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Management of Traumatic Bone Defects

  • Richard P. MeinigEmail author
  • Hans-Christoph Pape

Abstract

The management of traumatic bone defects requires explicit knowledge of vascularity, options for soft tissue coverage and bone regeneration. Therapy should begin directly after admission and includes temporizing stabilization of the limb. This should be in association with initial bone and soft tissue debridement and revascularization if needed. Then, the limb is definitively stabilized with near anatomic length, alignment, and rotation as well as restoration of a soft tissue envelope. In most cases, the bone defect is frequently managed at this stage with a temporizing antibiotic PMMA spacer to induce an osteogenic reactive membrane while ensuring a sterile environment. An enhanced biological and sterile bed is thus created for subsequent bone grafting at 4–6 weeks. At this stage, bone regeneration is accomplished by autologous bone grafting using conventionally harvested iliac bone grafts or reamed intramedullary harvest from the femur or tibia. Resorbable polymer membranes can also be utilized if needed to contain the bone graft in situations such as vertebral column defects with exposed neural elements or in the forearm to minimize the formation of a synostosis. This algorithm allows for early function of the affected limb with widely available implants and conventional surgical techniques. The morbidity is relatively low and the success rate is high for regeneration of commonly encountered traumatic bone defects.

Keywords

Bone defect regeneration Medullary bone graft harvest Autologous bone transplant Induced bone regeneration membrane Polymeric bone graft membrane 

References

  1. 1.
    Wiese A, Pape HC. Bone defects caused by high-energy injures, bone loss, infected nonunions, and nonunions. Orthop Clin North Am. 2010;41:1–4.CrossRefPubMedGoogle Scholar
  2. 2.
    Abdel-Aal AM. Ilizarov bone transport for massive tibial bone defects. Orthopedics. 2006;29(1):70–4.PubMedGoogle Scholar
  3. 3.
    Webb LW, Bosse MJ, Castillo RC, Mackenzie EJ. Analysis of surgeon controlled variable in the type III open tibial diaphysis fracture. J Bone Joint Surg Am. 2007;89:923–8.PubMedGoogle Scholar
  4. 4.
    McNamara MG, Heckman JD, Corley EG. Severe open fractures of the lower extremity: a retrospective evaluation of the mangled extremity severity score. J Orthop Trauma. 1994;8:81–4.CrossRefPubMedGoogle Scholar
  5. 5.
    Roberts CS, Pape HC, Jones AL, Malkini AL, Rodriquez JL, Giannoulis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. J Bone Joint Surg Am. 2005;87:434–49.CrossRefGoogle Scholar
  6. 6.
    Parekh AA, Smith W, Silva S, et al. Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation. J Trauma. 2008;64(3):736–9. 5. Ristiniemi J, Lakovaara M, Flinikkila T, et al. Staged method using antibiotic beads and subsequent autografting for large traumatic tibial bone loss: 22 of 23 fractures healed after 5–20 months. Acta Orthop. 2007;78(4):520–7.Google Scholar
  7. 7.
    Adams K, Crouch L, Cierney G, Calhoun J. In vitro and in vivo evaluation of antibiotic diffusion from antibiotic impregnated polymethylmethracylate beads. Clin Orthop Relat Res. 1992;278:244–52. 15.Google Scholar
  8. 8.
    Klaue K, Anton C, Knothe U, et al. Biological implementation of in situ induced autologous foreign body membranes in consolidation of massive cancellous bone grafts. J Bone Joint Surg Br. 1993;79:236.Google Scholar
  9. 9.
    Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am. 2010;41:27–37.CrossRefPubMedGoogle Scholar
  10. 10.
    Viateau V, Bensidhoum M, Guilleman G, et al. Use of the induced membrane technique for bone tissue engineering purposes: animal studies. Orthop Clin North Am. 2010;41:49–56.CrossRefPubMedGoogle Scholar
  11. 11.
    Ristiniemi J, Lakovaara M, Flinikkila T, et al. Staged method using antibiotic beads and subsequent autografting for large traumatic tibial bone loss: 22 of 23 fractures healed after 5–20 months. Acta Orthop. 2007;78(4):520–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Marino JT, Ziran B. Use of solid and cancellous autologous bone graft for fractures and nonunions. Orthop Clin North Am. 2010;41:15–6.CrossRefPubMedGoogle Scholar
  13. 13.
    Conway JD. Autograft and nonunions: morbidity with intramedullary bone graft versus iliac crest bone graft. Orthop Clin North Am. 2010;41:75–84.CrossRefPubMedGoogle Scholar
  14. 14.
    Dick W. Use of the acetabular reamer to harvest autogenic bone graft material: a simple method for producing bone paste. Arch Orthop Trauma Surg. 1986;185:225–8.Google Scholar
  15. 15.
    McCall TA, Brokaw DS, Jelen BA, et al. Treatment of large segmental bone defects with reamer-irrigator-aspirator bone graft: technique and case series. Orthop Clin North Am. 2010;41:63–73.CrossRefPubMedGoogle Scholar
  16. 16.
    Blum B, Moseley J, Miller L, et al. Measurement of bone morphogenetic proteins and other growth factors in demineralized bone matrix. Orthopedics. 2004;27(1):161–5.Google Scholar
  17. 17.
    Hernigou P, Poignard A, Buejean F, et al. Percutaneous autologous bone-marrow grafting for nonunions. Influence of number and concentration of progenitor cells. J Bone Joint Surg Am. 2005;87(7):1490–7.Google Scholar
  18. 18.
    Janhangir AA, Nunley RM, Mehta S, et al. Bone graft substitutes in orthopaedic surgery. J Am Acad Orthop Surg. 2008;2(1):35–7.Google Scholar
  19. 19.
    Jones AL, Bucholz RW, Bosse MJ, et al. Recombinant human BMP-2 and autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. A randomized, controlled trial. J Bone Joint Surg Am. 2006;88(7):1431–41.PubMedGoogle Scholar
  20. 20.
    Meinig RP. Clinical use of resorbable polymeric membranes in the treatment of bone defects. Orthop Clin North Am. 2010;41:39–47.CrossRefPubMedGoogle Scholar
  21. 21.
    Gugala Z, Lindsey RW, Gogolewski S. New approaches in the treatment of critical-size segmental defects in long bones. Macromol Symp. 2007;253:147–61.CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  1. 1.Orthopaedic ServicesPenrose-St Francis Health Care SystemColorado SpringsUSA
  2. 2.Department of Orthopaedic Trauma SurgeryUniversity of Aachen, Medical CenterAachenGermany

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