Special Issue on Open Fractures and Fracture-Related Infections

OPEN

Managing bone loss in open fractures

Andrew Adamczyk, MD, MSc∗, Bradley Meulenkamp, MD, FRCSC, Geoffrey Wilken, MD, FRCRC,
Steven Papp, MD, MSc, FRCSC
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Abstract
Segmental bone loss continues to pose substantial clinical and technical challenges to orthopaedic surgeons. While several surgical options
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exist for the treatment of these complex patients, there is not a clear consensus or specific guidelines on the optimal management of these
injuries as a whole. Many factors must be taken into consideration when planning surgery for these individuals. In order for these techniques
to yield optimal results, each injury must be approached in a step-wise and multidisciplinary fashion to ensure that care is taken in bone and
wound bed preparation, that soft tissues are healthy and free of contaminants, and that the patient’s medical condition has been optimized.
Through this article, we will answer relevant questions and discuss common obstacles and challenges encountered with these complex
injuries. We will also review the many treatment options available or in development to address this problem.
Keywords: bone loss, lower extremity fracture, open fracture

1. Introduction 2. When and where is bone loss a problem?

Segmental bone loss continues to pose substantial clinical and
Significant bone loss is only seen in a small subset of orthopaedic
technical challenges to orthopaedic surgeons. It is most
fractures. In a 10-year prospective audit of admissions at the
commonly observed in the traumatic setting as a result of open
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Edinburgh Orthopaedic Trauma Unit between 1988 and 1998,

fractures and infection. While several surgical options exist for
fractures with bone loss accounted for only 0.4% of all fractures.
the treatment of these complex patients, there is not a clear
However, bone loss was observed in 11.4% of all open
consensus or specific guidelines on the optimal management of
fractures[1] and was most commonly associated with Gustilo
these injuries as a whole. Moreover, good long-term functional
et al [2,3] IIIB and IIIC type injuries. Importantly, this was a young,
outcomes are limited by the high rates of complications and
active population of high-energy trauma patients with mean age
reoperations. Many factors must be taken into consideration
of 37 years, with 71% of the cohort males.
when planning surgery for these individuals: patient factors (i.e.,
The tibia is the most common site of traumatic bone loss. Its
age, presence of chronic disease, nutritional status, psychosocial
limited soft tissue coverage predisposes it to open fractures and
impact, smoking, etc), the state of surrounding soft tissues and
bone extrusion in the high-energy setting. Open fractures of the
blood supply, and finally the location and size of the bony defect.
upper extremity and axial skeleton are less common and
Through this review, we will describe this patient demographic
therefore less likely to present with associated bone loss. Of all
and how to appropriately assess and plan for operative
patients presenting with substantial bone loss, 68% were in the
management. We will address the concept of “critical” bone
tibia, 22% in the femur, with the remainder found in other
loss and the debate of what bone to keep or to discard in the initial
locations.[1] Based on these numbers, we will focus our
debridement of an open fracture. Last we will review the different
discussion on bone loss in open fractures of the lower
management options available and when they may be best
extremity.
utilized, along with some innovative techniques that may change
how we approach this difficult orthopaedic problem.
3. Acute assessment and management
Source of Funding: Nil. Bone defects associated with complex open fractures require a
The authors have no conflicts of interest to disclose. careful approach and planning. When assessing these patients in
The study was deemed exempt from Institutional Review Board approval and the acute setting, the initial step is to establish whether the limb is
Animal Use Committee review. salvageable. With the advent of new surgical techniques such as
The Ottawa Hospital, Division of Orthopaedics, University of Ottawa, Ottawa, bone transport,[4] acute limb shortening and lengthening,[5]
Ontario, Canada massive allografts or vascularized fibular allografts,[6] induced
∗
Corresponding author. Address: Division of Orthopaedic Surgery, University of membrane techniques (Masquelet technique)[6,7] and bone
Ottawa, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada. grafting with bone morphogenic protein (BMP),[8] large areas
E-mail address: [email protected] (A. Adamczyk).
of segmental bone loss do not necessarily preclude limb-salvage.
Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on However, if the limb is severely mangled, has extensive soft tissue/
behalf of the Orthopaedic Trauma Association.
This is an open access article distributed under the terms of the Creative
muscle loss, severe neurovascular compromise, or an extensive
Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC- period of ischemia, then amputation may be the best early
ND), where it is permissible to download and share the work provided it is treatment option,[9] especially if performed as an initial life-
properly cited. The work cannot be changed in any way or used commercially saving procedure. However, in most cases the decision between
without permission from the journal.
amputation and limb-salvage can be made in conjunction with
OTA (2020) e059 the patient and their family. In appropriate cases, it is important
Received: 2 November 2019 / Accepted: 22 November 2019 that amputation is presented as a viable treatment option
Published online 23 March 2020 alongside limb-salvage, and not simply as a treatment failure
http://dx.doi.org/10.1097/OI9.0000000000000059 given the lack of clear superiority of limb-salvage over

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amputation for most patients in the Lower Extremity Assessment factors to be considered and will be covered elsewhere in this
Project trial.[10] current symposium.
Early initiation of intravenous antibiotics is crucial.[11,12] When addressing the traumatic or iatrogenic bone void caused
First-generation cephalosporins should be administered prompt- by radical bony debridement prior to closure, antibiotic
ly for Gustillo-Anderson Grade I and II open fractures. Most impregnated polymethylmethacrylate (PMMA) spacers have
authors recommend additional gram-negative coverage in the provided an excellent option. They not only provide a local
form of an aminoglycoside for grade III injuries.[2,13] In the high concentration of antibiotic elution, but increase fracture
setting of fecal contamination or possible clostridial contamina- stability, maintain adequate soft tissue tension, and prevent
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tion, penicillin is also recommended.[14] Prophylactic antibiotics fibrous ingrowth. This technique is not only used in the case of
should not be continued longer than 24-hours after each surgical staged induced membrane (Masquelet) technique, but also in
debridement since longer courses have not yielded a reduction in cases of delayed closure where the goal is to decrease the local
infection rates and could lead to greater rates of antibiotic bio-burden prior to proceeding with primary closure or soft tissue
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resistance.[15,16] coverage and grafting.

Local antibiotic delivery into the wound at the time of surgical At the end of the initial treatment phase, these patients will
debridement appears to be a promising adjunct to systemic have a variable amount of bone loss which will remain a
antibiotic prophylaxis alone. However, more research on this management challenge. When should this defect be treated? Can
topic is necessary before stronger conclusions can be drawn.[17,18] it be treated with observation? Is there a “critical sized defect”
After initial assessment and initiation of antibiotics, the focus that always needs a second intervention? What is best treatment
shifts to thorough surgical debridement and stabilization of the for this defect? These questions all remain important issues and
open injury. Debridement has often been guided by surgical will be addressed below.
principle rather than evidence-based technique. Recent literature
states that open fractures should be debrided until “stable” and
4. Can we define “critical” bone defect?
“all necrotic tissue and organic and inorganic contaminants have
been removed.”[19] This involves working through the open Bone loss can happen at the time of injury via fragment extrusion
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fracture site, extending the wound proximally and distally and or iatrogenically during debridement of an open fracture when
completing an excisional debridement of all nonviable skin, devitalized bone is removed. Although classification systems exist
subcutaneous tissue, muscle, periosteum, and bone with the goal for the description of open fractures, their ability to describe the
of achieving a healthy and clean surgical wound. The “tug test” extent of bone loss is lacking.[2,3] Describing bone loss should
can be used to assess the viability of cortical fragments within the begin with a description by anatomical bone location: diaphyseal,
wound[20] and consists of removing fragments that are easily metaphyseal, or articular. The extent of the defect is then
removed using a pair of forceps or 2 fingers. These fragments are described by stating its length and whether the segment presents
assumed to have insufficient viability for survival and are partial or complete circumferential bone loss. When Orthopaedic
therefore discarded. This concept holds true primarily for cortical Trauma Association members were surveyed with regards to the
fragments of the diaphysis considering its poor surrounding soft definition of a “critical-sized” segmental bone defect, a precise
tissue environment and blood supply. Metaphyseal fragments are size and volume of bone fitting this criteria was not defined.[29]
much less commonly loose or free given the rich periosteum and Some authors have suggested that this usually occurs when the
musculotendinous attachments. Additionally, metaphyseal frag- length of the defect is 2 to 2.5 times the diameter of the bone
ments may contain articular cartilage and/or critical ligamentous involved.[30] Others have described this entity as a defect length
attachments which warrant consideration for retention. All greater than 1 cm and greater than 50% loss of the circumference
viable fragments and reconstructible osteochondral or articular of the bone.[1,31] In general, a “critical” defect is regarded as one
fragments should be preserved.[20–22] that will not heal spontaneously despite surgical stabilization and
In contradiction to the above, a specific scenario relevant to requires further surgical intervention, such as bone grafting.[1,32]
the concept of “critical” sized defect is the very large segmental The SPRINT study remains one of the largest randomized
fragment devoid of soft tissue attachment that, if removed, control trials in surgical history, yet despite including over 1000
significantly worsens the reconstruction challenge. The decision tibia fractures, bone loss was relatively uncommon. In this study
to keep or remove this fragment requires weighing the value of of 1125 patients with tibia fractures, only 37 (3%) had a
the fragment and the risk-benefit ratio of both scenarios. For “critical” bone defect defined as greater than 1 cm in length and >
example, the comparison between a “low value” fragment such 50% of the cortical diameter. Of these 37 patients, 47% achieved
as a moderate sized cortical piece of diaphyseal bone, which can union without additional treatment, suggesting that although
be managed with contemporary techniques and the “high worrisome, this “critical” size defect may not be truly
value” fragment such as the large osteoarticular segment or “critical.”[31] A study conducted by Haines et al may offer the
whole extruded bone that may not be replaceable.[23] Methods most detailed assessment of fracture gap size. In their study, the
on how to treat and reimplant large extruded segments of bone average radiographic apparent bone gap (RABG) measures bone
in an acute and delayed fashion in the open fracture setting have loss on all 4 cortices (Fig. 1). A RABG of < 25 mm had a union
been described in the literature and have demonstrated good rate of 54% and a RABG >25 mm had a union rate of 0%.[33]
results despite going against popular belief; however, this It is important to understand the complex nature of bone
evidence is largely low-level, based on case reports and case healing. The definition of “critical sized” defect is likely
series.[24–27] oversimplified and therefore, bone gap size should not be used
No matter the debridement technique chosen, once thorough in isolation to make clinical decisions. Rather, multiple factors
debridement has been performed, the wound should be from an anatomical, biomechanical, and biological perspective
thoroughly irrigated in the operating room.[28] Issues such as all play a role in predicting nonunion. Anatomical location of the
timing of surgery, amount and type of fluid to be used, primary vs defect has a significant impact on healing potential. For example,
delayed closure, and timing of flap coverage are all important segmental defects of the femur often present favorable soft tissue

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Figure 1. Defining the lower limit of a “Critical Bone Defect” in open diaphyseal tibial fractures. (Taken from Haines NM, Lack WD, Seymour RB, and Bosse MJ.
Defining the lower limit of a “Critical bone defect” in open diaphyseal tibial fractures. J Orthop Trauma 30, e158–e163 (2016).)

environment with spontaneous healing reported in segmental corrected, spontaneous healing of the nonunion without
defects measuring as much as 6 to 15 cm in length.[34] In contrast additional surgical intervention occurred in >25% of patients.[37]
to the femur, the tibia has relatively poor outcomes with lack of Other patient factors such as diabetes, radiation therapy, and
spontaneous healing in segments of bone loss as low as 1 cm with alcohol abuse have also been associated with nonunion.[38]
greater than 50% cortical circumference.[35,36] In the setting of Finally, poor vascular supply to the affected extremity is
nonunion, the biological environment is often the rate-limiting invariably associated with failure of bony and soft tissue
factor, with impaired cellular and molecular signaling, regardless reconstruction. Consultation with a vascular surgeon is recom-
of biomechanical stability. [1,29,31] mended for patients with compromised perfusion, as revascular-
ization may be indicated. The treatment and optimization of these
patients is necessarily multidisciplinary and the source of
5. Surgical management of bone defects in open motivation for many centers to create limb salvage teams which
fracture are better equipped to help treat these modifiable risk factors and
improve the rate of successful outcomes.
5.1. Patient optimization
Patient optimization is a crucial step that cannot be overlooked.
5.2. Induced membrane technique (Masquelet)
Bone healing is predicated on both mechanical stability and a
favorable biological environment; therefore, ignoring this step Although autologous bone grafting has been successful for bone
may be detrimental to overall outcomes. Tobacco cessation, defects < 5 cm in size, defects beyond this size have been
glycemic control, nutritional optimization, and management of associated with a high failure rate due to secondary graft
metabolic and endocrine abnormalities are interventions that resorption and consolidation failure.[7] To address this, Mas-
should be optimized. In a study of 37 nonunions, patients who quelet and Begue described an alternative induced membrane
were referred for metabolic and endocrine testing, abnormalities technique with 3 main benefits.[7] The first benefit is that the
such as vitamin D deficiency, thyroid, and parathyroid disorders PMMA spacer maintains the defect space, preventing surround-
and hypogonadism were found in > 80% of cases with otherwise ing tissue contracture. Second, the membrane created is rich in
unexplained nonunions.[37] With these metabolic abnormalities growth factors including vascular endothelial growth factor,

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transforming growth factor-ß1, BMP-2 and core binding factor phase can often last twice as long as the transport phase.[47] The
alpha-1, that improve graft consolidation by stimulating cell main advantages of using distraction osteogenesis for the
proliferation and differentiation into the osteoblastic lineage.[39] management of segmental bone defects are reliability, ability to
Finally, the membrane creates a separate compartment, protect- bear weight during reconstruction, and, most importantly, the
ing autograft from resorption. absence of limits with regards to size of the defect that can be
The Masquelet technique occurs in 2 stages. The first stage reconstructed. The disadvantages, however, are the length of time
consists of radical bony debridement followed by the placement required to achieve consolidation (an average of 10–12 months for
of a PMMA cement spacer. The bone defect is then stabilized with a defect of 10 cm in size) and the resultant physical and
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external fixation (as originally described), internal fixation, or an psychological burden on the patient with prolonged transports.
intramedullary rod. To allow enough time for the membrane Another method of distraction osteogenesis that has minimized
maturation, the second stage is delayed to allow ideal biologic transport time has been that of bifocal distraction osteogenesis,
and wound bed conditions. The ideal biologic timing is 4 weeks; which involves performing a metaphyseal corticotomy at both
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however, the soft tissues may not be mature enough at this time ends of the defect. This has been demonstrated to reduce
and this often delays surgeon intervention this early. Typically, transport time by 2.5 times as well as that of consolidation by
the second stage is completed 6 to 12 weeks following spacer between 1.3 and 1.9 times. However, this technique also
placement. At this time the membrane is carefully incised and demonstrated slower maturation of regenerated bone. Further-
preserved while the spacer is removed. The void is then filled with more, this technique requires complex frame construct and
autologous bone graft, with or without allograft or other bone meticulous frame management by both surgeon and patient.[47]
substitutes as needed as graft extender. A graft extender should In a recent long-term study looking at the Ilizarov technique,
not exceed a 3:1 ratio of autograft to allograft.[7,40] although all patients eventually achieved union, the rate of union
The time required prior to initiation of full weight bearing is was 91.2% with a 29% reoperation rate.[48] Other studies have
fracture and fixation dependent. By definition, fixation of any reported union rates between 92% and 94%,[46,49] with 1 study
segmental defect requires a load-bearing fixation construct, since requiring secondary bone grafting in 36% of patients to achieve
no initial bone-to-bone contact exists at the outset to share load union.[46] Neurovascular complications and amputation rates
have been reported at 2.2% and 2.9% respectively.[49]
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with the implant. Also, the time required for the bone graft to
incorporate and corticate to a degree that it can bear load is often Hybrid techniques in bone transport have demonstrated a
much longer than in typical fracture healing. As a result, the decrease in time required for external fixation by stabilizing the
fixation construct must be able to withstand both high peak loads bone with internal fixation during the consolidation phase.
and many cycles of submaximal loads without failure. With Kocaoglu et al[50] transported bone over an IM nail with an
multiplanar external fixators coupled with hydroxyapatite average defect size of 10 cm (femur) and 7 cm (tibia). The external
coated external fixation pins, locked IM nails, locking plate fixator index (EFI), which is calculated by dividing the number of
technology, and allograft cortical substitution, very stable and days in the external fixation by the total length of the defect, was
rigid fixation constructs can be created and immediate full weight 13.5 d/cm.[50] Once the transported segment reaches the docking
bearing may be permitted. However, the optimal mechanical site and the frame is removed, the segment is secured using
environment for graft healing remains unknown, though locking screws through the nail. Oh et al,[51] using a similar
Masquelet has empirically recommended high initial fixation technique, demonstrated 100% union with no malunion and an
rigidity to promote incorporation followed by more flexible EFI of 13.4 days. This hybrid technique has led to increased
fixation to promote remodeling and cortication.[40] patient comfort, decreased complications with more convenient
Masquelet and Begue’s initial series of 35 patients with defects and rapid recovery. However, these devices are significantly more
ranging from 5 to 24 cm in length demonstrated graft incorpo- costly and present an increased risk for subsequent deep infection
ration and defect healing in 89% of patients.[7] This has since due to the use of an internal fixation device.[39]
been replicated in other studies with success rates of 85% to 92%
reported;[41] however, multiple interventions may be required to
5.4. Acute limb shortening and lengthening
achieve union with this technique.[42–44] In summary, the
Masquelet technique is reliable and allows for reconstruction Although uncommon, if faced with segmental bone loss in the
of large segmental bone defects. Its advantage over distraction upper extremity, limb shortening is a viable option as function is
osteogenesis is that time to union is not dependent on the size of not dependent on limb length symmetry.[39] This technique can
the bone defect, whereas its main disadvantage is the need for also be utilized in the lower extremity, but less commonly. It is the
sufficient volumes of autologous bone graft to be successful. simplest and presumably fastest treatment option for segmental
bone loss. It allows for early primary closure without soft tissue
tension, which can allow for delayed lengthening via distraction
5.3. Distraction osteogenesis
osteogenesis once the soft tissue envelope has healed.[52] However,
Management of segmental bone loss with distraction osteogenesis a major known complication of acute shortening is kinking of the
involves the transportation of a segment of bone in a controlled arterial system and is most commonly seen with shortening of more
fashion, typically via the use of an external fixator or an IM device. than 3 to 5 cm5; therefore, thorough monitoring of pulses during
This was initially described by Ilizarov while treating nonunions and after surgery is paramount to prevent this complication. Also,
with fine wire circular frames.[45] With the advent of the spatial and acute limb shortening can impair muscle contractile function if the
monolateral frames, this technique has gained further populari- muscle length-tension relationship is excessively altered.
ty.[39] In brief, once the frame has been applied with fine wire or half
pins, a metaphyseal corticotomy is performed and the transport
phase begins. This may occur at a rate of up to 1 mm per day.[46] 5.5. Vascularized fibular allograft
Once the transported segment reaches the docking site, it is The vascularized fibular graft was developed in the 1970s as the
compressed for weeks until healing occurs. The consolidation microvascular field evolved. It had been the preferred choice for

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defects > 10 cm; however, it has lost some of its popularity with in-vitro and in-vivo animal models, if proven to be fruitful for the
the dawn of the improved induced membrane techniques and treatment of “critical” bone defects, it may be able to solve the
distraction osteogenesis. The main drawbacks of this technique problem of donor site morbidity in the case of autograft harvest
are the associated donor side morbidity and the need for a as well as disease transmission, lack of osteogenicity, cost, and an
microvascular trained surgeon to perform the procedure. In a already limited supply of allograft bone. To do so, 3D bioprinting
study looking at its use in the treatment of type III tibia fractures, combines a biocompatible scaffold that recapitulates the natural
a donor site morbidity of 30% was reported.[53] Furthermore, bone extracellular matrix niche, inclusion of osteogenic cells to
restricted weight bearing is required to prevent fractures during secrete the necessary extracellular matrix, and morphogenic
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fibular hypertrophy, which can take up to 2 years. Despite signals that spatiotemporally biodirect the cells to the phenotypi-
prolonged protected weight-bearing, approximately 20% frac- cally desirable type and sufficient vascularization to meet the
ture during the first year.[54] When resecting the fibula in this growing tissue nutrient supply and metabolic needs.[66] Bio-
technique, bone can be taken as close as 4 cm to the fibular head printing also provides a much better compressive modulus, one
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without compromising the proximal tibiofibular joint and up to 6 that can exceed 500 kPa, approximating human tissue compres-
cm proximal to the ankle joint without causing ankle instabili- sive moduli,[67] where conventional bone grafts possess poor
ty.[54] Despite its significant donor site morbidity and fracture compressive modulus.[68] These prints would not only be patient
risk, union typically occurs within 6 to 9 months, which is specific from a geometric standpoint but also the level of tissue
substantially shorter than other reconstruction techniques with insufficiency and the anatomy of the composite tissue as well as
union rates reported as high as 97%.[53,55] vascular network. As this technology evolves, this additive
manufacturing technique may be used to reconstruct bone as well
as articular cartilage in areas where our current available clinical
6. Modern techniques in the management of bone
technologies and tissue manufacturing strategies fail.
defects
Current treatment modalities pose a significant burden to the
7. Conclusion
patients both physically and psychologically as these treatments
“Critical” bone loss associated with open fractures is a relatively
on 08/02/2023

are lengthy and cumbersome for the patient to live with on a daily
basis. To address these issues, both technique and technology uncommon but very challenging problem. The tibia and the
must evolve in order to better treat this problem and allow femur are the most commonly involved sites, and bone loss in the
patients to achieve a better quality of life during treatment. upper extremities and articular surfaces is rare. Bone defects can
vary dramatically in size and selecting the most appropriate
treatment plan to address a given defect, must be carefully
6.1. Plate-assisted bone segment transport (PABST)
thought out on a case-by-case basis. Detailed discussion and
Although only a case report, Barinaga et al[56] were recently able shared decision making with the patient is critical since these are
to treat a 51-year-old male presenting with a type IIIB tibia often life-changing injuries and surgical procedures that have
fracture with segmental bone loss with an all inside technique, lasting impacts on quality of life.
involving a combination of internal fixation for bony stability There are many techniques available to treat these complex
and the PRECISE 2 IM Limb Lengthening System (Nuvasive), injuries and determining the best approach for each scenario remains
which they used for all inside distraction osteogenesis. Although controversial. In order for these techniques to yield optimal results,
this novel IM system cannot be used for all sizes of defect, it does each injury must be approached in a step-wise and multidisciplinary
allow for up to 80 mm of lengthening. This system may also fashion to ensure that care is taken in bone and wound bed
provide more precise distraction as it is capable of bidirectional preparation, that soft tissues are healthy and free of contaminants,
control, which allows for both distraction and compression (i.e., and that the patient’s medical condition has been optimized. With
the accordion technique).[57–60] To their knowledge, this group is the advances in all inside distraction osteogenesis techniques as well
the first to describe the use of this IM system to correct a “critical” as 3D bioprinting with enhanced biologics, restoring satisfactory
bone defect via segmental bone transport without shortening or limb function may not pose as much of a burden physically,
concurrent use of an external fixation device and have coined psychologically, and economically as it continues to today.
the technique as plate-assisted bone segment transport. The
advantages of this technique are that it reduces joint stiffness and
7.1. Case 1
muscle contracture associated with shortening and secondary
lengthening,[61–63] it eliminates the need of an external fixation Eighty-seven-year-old female was involved in a motor vehicle
device which is uncomfortable for the patient and associated with accident in July of 2017. On initial assessment, she presents an
several postoperative complications; and lastly, the magnetic open distal femur fracture with segmental bone loss, ipsilateral
device removes the need for subcutaneous receiver antenna;[64,65] intertrochanteric hip fracture (initial x-rays not available), right
therefore, potentially removing a source of failure. Although closed wrist fracture, left bimalleolar ankle fracture, intracranial
further work remains to be done regarding this technique, it does hemorrhage, flail chest injury, and multiple spinal fractures.
look promising for the future. Prior to arriving at our center, she is treated at an outside
Level 1 Trauma Centre for her above-mentioned injuries.
Primary treatment of her open femur fracture with associated
6.2. Three-dimensional bioprinting
14 cm segmental bone defect involved irrigation and debride-
Three-dimensional (3D) bioprinting is a tissue engineering ment, open reduction and internal fixation with distal femoral
fabrication method that uses spatial patterning of living cells locking plate and placement of PMMA spacer in 1st stage
and other biological materials assembling them in a layer-by- Masquelet technique, as well as supplementary ipsilateral short
layer deposition approach for the construction of living tissue and InterTAN femur nail for treatment of her basicervical femoral
organ analogs.[66] Although most of this work has been mainly in neck fracture (Fig. 2).

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Figure 2. (A) AP, (B) lateral left femur (C) AP pelvis, and (D) Iateral left hip 3 weeks postop from irrigation and debridement, with open reduction internal fixation of
distal femur, short InterTan and first stage Masquelet technique at an outside tertiary care center.

Figure 3. (A) AP, (B) lateral left femur, and (C) AP left hip postoperative day 1 from second stage masquelet technique with fibullar strut allograft.

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Figure 4. (A) AP and (B) lateral left femur 6 months postop, demonstrating maintenance of internal fixation stability, and good consolidation.

Figure 5. (A) AP and (B) lateral left femur 1 year postop, demonstrating maintenance of hardware fixation, and complete graft consolidation.

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Due to the patients’ history of atrial fibrillation, osteoporosis, 14. Carver DC, Kuehn SB, Weinlein JC. Role of systemic and local antibiotics
in the treatment of open fractures. Orthop Clin North Am. 2017;48:137–
and previous left patella fracture treated with surgical
153.
fixation, the patient received an anesthesia consult, as well as 15. Hoff WS, Bonadies JA, Cachecho R, et al. East Practice Management
an endocrinology consult for patient optimization prior to Guidelines Work Group: update to practice management guidelines for
proceeding with 2nd stage Masquelet. Approximately 8 weeks prophylactic antibiotic use in open fractures. J Trauma. 2011;70:751–
following her initial injury, she was treated with removal of 754.
16. Dellinger EP, Caplan ES, Weaver LD, et al. Duration of preventive
hardware and PMMA spacer, saucerization of distal femur, antibiotic administration for open extremity fractures. Arch Surg.
revision of left distal femoral fixation, fibular strut allograft, 1988;123:333–339.
d+W96/6Wz8fArQLUA9m0+oC1S1f/aVFQHv40a7At9XDeU361XgvTvqXn6jZHXEXHSOHEYuGmhWMVaVxwgvO9qVchRI2en9oYEDk=

autogenous RIA autograft from right femur with prophylactic 17. Tennent DJ, Shiels SM, Sanchez CJJr, et al. Time-dependent
retrograde intramedullary nail, and with cancellous allograft effectiveness of locally applied vancomycin powder in a contaminated
traumatic orthopaedic wound model. J Orthop Trauma. 2016;30:531–
with Infuse BMP graft (Fig. 3, postoperative day 1). Postopera-
537.
tively she was made weight-bearing as tolerated and received
Downloaded from http://journals.lww.com/otainternational by k38zdtHxkv6Rmgh4wgFdUkMsT1GhsfV9rejAJieU

18. Caroom C, Moore D, Mudaliar N, et al. Intrawound vancomycin

standard DVT prophylaxis. powder reduces bacterial load in contaminated open fracture model. J
Overall, the patient did very well. She was weight bearing short Orthop Trauma. 2018;32:538–541.
distances with no presence of wound issues at her 4-week follow- 19. Bosse MJ, Murray CK, Carlini AR, et al. Assessment of severe extremity
wound bioburden at the time of definitive wound closure or coverage:
up. Two months postoperatively the patient presented good correlation with subsequent postclosure deep wound infection (Bio-
mobilization with limited restrictions using a 4-wheel walker. burden Study). J Orthop Trauma. 2017;31 (suppl 1):S3–S9.
Her left knee range of motion was measured to be 0° to 100° at 20. Mauffrey C, Bailey JR, Bowles RJ, et al. Acute management of open
that time. She was fitted with a shoe lift, however, due to her fractures: proposal of a new multidisciplinary algorithm. Orthopedics.
2012;35:877–881.
associated 3.5 cm leg length discrepancy with the left leg being
21. Swiontkowski MF. Criteria for bone debridement in massive lower limb
shorter postinjury. When she was seen for her 6-month follow- trauma. Clin Orthop Relat Res. 1989;41–47.
up, she had progressed with her mobilization using only a cane 22. Zalavras CG, Marcus RE, Levin LS, et al. Management of open fractures
inside the house and even going without any walking aids on and subsequent complications. J Bone Joint Surg Am. 2007;89:884–895.
occasion. Her x-rays also demonstrated excellent consolidation 23. Toogood P, Miclau T. Critical-sized bone defects: sequence and
planning. J Orthop Trauma. 2017;31 (suppl 5):S23–S26.
on 08/02/2023

of the graft (Fig. 4). Finally, when she was seen for her 1-year 24. Meininger AK, Figuerres BF, Parameswaran AD, et al. Extruded
follow-up, the patient had progressed to mobilization without osteoarticular distal tibia: success at 18-month follow-up with
any walking aids most of the time and her fracture had reimplantation. J Orthop Trauma. 2010;24:e102–107.
demonstrated full bony union (Fig. 5). The above case and 25. Farrelly E, Ferrari L, Roland D, et al. Reimplantation of an extruded
osteoarticular segment of the distal tibia in a 14-year-old girl. Case report
associated de-identified images were used after receiving patient
and review of the literature. J Orthop Trauma. 2012;26:e24–28.
consent. 26. Afshar A. Reimplantation of a large extruded segment of bone in an open
fracture. J Hand Surg Am. 2017;42:128–134.
References 27. Rathore S, Reddy IV, Ashwin Kumar AH. A novel technique for
reimplanting extruded bone fragments in open fractures. Trauma Case
1. Keating JF, Simpson AH, Robinson CM. The management of fractures Rep. 2016;4:5–11.
with bone loss. J Bone Joint Surg Br. 2005;87:142–150. 28. Srour M, Inaba K, Okoye O, et al. Prospective evaluation of treatment of
2. Gustilo RB, Mendoza RM, Williams DN. Problems in the management open fractures: effect of time to irrigation and debridement. JAMA Surg.
of type III (severe) open fractures: a new classification of type III open 2015;150:332–336.
fractures. J Trauma. 1984;24:742–746. 29. Obremskey W, Molina C, Collinge C, et al. Current practice in the
3. Gustilo RB, Merkow RL, Templeman D. The management of open management of open fractures among orthopaedic trauma surgeons. Part
fractures. J Bone Joint Surg Am. 1990;72:299–304. b: management of segmental long bone defects. A Survey of Orthopaedic
4. Cattaneo R, Catagni M, Johnson EE. The treatment of infected Trauma Association Members. J Orthop Trauma. 2014;28:e203–207.
nonunions and segmental defects of the tibia by the methods of Ilizarov. 30. Pipitone PS, Rehman S. Management of traumatic bone loss in the lower
Clin Orthop Relat Res. 1992;143–152. extremity. Orthop Clin North Am. 2014;45:469–482.
5. El-Rosasy MA. Acute shortening and re-lengthening in the management 31. Sanders DW, Bhandari M, Guyatt G, et al. Critical-sized defect in the
of bone and soft-tissue loss in complicated fractures of the tibia. J Bone tibia: is it critical? Results from the SPRINT trial. J Orthop Trauma.
Joint Surg Br. 2007;89:80–88. 2014;28:632–635.
6. Toros T, Ozaksar K. Reconstruction of traumatic tubular bone defects 32. Nauth A, Schemitsch E, Norris B, et al. Critical-size bone defects: is there
using vascularized fibular graft. Injury. 2019;[Epub ahead of print]. a consensus for diagnosis and treatment? J Orthop Trauma. 2018;32
7. Masquelet AC, Begue T. The concept of induced membrane for (suppl 1):S7–S11.
reconstruction of long bone defects. Orthop Clin North Am. 2010;41:27–37. 33. Haines NM, Lack WD, Seymour RB, et al. Defining the lower limit of a
8. Johnson EE, Urist MR, Finerman GA. Resistant nonunions and partial or “critical bone defect” in open diaphyseal tibial fractures. J Orthop
complete segmental defects of long bones. Treatment with implants of a Trauma. 2016;30:e158–163.
composite of human bone morphogenetic protein (BMP) and autolyzed, 34. Hinsche AF, Giannoudis PV, Matthews SE, et al. Spontaneous healing of
antigen-extracted, allogeneic (AAA) bone. Clin Orthop Relat Res. large femoral cortical bone defects: does genetic predisposition play a
1992;229–237. role? Acta Orthop Belg. 2003;69:441–446.
9. Southam BR, Archdeacon MT. “Iatrogenic” segmental defect: how i 35. Blick SS, Brumback RJ, Lakatos R, et al. Early prophylactic bone grafting
debride high-energy open tibial fractures. J Orthop Trauma. 2017;31 of high-energy tibial fractures. Clin Orthop Relat Res. 1989;1:21–41.
(suppl 5):S9–S15. 36. Court-Brown CM, McQueen MM, Quaba AA, et al. Locked intra-
10. MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb- medullary nailing of open tibial fractures. J Bone Joint Surg Br.
threatening lower limb trauma: lessons learned from the Lower 1991;73:959–964.
Extremity Assessment Project (LEAP). J Am Acad Orthop Surg. 37. Brinker MR, O’Connor DP, Monla YT, et al. Metabolic and endocrine
2006;14 (10 Spec No.):S205–210. abnormalities in patients with nonunions. J Orthop Trauma.
11. Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia 2007;21:557–570.
fractures: immediate antibiotic prophylaxis minimizes infection. J 38. Niikura T, Lee SY, Sakai Y, et al. Causative factors of fracture nonunion:
Orthop Trauma. 2015;29:1–6. the proportions of mechanical, biological, patient-dependent, and
12. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture patient-independent factors. J Orthop Sci. 2014;19:120–124.
wounds. Clin Orthop Relat Res. 1989;36–40. 39. Mauffrey C, Barlow BT, Smith W. Management of segmental bone
13. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one defects. J Am Acad Orthop Surg. 2015;23:143–153.
thousand and twenty-five open fractures of long bones: retrospective and 40. Masquelet A, Kanakaris NK, Obert L, et al. Bone repair using the
prospective analyses. J Bone Joint Surg Am. 1976;58:453–458. Masquelet technique. J Bone Joint Surg Am. 2019;101:1024–1036.

8
 Adamczyk et al OTA International (2020) e059 www.otainternational.org

41. Hartsock LA, Barfield WR, Kokko KP, et al. Randomized prospective 54. Khira YM, Badawy HA. Pedicled vascularized fibular graft with Ilizarov
clinical trial comparing reamer irrigator aspirator (RIA) to standard external fixator for reconstructing a large bone defect of the tibia after
reaming (SR) in both minimally injured and multiply injured patients tumor resection. J Orthop Traumatol. 2013;14:91–100.
with closed femoral shaft fractures treated with reamed intramedullary 55. Cavadas PC, Landin L, Ibanez J, et al. Reconstruction of major traumatic
nailing (IMN). Injury. 2010;41 (suppl 2):S94–98. segmental bone defects of the tibia with vascularized bone transfers. Plast
42. Karger C, Kishi T, Schneider L, et al. Treatment of posttraumatic bone Reconstr Surg. 2010;125:215–223.
defects by the induced membrane technique. Orthop Traumatol Surg 56. Barinaga G, Beason AM, Gardner MP. Novel surgical approach to
Res. 2012;98:97–102. segmental bone transport using a magnetic intramedullary limb
43. McCall TA, Brokaw DS, Jelen BA, et al. Treatment of large segmental lengthening system. J Am Acad Orthop Surg. 2018;26:e477–e482.
bone defects with reamer-irrigator-aspirator bone graft: technique and 57. Catagni MA, Guerreschi F, Lovisetti L. Distraction osteogenesis for bone
d+W96/6Wz8fArQLUA9m0+oC1S1f/aVFQHv40a7At9XDeU361XgvTvqXn6jZHXEXHSOHEYuGmhWMVaVxwgvO9qVchRI2en9oYEDk=

case series. Orthop Clin North Am. 2010;41:63–73. repair in the 21st century: lessons learned. Injury. 2011;42:580–586.
44. Apard T, Bigorre N, Cronier P, et al. Two-stage reconstruction of post- 58. De Bastiani G, Aldegheri R, Renzi-Brivio L, et al. Limb lengthening by
traumatic segmental tibia bone loss with nailing. Orthop Traumatol Surg callus distraction (callotasis). J Pediatr Orthop. 1987;7:129–134.
Res. 2010;96:549–553. 59. Makhdom AM, Cartaleanu AS, Rendon JS, et al. The accordion
Downloaded from http://journals.lww.com/otainternational by k38zdtHxkv6Rmgh4wgFdUkMsT1GhsfV9rejAJieU

45. Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Jt Dis maneuver: a noninvasive strategy for absent or delayed callus formation
Orthop Inst. 1988;48:1–11. in cases of limb lengthening. Adv Orthop. 2015;2015:912790.
46. Chaddha M, Gulati D, Singh AP, et al. Management of massive 60. Ilizarov GA. Clinical application of the tension-stress effect for limb
posttraumatic bone defects in the lower limb with the Ilizarov technique. lengthening. Clin Orthop Relat Res. 1990;8–26.
Acta Orthop Belg. 2010;76:811–820. 61. Rigal S, Merloz P, Le Nen D, et al. Bone transport techniques in
47. Borzunov DY. Long bone reconstruction using multilevel lengthening of posttraumatic bone defects. Orthop Traumatol Surg Res. 2012;98:103–
bone defect fragments. Int Orthop. 2012;36:1695–1700. 108.
48. Lowenberg DW, Buntic RF, Buncke GM, et al. Long-term results and 62. Iacobellis C, Berizzi A, Aldegheri R. Bone transport using the Ilizarov
costs of muscle flap coverage with Ilizarov bone transport in lower limb method: a review of complications in 100 consecutive cases. Strategies
salvage. J Orthop Trauma. 2013;27:576–581. Trauma Limb Reconstr. 2010;5:17–22.
49. Papakostidis C, Bhandari M, Giannoudis PV. Distraction osteogenesis in 63. Dahl MT, Gulli B, Berg T. Complications of limb lengthening. A learning
the treatment of long bone defects of the lower limbs: effectiveness, curve. Clin Orthop Relat Res. 1994;10–18.
complications and clinical results; a systematic review and meta-analysis. 64. Dincyurek H, Kocaoglu M, Eralp IL, et al. Functional results of lower
Bone Joint J. 2013;95-B:1673–1680. extremity lengthening by motorized intramedullary nails. Acta Orthop
50. Kocaoglu M, Eralp L, Rashid HU, et al. Reconstruction of segmental Traumatol Turc. 2012;46:42–49.
bone defects due to chronic osteomyelitis with use of an external fixator 65. Krieg AH, Lenze U, Speth BM, et al. Intramedullary leg lengthening with
on 08/02/2023

and an intramedullary nail. J Bone Joint Surg Am. 2006;88:2137–2145. a motorized nail. Acta Orthop. 2011;82:344–350.
51. Oh CW, Apivatthakakul T, Oh JK, et al. Bone transport with an external 66. Dhawan A, Kennedy PM, Rizk EB, et al. Three-dimensional bioprinting
fixator and a locking plate for segmental tibial defects. Bone Joint J. for bone and cartilage restoration in orthopaedic surgery. J Am Acad
2013;95-B:1667–1672. Orthop Surg. 2019;27:e215–e226.
52. Sen C, Kocaoglu M, Eralp L, et al. Bifocal compression-distraction in the 67. Hoenig E, Winkler T, Mielke G, et al. High amplitude direct compressive
acute treatment of grade III open tibia fractures with bone and soft-tissue strain enhances mechanical properties of scaffold-free tissue-engineered
loss: a report of 24 cases. J Orthop Trauma. 2004;18:150–157. cartilage. Tissue Eng Part A. 2011;17:1401–1411.
53. Zhen P, Hu YY, Luo ZJ, et al. One-stage treatment and reconstruction of 68. Khanarian NT, Jiang J, Wan LQ, et al. A hydrogel-mineral composite
Gustilo Type III open tibial shaft fractures with a vascularized fibular scaffold for osteochondral interface tissue engineering. Tissue Eng Part
osteoseptocutaneous flap graft. J Orthop Trauma. 2010;24:745–751. A. 2012;18:533–545.