Multistage surgical strategy combining bone transport and antibiotic cement in a complex lower extremity crush injury: achieving limb salvage and infection control.

Background: High-energy lower extremity crush injuries with concurrent infection and segmental bone defects present significant therapeutic challenges, often complicated by recalcitrant osteomyelitis and compromised bone healing. Traditional approaches frequently fail to achieve simultaneous infection eradication and structural reconstruction. This case demonstrates how a staged surgical protocol combining bone transport and antibiotic cement spacer technology addresses these dual challenges.

Case report: A 45-year-old male sustained an open tibiofibular fracture of the left lower extremity with extensive soft tissue loss after a traffic accident. He initial underwent open reduction and internal fixation (ORIF) with titanium plates and external fixation. Subsequently, he developed chronic osteomyelitis caused by Escherichia coli. A multidisciplinary team implemented a four-phase protocol: Phase I (Feb-Jun 2020): Radical debridement, removal of infected titanium plate, split-thickness skin grafting, and triangular external fixation. Phase II (Jun-Jul 2020): Ilizarov circular frame application and vancomycin/tobramycin-impregnated bone cement implantation after further debridement. Phase III (Jul 2020-Mar 2021): Bone transport initiated at 1 mm/day to reconstruct a 20 cm tibial defect using a hybrid Ilizarov-U frame. Phase IV (Mar 2021-Feb 2022): External fixator removal after radiographic consolidation, followed by fibular titanium plate extraction. Postoperative follow-up at 26 months demonstrated complete bony union, resolved infection, and restored ambulatory capacity, with minor limitations in knee/ankle range of motion.

Conclusion: This case validates the efficacy of a staged, multidisciplinary approach. It combines aggressive infection control (antibiotic cement spacers and serial debridement) with bone transport techniques for limb salvage in complex crush injuries. The protocol achieved synchronous soft tissue repair and segmental defect reconstruction. This approach emphasizes the critical role of patient compliance, dynamic mechanical stabilization, and incremental soft tissue optimization. This strategy offers a reproducible framework for managing high-energy trauma complicated byosteomyelitis and critical bone loss.