Traumatic bone defects may be primary, as a consequence of an open fracture with bone loss, or secondary, after development of an aseptic or septic nonunion (Fig. 10A.3). Septic nonunions will be considered later under infection.

Several methods have been proposed for the management of primary traumatic skeletal defects. Some authors have implemented immediate radical debridement and reconstruction, within 72 hours from the traumatic incident. However, the consensus on this demanding problem appears to be early soft tissue coverage within the first 7-10 days, after serial debridement of the open fracture. Subsequently, reconstruction of the defect can be undertaken when a stable, well-vascularized and free from infection soft tissue envelope is present.

In long-standing aseptic nonunions, debridement of the fibrous tissue and avas-cular bone ends may increase an existing gap and result in a large secondary bone defect. In these cases, considerable difficulties may arise, related to previous vessel injury and to extensive scarring of the soft tissue envelope, as has been pointed out in the surgical technique discussion.

Fig. 10A.3. Complete loss of the lower mandible, and final appearance on a 3D imaging after reconstruction with a free vascularized fibula appropriately shaped with four osteotomies, to create the shape of the lower mandible.

Overall union rates greater than 90% have been reported in the absence of infection.

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