Fibulectomy, Tibial Shortening, and Ankle Arthrodesis as an Alternative Treatment of Nonhealing Wounds Following Open Ankle Fracture in Compromised Elderly Adults

Ankle fractures are a common lower limb fracture in adults and account for 9% of fractures overall. The prevalence and severity of ankle fractures in the elderly has been steadily increasing. It is estimated that there will be a 3-fold increase in ankle fractures in the elderly over the next 30 years, largely due to increasing life span. Currently, the incidence of ankle fractures in elderly persons over the age of 65 is 4.2 per 1000 in the United States. High-grade soft tissue wounds of the distal lower extremity are difficult to treat in the setting of exposed bone or implant and the degree of difficulty is compounded in elderly patients. Local flap options are limited and include distally based flaps, proximally based flaps, and perforator-based flaps. However, due to the soft tissue trauma associated with ankle fractures, flaps based on distal vasculature are frequently precluded because the required vasculature is within the zone of trauma. Proximally based and perforator flaps require no damage to the intervening blood supply and have their own restrictions, including limited arc of rotation of medial plantar artery and donor site morbidity of perforator and dorsalis pedis flaps. Free tissue transfer is the gold standard alternative when reliable local flaps are not available for wound coverage. However, medical comorbidities associated with trauma (organ failure, respiratory insufficiency, acidosis, etc) or the elderly (coronary artery disease, peripheral vascular disease, etc) can contraindicate this course. Questions remain regarding how to treat soft tissue defects when the use of tissue transfer is contraindicated. When soft tissue and bony problems occur about the ankle in compromised patients, reconstructive options are limited. Distal fibulectomy and tibiotalar arthrodesis has not been previously described as a salvage technique to obtain adequate wound closure in the setting of soft tissue loss following Gustilo III distal lower extremity fracture. We present 4 elderly patients with persistent nonhealing soft tissue wounds around the ankle after Gustilo III ankle fractures. Free flap coverage was deemed a poor option in these patients. In an attempt for limb salvage, we performed distal fibulectomy and tibial shortening to allow primary soft tissue closure with redundant skin, followed by ankle arthrodesis for ankle stability. In 3 cases a hindfoot fusion nail was utilized and in 1 case arthrodesis was achieved with a ring fixator.