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

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.

Single stage total talectomy with tibio-calcaneal arthrodesis in adult patients has been rarely reported in the literature. In patients with severe rigid, unbraceable equinovarus deformities, talectomy can offer excellent correction. We performed single stage total talectomy with tibiocalcaneal arthrodesis on 11 feet in 10 patients (6F; 5M) of average age 67 years (range 54–77 years). 6 patients had neuropathic deformity, 2 had failed fusion procedures and 2 had severe Rheumatoid hindfoot disease. The fusion was undertaken using a hindfoot nail and screws in 5 patients, plate and screws in 4 patients, a hindfoot nail in 1 and cancellous screws in 1 patient. All patients followed the standard post operative protocol and were reviewed at 2, 6 and 12 weeks and thereafter every 4 weekly till union. All patients were mobilised strictly non weight bearing for the first 6 weeks and thereafter, touch weight bearing was allowed with the leg in a protective cast. Full weight bearing was allowed once the fusion had consolidated. Fusion was achieved in 7 feet (64%) at an average time of 17 weeks. In 4 patients, non-union persisted but they were pain free at latest review and would not consider further surgery. Average duration of follow-up was 20 months (range 6–24 months). All patients had stiff hindfeet with a jog of movement at the tibio navicular articulation. All patients had a stable, plantigrade, braceable foot and were community ambulators. All patients were satisfied with the outcome. Total talectomy with tibiocalcaneal arthrodesis is a useful procedure to correct severe rigid equinovarus deformities in adults. The tibionavicular articulation forms a pseudarthrosis and retains a jog of movement. Retention of the head of the talus with talotibial arthrodesis is unnecessary. We recommend this procedure as a salvage option in this difficult problem

Purpose: The vast majority of forefoot infectious in neuropathy patients are plantar ulcers in diabetics. When conservative treatment is unsuccessful, radical treatment may be indicated, but correct choice of the amputation level is essential. The purpose of this work was to evaluate outcome after tibiocalcaneal arthrodesis achieved with an Ilizarof fixator. Material and methods: The procedure was performed in nine patients between 1991 and 2002. Male gender predominated (seven men). Mean age was 65 years. Eight patients had diabetes and seven of them had complicated mal perforant. Two patients had bilateral involvement so a total of eleven arthrodeses were performed. The procedure began with de-articulation of the Chopard space and talectomy. After high section of the lateral maleolus, the tibia was cut flush with the joint. The calcaneal cut was vertical passing just behind the tarsal sinus. After verticalising the calcaneum, the two cut surfaces were joined. Arthrodesis was maintained with a circular Ilizarof fixator using two rings on the tibia and one on the calcaneum. Results: At mean 20 months, we reviewed ten arthrodeses. Good results were obtained for seven and failure was observed in three (necrosis = 2 and severe suppuration = 1). All these problems resolved and fusion was achieved at five months on average. The type of diabetes, renal failure, duration of the infection, presence of severe contralateral lesions, and type of germ involved appeared to affect outcome. Discussion: Alternatives to the Pirogoff procedure include Chopard amputation, with or without subtalar arthrodesis, and Syme amputation. The technique used in this cohort offers several advantages. The circular external fixator avoids the classic cross screwing in an infectious setting. The mechanical properties of the Ilizarof fixator favour healing and bone fusion. Finally, vericalisation of the calcaneum produces a longer stump so excessively anterior cicatrisation, which can be bothersome for the orthesis, is avoided. Conclusion: This surgical technique provides a radical treatment for proximal osteoarticular infections of the forefoot, often observed in diabetics. Indications are exceptional and should be reserved for lesions which are inaccessible to transmetatarsal amputation. The arthrodesis cannot be achieved without healthy talar stock. The procedure produces a long stable stump which is painless and easy to fit

Ankle arthrodesis is considered a valid reconstructive option after bone tumor resection of the distal tibia, distal fibula and of the talus. The purpose of the present study was the review of author’s experience in ankle arthrodesis for bone tumors with the employ of bone grafts. Over the last 15 years, 17 ankle arthrodesis were performed in author’s Institution for oncological pathologies. Average age at the time of surgery was 41 years (4–75). Twelve patients had a malignant tumor (3 osteosarcoma, 2 fibrosarcomas, 1 Ewing sarcoma, 1 emangioendotelioma, 1 condrosarcoma, 1 pleomorphic sarcoma, 1 adamantinoma and 2 metastases from renal carcinoma) and 5 patients had a benign tumor (4 giant cell tumors, 1 condroblastoma). In 13 cases the tumor involved the distal tibia, in 2 cases the distal fibula and in 2 cases the talus. In 15 patients we performed a tibiotalar arthrodesis and in 2 patients (tumors of the talus) a tibiocalcaneal arthrodesis. The bone defect after resection was reconstructed with: cortical structural autografts from controlateral tibia and autologous bone chips from iliac crest in 5 patients; cortical structural autografts from controlateral tibia + cortical structural allografts + autologous bone chips from iliac crest in 2 patients; cortical structural allografts + autologous bone chips from iliac crest in 2 patients; structural autografts in 4 patients; autogenous vascolarized fibula in 4 patient with cortical allograft in 3 cases and autograft in 1 case. Stabilization was obtained by intramedullary anterograde nailing in 8 patients, plate in 2, two or multiple screws in 7 (including two tibiocalcaneal arthrodesis). Three patients died before this review (1, 1.5, 7 years after surgery: 1 Ewing sarcoma, 2 patients with metastases from kidney cancer). Follow-up for alive patients ranged from 14 to 146 months (average 53). Two local recurrences were observed, in a Ewing sarcoma in 1 case and in a giant cell tumor in 1 case. One patient is alive with lung metastases but no signs of local recurrence. In all patients but one the arthrodesis healed successfully. In one case a deep infection occurred (with wound dehiscence) and the arthrodesis did not heal. Complications included 1 deep infection, 1 superficial infection of the donor site (controlateral leg) and 1 fracture of the controlateral tibia (donor site of cortical autograft) treated with plaster cast. Three patients underwent a secondary surgical procedure: two partial hardware removals and one myocutaneous sural flap. The low rate of local recurrence (1/5 in benign tumors and 1/12 in malignant tumors) and the high percentage of bone union (16 out of 17) together with the satisfactory functional outcome showed that ankle arthrodesis with bone grafts can be an oncologically safe and a meccanically successful procedure in bone tumor surgery