Abstract
Background:
Charcot neuroarthropathy (CN) involving both the hindfoot and midfoot represents a severe form of the disease and is often associated with significant instability, deformity, and an increased risk of ulceration. Although early-stage midfoot CN may be managed conservatively, combined hindfoot-midfoot involvement typically necessitates complex surgical reconstruction.
Methods:
This retrospective longitudinal case series included 21 consecutive patients with combined hindfoot and midfoot CN treated surgically at a tertiary care center in South India between 2019 and 2024. All procedures were performed by a single senior foot and ankle surgeon. Primary outcome was defined as limb salvage, operationalized as the achievement of an ulcer-free, plantigrade foot with autonomous ambulation at 12 months postoperatively.
Results:
The mean age of the cohort was 57.2 ± 8.2 years, with 14 of 21 patients (66.7%) being male. All patients (21/21, 100%) had Brodsky IV CN. Combined hindfoot-midfoot reconstruction was undertaken in 12 (57.1%), whereas 9 patients (42.9%) underwent isolated hindfoot reconstruction, with preservation of a stable or minimally involved midfoot to function as a pseudo joint at the level of the Chopart joint. Overall, metal hardware failure occurred in 2 (9.5%), with a mean time to implant breakage of 15.5 ± 3.5 months. Radiologic bony union was achieved in 16 of 21 hindfoot (76.2%) and 6 of 21 midfoot (28.6%). Recurrence of CN occurred in 1 (4.8%), contralateral CN in 3 (14.3%), and ulcer recurrence in 5 (23.8%). Limb salvage was achieved in all patients (21/21, 100%).
Conclusion:
Surgical reconstruction of combined hindfoot and midfoot CN was associated with 100% limb salvage and clinical outcomes in this single-center series; however, these findings should be interpreted cautiously given the small sample size and the high rates of surgical site infection (38.1%) and low midfoot bony union (28.6%) observed. Future research with larger cohorts and extended follow-up focusing on functional outcomes is needed to enhance understanding and optimize treatment strategies.
Level of Evidence:
Level IV, retrospective observational case series.
Keywords
Introduction
Surgical reconstruction of combined hindfoot and midfoot deformities in Charcot neuroarthropathy (CN) remains a complex and evolving challenge. 1 Although the midfoot is typically the common site of involvement, 2 especially in the medial column around the naviculo-cuneiform joint, disease progression often extends laterally and into the hindfoot. 3 Midfoot CN often results in characteristic deformities, most notably the classic rocker-bottom foot with forefoot abduction. Less commonly, dorsal subluxation or dislocation and forefoot adduction may be observed. 4 Although midfoot CN usually progresses gradually and can often be managed with bracing, involvement of the hindfoot and ankle tends to cause more severe and rapidly progressive instability. 5 Ankle involvement compromises joint integrity and increases the risk of ulceration, particularly over the malleolar prominences. Because the mechanical axis of the lower limb passes through the central region of the ankle, even minor deformities may advance, leading to malalignment such as valgus or varus deformity or instability, and ultimately causing subluxation or dislocation. 6 It is hypothesized that coronal plane deformities of the hindfoot and ankle generate abnormal compensatory forces in the midfoot and forefoot, exacerbating the structural breakdown. 7
Approximately one-third of CN patients requiring surgical correction present with concurrent midfoot and hindfoot involvement. 3 The goal of reconstruction is to create a stable, plantigrade, ulcer-free foot capable of full weight-bearing in customised footwear. 8 There is limited data on the outcomes of CN involving both the hindfoot and midfoot. This case series aims to address this gap by evaluating the clinical outcomes in patients with combined hindfoot and midfoot involvement.
Materials and Methods
This retrospective longitudinal observational case series was conducted at a tertiary care center in South India between 2019 and 2024. All surgeries were performed by a single senior foot and ankle surgeon. Adult patients (≥18 years) with a confirmed diagnosis of diabetes mellitus (DM) and CN involving both the hindfoot and midfoot who underwent surgical reconstruction during the study period were eligible for inclusion. Only patients with complete clinical and radiologic records were included. Patients with a postoperative follow-up duration of less than 12 months were excluded from the analysis. In bilateral cases, the more severely affected limb was selected as the index limb for analysis. A total of 167 patients with CN were identified during the study period; of these, 76 underwent surgical intervention. A total of 21 consecutive patients met the inclusion criteria and were included in this study.
The variables assessed included demographic variables (age and sex), clinical variables (laterality, glycaemic control measured by HbA1c, comorbidities including DM, hypertension, chronic kidney disease, coronary artery disease, and rheumatoid arthritis, history of post-traumatic CN, and presence of ulceration at presentation), and disease-specific variables (Brodsky classification and Eichenholtz stage). Surgical variables included type of reconstruction performed (hindfoot or combined hindfoot and midfoot reconstruction), tendo-Achilles lengthening (TAL), and use of an antibiotic cement–impregnated titanium elastic nail system (ACI-TENS). Postoperative and outcome variables included duration of non–weight-bearing total contact cast (TCC), total duration of TCC, duration of Charcot restraint orthotic walker (CROW) boot use, surgical site infection, partial or complete implant removal, metal hardware failure, radiologic union status of the hindfoot and midfoot (bony union, fibrous union/nonunion), recurrence of CN, contralateral CN involvement, ulcer recurrence, limb salvage, and duration of follow-up.
Surgical procedures were individualized and consisted of osteotomies, arthrodesis, and with adjunct procedures such as TAL and ACI-TENS as needed. Postoperatively, all patients were maintained strictly non-weight-bearing in a short leg splint for 4 weeks, with regular dressing changes until wound healing. This was followed by a non–weight-bearing TCC (mean duration, 2.6 ± 0.7 months) and then partial weight bearing in a TCC with walker assistance (mean duration, 3.9 ± 1.0 months). Patients subsequently progressed to a CROW boot for a mean duration of 5.6 ± 1.6 months and were later transitioned to customized footwear incorporating high ankle support, a forefoot rocker-bottom stiff outsole, and a custom-molded insole designed based on 3D foot scanning and plantar pressure assessment.
The primary outcome was the achievement of an ulcer-free plantigrade foot with autonomous ambulation at 12 months postoperatively. Secondary outcomes included recurrence of CN, ulcer recurrence, surgical site infections, implant removal, and contralateral CN. All data were entered in Microsoft Excel and analyzed using Jamovi version 2.6.26 statistical software. Continuous variables were expressed as mean ± SD or median with IQR and range depending on data distribution. Categorical variables were presented as frequencies and percentages. All analyses were descriptive and exploratory in nature; no inferential comparisons between subgroups were performed. Ethical approval was obtained from the institutional review board, prior to data collection. Informed consent was waived because of the retrospective nature of the data analysis and anonymization of patient information.
Surgical Technique
Figure 1 illustrates the treatment algorithm for the management of combined hindfoot and midfoot CN (Brodsky type IV). The surgical procedure is typically performed during Eichenholtz stage 3. However, in cases where the foot is at risk of amputation due to a non-healing ulcer and instability, surgery may be necessary earlier, during stages 1 or 2. For non-ulcerated stage 1 cases, the initial treatment approach consists of offloading using a TCC until osseous consolidation is achieved. Once the consolidation is achieved, surgical reconstruction is done.
Treatment algorithm for combined hindfoot and midfoot Charcot neuroarthropathy (Brodsky type IV). The algorithm outlines the decision-making pathway based on the presence or absence of ulceration. In patients without ulcers, management proceeds toward definitive reconstruction based on the degree of instability. In patients with active ulceration, initial management focuses on infection control and stabilization, followed by staged reconstruction. Surgical options include isolated hindfoot reconstruction in cases with a stable or minimally involved midfoot (allowing a functional pseudo-joint at the Chopart level), or combined hindfoot-midfoot reconstruction in cases with significant midfoot involvement and instability.
As part of the preoperative evaluation protocol at our institution, all patients undergo comprehensive optimization of existing medical comorbidities, including glycaemic control and cardiac assessment, in collaboration with a multidisciplinary team. Patients without palpable peripheral pulses are referred for non-invasive vascular imaging. If vascular compromise is identified, they are evaluated for possible revascularization. Patients with inadequate limb perfusion who are not suitable candidates for revascularization are excluded from reconstructive procedures. 9
A one-stage surgical procedure is performed in patients who present with instability alone, without active infection or ulceration. In contrast, patients with active infection, ulceration, and instability usually require a 2-stage surgical approach. 10 The first stage consists of meticulous surgical debridement to remove all infected and nonviable bone and soft tissue. During this process, deep tissue and bone specimens are obtained for microbiological analysis. In infected and unstable cases where both infection control and interim mechanical stability need to be addressed, ACI-TENS is utilized. 11 This approach provides infection control, while also addressing mechanical stability temporarily. The ACI-TENS delivers targeted antimicrobial therapy through sustained high local concentrations of antibiotics at the infection site. The limb was further immobilized with TCC.
Once wound management is optimized and infection is adequately controlled, the patient is taken up for ACI-TENS nail removal followed by definitive fixation, performed either as a single-stage or staged procedure. The typical interval for wound healing and subsequent definitive reconstructive surgery ranges from 6 to 8 weeks. Percutaneous Triple Hemisection of TA is performed as an initial procedure to all the fixations.
Definitive fixation is broadly performed in 2 ways, based on the degree of instability: combined hindfoot-midfoot reconstruction and isolated hindfoot reconstruction. In the latter, a stable or minimally involved midfoot is preserved to function as a pseudo-joint at the level of the Chopart joint.
Combined hindfoot and midfoot reconstruction: The hindfoot stabilization is achieved initially through the standard transfibular approach for tibiotalocalcaneal (TTC) nail (Matrix) fixation. Once both the ankle and subtalar joint was prepared, the nail was inserted from the heel region for stabilization of the hindfoot. The entry point of nail into the tibia was deliberately kept lateral for the medial fixation of either plate or beam screw. Once the hindfoot was stabilized in a few initial cases, we used a 3.5-mm locking compression plate (LCP Synthes) dorsally and bend it as per the foot shape and added the anterior stabilization or 3.5 LCP kept medially spanning from the talus to the cuneiform. In later cases, we used beam screw (Marquardt) directed from the first metatarsal into the medial aspect of the talus of tibia if the talus is absent (Figure 2).
Hindfoot reconstruction alone: In those patients where the midfoot deformity was not much involved and reasonably stable, the hindfoot stabilization was done alone with a TTC nail. At times when the talus has been destroyed fully, a tibiocalcaneum arthrodesis has been done. However, extra screws were added for the superconstruct fixation of the hindfoot from the calcaneum directed to the tibia. 9 In 2 cases where we had near total destruction of the calcaneum, the hindfoot was stabilized with multiple headless 6.5-mm screws for stability (Figure 3).
Combined hindfoot and midfoot reconstruction: (A) preoperative lateral view; (B) preoperative AP foot; (C) preoperative AP ankle; (D) postoperative lateral view; (E) postoperative AP foot; (F) postoperative AP ankle; (G) postoperative Saltzman hindfoot alignment view. AP, anteroposterior.
Hindfoot-only reconstruction for combined hindfoot and midfoot Charcot neuroarthropathy: (A) preoperative AP ankle; (B) preoperative AP foot; (C) preoperative Saltzman hindfoot alignment view; (D) preoperative lateral view; (E) postoperative AP ankle; (F) postoperative AP foot; (G) postoperative Saltzman hindfoot alignment view; (H) postoperative lateral view. AP, anteroposterior.
Results
A total of 21 patients were included in the analysis, with a mean age of 57.2 ± 8.2 years (range, 41-71 years). The cohort comprised 14 males (66.7%) and 7 females (33.3%). CN most frequently involved the right foot in 12 (57.1%), with bilateral involvement in 2 (9.5%). All patients (n = 21, 100%) had DM, with hypertension present in 10 (47.6%). Other comorbidities included chronic kidney disease, coronary artery disease, and rheumatoid arthritis, each affecting 1 patient (4.8%). The mean HbA1c level was 8.9% ± 1.6% (range, 7.4-13.3). The median follow-up duration was 33.6 months (IQR 13.4; range, 12-81 months). All patients (n = 21, 100%) were classified as Brodsky type IV. According to the Eichenholtz staging system, 14 (66.7%) presented in the advanced fragmentation stage, 4 (19.0%) in early fragmentation, and 3 (14.3%) in the consolidation stage. Post-traumatic CN was identified in 2 (9.5%). Ulceration at presentation was noted in 8 (38.1%).
With respect to surgical management, 12 (57.1%) underwent combined hindfoot and midfoot reconstruction, whereas 9 (42.9%) underwent isolated hindfoot reconstruction. TAL was performed in all patients (n = 21, 100%), whereas ACI-TENS nail fixation was used in 5 patients (23.8%). Postoperative complications included surgical site infection in 8 (38.1%). Surgical site infection was observed in 1 patient with an anterior plate, whereas 7 patients developed infection at the lateral incision site. Partial implant removal was required in 1 (4.8%) due to wound dehiscence. Complete implant removal was performed in 4 (19.0%), including 2 for persistent infection, 1 for implant loosening, and 1 due to hardware failure. Overall, metal hardware failure occurred in 2 (9.5%), involving 1 contoured anterior plate (associated with non-union in midfoot) and 1 TTC nail (associated with premature weight bearing and uncontrolled DM due to patient noncompliance) leading to instability in both hindfoot and midfoot and resulting in a revision surgery. The mean time to implant breakage was 15.5 ± 3.5 months (range, 13-18 months; n = 2), whereas the median time to implant removal was 15.0 (9.8) months (range, 3-22 months; n = 6). The median time to ulcer recurrence was 15 months (IQR, 11 months; range, 7-36 months; n = 5), with ulcers occurring at the forefoot (pivot point effect), over a bony prominence (osteophyte), and as a pressure ulcer related to worn-out customized footwear. Two additional cases involved surgical site infections necessitating implant removal.
The mean duration of non–weight-bearing TCC was 2.6 ± 0.7 months, followed by a total TCC duration of 3.9 ± 1.0 months and CROW boot use for 5.6 ± 1.6 months. Radiologic outcomes demonstrated bony union in 16 (76.2%) hindfoot and in 6 (28.6%) midfoot region. Fibrous union was observed in 5 (23.8%) in the hindfoot and 15 (71.4%) in the midfoot. During follow-up, recurrence of CN was observed in 1 (4.8%), contralateral involvement in 3 (14.3%), and ulcer recurrence in 5 (23.8%). Limb salvage was achieved in all patients (n = 21, 100%) (Table 1).
Patient Demographics and Clinical Characteristics. a
Abbreviations: ACI-TENS, antibiotic cement–impregnated titanium elastic nail system; CROW, Charcot restraint orthotic walker; TA, tendo-Achilles; TCC, total contact cast.
For categorical variables, the data are expressed as n (%); for continuous variables, mean ± SD. Median (IQR) and range indicate minimum-maximum values.
Discussion
As there is an epidemiologic shift in the population, diabetes and its long-term complications are drawing growing attention and placing increasing demands on the health care system. CN is frequently misdiagnosed or overlooked, particularly by nonspecialist health care providers, with one study reporting misdiagnosis in approximately 79% of cases. 12 As a result, by the time patients present to our foot and ankle department, the disease has often progressed significantly, frequently involving multiple regions of the foot. In cases observed at our institution, amputation had been recommended elsewhere for most of the patients. Lower-extremity amputation is associated with a high five-year mortality rate, reported between 46.2% and 56.6%, highlighting the severity of outcomes following both minor and major amputations.13,14 It also significantly affects patient’s quality of life. 15 Although limb salvage may be a prolonged process, managing it within a multidisciplinary clinic is essential to reduce the considerable morbidity and mortality associated with major limb amputations. 16
CN involving both the midfoot and ankle signifies a severe and debilitating stage of the disease. 17 Although midfoot involvement often follows a gradual course and may respond to TAL and TCC, 18 hindfoot and ankle involvement typically leads to rapidly progressive instability and more serious functional impairment. 6 If left unaddressed, this instability can result in progressive deformity such as varus or valgus of the ankle, leading to abnormal pressure distribution on the medial or lateral side of the foot during walking. The accompanying loss of protective sensation further increases the risk of skin breakdown, ulceration, and infection. 19 The management of CN with infected ulcers, especially in the stage of fragmentation, is a challenging situation as it involves treating the infection and instability simultaneously. Surgical reconstruction is the preferred approach, particularly for patients with persistent instability or recurrent ulcers unresponsive to conservative management. 20
The primary objective of reconstructive surgery is limb salvage by preventing amputation, 21 while simultaneously aiming to restore a functional, pain-free foot with a stable, plantigrade alignment that facilitates appropriate load distribution and accommodates customised footwear.22,23 Key principles in combined deformity correction include achieving a normal calcaneal pitch, restoring both lateral and dorsal Meary lines, maintaining near-normal tibial-to-calcaneal alignment, and aiming for a positive cuboid height where feasible (recognizing that this may not always be attainable in severe deformities). 17 Surgically, 2 main approaches exist: single-stage and 2-stage procedures. In the presence of infection, a 2-stage surgical protocol is typically indicated. The first stage focuses on infection control, whereas the second stage involves definitive reconstructive arthrodesis once the infection is adequately managed. 10
In infected cases, some surgeons prefer external or hybrid fixation techniques. 24 Ilizarov external fixators have demonstrated favourable outcomes in managing infection, instability, non-union, and deformity.21,25 -27 However, external fixation presents several limitations, including poor patient compliance, the need for meticulous long-term pin site care, and psychological distress associated with the device. 28 At our institution, the ACI-TENS nail is used as a first-stage procedure in the staged reconstruction of infected, unstable Charcot feet. This approach was associated with favourable outcomes in terms of infection control and ulcer healing in this case series.
Various reconstructive arthrodesis techniques have been employed in the management of CN, ranging from external fixation with circular ring fixators to internal fixation using intramedullary or extramedullary devices such as screws, plates, bolts, or their combinations. 29 Among these, intramedullary nailing offers distinct biomechanical advantages, including improved rotational stability, increased bending stiffness, and better dynamic compression. These characteristics make it especially suitable for use in patients with the relatively osteopenic bone commonly seen in CN. 19 In this case series, extramedullary dorsal plating was used in 2 initial cases; however, it was associated with failures due to wound dehiscence and hardware breakage (Figure 4).
Implant complications following Charcot neuroarthropathy reconstruction. (A) Breakage of an anterior contoured locking compression plate (LCP) at 13 months postoperatively. (B) Postoperative radiograph of another case following hindfoot (HF) only reconstruction. (C) Breakage of the tibiotalocalcaneal (TTC) nail at 18 months postoperatively.
The super-construct method is particularly suited for patients with poor bone quality and expected prolonged healing. To enhance stability, fixation is extended across unaffected joints using larger, stronger implants positioned to maximize mechanical advantage, despite increased technical demands. 30
An emerging alternative for the management of combined midtarsal and hindfoot collapse in CN is the flipper foot technique with ankle arthrodesis, as described by Loveland et al. 31 This approach involves a tibiotalocalcaneal or tibiocalcaneal fusion combined with a corrective midfoot osteotomy, creating a stable hindfoot-ankle construct while preserving a motion segment anterior to the ankle, typically at the talonavicular joint. By maintaining limited forefoot motion, this technique allows a more functional gait compared with pantalar arthrodesis, which results in a completely rigid and often poorly functional foot.
In the protocol described by Kavarthapu et al, 1 patients were maintained non–weight-bearing in a TCC for a minimum of 3 months postoperatively. In our cohort, patients were initially kept strictly non–weight-bearing in a short leg splint for 4 weeks to facilitate wound care, followed by transition to a non–weight-bearing TCC for a mean duration of 2.6 ± 0.7 months. The total mean non–weight-bearing period in our series was therefore shorter than the minimum recommended in the Kavarthapu protocol, and patient non-compliance further reduced protected periods in some cases; this may have been associated with the lower midfoot bony union rate observed in our cohort (6/21; 28.6%) compared with that reported by Kavarthapu et al 1 (31/34; 91.2%).
In the series reported by Kavarthapu et al 1 involving 34 patients, full bony union was achieved in 31 patients (91.2%) at the midfoot and in 27 patients (79.4%) at the hindfoot. In contrast, our series demonstrated lower rates of bony union, with radiologic union observed in 16 patients (76.2%) at the hindfoot and 6 patients (28.6%) at the midfoot. Correspondingly, stable fibrous union was more frequent in our cohort, occurring in 5 patients (23.8%) at the hindfoot and 15 patients (71.4%) at the midfoot. If the fibrous union is stable, no further intervention is required. Although osseous fusion across the prepared joints is ideal, a stable pseudoarthrosis at the junction that allows the use of customized footwear and does not result in instability is considered an acceptable outcome. 17
Despite the potential for complications, prior literature has reported improvements in quality of life and reductions in mortality risk among CN patients following surgical treatment.32,33 Metalwork failure remains a major challenge in internal fixation for Charcot foot reconstruction. Kummen et al 3 reported a 24% rate of major hardware failure, with complications occurring predominantly in cases involving combined hindfoot and midfoot procedures. Procedures involving both the hindfoot and midfoot show a 12-fold increase in hardware failure and non-union, with complications occurring predominantly in the midfoot region. Similarly, Kavarthapu et al 1 observed implant-related complications in 5 of 35 feet, of which 3 required implant removal; failures included combined nail and plate breakage in 2 patients and isolated midfoot plate failure in 3. However, in our case series, metal failure was observed in 2 patients (9.5%), which may have been associated with the relatively short follow-up period and the use of protective offloading and bracing. Ulcer recurrence was observed in 5 patients (23.8%) at a median of 15 months postoperatively, with identifiable mechanical or footwear-related causes in each case. Given the altered biomechanics following combined hindfoot-midfoot reconstruction—including loss of normal sagittal plane motion, stress redistribution to the forefoot, and susceptibility to pivot-point ulceration—ongoing surveillance and maintenance of customized footwear represent critical components of long-term management in this population.
Limitations and Conclusion
In this series, limb salvage was achieved in all 21 patients (100%). The small sample size and retrospective nature of this case series limit the generalizability of findings. Additionally, the lack of functional outcome scores or quality-of-life assessments restricts the evaluation of patient-centered outcomes. This case series adds to the limited literature on surgical outcomes for combined hindfoot and midfoot CN and supports further prospective study in this high-risk population. Careful patient selection, meticulous surgical technique, appropriate offloading, and structured postoperative monitoring were features of the approach associated with this outcome in the present cohort.
Supplemental Material
sj-pdf-1-fao-10.1177_24730114261445393 – Supplemental material for Surgical Management of Charcot Neuroarthropathy Involving the Hindfoot and Midfoot: A Case Series
Supplemental material, sj-pdf-1-fao-10.1177_24730114261445393 for Surgical Management of Charcot Neuroarthropathy Involving the Hindfoot and Midfoot: A Case Series by Rajesh Simon, Ani Susan Abraham, Dennis P. Jose and Pratik Vishavadia in Foot & Ankle Orthopaedics
Footnotes
ORCID iDs
Ethical Considerations
The study was approved by the institutional ethics committee of Lakeshore Hospital.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
