Introduction. Bone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique. Methodolgy. Patients were identified through our limb reconstruction database and clinic notes, operative records and radiographs were reviewed. Since 2019, 8 patients (5 male : 3 female) have undergone bone transport via our modified balanced cable transport technique. Average age at time of transport was 39.6 years (range 21–58 years) with all surgeries performed by the senior author. Patients were followed up until radiological union. We recorded the length of bone transport achieved as well as any problems, obstacles or complications encountered during treatment. We evaluated outcomes of full weight bearing and return to function as well as radiological union. Results. 4/8 bone defects were due to severely comminuted open fractures requiring extensive debridement. All other cases had previously undergone fixation of tibial fractures which had failed due to infection, soft tissue defects or mal-reduction. The mean tibial defect treated with bone transport was 41mm (range 37–78mm). From the start of cable transport to removal of external fixator our patients spent an average of 201 days in frame. 7/8 patients underwent a 2-week pin-site holiday and subsequent insertion of intramedullary nail 2 weeks later. One patient had sufficient bony union to not require further internal fixation after frame removal. 10 problems were identified during treatment. These included 4 superficial infections treated with antibiotics alone and 5 issues with hardware, which could be resolved in the outpatient clinic. 1 patient had their rate of transport slowed due to poor skin quality over the site of the regenerate. 4 obstacles resulted in a return to theatre for additional procedures. 1 patient had a re-do corticotomy and 3 had revision of their internal cable transport constructs due to decoupling or screw pull out. 1 patient had residual ankle joint equinus following treatment which required an Achilles tendon lengthening procedure. Another patient underwent treatment for DVT. There were no deep infections identified and no significant limb length discrepancies or deformities. Conclusions. Overall, we have found that our modified balanced cable transport technique has allowed for successful bone transport for significant defects of the tibia. We have learned from the obstacles encountered during this case series to avoid unnecessary return trips to theatre for our future transport patients. The internal cable system allowed all patients to complete their planned transport without excessive pin tract scarring or pain. Early conversion to intramedullary nail allowed for a shorter time in frame with continued full weight bearing as the regenerate consolidated. No metalwork failure or deformity has occurred in relation to docking site union. All patients have made a good return to pre-operative function during their follow-up period with no evidence of late complications such as deep infection

The segmental bone transport allows the reconstruction of large scale bone defects resulting after a redical debridement due to an infection or after trauma. We use the Ilizarov fixator for the segmental transport. The part of the bone that has to be moved through the defect is pulled by a lateral and a medial towing rope. To determine continuously the forces of tension in the wires and to detect early complications of the bone transport we implanted in each wire a load cell with a resistance strain gauge. The knowledge of the resulting forces leads to the development of an automatic forced controlled bone transport. Since 09/2004 we have measured the forces of tension in the wires in 77 patients undergoing a segmental bone transport due to a long-extending osteomyelitis. The average age was 47,2 (6 to 68). In 12 patients we had to treat a bone defect of the thigh (average size of the defect 12,5 cm), in 55 patients 56 large scale bone defects of the lower leg (average size of the defect: 8,6 cm ranging from 6,0 to 20,0 cm). We implanted a load cell with a resistance strain gauge in the lateral and medial towing rope. This way we could, after converting the measured values from analog to digital, the impacting forces. In all patients we were able to meausure continuously rising forces of tension. Lwe noticed forces which didn´t change much. At the end the bone transport we again found rising forces of tension. We noticed higher forces in the lateral wires, on femur and on tibia. Due to the measurement of the acting forces we were abel to perform a bone transport without close X-ray-monitoring. Complications such as premature ossification of the new building bone were identified and treated in an early stage.at. We developed a theoretical model drawing into consideration the interfering forces caused by the regenerating bone, the soft tissue, the friction of the wire, adherend soft tissue and geometry otf the wire. The forces calculated using this model were similar to the acting forces we found when measuring the forces of the bone transport. We now record the data on memory cards. A control of the data is possible over long-distance. We now started a model of an automatic bone transport controlled by the the acting forces. Our aim is to perform such an automatic bone transport in patients

Introduction. We demonstrate the preliminary results with a novel technique to solve large bone defects using two lengthening nails, working together and aligned in a custom made device. An illustrative case that successfully produced 17 cm bone in 3.5 months, is presented. Materials and Methods. A 28 year old healthy male presented with a slowly growing mass in the left femur. No general symptoms were reported, no weight loss, no previous illness. Histopathology, CT and MRI scans revealed a malignant diaphyseal bone tumor. A three-stage trifocal bone transport was projected and conducted based on a 3D model test. Results. Trifocal bone transport using two lengthening nails in a custom made device, reduced the 17 cm bone defect in 3.5 months. Follow up was 9 months. Conclusions. The presented technique successfully solved the clinical problem and is a showcase for further developments of internal devices for complex and large bone losses and lengthenings

Aim. Untreated or improperly managed osteomyelitis can lead to several complications, bone loss being one of the most challenging to manage. Bone transport is just one of the surgical options available for filling the bone gaps and promote bone union. This presentation focuses on bone transport for long bones gaps in paediatric age group, highlighting its advantages and disadvantages, its indications and its complications. Method. Between 2006 and 2014. 71 patients underwent a procedure of bone transport. Out of them, 39 were males and 32 females, with an average age at presentation of 8.7 years. The bone involved were tibia (27 right, 25 left), femur (4 right, 9 left), radius (1 right, 4 left) and ulna (1 right). Clinically speaking, the children presented with one of the following picture:. ‐. Pathological fracture, with sequestration without or minimum involucrum formation. ‐. Extensive, extruded diaphyseal sequestrum, with loss of soft tissues. ‐. Post-surgical gap, with residual or quiescent infection. Bone transport was preceded by one of the following procedure: sequestrectomy, sequestrectomy and external fixation, external fixation with sequestrum in situ. Monolateral fixator was used in 46 patients, ring fixator in 25. Bone transport started 7 days after the osteotomy, at the rhythm of 1 mm per day. Plastic surgery procedures were used in 3 kids. Results. Bone reconstruction was primarily obtained in 50 patients; non-union at the docking point was observed in 18. It required additional procedures of bone graft or site refreshening, associated with external fixation. Pins replacements and/or fixator adjustment were required in 24 patients. Several procedures were required during transport to overcome technical mistakes or to handle unexpected complications. All patients were able to walk unsupported. Reduced knee flexion was observed in 11 patients, knee fusion in 4, ankle fusion in 3, limb length discrepancy in 20, axial deformity in 6. Conclusions. Bone transport has proved to be a reliable technique for managing segmental bone defects in children. It requires long time and it is prone to several complications. Strict medical supervision is necessary all along the process. Besides filling the gap, it can achieve limb equalization when needed. The presence of infection is not a contraindication to concurrent sequestrectomy and transport. The treatment is long, challenging, strenuous for the patient, the family and the medical staff but the results can be rewarding in terms of limb function

Aim. To evaluate the results and complications of bone transport in the treatment of massive tibial bone defects, using the Ilizarov method. Methods. 15 patients underwent bone transport using the Ilizarov technique to treat massive tibial bone defects. The average age of the patients was 8.7 years (3–24 years) and the mean bone defect was 10.8 cms. Following a latent period of 1 week, distraction of the transport doughnut was commenced at 1mm/24 hours in 4 quarterly turns. A docking procedure was performed in 7 cases which involved freshening of the bone ends and autogenous bone grafting from the iliac crest. Following docking the fixator was removed once the regenerate had consolidated. Results. The fixators were removed after a mean 12.3 months (range 8–21 months). 1 patient required adjustment of the frame under anaesthetic due to translation of the docking doughnut and poor alignment. All patients had at least one superficial pin site infection successfully treated with oral antibiotics. Deep infection at the docking site was seen in 1 patient needing debridement and split skin grafting. There were no neuro-vascular complications. 1 patient had a recurvatum deformity at the regenerate due to early frame removal. There were no early fractures. Re-fracture of the docking site occurred in one patient, 17 months after the removal of the original frame. This needed open reduction and internal fixation. Non union at the docking site was seen in 3 patients, needing open reduction, internal fixation with bone grafting (1 case) and excision of non-union and compression with a further frame (2 cases). Conclusion. Massive bone transport in the tibia is an orthopaedic challenge. This paper highlights the complications of this procedure. It confirms the viability of this method but emphasises careful counselling of both the patient and parents prior to the commencement of such difficult treatment

Aim. Infected segmental defects are one of the most feared complications of open tibial fractures. This may be due to prolonged treatment time, permanent functional deficits and high reinfection and non-union rates. Distraction osteogenesis techniques such as Ilizarov acute shortening with bifocal relengthening (ASR) and bone transport (BT) are effective surgical treatment options in the tibia. The aim of this study was to compare ASL with bone transport in a consecutive series of complex tibial infected non-unions and osteomyelitis, for the reconstruction of segmental defects created at surgical resection of the infection. Method. In this single centre series, all patients with a segmental defect (>2cm) of the tibia after excision of infected non-union or osteomyelitis were eligible for inclusion. Based on clinical features, bone reconstruction was achieved with either ASR or BT using an Ilizarov fixator. We recorded the external fixation time (months), the external fixation index (EFI), comorbidities, Cierny-Mader or Weber-Cech classification, follow-up duration, time to union, number of operations and complications. Results. Overall, 43 patients with an infected tibial segmental defect were included. An ASR was performed in 19 patients with a median age of 40 years (range: 19 – 66 years). In this group, the median bone defect size was three cm (range: 2 – 5 cm); and the median frame time eight months (range: 5 – 16 months). BT was performed in 24 patients with a median age of 44 years (range: 21 – 70 years). The median bone defect size was six cm (range: 3 – 10 cm), and the median frame time ten months (range: 7 – 17 months). The EFI in the ASR group and the BT group measured 2.2 months/cm (range: 1.3 – 5.4 months/cm) and 1.9 months/cm (range: 0.8 – 2.8 months/cm), respectively. The comparison between the EFI of the ASL group and the BT group showed no statistically significant difference (p=0.147). Five patients of the ASR group (7 surgeries) and 19 patients of the BT group (23 surgeries) needed further unplanned surgery (p=0.001). Docking site surgery was significantly more frequent in BT; 66.7%, versus ASL; 5.3% (p=0.0001). Conclusion. Acute shortening/relengthening and bone transport are both safe and effective distraction osteogenesis techniques for the treatment of infected tibial non-unions. They share similar frame times per centimetre of defect. However, ASR demonstrated a statistically significant lower rate of unplanned surgeries

We present our experience of lower limb reconstruction for patients with obvious defects in the tibia, by bone transport using a stacked Taylor Spatial Frame. A retrospective review of 40 patients treated between 2003 and 2009. There were 19 cases of infected non union, 9 cases of acute bone loss following fracture, 6 cases of chronic osteomyelitis, 4 cases of aseptic non union, 1 case of neurofibromatosis and 1 case of a loose and infected total ankle replacement. Twenty-eight out of the 40 patients reviewed have completed their treatment. Of these 28 patients, bony union was achieved in 23 patients, of whom 22 were assessed at discharge to have regained good to excellent limb function, a functional assessment was not available for review in the remaining patient. In 5 patients, docking site union failed, 3 of whom then underwent below knee amputation. Two patients required treatment with an intramedullary nail following frame treatment to achieve consolidated union of the docking site. Anatomic sagittal and coronal alignment was achieved in 19 out of 23 patients. The mean bone regenerate was 53.3 mm (range: 15-180mm), with a mean healing index of 9.2 days/mm (range: 4.4-25 days/mm). The majority of patients experienced at least one complication, these included pin site and soft tissue infections, refracture, nerve palsy and joint stiffness. Surgical stimulation of the docking site was required in 12 of the 28 patients to promote union. The use of a stacked Taylor Spatial Frame system is effective for restoring bone length and limb function in patients with bone loss following complex trauma and orthopaedic cases. The computer assisted nature of the spatial frame allows for predictable bone regenerate, minimal residual deformity and accurate bone docking

Introduction. We present our experience of lower limb reconstruction for patients with obvious defects in the tibia, by bone transport using a stacked Taylor Spatial Frame. Methods. A retrospective review of 40 patients treated between 2003 and 2009. There were 19 cases of infected non union, 9 cases of acute bone loss following fracture, 6 cases of chronic osteomyelitis, 4 cases of aseptic non union, 1 case of neurofibromatosis and 1 case of a loose and infected total ankle replacement. Results. 28 out of the 40 patients reviewed have completed their treatment. Of these 28 patients, bony union was achieved in 23 patients, of whom 22 were assessed at discharge to have regained good to excellent limb function; a functional assessment was not available for review in the remaining patient. In 5 patients docking site union failed, 3 of whom then underwent below-knee amputation. Two patients required treatment with an intramedullary nail following frame treatment to achieve consolidated union of the docking site. Anatomic sagittal and coronal alignment was achieved in 19 out of 23 patients. The mean bone regenerate was 53.3 mm (range: 15-180mm), with a mean healing index of 9.2 days/mm (range: 4.4-25 days/mm). The majority of patients experienced at least one complication; these included pin site and soft tissue infections, refracture, nerve palsy and joint stiffness. Surgical stimulation of the docking site was required in 12 of the 28 patients to promote union. Conclusion. The use of a stacked Taylor Spatial Frame system is effective for restoring bone length and limb function in patients with bone loss following complex trauma and orthopaedic cases. The computer assisted nature of the spatial frame allows for predictable bone regenerate, minimal residual deformity and accurate bone docking

Background:. Wide resection of infected bone increases the chances of eradication of infection in patients with chronic osteomyelitis. Aggressive debridement is, however, frequently complicated by the creation of large bone defects. The use of antibiotic-impregnated PMMA spacers, as a customized dead space management tool, has recently grown in popularity. In addition to certain biological advantages, the spacer also offers a therapeutic benefit by serving as a vehicle for delivery of local adjuvant antibiotics. Methods:. This retrospective case series involved 11 patients with chronic osteomyelitis, managed with tibial bone transport through an induced membrane using circular external fixation. All patients were treated according to a standardized treatment protocol and we review the anatomic nature of the disease, the physiological status of the host, the surgical procedures performed, as well as the outcome of treatment in terms of eradication of infection, time to union and the complications that occurred. Results:. Nine patients, with a mean bone defect of 6 cm (range: 2–8 cm) were included in the study. At a mean follow-up of 24 months (range: 14–45 months) eradication of osteomyelitis was achieved in all patients without the need for reoperation for infection. Failure of the skeletal reconstruction occurred in two patients. Six major and four minor complications were experienced. After a mean time of 70 weeks (range: 30 to 104 weeks) in the circular external fixator all but one docking site had united and all regenerated segments were consolidated. Conclusion:. Bone transport, using circular external fixation, through the induced membrane created by the temporary insertion of a PMMA appears to be a useful technique in the management of post-infective tibial bone defects larger than 4 cm in size. Patient selection appears to be a crucial step in ensuring a successful outcome in terms of the resolution of infection

We did a retrospective comparative analysis of twenty five patients treated with Ilizarov bone transport [IBT] and twenty one patients treated with vascularised fibular graft [VFG] from 1994 to 2003 in one institution, for post traumatic tibial bone defects of more than six centimetres. The aim of the study was to find out if there were any differences in achieving radiological end points, bone and functional score and return to work (final outcome), hospital stay and operating time (logistic factors) and complication rates. The mean defect size in the IBT group was 11.9 centimetres and in the VFG group 14.6 centimetres. Twenty one and sixteen patients in the IBT and VFG group respectively achieved the radiological end point that is union of the defect and graft hypertrophy [p 0.5]. Nineteen patients in the IBT group and fifteen in the VFG group returned to productive work [p 0.72]. Bone and functional results were analyzed by Paley's evaluation system and there were no significant differences in the two groups of patients [bone result p 0.97 and functional result p 0.1]. The logistic factors were significantly less of IBT group [p < 0.05]. Two patients in the IBT group and one patient in the VFG group had amputation and one patient in VFG group died. Three cases in the VFG group had flap loss. Stress fracture of the graft occurred in eight patients in the VFG group [p 0.0007]. The final outcome was same in both groups. Hospital stay, operating time and refractures were significantly less in IBT group

Introduction. Paediatric tibial fractures, unlike femoral fractures do not have much potential for overgrowth. In simple factures of the tibial shaft treated non-operatively the major problems are shortening and malunion. In complex injuries with extensive soft tissue disruption and bone loss, the long-term aim of reconstruction is to achieve union with a fully functional limb without limb-length inequality. Methods. Four children (Age range 6-12 years) who sustained high-energy grade III open fractures of the tibia were treated with acute shortening and bone transport. Any soft tissue reconstructive and secondary grafting procedures for delayed union were recorded. The children were prospectively followed up to fracture union. Distraction ostegenesis proceeded until limb length equality was achieved and the regenerate allowed to consolidate. Results. Three children had grade 3B injuries, 2 requiring flap reconstruction. One had a grade 3A injury. Mean acute shortening was 4.4cm (Range 2-9cm). Distraction osteogenesis was used to achieve limb-length equalisation. 2 children required secondary bone graft procedures to achieve union. At 3 years from injury, all children had overgrowth of the injured leg averaging 2cm. Discussion. Despite achieving equal limb lengths at the end of distraction osteogenesis the injured tibia overgrew by a mean of 2cm at three years post injury. This would suggest that even in the presence of extensive soft tissue trauma, as seen in these high energy injuries, the increased blood flow associated with metaphyseal corticotomy stimulates epiphyseal activity resulting in overgrowth. The value of stopping adjustments just short of achieving limb length equality to allow for expected overgrowth in the injured tibia merits further investigation

Purpose. To demonstrate experience of bone transport arthrodesis of the knee with simultaneous lengthening in the treatment of infected peri-articular fracture fixation associated with large condylar defects. Methods. Four patients (3 male/1 female), mean age 46.5 years (37–57 y) with post-traumatic osteomyelitis involving the knee were treated by radical debridement, removal of all metalwork and frame application. Substantial condylar defects resulted (6–10 cm) with loss of extensor mechanism. Parenteral antibiotics were administered for several weeks. Two patients required muscle flaps. Bone transport was utilised to achieve an arthrodesis whilst simultaneously lengthening. In three cases a ‘peg in socket’ construct was fashioned to ensure stability of the arthrodesis. Results. Arthrodesis was successfully achieved in all patients at an average time of 25 months (range 19–31 months). The median number of interventions undertaken was 9 (range 8–12). The mean limb length discrepancy at end of treatment was 3 cm (range 3–4 cm). No infection has recurred after a minimum 2 year follow up. Patient factors had considerable influence on the time spent in frame; two patients developed DVT; one complicated by PE, and two required surgical correction of equinus contracture using frames. Conclusion. Bone loss is associated with reduction in the success rate of any arthrodesis. In this series the bone efects were associated with established infection which further compromises bone healing. However, by optimising the host environment with eradication of infection, ensuring well vascularised soft tissue coverage, and using Ilizarov techniques to overcome the bony defect, one can provide a stable arthrodesis and limb salvage

Aim

Post traumatic distal tibia osteomyelitis (DTOM) with an upper ankle joint involvement is a serious complication after primary osteosynthesis and can be a nightmare for the patient and the surgeon as well. Our aim was to identify mayor complications during treatment and to find the way to prevent or treat them.

Distal tibial bone loss involving the ankle is a devastating injury with few options for reconstruction. The purpose of our study was to look at the long term results of ilizarov technique used to achieve lengthening of tibia and fusion at the ankle.

17 cases (16 post traumatic and one post tumor resection) admitted to one institution between 1994 and 2003. 13 cases were done in bifocal and four in trifocal mode.

The duration of follow up was 12 to 84 months The average age was 33 years (Range 7-71). The mean length of the defect was 4.5 cm (Range 1-12). Union of the fusion site occurred in 88 % (15/17) of the patients with mean duration to docking and union being 8 months. The mean time in fixator was 13 months (Range 5 to 29).

Average number of surgeries per patient was 3.2. Five patients required free vascularised grafts before the index procedure and 4 patients required realignment at the docking site. Functional results – Fourteen (77.5%) of the patients could walk without support or bracing and twelve patients (71%) returned to same or modified occupation.

Complications – Two non-union.

Deformity – Fusion site equinus deformity occurred with non union after re-fracture in one case. There were 2 cases of residual fore-foot equinus.

Residual low grade infection with discharging sinus was present in two patients. One patient needed change of wires for Pin tract infection. Our study showed 76% good and excellent scores on functional scoring but also demonstrates the high morbidity associated with this procedure. In spite of the steep learning curve and high complication rates the procedure can be undertaken in specialised centres for highly motivated patients to achieve good functional results.

Introduction. Fibrous dysplasia is a pathological condition, where normal medullary bone is replaced by fibrous tissue and small, woven specules of bone. Fibrous dysplasia can occur in epiphysis, metaphysis or diaphysis. Occationally, biopsy is necessary to establish the diagnosis. We present a review of operative treatment using the Ilizarov technique. The management of tibial fibrous dysplasia in children are curettage or subperiosteal resection to extra periosteal wide resection followed by bone transport. Materials and Methods. A total of 18 patients were treated between 2010 – 2020; 12 patients came with pain and 6 with pain and deformity. All patients were treated by Ilizarov technique. Age ranges from 4–14 years. 12 patients by enbloc excision and bone transportation and 6 patients were treated by osteotomy at the true apex of the deformity by introducing the k/wires in the medullary cavity with stable fixation by Ilizarov device. The longest duration for bone transport was 16 weeks (14–20 weeks) for application, after deformity correction was 20 weeks. We have never used any kind of bone grafts. Results. All the 18 patients were treated successfully by Ilizarov compression distraction device. The patients with localized tibial pathology with deformity had the shortest period on the Ilizarov apparatus, 14 weeks. Conclusions. Preservation and bone regeneration by distraction histogenesis constitutes a highly conservative limb saving surgery. Patients with bone defects of <10 cm, a great deal of preserved healthy tissue and good prognosis are good candidates for these methods

Introduction. Intraoperative assessment of coronal alignment is important when performing corrective osteotomies around the knee and ankle, limb lengthening and trauma surgery. The Joint Angle Tool (JAT) provides surgeons with information about the anatomic and mechanical axes intraoperatively based on true anteroposterior radiographs. Aim: Presentation of the JAT, a low-cost goniometer for intraoperative assessment of the lower limb alignment. Materials and Methods. The JAT consists of pre-printed joint orientation angles of the anatomic and mechanical axis including normal variations on a plastic sheet. It is placed on the screen of the image intensifier after obtaining a true anterior-posterior image. The pre-printed joint orientation angles can intraoperatively assist the surgeons in achieving the pre-planned axis correction. Here, its feasibility is demonstrated in four cases. Results. Here, we present the intraoperative use of JAT in four cases:. 77 mm femoral bone transport due to non-union utilizing a bone transport nail,. distal femoral osteotomy correcting coronal and torsional malalignment using a retrograde intramedullary trauma nail,. proximal / high tibial open wedge osteotomy with an intramedullary implant correcting varus malalignment in a hypophosphatemic rickets patient, and. a supramalleolar, closing wedge osteotomy realigning the anatomic axis with a plate and screws. Conclusions. The JAT is a modified goniometer which allows intraoperative assessment of the mechanical and anatomic axis. JAT is applicable throughout the entire surgical procedure irrespective of the method of internal fixation and may provide additional reassurance of correct alignment. The JAT consists of a plastic sheet with printed joint orientation angles and their normal variation. JAT is freely available from . profeedback.dk/JAT/JAT.pdf. for use and modification according to Creative Commons license (CC BY-SA 4.0)

Introduction. The reconstruction of segmental long bone defects remains one of the holy grails of orthopaedic surgery. The optimal treatment of which remains a topic of great debate. This study aimed to evaluate the outcomes following the management of critical-sized bone defects using a classification-based treatment algorithm. Materials & Methods. A retrospective review of all patients undergoing treatment for segmental diaphyseal defects of long bones at a tertiary-level limb reconstruction unit was performed. The management of the bone defect was standardised as per the classification by Ferreira and Tanwar (2020). Results. A total of 96 patients (mean age 39.8, SD 15.2) with a minimum six months follow-up were included. Most bone defects were the result of open fractures (75/96) with 67% associated with Gustilo-Anderson IIIB injuries. There was a statistical difference in the likelihood of union between treatment strategies with more than 90% of cases undergoing acute shortening and bone transport achieving union and only 72% of cases undergoing the induced membrane technique consolidating (p=0.049). Of those defects that consolidated, there was no difference in the time to bone union between strategies (p=0.308) with an overall median time to union 8.33 months (95% CI 7.4 — 9.2 months). The induced membrane technique was associated with a 40% risk of sepsis. Conclusions. This study reported the outcomes of a standardised approach to the management of critical-sized bone defects. Whilst overall results were supportive of this approach, the outcomes associated with the induced membrane technique require further refinement of its indications in the management of critical-sized bone defects

Aim. The reconstruction of bone critical size defects of the tibia is one of the most complex therapeutic challenges in the orthopedic field. This study aims to describe and evaluate our three-staged surgical protocol of reconstruction of infected defects of the tibia emphasizing in limb salvage rate, resolution of infection, functional outcome and patient satisfaction. Method. A retrospective review was performed in all cases of complex infected tibia fracture with combined soft and bone tissue loss treated in a specialized limb reconstruction center between 2010 and 2018. In all cases, a three-stage protocol was performed: 1) Infected-limb damage control with radical debridement, 2) Soft tissue coverage with vascularized or local flap 3) Bone reconstruction procedure. The minimum follow-up required was 12 months after external fixator removal. Results. Twenty-eight patients with a mean age of 42 years were included. The mean soft tissue defect was 91.7 cm2 and the mean bone defect was 5.8 cm. 67.85% of the cases were classified as a type IV B-local osteomyelitis. The median global treatment time was 456 days. The External Fixator Time (EFT) was 419, 284, 235 for bone transport, shortening-lengthening and acute shortening groups respectively. The median Bone Healing Index (BHI) was 1.82 months/cm in bone transport group and 2.15 months/cm in shortening-lengthening group. The limb salvage rate was 92.85%. Infection resolution rate was 96,42%. We achieved bone union in 92,85% of the cases. Regarding ASAMI bone score, 92.8% of the cases were “good-or-excellent”. Two patients underwent a delayed amputation. Eight cases of non-progressive Docking Site (DS) healing were observed. Nineteen non-expected reinterventions were performed. Functional data: the mean VAS score was 1.0. The mean LEFS score was 55.88 (55.88/80). Regarding ASAMI functional score, 78,6% of the cases were “good-or-excellent”. More than 80% of the patients could return to work. 100% of the patients were “very satisfied” or “moderately satisfied” (75% and 25% respectively). Conclusions. Our results demonstrate that our three-stage surgical approach in infected tibial bone defects with soft tissue damage can result in high infection resolution, good functional outcome, good patient satisfaction and an acceptable limb salvage rate despite the large time of treatment and unexpected reinterventions

Introduction. Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation. Materials & Methods. Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport. Results. Case 2 - A 12-year-old girl was referred with a three-month history of lateral left ankle swelling. X-ray demonstrated an aneurysmal bone cyst in the distal fibula metaphysis. The cyst grew from 4.2 × 2.3cm to 5.2 × 3.32cm in 2 months. A distal fibula resection (6.2cm) with syndesmosis fixation and hexapod cable transport frame were undertaken. The frame was in situ for 13 weeks and during this time she required an additional osteotomy for premature consolidation and had one pin site infection. After 13 weeks a second syndesmosis screw was placed, frame removed, and a cast applied. 3 months later she had fibular plating, BMAC and autologous iliac crest bone graft for slow union. At 3 years post-operative she has no evidence of recurrence, is pain-free and has no functional limitation. Conclusions. We describe two cases of ankle syndesmosis preservation using cable transport for juxta-articular aneurysmal bone cysts. This allows wide resection to prevent recurrence while also preserving primary ankle stability and leg length in children. Both children had a minor complication, but both had an excellent final outcome. Cable bone transport and prophylactic syndesmosis stabilization allows treatment of challenging juxta-articular aneurysmal bone cysts about the ankle. These techniques are especially useful in large bone defects

Introduction. Treatment of non-union in open tibial fractures Gustilo-Anderson(GA)-3A/3B fractures remains a challenging problem. Most of these can be dealt using treatment methods that requires excision of the non-union followed by bone grafting, masquelet technique, or acute shortening. Circular fixators with closed distraction or bone transport also remains a useful option. However, sometimes due to patient specific factors these cannot be used. Recently antibiotic loaded bone substitutes have been increasingly used for repairing infected non-unions. They provide local antibiotic delivery, fill dead space, and act as a bone conductive implant, which is resorted at the end of a few months. We aimed to assess the outcome of percutaneous injection of bone substitute while treating non-union of complex open tibial fractures. Materials & Methods. Three cases of clinical and radiological stiff tibial non-union requiring further intervention were identified from our major trauma open fracture database. Two GA-3B cases, treated with a circular frame developed fracture-related-infection(FRI) manifesting as local cellulitis, loosened infected wires/pins with raised blood-markers, and one case of GA-3A treated with an intramedullary nail. At the time of removal of metalwork/frame, informed consent was obtained and Cerament-G. TM. (bone-substitute with gentamicin) was percutaneously injected through a small cortical window using a bone biopsy(Jamshedi needle). All patients were allowed to weight bear as tolerated in a well-fitting air-cast boot and using crutches. They were followed up at 6 weekly intervals with clinical assessment of their symptoms and radiographs. Fracture union was assessed using serial radiographs with healing defined as filling of fracture gap, bridging callus and clinical assessment including return to full painless weight bearing. Results. Follow-up at 6 months showed all fractures had healed with no defect or gaps with evidence of new trabecular bone and significant resorption of Cerament-G. TM. at final follow-up. There was no evidence of residual infection with restoration of normal limb function. Fractures with no internal fixation showed a mild deformity that had developed during the course of the healing, presumed due to mild collapse in the absence of fixation. These were less than 10 degrees in sagittal and coronal planes and were clinically felt to be insignificant by the patients. Conclusions. Cerament-G's unique combination of high dose antibiotics and hydroxy apatite matrix provided by calcium sulphate might help provide an osteoconductive environment to allow these stiff non-unions to heal. The matrix appears to provide a scaffold-like structure that allows new bone in-growth with local release of antibiotics helping reduce deep-seated infections. The final deformation at fracture site underlines the need for fixation- and it is very unlikely that this technique will work in mobile nonunions. Whilst similar fractures may heal without the use of bone substitute injections, the speed of healing in presence of significant fracture gap suggests the use of these bone substitutes did help in our cases. Further studies with a larger cohort, including RCTs, to evaluate the effectiveness of this technique compared to other methods are needed