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Charcot neuroarthropathy

35 citationsUpdated Sep 2026

Overview

Foot and ankle Charcot neuroarthropathy presents a complex reconstructive challenge, particularly when severe deformity, ulceration, or instability is present. Operative correction and salvage procedures for these neuropathic fractures and deformities result in stability in 93% of patients [3]. However, reconstructive surgery in this population is demanding and should not be contemplated unless an experienced team is available [3]. Arthrodesis of the affected joint serves as a salvage management option that yields acceptable clinical and radiological outcomes [1]. For patients with severe Charcot hindfoot deformity, single-stage correction using an intramedullary hindfoot arthrodesis nail is an effective treatment modality, provided a multidisciplinary care plan is delivered [6]. Similarly, the use of retrograde intramedullary compression nails results in good rates of limb salvage when employed for hindfoot reconstruction in patients with Charcot arthropathy [7].

Tibiotalocalcaneal arthrodesis by hindfoot nailing is effective in diabetic patients with Charcot foot joints, demonstrating comparable and superior outcomes regarding patient satisfaction and complication rates when compared to previous studies [14]. The Ilizarov method of closed arthrodesis should always be considered for neuropathic ankles in suitable patients [16]. In cases involving Charcot-Marie-Tooth disease, triple arthrodesis can preserve acceptable function in the majority of patients with foot deformities and instabilities [9]. Revision tibiotalar arthrodesis leads to satisfactory limb salvage in a majority of patients [10]. Extended arthrodesis of the ankle and hindfoot in patients with post-traumatic osteoarthrosis usually provides an effective alternative to amputation but should be regarded as a salvage procedure [48].

Although loss of a major motion segment frequently leads to arthritis in surrounding joints, most patients experience improvement in pain relief and function and remain satisfied with their outcome for decades after the procedure [20]. When evaluating these outcomes, the FAOS and FAAM are promising measures for patients with foot and ankle conditions, but their shortcomings should be taken into account when interpreting results in clinical settings or trials [2].

Anatomy & Pathophysiology

Pathophysiology

The pathogenesis of Charcot neuroarthropathy remains incompletely understood, with no single unifying theory explaining the underlying pathologic processes [11]. Multiple mechanisms are likely responsible for the condition [11]. The neurotraumatic theory posits that Charcot neuroarthropathy represents an exaggerated overuse injury, where insensate joints sustain repetitive microtrauma or a single traumatic event [11]. Abnormal sensation prevents the affected individual from adopting normal protective mechanisms, specifically offloading and activity modification, and from seeking medical attention [11]. However, reports of Charcot changes in non–weight-bearing joints, such as the shoulder, and in the hips of bedridden patients, have cast doubt on the neurotraumatic theory as the primary cause [11]. The neurovascular theory proposes that autonomic dysfunction leads to increased blood flow via arteriovenous shunting, resulting in bone resorption and weakening [11]. Bone turnover markers are elevated in acute Charcot neuroarthropathy compared with controls, whereas bone formation markers remain unchanged, indicating increased osteoclastic activity [11]. Several studies have shown an increase in bone resorption markers in Charcot neuroarthropathy [11]. Bone density analysis confirms the presence of osteopenia and indicates an increased risk for neuropathic fractures in Charcot neuroarthropathy [11].

Bony Anatomy

The ankle mortise is formed by the tibial plafond, medial malleolus, and lateral malleolus, articulating with the dome of the talar body [52]. The ankle mortise widens and the ankle becomes more stable in dorsiflexion owing to the shape of the talar dome, which is wider anteriorly and narrower posteriorly [52]. Specifically, the ankle mortise widens 1 to 1.5 mm during motion from plantar flexion to dorsiflexion [52]. Medial and superior clear spaces appear wider with the foot in plantar flexion [52]. A simplified model of the ankle joint has a horizontal axis from anteromedial to posterolateral and a coronal axis from superomedial directed distally and laterally to the tip of the fibula [52]. The ankle is responsible for most sagittal plane motion of the foot and ankle, allowing 23 to 48 degrees of plantar flexion and 10 to 23 degrees of dorsiflexion [52]. The ankle also contributes to inversion, eversion, and rotation [52]. The distal tibiofibular joint consists of the convex medial surface of the distal fibula and the concave incisura fibularis of the distal lateral tibia [52]. The fibula rotates approximately 2 degrees within the incisura during ankle motion and ambulation [52]. Ankle dorsiflexion results in external rotation and proximal translation of the fibula [52].

Ligaments

Lateral ankle ligaments function as restraints to varus and inversion forces at the ankle [52]. The anterior talofibular ligament (ATFL) originates from the anteroinferior aspect of the lateral malleolus, 1 cm proximal to its tip, and extends to the lateral aspect of the talar neck [52]. The calcaneofibular ligament (CFL) extends from the tip of the lateral malleolus to the lateral aspect of the calcaneus [52]. The posterior talofibular ligament (PTFL) extends from the posterior lateral malleolus to the posterolateral talus [52]. The ATFL is the weakest ankle ligament, while the PTFL is the strongest [52]. The distal tibiofibular joint (ankle syndesmosis) and fibula provide stability against lateral talar translation [52]. The deltoid ligament complex is the primary ankle stabilizer during stance [52]. The deep deltoid ligament extends from the apex of the medial malleolus to the medial talar body and functions primarily to resist lateral talar translation and external rotation [52]. The posterior deep deltoid is the most important component of the deep deltoid ligament [52]. The superficial deltoid ligament extends from the distal medial malleolus to the navicular bone, sustentaculum tali of calcaneus, medial talus, and spring ligament, functioning primarily to resist valgus and eversion ankle forces [52].

The deltoid ligament on the medial side of the ankle is composed of two distinct layers: the superficial and deep layers [58]. The deltoid ligament consists of at most six bands, of which only three are constant: the tibionavicular ligament, tibiospring ligament, and deep posterior tibiotalar ligament [58]. The superficial layer of the deltoid ligament is a broad, bandlike structure that originates from the anterior malleolus and fans out to insert into the navicular, neck of the talus, sustentaculum tali, and posteromedial talar tubercle [58]. The tibiocalcaneal portion of the superficial deltoid ligament is the strongest component and resists eversion of the calcaneus [58]. The deep portion of the deltoid ligament is the primary medial stabilizer of the ankle joint [58]. The deep portion of the deltoid ligament is organized into two short, thick, discrete bands: the anterior and posterior deep tibiotalar ligaments [58]. Both the anterior and posterior deep tibiotalar ligaments are intra-articular but extrasynovial [58]. The deep posterior band comprises the largest band of the deltoid complex [58]. The anterior deep tibiotalar ligament arises from the anterior malleolus and attaches to the medial aspect of the talus [58]. The posterior deep tibiotalar ligament originates from the posterior malleolus and inserts on the medial body of the talus [58]. The deltoid ligament has a rich vascular supply from three separate extraosseous sources: the medial tarsal artery, the posterior tibial artery, and the tibialis anterior artery [58]. There is also a component of intraosseous vascular supply to the deltoid ligament from either the talus or the medial malleolus [58]. The deltoid ligament, and specifically the tibiocalcaneal ligament, primarily prohibits eversion and abduction [58]. The deep deltoid, primarily the deep posterior tibiotalar ligament, functions to resist external rotation when the foot is dorsiflexed [58]. The deep deltoid is responsible for the greatest restraint against lateral translation [58]. Valgus tilting of the talus within the mortise requires complete rupture of both the superficial and deep deltoid [58]. The deep deltoid ligament has the highest load to failure at 713.8 N ± 69.3 compared with the lateral collateral ligaments [58]. The dominant mode of failure for the deep deltoid ligament occurs as an intrasubstance rupture near its talar insertion [58]. The failure of the superficial deltoid ligament is most commonly at its insertion on the anterior malleolus [58].

Neurovascular Anatomy

The main function of the nerves in the foot and ankle is to provide sensation [90]. The tibial nerve and its branches, the medial and lateral plantar nerves, innervate the intrinsic musculature of the foot [90]. The deep peroneal nerve innervates the extensor digitorum brevis and extensor hallucis brevis muscles [90]. Denervation of motor nerves in the foot can lead to clawing of the toes because of a resulting imbalance of intrinsic and extrinsic muscles [90]. The long-term morbidity of nerve injuries of the foot is predominantly related to sensory nerve injury, except when a tibial nerve injury causes intrinsic muscle function loss [90]. The two main problems associated with foot and ankle nerve injuries are the lack of sensation in the distal distribution of the nerve and the formation of a painful neuroma [90]. When a nerve injury occurs in a weight-bearing area of the foot, the presence of a painful neuroma often leads to complex regional pain syndrome type I [90]. The superficial peroneal nerve penetrates the deep fascia and lies subcutaneously 8 to 10 cm proximal to the tip of the lateral malleolus, anterior to the subcutaneous border of the shaft of the fibula [56]. The deep peroneal nerve accompanies the anterior tibial artery, which can usually be palpated beneath the superior extensor retinaculum 4 to 5 cm proximal to the distal articular surface of the tibia [56]. The deep peroneal nerve lies between the tendons of the anterior tibial and the extensor digitorum longus, and just lateral to the extensor hallucis longus [56]. The saphenous nerve is located just medial or posterior to the saphenous vein and in a slightly deeper plane, 3 to 5 cm proximal to the tip of the medial malleolus [56].

Classification

Mansoura: The Mansoura classification is designed for foot and ankle Charcot arthropathy. It demonstrates acceptable reliability, which is comparable to other classification systems [32].

Clinical Presentation

The clinical examination remains the irreplaceable stage in assessing foot and ankle disorders [5]. This process comprises a complete inventory of the patient's complaints and data obtained from the physical examination [5]. The examination must be based on prerequisite knowledge of functional anatomy covering bone and joint, ligament, muscle, skin, and neurovascular components [5]. Its primary objective is to establish consistency between disparate symptoms to link them in a logical pathogenic causal pattern [5]. In the absence of such consistency, recourse to more sophisticated investigations such as CT scan, MRI, or an intra-articular local anaesthetic test becomes worthwhile [5].

Nerve entrapment syndromes of the foot and ankle are a relatively infrequent but important cause of foot pain [4]. The neurotraumatic theory suggests that Charcot neuroarthropathy is an exaggerated overuse injury in which insensate joints are subjected to repetitive microtrauma or a single traumatic event [11]. Bone density analysis confirms the presence of osteopenia and indicates an increased risk for neuropathic fractures [11]. Additionally, bone turnover markers have been found to be elevated in acute Charcot neuroarthropathy compared with controls, whereas bone formation markers have been found to be unchanged [11].

Investigations

Clinical Examination: The clinical examination should concentrate on establishing consistency between symptoms to link them in a logical pathogenic causal pattern [5]. A discrepancy between ankle dorsiflexion on physical examination and 3D gait analysis is associated with the severity of planovalgus deformity evaluated on weightbearing lateral foot radiographs [42].

Plain Radiography: AP, mortise, and lateral weight-bearing ankle x-rays may not demonstrate subtle osteochondral lesions [62].

MRI: MRI is sensitive for all osteochondral lesions, but the edema pattern frequently overestimates severity of injury [62]. Linear fluid signal deep to subchondral bone on MRI indicates an unstable osteochondral injury [62]. MRI has a sensitivity of 92% for predicting stable versus unstable osteochondral lesions [62]. Two distinct ATFL fascicles may be identified in the majority of ankles on MRI [33]. The magnetic resonance scan proved to be of great benefit in the establishment of the diagnosis preoperatively for congenital abnormalities of the peroneal tendons [50].

CT: Weight-bearing CT scans better demonstrate the true orientation of bones and joints during loading compared to standard imaging [41]. Weight-bearing CT scans aid in the diagnosis and preoperative planning of complex foot and ankle pathologies [41]. CT scan is helpful for bony lesions, determining integrity of subchondral bone, identifying cysts, and preoperative planning for osteochondral lesions [62].

Other Considerations: Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint seem not to be indicative for a successful outcome of an arthrodesis of the affected joint [29]. The FAOS and the FAAM are promising outcome measures for evaluation of patients with foot and ankle conditions [2]. Shortcomings of the FAOS and FAAM should be taken into account when interpreting results in clinical setting or trials [2].

Treatment

Non-Operative

Orthotic devices can have a notable clinical impact on physical function, despite limited high-quality evidence [21].

Operative

Indications: Arthrodesis serves as a salvage management option for foot and ankle Charcot neuroarthropathy deformity correction [1]. Operative correction and salvage result in stability in 93% of patients who present with severe deformity [3]. The use of a retrograde intramedullary nail as a treatment of choice in the reconstruction of Charcot neuroarthropathy ankle is recommended before an ulcer occurrence [26].

Surgical Approach / Technique: Tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies [14]. Results suggest that satisfactory outcomes can be achieved by tibiotalocalcaneal arthrodesis using intramedullary nailing [102]. Tibiotalar arthrodesis is a safe therapy with 80% good results, providing pain relief, full weight-bearing, and increased walking distance [93]. This procedure produces a satisfactory rate of ankle arthrodesis and an ankle that is functional, durable, and cosmetically superior to most of those that are arthrodesed by other procedures [36].

Implant Selection: Hydroxyapatite (HA)-coated screws are recommended for the reconstruction of Charcot neuroarthropathy ankle [26].

Other Considerations: By providing a foot and ankle that are stable during weight-bearing, as well as a plantigrade foot, arthrodesis greatly decreases the chances of recurrent ulcerations and infections in a neuropathic limb [18]. Locally obtained autologous bone grafts are effective for achieving arthrodesis while managing foot and ankle charcot’s neuroarthropathy [1].

Complications

Arthrodesis Failure: Arthrodesis may fail in patients with open fractures, deep infection, bone loss, poor soft tissues, and systemic disorders such as diabetes, rheumatoid arthritis, neuropathy, stroke and those who smoke [34].

Internal Fixation Complications: Internal fixation in patients with complex ankle pathology may result in a high rate of nonunion, with recurrent infection and further soft-tissue compromise [34].

Other Considerations: Rates of hindfoot union and intact metalwork were noted in over 80% of patients following hindfoot Charcot reconstruction [38]. An analysis of fifty ankle fusions revealed sufficient post-operative complaints to emphasize the need for careful patient selection [13]. Posterior ankle and hind foot arthroscopy can be performed with low rate of major postoperative complication [105].

Recovery

Other Considerations: Orthotic devices can have a notable clinical impact on physical function despite limited high-quality evidence [21].

Key Evidence

  • [L4] Foot and ankle Charcot neuroarthropathy deformity correction by arthrodesis of the affected joint as a salvage management option resulted in acceptable clinical and radiological outcomes. [1] (10.1186/s13018-024-05036-9)
  • [L1] The best available evidence retrieved in this review showed that the FAOS and the FAAM are promising outcome measures for evaluation of patients with foot and ankle conditions, but their shortcomings should be taken into account when interpreting results in clinical setting or trials. [2] (10.1007/s00167-017-4748-7)
  • [L5] Reconstructive surgery is challenging and should not be contemplated unless an experienced team is available, but operative correction and salvage result in stability in 93% of patients who present with severe deformity. [3] (10.5435/00124635-199901000-00002)
  • [L5] Nerve entrapment syndromes of the foot and ankle are a relatively infrequent but important cause of foot pain. [4] (10.5435/00124635-199709000-00004)
  • [L5] [5] (10.1016/j.otsr.2009.03.008)
  • [L4] Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered. [6] (10.1302/0301-620x.97b1.34542)
  • [L4] The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. [7] (10.1302/0301-620x.100b2.bjj-2017-0374.r2)
  • [L4] Evaluation of the surgical results in the present series suggests that triple arthrodesis can preserve acceptable function in the majority of patients with foot deformities and instabilities which are caused by Charcot-Marie-Tooth disease. [9] (10.1007/bf00662284)
  • [L4] Revision tibiotalar arthrodesis leads to satisfactory limb salvage in a majority of patients. [10] (10.2106/jbjs.g.00506)
  • [L5] [11] (10.5435/00124635-200909000-00003)
  • [L2] This study provides evidence supporting the effectiveness of tibiotalocalcaneal arthrodesis by hindfoot nailing in diabetic patients with Charcot foot joints and demonstrated comparable and superior outcomes in terms of patient satisfaction and complication rate when compared to previous studies. [14] (10.1186/s13018-024-04787-9)
  • [L3] Due to its great advantages, the Ilizarov method of closed arthrodesis should always be considered for neuropathic ankles in suitable patients. [16] (10.1302/0301-620x.102b4.bjj-2019-1158.r1)
  • [L4] By providing a foot and ankle that are stable during weight-bearing, as well as a plantigrade foot, this procedure greatly decreases the chances of recurrent ulcerations and infections in a neuropathic limb. [18] (10.2106/00004623-199307000-00012)
  • [L5] Although loss of a major motion segment frequently leads to arthritis in surrounding joints, most patients have improvement in pain relief and function and are satisfied with their outcome for decades after the procedure. [20] (10.5435/00124635-200409000-00007)
  • [L4] Despite limited high-quality evidence, orthotic devices can have a notable clinical impact on physical function. [21] (10.5435/jaaos-d-23-00832)
  • [L1] [26] (10.3389/fsurg.2022.820826)
  • [L3] Fluoroscopically-guided anesthetic injections of the supposed painful foot-ankle joint seem not to be indicative for a successful outcome of an arthrodesis of the affected joint. [29] (10.1186/1471-2474-15-11)
  • [L4] Mansoura classification for foot and ankle Charcot arthropathy has acceptable reliability which is comparable to other classifications. [32] (10.1186/s13018-025-06093-4)
  • [L3] Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. [33] (10.1007/s00167-022-07275-x)
  • [L4] [34] (10.1302/0301-620x.95b3.29885)
  • [L4] This procedure produces a satisfactory rate of ankle arthrodesis and an ankle that is functional, durable, and cosmetically superior to most of those that are arthrodesed by other procedures. [36] (10.2106/00004623-198365020-00011)
  • [L3] Rates of hindfoot union and intact metalwork were noted in over 80% of patients. [38] (10.1302/0301-620x.104b6.bjj-2022-0127)
  • [L5] Weight-bearing CT scans better demonstrate the true orientation of bones and joints during loading compared to standard imaging, aiding in the diagnosis and preoperative planning of complex foot and ankle pathologies. [41] (10.5435/jaaos-d-19-00700)
  • [L3] The discrepancy between ankle dorsiflexion on physical examination and 3D gait analysis was associated with the severity of planovalgus deformity evaluated on weightbearing lateral foot radiographs. [42] (10.1186/s12891-020-03285-3)
  • [L4] Extended arthrodesis of the ankle and hindfoot in patients with post-traumatic osteoarthrosis usually provides an effective alternative to amputation but should be regarded as a salvage procedure. [48] (10.2106/00004623-199274070-00011)
  • [L5] [90] (10.5435/00124635-200505000-00005)
  • [L3] Tibiotalar arthrodesis is a safe therapy with 80% good results, providing pain relief, full weight-bearing, and increased walking distance. [93] (10.1007/bf00434542)
  • [L4] Results suggest that satisfactory outcomes can be achieved by tibiotalocalcaneal arthrodesis using intramedullary nailing. [102] (10.1007/s00167-015-3548-1)
  • [L4] Posterior ankle and hind foot arthroscopy can be performed with low rate of major postoperative complication. [105] (10.1177/2325967114s00206)

See Also

References

[1] Locally obtained autologous bone grafts are effective for achieving arthrodesis while managing foot and ankle charcot’s neuroarthropathy: short to mid-term results from a specialized north African foot and ankle surgery unit. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-05036-9

[2] Measurement properties of the most commonly used Foot- and Ankle-Specific Questionnaires: the FFI, FAOS and FAAM. A systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2017. DOI: 10.1007/s00167-017-4748-7

[3] Management of Neuropathic Fractures in the Foot and Ankle. Journal of the American Academy of Orthopaedic Surgeons. 1999. DOI: 10.5435/00124635-199901000-00002

[4] Nerve Entrapment Syndromes of the Foot and Ankle. Journal of the American Academy of Orthopaedic Surgeons. 1997. DOI: 10.5435/00124635-199709000-00004

[5] Clinical examination of the foot and the ankle. Data collection and interpretation of the pathogenic causal sequence of disorders. Orthopaedics & Traumatology: Surgery & Research. 2009. DOI: 10.1016/j.otsr.2009.03.008

[6] Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail. The Bone & Joint Journal. 2015. DOI: 10.1302/0301-620x.97b1.34542

[7] Mid-term follow-up of patients with hindfoot arthrodesis with retrograde compression intramedullary nail in Charcot neuroarthropathy of the hindfoot. The Bone & Joint Journal. 2018. DOI: 10.1302/0301-620x.100b2.bjj-2017-0374.r2

[9] Foot and ankle fusions in Charcot-Marie-Tooth disease. Archives of Orthopaedic and Trauma Surgery. 1993. DOI: 10.1007/bf00662284

[10] Revision Tibiotalar Arthrodesis. The Journal of Bone & Joint Surgery. 2008. DOI: 10.2106/jbjs.g.00506

[11] Charcot Neuroarthropathy of the Foot and Ankle. Journal of the American Academy of Orthopaedic Surgeons. 2009. DOI: 10.5435/00124635-200909000-00003

[13] Midterm Outcomes Following Conversion of Failed Ankle Arthrodesis to Total Ankle Arthroplasty, Including Patients With a Deficient Fibula.. 2025.

[14] Association between the procedure of tibiotalocalcaneal arthrodesis by hindfoot nailing and quality of life in Charcot’s joint. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04787-9

[16] Closed arthrodesis in infected neuropathic ankles using Ilizarov ring fixation. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b4.bjj-2019-1158.r1

[18] Salvage, with arthrodesis, in intractable diabetic neuropathic arthropathy of the foot and ankle.. The Journal of Bone & Joint Surgery. 1993. DOI: 10.2106/00004623-199307000-00012

[20] Fusion in Posttraumatic Foot and Ankle Reconstruction. Journal of the American Academy of Orthopaedic Surgeons. 2004. DOI: 10.5435/00124635-200409000-00007

[21] Orthotic Devices for the Foot and Ankle. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-23-00832

[26] Charcot Neuroarthropathy: Current Surgical Management and Update. A Systematic Review. Frontiers in Surgery. 2022. DOI: 10.3389/fsurg.2022.820826

[29] Can diagnostic injections predict the outcome in foot and ankle arthrodesis?. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-11

[32] Interobserver and intraobserver reliability of a new prognostic classification for foot and ankle charcot arthropathy. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06093-4

[33] Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI. Knee Surgery, Sports Traumatology, Arthroscopy. 2022. DOI: 10.1007/s00167-022-07275-x

[34] Outcome of arthrodesis of the hindfoot as a salvage procedure for complex ankle pathology using the Ilizarov technique. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b3.29885

[36] Compression arthrodesis of the ankle. Evaluation of a cosmetic modification.. The Journal of Bone & Joint Surgery. 1983. DOI: 10.2106/00004623-198365020-00011

[38] Predictors of metalwork failure and nonunion after hindfoot Charcot reconstruction. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b6.bjj-2022-0127

[41] Weight-bearing CT Scans in Foot and Ankle Surgery. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-19-00700

[42] Discrepancy between true ankle dorsiflexion and gait kinematics and its association with severity of planovalgus foot deformity. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03285-3

[48] Pantalar and tibiotalocalcaneal arthrodesis for post-traumatic osteoarthrosis of the ankle and hindfoot.. The Journal of Bone & Joint Surgery. 1992. DOI: 10.2106/00004623-199274070-00011

[50] Congenital abnormalities of the peroneal tendons have been described, but the descriptions have been based primarily on anatomical dissections2'3. There have been few clinical reports on developmental anomalies that caused symptoms"4'5. The following case is an example of that phenomenon.. 1991.

[52] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > BIOMECHANICS OF THE FOOT AND ANKLE.

[56] Campbell S Operative Orthopaedics 4 Volume Set. MULTIPLE Z-PLASTY RELEASE OF A CONGENITAL RING > ANKLE BLOCK.

[58] Orthopaedic Knowledge Update Sports Medicine 6. Ankle and Foot Injuries and Other Disorders > Ankle Sprains > Medial Ankle Injury.

[62] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > OSTEOCHONDRAL LESIONS.

[90] Nerve and Tendon Lacerations About the Foot and Ankle. Journal of the American Academy of Orthopaedic Surgeons. 2005. DOI: 10.5435/00124635-200505000-00005

[93] Role of internal and external fixation in ankle fusion. Archives of Orthopaedic and Trauma Surgery. 1996. DOI: 10.1007/bf00434542

[102] Tibiotalocalcaneal arthrodesis using an intramedullary nail: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2015. DOI: 10.1007/s00167-015-3548-1

[105] Posterior Ankle and Hind Foot Arthroscopy. Orthopaedic Journal of Sports Medicine. 2014. DOI: 10.1177/2325967114s00206

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i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.