Endoscopy-assisted treatment of metaphyseal osteomyelitis focus in the distal tibia after osteosynthesis of comminuted pilon fracture

Abstract

The submitted case study concerns a 36-year-old patient with a ladder fall injury, who suffered a comminuted right pilon fracture type C3 according to the AO classification. The primary treatment consisted in fixing the fracture with an ankle spanning external fixation and subsequent internal osteosynthesis after the recovery of soft tissues. At four weeks, an infection with fistula developed on the anterior face of the distal tibia. The patient was repeatedly treated with excochleation of suspected focus of osteomyelitis, soft tissue drainage by VAC system, application of antibiotics based on the microbial agent susceptibility. Despite the aforementioned care, recurrent infection outbreaks occurred. Neither the CT scan, nor the scintigraphy revealed the focus of infection. Due to our concerns about the severe destruction also of the vital spongy osseous tissue caused by repeated non-targeted interventions in the medullar cavity, the cavity in the metaphysis of the distal tibia was subsequently treated by a less invasive endoscopic technique. The rigid arthroscope was inserted through a drilled hole in the cortical bone on the anterior face of pilon into the osteomyelitic cavity, from where purulent collection was drained. The cavity was filled with saline solution and the entire surface of the cavity was systematically treated with arthroscopic bone cutter into the depth when capillary bleeding appeared. Throughout the procedure the cavity was being rinsed with a large quantity of saline solution. The patient healed with a very good functional outcome.