Introduction. Circular frames for ankle fusion are usually reserved for complex clinical scenarios. Current literature is heterogenous and difficult to interpret. We aimed to study the indications and outcomes of this procedure in detail. Materials & Methods. A retrospective cohort study was performed based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiological and clinical outcomes, and adverse events. Factors influencing radiological and clinical outcomes were analysed. Results. 47 patients were included, with a mean follow-up of three years. The mean age at time of surgery was 63.6 years. Patients had a median of two previous surgeries. The median LOS was 8.5 days, and median EFT was 237 days. Where simultaneous limb lengthening was performed, the average lengthening was 2.9cm, increasing the EFT by an average of 4 months. Primary and final union rates were 91.5% and 95.7% respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and re-operations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT. Conclusions. Complex ankle fusion using circular frames can achieve good outcomes in complicated clinical scenarios, however patients can expect a prolonged time in the frame and high rates of adverse events. Multiple risk factors were identified for poorer outcomes, which should be considered in patient counselling and prognostication

Background. Open or arthroscopic ankle fusion (AAF) is a successful operative treatment for end-stage ankle arthritis. Evidence suggest that AAFs have better outcomes. In addition to the operative technique other patient-factors can influence outcomes. The most significant complication of ankle fusion is a non-union. To better understand the risk factors related to this we undertook a retrospective investigation of primary AAFs. Methods. We reviewed all AAFs conducted at our institution over a 10-year period. Patients excluded if they had simultaneous fusion of neighbouring joints or were lost to follow-up. The primary outcome variable was radiographic union. Other operative complications were analysed as secondary outcomes. Two hundred and eighty-four eligible AAFs in 271 patients were performed over the study period. Results. The overall non-union rate was 7.7 %. Univariate logistic regression analysis found that smoking (6.2% non-union in non-smokers vs 24% in smokers) and prior triple fusion (5.5% non-union in the absence of prior triple fusion vs 70% in the presence of a prior triple fusion) were independent risk factors for non-union. Multivariate analysis showed that only prior triple fusion was predictive (OR 40.0 [9.4,170.3], p < 0.0001). Increasing age, obesity (BMI >30), surgical grade (trainee vs consultant), diabetes or the degree of weightbearing status post-operatively were not significant risk factors of non-union. The leading cause of reoperation was the removal of metal (18%). There were 5 superficial (1.8%) and 4 deep (1.4%) infections. Kaplan-Meier survival analysis showed a 75% ‘survivorship’ of the subtalar joint at 10 years following an arthroscopic ankle fusion. Conclusion. This is the largest case series of AAFs in the literature and the first to demonstrate that patients who had an AAF performed after a previous triple fusion have unacceptably high non-union rates and may benefit from other surgical options. This study data could also useful for patient consenting purposes

Background. Total ankle replacements (TARs) are becoming increasingly more common in the treatment of end stage ankle arthritis. As a consequence, more patients are presenting with the complex situation of the failing TAR. The aim of this study was to present our case series of isolated ankle fusions post failed TAR using a spinal cage construct and anterior plating technique. Methods. A retrospective review of prospectively collected data was performed for 6 patients that had isolated ankle fusions performed for failed TAR. These were performed by a single surgeon (IW) between March 2012 and October 2014. The procedure was performed using a Spinal Cage construct and grafting in the joint defect and anterior plating. Our primary outcome measure was clinical and radiographic union at 1 year. Union was defined as clinical union and no evidence of radiographic hardware loosening or persistent joint lucent line at 1 year. Results. The mean follow-up was 37.3 months (SD 13.2). Union was achieved in 5 of the 6 patients (83%). One patient had a non-union that required revision fusion incorporating the talonavicular joint that successfully went on to unite across both joints. Another patient had radiographic features of non-union but was clinically united and asymptomatic and one required revision surgery for a bulky symptomatic lateral malleolus with fused ankle joint. Conclusion. The failing TAR presents a complex clinical situation. After removal of the implant there is often a large defect which if compressed leads to a leg length discrepancy and if filled with augment can increase the risk of non-union. Multiple methods have been described for revision, with many advocating fusion of both the ankle joint and subtalar joint. We present our case series using a spinal cage and anterior plating that allows preservation of the subtalar joint and a high rate of union

Objectives. Our objective was to perform a systematic review of the literature and conduct a meta-analysis to investigate the outcomes of open versus arthroscopic methods of ankle fusion. Methods. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards, we performed a systematic review. Electronic databases MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised and non-randomised studies comparing outcomes of arthroscopic and open ankle arthrodesis. The Newcastle-Ottawa scale was used to assess the methodological quality and risk of bias of the selected studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data. Results. We identified one prospective cohort study and 5 retrospective cohort studies, enrolling a total of 286 patients with ankle arthritis. Our analysis showed that open ankle fusion was associated with a lower fusion rate (OR 0.26, 95% CI 0.13–0.52, P = 0.0002), longer tourniquet time (MD 16.49, 95% CI 9.46–23.41, P<0.00001), and longer length of stay (MD 1.60,95% CI 1.10–2.10, P<0.00001) compared to arthroscopic ankle fusion; however, there was no significant difference between two groups in terms of infection rate (OR 2.41, 95% CI 0.76–7.64, P = 0.14), overall complication rate (OR: 1.54, 95% CI 0.80–2.96, P = 0.20), and operation time (MD 4.09, 95% CI −2.49–10.66, P = 0.22). The between-study heterogeneity was high for tourniquet time but low or moderate for other outcomes. The direction of the effect sizes remains unchanged throughout sensitivity analyses. Conclusions. The best available evidence demonstrates that arthroscopic ankle fusion may be associated with a higher fusion rate, shorter tourniquet time, and shorter length of stay compared to open ankle fusion. We found no significant difference between two groups in terms of infection rate, overall complication rate, and operation time. The best available evidence is not adequately robust to make definitive conclusions. Long-term results of the comparative efficacy of arthroscopic ankle fusion over open ankle fusion are not currently available. Further high quality randomised controlled trials that are adequately powered are required

Background:. Avascular necrosis (AVN) of the talus is a painful condition caused by trauma, steroids, alcoholism and haematological disorders. It is difficult to treat and at present there is insufficient evidence in favour of any particular strategy. The aim of operative therapy should be to relieve symptoms, maintain the normal architecture of the talus and treat associated arthritis. Small case series have described early core decompression, retrograde tibiotalocalcaneal arthrodesies and open tibio-calcaneal arthrodesis. Open procedures risk further talar collapse by disrupting its blood supply, and tibiotalocalcanal fusion sacrifices both the ankle and subtalar joints. The hypothesis is that arthroscopic ankle fusion relieves symptoms of AVN talus while preserving the subtalar joint and preventing further collapse. Methods:. A case study was performed of 16 patients with AVN who underwent arthroscopic ankle fusion at the Nuffield Orthopaedic Centre, Oxford, UK between 1998 and 2012. Clinical notes, radiographs and MRI was used to investigate the cause, co-morbidities and treatment outcomes following arthroscopic ankle fusion. Our primary outcome was fusion rate. Secondary outcomes included peri-operative complications, ongoing pain and subsequent operative intervention. Results:. The average age at the time of operation was 53.5 years (range 17 to 69). The presumed causes of AVN talus were steroids (3 patients), trauma (3 patients), haematological (2 patients), and alcoholism. The aetiology was unknown in 7 patients. Clinical and radiological fusion at the ankle joint was confirmed in 14/16 patients (2 were followed elsewhere). 11 patients were satisfied with the result at discharge, reporting no post operative complications. 3 patients had ongoing pain. 2 patients reported metalware irritation. 2 patients underwent a subsequent subtalar fusion. Conclusions:. Arthroscopic ankle fusion is a safe and reliable treatment of symptomatic AVN talus. It is a minimally invasive procedure potentially improving blood supply to the the talus and sparing the subtalar joint

We present the results of ankle fusion using the Ilizarov technique for bone loss around the ankle in 20 patients. All except one had sustained post-traumatic bone loss. Infection was present in 17. The mean age was 33.1 years (7 to 71). The mean size of the defect was 3.98 cm (1.5 to 12) and associated limb shortening before the index procedure varied from 1 cm to 5 cm. The mean time in the external fixator was 335 days (42 to 870). Tibiotalar fusion was performed in 19 patients and tibiocalcaneal fusion in one. Associated problems included diabetes in one patient, pelvic and urethral injury in one, visual injury in one patient and ipsilateral tibial fracture in five. At the final mean follow-up of 51.55 months (24 to 121) fusion had been achieved in 19 of 20 patients. A total of 16 patients were able to return to work. The results were graded as good in 11 patients, fair in six and poor in three. The mean external fixation index was 8.8 days/mm (0 to 30). One patient with diabetes developed severe infection which required early removal of the fixator. Refractures occurred in three patients, two of which were at the site of fusion and one at a previous tibial shaft fracture site. Equinus deformity of the ankle fusion occurred after a further fracture in one patient. There were two patients with residual forefoot equinus, and one developed late valgus at the fusion site. Poor consolidation of the regenerated bone in two patients was treated by bone grafting in one and by bone and fibular strut grafting in the other. Residual soft-tissue infection was still present in two patients

Ankle fusion (AF), a durable intervention for ankle arthritis, has been the management of choice but restricts mobility. Recently, total ankle replacement (TAR) has been offered to patients looking to maintain mobility. The aim was to compare the biomechanics of AF and TAR while walking on inverted and everted slopes which create a greater demand for complex foot mobility than level walking. A ten-camera motion detection setup captured trials as patients walked in both directions over a 5⁰ lateral slope with embedded force plates. Moments (Nm/Kg) across the knee and ankle were exported from Visual 3D in the sagittal and frontal plane, and data were reported as means with 95% confidence intervals. 15 patients were recruited (6 TAR, 9 AF). The median age, follow-up and BMI was 67 years, 4 years and 35.8 kg/m² in AF, and 73 years, 7 years and 28.1 kg/m² in TAR, respectively. During inverted slope walking (4 TAR, 7 AF), abduction moments across (i) the knee: TAR 0.38 (0.37–0.39) vs AF 0.37 (0.27–0.52) and (ii) the ankle: TAR 0.20 (0.13–0.27) vs AF 0.25 (0.18–0.32), and extension moments across (i) the knee: TAR 0.68 (0.38–0.97) vs AF 0.85 (0.69–1.01) and (ii) the ankle: TAR 1.46 (1.30–1.62) vs AF 1.30 (1.08–1.52). During everted walking (5 TAR, 7 AF), abduction moments across (i) the knee: TAR 0.41 (0.30–0.52) vs AF 0.46 (0.27–0.66) and (ii) the ankle: TAR 0.24 (0.11–0.38) vs AF 0.26 (0.18–0.33), and extension moments across (i) the knee: TAR 0.76 (0.54–0.99) vs AF 0.93 (0.72–1.14) and (ii) the ankle: TAR 1.39 (1.19–1.59) vs AF 1.26 (1.04–1.48). There were no differences in abduction moments during inverted or everted slope walking. However, patients with AF had increased extension moments across the knee, particularly on inverted slopes, suggesting that AF creates a greater demand for knee compensation than TAR

The outcome of arthroscopic ankle fusion has been favourably reported in the literature. The technique allows for early weight-bearing and results in fusion earlier than that of open techniques. All authors state that it a demanding procedure that has a significant learning curve. The purpose of this presentation is to report on that learning curve by analysing the first two years experience of one surgeon. Technical details, difficulties encountered and outcomes are described. We analysed the results of arthroscopic ankle fusion in 14 consecutive ankles in 13 patients over a two-year period. Average age at fusion was 59 years. There were 12 male patients and one female. Indication for surgery was osteoarthritis in all patients. All were non-smokers at the time of surgery. Anti-inflammatory drugs were not prescribed on discharge, All patients underwent pre-operative sciatic nerve block using a nerve stimulator. Fixation of the fusion was performed with two screws in 13 ankles and a single screw in one. Mean tourniquet time was 117 minutes (first 4 cases averaged 124 minutes; last 4 averaged 105 minutes). Mean hospital stay was a single night. All patients were treated post-operatively with plaster cast immobilisation for two weeks (non-weight bearing). Subsequently, they were instructed to fully weight bearing as tolerated in a removable walking boot. Radiological union was achieved in 11 ankles within 3 months. One ankle fused at between 9–12 months post-operatively. One ankle failed to unite due to inadequate joint access and preparation and underwent later open revision with bone grafting. One case of superficial portal wound infection treated successfully with antibiotics. No thrombo-embolic events. All patients had excellent or good clinical results at last follow up. Patient selection issues and intra-operative learning points are discussed. With adequate training, arthroscopic ankle fusion is a safe and reliable technique. The level of accuracy and precision required for consistently good surgical results will vary depending upon the characteristics of surgical task being undertaken. Training surgeons to achieve these results rapidly and effectively is a continuing challenge. Resurfacing arthroplasty for cam type deformity (a common cause of early osteoarthritis) is a technically demanding operation. We considered it desirable that the operation should be performed within +/− 10¡ of the desired angular orientation, and +/− 6mm of entry point translation in 95% of cases. To achieve that level of accuracy, without learning slowly on real patients, technological aids are now available. Using 3 models of varying severity of cam, we assessed the efficacy of 3 systems of instrumentation in delivering the level of accuracy and precision that is needed to ensure the excellent results that this surgeon and patient group expects

Introduction: Severe haemophilia affects 1 in 10,000 men. The ankle along with the hip and knee are commonly affected. Ankle fusion is the preferred surgery for end stage arthritis in the younger patient although debate exists as to the preferred technique. We conducted a retrospective review of the arthroscopic ankle fusions on haemophiliacs from Oxford and compared data with that of a specialist unit in London using an open technique. Materials and Methods: We reviewed 22 ankles (22 patients) from Oxford and 10 ankles (8 patients) from London. 90% had Type A haemophilia with similar regular monthly Factor VIII usage: 17941 U/month (Oxford) compared with 17992 (London). 73% of patients in the Oxford Group and 100% of the London group had Hepatitis C and/or HIV. Results: Union was achieved in all patients. The mean time to union in the open group was 9.1 weeks (Mode- 8 weeks, Range 7–14) compared to 12.2 weeks (Mode- 12 weeks, Range 8–24) in the arthroscopic group. Screw removal was required in 4 patients (3 arthroscopic v’s 1 open). 1 patient in the arthroscopic group suffered a pseudoaneurysm of the dorsalis pedis artery. The arthroscopic group spent less time in hospital- 5.7 days compared to 9.5. Factor VIII usage was less in the arthroscopic group- 32,882 Units compared to 40013. Discussion: Patients of this nature should be managed in centres used to dealing with their complex needs. Arthroscopic ankle fusion in haemophiliacs is safe for these patients. Although arthroscopic fusion may take slightly longer to unite, there are benefits in terms of reduced patient stay and factor VIII requirement and therefore costs

Introduction: Although more than 30 different surgical procedures to achieve solid ankle fusion were described, after septic joint destruction or ongoing infection external fixation is preferred. In 1999 the referring institution reported on 45 cases with internal (screw) fixation and additional external fixation [. 1. ]. Later on we used hybrid external fixation including transfixation of the midfoot [. 2. ]. Since range of motion of the middle and forefoot is of great importance for limb function we designed a prospective study to compare fusion rate and limb function after ankle fusion without foot or midfoot transfixation. Patients and Methods: Between 9/2000 and 2/2002 18 patients with septic ankle destruction were admitted for ankle fusion. 10 patients were treated with a fine wire ring fixator using 2 full rings in the tibia and one 5/8 shaped ring in the calcaneus and talus. Compression was applicated only between the distal tibia and the talus. Every 14 days the wires were retensioned. 8 patients were treated with a titanium compression nail in an antegrad technique. All operations were done by one surgeon. 14 patients had a posttraumatic osteitis complicated in 6 cases by polyneurophathy and in two cases previous fusion failed. 4 patients suffered from diabetic polyneuropathy, 2 of them with ongoing infection. In both techniques weight bearing was allowed after 3 weeks. Results: External fixator was removed 16 weeks after operation on average (14w–18w). Solid fusion was achieved in 16 cases (88%). In 3 patients the fistula persisted in one of them fusion failed. Dynamic pedobarography showed better results in patients without fixation of the subtalar joint. (Compression nail). Conclusion: The study showed similar fusion rates compared with surgical procedures including transfixation of the whole foot. Range of motion of the not fused joints of the foot was better because early physioptherapy was performed. The fixation of the fore and mid foot is not necessary to achieve solid fusion by increased stability

The December 2022 Foot & Ankle Roundup. 360. looks at: Evans calcaneal osteotomy and multiplanar correction in flat foot deformity; Inflammatory biomarkers in tibialis posterior tendon dysfunction; Takedown of ankle fusions and conversion to total ankle arthroplasty; Surgical incision closure with three different materials; Absorbable sutures are not inferior to nonabsorbable sutures for tendo Achilles repair; Zadek’s osteotomy is a reliable technique for treating Haglund’s syndrome; How to best assess patient limitations after acute Achilles tendon injury; Advances in the management of infected nonunion of the foot and ankle

Numerous techniques have been described for ankle arthrodesis. Arthroscopic arthrodesis with internal fixation has evolved to reduce the complications associated with open arthrodesis. We present our technique of arthroscopic ankle fusion using two medial cannulated screws with specially designed dished washers. The tibiotalar joint is debrided arthroscopically and internal fixation is achieved with two medial cannulated screws with designed dished washers. Seven ankle arthrodeses were performed on six patients; one underwent bilateral arthrodesis. All the patients suffered from OA (four post traumatic) and were aged between 53–61 (mean 55.4). There were four males and two females. The follow up ranged from 8–18 months (mean 10). All the patients achieved ankle fusion. Time for fusion ranged from 6 to 18 weeks, five fused within 12 weeks. Pre operative pain scores improved from 6–10 out of 10 (mean 7.2) to 1–3 out of 10 (mean 1.4) post-operative. Post-operative AAFOS ankle hind foot score ranged from 74–89 out of 100 (mean 81.8). One patient required further operations for adjustment of fixation and one suffered a stress fracture at the level of the proximal screw. This method of arthroscopic ankle fusion provides an effective alternative to open arthrodesis for selected patients with OA achieving good initial results

Statement of purpose. To describe the results and technique of ankle fusion following failed Total Ankle Replacement (TAR) in a limb reconstruction unit. Methods. Retrospective case note, microbiology and imaging review was performed on four consecutive patients referred to the limb reconstruction unit for salvage of infected total ankle replacement surgery since 2009. The patients were identified from operative list and tertiary referral records. A review of the current literature regarding TAR was performed. Results. Three patients were treated with a two stage surgical approach with initial removal of metalwork, debridement of infected tissue and temporary spanning external fixation. Local and systemic antibiotic therapy was then implemented for an average period of 53 days (range 48–61 days), before definitive fixation with a circular frame. One patient showed no clinical evidence of infection during preoperative investigation or intraoperatively, and was therefore treated with a single stage procedure with application of a circular frame. All four patients grew Staphylococci on culture of excised tissue and in one case there was additional growth of Proteus species. Bony union was achieved after fusion with a circular frame in all cases. Conclusion. TAR is gaining popularity for the treatment of severe talocrural arthritis, and several series with medium term results report low numbers of infected cases requiring revision. This case series discusses and describes the management strategy for failed TAR due to infection employed by a limb reconstruction unit

As an alternative to ankle replacement, ankle arthrodesis remains a mainstay in the treatment of end-stage arthritis. Arthroscopic techniques for ankle arthrodesis have more recently been developed, although there has been limited research exploring the cost of arthroscopic (AAA) versus open ankle arthrodesis (OAA), and comparing ankle fusions to replacement (TAA). We hypothesise that resource use after AAA will be lower than that after OAA, and both will be lower than TAA. We performed a retrospective review of a prospectively collected database. The COFAS database was used to identify patients with >2 years of follow up who have undergone AAA, OAA or Hintegra TAA at St Paul's Hospital between 2003–2010. Ninety patients with TAA, 52 with AAA and 56 with OAA met our inclusion criteria. The following data were documented: patient demographics (age, gender, presence of diabetes, inflammatory arthritis or any smoking history), factors related to the index surgery (type of surgery, OR time, length of stay) and factors relating to the post-operative course (number of post-operative clinic visits, OR time for re-operations, length of stay for additional hospital admissions). In terms of the index surgery, AAA required less initial OR time compared to either OAA or TAA. Initial length of hospital stay was significantly longer for both TAA and OAA, compared to AAA. Patients attended more follow-up visits after TAA or OAA compared to after AAA. In terms of additional OR time required, no significant differences were found among the groups. The most common reason for re-operation was infection or wound breakdown (38% of re-operations), followed by removal of hardware (15%). TAA also required significantly more additional days in hospital compared to either OAA or AAA. For all significant comparisons, p < 0.05. For each primary TAA, on average an additional one hour of surgery, three days in hospital and seven clinic visits were required on top of the cost factored for the primary arthroplasty. For each primary AAA, an additional four clinic visits, 23 minutes of revision surgery and one day in hospital were required. For each primary OAA, an average additional five clinic visits, three minutes of OR time, and 0.2 days of additional hospital stay occurred during follow up. Using several measures of resource use, we find that arthroscopic ankle fusions compare favourably to both ankle replacements and open ankle fusions. We also show that resource utilisation measurements can be a useful surrogate for complications, and that resource utilisation can demonstrate the practical implications of complications for patients, surgeons and health care resources

Purpose of the study: Theoretically, long-term functional and radiographic degradation is predictable after ankle fusion, but sound evidence from consecutive analysis of the same cohort is lacking. The purpose of this study was to evaluate the same cohort of patients who underwent ankle fusion. Material and Methods: The cohort included 52 ankle fusions which had been analyzed in 1984 at seven years (2–22 years) of follow-up then again in 2000 using the same evaluation criteria. Among the 52 patients, six were lost to follow-up, 20 had died and one had undergone leg amputation. The second analysis thus included 25 patients (18 men and 7 women), mean age 62±12.6 years (40–94) at the 2000 assessment performed 23±4.5 years (19–36 years) after the fusion. Functional outcome was assessed with the 100-point Duquennoy scale. Osteoarthritis of the subtalar and mediotarsal joints were assessed preoperatively and at follow-up using the same scale. Results: The functional outcome did not deteriorate significantly between 1984 and 2000. The mean score was 65.8±22.6 (19–92) in 1984 and 64.7±18.3 (34–90) in 2000 (p=0.67). Fifteen patients (60%) had a good or very good outcome at seven years, and 14 (56%) at 23 years. Between 1984 and 2000, ten patients improved their score (on average 10.4 points, range 1–21 points), two had an unchanged score and thirteen a lower score (on average 10 points, range −1 to −24). Ten of these thirteen patients developed severe intercurrent conditions explaining the degradation. At last follow-up, sixteen ankles were pain free or nearly pain free. Twelve patients considered their ankle as a forgotten problem and had no regrets concerning the operation. The evolution of the subtalar joint in 16 cases (nine fusions including five at the same time as the ankle fusion and four performed within four years) showed that all developed early osteoarthrtic degradation with aggravation between 1984 and 2000, leading in the majority of cases to severe degenerative disease. This osteoarthritis was painful in less than one-third of the cases (including the four secondary subtalar fusions and the four sub-talar fusions which were painful at mobilization). The mediotarsal joints degradation was later and less severe than for the subtalar joint with a majority of moderate osteoarthritis. Ten ankles exhibited compensatory hypermobility of the forefoot measured at more than 15° without pain. Discussion: This long-term follow-up with two successive assessments using the same evaluation criteria did not demonstrated late degradation of function expected after ankle fusion. It did show however the presence of radiographic degradation of the subtalar joint but with little clinical expression at a minimal follow-up of 19 years. There was no need for complementary fusion between 4 and 23 years follow-up

A retrospective study involving thirty-six patients with thirty-seven ankle fusions was undertaken to assess the rate of fusion, the subjective and objective results, the residual subtalar and midtarsal movement, and the functional disability. Fusion occurred in thirty-one ankles (84 per cent). Twenty-four patients were reviewed, on average 7.5 years after fusion, and eighteen had good or excellent results; only four had been unable to return to their previous employment. The conclusion is that fusion is still a good treatment for the painful post-traumatic arthritis ankle, the resulting functional disability being minimal

Aims: To show that ankle fusion using an intra-medullary nail is effective with low morbidity and high patient satisfaction and improvement in postoperative AOFAS scores in selected patients. Methods: The þrst twenty ankle fusions performed with the Biomet intra-medullary nailing system by one surgeon were reviewed over a two year period. The Biomet system offers superior advantages, allowing longitudinal compression and posterior to anterior distal locking in the calcaneus. Data sets were recorded for each patient. Information with regard to each patients age, sex, occupation, presenting complaint, mechanism of injury if applicable, index procedure if applicable, diabetic status, associated comorbidities and smoking habitus were recorded. The pre-operative and post-operative AOFAS score was also recorded for each patient. Results: All patients except one showed a marked improvement in their AOFAS score when treated with intra-medullary nail for ankle fusion. The average improvement in score was 150%. Morbidity from the procedure was low. There was one case of mortality not attributed to the nail. 19 out of 20 patients went on to solid fusion. Conclusion: The use of an intra-medullary nail for fusion of the ankle is a reliable technique in selected cases. AOFAS scores consistently improve, morbidity is low and fusion is usually successful. We would advocate this technique for fusion

Introduction

We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy.

Fragility ankles fractures in the geriatric population are challenging to manage, due to fracture instability, soft tissue compromise, patient co-morbidities. Traditional management options include open reduction internal fixation, or conservative treatment, both of which are fraught with high complication rates. We aimed to present functional outcomes of elderly patients with fragility ankle fractures treated with tibiotalocalcaneal nails.

171 patients received a tibiotalocalcaneal nail over a six-year period, but only twenty met the inclusion criteria of being over sixty and having poor bone stock, verified by radiological evidence of osteopenia or history of fragility fractures. Primary outcome was mortality risk from co-morbidities, according to the Charlson co-morbidity index (CCI), and patients’ post-operative mobility status compared to pre-operative mobility. Secondary outcomes include intra-operative and post-operative complications, six-month mortality rate, time to mobilisation and union.

The mean age was 77.82 years old, five of whom are type 2 diabetics. The average CCI was 5.05. Thirteen patients returned to their pre-operative mobility state. Patients with low CCI are more likely to return to pre-operative mobility status (p=0.16; OR=4.00).

Average time to bone union and mobilisation were 92.5 days and 7.63 days, respectively. Mean post-operative AOFAS ankle-hindfoot and Olerud-Molander scores were 53.0 (range 17-88) and 50.9 (range 20-85), respectively. There were four cases of broken distal locking screws, and four cases of superficial infection. Patients with high CCI were more likely to acquire superficial infections (p=0.264, OR=3.857). There were no deep infections, periprosthetic fractures, nail breakages, non-unions.

TTC nailing is an effective treatment methodology for low-demand geriatric patients with fragility ankle fractures. This technique leads to low complication rates and early mobilisation. It is not a life-changing procedure, with many able to return to their pre-operative mobility status, which is important for preventing the loss of socioeconomic independence.

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