Background: The optimal therapeutic approach for people suffering with unstable Charcot arthropathy of the midfoot is unclear. The purpose of this study was to examine the cost-effectiveness of three competing treatment strategies for adults suffering with unstable, midfoot Charcot arthropathy.

Methods: A Markov model was utilized to compare Charcot reconstruction (CR), primary transtibial amputation (TTA) and lifetime bracing in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated ulcer, and infected ulcer. Data regarding costs and probabilities were obtained from available literature. Primary outcomes included long-term costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs). Willingness-to-pay was set at $100,000 USD.

Results: TTA failed to show cost-effectiveness in comparison to other strategies available. Lifetime bracing was cost-effective in all clinical scenarios, with ICERs ranging from $6,970 to $15,010. CR was also cost-effective in the non-ulcerated and ulcerated scenarios, and offered the greatest potential for maximal QALYs gained, but failed to show value in the infected ulcer scenario. For CR to be cost-effective in the infected ulcer scenario, costs of surgery would need to lessen to $40,000 or complication rates would need to remain under 50%. The results in the non-ulcerated and ulcerated cohorts were robust to multiple sensitivity analyses.

Conclusion: Bracing is a cost-effective option in all stages of Charcot arthropathy while CR appears to be only cost-effective when performed early (i.e., in the non-ulcerated and uncomplicated ulcerated patient). An opportunity for shared-decision making exists in the early stages of Charcot arthropathy, where patient goals and expectations may be assessed while multiple cost-effective options are still available.


A.E. Fleischer: None. R.H. Albright: None. D.G. Armstrong: None. D. Wukich: Consultant; Self; Orthofix, Wright Medical. Other Relationship; Self; Arthrex.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at