September
First principle to debride all non-viable tissue.
Some adjuncts such as vital staining, Doppler flow cytometry and CT may help determine the level of bone resection.
Acute limb shortening
Relaxes soft tissue but may result is redundant tissue Limited to defects <3cm
Autologous nonvascularised cancellous bone graft
Should be delayed until 6 weeks to allow healing of any flaps any marginal tissue May be posterolateral as described by Harmon with the patient prone (not applicable to the proximal tibia where the neurovascular bundle is in close proximity). May also use anterolateral or posteromedial graft if under flap. Note to overlap cortical bone by at least 1cm. Reaming of canals removes any sealing callous and helps re-establish medullay blood supply. May use up to 4cm.
Bone Transport Distraction Osteogenesis
Osteotomy made in metaphyseal region. 5 day latent period then 1mm per distraction with 2-3 days consolidation. Graft applied to docking site as well as freshening up the ends. Ring fixators best method. May alternatively shorten the limb then secondarily distract. Good if large injury to fibula but may have period of redundant tissue. Has treated defects up to 30cm in adults.
Free Vascularised Bone Transfer
Rib, fibula or iliac crest. Taken on nutrient vessel. Important to have 2cm of overlap at each end. 7cm of fibula left proximally to avoid knee of CPN injury. Union time 3-6months at 90% Fracture rate up to 25% in the first year. At 2 years adequate hypertrophy occurred. 20% donor site morbidity. Advantage of immediate fixation.
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