Aims. Tibiotalocalcaneal (TTC) fusion is used to treat a variety of conditions affecting the ankle and subtalar joint, including osteoarthritis (OA), Charcot arthropathy, avascular necrosis (AVN) of the talus, failed total ankle arthroplasty, and severe deformity. The prevalence of postoperative complications remains high due to the complexity of hindfoot disease seen in these patients. The aim of this study was to analyze the relationship between preoperative conditions and postoperative complications in order to predict the outcome following primary TTC fusion. Methods. We retrospectively reviewed the medical records of 101 patients who underwent TTC fusion at the same institution between 2011 and 2019. Risk ratios (RRs) associated with age, sex, diabetes, cardiovascular disease, smoking, preoperative ankle deformity, and the use of bone graft during surgery were related to the postoperative complications. We determined from these data which pre- and perioperative factors significantly affected the outcome. Results. Out of the 101 patients included in the study, 29 (28.7%) had nonunion, five (4.9%) required below-knee amputation (BKA), 40 (39.6%) returned to the operating theatre, 16 (15.8%) had hardware failure, and 22 (21.8%) had a postoperative infection. Patients with a preoperative diagnosis of Charcot arthropathy and non-traumatic OA had significantly higher nonunion rates of 44.4% (12 patients) and 39.1% (18 patients) (p = 0.016) and infection rates of 29.6% (eight patients) and 37% (17 patients) compared to patients with traumatic arthritis, respectively (p = 0.002). There was a significantly increased rate of nonunion in diabetic patients (RR 2.22; p = 0.010). Patients with chronic kidney disease were 2.37-times more likely to have a nonunion (p = 0.006). Patients aged over 60 years had more than a three-fold increase in the rate of postoperative infection (RR 3.60; p = 0.006). The use of bone graft appeared to be significantly protective against postoperative infection (p = 0.019). Conclusion. We were able to confirm, in the largest series of TTC ankle fusions currently in the literature, that there remains a high rate of complications following this procedure. We found that patients with a Charcot or non-traumatic arthropathy had an increased risk of nonunion and postoperative infection compared to individuals with traumatic arthritis. Those with diabetes, chronic kidney disease, or aged over 60 years had an increased risk of nonunion. These findings help to confirm those of previous studies. Additionally, our study adds to the literature by showing that autologous bone graft may help in decreasing infection rates. These data can be useful to surgeons and patients when considering, discussing and planning TTC fusion. It helps surgeons further understand which patients are at a higher risk for postoperative complications when undergoing TTC fusion. Cite this article: Bone Joint J. 2020;102-B(3):345–351

Abstract. Background. Tibiotalocalcaneal (TTC) fusion is indicated for severe arthritis, failed ankle arthroplasty, avascular necrosis of talus and as a salvage after failed ankle fixation. Patients in our study had complex deformities with 25 ankles having valgus deformities (range 50–8 degrees mean 27 degrees). 12 had varus deformities (range 50–10 degrees mean 26 degrees) 5 ankles an accurate measurement was not possible on retrospective images. 10 out of 42 procedures were done after failed previous surgeries and 8 out of 42 had talus AVN. Methods. Retrospective case series of patients with hindfoot nails performed in our centre identified using NHS codes. Total of 41 patients with 42 nails identified with mean age of 64 years. Time to union noted from X-rays and any complications noted from the follow-up letters. Patients contacted via telephone to complete MOXFQ and VAS scores and asked if they would recommend the procedure to patients suffering similar conditions. 17 patients unable to fill scores (5 deceased, 4 nails removed, 2 cognitive impairment and 6 uncontactable). Results. In our cohort 33/38 of hindfoot nails achieved both subtalar and ankle fusion in a mean time of 7 months. 25 patients with 26 nails had mean follow up with post op scores of 4 years. Their Mean MOXFQ scores were (Pain: 12.8 Walking: 12 Social: 8) and visual analogue pain score was 3. 85% of patients wound recommend this surgery for a similar condition. 20 complications with 15 requiring surgery(5 screw removals, 1 percutaneous drilling, 1 fusion site injection, 8 nail revisions). Conclusion. In our experience hindfoot nail TTC fusion reliably improves the function of patients with severe symptoms in a variety of pathophysiological conditions and complex deformities. Most of our patients would recommend this procedure. There is a lack of studies with long-term follow-up

Objective: To critically appraise the use of hindfoot nailing as an alternative treatment for fragility fractures of the ankle. Summary of background data: Ankle fractures are common. The peak incidence now lies in women between the ages of 75 and 84. These fractures are inherently unstable and it is known that anatomical reduction and stable fixation leads to a rapid return of function. Although this is usually achieved by open reduction and plate and screw fixation, in older patients poor bone quality and compromised wound healing can lead to unacceptably high complication rates. Conservative management of these patients also has its problems with anatomical congruity being difficult to achieve and maintain. Method: We reviewed 13 patients who underwent minimally invasive intramedullary nailing to fuse the tibiotalocalcaneal joint as primary or revision treatment for an ankle fracture. Olerud and Molander Scale, and SF36 were used as outcome measures. Results: There were 12 females and 1 male with a mean age of 81.5 (range 64 to 93). One nail was revised after 22 days due to valgus deformity and one patient suffered a minor wound (breakdown / infection). Half of the patients were discharged in the first two weeks after the operation. They all achieved pain free full weight bearing on the fractured ankle and gained a comparable function to their pre-operative state. The mean follow up period was 9 months (range of 2 – 62 months). Conclusion: Minimally invasive tibiotalocalcaneal fusion is a very useful and successful way of restoring function following a fragility fracture of the ankle. We recommend its use in the cases of fragility fracture of the ankle with poor soft tissue

Purpose To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN). Method We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, two patients died of unrelated causes and four patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post-traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the American Orthopaedic Foot and Ankle (AOFAS) hindfoot score and with three independent observers reviewing radiographs. Results Radiologically 17 ankles fused, three probably fused whilst 16 (33%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Postoperatively the mean AOFAS score was 51, 25 patients were satisfied (of these 50% had radiological non-union) and 19 would undergo the same procedure again. Conclusion Despite a high rate of ankle and subtalar non-union, most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and subtalar joint arthritis, patients should be warned of the potential for non-union and high complication rates

Purpose: To investigate the outcome of tibiotalocalcaneal (TCC) fusion using the retrograde intramedullary nail (IMN). Methods and results: We reviewed clinical and radiological outcome of 42 patients who underwent TTC fusion with a retrograde IMN in a single health region from 1996 to 2003. Out of 42 patients, four patients died of unrelated causes and two patients were lost to follow up. Finally, 36 patients (20 males, 16 females) were followed up. Mean age was 63 years and the follow up averaged 10 months. Degenerative arthritis (primary and post traumatic) and rheumatoid arthritis made up the majority of the preoperative diagnoses. Clinical outcome was assessed using the AOFAS hindfoot score and three independent observers reviewing radiographs. Radiologically 22 ankles fused, three probably fused whilst 11 (30%) had evidence of non-union. The majority of subtalar joints failed to unite, reflected by the high rate of distal screw breakage. Primary bone grafting appeared to aid union however smoking, age and the use of an open approach did not seem to be significant factors. Other than non-union complications included two nail fatigue fractures, two deep infections, seven screw breakages, six wound problems and one fractured tibia. Post operatively the mean AOFAS score was 51, 25 patients were satisfied (of these 20% had radiological non-union) and 19 would undergo the same procedure again. Conclusion: Despite a high rate of ankle and subtalar non-union most of the patients were satisfied with the procedure and would undergo the same operation again. Technical errors apart, the high rate of complications and non-union probably reflected the advanced nature of the disease process and deformity in this group of patients. Although IMN TTC fusion remains a viable option in the management of concurrent ankle and sub-talar joint arthritis, patients should be warned of the potential for non-union and high complication rates

The February 2023 Foot & Ankle Roundup. 360. looks at: Joint inflammatory response in ankle and pilon fractures; Tibiotalocalcaneal fusion with a custom cage; Topical application of tranexamic acid can reduce blood loss in calcaneal fractures; Risk factors for failure of total ankle arthroplasty; Pain catastrophizing: the same as pain forecasting?

Background: Complex tibiotalar (TT) and tibiotalocalcaneal (TTC) fusions are performed for significant ankle and hindfoot arthritis and/or deformity. Literature suggests several methods of fixation including crossed screws, plates, nail and external fixation. These are technically difficult operations with reported complication rates as high as 30–80%. We present a retrospective cohort study of angle blade plate and PHILOS plate fixation for these patients in our hospital. Methods: This study describes 21 consecutive patients with 22 TT or TTC fusions between December 2005 and May 2009. The surgery was performed for severe deformity or arthritis as a result of: osteoarthritis(2), post-traumatic arthritis(4), rheumatoid arthritis (7), Charcot arthropathy (5), avascular necrosis(1), and post traumatic avascular necrosis (3). The senior author performed all of the operations. In the first ten cases (two TT and eight TTC) an angle blade plate was used, A PHILOS plate was used in the subsequent ten cases (three TT and seven TTC). One patient had bilateral TTC fusions with a blade plate on one side and a PHILOS plate on the other. There were eight male and 13 female patients. All the procedures were performed through a lateral transfibular approach. The patients were followed up regularly with clinical and radiological evaluation until union or otherwise. Results: Fusion was achieved in 19 out of 21 patients (90.5%) and 20 out of 22 arthrodeses (90.9%). All five TT fusions went on to union (100%). Fifteen out of 17 TTC fusions united (88.2%). One TTC fusion using an angle blade plate needed revision surgery for non-union of subtalar joint. In the PHILOS group one patient developed MRSA infection of the surgical site leading to non-union. This necessiated removal of metal and prolonged treatment with intravenous antibiotics. The patient now has a relatively painless fibrous ankylosis. Conclusion: TT and TTC fusions are complex operations performed for severe arthritis and deformity, often on patients with significant co-morbidities. It is a salvage procedure to relieve pain and/or correct deformity of the foot and ankle. This study suggests that both the angle blade plate and PHILOS plate provide a stable fixed angle construct, which achieves a high rate of bony union with alignment correction

Introduction:

TTC fusion for the salvage of failed TARs with significant bone loss using a hindfoot nail and femoral head allograft has been reported in a number of small series. We present our experience of this procedure.

The April 2014 Foot & Ankle Roundup. 360 . looks at: Hawkins fractures revisited; arthrodesis compared with ankle replacement in osteoarthritis; mobile bearing ankle replacement successful in the longer-term; osteolysis is an increasing worry in ankle replacement; ankle synostosis post-fracture is not important; radiofrequency ablation for plantar fasciitis; and the right approach for tibiotalocalcaneal fusion

Introduction and Aims: Numerous internal as well as external fixation techniques have been reported for achieving tibiotalocalcaneal fusion in rheumatoid arthritis with varying results. The purpose of this study was to assess the union rate and functional outcome following tibiotalocalcaneal fusion using the locked supracondylar nail. Method: Twenty-four patients (27 ankles) were followed up. The mean age being 57 years (44–73 years) and mean follow-up was 37.4 months (10–74 months). Severe disabling ankle pain was the indication for operation in all cases. Standard operative technique and post-operative mobilisation protocol was followed. Seventeen cases had ankle debridement. The severity of rheumatoid arthritis was assessed using the Fries scoring system. Results were analysed using Rheumatoid ankle score (RAS), modified American Orthopaedic Foot & Ankle Society Score (AOFAS). All the patients were evaluated for clinical and radiological evidence of union. Results: The mean Fries score of 2.3 suggest that most of the patients in the study group were affected by severe rheumatoid arthritis. The mean RAS score was 77 (35–95) and mean AOFAS score was 74.6 (40–95). Using the rheumatoid ankle scoring system, five ankles (20%) were rated excellent, ten ankles (40%) were rated good, six ankles (24%) were rated fair and four (16%) were rated poor. In general, patients who had ankle debridement at the time of nailing fared well in terms of clinical, radiological union and ankle scoring. Conclusion: Tibiotalocalcaneal arthrodesis with supracondylar nail in rheumatoid arthritis provides pain-free stable joint and satisfactory functional outcome. Better functional results are achieved with bony union and this can be achieved only with joint debridement

Fragility ankle fractures are traditionally managed conservatively or with open reduction internal fixation (ORIF). Tibiotalocalcaneal (TTC) fusion is an alternative option for the geriatric patient. This systematic review and meta-analysis provides a detailed analysis of the functional and clinical outcomes of hindfoot nailing for fragility ankle fractures presented so far in the literature. A systematic search was performed on MEDLINE, EMBASE, Cochrane Library, Scopus, Web of Science, identifying fourteen studies for inclusion. Studies including patients over 60 with a fragility ankle fracture, treated with TTC nail were included. Patients with a previous fracture of the ipsilateral limb, fibular nails, and pathological fractures were excluded. Subgroup analyses were performed according to (1) open vs closed fractures, (2) immediate post-operative FWB vs post-operative NWB, (3) majority of cohort are diabetics vs minority of cohort are diabetics. Meta-regression analyses were done to explore sources of heterogeneity, and publication bias was assessed using Egger's test. The pooled proportion of superficial infection, deep infection, implant failure, malunion, and all-cause mortality was 0.10 (95%CI:0.06-0.16; I2=44%), 0.08 (95%CI:0.06-0.11, I2=0%), 0.11 (95%CI:0.07-0.15, I2=0%), 0.11 (95%CI:0.06-0.18; I2=51%), and 0.27 (95%CI:0.20-0.34; I2=11%), respectively. The pooled mean post-operative OMAS score was 54.07 (95%CI:48.98-59.16; I2=85%). The best-fitting meta-regression model included age and percentage of male patients as covariates (p=0.0263), and were inversely correlated with higher OMAS scores. Subgroup analyses showed that studies with a majority of diabetics had a higher proportion of implant failure (p=0.0340) and surgical infection (p=0.0096), and a lower chance of returning to pre-injury mobility than studies with a minority of diabetics (p=0.0385). Egger's test (p=0.56) showed no significant publication bias. TTC nailing is an adequate alternative option for fragility ankle fractures. However, current evidence includes mainly case series with inconsistent outcome measures reported and post-operative rehabilitation protocols. Prospective RCTs with long follow-up times and large cohort sizes are needed to clearly guide the use of TTC nailing for ankle fractures

Aims. Retrospective review of a consecutive series of 1,168 total ankle replacements (TAR) performed at Wrightington, to analyse modes of failure and clinical outcomes following TAR failure. Methods. All patients undergoing TAR between November 1993 – June 2019 were collated (4–25 year follow-up; mean 13.7 years). 6 implants were used (300 STAR, 100 Buechal Pappas, 509 Mobility, 118 Zenith, 41 Salto and 100 Infinity). 5 surgeons, all trained in TAR, performed the surgery. Modes of failure were collated and clinical and radiological outcomes recorded for the revisional surgery following failure of the TAR. Results. 156 (13.4%) TARs failed (47STAR 15.6%, 16BP 16%, 77Mobility 15.1%, 6Salto 14.6%, 10Zenith 8.5% and 0Infinity 0%). Mean time to failure 5.8 years (0.1- 21.4 years). The 4 most common modes of failure were 44.9% aseptic loosening, 11.5% gutter pain, 10.9% infection and 10.3% recurrent edge loading. 50 underwent conversion to tibiotalocalcaneal (TTC) fusion with nail with 9 (18%) failing to fuse. 31 underwent revision TAR with 2 (6.5%) subsequently failed. 22 underwent ankle fusion with 10 (45%) failing to fuse. 21 underwent polyethylene exchange of which 8 (38%) had further poly failure. 20 (12.8%) were managed conservatively, 2 (1.3%) required below knee amputation and 6 were listed but lost to follow-up. 81 of the 1168 (7%) consecutive cohort were lost to follow-up. Conclusions. 13.4% of the TAR cohort have failed at average follow-up 13.7 years. There was no difference in failure modes across the implant designs. Whilst the fixed bearing has the shortest follow-up, it may be performing better as there have been no failures so far. Prior to October 2016, most revisions were to fusion (TTC 18% failure rate, ankle 45% failure rate), whereas post 2016, 57% patients elected for revision TAR (6.5% failure)

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

Tibiotalocalcaneal fusion is generally reserved for complex cases such as severe deformity or bone loss, infection, Charcot and revision procedures. Subsequently published series have been small and there are no studies comparing plate fixation and intramedullary nailing. We present the outcomes in the largest series to date and have also compared the union rate and complication rate between blade plate fixation (36) and intramedullary nailing (46). Both groups were well matched for patient and disease factors. There was a non-statistically significant trend towards better outcomes with nails. Further analysis was conducted comparing the two fixation methods by the indication for surgery, there were no statistically significant differences, the reasons for these findings are discussed

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

Tibiotalocalcaneal (TTC) arthrodesis using a retrograde nail is a common salvage procedure for a range of indications. Previous work has suggested subtalar joint preparation is unnecessary to achieve satisfactory results. We examine the incidence of symptomatic subtalar nonunion following tibiotalocalcaneal fusion in a series of patients, all of whom had full preparation of the subtalar joint, and consider the possible contributing factors. We performed a retrospective review of all patients who underwent TTC arthrodesis from 2004–2010. All fusions were performed by the same surgeon with full preparation of both tibiotalar and subtalar joints. 61 TTC arthrodeses were performed in 55 patients (mean age = 59 years) using an intramedullary retrograde nail. Mean follow-up was 18 months (6–48 months). Fifty-six ankles (92%) achieved satisfactory union. Five patients (8%) had symptomatic non-union: 4 patients of the subtalar joint - with 3 patients undergoing revision subtalar arthrodesis and 1 patient of the tibiotalar joint. Nine patients required removal of the calcaneal screw (16%) – all had evidence of isolated subtalar nonunion prior to metalwork failure. Eight of these patients achieved asymptomatic union following screw removal. Subtalar nonunion following TTC fusion has resulted in recent changes to nail design to increase stability across the subtalar joint. Our results demonstrate a favourable overall nonunion rate with isolated subtalar nonunion making up the majority of cases. We also observed a significant rate of distal screw loosening, also associated with subtalar nonunion prior to screw removal, the significance of which merits further investigation

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

Introduction: The objective of this study was to investigate the clinical, radiographic and subjective outcome after salvage arthrodesis for failed total ankle arthroplasty (TAA), with a focus on salvage in inflammatory joint disease (IJD). Methods: Between 1994 and 2005, salvage arthrodesis for failed mobile-bearing TAA was performed in 18 ankles. Primary diagnosis was IJD 15 and osteoarthritis 3. Tibiotalar fusion was performed in 7 and tibiotalocalcaneal fusion in 11 ankles (in 9 out of these, the subtalar joint was already ankylosed). Serial radiographs were studied retrospectively by an independent observer for time to union. Clinical outcome at latest follow-up was measured by the AOFAS score, by the Foot function Index and by VAS scores for pain, function and satisfaction. Results: Blade plates were used in 7 ankles, all united. Nonunion developed in 7 IJD ankles stabilized by either a nail or screws or multiple K-wires. Revision arthrodesis was done for 4 nonunions, 3 were successful. Eleven patients (8 fused ankles, 3 nonunions) were available for clinical evaluation. At follow-up, their mean AOFAS score was 62.4; mean overall FFI was 70.1; VAS for pain was 20.1, for function 64.3, for satisfaction 73.8. Conclusions: Blade plate fixation is successful in salvage ankle arthrodesis. An high nonunion rate was found after salvage ankle arthrodesis in IJD with other methods of fixation. Several publications on primary arthrodesis also show an elevated nonunion rate in IJD. Clinical results were relatively good. The three non-unions in follow-up had subjective results similar to the fused ankles

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