From Discrete Patching to Continuous Deformation: Viscoelastic Boundary Control in Infected Distal Tibial Nonunion
Chi-Ming Chiang
Chi-Ming Chiang
1) Center for General Education, Chung Yuan Christian University, Taiwan, China.
2) Department of Orthopedics, Chon-Inn Hospital, Chon-Inn Medical Corporation, Taiwan, China.
Infected nonunion of the distal tibia represents a dual failure mode: a stochastic biological void
(infection, necrosis, and bone loss) and a geometric boundary deficit (a soft-tissue envelope that cannot
be closed). Conventional reconstruction often treats the soft-tissue problem as an additive filling task,
typically combining a vascularized flap with split-thickness skin grafting (STSG) or negative-pressure
wound therapy (NPWT). We report a resource-sparing alternative framed as viscoelastic boundary
control. A middle-aged woman presented with an infected, draining nonunion of the distal third tibia.
After radical debridement to bleeding bone and culture-guided antibiotics, structural continuity was
restored using autologous mid-shaft fibular corticocancellous struts. A distally based medial hemisoleus
flap, pivoting on distal posterior tibial perforators, provided reliable vascular coverage. Instead of STSG
or NPWT, stepwise bedside dermatotraction was applied using reinforced adjustable ties constructed
with doubled-suture NICE knots, tightened in 1-3 mm increments under vigilant perfusion monitoring.
Progressive approximation culminated in delayed primary closure with complete epithelialization,
preserved flap viability, and satisfactory cosmesis. This case illustrates how converting a spatial deficit
into a time-domain problem can exploit skin stress relaxation and creep to achieve a topologically
continuous closure, potentially reducing donor-site morbidity and interface complexity in biologically
compromised distal tibial reconstruction.
