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At Presentation
25 year old young man, had a bad accident about 10 months back. The tibia was fractured in two places (segmental fracture) with injury to the blood vessel and nerve. He underwent a number of surgeries namely arterial grafting, muscle flap, skin grafting, Ilizarov fixation before presenting to us with discharging sinuses, inability to walk and lack of confidence.
X-rays at Presentation
The x-rays showed nonunion at both the upper and lower fracture sites. The lower fracture site showed infection and dead bone. The fixator was not holding the bone fragments in good alignment and the wires were all loose and some of them were infected.
PET Scan
The FDG PET Scan showing active infection at the lower fracture site. An arterial DSA (Digital Subtraction Angiogram) was done to determine the course and patency of the arteries.
Sequestrum â“ Dead Bone
The dead bone was excised. The line of demarcation between the dead and viable bone is shown here in the picture on the left (yellow arrow).

In surgery the dead bone (sequestrum) & all the infective tissue was removed. An intra-medullary V-nail was applied to keep the bone aligned and antibiotic loaded calcium sulphate pellets were instilled in the proximal and distal fracture sites to control infection.

4 Weeks
The calcium sulphate pellets are completely absorbed. The infection is settled and the sinuses healing well. The upper fracture is showing signs of healing.
Bone Transport
The Ilizarov fixator is applied while the intra-medullary nail is still inside. An osteotomy was done in the proximal aspect for the purpose of bone transport.
5 Weeks