Management strategies for bone loss in tibial shaft fractures.

Fifty open tibial fractures with circumferential cortical bone loss were reviewed. Prospective treatment protocols included fracture stabilization with repeated irrigation and debridement followed by wound coverage. Bony stabilization was accomplished using external fixators, small diameter unreamed interlocking nails, and, in rare instances, plate fixation. Bone graft procedures included posterolateral bone graft, elevation of the free flap or direct anterolateral grafting, bone transport techniques, and free vascularized fibula transfer. Average followup was 18 months (range, 9-40 months). The index graft procedure was used in 30 patients (60%) for fracture healing. The rate of union was 98%, with an average total treatment time of 42.4 weeks (range, 23-80 weeks). Malunion was more likely to develop in patients treated with external fixation and posterolateral bone graft (p = 0.007). Intramedullary nails with direct bone grafting had shorter times to union and shorter 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 reconstruction had no correlation to the development of nonunion or infection. They were valuable in determining malunion and total treatment time. These data confirm that carefully staged reconstruction leads to successful outcomes.