The clinical question
Charcot neuroarthropathy in a non-infected but threatening hindfoot. The patient has an unstable rocker-bottom deformity with a pre-ulcerous lateral malleolus and deformity progressing fast enough that a bracing strategy is not going to hold. The question is not whether to operate — the limb is threatened. The question is what operation gives us the best chance at a stable, plantigrade, brace-able limb that he can continue to work on.
Imaging
The radiographs told the story on presentation — loss of talar height, calcaneal pitch near zero, and midfoot collapse. CT gave us the bone-quality read: fragmented talar body, disorganized tibiotalar and subtalar joints, and an intact enough calcaneus to accept a nail. MRI was obtained to rule out osteomyelitis before we committed to a large internal fixation construct. Edema pattern without discrete abscess.
The decision
Tibiotalocalcaneal fusion with a retrograde intramedullary nail, transfibular approach, structural allograft to the tibiotalar void. The alternatives considered — isolated ankle fusion with a separate subtalar fusion, or a plate-and-screw construct — were not adequate given the extent of his neuropathic destruction. The retrograde nail gives us the strongest construct available for a Charcot patient who will not follow a strict non-weightbearing protocol.
Operative approach
Lateral transfibular approach. Fibular osteotomy and retraction. Preparation of the tibiotalar and subtalar joints down to bleeding subchondral bone. Intraoperative cultures sent as a precaution. Structural allograft packed into the void between the distal tibia and the residual talar body. Retrograde nail inserted through a plantar stab incision, with static proximal and distal interlocks and a posterior-to-anterior calcaneal interlock for rotational stability.
Fibula replaced over the construct as a lateral onlay graft with screw fixation for additional structural support.
Outcomes
Non-weightbearing for twelve weeks in a short-leg cast, then boot with partial weightbearing for another four weeks, then custom diabetic footwear with a rocker sole at four to five months. No wound complication. Cultures negative. At six months he was walking in his custom shoes, had returned to modified-duty work, and imaging showed consolidation without hardware failure. At one year the fusion was solid and he had resumed full work duties.
References
The Charcot reconstruction literature on superconstruct principles, particularly the Sammarco and Pinzur work, remains foundational. More recent comparative series on retrograde nail versus plate constructs are the primary references for implant choice.