MANAGEMENT STRATEGIES FOR BONE LOSS IN TIBIAL SHAFT FRACTURES

Fifty open tibial fractures with circumferential cortical bone loss we re reviewed. Prospective treatment protocols included fracture stabili zation with repeated irrigation and debridement followed by wound cove rage. Bony stabilization was accomplished using external fixators, sma ll diameter unreamed interlocking nails, and, in rare instances, plate fixation. Bone graft procedures included posterolateral bone graft, e levation of the free flap or direct anterolateral grafting, bone trans port techniques, and free vascularized fibula transfer. Average follow up was 18 months (range, 9-40 months). The index graft procedure was u sed in 30 patients (60%) for fracture healing. The rate of union was 9 8%, with an average total treatment time of 42.4 weeks (range, 23-80 w eeks). Malunion was more likely to develop in patients treated with ex ternal fixation and posterolateral bone graft (p = 0.007). Intramedull ary nails with direct bone grafting had shorter times to union and sho rter total treatment times. The use of free vascular fibular transfers in acute injuries was not successful. Good results were obtained with bone transport techniques. Developing a healthy soft tissue envelope before reconstruction of these injuries is important. Techniques of re construction had no correlation to the development of nonunion or infe ction. They were valuable in determining malunion and total treatment time. These data confirm that carefully staged reconstruction leads to successful outcomes.