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Complex Bone Reconstruction

Introduction

Complex bone reconstruction is a highly advanced surgical procedure that involves techniques to restore severely damaged bones. It usually combines a variety of procedures tailored to a specific patient’s needs, based on the extent of bone loss, available bone stock, quality of adjacent soft tissue envelope, presence of infection, vascular supply, sensory disturbance as well as functional level and patient’s expectations. 

Reconstruction of large bone defects and deformities after bone tumour resection, severe trauma with bone loss or extensive bone infection often necessitates removal of a large portion of the bone (to eliminate abnormal bone tissue) and its reconstruction comprising of bone regenerative techniques, bone grafts, artificial implants to reestablish adequate bone stock and restore limb function.

Indications and Contraindications

Complex Bone Reconstruction Indications

Complex bone reconstruction is recommended when conventional treatments prove insufficient to restore bone integrity. Common indications include:

  • Severe Trauma: Where extensive bone damage or bone loss occurs, usually in high-energy injury.
  • Nonunion or Malunion: Where fractured bones fail to heal or heal with deformity, and a large segment of abnormal bone needs resection or bone heals with significant shortening.
  • Bone Infections: A large segment of bone is destroyed by the infection process, necessitating its removal.
  • Tumours or Cysts: Where a large bone defect results from tumour resection.
    Congenital Deformities: Inborn bone abnormalities that impair function and mobility due to deformity or segmental shortening of bone.

Contraindications

Not every patient is a suitable candidate for complex bone reconstruction.

  • Severe General Medical Conditions: Reconstruction procedures, due to their complexity and length, often carry an increased risk of surgical or anaesthetic complications, that may outweigh potential benefits from the surgery. Some conditions (uncontrolled diabetes, compromised immune systems, cardiovascular disease, nutritional deficiencies, smoking etc.) also compromise healing or rehabilitation.
  • Active Infections: Ongoing infections compromise healing.
  • Inadequate Commitment: Successful recovery requires active participation in post-surgery rehabilitation, which might be a challenge for some patients.
  • Unrealistic expectations: not always a surgery can provide the patient with a complete functional and cosmetic reconstruction.

Benefits and Risks

By restoring bone stock, proper alignment and stability in patients with severe bone damage, there is a potential chance to improve their mobility, function, and quality of life. However, bone reconstruction is a difficult and engaging process both for the patient as well as the medical team. Recovery can take several months to years and commitment to rehabilitation as well as follow-up appointments is essential for optimal outcomes.

Surgical Approach

 Some of the common types of complex bone reconstruction procedures include:

Bone Grafting

Bone Grafting is a procedure of filling the gap in a bone with bone from another source

    • Autograft: Bone is harvested from the patient’s own body: iliac crest, tibia or heel bone. Autografts are superior, as they provide structural support and promote bone healing.
    • Allograft: Bone is obtained from a donor and processed to remove cellular components to eliminate its immunity and possibility of infection. In bone tumour surgery large structural bone grafts comprising of significant bone segments can be employed.
    • Synthetic bone substitutes: Ceramic, polymers, or metals, are used to replace missing bone tissue and provide structural support. Calcium based materials will be resorbed and replaced with patient’s own bone over a period of time, other materials will integrate and remain in the patient’s bone.

 

Deformity correction

Deformity within the bone or around the joint needs to be corrected with acute or gradual techniques to adjust the mechanical axis of the reconstructed limb [refer to the chapter on deformity correction].

 

Bone Lengthening or Bone Transport

In case of a bone shortening or a significant bone defect, procedures to grow new bone are employed [refer to the chapter on limb lengthening].

    • Distraction Osteogenesis is a procedure that involves cutting healthy bone fragments and distracting their ends while new bone tissue forms between them. This allows for the bone to lengthen to adequate dimension and the bone regenerate to heal and remodel into normal bone tissue.
    • Bone Transport: in case of a significant gap the remaining healthy bone is distracted like in distraction osteogenesis to increase its length; simultaneously the bone defect is being gradually closed.

 

Bone lengthening, bone transport or deformity correction can be performed using a variety of instruments such as motorised nails, external fixator devices or circular frames.

 

Vascularised Bone Grafts

A segment of the fibula, along with its blood supply is harvested from the patient’s lower leg and is transplanted to a site requiring reconstruction. This technique is often used in cases where large bone defects need to be addressed.

 

Bone Regeneration Techniques

    • Stem Cell Therapy: Stem cells derived from the patient’s own body (bone marrow) are used to stimulate bone regeneration and healing.
    • Bone Morphogenetic Proteins (BMPs): Growth factors that can induce bone formation are injected to promote bone healing.

The above techniques for bone reconstruction need to be supplemented with a range of bone fixation techniques:

Internal Fixation:

    1. Metal Plates and Screws: These implants are used to stabilize fractured bones and hold them in the correct position while healing takes place. They are commonly used in cases of fractures or bone deformities.
    2. Intramedullary Nailing: A metal rod is inserted into the medullary canal (inside the bone) to provide stability and support for fractures. This technique is often used for long bone fractures.

External Fixation:

      1. Circular External Fixation: This involves the use of rings connected by rods that are fixed outside the body to provide stability and control bone alignment. It is often used for complex fractures, deformities, and bone lengthening procedures.
      2. Unilateral External Fixation: In this technique, a single rod or frame is attached externally to the bone, allowing controlled movement and stabilization.

 

Each type of complex bone reconstruction procedure is chosen based on the specific condition, location, and severity of the bone defect. Surgeons work closely with patients to determine the most suitable approach that will offer the best chances of successful bone restoration and recovery.

In many cases, bone reconstruction needs to be combined with soft tissue reconstruction to provide adequate soft tissue coverage for better healing, or with muscle transfers for better function.

Pre-Surgery Information

The following is what can be expected before a complex bone reconstruction procedure:

  1. Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
  2. Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
  3. Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.  
  4. Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
  5. Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
  6. Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

  • Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
  • A hospital gown will be given, and the operation site will be shaved and cleaned.
  • Betadine skin prep will be applied to the area above the operation site and wrapped.
  • All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

  1. Anaesthesia: General anaesthesia or regional anaesthesia (spinal, epidural etc.) is used to ensure a pain-free procedure.
  2. Incision: An incision will be determined by the nature of bone deficiency and deformity and fixation methods used.
  3. Bone resection and/or deformity correction:  Unhealthy or deformed bone tissue will be removed.
  4. Fixation: An appropriate implant is inserted onto the bone (plates), into the bone (nails) or over the whole limb (external fixator), with an aim to maintain the correct position of bone fragments. 
  5. Filling the bone voids: If a resultant bone defect is small it can be filled with bone graft. A large defect will be reconstructed with pre planned technique either during the surgery or after – gradually – in the process of bone lengthening or transport.
  6. Anatomical alignment and stability of fixation are confirmed with x-rays.
  7. Additional reconstructive procedures: if indicated, soft tissue repair or reconstruction is performed at the same time as bone reconstruction.
  8. Closure: The incision is closed using sutures. Dressing is applied and Vacuum Assisted Wound Closure may be indicated in case of soft tissue compromise or infection. Immobilisation may be indicated.

Post-Surgery Information

  1. Hospital Stay: Bone reconstruction is a serious surgery, you’ll typically be admitted into a hospital for several to weeks days for monitoring, initial rehabilitation and learning how to handle bone lengthening or bone correction programs.
  2. Pain Management: Pain medications will be administered to keep you comfortable. Bone reconstruction is an ongoing process and long periods of pain management are usually expected.
  3. Immobilisation: When necessary, a cast, splint or brace may be used to protect your surgical site. The length of its use will depend on the primary condition and reconstructive procedures performed.
  4. Weight-Bearing: When necessary, you will remain non-weight-bearing for a period of time. Then you will commence weight-bearing gradually, with crutches, boots, or brace protection, following your surgeon’s instructions.
  5. Follow-Up: Regular follow-up appointments with the team will help monitor your progress and address any concerns:
    • 1 week postop: for wound check,
    • 2 weeks postop: for sutures removal. If you need gradual correction or lengthening of bone, you will usually receive a program during this visit. In this case, you will need x-rays follow-up every two weeks, until the program has been completed.
    • 6 weeks postop: for x-ray assessment of healing progressing,
    • Later at 3, 6, 9, 12 months postop and further annually an x-ray will be mandatory.
  6. Physical Therapy: A tailored rehabilitation program will help regain strength, flexibility, and mobility.
  1. Lifestyle Adjustments: Patients need to modify their activities and household environment to accommodate the lengthy bone reconstruction process, to ensure optimal healing and comfort.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000

Call on +61 2 8882 9011

X-ray facilities at all locations | Urgent appointments available if necessary.

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Professor Munjed Al Muderis

Professor Munjed Al Muderis is an orthopaedic surgeon and a clinical professor at Macquarie University and The Australian School Of Advanced Medicine. He specialises in hip, knee, trauma and osseointegration surgery. He is a fellow of the Royal Australasian College of Surgeons and Chairman of the Osseointegration Group of Australia.

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Disclaimer

Information provided via this website is for educational and communication purposes only. The material presented is neither intended to convey the only, nor necessarily the best, method or procedure, but rather represents techniques and procedures used by Professor Munjed Al Muderis. Professor Munjed Al Muderis disclaims any and all liability for injury and/or other damages which result from an individual using techniques presented on this website. Professor Munjed Al Muderis, to the best of his knowledge, believes the information presented is current and applicable to work being done by orthopaedic surgeons worldwide.