1. BONE LOSS &TRANSPORT Discussant R N Mbuva

2. Priorities in open fractures ABCDE (resuscitate) Restore blood supply Debride adequately Restore soft tissue envelope integrity Restore skeletal stability Rehabilitate

3. Bone loss initial treatment Antibiotic treatment Tetanus toxoid Irrigation and debridement External fixation Antibiotic bead spacers-availability Soft tissue coverage Sterilization and re-implantation

4. Reconstruction modalities Over joint surface -osteochondral allograft -total joint or hemi- arthroplasty -arthrodesis

5. Diaphyseal defects 1.Autogenous bone graft cancellous cortical vascularized 2.Allogeneic bone graft cancellous cortical Demineralized bone matrix

6. diaphysis 3.Distraction osteogenesis multifocal shortening/ lengthening bone transport 4.Salvage procedures shortening one bone forearm

7. Bone grafting Osteogenesis - bone formation 1. Survival and proliferation of graft cells 2. Osteoinduction - host mesenchymal cells Osteoconduction Structural Support

8. Graft incorperation 1.Hemorrhage 2.Inflammation 3.Vascular invasion 4.Osteoclastic resorbtion/ Osteoblastic apposition 5.Remodelling and reorientation N/B cancellous graft fastest limited by size of graft

9. PAPINEAU TECHNIQUE Direct open cancellous grafting of granulation bed typically large metaphyseal defect

10. allograft Slower than autograft Cortical strut graft-structural support -weakly osteogenic -revascularize slowly Cancellous allograft-same as autograft-rhBMP

11. Vascularized graft 1Pedicled ipsilateral fibula 2Free bone flap -fibula -iliac crest -rib Structural support, rapid healing, independent of host bed will hypertrophy

12. classification Depends on the site of loss

13. Classification salai et al.Arch Orthop Trauma Surg 119 typeDEFECTSIZEARTICULAR IAMINOR<1cc or <1cm 2 EITHER BMINOR<1cc or <1cm2EITHER IIAMAJOR<1cc or <1cm2NON-ARTICULAR BMAJOR<1cc or <1cm2NON ARTICULAR IIIAMAJOR<1cc or <1cm2ARTICULAR BMAJOR<1cc or <1cm2ARTICULAR

14. classification Robinson et al's classification of tibial bone loss. Grade Maximal bone loss (%) Maximum lengthof bone loss (cm) 1 Trivial Wedge < 25% 0 2 Minor Wedge 25% to 50% Wedge > 50% to < 100% < 2.5 3.Moderate Wedge > 50% but < 100% 2.5-10 Circumferential < 2.5 4.Severe Wedge > 50% but 10 Circumferential >2.5

15. Distraction osteogenesis Can be achieved using monoplanar or ring fixators

16. Ilizarov external fixator

17. Hybrid(taylor) fixator

18. Suv external fixator

19. Joshi external stabilization system (JESS frame)

20. ilizarov Principles used in application -support - Control infection

21. Stages of ilizarov technique 1.fixator application and latency period 4-7 days 2.distraction/compression1-4 or5/12 3.Period of immobility and fixation of the bone position-2x distraction 4.Discontinuation of distraction-compression &frame dynamization-15-20/7 5.Period of immobilization-cast or brace- optional

22. CORTICOTOMY/COMPACTOTOMY Definition i)corticotomy-cortical osteotomy with transection of the bone cortex preserving periosteum and medullary canal ii)latency-period of time after corticotomy and distraction

23. iii)rate-1mm/day iv)rhythm-frequency of applied distraction 4xdaily v)Healing index-no. of months from operation to full unaided wt bearing

24. corticotomy Closed Open Ideal –long oblique -metaphyseal -without comminution -closed

25. corticotomy Level of corticotomy -avoid nutrient vessels metaphyseal segment suitable -local site: avoid old scars infection zone of sclerosis porosis cyst formation

26. corticotomy monofocal Lengthening upto 5cm Bone fragment transport upto 5-7cm Stimulation of local blood circulation and osteogenesis without significant lengthening Gradual correction of bone deformity bifocal 10-12cm 10-16 cms Stimulation of osteogenesis in metabollic disease e.g pagets,OI,olliers disease Simultaneous lengthening at one level and correction of deformity at another level

27. Distraction Rate 1mm/day Indications for increased distraction 1.young patients 12-14yrs 2.premature bone consolidation 3.uncomplicated bone cut

28. Indications for reduced distraction 1.severe pain after creating a gap of 3-4cm 2.neovascular problems 3.poor regeneration

29. Metaphyseal areas of corticotomy

30. Corticotomy in osteomyelitis

31. Distraction histogenesis of soft tissues 2 mechanisms -reorganization of collagen to stretch -neohistogenesis Ilizarov -muscles respond by stretching without cell proliferation Dyachkova-new schwann cells and active myelination seen in distraction

32. Docking Assesment – 1.when atleast three sites of contact 2.Callus is cylindrical 3.stress test doesn’t elicit pain

33. Docking Once edges dock healing improved by -bone grafting -tecerration -plug end into the medulla - compression -medical management-ultrasonic or pulsed electromagnetic waves

34. Complications of ilizarov fixation Complications may arise -Preventable -Correctable -no interference with treatment

35. Classification of complications 1.General 2.Specific 3.inflammatory

36. general a) immediate -neurologic compromise -vessel penetration -comminuted fracture of osteotomized bone -displacement of osteotomized fragment

37. General b)Delayed -pain -compartment syndrome -muscle contracture -neurologic compromise -local edema -hypertension -joint subluxation

38. specific a)Early complications -local skin tightness -local edema with circ,compromise -premature healing at corticotomy site -local pain with motion

39. specific b)Delayed -break in wires -axial deviation of distracted fragments -joint stiffness -partial development of regenerate bone - delayed development of regenerate

40. specific c) late iatrogenic complications -pseudoarthrosis -angulation of regenerate -fracture of regenerate -psychological incompatibility

41. inflammatory Any time in the course of treatment -pin tract infection -phlebitis -osteomyelitis

42. Conclusion Although the technique is labor intense and requires skill it is superior to monoplanar models in distraction osteogenesis