Microsurgery in bone loss and non-union of lower limb

The non-union and segmental bone loss management in the lower limb has always been the greatest challenge for orthopedic surgeons, with a significant socioeconomic impact. The outcomes for patients can be poor, resulting in permanent disability and inability to return to work. Bone reconstruction aims to provide stability and re-establish limb length and function, but there is no consensus in the literature on the management of bone loss and non-union of the lower limb. Surgical possibilities: Several strategies have been proposed, usually characterized by several steps, but with relatively unpredictable outcomes. These techniques can be divided into traditional procedures (such as Ilizarov bone transport and Masquelet technique) and microsurgical vascularized bone flaps (such as fibular flap, corticoperiosteal femoral condyle flap, and iliac crest flap), which have different indications. In our experience, in case of complete bone loss, a traditional bone graft should be used if the defect is less than 5 cm and a microvascular bone graft if the loss is more than 5 cm or poor local conditions are present. Concerning bone stabilization, all these cases can be treated either with a circular external fixator or internal fixation, depending on the circumstance. Regarding treatment timing, one-stage reconstructions have many advantages, such as shorter hospitalization times, reduced medical costs and shorter morbidity times, but this approach is more aggressive because it requires radical debridement of damaged, devitalized, or infected tissue. Moreover, this approach has a higher complication rate in compromised patients or patients with polymicrobial cultures or acute bone loss. Indeed, a more cautious two-stage approach consisting of a complete rest period with an external fixator, should be recommended in these cases.