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Case Report
- Reconstruction of a 20-cm tibial bone defect after recurrent fracture-related infection using the induced membrane technique and rhBMP-2 augmentation with limited autogenous bone availability: a case report
- Whee Sung Son
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DOI: https://doi.org/10.12671/jmt.2026.00143
Published online: August 21, 2026
Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
- Correspondence to: Whee Sung Son Department of Orthopedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, 170 Hyonchung-ro, Nam-gu, Daegu 42415, Korea Email: oswsson@gmail.com
• Received: March 30, 2026 • Revised: June 28, 2026 • Accepted: June 29, 2026
© 2026 The Korean Orthopaedic Trauma Association
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Abstract
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Fracture-related infection (FRI) poses the combined challenges of infection control and reconstruction of critical-sized bone defects. These challenges are amplified in recurrent cases with severely limited autogenous bone availability. We report a 61-year-old male patient with recurrent right tibial FRI after multiple operations and a 20-cm segmental defect. Suspected residual infectious foci were mapped by comparing preoperative fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) with post-debridement CT and were evaluated using site-specific pre- and post-debridement cultures. After a second targeted debridement, all post-debridement cultures were negative, and no clinical or laboratory evidence of active infection was observed during a 2-week antibiotic-free interval. The defect was subsequently reconstructed using the induced membrane technique with 30 cm³ of autogenous cancellous bone, 60 cm³ of demineralized bone matrix, and 9 mg of recombinant human bone morphogenetic protein-2 (rhBMP-2) delivered on a 20 cm³ hydroxyapatite carrier. Radiographic union was achieved, and no clinical evidence of infection recurrence was observed at 1 year. This case suggests the feasibility of combining PET/CT- and culture-guided anatomically targeted debridement with rhBMP-2-augmented induced membrane reconstruction when autogenous graft volume is severely limited.
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Level of evidence V.
Introduction
Fracture-related infection (FRI) represents a major challenge in orthopedic trauma surgery, associated with significant morbidity, prolonged treatment, and profound socioeconomic consequences [1,2]. Despite advances in surgical and antimicrobial strategies, FRI continues to cause significant functional impairment and, in severe cases, limb amputation [3,4]. Management remains challenging due to two interrelated but compounding problems. First, infection recurrence persists, with reported rates of 9%–35% despite protocolized surgical management [5,6]. Second, repeated radical debridement, necessary for adequate infection management, inevitably results in bone loss that can culminate in critical-sized defects [7]. Consequently, management requires both infection control and complex skeletal reconstruction, rendering FRI management a dual and formidable challenge.
Recurrence of FRI following reconstruction is particularly devastating, requiring repeated radical resection that can enlarge an already critical-sized defect. Management of recurrent cases is further complicated when autogenous bone sources have been exhausted by prior procedures, leaving the surgeon with limited reconstructive options. However, before any reconstructive strategy can be undertaken, a prerequisite challenge must be addressed: accurate identification and thorough clearance of residual infection are essential.
This case illustrates a convergence of challenges: recurrent FRI with an enlarging tibial bone defect and substantial depletion of autogenous bone graft sources. The objective of this case report is to describe the surgical strategy employed to achieve infection clearance and skeletal reconstruction under severely depleted biological conditions, with the aim of serving as a practical reference for surgeons encountering a similarly complex convergence of recurrent FRI, critical-sized bone defect, and extremely limited autogenous bone donor sites.
Case report
Written informed consent was obtained from the patient for the publication of this case report and all accompanying clinical images.
A 61-year-old male patient was referred to our institution for management of right tibial FRI. Surgical history included extensive autologous bone harvesting from the bilateral anterior iliac crests, left posterior iliac crest, and the right fibula ~15 years earlier for the treatment of left tibial FRI. Six years prior, he sustained a right tibial shaft fracture and subsequently underwent multiple revision surgeries at an outside institution, resulting in FRI in the right tibia. Due to repetitive treatment failure and infection recurrence, he was transferred to our center for further care. At our institution, a pre- and post-debridement, culture-based staged surgical protocol was initiated, comprising three consecutive debridement procedures, with concomitant anterolateral thigh free-flap coverage to address soft-tissue deficiency. Following three staged debridements, negative post-debridement cultures, and anterolateral thigh free-flap coverage, the 20-cm defect was reconstructed using the maximum safely obtainable volume of autogenous bone supplemented with recombinant human bone morphogenetic protein-2 (rhBMP-2) and demineralized bone matrix (DBM) (Fig. 1). Four months after the initial reconstruction, infection recurred, creating the combined challenge of managing recurrent FRI and reconstructing a critical-sized defect with severely limited remaining autogenous graft availability (Fig. 2).
Upon confirmed recurrence, preoperative fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) was analyzed in conjunction with prior magnetic resonance imaging (MRI) obtained at initial presentation. Comparative review showed that FDG uptake was greatest in the proximal tibia at previous external-fixator pin sites, with additional uptake in the reconstructed diaphyseal segment. Because FDG avidity is not specific for infection, these regions were regarded as suspected residual foci and were correlated with operative findings and site-specific cultures. The proximal findings raised concern for incomplete prior debridement rather than proving it on imaging alone (Fig. 2).
The first re-debridement was subsequently performed, with removal of the intramedullary nail and all previously grafted materials, followed by targeted resection of the FDG-avid lesion of the proximal tibia as identified via FDG-PET/CT. Intraoperative pre- and post-debridement cultures were obtained to identify the causative organism and assess debridement adequacy [5,8]. Following this procedure, post-debridement CT was systematically compared with the preoperative FDG-PET/CT. This comparison revealed anatomical regions that demonstrated FDG uptake on the preoperative scan but appeared incompletely resected on the post-debridement CT. Positive post-debridement culture at corresponding sites confirmed residual infection. These combined imaging and microbiological findings identified specific foci requiring further resection (Fig. 3).
At recurrence, extensive purulent drainage and widespread soft-tissue involvement were present. Given the risk of unnecessary soft-tissue sacrifice with immediate re-debridement, intravenous antibiotic therapy was first administered to optimize the soft-tissue condition and maximize soft-tissue preservation prior to the second surgical intervention. Following 6 weeks of culture-directed systemic antibiotic therapy and a 2-week antibiotic-free interval, a second targeted re-debridement was performed to address residual foci identified by combined imaging and microbiological analyses. Second post-debridement CT confirmed complete excision of all regions that had shown FDG uptake on the preoperative PET/CT, and repeat post-debridement cultures were negative, indicating that the planned debridement had been achieved with both radiological and microbiological clearance (Fig. 3).
Culture-directed antibiotic therapy was continued for 6 weeks, followed by a 2-week antibiotic-free interval. Serial inflammatory markers monitored during and after this period confirmed the absence of recurrence before proceeding to the next stage. Antibiotic selection was guided by the evolving microbiological profile across the two re-debridements, in consultation with the infectious disease department. After the first re-debridement, selected post-debridement samples remained positive for methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant S. aureus (MRSA), indicating that additional resection was required. At the second re-debridement, two pre-debridement samples yielded MSSA, whereas all post-debridement cultures showed no growth. Vancomycin was used after the first re-debridement to cover MRSA, and cefazolin was used after the second procedure on the basis of the MSSA isolates and the absence of MRSA in the second set of cultures. Microbiological findings and antibiotic regimens are summarized in Table 1.
After completion of culture-directed antibiotic therapy and a 2-week antibiotic-free interval, the absence of clinical signs of infection recurrence, normalization or stability of inflammatory markers, and negative post-debridement cultures supported proceeding to reconstruction. Definitive fixation was achieved with intramedullary nailing, followed by insertion of an antibiotic-loaded cement spacer into the defect according to the induced membrane technique in preparation for staged bone reconstruction 6 weeks later. Partial weight-bearing with crutch assistance was initiated, and rehabilitation was commenced. Bone reconstruction was performed 6 weeks after spacer insertion.
At the second stage, the induced membrane was incised, and the cement spacer was removed. The estimated volume of the bone defect was approximately 120.75 cm³, derived from CT by averaging the cross-sectional areas of the proximal and distal remnant tibial segments and multiplying by the length of the defect. Because the autogenous donor sites had been substantially depleted by repeated prior harvesting, only 30 cm³ of cancellous bone was harvested from bilateral iliac crests, which was markedly insufficient for a defect of this size. To address this limitation, 9 mg of rhBMP-2 with 20 cm³ of a hydroxyapatite (HA) carrier (Novosis; CGBio) was used as the principal osteoinductive component to compensate for the substantially insufficient autogenous bone (off-label use, with written informed consent obtained from the patient). In addition, 60 cm³ of DBM was used as a volume expander. The graft composite, amounting to approximately 110 cm³ in total, was placed within the induced membrane chamber, followed by membrane closure (Fig. 4). The implanted volume was thus approximately 10 cm³ less than the estimated defect volume, a result attributable to both the limited autogenous bone available and the already high proportion of volume expander in the composite.
Following bone reconstruction, crutch-assisted partial weight-bearing ambulation began 2 weeks postoperatively. Serial radiographs demonstrated progressive consolidation of the grafted segment. At 6 months, consolidation of the grafted bone had progressed to bridge at least three of four cortices on orthogonal radiographs, meeting the prespecified radiographic criterion for union. At 1-year follow-up, complete consolidation of the reconstructed tibial segment was confirmed radiographically, with no clinical or laboratory evidence of infection recurrence. No rhBMP-2–related adverse events, including heterotopic ossification, seroma, or excessive soft-tissue swelling, were observed throughout the follow-up period. The patient fully resumed the activities of daily living without the use of assistive devices (Figs. 5, 6). A residual limb-length discrepancy of 1.7 cm was noted at final follow-up; however, this did not require lengthening intervention and did not impair the patient’s return to daily activities. The patient’s Lower Extremity Functional Scale score was 74 of a possible 80, indicating minimal functional limitation.
Discussion
This case report highlights two clinically significant achievements in the management of an extreme FRI scenario. First, in a patient with multiple recurrences of FRI despite repeated surgical intervention, infection was successfully managed through a systematic, image- and culture-guided debridement strategy. Integration of preoperative FDG-PET/CT with serial post-debridement CT, combined with a stringent pre- and post-debridement culture protocol, enabled precise anatomical localization of the residual infectious focus, objective verification of debridement completeness, and confirmation of microbiological clearance prior to reconstruction. This approach provides a novel framework for managing recurrent FRI when conventional imaging fails to reliably identify the source of infection recurrence. Second, and of greater reconstructive significance, this case represents, to the best of our knowledge, one of the largest tibial bone defects following FRI reconstructed by the induced membrane technique reported to date. In prior infection series, segmental tibial defects have generally ranged from approximately 6 to 15 cm [9-11], and although a tibial defect of 20 cm has been reconstructed in the aseptic setting [12], such an extensive defect has not previously been described in the tibia in the context of infection. Post-infection defects of comparable magnitude have to our knowledge been reported only in the femur [5]. This anatomical distinction is noteworthy, as the tibia is inherently more difficult to reconstruct: unlike the well-vascularized, muscle-enveloped femur, the anteromedial tibia is covered by only a thin, poorly vascularized soft-tissue layer, which compromises graft incorporation and heightens susceptibility to persistent or recurrent infection [8]. Notably, reconstruction was performed under conditions of near-complete depletion of autogenous bone graft sources, as the available donor sites had been extensively harvested by prior surgeries for bilateral tibial FRI, leaving only 30 cm³ of autogenous bone available.
The reconstruction strategy in this case was supported by accumulating evidence for the use of rhBMP-2 within the induced membrane technique. From a biological standpoint, the adequacy of graft bioactivity is critically dependent on the proportion of autogenous bone within the graft mixture. Cho et al. [13] demonstrated that a higher percentage of DBM in the graft mixture was inversely correlated with early volumetric change, suggesting that excessive reliance on bone substitutes with limited osteoinductive and osteogenic properties leads to increased early graft resorption. This principle is further supported by Masquelet et al., who recommend a graft composition of at least 70% autograft and 30% volume expander [14]. In the present case, the available autogenous bone volume of 30 cm³ was substantially insufficient relative to the estimated defect volume of 120.75 cm³, and the proportion of autograft was substantially below this recommended level, placing this reconstruction at high biological risk for graft resorption and delayed consolidation. In this context, rhBMP-2 served as the principal osteoinductive agent rather than a mere adjunct, compensating for the substantially deficient autograft volume and enhancing the overall osteoinductive potential of the graft mixture [15-17]. Son et al. [18] demonstrated that rhBMP-2 with a HA carrier in the induced membrane technique significantly increased bone density, corticalization, and shortened time to union compared with the induced membrane technique alone. Subsequently, the same group demonstrated in a preclinical rabbit model that rhBMP-2 with a HA/β-tricalcium phosphate/hydrogel carrier, used as a complete replacement for autogenous bone graft, achieved radiographic, biomechanical, and histological outcomes comparable or superior to autogenous bone graft alone within the induced membrane technique, establishing that a fully autograft-free strategy can be a viable reconstructive option [15]. The successful consolidation achieved in the present case further corroborates these findings, demonstrating that rhBMP-2 can effectively overcome the biological limitations imposed by critically insufficient autogenous bone, thereby potentially supporting graft incorporation even in the setting of a 20-cm critical-sized tibial defect.
The decision to proceed with the induced membrane technique with rhBMP-2, rather than other established reconstructive strategies, was also driven by patient-specific anatomical constraints. For a tibial defect of this magnitude, vascularized fibular bone graft and bone transport via distraction osteogenesis are commonly considered alternatives; however, neither was applicable in this case. Vascularized fibular graft was not feasible: the ipsilateral fibula had already been harvested for contralateral tibial reconstruction, and harvesting the contralateral fibula carried an unacceptable risk of peri-implant fracture given the poor bone quality of the previously reconstructed tibia. Bone transport was likewise excluded. With only 94 mm of proximal and 44 mm of distal tibial bone remaining, a proximal corticotomy would have left a residual proximal segment insufficient to achieve fixation capable of resisting the proximal deforming forces during transport. Stable fixation of both the proximal and distal segments—each conventionally secured with multiple fixation elements above and below the corticotomy—is a prerequisite for reliable distraction and docking [19], and the markedly limited length of the remaining proximal segment was judged inadequate for this purpose. Moreover, transport of a 20-cm defect would have required a prolonged distraction and consolidation period during which weight-bearing and rehabilitation would be substantially restricted, raising serious doubt as to whether this patient could ultimately regain satisfactory function. For these reasons, the induced membrane technique was selected as the reconstructive strategy. This approach provides sufficient stability throughout the reconstruction period through intramedullary nail fixation and, importantly, permits partial weight-bearing from the time of nailing, thereby allowing early rehabilitation.
The safety of rhBMP-2 in a previously infected site warrants acknowledgment. Available evidence suggests that rhBMP-2 can be used safely once infection has been definitively eradicated, with no evidence that it promotes reinfection [20,21]. Preclinical data further indicate that rhBMP-2 can partially overcome the inhibitory effects of infection on fracture healing without promoting pathogen persistence or biofilm formation [22,23]. Heterotopic ossification is a recognized concern with high-dose rhBMP-2 delivered on absorbable collagen sponges, which release nearly the entire protein load within the first day. The HA carrier used in this case provides sustained release over several weeks, and heterotopic ossification has not been reported with this delivery system. In a multicenter prospective trial of 81 patients treated with an HA carrier-based rhBMP-2 system for acute fractures with bone defects, no ectopic ossification, systemic complications, or severe inflammatory responses occurred, and the only device-related adverse event was a single localized seroma [17]. A prospective case series of long-bone nonunion treated with rhBMP-2 and HA granules likewise reported no adverse effects or antibody formation [24], and preclinical work has shown early bone regeneration with minimal inflammation and no ectopic ossification using the same carrier [25]. In the present case, no heterotopic ossification, seroma, local swelling, wound complication, or other adverse event attributable to rhBMP-2 was observed throughout the 1-year follow-up, and no infection recurrence occurred. rhBMP-2 had been grafted only after adequate infection management was confirmed prior to reconstruction—based on negative post-debridement cultures, resection of all lesions showing FDG uptake on preoperative PET/CT as verified by post-debridement CT, and the absence of elevated inflammatory markers and clinical signs of recurrence after an antibiotic-free interval. Nonetheless, as a single case, this report cannot establish the safety profile of rhBMP-2 in this setting, and its use for a critical-sized post-infection tibial defect represented off-label use, of which the patient was informed and provided written consent.
This study has several limitations. The primary limitation is its single case report design, which precludes statistical inference and limits the generalizability of the findings. However, the convergence of recurrent FRI, critical-sized bone defect, and extremely limited autogenous bone donor sites represents an exceptionally rare clinical scenario; given its rarity, a well-documented single case report may nonetheless serve as a valuable practical guide for surgeons confronting this challenging situation. In addition, the present outcome is based on a follow-up period of 1 year; accordingly, the possibility of late infection recurrence cannot be excluded, and longer-term follow-up is warranted to confirm the durability of the infection-free outcome. Third, rhBMP-2 was not used in isolation: it was combined with autogenous cancellous bone, DBM, an induced membrane, stable fixation, and soft-tissue coverage. The contribution of rhBMP-2 alone therefore cannot be isolated from these concurrent factors, and the successful consolidation should be interpreted as supporting the feasibility of the combined strategy rather than proving the efficacy of rhBMP-2. Nonetheless, given that only 30 cm³ of autogenous bone could be obtained from substantially depleted donor sites—far below the volume required for a 20-cm critical-sized tibial defect—it is difficult to conceive that reconstruction of a defect of this magnitude could have been achieved without the osteoinductive contribution of rhBMP-2. Fourth, regarding the infection management protocol, the use of post-debridement culture-based staging has been described and validated in prior studies, and its utility is supported by existing literature [5,8]. However, the integration of preoperative FDG-PET/CT with serial post-debridement CT as a tool for anatomically targeting residual infectious foci represents a less-established approach. It should also be noted that FDG-PET/CT cannot definitively confirm the presence of infection, as increased FDG uptake is not specific to infection and may also reflect inflammation, postoperative changes, or other non-infectious processes. Accordingly, in the present study, the anatomical extent of infection was ultimately determined on the basis of culture-positive areas rather than imaging findings alone, with FDG-PET/CT and serial post-debridement CT serving to guide anatomical localization rather than to establish a definitive diagnosis. Further studies with larger case series are therefore warranted to confirm the utility of this imaging-based localization approach. Finally, the optimal dose of rhBMP-2 relative to the defect length or volume remains undefined, and further studies are warranted to establish the appropriate amount of rhBMP-2 per unit of bone defect to guide reproducible and standardized application.
Having undergone multiple operations at other institutions without success, the patient had been faced with the prospect of amputation. He expressed profound satisfaction that his leg could ultimately be salvaged and that he was able to return to full, unrestricted daily activity.
No adverse or unanticipated events occurred during treatment or throughout the follow-up period.
In this patient, recurrent FRI was managed through an image- and culture-guided debridement strategy, followed by reconstruction of a 20-cm tibial defect by the induced membrane technique augmented with rhBMP-2, despite severely limited autogenous bone availability resulting from repeated prior debridement and grafting. At 1 year, complete consolidation had been achieved with no clinical evidence of infection recurrence. To our knowledge, this represents one of the largest post-FRI tibial defects reported to date.
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Author contributions
All the work was done by Whee Sung Son.
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Conflicts of interest
No potential conflict of interest relevant to this article was reported.
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Funding
None.
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Data availability
Not applicable.
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Acknowledgments
This case report was presented in the Case Discussion section of the 2026 Annual Congress of the Korean Orthopaedic Trauma Association (KOTA).
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Supplementary materials
None.
Article Information
Fig. 1.
Initial clinical presentation, intraoperative findings, and postoperative radiograph following primary bone reconstruction. (A) Clinical photograph and plain radiographs at initial presentation. Examination revealed soft-tissue breakdown. Radiographs showed extensive sclerotic bone changes, fracture nonunion, and valgus malalignment of the tibial shaft. Both iliac crests and the right fibula had been previously harvested for the management of left tibial fracture-related infection, substantially limiting the volume available from these donor sites. (B) Intraoperative photographs during debridement. Extensive devitalized bone and intraosseous pus drainage were identified at the time of surgery. Following segmental resection of the infected and necrotic bone, three consecutive debridement procedures, guided by post-debridement culture results, were performed to achieve microbiological clearance before proceeding to the subsequent stage. (C) Postoperative radiograph following the first bone reconstruction procedure, demonstrating reconstruction using the induced membrane technique with autogenous bone harvested from the ipsilateral iliac crest and posterior superior iliac spine, combined with recombinant human bone morphogenetic protein-2 and demineralized bone matrix.
Fig. 2.
Imaging findings at infection recurrence and comparison with prior imaging. (A) Clinical photograph showing active pus drainage, confirming infection recurrence. Plain radiograph at 4 months post-reconstruction and procedure at the time of confirmed infection recurrence. FDG-PET/CT image obtained at the time of infection recurrence. The red dotted circle highlights FDG uptake localized to the proximal tibial region and diaphyseal segment of the prior reconstruction, identifying these as the predominant sites of residual infection. (B) MRI obtained at the patient’s initial presentation to our institution and plain radiograph from the referring institution, both before fracture-related infection management. MRI shows signal changes at prior external-fixator pin sites in the proximal tibia (yellow dotted circle), corresponding to the area of predominant FDG uptake on PET/CT in (A). Comparative analysis confirms that the proximal tibial region, where only curettage had previously been performed, was the primary focus of infection recurrence. FDG, fluorodeoxyglucose; PET, positron emission tomography; CT, computed tomography; MRI, magnetic resonance imaging.
Fig. 3.
Sequential imaging-guided debridement strategy for infection recurrence: comparative analysis of FDG-PET/CT and post-debridement CT findings. (A) Preoperative FDG-PET/CT images obtained at the time of infection recurrence, showing the distribution and anatomical localization of FDG-avid lesions, which guided subsequent targeted debridement. (B) Post-debridement CT images following the first re-debridement procedure. Red arrows indicate anatomical regions that demonstrated FDG uptake on preoperative PET/CT but were identified as incompletely resected on post-debridement CT, representing residual infectious foci requiring further targeted resection. (C) Post-debridement CT after the second re-debridement. Green arrows indicate areas previously identified as inadequately resected on the post-first-debridement CT (red arrows in [B]), now demonstrating complete excision of the residual infectious foci. Comparison with preoperative PET/CT confirmed complete resection of the previously identified FDG-avid regions. (D) Intraoperative photograph and postoperative radiograph from the second re-debridement, showing targeted additional resection of the proximal tibial region guided by the combined imaging and microbiological analysis. The defect was filled with an antibiotic-loaded polymethylmethacrylate cement spacer, an antibiotic-loaded cement-coated rod was inserted into the intramedullary canal, and a 3.5-mm metaphyseal locking plate was employed for provisional fixation. FDG, fluorodeoxyglucose; PET, positron emission tomography; CT, computed tomography.
Fig. 4.
Intraoperative photographs and postoperative plain radiographs of the bone reconstruction procedure. (A) Intraoperative photographs showing bone reconstruction using the induced membrane technique. Only 30 cm³ of autogenous cancellous bone could be harvested from bilateral iliac crests, previously subjected to repeated harvesting, reflecting near-complete depletion of available autogenous bone. To address the 20-cm tibial bone defect, 9 mg of rhBMP-2 with a hydroxyapatite carrier was used as the primary osteoinductive supplement to compensate for the insufficient autogenous bone. Additionally, 60 cm³ of DBM served as a volume expander to fill the defect. (B) Postoperative plain radiographs following the bone reconstruction procedure. rhBMP-2, recombinant human bone morphogenetic protein-2; DBM, demineralized bone matrix.
Fig. 5.
Radiographic and clinical outcomes at 1 year following bone reconstruction. (A) Plain radiographs demonstrating complete consolidation of the reconstructed tibial segment and bone union, with no evidence of infection recurrence. (B) Computed tomography images confirming complete cortical bridging and consolidation of the grafted segment across all planes, consistent with solid bone union. (C) Clinical photograph demonstrating independent ambulation and performance of the illustrated functional activities at 1 year postoperatively.
Table 1.
Microbiological culture results and antibiotic regimens from the first and second debridement procedures
| Variable | Pre-debridement culture | Post-debridement culture | |
|---|---|---|---|
| 1st Debridement | IMP 4 | No growth | No growth |
| IMP 3 | MRSA | No growth | |
| IMP 2 | MSSA | No growth | |
| IMP 1 | MSSA | MSSA | |
| EMP lateral 1 | MSSA | MSSA | |
| EMP lateral 2 | MSSA | No growth | |
| EMP lateral 3 | MSSA | No growth | |
| EMP lateral 4 | MRSA | No growth | |
| EMP lateral 5 | MSSA | No growth | |
| EMP middle | MSSA | No growth | |
| EMP medial 1 | MSSA | No growth | |
| EMP medial 2 | MSSA | MRSA | |
| Center proximal | MSSA | Not separately sampleda) | |
| Center 1 | MSSA | MSSA | |
| Center 2 | MSSA | No growth | |
| Center anterior | MSSA | Not separately sampleda) | |
| Center posterior | MSSA | Not separately sampleda) | |
| Center distal | MSSA | Not separately sampleda) | |
| IMD | MSSA | MSSA | |
| EMD | MSSA | No growth | |
| Pus 1 | MSSA | NAb) | |
| Pus 2 | MSSA | NAb) | |
| Pus 3 | MSSA | NAb) | |
| 2nd Debridement | IMP 4 | No growth | No growthc) |
| IMP 3 | No growth | No growth | |
| IMP 2 | MSSA | No growth | |
| IMP 1 | No growth | No growth | |
| EMP lateral 1 | No growth | No growth | |
| EMP lateral 2 | No growth | No growth | |
| EMP lateral 3 | No growth | No growth | |
| EMP lateral 4 | No growth | No growth | |
| EMP lateral 5 | No growth | No growth | |
| EMP middle | No growth | No growth | |
| EMP medial | MSSA | No growth | |
| Center 1 | No growth | No growth | |
| IMD | No growth | No growth | |
| EMD | No growth | No growth | |
Antibiotic regimen after 1st debridement, Vancomycin × 6 wk → 2-wk drug holiday; Antibiotic regimen after 2nd debridement, Cefazolin × 6 wk → 2-wk drug holiday.
IMP, intramedullary proximal; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-sensitive Staphylococcus aureus; EMP, extramedullary proximal; IMD, intramedullary distal; EMD, extramedullary distal.
a)Not separately sampled; this site was included in the center 1 and center 2 post-debridement cultures. b)Not applicable; no pus was present, so no specimen could be obtained. c)All second post-debridement cultures were negative.
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XML DownloadReconstruction of a 20-cm tibial bone defect after recurrent fracture-related infection using the induced membrane technique and rhBMP-2 augmentation with limited autogenous bone availability: a case report
Fig. 1. Initial clinical presentation, intraoperative findings, and postoperative radiograph following primary bone reconstruction. (A) Clinical photograph and plain radiographs at initial presentation. Examination revealed soft-tissue breakdown. Radiographs showed extensive sclerotic bone changes, fracture nonunion, and valgus malalignment of the tibial shaft. Both iliac crests and the right fibula had been previously harvested for the management of left tibial fracture-related infection, substantially limiting the volume available from these donor sites. (B) Intraoperative photographs during debridement. Extensive devitalized bone and intraosseous pus drainage were identified at the time of surgery. Following segmental resection of the infected and necrotic bone, three consecutive debridement procedures, guided by post-debridement culture results, were performed to achieve microbiological clearance before proceeding to the subsequent stage. (C) Postoperative radiograph following the first bone reconstruction procedure, demonstrating reconstruction using the induced membrane technique with autogenous bone harvested from the ipsilateral iliac crest and posterior superior iliac spine, combined with recombinant human bone morphogenetic protein-2 and demineralized bone matrix.
Fig. 2. Imaging findings at infection recurrence and comparison with prior imaging. (A) Clinical photograph showing active pus drainage, confirming infection recurrence. Plain radiograph at 4 months post-reconstruction and procedure at the time of confirmed infection recurrence. FDG-PET/CT image obtained at the time of infection recurrence. The red dotted circle highlights FDG uptake localized to the proximal tibial region and diaphyseal segment of the prior reconstruction, identifying these as the predominant sites of residual infection. (B) MRI obtained at the patient’s initial presentation to our institution and plain radiograph from the referring institution, both before fracture-related infection management. MRI shows signal changes at prior external-fixator pin sites in the proximal tibia (yellow dotted circle), corresponding to the area of predominant FDG uptake on PET/CT in (A). Comparative analysis confirms that the proximal tibial region, where only curettage had previously been performed, was the primary focus of infection recurrence. FDG, fluorodeoxyglucose; PET, positron emission tomography; CT, computed tomography; MRI, magnetic resonance imaging.
Fig. 3. Sequential imaging-guided debridement strategy for infection recurrence: comparative analysis of FDG-PET/CT and post-debridement CT findings. (A) Preoperative FDG-PET/CT images obtained at the time of infection recurrence, showing the distribution and anatomical localization of FDG-avid lesions, which guided subsequent targeted debridement. (B) Post-debridement CT images following the first re-debridement procedure. Red arrows indicate anatomical regions that demonstrated FDG uptake on preoperative PET/CT but were identified as incompletely resected on post-debridement CT, representing residual infectious foci requiring further targeted resection. (C) Post-debridement CT after the second re-debridement. Green arrows indicate areas previously identified as inadequately resected on the post-first-debridement CT (red arrows in [B]), now demonstrating complete excision of the residual infectious foci. Comparison with preoperative PET/CT confirmed complete resection of the previously identified FDG-avid regions. (D) Intraoperative photograph and postoperative radiograph from the second re-debridement, showing targeted additional resection of the proximal tibial region guided by the combined imaging and microbiological analysis. The defect was filled with an antibiotic-loaded polymethylmethacrylate cement spacer, an antibiotic-loaded cement-coated rod was inserted into the intramedullary canal, and a 3.5-mm metaphyseal locking plate was employed for provisional fixation. FDG, fluorodeoxyglucose; PET, positron emission tomography; CT, computed tomography.
Fig. 4. Intraoperative photographs and postoperative plain radiographs of the bone reconstruction procedure. (A) Intraoperative photographs showing bone reconstruction using the induced membrane technique. Only 30 cm³ of autogenous cancellous bone could be harvested from bilateral iliac crests, previously subjected to repeated harvesting, reflecting near-complete depletion of available autogenous bone. To address the 20-cm tibial bone defect, 9 mg of rhBMP-2 with a hydroxyapatite carrier was used as the primary osteoinductive supplement to compensate for the insufficient autogenous bone. Additionally, 60 cm³ of DBM served as a volume expander to fill the defect. (B) Postoperative plain radiographs following the bone reconstruction procedure. rhBMP-2, recombinant human bone morphogenetic protein-2; DBM, demineralized bone matrix.
Fig. 5. Radiographic and clinical outcomes at 1 year following bone reconstruction. (A) Plain radiographs demonstrating complete consolidation of the reconstructed tibial segment and bone union, with no evidence of infection recurrence. (B) Computed tomography images confirming complete cortical bridging and consolidation of the grafted segment across all planes, consistent with solid bone union. (C) Clinical photograph demonstrating independent ambulation and performance of the illustrated functional activities at 1 year postoperatively.
Fig. 6. Chronological treatment timeline of the reported case.
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Reconstruction of a 20-cm tibial bone defect after recurrent fracture-related infection using the induced membrane technique and rhBMP-2 augmentation with limited autogenous bone availability: a case report
| Variable | Pre-debridement culture | Post-debridement culture | |
|---|---|---|---|
| 1st Debridement | IMP 4 | No growth | No growth |
| IMP 3 | MRSA | No growth | |
| IMP 2 | MSSA | No growth | |
| IMP 1 | MSSA | MSSA | |
| EMP lateral 1 | MSSA | MSSA | |
| EMP lateral 2 | MSSA | No growth | |
| EMP lateral 3 | MSSA | No growth | |
| EMP lateral 4 | MRSA | No growth | |
| EMP lateral 5 | MSSA | No growth | |
| EMP middle | MSSA | No growth | |
| EMP medial 1 | MSSA | No growth | |
| EMP medial 2 | MSSA | MRSA | |
| Center proximal | MSSA | Not separately sampled |
|
| Center 1 | MSSA | MSSA | |
| Center 2 | MSSA | No growth | |
| Center anterior | MSSA | Not separately sampled |
|
| Center posterior | MSSA | Not separately sampled |
|
| Center distal | MSSA | Not separately sampled |
|
| IMD | MSSA | MSSA | |
| EMD | MSSA | No growth | |
| Pus 1 | MSSA | NA |
|
| Pus 2 | MSSA | NA |
|
| Pus 3 | MSSA | NA |
|
| 2nd Debridement | IMP 4 | No growth | No growth |
| IMP 3 | No growth | No growth | |
| IMP 2 | MSSA | No growth | |
| IMP 1 | No growth | No growth | |
| EMP lateral 1 | No growth | No growth | |
| EMP lateral 2 | No growth | No growth | |
| EMP lateral 3 | No growth | No growth | |
| EMP lateral 4 | No growth | No growth | |
| EMP lateral 5 | No growth | No growth | |
| EMP middle | No growth | No growth | |
| EMP medial | MSSA | No growth | |
| Center 1 | No growth | No growth | |
| IMD | No growth | No growth | |
| EMD | No growth | No growth | |
Table 1. Microbiological culture results and antibiotic regimens from the first and second debridement procedures
Antibiotic regimen after 1st debridement, Vancomycin × 6 wk → 2-wk drug holiday; Antibiotic regimen after 2nd debridement, Cefazolin × 6 wk → 2-wk drug holiday. IMP, intramedullary proximal; MRSA, methicillin-resistant a)Not separately sampled; this site was included in the center 1 and center 2 post-debridement cultures. b)Not applicable; no pus was present, so no specimen could be obtained. c)All second post-debridement cultures were negative.
