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Tibial Defect Reconstruction: A Plea for Standardization

Mauffrey, Cyril MD, FACS, FRCS; Hak, David J. MD, MBA, FACS

Journal of Orthopaedic Trauma: October 2017 - Volume 31 - Issue - p S1–S2
doi: 10.1097/BOT.0000000000000975
Editorial
Free

Department of Orthopaedics, Denver Health Medical Center, Denver, CO.

Reprints: Cyril Mauffrey, MD, FACS, FRCS, Department of Orthopaedics, Denver Health Medical Center, 777 Bannock St, Denver, CO 80204 (e-mail: Cyril.mauffrey@dhha.org).

The authors report no conflict of interest.

Accepted July 14, 2017

The management of critical-sized segmental tibial defects remains one of the most challenging conditions for the orthopaedic trauma surgeon.1 Patients undergoing the reconstructive treatment pathway must be aware that they may require multiple complex surgeries with no guarantees of success. In addition, appropriate psychological, professional, financial, and familial support is essential.1 Defects originate from different root causes (acute posttraumatic or infected nonunion) with a large interprovider and intraprovider variability in treatment strategies from one case to another.2 From preoperative considerations (patient optimization, diagnosis, and imaging studies) to intraoperative decision making (staging with biopsies, void filling substances, implant selection, and segmental defect filling options) and postoperative management, “experts” will have their preferred way to manage a specific patient.3 The current standard is “dealers choice.”

With this special issue, our aim was to assemble a series of articles on segmental defects of the tibia. The topics follow a chronological framework that includes acute debridement of open tibial fractures, preoperative optimization of patients undergoing segmental tibial reconstructions, various surgical technique using different reconstruction treatment concepts (distraction osteogenesis, induced membrane), and original research on factors that may predict failure of nonunion treatment. It is our opinion that no concept is superior to another, although our experience has been that the induced membrane technique may have limitations in the setting of defect reconstruction after tibial infection when compared with bone transport. Our personal observations of the Masquelet technique for critical-size defects of the tibia are comparable with those recently reported by our colleagues in the UK,4 highlighting that the induced membrane technique may not always have the glorious reported results. The importance of patients' preoperative optimization with evaluation of immune deficiency, nutritional status, smoking cessation, and assessment of vitamin D levels cannot be overemphasized. The decision to shorten the tibia, use a posterolateral bone grafting, or bone transport is one that should take into account patients' preferences, surgeons' training and level of comfort, anatomical location of the defect on the tibia, and status of the fibula (intact or not).

Our recent Orthopaedic Research Society and International society for Fracture Repair workshop on tibia segmental defects in June 2017 in Marseilles, France,5 has highlighted several weaknesses and deficiencies in management algorithms. As an example, the role of preoperative magnetic resonance imaging to define the extent of osteomyelitis and guide resection, when required, remains to be defined because the results rarely alter the surgical strategies. The topic of infected tibia nonunion with an IM nail has demonstrated significant interobserver variability in the selection of the ideal treatment option. Exchange nailing versus implant preservation and bone grafting versus antibiotic nailing or ring fixator stabilization for infected nonunions of the tibia with an intramedullary nail are options that are selected based on preferences, training, comfort, and experiences rather than on scientific evidence.6 As academic orthopaedic traumatologist with a special interest on the topic, we are tasked to guide practices through the development of a consensus article.

Finally, it is thought provoking to see that many of the clinical cases shown at conferences start with “this is a case fixed at an outside facility and sent to us for the management of tibial infected non union.” This sentence highlights the importance of the acute management of open tibial fractures. At times, the lack of attention to details in the first few hours of the patient management is critical and certainly represents a root cause of their unsolvable complication. The “windows of opportunity” to do the “right thing” are scarce and will predict in many ways patients' outcomes (Fig. 1). We must ask ourselves who should take care of open tibial fractures? Although the British Orthopaedic Association together with the British Plastic Surgery Association have established, some years ago, a nationwide guideline7 recommending that patients presenting with open tibia fractures should be transferred to a hospital with the required expertise (Orthopaedic and plastic surgery support), our more complex health system still struggles with attempts at standardizing and centralizing care despite the critical need to optimize patients outcomes and reduce the burden of posttraumatic tibial infections/defects.

FIGURE 1

FIGURE 1

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REFERENCES

1. Mauffrey C, Barlow BT, Smith W. Management of segmental bone defects. J Am Acad Orthop Surg. 2015;23:143–153.
2. Hake ME, Oh JK, Kim JW, et al. Difficulties and challenges to diagnose and treat post-traumatic long bone osteomyelitis. Eur J Orthop Surg Traumatol. 2015;25:1–3.
3. Kadhim M, Holmes L Jr, Gesheff MG, et al. Treatment options for nonunion with segmental bone defects: systematic review and quantitative evidence synthesis. J Orthop Trauma. 2017;31:111–119.
4. Morris R, Hossain M, Evans A, et al. Induced membrane technique for treating tibial defects gives mixed results. Bone Joint J. 2017;99-B:680–685.
5. Available at: http://http://www.ors.org/event/2017-ors-isfr-segmental-bone-defects-workshop/.
6. Makridis KG, Tosounidis T, Giannoudis PV. Management of infection after intramedullary nailing of long bone fractures: treatment protocols and outcomes. Open Orthop J. 2013;7:219–226.
7. Available at: http://http://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf?sfvrsn=0.
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