Reconstruction of Thermal Necrosis of the Tibia after Intramedullary Fixation of Fracture by Vascularized Fibula Graft: Case Report

Intramedullary nailing is now a preferred method of fixation in long-bone shaft fractures, because of biomechanical and biological advantages. But during reaming of the isthmic portion, especially in a narrow medullary cavity in young patients, overzealous reaming will raise the bone temperature significantly and may cause necrosis of the bone and surrounding soft tissue, even to the skin. There are very few reports about this complication and treatment.

A 35-year-old woman slipped and fell down, sustaining oblique fracture of her right tibia. Five days later, the fracture was stabilized by reamed intramedullary nailing. At the first change of dressing, a pretibial blister was noted and managed conservatively. Two weeks later, pretibial skin had necrotized and infection of the bone followed. At 2 months after the initial operation, the nail and dead infected bone were removed, the defect was filled by antibiotic bone cement, and an external fixator was applied.

At 4 months after the initial operation, the tibial bone was reconstructed by a 15-cm long osteocutaneous vascularized fibular graft. The grafted bone survived. But osteomyelitis recurred at the remaining metaphysis of the tibia, which was controlled by sequestrectomy. Sound bony union was achieved and full weight-bearing without any support became possible at 18 month from the onset of trauma.

It appears that severe thermal injury due to intramedullary reaming results in more extensive bony necrosis along the nail than is expected. More aggressive and repeated sequestrectomy would be required to prevent recurrence of infection of the bone before application of the vascularized bone graft.