Surgical Discussion

Patient positioning:  Supine positioning was utilized for the procedure, allowing access for closed reduction and intramedullary nailing.

Anatomical surgical approach:  A minimally invasive approach was employed for intramedullary nailing of the tibia. This involved small incisions for guidewire insertion and nail placement, avoiding extensive dissection to preserve the compromised soft tissue envelope.

Initial management failed at six weeks postoperatively, with valgus collapse and medial wound development, suggesting infection in the context of peripheral vascular disease. The decision was made to remove all implants, perform debridement, ream the canal, and initiate a two-week course of intravenous antibiotics. A tensioned fine wire frame was applied to manage the septic nonunion and deformity. The frame included fibular osteotomy and lengthening, syndesmosis takedown for planned arthrodesis, and medial gutter debridement. Olive wires were used to correct deformity acutely in the operating room, and the frame was locked statically.

Postoperative protocol:   The patient remained non-weight bearing until surgical and medial wounds healed at six weeks. Weight-bearing was then allowed, with dynamization of the frame at five months and removal at six and a half months.

Follow up:   Not specified.

Orthopaedic implants used:   Intramedullary nail, tensioned fine wire frame with olive wires.