Surgical Management of Charcot Neuroarthropathy Involving the Hindfoot and Midfoot: A Case Series

Background: Charcot neuroarthropathy (CN) involving both the hindfoot and midfoot represents a severe form of the disease and is often associated with significant instability, deformity, and an increased risk of ulceration. Although early-stage midfoot CN may be managed conservatively, combined hindfoot-midfoot involvement typically necessitates complex surgical reconstruction. Methods: This retrospective longitudinal case series included 21 consecutive patients with combined hindfoot and midfoot CN treated surgically at a tertiary care center in South India between 2019 and 2024. All procedures were performed by a single senior foot and ankle surgeon. Primary outcome was defined as limb salvage, operationalized as the achievement of an ulcer-free, plantigrade foot with autonomous ambulation at 12 months postoperatively. Results: The mean age of the cohort was 57.2 ± 8.2 years, with 14 of 21 patients (66.7%) being male. All patients (21/21, 100%) had Brodsky IV CN. Combined hindfoot-midfoot reconstruction was undertaken in 12 (57.1%), whereas 9 patients (42.9%) underwent isolated hindfoot reconstruction, with preservation of a stable or minimally involved midfoot to function as a pseudo joint at the level of the Chopart joint. Overall, metal hardware failure occurred in 2 (9.5%), with a mean time to implant breakage of 15.5 ± 3.5 months. Radiologic bony union was achieved in 16 of 21 hindfoot (76.2%) and 6 of 21 midfoot (28.6%). Recurrence of CN occurred in 1 (4.8%), contralateral CN in 3 (14.3%), and ulcer recurrence in 5 (23.8%). Limb salvage was achieved in all patients (21/21, 100%). Conclusion: Surgical reconstruction of combined hindfoot and midfoot CN was associated with 100% limb salvage and clinical outcomes in this single-center series; however, these findings should be interpreted cautiously given the small sample size and the high rates of surgical site infection (38.1%) and low midfoot bony union (28.6%) observed. Future research with larger cohorts and extended follow-up focusing on functional outcomes is needed to enhance understanding and optimize treatment strategies. Level of Evidence: Level IV, retrospective observational case series.