case_images: PMC11720336_01
case_images: Initial fracture 2016-2017. June 2016, 3 months after the initial fracture. The pins have been removed owing to septic arthritis and osteomyelitis. The fracture remains unstable with marked bone destruction (A); 1 year after the initial injury the fracture and osteomyelitis had healed but resulted in a marked tibial slope with gradually increasing varus deformity and leg length discrepancy. A medial physeal bony bridge was noted (B)
case_images: 13256_2024_5022_Fig1_HTML.jpg
case_images: PMC11720336_01_13256_2024_5022_Fig1_HTML.jpg
case_images: Fig1
case_images: The pins were subsequently removed, the arthritis drained, and intravenous antibiotics treatment was commenced (Fig. 1A). However, the healed fracture did result in a medial slope in the tibial physis, a varus deformity of 30 , and leg length discrepancy (Fig. 1B).
case_images: Pseudoarthrosis 2022. Almost 8 years after the initial fracture, in August 2022, a surgical correction with a tibial osteotomy was performed. The osteotomy was stabilized with a total of four percutaneous pins (A). The pins, in combination with a chevron osteotomy, were chosen with the intention of increasing stability and decreasing the risk of implant infection. Despite this a pseudoarthrosis developed that was eventually infected. In an ambition to retain stability, a titanium elastic nail was inserted in January 2023 (B)
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case_images: PMC11720336_01_13256_2024_5022_Fig2_HTML.jpg
case_images: Fig2
case_images: The osteotomy was stabilized with a total of four percutaneous pins (Fig. 2A). In January 2023, the pins were removed in the operating room, but the osteotomy remained unstable and was stabilized with an intramedullary titanium elastic nail (Fig. 2B), and 2 weeks later the patient presented again at the ED with a suspected osteomyelitis and wound infection around the nail entry point.
case_images: Post-surgery with CERAMEMT  V 2023. X-ray post-surgery in March 2023, with extensive debridement and implantation of CERAMENT  V with vancomycin
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case_images: PMC11720336_01_13256_2024_5022_Fig3_HTML.jpg
case_images: Fig3
case_images: In an attempt to promote healing, the patient underwent an extraction of the nail, open debridement, and implantation of CERAMENT  V with vancomycin (Bonesupport AB, Lund, Sweden) in March 2023 (Fig. 3).
case_images: Single-photon emission computed tomography/computed tomography and magnetic resonance imaging. Healed fracture in October 2023. Perfusion scintigraphy with single-photon emission computed tomography/computed tomography of the lower extremities performed 15 minutes after intravenous injection of (99mTc)-tetrofosmin. The sensitivity factor of the camera detector was derived using phantom measurements to semi-quantify the perfusion. The fracture area was segmented on the basis of low-dose computed tomography images, and the proportion of a given activity in an area was calculated. Before the treatment, 0.13% of given activity was measured per 100 mL volume in the fracture area (A). After treatment, perfusion has decreased in both visual assessment and semi-quantification, which measured 0.09% of given activity per 100 mL volume (B). The magnetic resonance imaging verified bony union and no signs of infection, represented by a coronary short-tau inversion recovery sequence (C)
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case_images: PMC11720336_01_13256_2024_5022_Fig4_HTML.jpg
case_images: Fig4
case_images: The SPECT/CT revealed slightly decreased perfusion in the affected tibia after HBOT, which can be expected with a healed infection (Fig. 4).