Advances in the design of the components for total ankle replacement have led to a resurgence of interest in this procedure.

Between January 1999 and December 2004, 16 patients with a failed total ankle replacement were referred to our unit. In the presence of infection, a two-stage salvage procedure was planned. The first involved the removal of the components and the insertion of a cement spacer. Definitive treatment options included hindfoot fusion with a circular frame or amputation. When there was no infection, a one-stage salvage procedure was planned. Options included hindfoot fusion with an intramedullary nail or revision total ankle replacement. When there was suspicion of infection, a percutaneous biopsy was performed. The patients were followed up for a minimum of 12 months.

Of the 16 patients, 14 had aseptic loosening, five of whom underwent a revision total ankle replacement and nine a hindfoot fusion. Of the two with infection, one underwent fusion and the other a below-knee amputation. There were no cases of wound breakdown, nonunion or malunion.

Management of the failed total ankle replacement should be performed by experienced surgeons and ideally in units where multidisciplinary support is available. Currently, a hindfoot fusion appears to be preferable to a revision total ankle replacement.

In a prospective randomised study 31 patients were allocated to either arthrodesis or Mayo resection of the first metatarsophalangeal joint as part of a total reconstruction of the rheumatoid forefoot. Of these, 29 were re-examined after a mean of 72 months (57 to 80), the Foot Function Index was scored and any deformity measured. Load distribution was analysed using a Fscan mat in 14 cases, and time and distance were measured in 12 of these patients using a 3D Motion system. We found excellent patient satisfaction and a significant, lasting reduction of the Foot Function Index, with no statistically significant differences between the groups. There were no significant differences in recurrence of the deformity, the need for special shoes, gait velocity, step length, plantar moment, mean pressure or the position of the centre of force under the forefoot. The cadence was higher and the stance phase shorter in the fusion group.

These results suggest that a Mayo resection may be an equally good option for managing the first metatarsophalangeal joint in reconstruction of the rheumatoid forefoot.