Combination of pedicled fibular graft and latissimus dorsi free flap in complex tibial bone defect reconstruction after high-energy trauma: a case report

High-energy open tibial fractures with segmental bone loss and extensive soft-tissue necrosis remain limb-threatening, especially when only one recipient artery is patent. We report a 37-year-old man with a Gustilo-Anderson type IIIB open distal tibial fracture, posterior tibial artery injury, a 7-cm tibial defect and a 14 x 25 cm soft-tissue defect after serial debridement. After emergency external fixation and revascularization, the wound was optimized with repeated debridement and circumferential negative-pressure wound therapy. Definitive reconstruction used a vascularized pedicled fibular graft from the injured leg to bridge the tibial defect, combined with a latissimus dorsi free flap for coverage; the thoracodorsal artery was anastomosed end-to-side to the posterior tibial artery under 3D magnification. The flap survived without infection or secondary necrosis, allowing early rehabilitation with stable coverage and maintained alignment.