Background. Charcot neuroarthropathy is a destructive disease characterized by progressive bony fragmentation as a result of the isolated or accumulative trauma in patients with decreased sensation that manifests as dislocation, periarticular fractures and instability. Although amputation can be a reasonable cost economic solution, many patients are willing to avoid that if possible. We explored here one of the salvage procedures. Methods. 23 patients with infected ulcerated unstable Charcot neuroarthropathy of the ankle were treated between 2012 and 2017. The mean age was 63.5 ±7.9 years; 16 males and 7 females. Aggressive open debridement of ulcers and joint surfaces, with talectomy in some cases, were performed followed by external fixation with an Ilizarov frame. The primary outcome was a stable plantigrade infection free foot and ankle that allows weight bearing in accommodative foot wear. Results. Limb salvage was achieved in 91.3% of cases at the end of a mean follow up time of 25 months (range: 19–32). Fifteen (71.4%) solid bony unions were evident clinically and radiographically, while 6 (28.5%) patients developed stable painless pseudoarthrosis. Two patients had below knee amputations due to uncontrolled infection. Conclusion. Aggressive debridement and arthrodesis with ring external fixation can be used successfully to salvage severely infected Charcot arthropathy of the ankle. Pin tract infection, delayed wound healing and stress fracture may complicate the procedure but can be easily managed. Amputation may be the last resort in uncontrolled infection

Introduction

Severe, multiplanar, fixed, pantalar deformities present a challenge to orthopaedic surgeons. Surgical options include limb salvage or amputation. This study compares outcomes of patients with such deformities undergoing limb preservation with either pantalar fusion (PTF) or talectomy and tibiocalcaneal fusion (TCF), versus below knee amputation (BKA).

Introduction

Uncontrolled deep sepsis in the diabetic foot often leads to below knee amputation (BKA). However, for deep sepsis in the forefoot, a transmetatarsal amputation can be curative while preserving the native ankle and hindfoot and allowing mobility without a prosthesis. We critically examined the outcome of transmetatarsal amputation in our diabetic patients with forefoot ulceration and proven osteomyelitis.

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.

Limited forefoot amputation in diabetic patients with osteomyelitis is frequently required. We retrospectively reviewed diabetic patients with osteomyelitis, an unhealed ulcer and blood pressure in the toe of > 45 mmHg who underwent limited amputation of the foot with primary wound closure. Between 2006 and 2012, 74 consecutive patients with a mean age of 67 years (29 to 93), and a median follow-up of 31 months, were included. All the wounds healed primarily at a median of 37 days (13 to 210; mean 48). At a median of 6 months (1.5 to 18; mean 353 days), 23 patients (31%) suffered a further ulceration. Of these, 12 patients (16% of the total) required a further amputation.

We conclude that primary wound closure following limited amputation of the foot in patients with diabetes is a safe and effective technique when associated with appropriate antibiotic treatment.

Cite this article: Bone Joint J 2013;95-B:1083–7.

Aims

The Vantage Total Ankle System is a fourth-generation low-profile fixed-bearing implant that has been available since 2016. We aimed to describe our early experience with this implant.

Introduction. Bone tumours of the foot are rare, representing 3–6% of all bone tumours. Of these 15–25% are thought to be malignant. Obtaining clear surgical margins remains an important factor in improving outcome from tumours. However, the anatomical complexity of the foot can lead to an inadequate resection, particularly if the operating surgeon is attempting to preserve function. The aim of this paper is to identify the clinical course of patients suffering from malignant bone tumours of the foot. Method. A prospective tumour registry over a 30 yr period was used to identify patients with a malignant bone tumour of the foot. Patient demographics along with the site of primary malignancy, region of the foot involved and clinical management were recorded. Results. 70 patients with a malignant foot tumour were identified. 25(35%) were chondrosarcomas, 20 Ewings Sarcoma, 10 Osteosarcoma and 15 were metastatic lesions. Of those diagnosed with a primary bone tumour, 8(14.5%) were referred following a “whoops” procedure. The median length of symptoms prior to diagnosis was 52 weeks. The most common regions affected were the 1. st. Ray (31%) and Calcaneus (22%). The mainstay of treatment involved either Ray or Below Knee Amputation in 70% of cases. 11 patients developed either local recurrence or metastatic disease. Conclusion. We present the largest single centre review of malignant bone tumours affecting the foot. Our series confirms that patients often have to suffer with protracted symptoms prior to the establishment of the correct diagnosis. The variety of differential diagnoses may explain the long delay in diagnosis. Worryingly, 14.5% of the primary bone malignancies in our series underwent a “whoops” procedure. This highlights further that physicians need to maintain a high index of suspicion when treating a patient with foot symptoms, even when the symptoms may be protracted

Introduction. The Mobility™ prosthesis [Depuy] is the most extensively used TAR in the UK, though there are few published results. We present our complete experience of the Mobility prosthesis in a diverse population. Methods. From March 2005 to December 2009, 84 consecutive Mobility ankle replacements were performed by the senior author, in 79 patients (28 female, 51 male) with mean age 64.5 years (43–80). This complete cohort included the first and last cases with this implant. Mean follow-up was 50.1±18.2 months (range 14–86). Patients with ankle replacements in situ, were reviewed clinically and radiologically. Clinical outcome measures were: AOFAS score, MOXFQ (adapted for the ankle), and VAS for pain. Post-operative radiographs were reviewed to assess component position and examine for zones of lucency. Results. At final review, 1 patient had died (unrelated), 13 had been revised as follows: . Arthrodesis 7. Further TAR 2. Talus only revised 1. Tibia only revised 1. Amputation 2 (one for an unrelated problem). Exchange of bearing had been carried out in 4. Intra-operative malleolar fractures occurred in 4.8% and were internally fixed. 62 patients attended for clinical review and 8 completed postal questionnaires. At follow up:. Mean AOFAS hindfoot score was 72.4±17.5 (0–100). Mean MOXFQ scores were:. Walking/Standing 40.8±28.4. Pain 31.6±20.8. Social 23.1±23.0. Mean VAS 2.7±2.3. Survival of the implant was:. 91.7 (CI 83.4–96.0) at 2 years. 89.2 (CI 80.2–94.2) at 3 years. 84.1 (CI 73.4–90.8) at 4 years. 84.1 (CI 73.4–90.8) at 5 years. 78.9 (CI 62.6–88.7) at 6 years. Conclusion. This study is a complete review and our failure rate is comparable to other publications. Early failures included some poor case selections with large pre-operative deformity and reflects the initial period of the learning curve of TAR. Longer term follow up is needed to evaluate for ongoing failures and monitor progressive radiolucency

Aims

In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.

Aims

This is a multicentre, non-inventor, prospective observational study of 503 INFINITY fixed bearing total ankle arthroplasties (TAAs). We report our early experience, complications, and radiological and functional outcomes.

Aims

To assess the characteristic clinical features, management, and outcome of patients who present to orthopaedic surgeons with functional dystonia affecting the foot and ankle.

Aims

We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre.

Aims

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Aims

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.

Macrodactyly of the foot is a rare but disabling condition. We present the results of surgery on 18 feet of 16 patients, who underwent ray amputation and were followed-up for more than two years at a mean of 80 months (25 to 198).

We radiologically measured the intermetatarsal width and forefoot area pre-operatively and at six weeks and two years after surgery. We also evaluated the clinical results using the Oxford Ankle Foot Questionnaire for children (OxAFQ-C) and the Questionnaire for Foot Macrodactyly.

The intermetatarsal width and forefoot area ratios were significantly decreased after surgery. The mean OxAFQ-C score was 42 (16 to 57) pre-operatively, improving to 47 (5 to 60) at two years post-operatively (p = 0.021). The mean questionnaire for Foot Macrodactyly score two years after surgery was 8 (6 to 10).

Ray amputation gave a measurable reduction in foot size with excellent functional results. For patients with metatarsal involvement, a motionless toe, or involvement of multiple digits, ray amputation is a clinically effective option which is acceptable to patients.

Cite this article: Bone Joint J 2015;97-B:1364–9.

Charcot neuro-osteoarthropathy (CN) of the midfoot presents a major reconstructive challenge for the foot and ankle surgeon. The Synthes 6 mm Midfoot Fusion Bolt is both designed and recommended for patients who have a deformity of the medial column of the foot due to CN. We present the results from the first nine patients (ten feet) on which we attempted to perform fusion of the medial column using this bolt. Six feet had concurrent hindfoot fusion using a retrograde nail. Satisfactory correction of deformity of the medial column was achieved in all patients. The mean correction of calcaneal pitch was from 6° (-15° to +18°) pre-operatively to 16° (7° to 23°) post-operatively; the mean Meary angle from 26° (3° to 46°) to 1° (1° to 2°); and the mean talometatarsal angle on dorsoplantar radiographs from 27° (1° to 48°) to 1° (1° to 3°).

However, in all but two feet, at least one joint failed to fuse. The bolt migrated in six feet, all of which showed progressive radiographic osteolysis, which was considered to indicate loosening. Four of these feet have undergone a revision procedure, with good radiological evidence of fusion. The medial column bolt provided satisfactory correction of the deformity but failed to provide adequate fixation for fusion in CN deformities in the foot.

In its present form, we cannot recommend the routine use of this bolt.

Cite this article: Bone Joint J 2015; 97-B:809–13

We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site.

Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients.