Case 39: Ilizarov Ankle Fusion

Jason H. Calhoun and Anne C. Sullivan

Contents Abstract
1 Brief Clinical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279
A 27 year old male developed osteomyelitis after
standard current treatment of an open bimalleolar
2 Preoperative Clinical Photos and Radiographs . . . . . . . . . . 281
(pilon) ankle fracture, despite successful fracture healing.
3 Preoperative Problem List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 He underwent osteomyelitis treatment, including
4 Treatment Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 hardware removal, intravenous (IV) antibiotic therapy,
several further debridement procedures, and local
5 Basic Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281
antibiotic delivery via CaSO4/tobramycin/vancomycin
6 Images During Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 beads. He was ultimately treated with Ilizarov fine wire
7 Technical Pearls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 external fixation frame (Ilizarov) arthrodesis. Solid fusion
8 Outcome Clinical Photos and Radiographs . . . . . . . . . . . . . . . 285 occurred after 4 months in the frame. The frame was then
removed and the fusion continued to mature over time.
9 Avoiding and Managing Problems . . . . . . . . . . . . . . . . . . . . . . . . . 285
10 Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
References and Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 1 Brief Clinical History

This 27 year old man sustained an (pilon variant) open

bimalleolar ankle fracture, in a motor vehicle accident. He
was treated with immediate irrigation, debridement, and
open reduction and internal fixation (ORIF) at the time of
his injury in January 2009 (Figs. 1 and 2). He developed
cellulitis 2 months post-operatively and was managed with
oral cephalosporin and retention of hardware. He continued
to have pain, mild redness, and minimal local swelling, so
14 months later, he underwent debridement of osteophytes,
drilling of an osteochondral lesion of the tibia plafond, and a
tarsal tunnel release, along with hardware removal (Fig. 3).
Cultures were negative at this time. The patient continued to
have problems and 4 months later had irrigation and
debridement (I & D) of the medial malleolus, with cultures
positive for MSSA, and IV antibiotics for 6 weeks. He also
J.H. Calhoun (*)
received oral antibiotics but continued to have joint pain and
Department of Musculoskeletal Sciences, Spectrum Health Medical
Group MC999, Grand Rapids, MI, USA destruction of the talus, evidence of CiernyMader stage
e-mail: jason.calhoun@spectrumhealth.org; jason.calhoun@att.net 4Bls osteomyelitis. At surgery, the joint tissue appeared
A.C. Sullivan purulent, so an intra-operative frozen section was sent to
Department of Orthopaedic Surgery, The Ohio State University, pathology. This showed >50 white blood cells/high-power
Columbus, OH, USA field. The tissue looked too infected to proceed with fusion
e-mail: suileabhainac@gmail.com; anne.Sullivan@osumc.edu
reconstruction, so it was decided to debride and treat with

# Springer International Publishing Switzerland (outside the USA) 2015 279

S.R. Rozbruch, R.C. Hamdy (eds.), Trauma/Foot and Ankle,
DOI 10.1007/978-3-319-18026-7_110
280 J.H. Calhoun and A.C. Sullivan

Fig. 1 (a and b) Injury

radiographs

antibiotics and delay frame placement for fusion. At this

Fig. 2 Initial internal fixation radiograph
point, the patient and family needed to decide whether to
proceed with limb salvage or below the knee amputation. As
the bacterium was not known yet, local antibiotic depot with
biodegradable antibiotic beads of CaSO4 with tobramycin
and vancomycin was placed. The patient was also started on
intravenous cephalosporin intra-operatively, which was
continued for 6 weeks. Three months later, the patient
underwent repeat I & D and Ilizarov frame placement for
fusion of the ankle. At this time, we again placed
biodegradable antibiotic beads of CaSO4 with tobramycin
and vancomycin and prescribed oral antibiotics for 6 weeks,
as cultures were negative. His fusion was solid 4 months
later and the frame was removed. Two months after frame
removal, 28 months after the injury, he developed a flare
of his infection (slight redness and swelling with significant
pain and no radiologic changes) in August 2011 and was
treated with minimal I & D placement of biodegradable
antibiotic beads with tobramycin and vancomycin. He
ultimately had cultures again positive for MSSA and
received 6 weeks of oral cephalosporin with resolution of
his symptoms. His last radiograph, 3 years after the injury,
shows a healed fracture and solid ankle fusion. He remains
on 300 mg of Neurontin TID for chronic pain.
Case 39: Ilizarov Ankle Fusion 281

Fig. 3 (a and b) Twenty-one months postfracture, note tibiotalar erosion. Patient had previous hardware removal, repeat I & D, cultures + for
MSSA, IV antibiotics for 6 weeks. Continued to have pain and signs of talar erosion 1 month after previous I & D

(cellulitis) during initial healing period. Retention of

2 Preoperative Clinical Photos hardware and empiric administration of oral antibiotics
and Radiographs allowed continued stabilization of the fracture during the
initial healing phase. After the fracture healed, treatment of
See Figs. 1, 2, and 3. residual infection was pursued by repeat I & D procedures
and local biodegradable depot antibiotics to clear the
infection from the ischemic local tissue area. The ankle
joint remained painful due to postinfectious and post-
3 Preoperative Problem List
traumatic arthritis, so he elected fusion for limb salvage
versus amputation. The Ilizarov frame was used to compress
Osteomyelitis of tibia, fibula, and talus
and promote fusion of the ankle.
Arthritis of ankle joint
Even after the joint was fused and the frame removed,
Chronic pain
the patient again had to be treated for a flare of his infection
Deep venous thrombosis
with a repeat I & D with cultures and local antibiotic
Lupus anticoagulant disorder
delivered by CaSO4 and IV antibiotics with eventual
Depression
success.
Pulmonary embolism

4 Treatment Strategy
The patient required a stepwise approach to fracture healing,
eradication of infection, and limb salvage. Fracture healing
was achieved first, despite noted soft tissue infection
5 Basic Principles
CiernyMader staging is used to direct the principles of
treatment of osteomyelitis.
Patient selection is defined by the physiologic status of
the host, ranging from A, healthy with normal healing
282 J.H. Calhoun and A.C. Sullivan

Fig. 4 (a and b) In cast 1 month

after repeat debridement and
CaSo4 biodegradable antibiotic
bead placement (2 years s/p initial
injury)

Fig. 5 (a and b) Ilizarov frame

placement immediate postop

ability, to B which is compromised locally (l) and
systemically (s) to C which is compromised where the
ability to heal is very low; i.e., the treatment is worse than
the disease (Quote from George Cierny).
The anatomic extent of disease is defined by categories
14. 1 is medullary, 2 superficial (i.e., contiguous with skin
ulcer or wound), 3 localized (sequestrum), and 4 diffuse
(nonunion or joint).
Treatment takes into account both the host classification
and extent of disease, looking at the hosts ability to respond
to the chosen management option(s). Initial treatment can be
used to change the stage of osteomyelitis, such as by
debridement procedures, dead space management,
stabilization of nonunion or joint destruction with internal
or external fixation, and soft tissue flaps. The host status to
heal can also be improved with culture-directed antibiotics
Case 39: Ilizarov Ankle Fusion 283

Fig. 6 (a and b) In frame for

2 months. Fusion not judged to be
complete

Fig. 7 In frame for 4 months.

Fusion judged to be solid/
complete

and optimization of systemic factors such as renal failure,
diabetes, cardiac and pulmonary disease, smoking, and
drug abuse. This both decreases the bio-burden and
improves the hosts ability to respond to physiologic
compromise caused by infectious process. The course of
therapy is chosen in order to produce improvement in
patients quality of life without causing overwhelmingly
negative effects.
This case is initially stage 4Bls, signifying diffuse
osteomyelitis in host type B with local (l) compromise,
(due to ischemic local tissue because of scarring from his
open injury and surgery, scleroderma, and venous stasis due
284 J.H. Calhoun and A.C. Sullivan

Fig. 8 (a and b) Frame removal

at 4 months

Fig. 9 (a and b) Two months

after frame removal, swollen, red
painful. Cultures negative, I & D,
placement CaSO4 antibiotic
beads, 6 weeks oral antibiotics
Case 39: Ilizarov Ankle Fusion 285

to DVT), and systemic (s) compromise, (due to smoking,

scleroderma, deep vein thrombosis, and psychological issues),
but otherwise good soft tissue and host. Osteomyelitis is stage
4, diffuse. The patient transitions over time and with
continuing treatment to become host type A, essentially in
good health with minimal comorbidity and good soft tissue
envelope. Therapy to down-stage (manage and alter the
stage) consists of debridement to good bleeding tissue, deep
cultures for appropriate antibiotics, dead space management
with depot antibiotics, and ultimately reconstruction and limb
salvage. The initial large burden of inert material (fracture
fixation hardware) was removed, and later burden of arthritis
secondary to infection is dealt with in the process (Calhoun
et al. 2009).

6 Images During Treatment

See Figs. 4, 5, 6, and 7.

7 Technical Pearls

1. Treatment of open pilon fractures is still challenging

(Crist et al. 2011).
2. Maintenance of internal fixation until healing of fracture
is generally recommended but does not have high success
(Berkes et al. 2010).
3. Treatment of osteomyelitis can be directed by
CiernyMader staging. Therapy is debridement to good
bleeding tissue, deep cultures for appropriate antibiotics,
dead space management with depot antibiotics, and
reconstruction to down-stage and limb salvage
(Calhoun et al. 2009).
4. Ankle Fusion with Ilizarov technique (Fragomen
et al. 2012).
8 Outcome Clinical Photos
and Radiographs
See Figs. 8, 9, 10, and 11.
9 Avoiding and Managing Problems
Prevention of pin site infections: Patients are instructed
to gently clean pin sites with soap and water, and
showering (not soaking) is commonly encouraged.
Avoid overly vigorous cleaning and cytotoxic agents.
Fig. 10 Ten months after frame removal, 6 months after last I &
D. Finally doing well!
Prophylactic oral antibiotics often prescribed for 57
days if/when pin sites drain or start to become painful or
erythematous.
Use of CaSO4 antibiotic beads is off-label in some
places, including the USA. Typical recipe is 20 g
CaSO4 with appropriate fluid reconstitution +1 g
vancomycin powder +0.4 g tobramycin powder.
Beginning to mix the CaSO4 with its fluid prior to
adding antibiotic powder seems to promote faster
setting than mixing all powders and then adding
fluid. Aminoglycosides are avoided or carefully
managed in patients with renal compromise (Nayak-
Rao 2010).
Absorbable beads (rather than polymethyl methacrylate
beads) avoid the problem of requiring the additional
procedure for removal as well as avoiding the possibility
of them becoming secondarily colonized when no further
antibiotic remains to be eluted.
286
Fig. 11 (a and b) Last X-ray
17 months after frame placed.
Chronic pain, Rx with Neurontin
10 Cross-References
Case 10: Infected Nonunion of the Tibia
Case 75: Ilizarov Correction Ankle Equinus due to
Neuropathy
References and Suggested Reading
Berkes M, Obremskey WT, Scannell B, Ellington JK, Hymes RA,
Bosse M (2010) Maintenance of hardware after early postoperative
infection following fracture internal fixation. J Bone Joint Surg Am
92(4):823828. doi:10.2106/JBJS. PMID: 20360504
Calhoun JH, Manring MM, Shirtliff ME (2009) Osteomyelitis of the
long bones. Semin Plast Surg 23(2):5972
Cierny G III, McLaren AC, Wongworawat MD (eds) (2009)
Orthopaedic knowledge update: Musculoskeletal infection.
Musculoskeletal infection society, American academy of
orthopaedic surgeons, Rosemont, IL
J.H. Calhoun and A.C. Sullivan
Crist BD, Khazzam M, Murtha YM, Della Rocca GJ (2011) Pilon
fractures: advances in surgical management. J Am Acad Orthop
Surg 19(10):612622. PMID: 21980026
Ferguson JY, Dudareva M, Riley ND, Stubbs D, Atkins BL, McNally
MA (2014) The use of a biodegradable antibiotic-loaded calcium
sulphate carrier containing tobramycin for the treatment of chronic
osteomyelitis: a series of 195 cases. Bone Joint J 96-B(6):829836.
doi:10.1302/0301-620X.96B6.32756
Fragomen AT, Borst E, Schachter L, Lyman S, Rozbruch SR (2012)
Ankle fusion with Ilizarov technique. Complex ankle arthrodesis
using the Ilizarov method yields high rate of fusion. Clin Orthop
Relat Res 470(10):28642873. PMID: 22777590
Lalidou F, Kolios G, Drosos GI (2014) Bone infections and bone graft
substitutes for local antibiotic therapy. Surg Technol Int
24:353362
Nayak-Rao S (2010) Aminoglycoside use in renal failure. Indian J
Nephrol 20(3):121124. doi:10.4103/0971-4065.70839. PMCID:
PMC2966976
Roberts R, McConoughey SJ, Calhoun JH (2014) Size and
composition of synthetic calcium sulfate beads influence dissolution
and elution rates in vitro. J Biomed Mater Res B Appl Biomater
102(4):667673. doi:10.1002/jbm.b.33045. Epub 2013 Oct 24