Progress in clinical diagnosis and treatment of diabetic Charcot neuroarthropathy of foot and ankle_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YUE Yang ¹ , FENG Hui ¹ , LIU Peilong ² , LIU Liang ² , LIANG Jingqi ² , LIANG Xiaojun ² ,  ZHAO Hongmou ²

1. Xi’an Medical University, Xi’an Shaanxi, 710016, P. R. China;
2. Department of Foot and Ankle Surgery, Honghui Hospital of Xi’an Jiaotong University, Xi’an Shaanxi, 710054, P. R. China;

Corresponding author：

ZHAO Hongmou, Email: zhao_hongmou@hotmail.com

Keywords：

Charcot neuroarthropathy; diabetes; foot and ankle; conservative treatment; surgical treatment

DOI：

10.7507/1002-1892.202307068

Video：

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Objective To summarize the progress of clinical diagnosis and treatment of diabetic Charcot neuroarthropathy (CNO) of foot and ankle to provide reference for clinical treatment. Methods The research literature on diabetic CNO of foot and ankle at home and abroad was widely reviewed, and the stages and classification criteria of CNO were summarized, and the treatment methods at different stages of the disease course were summarized. Results CNO is a rapidly destructive disease of bone and joint caused by peripheral neuropathy, which leads to the formation of local deformities and stress ulcers due to bone and joint destruction and protective sensory loss, which eventually leads to disability and even life-threatening. At present, the modified Eichenholtz stage is a commonly used staging criteria for CNO of foot and ankle, which is divided into 4 stages by clinical and imaging manifestations. The classification mainly adopts the modified Brodsky classification, which is divided into 6 types according to the anatomical structure. The treatment of diabetic CNO of foot and ankle needs to be considered in combination with disease stage, blood glucose, comorbidities, local soft tissue conditions, degree of bone and joint destruction, and whether ulcers and infections are present. Conservative treatment is mainly used in the active phase and surgery in the stable phase. Conclusion The formulation of individualized and stepped treatment regimens can help improve the effectiveness of diabetic CNO of foot and ankle. However, there is still a lack of definitive clinical evidence to guide the treatment of active and stable phases, and further research is needed.

Citation： YUE Yang, FENG Hui, LIU Peilong, LIU Liang, LIANG Jingqi, LIANG Xiaojun, ZHAO Hongmou. Progress in clinical diagnosis and treatment of diabetic Charcot neuroarthropathy of foot and ankle. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(11): 1438-1443. doi: 10.7507/1002-1892.202307068 Copy

1.	La Fontaine J, Lavery L, Jude E. Current concepts of Charcot foot in diabetic patients. Foot (Edinb), 2016, 26: 7-14.
2.	Schoots IG, Slim FJ, Busch-Westbroek TE, et al. Neuro-osteoarthropathy of the foot-radiologist: friend or foe? Semin Musculoskelet Radiol, 2010, 14(3): 365-376.
3.	Pinzur MS, Evans A. Health-related quality of life in patients with Charcot foot. Am J Orthop (Belle Mead NJ), 2003, 32(10): 492-496.
4.	Yammine K, Boulos K, Assi C, et al. Amputation and mortality frequencies associated with diabetic Charcot foot arthropathy: a meta-analysis. Foot Ankle Surg, 2022, 28(8): 1170-1176.
5.	Chantelau E. The perils of procrastination: effects of early vs delayed detection and treatment of incipient Charcot fracture. Diabet Med, 2005, 22(12): 1707-1712.
6.	Ehrlich GE. Charcot joints. Arch Intern Med, 1966, 118(5): 521.
7.	Shibata T, Tada K, Hashizume C. The results of arthrodesis of the ankle for leprotic neuroarthropathy. J Bone Joint Surg (Am), 1990, 72(5): 749-756.
8.	Wukich DK, Schaper NC, Gooday C, et al. Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus (IWGDF 2023). Diabetes Metab Res Rev, 2023. doi: 10.1002/dmrr.3646.
9.	Brodsky JW. The diabetic foot//Surgery of the Foot and Ankle. Amsterdam: Elsevier, 2007: 1281-1368.
10.	Trepman E, Nihal A, Pinzur MS. Current topics review: Charcot neuroarthropathy of the foot and ankle. Foot Ankle Int, 2005, 26(1): 46-63.
11.	Pakarinen TK, Laine HJ, Mäenpää H, et al. The effect of zoledronic acid on the clinical resolution of Charcot neuroarthropathy: a pilot randomized controlled trial. Diabetes Care, 2011, 34(7): 1514-1516.
12.	Jeffcoate WJ, Game F, Cavanagh PR. The role of proinflammatory cytokines in the cause of neuropathic osteoarthropathy (acute Charcot foot) in diabetes. Lancet, 2005, 366(9502): 2058-2061.
13.	Pasquier J, Thomas B, Hoarau-Véchot J, et al. Circulating microparticles in acute diabetic Charcot foot exhibit a high content of inflammatory cytokines, and support monocyte-to-osteoclast cell induction. Sci Rep, 2017, 7(1): 16450.
14.	Saltzman CL, Hagy ML, Zimmerman B, et al. How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet? Clin Orthop Relat Res, 2005, (435): 185-190.
15.	Verity S, Sochocki M, Embil JM, et al. Treatment of Charcot foot and ankle with a prefabricated removable walker brace and custom insole. Foot Ankle Surg, 2008, 14(1): 26-31.
16.	Pinzur MS, Lio T, Posner M. Treatment of Eichenholtz stage Ⅰ Charcot foot arthropathy with a weightbearing total contact cast. Foot Ankle Int, 2006, 27(5): 324-329.
17.	Armstrong DG, Nguyen HC, Lavery LA, et al. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care, 2001, 24(6): 1019-1022.
18.	Knowles EA, Boulton AJ. Do people with diabetes wear their prescribed footwear? Diabet Med, 1996, 13(12): 1064-1068.
19.	de Souza LJ. Charcot arthropathy and immobilization in a weight-bearing total contact cast. J Bone Joint Surg (Am), 2008, 90(4): 754-759.
20.	Griffiths DA, Kaminski MR. Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study. J Foot Ankle Res, 2021, 14(1): 44.
21.	McCrory JL, Morag E, Norkitis A, et al. Healing of Charcot fractures: skin temperature and radiographic correlates. Foot, 1998, 8(3): 158-165.
22.	Rastogi A, Bhansali A, Jude EB. Efficacy of medical treatment for Charcot neuroarthropathy: a systematic review and meta-analysis of randomized controlled trials. Acta Diabetol, 2021, 58(6): 687-696.
23.	Hastings MK, Sinacore DR, Fielder FA, et al. Bone mineral density during total contact cast immobilization for a patient with neuropathic (Charcot) arthropathy. Phys Ther, 2005, 85(3): 249-256.
24.	Game FL, Catlow R, Jones GR, et al. Audit of acute Charcot’s disease in the UK: the CDUK study. Diabetologia, 2012, 55(1): 32-35.
25.	Petrova NL, Edmonds ME. Conservative and pharmacologic treatments for the diabetic Charcot foot. Clin Podiatr Med Surg, 2017, 34(1): 15-24.
26.	Das L, Bhansali A, Prakash M, et al. Effect of methylprednisolone or zoledronic acid on resolution of active Charcot neuroarthropathy in diabetes: A randomized, double-blind, placebo-controlled study. Diabetes Care, 2019, 42(12): e185-e186.
27.	Petrova NL, Donaldson NK, Bates M, et al. Effect of recombinant human parathyroid hormone (1-84) on resolution of active Charcot neuro-osteoarthropathy in diabetes: A randomized, double-blind, placebo-controlled study. Diabetes Care, 2021, 44(7): 1613-1621.
28.	Schulze S, Neuber C, Möller S, et al. Impact of sulfated hyaluronan on bone metabolism in diabetic Charcot neuroarthropathy and degenerative arthritis. Int J Mol Sci, 2022, 23(23): 15146.
29.	Greco T, Mascio A, Comisi C, et al. RANKL-RANK-OPG pathway in Charcot diabetic foot: pathophysiology and clinical-therapeutic implications. Int J Mol Sci, 2023, 24(3): 3014.
30.	Busch-Westbroek TE, Delpeut K, Balm R, et al. Effect of single dose of RANKL antibody treatment on acute Charcot neuro-osteoarthropathy of the foot. Diabetes Care, 2018, 41(3): e21-e22.
31.	Mittlmeier T, Klaue K, Haar P, et al. Should one consider primary surgical reconstruction in charcot arthropathy of the feet? Clin Orthop Relat Res, 2010, 468(4): 1002-1011.
32.	Burns PR, Wukich DK. Surgical reconstruction of the Charcot rearfoot and ankle. Clin Podiatr Med Surg, 2008, 25(1): 95-120.
33.	Pinzur MS, Sostak J. Surgical stabilization of nonplantigrade Charcot arthropathy of the midfoot. Am J Orthop (Belle Mead NJ), 2007, 36(7): 361-365.
34.	Baravarian B, Van Gils CC. Arthrodesis of the Charcot foot and ankle. Clin Podiatr Med Surg, 2004, 21(2): 271-289.
35.	Pakarinen TK, Laine HJ, Honkonen SE, et al. Charcot arthropathy of the diabetic foot. Current concepts and review of 36 cases. Scand J Surg, 2002, 91(2): 195-201.
36.	Rinkel WD, Fakkel TM, Castro Cabezas M, et al. (Cost-) effectiveness of lower extremity nerve decompression surgery in subjects with diabetes: the DeCompression (DECO) trial-study protocol for a randomised controlled trial. BMJ Open, 2020, 10(4): e035644.
37.	Coughlin MJ, Saltzman CL, Anderson RB. Mann’s surgery of the foot and ankle. 9th ed. Amsterdam: Elsevier, 2013: 1319-1322.
38.	Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care, 2011, 34(9): 2123-2129.
39.	Wukich DK, Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complications, 2009, 23(6): 409-426.
40.	Sammarco VJ. Superconstructs in the treatment of charcot foot deformity: plantar plating, locked plating, and axial screw fixation. Foot Ankle Clin, 2009, 14(3): 393-407.
41.	Assal M, Stern R. Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy. J Bone Joint Surg (Am), 2009, 91(4): 812-820.
42.	Sammarco VJ, Sammarco GJ, Walker EW, et al. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. J Bone Joint Surg (Am), 2009, 91(1): 80-91.
43.	Eschler A, Wussow A, Ulmar B, et al. Intramedullary medial column support with the Midfoot Fusion Bolt (MFB) is not sufficient for osseous healing of arthrodesis in neuroosteoarthropathic feet. Injury, 2014, 45 Suppl 1: S38-S43.
44.	Marks RM, Parks BG, Schon LC. Midfoot fusion technique for neuroarthropathic feet: biomechanical analysis and rationale. Foot Ankle Int, 1998, 19(8): 507-510.
45.	Siebachmeyer M, Boddu K, Bilal A, et al. Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail. Bone Joint J, 2015, 97-B(1): 76-82.
46.	Berend ME, Glisson RR, Nunley JA. A biomechanical comparison of intramedullary nail and crossed lag screw fixation for tibiotalocalcaneal arthrodesis. Foot Ankle Int, 1997, 18(10): 639-643.
47.	Bajuri MY, Ong SL, Das S, et al. Charcot neuroarthropathy: current surgical management and update. A systematic review. Front Surg, 2022, 9: 820826.
48.	El-Mowafi H, Abulsaad M, Kandil Y, et al. Hybrid fixation for ankle fusion in diabetic charcot arthropathy. Foot Ankle Int, 2018, 39(1): 93-98.
49.	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): 420-425.
50.	Choi Y, Kwon YW, Sim YS, et al. Achilles tenodesis for calcaneal insufficiency avulsion fractures associated with diabetes mellitus. J Orthop Surg Res, 2017, 12(1): 192.
51.	Yu SM, Yu JS. Calcaneal avulsion fractures: an often forgotten diagnosis. AJR Am J Roentgenol, 2015, 205(5): 1061-1067.
52.	Farber DC, Juliano PJ, Cavanagh PR, et al. Single stage correction with external fixation of the ulcerated foot in individuals with Charcot neuroarthropathy. Foot Ankle Int, 2002, 23(2): 130-134.
53.	Karapinar H, Sener M, Kazimoglu C, et al. Arthrodesis of neuropathic ankle joint by Ilizarov fixator in diabetic patients. J Am Podiatr Med Assoc, 2009, 99(1): 42-48.
54.	Alammar Y, Sudnitsyn A, Neretin A, et al. Closed arthrodesis in infected neuropathic ankles using Ilizarov ring fixation. Bone Joint J, 2020, 102-B(4): 470-477.
55.	Wukich DK, Raspovic KM, Hobizal KB, et al. Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes. Diabetes Metab Res Rev, 2016, 32 Suppl 1: 292-296.
56.	ElAlfy B, Ali AM, Fawzy SI. Ilizarov external fixator versus retrograde intramedullary nailing for ankle joint arthrodesis in diabetic Charcot neuroarthropathy. J Foot Ankle Surg, 2017, 56(2): 309-313.
57.	Sohn MW, Stuck RM, Pinzur M, et al. Lower-extremity amputation risk after charcot arthropathy and diabetic foot ulcer. Diabetes Care, 2010, 33(1): 98-100.
58.	Wukich DK, Sadoskas D, Vaudreuil NJ, et al. Comparison of Diabetic Charcot patients with and without foot wounds. Foot Ankle Int, 2017, 38(2): 140-148.
59.	Caravaggi CM, Sganzaroli AB, Galenda P, et al. Long-term follow-up of tibiocalcaneal arthrodesis in diabetic patients with early chronic Charcot osteoarthropathy. J Foot Ankle Surg, 2012, 51(4): 408-411.
60.	Andronic O, Boeni T, Burkhard MD, et al. Modifications of the pirogoff amputation technique in adults: A retrospective analysis of 123 cases. J Orthop, 2019, 18: 5-12.

1. La Fontaine J, Lavery L, Jude E. Current concepts of Charcot foot in diabetic patients. Foot (Edinb), 2016, 26: 7-14.
2. Schoots IG, Slim FJ, Busch-Westbroek TE, et al. Neuro-osteoarthropathy of the foot-radiologist: friend or foe? Semin Musculoskelet Radiol, 2010, 14(3): 365-376.
3. Pinzur MS, Evans A. Health-related quality of life in patients with Charcot foot. Am J Orthop (Belle Mead NJ), 2003, 32(10): 492-496.
4. Yammine K, Boulos K, Assi C, et al. Amputation and mortality frequencies associated with diabetic Charcot foot arthropathy: a meta-analysis. Foot Ankle Surg, 2022, 28(8): 1170-1176.
5. Chantelau E. The perils of procrastination: effects of early vs delayed detection and treatment of incipient Charcot fracture. Diabet Med, 2005, 22(12): 1707-1712.
6. Ehrlich GE. Charcot joints. Arch Intern Med, 1966, 118(5): 521.
7. Shibata T, Tada K, Hashizume C. The results of arthrodesis of the ankle for leprotic neuroarthropathy. J Bone Joint Surg (Am), 1990, 72(5): 749-756.
8. Wukich DK, Schaper NC, Gooday C, et al. Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus (IWGDF 2023). Diabetes Metab Res Rev, 2023. doi: 10.1002/dmrr.3646.
9. Brodsky JW. The diabetic foot//Surgery of the Foot and Ankle. Amsterdam: Elsevier, 2007: 1281-1368.
10. Trepman E, Nihal A, Pinzur MS. Current topics review: Charcot neuroarthropathy of the foot and ankle. Foot Ankle Int, 2005, 26(1): 46-63.
11. Pakarinen TK, Laine HJ, Mäenpää H, et al. The effect of zoledronic acid on the clinical resolution of Charcot neuroarthropathy: a pilot randomized controlled trial. Diabetes Care, 2011, 34(7): 1514-1516.
12. Jeffcoate WJ, Game F, Cavanagh PR. The role of proinflammatory cytokines in the cause of neuropathic osteoarthropathy (acute Charcot foot) in diabetes. Lancet, 2005, 366(9502): 2058-2061.
13. Pasquier J, Thomas B, Hoarau-Véchot J, et al. Circulating microparticles in acute diabetic Charcot foot exhibit a high content of inflammatory cytokines, and support monocyte-to-osteoclast cell induction. Sci Rep, 2017, 7(1): 16450.
14. Saltzman CL, Hagy ML, Zimmerman B, et al. How effective is intensive nonoperative initial treatment of patients with diabetes and Charcot arthropathy of the feet? Clin Orthop Relat Res, 2005, (435): 185-190.
15. Verity S, Sochocki M, Embil JM, et al. Treatment of Charcot foot and ankle with a prefabricated removable walker brace and custom insole. Foot Ankle Surg, 2008, 14(1): 26-31.
16. Pinzur MS, Lio T, Posner M. Treatment of Eichenholtz stage Ⅰ Charcot foot arthropathy with a weightbearing total contact cast. Foot Ankle Int, 2006, 27(5): 324-329.
17. Armstrong DG, Nguyen HC, Lavery LA, et al. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care, 2001, 24(6): 1019-1022.
18. Knowles EA, Boulton AJ. Do people with diabetes wear their prescribed footwear? Diabet Med, 1996, 13(12): 1064-1068.
19. de Souza LJ. Charcot arthropathy and immobilization in a weight-bearing total contact cast. J Bone Joint Surg (Am), 2008, 90(4): 754-759.
20. Griffiths DA, Kaminski MR. Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study. J Foot Ankle Res, 2021, 14(1): 44.
21. McCrory JL, Morag E, Norkitis A, et al. Healing of Charcot fractures: skin temperature and radiographic correlates. Foot, 1998, 8(3): 158-165.
22. Rastogi A, Bhansali A, Jude EB. Efficacy of medical treatment for Charcot neuroarthropathy: a systematic review and meta-analysis of randomized controlled trials. Acta Diabetol, 2021, 58(6): 687-696.
23. Hastings MK, Sinacore DR, Fielder FA, et al. Bone mineral density during total contact cast immobilization for a patient with neuropathic (Charcot) arthropathy. Phys Ther, 2005, 85(3): 249-256.
24. Game FL, Catlow R, Jones GR, et al. Audit of acute Charcot’s disease in the UK: the CDUK study. Diabetologia, 2012, 55(1): 32-35.
25. Petrova NL, Edmonds ME. Conservative and pharmacologic treatments for the diabetic Charcot foot. Clin Podiatr Med Surg, 2017, 34(1): 15-24.
26. Das L, Bhansali A, Prakash M, et al. Effect of methylprednisolone or zoledronic acid on resolution of active Charcot neuroarthropathy in diabetes: A randomized, double-blind, placebo-controlled study. Diabetes Care, 2019, 42(12): e185-e186.
27. Petrova NL, Donaldson NK, Bates M, et al. Effect of recombinant human parathyroid hormone (1-84) on resolution of active Charcot neuro-osteoarthropathy in diabetes: A randomized, double-blind, placebo-controlled study. Diabetes Care, 2021, 44(7): 1613-1621.
28. Schulze S, Neuber C, Möller S, et al. Impact of sulfated hyaluronan on bone metabolism in diabetic Charcot neuroarthropathy and degenerative arthritis. Int J Mol Sci, 2022, 23(23): 15146.
29. Greco T, Mascio A, Comisi C, et al. RANKL-RANK-OPG pathway in Charcot diabetic foot: pathophysiology and clinical-therapeutic implications. Int J Mol Sci, 2023, 24(3): 3014.
30. Busch-Westbroek TE, Delpeut K, Balm R, et al. Effect of single dose of RANKL antibody treatment on acute Charcot neuro-osteoarthropathy of the foot. Diabetes Care, 2018, 41(3): e21-e22.
31. Mittlmeier T, Klaue K, Haar P, et al. Should one consider primary surgical reconstruction in charcot arthropathy of the feet? Clin Orthop Relat Res, 2010, 468(4): 1002-1011.
32. Burns PR, Wukich DK. Surgical reconstruction of the Charcot rearfoot and ankle. Clin Podiatr Med Surg, 2008, 25(1): 95-120.
33. Pinzur MS, Sostak J. Surgical stabilization of nonplantigrade Charcot arthropathy of the midfoot. Am J Orthop (Belle Mead NJ), 2007, 36(7): 361-365.
34. Baravarian B, Van Gils CC. Arthrodesis of the Charcot foot and ankle. Clin Podiatr Med Surg, 2004, 21(2): 271-289.
35. Pakarinen TK, Laine HJ, Honkonen SE, et al. Charcot arthropathy of the diabetic foot. Current concepts and review of 36 cases. Scand J Surg, 2002, 91(2): 195-201.
36. Rinkel WD, Fakkel TM, Castro Cabezas M, et al. (Cost-) effectiveness of lower extremity nerve decompression surgery in subjects with diabetes: the DeCompression (DECO) trial-study protocol for a randomised controlled trial. BMJ Open, 2020, 10(4): e035644.
37. Coughlin MJ, Saltzman CL, Anderson RB. Mann’s surgery of the foot and ankle. 9th ed. Amsterdam: Elsevier, 2013: 1319-1322.
38. Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care, 2011, 34(9): 2123-2129.
39. Wukich DK, Sung W. Charcot arthropathy of the foot and ankle: modern concepts and management review. J Diabetes Complications, 2009, 23(6): 409-426.
40. Sammarco VJ. Superconstructs in the treatment of charcot foot deformity: plantar plating, locked plating, and axial screw fixation. Foot Ankle Clin, 2009, 14(3): 393-407.
41. Assal M, Stern R. Realignment and extended fusion with use of a medial column screw for midfoot deformities secondary to diabetic neuropathy. J Bone Joint Surg (Am), 2009, 91(4): 812-820.
42. Sammarco VJ, Sammarco GJ, Walker EW, et al. Midtarsal arthrodesis in the treatment of Charcot midfoot arthropathy. J Bone Joint Surg (Am), 2009, 91(1): 80-91.
43. Eschler A, Wussow A, Ulmar B, et al. Intramedullary medial column support with the Midfoot Fusion Bolt (MFB) is not sufficient for osseous healing of arthrodesis in neuroosteoarthropathic feet. Injury, 2014, 45 Suppl 1: S38-S43.
44. Marks RM, Parks BG, Schon LC. Midfoot fusion technique for neuroarthropathic feet: biomechanical analysis and rationale. Foot Ankle Int, 1998, 19(8): 507-510.
45. Siebachmeyer M, Boddu K, Bilal A, et al. Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail. Bone Joint J, 2015, 97-B(1): 76-82.
46. Berend ME, Glisson RR, Nunley JA. A biomechanical comparison of intramedullary nail and crossed lag screw fixation for tibiotalocalcaneal arthrodesis. Foot Ankle Int, 1997, 18(10): 639-643.
47. Bajuri MY, Ong SL, Das S, et al. Charcot neuroarthropathy: current surgical management and update. A systematic review. Front Surg, 2022, 9: 820826.
48. El-Mowafi H, Abulsaad M, Kandil Y, et al. Hybrid fixation for ankle fusion in diabetic charcot arthropathy. Foot Ankle Int, 2018, 39(1): 93-98.
49. 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): 420-425.
50. Choi Y, Kwon YW, Sim YS, et al. Achilles tenodesis for calcaneal insufficiency avulsion fractures associated with diabetes mellitus. J Orthop Surg Res, 2017, 12(1): 192.
51. Yu SM, Yu JS. Calcaneal avulsion fractures: an often forgotten diagnosis. AJR Am J Roentgenol, 2015, 205(5): 1061-1067.
52. Farber DC, Juliano PJ, Cavanagh PR, et al. Single stage correction with external fixation of the ulcerated foot in individuals with Charcot neuroarthropathy. Foot Ankle Int, 2002, 23(2): 130-134.
53. Karapinar H, Sener M, Kazimoglu C, et al. Arthrodesis of neuropathic ankle joint by Ilizarov fixator in diabetic patients. J Am Podiatr Med Assoc, 2009, 99(1): 42-48.
54. Alammar Y, Sudnitsyn A, Neretin A, et al. Closed arthrodesis in infected neuropathic ankles using Ilizarov ring fixation. Bone Joint J, 2020, 102-B(4): 470-477.
55. Wukich DK, Raspovic KM, Hobizal KB, et al. Surgical management of Charcot neuroarthropathy of the ankle and hindfoot in patients with diabetes. Diabetes Metab Res Rev, 2016, 32 Suppl 1: 292-296.
56. ElAlfy B, Ali AM, Fawzy SI. Ilizarov external fixator versus retrograde intramedullary nailing for ankle joint arthrodesis in diabetic Charcot neuroarthropathy. J Foot Ankle Surg, 2017, 56(2): 309-313.
57. Sohn MW, Stuck RM, Pinzur M, et al. Lower-extremity amputation risk after charcot arthropathy and diabetic foot ulcer. Diabetes Care, 2010, 33(1): 98-100.
58. Wukich DK, Sadoskas D, Vaudreuil NJ, et al. Comparison of Diabetic Charcot patients with and without foot wounds. Foot Ankle Int, 2017, 38(2): 140-148.
59. Caravaggi CM, Sganzaroli AB, Galenda P, et al. Long-term follow-up of tibiocalcaneal arthrodesis in diabetic patients with early chronic Charcot osteoarthropathy. J Foot Ankle Surg, 2012, 51(4): 408-411.
60. Andronic O, Boeni T, Burkhard MD, et al. Modifications of the pirogoff amputation technique in adults: A retrospective analysis of 123 cases. J Orthop, 2019, 18: 5-12.

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