Dear Dr Maaty, 

here are papers to choose from. The authors are on Rg and can be contacted: 

Article Use of Implantable Bone Growth Stimulation in Charcot Ankle ...

Article Long-term results of triple arthrodesis in Charcot-Marie-Tooth disease

Article A Long-Term Study of Triple Arthrodesis for Correction of Pe...

Article Long-Term Results of Reconstruction for Treatment of a Flexi...

Article A Retrospective Comparative Analysis of Charcot Ankle Stabil...

Stage I is the fragmentation phase (acute stage) where plain radiographs demonstrate osteopenia, periarticular fragmentation, and subluxation or frank dislocation of joints. Clinically, the foot continues to be warm and edematous and may demonstrate increased ligamentous laxity.

Type 1: Midfoot is the most common location for this type, which affects approximately 60 percent of patients with Charcot neuroarthropathy.

stage I CN is successfully treated with immobilization and non-weightbearing in a total contact cast. The duration of the treatment is usually determined according to the practitioner's opinion that involved joints will be able to sustain physiologic stresses. In this phase, frequent follow-up and radiographic evaluation with serial casting is very important until erythema, color, and inflammation has resolved.

Non-surgical treatment

The non-surgical treatment of CN is usually considered for the acute stages and includes offloading of the involved foot, treating the bone disease, and preventing further fractures and/or dislocations. In addition, this treatment can also be used in certain chronic CN patients and foot ulcerations. Offloading is the most important step in the management strategy of acute CN for consolidating the progression of deformity. Total contact casting (TCC) has been considered as the gold standard in the treatment of neuropathic diabetic plantar foot ulcers \ The utilization of a TCC reduces the mechanical forces, inflammation, and edema; redistributes the plantar pressure; limits bone and joint destruction; and can consolidate the progression of deformity. Its overall aim is to maintain a plantigrade foot which can then allow weightbearing in a shoe or brace .

TCC should encase the entire foot and ankle, with all major bony prominences well-padded with cotton-based bandages. Frequent cast changes are critical in reducing complications because setting can lead to instability and ulceration within the cast, and patients should be closely monitored on a weekly basis. At each visit, the cast or device should be inspected and removed. Wounds should be inspected, if necessary sharply debrided, measured, and photographed. When the active phase has ended, the patient can be fitted with Charcot restraint orthotic walker and later, with a custom shoe or orthoses .The average cast duration in chronic CN with ulceration is 5 weeks, with progression to therapatic footwear at 12 weeks. Some patients may need a cast for over a year and complications may include simple skin macerations.

Ankle Charcot neuroarthropathy is a difficult condition in a difficult patient population so one must carefully evaluate the cost versus benefit prior to any surgical intervention .

One should only perform surgery in stage 0 and stage 1 Charcot if there is infection, concern for skin breakdown, severe dislocation or instability, or if conservative treatment has failed to obtain a stable, plantigrade foot.

Dear Dr. Maaty.

In adolescents and adults we prefer a preliminary progressive correction of this complex deformity by an external circular fixator like Ilizarov and then triple arthrodesis can be performed in good conditions by means of screws or/and staples. Sure, frame is removed.

In my experience those with a charcot ankle also have STJ involvement.  I have had my best results with IM nailing with a long nail that extends at least past midshaft of the tibia.  I have had more issues with using external fixation on these patients than nailing with pin tract infection and a couple that went on to non union and collapsed some time after frame removal.  I have one with a non union with a nail and with the neuropathy and rectus alignment functions very well in a crow boot.