A complex tibial fracture-related infection (FRI) after local-flap failure may require staged source control, dead-space management, and vascularized soft-tissue reconstruction. A 60-year-old man with type 2 diabetes developed FRI after an industrial injury causing a localized incomplete open tibial fracture with preserved alignment and no large segmental bone defect. Previous debridements, cement-based dead-space management, negative-pressure wound therapy, and soleus muscle-flap transfer failed. On 4 June 2026, repeat radical debridement was followed by temporary vancomycin-loaded polymethylmethacrylate for dead-space management. On 25 June, the cement was removed, repeat debridement was performed, and a 16 cm × 7 cm defect with exposed tibia and tendon and a large proximal dead space was reconstructed using a chimeric anterolateral thigh–vastus lateralis free flap. No additional skeletal reconstruction was required. At 9.5-week follow-up, the flap remained fully viable with stable coverage; CRP was 2.0 mg/L, IL-6 was 3.8 pg/mL, and ESR was 22 mm/h. This case illustrates a staged orthoplastic salvage strategy after local-flap failure. Longer follow-up is required to confirm definitive infection control, fracture union, and function.

Background/Objectives: Andersson lesions are uncommon discovertebral complications of ankylosing spondylitis and may be overlooked when a new mechanical pain pattern is attributed to chronic inflammatory disease. This report describes the diagnostic reasoning, operative decision-making, and short-term outcome of a severe lumbar lesion with three-column instability. Methods: A 38-year-old woman with a 15-year history of ankylosing spondylitis presented with progressive low-back pain, left L5 radiculopathy, and marked functional decline without major trauma. Radiographs, computed tomography, and magnetic resonance imaging were used to characterize the lesion and assess spinal instability and neural compression. A Cawley type E Andersson lesion at L4/5 with severe three-column instability was diagnosed. The patient underwent single-stage posterior–anterior circumferential reconstruction consisting of L4/5 decompression, long-segment L2-S2 fixation, anterior debridement, and tricortical iliac crest grafting. Results: A postoperative gastrocnemius intramuscular venous thrombosis was detected and treated with anticoagulation. At 3 months, the activity-related visual analog scale score improved from 8 to 1, the Oswestry Disability Index improved from 68% to 18%, independent ambulation was restored, and imaging showed stable instrumentation with progressive osseous bridging. At the latest 9-month telephone follow-up, the patient reported maintained pain relief, mobility, and daily function; no new imaging was available. Conclusions: A change from inflammatory to mechanical pain or the development of neurologic findings in ankylosing spondylitis should prompt targeted imaging for an Andersson lesion. In carefully selected patients with severe three-column instability and substantial anterior column deficiency, circumferential reconstruction may provide effective short-term stabilization and functional recovery. Because radiographic follow-up was limited to 3 months, definitive fusion and long-term construct durability cannot be established.