BACKGROUND Type IIIB open bone fractures include loss of soft tissue with periosteal stripping and need rapid surgical repair. The Ilizarov method of bone lengthening and reconstruction offers limb salvage as an alternative to amputation. CASE REPORT We report a case of a neglected type IIIB open fracture of the tibia with inadequate soft tissue coverage and periosteal stripping requiring an Ilizarov approach for limb salvage in a 65-year-old woman. Surgical debridement resulted in a large bone deficit of 13 cm. Acute shortening facilitated wound closure, and the remaining skin defect was treated with skin grafting. Bone transport and limb lengthening techniques, in addition to skin expansion and support, were used to restore the length of the tibia. The regenerated bone had to be fused with the talus since the tibial plafond was excised during debridement. The external fixator was removed after 643 days of treatment. An external fixation index of 49.6 d/cm was estimated. Excellent bone and good functional results were obtained according to the criteria of the Association for the Study and Application of the Method of Ilizarov. Skin invagination, bone translocation, and pin tract infection were the major postoperative issues. CONCLUSIONS This case showed that a multidisciplinary approach may be required for the successful management of neglected open fractures of the tibia and that the Ilizarov approach to both bone and soft tissue lengthening and reconstruction should be considered to ensure limb salvage and improve the final cosmetic appearance.