The older theory of cause of neuropathic arthropathy is loss of sensation combined with autonomic nerve dysfunction. A newer theory is that Charcot foot is caused by loss of protective sensation and motor neuropathy causing tendon imbalance which increases forces on the foot causing deformity, subluxation, fractures and ulceration [4, 13,14,15]. Rosebloom found about 90% of patients with diabetes have peripheral neuropathy [16]. But only 8.5% of diabetics will develop Charcot foot [17, 18].

Surgical intervention was usually reserved for managing deformity and ulceration during the chronic phase of Charcot foot [19]. The more recent approach of early tendon balancing ± percutaneous removal of plantar bone prominence with a small bur (exostectomy) in an early phase can prevent progression of deformity, ulceration and amputation without more risky and extensive procedures [4].

Several authors have reported positive clinical outcomes with arthrodesis in Charcot neuroarthropathy patients. However, determining the most suitable device for this procedure remains a challenge [20].

The management of diabetic neuroosteoarthropathy poses significant challenges for the orthopedic community and remains controversy [1]. Specifically, when dealing with nonplantigrade alignment of the midfoot and hindfoot, there is a high incidence of skin damage and ulcers at the site of bony deformities [1, 21]. Pinzur and other authors have outlined the primary goals in treating Charcot's feet, which include achieving a foot that is free from infection and ulcers in the long term, enabling the use of commercially available depth-inlay shoes and custom-accommodative foot orthoses, and maintaining long-term walking independence [22, 23].

Reconstruction arthrodesis techniques for the treatment of Charcot's feet vary, ranging from external fixation methods using ring fixators to internal techniques involving intra- and extramedullary implants such as plates, screws, or bolts or a combination of these approaches [14, 15, 24,25,26]. Postoperatively, extended healing periods may be required due to comorbidities associated with diabetes, such as peripheral artery disease, which can lead to complications such as infections, nonunion or malunion, stress fractures, fixation failure, metal-induced soft-tissue irritations, implant breakage, or loosening. Consequently, the reoperation rates associated with these complications are high [7]. Currently, there is a lack of general evidence-based treatment algorithms, and the literature provides inconsistent recommendations regarding the ideal treatment type and timing [7].

Our study showed significant improvements in the AOFAS score, which includes pain score, length of the walk, walking surface, walking disorder, sagittal alignment, back leg alignment, sustainability, alignment, and the total score. The EQ5D5L questionnaire also showed a significant improvement in the total score. These findings suggest that tibiotalocalcaneal arthrodesis with hindfoot nailing can lead to positive outcomes in diabetic patients with Charcot foot joints.

Eschler et al. conducted a study on arthrodesis of the medial column and reported that approximately 50% of patients expressed satisfaction with the treatment and experienced pain relief. In our study, we observed similar outcomes, with patient satisfaction and pain reduction. However, Eschler et al. also reported a high rate of minor and major complications, with only 2 out of 21 patients experiencing complication-free healing [27]. In contrast, our study demonstrated a significantly lower rate of complications, with less than 5% of patients experiencing complications.

Jin-Soo et al. employed a dorsal-modified sliding calcaneal plate for midfoot arthrodesis and achieved successful bone union in all 10 patients within 4 months. The satisfaction rate in their study was in line with that of other procedures. In our study, we also observed successful bone union, with a similar time frame for healing [23]. However, we did not need for a second surgery, which was required in 20% of patients in Jin-Soo et al.'s study.

Dalla Paola et al. enrolled 18 diabetic patients with hindfoot Charcot neuroarthropathy and reported limb salvage in all patients. Fourteen patients achieved complete bony union of ankle arthrodesis [28]. These results align with our study, which also demonstrated successful limb salvage and favorable outcomes in ankle arthrodesis, with a high percentage of patients achieving complete bony union. Lee et al. obtained similar results in their study involving seven patients [29].

Caravaggi et al. studied a cohort of 45 diabetic patients with Charcot neuroarthropathic ankle deformity and suggested performing ankle and hindfoot arthrodesis with an intramedullary nail during the early chronic stage of the disease. They suggested that this approach may reduce the risk of progressive deformation and complications [30]. Our study supports these findings, as we also recommend early surgical reconstruction to minimize the risk of complications in a similar patient population.

Yammine et al. conducted a comprehensive meta-analysis comparing external fixation and intramedullary nailing in Charcot neuroarthropathy patients. They found that the external fixation group had a greater rate of hardware and wound infection than did the intramedullary nailing group. The fusion rate was also greater in the intramedullary nailing group, while the amputation rate was lower [31]. These results align with our study, which also demonstrated a low rate of complications and a high fusion rate in patients treated with intramedullary nailing.

Our study has several limitations. First, the study was carried out between January 2020 and December 2021, restricting the ability to assess long-term outcomes beyond the 1-year follow-up period. Moreover, the data collection relied on self-reported measures and subjective assessments, which may introduce measurement bias. Furthermore, the study lacked a control group, making it difficult to assess the effectiveness of the treatment compared to alternatives. The improvement in outcomes (i,e quality of life, pain) could result from placebo (i,e individual bias) due to the absence of a double-blind procedure and future double-blinded RCT is needed. Also, further studies should include a longer follow-up period.