Authors: Charalampos Zalavras, Michael J Patzakis, Swapnil Shah, Randy Sherman, Paul Holtom
Title: Infected fractures of the distal tibia and ankle plafond: Limb salvage with free muscle flaps, bone grafting, and ankle fusion.
Addresses: LAC+USC Medical Center, 1200 N. State St., Room 3900, Los Angeles, CA 90033
Background:Infection following a fracture of the distal tibia or ankle plafond is a feared complication that can often result in amputation of the affected extremity. Few series in the literature have reported on infected fractures of the distal tibia and ankle plafond. Thus, the purpose of the current study is to present our experience with a limb salvage protocol for the management of this challenging problem.
Material and Methods: Six patients, 5 male and one female, with a mean age of 46.3 years (20 to 63 years) were treated by the senior author for infection following a fracture of the distal tibia and ankle plafond. Patients presented at our institution at a mean time of 15.7 months (4 to 51 months) after their initial injury having undergone 4.7 procedures on average. Our limb salvage protocol included 3 separate procedures: 1) radical debridement of all non-viable and infected tissue and stabilization of the ankle with a bridging external fixator, 2) soft tissue coverage with free muscle flaps, and 3) ankle fusion using iliac crest bone graft for filling of the existing defects. Surgical management was supplemented with 6 weeks of antibiotic therapy.
Results: At a mean follow-up of 4 years (2 to 10 years) limb-salvage was accomplished in all extremities (6/6, 100%). Infection was eradicated in all cases without any recurrence. Fusion of the ankle joint was achieved in all patients, with one patient requiring a supplemental bone grafting procedure for delayed healing of the fusion site. This was the only additional surgical procedure needed in our series. All patients are pain free and able to walk without assistive devices.
Discussion: Satisfactory outcome depends on the key elements of radical debridement, administration of antibiotics, dead space management and soft tissue coverage using free muscle flaps, autogenous bone grafting for ankle fusion, and stabilization of the ankle with a bridging external fixator until healing.
Significance: Limb salvage with free muscle flaps, bone grafting, and ankle fusion is a viable option for the management of infected distal tibia and ankle plafond fractures.