Lawrence DiDomenico, DPM, FACFAS

This is an older gentleman with diabetes who presented himself with an open wound of his medial ankle secondary to a valgus deformity.  Several years prior to his presentation, he presented with a closed ankle fracture.  An external fixator was applied and percutaneous fixation was performed.  Subsequently, because of his diabetic peripheral neuropathy, he had a slow gradual breakdown into a valgus deformity.   Consequently, he went on to develop an ulceration secondary to the chronic pressure from his mal – alignment.

Once an updated history and physical was performed along with vascular studies that included digital pressures (demonstrating adequate vascular supply), the patient was taken to surgery to obtain bone cultures and a biopsy to confirm or role out osteomylitis.  A bar - clamp external fixator was applied as a traction/ re –alignment external construct to re – align and off load the pressure ulcer to allow for soft tissue healing.  The biopsy and cultures were positive and infectious disease was consulted and the appropriate antibiotic was prescribed with intravenous care for 6 weeks.  During this time, the patients wound eventually closed because of the “off loading” and the re- alignment.  Once the patients ESR and CRP along with clinical wound healing had occurred, the patient was taken back to surgery for a permanent re- alignment arthrodesis.  The goal was to create a stable solid, plantigrade foot & ankle that would maintain anatomical alignment and be free of ulceration and infection.

Click on the images below for a larger view.

Pre op films non weight bearing

Pre op weight bearing films

Intra operative films demonstrating aggressive bone resection of the “diseased bone”

The next stage of the reconstruction consisted of an aggressive bone resection (diseased bone) and back filling of the large bony defect with allogenic bone and Hydroset, followed with rigid AO internal fixation. This was followed with careful wound closure and application of a circular external fixator to allow early weight bearing and to allow for access to the high risk wounds.

Intra –operative photos applying Hydroset to fill the remainder of the defect following allogenicbone packing

Intra operative radiographs demonstrating good anatomical alignment and a well packed bone void with allogenicbone and Hydroset

Subsequently all wounds healed satisfactory, the external fixator was removed and the patient was placed into a fracture boot.  He was slowly transferred into regular shoe gear.

Photos of external fixator

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