Tibiotalocalcaneal Arthrodesis Using the Induced Membrane Technique for Ankle Fracture-Related Infection With Joint Destruction

Aim Fracture-related infection (FRI) of the ankle represents a serious complication associated with functional impairment and reduced quality of life. In advanced cases with joint destruction, limb salvage is challenging, and no gold standard treatment exists. The induced membrane (Masquelet) technique combined with tibiotalocalcaneal (TTC) arthrodesis may be a valuable alternative. The aim of this study was to evaluate outcomes of this approach in patients with ankle FRI and joint destruction. Methods A retrospective multicenter study evaluated patients with ankle FRI/osteomyelitis treated with two-stage TTC arthrodesis with nail. The first stage consisted of radical debridement and placement of an antibiotic-loaded cement spacer, followed by a second stage with spacer removal, preservation of the induced membrane, bone grafting and TTC arthrodesis. Demographics, Charlson Comorbidity Index, injury characteristics, number of previous surgeries, bone defect size, BACH classification, microbiology, consolidation (RUST score), and complications were recorded. Primary outcome was infection control. Secondary outcomes included bone consolidation, functional outcomes, and quality of life (EQ-5D, MOXFQ). Treatment success was defined as infection control without further surgery for infection/nonunion, absence of fistula, no suppressive antibiotics, and no amputation. Results A total of 22 patients were included, with a mean age of 51.8 years and an average of 3 previous surgeries. The mean bone defect at the first stage measured 4.2 cm, and 72% of patients presented with a fistula. Median follow-up was 52 months. Regarding BACH classification, most frequent were B3 (100%), A1 (41%), C1 (59%) and H1 (77%). Soft tissue flap was required in 41% of patients. Polymicrobial infections were most frequent (27.3%). Infection eradication was achieved in 86.4% of cases. Bone consolidation was observed in 82% of patients (mean time to union 9.3 months; mean RUST score 8.8). Overall treatment success was achieved in 72.7%. Reinterventions related to treatment failure were required in 27.3% of cases; a persistent fistula was noted in 13.6%, and one patient (4.5%) required amputation. Notably, no patients required chronic suppressive antibiotic therapy Functional outcomes showed moderate impairment, with a mean MOXFQ score of 42.7. Quality of life (EQ-5D) reached a mean of 0.65, suggesting overall acceptable outcomes within this high-risk population. Conclusions Ankle FRI with joint destruction remains a highly challenging clinical scenario. A two-stage Masquelet-like TTC arthrodesis represents a reproducible limb salvage strategy, achieving satisfactory rates of infection control, bone consolidation, and functional outcomes despite the severity of cases. This approach may be considered a valuable option when joint preservation is not feasible.