Journal of Foot and Ankle Surgery (Asia-Pacific)
Volume 11 | Issue 1 | Year 2024

A Two-step Protocol for Managing the Severe Consequences of Septic Arthritis in the Ankle

Chandan Narang1, Girish Motwani2, Rehan Ahmed3

1Department of Foot & Ankle Orthopedics, Suyog Hospital, Nagpur, Maharashtra, India

2,3Department of Orthopedics, Suyog Hospital, Nagpur, Nagpur, Maharashtra, India

Corresponding Author: Chandan Narang, Department of Foot & Ankle Orthopedics, Suyog Hospital, Nagpur, Maharashtra, India, Phone: +91 6359787115, e-mail:

Received: 13 December 2023; Accepted: 16 February 2023; Published on: 30 December 2023


Aim: The aim of this study was to report a novel two-step technique for managing the severe consequences of septic ankle arthritis.

Background: Septic ankle arthritis is a challenging orthopedic disease with a high risk of morbidity and mortality. Early treatment is essential to avoid irreparable articular cartilage damage and erosion, osteomyelitis, and dysfunctional painful foot and ankle deformities. Therefore, an aggressive surgical approach is essential to prevent severe extremity-threatening arthritis.

Case description: We report that three of the cases of challenging septic ankle and ankle arthritis were treated with a two-phase protocol. The first stage included radical debridement, microbiological evaluation, insertion of vancomycin-coated biogranules, and administration of empirical intravenous antibiotics. In the second stage, deformity correction was performed by osteotomy and fixation. All three were asymptomatic at 6 months follow-up, had no discomfort in daily life and were able to perform fully functional activities.

Conclusion: Two-stage protocol is a reliable way to manage septic arthritis of the ankle, with significant bone loss in the talar region and related deformities. It provides a good functional outcome of the limb with rigidness. It gives rigid, stable fixation using tibiotalocalcaneal nails.

How to cite this article: Narang C, Motwani G, Ahmed R. A Two-step Protocol for Managing the Severe Consequences of Septic Arthritis in the Ankle. J Foot Ankle Surg (Asia-Pacific) 2024;11(1):13–24.

Source of support: Nil

Conflict of interest: None

Patient consent statement: Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Case report, Osteotomy, Pantalar arthrodesis, Radical debridement, Septic ankle arthritis, Tibiotalocalcaneal nail


Septic arthritis is itself a big challenge for orthopedic surgeons. Among all patients suffering from infectious arthritis, there is a limited prevalence of septic ankle arthritis (3.4–15%).1,9 Septic arthritis destroys load-bearing joints more rapidly.8 A septic ankle arthritis is a devastating illness associated with a significant risk of morbidity and death—hence, precise knowledge of the illness is essential. It needs to be treated in a prompt and urgent manner.10-15 Hematogenous spread from other locations, direct infusions, trauma, or contiguous dissemination from neighboring tissues may cause joint infections. Evidence is available in support of Streptococcus aureus being the most prevalent microbe isolated from infected ankle joints and an early aggressive approach is needed.10,14,18 A criterion used by Newmann for diagnosis of septic arthritis requires factors as follows—organism isolated from the joint (grade A); organisms isolated from other sources (grade B); and no organism isolated but histological or radiological signs of infection or turbid fluid aspirated from the joint (grade C).16-19 There are many risk factors for patients who are susceptible to septic arthritis including diabetes, trauma, previous joint surgery, obesity, age >80 years, nicotine abuse, alcoholism, trauma, inflammatory or degenerative arthropathies, chronic lung condition causing breathlessness, cancerous condition, cutaneous ulcer, chronic renal and chronic kidney disease, or IV or history of local steroid injection inside the joint.10,14,15,18,20-24 Early management must consist of an open surgical technique, followed by the use of suitable empirical antibiotics or antibiotics that are in line with culture findings.

Insufficient therapy may result in osteomyelitis, infective synovitis, or irreversible damage to the bone or cartilage in the joint, resulting in chronic pain and disability in the form of difficulty in walking.11,12,18 The principles of treatment consist of control of infection which includes debridement with synovectomy with culture and sensitivity followed by appropriate empirical antibiotics regimen with periodic pathological markers [white blood corpuscles, C-reactive protein (CRP)], radiological evaluation [X-rays and magnetic resonance imaging (MRI)], histopathological, and microbiological evaluation to check the control of infection.5 We followed a similar protocol of treating this condition in two stages.8,10,19 There is a paucity of literature on such unique techniques for controlling septic ankle arthritis. Hence, more research is required to draw a definitive conclusion.

The three patients included here have all given their written approval for the publishing of this report and any related photos.


Case 1

A 34-year-old woman presented with persistently active seropurulent secretory sinuses on the anteromedial aspect of her left ankle with cuticular necrosis for the past 6 weeks at our hospital (Fig. 1). She has no history of trauma. She had a history of fever during the past 2 months. The patient reports that she underwent multiple surgeries on her left ankle during childhood (data not available). Ankle and subtalar talonavicular joint. She developed a cavity deformity in her left foot. She has no neurovascular disease.

Fig. 1: Discharging sinus over the anteromedial aspect of the ankle

According to the results of the laboratory tests, the total white blood cell (WBC) count is 8,900, CRP level of 7, local pus culture, and susceptibility to no microbial growth. On radiological examination, an anteroposterior (AP) left ankle X-ray showed a deformed fibula, reduced tibiotalar joint space, destruction of articular cartilage with talar-varus deformity, and signs of chronic septic arthritis.

In the lateral view, the tibiotarsal joint was damaged along with anterior subluxation of the tibia towards the talus (Fig. 2). MRI revealed widespread synovial thickening and tibial synovial effusion, synovitic joint changes with subchondral degenerative changes, and along the talar dome, anterior surface of the talus, and tibia and fibula joint margins showed osteochondral defects with significant articular cartilage loss (Fig. 3). She is a woman suitable for her age without complications. Based on the clinical and radiological evaluation, and taking into account the patient’s medical background and the degree of the ankle deformity, we diagnosed her with chronic septic ankle arthritis with tibiotarsal osteomyelitis.

Figs 2A and B: X-ray AP view and a lateral view showing chronic septic arthritis of ankle joint

Figs 3A and C: MRI left ankle: (A) Subchondral cyst of ankle; (B) Articular cartilage damage and deformed talus with loss of cartilage, and (C) Chronic synovitis with hyperplasia

A two-stage procedure was performed to get rid of the infection and fix the deformity, preserving the limb. The aim of the first stage was to control the infection followed by transfibular oblique osteotomy with meticulous joint preparation and finally deformity correction with stable fusion. With one comprehensive debridement of the contaminated tissue, an open arthrotomy of the ankle joint that involved the sinus was carried out using an anteromedial approach. The distal tibia and talus underwent minimal osteotomy because the infection extended into the bone beyond the articular cartilage, an antibiotic-vancomycin-coated absorbable calcium sulfate antibiotic carrier was then inserted into the void to control the residual infection (Fig. 4). Temporary stabilization of the ankle joint was done using Kirschner (K) wires. The patient’s infected tissues were cultured, but no microorganisms were found there, and the results of the acid-fast bacilli stain were also unfavorable. In the transfibular postoperative (postop) period, the patient is treated with IV antibiotics on an empirical basis. The second stage of treatment is the correction of deformity including tibiotalocalcaneal (TTC) nail arthrodesis with maintaining length. Around 3 months later, the Department of Pathology received frozen biopsies of the bone and surrounding tissues to check for the presence of an infection.

Figs 4A and B: Vancomycin-coated beads insertion into postdebridement void

We proceeded with the second stage of surgery using a transfibular approach (Fig. 5), oblique osteotomy of the fibula (Fig. 6), and bone preparation techniques used on the tibia and talus including nibbling, drilling, and burr. This will enhance mesenchymal cells and the arthrodesis process. An autograft harvested from the ipsilateral fibula is used to provide structural support and stability while maintaining leg length and is placed perpendicular to the tibiotalar to correct foreshortening (Figs 789). The foot was fixed at 0° of dorsiflexion and 5° of valgus. (Fig. 10). Retrograde nail for spanning tibiotalar and subtalar joint inserted along with posteroanterior screw insertion into the calcaneus, and along with that, two screws of the tibia were inserted (Figs 1112131415). Following up with patients after 6 months reveals remarkable radiological and clinical results (Figs 16 and 17).

Fig. 5: Incision for transfibular osteotomy

Fig. 6: Oblique transfibular osteotomy mini saw

Fig. 7: Oblique transfibular osteotomy

Fig. 8: Autogenous ipsilateral fibula strut

Figs 9A and B: Position of fibula graft in ankle joint

Fig. 10: Provisional K-wire fixation for maintaining the reduction in heel in 5° valgus

Fig. 11: Intramedullary TTC fusion nail insertion

Fig. 12: Insertion of posteroanterior calcaneal screw

Fig. 13: Intramedullary TTC fusion nail insertion

Fig. 14: Closure

Figs 15A and B: Final postop X-ray of left ankle—AP and lateral

Figs 16A and B: A 6-month postop weight-bearing AP and lateral view

Figs 17A and B: A 6-month postop clinical images

Case 2

A male, 56, presented to our hospital with persistent serous purulent discharge from the medial ankle near the scar on his left ankle that had been present for 9 months (Fig. 18). He cannot put weight on his left ankle. He has multiple visible scars on his feet and ankles from multiple surgeries for a dislocated left ankle and a fractured talonavicular joint. He has severe discomfort in activities of daily living because of his ankle—limp and sharp pain in the ankle even after a short walk. He is completely unable to bear the weight of his left ankle. On physical examination, he had tenderness in his left ankle and subtalar joints, and a limited range of motion in his tibiotalar and subtalar joints. He had full toe movement. His total leukocyte count was 6,700, a CRP level of 9, and the patient was already on antibiotic therapy, so culture and local pus susceptibility showed no microbial growth. However, he has no comorbidities or addictions.

Fig. 18: Clinical picture showing scars of previous multiple attempts of surgery

A similar two-step operation was attempted to immediately control the infection, correct the deformity, and allow limb preservation. For arthrotomy and deformity correction, the anteromedial surgical approach was adopted. Initially, an arthrotomy with significant diseased tissue debridement was performed on the ankle joint. After debridement and synovectomy, an antibiotic-coated pallet was placed in the cavity created (Fig. 19). The ankle is fixed with a K-wire. Laboratory markers, radiological studies, X-rays, MRIs, and tissue and bone biopsies were used to confirm the absence of infection in the joints. The patient was examined at regular follow-up visits. Waited 3 months before the next intervention (Fig. 20).

Figs 19A and B: Ankle AP and lateral immediate postop X-ray showing cavity created at ankle joint filled with antibiotic pallets and fixed with K-wires

Figs 20A and B: Ankle AP view and lateral view show control of infection

A transfibular approach (Figs 21 and 22) was followed, followed by an oblique fibular osteotomy (Fig. 23), and resurfacing of the ankle and subtalar joints for fusion. Autologous fibular bone grafts are used to preserve leg length while providing stability and support to the structure. A graft from the harvested fibula is used (Fig. 24). The foot was positioned in a dorsiflexion position of 0°. Clinically and radiographically good results were observed at 6 months (Figs 252627).

Fig. 21: Skin marking for transfibular approach

Fig. 22: Skin incision for transfibular approach

Fig. 23: Mini saw used for oblique osteotomy of fibula

Fig. 24: Fibula graft

Figs 25A and B: A 3-month postop AP and lateral view X-ray

Figs 26A and B: A 6-month postop AP and lateral view

Figs 27A and C: A 6-month postop clinical pictures

Case 3

After a car accident, a female patient, age 47, sustained a pilon fracture with poor soft tissue condition. She underwent external fixation 3 days after her injury, followed by internal fixation of the fracture with open reduction at another hospital (Fig. 28). Bone grafting was then attempted (Fig. 29). Ultimately, she presented to our hospital with an active seropurulent discharge and a sinus on the inside of her ankle. She had multiple scars on the medial aspect of the ankle. She had a tender swelling along with a limited range of motion in the tibiotalar and subtalar joints. She had a slight flatfoot deformity in her ankle. She had full toe movements. According to the results of the laboratory tests, the total WBC count is 8,900, and the CRP level is 7. Her cultures and susceptibilities showed no microbial growth, as she was already on oral antibiotics. She underwent a computed tomography scan of her ankle to rule out osteomyelitis. She was diagnosed with a case of septic nonunion of the distal tibia due to infectious ankle arthritis with an implant in situ. However, she has no comorbidities.

Figs 28A to C: Clinical pictures showing management done during immediate posttraumatic period

Figs 29A to C: AP and lateral view of ankle showing the failed internal fixation

A two-step operation was designed to carry out the step-by-step procedure. The first phase began with the removal of the implant, debridement, synovectomy, stabilization with a transarticular Steinmann pin, and insertion of antibiotic-coated granules (Fig. 30).

Figs 30A to C: Implant removal done and vancomycin-coated pellet inserted

After several rounds of regular follow-up, pathological and radiological markers—bone biopsies were used to confirm the joints were free of infection. Preparation for non-union and fusion was scheduled after 3 months. A second stage revision surgery was performed in the non-deformed position with chip bone grafting (Fig. 31) with TTC nails of the ankle and subtalar joints (Fig. 32). After 6 months of intervention, an X-ray revealed signs of union (Fig. 33). The patient was able to walk alone, was fully weight-bearing, and had normal hindfoot alignment (Fig. 34).

Fig. 31: Autogenous chip bone graft insertion

Figs 32A to C: Fusion with TTC nail

Figs 33A to C: A 6-month postop X-ray showing excellent signs of union

Figs 34A to C: A 6-month postop clinical images


Pantalar arthrodesis is a good salvage operation to prevent amputation of the septic tibiofibular joint and subtalar joint. The outcomes of infected ankle arthritis arthrodesis using various fixation techniques have been documented in the literature.25-27 Some examples of techniques include ring fixator, hybrid, or mono fixator3,7,11,22,24 and internal fixation,25,26 or the combination of two different types of fixation system.13,20,21,27

Thordarson et al.24 reported favorable outcomes for four patients who had a two-stage fusion with an external monofixator. According to their findings, an aggressive approach and timely treatment are essential to save an infected ankle. According to Richter et al.20, using an external Arbeitsgemeinschaft für Osteosynthesefragen frame fixator to treat septic ankle joints successfully results in a union. The rate of the union following primary arthrodesis is 62%, while the rate following revision is only 39% of patients. According to the findings of their research, the common complications include problems with wound healing (22%), nonunion (15%), pin tract infections (18%), and revisions (23%). Both internal and external fixation may be utilized for ankle arthrodesis, and each offers certain benefits that have been shown to be effective.27 As a consequence of “one-stage” arthrodesis with internal fixation using a staple, screw, or a combination of both, 85.0% of patients had their infection completely eliminated, according to Klouche et al.10 Simoni et al.21 described the outcomes of a “two-stage” surgical procedure for arthrodesis—the first stage involved precise debridement and management of the remaining area up until the infection returned to normal, then ankle joint arthrodesis with a success rate of 91.25% in terms of fusion in 57 patients. Weight-bearing ankle foot discomfort (27%) and ankle foot pain with surgical wound dehiscence (12.25%) were the most common side effects. A total of 50 patients underwent TTC arthrodesis with hindfoot intramedullary nail fixation. According to Boer et al., 96% of patients reported positive outcomes, and the complication rate was relatively low.2 According to Richter et al.,20 45 patients had arthrodesis utilizing an open method of fixation using corticocancellous screw and anterior plate, or compression screw alone, with an 86.6% of union rate.

From a biomechanical standpoint, they claimed that external fixation and internal osteosynthesis are both viable treatments. An external fixator avoids torsional rotation—however, it provides insufficient stability for plantar flexion-dorsiflexion motions in the fusion gap. Consequently, internal fixation using plates and screws becomes necessary to neutralize these movements.

Persaud et al.19 presented a phased technique for limb salvage in a patient with advanced-stage degenerative joint disease after ankle septic arthritis—employing external and internal fixation, infection management, and an autologous pillar graft. In our patient, we observed limb length decrease due to septic arthritis, which was similar to the results described above. We performed fibula osteotomy as we used the ipsilateral fibula as an autogenous graft fibula. Clinical and radiological imaging revealed no arthritic changes and no subtalar joint discomfort in the patient. The plate is not amenable to it. So, we did subtalar fusion due to loss of talus height and thus, provide a stable rigid fixation. We attempted tibiotalar arthrodesis using TTC nail fusion rather than anterior plate arthrodesis, with favorable clinical and radiological results at the 6-month follow-up.


In our experience of three cases, we found that the two-stage protocol is a reliable way to manage septic arthritis of the ankle, with significant bone loss in the talar region and related deformities. It provides a good functional outcome for the limb with rigidness. It gives rigid, stable fixation using the TTC nail.


1. Adams JC. Arthrodesis of the ankle joint; experiences with the transfibular approach. J Bone Joint Surg 1948;30B(3):506–511.

2. Boer R, Mader K, Penning D, et al. Tibiotalocalcaneal arthrodesis using a reamed retrograde locking nail. Clinorthop 2007;463:151–156. DOI: 10.1097/BLO.0b013e31814fb1bb

3. Cierny G 3rd, Cook WG, Mader JT. Ankle arthrodesis in the presence of ongoing sepsis. Indications, methods, and results. Orthop Clin North Am 1989;20(4):709–721.

4. Cameron SE, Ullrich P. Arthroscopic arthrodesis of the ankle joint. Arthroscopy 2000;16(1):21–26. DOI: 10.1016/s0749-8063(00)90123-3

5. Esterhai JL Jr, Gelb I. Adult septic arthritis. Orthop Clin North Am 1991;22(3):503–514. DOI: 10.1016/S0030-5898(20)31678-3

6. Hogan A, Heppert VG, Suda AJ. Osteomyelitis. Arch Orthop Trauma Surg 2013;133(9):1183–1196. DOI: 10.1007/s00402-013-1785-7

7. Johnson EE, Weltmer J, Lian GJ, et al. Ilizarov ankle arthrodesis. Clin Orthop Relat Res 1992;280:160–169.

8. Kang SN, Sanghera T, Mangwani J, et al. The management of septic arthritis in children: systematic review of the English language literature. J Bone Joint Surg Br 2009;91(9):1127–1133. DOI: 10.1302/0301-620X.91B9.22530

9. Kazemi K, Arab AM, Abdollahi I, et al. Electromiography comparison of distal and proximal lower limb muscle activity patterns during external perturbation in subjects with and without functional ankle instability. Hum Mov Sci 2017;55:211–220. DOI: 10.1016/j.humov.2017.08.013

10. Klouche S, El-Masri F, Graff W, et al. Arthrodesis with internal fixation of the infected ankle. J Foot Ankle Surg 2011;50(1):25–30. DOI: 10.1053/j.jfas.2010.10.011

11. Kollig E, Esenwein SA, Muhr G, et al. Fusion of the septic ankle: experience with 15 cases using hybrid external fixation. J Trauma 2003;55(4):685–691. DOI: 10.1097/01.TA.0000051933.83342.E4

12. Love C, Palestro CJ. Nuclear medicine imaging of bone infections. Clin Radiol 2016;71(7):632–646. DOI: 10.1016/j.crad.2016.01.003

13. Mann RA, Rongstad KM. Arthrodesis of the ankle: a critical analysis. Foot Ankle Int 1998;19(1):3–9. DOI: 10.1177/107110079801900102

14. Mann RA, Van Manen JW, Wapner K, et al. Ankle fusion. Clin Orthop Relat Res 1991;268:49–55.

15. Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults. Lancet 2010;375(9717):846–855. DOI:10.1016/S0140-6736(09)61595-6

16. Motley TA, Carpenter BB. Pantalar arthrodesis Chapter 61—McGlamry’s comprehensive Textbook of Foot and ankle surgery. 4th edn. Wolters Kluwer/Lippincott Williams and Wilkins; 2012;1. p. 855.

17. Movassaghi K, Wakefield C, Bohl DD, et al. Septic arthritis of the native ankle. JBJS Rev 2019;7(3):e6. DOI: 10.2106/JBJS.RVW.18.00080

18. Newman JH. Review of septic arthritis throughout the antibiotic era. Ann Rheum Dis 1976;35(3):198–205. DOI: 10.1136/ard.35.3.198

19. Persaud SJ, Zdenek C, Catanzariti AR. Staged surgical intervention in the treatment of septic ankle arthritis with autologous circular pillar fibula augmentation: a case report. Foot Ankle Online J 2017;10(3):28–33. DOI: 10.3827/faoj.2017.1003.0006

20. Richter D, Hahn MP, Laun RA, et al. Arthrodesis of the infected ankle and subtalar joint: technique, indications, and results of 45 consecutive cases. J Trauma 1999;47(6):1072–1078. DOI:10.1097/00005373-199912000-00013

21. Simoni G, Maccauro G, Fenga D, et al. Arthrodesis of the ankle joint in septic osteoarthritis: six years long term outcomes in authors’ personal experience. Eur Rev Med Pharmacol Sci 2019;23(2 Suppl):139–144. DOI: 10.26355/eurrev_201904_17483

22. Stone JW. Arthroscopic ankle arthrodesis. Foot Ankle Clin 2006;11(2):361–368. DOI: 10.1016/j.fcl.2006.03.007

23. Suda AJ, Richter A, Abou-Nouar G, et al. Arthrodesis for septic arthritis of the ankle: risk factors and complications. Arch Orthop Trauma Surg 2016;136(10):1343–1348. DOI: 10.1007/s00402-016-2520-y

24. Thordarson DB, Patzakis MJ, Holtom P, et al. Salvage of the septic ankle with concomitant tibial osteomyelitis. Foot Ankle Int 1997;18(3):151–156. DOI: 10.1177/107110079701800307

25. Vispo Seara JL, Barthel T, Schmitz H, et al. Arthroscopic treatment of septic joints: prognostic factors. Arch Orthop Trauma Surg 2002;122(4):204–211. DOI: 10.1007/s00402-001-0386-z

26. Wang L, Gui J, Gao F, et al. Modified posterior portals for hindfoot arthroscopy. Arthroscopy 2007;23(10):1116–1123. DOI: 10.1016/j.arthro.2007.04.015

27. Weston V, Coakley G. British Society for Rheumatology (BSR) Standards, Guidelines and Audit Working Group. Guideline for the management of the hot swollen joint in adults with a particular focus on septic arthritis. J Antimicrob Chemother 2006;58(3):492–493. DOI:10.1093/jac/dkl295

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