Charcot neuroarthropathy (CN) is a rare joint destructive process that occurs in the setting of peripheral neuropathy. CN can cause deformity and joint instability and has been shown to decrease quality of life. Given the rarity but severity of this condition, a better understanding of the epidemiology and treatment trends are needed. Therefore, the purpose of this study was to explore recent trends in the observed cumulative burden of CN as well as the incidence of different surgical treatments. This study utilized a large commercial insurance claims database to estimate the diagnostic cumulative burden of CN from 2009 to 2019. Patients were identified through International Classification of Disease codes. Current procedural terminology (CPT) codes were cross-matched with diagnostic codes to identify patients who underwent surgical procedures related to their CN. Incidence rates of procedures were calculated to assess for trends in management, stratified by age, sex, and geographic region. From 2009 to 2019, the cumulative case rate of CN increased from 2.96 to 5.00 patients per 10 000 people (estimated 12 836 observed cases starting in 2009 to 167 145 observed cumulative cases by 2019) in the United States. In this time period, the total incidence of surgical procedures performed for these patients increased from 4.35 to 9.70 procedures per 100 000 person-years. The most common procedures included debridement and excision/resection procedures (75.21%) and arthrodesis or osteotomy procedures (9.85%). Current epidemiological trends for CN are not well known. This study demonstrated an increasing case burden of CN within the United States, alongside increasing incidences of surgical procedures for this disease. These trends provide important insights for patient-specific and public health advocacy. Future studies should continue to explore the contributory financial, cultural, and educatory factors of this disease.Levels of Evidence: III Retrospective cohort study.

Charcot neuroarthropathy (CN) is a rare but severely disabling complication most commonly seen in patients with longstanding diabetic peripheral neuropathy. CN is characterized by progressive destruction, dislocation, and deformity of the foot and ankle joints, often accompanied by altered biomechanics, chronic ulceration, secondary infection, and, in advanced cases, a high risk of amputation or even mortality. The early clinical presentation of CN is frequently atypical, with mild or painless swelling, warmth, and erythema due to underlying sensory deficits, which can easily lead to misdiagnosis as other rheumatic or autoimmune joint disorders such as rheumatoid arthritis and gout. In this report, we present the case of a 60-year-old woman with a 12-year history of type 2 diabetes mellitus who developed persistent swelling and pain in her left ankle for eight months, along with progressive numbness in her left foot for six months. Her initial laboratory and imaging findings suggested a diagnosis of rheumatoid arthritis combined with gout, resulting in the administration of anti-rheumatic and uric acid-lowering therapies, which proved ineffective. Further diagnostic workup, including advanced imaging modalities, neuroelec-trophysiological testing, and synovial biopsy, ultimately confirmed the diagnosis of diabetic Charcot neuroarthropathy, revealing severe joint dislocation, bone fragmentation, and extensive osteolysis. The patient received comprehensive management, including strict glycemic control, anti-osteoporosis treatment, neurotrophic support, and ultimately underwent left ankle multi-joint fusion surgery. During postoperative follow-up, the patient demonstrated significant improvement in limb function, with no recurrence of ulcers or infection. This case highlights the importance of considering CN in diabetic patients with unilateral, painless joint swelling, deformity, and sensory disturbance. Accurate differential diagnosis from rheu-matic and autoimmune diseases, early recognition, and standardized intervention are crucial to prevent irreversible deformity and reduce the risk of amputation, ultimately improving patient outcomes. Early multidisciplinary management and individualized treatment strategies play a key role in optimizing prognosis for patients with diabetic CN.

Diabetic Charcot Neuroarthropathy: A Contemporary Review of Molecular and Genetic Markers.

Current status and treatment choices of Charcot neuroarthropathy: A severe and rare complication of neuropathy

It is well documented that limb salvage interventions may induce or exacerbate biomechanical dysfunction in the residual limb. As a result, patients with Charcot's neuroarthropathy (CN) are at theoretical risk for progression of or novel neuroarthropathic breakdown, which has been observed in the midfoot after amputation; however, this has not been investigated in rearfoot interventions such as partial calcanectomy. We retrospectively identified eight patients during a 7.25-year period who had a history of CN and partial calcanectomy in the ipsilateral limb. Patients with contralateral involvement were excluded, and included medical records were analyzed and radiographically characterized. The mean patient age was 73.9 years (range, 59-86 years), and the mean body mass index was 31.4 (range, 22-50). Two patients (25.0%) demonstrated multijoint breakdown. Two feet (25.0%) were characterized as Sanders-Frykberg (SF) II, one (12.5%) as SF III, and three (37.5%) as SF IV/V breakdown. Three patients developed CN a mean of 350.3 days after partial calcanectomy was performed. The mean age and body mass index of patients who experienced post-vertical contour calcanectomy CN was 70.7 years (range, 59-83 years) and 29.0 years (range, 22-35 years), respectively. All instances of postcalcanectomy CN resulted in rearfoot breakdown, with one (33.3%) isolated to the tibiotalar joint and two (66.7%) at the tibiotalar and subtalar joints. A 66.7% limb salvage rate was found in patients who developed postcalcanectomy CN. We conclude that partial calcanectomy in patients with antecedent CN does not result in clinically significant changes that further threaten the limb but identified three instances where partial calcanectomy destabilized the rearfoot and resulted in rearfoot CN breakdown. Although this knowledge should not discourage the use of calcanectomies, clinicians should be cognitive of complications such as CN breakdown that can further threaten the limb.

Charcot neuroarthropathy is characterized by progressive joint destruction resulting from the loss of pain sensation. The most common manifestation is Charcot foot associated with diabetic peripheral neuropathy, which is a serious complication that often leads to amputation due to ulcers or infection. Early diagnosis is challenging but crucial as it strongly influences treatment outcomes. Off-loading is the cornerstone of management, and surgical intervention should be considered in advanced cases. The primary goals of treatment are to minimize deformity, prevent ulceration, and preserve the functional ambulatory foot. Lifelong management is essential to achieve favorable outcomes.

Medial column nails have been introduced into Charcot's neuroarthropathy reconstruction as superconstruct fixation with high fatigue strength and pullout resistance. Similar to intramedullary nailing throughout other long-bone fixation, injury to neurovascular and musculotendinous structures secondary to percutaneous interlocking screw fixation may exist. We sought to identify structures at risk for injury during the interlocking of a medial column nail. Medial column nails were inserted into ten cadaveric limbs. The proximal (talar), middle (first metatarsal), and distal (first metatarsal) locations for the interlocking screws were drilled, and a 0.062 Kirschner wire was inserted into respective drillholes to simulate interlocking screws. After dissection, the distances of each Kirschner wire to nearby anatomical structures were measured. Levels of risk were assigned to each soft-tissue structure based on distance to each Kirschner wire: high (0-3.5 mm), intermediate (3.6-7.0 mm), and low (>7.0 mm). A 3.5-mm threshold for each category was used because this represented a multiple of the diameter of the interlocking screws. Mean ± SD and ranges are reported for structures at high and intermediate risk for injury. Proximally, the deltoid ligament (ten of ten), posterior tibial tendon (eight of ten), and saphenous vein (six of ten) were at high or intermediate risk for injury consistently. At the middle screw, the medial dorsal cutaneous nerve and the medial marginal vein were at high or intermediate risk in ten and eight specimens, respectively. At the distal interlocking screw, the medial dorsal cutaneous nerve was at high risk for injury in all ten specimens. There is high and intermediate risk to many musculotendinous and neurovascular structures when performing percutaneous interlocking screws in a medial column nail. These findings serve to educate surgeons of the anatomical considerations they must have when performing medial column nailing for reconstruction of Charcot's foot.

Research Type: Level 2 - Prospective comparative study, Meta-analysis of Level 2 studies or Level 1 studies with inconsistent results Introduction/Purpose: Charcot Neuroarthropathy (CNA) is a progressive and destructive joint condition resulting from a combination of peripheral neuropathy and repeated microtrauma. Non-surgical interventions alleviate pressure from the joint and are the primary treatment option for early stages of CNA. Delaying treatment can result in foot deformities, ulceration, infection and amputation. Understanding the relationship between gait kinematics and plantar pressure distributions of CNA patients may provide useful information in staging and management. 3D gait analysis technology for diagnosing and assessing gait abnormalities exists, but it is often inaccessible and costly. The aim of this study was to assess plantar pressures and two-dimensional kinematics of CNA patients during gait analyses. Four cohorts were compared (1) affected and non-affected limbs, (2) CNA patients and healthy controls. Methods: Following institutional review board approval, the study was conducted at a single institution using a case-controlled prospective selection of patients treated by two orthopaedic foot and ankle surgeons from June 2024 – December 2024. Fourteen patients diagnosed with CNA (n=14) and eleven control patients (“Healthy”) were placed in a diabetic slipper with F-64 TEKSCAN insole matrix system sensors. Adhesive-colored markers were placed on their greater trochanter, lateral knee, lateral malleolus, and distal fifth metatarsal. Using a handrail, participants walked at 0.6 mph and 1.0 mph on a treadmill. Maximum mean force as well as the percentage contribution of each discretized region: (hindfoot, midfoot, metatarsals and forefoot) were analyzed and normalized to the participant bodyweight. Angular range of motions (ROM) of the hip, knee, and ankle joints were measured. Two comparisons were made using the data: (1) Affected limb versus non-affected contralateral limb, (2) CNA patients vs control data. Results: Gait analysis was successful for all participants at both speeds. Hindfoot and metatarsal forces were significantly lower in CNA patients compared to controls for both speeds (p < 0.000001 and p < 0.01, respectively) (Fig. A,B). Midfoot forces were significantly higher in CNA patients compared to controls at both speeds (p = 0.002). There were no statistically significant differences between forefoot forces in CNA and controls at either speed. There were no statistically significant differences between affected and contralateral limbs of CNA patients. (Fig. C,D). On kinematic analysis, knee range of motion was significantly lower in CNA patients than controls (p < 0.00001) at 1.0 mph whereas there were no significant differences measured with the other two joints (Fig. E). Conclusion: Gait pattern abnormalities were observed in participants with CNA at both walking speeds. Greater midfoot plantar forces recorded for CNA patients highlight a common consequence of CNA, midfoot collapse. This is also evidenced by decreased plantar forces of the hindfoot and metatarsals of the CNA patients compared to controls. This data in combination with a decreased ROM of the knee joint reiterate the benefits of performing both gait analysis and collecting plantar force data to better categorize and treat patients with CNA. Future directions include creating specific devices to help mitigate higher midfoot pressures within the CNA population. Figure 1: Plantar Force results for each region of interest including comparisons of bilateral mean CNA patient forces versus healthy controls (A-B) and the CNA affected limb versus the contralateral (C-D). The mean angular range of motion on 2D gait analysis of affected limb of CNA patients versus the mean healthy control. Error bars indicate + standard deviations, * indicate p<0.05.

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/Purpose: The use of weight-bearing computed tomography (WBCT) scans has steadily increased within the past five years and has shown to aid in the diagnosis and progression of foot and ankle orthopedic pathologies.1 WBCT allows the visualization of pathologies associated with impingement, joint space narrowing, and malalignment that would not be appreciated using other forms of radiographic imaging.1,3 However, current standards involve using two-dimensional (2D) imaging as a method of diagnosis in three-dimensional (3D) deformities of Charcot neuroarthropathy (CN).1,2,3 The purpose of this study was to quantify and compare the angular and distance measurements represented in standard 2D weight-bearing imaging and 3D WBCT for deformities detected in CN patients. Methods: The 2D weight-bearing radiographs and 3D WBCT scans were measured for 10 patients with CN, from 2019 to 2024. 2D measurements were obtained by annotating planar radiographs. The 3D measurements were obtained by manually placing fiducials on anatomic landmarks. These fiducials were then input into a custom-built code to automatically transform the foot into a patient specific anatomic coordinate system and calculate all angle and distance measurements either in 3D or as projected on their true anatomic plane (Figure 2). Each radiograph and WBCT was measured by three observers. Statistical analysis included representing 2D and 3D measurements as means +/- standard deviation, and any variation between the two methods was evaluated using paired t-test. This study was approved by our institutions IRB. Results: The AP talocalcaneal angle was significantly greater in 3D WBCT compared to weight-bearing radiographs (140.63 ± 35.39º vs. 25.35 ± 23.94º, p < 0.0001). Similarly, the talonavicular angle was significantly greater in 3D WBCT compared to weight-bearing radiographs (9.06 ± 11.36º vs. 2.04 ± 1.27º, p = 0.0012). The medial column heights were significantly greater (22.45 ± 19.03 mm vs. 11.85 ± 14.18 mm, p = 0.016) and lateral column heights were significantly greater (17.50 ± 16.63 mm vs. 9.40 ± 13.28 mm, p = 0.027) in 3D WBCT compared to weight-bearing radiographs. Conversely, the tibiotalar angle was significantly lower in 3D WBCT compared to weight-bearing radiographs (93.06 ± 6.83º vs. 124.99 ± 10.87º, p < 0.0001) (Figure 1). Conclusion: This study compared weight-bearing 2D radiographs and 3D WBCT for CN and found significant differences in several angular and distance measurements used to describe the pathological deformities. Therefore, true pathological alignment of the joints and deformities evident in CN deviate from weight-bearing 2D radiographs compared to 3D WBCT. This potentially enables earlier and improved detection, and better understanding of the severity of deformity in CN. With the increase in use of WBCT in foot and ankle orthopedics, this study incorporates a novel method of analyzing WBCT data in order to aid in the diagnosis and progression of CN.

Primary Total Knee Arthroplasty in Patients Who Have Neuromuscular Disorders and Genu Recurvatum Using a Rotating-Hinge Implant: A Case Series with a Mean Four-Year Follow-Up.

Research Type:Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studiesIntroduction/Purpose:Charcot neuroarthropathy represents a challenging clinical problem, often leading to severe deformities, ulceration, and a high risk of amputation. For more severe deformities, surgical management can be indicated in the form of midfoot, hindfoot, or ankle arthrodesis. Despite its prevalence, the risk of post-surgical amputation remains high. This study aims to describe patients undergoing either midfoot or ankle/hindfoot arthrodesis for Charcot arthropathy, the rates of surgical complications within 6-months of surgery, and how these outcomes differ between patients undergoing midfoot and ankle/hindfoot arthrodesis.Methods:This retrospective cohort study utilized the Nationwide Readmissions Database (NRD) to examine 8,218 patients diagnosed with Charcot neuroarthropathy who underwent either midfoot (N=5,187; 63.1%) or hindfoot/ankle (N=3,032; 36.9%) arthrodesis between 2015 and 2020. Patient demographics, comorbidities, postoperative complications, readmission, reoperation, and mortality rates were compared between fusion locations.Results:The study cohort was predominantly male (53.2%) with a mean age of 61.7 years. Patients undergoing hindfoot/ankle arthrodesis were associated with statistically significantly higher rates of numerous comorbidities as compared to midfoot arthrodesis, including deficiency anemias, liver disease, fluid electrolyte disorders, obesity, COPD, coagulopathy. Employing multivariate regression analysis to control for differences in demographics and comorbidities, patients undergoing hindfoot/ankle fusion were at statistically significantly increased risk of any complication (OR=1.235), infection (OR=1.524), any amputation (OR=1.253), BKA (OR=1.375), full ray/foot amputation (OR=1.352), partial ray amputation (OR=1.407), and reoperation for incision and drainage (OR=1.195).Conclusion:Patients undergoing hindfoot/ankle arthrodesis for Charcot neuropathy face a significantly higher risk of complications, including infections and various types of amputations, compared to those undergoing midfoot arthrodesis. Physicians should prioritize the management of comorbid conditions and consider socioeconomic factors when planning foot or ankle arthrodesis for patients with CN.

Background:Despite the safety and versatility of circular external fixators (CEFs) for many indications, there is limited information on their contemporary usage and the factors contributing to their potential underutilization. This study aims to estimate the prevalence of contemporary CEF use, characterize barriers to adoption, and identify potential solutions among American Orthopaedic Foot & Ankle Society (AOFAS) members.Methods:A multibranched survey was designed for distribution to all active practicing members of the AOFAS to collect data on demographics, training background, CEF usage profile, provider opinions, barriers to device adoption, and factors that could encourage greater use. Data were collected through Qualtrics XM. Statistical analysis analyzing respondent differences included descriptive statistics, χ2 tests for independence, and unpaired t tests.Results:Of 169 participants, 27.81% reported not using CEFs in their practice despite 94.08% of respondents agreeing that their use is critical for certain patients. Overall, 70.21% of nonusers believed it could have a role in their practice but had hesitations. In addition, 59.76% of participants received minimal to no exposure in residency, and this was a significant predictor for current usage (P = .0119). CEFs are most commonly used for Charcot neuroarthropathy (86.07%), infection management (83.60%), and other deformity corrections (65.67%). Nonusers are more likely to believe CEFs take too long to assemble intraoperatively, express greater concern about postoperative burden, and are less confident in postoperative care compared to users (all P < .01). The most popular interventions that would facilitate usage were access to longitudinal mentorship, further technological advancement, and attending non–industry-sponsored courses.Conclusion:Perceived lengthy operative time, postoperative burden, and lack of postoperative management confidence were predominant reasons for the lack of CEF use. This survey suggests that these barriers could be addressed by more exposure during training, attending non–industry-sponsored courses, and longitudinal mentorship.Level of Evidence:Level IV, cross-sectional study.

Research Type: Level 5 - Case report, Expert opinion, Personal observation Introduction/Purpose: Diabetic Charcot neuroarthropathy (DCA) is one of the diabetic complications characterized by painless progressive and destructive osteoarthropathy. The presence of peripheral neuropathy is currently considered an important prerequisite for the DCA. However, the specific pathogenic mechanism of DCA neuropathy remains unclear. Thus, we tried to quantify the nerve fibers in the DCA synovial tissue by the different immunologic stains. Methods: Synovial tissue samples were collected from DCA and OA patients (7 for each), and NGF expression was analyzed using DNA methylation analysis and single-cell sequencing analysis. The distribution of different nerve fibers in the synovium of DCA patients and the relationship between NGF were examined by staining with HE, immunohistochemistry (NGF), and immunofluorescence (PGP9.5, CGRP, TH and VIP) Results: Compared with OA, total nerve fiber density (PGP9.5+) in the DCA synovium was increased, and sensory nerve fibers (CGRP+) was significantly increased. No significant difference was found in adrenergic sympathetic fibers (TH+). Nerve growth factor (NGF) was significantly increased in the synovium of DCA. Conclusion: These results suggest that the increased CGRP and relatively low adrenergic sympathetic fibers may be responsible for the local dramatic inflammation and dilated blood vessels. Lesions in the sensory pathway may block the neurofeedback regulation, and resulting in excessive release of local pro-inflammatory NGF, sensory neuropeptides leading to uncontrolled local inflammatory factors releasing. Figure 1. The genome-wide methylation analysis of patients with DCA revealed that the NGF signaling pathways were among the TOP30 signaling pathways identified in the KEGG database. Synovial single cell sequencing results evealed an upregulation of NGF expression in synovial fibroblasts. Cell classification analysis further demonstrated that the increased NGF expression was observed in secretory, invasive, and protective FLS subpopulations, accompanied by a corresponding elevation in RAMP (receptor of CGRP) expression. Compared with OA, we found that the total nerve fiber density (PGP9.5+) in the DCA synovium was increased, and the number of sensory nerve fibers (CGRP+) was significantly increased.

Diabetes increases the risk of fracture, delays wound and bone healing, and at the most severe spectrum may lead to Charcot neuroarthropathy characterised by a progressive collapse of bone and joint structures. The presence of peripheral neuropathy, in particular measurable reduced sensation, is a defining aspect of the condition.The clinical presentation of patients with fractures and diabetes, and patients with Charcot neuroarthropathy will be discussed. Patients may present with an acute limb threatening condition or with the sequelae of advanced chronic deformity. Assessment and treatment pathways have been developed, requiring a multidisciplinary approach - involving the diabetologist, podiatrist, radiologist, microbiologist, orthotist, vascular, plastic and orthopaedic surgeon.Surgical treatment of Charcot deformity is regularly performed at our unit, a tertiary referral centre for this condition. Deformity reconstruction using one- or two-stage surgery is performed using anatomic reconstruction and long segment fixation, followed by a period of protection in a non load-bearing cast. Every patient with advanced peripheral neuropathy is at high risk of amputation. Limb salvage in our series of more than 100 patients is at 85 – 95%, mainly depending on pre-existing vascular disease.The role of peripheral neuropathy on bone maintenance, fracture and bone healing, and ability to load-bear is ill understood and requires close working relations of scientists and clinicians - but has direct consequences for prevention and treatment.

Background. Midfoot pathology accounts for 60-70% of all deformities in diabetic Charcot neuroarthropathy. However, the available classifications of this pathology are few and have certain disadvantages. The aim of the study — to analyze X-rays of patients to investigate the displacement patterns of the midfoot bone and joint structures in Charcot neuroarthropathy, and, based on the identified displacement trends, to develop an anatomical and radiological classification of midfoot deformities. Methods. A retrospective analysis was performed on the foot X-rays of 416 patients (436 feet) with midfoot pathology in Charcot neuroarthropathy. Of these, 233 X-rays were provided by inpatient hospitals, and 203 — on an outpatient basis. Only X-rays taken in anteroposterior and lateral views were included in the analysis. We assessed the alignment of bones within the foot joints, the extent of destruction, and the direction of the displacement of bony structures. Results. The following types of lesions are identified. 1A — involvement of the navicular bone and talar head with the preservation of the lateral column anatomy. 1B — simultaneous involvement of the talonavicular and calcaneocuboid joints. 1C — subluxation or dislocation of the talonavicular joint with transition to the lateral parts of the tarsometatarsal joint with plantar dislocation of the cuboid bone and preservation of anatomical integrity in the calcaneocuboid joint. 1D — complete displacement of the navicular bone with the dislocation of the talonavicular, naviculocuneiform and tarsometatarsal joints. 2 — deformation (subluxation, dislocation, fracture-dislocation) of the naviculocuneiform joint, with involvement of the lateral column in the metatarsocuboid joint and flattening of the medial column. 3 — isolated involvement of the Lisfranc joint. 4A — isolated involvement (subluxation or dislocation) of the first cuneometatarsal joint without visible deformity in the affected area. 4B — dislocation of the medial naviculocuneiform and medial cuneometatarsal joints with the displacement of the medial cuneiform bone relative to the other foot bones. 5 — varus deformity of the foot with fractures of the metatarsal bones. Conclusion. A new classification of Charcot midfoot lesions is intended to guide the selection of key reconstructive surgical interventions for this pathology.

Purpose This study aims to introduce a hybrid fabrication protocol for patient-specific therapeutic footwear [ankle-foot orthoses (AFOs) and insoles] to address biomechanical challenges of Charcot neuroarthropathy (CNA), aiming for enhanced customization and precision over traditional methods. Design/methodology/approach The protocol integrates medical imaging [three-dimensional (3D) segmentation], dynamic gait analysis, computer-aided design and manufacturing (CAD/CAM) and additive manufacturing [AM; ethylene-vinyl acetate, fused deposition modeling polylactic acid, mask stereolithography (MSLA) resin]. Finite element analysis (FEA) and material testing were conducted. A clinical case (a 69-year-old female with midfoot CNA) validated the workflow. Findings The results demonstrated that the custom-designed 5-mm-deep off-loading insoles achieved a significant reduction in pressure in the targeted midfoot regions, decreasing lateral pressure by 55.4% and medial pressure by 62.6%. However, this off-loading led to a compensatory increase in pressure on the lateral forefoot (+11.9%), highlighting the necessity for iterative design adjustments based on individual biomechanical responses. Material testing indicated that MSLA resin, when cured for 10 min, exhibited mechanical properties comparable to traditional polypropylene, successfully mimicking its biomechanical function and reducing displacements by 8.7% during midstance phases. Furthermore, the hybrid manufacturing approach proved cost-effective and time-efficient, with insoles costing $13.16 to produce in 25 min and AFOs costing between $5.88 and $9.08 with production times ranging from 12 to 40 h, offering substantial advantages over conventional fabrication techniques. Research limitations/implications Single-subject validation limits generalizability. Simulations were static; real-world durability under dynamic loading remains unverified. Material testing excluded other potential polymers. Future studies should involve diverse cohorts and long-term clinical trials to assess functional outcomes. Practical implications The protocol offers clinics a scalable, cost-efficient alternative to traditional methods, enabling rapid production of customizable devices. Replaceable insoles extend footwear lifespan, reducing long-term costs. MSLA resin’s tunable properties allow tailored stiffness, enhancing adaptability for varying patient needs. Social implications By mitigating ulcer recurrence and amputation risks, this approach improves mobility and quality of life for diabetic patients. Lower healthcare costs and reduced dependency on labor-intensive methods benefit resource-constrained settings, addressing a critical public health challenge. Originality/value This study presents a novel, integrated hybrid protocol combining imaging, gait analysis, CAD/CAM, AM, FEA and material science for customized CNA footwear, which offers significant advantages in cost, time and precision. It highlights the need for balancing off-loading and durability, advocating patient-specific simulations to manage compensatory pressures.

ABSTRACTBackgroundAcute Charcot neuroarthropathy (CN) is a rare but serious complication of diabetes that requires timely diagnosis and evidence‐based management to prevent long‐term disability. In regional or rural settings, delivering evidence‐based care is particularly challenging due to systemic and contextual barriers.ObjectiveTo explore the perceptions of patients and health professionals about assessment, diagnosis and management of acute CN in a regional Victorian health service.MethodThis study used a qualitative research design, utilising thematic analysis of semi‐structured interviews with patients with previous acute CN and focus groups with health professionals (orthopaedic surgeons, podiatrists and prosthetists and orthotists) involved in the assessment and management of patients with acute CN. Two assessors used inductive thematic analysis to identify key themes related to acute CN care delivery.ResultsFour overarching themes were identified: (1) barriers to evidence‐based care, including delayed diagnosis, limited access to skilled clinicians and diagnostic tools and the burden of treatment; (2) enablers, such as timely access to knowledgeable clinicians and resources; (3) mitigating factors, including patient engagement, empathetic communication and multidisciplinary support and (4) strategies for improvement, such as public and professional education, upskilling of health professionals and integration of psychological and person‐centred support.ConclusionImproving outcomes for people with acute CN in regional or rural settings requires a multifaceted approach. Enhancing awareness, building workforce capacity and embedding patient‐centred care practices are essential to ensure timely diagnosis, equitable access to treatment and improved quality of life.

Minority disparities have been documented in the diabetic community since the late 1990s. Historically, the literature acknowledges that higher rates of diabetes-related complications occur in this subgroup. Despite this, disparities among patients with Charcot's neuroarthropathy have yet to be explored. We compared incidence and management among patients with Charcot's neuroarthropathy with emphasis on racial and geographic differences. We retrospectively reviewed patients from two hospitals, an inner-city tertiary center and a suburban facility, between 2013 and 2022. Patients were managed by the same attending physician as either referrals or initial consultations for a diagnosis of Charcot's neuroarthropathy of the foot and ankle. Patient selection was performed via International Classification of Diseases, 10th Revision codes associated with Charcot's joint of the foot. Of 120 patients identified, 87.5% were nonminority white individuals. The minority community had an increased frequency of medical comorbidities. Minorities were two times more likely to undergo a staged reconstruction. Compared with suburban patients, inner-city patients, on average, had higher hemoglobin A1c levels and more ulceration and osteomyelitis. Similarly, this cohort was more apt to undergo reconstructive surgery and had a reduced mortality rate. Although there may be a correlation with medical comorbidities in minority communities, there does not seem to be a difference in the management of Charcot's neuroarthropathy. Location has the potential to play a role in diagnosis, management, and potential outcomes, likely due to access to health care and community education. More prospective studies are warranted to better understand the influence of racial and geographic differences on management of the Charcot foot.

Whether a sequela of neuropathy or a result of infectious processes to dysvascular changes, talar degeneration in the Charcot ankle proves difficult to treat. Total resection followed by bone void filler or grafts is costly, with varying levels of success. Although tibiocalcaneal fusion allows stabilization, this approach remains a procedure of last resort before amputation. This series presents outcomes of partial talectomy with tibiotalocalcaneal arthrodesis. Nineteen patients with Charcot's neuroarthropathy necessitating a tibiotalocalcaneal fusion were included in this study. Tibiotalocalcaneal arthrodesis was performed using a partial talectomy with a combination of internal with and without external fixation constructs. Among this cohort of 19 patients followed up for a mean ± SD of 22.0 ± 14.8 months, 21% had osteomyelitis of the talus, and 32% presented with a wound at the time of surgery. Successful primary tibiotalocalcaneal arthrodesis with a partial talectomy was reached in 79% of patients. Of patients necessitating revision, two continued with a tibiotalocalcaneal arthrodesis, and the remaining two reverted to a tibiocalcaneal arthrodesis. No patients experienced a major amputation. Unstable ankle Charcot's deformity with osseous degeneration poses a serious threat of limb loss without surgical reconstruction. Total talectomy allows complete resection of nonviable bone; however, this irreversible approach removes possibly viable native tissue. Partial talectomy proves an effective option by minimizing osseous resection, allowing primary arthrodesis between autogenous osseous segments. Moreover, in patients with failed partial talectomy, conversion to tibiocalcaneal arthrodesis proved viable. Before total removal of native bone, partial talectomy should be considered.

Flap-based and podoplastic limb salvage in the foot and ankle is difficult due to the presence of biomechanical forces that can impact flap healing and complication rates and, in turn, limb salvage rates. For this reason, external fixation is indicated to neutralize forces across the flap interface and allow for optimal flap take and healing. Although external fixation for flap immobilization is the current standard of care, not much is known about how duration and timing may impact complication and salvage rates. We retrospectively identified and analyzed complication and limb salvage rates in 18 patients who underwent flap-frame immobilization with a multiplanar external fixator during a 4.75-year period. Patients ranged in age from 40 to 75 years (mean, 55.5 years). Sixteen patients (88.9%) had diabetes mellitus, and all had defects that were a mean of 110.9 cm2 (range, 36-500 cm2) and required the use of a local or free flap. Thirteen defects (72.2%) were in the plantar region, with the remaining five (27.8%) in nonplantar regions. Eleven flaps (61.1%) were fasciocutaneous, and the remaining seven (38.9%) were vascularized muscle flaps. All of the flaps were immobilized with either a three- or four-ring circular external fixator. Overall, a 66.7% limb salvage rate (12 of 18) was observed with mean follow-up of 2.4 years, or 892.6 days (range, 222-1,555 days). Seven minor flap complications (38.9%) required a return to the operating room. External fixation is an essential tool in flap-based limb salvage. These findings hint that the "Goldilocks zone" of duration is approximately 28 to 35 days. Furthermore, we believe that risk factors such as open amputation, increased defect size, and presence of Charcot's neuroarthropathy impact limb salvage rates regardless of duration and timing of flap-frame immobilization.