Failed Ankle Fracture Repair with Exposed Bone Saved with Tibial Nail


A 59 yo male presented to us exactly how you see pictured. He was 6 weeks out from bi-malleolar ORIF — he was instructed by the index surgeon he could bear weight in a walking boot as tolerated due to the 6 week x-rays showing good alignment & what they felt was interval healing. Unfortunately, the neuropathic DM went home, & walked on the right ankle without boot on, converting himself to an open Charcot ankle fracture. The patient as stated, presented to us after the fibula plate had been removed, & had been debrided. …. Timing was tricky as I was leaving town the day after patient presented, so I asked my partner Clay Strong, MD to take the patient to the OR, & try to achieve closure prior to what obviously would be definitively treated with a TTC arthrodesis.

Dr. Strong placed the patient in delta frame you see pictured, excised fibula, closed the lateral wound, & placed a wound vac. The patient was directly admitted from our office to hospital. A PICC line was placed, & he was started on antibiotics (although every culture taken from the lateral plate removal, to the TTC arthrodesis was negative).After approximately 15 days in the delta frame, lateral incision looked healthy, labs were normal (aside from A1C of 9) (& small wound at tip of ipsilateral great toe was healed), patient was scheduled for TTC with the Dynanail.

To avoid compromising the lateral tissues given multiple iatrogenic violations we elected to use medial approach — this also gave us access to remaining HW.

Due to the amount of vascularity provided by the medial mall & surrounding envelope we elected not to excise it, despite the risks associated with index hardware being placed there. The open fracture was treated early, & aggressively by both us, & the index surgeon & yielded neg cultures.

Fixation of the medial mall certainly may be criticized. We used a screw designed for the nail which only offered decent compression. We wanted something fully threaded due to cancellous nature of the bone, & recent screw holes.

The CT was performed at closer to 11 wks than 10, & demonstrates uniting bone. Pt is now 12+ wks from DOS, & transitioning to shoes w/ orthosis for mild varus.