Introduction: Tutobone is a solvent-preserved cancellous bovine bone substitute. There is little published about its use in humans. We have been using it as a wedge graft to correct deformity in hindfoot fusion surgery. Aim: To review the outcome following the use of Tutobone in hindfoot fusion and compare it with a control group without Tutobone. Method: We performed a retrospective review of all hindfoot fusion performed by the senior author (AG) from 1 Sep 2004 to 31 Jan 2008. We excluded all revision procedures for non-union or malunion. A CT or MRI scan was performed to assess union and graft incorporation in the Tutobone patients at more than six months postoperatively. In the control group fusion was assessed with plain radiographs. The difference in proportion of fusion with complete fusion by six months post-operatively was assessed with a Fisher’s exact test. Results: There were eleven patients in the Tutobone group (1 ankle, 7 subtalar and 3 triple fusions) and 35 in the control group (15 ankle, 11 subtalar, 3 pantalar and 6 triple fusions). All Tutobone patients had partial union on CT/MRI scans. The Tutobone graft had not incorporated at a mean time interval of 14 months post surgery. 30 out of 35 control patients had fused by six months and 33 out of 35 controls were fused by 12 months. The rate of complete fusion between the two groups at six months was statistically significant (p< 0.0001). Two Tutobone patients developed an inflammatory reaction at more than six months post fusion. This reaction is not infective and appears to be a reaction to the Tutobone. Conclusion: Tutobone should not be used in hindfoot fusion surgery

One assumed function of Total Ankle Replacement (TAR) is that by maintaining ankle joint motion we can protect the other hind foot joints from further degredation. 1. However, there is no work to our knowledge that compares hindfoot outcomes between TAR and arthrodesis. Sokolowski et al. found that 68% of TAR patients had no radiological progression of subtalar arthritis after TAR, and 4% went on to fusion. 2. However, no evaluation of the other hindfoot joints was made and no comparison made to other treatment. We performed a retrospective review of all patients at our centre who had had a TAR or ankle arthrodesis since 2002. Case notes and imaging were reviewed and all instances of hindfoot treatment (injections or surgical procedures) noted. Patients were excluded who had no documentation, were followed up at other hospitals, had prior hindfoot fusion, or were having staged surgeries at the time of index treatment. Chi squared analysis was used to compare the cohorts. 214 arthrodesis cases and 302 TAR were eligible. The average age was 57. Average time to follow up was 13 years (4–21). At the time of abstract submission 107 sets of notes had been reviewed fully. Full analysis will be performed by conference. 14% of TAR patients went on to have further procedures to the hindfoot joints while 35% of arthrodesis patients had further procedures (p=0.014). There was also a significant difference in the number of patients progressing to fusion of a further hindfoot joint between groups (TAR- 4%, arthrodesis- 20%, p=0.01). These data suggest that TAR are protective of symptomatic change of hindfoot joints. Patients with TAR had fewer hindfoot fusions than those with arthrodesis and also fewer procedures of any form, including injections

Revision options for a failed Total ankle arthroplasty (TAA) have historically been limited to complex hindfoot fusions, bespoke ankle arthroplasty revision or amputation. The patient outcomes of these procedures has been felt to be poor. The introduction of the INBONE-II and INVISION ankle arthroplasty revision systems has created a range of revision arthroplasty options, with the possibility of improved patient outcomes. We aim to report on the early results of 20 sequential revision TAA. All patients undergoing revision TAA with INBONE-II or INVISION had prospective collection of pre-operative and post-operative MOx-FQ and EQ-5D scores. Between September 2013 and June 2019 23 patients underwent revision TAA with mean time from implantation of 35 months (6 to 74). Those with greater than 1 year follow-up had scores included. Other outcomes included radiographic assessment for loosening and revision. 13 patients had INBONE-II and 10 INVISION. None required revision at the time of review. Pre-operative MOx-FQ averaged 40.6 (13.4 pain, 21 walking, 6.2 social). Post-operative MOx-FQ averaged 17.4 (6.2 pain, 8.1 walking, 3.1 social). Average EQ-5D improved from 8 to 6.6 and average EQ-VAS from 60 to 80. On radiograph review one patient had radiolucent lines around their INBONE-II stem evident at 1 year. This had not progressed by 4 years total follow-up. Another patient had uncoupling of part of the stem of her INBONE-II but had not required revision. This was attributed to surgeon error. Revision TAA using the INBONE-II and INVISION systems shows promising early results relating to loosening and revision and good maintained improvement in MOx-FQ and EQ-5D scores. This provides further evidence that patients with a failed TAA can safely have revision rather than having to commit to complex ankle/hindfoot fusion. This provides surgeons with flexibility particularly in those patients with other hindfoot arthritis or arthrodesis

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

Preoperative talar valgus deformity increases the technical difficulty of total ankle replacement (TAR) and is associated with an increased failure rate. Deformity of ≥15° has been reported to be a contraindication to arthroplasty. The goal of the present study was to determine whether the operative procedures and clinical outcomes of TAR for treatment of end-stage ankle arthritis were comparable for patients with preoperative talar valgus deformity of ≥15° as compared to those with <15°. We will describe the evolving surgical technique being utilized to tackle these challenging cases. Fifty ankles with preoperative coronal-plane tibiotalar valgus deformity of ≥15° “valgus” group) and 50 ankles with valgus deformity of <15° (“control” group) underwent TAR. The cohorts were similar with respect to demographics and components used. All TARs were performed by a single surgeon. The mean duration of clinical follow-up was 5.5 years (minimum two years). Preoperative and postoperative radiographic measurements of coronal-plane deformity, Ankle Osteoarthritis Scale (AOS) scores and Short Form (SF)-36 scores were prospectively recorded. All ancillary (intraoperative) and secondary procedures, complications and measurements were collected. The AOS pain and disability subscale scores decreased significantly in both groups. The improvement in AOS and SF-36 scores did not differ significantly between the groups at the time of the final follow-up. The valgus group underwent more ancillary procedures during the index surgery (80% vs 26%). Tibio-talar deformity improved significantly toward a normal weight-bearing axis in the valgus group. Secondary postoperative procedures were more common in the valgus group (36%) than the controls (20%). Overall, re-operation was not associated with poorer patient outcome scores. Metal component revision surgery occurred in seven patients (three valgus and four controls). These revisions included two deep infections (2%), one in each group, which were converted to hindfoot fusions. Therefore, 94% of the valgus group retained their original components at final follow-up. Thus far, this is the largest reported study that specifically evaluates TAR with significant preoperative valgus alignment, in addition to having the longest follow-up. Satisfactory midterm results were achieved in patients with valgus mal-alignment of ≥15°. The valgus cohort required more procedures during and after their TAR, as well as receiving more novel techniques to balance their TAR. Whilst longer term studies are needed, valgus coronal-plane alignment of ≥15° should not be considered an absolute contraindication to TAR if the associated deformities are addressed

Background. Subtalar fusion is traditionally an open procedure with potentially significant complications but there is little published on arthroscopic subtalar arthrodesis. Methods. We present the first UK series of 33 arthroscopic subtalar fusions in 32 patients, with a variety of pathologies. Results. There were 14 males and 18 females operated on between March 2004 and February 2009. Patients with previous hindfoot fusions were excluded as were patients who underwent combined arthroscopic hindfoot fusions. All patients had surgery by the senior author and followed an identical post-operative management plan. No patients were lost to follow-up. Successful outcome was taken as clinical and radiological evidence of fusion. We report a 100% union rate with 75.8% [25/33] union by 12 weeks, 97% [32/33] by 16 weeks with a single outlier achieving fusion at 22 weeks. There were no wound breakdowns, deep infections, neuromas or thrombotic events. Two patients required removal of metalwork. One patient developed mild CRPS and a further patient became symptomatic from concomitant calaneo-cuboid and talo-navicular joint arthrosis. Discussion. Previous authors have reported variable complication rates and significant rates of delayed and non-unions following open subtalar fusion. This technique respects the soft tissue envelope and therefore is less traumatic to the hindfoot. Our early results suggest that isolated arthroscopic subtalar fusion is a safe and reliable technique, even in patients with deformity, with an excellent union rate and minimal complications

Aim: To report the clinical and radiological results of patients undergoing hindfoot fusion using an intramedullary nail. Methods: Retrospective review of notes of patients undergoing combined ankle and subtalar arthrodesis using retrograde intramedullary nailing. The procedure is performed mainly for the treatment of complex hindfoot deformities or following failed total ankle arthroplasty. Outcome was assessed by notes review, clinical examination and telephone questionnaire. Results: Between 1995 and 2001 56 arthrodeses in 52 patients have been performed. The average follow up is 3 years. Approach to the joints was via an anterolateral incision unless previous surgery dictated otherwise. All cases utilised an ACE¨ humeral nail which was locked proximally and distally. Most procedures utilised bone graft from the þbula, proximal tibia, iliac crest or allograft femoral head. Mean tourniquet time was 114 mins. Post-operative management generally consisted of 3 months plaster immobilisation. Post-operative complications included deep infection, amputation, stress fracture, non-union & prominent metalwork. At review 90% of patients were satisþed and approximately 90% felt the pain level & function of their foot had improved. Average postoperative AOFAS hindfoot score was 65. Conclusion: Hindfoot fusion by intramedullary nailing is an effective technique in complex cases of deformity and in many cases is the only alternative to amputation. Patient satisfaction appears to be high but the procedure is demanding and the complication rate can be signiþcant

Simultaneous arthrodesis of the ankle and subtalar joints is an established treatment option for combined ankle and subtalar arthritis or complex hindfoot deformities. The use of a curved intra medullary nail has potential advantages in terms of stability, hindfoot alignment and avoidance of the lateral neurovascular bundle. We devised a comparative description of the results of hindfoot fusion using a curved locking nail before and after the introduction of anatomically specific modifications to the device through a retrospective review of notes and radiographs of patients undergoing simultaneous ankle and subtalar fusion by retrograde intramedullary nailing using an ACE¯ (Humeral Nail. Patients undergoing the same procedure using the Tibiotalocalcaneal [TTC] Nail System [DePuy] were recruited and studied prospectively. The outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire. Between 1996 and 2004, 71 arthrodeses in 67 patients have been performed. The average follow up is 27 months [3-73] and mean age 58 years. Fifty-two arthrodeses utilised the ACE humeral nail and nineteen used the newer TTC nail. Both nailing systems are locked proximally and distally and provide a short radius laterally directed distal curve. Mean time to union is 4.3 months [3-10]. Average AOFAS hindfoot score post-operatively is 65, with a mean improvement of 40 points from the pre-operative score in the TTC nail group. Post-operative complications included deep infection, amputation and a non-union rate of 10% overall. In the humeral nail group, four symptomatic stress reactions [8%] and three fractures of the tibia [6%] occurred at the tip of the nail. No stress-riser effect has to date been seen in the TTC nail group. Prominent metalwork removal has also been significantly reduced in the TTC nail group. Our results show hindfoot fusion using a curved intramedullary nail to be an effective technique in complex cases of hindfoot arthritis and deformity. Anatomically specific alterations to the nail have resulted in a significant reduction in certain complications. Alternate proximal locking options in the TTC nail have reduced prominent metalwork and, more significantly, the incidence of stress reactions and fractures appears to have been eliminated

Background: Diagnostic and operative codes are routinely collected on every patient admitted to National Health Service (NHS) hospitals in England and Wales (hospital episode statistics, HES). The data allows for linkage of post-operative complications and primary operative procedures, even when patients are re-admitted following a successful discharge. Morbidity and mortality data on foot and ankle surgery (F& A) has not previously been available in large numbers for NHS patients. Methods: All HES data for a 44-month period prior to August 2008 was analysed and divided into four groups – hindfoot fusion, ankle fracture surgery, ankle replacement and a control group. The control group was of first metatarsal osteotomy, which is predominantly day case surgery where no above ankle cast is used. The incidence of pulmonary embolism (PE) and all cause mortality (MR) within 90 days, and a return to theatre (RTT, as a complication of the index procedure) within 30 days was calculated for each group. Results: 7448 patients underwent a hindfoot fusion. PE, RTT and MR were 0.11%, 0.11% and 0.12% respectively. 58732 patients had operative fixation of an ankle fracture. PE, RTT and MR were 0.16%, 0.08% and 0.35%. 1695 patients had an ankle replacement. PE, RTT and MR were 0.06%, 0.35% and zero. 35206 patients underwent a first metatarsal osteotomy. PE, RTT and mortality rates were 0.02%, 0.01% and 0.03%. Discussion: There is controversy regarding the use of venous thrombo-embolic (VTE) prophylaxis in foot and ankle surgery. Non-fatal PE in F& A surgery has previously been reported as 0.15%. NICE guidelines recommend low molecular weight heparin (LMWH) for all inpatient orthopaedic surgery. 94% of F& A surgeons prescribe LMWH to post operative elective inpatients in plaster according to a previous British Orthopaedic foot and ankle society survey. VTE events, RTT and mortality rates for all groups were extremely low, including inpatient procedures requiring prolonged immobilisation. We question the widespread use of LMWH

Aim. To report the clinical and radiological results of patients undergoing hindfoot fusion using an intramedullary nail. Methods. Retrospective review of notes and radiographs of the patients of 2 surgeons who perform combined ankle and subtalar arthrodesis using retrograde intramedullary nailing with an ACE® humeral nail. The procedure is performed mainly for the treatment of combined ankle and subtalar arthritis or complex hindfoot deformities. Outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire. Results. Between 1995 and 2001 54 arthrodeses in 51 patients have been performed. The average follow up is 3 years. Approach to the joints was via a vertical anterolateral incision unless previous surgery dictated otherwise. All cases utilised an ACE® humeral nail which was locked proximally and distally. Most procedures utilised bone graft from the fibula, proximal tibia, iliac crest or allograft femoral head. Mean tourniquet time was 122 mins. Intra operative complications included one fractured tibia and one fractured medial malleolus. Postoperative management generally consisted of 3 months plaster immobilisation. Only 3 cases were immobilised significantly longer than this. Postoperative complications included deep infection, amputation, stress fracture, non-union & prominent metalwork. At review almost 78% of patients were satisfied with the results of surgery and approximately 80% felt the pain level & function of their foot had improved. Average postoperative AOFAS hindfoot score was 73. Conclusion. Hindfoot fusion by intramedullary nailing is an effective technique in complex cases of deformity and in many cases is the only alternative to amputation. Patient satisfaction appears to be high but the procedure is demanding and the complication rate can be significant

Hindfoot fusions are not new and can be a very valuable tool to address a variety of hindfoot problems. It is, however, not a procedure without significant issues. With the combination of a subtalar and talo-navicular fusion most of the ability to compensate for uneven terrain is lost, as is the ability to compensate for minor misalignments in the foot itself. It is therefore extremely important to be diligent in planning and execution of a triple arthrodesis. Deformities should be corrected, but not over-corrected. It is seldom that in situ fusions of deformities are indicated. Stable internal fixation is recommended to avoid loss of correction in the healing period. Indications, surgical approach and rationale for treatment will be discussed

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

The mid foot joints are usually the first to be affected in Charcot neuroarthropathy(CN). Reconstruction is technically demanding and fraught with complications. Fixation methods have evolved over time from cancellous screws, plates, bolts and a combination of these. We present our experience of mid foot fusion in CN from a tertiary diabetic foot centre. In this series we undertook mid foot corrective fusion in 27 feet (25patients) and are presenting the results of those with a minimumof six months follow up. Twelve of these had concurrent hindfoot fusion. Eleven patients had type 1 diabetes, 12 had type 2 and 2 were non-diabetics. 23 patients were ASA grade3 and 2 were ASA 2. 21 feet had ulcers preoperatively and mean HbA1c was 8.2. 13 patients had diabetic retinopathy and 6 had nephropathy. Average patient age was 59 (43 to 80) and our mean follow up was 35 months (7 to 67). One patient was lost to follow up and 2 patients died. 18 patients had plates, 3 had bolts and 6 had a combination. Complete follow up data was available for 26 feet in 24 patients. Satisfactory correction of deformity was achieved in all patients. The mean correction of calcaneal pitch was from 0.6 preoperatively to 10.6 degrees postoperatively, mean Meary angle from 22 to 9 degrees, talo- metatarsal angle on AP view from 33 to 13 degree. Bony union was achieved in 21 out of 26 feet and atleast one joint failed to fuse in 5. 19 out of 24 patients were able to mobilize fully or partially weight bearing. We had 6 patients with persisting and 3 withrecurrent ulceration. Seven repeat procedures were carried out which included 2 revision fixations. 4 out of 5 non-unions were seen where bolts were used alone or supplemented with plates. With our technique and a strict protocol 100% limb salvage and 81% union was achieved. 80% patients were mobile and ulcer healing was achieved in 72%. Corrective mid foot fusion is an effective procedure in these complex casesbut require the input of a multidisciplinary team for perioperative care

Introduction. Historically, surgeons have focused on isolated simple coalition resection in symptomatic tarsal coalition with concomitant rigid flat foot. However, a review of literature suggests that coalitions with severe preoperative planovalgus malposition treated with resection alone are associated with continued disability and deformity. We believe that concomittant severe flatfoot should be considered as much as a pathological component and pain generator as the coalition itself. Our primary hypothesis is that simple resection of middle facet tarsal coalitions and simultaneous flat foot reconstruction can improve clinical outcomes. Methods. Thirteen consecutively treated patients (eighteen feet) were retrospectively reviewed from the senior author's practice. Clinical examination, American Orthopaedic foot and Ankle Society (AOFAS) hindfoot scores, and radiographic assessments were evaluated after resection of middle facet tarsal coalitions with simultaneous flat foot reconstruction. Results. All patients with resection and simultaneous flat foot reconstruction (calcaneal lengthening, medial cuneiform osteotomy) were satisfied and would have the same procedure again. Most patients were able to return to a higher level of sporting activity compared with preoperative ability. None of the patients had a fair or poor outcome as adjudged by their AOFAS scores. Conclusion. Our study shows that concomittant flatfoot reconstruction in patients with symptomatic middle facet tarsal coalition increased hindfoot motion, corrected malalignment and significantly improved pain. We believe that coalition resection and concomitant flatfoot reconstruction is better option than surgical resection alone or hindfoot fusion in this cohort of patients. Triple arthrodesis should be reserved as a salvage procedure

Posterior tibial tendon dysfunction is a well-recognised condition. It commonly occurs in middle aged overweight women. In contrast to most tendon pathology, the tendon is still often intact and the tendon is stretched rather than completely ruptured. The diagnosis can be made on clinical grounds. Clinical features include acquired flatfoot deformity, inability to perform a single heel raise, ‘too many toes’ sign and loss of inversion power with the foot in forced plantarflexion. Disease is staged into four stages, Stage II is the most common presentation. Treatment options for Stage I are non-operatively including rest and antiinflammatories. Surgical treatment for this is required if this fails or progresses to next stage. Treatment for Stage II disease is most commonly a tendon transfer using FDL tendon transfer and some bony procedure, most commonly calcaneal osteotomy. More recently move to sub-classify Stage II into sub-classification depending on severity of hindfoot valgus and presence of fixed forefoot varus. Other treatment options for Stage II include lateral column lengthening or medial column shortening procedures. Stage III disease is fixed deformity which is classically treated with triple arthrodesis. Stage IV deformity is fixed deformity with ankle valgus. Difficult condition to treat. This requires ankle and hindfoot fusion

Purpose: The purpose of the study was to compare the maximum compression force of three different 6.5 mm cancellous screws commonly used in hindfoot fusions. Materials and methods: Screw 1 was a solid core standard fragment partially threaded cancellous screw (Smith and Nephew). Screw 2 was a titanium cannulated screw with a medium thread pitch (Asnis III, Stryker). Screw 3 was also a titanium cannulated screw with a large core diameter but with a small thread pitch (Ace, DePuy). Four different densities of polyurethane foams were used simulating cancellous bone and the compression. Results: Screw 3 had the highest compression force in tests with the low density foams (p< 0.05) and screw 1 performed better in higher density foams (p< 0.05). In medium density foams, both screws 1 and 3 showed significantly more compression than screw 2 (p< 0.05). Clinical relevance: The results indicate that the 6.5 mm standard fragment non-cannulated cancellous screw may provide more compression in a normal density bone whereas in an osteoporotic bone a cannulated titanium screw may be preferred for producing better compression during arthrodesis

In the belief that many of the barriers that patients face when deciding upon an ankle or hindfoot fusion procedure stem from inadequate information about the procedure and its outcomes, the novel concept of a “Fusion forum” has been developed: a nurse-led informal group meeting to facilitate patients’ understanding and perception of fusion procedures. The aims were to provide more in-depth information than it is possible to deliver during the limited time of an initial doctor-patient consultation, to get the patient to meet and question a guest (an expatient who has previously had a fusion procedure) and to allow patients time to reflect upon their choices. The value of the fusion forum has been evaluated by a questionnaire which was completed by the first 48 patients who attended the forum. 96% (46/48) of respondents felt that the quality of information that they were given was excellent or good. No respondent thought that the information was unsatisfactory. Patients were asked how valuable they had found meeting the guest. Four patients did not respond to this question. All of the respondents thought that meeting another patient who had already undergone the procedure was excellent or good. The mechanics of setting up a foot and ankle fusion forum is discussed, along with the lessons learnt from the first cohort of patients. This process has been found to greatly increase patient understanding of arthrodesis. It has been found during the consent process in pre-admission clinic that patients demonstrate a more in-depth understanding of the operative procedure, a more comprehensive knowledge of what the whole process involves, as well as the relative risks and benefits and the expected time of recovery

Objectives. To evaluate the effects of ankle/hindfoot arthrodesis in rheumatoid arthritis (RA) patients on gait pattern of the knee and hip. Methods. In this prospective follow-up study 14 RA patients scheduled for ankle/hindfoot arthrodesis were included. Three-dimensional gait analyses of joint angles, moments and work were performed at the index operation and after 13 months of follow-up. Each patient underwent clinical assessments of pain while walking, overall evaluation of disease activity, Health Related Quality of Life Questionnaire (EQ-5D), activity limitations, maximum walking distance, difficulty with walking surface and gait abnormality. For comparisons of pre- versus post-operative conditions, Wilcoxon’s matched pairs test and Friedman ANOVA by rank test were used. Results. At follow-up after ankle/hindfoot fusion surgery, RA patients demonstrated a statistically significant improvement in mean range of joint motions, moments and work in the overlying joints such as the knee and hip. Moreover, there was significantly less pain, disease activity, activity limitation, difficulty with walking surface and gait abnormality. EQ-5D and maximum walking distance were also significantly improved at follow-up. Conclusions. Our results demonstrate that ankle/hindfoot arthrodesis in RA is an effective intervention to reduce pain and to improve Health Related Quality of Life and functional ability. Moreover, the overlying leg joints experience an improvement in joint motion, muscle-generated joint moments and work during walking. Three-dimensional gait analysis may assist future investigations of the effects of orthopaedic surgery on functional mobility in RA to prevent irreversible disablement

The resurgency of ankle replacement in the last 10 years has prompted a need for effective management of failing prostheses. We present the early to mid-term results for revision surgery of 17 arthroplasties in 17 patients from our tertiary referral centre. Between 1999 and 2004, two Consultant Foot and Ankle Surgeons revised failing ankle arthroplasties in 17 patients (age range 51–74 years). All patients were assessed with tissue cultures and histology that were harvested at the time of surgery and managed in conjunction with a specialist Bone Infection Unit. Intraoperative frozen section was used to aid management, but usually pre-operative decisions had been made which included. one or two stage reimplantation. fusion with an intramedullary nail or Ilizarov frame. amputation, and. Ilizarov fusion combined with proximal tibial lengthening for excessive bone loss. Many of the patients had had previous “revision surgery” such as change of meniscal components, arthroscopic debridements and excision of impingeing osteophytes. Indications for implantation had been osteoarthritis in 59%, rheumatoid arthritis in 18% and post-trauma in 23%. Heel shift procedures to correct malalignment had been performed in 12%. The implants comprised 15 Scandinavian Total Ankle Replacements (STAR), one Agility and one Buechel-Pappas. Three patients had fractured malleoli secondary to bone loss. Cultures and histology confirmed the presence of infection in 24% (defined as positive histology and more than 2/6 positive cultures) with aseptic loosening in the remainder. One infected patient underwent amputation at his request. Six non-infected patients had successful revision of two or three components, one infected patient had Ilizarov fusion and lengthening. The remainder underwent successful hindfoot fusion over a locked intramedullary nail, even in the presence of infection, with suppression to union

Material: 100 consecutively performed Total Ankle Arthroplasties (TAA) of the Mobility design carried out at Schultess Clinic Zurich and 100 from Wrightington Hospital Wigan were entered into the study. The male: female ratio was 1:1. Age 62 (range 24 to 95 years). The diagnosis was primary OA (59%), OA resulting from a major injury in the past (20%) and rheumatoid arthritis (21%). We considered more than 20 degrees varus or valgus to be a contraindication to TAA. Methods: The Mobility TAA is three component, cobalt chrome uncemented design. The tibial component has a stem and the talar component has two fins for secure bony incorporation. At the time of TAA ancillary procedures such as gastrocnemius lengthening were performed if required. Results: The follow-up was 36 months (24 to 50). The most frequently performed ancillary procedure was gastro-soleus lengthening and this was carried out in 20% of cases. Osteotomy of os calcis and talo-navicular or other hindfoot fusion was performed in approximately 8%. The severity of pain was measured on the visual analogue scale before and at follow-up and this improved from 8.5 to 1.6. The average range of motion measured radiographically improved from 25 deg to 30 deg. The most frequent persistent complaint was that of occasional troublesome antero-medial pain. 92% patients were satisfied with the outcome. Complications were 6% intra-operative malleolar fractures. These did not lead to long term problems. Delayed wound healing occurred in 4% but all healed fully by three months. Late medial malleolar fractures occurred in 2%. Early infection occurred in one patient and was successfully treated by washout and antibiotics. Revision to fusion or change of tibilal and/or talar implant was required in 2.5% (5 patients) due to aseptic loosening and a technical error in one further patient treated three years ago led to subluxation of the insert. This was changed for an 11mm insert with a successful outcome to present time. Conclusion: These results are an improvement on those acheived by the same surgeons prior to this study using other types of implant. We believe this is due to improved instrumentation and implant design and a better understanding of the indications particularly the need to be very cautious in recommending replacement to patients with severe varus or valgus deformities