Figure 6

(a) A 24-year-old female patient sustained a recalcitrant infected nonunion of the left tibia. (b) According to the Multi-staged IMT protocol, we performed thorough debridement, placed an antibiotic-loaded PMMA spacer, and provided temporary bony stabilization. Soft tissue defects were covered using an anterolateral thigh flap (stage 1). (c) As PDCP had been identified at EMP and IMP (pseudomonas and MRSA), targeted debridement at proximal area of bone defect (red arrow head, sequestrum) and temporary fixation using antibiotics loaded PMMA coated intramedullary rod was performed (repetitive stage1). (d) After confirming all PDCN at previous stage, definitive fixation using IM nail was performed. An antibiotic-loaded PMMA spacer was reinserted into the bone defect for staged bone grafting to confirm that the infection had been eradicated (stage 2). Prompt partial weight bearing exercise was allowed after definitive fixation. (e) The 6-cm sized segmental bone defect was filled with autogenous bone (45 g) and DBM (15 g) in induced membrane chamber (yellow arrow head) at 16 weeks after stage 2 (stage 3). (f) Two years follow up radiographs show complete consolidation of the grafted bone without recurrent infection. The injured limb recovered to full function.