Management of composite tibial and soft tissue defects via intramedullary bone transport devices and microvascular free flaps: A treatment algorithm and presentation of two cases

Background

Tibial malunion and nonunion are complications that may follow the repair of traumatic tibial shaft fractures. Management may sometime require osteotomy and bone transport. In recent years, there has been a paradigm shift in the management of intercalary tibial defects away from bone transport via external fixation towards intramedullary lengthening nails. This shift necessitates a re-evaluation of the approach to infection and soft tissue defects.

Cases

We describe the case of a young man with a two-year history of infected tibial nonunion who underwent osteotomy and debridement before requiring free tissue transfer and eventual bone transport. Second, we present the case of a middle-aged man with a 30-year history of infected tibial malunion. Prior to placement of the intramedullary nail, debridement and osteotomy were performed, followed by two free anterolateral thigh flaps and tissue rearrangement.

Discussion

The use of free tissue transfers and emphasis on achieving an anatomically correct lower extremity prior to the initiation of bone transport resulted in minimal external fixation time, treatment compliance, and satisfactory clinical outcomes. Although multiple treatments can produce successful bone transport, no cohesive treatment algorithm exists that addresses infection, external fixation time, healing, and psychological burden.

Conclusion

The paradigm shift towards intramedullary bone transport devices requires the use of antibiotic implants and prioritization of the soft tissue envelope prior to device implantation to prevent hardware infection and reoperation. An algorithmic management approach by an orthoplastic surgical team that includes an orthopedic surgeon and microsurgeon is recommended.