Distal Tibial Atrophic Pseudoarthrosis Treated with Vascularized Fibular Graft and Ankle Arthrodesis Nail: A...

Tibial pseudoarthrosis is an uncommon but serious complication following high-energy trauma, particularly in complex distal tibial fractures such as pilon fractures. Atrophic pseudoarthrosis, characterized by avascular bone ends and a lack of biological activity, is often associated with risk factors such as smoking, soft-tissue damage, and multiple surgical interventions. Its management is particularly challenging, requiring a tailored approach that restores both mechanical stability and the biological environment for bone healing. Orthoplastic strategies have emerged as essential in cases with significant bone loss and compromised soft-tissue coverage.

We present the case of a 42-year-old male, a chronic smoker, who sustained a comminuted pilon fracture and fibular shaft fracture following a fall. Initial management included external fixation, followed by open reduction and internal fixation, and subsequent application of a hexapod fixator due to delayed healing. Persistent non-union and soft tissue compromise led to multiple reconstructive procedures, including autologous bone grafting and an anterolateral thigh free flap. Eleven months after the initial injury, the patient was referred to our orthoplastic unit. Diagnostic studies confirmed atrophic pseudoarthrosis of the distal tibia. A two-stage surgical approach was undertaken: First, debridement and placement of an antibiotic-impregnated cement spacer; second, tibiocalcaneal arthrodesis with an intramedullary nail and reconstruction using a contralateral free fibular flap. Post-operative recovery was favorable, with early signs of consolidation and good functional outcomes.

This case underscores the importance of a multidisciplinary, staged approach in managing complex tibial pseudoarthrosis. Orthoplastic collaboration enables successful limb salvage by addressing both osseous and soft tissue challenges, optimizing conditions for definitive bone healing and functional restoration.