Hybrid “Parhar Salvage” technique for infected proximal tibia nonunion in an adolescent: A complex limb salvage strategy combining Masquelet, flap coverage, and hybrid fixation

Abstract

Infected nonunions of the proximal tibia in adolescent patients represent a complex clinical problem due to the combination of segmental bone loss, chronic osteomyelitis, and compromised soft-tissue envelope. These cases demand a carefully planned, multistaged reconstructive approach to achieve limb salvage, infection control, and functional recovery. We report the case of an 18-year-old male presenting with a chronically infected nonunion of the proximal tibia following two failed surgeries for fracture fixation. The patient exhibited persistent pain, draining sinuses, and instability, with radiographs showing extensive metaphyseal bone loss and sequestrum formation. Stage 1 involved aggressive surgical debridement, removal of all infected hardware and necrotic tissue, followed by application of a knee-spanning external fixator and placement of an antibiotic-impregnated polymethyl methacrylate cement spacer as part of the Masquelet technique. After that, Stage 2 was performed, which included insertion of a fibular strut graft and autologous iliac crest cancellous graft within the induced membrane. A long lateral locking compression plate was used for internal fixation, augmented with medial and anterior external rods to form a hybrid construct. A gastrosoleus flap was used to achieve soft-tissue coverage over the anterior tibial defect. The patient was followed-up for 2 years postoperatively. Radiographic evaluation confirmed complete osseous union, incorporation of the fibular graft, and maintenance of limb alignment. The flap healed without complication. Mild equinus deformity due to soft-tissue scarring was corrected with tendo-Achilles lengthening.