SALVAGE OF SEVERELY DESTROYED INFECTED REAR FOOT USING ANTIBIOTIC-IMPREGNATED BONE GRAFT

Abstract

Infection of the rear foot and ankle joint often leads to destruction of the bony structures leaving amputation as the only reasonable choice. New techniques using antibiotic impregnated bone grafts have proven efficient even under extreme circumstances. We report of their first application in apparently hopeless cases of rear foot infection.

Between 2004 and 2006 eight patients were operated because of florid infection of a severely destroyed rearfoot. In all cases the pre-treating surgeons suggested amputation below the knee as the only remaining possibility, which was refused by the patients. There were 3 men and 5 women. All patients had multiple surgery (min. 4, max. 72). The duration of infection was between 2 and 26 years. Diagnoses were: 4 St.p. open fracture, 2 Neuropathy, 1 Immunosuppression (kidney X), and 1 Rheumatoid arthritis.

Preoperative diagnostic measures included MRI and Bone Scans, localising the sites of infection. We performed radical debridement of all infected areas, intensive pulsed lavage, filling of defects with antibiotic bone compound (ABC) and stabilization using screws (4x) or the Ilizarov device (1x), respectively. Wounds could be closed primarily in 7 cases; in one case a fasciocutaneous suralis flap was necessary for closing. All patients were followed prospectively with a minimum period of 3 months and a maximum of 3 years.

Wound healing was completed uneventfully within 3 weeks. Surgery was always followed by a period of more than 6 months without any signs of infection. Re-intervention because of recurrence was necessary in 4 cases, whereas during all operations conditions were markedly improved compared to the foregoing intervention. So far 2 patients required 4 re-revisions of which one is awaiting a fifth revision, 1 patient one re-revision, and 1 patient decided to have the leg amputated. Six cases could be supplied with a custom-made shoe and were fully weight-bearing without pain or sign of infection at the last follow-up.

Reconstruction of the infected rearfoot is feasible even under extremely unfavourable conditions using antibiotic impregnated bone grafts. Fifty percent of cases may expect long-standing salvage with a weight-bearing limb. The other 50% must expect repeated surgery. It may be discussed, whether amputation in such cases could provide for a more favourable situation. However, we do believe that the decision for amputation shall be the sole decision of the patient. As long as the patient wants to keep his limb, being aware of all consequences thereafter, the surgeon is obliged to maintain the function of the foot as well as possible. Reconstruction with ABC seems to offer a promising tool for that purpose. So far 7 out of the 8 patients treated have been satisfied with the result and they would have it repeated in case of recurrence. They are aware that recurrence may occur but they should not show fear of the possibility of another revision since the hospital stays are short, discomfort is tolerable and rehabilitation is quick.