Eradication of infection was achieved with wound excision, removal of all poorly vascularized bone, hardware removal, culture-specific antibiotics, stability, and wound closure. The external fixator was used with pin fixation maintained outside the zone of infection. The rings were manipulated to allow for a tension-free wound closure with no regard for the position of the bone ends. A fibular resection was performed to allow for shortening of the defect site independently from the future lengthening site. This also assisted with wound closure.

Five deep soft tissue cultures were sent for aerobic, anaerobic, fungal, and mycobacterial investigation. Intravenous antibiotics were started empirically and were altered based on sensitivities. The challenged soft tissue was allowed to heal for 2 weeks before gradually correcting the proximal deformity and shortening the bone defect site. The use of external fixation was critical for its ability to gradually move the bone and stretch soft tissues. The lengthening osteotomy was delayed to prevent contamination of the osteotomy site and to minimize stress on the soft tissues. The patient was encouraged to stretch the gastrocnemius and soleus muscles to prevent contracture during distal tibial lengthening. Acute closure of a contaminated wound is possible after a thorough debridement of all tissues.

See Figs. 3, 4, 5, 6, and 7.