In amputation or amputation-like injuries of lower limbs, only in a few cases reconstructive treatment with microsurgery is encouraged, according to evaluation of lesion by Mangled Extremity Severity Score (MESS). Replantation cases may require substantial bone shortening, as consequence to seriousness of the trauma or a deliberate choice to enable primary vessel and nerve repair. Callus distraction technique by external fixation, circular or axial, is a common method for recover lengthening in these cases of replanted or revascularized extremities.

We report six cases of lower limb replantation or revascularisation, with primary bone shortening from 3 to 7 cm and secondary lengthening by callus distraction.

It was always obtained equalization of lower extremities, with successful rehabilitation of the patients and low onset of complications during treatment.

In the last few years the study of the biology of fracture repair processes has isolated chemical mediators that induce and modulate bone repair. In orthopaedic surgery and traumatology, in cases of unsuccessful fracture setting, loss of bone and in the treatment of bone cavities it is advisable to associate a biological substitute in order to restore bone continuity and to maintain the mechanical properties of the skeletal segment.

Platelets contain several growth factors (PDGF, TGFβ, EGF, IGF) capable of stimulating the proliferation of mesenchymal and mature cells such as fibroblasts and osteoblasts. The autologous platelet gel is obtained by separating and concentrating platelets from 450 ml of a patient’s blood. This procedure is simple, with a low risk of infections. It is free of immunogenic risk and it is comparatively cheap, considering the risk connected with a possible graft of homologous bone or with the use of allo- or xenograft.

From 2003 we applied autologous platelet gel in eight patients: two cases of humerus pseudoarthrosis for exposed and plurifragmentary fractures, one with vascular and nerve injury; one forearm infected pseudoar-throsis with loss of bone and soft tissues caused by local drug injections; one infected ulnar pseudoarthrosis for high energy exposed proximal forearm and elbow fracture; one distal radius non-union after sub-amputation of distal forearm; one distal radius resection for TGC and implant of allograft epiphysis; one massive osteomyelitis of entire forearm after exposed distal radius fracture; and one humerus fracture in re-implanted arm with elbow arthrodesis.

The patients were treated with surgical curettage of bone, iliac bone graft and autologous platelet gel; two received a vascularised fibular graft, all stabilised with internal fixation and six stabilised also with external fix-ation. They were immobilised for a mean of 3 months; then with a partial tutor they started physiotherapy. At the follow-up they were evaluated clinically and radiologically and with the DASH score.

None of the patients had local or general post-operative complications; X-ray showed the restoration of regular skeletal filling. Only in one case was bone reabsorption seen in the distal humerus. All patients were satisfied and four of them returned to their pre-surgical occupation.

The results of this application are difficult to standardise because of the complexity of each case. Imaging techniques are currently the only means to validate the remodelling process and to demonstrate its faster pace with platelet gel application. We are satisfied by the use of autologous platelet gel as a possible co-treatment in cases characterised by multiple surgical treatments with inactive pseudarthrosis and osteoepenia. The application is also simple, and the cost is relatively low with respect to the results obtained.

Enchondroma of the hand is a common benign tumour composed of mature cartilage; it is usually asymptomatic and found accidentally or after pathologic fractures. Malignant transformation may occur, though only very rarely. The age of the patients varies widely. The small bones of the hand are the most frequent anatomic site for this pathology.

Enchondromas are conventionally treated by curettage and the bone defect is then filled with morceellised autologous bone chips from the iliac crest or with an allograft. Recently, bone substitutes have also been used instead of autologous or allogenic bone graft.

Calcium phosphate cement is a promising injectable biomaterial able to increase the number of osteoblasts without inducing a marked de-differentiation, an effect that is useful when a high number of bone forming cells are required. This bone substitute has been used successfully for the treatment of distal radius fractures and or mal-unions, femoral neck fractures, tibial plate fractures, complex calcaneal fractures and enchondromas.

From 2001 we treated 12 patients who were diagnosed as having solitary enchondromas, nine in the hand (four metacarpal bones and five finger bones); 6 patients had an associated pathologic fracture that occurred as a result of simple trauma. A surgical treatment with a complete removal of the tumour and the injection of Norian SRS cement into the cavity and fluoroscopic control was performed as a standardised procedure in all cases. The patients allowed to perform complete range of motion 3 weeks after surgery. At follow-up they were evaluated by clinical examination, X-ray and the DASH questionnaire.

None of the patients had swelling or deformity or tendon injuries or wound infection. Four patients had a slight loss of flexion at the MF joint but none considered this a functional limitation; all the others regained a complete ROM. All the patients returned to their presurgical occupation. Five of them complained of a hypertrophic scar. The X-ray showed a complete fill of the bone gap. They were satisfied and the mean DASH score was 6.06.

Clinical results have been reported with simple curettage without bone grafting or bone substitutes, but these two elements minimise the volume of the bone defect, maintain bone strength and promote new bone formation. Autologous bone graft caused pain in the donor site. Reconstruction of the tumour cavity provides immediate mechanical stability and good functional outcome.

Various kinds of bone have been used as a donor for vascularised bone grafts (VGF) to the upper extremities; among them the fibula has been widely used because of its structural characteristics and low donor site morbidity. Vascularised fibular graft is indicated in patients with large bone defects, bone tumour resection, established or infected non-union, congenital pseudarthrosis, avascular necrosis or bone defects surrounded by scarred, infected and poorly vascularised soft tissue or failure of conventional techniques.

Between 1994 and 2003 nine patients were treated with vascularised fibular graft (VFG) and five for reconstruction of upper extremities defects, following trauma of the forearm with failure of conventional treatments. Four were male and one were female; the mean age was 32 years; the reconstructed sites were four radius and one ulna. The mean lengths of the bone defect was 9 cm. All patients were evaluated pre-operatively with angiography and/or magnetic resonance imaging. Two patients had a concomitant arthrodesis of the wrist. The bone graft was stabilised with plates (AO/LCP), screws, K-wires and the forearm was immobilised in plaster or with external fixation for several months. Cancellous iliac bone graft was packed about the proximal and distal junctions. In two recent cases autologous platelet gel was added at the sites of fixation.

Bone healing was assessed clinically by the absence of pain and mobility on stress, and radiologically. Patients’ satisfaction and function results were assessed by the DASH questionnaire. After an average duration of follow-up of 48 months (from December 1996 to December 2003), all but one of the patients had radiographic evidence of osseous union of both bone junctions. All wounds healed primarily and no patient had problems related to the donor leg. Three patients had returned to their pre-injury occupation.

Vascularised fibula transfer is a valuable technique for the reconstruction of extensive long-bone defects in the upper extremities. The fibula allows a transfer of a bone that is structurally similar to the radius and is of sufficient length for the reconstruction of most skeletal defects in the forearm. In these serious forearm injuries, rapidity of fracture healing is not the primary issue, but rather control of infection and bone stability. The only disadvantage of VFG is that it is more costly; because more technical expertise is required for the microvascular work and the operating time is extended. The reliability and the value of vascularised fibula transfer will increase, with further experience, careful patient selection and appropriate pre and post-operative technical details.