It is widely recognized that diabetes melitus (DM) increases the likelihood of postoperative complications following foot and ankle surgery [1,2], not to mention that this condition is the most significant risk factor for amputation following tibiotalocalcaneal arthrodesis (TTCA) [3]. Charcot neuroarthropathy (CN) in particular, is a severe chronic complication of diabetes which causes progressive bone and joint destruction, thus leading to deformity, altered biomechanics, and increased risk of ulcer development. More specifically, with a prevalence of 10% in diabetic patients with established peripheral neuropathy [4], the above condition occurs not only as a result of autonomic dysfunction with associated increased blood flow through arteriovenous (AV) shunting, but also due to repetitive microtrauma secondary to insensate joints [5].

From an epidemiological standpoint, the lifetime risk of developing a diabetic foot ulcer ranges between 19% and 34% [6]. In the presence of active foot ulcerations, infection and osteomyelitis develop in 50%–60% and 20% of patients, respectively. Furthermore, a 20% incidence of lower extremity amputation occurring as a late sequalae of moderate to severe unmanageable infections has been documented [6,7]. Given the above, the economic burden inflicted on the health care systems is considerable, with the estimated cost for the National Health System in the United Kingdom varying between 837 and 962 million pounds for 2014–2015 [8].

Diabetic patients suffering from CN may progressively develop deformity in their feet, which sometimes warrants surgical reconstruction. The treatment goal of CN is to achieve a plantigrade infection-free foot that can be managed with therapeutic footwear. The current indications for surgical correction include clinically and radiographically nonplantigrade foot deformity with or without an open wound and osteomyelitis [9]. The surgical methods to achieve this objective are as follows: exostectomy, arthrodesis of midfoot and/or hidfoot and/or ankle, amputations, reconstruction of midfoot or/and hindfoot using large medial plate and screw constructs, intramedullary nails, ‘beaming’ with large intramedullary screws placed percutaneously through the metatarsals into the hindfoot thus causing less soft tissue irritation and achieving improved compression, external thin-wire frame fixation and combined internal and external fixation [[9], [10], [11], [12]].

Of note, given the immunocompromised status of the diabetic individuals, patients with surgical reconstructions tend to be prone to infections that could be either superficial or deep-seated in nature. Although multiple methods describing as to how to eradicate such a deep-seated infection have been reported in the literature (featuring antibiotic therapy, surgical debridement, removal of metalwork, panarthrodesis, external fixation, skin graft application, and amputations), no clear guidelines have been established for this group of patients as of yet [[13], [14], [15]]. Therefore, the purpose of this study was to systematically review the infection-related outcomes following internal fixation of Charcot feet in diabetic population.