When A Venous Ulcer Leads To A Rigid Varus Ankle Deformity

This author details the treatment of a patient’s rigid varus deformity, which caused calluses and wounds, and prevented her from wearing shoe gear.

   A 56-year-old patient with venous disease presented after she began walking on the side of her left foot to avoid painful motion at the medial ankle where she had a longstanding painful venous ulcer. Over several years a resultant rigid varus deformity prevented her from wearing most shoe gear and led to calluses and wounds along the lateral column. The patient has poorly controlled schizophrenia complicating her treatment course.

   Biopsies of the longstanding venous ulcer confirmed the diagnosis and revealed it to be free of atypia/cancer, vasculitis, etc. The patient had evidence of osteomyelitis in the medial tibia beneath the chronic ulcer as detected by a white blood cell labeled bone scan. The patient had surgery to resect the chronic bone infection in the tibia and at the same time, we staged the ankle/rearfoot arthrodesis, which required a talectomy. We implanted antibiotic beads into the medial tibia and the ankle space where the talus had been removed. We employed a circular ring external fixator for stability, and gradual deformity correction, stretching the soft tissues slowly over time to bring the forefoot and rearfoot into a rectus forefoot to rearfoot position.

   At six weeks, we removed the antibiotic beads and the medial venous ulcer had healed. We prepared the distal tibia and calcaneus for tibiocalcaneal arthrodesis. We adjusted the circular ring external fixator to compress across the fusion site along the threaded rods. After an additional 10 weeks, we had radiographic evidence of a satisfactory tibiocalcaneal arthrodesis. At this point, the patient was ready for an ankle foot orthosis and was able to begin using extra-depth shoe gear with Plastazote inserts.

   Dr. Dauphinée is the Immediate Past President of the Texas Podiatric Medical Association. He is a Fellow of the American College of Foot and Ankle Surgeons, the American Society of Podiatric Surgeons, the Association of Extremity Nerve Surgeons, the American College of Certified Wound Specialists and the American Professional Wound Care Association. Dr. Dauphinée is the Founding Medical Director of the Center for Wound Healing and Hyperbaric Medicine at North Texas Hospital in Denton, Texas. He is the founder and managing partner of Complete Foot and Ankle Care of North Texas, PA.