An otherwise healthy, nonsmoking, 31-year-old male (25.0 kg/m2) was involved in a dirt bike accident and sustained an isolated type II distal diaphyseal tibia fracture with an associated segmental fibula fracture (Figure 1). Neurovascular assessment demonstrated no deficits, and inspection of the leg revealed a 1 cm transverse wound contaminated with grass. The patient initially underwent bedside irrigation and received intravenous (IV) cefazolin, gentamicin, and penicillin G. A splint was applied. Intraoperative irrigation and debridement (I&D) followed by placement of a suprapatellar IMN was completed within the first 24 hours after the patient's arrival. The patient received two doses of IV Ancef postoperatively and was uneventfully discharged with nonweightbearing status on the affected extremity. The patient developed progressive knee discomfort and by week four reported severe pain; examination at that juncture identified a large knee effusion, erythema, and minimal tolerance for knee range-of-motion (ROM). Inspection of the fracture site showed mild erythema with serosanguinous drainage. Aspiration of the knee demonstrated cloudy yellow fluid and, its analysis, a white cell count >100,000 with 96% neutrophils; cultures grew gram-negative rods. At this time, patient care was transferred to the senior author.
I&D of the knee, fracture site, and intramedullary canal was completed following the removal of hardware. Discolored fluid was noted in the knee with palpable loculations in the suprapatellar pouch. Grass was identified in the knee and at the fracture site. A synovectomy of the loculated tissue in the knee was completed, and the surgical footprint at the fracture site was extended proximally and distally to permit local debridement of the bone and soft tissue; nonviable skin was excised resulting in a 1 x 3 cm soft-tissue defect directly over anteromedial tibial fracture site. A reamed irrigator aspirator (RIA) was used to debride the entirety of the intramedullary canal. A total of two separate debridements were performed. Following the second debridement, the soft-tissue defect was too large for primary closure and discussion with the patient included a flap for soft-tissue coverage or use of a Taylor spatial frame with induced deformity to allow primary soft-tissue closure. The patient opted for a frame.
A three-ring frame was applied to the tibia followed by application of Fast-Fx (Smith & Nephew, Memphis, TN) struts between the rings above and below the fracture site. An anatomic reduction of the tibia was completed prior to wound closure, and the strut lengths were recorded; baseline pulses were monitored with a Doppler, and capillary refill was noted. The fracture site was shortened and varus recurvatum deformity was induced until tension-free primary closure of the wound was possible; the struts were fastened, vascular status reassessed, and wound closed (Figures 2 and 3(a)). Postoperatively, the patient had no change in neurovascular status.
Patient's sutures were maintained for four weeks (wound healed) at which point deformity correction commenced at a rate of 0.75 mm per day for a 27-day period (Figure 4). Throughout the 27-day period, the patient was evaluated weekly, the soft tissues remained intact, near-anatomic alignment was achieved, there were no signs or symptoms of infection, and the patient completed parenteral antibiotics prescribed by the infectious disease team to treat Enterobacter cloacae and Enterococcus faecalis. Once anatomic alignment was achieved, the fracture site was compressed, the foot ring was removed, the patient initiated weightbearing, and the patient was evaluated monthly. At week 24, the frame was removed as radiographic fracture union was achieved (Figure 5). At final follow-up (postoperative month 16), the patient displayed a nonantalgic gait, fully healed surgical sites (Figure 3(c)), and no signs of infection and was working full-time as an auto mechanic.