Twenty patients with severe neuropathic (Charcot) ankle deformities underwent 21 attempted ankle fusions with a retrograde locked intramedullary nail as an alternative to amputation. All had insensate heel pads and had failed at nonoperative methods of accommodative ambulatory bracing. In 11, the talus was either absent, or the deformity was of sufficient magnitude to require talectomy to align the calcaneus under the tibia for plantigrade weightbearing. Ages ranged from 28 to -68 (average 56.3) years. Nineteen were diabetic, 12 being insulin-dependent. Their average body weight was 102 kg, with 11 greater than 90 kg at the time of surgery. Eight had chronic large full thickness ulcers overlying, but not involving bone of the medial malleolus, medial midfoot, or proximal fifth metatarsal, at the time of surgery. At a follow-up of 12 to 31 months, 19 achieved bony fusion. In the 10 patients where talectomy was not required, fusion was achieved at an average of 5.3 months without complications. In the patients who required talectomy, six of the patients required eight additional operations to achieve fusion. Three achieved fusion following removal of the nail and prolonged bracing. One opted for ankle disarticulation for chronic persistent infection, rather than attempt reoperation. One died of unrelated causes during the early postoperative period. Retrograde locked intramedullary ankle fusion is a reasonable alternative to amputation in the neuropathic (Charcot) ankle that cannot be controlled with standard bracing techniques. The potential for morbidity requiring reoperation is greatly increased when the deformity is of sufficient magnitude to require talectomy to achieve alignment of the calcaneus in a plantigrade weight-bearing position under the tibia or when there are large open ulcers.