A twenty-year-old woman was struck by an automobile, sustaining an open (Gustilo type-IIIB) diaphyseal fracture of the left tibia (AO-OTA 42-C3). There was extensive loss of the soft-tissue envelope over the medial, anterior, and posterior aspects of the leg. On admission, the wound was debrided and an external fixator was applied for temporary immobilization. Two more debridements were necessary to remove all contamination. Subsequently, the soft-tissue defect was covered with a vascularized rectus abdominis muscle flap six weeks after initial presentation. The recovery of the patient was complicated by wound infection with Klebsiella pneumoniae and Escherichia coli, for which she was treated with imipenem. Six months after the injury, she was referred to our institution for the treatment of an infected tibial nonunion. The external fixator was still in place. The muscle flap was viable, but there was persistent serous discharge from a sinus. Radiographs showed a large diaphyseal segmental bone defect in the tibia (Fig. 1). The two remaining problems were fracture site infection and a lack of skeletal continuity in an area where a severe, nearly circumferential, soft-tissue degloving injury had occurred and for which a free muscle flap had already been performed.
Diaphyseal defects too long to be bridged by conventional cancellous bone-grafting need complex reconstruction. One option, distraction osteogenesis, requires specialized equipment and expertise and is associated with a high rate of complications. Vascularized bone-grafting also needs special expertise, is associated with donor-site morbidity, and requires a long time for osseous incorporation and consolidation. Moreover, the recipient site may not have appropriate vessels left to allow anastomosis, as was the situation in this patient. The induced membrane technique is a relatively simple method that can …
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