Background. The treatment of chronic calcaneal osteomyelitis is a challenging and increasing problem because of the high prevalence of diabetes mellitus and operative fixation of heel fractures. In 1931, Gaenslen reported treatment of hematogenous calcaneal osteomyelitis by surgical excision through a midline, sagittal plantar incision. We have refined this approach to allow successful healing and early mobilization in a modern series of complex patients with hematogenous, diabetic, and postsurgical osteomyelitis. Methods. Twenty-eight patients (mean age 54.6 years, range 20–94) with Cierny-Mader stage IIIB chronic osteomyelitis were treated with sagittal incision and calcaneal osteotomy, excision of infected bone, and wound closure. All patients received antibiotics for at least 6 weeks, and bone defects were filled with an antibiotic carrier in 20 patients. Patients were followed for a mean of 31 months (SD 25.4). Primary outcome measures were recurrence of calcaneal osteomyelitis and below-knee amputation. Secondary outcome measures included 30-day postoperative mortality and complications, duration of postoperative inpatient stay, footwear adaptions, mobility, and use of walking aids. Results. All 28 patients had failed previous medical and surgical treatment. Eighteen patients (64%) had significant comorbidities. The commonest causes of infection were diabetes ± ulceration (11 patients), fracture-related infection (4 patients), pressure ulceration, hematogenous spread, and penetrating soft tissue trauma. The overall recurrence rate of calcaneal osteomyelitis was 18% (5 patients) over the follow-up period, of which 2 patients (7%) required a below-knee amputation. Eighteen patients (64%) had a foot that comfortably fitted into a normal shoe with a custom insole. A further 6 patients (21%) required a custom-made shoe, and only 3 patients required a custom-made boot. Conclusion. Our results show that a repurposed Gaenslen calcanectomy is simple, safe, and effective in treating this difficult condition in a patient group with significant local and systemic comorbidities

Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to functionally block the ankle and subtalar joints to treat severe ankle and hindfoot disease. Complication rates range between 20-40%, with below-knee amputation rate 1.5-19%. The heterogeneous patient cohort and indication(s) for surgery make post-operative outcomes difficult to predict. Consulting patients about potential pain and functional outcomes is difficult. When researching this area commonly, PROM data is used, less frequently functional objective measures like the 2-minute-walk-test (2MWT) are used. The aim was to compare the PROMs and objective outcomes between patients who underwent TTCA and BKA. Fifty-two patients underwent a TTCA using an intramedullary hindfoot nail. Indications for TTCA, post-traumatic OA, failed arthrodesis and malalignment. These patients were compared to 11 patients who underwent unilateral below knee amputation (BKA) due to trauma. Outcomes measures PROMs AOFAS ankle hindfoot scale and Shor-Form 36 (SF-36). Objective measures; 2MWT, Timed-up-and-go (TUG). Mean age TTCA 55.9, BKA 46.4. Average follow-up time 53 months. TTCA group had average 6.3 operations prior to arthrodesis (range 1-23). Of the TTCA group two ankles did not unite (7%), all complication rate 35%, 18% reported no pain. A significant negative correlation was demonstrated between the clinical outcome and the number of surgeries prior to the TTCA. TUG and 2MWT had significantly (p<0.05) better outcomes for the BKA group compared to TTCA. SF-36 BKA patients scored higher than the TTCA patients on physical functioning (p<0.01) and mental health (p<0.05) subscales as well as the mental component score (p<0.05). This study gives clinicians evidence about the natural history of hindfoot arthrodesis and functional outcomes from BKA. Hopefully this study will improve evidence to help patients and surgeons make decisions about expected surgical outcomes from TTCA and BKA procedures

Introduction. Osseointegration is a potential treatment option for transfemoral amputees experiencing socket related problems. Till this date, there is little data assessing the feasibility and advantages of osseointegration in individuals with transtibial amputations. Materials and Methods. We prospectively followed 91 patients undergoing transtibial osseointegration from 2014–2018 who either 1) reported pain or mobility dissatisfaction with socket prosthesis; 2) had an intact limb with incapacitating pain, complex deformity, or profound distal weakness or 3) were recent amputees preferring osseointegration. Adverse events were monitored including infection, periprosthetic fracture, implant breakage, aseptic loosening, revision surgery/additional amputation and death. Functional outcomes were measured using the Questionnaire of persons with a Trans-femoral amputation (Q-TFA) and mobility was assessed using Six Minute Walk Test (6MWT) and Time Up and Go (TUG). Results. Following osseointegration surgery, there was a significant increase in the Q-TFA global score, the 6MWT and the K-levels during follow-up. At one year following Osseointegration surgery, all patients were pain-free, the 11 patients who were wheelchair-bound prior to surgery were ambulatory, and the other 27 patient unable to walk prior to surgery, demonstrated improved mobility. There were 7 cases of implant removals due to pain and loosening and 10 cases of revisions within an average of 1.8 years, of which 1 was aseptic loosening, 6 due to infection, 1 failure to integrate and 2 implant fractures. No periprosthetic bone fractures occurred. Conclusions. Transtibial osseointegration results in improved functional outcomes after amputation. Complications are manageable and should decrease with surgical and implant improvements

Objectives. The surgical challenge with severe hindfoot injuries is one of technical feasibility, and whether the limb can be salvaged. There is an additional question of whether these injuries should be managed with limb salvage, or whether patients would achieve a greater quality of life with a transtibial amputation. This study aims to measure functional outcomes in military patients sustaining hindfoot fractures, and identify injury features associated with poor function. Methods. Follow-up was attempted in all United Kingdom military casualties sustaining hindfoot fractures. All respondents underwent short-form (SF)-12 scoring; those retaining their limb also completed the American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS F&A) outcomes questionnaire. A multivariate regression analysis identified injury features associated with poor functional recovery. Results. In 12 years of conflict, 114 patients sustained 134 fractures. Follow-up consisted of 90 fractures (90/134, 67%), at a median of five years (interquartile range (IQR) 52 to 80 months). The median Short-Form 12 physical component score (PCS) of 62 individuals retaining their limb was 45 (IQR 36 to 53), significantly lower than the median of 51 (IQR 46 to 54) in patients who underwent delayed amputation after attempted reconstruction (p = 0.0351). Regression analysis identified three variables associated with a poor F&A score: negative Bohler’s angle on initial radiograph; coexisting talus and calcaneus fracture; and tibial plafond fracture in addition to a hindfoot fracture. The presence of two out of three variables was associated with a significantly lower PCS compared with amputees (medians 29, IQR 27 to 43 vs 51, IQR 46 to 54; p < 0.0001). Conclusions. At five years, patients with reconstructed hindfoot fractures have inferior outcomes to those who have delayed amputation. It is possible to identify injuries which will go on to have particularly poor outcomes. Cite this article: P. M. Bennett, T. Stevenson, I. D. Sargeant, A. Mountain, J. G. Penn-Barwell. Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years. Bone Joint Res 2018;7:131–138. DOI: 10.1302/2046-3758.72.BJR-2017-0217.R2

Introduction. Advances in the management of open tibial fractures have reduced the incidence of long-term complications of these injuries. However, a number of patients continue to suffer from sequelae such as infection, non-union and malunion. Many orthopaedic surgeons believe a below-knee amputation with a well-fitted prosthesis is a better alternative to limb reconstruction surgery. There are few studies that evaluate the long-term functional outcomes of amputees against patients who have undergone limb salvage procedures, and their results are conflicting. The hypothesis of this study is that patients who have undergone limb salvage have as good or better outcomes than those who have had below-knee amputations. Methods. This is a retrospective case study. One group (n=12) had been treated with below-knee amputation following a variety of lower limb fractures. The other group (n=11) had developed complications following tibial fractures and undergone limb salvage surgery using the Ilizarov method. The groups were compared by means of a postal questionnaire, comprising the Oswestry Disability Index and the SF-36 Health Survey. Results. There were no statistically significant differences between the groups for any of the health scales measured. However, for the two scales in the SF-36 measuring functional health (Physical Functioning and Role-Physical) the differences were much lower than for any of the other scales (both p=0.13). The 95% confidence intervals for the difference between the means for each group were -6.4 to 45.4 for PF and -7.4 to 61.2 for RP. Discussion. This study provides evidence that limb conserving surgery offers a genuine improvement in long term functional health. The failure to reach statistical significance is a reflection of the relatively small numbers of patients affected and the difficulties in collecting data retrospectively

A retrospective case control study of all rehabilitated patients who suffered amputations of the lower extremity by sepsis was performed in the HELIOS centre of rehabilitation for amputees, Bad Berleburg, Germany. This study examines patients who had undertaken an amputation of the lower extremity caused by severe sepsis and septic shock. Methods: Case control study. The clinical reports of 448 patients with amputations of the lower extremity clinically rehabilitated from 2010 to 2013 were systematically and statistically evaluated. Sepsis is classified in 4 categories: SIRS, sepsis, severe sepsis and septic shock. Epidemiology: The mean age of the amputees was 61.33 years, with 25 men and 11 women. Marital status: 16 patients are married (44.44%), 7 divorced, 5 widowed, 7 unmarried, 1 unknown. 24 patients are retired (66.67%). School-leaving qualifications: 22 elementary school (61.11%), 8 secondary school, 1 high school, 5 unknown. Health insurance: AOK 10 patients (27.77%), BEK 7 patients (19.44%), pension insurance 9 patients (25.0%). The medial time of hospitalization in the clinic for rehabilitation of the amputated patients suffering sepsis was 27.23 days. Results: 36 patients, – 8.03 % of all – with 39 amputations, suffered a loss of the lower extremity caused by severe sepsis and septic shock: 1 patient suffered an exarticulation of both hips, 20 patients suffered a transfemoral amputation (1 patient had a transfemoral amputation of both legs), 17 patients lost their leg by transtibial amputation (1 patient had a transtibial amputation of both legs). 13 patients presented a sepsis by MRSA (multiresistant Staph. aureus 36.11%), 8 patients with MSSA (multisensible Staph. aureus), 4 patients with multiresistant Acinetobacter (8.33%), 2 patients with MRSE (multiresistant Staph. epidermidis), 13 patients with other multiresistant germs (36.11%) such as Streptococcus B, Enterococcus faecalis, Enterobacteriaceae, Klebsiella. Mobility class of amputees at the beginning of hospitalization: class 0 (= non walkers) all 36 patients (100%). Mobility class of amputees at the end of hospitalization: class 0 (= non walkers) are 5 patients (27.78%), class 1 (= only inside walkers) are 5 patients (13.89%), class 2 (= inside and little outside walkers) are 18 patients (50.00%), class 3 (= inside and good outside walkers) are 3 patients (8.33%). Amputation of the lower extremity following severe sepsis and septic shock is not rare – in our group we found more than 8%

Aim. Chronic osteomyelitis of the calcaneus is a frequent problem in a population of diabetic patients, patients with neurologic disorders or bedridden patients with ulcers. Partial calcanectomy is an alternative option which avoid major amputation. The aim of this retrospective study was to determine the effectiveness of partial calcanectomy for treating chronic osteomyelitis of the calcaneux. Method. We conducted a retrospective review of patients who underwent in our department a partial calcanectomy between 2006 and 2015. All patients with a complete set of radiographs and adequate follow-up (minimum 2 years) were included. We reviewed these cases to determine healing rate, microbiological analysis, risk factors of failure (comorbidities), limb salvage rate and survival rate. We analyzed specifically the footwear and the functional subjective evaluation according to the LEFS score (Lower Extremity Functional Scale). Results. Twenty-four patients were included (24 foot). There were 17 men and the mean age was 65.2 years. The control of the infection and the healing was obtained in 15 cases. An additional surgery was required in 46% of the cases. A transtibial amputation has been realized in 9 cases because of uncontrolled infection. The existence of a preoperative vascular disease increased 5,9 times the risk of amputation after a partial calcanectomy (p=0,033). The type of germ was not related to the risk of recurrence. Soles were necessary for 60% of the patients with a successful partial calcanectomy (n=15). The average LEFS score was 51/80. Conclusion. The treatment of the chronic osteomyelitis of the calcaneus was a therapeutic challenge for these patients. The partial calcanectomy is a useful procedure for limb salvage, but the selection of patients must be rigorous. In our study, arteriopathic patients had a high risk of amputation after partial calcanectomy. When the healing is acquired, the patients were satisfied and presented a good function

Chronic calcaneal osteomyelitis is a rare and not usually part of the initial differential diagnosis of pseudotumoral calcaneal lesions. Presentation of surgical and functional outcomes of a case of a total calcanectomy. This can be seen as a foot rescue alternative in patients with chronic calcaneal osteomyelitis. We present the case of a 60 year- old patient with complaints of diffuse and intermittent pain in the left heel with 3 years of evolution. Radiographically, lytic lesion image sclerotic edges that covers the entire calcaneus, with preservation of cortical. MRI shows holo-calcaneal lesions compatible with tumor, infectious or inflammatory lesion. A biopsy is inconclusive. Negative microbiology results. Regular analytical study. It was decided to conduct a total calcanectomy. Procedure took place without complications. Patient still skin healing phase, without any pain complaint. It presents iconographic material made if and procedure. The total calcanectomy is an alternative procedure to transtibial amputation in patients with chronic calcaneal osteomyelitis

Background: Amputation of the distal fibula for malignant tumors is accepted practice. Few studies have reported limb salvage surgery for malignant tumors of the distal fibula. After distal fibulectomy, the main concerns are local recurrence of the tumor and ankle instability and deformity related to total resection of the lateral malleolus. Our objective was to analyze the oncologic and functional outcome of lateral malleolus en bloc resection for malignant tumors of the distal fibula, with special attention to operative techniques, reconstruction methods, and postoperative complications. Methods: The authors identified ten patients who had malignant tumors of the distal fibula requiring total resection of the lateral malleolus. The patients’ medical records, operative reports, radiographs, and the histologic specimens were reviewed. There were four children (mean age, 7.5 years) and six adults (mean age, 42.16 years). The distal metaphysis was involved in seven patients and the epiphysis in three. There were four osteosarcomas, three chondrosarcomas, two Ewing sarcomas, and one adamantinoma. The most common symptoms at presentation were a palpable mass in nine patients, ankle pain in six, and pathologic fracture in one. The mean duration of symptoms before diagnosis and treatment was nineteen months. All patients had operative treatment; two patients with osteosarcoma had perioperative chemotherapy and one patient with Ewing sarcoma had radiotherapy and chemotherapy and another patient with Ewing sarcoma had chemotherapy only. Two types of “en bloc” resection of the distal fibula were performed. Wide (type II) extra-articular resection was performed in seven patients. Marginal (type I) intra-articular resection of the distal fibula was performed in three patients. After resection, a primary ankle arthrodesis was performed in four adults and postoperative bracing without any reconstruction in four children and two adults. Results: Within a mean follow-up time of 14.4 years (range, three to thirty years), tumor recurred locally in two patients after a marginal type I resection of a chondrosarcoma, and in one after a type II wide extra-articular resection of an osteosarcoma. All ten patients were disease-free at latest follow-up examination. Six patients had reoperation. A below-knee amputation was performed in three patients for chronic osteomyelitis, for local recurrence of chondrosarcoma, and for a late adamantinoma of the tibia. One patient had further soft tissue and bone reconstructive surgery for lateral talus subluxation and cavovarus deformity. Another patient required ankle arthrodesis for recurrent ankle instability and ankle joint degenerative changes. One patient had wide re-resection for local recurrence of an osteosarcoma. All ten patients were ambulatory at latest follow-up evaluation. Four adult patients who underwent primary arthrodesis and one child who had no initial reconstruction and had late ankle arthrodesis had a satisfactory outcome, with an ISOLS functional score of 27.6 (92%). Two adolescents who had postoperative bracing without any soft tissue reconstruction had an ISOLS functional score of 24 (80%) with no ankle pain and satisfactory function; they used an ankle-foot orthosis during sports activities. Three patients who subsequently required below-knee amputation used a below-knee prosthesis for ambulation. Conclusions: Limb salvage surgery for high-grade malignant tumors of the distal fibula can be achieved by wide extra-articular resection. For low-grade malignant tumors or high-grade tumors responding to adjuvant therapy, a more conservative marginal intra-articular resection may be adequate. Primary arthrodesis is indicated in adults after wide extra-articular resection. In children, repair of the lateral soft tissues and reconstruction of the tibiofibular mortise is necessary after tumor resection to avoid late ankle deformity or instability

Aims. Ilizarov described four methods of treating non-unions but gave little information on the specific indications for each technique. He claimed, ‘infection burns in the fire of regeneration’ and suggested distraction osteogenesis could effectively treat infected non-unions. This study investigated a treatment algorithm for described Ilizarov methods in managing infected tibial non-union, using non-union mobility and segmental defect size to govern treatment choice. Primary outcome measures were infection eradication, bone union and ASAMI bone and function scores. Patients and Methods. A consecutive series of 79 patients with confirmed, infected tibial non-union, were treated with one of four Ilizarov protocols, consisting of; monofocal distraction (26 cases), monofocal compression (19), bifocal compression/distraction (16) and bone transport (18). Median non-union duration was 10 months (range 2–168). All patients had undergone at least one previous operation (mean 2.2; range 1–5), 38 had associated limb deformity and 49 had non-viable non-unions. Twenty-six cases (33%) had a new simultaneous muscle flap reconstruction at the time of Ilizarov surgery and 25 had pre-existing flaps reused. Treatment algorithm based on assessment of bone gap and non-union stiffness, measured after resection of non-viable bone. Results. The treatment algorithm was easy to apply, being based on easily assessable criteria. Infection was eradicated in 76 cases (96.2%) at a mean follow-up of 40.8 months (range 6–131). All three cases of infection recurrence occurred in the monofocal compression group. They required repeat excision and Ilizarov distraction in two cases and below-knee amputation in one. Union was achieved in 68 cases (86.1%) with the initial Ilizarov methods alone. Union was highest amongst the monofocal distraction and bifocal compression/distraction groups, 96.2% and 93.8% respectively. Mean external fixator time was 7.5 months (range 3–17). Monofocal compression was successful in only 73.7% of mobile non-unions, with significantly lower ASAMI scores and a 26.3% re-fracture rate. Bone transport secured union in 77.8% (14/18) but with a 44.4% unplanned reoperation rate. However, after further treatment, infection-free union following bone transport was 100%. Conclusion. We cannot recommend Ilizarov monofocal compression in the treatment of infected, mobile non-unions. Distraction (monofocal or bifocal) was effective and is associated with higher rates of union and infection clearance

Aims

Revision rates for ankle arthroplasties are higher than hip or knee arthroplasties. When a total ankle arthroplasty (TAA) fails, it can either undergo revision to another ankle replacement, revision of the TAA to ankle arthrodesis (fusion), or amputation. Currently there is a paucity of literature on the outcomes of these revisions. The aim of this meta-analysis is to assess the outcomes of revision TAA with respect to surgery type, functional outcomes, and reoperations.

Background. Subtalar nonunion has a detrimental effect on patients' function, and pose a significant challenge for surgeons particularly in the setting of higher risk factors. Methods. We retrospectively analyzed a consecutive series of 49 subtalar nonunions between October 2001 and July 2013. Patient records and radiographs were reviewed for specific patient demographics and comorbidities, subsequent treatments, revision fusion rate, use of bone graft, complications, and clinical outcome. Results. Forty-nine patients with a mean age of 49 years (range 23–80) were included. Sixteen (32%) were heavy smokers (>1 pack per day) and five (10%) had diabetes. Forty one (84%) of the nonunions were symptomatic and underwent a revision procedure at a mean of 16 months (range 2.8 to 57) from the time of the primary arthrodesis. Four of these patients required a triple arthrodesis at the time of revision. Bone graft was used in all cases, and in 25 cases (61%) additional adjuvant orthobiologics. Thirty-two (78%) of the patients achieved a solid arthrodesis at a mean of 3.4 months (range 1.4 to 7.6). Patients who were diabetic and smokers as a group had a 68% rate of union. Of the nine nonunions following a revision arthrodesis, five were in the setting of a prior ankle arthrodesis, three were complicated by a deep infection, and one had no obvious risk factors. Four of the repeat nonunions elected to not undergo an additional procedure, two had a successful third attempt at arthrodesis, one had an additional nonunion followed by a successful fourth attempt at arthrodesis, one had a successful tibiotalocalcaneal arthrodesis, and one ultimately required a below-knee amputation. Discussion. Management of subtalar nonunions pose a significant challenge with a low rate of arthrodesis at 78% fusion rate, but which can be achieved with rigid fixation and utilization of bone graft and orthobiologics

Aims

Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach.

Aims

Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier.

The Zenith. TM. total ankle replacement (Corin, Cirencester) is a mobile-bearing implant based on the Buechal Pappas design. Key features are the simple fully-jigged instrumentation aiming to improve accuracy and reproducibility of implant positioning, cementless calcium phosphate coated surfaces for improved early osseointegration, and titanium nitride-coated bearing surfaces to resist wear. We present early to mid-term survival data for 155 total ankle replacements implanted by three surgeons in our institute. Case records of all patients undergoing Zenith. TM. Total Ankle Replacement by three senior surgeons, including a member of the design team, between 2007 and 2014 were examined. Patients were examined clinically and radiographically annually after the early postoperative period. The primary outcome measure was implant survival. Secondary outcome measures included complication rates, parameters of radiographic alignment, and radiographic evidence of cysts and loosening. One hundred and fifty-five cases were performed for a mixture of primary pathologies, predominantly primary or posttraumatic arthrosis. Mean follow-up was 50 months. Implant survival was 99.0% at 3 years (n=103), 94.0% at 5 years (n=50), and 93.8% at 7 years (n=16). One patient was revised to arthrodesis for aseptic loosening, one arthrodesis was performed for periprosthetic infection with loosening, and one below-knee amputation was performed for chronic pain. Three cases underwent further surgery to address cysts, and 7 malleolar fractures were reported. Medial gutter pain was experienced by 9% of patients. Overall, our data show excellent early and mid-term survivorship for the Zenith. TM. Total Ankle Replacement. Simple fully-jigged instrumentation allows accurate and reproducible implant alignment

Introduction. Diabetes is increasing on a global scale. By 2030, 10% of the global population, ½ billon people, are predicted to have diabetes. Potentially there will be a corresponding increase in number of patients referred for surgery. Traditional surgical management of these patients is challenging. Presented is a case series utilizing Minimally Invasive Surgical Techniques of percutaneous metatarsal neck osteotomies, metatarsal head debridement, mid-foot closing-wedge osteotomies and hind-foot arthrodesis, for the surgical management of diabetic foot pathology. The potential socio-economic benefits analysis with regards to reduction in out-patient and theatre time, patient length of stay and time to healing are also postulated. Methods. Minimally Invasive Surgical Techniques of metatarsal neck osteotomy, metatarsal head debridement, closing wedge osteotomy, mid-fusion and hind-foot arthrodesis nailing are described. Procedures are preformed as day cases with fluoroscopic guidance. Low speed, high torque burrs and wedges, create the osteotomies, which can be held with percutaneous fixation. Comparative cost analysis of conservative treatment, including clinic visits, out-patient debridement, dressings, intravenous and oral antibiotics, versus Minimally Invasive Surgical Techniques is presented. Results. Six patients had metatarsal osteotomies for mechanical ulceration. Five reported good outcome. One patient required revision to forefoot arthroplasty due to mal-union. Five patients had debridement of metatarsal heads, which healed on average at six to eight weeks. Eight patients had mid-foot arthrodesis. Two infected cases required removal of metalwork. Three patients had hind-foot arthrodesis for arthritis following ankle fracture with degeneration and deformity. Patients had good short and early medium term outcomes, with no reports of below-knee amputation. This technique is reproducible once the initial learning curve is mastered. Comparative cost analysis, suggests significant financial savings by reducing inpatient admissions, clinic visits and theatre time. Conclusion. Minimally Invasive Surgical Techniques may provide an alternative surgical management for diabetic patient with foot and ankle pathology

We reviewed 78 femoral and tibial non-unions treated between January 1992 and December 2003. Of these, we classified 41 as complex non-unions, because of infection (22), bone loss or prior failed surgery to produce union. These were treated with Ilizarov frames. 39 of the 41 nonunions healed successfully at a median time of 11 months. Using the ASAMI scoring system, we had 17 excellent, 14 good, 4 fair and 6 poor bone results. The functional results were excellent in 14, good in 14, fair in 2 and poor in 2. All but 2 patients were extremely satisfied with the results. The average cost of treatment to the treating hospital was approximately £30,000 per patient. In comparison the cost for a patient with a below-knee amputation was £999 per year. This would amount to a cost of £36,000 per patient in their lifetime. There is therefore not a great difference between the cost of limb salvage and amputation. The difference that exists favours limb salvage, if patient selection can accurately predict the salvage of a useful limb. Early referral to tertiary centres would reduce the morbidity and the prolonged time off work. The results justify the expense but the NHS needs to make financial provision for reconstruction of complex nonunions

Presenters Position:. Purpose of Study:. To perform a retrospective audit of the spectrum of management of tibial pseudarthrosis by a single surgeon over a seven year time period. Description of Methods:. All discharge summaries and operation logs from 2004 to 2011 were reviewed to identify patients, and their case notes and x-rays were examined. Patients were contacted telephonically for follow-up examination. Summary of Results:. Eleven patients presented with pseudarthrosis or bowing of the tibia (six females, five males, age range 4 months–7 years). Three were being treated conservatively and two patients had undergone primary below-knee amputation for severe deformity and functional deficit. Six patients had undergone resection of the pseudarthrosis with intramedullary fixation with a Williams' rod. Three of these patients had Neurofibromatosis type 1. In all instances autogenous iliac crest bone graft was used. Fibular osteotomy was performed in five of these patients and the fibula was stabilised with a K-wire in four patients. All patients were discharged in an above knee cast. Mean follow-up from 1st surgery was 23.75 (1.5–72) months. In one patient, histology confirmed suspected fibrous dysplasia. One patient had had a revision procedure 12 months prior to last follow-up for re-fracture and rod displacement. Mean residual deformity was recorded as 4.2° (1° to 10°) valgus and 6.6° (−2° to 20°) anterior bowing. We had no instances of non-union or sepsis at latest follow-up in this small series. Conclusion:. Patients with tibial pseudarthrosis have a wide spectrum of presentation. Not every patient requires immediate surgery. Our treatment aim in the young patient is to maintain optimum ambulation, clinical union and alignment with radiographic appearance assuming secondary consideration. In our hands, internal fixation using a Williams' rod with autograft is safe and effective as the initial surgical procedure. Continued follow-up of these patients is mandatory as the risk of complications is high even after apparent union

The purpose of this study is to present the surgical and functional results of a partial and total calcanectomy procedure as a foot salvage alternative in patients with extensive chronic osteomyelitis of the calcaneus. Material: A retrospective review identified 19 calcanectomies in 16 patients: 5 partial, 11 total and 3 partial to total. The primary diagnosis was insulin-dependent diabetes mellitus (3 patients), neurophatic ulceration (2 patients), infected osteosynthesis (4 patients) and open fracture (7 patients). The average age of the patients was 42.36 years (range from 22 to 60). Prior procedures included removal of osteosynthesis, debridement, Gaenslen’s procedure and skin grafting. Operation was based in Martini’s technique. Most common bacteria were Staphylococcus aureus. Antibiotic treatment was based in cultures and has changed during this period of time. Results: Four patients were lost (2 died) and the rest average follow-up was 9.8 years (range from 1 to 19 years). Recurrence of infection was present in 3/5 partial calcanectomies and in 1/14 of total calcanectomies. Talonavicular subluxation occurred as a late complication in the patient with recurrence after total calcanectomy and underwent a below-knee amputation. An assessment of functional ambulation was performed in all 16 patients according Volpicelli scale; the lost patients were recorded last time they were visited. All ambulatory patients needed a modified heel-containment orthosis. Conclusions: Total calcanectomy is an alternative procedure to a bellow-knee amputation in patients with chronic osteomyelitis of the calcaneus. In our hands, partial calcanectomy has worse results in eradication of infection and we have left it

Introduction. We present our experience of lower limb reconstruction for patients with obvious defects in the tibia, by bone transport using a stacked Taylor Spatial Frame. Methods. A retrospective review of 40 patients treated between 2003 and 2009. There were 19 cases of infected non union, 9 cases of acute bone loss following fracture, 6 cases of chronic osteomyelitis, 4 cases of aseptic non union, 1 case of neurofibromatosis and 1 case of a loose and infected total ankle replacement. Results. 28 out of the 40 patients reviewed have completed their treatment. Of these 28 patients, bony union was achieved in 23 patients, of whom 22 were assessed at discharge to have regained good to excellent limb function; a functional assessment was not available for review in the remaining patient. In 5 patients docking site union failed, 3 of whom then underwent below-knee amputation. Two patients required treatment with an intramedullary nail following frame treatment to achieve consolidated union of the docking site. Anatomic sagittal and coronal alignment was achieved in 19 out of 23 patients. The mean bone regenerate was 53.3 mm (range: 15-180mm), with a mean healing index of 9.2 days/mm (range: 4.4-25 days/mm). The majority of patients experienced at least one complication; these included pin site and soft tissue infections, refracture, nerve palsy and joint stiffness. Surgical stimulation of the docking site was required in 12 of the 28 patients to promote union. Conclusion. The use of a stacked Taylor Spatial Frame system is effective for restoring bone length and limb function in patients with bone loss following complex trauma and orthopaedic cases. The computer assisted nature of the spatial frame allows for predictable bone regenerate, minimal residual deformity and accurate bone docking