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Reconstruction of a Large Bone Defect in Tibia–A Case Report

 Nirmal Kumar Sinha*,Raja Ram Pai**

* Asso.Professor
** Ex-Asso.Profesor
 Department of Orthopaedics,Manipal College of Medical Sciences, Pokhara,Nepal

Address for Correspondence:

Dr.Nirmal Kumar Sinha
Asso.Professor,Department of Orthopaedics,
Manipal College of Medical Sciences
Ph: 00977-61-526416


Reconstruction of large bone defect is a major orthopedic challenge. We are presenting a case of 12 cm long bone defect in upper tibia following tumor excision. Distal corticotomy and bone transport using the Ilizarov technique was done to gain bone regeneration. The residual gap at docking site was bridged with bone grafting and buttress plating.

Keywords: Ilizarov Technique, bone defect

J.Orthopaedics 2007;4(4)e19


Bone construction to bridge a large bone defect is a challenging orthopaedic situation. There are several options to bridge a defect upto 6 cm, but a reliable option for a bone gap of more than 6 cm is limited1,2 Many times, multiple or composite operative procedures are needed for a successful outcome. We are presenting a case report of bone reconstruction of 12 cm long bone defect of upper tibia which resulted from a tumor resection. We used the bone transport technique of Ilizarov1,2,3,4,5  to regenerate bone & then did buttress plating along with bone graft to achieve a complete osseous construction.

Case Report :

A 35 year old lady presented to us on April2004 with a history of swelling in upper part of tibia of 2 year duration, there was sudden increase in pain one day before admission. X-ray showed an expansile osteolytic lesion with trabeculations at upper metadiaphyseal region. There was also an evidence of pathological fracture [picture-1]. Radiologically it was diagnosed as an aggressive aneurysmal bone cyst with pathological fracture. On 30/04/2004 patient underwent resection of the tumor and Ilizarov fixation. Distally the resection was done through normal bone, and proximally marginal excision and chemical cauterization was done. There was thin slice of metaphyseal bone proximally and bone gap of 12cm. Histopathology report was consistent with aneurysmal bone cyst. Bone transport was started after a latency period of 14 days. Bone transport was done at a rate of .25mm every 6 hours (1mm per day) [picture-3]. The transport was completed by 4months (August2004), the rings were retained for another 7 months (March2005) to allow maturation of the regenerate. The proximal ring became loose because of pin tract infection.  

The Ilizarov rings were removed at the end of 11 months (March2005). Patient had non union like situation the upper part. The pin tract infection subsided after the removal of ring fixator (by May2005), then the patient was reoperated on 30th May 2005 & bone freshening, buttress plating and bone grafting was done. There was sound union by November 2005. At 30 month follow up [picture-4] the patient had 130° knee flexion and complete extension. There was terminal restriction of ankle movements. There was no functional disability. No recurrence of the tumor.

        Fig.1                                  Fig.2




The osseous reconstruction of a large segmental defect in a long bone requires an surgical endeavour which is technically difficult, time consuming and often leads to multiple operative procedures1.The whole procedure is physically, psychologically     and economically demanding to the patient & it has no guarantee of a satisfactory outcome. For a segmental defect of more than 6 cm of tibia, what is preferred is vascularised fibular graft and ring external fixator using Ilizarov technique1,2. The first option necessitates a vascular sacrifice, may lead to a graft fracture & requires enough bone at both side for fixation. This procedure was abandoned in our case once it was found peroperatively that proximal metaphysical part was too small to hold the fibular graft.

Bone transport with the  Ilizarov technique is a favoured method of treating a segmental defect of tibia2 We have done distal corticotomy with distraction osteogenesis using  the Ilizarov technique1,2,3,4.5 to regenerate a bone segment of 12 cm length. Compared to other methods, it is usually safer, less expensive and simpler to perform2. However, like other methods, it has its list of complications and drawbacks. It is inconvenient to the patient and requires patient’s compliance and cooperation. It has a long fixator time. In our case it was 11 months. There was pin tract infection at 2 different occasions which required antibiotics & dressings. The concave under-surface of the proximal metaphysical part was filled up with fibrous tissue by the time , the ‘transport disc’ reached there. The leading edge of the transport disc was also covered with fibrocartilagenous cap. This necessitated the excision of fibrous tissue, bone grafting and buttress plating. The whole tibia was fully reconstructed clinically and radiologically at 17 months after initiation of treatment.

Ilizarov technique is a safe & reliable procedure to bridge a large bone defect like this case.

Reference :

1. Keating JF, Simpson AHRW, Robinson CM The management of fractures with bone loss Journal of Bone & Joint Surgery [Br] 2005;87-B:142-150

2. Sen C, Eralp L, Gunes T, Erdem M, Ozden VE, Kocaoglu MAn alternative method for the treatment of nonunion of the tibia with bone loss Journal of Bone & Joint Surgery [Br] 2006;88-B;783-789

3. Goulet JA & Hak DJ Nonunion & malunions of the tibia

In:Chapman Michael W,Chapman’s Orthopaedic Surgery,Vol 1 Third Edition Lippincott Williams & Wilkins, 2001 977-999

4. Green SA Management of fractures, nonunions, and malunions with Ilizarov techniques In:Chapman Michael W, Chapman’s Orthopaedic Surgery,Vol 1 Third Edition Lippincott Williams & Wilkins ,2001 1001-1107

5.Ilizarov GA Lengthening of upper & lower limb segments In: Ilizarov GA Transosseous Osteosynthesis Spring-Verlag 287-328


This is a peer reviewed paper 

Please cite as : SNirmal Kumar Sinha : Reconstruction of a Large Bone Defect in Tibia–A Case Report

J.Orthopaedics 2007;4(4)e19





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