Purpose. The goal of Total Ankle Arthroplasty (TAA) is to relieve pain and restore healthy function of the intact ankle. Restoring intact ankle kinematics is an important step in restoring normal function to the joint. Previous robotic laxity testing and functional activity simulation showed the intact and implanted motion of the tibia relative to the calcaneus is similar. However there is limited data on the tibiotalar joint in either the intact or implanted state. This current study compares modern anatomically designed TAA to intact tibiotalar motion. Method. A robotic testing system including a 6 DOF load cell (AMTI, Waltham, MA) was used to evaluate a simulated functional activity before and after implantation of a modern anatomically designed TAA (Figure 1). An experienced foot and ankle surgeon performed TAA on five fresh-frozen cadaveric specimens. The specimen tibia and fibula were potted and affixed to the robot arm (KUKA Robotics Inc., Augsburg, Germany) while the calcaneus was secured to a fixed pedestal (Figure 1). Passive reflective motion capture arrays were fixed to the tibia and talus and a portable coordinate measuring machine (Hexagon Metrology Group, Stockholm, Sweden) established the location of the markers relative to anatomical landmarks palpated on the tibia. A four camera motion capture system (The Motion Monitor, Innovative Sports Training, Chicago, IL) recorded the movement of the tibia and talus. The tibia was rotated from 30 degrees plantar flexion to 15 degrees dorsiflexion to simulate motions during the stance phase of gait. At each flexion angle the robot found the orientation which zeroed all forces and torques except compressive force, which was either 44N or 200N. Results. Preliminary data indicates the tibiotalar motion of the TAA is similar to the intact ankle. The pattern and magnitude of tibiotalar translations and rotations are similar between the intact and implanted states for both 44N and 200N compressive loads (Figure 2). The most variation occurs with internal-external rotation. Increased translation especially in the anterior-posterior directions was observed in plantarflexion while the mediolateral translation remained relatively centered moving less than a millimeter. The intact talus with respect to the calcaneus had less than 3 degrees of rotation over the whole arc of ankle flexion (Figure 3). The angular motion of the implanted talus was similar in pattern to the intact talus, however there were offsets in all three angular directions which changed depending on the loading (Figure 3). This indicates that most of the motion that occurs between the intact tibial calcaneal complex occurs in the tibiotalar joint. Conclusion. Although more investigation is required, this study adds to the limited available tibiotalar kinematic data. This current study suggests the anatomical TAA design allows the tibiotalar joint to behave in similar way to the intact tibiotalar joint. Restoring intact kinematics is an important step in restoring normal function to the joint. For figures/tables, please contact authors directly.

Aim. The aim of this work was to evaluate, via foot and ankle TC scans, the outcomes of the use of a bone substitute (CERAMENT|™G) and the growth of native bone in the treatment of osteomyelitis (OM) of the diabetic foot. Method. In nine patients from July 2014 to December 2016 we used a Calcium Sulphate Hemihydrate + Hydroxyapatite + Gentamicin Sulfate (CSH + HA + GS) compound to fill resected bone voids following surgical intervention in OM diabetic foot cases. Of these nine patients, three were female and six were male and their ages were between 49 and 72 years. Four patients had hindfoot involvement and underwent partial calcanectomy. Two patients presented a rocker-bottom Charcot foot pattern III according to Sanders and Frykberg's classification and were treated with esostectomy of the symptomatic bony prominence of the midfoot. One patient presented OM of the 3°, 4° and 5° metatarsal bones. One patient underwent partial resection of the midfoot and hindfoot with arthrodesis stabilised by an internal-external hybrid fixator. One patient with a Charcot foot pattern IV-V underwent partial talectomy and calcanectomy with arthrodesis stabilised by an internal-external hybrid fixator. In all these patients - after removal of the infected bone - we applied 10 to 20 ml CSH + HA + GS filling the residual spaces with the aim of stabilising the remaining bone fragments. The uniqueness of this product is that it induces native bone growth, while the synthetic bone disappears and antibiotic is released into the surrounding tissues. In March 2018, the above nine patients underwent foot and ankle TC scans to evaluate bone growth. Results. The first four patients showed new bone formation in the calcaneus. Two patients with previous midfoot destruction showed chaotic but stable bone formation. The patient with metatarsal OM showed partial bone healing with residual pseudoarthrosis. Both the two patients who underwent arthrodesis with hybrid fixators showed a plantigrade and stable foot even though a heel wound is still present in one of the patients. All patients except this one are now wearing suitable shoes as post-operative wounds have healed. The patient still with the heel wound is walking with an aircast brace. Conclusion. The TC scans have shown new bone formation sufficient to stabilise the foot and allow ambulation. In particular, very good results come from the filling of the calcaneus, probably due to the anatomy of the bone itself

Aim. Chronic osteomyelitis of the calcaneus is a frequent problem in a population of diabetic patients, patients with neurologic disorders or bedridden patients with ulcers. Partial calcanectomy is an alternative option which avoid major amputation. The aim of this retrospective study was to determine the effectiveness of partial calcanectomy for treating chronic osteomyelitis of the calcaneux. Method. We conducted a retrospective review of patients who underwent in our department a partial calcanectomy between 2006 and 2015. All patients with a complete set of radiographs and adequate follow-up (minimum 2 years) were included. We reviewed these cases to determine healing rate, microbiological analysis, risk factors of failure (comorbidities), limb salvage rate and survival rate. We analyzed specifically the footwear and the functional subjective evaluation according to the LEFS score (Lower Extremity Functional Scale). Results. Twenty-four patients were included (24 foot). There were 17 men and the mean age was 65.2 years. The control of the infection and the healing was obtained in 15 cases. An additional surgery was required in 46% of the cases. A transtibial amputation has been realized in 9 cases because of uncontrolled infection. The existence of a preoperative vascular disease increased 5,9 times the risk of amputation after a partial calcanectomy (p=0,033). The type of germ was not related to the risk of recurrence. Soles were necessary for 60% of the patients with a successful partial calcanectomy (n=15). The average LEFS score was 51/80. Conclusion. The treatment of the chronic osteomyelitis of the calcaneus was a therapeutic challenge for these patients. The partial calcanectomy is a useful procedure for limb salvage, but the selection of patients must be rigorous. In our study, arteriopathic patients had a high risk of amputation after partial calcanectomy. When the healing is acquired, the patients were satisfied and presented a good function

When total ankle arthroplasty (TAA) is performed, although tibial osteotomy is instructed to be perpendicular to long axis of tibia, there is no established index for the talar bone corrective osteotomy. Then, we have been deciding the correction angle at the plan for adjustment of the loading axis through whole lower extremities. We studied 17 TAA cases with rheumatoid arthritis (RA). X-ray picture of hip to calcaneus view (hip joint to tip of the calcaneus) defined to show more approximated loading axis has been referred for the preoperative planning. Furthermore, the data of correction angle has been reflected to pre-designed custom-made surgical guide. If soft tissue balance was not acceptable, malleolar sliding osteotomy was added. The distance between the centre of ankle joint and the axis (preD) was measured (mm) preoperatively, and the distance between the centre of prosthesis and the axis (postD) was measured postoperatively. Next, the tilting angle between tibial and talar components (defined as the index of prosthesis edge loading) were measured with X-rays during standing. Tibio Calcaneal (TC) angle was also measured pre and postoperatively. TC angle was significantly improved from 8.3±6.0° to 3.5±3.6° postoperatively (P=0.028). PreD was 12.9±9.6mm, and that was significantly improved to 4.8±6.3mm (postD) (P=0.006). Within 17 cases, 8 cases showed 0–1mm of postD, 4 cases showed 1–5mm of postD, remaining 5 cases concomitant subtalar fusion with severe valgus and varus hindfoot deformity showed over 8mm of postD. All of the 12 cases showing within 5mm of postD indicated within 13mm of preD. The tilting angle between components was 0.17±0.37° postoperatively. Taken together, pre-designed corrective talar osteotomy based on preoperative planning using hip to calcaneus view was useful to adjust the mechanical axis for replaced ankle joint in RA cases. Furthermore, after surgery, the hip to calcaneus view was useful to evaluate post-operative mechanical axis of whole lower extremities

Three dimensional printing is an emerging new technology in medicine and the current educational value of 3D printed fracture models is unknown. The delayed surgery and need for CT imaging make calcaneal fractures an ideal scenario for preoperative 3D printed (3Dp) fracture models. The goal of this study is to assess if improvements in fracture understanding and surgical planning can be realized by trainees when they are given standard CT imaging and a 3Dp model compared to standard CT imaging and a virtual 3D rendering (3D CT). Ethics approval was granted for a selection of calcaneal fracture imaging studies to be collected through a practice audit of a senior orthopaedic trauma surgeon. 3Dp models were created in house. Digital Imaging and Communications in Medicine (DICOM) files of patient CT scans were obtained from local servers in an anonymized fashion. DICOM files were then converted to .STL models using the Mimics inPrint 2.0 (Materialise NV, Leuven, Belgium) software. Models were converted into a .gcode file through a slicer program (Simplify3D, Blue Ash, OH USA). The .gcode files were printed on a TEVO Little Monster Delta FDM printer (TEVO USA, CO USA) using 1.75mm polylactic acid (PLA) filament. Study participants rotated through 10 workstations viewing CT images and either a digital 3D volume rendering or 3Dp model of the fractured calcaneus. A questionnaire at each workstation assessed fracture classification, proposed method of treatment, confidence with fracture understanding and satisfaction with the accuracy of the 3Dp model or 3D volume rendering. Participants included current orthopaedic surgery trainees and staff surgeons. A total of 16 residents and five staff completed the study. Ten fracture cases were included in the analysis for time, confidence of fracture understanding, perceived model accuracy and treatment method. Eight fracture cases were included for assessment of diagnosis. There were no cases that obtained universal agreement on either Sanders classification or treatment method from staff participants. Residents in their final year of studies had the quickest mean time of assessment (60 +/− 24 sec.) and highest percentage of correct diagnoses (83%) although these did not reach significance compared to the other residency years. There was a significant increase in confidence of fracture understanding with increasing residency year. Also, confidence was improved in cases where a 3Dp model was available compared to conventional CT alone although this improvement diminished with increasing residency year. Perceived accuracy of the cases with 3Dp models was significantly higher than cases without models (7 vs 5.5 p < 0.0001). This is the first study to our knowledge to assess trainee confidence as a primary outcome in the assessment of the educational value of 3Dp models. This study was able to show that a 3Dp model aides in the perceived accuracy of fracture assessment and showed an improvement in trainee confidence, although the effect on confidence seems to diminish with increasing residency year. We propose that 3D printed calcaneal fracture models are a beneficial educational tool for junior level trainees and the role of 3Dp models for other complex orthopaedic presentations should be explored

The lack of a universal, consistent protocol for the subjective, objective and radiographic evaluation of these injuries has hampered the comparison of results. Methods. 45 patients with complex fractures of the calcaneus were included in this prospective study, which was undertaken from July 2003 to December 2005. The fracture classification of Essex-Lopresti was used. We also observed the extent of secondary fracture lines extending from the primary shear line (on axial and external oblique plain radiographs) to establish comminution. The external oblique view for subtalar joint was performed with the patient supine, the knee at about 60 degree of flexion and the limb rotated externally 45 degree with a vertical X ray beam. All of these patients were managed by an external fixator using the principle of ligamentotaxis. Patients were evaluated by AOFAS. Results. We identified two broad patterns of secondary lines on plain X-rays:. with anterior secondary fracture lines and. with posterior secondary fracture lines. There were 20 cases of tongue type and 25 of joint depression type fracture pattern by the Essex-Lopresti classification. Forty two (93.4%) patients had fractures with posterior secondary fracture line and 3 (6.7%) patients had anterior secondary lines. The calcaneo-cuboid type of anterior secondary line pattern was present in 2 (4.5%) cases, and the plantar type in only 1 (2.5%) case. We observed posterior secondary line Type A pattern in 2 (4.5%) cases, depression / central depression type B in 20 (44.5%) cases, tongue shaped Type C pattern in 16 (36.5%) cases and Type D severely comminuted fracture line pattern in 4 (8.7%) cases. Conclusion. Comminution was significantly associated with prognosis and final outcome. Evaluation of secondary fracture lines corresponds with comminution of fractures of the calcaneus and the final outcome of these fractures. NO DISCLOSURES

INTRODUCTION. Proper ligament engagement is an important topic of discussion for total knee arthroplasty; however, its importance to total ankle arthroplasty (TAA) is uncertain. Ligaments are often lengthened or repaired in order to achieve balance in TAA without an understanding of changes in clinical outcomes. Unconstrained designs increase ankle laxity,. 1. but little is known about ligament changes with constrained designs or throughout functional activity. To better understand the importance of ligament engagement, we first investigated the changes in distance between ligament insertions throughout stance with different TAA designs. We hypothesize that the distance between ligaments spanning the ankle joint would increase in specimens following TAA throughout stance. METHODS. A validated method of measuring individual bone kinematics was performed on pilot specimens pre- and post-TAA using a six-degree-of-freedom robotic simulator with extrinsic muscle actuators and motion capture cameras (Figure 1). 2. Reflective markers attached to surgical pins and radiopaque beads were rigidly fixed to the tibia, fibula, talus, calcaneus, and navicular for each specimen. TAAs were performed by a fellowship-trained foot and ankle surgeon on two specimens with separate designs implanted (Cadence & Salto Talaris; Integra LifeSciences; Plainsboro, NJ). Each specimen was CT-scanned after robotic simulations of stance pre- and post-TAA. Specimens were then dissected before a 3D-coordinate measuring device was used to digitize the ligament insertions and beads. Ligament insertions were registered onto the bone geometries within CT images using the digitized beads. Individual bone kinematics measured from motion capture were then used to record the point-to-point distance between centers of the ligament insertions throughout stance. RESULTS. Results from the pilot specimens are presented for the calcaneofibular ligament (CFL) only. The distance between the CFL insertions was larger throughout stance following Cadence implantation (Figure 2A) and was decreased throughout most of stance following Salto Talaris implantation (Figure 2B). The percent change in CFL distance with respect to static standing was also increased with the Cadence implant (Figure 2C) and similar to intact following Salto Talaris implantation (Figure 2D). Ankle motion was similar to intact with the Cadence (Figure 3A) and was decreased with the Salto Talaris (Figure 3B). DISCUSSION. This study suggests that ligament length during stance changes following TAA. The Cadence implant similarly replicated ankle kinematics but CFL length was increased throughout stance which supports our hypothesis. In contrast, the Salto Talaris implant reduced ankle motion and decreased the CFL length. Although the slack length and pre-strain of the CFL were unknown, the distance between insertions from the pilot specimens provides preliminary insight into how ligament mechanics change post-TAA during functional activity. CLINICAL RELEVANCE. Preliminary results of ligament length changes throughout stance may indicate that ligament mechanics change post-TAA and could affect patient outcomes. Changes may be even more pronounced when a soft tissue release or reconstruction is performed to correct malalignment. For any figures or tables, please contact the authors directly

We present our experience of using tension band plates to achieve guided growth in children for correction of calcaneus deformity of the ankle. 11 consecutive patients (13 ankles) fulfilled the inclusion criteria over a 4-year period. All underwent surgical treatment using a flexible two hole plate and screws on the posterior aspect of distal tibial physis. Measurements were done on preoperative, intraoperative screening and 1-year post operative plain AP and lateral ankle radiographs. The anterior distal tibia angle (ADTA), lateral distal tibial angle (LDTA) and screw divergence angle (angle subtended by lines passing through the long axis of the screws) were used to assess the deformity correction. A 2 tailed student t-test was carried out on the initial and 1-year post-op measurements to determine statistical significance with a p value <0.05 considered as significant. There were 10 residual clubfoot deformities, 2 post-traumatic deformities and 1 spinal tumor causing deformity. The average age of the patients was 10 years 5 months (range 4 to 13 years). There were 9 males and 2 females. The ADTA showed a statistically significant change with a p value of 0.0008 with a mean correction of 8.6 degrees (range of 2.3 to 15.6 degrees). The SDA demonstrated a mean correction of 15.4 degrees (range 0.3 to 41.8 degrees), p=0.002. The LDTA did not change significantly (p= 0.08), thus confirming no coincidental coronal plane deformity had occurred. 5 ankles required revision of fixation due to metalwork reaching its maximum limit of divergence at an average of 1 year. 2 ankles had screw pulled out due to osteolysis around the screw. There were no cases of infection. We report satisfactory short-term results of correction of calcaneus deformity using a flexible tension band plate and screws system

Introduction. The gastrocnemius tendon extends from the musculotendinous junction proximally to the conjoint junction with soleus distally. The morphology of the junction has not, to our knowledge, been described previously. Lengthening of the gastrocnemius tendon is a standard surgical procedure in surgery for cerebral palsy. The aims of the study were to describe the morphology of the conjoint junction and to identify the location of the gastrocnemius tendon relative to palpable bony landmarks to assist with incision planning. Methods. Twenty-one embalmed adult cadaveric specimens were dissected to document the morphology of the conjoint junction. The location of the gastrocnemius tendon was measured relative to the distance between the palpable bony landmarks of the calcaneus and the head of the fibula. Results. The conjoint junction morphology was transverse in 9/21 (43%), oblique in 6/21 (29%), and arcuate as an inverted ‘U’ in 4/21 legs (19%) and ‘U’ shaped in 2/21 legs (9%). On the medial side of the leg the gastrocnemius tendon was located between 35% and 43% of the distance between the calcaneus and fibula head. The corresponding distances for the midline were 39% and 56% and for the lateral side 40% and 50%. Conclusion. The morphology of the conjoint junction varied in the specimens studied. An indication of the site of the gastrocnemius tendon relative to identifiable bony landmarks may help in incision planning either for open or endoscopic gastrocnemius lengthening

This is a retrospective study examining the injury pattern, management and short-term outcomes of British Military casualties sustaining hindfoot fractures from the conflicts in Iraq and Afghanistan. In the 12-years of war, 114 patients sustained 134 hindfoot injuries. The calcaneus was fractured in 116 cases (87%): 54 (47%) were managed conservatively, with 30 (26%) undergoing internal fixation. Eighteen-month follow-up was available for 92 patients (81%) and 114 hindfeet (85%). Nineteen patients (17%) required trans-tibial amputation in this time, with a further 17 (15%) requiring other revision surgery. Deep infection requiring surgical treatment occurred in 13 cases (11%) with S. aureus the commonest infective organism (46%). Deep infection was strongly associated with operative fracture management (p=0.0022). When controlling for multiple variables, the presence of deep infection was significantly associated with a requirement for amputation at 18 months (p=0.001). There was no association between open fractures and requirement for amputation at 18 months (p=0.926), nor was conservative management associated with amputation requirement (p=0.749)

The lower limbs of vehicle occupants are vulnerable to severe injuries during under vehicle explosions. Understanding the injury mechanism and causality of injury severity could aid in developing better protection. Therefore, we tested three different knee positions in standing occupants (standing, knee in hyper-extension, knee flexed at 20˚) of a simulated under‐vehicle explosion using cadaveric limbs in a traumatic blast injury simulator; the hypothesis was that occupant posture would affect injury severity. Skeletal injuries were minimal in the cadaveric limbs with the knees flexed at 20˚. Severe, impairing injuries were observed in the foot of standing and hyper‐extended specimens. Strain gauge measurements taken from the lateral calcaneus in the standing and hyper-extended positions were more than double the strain found in specimens with the knee flexed position. The results in this study demonstrate that a vehicle occupant whose posture incorporates knee flexion at the time of an under‐vehicle explosion is likely to reduce the severity of lower limb injuries, when compared to a knee extended position

Anti-vehicle mines (AV) and Improvised Explosive Devices (IEDs) remain the most prevalent threat to Coalition troops operating in Iraq and Afghanistan. Detonation of these devices results in rapid deflection of the vehicle floor resulting in severe injuries to calcaneus. Anecdotally referred to as a ‘deck-slap’ injury, there have been no studies evaluating the pattern of injury or the effect of these potentially devastating injuries since World War II. Therefore the aim of this study is to determine the pattern of injury, medical management and functional outcome of UK Service Personnel sustaining calcaneal injuries from under-vehicle explosions. From Jan 2006 – Dec 2008, utilising a prospectively collected trauma registry (Joint Theatre Trauma Registry, JTTR), the records of all UK Service Personnel sustaining a fractured calcaneus from a vehicle explosion were identified for in depth review. For each patient, demographic data, New Injury Severity Score (NISS), and associated injuries were recorded. In addition, the pattern of calcaneal fracture, the method of stabilisation, local complications and need for amputation was noted. Functional recovery was related to the ability of the casualty to return to military duties. Forty calcaneal fractures (30 patients) were identified in this study. Mean follow-up was 33.2 months. The median NISS was 17, with the lower extremity the most severely injured body region in 90% of cases. Nine (30%) had an associated spinal injury. The overall amputation rate was 45% (18/40); 11 limbs (28%) were amputated primarily, with a further 3 amputated on return to the UK. Four (10%) casualties required a delayed amputation for chronic pain (mean 19.5 months). Of the 29 calcaneal fractures salvaged at the field hospital, wound infection developed in 11 (38%). At final follow-up, only 2 (6%) were able to return to full military duty with 23 (76%) only fit for sedentary work or unfit any military duty. Calcaneal injuries following under-vehicle explosions are commonly associated with significant polytrauma, of which the lower limb injury is the most severe. Spinal injuries were frequently associated with this injury pattern and it is recommended that radiological evaluation of the spine be performed on all patients presenting with calcaneal injuries from this injury mechanism. The severity of the hindfoot injury witnessed is reflected by the high infection rate and amputation rate seen in this cohort of patients. Given the high physical demands of a young, active military population, only a small proportion of casualties were able to return to pre-injury duties. We believe that the key to the reduction in the injury burden to the soldier lies in the primary prevention of this injury. Work is currently on going to develop experimental and numerical models of this injury in order to drive future mitigation strategies

Aim. The current treatment concepts of acute and chronic osteomyelitis are associated with unsolved challenges and problems, underlining the need for ongoing medical research. The invention and prevalence of an absorbable, gentamicin-loaded ceramic bone graft, that is well injectable for orthopedic trauma and bone infections, enlarges the treatment scope regarding the rise of posttraumatic deep bony infections. This substance can be used either for infection, dead-space, or reconstruction management. The bone cement, eluting antibiotics continuously to the surrounding tissue, outperforms the intravenous antibiotic therapy and enhances the local concentration levels efficiently. This study aims to evaluate the power and practicability of bone cement in several locations of bony infections. Method. The occurrence of posttraumatic infections with acute or chronic osteomyelitis increases in trauma surgery along with progression of high impact injuries and consecutively high incidence of e.g. open fractures. We present a case-series of 33 patients (18w/15m; 56,8±19,4 years) with posttraumatic osteomyelitis at different anatomic sites, who were treated in our level I trauma center. All of these patients received antibiotic eluting bone cement (Cerement® G) for infection and reconstruction management. Results. With admission to our trauma-center all patients with obvious or suspected osteomyelitis undergo an interdisciplinary pre-work up, including thorough clinical examination and different measures of diagnostic imaging, ultimately leading to the definition of an individual treatment plan. We diagnosed 33 bone infections anatomically allocated to the proximal and distal femur (12x), the pelvis (2x), distal tibia (3x), tibial diaphysis (10x), the ankle joint (4x) and calcaneus (2x). According to Cierny-Mader we diagnosed grade I (6), II (7), III (13) and IV (7). These 33 patients were treated (1) with surgical debridement, (2) with Cerament G, (3) bone stabilisation (including nail osteosynthesis, arthrodesis nails, plates, or external ring fixation), (4) optionally VAC-conditioning, and (5) optionally soft tissue closure with local or free flaps. The overall number of surgery was 2.9±2.26. We observed very good clinical, functional and radiological results by using bone cement augmented with gentamicin. The overall recurrence rate of infection is low (12%, 4/33). “White fluid” secretion was observed in six cases. Conclusions. Current concepts for treatment of osteomyelitis include radical surgical debridement and additional antibiotic therapy. It could be demonstrated that the usage of an antibiotic biocement with osteoconductive characteristics enlarges the success rate in septic bone surgery. The treatment concepts, however, remain complex, time consuming, require a high patient compliance, and are highly individually

Chronic calcaneal osteomyelitis is a rare and not usually part of the initial differential diagnosis of pseudotumoral calcaneal lesions. Presentation of surgical and functional outcomes of a case of a total calcanectomy. This can be seen as a foot rescue alternative in patients with chronic calcaneal osteomyelitis. We present the case of a 60 year- old patient with complaints of diffuse and intermittent pain in the left heel with 3 years of evolution. Radiographically, lytic lesion image sclerotic edges that covers the entire calcaneus, with preservation of cortical. MRI shows holo-calcaneal lesions compatible with tumor, infectious or inflammatory lesion. A biopsy is inconclusive. Negative microbiology results. Regular analytical study. It was decided to conduct a total calcanectomy. Procedure took place without complications. Patient still skin healing phase, without any pain complaint. It presents iconographic material made if and procedure. The total calcanectomy is an alternative procedure to transtibial amputation in patients with chronic calcaneal osteomyelitis

Aim. To demonstrate the use of indium-111 white-cell labelled SPECT CT (In111-WC-SPECT-CT) in bone infection. Method. This novel imaging modality is useful in bone infection. We present three cases of complex osteomyelitis to illustrate this. All were imaged with conventional modalities, but conclusive diagnosis could not be achieved. In111-WC-SPECT-CT was used to provide the definitive imaging that allowed successful treatment. Results. Case 1- A 29 y/o Male with spina bifida presented with chronic calcaneal osteomyelitis. Previous treatment included debridement, but recurrent infection ensued. MRI showed widespread changes consistent with infection throughout the calcaneus and a below knee amputation was planned. In111-WC-SPECT-CT (Figure 1) showed a distinct localised nidus of infection. A targeted sequestrectomy was performed and the patient has been infection free for four years. He was spared the amputation. Case-2- A 73 y/o male presented with a radiation induced colo-cutaneous fistula and pelvic chronic osteomyelitis. Surgical treatment included multiple debridements and sequestrectomy. He re-presented pain with pain in his pelvis six months later. MRI was performed and oedema seen in the bone. This was presumed to be infection and further surgery was planned. An In111-WC-SPECT-CT was then performed and confirmed no residual bone infection. The patient was spared surgery. Case-3- A 38 y/o female was involved in an RTA 6 months prior to presentation. She underwent fixation of her tibia with skin grafting for an open fracture. There was clinical suspicion of deep infection. The metalwork made MRI difficult to interpret. An In111-WCC-SPECT-CT confirmed infection around the metal screw and this evidence instigated a prolonged course of antibiotics to suppress the infection. The screw will be removed after the fracture heals. Conclusions. In-111-WC-SPECT-CT is an emerging imaging modality. We present three cases of complex bone and joint infection; where this imaging has altered the course of treatment

Restoration of natural range and pattern of motion is the primary goal of joint replacement. In total ankle replacement, proper implant positioning is a major requirement to achieve good clinical results and to prevent instability, aseptic loosening, meniscal bearing premature wear and dislocation at the replaced ankle. The current operative techniques support limitedly the surgeon in achieving a best possible prosthetic component alignment and in assessing proper restoration of ligament natural tensioning, which could be well aided by computer-assisted surgical systems. Therefore the outcome of this replacement is, at present, mainly associated to surgeon's experience and visual inspection. In some of the current ankle prosthetic designs, tibial component positioning along the anterior/posterior (A/P) and medio/lateral axes is critical, particularly in those designs not with a flat articulation between the tibial and the meniscal or talar components. The general aim of this study was assessing in-vitro the effects of the A/P malpositioning of the tibial component on three-dimensional kinematics of the replaced joint and on tensioning of the calcaneofibular (CaFiL) and tibiocalcaneal (TiCaL) ligaments, during passive flexion. Particularly, the specific objective is to compare the intact ankle kinematics with that measured after prosthesis component implantation over a series of different positions of the tibial component. Four fresh-frozen specimens from amputation were analysed before and after implantation of an original convex-tibia fully-congruent three-component design of ankle replacement (Box Ankle, Finsbury Orthopaedics, UK). Each specimen included the intact tibia, fibula and ankle joint complex, completed with entire joint capsule, ligaments, muscular structures and skin. The subtalar joint was fixed with a pin protruding from the calcaneus for isolating tibiotalar joint motion. A rig was used to move the ankle joint complex along its full range of flexion while applying minimum load, i.e. passive motion. In these conditions, motion at the ankle was constrained only by the articular surfaces and the ligaments. A stereofotogrammetric system for surgical navigation (Stryker-Leibinger, Freiburg, Germany) was used to track the movement of the talus/calcaneus and tibial segments, by using trackers instrumented with five active markers. Anatomical based kinematics was obtained after digitization by an instrumented pointer of a number of anatomical landmarks and by a standard joint convention. The central point of the attachment areas of CaFiL e TiCaL was also digitised. Passive motion and ankle joint neutral position were acquired, and the standard operative technique was performed to prepare the bones for prosthesis component implantation. The final component for the talus was implanted, the tibial component was initially positioned well in front of the nominal right (NR) position, the meniscal bearing was instrumented with an additional special tracker, and passive motion was collected again in passive flexion. Data collection was repeated for progressively more posterior locations for the tibial component, for a total of six different locations along the tibial A/P axis: three anterior (PA), the NR, and two more posterior (PP), approximately 3 to 5 mm far apart each. The following three-dimensional kinematics variables were analyzed: the three anatomical components of the ankle joint (talus-to-tibial) rotation (dorsi/plantar flexion, prono/supination and internal/external rotation respectively in the sagittal, frontal and transverse planes), the meniscal bearing pose with respect to the talar and tibial components, the ‘ligament effective length fraction’ as the ratio between the instantaneous distance between the ligament attachment points and the corresponding maximum distance, and the instantaneous and mean helical axes in the tibial anatomical reference frame. In all specimens and in all conditions, physiological ranges of flexion, prono/supination and internal/external rotation were observed at the ankle joint. A good restoration of motion was observed at the replaced joint, demonstrated also by the coupling between axial rotation and flexion and the physiological location of the mean helical axis, in all specimens and in most of the component positions. Larger plantar- and smaller dorsi-flexion were observed when the tibial component was positioned more anteriorly than NR, and the opposite occurred for more posterior positions. In regards to the meniscal bearing, rotations were small and followed approximately the same patterns of the ankle rotations, accounted for the full conformity of the articulating surfaces. Translations in A/P were larger than in other directions, the bearing moving backward in plantarflexion and forward in dorsiflexion with respect to both components. It was observed that the closer to NR the position of the tibial component is, the larger this A/P motion is, accounted mainly to the associated larger range of flexion. The change of CaFiL and TiCaL effective length fraction over the flexion arc was found smaller than 0.1 in three specimens, smaller than 0.2 in the fourth, larger both in more anterior and more posterior locations of the tibial component. The simulated malpositioning did not affect much position and orientation of the mean helical axis in both the transversal and frontal planes. The experimental protocol and measurements were appropriate to achieve the proposed goals. All kinematics variables support the conclusion that the ankle replaced with this original prosthesis behaves as predicted by the relevant computer models, i.e. physiological joint motion and ligament tension is experienced resulting in a considerable A/P motion of the meniscal bearing. These observations are particularly true in the NR postion for the prosthesis, but are somehow correct also in most of the tibial malpositions analysed, in particular those on the back

The appearance of a tumor as a result of chronic osteomyelitis is a relatively rare complication and of late-onset, with a low frequence in the modern world. For the majority of patients, the interval between the onset of primitive osteomyelitis and malignant degeneration is of several decades. We present our cases and the protocol of treatment used. From January 1977 to December 2014 we treated 36 patients (33M, 3F) suffering from squamous cell tumor out of a series of 247 tibial and 74 calcaneal osteomyelitis. 26 patients had chronic osteomyelitis of tibia, 10 of the calcaneus. Based on the functional needs of patients after resection of the tumor, in 18 we applied the Ilizarov apparatus, in 14 we opted for a two steps surgery, with the help of plastic surgeon; four required amputation. 29 patients healed. After 2-years of follow up 3 patients underwent to an amputation in the proximal third of the leg, 4 had a local recurrence. All patients were assessed by SF32 and the QoL test. Squamous cell tumor is the most common malignant tumor in chronic osteomyelitis. For the diagnosis of malignant transformation from a chronic ulcer there is a thorough process. Serial biposies must be performed, especially with the emergence of new clinical signs (increased pain, a bad smell, and changes in secretion by the wound). The definitive treatment is often amputation proximal to the tumor or wide local excision in combination with adjuvant chemotherapy and radiotherapy in selected patients. Early detection can sometimes allow limb salvage. However, the most effective treatment is prevention with the definitive treatment of osteomyelitis, including appropriate debridement, wide excision of the affected area, and early reconstruction

Aim. Open fractures with bone loss and skin lesions carry a high risk of infection and complication. Treatment options are usually a two-stage approach (debridement, temporary stabilization with external fixation followed by open reduction and stabilization with plate). We describe an experience for a single stage procedure with an antibiotic eluting bone graft substitute (BGS) for prophylaxis of implant-related infection. Method. Between December 2014 and January 2016 were analysed the data of twenty-six patients with open fractures (Gustilo and Anderson grade I and II) or with skin lesion and high risk of contamination and bone loss. They where treated with debridement of soft tissue, closed reduction of fracture, placement of a plate augmented with BGS eluting antibiotic (gentamicin (1) and/or Vancomicin (2)). Ampicillin and sulbactam 3g three times daily was used as systemic antibiotic prophylaxis minimum for one week. Clinical outcome and radiographic bone defect filling were assessed by blinded observers. Results. From 2014 to 2015 twelve male and fourteen female with mean age 53yrs (24–77) were treated with plate and BGS. Fracture locations were four distal femur (m:4; f: 1), four tibial plateau (m:3; f:1), one proximal humerus (f:1), seven calcaneus (m:4; f: 3), one talus (m:1), four forearm (m:3), one elbow (f:1) and two phalanx (m: 2). Follow up was fourteen month (range: 3 – 26 months). During follow-up no implant-related infection was observed. One patient developed sterile seroma, which was treated conservatively. The calcium sulphate phase of BS dissolved in all cases within 4–6 weeks. Bone ingrowth was assessed at 1, 2, 3, 6 and 12 months. On six patients large bone was treated with a revision surgery (autologous cancellous bone graft combined with BGS and antibiotic. No complications were reported. Conclusions. We suggest the application of poly therapy for the treatment of bone defects. BGS eluting antibiotic is easy to use and offers the opportunity for a one-stage procedure and might reduce the risk of implanted-related infection and allow early joint mobilization. Good early clinical outcomes were observed in almost all cases. More studies and larger series are necessary to confirm the potential for the prophylaxis of infection in the treatment of open fractures. (1): CERAMENT™|G. (2): CERAMENT™|V”

Open fractures carry a high risk of infection. Our objective was to evaluate the effect of a resorbable bone substitute (BS) (calcium sulphate and hydroxyapatite) eluting Gentamicin (Cerament™| G) in the prevention of bone infection and nonunion after open fracture and/or skin lesion. The data of patients undergoing osteosynthesis augmented with BS and Gentamicin between December 2012 and April 2015 were retrospectively analyzed from a prospectively established database. Patients were treated for open fractures grade 1 Gustilo or skin lesion with high risk of contamination. Surgical technique included initial debridement, open reduction and internal fixation (ORIF), implantation of BS and Gentamicin, soft tissue closure, and systemic antibiotic therapy for 2 weeks in all cases. Clinical outcome and radiographic bone defect filling were assessed by blinded observers. From 12/2013 to 4/2015 nine male and six female with mean age 53yrs (24–77) were treated with ORIF and BS and Gentamicin for open fractures. Fracture locations were tibial plateau (two), tibia (two), proximal humerus (one), calcaneus (four), talus (one), forearm (three), and elbow (one) distal femur (one). at final follow-up (mean 11.1 months; range 7–13). One patient developed a sterile seroma, which was treated conservatively. No post-operative infection occurred during the follow-up period. The calcium sulphate phase of BGS dissolved within 4–6 weeks in all cases. Bone ingrowth was assessed at 1, 2, 3, 6 and 12 months and new bone formation was observed at 6 months. One patient with an exposed comminuted fracture and large bone defect showed poor bone regeneration and was treated with a revision surgery (exchange of plate, autologous cancellous bone graft combined with BGS and Gentamicin. No complications were reported. The use of this bone substitute is well documented in the literature. The new product containing 175 mg gentamicin in 10 ml shows a high release of gentamicin in in-vitro testing, comparable to the elution profile of PMMA beads that some authors suggested to use to reduce the risk of infection. However, the use of this antibiotic carrier in order to prevent bone infection after open fracture has not been studied yet. In this case series 15 patients have been treated and good early clinical outcomes were observed in almost all cases. This material is highly osteoconductive and has a potential for the prophylaxis of infection in the treatment of open fractures. Further investigations and larger series are necessary to show the prophylactic effect in detail

Introduction. Review of the literature indicates variable results for ankle arthrodesis with many complications. With improved prothesis and technique for total ankle arthroplasty and an increase in severe ankle deformities such as Charcot's joint and the neuropathic diabetic foot we are faced with the need to decrease the variables in ankle arthrodesis in primary and salvage arthrodesis. We will review current methods for ankle arthrodesis and critic how they deal with primary and revision ankle arthrodesis surgery. Materials and methods. A customised plate or modified synthes proximal tibial plate and technique for salvage of complex pathology utilising a anterior approach and application of a contoured ustomised plate with co-axial screw fixation. Anterior incision was performed with removal of the lateral malleolus, for bone grafting in revision cases only. Thirteen arthrodeses were performed; four of these were pan-talar. All patients underwent objective and subjective assessments including overall patient satisfaction. The American Orthopaedic Foot and Ankle Society ankle/hind foot scoring system was used. The aim of this study is to identify the time taken to achieve radiologic arthrodesis, complications encountered, the required post-operative recovery for arthrodesis to be achieved and the overall patient satisfaction of results in the early to midterm post-operative period have been followed up for three years. Conclusion. The technique offers considerable flexibility allowing the calcaneus to be incorporated in the proposed arthrodesis where necessary. With multiple points for fixation and coaxial screw entry points the contoured customised plate provides a rigid fixation for arthrodesis stabilisation with added compression being the major advantage of this technique