Management of Large Infected Bone Defects around the Ankle with

Bone Transport over a Retrograde Nail

Martin McNally¹ and Erik Formanek²

¹The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, United Kingdom
²Department of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway

 

Background

Ankle fusion is a good treatment for complex pathology around the ankle¹. However, both trauma and infection can create large bone defects making fusion difficult². We describe two cases with large, infected defects around the ankle, managed with a novel technique. One had severe infection of a total ankle replacement (PJI) and the other sustained major open trauma of the distal tibia and ankle joint with infection (FRI), while serving in the Ukrainian armed forces.

Method

Both patients had excision of the dead and compromised tissues around the ankle, creating major segmental bone defects (5 and 8cm respectively).  Deep tissue sampling and local and systemic antimicrobial therapy were performed. The defect was stabilized by a retrograde intramedullary nail and an Ilizarov circular fixator. The soft tissue defects were closed at the time of nail insertion, including an ALT flap in the FRI case. The bone defect was managed with bone transport over the IM nail. Cultures revealed complex polymicrobial infections with multi-resistant organisms.

Once the bone transport had reached docking, the ‘ankle’ was fused with internal fixation and the Ilizarov frame removed. Both cases united with eradication of infection at final review. Function was good with comfortable walking for several kilometres.

Discussion

This technique, combining retrograde nailing, antegrade bone transport and local antimicrobials was effective in these difficult cases. It can be performed in one or two stages. We recommend avoiding delays in definitive treatment and antibiotic-coating of the IM nail to avoid colonisation of the implant³.

1. Kugan R, et al.  J Bone Joint Surg[Br]  2013; 95-B: 371-377.
2. Gross C, et al. Foot & Ankle Specialist 2015;8(2): 143-151.
3. Pomeroy E, et al. J Ortho Sci Res. 2024; 5(1): 1-7.