Treatment of Infection After Tibial Intramedullary Nailing With Bone Distraction Combined With Free Anterolateral Thigh Flap for Concomitant Soft-tissue Defect

A 57-year-old man presented with a tibial shaft fracture treated with tibial intramedullary nail fixation and plate and screw fixation for fibular fracture. Two weeks postoperatively, the patient developed skin sloughing with exposed bone and metal at the fracture site. Three weeks postoperatively, a physical examination revealed swelling of the left lateral malleolus and lower leg, a skin defect of approximately 3 × 5 cm² at the lower third of the left tibia with an exposed fracture site and hardware in between the fracture fragments. The patient underwent debridement, removal of the intramedullary nail, vacuum sealing drainage, removal of the fibular plate, repositioning, and application of an external fixator. Antibiotic-impregnated bone cement was applied at the fracture site. One week postoperatively, the medullary canal was debrided, and a free anterolateral thigh flap was designed to repair the skin defect. Approximately 5 cm of the opposed fracture fragments was removed from the tibia, and antibiotic-calcium sulfate bone substitutes were applied to the fracture site. Definitive fixation was obtained by a circular external fixation and a minimally invasive osteotomy of the proximal tibia was performed. The patient had no recurrence of infection, and his limb function has recovered well.