This author discusses using a tibio-talo calcaneal fusion with an intramedullary rod in a distal tibia-fibula fracture in a patient who had sustained two nonunions following open reduction internal fixation.
A 33-year-old female with mild mental disabilities presented to me after being referred from an outside facility. She had sustained a distal tibia and fibula fracture over a year prior to presentation and had open reduction internal fixation (ORIF) per the referring surgeon.
A nonunion developed and a second ORIF was attempted per the referring physician. A second nonunion developed and a small draining sinus was present at the proximal aspect of the incision, which was otherwise healed. The patient had not been able to bear weight on that limb in over a year. She had good support from her family and she was a pack-a-day smoker. Seeking a second opinion, the original surgeon referred her to me.
The workup began with X-rays and a clinical exam. A non-articular distal tibial nonunion was present alongside a healed fibular fracture. The hardware, consisting of locking plate and screws, was poorly placed and the limb was unstable at the fracture site. The nonunion site was mobile and offered no stability with weightbearing. The ankle also had motion and appeared well preserved. Surprisingly, the patient had minimal pain at the fracture site but could not bear weight due to the unstable nature of the nonunion. The sinus tract was pinpoint in size and had a non-odorous clear drainage.
I discussed the options involving continuing non-weightbearing in a boot with a bone stimulator, a reconstruction attempt and below the knee amputation. She elected for reconstruction.
She went to the operating room for a bone biopsy to assess for osteomyelitis. The biopsy occurred with minimal anterior incisions. This was negative for both the micro and pathology specimens. I required that she discontinue smoking in order to proceed with a salvage attempt. At six weeks, she had stopped smoking and the sinus tract had resolved.
I booked the patient for a reconstruction attempt. In an effort to gain stability, I chose a tibio-talo-calcaneal fusion. The nonunion site had failed two ORIF attempts. Accordingly, a definitive, stable limb was more likely to succeed than a third ORIF of only the fracture site.
Intraoperatively, the first objective was hardware removal and to freshen up the nonunion site. Viable bone was prevalent and bleeding after removal of nonviable, necrotic bone. I then performed a joint takedown with a fibula harvest for added bone graft. I utilized a bone mill after decorticating the distal fibula. Allograft bone with bone marrow aspirate harvested from the calcaneus filled the voids due to bone loss.
I achieved reduction and maintained it with a combination of K-wires and bone clamps. Fluoroscopy verified appropriate alignment and I placed the intramedullary rod in standard fashion. Standard wound closure occurred and a posterior splint with Jones dressing was applied.
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.
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.