Single-Stage Reamed Intramedullary Nailing for the Management of Infected Tibial Nonunion: A Preliminary Case Report

Abstract

Background: Complex cases are now recognised within the standardised diagnostic framework for Fracture-related Infection (FRI), which often leads to prolonged morbidity and reduced quality of life for patients. Managing infected tibial nonunions is among the most challenging issues in orthopaedic surgery. Aim: To report the preliminary outcomes and surgical technique of a single-stage salvage strategy for a chronically infected tibial nonunion using aggressive mechanical debridement, sequential reaming, and autologous bone grafting in a resource-limited clinical setting. Presentation of Case: A 61-year-old male presented with a non-healing wound, exposed hardware, and serosanguinous discharge on his left middle tibia, following a complex surgical history since 2018, including multiple ORIFs and external fixation. Clinical examination and laboratory tests (elevated WBC, ESR, and CRP) confirmed a chronic, low-grade FRI. The patient underwent a single-stage procedure involving removal of the colonised plate, aggressive debridement until the "paprika sign" was observed, and sequential intramedullary reaming. Stability was achieved using a reamed intramedullary nail, supplemented by an autologous cancellous bone graft harvested from the proximal tibia and a chipping osteotomy to create a "biological chamber" for healing. Discussion: At the two-month follow-up, the surgical wound has healed by primary intention without recurrent sinus tracts. While radiographic union is pending and inflammatory markers remain elevated, this case suggests that a single-stage approach may provide a feasible pathway for combining rigid internal stability with biological restoration in specific clinical scenarios. The transition to a load-sharing intramedullary nail follows the Rittmann Principle, where stability serves as a potent anti-infective measure. Aggressive debridement and sequential reaming were critical for biofilm disruption, while the chipping osteotomy and autograft provided a necessary osteogenic environment. Conclusion: A single-stage protocol involving aggressive debridement and chipping osteotomy is presented as a potentially viable and cost-effective alternative for managing infected tibial nonunions when advanced antimicrobial hardware is unavailable. However, its long-term efficacy remains to be confirmed, and prolonged follow-up is mandatory to ensure definitive union and eradication of infection.