Abstract
Background
Midfoot Charcot neuroarthropathy is a progressive disorder, commonly affecting people with diabetic neuropathy. It can lead to foot collapse, plantar prominence, ulcers, infection, and even limb loss. In severe cases, staged reconstruction and tibiotalocalcaneal arthrodesis (fusion of the tibia, talus, and calcaneus) can salvage the limb. However, the durability of these corrections on radiographs remains unclear. This study evaluated radiographic changes and short-term clinical outcomes after staged reconstruction and tibiotalocalcaneal arthrodesis for midfoot Charcot neuroarthropathy.
Study design
Retrospective, consecutive case series (Level IV) design.
Methods
Eight patients (eight limbs) treated at a single limb-salvage center from March 2023 to September 2024 were included. All had diabetes and preoperative ulceration. Paired 1- and 12-month postoperative weight-bearing radiographs were analyzed for talo-first metatarsal angle, Meary’s angle, calcaneal pitch, and medial cuneiform height. Paired t -tests compared values. Secondary outcomes were wound-free limb preservation, union, reoperation, and ambulatory status.
Results
The talo-first metatarsal angle increased (12.1° to 17.5°, p =.010), calcaneal pitch and medial cuneiform height decreased (18.5° to 9.1°, p =.032; 14.2 mm to 5.1 mm, p =.003), and Meary’s angle increased (8.7° to 12.1°, p =.22). All limbs achieved union, remained wound-free, avoided reoperation, and were ambulatory at 12 months.
Summary
Despite measurable postoperative radiographic settling, staged Charcot reconstruction followed by tibiotalocalcaneal arthrodesis maintained wound-free limb preservation, union, and independent ambulation at 12 months.
Introduction
Charcot neuroarthropathy of the foot and ankle is one of the most challenging conditions in limb-salvage surgery. Progressive osseous collapse, ligamentous insufficiency, peripheral neuropathy, and altered plantar loading may lead to deformity, ulceration, infection, and major amputation. ,, In advanced cases, operative treatment is generally considered when ulceration recurs, bracing fails, or the extremity becomes nonplantigrade and unbraceable.
Tibiotalocalcaneal arthrodesis with retrograde intramedullary fixation is an accepted salvage option for severe Charcot deformity of the ankle and hindfoot. ,,,,,,,,, Prior series have shown that this strategy can preserve the limb in medically complex patients. However, complications remain common. Infection, hardware failure, recurrent deformity, and nonunion are key concerns. ,,,,,,,, In this population, clinical success is often defined by maintaining a stable, braceable, ulcer-free extremity rather than by perfect radiographic correction alone. ,,,,,
Less is known about how midfoot-dominant Charcot deformity behaves on interval radiographs after staged reconstruction ending in tibiotalocalcaneal arthrodesis. Defining postoperative settling may clarify follow-up radiographs, improve patient counseling, and help surgeons separate expected loss of correction from clinical failure.
We sought to determine whether measurable radiographic settling occurred between early postoperative follow-up and 12-month follow-up after staged reconstruction and tibiotalocalcaneal arthrodesis for midfoot Charcot neuroarthropathy. We hypothesized that medial column settling would occur over time despite preservation of union, wound-free limb salvage, and independent ambulation. Our primary aim was to quantify interval change in radiographic alignment variables, and our secondary aim was to describe short-term clinical limb-salvage outcomes in this retrospective consecutive case series.
Patients/Materials and methods
Study design and patient selection
After obtaining institutional review board approval or exemption, we performed a retrospective chart and radiographic review of consecutive patients treated at a single tertiary limb-salvage practice from 03/2023 through 09/2024.
Patients were eligible if they had midfoot Charcot neuroarthropathy and completed a staged reconstruction that ended in tibiotalocalcaneal arthrodesis with a retrograde intramedullary device. Providers collected standardized postoperative weight-bearing radiographs at about 1 month and 12 months after arthrodesis. The analysis excluded patients who died before 12-month imaging, underwent below-knee amputation before 1 year, did not complete staged tibiotalocalcaneal arthrodesis, or missed 12-month radiographs.
We did not perform priori power analysis because we designed this investigation as an exploratory retrospective case series of all consecutive eligible limbs during the study interval.
Intervention
All patients had a staged reconstructive approach for severe Charcot deformity. The first stage consisted of deformity correction with midfoot osteotomy. Achilles tendon lengthening or tenotomy was added when indicated. Multiplanar circular external fixation restored alignment and protected compromised soft tissues. Definitive reconstruction involved tibiotalocalcaneal arthrodesis with retrograde intramedullary fixation. The staged approach was chosen to improve alignment, protect the soft-tissue envelope, and maximize limb preservation in patients at high risk due to diabetes and prior ulceration ( Fig. 1 ).
Mean Radiographic Change (12-Month– 1-Month) Following TTC Arthrodesis for Midfoot Charcot Neuroarthropathy ( n = 8). Bar graph demonstrates the mean change (± standard deviation) in four radiographic alignment parameters comparing 1-month and 12-month postoperative values. Positive values indicate an increase, and negative values indicate a decrease over time. Significant increases were observed in the Talo–1MT angle ( p = 0.010), while calcaneal pitch ( p = 0.032) and medial cuneiform height ( p = 0.003) decreased significantly, suggesting progressive lowering of the medial arch. Meary’s angle showed a non-significant increase ( p = 0.22).
Radiographic and clinical variables
The primary outcome variables were changes in 4 postoperative radiographic measurements obtained on standardized weight-bearing radiographs: anteroposterior talo-first metatarsal angle, lateral Meary’s angle, calcaneal pitch, and medial cuneiform height. These variables were selected to characterize interval maintenance of midfoot and medial column alignment after reconstruction.
Two reviewers independently obtained all radiographic measurements. In the event of disagreement, they reviewed the measurements together and recorded a consensus value. Clinical secondary outcomes wer:e wound-free limb preservation (retention of the limb without recurrent ulceration or wound breakdown during follow-up), radiographic union (bridging osseous consolidation across fusion interfaces), clinical union (absence of pathologic motion or focal pain at the arthrodesis site with functional ambulation), reoperation within 12 months, and ambulatory status at final follow-up. Radiographic union was determined by the treating surgeons.
Statistical analysis
Continuous variables were summarized as mean ± standard deviation, and categorical variables were summarized as counts and proportions. Paired-sample t tests were used to compare 1-month and 12-month radiographic measurements. Statistical significance was defined at the 5% level (p ≤.05). Given the small sample size, no multivariable analysis was performed, and all inferential analyses were considered exploratory.
Results
Cohort characteristics and study flow
Twelve limbs met the initial screening criteria. Four limbs were excluded from paired radiographic analysis because 1 patient died before 12-month radiographs, 1 underwent below-knee amputation before 1 year, 1 lacked 12-month imaging, and 1 did not undergo definitive tibiotalocalcaneal arthrodesis. The final analytic cohort, therefore, consisted of 8 limbs from 8 patients ( Table 1 ).
Table 1
Cohort characteristics and study flow.
| Variable | Value |
|---|---|
| Limbs screened | 12 |
| Limbs included in paired radiographic analysis | 8 |
| Mean age, years | 59.8 ± 8.6 |
| Sex | 4 male, 4 female |
| Laterality | 4 left, 4 right |
| Diabetes mellitus | 8 of 8 |
| Prior ulcer history | 8 of 8 |
| Exclusions | 1 deceased before 12-month radiographs; 1 below-knee amputation before 1 year; 1 without 12-month radiographs; 1 without definitive tibiotalocalcaneal arthrodesis |
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