Publication:

One-stage management of bilateral polymicrobial tibial fracture-related infection using Ilizarov fixation and staged reconstruction

Fracture-related infection (FRI) is a serious complication of high-energy open tibial fractures, particularly Gustilo–Anderson type IIIb injuries. Simultaneous bilateral tibial FRI caused by multidrug-resistant (MDR) gram-negative organisms is exceptionally rare and poses major reconstructive challenges. We report a 34-year-old obese male smoker who developed acute bilateral tibial FRI following bilateral Gustilo IIIb tibial fractures and a displaced left femoral-neck fracture that had been initially stabilized elsewhere using temporary monolateral external fixation. During a single hospital admission at our tertiary center, management included radical bilateral debridement with multiple deep-tissue cultures, high-volume irrigation, and application of bilateral Ilizarov circular external fixation, followed by early split-thickness skin grafting, culture-directed intravenous antibiotics with subsequent oral therapy, and delayed cementless total hip arthroplasty (THA). Deep cultures from both tibiae grew MDR Klebsiella pneumoniae and Acinetobacter baumannii, both sulbactam-susceptible, fulfilling the confirmatory criteria of the FRI Consensus Group. The patient received five weeks of intravenous cefepime–sulbactam followed by seven weeks of oral levofloxacin (total 12 weeks). The Ilizarov frames provided stable fixation and supported mobilization, and THA at week eight restored limb length and hip function. The frames were removed at six months, and radiographs confirmed complete bilateral union at one year. At two years, the patient remained infection-free, had returned to full work duties, and demonstrated excellent functional outcomes (Harris Hip Score 93; AOFAS Ankle–Hindfoot 88 and 90), with only minor pin-site infections managed conservatively. This case adds evidence that coordinated single-admission staged reconstruction can achieve durable infection eradication, fracture union, and high functional recovery even in bilateral MDR tibial FRI.