The Joint EBJIS-MSIS 2026 Conference

INTRODUCTION: Infected distal tibial nonunion, complicated by bone loss, limb length discrepancy and multiplanar deformity, presents a major orthopaedic reconstructive challenge. Current evidence advocates an aggressive, multidisciplinary approach to avoid amputation. Successful treatment relies on a crucial triad: infection eradication, mechanical stabilisation and bone reconstruction. This case demonstrates a successful staged salvage using distraction osteogenesis with the Ilizarov technique and targeted antimicrobial therapy.

CASE REPORT:

Id.: 28-year-old male, from Guinea-Bissau.
History: open tibial fracture (2019)with multiple unsuccessful previous surgical interventions (plate and screws, K wires), complicated with chronic osteomyelitis.
At admission (2023): chronic draining sinus + limb shortening +complex deformity (combined recurvatum and varus deformity and compensatory ankle equinus).

Surgical timeline:

Stage 1

Radical debridement with sequestrectomy,

Local antibiotic with cement spacer (Vanco/Flucloxa), Proximal tibial osteotomy

Ilizarov application

Stage 2

Docking site preparation

Autologous cancellous bone graft (iliac crest)

Bone transport

Total defect: 7 cm

Distraction rate: 0.75 mm/day (0.25x3/day)

Distraction completed

Ilizarov removal (12m follow-up)

Multidisciplinary Infectious Management:

Initial Flora S. epidermidis & S. caprae Initial antibiotherapy: Vancomycin + Rifampicin 450mg bid, 14 days

The Challenge: ESBL Targeted Therapy: Ertapenem id for 12 weeks to avoid AmpC induction risk associated with other beta-lactams.

Close collaboration with the Infectious diseases department was pivotal to avoiding therapeutic failure in the septic environment.

Results & Outcome: Radiographic consolidation at 12 months. Pain-free, mobilization with PWB. No clinical or lab evidence of infection (CRP normalization (0.1 mg/dL)).

Discussion & Conclusion: This case highlights the importance of a multidisciplinary and staged approach.

A staged radical debridement (down to viable, bleeding bone margins), ensuring biological clearance, combined with targeted antimicrobial therapy for multidrug-resistant polymicrobial flora, enabled conversion of a severe septic environment into a suitable biological bed for bone transport, underscoring the importance of close collaboration with infectious diseases specialists in complex limb salvage.

While techniques such as the Masquelet-induced membrane, nail-guided bone transport, or retrograde nailing could be valid alternatives, the Ilizarov method proved most advantageous in this case. It allowed for simultaneous management of infection, large-volume bone transport (>5 cm), and correction of the mechanical deformity, without placing definitive internal hardware, avoiding amputation.

Key Takeaways: Limb salvage in complex, multidrug-resistant infected distal tibial nonunions with severe bone loss is achievable.

Radical surgical debridement: Essential to convert septic terrain into a biological bed.
Ilizarov bone transport: Effectively managed infection, bone defect, and deformity.
Targeted Antibiotics: Essential role of ID specialists in managing ESBL-producing bacteria.

The Joint EBJIS-MSIS 2026 Conference

Limb Salvage in Multidrug-Resistant Infected Distal Tibial Nonunion: Staged Debridement and Ilizarov Bone Transport

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