Abstract Background Advanced Charcot neuro-osteoarthropathy involving the hindfoot is associated with severe deformity, instability, ulceration, infection, and major lower-limb amputation. Non-traumatic calcaneal fracture associated with diabetic Charcot hindfoot collapse is uncommon and difficult to treat because of neuropathy, impaired bone quality, tendon imbalance, soft tissue compromise, and a high risk of fixation failure. Reports describing long-term functional limb preservation in patients with advanced Charcot hindfoot collapse associated with severe metabolic bone impairment remain limited. Case presentation A 63-year-old Japanese woman with a 36-year history of type 1 diabetes mellitus presented with progressive right hindfoot deformity and ulceration without major trauma. Radiographs and computed tomography demonstrated advanced Charcot hindfoot collapse with a non-traumatic calcaneal fracture classified as Eichenholtz stage III and Brodsky type 3B. Preoperative evaluation demonstrated severe vitamin D deficiency and elevated bone turnover markers. The patient underwent corrective osteotomy of the calcaneus, Achilles tendon Z-lengthening, internal fixation with headless compression screws, autologous iliac bone grafting, and circular external fixation. A staged postoperative unloading protocol was used, followed by gradual protected loading. Sequential metabolic therapy was administered after surgery. Bone union was achieved at approximately 3 months, and the external fixator was removed at 3.5 months. During long-term follow-up, glycaemic control and bone mineral density improved. At 8 years after surgery, the patient remained ambulatory with preserved plantigrade alignment and without recurrent ulceration, infection, fixation failure, or amputation. The American Orthopaedic Foot & Ankle Society ankle-hindfoot score was 94. Interpretation of pain scores was limited by profound diabetic neuropathy. Conclusions This case illustrates an integrated multidisciplinary limb-salvage strategy combining mechanical reconstruction, staged postoperative offloading, and metabolic optimisation in a patient with advanced diabetic Charcot hindfoot deformity complicated by severe metabolic bone impairment. The favourable long-term outcome should be interpreted as hypothesis-generating rather than evidence for the efficacy of any individual adjunctive therapy.
Nozaka et al. (Thu,) studied this question.