Purpose: Reconstruction of massive bone loss with cancellous bone deposited in a pseudomembrane induced by a cemented strut was performed in 40 procedures. We evaluated the 5-year results of this technique for the treatment of gaps measuring more than 5 cm.

Material and methods: We reviewed 12 patients; all had suffered major loss of tibial bone. The operations consisted in resection, insertion of a cement strut, and closure with a local are free flap over he disinfected soft tissues. The second operation at least two years later used a fragmented autologous cancellous graft leaving the membrane intact. The fibula was used as a tutor whenever possible. Bone losses measured 5 to 25 cm in young men who had infection after trauma or, in one patient, tumour resection. We analysed clinical and radiological outcome.

Results: All patients were seen five to ten years after initial management. At last follow-up, all wounds had dried and bone healing was solid. All had required secondary repeated grafts, realignment surgery (for valgus and varus) or operations related to the initial injury (arthrodesis, claw toe). Generally, the patients had resumed their occupational and recreational activities. The walking distance was not limited and single leg stance was painless. The radiological analysis demonstrated a trend towards graft tubulisation.

Discussion: The stut technique using cement induces the formation of a pseudo-synovial membrane. This technique has been used for more than ten years in our unit to treat circumferential defects. Bone healing was achieved in all patients. The main complication was valgus malalignment which almost always requires surgical correction. Rapid healing is not a function of the extent of the gap but rather the radical nature of the resection and the quality of the cover. This technique should be compared with other alternatives used to fill major bone gaps (Illizarov, vascularised bone transfer).

Purpose: Demonstrate the importance of surgical repair of soft tissue damage in an orthopaedic surgery unit.

Material and methods: This retrospective study included 455 patients who underwent soft tissue flap surgery between April 1980 and April 2000. There were a total of 556 flaps, hand and finger flaps were excluded from the analysis. Overall results concerning the general treatment for the underlying conditions was not analysed. There were 132 women and 313 men, mean age 42 years. Among these patients 276 (60%) were referred from other hospitals for secondary care. Most of the tissue damage (373 patients among the 455) concerned the lower limb. The soft tissue loss was part of a bone and joint problem in most cases, including: septic nonunion and osteitis (189 patients), trauma and complications after planned orthopaedic surgery (74 patients), grade IIB or IIIC open fractures according to the Gustilo classification (66 patients). There were a total of 485 pediculated or fasciocutaneous muscle flaps and 71 free flaps.

Results: Flap survival rate was 90.32%. The result was total necrosis of the flap in 9.68%. The rate of failure was 30% for free flaps and 5% for pediculated flaps.

Discussion: This study demonstrated the usefulness of surgical care of soft tissue damage in an orthopaedic surgery unit, particularly for trauma and infection patients. The large number of pediculated flaps is an expression of the reliability of this technique easily applied in a polyvalent orthopaedics traumatology unit. The high rate of failure for free flaps is related to the inherent risk of secondary repair and the inflammatory or infected nature of the soft tissues and also the difficulty encountered in controlling this type of surgery under such conditions. The data reported here allow individual analysis by type of pathology.

Conclusion: Overall management of bone and joint disease patients requires proper skill in soft tissue repair.