J Korean Foot Ankle Soc.  2025 Mar;29(1):34-40. 10.14193/jkfas.2025.29.1.34.

Comprehensive Management of Presumed Underlying Charcot Arthropathy with a Subsequent Traumatic Ankle Fracture in a Patient with Diabetes Mellitus, End-Stage Renal Disease: A Case Report

• Choi GW
• Lim JW
• Park SH

• KMID: 2565870
• DOI: http://doi.org/10.14193/jkfas.2025.29.1.34

Abstract

Charcot neuroarthropathy (CN), also known as Charcot arthropathy, is a complex, progressive disorder primarily affecting the foot and ankle. This case report describes a multifaceted management strategy for a 54-year-old male with diabetes mellitus, end-stage renal disease, and presumed underlying Charcot arthropathy who experienced a traumatic ankle fracture. The initial surgical plans were delayed because of systemic infection indicators, including elevated C-reactive protein levels and high fever. The patient underwent multiple surgical interventions and faced challenges, including metal failure, implant-associated infection, and tibiotalar joint dislocation. A multidisciplinary approach involving orthopedic surgeons, nephrologists, and endocrinologists was crucial for managing the case effectively. In particular, the patient declined a below-knee amputation and opted for comprehensive surgical intervention, resulting in improved functionality at the latest follow-up. This case highlights the complexities of managing CN in patients with multiple comorbidities and emphasizes the need for a nuanced, patient-centered approach.

Keyword

Charcot neuroarthropathy; Tibiotalocalcaneal fusion; Traumatic ankle fracture; Multidisciplinary approach; Patient-centered care

Figure

• 

  Figure 1 (A) Initial radiograph imaging upon admission showing a right ankle trimalleolar fracture. (B) Initial clinical picture upon admission showing a right ankle trimalleolar fracture.

• 

  Figure 2 (A) Clinical picture on Day 5 showing the formation of a hemorrhagic bulla. (B) Clinical picture on Day 9 showing the formation of a hemorrhagic bulla.

• 

  Figure 3 Post-operative radiograph following right ankle open reduction and internal fixation.

• 

  Figure 4 Post-cast radiograph following the application of a short leg cast after the reduction of swelling.

• 

  Figure 5 (A) Five weeks post-surgery, radiograph confirming non-union and lateral displacement of the fractures. (B) Findings of metal failure and tibiotalar joint dislocation observed during COVID-19 isolation.

• 

  Figure 6 (A) Post-operative radiograph after applying external fixator for septic ankle findings. (B) Intra-operative clinical picture applying external fixator for septic ankle findings.

• 

  Figure 7 (A) Post-operative radiograph after tibiotalocalcaneal fusion using a retrograde T2 nail. (B) Clinical findings showing a medial wound defect at the time of surgery.

• 

  Figure 8 Clinical picture showing the application of Kerecis to cover the medial wound defect.

• 

  Figure 9 Radiograph at 3 months post-tibiotalocalcaneal fusion.

• 

  Figure 10 Clinical picture of soft tissue defect at the sole at 6 months post-tibiotalocalcaneal fusion.

• 

  Figure 11 (A) Radiograph at 3 months post-TTC fusion. (B) CT scan at 6 months post-TTC fusion showing soft tissue defect at the sole, extending posteriorly to form a sinus tract or abscess. TTC: tibiotalocalcaneal.

• 

  Figure 12 Findings at 8 months post-tibiotalocalcaneal fusion showing fever and operation site infection, accompanied by concurrent metal failure.

• 

  Figure 13 Post-operation radiograph following metal removal and anti-cement arthroplasty due to findings of implant-associated infection.

• 

  Figure 14 (A) Post-operation radiograph showing vancomycin-mixed cement filling, TTC fusion using a proximal humeral internal locking system (PHILOS) plate on the lateral side, and additional fixation with a 6.5 threaded cannulated screw. (B) Day 10 post-revision TTC fusion medial and lateral clinical pictures. TTC: tibiotalocalcaneal.

• 

  Figure 15 Two months post-revision tibiotalocalcaneal fusion with well-maintained radiograph.

• 

  Figure 16 One-year post-revision tibiotalocalcaneal fusion with well-maintained radiograph.

Reference

Yousaf S., Dawe EJC., Saleh A., Gill IR., Wee A. 2018. The acute Charcot foot in diabetics: diagnosis and management. EFORT Open Rev. 3:568–73. doi: 10.1302/2058-5241.3.180003. DOI: 10.1302/2058-5241.3.180003. PMID: 30662765. PMCID: PMC6335590.

Frykberg RG., Belczyk R. 2008. Epidemiology of the Charcot foot. Clin Podiatr Med Surg. 25:17–28. doi: 10.1016/j.cpm.2007.10.001. DOI: 10.1016/j.cpm.2007.10.001. PMID: 18165108.

Kim SH., Kim WJ., Park ES., Kim JY., Lee YK. 2022. Iatrogenic ankle Charcot neuropathic arthropathy after spinal surgery: a case report and literature review. Medicina (Kaunas). 58:1776. doi: 10.3390/medicina58121776. DOI: 10.3390/medicina58121776. PMID: 36556978. PMCID: PMC9785748.

Shah M. Charcot arthropathy [Internet]. Medscape;Newark (NJ): Available from: https://emedicine.medscape.com/article/1234293. cited 2020 Feb 3.

Trieb K. The Charcot foot: pathophysiology, diagnosis and classification. Bone Jt J. 98:1155–9. doi: 10.1302/0301-620X.98B9.37038. DOI: 10.1302/0301-620X.98B9.37038. PMID: 27587513.

Ramakanth R., Sundararajan SR., D'souza T., Rajasekaran S. 2023. Hindfoot fusion with various auxiliary techniques in Charcot's management. Int J Orthop Surg. 31:65–73. doi: 10.4103/ijors.ijors_18_23. DOI: 10.4103/ijors.ijors_18_23.

Herrera-Pérez M., Díaz-Fernández R., Rendón-Díaz D., Boluda-Mengod J., Pais-Brito JL., Tejero S. 2020. Tibiotalocalcaneal fusion with antibiotic cement-coated nails for refractory deep infection after ankle ORIF. Foot Ankle Int. 41:1391–7. doi: 10.1177/1071100720939884. DOI: 10.1177/1071100720939884. PMID: 32713190.