Review Question - QID 211133

A 32-year-old male sustained a right grade IIIB open tibial shaft fracture 10 months ago when he fell down a ledge while hiking. Due to the location of the injury, it took EMS 15 hours to transport the patient to the ED, where IV antibiotics were promptly started. Subsequently, the patient underwent external fixation with serial debridements followed by definitive flap coverage and unreamed intramedullary nailing six days after the injury. The patient continues to have pain in the leg with weight-bearing but denies any fevers or chills. His surgical wounds appear well-healed with a small sinus tract over the open fracture site. Figures A and B are the current radiographs. Recent labs reveal an ESR, CRP and 25-hydroxyvitamin D2 of 32 mm/hr (reference 0-20 mm/hr), 15 mg/dL (reference 0-3 mg/dL), and 50 ng/mL (reference 20-100 ng/mL). What factor is most likely associated with this patient's current condition?