Surgical Discussion

Patient positioning:  Supine positioning on a radiolucent table to facilitate access for intramedullary nailing and fasciotomy.

Anatomical surgical approach:  Anteromedial approach to the tibia for intramedullary nailing, with additional incisions for fasciotomy along the anterior, lateral, and posterior compartments of the leg. The proximal fibula was addressed through a lateral approach for IM nailing.

The initial surgical intervention focused on stabilizing the fracture and managing the soft tissue injury with VAC therapy and planned flap coverage. At 9 months post-injury, the patient presented with septic nonunion characterized by intermittent serous drainage at the fracture site. Laboratory workup confirmed infection with MSSA. Treatment involved removal of the tibial nail, reaming with cultures taken from reamings, insertion of an antibiotic-coated nail using PMMA mixed with vancomycin and tobramycin, and systemic antibiotics targeting MSSA. Once infection markers normalized, exchange nailing was performed.

Postoperative protocol:   Initial non-weight bearing status postoperatively, progressing to weight bearing as tolerated at 3 months once soft tissue healing was confirmed. Following antibiotic nail insertion, weight bearing was allowed to promote dynamization and healing around the nail.

Orthopaedic implants used:   Intramedullary nails for tibia and fibula, wound VAC system, PMMA antibiotic-coated nail (vancomycin and tobramycin). Technique for abx nail if you’ve never done it. 1) 40 French chest tube, mineral oil. 2) threaded ilizarov rod and eyelet 3) table top bender 4) pmma and Vanc/tobra . . . Measure and cut ilizarov rod to length, anticipating the herzog bend and eyelet. Cut chest tube to a little longer length, lube up the inside w mineral oil. Place rod into tube. Mix 4g vanc, 2.4g tobra w 40g pmma. Inject cement into chest tube slowly. Allow to harden (be patient!). Cut chest tube off nail w 10blade. Enjoy your creation!!! . . . Depending on the nonunion’s stability, you can let the patient weight bear on the abx nail- often they will heal around it. If highly unstable, add an ex-fix.