CHARCOT ANKLE FUSION WITH A RETROGRADE LOCKED INTRAMEDULLARY NAIL

Twenty patients with severe neuropathic (Charcot) ankle deformities un derwent 21 attempted ankle fusions with a retrograde locked intramedul lary nail as an alternative to amputation, Ail had insensate heel pads and had failed at nonoperative methods of accommodative ambulatory br acing. In 11, the talus was either absent, or the deformity was of suf ficient magnitude to require talectomy to align the calcaneus under th e tibia for plantigrade weightbearing. Ages ranged from 28 to -68 (ave rage 56.3) years. Nineteen were diabetic, 12 being insulin-dependent, Their average body weight was 102 kg, with 11 greater than 90 kg at th e time of surgery. Eight had chronic large full thickness ulcers overl ying, but not involving bone of the medial malleolus, medial midfoot, or proximal fifth metatarsal, at the time of surgery. At a follow-up o f 12 to 31 months, 19 achieved bony fusion. In the 10 patients where t alectomy was not required, fusion was achieved at an average of 5.3 mo nths without complications. In the patients who required talectomy, si x of the patients required eight additional operations to achieve fusi on. Three achieved fusion following removal of the nail and prolonged bracing. One opted for ankle disarticulation for chronic persistent in fection, rather than attempt reoperation. One died of unrelated causes during the early postoperative period. Retrograde locked intramedulla ry ankle fusion is a reasonable alternative to amputation in the neuro pathic (Charcot) ankle that cannot be controlled with standard bracing techniques. The potential for morbidity requiring reoperation is grea tly increased when the deformity is of sufficient magnitude to require talectomy to achieve alignment of the calcaneus in a plantigrade weig ht-bearing position under the tibia or when there are large open ulcer s.