Management of large infected tibial defects with radical debridement and staged double-rib composite free transfer

Seven patients with tibial fractures complicated by large infected tibial defects were treated with a two-stage protocol. In the first stage, antibiotic-impregnated polymethylmethacrylate (PMMA) bead chains were used to obliterate the debrided osseous defect, and a meshed porcine skin was used for temporary wound coverage. In the second stage, the bead chains were removed, and the defects were reconstructed with a microvasculized double- rib and serratus anterior muscle composite free transfer. The interval between the first and second operations was 2 to 4 weeks. The bone defects ranged from 6 to 9 cm, and the skin defect areas ranged from 20 to 40 cm². Wound healing and bony union was achieved in all seven cases. Minor pin track infection was seen in one patient. Stress fractures in two cases were successfully managed with patellar tendon short-leg bracing for 6 months in one case and a plate internal fixation in the other case. Within 2 years, all seven patients returned to light work without any external support, and all of their most recent radiographs showed good consolidation and hypertrophy of grafted rib bones. No recurrence of osteomyelitis was observed during an average follow-up of 37 months (out of a range of 24 to 50 months). We conclude that this treatment protocol provides rapid recovery from osteomyelitis and the double-rib graft is a useful, durable alternative for large tibial defect management.