Management of an 8 cm Gap Nonunion in a Grade IIIB Open Tibial Fracture using Combined Intramedullary Nailing and Ilizarov Technique: A Case Report with 3-Year Follow-Up

Abstract Gap nonunions following high-grade open tibial fractures remain one of the most challenging scenarios in orthopedic trauma. This report describes the management of a 60-year-old male who sustained a Grade IIIB open fracture of both bones of the left leg in a road traffic accident. Initial external fixation and soft tissue reconstruction were performed, but he was lost to follow-up and presented 18 months post-injury with an 8 cm gap nonunion. He was treated using a novel combined approach of intramedullary interlocking nailing and Ilizarov ring fixation. Challenges such as fibrous canal obstruction, soft tissue interposition, and equinus deformity were addressed in staged procedures. At 3 years follow-up, the patient achieved full weight-bearing and returned to work with a satisfactory functional outcome. This case highlights the efficacy of hybrid fixation in addressing large tibial bone defects with associated soft tissue complications.