Managing Bone Defects

Abstract

The management of bone defects caused by trauma and nonunion continues to represent a substantial clinical challenge in the management of orthopaedic trauma patients. A variety of treatment options have been described and reported in the literature. The relative rarity of these injuries means that high level, comparative evidence to guide their management is sparse. As such, treatment decisions must be based on knowledge of the available evidence, contemporary fracture management principles, and consideration of patient and surgeon factors. This article reviews the available evidence for the different treatment options available for the management of bone defects.

Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects

“…Bone transport is characterized by the gradual translocation of a segment of bone, often together with its surrounding soft tissue envelope, from an adjacent healthy area into the region of bone loss [1,4,5,7,[9][10][11][12][36][37][38][39][40][41][42][43] . A low energy osteotomy or corticotomy [29,30,49] is performed at a location outside the zone of injury, and the external fixator used to gradually transport the bone segment under carefully controlled mechanical conditions.…”

“…Distraction histogenesis [25,[28][29][30] techniques and methods using external fixation for gradual correction have dramatically expanded the options available for the treatment of tibial non-unions and associated bone defects [1,2,[9][10][11][12]23,[31][32][33][34][35] . These methods, pioneered by Ilizarov [29,32] , have been used successfully outside Russia for over 30 years [1,2,15,16,[34][35][36] .…”

“…The Ilizarov method for the treatment of tibial non-unions associated with bone defects generally involves bifocal or trifocal osteosynthesis [1,34] , compressing bone at one level to achieve union while simultaneously applying distraction to the same bone at another level to regenerate bone mass. These Ilizarov methods of limb salvage include both bone transport [1,4,5,7,[9][10][11][12]34,[36][37][38][39][40][41][42][43] and acute shortening/lengthening [5,[7][8][9]36,[44][45][46][47][48] .…”

“…Acute shortening/lengthening is characterized by shortening of the limb through the region of the bone defect itself, and can be performed acutely, gradually, or as a combination [5,[9][10][11][12]36,[44][45][46][47][48] . The shortened limb is concurrently lengthened to equalize limb lengths through bifocal osteosynthesis, analogous to the technique used for bone transport.…”

“…There are several treatment options available to manage patients who have tibial non-unions with bone defects in the presence or absence of infection [1,[9][10][11][12][13] . These include cancellous bone grafting [4,[14][15][16] , Papineau open cancellous bone grafting [17] , vascularized free-tissue transfers [18][19][20] , and combined approaches with both microvascular tissue transfers and bone grafts [3] .…”