Modifier Pirogoff amputation with retrograde intramedullary fixation following failed limb salvage for an infected open ankle fracture in a frail elderly patient

Management of open ankle fractures in frail elderly patients with diabetes remains highly challenging, particularly in the presence of soft-tissue defects and infection, where limb salvage is often not feasible and functional outcomes after major amputation are poor. We report the case of an 84-year-old woman with an open ankle fracture-dislocation complicated by extensive soft-tissue loss and Pseudomonas aeruginosa infection. Despite repeated debridements, progressive necrosis and infection led to failure of limb salvage. Reconstructive options were contraindicated due to severe comorbidities. After interdisciplinary evaluation and shared decision-making, a Pirogoff amputation was performed with retrograde intramedullary fixation. At 8-month follow-up, the patient achieved full weight-bearing ambulation with complete soft-tissue healing. This case illustrates that a modified Pirogoff amputation may be considered in carefully selected frail elderly patients with infected open ankle fractures when conventional limb salvage has failed and transtibial amputation or microsurgical reconstruction is not suitable. The educational value of this case lies in the use of the rotated calcaneus and preserved plantar tissues to achieve soft-tissue coverage of a large distal tibial defect while creating a stable distal weight-bearing stump suitable for prosthetic rehabilitation.