrects abnormal biomechanics with minimal disruption of the surrounding tissue leading to lower risk of infection.² External circular frames can also be used either in isolation or in conjunction with internal fixation.

CN leads to loss of foot and ankle sensation in patients most commonly with diabetes. Microfracture and disorganized bone healing results in a rocker bottom deformity of the midfoot.⁸ The gradual and progressive destruction of the architecture of the midfoot arch increases the risk of ulceration and osteomyelitis. Initially, the medial column is affected, where deformity may remain static or progress to the lateral column.²¹

Secondary changes in collagen fibers due to glycosylation caused by sensorimotor and autonomic neuropathy result in progressive tightness of the gastrocnemius and soleus muscle complex. The resulting equinus deformity of the ankle and talus, +/− cuneiforms is countered by opposing forces from the tibialis anterior and posterior muscles.⁸,¹²,²² Ultimately, a midfoot break occurs due to failure of the plantar osseous-ligamentous structures. Ulceration occurs due to the increased peak plantar pressures in the forefoot and midfoot caused by the rocker bottom deformity.

Classification systems are important tools for understanding the progression and severity of CN and determining the appropriate treatment approach. Two commonly used classifications for CN are the Eichenholz and Brodsky classifications, based on the disease’s clinical, anatomical, and radiological location.²³,²⁴ The Eichenholz classification is a three-stage system based on the degree of osteolysis. In contrast, the Brodsky classification is a four-stage system based on the degree of bone and joint destruction. These classifications are widely used and have been validated in several studies.

The Tiruveedhula classification combines clinical features and radiographic parameters with the anatomic location of the disease to determine which patients would benefit from percutaneous tendo-Achilles lengthening and total contact casting (TCC).²⁵ This classification system is useful for determining the appropriate surgical intervention for patients with CN.

Sammarco midfoot classification helps to determine which midfoot pattern may benefit from the “superconstruct” fixation method.²⁶ This classification system helps to identify the specific midfoot pattern and select the appropriate surgical technique to correct the deformity.

Despite the usefulness of these classification systems, there are also limitations, such as the patient’s functional status or the presence of ulceration, so each should be used in conjunction with other clinical and functional assessments to ensure accurate diagnosis and management of CN.