Hindfoot and Ankle Charcot Reconstruction

Abstract

Hindfoot and ankle Charcot neuroarthropathy (CN) deformities can be devastating, limb-threatening illnesses with high rates of complications. The fragmentation and collapse of the transverse tarsal, subtalar, and ankle joints can lead to significant deformity resulting in ulceration, osteomyelitis, and angular deformities. These issues preclude the use of normal gear and cause difficulty with ambulation. Charcot of the hindfoot and particularly of the ankle often has profound instability making bracing difficult or impossible. This can lead to a below-knee amputation in 30–50% of Charcot ankle cases, which, in many cases, can be a more stable outcome rather than limb salvage.

Nonoperative treatment mainstays include total contact casting, custom bracing, Charcot Restraint Orthotic Walkers (CROW), modified AFO’s or Arizona-type braces, and accommodative inserts with custom, extra depth shoes. In many cases of hindfoot and ankle CN, some sort of bracing may be needed for long-term protection. When nonoperative treatment fails or the pathology is progressive, unstable and/or unbraceable, operative intervention is considered. The goals of operative intervention are to create a stable and braceable limb, to eradicate osteomyelitis or infection if present, to reduce deformities at risk for ulceration, and to hopefully get the patient ambulating and returning some quality of life.

Options for operative treatment of Charcot hindfoot and ankle consist of external fixation, internal fixation, or a hybrid of both. In our hands, we frequently use combination fixation of internal beams/screws/retrograde nails and circular ring external fixation. Cases are evaluated individually and fixation constructs adjusted accordingly. In cases with active infection, frequently only external fixation is used during the initial stage in order to stabilize the soft tissues and clearance of infection. Once active infection has been resolved, internal fixation support is added for additional long-term stability.