Initial Management and Treatment Course Until Malunion: Definitive fixation was performed on post-injury day 4, when the soft tissues were deemed amenable to surgery. Patient underwent uneventful open reduction and fixation (ORIF) of both the fibular and medial malleolus. Intraoperatively, a vertical extension of the medial malleolar fracture was identified, and thus, an anti-glide construct was used with a plate; intraoperative external rotation stress was negative (Fig. 19.2a–c). The patient tolerated her surgery well and was discharged to a skilled nursing facility on postoperative day 3. The patient returned for her first postoperative visit at the 3-week time-point, when her wounds were healed and sutures removed. At this time, she was casted with the plan of being non-weight bearing for a minimum of 12 weeks. However, after her first follow-up appointment, she was lost to follow-up until the 7-month time-point and had been noncompliant with weight bearing precautions.

Work-Up and Arriving at the Correct Diagnosis : Due to her neuropathy, the patient experienced minimal pain and thus was noncompliant with weight bearing precautions. She eventually eroded through her cast, which was self-discontinued at home. She returned to the office noting intermittent warmth and swelling of her left lower extremity.

Laboratory work-up revealed a slightly elevated white blood cell count (12.5 g/mcL, ref. range: 4.5–11.5 g/mcL) with elevated inflammatory markers (ESR 45, ref. range 0–10; CRP 110, ref. range 0–7). Joint aspiration confirmed suspicion of infection with a cell count of 75 K and 92% PMNs; cultures grew out methicillin-sensitive Staph Aureus (MSSA).

Radiographs revealed complete fixation failure of the medial side with concomitant joint space obliteration in the midst of an ongoing Charcot arthropathy (Fig. 19.3a–c). Closer examination of the radiographs reveals not only a complete loss of height (Fig. 19.3c), but also severe shortening of the entire hindfoot complex due to the bony destruction of the talus, as seen on the mortise view (Fig. B). The AP view (Fig. 19.3a) shows medialization of the hindfoot complex in relation to the tibia further adding to the deformity. At this juncture, this patient had an infected ankle fracture malunion with significant deformity, namely loss of height, hindfoot shortening, and valgus deformity.

Staged Treatment Leading Up to Definitive Surgery: Initial treatment required urgent irrigation and debridement (I&D), removal of hardware, placement of an antibiotic spacer, and 6 weeks of intravenous (IV) antibiotics. During this initial , debridement, care was taken to plan for the definitive surgery and utilizing incisions that would be used again. Furthermore, the goals of anatomic restoration of the deformity were applied during this stage (fibular and tibial osteotomy through the medial malleolus). Through a direct anterior approach, the remaining portion of the eroded medial malleolus was resected and all necrotic, infected tissue removed along with the hardware. A large enough antibiotic spacer (created with vancomycin/tobramycin in a 3:2 ratio) was made not only to restore height but overall length, which was maintained with an antibiotic tibiotalocalcaneal (TTC) nail prior to spacer placement (Fig. 19.4a–c). The patient tolerated the procedure well, made non-weight bearing, casted, and was treated with oxacillin 2 g IV q24 h for 6 weeks. Inflammatory markers down-trended during this time period and after a 2-week antibiotic holiday, repeat joint aspiration was negative. She was deemed to be ready for definitive treatment.