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Bone Grafting for Tibial Fracture

- See: Tibial Non Unions

- Discussion:
    - up to 60% of high energy open tibial will fail to heal by 20 weeks, and therefore MD must decide which fractures require
             early bone grafting and which do not;
    - large tibial defects:
         - w/ defects less than 6 cm iliac crest bone grafting may be sufficient;
                - tibial-fibular synostosis using cancellous bone may be indicated in some cases;
         - w/ defects greater than 6 cm, tibial lengthening or free fib transfer from contralateral leg may be indicated;
               (see free fibular harvest);
    - open frx:
         - indications for bone grafting include segmental defects (more than 2 cm of bone loss may require bone transport), and/or loss of
                more than 50% of the cortical surface;
         - after soft tissue coverage is adressed, consider bone grafting;
         - open fractures treated w/ external fixation:
                - delayed union is so common that some almost always plan early elective bone grafting at 2-3 weeks post injury;
    - timing:
         - as soon as soft tissue envelope is closed and non-infected, bone grafting may be considered;
         - some recommend bone grafting 5-7 days after debridement, but others argue that early bone grafting may result in resorption of
                   the graft and/or increase in the rate of infection;

- Management of Tibial Defects
     - grafting options:
            - osteogenic proteins
            - pure cancellous bone
                        - some recommend adding powered antibiotic to the cancellous graft;
            - free fibular graft;
            - papineau technique 
            - synthese reamer aspirator
                 - references: 
                         - Reamer--aspirator bone graft and bi Masquelet technique for segmental bone defect nonunions: a review of 25 cases.
                         - Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series 
                         - Treatment of recalcitrant, multiply operated tibial nonunions with the RIA graft and rh-BMP2 using IM nails 
            - masquelet technique
            - posterolateral bone grafting (bone graft harvest technique):
                    - used most in middle and distal third fractures;
                    - advantages:
                    - allows a virgin approach to be used which avoids subjecting previously traumatized area to more insult;
                    - has been successful in treating infected non unions & can be performed w/o disturbing anteromedial soft tissue defects;
                    - allows a large amount of cancellous bone graft to be applied;      
            - posteromedial bone grafting:
                    - may be indicated in proximal third fractures, where posterolateral bone grafting cannot be used due to risk of
                             neurovascular injury;
            - anterolateral bone graft:
                    - not typically utilized due to the following disadvantages:
                    - risk of increasing compartment pressure and therefore only small amounts of bone graft may be added;
                    - in fractures that were originally open, anterolateral grafting may require an incision adjacent to or thru the original
                              incision site (which can result in wound healing problems or may stir up a chronic nidus of infection);
                    - references:
                              - Anterolateral approach in bone grafting for ununited fractures of the tibia.  
                              - Guidelines for treatment of open fractures and infected pseudoarthroses by external fixation.  
                              - Central bone grafting for nonunion of fractures of the tibia: a retrospective series.

- Bone Transport Methods:
    - distraction histiogenesis
    - limb lengthening fixators
    - tibial lengthening
    - fibular transport:
           - in the report by Atkins RM, et al (1999), the authors discuss a method of tibialisation of the fibula (for massive tibial bone loss)
                   using the Ilizarov fixator system;
                   - all had successful transport, proximal and distal union, and hypertrophy of the graft without fracture;
                   - one developed a squamous-cell carcinoma which ultimately required amputation of the limb;
                   - advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or
                   - ref: Ipsilateral vascularised fibular transport for massive defects of the tibia.  

Early prophylactic bone grafting of high-energy tibial fractures.

Acute and definitive management of traumatic osteocutaneous defects of the lower extremity.

The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury.

Autologous marrow injection as a substitute for operative grafting of tibial nonunions.

Management strategies for bone loss in tibial shaft fractures.

Segmental tibial defects. Comparing conventional and Ilizarov methodologies.

Skeletal defects. A comparison of bone grafting and bone transport for segmental skeletal defects.

Management of open fractures with sterilization of large, contaminated, extruded cortical fragments.

Posterolateral bone graft of the tibia.

The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury.

Recombinant Human Bone Morphogenetic Protein-2 for Treatment of Open Tibial Fractures.

Ipsilateral fibular transfer for a large tibial defect caused by a gunshot injury: case report.

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