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A 34-year-old woman developed Staphylococcus aureus osteomyelitis after intramedullary rodding of a tibia fracture.
 FIG. 16-37. The bony infection was debrided and the patient was placed in external fixation. A large tibial defect was present. External wound.
 FIG. 16-38. X ray of bony defect.
 FIG. 16-39. The contralateral fibula and the lateral half of the soleus muscle were selected for bone reconstruction and tension-free vascular wound closure.
 FIG. 16-40. The right fibula and hemisoleus were isolated on the peroneal artery as a single myosseous transplant. Donor leg skin markings, midlateral approach.
 FIG. 16-41. Fibula ready for transfer.
 FIG. 16-42. Transferred to the opposite leg, the pedicle was anastomosed end-to-end to the anterior tibial vessels, and the fibula fixed in place with screws.
 FIG. 16-43. Early postoperative follow-up shows complete survival of the muscle, and blood flow by bone scan in the fibula at 4 days showed good uptake in the fibula.
 FIG. 16-44. Early x ray of graft.
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 FIG. 16-45. Late follow-up shows a healed wound at 3 years, with hypertrophy of the fibula wound.
 FIG. 16-46. X ray.
 FIG. 16-47. The donor scar is minimal and the patient is ambulatory with a cane.
 FIG. 16-48. The patient is shown walking. Unfortunately, she developed a stress fracture, which healed with additional bone grafts and prolonged casting. Such fractures in fibular grafts are common. Prolonged splinting is needed to protect the graft until it has hypertrophied, usually for over 2 years.
CASE 6
A 6-year-old boy developed osteomyelitis after an open tibial fracture.
 FIG. 16-49. Despite combined surgical drainage and long-term antibiotics, a large bony sequestrum remained, as shown in x ray.
 FIG. 16-50. The wound was widely debrided and closed with a free gracilis flap. Wound is shown after debridement.
 FIG. 16-51. A gracilis muscle transplant was used to fill the defect, help control infection, and close the wound.
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