Description of patient (type of occupation, indication of age, intensity of sport):
55 year old purser (female) without comorbidities (only tobacco use).
History and previous treatment:
The patient was severely injured 5 years ago in a plane crash inducing bilateral pilon and calcaneal fracture. Left ankle was opened requiring a free flap however evolving to a septic OA that required a pantalar fusion. Right ankle had ORIF of both pilon and calcaneal fracture.
Deep right ankle pain although wearing orthotic shoes due to her left pantalar fusion. Limping with a walking distance limited to 2 blocks without crutches.
Two scares: medial on the malleolus; lateral L-shape on the calcaneus.
Well-aligned right ankle with a plantigrade foot. Ankle range of motion: 15° and painful. Fixed painless subtalar joint. Painless Chopart joints with limited 15° range of motion. Anterior Tibialis and posterior Tibialis pulses are okay.
Motor deficit of the intrinsic muscles of the foot with some numbness of the forefoot alluding sequela of a compartment syndrome or a crush syndrome.
[Picture 1 + 2]
TT and ST end staged OA. Aligned foot & ankle. Malunited medial maleolus.
Tibia and Fibula synostosis.
Additional investigation (CT/MRI):
[Picture 3 + 4]
Limited bone stock deficiency.
Right ankle post-traumatic OA with a stiff subtalar joint and a contralateral pantalar fusion.
Question(s) to this case:
What would you do ?
1. Ankle fusion with the risk of nonunion and secondary subtalar pain ?
2. Pantalar fusion with a higher risk of nonunion and although he has already one on the lateral ankle ?
3. Ankle arthroplasty saving some motion and hope to "live to fight another day"?
I would advice performing an ankle prosthesis, in order to preserve motion and thus protect the subtalar joint from further deterioration. Also the fact that the patient has a pantalar fusion on the contralateral side makes a fusion less attractive.