We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ‑5D‑5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012).

Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered.

Cite this article: Bone Joint J 2015;97-B:76–82.

The use of autograft bone is the best option when undertaking a procedure that requires bone graft because it is osteogenic, osteoconductive and osseo-inductive. Pain, morbidity and complications associated with harvesting iliac or non-iliac sites occur in between 6% and 30% of cases. An alternative source of graft with possibly a lower morbidity is the intramedullary canal. In this study, 28 patients undergoing 30 arthrodesis procedures on the hindfoot had a mean of 48 cm³ (43 to 50) of bone harvested locally from the hindfoot or the tibial shaft by antegrade or retrograde reaming. No patient sustained a fracture of the calcaneum, talus or tibia. There was no morbidity except for one complication when the reamer breached the medial tibial cortex. This healed uneventfully.

This method of using the reamer–irrigator–aspirator system is an extension of the standard technique of intramedullary reaming of the lower limb: it produces good-quality bone graft with viable growth factors consistent with that of the iliac crest, and donor site morbidity is low. This is an efficient method of obtaining autologous bone for use in arthrodesis of the ankle or hindfoot.

Aims. Hindfoot arthrodesis with retrograde intramedullary nailing has been described as a surgical strategy to reconstruct deformities of the ankle and hindfoot in patients with Charcot arthropathy. This study presents case series of Charcot arthropathy patients treated with two different retrograde intramedullary straight compression nails in order to reconstruct the hindfoot and assess the results over a mid-term follow-up. Patients and Methods. We performed a retrospective analysis of 18 consecutive patients and 19 operated feet with Charcot arthropathy who underwent a hindfoot arthrodesis using a retrograde intramedullary compression nail. Patients were ten men and eight women with a mean age of 63.43 years (38.5 to 79.8). We report the rate of limb salvage, complications requiring additional surgery, and fusion rate in both groups. The mean duration of follow-up was 46.36 months (37 to 70). Results. The limb salvage rate was 16 of 19 limbs. Three patients had to undergo below-knee amputation due to persistent infection followed by osteomyelitis resistant to parenteral antibiotic therapy and repeated debridement. Complications including infection, hardware removal, nonunion, and persistent ulcers requiring further intervention were also observed. Postoperative functional scores revealed significant improvement compared with preoperative scores on American Orthopaedic Foot and Ankle Society (AOFAS) – Hindfoot scale, Foot Function Index (FFI), visual analogue scale (VAS), and Foot and Ankle Outcome Score (FAOS). Conclusion. The use of retrograde intramedullary compression nail results in good rates of limb salvage when used for hindfoot reconstruction in patients with Charcot arthropathy. Cite this article: Bone Joint J 2018;100-B:190–6

Aims

The aim of this study was to present a series of patients with aseptic failure of a total ankle arthroplasty (TAA) who were treated with fusion of the hindfoot using a nail.

Introduction. Tibiocalcaneal arthrodesis with a retrograde intramedullary nail is an established procedure considered as a salvage in case of severe arthritis and deformity of the ankle and subtalar joints [1]. Recently, a significant development in hindfoot arthrodesis with plates has been indicated. Therefore, the aim of this study was to compare a plate specifically developed for arthrodesis of the hindfoot with an already established nail system [2]. Method. Sixteen paired human cadaveric lower legs with removed forefoot and cut at mid-tibia were assigned to two groups for tibiocalcaneal arthrodesis using either a hindfoot arthrodesis nail or an arthrodesis plate. The specimens were tested under progressively increasing cyclic loading in dorsiflexion and plantar flexion to failure, with monitoring via motion tracking. Initial stiffness was calculated together with range of motion in dorsiflexion and plantar flexion after 200, 400, 600, 800, and 1000 cycles. Cycles to failure were evaluated based on 5° dorsiflexion failure criterion. Result. Initial stiffness in dorsiflexion, plantar flexion, varus, valgus, internal rotation and external rotation did not differ significantly between the two arthrodesis techniques (p ≥ 0.118). Range of motion in dorsiflexion and plantar flexion increased significantly between 200 and 1000 cycles (p < 0.001) and remained not significantly different between the groups (p ≥ 0.120). Cycles to failure did not differ significantly between the two techniques (p = 0.764). Conclusion. From biomechanical point of view, both tested techniques for tibiocalcaneal arthrodesis appear to be applicable. However, clinical trials and other factors, such as extent of the deformity, choice of the approach and preference of the surgeon play the main role for implant choice. Acknowledgements. This study was performed with the assistance of the AO Foundation

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: Non-union is a potential complication following hindfoot arthrodesis and occurs at a rate of 5–10% as reported in the literature. Following the procedure, patients are usually kept non-weight bearing (NWB) for 6–8 weeks followed by protected full weight bearing (FWB) for further 6 weeks. Based on radiological and clinical evidence of bony union at 12 weeks patients are allowed to mobilise FWB without protection. Aim: The aim of this study is to evaluate the effect of early post operative weight bearing on the union rate, following hindfoot arthrodesis. Method: In this retrospective study data was collected on patients who had hindfoot arthrodesis from 2003 to 2008 by a single surgeon. Two post operative mobilisation protocols were used and the union rates were compared. Protocol 1: 6 weeks NWB, 3 weeks partial weight bearing (PWB), 3 weeks FWB in plaster. Protocol 2: 2 weeks NWB, 4 weeks PWB, 6 weeks FWB in plaster. Results: 128 hindfoot joint arthrodesis were performed in 73 patients. Non-union rate was 2%(1 in 44) in early weight bearing group and 20% (4 in 16) in late weight bearing group. Union rate following the revision surgery with bone graft was 100% in both groups. Conclusion: The union rate following hindfoot surgery significantly improves (p=0.01) with early post-operative weight bearing

Non-union is a potential complication following hindfoot arthrodesis and occurs at a rate of 5–10% as reported in the literature. Following the procedure, patients are usually kept non-weight bearing (NWB) for 6–8 weeks followed by protected full weight bearing (FWB) for further 6 weeks. Based on radiological and clinical evidence of bony union at 12 weeks patients are allowed to mobilise FWB without protection. The aim of this study is to evaluate the effect of early post operative weight bearing on the union rate, following hindfoot arthrodesis. In this retrospective study data was collected on patients who had hindfoot arthrodesis from 2003 to 2008 by a single surgeon. Two post operative mobilisation protocols were used and the union rates were compared. Protocol 1: 6 weeks Non weight bearing (NWB), 3 weeks partial weight bearing (PWB), 3 weeks full weight bearing (FWB) in plaster. Protocol 2: 2 weeks NWB, 4 weeks PWB, 6 weeks FWB in plaster. One hundred and twenty-nine hindfoot joint arthrodesis were performed in 73 patients. Non-union rate was 1% (1 in 95 joints) in early weight bearing group and 20% (7 in 34 joints) in late weight bearing group. Union rate following the revision surgery with bone graft was 100% in both groups. Early weight bearing following hindfoot arthodesis is safe, provides a more comfortable mobilisation for the patient and has no adverse effect on the union rate

Objectives. To evaluate the effects of ankle/hindfoot arthrodesis in rheumatoid arthritis (RA) patients on gait pattern of the knee and hip. Methods. In this prospective follow-up study 14 RA patients scheduled for ankle/hindfoot arthrodesis were included. Three-dimensional gait analyses of joint angles, moments and work were performed at the index operation and after 13 months of follow-up. Each patient underwent clinical assessments of pain while walking, overall evaluation of disease activity, Health Related Quality of Life Questionnaire (EQ-5D), activity limitations, maximum walking distance, difficulty with walking surface and gait abnormality. For comparisons of pre- versus post-operative conditions, Wilcoxon’s matched pairs test and Friedman ANOVA by rank test were used. Results. At follow-up after ankle/hindfoot fusion surgery, RA patients demonstrated a statistically significant improvement in mean range of joint motions, moments and work in the overlying joints such as the knee and hip. Moreover, there was significantly less pain, disease activity, activity limitation, difficulty with walking surface and gait abnormality. EQ-5D and maximum walking distance were also significantly improved at follow-up. Conclusions. Our results demonstrate that ankle/hindfoot arthrodesis in RA is an effective intervention to reduce pain and to improve Health Related Quality of Life and functional ability. Moreover, the overlying leg joints experience an improvement in joint motion, muscle-generated joint moments and work during walking. Three-dimensional gait analysis may assist future investigations of the effects of orthopaedic surgery on functional mobility in RA to prevent irreversible disablement

Introduction: Non-union occurs at a rate of 5–10 % following ankle and hindfoot arthrodesis, but the effect of early weight bearing on union rate in these patients has not been studied. Materials and Method: We have looked at the union rate following ankle and hindfoot arthrodesis with an early weight bearing protocol in a single surgeon series between 2003 and 2008. Data was collected retrospectively on 108 patients with a total of 198 ankle and hindfoot joint arthrodesis. Results: The non-union rate was 3.4% (9 in 154 joints) in the early weight bearing group and 18% (8 in 44 joints) in the late weight-bearing group. Union rate following revision surgery with bone graft was 100% in both groups. Discussion: Early weight bearing following ankle and hind-foot arthrodesis has no adverse effect on the union rate

Introduction: Foot and ankle involvement in rheumatoid arthritis is common. Pain and disability secondary to planovalgus deformity and the arthritic process are difficult to control with conservative measures. Arthroplasty of the ankle is associated with high failure rates and does not completely correct the deformity. Arthrodesis of the hindfoot is a good option to alleviate pain, correct the deformity and improve functional ability, however has not been well reported in the literature. Aims: To determine change in quantitative measures of patient health, pain and functional ability following hindfoot arthrodesis in patients with rheumatoid arthritis, and to assess patient satisfaction postoperatively. Methods: 24 consecutive additive hindfoot arthrodeses were performed by a single surgeon on 22 patients with rheumatoid arthritis. Patients were assessed preoperatively using the Short Form-12 Health Survey (SF-12), Manchester-Oxford Foot Questionnaire (MOXFQ) and pain scores. These assessments were repeated at 6 and 12 months postoperatively, with an additional satisfaction questionnaire. Results: There was a marked and sustained improvement in the post-operative SF-12, MOXFQ and pain scores, with 71% of patients reporting no pain at 12 months. 19 out of 22 patients reported being satisfied or very satisfied with the operation. Bony union was achieved in all patients, both on clinical and radiological criteria. Most patients returned to normal footwear, some with slight modification to facilitate a more normal gait cycle. Conclusions: This study shows that additive hindfoot arthrodesis can be a very effective procedure in the management of moderate to severe ankle and hind-foot disease in rheumatoid arthritis. Patients should be counselled regarding the considerable recovery period; however significant improvement in the patient’s general health, foot function and pain can be expected

Locked plates confer angular stability across fusion sites, and as such are more rigid than either screws or intramedullary nails. This gives the advantage of reducing motion to enhance union rates and potentially allowing early weight bearing. The Philos plate (Synthes) is a contoured locking plate designed to fix humeral fractures but which also fits the shape of the hindfoot and provides strong low profile fixation. Its successful use for tibiotalocalcaneal (TTC) arthrodesis has been reported. Our aim was to prospectively evaluate the use of the Philos plate in hindfoot arthrodesis Twenty-one hindfoot arthrodeses were performed using the Philos plate between Oct 2008 and Jan 2010. Patients were followed up for a minimum of 1 year and had preoperative and 6 monthly AOFAS hindfoot scores and serial radiographs until union. Overall there were 15 ankle fusions, 5 tibiotalocalcaneal fusions and 1 subtalar fusion. At 6 months there were 13 unions and 9 non-unions (4 ankle, 5 TTC) giving a non-union rate of 38% overall and 25% for ankle fusions in isolation. Mean AOFAS scores at 6 months were 74/100 for the union group and 47 for non-unions (chi squared p < 0.001). No patient in the non-union group went on to fuse within a year without further surgery. Both groups had similar case mixes including osteoarthritis, AVN of the talus and failed arthroplasty. They also had similar co-morbidities, rates of smokers and bone grafting. Our conclusion is that the high non-union rates are probably due to the lack of compression conferred across the join by the Philos plate as there is no compression hole and we did not supplement the fixation with a lag screw. We recommend using locked plates for hindfoot arthrodesis only with additional compression

Introduction: Non-union following hindfoot arthrodesis remains a significant risk in foot and ankle surgery. In the reported series of revision hindfoot arthrodeses non-union rates range from 9 to 25% with approximately half these patients going on to a transtibial amputation. Bone morphogenic proteins (BMP) are a group of naturally occurring proteins with strong osteoinductive properties, which have shown promise in the treatment of fracture non-unions and primary hindfoot arthrodesis surgery. This article reports our experiences with rhBMP-7 as an adjunct to revision arthrodesis surgery in this high-risk subset of patients. Methods: Eight patients with at least one previous non-union and two or more risk factors for non-union and one patient on steroids with a failed total ankle replacement were prospectively recruited to the study. A revision arthrodesis procedure with internal fixation was performed according to the senior author’s revision protocol with the addition of 3.5mg rhBMP-7 combined with 40mls of bone marrow aspirate. Bone graft was used only if there was structural bone loss. Outcome was assessed clinically and radiologically. Results: Follow-up ranges from 3 to 22 months (average 13 months). Clinically 8 of the 9 patients had a pain free, stable arthrodesis. Seven patients were satisfied with their functional improvement and pain relief. Radiologically two patients have united, six patients have partial unions with ongoing progression towards union and one patient has a painless non-union. There was one wound infection and one malunion. No complications related to rhBMP-7 were experienced. Conclusion: Revision arthrodesis with adjuvant rhBMP-7 has led to limb salvage in this group of high-risk patients. However, rhBMP-7 is not a panacea for achieving union and does not replace meticulous surgical planning and technique. Achieving bony union in this subset of patients remains a high risk and protracted process. No concerns about the short-term safety of rhBMP-7 were raised

Aim. The incidence of deep infections after internal fixation of ankle and lower leg fractures is estimated 1 to 2%. Hindfoot arthrodesis by retrograde intramedullary nailing (IMN) is a potential alternative to external fixation for post-infectious ankle destruction. The aim of this study was to evaluate the clinical results, complications and effects of soft tissue management with this treatment modality. Method. This is a single-center retrospective review of routine hospital data from 21 patients (15 men, 6 women, median age 65 [range, 21 to 87] years) undergoing IMN arthrodesis of the hindfoot for post-traumatic infections between January 1st, 2012 and March 15, 2018. We observed four bimalleolar, eight trimalleolar, three pilon fractures, and six distal lower leg fractures. Six and three patients had sustained second- and third degree open fractures, respectively. Early- and late-onset surgical infections were observed in 8 and 13 cases. Four participants had diabetes mellitus, two arterial occlusive disease, and four had both. Six patients were smokers. Results. Intraoperative cultures before implanting the nail revealed staphylococcus aureus in 12, staphylococcus epidermidis in five, and enterococcus faecalis in eight cases. After a median follow-up of 21 months, infection was considered cured in 19 / 21 subjects (90%, 95% confidence interval 70 – 99%). Soft tissue comminution required coverage with a suralis flap in five patients, and with a latissimus dorsi flap in another three. Mesh graft was necessary in 8 / 21 reconstructions. Conclusions. Tibiotalocalcaneal fusion by IMN is an effective salvage procedure for post-traumatic ankle infections. Arthrodesis and definitive wound closure or plastic flap coverage can be performed as single-stage surgery. By resecting the prominent distal fibula, lateral soft tissue defects can be managed more easily. The small sample size prohibited a more detailed analysis of exposure variables, but 8 / 13 patients in this cohort had at least one known risk factor for infection and prolonged healing

We reported the outcomes of patients with Charcot neuropathy who underwent hind foot deformity correction using retrograde intramedullary nail arthrodesis. Twenty one feet in 20 patients, aged 45 to 83 years, with a mean BMI of 32.7 and a median ASA score of 3, were included in this study. All patients presented with severe hindfoot deformities and 15 had recurrent ulceration. All patients were treated with hindfoot corrective fusion and seven patients also underwent simultaneous mid foot fusion using a bolt or locking plate. After a mean follow up of 26 months, none of the cases required any form of amputation. Eighty percent of patients with ulceration achieved healing and all but one patient returned to independent ambulation. One nail fracture and three mid foot metal work failure resulted in fixation failure requiring revision surgery. Distal locking screw displacement occurred only with standard screws but not with hydroxyapatite-coated screws. The AAOS-FAO score improved from 50.7 to 65.2 (p=0.015). The EQ-5D-5L improved from 0.63 to 0.67 (p=0.012) and the SF-36 PCS from 25.2 to 29.8 (p=0.003). Single stage deformity correction with intramedullary hindfoot arthrodesis nail is a viable treatment option for severe Charcot hindfoot deformity with ulceration and instability

Introduction:. The purpose of this study was to elucidate the specific radiographic effects that the Cotton osteotomy confers when used in combination with other reconstructive procedures in the management of the flexible flat foot deformity. Methods:. Between 2002–2013, 198 Cotton osteotomies were retrospectively identified following IRB approval. 131 were excluded on the basis of ipsilateral mid/hindfoot arthrodesis, inadequate radiographs or being less than 18yrs old at time of surgery. Parameters including the articular surface angles of the hindfoot/forefoot, Meary's angle and a newly defined Medial Arch Sag Angle (MASA) were recorded. A matched group of patients who did not undergo a Cotton osteotomy but who underwent similar hindfoot reconstructive procedures served as historic controls. Results:. 67 Cotton osteotomies in 59 patients with a mean age of 45 years (range, 18–80) were evaluated. Concomitant procedures included combinations of tibialis posterior tendon (PTT) reconstruction, Evans lateral column lengthening, medial displacement calcaneal osteotomy (MDCO). In all patients who underwent a Cotton osteotomy, there were statistically significant improvements in the articular surface angles along the medial side of the foot (p < 0.05). Improvement in arch height was also found to be statistically significant (p < 0.05). In comparison to matched controls, the Cotton osteotomy did not improve Meary's angle but provided an additional 11.21° of MASA correction (p < 0.05) when used in in conjunction with the Evans procedure and PTT reconstruction. A similar trend was seen with MDCO and PTT reconstruction. Discussion:. This study confirms the Cotton osteotomy is a powerful surgical adjunct in flatfoot reconstruction and quantifies the additional 11.21° of MASA correction it provides when the Cotton osteotomy is added to a calcaneal osteotomy and PTT reconstruction. This has relevance as an alternative for selection of a medial column stabilization procedure, which is joint sparing

Ankle osteomyelitis after open pilon-fractures remain one of the most challenging scenarios. Ankle-fusion using an external frame is a classical option but in some cases of non-compliance patients could be not ideal. The purpose of this report was to evaluate our results using a new staged salvage protocol in cases where an external-frame arthrodesis is not recommended due to the issue of a non-compliance patient. During the first stage we resect all the infected tissues and an antibiotic-loaded cement spacer is used to obliterate the dead space, to reach some kind of stability and to achieve a high concentration of local antibiotic. A free or keystone flap is used if needed and a posterior splint is placed. After a course of targeted systemic antibiotics the second stage is schedule. During the second stage after the spacer removal, a self-made antibiotic coating retrograde hindfoot arthrodesis nail is used in order to achieve ankle fusion. We use a bone-substitute loaded with gentamicin (Cerament-G®) to fill the bone defects and to achieve high concentration of local gentamicin, to protect bone healing and to decrease the risk of relapse. We present four patients with ankle-osteomyelitis after open pilon fracture treated by such protocol. We receive all patients > 6 months after the initial fracture. In all cases type III-B open pilon fracture was the initial injury. All the patients presented psychological disturbances and the possibility of perform an external frame reconstruction was considered not indicated. At presentation, all patients have compromised skin around the distal tibia area. According to the Cierny/Mader osteomyelitis classification all patients were Type IV-Blocal. Compromises soft tissues were treated with an ALT free flap in two cases and with a Keystone flap in two cases. 10 mL paste of Cerament-G® was used in each case with a single case where a white-draining event was present without further complication. Tibiotalocalcaneal fusion was achieved after 4 months in all cases. At average of 7 months of follow-up, none of the four fused ankles has required further surgery and no infection relapse was observed. The use of this salvage treatment protocol has proven safe and useful for such difficult problem in these difficult patients, with a relatively low associated complication rate. Cerament-G® is a useful tool in order to fill all the bone voids, promote bone healing and simultaneously to protect the surgical area due to the high local concentration of gentamicin

Background: Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis. Methods: Retrospective review identified 13 patients who had 14 combined ankle and subtalar arthrodeses performed arthroscopically, with no bone grafting. The procedure was performed for the treatment of combined ankle and subtalar arthritis or hindfoot deformity. The majority had fixation using 6.5mm ASNIS screws (Stryker (Kalamazoo, Michigan, USA)) introduced percutaneously, although in one case a hindfoot nail was used. Outcome was assessed by a combination of chart review, clinical examination and questionnaire. Follow up averaged 16 (6 to 33) months. Results: At follow up average patient satisfaction was 9.7/10. Average time to fusion was 12 (10–20) weeks. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 67 (41–83). Nine patients had no complications. Postoperative complications were pulmonary embolus, non-union, late stress fracture and infection. Conclusion: Arthroscopic hindfoot arthrodesis is an effective technique, and allows treatment in patients whose soft tissues would not tolerate an open procedure, where often the only alternative is amputation. Patient satisfaction is high, with a short inpatient stay, but the procedure itself is demanding

Introduction. Degenerative, inflammatory, and posttraumatic arthritis of the ankle are the primary indications for total ankle arthroplasty. Ankle arthrodesis has long been the “gold standard” for the surgical treatment. Total Ankle Arthroplasty. implant survivorship has been reported to range from 70% to 98% at three to six years. The combination of younger age and hindfoot arthrodesis or osteoarthritis may lead to a relative increase in failure rates after TAA. Intraoperative complication include malaligment, fracture and tendon Postoperative complications include syndesmotic nonunion, wound problems, infections and component instability and lysis. After TAA few difficulties mainly due to poor Talar and Tibial bone stock. It is difficult to stabilize the fusion and usually there is shortening after removal of the implant. Also there is a need for massive bone graft-allograft or autograft. In cases when there is significant bone loss there is a need for stable reconstruction and stabilization of the hindfoot. Bone grafting with structural bone graft may collapse and it has to be stabilized with screws or nail. Methods. We developed technique which included distraction of the fusion area and inserting a Titanium cylindrical spinal cage filled with bone graft. Than guide wire was inserted in through the cage under fluoroscopy and a compression screw was introduced causing compression of the fusion area against the cage gaining stabilization of the fusion area. Results. By 6 months all the patients were fused and could walk full weight bearing with no pain. Discussion and Conclusions. Spinal cages are widely used in spine fusions in order to achieve stable spacer. Usually it has to be stabilized using posterior fusion stabilizing system. By performing distraction of the fusion area by spinal cage used as spacer and compression at the same time using compression screw we achieved primary good stability with minimal shortening

Open Tibiotalocalcaneal fusion has been shown to be an effective treatment for arthritis and complex foot deformities, but with a high complication rate. We are reporting the results of the first 14 feet undergoing arthroscopic tibiotalocalcaneal arthrodesis. Methods: Retrospective review identified 13 patients who had 14 combined ankle and subtalar arthrodeses performed arthroscopically, with no bone grafting. The procedure was performed for the treatment of combined ankle and subtalar arthritis or hindfoot deformity. The majority had fixation using 6.5 mm ASNIS screws (Stryker (Kalamazoo, Michigan, USA)) introduced percutaneously, although in one case a hindfoot nail was used. Outcome was assessed by a combination of chart review, clinical examination and questionnaire. Follow up averaged 16 (6 to 33) months. Results: At follow up average patient satisfaction was 9.7/10. Average time to fusion was 12 (10–20) weeks. The average postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was 67 (41–83). 9 patients had no complications. Postoperative complications were pulmonary embolus, non-union, late stress fracture and infection. Conclusion: Arthroscopic hindfoot arthrodesis is an effective technique, and allows treatment in patients whose soft tissues would not tolerate an open procedure, where often the only alternative is amputation. Patient satisfaction is high, with a short inpatient stay, but the procedure itself is demanding