Tibiotalocalcaneal Arthrodesis with Retrograde Intramedullary Nail in Patients with Charcot Neuroarthropathy of the Ankle and Hindfoot
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Published:
Jun 27, 2025
Keywords:
Charcot neuroarthropathy, ankle, hindfoot, diabetes mellitus, tibiotalocalcaneal arthrodesis, retrograde intramedullary nail
Main Article Content
Abstract
Introduction: Tibiotalocalcaneal (TTC) arthrodesis is the treatment of choice for the surgical management of Charcot neuroarthropathy (CN) affecting the ankle. The primary goal is to avoid major amputation and restore a functional lower limb suitable for ambulation, thereby improving patients’ quality of life.
Objective: To describe the clinical and radiological characteristics and evolution of patients with diabetes mellitus and Charcot neuroarthropathy who underwent TTC arthrodesis using a straight retrograde intramedullary compression nail.
Materials and Methods: This retrospective case series included consecutive patients with CN of the ankle and hindfoot and diabetes mellitus who underwent TTC arthrodesis with a retrograde intramedullary nail. Radiographic union, complications, reoperations, limb salvage, and preoperative metabolic parameters (serum albumin and HbA1c) were evaluated.
Results: Eight patients were included, with a median follow-up of 58 months (IQR 40.75–75.5). The median preoperative HbA1c was 6.6% (IQR 5.7–7), and the median serum albumin level was 3.41 g/dL (IQR 3.05–3.71). Three patients required revision surgery. Radiographic union was achieved in seven patients; two developed stable fibrous union, and one patient remains under follow-up.No patient required amputation.
Conclusions: TTC arthrodesis with a retrograde intramedullary nail is a viable surgical option fordiabetic patients with Charcot neuroarthropathy involving the ankle. Optimizing preoperative metabolic status and comorbidities, along with appropriate management of osteomyelitis, is essential to reduce complications and promote bone healing.
Objective: To describe the clinical and radiological characteristics and evolution of patients with diabetes mellitus and Charcot neuroarthropathy who underwent TTC arthrodesis using a straight retrograde intramedullary compression nail.
Materials and Methods: This retrospective case series included consecutive patients with CN of the ankle and hindfoot and diabetes mellitus who underwent TTC arthrodesis with a retrograde intramedullary nail. Radiographic union, complications, reoperations, limb salvage, and preoperative metabolic parameters (serum albumin and HbA1c) were evaluated.
Results: Eight patients were included, with a median follow-up of 58 months (IQR 40.75–75.5). The median preoperative HbA1c was 6.6% (IQR 5.7–7), and the median serum albumin level was 3.41 g/dL (IQR 3.05–3.71). Three patients required revision surgery. Radiographic union was achieved in seven patients; two developed stable fibrous union, and one patient remains under follow-up.No patient required amputation.
Conclusions: TTC arthrodesis with a retrograde intramedullary nail is a viable surgical option fordiabetic patients with Charcot neuroarthropathy involving the ankle. Optimizing preoperative metabolic status and comorbidities, along with appropriate management of osteomyelitis, is essential to reduce complications and promote bone healing.
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How to Cite
Parise, A. C., Cafruni, V. M., Carrasco, N. M., Parma, J. M., Brué, J., Villena, D. S., Conti, L. Ángel, Sotelano, P., & Santini Araujo, M. G. (2025). Tibiotalocalcaneal Arthrodesis with Retrograde Intramedullary Nail in Patients with Charcot Neuroarthropathy of the Ankle and Hindfoot. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 90(3), 209-218. https://doi.org/10.15417/issn.1852-7434.2025.90.3.2117
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Clinical Research
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References
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2. Rosemberg DL, Sposeto RB, Godoy-Santos AL. Arthrodesis in the deformed Charcot foot. Foot Ankle Clin
2022;27(4):835-46. Disponible en: https://linkinghub.elsevier.com/retrieve/pii/S1083751522000936
3. Ögüt T, Yontar NS. Surgical treatment options for the diabetic Charcot hindfoot and ankle deformity. Clin Podiatr Med Surg 2017;34(1):53-67. https://doi.org/10.1016/j.cpm.2016.07.007
4. Papa J, Myerson M, Girard P. Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle. J Bone Joint Surg 1993;75(7):1056. Disponible en:
https://journals.lww.com/jbjsjournal/abstract/1993/07000/salvage,_with_arthrodesis,_in_intractable_diabetic.12.aspx
5. Dalla Paola L, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, et al. Use of a retrograde nail for ankle
arthrodesis in Charcot neuroarthropathy: a limb salvage procedure. Foot Ankle Int 2007;28(9):967-70.
https://doi.org/10.3113/FAI.2007.0967
6. Brandão RA, Weber JS, Larson D, Prissel MA, Bull PE, Berlet GC, et al. New fixation methods for the treatment of the diabetic foot: Beaming, external fixation, and beyond. Clin Podiatr Med Surg 2018;35(1):63-76. https://doi.org/10.1016/j.cpm.2017.08.001
7. Ayoub MA. Ankle fractures in diabetic neuropathic arthropathy: can tibiotalar arthrodesis salvage the limb? J Bone Joint Surg Br 2008;90(7):906-14. https://doi.org/10.1302/0301-620X.90B7.20090
8. Trepman E, Nihal A, Pinzur MS. Current topics review: Charcot neuroarthropathy of the foot and ankle. Foot Ankle Int 2005;26(1):46-63. https://doi.org/10.1177/107110070502600109
9. Wukich DK, Mallory BR, Suder NC, Rosario BL. Tibiotalocalcaneal arthrodesis using retrograde intramedullary nail fixation: Comparison of patients with and without diabetes mellitus. J Foot Ankle Surg 2015;54(5):876-82. https://doi.org/10.1053/j.jfas.2015.02.019
10. Griffin MJ, Coughlin MJ. Evaluation of midterm results of the Panta Nail: An active compression tibiotalocalcaneal arthrodesis device. J Foot Ankle Surg 2018;57(1):74-80. Disponible en:
https://linkinghub.elsevier.com/retrieve/pii/S1067251617304982
11. Caravaggi CMF, Sganzaroli AB, Galenda P, Balaudo M, Gherardi P, Simonetti D, et al. Long-term follow-up of tibiocalcaneal arthrodesis in diabetic patients with early chronic Charcot osteoarthropathy. J Foot Ankle Surg 2012;51(4):408-11. https://doi.org/10.1053/j.jfas.2012.04.007
12. Caravaggi C, Cimmino M, Caruso S, Dalla Noce S. Intramedullary compressive nail fixation for the treatment of severe Charcot deformity of the ankle and rear foot. J Foot Ankle Surg 2006;45(1):20-4.
https://doi.org/10.1053/j.jfas.2005.10.003
13. DeVries JG, Berlet GC, Hyer CF. A retrospective comparative analysis of Charcot ankle stabilization using an intramedullary rod with or without application of circular external fixator--utilization of the Retrograde Arthrodesis Intramedullary Nail database. J Foot Ankle Surg 2012;51(4):420-5. https://doi.org/10.1053/j.jfas.2012.03.005
14. Ettinger S, Plaass C, Claassen L, Stukenborg-Colsman C, Yao D, Daniilidis K. Surgical management of
Charcot deformity for the foot and ankle-radiologic outcome after internal/external fixation. J Foot Ankle Surg 2016;55(3):522-8. https://doi.org/10.1053/j.jfas.2015.12.008
15. Myers TG, Lowery NJ, Frykberg RG, Wukich DK. Ankle and hindfoot fusions: comparison of outcomes in patients with and without diabetes. Foot Ankle Int 2012;33(1):20-8. https://doi.org/10.3113/FAI.2012.0020
16. Wukich DK, Lowery NJ, McMillen RL, Frykberg RG. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am 2010;92(2):287-95. https://doi.org/10.2106/JBJS.I.00080
17. Richman J, Cota A, Weinfeld S. Intramedullary nailing and external ring fixation for tibiotalocalcaneal arthrodesis in Charcot arthropathy. Foot Ankle Int 2017;38(2):149-52. https://doi.org/10.1177/1071100716671884
18. Regauer M, Grasegger V, Fürmetz J, Kussmaul AC, Böcker W, Ehrnthaller C. High rate of complications after corrective midfoot/subtalar arthrodesis and Achilles tendon lengthening in Charcot arthropathy type Sanders 2 and 3. Int Orthop 2023;47(1):141-50. https://doi.org/10.1007/s00264-022-05567-y
19. Raspovic KM, Liu GT, Lalli T, Van Pelt M, Wukich DK. Optimizing results in diabetic Charcot reconstruction. Clin Podiatr Med Surg 2019;36(3):469-81. https://doi.org/10.1016/j.cpm.2019.02.010
20. Lee M, Choi WJ, Han SH, Jang J, Lee JW. Uncontrolled diabetes as a potential risk factor in tibiotalocalcaneal fusion using a retrograde intramedullary nail. Foot Ankle Surg 2018;24(6):542-8.
https://doi.org/10.1016/j.fas.2017.07.006
21. Akiboye F, Rayman G. Management of hyperglycemia and diabetes in orthopedic surgery. Curr Diab Rep 2017;17(2):13. https://doi.org/10.1007/s11892-017-0839-6
22. Cancienne JM, Cooper MT, Laroche KA, Verheul DW, Werner BC. Hemoglobin A as a predictor of postoperative infection following elective forefoot surgery. Foot Ankle Int 2017;38(8):832-7.
https://doi.org/10.1177/1071100717705140
23. Li S, Zhang J, Zheng H, Wang X, Liu Z, Sun T. Prognostic role of serum albumin, total lymphocyte count, and mini nutritional assessment on outcomes after geriatric hip fracture surgery: A meta-analysis and systematic review. J Arthroplasty 2019;34(6):1287-96. https://doi.org/10.1016/j.arth.2019.02.003
24. Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z. Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am 2003;85(9):1667-72. https://doi.org/10.2106/00004623-200309000-00003
25. Wukich DK, Frykberg RG, Kavarthapu V. Charcot neuroarthropathy in persons with diabetes: It’s time for a paradigm shift in our thinking. Diabetes Metab Res Rev 2024;40(3):e3754. https://doi.org/10.1002/dmrr.3754
2. Rosemberg DL, Sposeto RB, Godoy-Santos AL. Arthrodesis in the deformed Charcot foot. Foot Ankle Clin
2022;27(4):835-46. Disponible en: https://linkinghub.elsevier.com/retrieve/pii/S1083751522000936
3. Ögüt T, Yontar NS. Surgical treatment options for the diabetic Charcot hindfoot and ankle deformity. Clin Podiatr Med Surg 2017;34(1):53-67. https://doi.org/10.1016/j.cpm.2016.07.007
4. Papa J, Myerson M, Girard P. Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle. J Bone Joint Surg 1993;75(7):1056. Disponible en:
https://journals.lww.com/jbjsjournal/abstract/1993/07000/salvage,_with_arthrodesis,_in_intractable_diabetic.12.aspx
5. Dalla Paola L, Volpe A, Varotto D, Postorino A, Brocco E, Senesi A, et al. Use of a retrograde nail for ankle
arthrodesis in Charcot neuroarthropathy: a limb salvage procedure. Foot Ankle Int 2007;28(9):967-70.
https://doi.org/10.3113/FAI.2007.0967
6. Brandão RA, Weber JS, Larson D, Prissel MA, Bull PE, Berlet GC, et al. New fixation methods for the treatment of the diabetic foot: Beaming, external fixation, and beyond. Clin Podiatr Med Surg 2018;35(1):63-76. https://doi.org/10.1016/j.cpm.2017.08.001
7. Ayoub MA. Ankle fractures in diabetic neuropathic arthropathy: can tibiotalar arthrodesis salvage the limb? J Bone Joint Surg Br 2008;90(7):906-14. https://doi.org/10.1302/0301-620X.90B7.20090
8. Trepman E, Nihal A, Pinzur MS. Current topics review: Charcot neuroarthropathy of the foot and ankle. Foot Ankle Int 2005;26(1):46-63. https://doi.org/10.1177/107110070502600109
9. Wukich DK, Mallory BR, Suder NC, Rosario BL. Tibiotalocalcaneal arthrodesis using retrograde intramedullary nail fixation: Comparison of patients with and without diabetes mellitus. J Foot Ankle Surg 2015;54(5):876-82. https://doi.org/10.1053/j.jfas.2015.02.019
10. Griffin MJ, Coughlin MJ. Evaluation of midterm results of the Panta Nail: An active compression tibiotalocalcaneal arthrodesis device. J Foot Ankle Surg 2018;57(1):74-80. Disponible en:
https://linkinghub.elsevier.com/retrieve/pii/S1067251617304982
11. Caravaggi CMF, Sganzaroli AB, Galenda P, Balaudo M, Gherardi P, Simonetti D, et al. Long-term follow-up of tibiocalcaneal arthrodesis in diabetic patients with early chronic Charcot osteoarthropathy. J Foot Ankle Surg 2012;51(4):408-11. https://doi.org/10.1053/j.jfas.2012.04.007
12. Caravaggi C, Cimmino M, Caruso S, Dalla Noce S. Intramedullary compressive nail fixation for the treatment of severe Charcot deformity of the ankle and rear foot. J Foot Ankle Surg 2006;45(1):20-4.
https://doi.org/10.1053/j.jfas.2005.10.003
13. DeVries JG, Berlet GC, Hyer CF. A retrospective comparative analysis of Charcot ankle stabilization using an intramedullary rod with or without application of circular external fixator--utilization of the Retrograde Arthrodesis Intramedullary Nail database. J Foot Ankle Surg 2012;51(4):420-5. https://doi.org/10.1053/j.jfas.2012.03.005
14. Ettinger S, Plaass C, Claassen L, Stukenborg-Colsman C, Yao D, Daniilidis K. Surgical management of
Charcot deformity for the foot and ankle-radiologic outcome after internal/external fixation. J Foot Ankle Surg 2016;55(3):522-8. https://doi.org/10.1053/j.jfas.2015.12.008
15. Myers TG, Lowery NJ, Frykberg RG, Wukich DK. Ankle and hindfoot fusions: comparison of outcomes in patients with and without diabetes. Foot Ankle Int 2012;33(1):20-8. https://doi.org/10.3113/FAI.2012.0020
16. Wukich DK, Lowery NJ, McMillen RL, Frykberg RG. Postoperative infection rates in foot and ankle surgery: a comparison of patients with and without diabetes mellitus. J Bone Joint Surg Am 2010;92(2):287-95. https://doi.org/10.2106/JBJS.I.00080
17. Richman J, Cota A, Weinfeld S. Intramedullary nailing and external ring fixation for tibiotalocalcaneal arthrodesis in Charcot arthropathy. Foot Ankle Int 2017;38(2):149-52. https://doi.org/10.1177/1071100716671884
18. Regauer M, Grasegger V, Fürmetz J, Kussmaul AC, Böcker W, Ehrnthaller C. High rate of complications after corrective midfoot/subtalar arthrodesis and Achilles tendon lengthening in Charcot arthropathy type Sanders 2 and 3. Int Orthop 2023;47(1):141-50. https://doi.org/10.1007/s00264-022-05567-y
19. Raspovic KM, Liu GT, Lalli T, Van Pelt M, Wukich DK. Optimizing results in diabetic Charcot reconstruction. Clin Podiatr Med Surg 2019;36(3):469-81. https://doi.org/10.1016/j.cpm.2019.02.010
20. Lee M, Choi WJ, Han SH, Jang J, Lee JW. Uncontrolled diabetes as a potential risk factor in tibiotalocalcaneal fusion using a retrograde intramedullary nail. Foot Ankle Surg 2018;24(6):542-8.
https://doi.org/10.1016/j.fas.2017.07.006
21. Akiboye F, Rayman G. Management of hyperglycemia and diabetes in orthopedic surgery. Curr Diab Rep 2017;17(2):13. https://doi.org/10.1007/s11892-017-0839-6
22. Cancienne JM, Cooper MT, Laroche KA, Verheul DW, Werner BC. Hemoglobin A as a predictor of postoperative infection following elective forefoot surgery. Foot Ankle Int 2017;38(8):832-7.
https://doi.org/10.1177/1071100717705140
23. Li S, Zhang J, Zheng H, Wang X, Liu Z, Sun T. Prognostic role of serum albumin, total lymphocyte count, and mini nutritional assessment on outcomes after geriatric hip fracture surgery: A meta-analysis and systematic review. J Arthroplasty 2019;34(6):1287-96. https://doi.org/10.1016/j.arth.2019.02.003
24. Pinzur MS, Stuck RM, Sage R, Hunt N, Rabinovich Z. Syme ankle disarticulation in patients with diabetes. J Bone Joint Surg Am 2003;85(9):1667-72. https://doi.org/10.2106/00004623-200309000-00003
25. Wukich DK, Frykberg RG, Kavarthapu V. Charcot neuroarthropathy in persons with diabetes: It’s time for a paradigm shift in our thinking. Diabetes Metab Res Rev 2024;40(3):e3754. https://doi.org/10.1002/dmrr.3754