We used the Ilizarov circular external fixator to treat 16 patients with persistent nonunion of the diaphysis of the humerus despite surgical treatment. All patients had pain and severe functional impairment of the affected arm. In ten, nonunion followed intramedullary nailing. We successfully treated these by a closed technique. The nail was left in place and the fracture compressed over it. The fractures of the other six patients had previously been fixed by various methods. We explored these nonunions, removed the fixation devices and excised fibrous tissue and dead bone before stabilising with the Ilizarov fixator. In five patients union was achieved. Bone grafting was not required. In the single patient in whom treatment failed, there had been a severely comminuted open fracture. All except one patient had reduction of pain, and all reported an improvement in function.

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We reviewed 26 consecutive men of mean age 28 years who had had wedge bone grafting and Herbert screw fixation for symptomatic established nonunion of the waist of the scaphoid. The period between injury and operation averaged 30 months (10 to 96), and 11 of the 26 patients had had previous operations, seven with bone grafts.At a mean follow-up of 14 months (6 to 42) 25 fractures (95%) had united at a median time of four months. Symptoms were improved in all patients. The outcome was not related to the time between injury and surgery or to pre-existing degenerative changes. Previous surgery carried a worse prognosis.The technique is difficult but can achieve union even when previous surgery and bone grafting have failed. The usual result is improved function and some relief of pain.

Between 1994 and 1999, we treated six patients with avascular necrosis of the talus by excision of the necrotic body of the talus and tibiocalcaneal fusion using an Ilizarov frame. This was combined with corticotomy and a lengthening procedure. Shortening was corrected in all patients except two, who were over 60 years of age. All patients had previous operations which had failed. All achieved solid bony fusion, with five out of six having either a good or an excellent result. We conclude that this is an effective reconstructive technique which gives a good functional result.

Between 1994 and 1999, we treated six patients with avascular necrosis of the talus by excision of the necrotic body of the talus and tibiocalcaneal fusion using an Ilizarov frame. This was combined with corticotomy and a lengthening procedure. Shortening was corrected in all patients except two, who were over 60 years of age.All patients had previous operations which had failed. All achieved solid bony fusion, with five out of six having either a good or an excellent result.We conclude that this is an effective reconstructive technique which gives a good functional result. [Br] 2001;83-B:199-203. J Bone Joint Surg Received 28 June 2000; Accepted 4 August 2000It is not possible to predict with certainty the degree of avascular necrosis which may occur after a fracture of the talus, or the severity of symptoms which will result from such an injury. Immediately after the fracture every attempt should be made to preserve the talus. If avascular necrosis occurs the results are usually disabling. We could find no published review of the types of surgery carried out at this stage. The surgical options include talectomy, tibiotalar arthrodesis, pantalar arthrodesis, tibiocalcaneal arthrodesis, or below-knee amputation. All of these procedures produce long-term problems.Tibiocalcaneal fusion, as described by Reckling, 1 gives the best functional result, but at the expense of shortening. We have used a modification of his technique, using an Ilizarov frame to compress the arthrodesis while, at the same time, lengthening the leg at an upper tibial corticotomy. For patients over the age of 60 years we have accepted the shortening produced by the surgery and not attempted to lengthen the leg because this extra surgical procedure increases the complications. Patients and MethodsBetween 1994 and 1999 we carried out six unilateral tibiocalcaneal fusions for avascular necrosis of the talus, using a modification of the method originally described by Reckling. 1 This was combined in patients below the age of 60 years with a proximal tibial corticotomy and callotasis distraction to correct the shortening which resulted from the talar resection. Trauma was the cause of the avascular necrosis in five patients; the sixth had a failed primary ankle arthrodesis complicated by avascular necrosis of the talus (Table I). Their mean age was 45 years (27 to 67), and the mean number of previous operative procedures for each ankle was five (1 to 16). The mean delay from the initial injury to the time of operation for tibiocalcaneal fusion was 56 months (2 to 231).The distal fibula was excised using a lateral incision and the peroneii and extensor digitorum longus divided in a Z fashion between sutures. A medial incision allowed the necrotic body of the talus to be excised and the ankle to be dislocated medially to expose the distal tibia. Cuts were made with an oscillating saw in transverse and coronal planes as shown by the dotted line in Figure 1, with resection to healthy bleeding bone. The cut surfaces between the tibia and calcaneus were...