September 2026

ORTHOPAEDICS

CASE REPORT: ADVANCED SALVAGE STRATEGIES FOR A COMPLEX WEBER C ANKLE FRACTURE

Featuring: ​Anish R. Kadakia, MD
Weber C ankle fractures can be deceptively difficult injuries. Beyond the fracture pattern itself, the initial trauma can compromise the syndesmosis, deltoid ligament, cartilage and distal tibial bone biology. At Northwestern Medicine, complex post-traumatic ankle cases are evaluated through that broader lens — not only whether the ankle can be realigned, but whether the biology and mechanics of the joint can support durable reconstruction.
 
I cared for a woman in her 30s who was referred to my practice after prior treatment elsewhere for a Weber C ankle fracture. When I evaluated her, she had persistent syndesmotic malreduction with a widened medial clear space after fibular fixation and syndesmotic screw placement. The challenge was not simply that she had undergone prior surgery; it was that the ankle remained unstable after a high-energy injury that likely affected the joint surface and surrounding soft tissues from the outset.
Initial presentation after prior fixation, demonstrating persistent syndesmotic malreduction and medial clear space widening.
 
My first priority was to restore alignment and stability while preserving future options for a young patient. I performed revision reconstruction of the fibula, allograft reconstruction, syndesmotic stabilization and deltoid revision. Although alignment improved, she developed progressive ankle arthritis with valgus collapse within the first year. That rapid progression became an important diagnostic clue. The limiting factor was not only fixation or ligament stability, but likely compromised anterolateral distal tibial plafond biology from the original injury.
 
Because of her age, each decision required balancing durability with the desire to preserve the ankle when appropriate. I monitored her with bracing and observation, then considered the full spectrum of reconstructive options, including ankle fusion, total ankle replacement, allograft reconstruction, tibial osteotomy and distraction arthroplasty.
 
Given her age and deformity pattern, I pursued a medial closing wedge tibial osteotomy with fibular osteotomy, biologic augmentation and fixation. When the osteotomy went on to nonunion, CT imaging clarified the underlying issue — the distal tibial bone biology was not healthy enough to support the reconstruction.
Progressive valgus collapse and distal tibial changes raised concern for compromised plafond biology.
 
The case ultimately required a definitive salvage strategy. The priority became removing nonviable bone, restoring mechanical stability and choosing a construct that could support healing under load. A truss/cage construct with additional biologic support was used, and the reconstruction was ultimately revised with a truss and nail as part of a tibi talocalcaneal fusion to provide reliable axial loading. Because this was a cage/bone-block fusion rather than a primary bone-to-bone fusion, I protected her in an AFO for about a year. She ultimately healed, and we continued to follow her for several years.
Final salvage reconstruction following revision of a complex Weber C fracture with syndesmotic injury.
 
What This Case Reinforces
  • Complex Weber C fractures require careful evaluation of injury biology, not just reduction and fixation.
  • Rapid arthritis, valgus collapse or sclerosis after reconstruction can signal compromised distal tibial plafond viability from the original trauma.
  • In young patients, joint-preserving strategies may be appropriate, but they depend on viable bone and cartilage.
  • When distal tibial bone biology is poor, definitive salvage with TTC fusion may offer a more reliable path to healing than repeated ankle-preserving reconstruction.
  • Cage or truss constructs should be planned with axial loading and postoperative protection in mind.
  • Successful salvage reconstruction depends on recognizing the full scope of the injury, adapting the treatment plan as new information emerges and maintaining a long-term commitment to restoring function for the patient.
Anish R. Kadakia, MD, FAAOS, Professor, Orthopaedic Surgery at Northwestern Medicine​

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