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Treatment Methods for Tibial Fracture Defects

- Discussion: 
     - see tibial non unions
     - OTA classification:
           - type I is there is loss of 50% of circumference of bone and less than 2 cm defect;
                    - consider exchange nailing
                    - ref: Critical-sized defect in the tibia: is it critical? Results from the SPRINT trial.
           - type2 if there is loss of more than 50% of circumference of bone (and/or fractures with gaps of 2-6 cm)
                    -  bone grafts or bone graft substitutes in addition to reamed exchange nailing
           - type 3 if there is a missing bone segment (more than 6 cm defect)
                    - requires bone transport techniques;
      - timing:
consider bone grafting at 6 weeks post injury;
The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury.
                    - Early prophylactic bone grafting of high-energy tibial fractures. 
                    - Study finds 47% primary union rate in tibia patients with ‘critical-sized’ bone defects
                    - Current Practice in the Management of Segmental Bone Defects Among Orthopaedic Trauma Surgeons.

- Treatment Options:
    - tibial bone grafting (bone graft harvest technique)
            - papineau technique:
                      - Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases.
            - posterolateral bone grafting
                      - tibial-fibular synostosis using cancellous bone may be indicated in some cases;
                      -  ref: Posterolateral bone graft of the tibia.
            - osteogenic proteins
            - cancellous bone grafting: / bone graft harvest technique:
                      - some recommend adding powered antibiotic to the cancellous graft;
                      - w/ defects less than 6 cm iliac crest bone grafting may be sufficient;
                      - ref: Autologous marrow injection as a substitute for operative grafting of tibial nonunions. 
            - synthese reamer aspirator

    - induced membrane:
    - free fibular transfer;
            - w/ defects greater than 6 cm, free fibular transfer from contralateral leg is indicated;
            - see free fibular harvest;
    - bone transport methods:
            - distraction histiogenesis
            - limb lengthening fixators
            - tibial lengthening
            - references:
                       - Segmental tibial defects. Comparing conventional and Ilizarov methodologies.
                       - Skeletal defects. A comparison of bone grafting and bone transport for segmental skeletal defects.
                       - Treatment of traumatic bone defects by bone transport.
                       - Distraction osteogenesis after acute limb-shortening for segmental tibial defects. Comparison of a monofocal and a bifocal technique in rabbits.
                       - Ilizarov bone transport treatment for tibial defects.
                       - Functional Outcome Following Bone Transport Reconstruction of Distal Tibial Defects. 
                       - Complications Encountered During Lengthening Over an Intramedullary Nail 
                       - Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases.
                       - Distal Tibial Reconstruction with Use of a Circular External Fixator and an Intramedullary Nail. The Combined Technique  

            - fibular transport:
                   - in the report by Atkins RM, et al (1999), the authors discuss a method of tibialisation of the fibula (for massive tibial bone loss) using the Ilizarov fixator system;
                    - all had successful transport, proximal and distal union, and hypertrophy of the graft without fracture;
                    - one developed a squamous-cell carcinoma which ultimately required amputation of the limb;
                    - advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or anastomoses;
                    - references:
                            - Ipsilateral fibular transposition in tibial nonunion using Huntington procedure: a 12-year follow-up study.
                            - Ipsilateral vascularised fibular transport for massive defects of the tibia. 
                            - Ipsilateral pedicle vascularized fibula grafts for reconstruction of tibial defects and non-unions. 
                            - Reconstruction of Bone Defects After Osteomyelitis with Nonvascularized Fibular Graft: A Retrospective Study in 25 children

Acute and definitive management of traumatic osteocutaneous defects of the lower extremity.
Management strategies for bone loss in tibial shaft fractures.
To Reconstruct or Not to Reconstruct?
Adult posttraumatic osteomyelitis of the tibia.
Management of Combined Bone Defect and Limb-length Discrepancy After Tibial Chronic Osteomyelitis