Tibiotalocalcaneal arthrodesis for Charcot neuroarthropathy, intramedullary nailing versus other fixation methods: A systematic review and meta-analysis

Objective: Tibiotalocalcaneal arthrodesis (TTCA) achieves a stable, plantigrade foot and prevents limb loss, particularly in Charcot neuroarthropathy (CN) patients. While intramedullary nailing (IMN) provides axial stability, other fixation methods remain valuable. This study aimed to compare IMN with other fixation methods for TTCA in CN patients. Methods: A systematic review examined adults with Charcot neuroarthropathy (CN) of the ankle or hindfoot undergoing tibiotalocalcaneal arthrodesis (TTCA) using retrograde intramedullary nailing (IMN), compared to alternative fixation methods. Studies published between 2000 and 2025 were eligible. Four databases were searched through October 2025, with reference lists screened. Two reviewers extracted data independently. Risk of bias was assessed using the Joanna Briggs Institute checklist, and publication bias was examined via funnel plots. Meta-analysis used a random-effects model (RevMan version 5.4.1), reporting standardized mean differences with 95% confidence intervals. Result: Four studies of 122 patients (72 IMN, 50 EF) showed IMN demonstrated a clinical trend toward higher fusion rates and improved functional recovery, although these differences did not consistently reach statistical significance (87.5% vs 74%), faster healing (16-20 vs 30-32 weeks), and better functional outcomes. Limb salvage rates were similar, but IMN had fewer pin and wound complications than EF. Analyses showed nonsignificant trends toward lower nonunion, complications, and amputation with IMN. IMN was preferable for selected CN patients with adequate soft tissue, while EF remained essential for infected limbs. Conclusion: Although IMN demonstrated favorable clinical trends including earlier weight-bearing and improved functional recovery, the differences in fusion, complication, and amputation rates did not consistently reach statistical significance. Given the limited number of retrospective studies and heterogeneity across cohorts, these findings should be interpreted cautiously.