The aims of the treatment of tibial infected nonunions with bone and soft tissue loss (generally consequent to open fractures) are: the healing of infection, the bone consolidation with preservation of lower limb length and the reconstruction of soft tissue loss. The epider-mato-fascio-osteoplasty according to Umiarov (a modification of bifocal or multifocal compression-distraction osteosynthesis) enables to treat wide areas of bone and soft tissue loss without a preventive sterilization of the infection neither soft tissues closure and without bone and skin grafts. An important point of the treatment is the prevention of complications such as: persistence of infection (due to an insufficient debridement), trouble in formation of bone regenerate and /or callus at the docking site (due to inadequate configuration of the external fixator, imperfect management of the phases of treatment, obstacles on bone transport), defect of skin coverage (due to an improper rate of bone and soft tissue transport), complications at the site of application of the device (inflammation or infection, breaking of the fixation elements), functional impairment (knee and ankle stiffness).

In the 54 patients treated the anatomical and functional results have been particularly favourable, thanks to an accurate preoperative planning and a careful postoperative management, diminishing the risks of complications.

Compression-distraction techniques (or circular external fixation methods) are a good alternative to other surgical methods based on bone grafts or bone substitutes, allowing “bone regeneration” through distractional osteogenesis and leading to a substantial advantage in the correction of long bone deformities, in selected bone tumours and in many types of non-unions.

Monofocal compression-distraction osteosynthesis is applied to correct long bone deformities in orthopaedics, basically through distraction epiphyseolisis, in which a gradual elongation of the epiphysis at the growth plate level is produced, and corticotomy-distraction, in which the gradual distraction is performed at metadiaphyseal level, after cortical osteotomy. In cases of hypertrophic non-unions (usually associated with limb shortening) the use of monofocal osteosynthesis basically relies on osteosynthesis with gradual distraction of the non-union site. These are cases where the fibrous or fibrocartilaginous tissue lying between the bone fragments is biologically active and gradual distraction highly affects its potential for regeneration.

Bifocal or plurifocal compression-distraction osteosynthesis is applied to correct wide bone defects through the technique of “internal lengthening” or “bone transport”. A corticotomy is performed at one of the two metaphyses of the affected long bone and the bone segment obtained by this corticotomy is gradually moved to fill the gap. In orthopaedics this technique shows its highest advantages in cases of bone tumours treated with segmentary resection, and in traumatology in atrophic non-unions and in infected non-unions with bone loss.

Between 1986 and 2003, distraction osteogenesis techniques were applied in 753 cases (638 patients) for several orthopaedic or traumatological problems. There were 430 men and 323 women. The average age was 24 years (min 3 years, max 48 years). The anatomical and functional results have been highly satisfactory, with a very low complication rate, and confirm the effectiveness of these techniques in selected cases in orthopaedics and traumatology.

Planning of surgical correction in sequelae of vitamin D-resistant rickets preliminarily requires the management of the metabolic defect with appropriate measures. In fact, surgery perfomed with the patient in a compensated metabolic condition greatly contributes to the prevention of recurrences.

The deformity most frequently observed is genu varum (where femur, tibia and fibula are usually all deformed), often combined with internal torsion. Compression-distraction systems (or circular external fixators) provide an easy control of the corticotomy fragments and a gradual correction of all kinds of deformity during the operative and post-operative phases. Careful pre-operative planning is necessary, which may require a multi-stage and/or a sequential strategy of management.

Between 1988 and 2002, 16 cases of sequelae of vitamin D-resistant rickets, with combined angular and torsional lower limb deformities, were treated with monofocal or bifocal tibial or femoral corticotomy and gradual correction with compression-distraction devices. There were nine men and seven women, with a mean age of 15 years. The Ilizarov system was used in 14 cases; in two cases the Volkov-Oganesian system was employed. The mean follow-up time was 8 years (range 1 – 15 years).

The anatomical and functional results have been highly satisfactory, with a very low complication rate. These techniques thus represent an excellent option in the management of such complex diseases.