Recalcitrant Ankle Arthrodesis Nonunion with Infection Treated with Antibiotic Cement-Coated Rod

A 64 year old man with Reiter syndrome presented with an infected nonunited ankle arthrodesis and a draining wound over the anteromedial aspect of his left ankle. He stated that he did not have fever, nausea, vomiting, or chills. The patient was currently taking chronic anti-inflammatory and immunosuppressive medications as well as 500 mg of dicloxacillin orally every 6 h. He was using a V.A.C.Ulta Negative Pressure Wound Therapy System (KCI, San Antonio, TX) that was changed three times a week. The man underwent resection of the nonunion and hindfoot fusion with an antibiotic cement-coated intramedullary rod at our center. The ankle was splinted post-operatively, and the limb was non-weight-bearing for 8 weeks. Then the patient transitioned to a short leg walking cast. Two months after the procedure, the patient developed progressive pain in his ankle. A computed tomography scan failed to show any osseous integration at the nonunion site. The patient underwent revision surgery, which consisted of exchange rodding with another antibiotic cement-coated intramedullary rod and supplemental posterior plating. Intra-operatively, persistent infection was noted. After the revision surgery, the patient was placed on intravenous antibiotics for 6 weeks. A non-weight-bearing cast was applied, and the patient was non-weight-bearing for 3 months. After antibiotics were administered intravenously for 6 weeks, the patient was given oral chronic suppressive antibiotic prophylaxis. Five months post-operatively, the patient was weight-bearing as tolerated and was using a Charcot restraint orthotic walker (CROW) boot and occasionally a crutch for long distances. He had radiographic evidence of union and did not have any clinical evidence of infection. At latest follow-up, he was stable and infection-free.