We report a case in which Ilizarov distraction osteogenesis was used to lengthen the portion of calcaneum that remained after a radical debridement for osteomyelitis. The patient was able to walk normally in unmodified shoes at the end of his treatment.

Salvage of a failed total ankle replacement is technically challenging and although a revision procedure may be desirable, a large amount of bone loss or infection may preclude this. Arthrodesis can be difficult to achieve and is usually associated with considerable shortening of the limb.

We describe a technique for restoring talar height using an allograft from the femoral head compressed by an intramedullary nail. Three patients with aseptic loosening were treated successfully by this method with excellent symptomatic relief at a mean follow-up of 32 months (13 to 50).

In this retrospective study, using the prospectively collected database of the AO-Documentation Centre, we analysed the outcome of 57 malunited fractures of the ankle treated by reconstructive osteotomy. In all cases the position of the malunited fibula had been corrected, in several cases it was combined with other osteotomies and the fixation of any non-united fragments. Patients were seen on a regular basis, with a minimum follow-up of ten years. The aim of the study was to establish whether reconstruction improves ankle function and prevents the progression of arthritic changes.

Good or excellent results were obtained in 85% (41) of patients indicating that reconstructive surgery is effective in most and that the beneficial effects can last for up to 27 years after the procedure. Minor post-traumatic arthritis is not a contraindication but rather an indication for reconstructive surgery. We also found that prolonged time to reconstruction is associated negatively with outcome.

Adamantinoma is a rare tumour of long bones that occurs most commonly in the tibia. Its pathogenesis is unknown. It is locally aggressive and recurrences are common after resection. Metastases have been reported in 10% to 20% of cases, most commonly in the lungs and rarely in the lymph nodes. We report a patient who developed a skeletal metastasis four years after resection of the primary tumour. There was no evidence of recurrence at the primary site or of secondary deposits in the lungs.

Rembrandt’s etching of a beggar with a wooden leg is notable because the two lower limbs of the presumed beggar are present and not deformed. Using the facilities of four specialised Dutch art institutes, we carried out a systematic investigation to find other etchings and engravings of subjects with artificial legs supporting non-amputated limbs, from the period 1500 to 1700 AD. We discovered 28 prints produced by at least 18 artists. Several offered clues to a disorder of a knee, the lower leg or the foot. All individuals were adult males, suggesting the probability of traumatic lesions. We conclude that in this period artificial legs were not only used in the case of absence of part of a lower limb, but also for other reasons, notably disorders of the knee, lower leg or foot. They may also have been used to attract compassion.

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.

Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience.

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group).

We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury.

The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups.

The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.