Case Report: Single-stage reconstruction of a tuberculous calcaneal defect with a titanium mesh cage and autologous iliac crest bone graft

Background Tuberculosis of the foot and ankle is uncommon and is often recognised only after considerable bone destruction. Residual defects are usually treated with bone grafting, arthrodesis, or the staged Masquelet technique. Titanium cages have been used for infected hindfoot and distal tibial defects, but only as part of staged procedures and not in tuberculosis. Case presentation A 29-year-old woman presented with a 4-month history of right ankle pain, swelling, a discharging sinus, and constitutional symptoms. Tuberculosis had been confirmed by biopsy in August 2023, and she had been declared cured after 6 months of antituberculous therapy (ATT), but the discharge returned shortly afterwards. A pus smear before surgery was negative for acid-fast bacilli. Contrast-enhanced computed tomography showed destruction of the anterior calcaneus with sequestra, erosion of the inferior cuboid, and a fluid collection extending into the calcaneocuboid and subtalar joints. Through a lateral approach, debridement and sequestrectomy left a 3 cm defect. In the same operation, the defect was reconstructed with a titanium mesh cage filled with ipsilateral iliac crest autograft, a bone substitute, and recombinant human bone morphogenetic protein-2 (rhBMP-2). ATT was not restarted. Full weight-bearing began at 12 weeks. At 1 year, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 92, the visual analogue scale (VAS) pain score was 0, ankle motion was full, the graft had incorporated, and there was no sign of recurrence. Conclusion A standard mesh cage filled with iliac crest autograft allowed single-stage, joint-preserving reconstruction of a tuberculous calcaneal defect, even with an active sinus. Complete surgical removal of the infected bone appears to have been central to the result. Omitting ATT after surgery is not recommended, and this experience should not be applied to pyogenic osteomyelitis.