The incidence of periprosthetic fractures of the ankle is increasing. However, little is known about the outcome of treatment and their management remains controversial. The aim of this study was to assess the impact of periprosthetic fractures on the functional and radiological outcome of patients with a total ankle arthroplasty (TAA). A total of 505 TAAs (488 patients) who underwent TAA were retrospectively evaluated for periprosthetic ankle fracture: these were then classified according to a recent classification which is orientated towards treatment. The outcome was evaluated clinically using the American Orthopedic Foot and Ankle Society (AOFAS) score and a visual analogue scale for pain, and radiologically. . A total of 21 patients with a periprosthetic fracture of the ankle were identified. There were 13 women and eight men. The mean age of the patients was 63 years (48 to 74). Thus, the incidence of fracture was 4.17%. . There were 11 intra-operative and ten post-operative fractures, of which eight were stress fractures and two were traumatic. The prosthesis was stable in all patients. Five stress fractures were treated conservatively and the remaining three were treated operatively. . A total of 17 patients (81%) were examined clinically and radiologically at a mean follow-up of 53.5 months (12 to 112). The mean AOFAS score at follow-up was 79.5 (21 to 100). The mean AOFAS score in those with an intra-operative fracture was 87.6 (80 to 100) and for those with a stress fracture, which were mainly because of varus malpositioning, was 67.3 (21 to 93). Periprosthetic fractures of the ankle do not necessarily adversely affect the clinical outcome, provided that a treatment algorithm is implemented with the help of a new classification system. . Cite this article: Bone Joint J 2015;97-B:950–6

Background. Charcot neuroarthropathy is a destructive disease characterized by progressive bony fragmentation as a result of the isolated or accumulative trauma in patients with decreased sensation that manifests as dislocation, periarticular fractures and instability. Although amputation can be a reasonable cost economic solution, many patients are willing to avoid that if possible. We explored here one of the salvage procedures. Methods. 23 patients with infected ulcerated unstable Charcot neuroarthropathy of the ankle were treated between 2012 and 2017. The mean age was 63.5 ±7.9 years; 16 males and 7 females. Aggressive open debridement of ulcers and joint surfaces, with talectomy in some cases, were performed followed by external fixation with an Ilizarov frame. The primary outcome was a stable plantigrade infection free foot and ankle that allows weight bearing in accommodative foot wear. Results. Limb salvage was achieved in 91.3% of cases at the end of a mean follow up time of 25 months (range: 19–32). Fifteen (71.4%) solid bony unions were evident clinically and radiographically, while 6 (28.5%) patients developed stable painless pseudoarthrosis. Two patients had below knee amputations due to uncontrolled infection. Conclusion. Aggressive debridement and arthrodesis with ring external fixation can be used successfully to salvage severely infected Charcot arthropathy of the ankle. Pin tract infection, delayed wound healing and stress fracture may complicate the procedure but can be easily managed. Amputation may be the last resort in uncontrolled infection

Background. Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option. Methods. A 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm. 2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. Results. Mean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length. Conclusion. Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages

Introduction. Stress fractures in the foot are common; the common practice is to look for any factor in the history or for any foot deformity that could cause the fracture. Once found, it is common to treat the fractures without further investigations. The aim of this study is to assess if we are missing any underlying metabolic disorder associated with such injury. Materials and methods. We studied 34 sequential cases referred for chronic foot pain. Stress fractures were confirmed either by classic x-ray's features or MRI. Clinical examination and further tests were performed for Vitamin D levels, Thyroid function, PTH, DEXA scan, Biochemical and bone profile. All stress fractures were treated conservatively. Results. Mean age was 50 (13–72) (22 Females, 9 Males), 29 patients were fit and healthy ASA 1, 5 cases were ASA 2. 12 cases presented with a precipitating event. 14 cases had a minor foot deformity (such as hallux valgus of minor pes planus). mean BMI 27.6. The blood tests newly diagnosed: 17 Vitamin D deficiencies cases, 2 hyperparathyroidism cases, one case of Cushing's Syndrome secondary to adrenal adenoma and one case of delay in puberty in addition to 3 osteoporosis cases. All fractures responded to conservative means of treatment and none needed surgical interventions. Discussion. The study shows that the incidence of endocrinological disorders is patients presenting with stress fractures is much higher than the incidence in the general population; for example the incidence of Cushing's syndrome is 1 per 130000 individuals while in our series was 1 per 34. This study raises the question if all patients presetting with stress fractures should be investigated for endocrinological disorders

Aims. The aim of this study was to present a series of patients with aseptic failure of a total ankle arthroplasty (TAA) who were treated with fusion of the hindfoot using a nail. Patients and Methods. A total of 23 TAAs, in 22 patients, were revised for aseptic loosening and balloon osteolysis to a hindfoot fusion by a single surgeon (NH) between January 2012 and August 2014. The procedure was carried out without bone graft using the Phoenix, Biomet Hindfoot Arthrodesis Nail. Preoperative investigations included full blood count, CRP and ESR, and radiological investigations including plain radiographs and CT scans. Postoperative plain radiographs were assessed for fusion. When there was any doubt, CT scans were performed. Results. The mean follow-up was 13.9 months (4.3 to 37.2). Union occurred at the tibiotalar joint in 22 ankles (95.6%) with one partial union. Union occurred at the subtalar joint in 20 ankles (87%) of cases with two nonunions. The nail broke in one patient with a subtalar nonunion and revision was undertaken. The only other noted complication was one patient who suffered a stress fracture at the proximal aspect of the nail, which was satisfactorily treated conservatively. Conclusion. This study represents the largest group of patients reported to have undergone revision TAA to fusion of the hindfoot with good results. Cite this article: Bone Joint J 2018;100-B:475–9

Background and objective. Metatarsals stress fractures are common in athletes and dancers. Occasionally, such fractures could occur without trauma in peripheral neuropathic patients. There is no published series describing outcome of stress fractures in these patients. This study analyse these fractures, treatment and outcome. Material and Method. Retrospective study, January 2005 to December 2010. From a total of 324 patients with metatarsal fractures, 8 patients with peripheral neuropathy presented with second metatarsal non-traumatic fractures. Fractures were initially treated in cast for more than three months but failed to heal. Subsequently, this led to fractures of 3rd, 4th and 5th metatarsals. All patients remained clinically symptomatic due to fracture non-union. Operative treatment with bone graft and plating was used. Postoperatively below knee plaster and partial weight bearing for 12 weeks. Clinical and radiological surveillance continued until bone union. Results. There were 2 male and 6 female patients, age (24–83). 22 metatarsals had clinical and radiological union. 1 patient needed 1st tarsometatarsal joint fusion along with metatarsals fractures fixation. This patient developed deep infection and required below knee amputation. 2 patients required metalwork removal. Patient's satisfaction score was 8/10. Conclusion. Our review suggests low energy metatarsal stress fractures treated nonoperatively provide limited success. Timely surgical intervention and internal fixation proved to be a valid treatment option

We present a series of 23 total ankle replacements revised for balloon osteolysis and aseptic loosening with a hind-foot fusion nail without the use of bone graft. This is the largest series of total ankle replacements revised to a hindfoot fusion with a nail presented in the literature. Initial assessment involved investigations to rule out infection and a CT scan of the ankle to assess the size of cysts. Patients underwent surgery in a single stage procedure. The surgery involved excision of the fibula and preparation of the sub-talar joint through a lateral incision; removal of the implant and preparation of the talar and tibial surface with flat cuts through an anterior incision and safe excision of the medial malleolus aided by a medial incision. The prepared surfaces were then compressed and fixed using a Biomet Phoenix Nail. Patients were then followed up to assess for clinical and radiographic union. This study involved 18 male and 4 female patients with an average age of 67. All patients had AES ankle replacements (Biomet) in-situ, undergoing revision surgery for aseptic loosening with balloon osteolysis. At a mean follow up of 13.9 months, 96% (22/23) of ankles achieved osseous union across the tibio-talar joint with 1 patient achieving a partial union. 91% (21/23) of patients achieved union across the subtalar joint with 2 patients identified as having a non-union. 1 patient with a subtalar non-union suffered a broken nail and required revision surgery. The only other identifiable complication was a single patient sustained a stress fracture at the proximal tip of the nail, which was treated conservatively. We believe this method is a reliable and reproducible method of achieving osseous union following a failed total ankle replacement without using graft. Although patients may have a leg length discrepancy, none have requested leg lengthening

Background. Total ankle replacement (TAR) design has evolved greatly in recent years and offers a reasonable alternative to ankle arthrodesis in a select patient population with end-stage arthritis. Originator series’ report good longevity and excellent patient reported outcomes (PROMs). We report our outcomes in an independent, non-inventor cohort. Method. We collected prospective data on consecutive patients undergoing total ankle replacement between April 2008 and March 2012, under the care of one Consultant Orthopaedic surgeon. The primary outcome measure was time to revision. Secondary outcomes measures included American Orthopaedic Foot and Ankle Society (AOFAS) scores, Visual Analogue Score (VAS) for pain, and complications. Results. 70 patients underwent TAR with a mean follow-up of 64 months (39–86). Three patients underwent revision of TAR to ankle arthrodesis, two for aseptic loosening and one for infection, equating to survivorship of 96%. Three patients sustained intra-operative fractures, one of the lateral malleolus and two of the medial malleolus. The patient who sustained the lateral malleolus fracture later went on to develop aseptic loosening requiring revision. One patient developed a late stress fracture of the medial malleolus. Two patients underwent open exploration, grafting of bone cysts and fixation for ongoing pain at a mean time of 4.5 years following the primary TAR. At the most recent review all patients reported improved AOFAS scores from 39.55 (21–52) to 82.10 (57–100) and VAS from 9.11 (6–10) to 1.79 (0–6) respectively. Conclusions. Longevity of the Zenith TAR in our non-inventor series is comparable to that of originator outcomes. Fractures are a recognized complication of TAR and when affecting the medial malleolus, do not appear to have an adverse effect on outcome. We feel that TAR offers an effective alternative solution to ankle arthrodesis with satisfactory relief of pain whilst preserving movement at the ankle joint

Aims

The purpose of this study is to examine the adductus impact on the second metatarsal by the nonosteotomy nonarthrodesis syndesmosis procedure for the hallux valgus deformity correction, and how it would affect the mechanical function of the forefoot in walking. For correcting the metatarsus primus varus deformity of hallux valgus feet, the syndesmosis procedure binds first metatarsal to the second metatarsal with intermetatarsal cerclage sutures.

There is a paucity of information on the arterial supply of the navicular, despite its anatomic neighbours, particularly the talus, being investigated extensively. The navicular is essential in maintaining the structural integrity of the medial and intermediate columns of the foot, and is known to be at risk of avascular necrosis. Despite this, there is poor understanding of the vascular supply available to the navicular, and of how this supply is distributed to the various surfaces of the bone. This study aims to identify the key vessels that supply the navicular, and to map the arterial supply to each surface of the bone. Cadaveric limbs (n=10) were dissected to identify source vessels for each navicular. The talus and navicular were removed, together with the source vessels, en bloc. The source vessels were injected with latex and processed using a new, accelerated diaphanisation technique. This quickly rendered tissue transparent, allowing the injected vessels to be visualised. Each navicular was then reconstructed using a digital microscribe, allowing a three dimensional virtual model of the bone to be assessed. The terminal points of each vessel were then mapped onto this model, allowing the distribution of each source vessel to be determined. This study will provide the as yet unpublished information on the arterial supply of the human navicular bone. The data will also give quantifiable evidence of any areas consistently restricted to single-vessel supply, and those consistently supplied by multiple vessels. This may help to explain the propensity of this bone to develop disorders such as osteochondritis, avascular necrosis and stress fractures which often have a vascular aetiology

Introduction. There is no published series described change in bone mineral density (BMD) after ankle replacement. We present the results of a prospective study examining the effect of total ankle replacement (TAR) upon local bone mineral density (BMD). Aim. To design a method and assess the effect of TAR loading on local ankle bones, by analysing the BMD of different area around ankle before and after Mobility TAR. Methods. 23 patients undergoing Mobility ankle arthroplasty for osteoarthritis had preoperative bone densitometry scans of the ankle, repeated at 1 and 2 years after surgery. BMD of 2 cm. 2. areas around ankle were measured. Pre- and postoperative data were compared. Results: Mean BMD within the lateral malleolus decreased significantly from 0.5g/cm. 2. to 0.42g/cm. 2. (17%, P > 0.01), at 1 & 2 years postoperatively. Mean BMD within medial malleolus decreased slightly from 0.67g/cm. 2. to 0.64 g/cm. 2. at the same period. However BMD at medial side metaphysic of tibia increased by 7%. There was little increase in BMD in tibia just proximal to implant and at talus. Discussion and Conclusion. Absence of stress shielding around distal tibia, just proximal to tibial component and talus indicates that ankle replacements implanted within the accepted limits for implant alignment, load distal tibia and talus. However, there was stress shielding over the lateral malleolus resulting in decreased BMD in lateral malleolus. Increase BMD at tibial metaphysis, proximal to medial malleolus indicates an increase in mechanical stress which may explain occasional postoperative stress fracture of medial malleolus or medial side ankle pain

We describe a surgical technique for ankle arthrodesis using an anterior approach to the ankle and internal fixation with an anteriorly-placed AO T plate. A total of 33 patients who had ankle arthrodeses have been followed retrospectively. Thirty-one (94%) of the ankles fused although two patients developed tibial stress fractures. Four patients had a superficial infection which did not prevent union. The surgical technique is simple, easily reproducible and gives excellent clinical results with a high rate of union

Metatarsus primus varus deformity correction is one of the main objectives in hallux valgus surgery. A ‘syndesmosis’ procedure may be used to correct hallux valgus. An osteotomy is not involved. The aim is to realign the first metatarsal using soft tissues and a cerclage wire around the necks of the first and second metatarsals. We have retrospectively assessed 27 patients (54 feet) using the American Orthopaedic Foot and Ankle Society (AOFAS) score, radiographs and measurements of the plantar pressures after bilateral syndesmosis procedures. There were 26 women. The mean age of the patients was 46 years (18 to 70) and the mean follow-up was 26.4 months (24 to 33.4). Matched-pair comparisons of the AOFAS scores, the radiological parameters and the plantar pressure measurements were conducted pre- and post-operatively, with the mean of the left and right feet. The mean AOFAS score improved from 62.8 to 94.4 points (p < 0.001). Significant differences were found on all radiological parameters (p < 0.001). The mean hallux valgus and first intermetatarsal angles were reduced from 33.2° (24.3° to 49.8°) to 19.1° (10.1° to 45.3°) (p < 0.001) and from 15.0° (10.2° to 18.6°) to 7.2° (4.2° to 11.4°) (p < 0.001) respectively. The mean medial sesamoid position changed from 6.3(4.5 to 7) to 3.6 (2 to 7) (p < 0.001) according to the Hardy’s scale (0 to 7). The mean maximum force and the force–time integral under the hallux region were significantly increased by 71.1% (p = 0.001), (20.57 (0.08 to 58.3) to 35.20 (6.63 to 67.48)) and 73.4% (p = 0.014), (4.44 (0.00 to 22.74) to 7.70 (1.28 to 19.23)) respectively. The occurrence of the maximum force under the hallux region was delayed by 11% (p = 0.02), (87.3% stance (36.3% to 100%) to 96.8% stance (93.0% to 100%)). The force data reflected the restoration of the function of the hallux. Three patients suffered a stress fracture of the neck of the second metatarsal. The short-term results of this surgical procedure for the treatment of hallux valgus are satisfactory. Cite this article: Bone Joint J 2014;96-B:502–7

Introduction. The standard practice of uncomplicated total ankle replacement (TAR) involves postoperative immobilisation. Periprosthetic fracture is a well-recognised complication following ankle arthroplasty. It occurs predominantly as a stress reaction on the medial tibial metaphysis during the postoperative rehabilitation period. Occasionally it occurs during surgery. We present fractures from a single-centre series of Mobility TARs. Materials and Methods. We have 133 TARs with 3 to 48 months' follow-up. 28 patients were excluded for the following reasons: other major procedure performed concurrently (osteotomy or tendon transfer), custom prosthesis, revision surgery, fusion conversions, or patients involved in a separate RCT (n = 16). We do not routinely immobilise patients postoperatively but allow partial to full weight-bearing as able. Outcome scores were compared to those without fractures. Results. 105 patients were included in the study. Nine (8.6%) patients sustained a periprosthetic fracture with no history of significant trauma. One of these was intraoperative; this was a posterior tibial fracture noticed on postoperative radiographs. The remainder (n = 8) were tibial metaphyseal stress fractures, all occurring within the first three months, most (n = 6) within six weeks. One occurred on the sixth post-op day and was managed in cast. Seven were asymptomatic at diagnosis and managed nonoperatively; one was fixed at three months due to radiological medial migration of the talus and one was fixed at seven months due to progression to symptomatic non-union. The remainder united. Between those with and without fractures, there was no significant difference in age (mean 61.4 vs. 62.1, p = 0.387), diagnosis leading to arthroplasty (OA, RA, PTOA), or outcome scores (12 months: 83 vs. 78, p = 0.237). Conclusion. Periprosthetic fracture remains a significant complication of total ankle arthroplasty. However, in our series, they do not lead to increased morbidity or worse outcome scores than patients without fractures and most can be managed nonoperatively

Aims

Preoperative talar valgus deformity ≥ 15° is considered a contraindication for total ankle arthroplasty (TAA). We compared operative procedures and clinical outcomes of TAA in patients with talar valgus deformity ≥ 15° and < 15°.

Aims

Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis.

Aims

Arthroplasty for end-stage hallux rigidus (HR) is controversial. Arthrodesis remains the gold standard for surgical treatment, although is not without its complications, with rates of up to 10% for nonunion, 14% for reoperation and 10% for metatarsalgia. The aim of this study was to analyze the outcome of a double-stemmed silastic implant (Wright-Medical, Memphis, Tennessee, USA) for patients with end-stage HR.

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration.

In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:1299–1311.

Aims

We report the long-term clinical and radiological outcomes of a consecutive series of 200 total ankle arthroplasties (TAAs, 184 patients) at a single centre using the Scandinavian Total Ankle Replacement (STAR) implants.

Aims

Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent.