The management of fractures with bone loss.

©2005 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.87B2. 15874 $2.00 J Bone Joint Surg [Br] 2005;87-B:142-50. Historically, because of the problems involved in initial limb salvage and the subsequent difficulty of reconstructing large skeletal defects many fractures with significant bone loss were treated by primary amputation. Modern techniques of fracture stabilisation and soft-tissue reconstruction mean that many more severely injured limbs with bone defects can now be salvaged in the acute phase of treatment. However, the problems involved in subsequently bridging or regenerating areas of skeletal loss with viable bone while maintaining limb length and alignment commensurate with satisfactory function, remain a substantial challenge. Attempting limb reconstruction in the presence of significant bone loss usually involves surgery which is technically difficult, time-consuming, physically and psychologically demanding for the patient, and with no guarantee of a satisfactory outcome. The function of the salvaged limb may be disappointing due to residual pain, joint stiffness and neurovascular deficit. The patient may require a secondary amputation due to refractory infection or nonunion. Thus, the correct initial decision as to whether to embark upon limb reconstruction or to perform a primary amputation is important, but difficult. Unfortunately, the relative rarity of these injuries and the considerable variation in their configuration dictate that prescriptive management based on established protocol is not possible. A flexible and individualised approach to treatment is required. In this review, we consider the assessment of these injuries with an overview of the current options available for treatment, and provide guidelines for their management.