Surgical Discussion

Patient positioning:  The patient was positioned supine for ease of access to both the anterior and posterior aspects of the lower leg, allowing for comprehensive debridement and fixation.

Anatomical surgical approach:  The surgical approach involved a meticulous radical debridement of all necrotic and contaminated tissues, followed by direct closure of the wound. The Ilizarov frame was applied circumferentially around the tibia for stabilization and bone transport. A reverse sural flap based on the peroneal artery perforator was planned for coverage of the soft tissue defect at the docking site.

During the procedure, a two-stage modified sural perforator flap was executed, with initial flap elevation and delayed inset to ensure optimal perfusion. Temporary negative pressure wound therapy (TPN) was utilized to prevent screw extraction complications. The application of morphogenetic protein at the bone docking site was performed to enhance osteogenesis. Subsequent reactivation of infection required removal of hardware and medullary canal debridement using RIA2, followed by insertion of an antibiotic-releasing nail.

Postoperative protocol:   Postoperative rehabilitation included non-weight bearing on the affected limb until adequate soft tissue healing and bone consolidation were achieved. Gradual weight-bearing was introduced as tolerated, with close monitoring for signs of infection or flap compromise.

Follow up:   Not specified.

Orthopaedic implants used:   Ilizarov external fixator, monolateral external fixator, reverse sural flap, TPN system, RIA2 system, antibiotic-releasing intramedullary nail.