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. Materials and Methods. Data were collected prospectively at the multidisciplinary diabetic foot clinic. We recorded demographic details, duration of diabetes, comorbidities, nature of ulceration, radiological findings, Texas wound score and details of surgery. Patients were followed up regularly in the diabetes clinic. Medical records were reviewed and complications recorded. Results. Between January 2005 and December 2008, eleven patients (nine male, two female) underwent transmetatarsal amputation for osteomyelitis resistant to antibiotic therapy. Mean age was 58.5 years. Of the ten followed up, six had an intact hindfoot stump in Feburary 2010 (mean 36 months, range 32-46). One patient died with the stump intact at 21 months. Five patients remained ambulatory, while two had already been using a wheelchair. Three patients required BKA for continued sepsis and ischaemia. Discussion. Given the high comorbidities of our patients, it is encouraging that 7 out of 10 patients had successful transmetatarsal amputations. Numbers are small, as the procedure has a relatively narrow indication (severe sepsis confined to the forefoot). In retrospect, pre-operative MRI might have helped to delineate the extent of necrosis, and might have led to better patient ion and a lower re-operation rate. Conclusions. BKA is not necessary for all diabetic feet with uncontrolled deep sepsis. Transmetatarsal amputation can preserve the hindfoot and maintain ambulatory function for three years or more, even in complex patients with comorbidities. Decision-making and perioperative care are challenging and require a dedicated multidisciplinary team

Charcot osteoarthropathy of the foot is a chronic and progressive disease of bone and joint associated with a risk of amputation. The main problems encountered in this process are osteopenia, fragmentation of the bones of the foot and ankle, joint subluxation or even dislocation, ulceration of the skin and the development of deep sepsis. We report our experience of a series of 20 patients with Charcot osteoarthropathy of the foot and ankle treated with an Ilizarov external fixator. The mean age of the group was 30 years (21 to 50). Diabetes mellitus was the underlying cause in 18 patients. Five had chronic ulcers involving the foot and ankle. Each patient had an open lengthening of the tendo Achillis with excision of all necrotic and loose bone from the ankle, subtalar and midtarsal joints when needed. The resulting defect was packed with corticocancellous bone graft harvested from the iliac crest and an Ilizarov external fixator was applied. Arthrodesis was achieved after a mean of 18 weeks (15 to 20), with healing of the skin ulcers. Pin track infection was not uncommon, but no frame had to be removed before the arthrodesis was sound. Every patient was able to resume wearing regular shoes after a mean of 26.5 weeks (20 to 45)

Salvage of a failed total ankle replacement is technically challenging and although a revision procedure may be desirable, a large amount of bone loss or infection may preclude this. Arthrodesis can be difficult to achieve and is usually associated with considerable shortening of the limb.

We describe a technique for restoring talar height using an allograft from the femoral head compressed by an intramedullary nail. Three patients with aseptic loosening were treated successfully by this method with excellent symptomatic relief at a mean follow-up of 32 months (13 to 50).