Introduction: The management of post-traumatic, tibial, segmental, skeletal defects is a difficult problem that often requires complex approaches for successful limb salvage. Bone transport and acute shortening with subsequent relengthening are two techniques that have been made possible using Ilizarov’s methods. Aim: To determine whether either technique offers any intrinsic advantage relative to the other. Methods: We carried out a retrospective review of charts and radiographs of 42 patients with post-traumatic tibial defects that had been managed using Ilizarov’s methods. The follow-up period averaged 26 months. We selected patients with defects between 3 cm and 10 cm to provide a suitable comparison. The patients were divided into two groups of 21 each, treated either by bone transport or acute shortening. Results: The defects averaged 7.0 cm in the transport group and 5.8 cm in the acute shortening group. The transport group averaged 12.5 months in the fixator; the acute shortening group averaged 10.1 months. However, the external fixation index was virtually identical in the two groups (mean 1.8 months/cm in the transport group and 1.7 months/cm in the acute shortening group). The complication rate, radiographic results, and functional results were slightly better in the acute shortening group. Conclusions: Both techniques demonstrated excellent results overall and the external fixation index was nearly identical for these related methods. The final results after treatment by acute shortening were found to be slightly better than the final results following bone transport. There may be a slight advantage to the use of this technique for smaller defects in properly selected patients

Introduction The purpose of this study was to compare the time to union following acute shortening and subsequent lengthening versus Bone Transport using the Ilizarov external fixator. Methods Eighteen patients with tibial non-unions (age range 26 to 63 years) were recruited between March 1995 and September 2001. Three subgroups of six patients each, were formed. Group 1 underwent Acute Shortening and subsequent Lengthening, whereas Group 2 underwent Bone Transport. Group 3 patients had defects < 1 cms but were still high energy injuries, therefore underwent application of a frame. This group was used as a comparison group. A proximal corticotomy was used for distraction osteogenesis. Bone grafting at the fracture or regenerate site was used if required to aid healing. All patients were followed-up to union. All three groups were similar for age, pre-injury health status including cigarette smoking. Ten infected non-unions were present. Most patients had at least two conventional operative interventions prior to referral to us for Ilizarov surgery. The mean bone resection in the Acute Shortening group (Group 1) was 4.6 cms and in the Bone Transport group (Group 2) was 5.9 cms. Patients in Group 2 had more procedures done before union was achieved. This included adjustment of frame/ reinsertion of wires to align transport segment for optimal docking and bone grafting at the docking/regenerate site. Four patients in Group 2 required bone grafting at the docking site compared to none in Group 1. Results Eradication of infection and union was achieved in all patients with average time in frame being 12.1 months in the Acute Shortening group, 17.2 months in the Bone Transport group and 8.0 months in the Frame stabilisation group. Using Paley’s bone result evaluation system, an excellent result was achieved in all patients of all groups. However, patients in the Acute Shortening group had a shorter time to union and needed fewer procedures. Conclusions We recommended that where feasible, acute shortening and lengthening is preferable to bone transport due to shorter union time and fewer procedures undertaken to achieve union. If this is not possible due to large defects, then a combination of acute shortening with transport to bridge the gap should be considered

Introduction: Treatment of defected pseudoarthrosis tibia remains controversial due to bone loss with/without infection arises from previous interventions. In the present study we evaluated the results of acute shortening and distraction osteogenesis in the treatment of tibia pseudoarthrosis with bone loss. Material and Methods: Eleven patients were treated with acute shortening and distraction osteogenesis. Mean age and bone loss was 27.5 years (range 10–44) and 8.9 cm (range 3.5–12) respectively. 7 of eleven patients is infected pseudoarthrosis. Enfected patients were type 4A according to Chierny-Mader classification. The 4 of infected patients were treated with two staged procedure. In the first stage antibiotic (teicoplanin) impregnated polymethylmetacrilate beads were placed to the space occurred as a result of excision of sclerotic bone segment and fixation was performed by external fixator or braces. Second stage composed of acute compression (shortening) and distraction osteogenesis. Other 3 infected and noninfected patients were treated with resection, acute shortening and distraction osteogenesis in one stage. In six cases docking site were grafted with autografts. Defects greater than 4 cm were gradually shortened 2mm/day in addition to acute shortening. Limb length inequality was solved with lengthening from proximal tibial corticotomy and achieving union of both sites about the same time. Results: Mean follow up, external fixator time and external fixator index was 48.3 months (21–80), 8.9 months (6–13) and 1,3 month/cm respectively. results were evaluated according to Paley’s bone and functional evaluation scoring. Eleven patient revealed excellent results with regard to bone evaluation and 10 patient revealed excellent and 1 patient revealed good results in terms of functional evaluation. In one patient fracture at the pseudoartrosis site occurred due to new trauma after removal of the fixator which was treated with circular external fixator. In the another patient, the lengthening regenerate side was low quality bone which need intra-medullary fixation and grafted with autograft. Conclusion: Acute shortening and distraction osteogenesis is a safe and successful procedure in the treatment of defected tibia pseudoarthrosis and is alternative to other treatments. Acute shortening and distraction osteogenesis was found to be successful and safe with regard to functional results in the treatment of defected tibia pseudoarthrosis. Besides we suggest it as an alternative due to lower rate of complications and less external fix-ator time compared to other Methods:

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

Tibial fractures complicated by bone and/or soft tissue loss present a great challenge. Traditional methods of limb reconstruction are lengthy and may not yield satisfactory functional results. Despite its tremendous contribution to the management of this condition, the Ilizarov technique of bone transport has several problems and difficulties. The present study was carried out between 1997 and 2002 and included 21 patients with tibial fractures complicated by bone and soft tissue defects as a result of open fractures or surgical debridement of infected non-unions. The bone loss ranged from three to eleven cm. (average 4.7 cm.). Ages ranged from 12 to 54 years (average 28.8 years). The follow-up ranged from 24 to 75 months. The procedure included resection of all devitalised tissues, acute limb shortening to close the defect, application of the external fixator and metaphyseal osteotomy for re-lengthening. In all patients the fractures united with well aligned limbs. Acute limb shortening of up to six cm. was done in the lower third of the leg. Limb lengthening was done in all cases and ranged from 3 to 9.5 cm. (average 4 cm.). An Ilizarov external fixator was used in nine cases (41%) and a monolateral fixator in 13 cases (59%) with a total of 22 applications. Residual leg length discrepancy of more than 3cm. occurred in four cases (19%). Complications included one refracture, one transient peroneal nerve palsy and one equinus contracture of ten degrees. Satisfactory results were obtained in 93% of cases. Acute limb shortening and re-lengthening converts a complicated limb reconstruction into a relatively simpler one of linear limb lengthening, without the difficulties of traditional Ilizarov techniques and eliminated the need for soft tissue flaps. It is better instituted early in the management of these cases to ensure better functional results and shorter treatment time

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

UK Objective. To evaluate the technique of transverse debridement, acute shortening and subsequent distraction histiogenesis in the management of open tibial fractures with bone and soft tissue loss thus avoiding the need for flap coverage. Methods. We present a retrospective review of 18 patients with Gustillo grade III open tibial fractures between 2006 and 2011. Initially managed with debridement to provide bony apposition through transverse wound excision. This allowed primary wound closure without tension, or mobilization of local muscle followed by split skin graft to provide cover. Temporary mono-lateral external fixation was utilized to allow soft tissue resuscitation, followed by Ilizarov frame for definitive fracture stabilization. In some cases it was possible to apply an Ilizarov frame at the time of initial debridement. Leg length discrepancy was subsequently corrected by corticotomy and distraction histiogenesis. Union was evaluated radiologically and clinically. Results. Mean age 36.4 years (18.4–59.2 years). Mean bone defect 3.5 cm (0.5–10 cm). Mean soft tissue defect 4.1 cm (1.8–10 cm). Mean follow up was 81 weeks (30–174 weeks). 16 fractures united, with a mean time to union of 38 weeks (24–79 weeks). There was one hypertrophic nonunion which united after a second frame. One patient was lost to follow up before fracture union. Three patients had pin site infections, two of which required intravenous antibiotics. One patient developed chronic osteomyelitis but manages with a discharging sinus. There were no amputations. Conclusion. Acute shortening followed by distraction histiogenesis is a safe method for the treatment of severe open tibial fractures with bone and soft tissue loss. The technique also avoids the morbidity, cost and logistical issues associated with the use of local or free tissue flaps

Material and methods:. Fifteen patients sustaining high energy Gustilo 3B injuries of the tibia were treated from 2003 to 2009 with initial debridement followed by application of an external fixation device allowing immediate acute shortening of the bone gap. The bone defects ranged from 3 cm to 5 cm. Wound management was achieved with a vacuum assisted closure device (VAC) until granulation tissue covering the exposed bone made coverage with split skin grafting possible. A delayed progressive lengthening procedure was used to equalize the leg length discrepancy after wound cover was achieved. Results:. The mean age of the 15 patients was 30 years and treatment times varied from 4 to 12 months. All fractures united with acceptable alignment and equalization of the leg length discrepancy. One patient required repeat procedures for a pin site infection by changing a wire. There was no deep sepsis. Conclusion:. This method is a satisfactory and safe alternative for the acute management of the compound wound, when plastic surgery skills are either unavailable or flap cover is contraindicated in the presence of sepsis or as a salvage procedure following flap failure. Wire placement needs to be carefully planned in order to accommodate initial VAC placement, followed by final definitive fixation after wound cover has been achieved

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 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. Discussion: Despite achieving equal limb lengths at the end of distraction osteogenesis the injured tibia overgrew by 1–2cm 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

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

Background. Ankle and hindfoot fusion in the presence of large bony defects represents a challenging problem. Treatment options include acute shortening and fusion or void filling with metal cages or structural allograft, which both have historically low union rates. Impaction grafting is an alternative option. Methods. A 2 centre retrospective review of consecutive series of 32 patients undergoing hindfoot fusions with impaction bone grafting of morselised femoral head allograft to fill large bony void defects was performed. Union was assessed clinically and with either plain radiography or weightbearing CT scanning. Indications included failed total ankle replacement (24 patients), talar osteonecrosis (6 patients) and fracture non-union (2 patients). Mean depth of the defect was 29 ±10.7 mm and mean maximal cross-sectional area was 15.9 ±5.8 cm. 2. Tibiotalocalcaneal (TTC) arthrodesis was performed in 24 patients, ankle arthrodesis in 7 patients and triple arthrodesis in 1 patient. Results. Mean age was 57 years (19–76 years). Mean follow-up of 22.8 ±8.3 months. 22% were smokers. There were 4 tibiotalar non-unions (12.5%), two of which were symptomatic. 10 TTC arthrodesis patients united at the tibiotalar joint but not at the subtalar joint (31.3%), but only two of these were symptomatic. The combined symptomatic non-union rate was 12.5%. Mean time to union was 9.6 ±5.9 months. One subtalar non-union patient underwent re-operation at 78 months post-operatively after failure of metalwork. Two (13%) patients developed a stress fracture above the metalwork that healed with non-operative measures. There was no bone graft collapse with all patients maintaining bone length. Conclusion. Impaction of morselised femoral head allograft can be used to fill large bony voids around the ankle and hindfoot when undertaking arthrodesis, with rapid graft incorporation and no graft collapse despite early loading. This technique offers satisfactory union outcomes without the need for shortening or synthetic cages

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

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

Aims: Fibular plating comprises a major component in the treatment of Pilon fractures with ORIF. However its necessity in fractures treated by EX.FIX has been questioned. In order to clarify this technical detail we carried out a retrospective study with Pilon fractures treated by circular þxators. Methods: Between 1992–2001, 65 pilon fractures were treated with circular þxators. Fractures were classiþed according to the systems of Ruedi Ð All-gower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Tension wire þxation at the fracture site was augmented by screws in 39 fractures. The lateral malleolus was internally þxed in 39(60%) patients. In 48(74%) patients the þxation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in þve fractures. Clinical and radiological results were evaluated. Results: Mean follow up was 3 years (1 to 10 years). On the basis of Ruedi-All-gower system, there was found negative correlation of the end result and þbular þxation in all the fractures types. However if Ovadia Beals system was used, þbular þxation was associated with better results in types II and III, but with inferior results in types IV and V. Conclusions: Ovadia Ð Beals classiþcation considers the metaphyseal defect and fracture comminution and should be chosen for the selection of the technique. In fractures with metaphyseal defect, þbular þxation does not allow acute shortening and makes bone transport more difþcult leading to poor results. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V

Fibular plating comprises a major component in the treatment of Pilon fractures with open reduction and internal fixation. However, its necessity when Pilon fractures are treated by hybrid fixation has been questioned. A retrospective clinical study with 65 high energy pilon fractures treated by circular fixators between 1996 and 2001 was undertaken, in order to clarify this technical detail. The mean age was 35 years (range 21 to 69 years). The fractures were classified according to the systems of Ruedi -Allgower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Hybrid fixation (tension wire fixation at the fracture site augmented by screws) was performed in 39 fractures. The lateral malleolus was internally fixed in 39(60%) patients. In 48(74%) patients the fixation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in five fractures. Clinical and radiological results were evaluated. Mean follow up was 3 years (range 1 to 10 years). On the basis of Ruedi-Allgower system, there was a negative correlation between the end result and fibular fixation in all the fractures types (p< 0.001). However, if Ovadia Beals system was used, fibular fixation was associated with better results in type II and III, but with inferior results in type IV and V. We conclude that in fractures with metaphyseal defect, fibular fixation does not allow acute shortening and makes bone transport more difficult leading to poor results. Ovadia – Beals classification considers the metaphyseal defect and the fracture comminution and should be chosen for the selection of the technique. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V

Background. To improve patient pathways we have, in selected patients, begun to acutely apply circular (rather than temporary monolateral) fixators with simultaneous or subsequent soft tissue closure. We present early results. Methods. Adult patients treated using an Ilizarov frame prior to soft tissue management were identified from our Ilizarov database. This data was supplemented by medical record review. Results. 26 cases were identified (22 open fractures (11 IIIA, 11 IIIB), 1 compartment syndrome and 3 infected salvage). All IIIA injuries were closed acutely alongside frame application. In IIIB fractures, 3 were closed following acute shortening, 1 required a local flap and 7 free tissue transfer. Soft tissue reconstruction was simultaneous to frame application in 5 patients, the remainder within 72 hours. In salvage cases, 2 required free and one a local muscle flap, all after frame application. There were no soft tissue cover failures. One patient underwent evacuation of a flap haematoma, there were no other unexpected returns to theatre for soft tissue problems. No patients required adjustment of frame components to allow soft tissue access. Conclusion. This approach appears to simplify treatment, reducing length of stay. We are collecting a matched patient series treated by traditional pathways for comparison

Purpose. To examine the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. Method. A retrospective review was conducted identifying patients from our trauma database. Inclusion criteria were age (4–17 years) and open lower-limb trauma. Outcome measures included time to soft tissue coverage, surgical techniques, trauma impact scores, health-related quality of life, union and complication rates. Results. We identified 26 patients. 24 patients had open tibia fractures including 10 patients with bone loss. In 9 patients primary skin closure was achieved by acute shortening. 17 patients required soft tissue coverage including 14 free vascularised muscle flaps (89% within 48 hours). The surgical techniques applied were: circular fine wire frame (16), external fixateur (5) and open reduction internal fixation (5). Median follow up time was 8 (3–45) months. The trauma impact scores showed one in three patients were at risk of PTSD. All fractures went on to unite over a median time of 4.2 (2–9) months. No deep infections occurred. Conclusion. All our patients had limb salvage, fracture union and near normal levels of physical scores in the short term. Close psychological follow up is advisable to minimise the risk of PTSD

Introduction: High energy tibial pilon fractures are usually associated with a significant bone loss in the metaphyseal area of the tibia. This study evaluates three different treatment options for the management of the metaphyseal bone loss. Materials and Methods: Betwwen 1996 and 2007, 85 high energy pilon fractures- Ovadia Beals type IV: 39 and V: 46- were treated and reviewed in our institution. Twenty four fractures were open, and fifty one closed fractures had soft tissue lesion grade1 or 2 according to Tscherne classification. To restore the bone continuity in tibia metaphyseal area bone graft substitutes were used in 53 fractures, acute shortening and proximal lengthening in 18 fractures and bone transport in 14 fractures. Evaluation was carried out according to the Ovadia-Beals evaluation system. Results: The mean average follow up was 6 years. Thirty seven fractures (70%) treated with bone graft substitutes achieved an excellent or good result. Eleven fractures (61%) treated with proximal tibia lengthening achieved an excellent or good result, whereas only eight fractures (57%) treated with bone transport achieved an excellent or good. Bone infection was recorded in 6 fractures, all in the group of the patients treated with bone graft substitutes. Conclusion: The management of the metaphyseal bone loss in the high energy tibial pilon fractures is a basic priority to achieve a satisfactory result. Hybrid external fixation with the use of bone graft substitutes seems to be a more suitable technique to these devastating injuries. However bone infection remains a major concern for these devastating injuries

Introduction: External fixation has evolved from a mean to hold a bone in position to one that allows a gradual correction and lengthening. Platelet gel has been reported to be effective in enhancing osteogenesis. The association of these techniques could be effective in the treatment of pottraumatic bone loss fracture. Materials and methods: Platelet gel has been obtained mixing 50 mL of autologous platelet concentrate to 2.5 mL of fibrin glue, produced from autologous FFP through CS-1 Cryoseal Thermogenesis. Patient 1: Male, 39 years old, smoker, bearing tibial non-union with 17 cm bone loss has been treated by trifocal technique with platelet gel in the docking site procedure with autologous bone graft. Patient 2: Male, 43 years old, smoker, suffering from exposed femoral fracture with sovracondilar bone loss, treated by acute shortening and proximal osteotomy in order to improve distractional ostogenesis according to Ilizarov method. Platelet gel had been positioned in the non-union sovracondilar site. Results. Patient 1 has reached a good bone repair in the platelet gel application site within 4 months. Patient 2 has healed within 3 months

We report our experience in treating victims of the recent Earthquake Disaster in Pakistan. Our experience was based on 2 humanitarian missions to Islamabad. First in October 2005, 16 days after the earthquake and the second in January 2006, three months later. The mission consisted of a team of orthopaedic and a second team of plastic surgeons. The orthopaedic team bought all the equipment for application of Ilizarov External Fixators (IEF). We treated patients who had already received basic treatment in the region of the disaster and subsequently had been evacuated to Islamabad. During the first visit we treated 12 injured limbs in 11 patients. 7 of these were children (ages 6 – 14). All the cases were complex and severe multifragmentary fractures associated with crush injuries. All of the fractures involved the tibia, which were treated with IEF. Nine fractures were type 3b open injuries. Eight were infected requiring debridement of infected bone and acute shortening of the limb segment. After stabilization, the plastic surgeons provided soft tissue cover. During the second, we reviewed all patients treated during our first mission. In addition we treated 13 new patients [Table 3] with complex non – unions. Eight out of 13 non-unions were deemed to be infected. All patients had previous treatment with monolateral fixators (AO type) as well as soft tissue coverage procedures, except one patient who had had a circular fixator (Ilizarov) applied by another team. All these patients had revision surgery with circular frames