Infected nonunion of the tibia

The treatment of infected nonunited fractures of the tibia using the techniques of Ilizarov was compared with autogenous cancellous bone graft application under a well vascularized soft tissue envelope. There were 10 patients in the Ilizarov group and 17 in the bone graft group. Soft tissue coverage with a free vascularized or a rotational muscle flap was used more frequently among the patients having bone graft (71%) than the Ilizarov group (30%). All 27 patients had bony defects (average, 3.7 cm; range, 1-18 cm). At an average followup of 6 years, 26 patients had a functional limb, and one patient (Ilizarov group) ultimately required a below knee amputation. Three patients in each group required a second plate and bone graft procedure to gain union. Infection persisted in four patients (all in the Ilizarov group). If a well vascularized soft tissue envelope is present (particularly after flap coverage), bone grafting procedures are safe and efficacious. The Ilizarov technique may be best suited for the treatment of very proximal or distal metaphyseal nonunions and nonunions associated with large leg length discrepancies.     

Knee arthrodesis with simultaneous lengthening using the Ilizarov method

OBJECTIVE: To determine whether knee arthrodesis with simultaneous lengthening using the Ilizarov method for a nonreconstructable knee joint with bone loss and infection is a successful salvage procedure. DESIGN: Retrospective review of patients. SETTING: University hospital-based orthopaedic practice. PATIENTS: From 1999 to 2001, 4 consecutive patients with a nonreconstructable knee joint, bone loss, and infection after trauma underwent knee arthrodesis with simultaneous lengthening. INTERVENTION: Arthrodesis of the knee with simultaneous limb lengthening through an osteotomy of the tibia and/or femur and the use of an Ilizarov frame. External bone stimulation was used at the knee arthrodesis site and the lengthening sites. Application of this device began during the early distraction phase and continued until frame removal. MAIN OUTCOME MEASURES: Bony union at the arthrodesis and bone lengthening sites, alignment of the lower extremity, limb length discrepancy, infection, pain, and outcome scales (SF-36 scores and American Academy of Orthopaedic Surgeons lower limb modules). RESULTS: Bony union of the knee arthrodesis and lengthening sites and good alignment were achieved in all 4 patients. Mean amount of lengthening was 5.4 cm (range 2.5-11.5 cm). Average time in frame was 11 months (range 6-17 months). Limb length discrepancy after treatment averaged 1.8 cm (range 0.6-3.7 cm). Mean duration of follow-up after frame removal was 35 months (range 28-48 months). At follow-up, infection had not recurred, pain was not present, and assistive devices were not needed for ambulation. Average SF-36 scores improved in all 8 categories, and the average American Academy of Orthopaedic Surgeons lower limb modules improved from a mean of 33 (range 11-37) to a mean of 68 (range 51-76). CONCLUSION: Knee arthrodesis with simultaneous lengthening can be performed successfully using the Ilizarov method. It enables surgeons to optimize limb length during knee arthrodesis. The use of external fixation and the avoidance of internal implants may be advantageous in the presence of or history of infection. The Ilizarov frame provides stability that allows weight bearing during treatment.     

小腿严重开放性骨折伴软组织缺损的治疗

目的 探讨小腿严重开放性骨折伴软组织缺损(Gustilo ⅢB型或ⅢC型)的治疗方法.方法 1990年1月至2008年12月,收治开放性胫腓骨骨折53例,其中Gustilo ⅢB型45例,ⅢC型8例.软组织缺损面积为6 cm×4 cm～18 cm×8 cm,8例伴骨缺损.急诊行骨折复位同定和血管修复,二期对软组织或骨缺损采用13种53块组织瓣移位或移植修复.骨折外固定支架固定35例,内固定16例,骨牵引及石膏固定2例.皮瓣或肌皮瓣47例,骨皮瓣6例.结果 51例获得随访,时间8个月～9年(平均18个月).骨折顺利愈合44例,愈合时间3.5～9.5个月,平均6.5个月.骨延迟愈合4例,骨不愈合3例,经手术植骨(5例)或骨外固定支架加压同定治疗(2例)均治愈.组织瓣移植53块,成活51块,坏死2块,成活率为96.2%.无截肢病例.结论 Gustilo ⅢB型或ⅢC型小腿严重开放性骨折,初期清创并采用以骨外支架为主的方法固定骨折,二期采用适当组织瓣移植修复软组织或骨缺损,是安全有效的治疗策略.     

Knee Arthrodesis as Limb Salvage for Complex Failures of Total Knee Arthroplasty

Patients with multiple failures of total knee arthroplasty (TKA) are challenging limb salvage cases. Twenty one patients over the last 10 years were referred to our service for knee fusion by arthroplasty surgeons who felt they were not candidates for revision TKA. Active infection was present in 76.2% and total bone loss averaged 6.6 cm. Lengthening was performed in 7/22 patients. Total time in Ilizarov frames was 9 months, with 93.3% union. Patients treated with IM fusion nails had 100% union. Average LLD increased from 3.6 to 4.5 cm following intervention, while those with concurrent lengthening improved to 1.6 cm. Findings suggest that bone loss and the soft-tissue envelope dictate knee fusion method, and multiple techniques may be needed. A treatment algorithm is presented.     

Microvascular soft-tissue coverage and distraction osteosynthesis for lower-extremity salvage

In our attempts to salvage massive lower-extremity injuries, even in the presence of severe peripheral vascular pathology, adequate soft-tissue coverage is no longer a limiting factor due to recent advances in microvascular composite tissue transfer. Restoration of tibial continuity without shortening has emerged as the last obstacle in the formidable task of salvaging lower extremities with grade III B and III C defects. Proposed solutions to this problem include conventional free cancellous bone-grafting applicable to small defects only, vascularized bone grafts, or shortening of the leg with subsequent elongation using the Ilizarov technique. We present our experience with 3 consecutive cases of lower-limb salvage, utilizing a new approach in which microsurgical soft-tissue reconstruction has been combined with bony reconstruction by distraction osteosynthesis. Bone transport by distraction osteosynthesis under a free flap performed while preserving the initial limb length throughout the treatment period proved to be superior to other methods in selected cases and is presented as a new technique for the management of problematic lower-limb injuries. © 1998 Wiley-Liss, Inc. 1998     

Tetrafocal leg reconstruction using combined Ilizarov/TSF technique

Treatment of segmental tibial bone defects after high-energy trauma or atrophic nonunion resection is challenging. In the last two decades, distraction osteogenesis Ilizarov bone transport has become a gold standard for the treatment of segmental tibial bone defects and lengthening in spite of the fact that frequent frame modifications and the need for sequential correction of deformities during bone transport are the main limitations of the device itself. The Taylor Spatial Frame applies the concept of the Stewart platform to the standard Ilizarov frame while applying the same principles of distraction osteogenesis postulated by Ilizarov. We report the case of a patient with two problems we could treat simultaneously: an ankle equinus contracture (a consequence of limb leg discrepancy) and infected tibial nonunion and soft-tissue damage complication after plating in a 41A3 type II Gustilo fracture of the left leg.     

Repair of tibial nonunions and bone defects with the Taylor Spatial Frame

OBJECTIVE: To investigate the outcomes of tibial nonunions and bone defects treated with the Taylor Spatial Frame (TSF) using the Ilizarov method. DESIGN: Retrospective. SETTING: Limb Lengthening and Deformity Service at an academic medical center. PATIENTS: Thirty-eight consecutive patients with 38 tibial nonunions were treated with the TSF. There were 23 patients with bone defects (average 5.9 cm) and 22 patients with leg-length discrepancy (LLD) (average 3.1 cm) resulting in an average longitudinal deficiency (sum of bone defect and LLD) of 6.5 cm in 31 patients (1-16). The average number of previous surgeries was 4 (0-20). At the time of surgery, 19 (50%) nonunions were diagnosed as infected. INTERVENTION: All patients underwent repair of the nonunion and application of a TSF. Patients with bone loss were additionally treated with lengthening. Infected nonunions were treated with 6 weeks of culture-specific antibiotics. MAIN OUTCOME MEASUREMENTS: Bony union, time in frame, eradication of infection, leg-length discrepancy, deformity, Short Form-36 (SF-36) scores, American Academy of Orthopaedic Surgeons (AAOS) lower-limb scores, and Association for the Study of the Method of Ilizarov (ASAMI) bone and functional results. RESULTS: Bony union was achieved after the initial treatment in 27 (71%) patients. The presence of bone infection correlated with initial failure and persistent nonunion (P=0.03). The 11 persistent nonunions were re-treated with TSF reapplication in 4, intramedullary rodding in 3, plate fixation in 2, and amputation in 2 patients. This resulted in final bony union in 36 (95%) patients. The average LLD was 1.8 cm (0-6.8) (SD 2). Alignment with deformity less than 5 degrees was achieved in 32 patients and alignment between 6 degrees and 10 degrees was achieved in 4 patients. Significant improvement of Short Form-36 (SF-36) scores was noted in physical role (P=0.03) and physical function (P=0.001). AAOS lower-limb module scores significantly improved from 56 to 82 (P<0.001). ASAMI bone and functional outcomes were excellent or good in 36 and 34 patients, respectively. The number of previous surgeries correlated inversely with the ASAMI bone (P=0.003) and functional (P=0.001) scores. CONCLUSIONS: One can comprehensively approach tibial nonunions with the TSF. This is particularly useful in the setting of stiff hypertrophic nonunion, infection, bone loss, LLD, and poor soft-tissue envelope. Infected nonunions have a higher risk of failure than noninfected cases. Treatment after fewer failed surgeries will lead to a better outcome. Internal fixation can be used to salvage initial failures.     

Combined single-stage osseous and soft tissue reconstruction of the tibia with the Ilizarov method and tissue transfer

OBJECTIVE: To determine the outcome of single-stage soft tissue and osseous reconstruction using the Ilizarov method and soft-tissue transfer. DESIGN: A retrospective review. SETTING:: A university-affiliated, tertiary-care center. PATIENTS/INTERVENTION: We identified 11 patients from a retrospective review from January 1994 to July 1999 who underwent single-stage soft tissue and osseous reconstruction using the Ilizarov method. All 11 patients had an initial traumatic mechanism to their tibia and had previous operative intervention before the combined procedure. The Ilizarov procedure was performed for infected tibial nonunion (8 cases), or complex fracture with soft-tissue loss (3 cases). MAIN OUTCOME MEASUREMENTS: Soft tissue transplant survival, union, range of motion, leg length discrepancy, the Association for the Study and Application of the Method of Ilizarov (ASAMI) score, radiographic parameters. RESULTS: There were 8 concomitant free tissue flaps and 3 local pedicled flaps. Two patients had primary bone grafting, and 5 others had addition of an antibiotic impregnated bone substitute. There were 8 cases of elective reconstructive surgery and 3 cases of acute traumatic fracture. The mean duration of Ilizarov application was 26 weeks (range, 7 to 42). Eight tibiae united primarily, and 3 healed after delayed bone grafting. There were 2 major flap complications. Both were successfully managed with repeat surgery. One patient sustained a repeat open fracture and subsequently received an amputation. According to the ASAMI score, there were 9 excellent results, 1 good result, and 1 poor result. CONCLUSION: Our study suggests that concomitant osseous and soft-tissue reconstruction with the Ilizarov technique and free or pedicled flaps is a viable option for patients with composite tissue defects.     

Management of post-traumatic bone defects of the tibia using vascularised fibular graft combined with Ilizarov external fixator

IntroductionPost-traumatic bone defects of the tibia present a difficult reconstructive challenge. Various methods of reconstruction are available, such as allografts, vascularised fibular graft (either free or pedicled) and bone transport technique.Patients and methodsFourteen patients with an average age of 34.1 years at operation (range, 12–65) with post-traumatic bony defects of the tibia were selected for reconstruction with vascularised fibular graft combined with Ilizarov external fixation. There were 12 male and two female. The size of the bony gap was 10.4 cm (range, 7–13) and the average length of the fibula used was 16.4 cm (range, 14–21).ResultsThe mean follow up period was 20.4 months (range, 10–37). All patients had bony union at both proximal and distal ends of the fibula primarily except one patient that required secondary iliac bone graft at the distal end of the fibula to obtain union. The average time for bone healing was 3.9 months (range, 3–9). The average time spent in Ilizarov frame was 5.9 months (range, 5–11). Unprotected full weight-bearing was achieved within an average of 7.3 months (range, 6–12).ConclusionVascularised fibular bone graft combined with an Ilizarov frame is a successful approach to safely and effectively reconstruct bone defects of the tibia. It has the advantages of vascularised fibular bone grafts together with the biomechanical advantages of Ilizarov frame that allows weight bearing to start almost immediately after surgery. This leads to a good outcome regarding the union and function.     

Management of massive posttraumatic bone defects in the lower limb with the Ilizarov technique

Massive bone defects have been treated by various methods with variable success rates. The Ilizarov technique has been advocated as a preferred method for treatment of large segmental defects. Twenty five patients with massive post traumatic bone defects of the lower limb (22 tibiae, 3 femurs) were treated using Ilizarov's technique. After radiological evaluation, the patients were subjected to bone transport. Bifocal osteosynthesis was performed in all except those needing >12 cm of bone transport. Distraction was started between day 4 and 7 at the rate of 1 mm per day in four increments. All were males with a mean gap of 8.9 cm (range: 5-17 cm), mean age of 28.24 years (16-40) and having undergone a mean of 2.6 previous surgeries. Mean time in Ilizarov frame was 8.8 months and external fixator index was 0.98 months. Mean duration of follow-up after frame removal was 23.5 months. Union was achieved in 23 (92%) cases. Bone grafting was required in 9 (36%) According to ASAMI criteria, bone results were excellent in 13, good in 1, and poor in 11 patients. Functional results were excellent in 6 patients, good in 9, fair in 4, and poor in 6 patients. A total of 72 complications occurred (2.88 complications per patient). Union was achieved in all except two patients. The Ilizarov external fixator offers a limb salvage solution even in large bone defects but the surgeon should set realistic goals both for himself and his patients while offering this method of treatment.     

Ilizarov bone transport treatment for tibial defects

OBJECTIVES: To evaluate the results and complications of Ilizarov bone transport in the treatment of tibial bone defects. DESIGN: Retrospectively reviewed consecutive series. METHODS: Nineteen patients with tibial bone defects were treated by the Ilizarov bone transport method. The mean bone defect was ten centimeters, and there were eight soft-tissue defects. The mean external fixation time was sixteen months. Ten patients required debridement of the bone ends and/or bone grafting of the docking site at the end of transport. RESULTS: Union was achieved in all cases. One refracture of the docking site required retreatment with the Ilizarov apparatus to achieve union. There was one residual leg length discrepancy greater than 2.5 centimeters and two angular deformities greater than 5 degrees. There were no recurrent or residual infections. Seven of the eight soft-tissue defects were closed by soft-tissue transport; the eighth required a free-vascularized flap. The bone results were graded as fifteen excellent, three good, and one fair. The functional results were graded as twelve excellent, six good, and one poor. There were twenty-two minor complications, sixteen major complications without residual sequelae, and three major complications with residual sequelae. To treat the bone defect and the complications, a mean of 2.9 operations per patient was required. CONCLUSIONS: Our results compare favorably with those for other methods of bone grafting as well as with those from other published accounts of the Ilizarov method, especially considering the large defect size in this series. The main disadvantage of the Ilizarov method is the lengthy external fixation time.     

Ipsilateral Fibular Transport Using Ilizarov–Taylor Spatial Frame for a Limb Salvage Reconstruction: a Case Report

Segmental bone defects of the tibia present a challenging problem, particularly when they are associated with soft tissue injuries or instability. Various techniques have been reported to treat bone loss in the tibia. This case report describes a patient with massive segmental bone loss associated with a soft tissue injury, which required a flap for coverage. The injury was treated with an ipsilateral fibular transport utilizing an Ilizarov/Taylor spatial frame. At one and a half year follow-up, the patient was able to walk without any support at home and wore a protective shell for outdoor activities. The outcome of this case study indicates that ipsilateral fibular transport using the Ilizarov method is a valuable technique for limb salvage reconstruction.     

Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame

Infected tibial nonunions with bone loss pose an extremely challenging problem for the orthopaedic surgeon. A comprehensive approach that addresses the infection, bone quality, and overlying soft-tissue integrity must be considered for a successful outcome. Acute shortening with an Ilizarov frame has been shown to be helpful in the treatment of open tibia fractures with simultaneous bone and soft-tissue loss. Cases in which the soft-tissue defect considerably exceeds bone loss may require an Ilizarov frame along with a concomitant soft-tissue procedure; however, there are a number of potential difficulties with vascularized pedicle flaps and free tissue flaps, including anastomotic complications, partial flap necrosis, and flap failure. The technique described in this report involves acute shortening and temporary bony deformation with the Ilizarov apparatus to facilitate wound closure and does not require a concomitant soft-tissue reconstructive procedure. Once the wound is healed, osseous deformity and length are gradually corrected by distraction osteogenesis with the Ilizarov/Taylor Spatial frame.     

Subacute reconstruction of lower leg and foot defects due to high velocity-high energy injuries caused by gunshots, missiles, and land mines

The present study reviews 215 male patients suffering high velocity-high energy injuries of the lower leg or foot caused by war weapons such as missiles, gunshots, and land mines. They were treated in the Department of Plastic and Reconstructive Surgery at Gulhane Military Medical Academy (Ankara, Turkey) between November 1993-January 2001. Severe soft-tissue defects requiring flap coverage and associated open bone fractures that were treated 7-21 days (mean, 9.6 days) after the injury were included in the study. Twenty-three of 226 extremities (10.2%) underwent primary below-knee amputation. The number of debridements prior to definitive treatment was between 1-3 (mean, 1.9). Gustilo type III open tibia fractures accompanied 104 of 126 soft-tissue defects of the lower leg. Sixty-four bone defects accompanied 83 soft-tissue defects of the feet. Eighteen local pedicled muscle flaps and 208 free muscle flaps (latissimus dorsi, rectus abdominis, and gracilis) were used in soft-tissue coverage of 209 defects. Overall, the free muscle flap success rate was 91.3%. Bone defects were restored with 106 bone grafts, 25 free fibula flaps, and 14 distraction osteogenesis procedures. Osseous and soft-tissue defects were reconstructed simultaneously at the first definitive treatment in 94% of cases. The mean follow-up after definitive treatment was 25 (range, 9-47) months. The average full weight-bearing times for lower leg and feet injuries were 8.4 months and 4 months, respectively. Early, aggressive, and serial debridement of osseous and soft tissue, early restoration of bone and soft-tissue defects at the same stage, intensive rehabilitation, and patient education were the key points in the management of high velocity-high energy injuries of the lower leg and foot.     

Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds

Severe lower extremity trauma frequently results in a soft-tissue deficit that mandates wound coverage using some form of vascularized flap. The recent rediscovery of inclusion of the deep fascia during elevation of random skin flaps has enhanced the viability of large local flaps as a reconstructive option in the lower leg. In selected cases of relatively uncontaminated, moderate-sized defects, the choice of this maneuver has permitted closure of many defects which previously might have required a complex microsurgical tissue transfer. This series of 41 random-based local fasciocutaneous flaps in the lower leg in 38 patients has in all cases except two been successful in achieving preferred wound healing. Flap necrosis occurred only in these two cases presumably due to peripheral vascular insufficiency necessitating limb amputation in one patient. Eight (19%) had some form of complication, most occurring in the subset of flaps used for distal third lower leg wounds. The fasciocutaneous flap is conceptually simple, rapidly elevated and inset, and minimizes the region of surgical insult for many multitrauma patients who otherwise might have to forego any attempt for limb salvage.     

Lower extremity salvage using a free flap associated with the Ilizarov method in patients with massive combat injuries

Nine patients with massive combat injuries of the lower extremities were treated with Ilizarov bone transport in conjunction with free muscle flap coverage. In 4 patients soft-tissue coverage was applied first, and distraction osteogenesis was initiated 4 to 6 weeks later. In 3 patients both methods were applied simultaneously, and in 2 patients soft-tissue coverage occurred after distraction. The bones healed well, and all flaps survived. The segmental defects ranged from 8 to 16.5 cm in greatest dimension. The total disability time from initial injury ranged from 16 to 25.5 months. In all patients, full union of the tibia was achieved, and no osteomyelitis occurred. However, in 2 patients the applied flap became depressed, necessitating another flap operation. Despite late treatment in all 9 patients, successful results were obtained. Maintaining the original length of the tibia and providing timely, definitive treatment offer the best outcome for repair of massive injuries of the lower extremities. The Ilizarov transport method, used in combination with muscle flap coverage, represents an effective therapy for repair of massive injury of the lower extremities.     

The reversed medial hemisoleus muscle flap and its role in reconstruction of an open tibial wound in the lower third of the leg

The usefulness of a reversed hemisoleus muscle flap as a local reconstructive option for soft-tissue coverage of an open tibial wound in the lower third of the leg has never been acknowledged. Over the past 2 years, 8 patients underwent soft-tissue reconstruction of an open tibial wound (3 x 3 to 10 x 6 cm) in the lower third of the leg with the reversed medial hemisoleus muscle flap modified by the author. The flap was dissected with attention to preserve several critical perforators from the posterior tibial vessels to the flap as possible while allowing adequate turnover of the flap to cover the exposed tibia or hardware. There was no total flap loss, and limb salvage was achieved in all patients. Only 2 patients developed insignificant distal flap necrosis, and they were treated subsequently with debridement and flap readvancement. All patients had reliable healing of their tibial wounds, with good reconstructive and cosmetic outcomes of their flap reconstructions during follow-up. Therefore, the author believes that the reversed medial hemisoleus muscle flap can be a good choice for soft-tissue coverage of a sizable open tibial wound in the lower third of the leg and may be used successfully to replace free tissue transfer in selected patients.     

Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases

OBJECTIVE: To evaluate the results of bifocal compression-distraction method for the acute treatment of open tibia fractures with bone and soft-tissue loss. DESIGN: Patients were selected for bifocal compression-distraction (shortening and lengthening) who had open tibia fractures with bone and soft-tissue loss and a Mangled Extremity Severe Score of 6 and below indicating good leg viability. PATIENTS: Bifocal compression-distraction osteogenesis using the Ilizarov type circular external fixator was applied to 24 patients with 14 grade IIIA and 10 grade IIIB open tibia fractures with bone and soft-tissue loss. Mean age of the patients was 30.6 years (range 18-53). The mean bone defect was 5 cm (range 3-8.5). The mean soft tissue defect was 2.5 x 3.5 (1 x 2-10 x 5) cm. INTERVENTIONS: Acute shortening at the fracture site was done for patients with bone defects up to 3 cm to achieve apposition of bone ends. Gradual shortening at a rate of 2 mm/d was done for patients who had bone defects more than 3 cm. Leg length discrepancy was overcome by lengthening at the same time through a corticotomy at a proximal or distal level depending on fracture localization, until there was equalization of leg lengths. RESULTS: Mean follow-up period was 30 months (range 18-60). Mean bone healing time was 7.5 months (range 4-11). The mean time in external fixation was 7.1 months (range 3-10), and the average external fixator index was 1.4 months/cm. Results were evaluated using the Paley bone and functional assessment scores. The bone assessment results were excellent in 21 and good in 3 patients. Functional assessment scores were excellent in 19, good in 4, and fair in 1 patient. Pin site infections were present in 10.7% of the pin sites. There were 52 complications in 24 patients, for a complication rate per patient of 2.08. Of the complications, 48.1% were problems (minor complications), 38.5% obstacles (major complications requiring a surgical solution), and 13.4% sequelae (true complications). Minor complications included soft tissue inflammation and infection, translation/angulation, and delayed maturation during distraction and transient knee contracture and loss of motion. All grade 1 and 2 soft tissue inflammations and infections healed with nonoperative therapy. Major complications included pin tract infection and reinfection, equinus deformity, frame failure, and premature consolidation, all of which required additional surgery to correct the problem. Sequelae included leg length discrepancy, loss of knee/ankle range of motion, knee flexion contracture, malalignment, and chronic osteomyelitis. CONCLUSION: Bifocal compression-distraction osteogenesis is a safe, reliable, and largely successful method for the acute treatment of open tibia fractures with bone and soft-tissue loss. Further nonoperative or operative treatment can correct most complications.     

Extreme bone lengthening using distraction osteogenesis after trauma: a case report

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 x 20 cm. An acute shortening using a 50 degrees angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.     

Postoperative course of patients treated with iliac osteocutaneous free flaps. A two- to five-year follow-up study

The clinical and radiologic course was reviewed in seven patients treated with an iliac osteocutaneous free flap (iliac flap) for treatment of large bone defects in the tibia and first metacarpal bone and overlying skin. Application of the iliac flap was followed by free bone grafting in four patients and aesthetic surgery in four patients. All patients obtained solid bony union and good skin coverage; none had complaints upon walking. An iliac flap was useful as a salvage procedure for the treatment of massive defect of bone and skin in extremities, especially in the lower one-third of the lower leg. Transient osteoporosis occurred before osteosclerosis and bony union. Bone remodeling with change in the trabecular pattern preceded transformation from cancellous to cortical bone.