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C OPYRIGHT Ó 2018 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Current Concepts Review

Charcot Neuroarthropathy of the Foot
and Ankle
Andrew Dodd, MD, FRCSC, and Timothy R. Daniels, MD, FRCSC

Investigation performed at St. Michael’s Hospital, Toronto, Ontario, Canada

ä Charcot neuroarthropathy (CN) is a systemic disease that generates pathological changes in the musculoskeletal
system, causing fractures, dislocations, and deformities involving the foot and ankle.

ä A common underlying cause of CN is diabetes mellitus; a substantial risk of ulceration and deep infection
contributes to a 15% rate of major amputation (i.e., at the level of the ankle or higher).

ä The goal of both nonsurgical and surgical treatment of CN is to obtain a stable, plantigrade foot free from
ulcerations; an equally important goal is to manage the patient’s diabetes and obesity.

ä The primary indications for surgery are recurrent ulceration, substantial deformity, deep infection, and pain;
common complications include nonunion, wound breakdown, and infection.

ä The principles of thorough joint preparation, deformity correction, and minimizing soft-tissue trauma are essential
when arthrodesis is performed for CN, which requires more robust (internal and/or external) fixation and prolonged
off-loading.

Charcot neuroarthropathy (CN) is a systemic disease that
causes weakening of the musculoskeletal system (ligaments and
bones), which ultimately leads to collapse, fracture, and joint
destruction affecting structures under substantial stress, par-
ticularly the foot1. Jean-Martin Charcot, for whom the disease
was named, described the entity in patients with tertiary
syphilis in 18682. CN has been associated with diabetes melli-
tus, spinal cord injuries, tertiary syphilis, alcoholic peripheral
neuropathy, Charcot-Marie-Tooth disease, and idiopathic
neuropathy3-5. CN is commonly associated with diabetes mel-
litus, specifically diabetic neuropathy1. Diabetes mellitus affects
29.1 million Americans (9.3% of the U.S. population), with 8.1
million of these likely undiagnosed6. The worldwide incidence
and prevalence of diabetic CN are difficult to assess accurately,
but the annual incidence has been reported to range from 0.1%
to 29% and the prevalence from 0.08% to 13%3.
CN has a negative impact on the quality of life of patients,
even when diagnosed early and managed appropriately7-9. Ap-
proximately 50% of patients require at least 1 operation of the
foot1,8. Ulceration and infection are common; CN is associated
with a rate of major amputation (i.e., at the level of the ankle or
higher) of 15%1,10, which increases to 35% to 67% in patients
with CN who present with an associated ulcer8,11. CN is
considered a major risk factor for below-the-knee amputation
in the diabetic population12.
Pathophysiology
The precise pathophysiology of CN has not been conclusively
determined because of its multifactorial etiology, variable pre-
sentation, and rate of progression. Historically, the 2 dominant
pathophysiological causes of CN included the neurotraumatic
and neurovascular theories. The neurotraumatic theory hy-
pothesized that repetitive microtrauma in an extremity that has
lost protective sensation causes an unregulated inflammatory
cascade, eventually resulting in the collapse and joint destruction
observed in CN2,13-15. In contrast, the neurovascular theory

Disclosure: No funding was provided for this study. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version
of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the
submitted work (http://links.lww.com/JBJS/E642).

J Bone Joint Surg Am. 2018;100:696-711 d http://dx.doi.org/10.2106/JBJS.17.00785

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foot that has lost protective sensation. Continued weight-

Fig. 1
Figs. 1-A and 1-B Charcot changes in the midfoot. Fig. 1-A Lateral weight-
bearing radiograph of the right foot of a 63-year-old man with a 20-year history
of type-II diabetes mellitus, demonstrating chronic Charcot (Eichenholtz
stage-III) changes with previous midfoot involvement. Note the prominent
fusion mass in the plantar aspect of the midfoot, placing the patient at risk for
plantar ulceration. Fig. 1-B Lateral weight-bearing radiograph of the right foot
of a 43-year-old man with a 5-year history of poorly controlled type-II diabetes
mellitus. Note the classic Eichenholtz stage-I changes including bone
resorption, fragmentation, and dislocation, with collapse of the midfoot
(navicular-cuneiform joints). This patient is at risk of developing a rocker-
bottom foot deformity and plantar-midfoot ulcerations.
bearing causes fractures, dislocations, and collapse, and further
accentuation of the deregulated inflammatory cascade. The
joints are primarily affected because they are the weak link in the
structural chain of the foot, not because of preferential targeting
of synovial articulations. Serial measurements of TNF-alpha
and IL-6 could help identify patients at risk of the Charcot
process and determine resolution of the acute phase of CN22.
Interestingly, the ability of the local vasculature to re-
spond to inflammation (vasodilation) appears necessary for the
development of CN17,18. Patients with peripheral vascular dis-
ease severe enough to impair this response seem to be protected
from developing CN17,18. However, some patients develop CN
first and subsequently develop vascular insufficiency26,27; it is
important for the physician to identify this group, as they need
to be managed carefully with respect to off-loading and surgery,
with different prognosis and treatment algorithms.
The end result of this pathological process is an unstable
pedal construct that cannot withstand the physiological forces
applied to the bones and joints during the 3 rocker-phases of
gait. The midfoot is a common area of collapse, as it is subjected
to substantial forces during weight transfer from hindfoot to
forefoot in the stance portion of the gait cycle (ankle rocker to
forefoot rocker); a contracture of the gastrocnemius, common
in diabetes mellitus, further increases force transmission
through the midfoot (Fig. 1). The result is the typical rocker-

proposed that alterations in the sympathetic nervous system

cause increased blood flow to the affected extremity, resulting in
vascular shunting, subsequent osteopenia, and pathological
fractures2,13-15. The 2011 American Diabetes Association Con-
sensus Conference favored a hybrid approach that includes
features of both theories, and trauma is now thought to initiate
the process in susceptible individuals16. Patients with limited
weight-bearing capabilities and those with peripheral vascular
disease are unlikely to develop CN17,18.
Two prerequisites for all cases of CN are inflammation
and autonomic neuropathy 19,20. Proinflammatory cytokines
including tumor necrosis factor alpha (TNF-alpha) and
interleukin-6 (IL-6) are consistently elevated in patients with
CN, whereas anti-inflammatory cytokines (i.e., IL-10) are de-
creased19,21,22. Neuropathy leads to abnormal neuropeptide
signaling, increased local inflammation23, receptor activator of
nuclear factor kappa-beta ligand (RANKL) activation, and
increased osteoclastic activity19,21,24, which causes substantial
bone resorption and fragility, increasing the risk of pathological
fracture. The heightened inflammatory reaction and hyper-
glycemic environment in diabetes denatures and weakens
tendons and ligaments (nonenzymatic glycosylation), further Fig. 2
destabilizing the mechanical environment25. The end result is Midfoot collapse and plantar prominence of the cuboid result in over-
fragility and instability of the bones, joints, and ligaments in a loading of the plantar structures and formation of a pressure ulcer.
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greater risk for osteomyelitis compared with smaller ulcers34,

Fig. 3
The temperature of the involved foot is typically 3° to 5°C higher than that of
the contralateral foot in patients with acute unilateral CN.
and a positive “probe to bone” test increases the likelihood of
osteomyelitis35. Up to 40% of patients with CN have ulceration
at initial presentation. Clinician preoccupation in diagnosing
the anticipated infection (osteomyelitis) can delay the diagnosis
and appropriate management of CN (Fig. 5)11,28. Dependent
rubor, present in CN, should decrease when the affected ex-
tremity is elevated for several minutes, but will not decrease if
infection is present5,30. The midfoot and hindfoot are com-
monly associated with foot deformity that requires surgical
intervention36. The forefoot may be more commonly affected
by CN than reported (Fig. 6); concomitant presentation of
ulceration and osteomyelitis in the forefoot caused by claw-toe
deformities unrelated to CN may confuse the diagnosis of
forefoot CN1,28,30,37,38.
Patients with CN have neuropathy, hyperdynamic cir-
culation, and “bounding” pulses13,29,31; loss of protective sen-
sation is common. Sensory peripheral neuropathy is best
measured with a 10-g Semmes-Weinstein monofilament39-41,
which was found in a systematic review of 30 studies involving
8,365 patients to have a sensitivity of 57% to 93%, specificity of
75% to 100%, positive predictive value of 84% to 100%, and
negative predictive value of 36% to 94%42. A 3-site test in-
cluding the plantar aspects of the great toe and third and fifth
metatarsal heads is recommended42. Nerve conduction studies
or electromyograms are rarely necessary for the diagnosis of

bottom deformity with plantar prominence of the cuboid,

which can overload the plantar structures of the foot and cause
pressure ulcers (Fig. 2).

Clinical Presentation
Diagnosis of CN is based primarily on a thorough history and
physical examination, with corroborating laboratory investi-
gations and diagnostic imaging. Patients typically present
with a warm, swollen, erythematous foot and/or ankle5,13,16,28-31.
The affected extremity is palpably warmer than the unaffected
foot and is 3° to 5°C warmer on the affected side (Fig. 3)28,32.
Despite the presence of peripheral neuropathy, 42 (76%) of 55
diabetic subjects in a longitudinal study of acute CN treatment
presented with pain28. Typically, less than one-half of patients
with CN are aware of their neuropathy. Approximately one-
third of patients report an inciting trauma11,30.
Differentiating CN from other inflammatory disease
processes is challenging because many patients present in a
manner that mimics inflammatory diseases. The diagnosis of
early CN, prior to the development of radiographic changes, is
often missed33. A careful history, physical examination, ap-
propriate investigations (primarily radiographs), and good
clinical acumen can obtain the diagnosis in the majority. Gout,
cellulitis, and osteomyelitis have overlapping symptoms and
physical findings16. The presence of ulceration, or a history of Fig. 4
ulceration, increases the odds of underlying osteomyelitis Acute CN with superimposed infection. Note the deep ulcer overlying the
(Fig. 4)5,34. An ulcer of >4.5 cm2 is associated with a threefold lateral aspect of the ankle.
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Diagnostic Imaging
The initial workup of a patient suspected of having CN should
start with weight-bearing plain radiographs (standing antero-
posterior and lateral images of both feet and ankles)16,29,31. A
normal finding on a weight-bearing radiograph is uncommon,
but its presence does not exclude early CN; a high index of
suspicion is necessary, and clinical factors need to be consid-
ered43-45. If the diagnosis is delayed and treatment has not been
initiated, classic radiographic changes are likely to develop,
including fragmentation, demineralization, joint dislocations,
osseous debris, and joint space obliteration (Fig. 7)14,30,46. Ra-
diographs are useful for following disease progression through
the 3 stages of the Eichenholtz classification system: develop-
ment (fragmentation), coalescence, and reconstruction and
reconstitution (Table I)47,48. Notably, the Eichenholtz stages are
identical to the process by which our musculoskeletal system
responds to acute injury49,50. The main limitations of radio-
graphs are their low sensitivity and specificity for CN51. Ra-
diographic changes occur up to 2 years after diagnosis and
treatment for clinical resolution of acute CN52, reflect the end
stages of the disease, and can be considered a confirmation of
its presence; they are not a means for early intervention.

Fig. 5
Severe deformity (Fig. 5-A) and ulceration (Fig. 5-B) secondary to acute CN,
in the absence of either soft-tissue infection or osteomyelitis. This pre-
sentation can be misdiagnosed as acute infection and therefore managed
inappropriately.

peripheral neuropathy39,40. In the absence of clinical sensory

neuropathy, a diagnosis of CN should be questioned28.
Laboratory investigations can help to differentiate CN
from infection in isolated cases; however, infection and CN
can coexist. In these situations, laboratory results are difficult
to interpret and must be assessed with the clinical presenta-
tion in mind. Diabetic patients can have a muted systemic
response to infection; traditional laboratory inflammatory
markers may be elevated only slightly or not at all28. A sub- Fig. 6
stantially elevated erythrocyte sedimentation rate (ESR) and Anteroposterior (Fig. 6-A) and lateral (Fig. 6-B) radiographs demonstrating
C-reactive protein (CRP) level are more consistent with (al- CN of the forefoot. Findings include fragmentation, joint destruction,
though not diagnostic of) a diagnosis of acute infection rather sclerosis, and joint subluxation. In the presence of ulceration, these
than CN22,32,37. findings can be misdiagnosed as osteomyelitis.
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The combination of technetium-99m-labeled sulfur colloid

(a bone marrow-labeling technique) and indium-111-labeled
white blood cells has excellent diagnostic capabilities for mus-
culoskeletal infection and can differentiate between CN and
osteomyelitis55-57. Positron emission tomography (PET) scanning
provides excellent sensitivity and specificity for the diagnosis of
osteomyelitis in the diabetic foot, is able to distinguish CN from
osteomyelitis better than MRI58-60, and is not affected by the
presence of metal from previous internal fixation60. The main
role for MRI is after the diagnosis of infection has been con-
firmed, as its excellent spatial resolution and soft-tissue imaging
aid in defining the extent of soft-tissue and bone infection for
surgical planning31,37,51.
Advanced imaging technologies such as MRI and PET
scans highlight the inadequacies of clinical examination and
radiographs in assessing the CN stage45,61,62 and are more ac-
curate for determining resolution of acute CN compared with
clinical assessment. Their role in guiding management remains
under investigation.
It is important for the clinician to have specific clinical
indications for ordering additional investigations (Table II), as
too many diabetic patients are subjected to costly investigations
with only minimal clinical workup51. The diagnosis of CN is
made on the basis of the history and physical examination, and
the use of advanced imaging is unnecessary in most situations.
For example, in the absence of an acutely infected or chronic
Fig. 7 nonhealing ulcer that can be probed to bone, MRI or nuclear
Figs. 7-A and 7-B A 52-year-old woman with long-standing type-II diabetes medicine examinations will provide limited additional clinical
mellitus. Fig. 7-A Lateral radiograph of the right foot and ankle, made when information over radiographs and/or a CT scan37. In most
she was first seen, demonstrates a fracture of the calcaneal tuberosity,
end-stage arthritis of the talonavicular joint, and Charcot neuroarthropathy 47,48
TABLE I Modified Eichenholtz Classification
of the forefoot. Fig. 7-B Lateral radiograph of the right foot and ankle, made
9 years later, demonstrates Charcot collapse of the ankle joint with os- Stage Clinical Findings Diagnostic Imaging*
seous fragmentation and collapse of the arch. Clinically, she presented
with a superficial ulcer over the medial malleolus. 0 Swelling, warmth, Normal findings on
erythema, neuropathy, radiographs, positive
and bounding pulses bone scan, bone edema
Radiographs are not necessarily useful in differentiating on MRI, and positive PET
scan
CN from osteomyelitis, a common diagnostic dilemma51.
Constitutional symptoms of spreading infection and sepsis in 1 Swelling, warmth, Osteopenia,
erythema, neuropathy, fragmentation,
the diabetic population can be muted; systemically infected
and bounding pulses fractures, and
patients may present with flu-like symptoms and only slightly dislocations on
abnormal blood work (i.e., complete blood-cell count, ESR, radiographs
and CRP). A thorough history and careful physical examina- 2 Reduction in swelling, Sclerosis, resorption of
tion are paramount to confirm a diagnosis of CN and/or warmth, and erythema bone fragments on
osteomyelitis. radiographs, reduced
In patients with CN, osteomyelitis is rare without deep edema on MRI, and
ulceration. When the presentation suggests CN and osteomy- reduced uptake on PET
elitis (i.e., patients presenting with CN and a deep or chronic scan
ulceration), diagnostic imaging can help to clarify the diag- 3 Absence of swelling, Sclerosis, fusions,
nosis. In isolation, magnetic resonance imaging (MRI) and a warmth, and erythema; arthritis, and deformity
varying degrees of on radiographs
traditional 3-phase bone scan have excellent sensitivity, but
deformity and stability
poor specificity for differentiating CN from osteomyelitis50,53. A
combination of nuclear medicine scans (i.e., white blood-cell *MRI = magnetic resonance imaging, and PET = positron emission
and bone marrow scintigraphy) is considered the best diag- tomography.
nostic test to differentiate between CN and osteomyelitis31,37,53,54.
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to remain active. In Europe, a double upright ankle-foot or-

TABLE II Indications for Diagnostic Imaging* thosis is commonly used to achieve this purpose. At our
Imaging Modality Indication institution, a metal stirrup has been used with the TCC (Fig. 8)
to successfully treat large neuropathic ulcers of the midfoot and
Radiographs Initial imaging for all patients with hindfoot67. Casts are changed weekly early in the disease to
foot symptoms accommodate the decrease in swelling of the limb and to allow
Nuclear imaging Combination used to differentiate for frequent inspection of the soft-tissue integument68,69.
with a bone-marrow osteomyelitis from CN in patient The duration of off-loading ranges from 2 to 6 months
scan with white with overlapping symptoms and
or longer11,13,28,31,68-71. Shorter immobilization periods increase
blood-cell scan current or previous ulceration
the risk of recurrence11. Most authors have recommended
CT scan Assessment of deformity and bone
following the disease clinically and discontinuing the TCC
stock for surgical planning
once the swelling and erythema have subsided, and the af-
MRI scan Assessment of extent of soft-
fected limb is within 2°C of the temperature in the unaffected
tissue infection and osteomyelitis
for surgical planning limb. However, little evidence exists to substantiate this gen-
erally accepted guideline68-71. Discontinuation of immobili-
PET scan Differentiation of osteomyelitis and
CN in a patient with overlapping zation on the basis of foot temperature is associated with low
symptoms and current or previous recurrence rates, but the temperature gradient is not associ-
ulceration; diagnosis of infection in ated with radiographic healing72,73. Recent studies that fol-
postoperative period lowed patients with acute CN using MRI and PET scans have
demonstrated that resolution periods were substantially lon-
*CN = Charcot neuroarthropathy, CT = computed tomography, ger than the immobilization period45,61. When guided by PET
MRI = magnetic resonance imaging, and PET = positron emission
tomography.
scans, it was found that patients were immobilized for twice as
long as when traditional clinical resolution criteria were
used45. The PET scan helps to determine the length of the
inflammatory response period, but it does not provide guidance
cases, additional imaging should be ordered by the orthopaedic regarding when musculoskeletal structural integrity is sufficient
surgeon rather than a nonsurgical physician, as this informa- to allow activity without cumbersome off-loading devices. In-
tion is more relevant to operative interventions than nonop- creased length of immobilization may allow for resolution of
erative treatment options. acute CN with decreased risk of development of fractures or
deformity45.
Treatment Historically, complete off-loading of the foot has been
The goal of management of CN is to obtain a stable, plantigrade recommended along with a TCC until resolution of active CN.
foot free of ulcerations, and both nonsurgical and surgical The benefit of a strict non-weight-bearing protocol has been
treatment options are available63. An equally important goal is challenged; several small studies have suggested that early
to manage the patient’s diabetes and obesity. The treating weight-bearing in a rigid immobilizer is safe and more attain-
surgeon can have a meaningful and positive influence on able68,70,71. Some authors have examined less resource-intense
medical management of the diabetes and overall health alternatives to a TCC early in the course of CN, including the use
through patient education. The threat of an impending am- of removable immobilizers, but these appear to be associated
putation is often in the forefront of the patient’s thoughts, and with an increased risk of recurrence and longer time to reso-
appropriate management of the diabetes can substantially de- lution of acute CN11,74,75. Protected weight-bearing in a non-
crease this risk64,65. Although 1 priority for some patients is to removable immobilizer with frequent follow-up appears to be
be able to wear “off-the-shelf ” shoes, with or without custom the safest course in treating acute CN.
inserts63,66, this goal is often unrealistic and needs to be ap- Medical management of CN has focused on decreasing
propriately managed. While some authors have encouraged bone turnover to prevent the pathological fractures charac-
early surgical intervention, this approach requires further study teristic of the disease. Markers of bone turnover are reduced
regarding potential benefits and influence on the natural with bisphosphonate use, but this has not translated to im-
history. proved clinical outcomes; several studies have found delayed
resolution of acute CN with bisphosphonate use11,76-79. The
Nonsurgical Treatment concept of medical management of CN requires further
In active CN (Eichenholtz stages 0, I, and II), the first line of study.
treatment is decreased physical activity and off-loading of the
affected extremity13,31. A total contact cast (TCC) remains the Surgical Treatment
standard method of immobilization in active CN in North Surgery can be considered an internal method of off-loading
America13,31. However, effectively reducing the patient’s activity attained by correction of deformity and stabilization of an
level is often not achievable; thus, bracing plays an important unstable construct. Surgery is indicated when nonsurgical
role in off-loading the foot and ankle while allowing the patient treatment has failed or is not feasible. Primary indications are
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Fig. 8
Figs. 8-A through 8-D A 65-year-old female patient with a 12-year history of type-II diabetes mellitus. Fig. 8-A A plantar hindfoot ulcer of the left foot, with a
circumference of 5 cm and a duration of 14 weeks. The patient had undergone local wound care with use of a removable cast-boot. Fig. 8-B The foot was
immobilized in a TCC with a metal stirrup, which allowed the patient to remain active while off-loading the foot and ankle. The cast was changed every 2 to
3 weeks. Fig. 8-C The TCC with stirrup was permanently removed after 9 weeks, and other than some central callus formation, the ulcer demonstrated
complete healing. Fig. 8-D The ulcer was fully healed, and the patient was able to bear full weight at 3 months following immobilization with the TCC.

recurrent ulceration (indicative of an unstable foot), substan-
tial axial malalignment, deep infection, and pain66. Surgical
procedures commonly performed for CN include exostectomy,
Achilles tendon lengthening, arthrodesis, and osteotomy80,81.
Exostectomy is preferred in a stable foot (i.e., able to withstand
physiological forces) with an osseous prominence causing ul-
ceration; if the foot is unstable, arthrodesis with deformity
correction is recommended. In cases of forefoot ulceration,
Achilles tendon lengthening can be helpful in off-loading the
forefoot. The most common anatomic site of surgical inter-
vention is the midfoot80.
The literature on surgical management of CN largely
comprises Level-IV studies of small case series without a
control group80. A PubMed search of English-language re-
ports on surgical management of CN produced 1 small, pilot
randomized clinical trial82; 1 prospective cohort study83; 2
retrospective cohort studies84,85; 21 prospective or retrospec-
tive case series86-106; and 8 case reports107-114 (Table III). Fusion
rates ranged from 50% to 100%, with an overall fusion rate of
84.0% (489 of 582) across 28 studies83,85-97,99,100,102-107,109-114 when
including stable fibrous unions, which are usually pain-free
and achieve the goal of deformity correction. Nonunion rates
across the same 28 studies ranged from 0% to 38%, with an
overall rate of 13.6% (79 of 582). The risk of amputation is
considerable, with below-the-knee amputations reported for
36 (5.8%) of 616 patients across 29 studies83,85-97,99-107,109-114.
Wound breakdown is often reported83,85,91,101,102, and infections
(superficial or deep, and/or around hardware or along pin
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TABLE III Original Reports of Surgical Management of the Charcot Foot*

Mean
Level Follow-
of No. of Patients Region up Outcomes and
Authors Study Design Evidence† (No. of Feet) of Foot Type of Surgery (mo) Complications
82
Wang et al. Pilot I 12 (12) in op. Midfoot Medial column 12 Postop. reulceration:
(2015) randomized group and 9 (9) arthrodesis with 0/12 in op. group and
clinical trial controls (TCC internal fixation and 3/9 (33%) in control
only) followed by TCC, group; tibial nerve
versus TCC alone conduction: same as
baseline in op. group,
and decreased
compared with baseline
in controls
83
ElAlfy et al. Prospective II 27 (27) Hindfoot Ankle arthrodesis 31 Good-to-excellent AOFAS
(2017) cohort with Ilizarov external Ankle-Hindfoot scale
fixation (n = 14) or results for 21/27
intramedullary nailing patients (78%);
(n = 13) complications in external
fixation group: 2/14
(14%) had nonunion; 8,
pin-track infections; 2,
revisions of loose pins; 3,
surgical wound infections;
and 1, wound breakdown;
complications in
intramedullary nailing
group: 3/13 (23%) had
nonunion; 2, removal and
replacement of backed-
out distal locking bolt;
and 1, superficial wound
infection
Ramanujam Retrospective III 60 (60) had Midfoot; Tarsometatarsal >6 7/116 (6%) had
84
et al. (2016) cohort (case Charcot with hindfoot arthrodesis; medial amputations, including
control) study ulceration and/or and/or lateral column 5/60 (8%) cases and
osteomyelitis; 56 arthrodesis; subtalar, 2/56 (4%) controls
(56) had Charcot double, or triple
without ulceration arthrodesis; ankle
or osteomyelitis arthrodesis; and
(control) tibiotalocalcaneal
arthrodesis; all using
circular external
fixation
85
Wukich et al. Retrospective III 177 (202) had Midfoot; 18 had soft-tissue NA 38/162 (23%) had
(2017) cohort study op. treatment; 68 hindfoot surgery; 22, primary nonunion; 18/180 (10%)
(78) had nonop. amputation; 162, subsequently required
treatment osseous surgery: transtibial amputation;
treatment of 66/180 (37%)
osteomyelitis, developed wound
exostectomy, dehiscence or op. site
osteotomy, and/or infection postop.
arthrodesis, with
internal and/or
external fixation
107
Aikawa et al. Case report IV 3 (3) Hindfoot Tibiocalcaneal fusion 21 3/3 (100%) had union;
(2016) with locking plate no intraop. or postop.
complications
Capobianco Case report IV 1 (1) Midfoot Midfoot deformity 12 Fully ambulatory
108
et al. (2010) correction using
medial column
locking plate and
screws and Ilizarov
circular external
fixator

continued
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TABLE III (continued)

Mean
Level Follow-
of No. of Patients Region up Outcomes and
Authors Study Design Evidence† (No. of Feet) of Foot Type of Surgery (mo) Complications
109
Cullen et al. Case report IV 4 (4) Midfoot Medial column fusion 18.5 1/4 (25%) had wound
(2013) using midfoot fusion infection and 1/4 (25%)
bolt had revision (implant
removal) at 13 mo, due to
distal migration of medial
column fusion bolt
Dalla Paola Prospective IV 45 (45) with Hindfoot Debridement and NA 39/45 (87%) had stable
86
et al. (2009) case series Charcot and single or double- ankle fusion and a
osteomyelitis stage arthrodesis plantigrade foot; 2/45
with external fixator (4%), revision
stabilization with
intramedullary nail; and
4/45 (9%), below-the-
knee amputation
Dalla Paola Prospective IV 18 (18) Hindfoot Ankle arthrodesis, 14 14/18 (78%) had
87
et al. (2007) case series tibiocalcaneal complete osseous union;
arthrodesis using a 4/18 (22%), fibrous
retrograde nail union, and were
ambulatory with a custom-
molded ankle foot
orthosis; no amputations
Early and Retrospective IV 18 (21) Midfoot Tarsometatarsal 28 2/21 (10%) had
89
Hansen (1996) case series fusion, subtalar nonunion; 2/21 (10%),
fusion, triple below-the-knee
arthrodesis, or amputation; 1/21 (5%)
pantalar fusion died (myocardial
infarction on 3rd postop.
day); 1/21 (5%) had
superficial infection
90
Ettinger et al. Retrospective IV 12 (12) Hindfoot Tibiocalcaneal >12 AOFAS Ankle-Hindfoot
(2016) case series arthrodesis, with scale improved by a
external fixation (n = mean of 42.4 points; in
7), intramedullary nail intramedullary nail group:
(n = 4), or dorsal 4/4 (100%) had fusion; in
plaster cast (n = 1) external fixation group:
4/7 (57%) had clinical
and radiographic fusion
and 3/7 (43%), moderate
radiographic fusion with
stable asymptomatic
pseudarthrosis
91
Grant et al. Retrospective IV 44 (50) Midfoot; Achilles tendon 30 7/50 (14%) had
(2009) case series hindfoot lengthening, nonunion; 2/50 (4%),
arthrodesis (Lisfranc, amputation; 13/50
midtarsal, and (26%), pin-track
midfoot) with internal infections; 9/50 (18%),
fixation and external wound dehiscences;
fixation for 8/50 (16%),
compression osteomyelitis; and 1 had
deep vein thrombosis
92
Herscovici et al. Retrospective IV 12 (12) Hindfoot Pantalar arthrodesis 46 Posttraumatic arthritis
(2011) case series posttraumatic using an cohort: 2/12 (17%) had
arthritis; 8 (8) intramedullary nail ankle nonunion and 1/12
Charcot (n = 11) or plates (8%), subtalar malunion;
and/or screws (n = 9) Charcot cohort: 3/8
(38%) had ankle
malunion; 2/8 (25%),
deep infection; and 1/8
(13%), superficial
infection

continued
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TABLE III (continued)

Mean
Level Follow-
of No. of Patients Region up Outcomes and
Authors Study Design Evidence† (No. of Feet) of Foot Type of Surgery (mo) Complications

Hockenbury Retrospective IV 10 (10) Hindfoot Tibiotalocalcaneal, 21 9/10 (90%) had stable

93
et al. (2007) case series tibiocalcaneal or fusion and 1/10 (10%),
pantalar stable ankle
arthrodesis, with pseudarthrosis; no
bone graft and infections or
implantable bone amputations
growth stimulator,
and internal fixation
110
Hong et al. Case report IV 1 (1) Hindfoot Hindfoot arthrodesis 32 Radiographic union at
(2015) with internal fixation, 12 wk and fully walking
or tibial osteotomy
111
Kučera et al. Case report IV 1 (1) Midfoot Resectional 24 Full weight-bearing at 6
(2014) arthrodesis of mo postop.; FAAM and
Lisfranc and SF-36 scores improved
midtarsal joints, with substantially
internal fixation
112
Latt et al. Case report IV 1 (1) Hindfoot Revision surgery for 15 Radiographic fusion
(2017) nonunion at tibiotalar at 13 wk; no pain,
joint following mild swelling, fully
tibiotalocalcaneal weight-bearing, and
arthrodesis, using well-aligned hindfoot
intramedullary nail at 17 wk; returned
to all activities by
7 mo
Matsumoto and Retrospective IV 10 (11) Midfoot Midfoot arthrodesis 29 11/11 (100%) achieved
94
Parekh (2015) case series with monolateral solid union; 1/11 (9%),
external fixator by superficial wound
itself or in infection; and no
combination with amputations
internal fixation
95
Myerson et al. Retrospective IV 26 (26) Hindfoot Tibiocalcaneal 48 24/26 (92%) had
(2000) case series arthrodesis using osseous fusion; 2/26
condylar blade plates (8%), nonunion; 2/26
with or without (8%), tibial stress
screws, and bone fractures; and no deep
graft infections or
amputation
113
Nasser et al. Case report IV 1 (1) Midfoot Medial column 4 At 4 mo postop.,
(2015) arthrodesis using walking independently
distal fibular locking in a Charcot restraint
plate orthotic walker
96
Pakarinen et al. Retrospective IV 10 (10) had op. Forefoot; Exostectomy (n = 6), 21 4/6 (67%) had
(2002) case series treatment and 22 midfoot; arthrodesis (n = 6), radiographic fusion;
(26), nonop. hindfoot and primary below- 2/6 (33%), nonunion;
treatment the-knee amputation and 2/10, (20%)
(n = 2) postop. wound
infection
97
Pelton et al. Retrospective IV Total of 32 (33); Hindfoot Tibiotalocalcaneal 14 2/10 (20%) Charcot
(2006) case series Charcot in 10 arthrodesis using patients had nonunion,
(10) intramedullary nail and 1 Charcot patient
fixation required rod and screw
removal
98
Rammelt et al. Retrospective IV Total of 38 (38); Hindfoot Tibiotalocalcaneal 23.6 Results not reported
(2013) case series Charcot in 5 (5) arthrodesis using separately for the 5
retrograde nailing Charcot patients; 6/43
with curved hindfoot (14%) had nonunion
arthrodesis nail

continued
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TABLE III (continued)

Mean
Level Follow-
of No. of Patients Region up Outcomes and
Authors Study Design Evidence† (No. of Feet) of Foot Type of Surgery (mo) Complications
88
Richter et al. Prospective IV 47 (48) Midfoot; Variety of procedures 12 47/48 (98%) had union;
(2015) case series and to correct deformity, 1/48 (2%), nonunion;
hindfoot using a midfoot and 3/48 (6%), surgical
fusion bolt revision due to loss of
correction; 5/48 (10%),
amputation (2 below-
the-knee, 1 midfoot,
and 2 forefoot); 3/48
(6%), bolt loosening;
10/48 (21%), wound-
healing problem; and
8/48 (17%), deep
wound infection
Sammarco and Retrospective IV 26 (27) Forefoot; Arthrodesis with 27.9 2 patients required
99
Conti (1998) case series midfoot; internal fixation: further reconstructive
hindfoot reduction of rocker- surgery; 2 patients
bottom deformity; required screw removal;
triple arthrodesis; no deep infections; no
ankle arthrodesis amputations; and 6/27
(22%) had nonunion
Sammarco Retrospective IV 22 (22) Midfoot Midfoot arthrodesis 52 16/22 (73%) had full
100
et al. (2009) case series with osseous union; 5/22 (23%),
resection and partial union (a single
osteotomy joint did not unite in an
otherwise stable foot);
1/22 (5%), nonunion; 1,
soft-tissue infection;
and no amputation
101
Schon et al. Retrospective IV 50 ankles; 22 Forefoot; Tibiocalcaneal NA In tibiocalcaneal fusion
(1998) case series hindfeet; 131 midfoot; arthrodesis (n = 6); group: 2/6 (33%) had
midfeet; and 18 hindfoot hindfoot fusion (n = solid union; 2/6, stable
forefeet 11); midfoot ORIF (n = pseudarthrosis; and
4); midfoot biplanar 2/6, below-the-knee
osteotomy and amputation; in hindfoot
arthrodesis (n = 37); fusion group: 1/11 (9%)
forefoot cheilectomy had below-the-knee
(n = 4); forefoot amputation; in midfoot
resection fusion group: 12/37
arthroplasty (n = 2); (32%) had wound
and complications; and in
metatarsophalangeal forefoot group, no
joint fusion (n = 1) complications
102
Shah and De Retrospective IV 11 (11) Hindfoot Tibiotalar arthrodesis 38 In internal fixation group:
(2011) case series using intramedullary 0 had nonunion; 1/5
nails (n = 5) or (20%), wound breakdown;
external fixator (n = 6) 1/5, superficial infection;
and 1/5, removal of distal
interlocking bolt after
osseous union; in
external fixation group:
2/6 (33%) had union;
2/6, stable fibrous
nonunion; 2/6, nonunion;
4/6 (67%), revision of
external fixation; 1/6
(17%), below-the-knee
amputation; 3/6 (50%),
wound infection; and 2/6
(33%), wound breakdown

continued
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TABLE III (continued)

Mean
Level Follow-
of No. of Patients Region up Outcomes and
Authors Study Design Evidence† (No. of Feet) of Foot Type of Surgery (mo) Complications

Siebachmeyer Retrospective IV 20 (21) Midfoot; Ankle and 25 20/21 (95%) returned

103
et al. (2015) case series hindfoot; tibiocalcaneal to full weight-bearing;
forefoot arthrodesis with 1/21 (5%) had tibiotalar
intramedullary nail nonunion; 2/21 (10%),
(n = 21); midfoot nail removal; and 3/4
fusion with bolt (75%) with
and/or locking plate simultaneous midfoot
(n = 7); and first MTPJ fusion underwent
fusion (n = 2) revision with a locking
plate due to bolt
migration
104
Tisdel et al. Retrospective IV 7 (8) Midfoot; Triple arthrodesis, 44 16/16 (100%) had
(1995) cases series hindfoot navicular excision, clinically stable fusion,
and talocuneiform and 1/8 (13%) had
arthrodesis wound infection
105
Volkering et al. Retrospective IV 16 (16) Hindfoot Tibiocalcaneal fusion NA 6/16 (38%) had
(2015) case series with internal fixation nonunion at talar head
and Ilizarov external or distal end of tibia;
fixator 2/16 (13%), below-the-
knee amputation; and
3/16 (19%), stress
fractures of tibia
Wiewiorski and Case report IV 1 (1) Midfoot Medial column fusion 24 Ambulatory without
114
Valderrabano with a solid bolt external bracing; well-
(2012) defined medial
longitudinal arch of the
foot; and no evidence of
implant failure or
loosening
106
Zarutsky et al. Retrospective IV Total of 41 (43); Hindfoot Arthrodesis with 27 For Charcot patients:
(2005) case series Charcot in 11 circular wire external 9/11 (82%) had union;
(11) fixators: ankle fusion, 1/11, nonunion; 1/11,
pantalar fusion, and “stable” nonunion;
tibiotalocalcaneal 1/11, malunion‡;
fusion 1/11, infection around
hardware; 1/11, below-
the-knee amputation
due to deep infection;
2/11 (18%),
osteomyelitis‡; and
1/11, tibial stress
fracture‡

*TCC = total contact cast, AOFAS = American Orthopaedic Foot & Ankle Society, NA = not available, FAAM = Foot and Ankle Ability Measure, SF-36 = Short Form-36, ORIF =
open reduction and internal fixation, and MTPJ = metatarsophalangeal joint. †Level of evidence assigned according to the table, “Levels of Evidence for Primary Research
Question” by The Journal of Bone & Joint Surgery (revised January 2015), which is available at http://journals.lww.com/jbjsjournal/Pages/Journals-Level-of-Evidence.
aspx, accessed November 3, 2017. ‡1 patient experienced multiple complications: osteomyelitis, tibial stress fracture, and malunion.

tracks) are common66,80,83,85,88,89,91,92,94,96,100,102,104,106,109. In part, these
complications may reflect the advanced stage of CN at the time
of surgery.
Arthrodesis
When arthrodesis is performed, more robust fixation and
prolonged immobilization and non-weight-bearing may im-
prove fusion rates. The concept of “superconstructs” high-
lights the need to manage CN differently than standard
arthritic conditions115. Adequate bone resection to decom-
press soft tissues, use of graft material to fill ‡50% of the
fusion space116, extension of fixation past the injury zone into
solid bone, and use of locking plate technology may help to
increase union rates and decrease soft-tissue complications115.
Axial screw placement, or “beaming” with a midfoot fusion
bolt (Fig. 9), is a less invasive method of obtaining rigid in-
ternal fixation and compression across extensive midfoot
involvement117, and high fusion rates with low complication
rates have been reported88,100,103,109. These are judgments that
are based on surgeon experience and patient-related factors,
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Fig. 9
Figs. 9-A and 9-B Radiographs of the foot of a 44-year-old woman with long-
standing diabetes. Fig. 9-A Classic midfoot involvement of CN with col-
lapse. Fig. 9-B At 8 months postoperatively, correction of the lateral
talometatarsal angle is demonstrated. Fixation was done with a combi-
nation of fusion bolts and plate-and-screw constructs.
adhering to the basic surgical principles of good joint prep-
aration and deformity correction.
In the setting of ulceration or active infection, external
fixation with ring fixators has been described with satisfactory
outcomes118,119. Some authors have recommended the use of
external fixation for feet with active infection, large soft-tissue
defects, and poor bone quality and the use of internal fixation
for osseous reconstruction of the foot with CN without a
wound or active infection and good bone quality120. A recent
systematic review of 11 studies describing 126 feet with CN
found that internal fixation had a reduced ulceration rate,
decreased risk for nonunion, and increased return to functional
ambulation compared with external fixation, but also had a
higher rate of overall complications, including amputation,
deep infection, and wound-healing complications121. Modern,
rigid, locking, low-profile plate-and-screw constructs have
been designed for CN to address some of the shortcomings of
traditional internal fixation constructs, but these have yet to be
studied in a scientific method to support industry claims.
Most patients with CN who require surgical interven-
tion are in a late stage of diabetes and have advanced end-
organ disease. Surgical stabilization of a foot with CN is often
considered a palliative intervention to allow the patient an
improved level of function before mortality from myocardial
infarction, renal failure, or stroke122. These factors should be
considered before subjecting the patient to the prolonged
C H A R C O T N E U R O A R T H R O PAT H Y OF THE FOOT AND ANKLE
periods of surgical rehabilitation that may be associated with
major surgical reconstruction or use of external fixation.
More study is required to help treating physicians determine
the risks versus benefits of the type of treatment (i.e., surgical
versus nonsurgical, major versus minor surgery, and period
of off-loading) best suited for their patient. There is no evi-
dence in the literature that new fixation technologies have an
impact on patient outcomes, and no type of fixation will
compensate for poor surgical technique. The treating sur-
geon should focus on standard surgical principles including
(1) minimizing soft-tissue trauma, (2) preparing the joint
adequately, (3) reducing deformity, and (4) ensuring ade-
quate stability. The exact implants used to meet these prin-
ciples are less important.
Adjuncts to surgical procedures are often instituted in
patients with CN. Options include mechanical and/or electrical
stimulation methods and biological augmentation, but few
studies have examined the use of these modalities in CN. In
1 case series using an implantable electrical bone stimulator, 9
of 10 patients achieved fusion93. In another study, arthrodesis
augmented with bone marrow aspirate and platelet concentrate
resulted in a fusion rate of 91.3% (42 of 46 feet)123. Early evi-
dence has demonstrated that reduced levels of growth factors
may be associated with nonunion124. Biological adjuvants such as
recombinant human platelet-derived growth factor125 and re-
combinant bone morphogenetic protein-2126 have demonstrated
TABLE IV Grades of Recommendation
Recommendation Grade*
The diagnosis of Charcot neuroarthropathy C
(CN) is based on a thorough history and
physical examination.
Advanced diagnostic imaging is usually not C
required for the diagnosis and management of
uncomplicated CN.
The goals of treatment of CN are to obtain a C
stable, plantigrade, ulcer-free foot.
Nonsurgical management of CN includes C
immobilization in a cast and off-loading of the
affected extremity.
Indications for surgery for CN include recurrent C
ulceration, deep infection, severe deformity,
and uncontrolled pain.
Adequate joint preparation, robust fixation, C
and prolonged immobilization and off-loading
are essential when arthrodesis is performed.
127
*According to Wright , grade A indicates good evidence (Level-I
studies with consistent findings) for or against recommending in-
tervention; grade B, fair evidence (Level-II or III studies with con-
sistent findings) for or against recommending intervention; grade C,
poor-quality evidence (Level-IV or V studies with consistent findings)
for or against recommending intervention; and grade I, insufficient
or conflicting evidence not allowing a recommendation for or
against intervention.
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success in foot and ankle arthrodesis, but not specifically in the
setting of CN.
Overview
Charcot neuroarthropathy remains a debilitating disease that is
challenging to manage. Unfortunately, in a substantial number
of patients, the diagnosis of CN is a reflection of an advanced
stage of the disorder associated with diabetes-related end-organ
disease. The goals of management are to obtain a stable,
plantigrade, ulcer-free foot, with minimal disruption to the
patient (Table IV). This includes proper management of the
diabetes, realistic expectations, counseling, improved methods
of off-loading the extremity (e.g., a metal stirrup cast), ap-
propriate treatment decisions (nonoperative and operative),
and appropriate operative techniques. A multidisciplinary ap-
proach with involvement of the entire circle of care is optimal.
Fear of amputation often places the surgeon in a unique po-
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Andrew Dodd, MD, FRCSC1
Timothy R. Daniels, MD, FRCSC2
1Division of Orthopaedic Surgery, University of Calgary, Calgary,
Alberta, Canada
2Division
of Orthopaedic Surgery, St. Michael’s Hospital and University of
Toronto, Toronto, Ontario, Canada
E-mail address for T.R. Daniels: danielst@smh.ca
ORCID iD for T.R. Daniels: 0000-0003-0962-6977
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