Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table to facilitate access to the tibial and fibular regions for debridement and subsequent procedures.

Anatomical surgical approach:  A longitudinal incision was made over the anteromedial aspect of the tibia, extending from the proximal to distal third, allowing for exposure of both the tibia and fibula. Radical debridement was performed to excise all necrotic and infected tissue. A provisional bone cement spacer was placed within the defect, and an elevated protective scaffold was constructed to maintain limb length and alignment.

The surgeon noted the extensive nature of the infection, necessitating thorough debridement to achieve a clean surgical field. Culture-guided antibiotic treatment was initiated postoperatively. After initial stabilization with a bone cement spacer, a bone substitute was applied, and an Ilizarov external fixator was used to facilitate bone transport at a rate of 1 mm per day. Walking training was incorporated into the rehabilitation protocol. Subsequently, conversion from external to internal fixation was achieved using a minimally invasive variable-angle distal tibial plate augmented with morphogenetic protein to promote osteogenesis.

Postoperative protocol:   The postoperative rehabilitation protocol included immediate weight-bearing as tolerated with the Ilizarov frame in place, followed by progressive walking training. After conversion to internal fixation, weight-bearing was continued as tolerated, with emphasis on range of motion exercises and strengthening.

Follow up:   Not specified.

Orthopaedic implants used:   Ilizarov external fixator, variable-angle distal tibial plate, bone cement spacer, bone substitute, morphogenetic protein.