Transmalleolar tibiotalocalcaneal fusion with biologic augmentation and fibular preservation for chronic Charcot ankle arthropathy: A retrospective cohort study

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BACKGROUND Charcot neuroarthropathy of the ankle presents significant surgical challenges with conventional tibiotalocalcaneal (TTC) fusion techniques often prioritizing mechanical stability while neglecting biological deficiencies, resulting in high non-union rates. This study evaluated a refined surgical approach integrating biological augmentation with fibular preservation. AIM To evaluate trans-malleolar TTC fusion with bone marrow aspirate (BMA)-soaked allograft and fibular preservation for chronic Charcot ankle arthropathy. METHODS We conducted a retrospective case series of 24 adult patients with chronic ankle Charcot arthropathy who underwent TTC fusion with biologic augmentation between 2023 and 2024 at a tertiary care trauma center. The technique involved a transmalleolar approach with fibular preservation, comprehensive joint preparation, and biologic augmentation using BMA-soaked allograft. Outcomes were assessed using the validated American Orthopedic Foot and Ankle Society hindfoot scale and Short Form-36 health survey with comprehensive radiographic evaluation. RESULTS At a mean follow-up of 1.5 years, 100% (24/24) of patients achieved successful TTC fusion confirmed by robust bony bridging. Mean American Orthopedic Foot and Ankle Society scores demonstrated significant improvement from 31.2 ± 9.1 preoperatively to 76.8 ± 14.2 at the final follow-up (P < 0.001), exceeding the minimal clinically important difference. Short Form-36 scores showed significant improvements across all domains with physical function scores improving from 29.4 ± 10.8 to 72.1 ± 15.3 (P < 0.001). Complications included breakage of both fibular fixation screws managed conservatively without compromising stability, nail protrusion requiring a minor removal procedure, and a periprosthetic tibial fracture treated conservatively with walker boot immobilization. No major infections, wound complications, or amputations were observed. CONCLUSION Trans-malleolar TTC fusion with BMA-soaked allograft and fibular preservation achieved high union and improved outcomes in chronic Charcot ankle arthropathy.

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