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

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.