PMC5328323_01
Clinical picture of the infected foot during admission to the emergency room. Note the extensive plantar fat pad and soft-tissue necrosis, calcaneal bone exposure, purulent drainage, forefoot necrosis, and epidermolysis.
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Figure 1 shows the clinical presentation of the infected foot when the patient was seen in our emergency facility. 
Clinical picture after the first surgical irrigation and debridement. Note the aggressive resection of all muscular structures of the central and lateral compartments of the foot, peroneal tendons, partial bone resection of the cuboid and fifth metatarsal base, and almost complete resection of the calcaneal bone (the anterior process of the calcaneus was maintained). Note the healthy exposed talar undersurface of the posterior facet of the subtalar joint.
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Provisional negative pressure wound therapy (ActiV.A.C. ; KCI, San Antonio, TX, USA) was installed (125 mmHg) and set to be continuous for the first 24 h and intermittent in the next 48 h (Figures 2 and 3).  
Negative pressure wound therapy application to the wound following the first surgical debridement.
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Provisional negative pressure wound therapy (ActiV.A.C. ; KCI, San Antonio, TX, USA) was installed (125 mmHg) and set to be continuous for the first 24 h and intermittent in the next 48 h (Figures 2 and 3).  
Intraoperative anteroposterior ankle fluoroscopic image. External fixation was performed to maintain a neutral positioning of the ankle and to allow stable soft-tissue healing. Four Schanz half-pins, two in the tibia proximally, one in the neck of the talus, and one in the base of the first metatarsal, were applied and connected.
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At that time, an external fixation was applied to maintain the ankle at 90  in the sagittal plane and a percutaneous fixation with Kirschner wire was used to maintain the correct relationship between lateral and medial columns of the foot (Figure 4).
Clinical picture of the surgical procedure of hindfoot reconstruction. Note the antibiotic-loaded polymethylmethacrylate bone cement positioned where once was the calcaneal bone, underneath the talar posterior facet of the subtalar joint.
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 Day 7: Forty grams of vancomycin-loaded polymethylmethacrylate bone cement (Surgical Simplex P , Miami, FL, USA) was used to fill the void of the calcaneus bone removed in prior surgical debridements (Figure 5).
In the same surgical procedure, the heel soft-tissue coverage was achieved through a free musculocutaneous latissimus dorsi flap.
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We used a free musculocutaneous latissimus dorsi flap (Figure 6) for soft-tissue coverage of the heel defect.
After adequate monitoring of the viability of the free musculocutaneous flap, multiple split-thickness skin grafts from the thigh were performed to cover the free muscle and granulation tissue surfaces on the heel and plantar aspect of the foot.
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Clinical picture of the patient's foot in a follow-up appointment at 12 weeks. The free flap and skin graft were fully integrated.
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 Week 12: The free flap and split-thickness skin graft had been fully integrated (Figure 8) and the external fixator and bone cement were then removed.
Intraoperative lateral foot fluoroscopic image, demonstrating the positioning of the femoral head bone allograft. Articular cartilage of the subtalar joint was prepared, aiming for an arthrodesis between the bone allograft and talar bone.
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The internal fixation was performed using three Acutrak headless compression screws (Acumed , Hillsboro, OR, USA) (Figures 9-13).      
Full-thickness posterolateral approach was performed, parallel to the edge of the free flap. Note the femoral head bone allograft and the anterior process of the calcaneus bone.
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The internal fixation was performed using three Acutrak headless compression screws (Acumed , Hillsboro, OR, USA) (Figures 9-13).      
Intraoperative lateral foot fluoroscopic image, showing the internal fixation arthrodesis procedure using headless compression screws between the femoral head bone allograft, talus, anterior process of the calcaneus and cuboid.
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The internal fixation was performed using three Acutrak headless compression screws (Acumed , Hillsboro, OR, USA) (Figures 9-13).      
Intraoperative clinical picture after the femoral head bone allograft had been coated with bioactive synthetic bone graft, aiming for a smooth plantar bone surface of the heel.
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The internal fixation was performed using three Acutrak headless compression screws (Acumed , Hillsboro, OR, USA) (Figures 9-13).      
Intraoperative lateral foot fluoroscopic image, demonstrating a more contoured and homogeneous plantar surface of the heel after the bioactive synthetic bone graft had been applied.
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The internal fixation was performed using three Acutrak headless compression screws (Acumed , Hillsboro, OR, USA) (Figures 9-13).      
Final clinical outcome. Note the symmetrical alignment in slight valgus of the hindfoot with complete healing of the soft tissue.
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Upon physical examination, a functional full range of motion of the ankle joint, with a 4+/5+ muscle power for dorsiflexion and plantarflexion, was noted (Figures 14 and 15).
Clinical picture demonstrating relatively preserved plantarflexion strength and competent gastrosoleus muscles when performing a heel raise test.
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Upon physical examination, a functional full range of motion of the ankle joint, with a 4+/5+ muscle power for dorsiflexion and plantarflexion, was noted (Figures 14 and 15).