Reconstruction of an extensive infection-related femoral segmental bone defect using a customized 3D-printed porous titanium scaffold and a free vascularized fibular flap: a case report and literature review

Abstract Background Extensive segmental bone defects caused by haematogenous osteomyelitis are challenging to reconstruct, particularly when multiple sites in the same limb are affected. Achieving infection control, mechanical stability, and biological bone reconstruction remains difficult using a single surgical technique. We report a case of ipsilateral femoral and tibial osteomyelitis with extensive bone loss, focusing on femoral reconstruction using a customized 3D-printed microporous titanium alloy scaffold combined with a free vascularized fibular flap following staged infection management. Case presentation A 22-year-old man presented with haematogenous osteomyelitis involving the left tibia (Cierny–Mader type III) and femur (Cierny–Mader type IV), complicated by a pathological femoral fracture. Following extensive debridement, a 13-cm anterolateral cortical defect remained in the tibia, together with a 17-cm segmental defect in the femoral shaft. Antibiotic-loaded cement spacers and internal fixation were initially used as part of the staged treatment. The tibial defect was subsequently reconstructed using the Masquelet technique with autologous bone grafting. However, persistent femoral infection necessitated repeated debridement, delaying definitive femoral reconstruction. After further debridement, intraoperative frozen-section histopathology demonstrated fewer than five neutrophils per high-power field, supporting the decision to proceed with reconstruction despite previously elevated inflammatory markers. The femoral defect was reconstructed using a customized 3D-printed microporous titanium alloy scaffold combined with a free vascularized fibular flap, supplemented by autologous cancellous bone grafting and anatomical locking plate fixation. At the 3-year follow-up, osseous union was observed at the fibular graft–host bone interfaces, with no clinically evident recurrence of infection or implant failure. The patient had returned to work and achieved a Lower Extremity Functional Scale score of 71/80. Conclusion This case illustrates the feasibility of combining a customized 3D-printed microporous titanium alloy scaffold with a free vascularized fibular flap for reconstruction of an extensive femoral defect following staged treatment of osteomyelitis. The scaffold provided initial structural support, while the vascularized fibular flap offered a potential source of long-term biological reinforcement. Although satisfactory bone healing and functional recovery were observed in this patient, further studies are required to establish the safety, reproducibility, and long-term effectiveness of this combined approach.