Tibiotalocalcaneal arthrodesis (TTCA) is a salvage procedure to functionally block the ankle and subtalar joints to treat severe ankle and hindfoot disease. Complication rates range between 20-40%, with below-knee amputation rate 1.5-19%. The heterogeneous patient cohort and indication(s) for surgery make post-operative outcomes difficult to predict. Consulting patients about potential pain and functional outcomes is difficult. When researching this area commonly, PROM data is used, less frequently functional objective measures like the 2-minute-walk-test (2MWT) are used. The aim was to compare the PROMs and objective outcomes between patients who underwent TTCA and BKA. Fifty-two patients underwent a TTCA using an intramedullary hindfoot nail. Indications for TTCA, post-traumatic OA, failed arthrodesis and malalignment. These patients were compared to 11 patients who underwent unilateral below knee amputation (BKA) due to trauma. Outcomes measures PROMs AOFAS ankle hindfoot scale and Shor-Form 36 (SF-36). Objective measures; 2MWT, Timed-up-and-go (TUG). Mean age TTCA 55.9, BKA 46.4. Average follow-up time 53 months. TTCA group had average 6.3 operations prior to arthrodesis (range 1-23). Of the TTCA group two ankles did not unite (7%), all complication rate 35%, 18% reported no pain. A significant negative correlation was demonstrated between the clinical outcome and the number of surgeries prior to the TTCA. TUG and 2MWT had significantly (p<0.05) better outcomes for the BKA group compared to TTCA. SF-36 BKA patients scored higher than the TTCA patients on physical functioning (p<0.01) and mental health (p<0.05) subscales as well as the mental component score (p<0.05). This study gives clinicians evidence about the natural history of hindfoot arthrodesis and functional outcomes from BKA. Hopefully this study will improve evidence to help patients and surgeons make decisions about expected surgical outcomes from TTCA and BKA procedures

Aim. The incidence of deep infections after internal fixation of ankle and lower leg fractures is estimated 1 to 2%. Hindfoot arthrodesis by retrograde intramedullary nailing (IMN) is a potential alternative to external fixation for post-infectious ankle destruction. The aim of this study was to evaluate the clinical results, complications and effects of soft tissue management with this treatment modality. Method. This is a single-center retrospective review of routine hospital data from 21 patients (15 men, 6 women, median age 65 [range, 21 to 87] years) undergoing IMN arthrodesis of the hindfoot for post-traumatic infections between January 1st, 2012 and March 15, 2018. We observed four bimalleolar, eight trimalleolar, three pilon fractures, and six distal lower leg fractures. Six and three patients had sustained second- and third degree open fractures, respectively. Early- and late-onset surgical infections were observed in 8 and 13 cases. Four participants had diabetes mellitus, two arterial occlusive disease, and four had both. Six patients were smokers. Results. Intraoperative cultures before implanting the nail revealed staphylococcus aureus in 12, staphylococcus epidermidis in five, and enterococcus faecalis in eight cases. After a median follow-up of 21 months, infection was considered cured in 19 / 21 subjects (90%, 95% confidence interval 70 – 99%). Soft tissue comminution required coverage with a suralis flap in five patients, and with a latissimus dorsi flap in another three. Mesh graft was necessary in 8 / 21 reconstructions. Conclusions. Tibiotalocalcaneal fusion by IMN is an effective salvage procedure for post-traumatic ankle infections. Arthrodesis and definitive wound closure or plastic flap coverage can be performed as single-stage surgery. By resecting the prominent distal fibula, lateral soft tissue defects can be managed more easily. The small sample size prohibited a more detailed analysis of exposure variables, but 8 / 13 patients in this cohort had at least one known risk factor for infection and prolonged healing

We reported the outcomes of patients with Charcot neuropathy who underwent hind foot deformity correction using retrograde intramedullary nail arthrodesis. Twenty one feet in 20 patients, aged 45 to 83 years, with a mean BMI of 32.7 and a median ASA score of 3, were included in this study. All patients presented with severe hindfoot deformities and 15 had recurrent ulceration. All patients were treated with hindfoot corrective fusion and seven patients also underwent simultaneous mid foot fusion using a bolt or locking plate. After a mean follow up of 26 months, none of the cases required any form of amputation. Eighty percent of patients with ulceration achieved healing and all but one patient returned to independent ambulation. One nail fracture and three mid foot metal work failure resulted in fixation failure requiring revision surgery. Distal locking screw displacement occurred only with standard screws but not with hydroxyapatite-coated screws. The AAOS-FAO score improved from 50.7 to 65.2 (p=0.015). The EQ-5D-5L improved from 0.63 to 0.67 (p=0.012) and the SF-36 PCS from 25.2 to 29.8 (p=0.003). Single stage deformity correction with intramedullary hindfoot arthrodesis nail is a viable treatment option for severe Charcot hindfoot deformity with ulceration and instability

Ankle osteomyelitis after open pilon-fractures remain one of the most challenging scenarios. Ankle-fusion using an external frame is a classical option but in some cases of non-compliance patients could be not ideal. The purpose of this report was to evaluate our results using a new staged salvage protocol in cases where an external-frame arthrodesis is not recommended due to the issue of a non-compliance patient. During the first stage we resect all the infected tissues and an antibiotic-loaded cement spacer is used to obliterate the dead space, to reach some kind of stability and to achieve a high concentration of local antibiotic. A free or keystone flap is used if needed and a posterior splint is placed. After a course of targeted systemic antibiotics the second stage is schedule. During the second stage after the spacer removal, a self-made antibiotic coating retrograde hindfoot arthrodesis nail is used in order to achieve ankle fusion. We use a bone-substitute loaded with gentamicin (Cerament-G®) to fill the bone defects and to achieve high concentration of local gentamicin, to protect bone healing and to decrease the risk of relapse. We present four patients with ankle-osteomyelitis after open pilon fracture treated by such protocol. We receive all patients > 6 months after the initial fracture. In all cases type III-B open pilon fracture was the initial injury. All the patients presented psychological disturbances and the possibility of perform an external frame reconstruction was considered not indicated. At presentation, all patients have compromised skin around the distal tibia area. According to the Cierny/Mader osteomyelitis classification all patients were Type IV-Blocal. Compromises soft tissues were treated with an ALT free flap in two cases and with a Keystone flap in two cases. 10 mL paste of Cerament-G® was used in each case with a single case where a white-draining event was present without further complication. Tibiotalocalcaneal fusion was achieved after 4 months in all cases. At average of 7 months of follow-up, none of the four fused ankles has required further surgery and no infection relapse was observed. The use of this salvage treatment protocol has proven safe and useful for such difficult problem in these difficult patients, with a relatively low associated complication rate. Cerament-G® is a useful tool in order to fill all the bone voids, promote bone healing and simultaneously to protect the surgical area due to the high local concentration of gentamicin

Introduction. Degenerative, inflammatory, and posttraumatic arthritis of the ankle are the primary indications for total ankle arthroplasty. Ankle arthrodesis has long been the “gold standard” for the surgical treatment. Total Ankle Arthroplasty. implant survivorship has been reported to range from 70% to 98% at three to six years. The combination of younger age and hindfoot arthrodesis or osteoarthritis may lead to a relative increase in failure rates after TAA. Intraoperative complication include malaligment, fracture and tendon Postoperative complications include syndesmotic nonunion, wound problems, infections and component instability and lysis. After TAA few difficulties mainly due to poor Talar and Tibial bone stock. It is difficult to stabilize the fusion and usually there is shortening after removal of the implant. Also there is a need for massive bone graft-allograft or autograft. In cases when there is significant bone loss there is a need for stable reconstruction and stabilization of the hindfoot. Bone grafting with structural bone graft may collapse and it has to be stabilized with screws or nail. Methods. We developed technique which included distraction of the fusion area and inserting a Titanium cylindrical spinal cage filled with bone graft. Than guide wire was inserted in through the cage under fluoroscopy and a compression screw was introduced causing compression of the fusion area against the cage gaining stabilization of the fusion area. Results. By 6 months all the patients were fused and could walk full weight bearing with no pain. Discussion and Conclusions. Spinal cages are widely used in spine fusions in order to achieve stable spacer. Usually it has to be stabilized using posterior fusion stabilizing system. By performing distraction of the fusion area by spinal cage used as spacer and compression at the same time using compression screw we achieved primary good stability with minimal shortening

Tibiotalocalcaneal arthrodeisis is performed for a variety of conditions, including advanced osteoarthritis, Charcot arthropathy, rheumatoid arthritis, post-traumatic arthrosis and foot deformities such as fixed equinovarus. There have been few published studies showing the results of such a procedure for limb salvage. Over a period of 11 years between 1996 and 2007, 18 patients underwent calcaneotalotibial arthrodeisis using either cannulated screws or a retrograde intramedullary locking nail. Post-operative rehabilitation regimes were standardised. VAS, AOFAS ankle-hindfoot, SF-36 and patient satisfaction scores were obtained and analysed. Eighteen patients (10 male and 8 female) with 19 ankles underwent tibiotalocalcaneal arthrodeisis at an average age of 52.3 (31.4 to 70.2 years). Seven patients had cavovarus deformity, six had osteoarthritis, three had Charcot's joint, two had failed previous fusions and one patient had a footdrop post-T12 tumour resection. Twelve right and seven left fusions were performed, with six cannulated screws and 13 retrograde nails. The mean time to complete fusion was 5.89 (3 to 11) months in 18 ankles (94.7%). There was one pseudoarthrosis (5.3%). Patients were followed up for an average of 35.6 (11 to 144) months. Four wound infections (21%) occurred post-operatively. Two patients died from unrelated caused whilst on follow-up. Thriteen patients returned for follow-up scoring. VAS scores improved from 7.85 to 2.54 (p=0.00). AOFAS ankle-hindfoot scores improved from 30.50 to 63.62 (p=0.00). SF-36 scores also improved in several parameters. Physical function improved from 40.38 to 66.15 (p=0.02); physical role improved from 15.38 to 53.85 (p=0.03); Bodily pain improved from 36.69 to 62.23 (p=0.00); emotional role improved from 69.23 to 100 (p=0.04); and mental health improved from 62.77 to 0.15 (p=0.04). Eleven patients (84.6%) reported good to excellent satisfaction and expectation scores. Hindfoot arthrodesis, via retrograde imtramedullary nailing or cannulated screw insertion, are effective techniques for treating complex foot deformities and often is the only alternative to amputation. Although a demanding procedure with high potential complications, they provide effective relief from pain, improves the quality of life, and has high patient satisfaction

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