Effectiveness of Total Hip Arthroplasty Combined With Hip Braces for Hip Charcot Arthropathy
Introduction Charcot neuroarthropathy, a rare non‐infectious disease, is characterized by a lack of periarticular sensory and progressive joint destruction, as first reported by William in 1703 . There are diverse causes of Charcot neuroarthropathy, including syphilis, peripheral nerve injury due to diabetes mellitus, tabes dorsalis, syringomyelia and congenital insensitivity to pain with anhidrosis . Charcot neuroarthropathy leads to few clinical manifestations but severe bony loss, resulting in notable articular impairment . The most common locations of Charcot neuroarthropathy are the knee joints, ankle joints and hip joints . While total knee arthroplasty has been reported significant improvement in pain and satisfactory clinical results for end‐stage knee Charcot neuroarthropathy when compared with other intervention , the best surgical treatment for hip Charcot neuroarthropathy is still controversial. Due to neurological lesion with deficit of superficial and deep sensitivity, in theory, Charcot neuroarthropathy of the hip can significantly affect risks associated with total hip arthroplasty (THA), especially dislocation . Hip braces have been reported to successfully restore primary stability in the unstable THA with adequate orientation of components . Previous study indicated that the hip brace is effective to prevent dislocation following THA through helping the patients recognize provocative positions and restricting the unconsciously excessive activity . Recently, a few literatures have described good outcomes of THA performed in patients with Charcot neuroarthropathy . However, to date, the effectiveness of THA for Charcot neuroarthropathy remains under debate. We here conducted a retrospective study that described the results of Charcot neuroarthropathy underwent THA with hip braces. The aim of this study is to illustrate (i) clinical results, (ii) radiographic results, (iii) complications, especially dislocation, (iv) survivorship. 

Materials and Methods The ethnic approval of this retrospective study was obtained from the institutional review board of the first affiliated hospital of Jinan university (NO. KY‐2022‐032). We retrospectively reviewed 11 consecutive patients (11 hips) with Charcot neuroarthropathy who underwent THA between August 1998 and August 2016. The following inclusion criteria were applied: (i) age > 18 years, (ii) classic radiographic findings of Charcot arthropathy, (iii) THA for affected limb, (iv) follow‐up time > 5 years. The exclusion criteria were: (i) patients without classic radiographic findings of Charcot arthropathy, (ii) follow‐up time of less than 5 years, (iii) presence of other joint pathologies that might confound the results, (iv) inability to comply with postoperative follow‐up requirements, and (v) severe comorbidities such as uncontrolled diabetes or advanced cardiovascular disease that could significantly impact surgical outcomes or postoperative recovery. Total of eight patients were excluded from the study, seven of eight patients did not have classic radiographic findings of Charcot arthropathy, and one of eight patients with follow‐up time less than 5 years. Therefore, 11 patients who underwent THA for Charcot hip joints were included in the ultimate study cohort. All surgeries were performed by same senior surgeon (NL). Preoperative templating was applied routinely in all patients. All surgeries were performed under spinal anesthesia. All patients underwent THA with posterolateral approach, performed in the lateral decubitus position. 2.1 Surgical Technique and Implants Osteotomy of femoral neck and removal of femoral head following hip exposure. The acetabulum was gradually expanded using an acetabular reamer, and then the cementless acetabular cup was press‐fitted. The cementless acetabular components were implanted with ultra‐high molecular weight polyethylene liner. On the femoral side, we performed a gentle rasping technique to prevent femoral diaphyseal fracture and inserted the cementless femoral implant into the femoral canal. Following the placement of the implant, we conducted an impingement test to prevent bone‐to‐implant or bone‐to‐bone. Cementless or cemented femoral stems were used based on femoral morphology. The posterior capsule and external rotators were repaired following reduction of hip joint. In this study, all patients used this hip abduction brace named Tehlin for 6 weeks postoperatively, initially on a full‐time basis, this may protect the operated hip joint from dislocation and benefit for soft tissues healing in the proper position. All participants were clearly educated to prevent crossing their legs, hip flexion more than 90°, and rotation more than 20° with the restriction of hip braces. The duration of hip brace wear for preventing dislocation was consistent with previous study . Detailed demographic information of participants were collected from electronic database, including age, sex, body mass index, and comorbidities (Table ). 2.2 Observation Measurements Patients were asked to evaluate pain intensity by visual analog scale (VAS) , Oxford Hip Score was used to evaluate hip function , University of California at Los Angeles (UCLA) activity score was used to evaluate physical activity level . The clinical information were acquired via a questionnaire before surgery; at three, six, and 12 months after THA and then once a year. The clinical records were retrospectively reviewed to evaluate intraoperative and postoperative complications, including periprosthetic fracture, dislocation, infection, loosening, nerve palsy, and deep vein thrombosis. And reoperation was defined as surgery performed to solve any problems after THA. Radiologic results were evaluated by anteroposterior radiograph of the hip joint. The inclination of the cup was measured as described by Engh et al. . The anteversion of the cup was measured as described by Liaw et al. . We analyzed the alignment of femoral stem using the criteria set out by Khalily and Lester . We analyzed the aseptic loosening for femoral and acetabular component using the criteria set out by Gruen et al. (zones 1 to 7)  and DeLee and Charnley  respectively. Leg length discrepancy (LLD) was defined as measuring the discrepancy of vertical distance from interteardrop line to the tip of less trochanter between two sides. If heterotopic ossification occurred it was graded according to Brooker et al. . 

Surgical Technique and Implants Osteotomy of femoral neck and removal of femoral head following hip exposure. The acetabulum was gradually expanded using an acetabular reamer, and then the cementless acetabular cup was press‐fitted. The cementless acetabular components were implanted with ultra‐high molecular weight polyethylene liner. On the femoral side, we performed a gentle rasping technique to prevent femoral diaphyseal fracture and inserted the cementless femoral implant into the femoral canal. Following the placement of the implant, we conducted an impingement test to prevent bone‐to‐implant or bone‐to‐bone. Cementless or cemented femoral stems were used based on femoral morphology. The posterior capsule and external rotators were repaired following reduction of hip joint. In this study, all patients used this hip abduction brace named Tehlin for 6 weeks postoperatively, initially on a full‐time basis, this may protect the operated hip joint from dislocation and benefit for soft tissues healing in the proper position. All participants were clearly educated to prevent crossing their legs, hip flexion more than 90°, and rotation more than 20° with the restriction of hip braces. The duration of hip brace wear for preventing dislocation was consistent with previous study . Detailed demographic information of participants were collected from electronic database, including age, sex, body mass index, and comorbidities (Table ). 

Observation Measurements Patients were asked to evaluate pain intensity by visual analog scale (VAS) , Oxford Hip Score was used to evaluate hip function , University of California at Los Angeles (UCLA) activity score was used to evaluate physical activity level . The clinical information were acquired via a questionnaire before surgery; at three, six, and 12 months after THA and then once a year. The clinical records were retrospectively reviewed to evaluate intraoperative and postoperative complications, including periprosthetic fracture, dislocation, infection, loosening, nerve palsy, and deep vein thrombosis. And reoperation was defined as surgery performed to solve any problems after THA. Radiologic results were evaluated by anteroposterior radiograph of the hip joint. The inclination of the cup was measured as described by Engh et al. . The anteversion of the cup was measured as described by Liaw et al. . We analyzed the alignment of femoral stem using the criteria set out by Khalily and Lester . We analyzed the aseptic loosening for femoral and acetabular component using the criteria set out by Gruen et al. (zones 1 to 7)  and DeLee and Charnley  respectively. Leg length discrepancy (LLD) was defined as measuring the discrepancy of vertical distance from interteardrop line to the tip of less trochanter between two sides. If heterotopic ossification occurred it was graded according to Brooker et al. . 

Statistical Methods In this study, the numbers of cases ( n ) and frequencies (percentages) were calculated for categorical variables. For continuous variables, normality tests were first conducted. Means ± standard deviations (SDs) were computed for variables that followed a normal distribution, and medians along with interquartile ranges were calculated for those that did not. To compare differences between two groups, Student's t ‐test was used for continuous variables, and the chi‐square test was used for categorical variables. Survivorship analysis was determined using the Kaplan–Meier estimator with 95% confidence intervals (CI) analysis according to the end point of reoperation following THA. The Kaplan–Meier estimator plots the probability of surviving in a given length of time while considering time in many small intervals. It estimates the probability that a patient will survive beyond any specified time. The Kaplan–Meier curve is able to provide a visual representation of the survival experience of a cohort over time, without assuming any underlying statistical distribution. We defined a p value < 0.05 as statistically significant. All statistical analyses were performed using SPSS software system (version 20.0, SPSS Inc. Chicago, IL). 

Results 4.1 Patient Characteristic The baseline demographic information of the participants were recorded in Table . All involved patients were diagnosed as syphilis by laboratory examinations. A total of 11 patients (seven females) underwent THA for Charcot neuroarthropathy, with average follow‐up of 81.73 months. The average age at THA was 58.09 ± 9.75 years old. The average body mass index was 24.02 ± 3.21 kg/m 2 . The average apparent leg‐length discrepancy was 0.83 ± 0.42 cm. Night of 11 patients walked only with the assistance of crutches. All patients carried out a sepsis evaluation before THA with inflammatory markers (erythrocyte sedimentation rate, c‐reactive protein) and white blood routine examination. All acetabular components were cementless. There was two acetabular bone loss (Type 2B according to Paprosky classification ) was treated with additional tantalum augments. Femoral components included nine cementless stems and two cemented stems. No constrained liners were applied. One patient was treated with antibiotic‐loaded cement spacer due to opaque synovial fluid and abnormal intraoperative synovial fluid leukocyte cell count. While both intraoperative synovial fluid cultures and intraoperative tissue sample cultures were negative, this case was diagnosed as Charcot neuroarthropathy according to typical radiographic findings. Finally, this patient removed antibiotic‐loaded cement spacer and accepted THA. Hence, we retrospectively included this case into the cohort. The specific details of the patients are presented in Table . 4.2 Clinical Results The average VAS reduced from 2.75 preoperatively to 0.58 postoperatively ( p < 0.001). The average Oxford Hip Score enhanced form 24.36 preoperatively to 46.82 postoperatively ( p < 0.001). Likely, there was significant improvement in average UCLA score from preoperative 2.55 to postoperative 4.55 ( p < 0.001) at the latest follow‐up (Table , Figure ). 4.3 Radiographic Results The average acetabular inclination was 44.09° ± 5.56° and the average acetabular anteversion was 16.59° ± 3.95°. In all but 1 patient, the femoral stems were aligned in a neutral position. The average LLD after THA was 0.83 ± 0.42 cm (Table ). No heterotopic ossifications were detected in follow‐up. 4.4 Complications Of the 11 THAs, one patient experienced posterior dislocation following installment of antibiotic‐loaded cement spacer (Figure ); this patient occurred posterior dislocation at 1‐month follow‐up while sitting down without hip brace, which received closed reduction under spinal anesthesia, and used a hip abduction brace until second‐stage THA; no recurrence of dislocation until the latest follow‐up. Two patients occurred intraoperative calcar fracture which were treated with wire cerclage (Figures and ); Due to the additional procedure of treating calcar fractures, the operative time and blood loss for these two cases were greater, at 95 and 105 min, and 290 and 305 mL, respectively; However, both patients walked with an aid 1 day postoperatively; The hospital stays for both were similar to the mean values, 14 and 13 days, respectively; In the most recent follow‐up, the patients were able to walk without aid and were satisfied. One patient experienced aseptic loosening of acetabular component while slipping down the stairs on postoperative day 10; Metal augment and new acetabular component were used in revision surgery for restoring stability of hip joint; the patient used hip abduction brace for 6 weeks after revision surgery; no recurrence of loosening until the most recent follow‐up (Figure ). One patient experienced posterior tibial vein thrombosis which were founded by ultrasound; After a 3‐month treatment with low molecular weight heparin, no subsequent complications occurred (such as pulmonary embolism) during the 6 years following the operation. There were no cases of superficial infection, periprosthetic infection, and nerve palsy in the latest follow‐up. 4.5 Survivorship The Kaplan–Meier survivorship free of any reoperation for any reason as the end point was 81.8% (2/11) (Figure ), with a mean follow‐up of 81.73 months. 

Patient Characteristic The baseline demographic information of the participants were recorded in Table . All involved patients were diagnosed as syphilis by laboratory examinations. A total of 11 patients (seven females) underwent THA for Charcot neuroarthropathy, with average follow‐up of 81.73 months. The average age at THA was 58.09 ± 9.75 years old. The average body mass index was 24.02 ± 3.21 kg/m 2 . The average apparent leg‐length discrepancy was 0.83 ± 0.42 cm. Night of 11 patients walked only with the assistance of crutches. All patients carried out a sepsis evaluation before THA with inflammatory markers (erythrocyte sedimentation rate, c‐reactive protein) and white blood routine examination. All acetabular components were cementless. There was two acetabular bone loss (Type 2B according to Paprosky classification ) was treated with additional tantalum augments. Femoral components included nine cementless stems and two cemented stems. No constrained liners were applied. One patient was treated with antibiotic‐loaded cement spacer due to opaque synovial fluid and abnormal intraoperative synovial fluid leukocyte cell count. While both intraoperative synovial fluid cultures and intraoperative tissue sample cultures were negative, this case was diagnosed as Charcot neuroarthropathy according to typical radiographic findings. Finally, this patient removed antibiotic‐loaded cement spacer and accepted THA. Hence, we retrospectively included this case into the cohort. The specific details of the patients are presented in Table . 

Clinical Results The average VAS reduced from 2.75 preoperatively to 0.58 postoperatively ( p < 0.001). The average Oxford Hip Score enhanced form 24.36 preoperatively to 46.82 postoperatively ( p < 0.001). Likely, there was significant improvement in average UCLA score from preoperative 2.55 to postoperative 4.55 ( p < 0.001) at the latest follow‐up (Table , Figure ). 

Radiographic Results The average acetabular inclination was 44.09° ± 5.56° and the average acetabular anteversion was 16.59° ± 3.95°. In all but 1 patient, the femoral stems were aligned in a neutral position. The average LLD after THA was 0.83 ± 0.42 cm (Table ). No heterotopic ossifications were detected in follow‐up. 

Complications Of the 11 THAs, one patient experienced posterior dislocation following installment of antibiotic‐loaded cement spacer (Figure ); this patient occurred posterior dislocation at 1‐month follow‐up while sitting down without hip brace, which received closed reduction under spinal anesthesia, and used a hip abduction brace until second‐stage THA; no recurrence of dislocation until the latest follow‐up. Two patients occurred intraoperative calcar fracture which were treated with wire cerclage (Figures and ); Due to the additional procedure of treating calcar fractures, the operative time and blood loss for these two cases were greater, at 95 and 105 min, and 290 and 305 mL, respectively; However, both patients walked with an aid 1 day postoperatively; The hospital stays for both were similar to the mean values, 14 and 13 days, respectively; In the most recent follow‐up, the patients were able to walk without aid and were satisfied. One patient experienced aseptic loosening of acetabular component while slipping down the stairs on postoperative day 10; Metal augment and new acetabular component were used in revision surgery for restoring stability of hip joint; the patient used hip abduction brace for 6 weeks after revision surgery; no recurrence of loosening until the most recent follow‐up (Figure ). One patient experienced posterior tibial vein thrombosis which were founded by ultrasound; After a 3‐month treatment with low molecular weight heparin, no subsequent complications occurred (such as pulmonary embolism) during the 6 years following the operation. There were no cases of superficial infection, periprosthetic infection, and nerve palsy in the latest follow‐up. 

Survivorship The Kaplan–Meier survivorship free of any reoperation for any reason as the end point was 81.8% (2/11) (Figure ), with a mean follow‐up of 81.73 months. 

Discussion 5.1 Main Finding of This Study The main findings of this study demonstrate that THA combined with hip braces is an effective management for Charcot arthropathy of the hip joint, resulting in improved functional scores, low dislocation rates, and satisfactory implant survival. Additionally, the use of hip braces may enhance patient awareness of their movements and help control their range of motion to minimize the risk of dislocation. 5.2 Outcome of THA for Charcot Neuroarthropathy in Previous Study Most end‐stage hip diseases are accompanied by severe joint destruction visible on imaging and intense pain . However, the Charcot hip joint is characterized by insensitivity to pain, resulting in deformity and severe hip joint destruction . Total hip arthroplasty is the therapeutic method for end‐stage hip disease, to restore the hip anatomical structure and improve hip joint function . Generally, if there is proper position of components, no impingement and appropriate soft tissues balance, THA for treating end‐stage hip disease does not easily result in postoperative dislocation . However, Charcot arthropathy differs from other end‐stage osteoarthropathies due to the lack of pain perception and neurologic lesions . Pain is a protective sensory mechanism, the neurologic lesion may lead to a higher risk of complications following THA, especially dislocation and loosening . Historically, most orthopedists have been reluctant to consider THA for patients with Charcot neuroarthropathy of hip due to the potential complications associated with hip arthroplasty in these patients. Garlicki reported the outcomes regarding one patient with Charcot arthropathy of hip who underwent THA for the first time. There was instability after THA . In 1988, Robb et al.  subsequently described recurrent dislocations after THA in one case with Charcot arthropathy of the hip. In a retrospective study, Gerhart and Scott  reported that all three total hip arthroplasties for Charcot arthropathy remained dislocated following repeated closed reduction. Nevertheless, in the past, a few literatures have reported satisfactory results of THA performed in patients with Charcot arthropathy of the hip. In a case report, Sprenger and Foley  described good results of THA for Charcot hip joint without dislocation or loosening at 7‐year follow‐up. Recently, Erdil et al.  reported on a case undergoing THA for Charcot hip joints. The short‐term results confirmed the success of surgical treatment, the patient could walk with full weight bearing and no complications occurred. Lately, Inoue et al.  published the satisfactory mid‐ to long‐term results of two cases who was treated with THA for Charcot arthropathy of the hip. No signs of implant loosening or breakage were observed over the follow‐up. Furthermore, Chalmers et al.  conducted a retrospective study with relatively large number of patients undergoing THA for Charcot hip joints and reported a significant improvement in clinical outcome and a good survivorship with an end point of revision for any reason at short‐ and mid‐term follow‐up. Their results did not suggest that Charcot arthropathy is contradiction to THA. In another case report, Rapala and Obrębski  reported two patients with Charcot hip joints successfully managed with cemented THA. The last radiological examinations did not indicate any sign of prosthetic loosening at 9.5‐year and 10‐year follow‐up. Similarly, Zhang et al. described a case of Charcot arthropathy secondary to syphilis, which was successfully treated with constrained THA, suggesting that THA could be an effective treatment option for these patients . The aforementioned studies show different treatments for Charcot hip joints, and a standard treatment strategy has not been established yet. Notably, Dagnino et al.  achieved satisfactory results using dual mobility implants for this condition. Therefore, we propose dual mobility implants may be an appropriate choice for acquiring hip joint stability in patients with Charcot arthropathy. 

Main Finding of This Study The main findings of this study demonstrate that THA combined with hip braces is an effective management for Charcot arthropathy of the hip joint, resulting in improved functional scores, low dislocation rates, and satisfactory implant survival. Additionally, the use of hip braces may enhance patient awareness of their movements and help control their range of motion to minimize the risk of dislocation. 

Outcome of THA for Charcot Neuroarthropathy in Previous Study Most end‐stage hip diseases are accompanied by severe joint destruction visible on imaging and intense pain . However, the Charcot hip joint is characterized by insensitivity to pain, resulting in deformity and severe hip joint destruction . Total hip arthroplasty is the therapeutic method for end‐stage hip disease, to restore the hip anatomical structure and improve hip joint function . Generally, if there is proper position of components, no impingement and appropriate soft tissues balance, THA for treating end‐stage hip disease does not easily result in postoperative dislocation . However, Charcot arthropathy differs from other end‐stage osteoarthropathies due to the lack of pain perception and neurologic lesions . Pain is a protective sensory mechanism, the neurologic lesion may lead to a higher risk of complications following THA, especially dislocation and loosening . Historically, most orthopedists have been reluctant to consider THA for patients with Charcot neuroarthropathy of hip due to the potential complications associated with hip arthroplasty in these patients. Garlicki reported the outcomes regarding one patient with Charcot arthropathy of hip who underwent THA for the first time. There was instability after THA . In 1988, Robb et al.  subsequently described recurrent dislocations after THA in one case with Charcot arthropathy of the hip. In a retrospective study, Gerhart and Scott  reported that all three total hip arthroplasties for Charcot arthropathy remained dislocated following repeated closed reduction. Nevertheless, in the past, a few literatures have reported satisfactory results of THA performed in patients with Charcot arthropathy of the hip. In a case report, Sprenger and Foley  described good results of THA for Charcot hip joint without dislocation or loosening at 7‐year follow‐up. Recently, Erdil et al.  reported on a case undergoing THA for Charcot hip joints. The short‐term results confirmed the success of surgical treatment, the patient could walk with full weight bearing and no complications occurred. Lately, Inoue et al.  published the satisfactory mid‐ to long‐term results of two cases who was treated with THA for Charcot arthropathy of the hip. No signs of implant loosening or breakage were observed over the follow‐up. Furthermore, Chalmers et al.  conducted a retrospective study with relatively large number of patients undergoing THA for Charcot hip joints and reported a significant improvement in clinical outcome and a good survivorship with an end point of revision for any reason at short‐ and mid‐term follow‐up. Their results did not suggest that Charcot arthropathy is contradiction to THA. In another case report, Rapala and Obrębski  reported two patients with Charcot hip joints successfully managed with cemented THA. The last radiological examinations did not indicate any sign of prosthetic loosening at 9.5‐year and 10‐year follow‐up. Similarly, Zhang et al. described a case of Charcot arthropathy secondary to syphilis, which was successfully treated with constrained THA, suggesting that THA could be an effective treatment option for these patients . The aforementioned studies show different treatments for Charcot hip joints, and a standard treatment strategy has not been established yet. Notably, Dagnino et al.  achieved satisfactory results using dual mobility implants for this condition. Therefore, we propose dual mobility implants may be an appropriate choice for acquiring hip joint stability in patients with Charcot arthropathy. 

Outcomes of THA Combined With Hip Braces for Charcot Arthropathy 6.1 Functional Scores In this series, the clinical outcomes improved obviously with respect to preoperative period. The mean VAS decreased from 2.75 preoperatively to 0.58 postoperatively. The average Oxford Hip Score enhanced form 24.36 preoperatively to 46.82 postoperatively. Likewise, the average UCLA score improved from preoperative 2.55 to postoperative 4.45 at the final follow‐up. Similarly, Chalmers et al.  reported that the Harris Hip score significantly improved from a mean of 43 (range, 34–56) preoperatively to a mean of 81 (range, 67–90) postoperatively. At the latest follow‐up, 75% of hips (9/12) had no pain and 25% of hips (3/12) had mild pain. They indicated that THA was a reliable treatment of relieving pain and improving mobility for hip Charcot arthropathy in spite of the lack of proprioceptive sensation and insensitivity to pain. Inoue et al.  described two patients with Charcot arthropathy of the hip could walk with aid without causing implant dislocation after THA at most recent follow‐up. Erdil et al.  presented a hip Charcot arthropathy underwent THA with normal range of motion of hip joint and the patient could walk with full weight bearing at final follow‐up. Total hip arthroplasty may be an appropriate therapeutic choice for reliving symptoms and improving hip joint function in these patients. 6.2 Complications Nevertheless, the published literatures have showed high incidence of complications in patients undergoing THA for Charcot neuroarthropathy (Table ). A recent retrospective study 12 THAs has noted the overall complication rate was high at 58% (7/12). There were three recurrent dislocations, two periprosthetic fractures, one femoral stem loosening, and one wound problem. They indicated that the high rate of complication was attributed to poor medical conditions (such as uncontrolled diabetes mellitus) in involved patients . Recent study have reported that patients with Charcot neuroarthropathy who underwent THA demonstrated higher rates of postoperative complications, including dislocation, wound infections, and the need for revision surgeries, compared to those without Charcot neuroarthropathy . Similar to the previous study, our results reported a high incidence of complications following THA in this cohort. Among the 11 patients who underwent surgery, five patients experienced complications (45.5%). Specifically, there were one cases of early postoperative dislocation, one case of postoperative prosthesis loosening, two cases of intraoperative femoral fractures, and one case of deep vein thrombosis (DVT) in the lower extremities. Patients with postoperative dislocation were treated with closed reduction and hip braces until stability was restored, and follow‐up showed no recurrence. The patient diagnosed with deep vein thrombosis (DVT) in the lower extremities was treated with low molecular weight heparin for anticoagulation therapy for 6 weeks without any signs of DVT. The two patients with intraoperative femoral fractures were treated with cerclage wiring, resulting in complete healing of the fractures and good stability of the femoral components. The intraoperative calcar fractures may be partly due to osteoporosis of patients with Charcot neuroarthropathy, which increase the risk of complications. Osteoporosis and local osteopenia have been proved to have a role in Charcot arthropathy development . If so, due to the high risk of osteoporosis in this population, appropriate application of anti‐osteoporosis treatment may be considered to mitigate this risk. Regarding surgical techniques, the instability of joint structures in these patients increases the difficulty of prosthesis implantation, further elevating the likelihood of complications. However, the dislocation rate (1/11) in this cohort was relatively lower compared with previous studies. Inoue et al.  reported both two patients with hip Charcot arthropathy who experienced early postoperative dislocations after THA. Chalmers et al.  reported a high rate of dislocation at 25% and suggested the use of dual mobility or other high stability constructs in patient with Charcot arthropathy. Dagnino et al.  reported the excellent clinical results of THA with dual mobility component in Charcot hip joint at 1‐year follow‐up. The x‐rays did not show periprosthetic fractures or implant mobilization and no any reoperations occurred. We considered that the lower dislocation rate may benefit from the application of hip abduction brace. The hip brace limited the range of joint motion, thereby reducing the risk of dislocation caused by involuntary movements. Hirata et al.  conducted a biomechanical study and suggested that patients undergoing arthroscopic femoroacetabular impingement syndrome correction surgery would benefit from the use of a hip brace because it can protect repaired tissues during early postoperative recovery. The application of hip brace helped the patients with Charcot neuroarthropathy recognize the provocative position and improved soft tissue healing without attenuation and detachment . Similarly, Woolson and Rahimtoola  suggested the prophylactic use of a hip brace during the first few weeks following THA to reduce dislocation, especially for elderly patients with a history of alcoholism, senility, or confusional states. Recently, a large sample study based on insurance database recommended the use of hip brace can promote good tissue healing in the denervated joint, especially in patients who have Charcot arthropathy . Roman et al.  verified the biomechanical benefits of hip braces in restricting movements that might result in dislocation after THA. Additionally, hip braces help enhance patient awareness, encouraging them to control their range of motion and reduce movements that risk joint dislocation. However, the research also showed that the actual extent of hip flexion exceeded the intended restriction set by the brace. This is crucially important, as it suggests that to effectively limit hip flexion to 90° clinically, the brace should be adjusted to a 70° flexion limit rather than 90° . The duration of brace wear is an important factor influencing the success of preventing postoperative dislocation. Due to the time required to form a soft tissue envelope after THA, authors suggested that hip precautions be enforced during the first 6 weeks after surgery . Hence, the results of this study suggest that the duration of brace wear would be 6 weeks. However, we also observed that prolonged use of the brace might lead to muscle weakness in some patients, necessitating further rehabilitation training to enhance muscle strength during the later stages. Although the complication rate in this study was relatively high, most of these issues were effectively managed through timely and appropriate interventions. For example, postoperative dislocation was successfully treated with closed reduction and stabilization using a hip brace, effectively preventing recurrence. Similarly, intraoperative femoral calcar fractures were treated with wire cerclage fixation. These outcomes highlight that, with effective management of complications, THA can still significantly enhance both the functional capacity and quality of life in patients with Charcot arthropathy. 6.3 Survivorship In this cohort, the survivorship was 81.8% (only two revisions occurred) at average 81‐month follow‐up. The causes of reoperation included dislocation and acetabular component loosening. Rapala and Obrębski  reported that survivorship with reoperation for any reason in patients undergoing THA for Charcot arthropathy was 50% at 9.5‐year follow‐up. The only one published cohort study reported an 67% survivorship free of reoperation at 5 years in the largest series of patients undergoing THA for Charcot neuroarthropathy . Aiming to ensure secure component fixation, most of components in their study were revision acetabular components fixed with adjuvant screw fixation. Similarly, all revised cases in our study utilized metal augment and revision acetabular component in order to achieve good coverage of cup and provide greater stability. 

Functional Scores In this series, the clinical outcomes improved obviously with respect to preoperative period. The mean VAS decreased from 2.75 preoperatively to 0.58 postoperatively. The average Oxford Hip Score enhanced form 24.36 preoperatively to 46.82 postoperatively. Likewise, the average UCLA score improved from preoperative 2.55 to postoperative 4.45 at the final follow‐up. Similarly, Chalmers et al.  reported that the Harris Hip score significantly improved from a mean of 43 (range, 34–56) preoperatively to a mean of 81 (range, 67–90) postoperatively. At the latest follow‐up, 75% of hips (9/12) had no pain and 25% of hips (3/12) had mild pain. They indicated that THA was a reliable treatment of relieving pain and improving mobility for hip Charcot arthropathy in spite of the lack of proprioceptive sensation and insensitivity to pain. Inoue et al.  described two patients with Charcot arthropathy of the hip could walk with aid without causing implant dislocation after THA at most recent follow‐up. Erdil et al.  presented a hip Charcot arthropathy underwent THA with normal range of motion of hip joint and the patient could walk with full weight bearing at final follow‐up. Total hip arthroplasty may be an appropriate therapeutic choice for reliving symptoms and improving hip joint function in these patients. 

Complications Nevertheless, the published literatures have showed high incidence of complications in patients undergoing THA for Charcot neuroarthropathy (Table ). A recent retrospective study 12 THAs has noted the overall complication rate was high at 58% (7/12). There were three recurrent dislocations, two periprosthetic fractures, one femoral stem loosening, and one wound problem. They indicated that the high rate of complication was attributed to poor medical conditions (such as uncontrolled diabetes mellitus) in involved patients . Recent study have reported that patients with Charcot neuroarthropathy who underwent THA demonstrated higher rates of postoperative complications, including dislocation, wound infections, and the need for revision surgeries, compared to those without Charcot neuroarthropathy . Similar to the previous study, our results reported a high incidence of complications following THA in this cohort. Among the 11 patients who underwent surgery, five patients experienced complications (45.5%). Specifically, there were one cases of early postoperative dislocation, one case of postoperative prosthesis loosening, two cases of intraoperative femoral fractures, and one case of deep vein thrombosis (DVT) in the lower extremities. Patients with postoperative dislocation were treated with closed reduction and hip braces until stability was restored, and follow‐up showed no recurrence. The patient diagnosed with deep vein thrombosis (DVT) in the lower extremities was treated with low molecular weight heparin for anticoagulation therapy for 6 weeks without any signs of DVT. The two patients with intraoperative femoral fractures were treated with cerclage wiring, resulting in complete healing of the fractures and good stability of the femoral components. The intraoperative calcar fractures may be partly due to osteoporosis of patients with Charcot neuroarthropathy, which increase the risk of complications. Osteoporosis and local osteopenia have been proved to have a role in Charcot arthropathy development . If so, due to the high risk of osteoporosis in this population, appropriate application of anti‐osteoporosis treatment may be considered to mitigate this risk. Regarding surgical techniques, the instability of joint structures in these patients increases the difficulty of prosthesis implantation, further elevating the likelihood of complications. However, the dislocation rate (1/11) in this cohort was relatively lower compared with previous studies. Inoue et al.  reported both two patients with hip Charcot arthropathy who experienced early postoperative dislocations after THA. Chalmers et al.  reported a high rate of dislocation at 25% and suggested the use of dual mobility or other high stability constructs in patient with Charcot arthropathy. Dagnino et al.  reported the excellent clinical results of THA with dual mobility component in Charcot hip joint at 1‐year follow‐up. The x‐rays did not show periprosthetic fractures or implant mobilization and no any reoperations occurred. We considered that the lower dislocation rate may benefit from the application of hip abduction brace. The hip brace limited the range of joint motion, thereby reducing the risk of dislocation caused by involuntary movements. Hirata et al.  conducted a biomechanical study and suggested that patients undergoing arthroscopic femoroacetabular impingement syndrome correction surgery would benefit from the use of a hip brace because it can protect repaired tissues during early postoperative recovery. The application of hip brace helped the patients with Charcot neuroarthropathy recognize the provocative position and improved soft tissue healing without attenuation and detachment . Similarly, Woolson and Rahimtoola  suggested the prophylactic use of a hip brace during the first few weeks following THA to reduce dislocation, especially for elderly patients with a history of alcoholism, senility, or confusional states. Recently, a large sample study based on insurance database recommended the use of hip brace can promote good tissue healing in the denervated joint, especially in patients who have Charcot arthropathy . Roman et al.  verified the biomechanical benefits of hip braces in restricting movements that might result in dislocation after THA. Additionally, hip braces help enhance patient awareness, encouraging them to control their range of motion and reduce movements that risk joint dislocation. However, the research also showed that the actual extent of hip flexion exceeded the intended restriction set by the brace. This is crucially important, as it suggests that to effectively limit hip flexion to 90° clinically, the brace should be adjusted to a 70° flexion limit rather than 90° . The duration of brace wear is an important factor influencing the success of preventing postoperative dislocation. Due to the time required to form a soft tissue envelope after THA, authors suggested that hip precautions be enforced during the first 6 weeks after surgery . Hence, the results of this study suggest that the duration of brace wear would be 6 weeks. However, we also observed that prolonged use of the brace might lead to muscle weakness in some patients, necessitating further rehabilitation training to enhance muscle strength during the later stages. Although the complication rate in this study was relatively high, most of these issues were effectively managed through timely and appropriate interventions. For example, postoperative dislocation was successfully treated with closed reduction and stabilization using a hip brace, effectively preventing recurrence. Similarly, intraoperative femoral calcar fractures were treated with wire cerclage fixation. These outcomes highlight that, with effective management of complications, THA can still significantly enhance both the functional capacity and quality of life in patients with Charcot arthropathy. 

Survivorship In this cohort, the survivorship was 81.8% (only two revisions occurred) at average 81‐month follow‐up. The causes of reoperation included dislocation and acetabular component loosening. Rapala and Obrębski  reported that survivorship with reoperation for any reason in patients undergoing THA for Charcot arthropathy was 50% at 9.5‐year follow‐up. The only one published cohort study reported an 67% survivorship free of reoperation at 5 years in the largest series of patients undergoing THA for Charcot neuroarthropathy . Aiming to ensure secure component fixation, most of components in their study were revision acetabular components fixed with adjuvant screw fixation. Similarly, all revised cases in our study utilized metal augment and revision acetabular component in order to achieve good coverage of cup and provide greater stability. 

Limitations and Strengths of This Study There are several limitations in present study. Due to the rarity of Charcot arthropathy, the sample size was extremely limited, making it challenging to implement complex statistical analyses. Therefore, the power of the data analysis may not be entirely sufficient to arrive at a conclusion. Our study lacks a comparative baseline without a control group, making it difficult to definitively establish efficacy or predict outcomes on a broader scale. Yet, there is only one cohort study  regarding this issue published before. We believe that the results of present study offer further evidence. All surgeries were performed by the same senior surgeon at a single medical institution, which limits the generalizability of the finds due to potential skill and experience bias among different surgeons. These limitations highlight the need for future multicenter studies with larger sample sizes, standardized protocols, and control groups to better evaluate the long‐term outcomes and generalizability of THA in Charcot arthropathy patients. Despite these limitations, the study offers significant contributions. It introduces a unique combined treatment approach with hip braces, which demonstrates potential advantages in reducing dislocation and improving postoperative stability. Furthermore, the study provides long‐term follow‐up data (average of 81.73 months) for a population whose surgical outcomes have not been systematically validated in previous literature. These findings address an important gap in clinical understanding and provide valuable evidence that could guide future studies and clinical practice. In the revised manuscript, we will discuss these limitations and contributions in detail and propose future research directions to build upon the findings presented here. 

Conclusions In conclusion, our results at a mean of 81.73 months reported satisfactory improvement of functional score and proper survival rate of components with reoperation for any cause as the end point, even though the incidence of complications was relatively high. Considering the restoration of hip joint and the improvement of mobility following THA, we suggest that THA may be a reasonable option to treat Charcot arthropathy of hip joint under a sufficient understanding about risk of complications. The anti‐osteoporosis treatment and the application of hip brace are proper method to reduce the risks of aseptic loosening and instability. Therefore, the authors of present study consider that Charcot's arthropathy may not be an absolute contraindication for the total hip arthroplasty. 

Long‐Teng Chao, Teng‐Feng Zhuang, Song‐Wei Huan: collected and analyzed the patient data. Si‐Min Luo, Chong‐Jie Wu, Wen‐Rui Wu, Zhen‐Gang Zha: designed the protocol of this study. Long‐Teng Chao: was a major contributor in writing the manuscript. Ning Liu, Huan‐Tian Zhang: were major contributor in the revision of this manuscript. All authors read and approved the final manuscript. 

The ethnic approval of this retrospective study was obtained from the institutional review board of the hospital and was in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. 

All the authors agreed with the publication guidelines of the journal and no patient identifiable data is included in this manuscript. Freely given, informed consent was obtained from all patients in this study for all procedures undertaken and all data obtained. 

The authors declare no conflicts of interest. 

