Case Report: Staged limb salvage and delayed ankle arthrodesis for chronic distal tibial osteomyelitis after failed fixation

Abstract

Chronic osteomyelitis of the distal tibia following failed fracture fixation is a challenging condition because of limited soft-tissue coverage, compromised vascularity, persistent infection, and difficulty achieving stable reconstruction. We report the case of a 34-year-old female who developed chronic post-traumatic osteomyelitis of the distal tibia after failed initial management of a distal tibial fracture. She presented with persistent pain, swelling, inability to bear weight, and a discharging sinus. Radiographic evaluation showed persistent distal tibial fracture pathology and failure of the initial fracture stabilization strategy, while the diagnosis of chronic osteomyelitis was supported by clinical findings, elevated inflammatory markers, intraoperative findings, and deep intraoperative cultures. Microbiological culture identified methicillin-resistant Staphylococcus aureus from deep intraoperative bone and soft-tissue specimens obtained during surgical debridement; no superficial wound swabs were used, and the patient was not receiving suppressive antibiotic therapy before sampling. A staged limb salvage approach was performed, beginning with radical debridement, removal of infected hardware, temporary external fixation, antibiotic-impregnated cement spacer placement, and targeted antibiotic therapy. After resolution of sinus drainage, complete wound healing, improvement of inflammatory markers, and control of infection, definitive reconstruction was performed with delayed ankle arthrodesis using an intramedullary nail. At 6 months after definitive ankle arthrodesis, corresponding to approximately 14 months after the original injury, the patient remained free of clinically evident recurrent infection, was ambulating independently without assistive devices, had a Visual Analogue Scale pain score of 0–1, and showed radiographic progression toward ankle fusion without implant failure. This case highlights the importance of staged infection control before definitive reconstruction and demonstrates that delayed ankle arthrodesis can provide a stable and functional limb in complex post-traumatic distal tibial osteomyelitis when joint preservation is not feasible. Management was undertaken in a resource-limited setting, where restricted access to advanced imaging and specialized reconstructive options influenced clinical decision-making and necessitated a pragmatic staged limb salvage approach.