Performing A Tibio-Talo Calcaneal Fusion After Two Post-ORIF Nonunions

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Author(s): 
Bradly W. Bussewitz, DPM

   I ordered a non-weightbearing protocol for eight weeks with eventual weightbearing and physical therapy. At four months, the patient was walking without aid. She is now over 18 months out from reconstructive surgery, uses no walking assistance, remains pain-free and has stopped smoking.

In Conclusion

There are some points to consider from this case.

• The choice of a joint destructive procedure vs third ORIF.
• Was a biopsy necessary to prove osteomyelitis was not present?
• Was smoking cessation necessary?

   A joint destructive procedure, the tibio-talo-calcaneal fusion, offered the best chance at a limb that could bear weight with a definitive operation. The lack of quality bone and soft tissue at the fracture site for the third ORIF made the decision easy. The tibio-talo calcaneal fusion is a great procedure to stabilize difficult revision cases.

   A biopsy is certainly not the only method to determine the presence of osteomyelitis but it is the one in which I have the most confidence. Labeled bone scans and magnetic resonance images also prove beneficial but in cases where one seeks definitive procedures, a bone biopsy sent to both microbiology and pathology offers reassurance that the limb is appropriately diagnosed.

   Tobacco cessation is likely beneficial in all surgery, both for bone and soft-tissue healing. The fact that this patient had a nonunion of over a year in duration meant smoking cessation was a must in my hands. The procedure is difficult enough given the presentation. If I am going to make the effort at salvage, then so can the patient.

   Dr. Bussewitz completed an Advanced Foot and Ankle Surgical Fellowship at Orthopedic Foot and Ankle Center in Westerville, Ohio and is in private practice in Iowa City, Iowa.

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