Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (> 95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation

Background:. Charcot arthropathy is a condition related to the loss of protective sensation of a joint. It normally presents in its early inflammatory phase, followed by bone destruction. Recognised treatment for this is total contact casting (TCC). However, in a small group this may be unsuccessful in preventing deformity progression. TCC can also be difficult in the presence of recalcitrant ulceration and deformed feet. Method:. 40 patients, with a diagnosis of Charcot foot, were followed from presentation in our unit over 3 years. An Ilizarov frame was used for two groups: those in the early phase who showed progressive deformity despite TCC (5 patients) and those with chronic ulceration (4 patients). Frames were modified to allow weight-bearing on the frame (with no foot contact). All other patents were treated with TCC. Results:. There were no amputations or cases of osteomyelitis. The Ilizarov frame successfully prevented further deformity when applied in the inflammatory phase. In patients with ulceration, deformity correction with a modified frame maintained correction and allowed the ulcers to heal rapidly whilst weight bearing. Conclusion:. Our series shows the Ilizarov frame can be used in the management of Charcot to prevent deformity progression and allow recalcitrant ulcers to heal following deformity correction

Three middle-aged patients with diabetes sustained fractures of the acetabulum which were treated by open reduction and internal fixation. In each, rapid dissolution of the femoral head occurred with minimal discomfort, typical of a Charcot arthropathy. The patients had no other evidence of neuropathic arthropathy. Charcot changes may occur after high-energy trauma in patients with diabetes

Background. The recommended indications for total ankle replacement (TAR) are limited, leaving fusion as the only definitive alternative. As longer-term clinical results become more promising, should we be broadening our indications for TAR?. Materials and Methods. Our single-centre series has 133 Mobility TARs with 3–48 months' follow-up. 16 patients were excluded who were part of a separate RCT. The series was divided into two groups. ‘Ideal’ patients had all of the following criteria: age >60y, BMI <30, varus/valgus talar tilt <10°, not diabetic, not Charcot, not post-traumatic. The ‘Not ideal’ group contained those who did not fit any single criteria. We compared complications and outcome scores between both groups. Results. The ‘Ideal’ group contained 44 ankles vs. 80 in the ‘Not ideal’ group (124 ankles in 117 patients). Complications were (‘Ideal’ vs. ‘Not ideal’): infection: 1 (deep) vs. 3; DVT/PE: 0; periprostheticfracture: 4 vs. 7; CRPS: 2 vs. 2; revision: 0 vs. 2. AOFAS scores showed variable significance (mean values). Pre-op: 27.9 vs. 25.7 (p = 0.459); 3months: 79.4 vs. 73.2 (p = 0.041); 6 months: 79.9 vs. 75.4 (p = 0.053); 12 months: 79.7 vs. 75.8(p = 0.228), 36 months: 77.3 vs. 79.0 (p = 0.655). Further subgroup analysis has been performed. Discussion. Our results show that indications for TAR can be widened without further morbidity. Each case must be treated individually and accounted for other factors. Varus/valgus tilt can be corrected with appropriate calcaneal osteotomy +/- tendon transfers as a staged or combined procedure. TAR may be considered in younger patients based on functional and occupational demands. We may no longer be able to deter patients on BMI alone. Diabetic patients do not appear to have a higher complication rate. Conclusion. We have increasing evidence that we should now be considering TAR as the primary treatment for disabling ankle arthritis rather than fusion