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Background:
Systematic Review

Post-Traumatic Segmental Tibial Defects Management: A Systematic Review of the Literature

by
Giovanni Marrara
1,2,
Biagio Zampogna
1,2,3,4,*,
Viktor Dietrich Schick
1,2,
Leone Larizza
1,2,
Paolo Rizzo
1,2,
Ilaria Sanzarello
1,2,
Matteo Nanni
1,2 and
Danilo Leonetti
1,2
1
BIOMORF Department of Biomedical and Dental Sciences and Morphological and Functional Images, University of Messina, Via Consolare Valeria 1, 98168 Messina, Italy
2
Department of Orthopaedic and Trauma Surgery, A.O.U. Policlinico “G.Martino”, Via Consolare Valeria 1, 98124 Messina, Italy
3
Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo 200, 00128 Rome, Italy
4
Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery, Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo 21, 00128 Rome, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci. 2025, 15(1), 64; https://doi.org/10.3390/app15010064
Submission received: 7 October 2024 / Revised: 22 December 2024 / Accepted: 23 December 2024 / Published: 25 December 2024
(This article belongs to the Special Issue Orthopedic Trauma and Fractures: From Pathophysiology to Novel Therapeutic Approaches)
Browse Figure
Figure 1
<p>PRISMA flow chart of the literature search.</p> ">
Versions Notes

Abstract

:
Introduction: Segmental tibial defects pose significant challenges in orthopedic surgery due to their complexity and high complication rates. This systematic review aimed to evaluate both the effectiveness and outcomes of distraction osteogenesis (D.O.) and the Masquelet technique in treating post-traumatic segmental tibial defects. Materials and Methods: A literature search was performed on PubMed, Scopus, and Cochrane. Relevant retrospective and prospective observational studies with a minimum of 12 months follow-up were included. The primary outcome was bone union rate; the secondary outcomes were the type and rate of complications and the clinical and radiological outcomes. Results: Twenty-seven studies met the inclusion criteria, 18 studies reported data on D.O. and 9 on the Masquelet technique. D.O. demonstrated an overall union rate of 79.4% across 422 patients, and the Masquelet technique demonstrated an overall bone union rate of 85% across 113 patients. For D.O., on average, there was one complication per patient, and with the Masquelet technique, there were 0.5 complications per patient. Conclusions: D.O. and the Masquelet technique are the main treatment options for post-traumatic segmental tibial defects. Although union rates are similar, the Masquelet technique showed fewer complications. Treatment choice should consider patient-specific factors and more comparative studies are needed.

1. Introduction

Segmental tibial defects pose significant challenges to surgeons regarding treatment and reconstruction [1]. They can lead to prolonged treatment courses, repeated surgeries, and potential complications, impacting both the physical and mental well-being of patients. The thin, soft tissues, high energy mechanisms of injury, poor vascularity in the tibial diaphysis, and the risk of infection and nonunion make segmental tibial defects especially difficult to treat [2,3,4]. Significant amounts of time, effort, and resources are required from both the surgeon and the patient [5,6]. It is, therefore, essential not only to correctly identify patients who will benefit from surgery but also to counsel and motivate them to comply with the treatment procedure over a prolonged period [5]. Once a patient has been selected for treatment, all modifiable risk factors should be identified and addressed appropriately to optimize the patient before surgery [5]. As Mauffrey et al. explain, “optimal patient characteristics for segmental bone defect reconstruction include a reliable and well-informed patient with a stable soft-tissue envelope, adequate nutritional status, and the absence of tobacco use and infection” [6] (p. 143). Especially because surgical procedures are burdensome and come with associated risks for complications, it must be determined if a defect is, in fact, significant and critical enough to warrant the use of a specialized reconstructive technique and, on the other hand, if the limb is salvageable. The two most utilized techniques to treat segmental bone defects in the tibia are distraction osteogenesis (D.O.) and the Masquelet technique [4]. D.O., initially described by Ilizarov, is a surgical technique designed to address segmental bone defects by gradually moving a segment of bone to close the gap [7]. This method utilizes either an external fixator or an intramedullary nail and consists of three main phases: an initial latency phase allowing early healing, an active distraction phase where the device is adjusted to stretch the bone segments, and a consolidation phase where the new bone matures [6]. The Masquelet technique, also known as the induced membrane technique, is a two-stage surgical procedure for treating large bone defects, initially described by Dr. Alain Masquelet in the 1980s [8]. In the first stage, a polymethylmethacrylate (PMMA) cement spacer is inserted into the defect after thorough debridement, inducing a biological membrane that promotes healing. This membrane is rich in growth factors and supports vascularization. After 6 to 8 weeks, during the second stage, the spacer is removed, and the defect is filled with an autologous bone graft [8]. Although outcomes are generally favorable and a lot can be achieved with the described surgical techniques, in some instances where the injury is too severe, it might be preferable to amputate right away instead of exposing the patient to repeated failures of prolonged, painful treatments that might ultimately lead to amputation [9,10]. While a segmental defect refers to bone loss in a segment of a bone, a critical defect is a defect that does not heal despite surgical fixation and needs further surgical intervention [11,12]. Following these definitions, most segmental defects are considered critical [12]. The current systematic review aims to determine which technique, distraction osteogenesis (external fixator or transport nail) or Masquelet, is preferable for treating post-traumatic segmental tibial defects.

2. Materials and Methods

2.1. Search Strategy

A systematic review of the medical literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [13]. PubMed, Scopus, and the Cochrane Library were searched. The following search strings were used on PubMed: (((“masquelet”[All Fields] OR “masquelet s”[All Fields]) AND (“tibia”[MeSH Terms] OR “tibia”[All Fields] OR “tibias”[All Fields] OR “tibia s”[All Fields] OR “tibiae”[All Fields])) OR ((“induce”[All Fields] OR “induced”[All Fields] OR “inducer”[All Fields] OR “inducers”[All Fields] OR “induces”[All Fields] OR “inducibilities”[All Fields] OR “inducibility”[All Fields] OR “inducible”[All Fields] OR “inducing”[All Fields]) AND (“membranal”[All Fields] OR “membrane s”[All Fields] OR “membraneous”[All Fields] OR “membranes”[MeSH Terms] OR “membranes”[All Fields] OR “membrane”[All Fields] OR “membranous”[All Fields]))) AND (“tibia”[MeSH Terms] OR “tibia”[All Fields] OR “tibias”[All Fields] OR “tibia s”[All Fields] OR “tibiae”[All Fields]), and (((“osteogenesis, distraction”[MeSH Terms] OR (“osteogenesis”[All Fields] AND “distraction”[All Fields]) OR “distraction osteogenesis”[All Fields] OR (“distraction”[All Fields] AND “osteogenesis”[All Fields])) AND (“tibia”[MeSH Terms] OR “tibia”[All Fields] OR “tibias”[All Fields] OR “tibia s”[All Fields] OR “tibiae”[All Fields])) OR ((“bone and bones”[MeSH Terms] OR (“bone”[All Fields] AND “bones”[All Fields]) OR “bone and bones”[All Fields] OR “bone”[All Fields]) AND (“biological transport”[MeSH Terms] OR (“biological”[All Fields] AND “transport”[All Fields]) OR “biological transport”[All Fields] OR “transport”[All Fields] OR “membrane transport proteins”[MeSH Terms] OR (“membrane”[All Fields] AND “transport”[All Fields] AND “proteins”[All Fields]) OR “membrane transport proteins”[All Fields] OR “transporter”[All Fields] OR “transporters”[All Fields] OR “transportable”[All Fields] OR “transportation”[MeSH Terms] OR “transportation”[All Fields] OR “transportations”[All Fields] OR “transported”[All Fields] OR “transporter s”[All Fields] OR “transporting”[All Fields] OR “transports”[All Fields]))) AND (“tibia”[MeSH Terms] OR “tibia”[All Fields] OR “tibias”[All Fields] OR “tibia s”[All Fields] OR “tibiae”[All Fields]). Scopus and Cochrane were searched with the following strings: (((masquelet) AND (tibia)) OR (induced membrane)) AND (tibia), and (((distraction osteogenesis) AND (tibia)) OR (bone transport)) AND (tibia). The article selection process consisted of two phases. In the first phase, the titles and abstracts were screened for relevance. In the second phase, relevant full-text articles were retrieved and assessed for eligibility. Two reviewers (G.M. and V.D.S.) screened the abstracts and evaluated the full articles independently. Doubts or disagreements regarding the inclusion of an article were resolved with the third reviewer (B.Z.).

2.2. Inclusion and Exclusion Criteria

Inclusion criteria (Table 1) were defined prior to the literature search and were formulated according to the “Population, Intervention, Comparison, Outcome, Study Design (PICOS)” format. Studies were considered eligible if they met the following inclusion criteria. Population: cohorts with patients ≥ 16 years old, suffering from post-traumatic segmental tibial defects; intervention: any type of distraction osteogenesis or Masquelet technique for the treatment of post-traumatic segmental tibial defects; comparison: patient cohorts treated with D.O. or Masquelet for post-traumatic segmental tibial defects; outcome: the primary outcome of interest was bone union rate. The secondary outcomes of interest were infection rate, the type and rate of other complications, and clinical and radiological outcomes. A mean follow-up of at least 1 year was required for inclusion. Study design: both experimental (randomized control trials—RCTs) and observational studies (case series or prospective or retrospective cohort studies) in English were included. Exclusion criteria were the following: (1) studies on segmental bone defects with an etiology other than trauma (e.g., infection, bone tumor, or pseudoarthrosis); (2) studies on post-traumatic segmental defects in bones other than the tibia; (3) studies that did not adequately report on at least the primary outcome of interest; (4) studies with an inadequate follow-up; (5) studies on patients < 16 years old; (6) case reports and studies with cohort sizes of 5 patients or less; (7) animal or biomechanical studies.

2.3. Data Extraction

The following parameters were extracted and analyzed: number of patients, patient demographics (age and sex), type of procedure (D.O. or Masquelet), bone defect size, bone union rate, mean follow-up, and the type and number of intra- and postoperative complications. For D.O., the external fixation time and the bone and functional outcomes according to the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria [14] were recorded (Table 2). The ASAMI criteria provide a standardized way to assess the success of D.O. procedures, allowing for comparison between different studies and techniques. For the Masquelet technique, the time from injury to procedure, the number of previous surgeries, and the time to union were recorded.

2.4. Quality Assessment

The quality of the included studies was assessed by two reviewers (G.M. and V.D.S.) according to the Methodological Index for Non-Randomized Studies (MINORS) score [16]. The MINORS contains 12 items, with the first 8 items specifically designed for non-comparative studies. Each item is scored from 0 to 2, with 0 indicating that the item was not reported, 1 indicating it was reported but inadequately, and 2 indicating it was reported and adequate. The maximum score for non-comparative studies is 16, and for comparative studies is 24. The 12 items in MINORS are (1) a clearly stated aim, (2) inclusion of consecutive patients, (3) prospective collection of data, (4) endpoints appropriate to the aim of the study, (5) unbiased assessment of the study endpoint, (6) follow-up period appropriate to the aim of the study, (7) loss to follow up less than 5%, and (8) prospective calculation of study size. For comparative studies, MINORS includes 4 additional items: (9) an adequate control group, (10) contemporary groups, (11) baseline equivalence of groups, and (12) adequate statistical analyses. The reliability of MINORS was established through good inter-reviewer agreement, high test–retest reliability, and good internal consistency. Its external validity was demonstrated by its ability to identify high-quality studies compared to the CONSORT statement for randomized trials [16].

3. Results

A total of 4778 studies were initially identified. After screening, 273 were retrieved and assessed for eligibility. Finally, 27 articles met the inclusion criteria (Figure 1), 18 reported results obtained with D.O., and 9 reported results obtained with the Masquelet technique. They were subsequently assessed for methodological quality according to the MINORS criteria (Table 3). The range of scores was 9–12, with an average score of 10.3, indicating an overall moderate level of methodological quality (CS case series, PS prospective study, and RS retrospective study). Characteristics of the included studies for D.O. can be seen in Table 4. A total of 422 patients were included (316 males and 106 females). The number of patients in each study ranged from 10 to 58, with an average of 23 patients per study. The patients’ ages ranged from 16 to 65 years, with a mean age of 35.7. The follow-up was from 8 to 144 months, with a mean follow-up time of 32.9 months. The outcomes of the included studies for D.O. can be seen in Table 5. The size of the bone defects ranged from 1.6 to 20 cm, with a mean bone defect size of 7.4 cm. The bone union rate ranged from 22% to 100%, with 17 of the 18 included studies reporting a union rate of at least 61.5%. Out of the 422 included patients, 335 reached bone union, resulting in an overall bone union rate of 79.4%. The external fixation time ranged from 1.2 to 37 months, with a mean of 10.5 months. Bone results according to the ASAMI criteria were reported for 361 patients included in 16 studies. The bone results were excellent in 245 (67.9%), good in 70 (19.4%), fair in 23 (6.4%), and poor in 23 (6.4%) patients, respectively. The functional results were reported for 400 patients included in 17 studies. They were excellent in 244 (61%), good in 108 (27%), fair in 39 (9.8%), and poor in 9 (2.3%) patients, respectively. The combined excellent and good rate in bone results was 87.3%, and the combined excellent and good rate in functional results was 88%.
A total of 415 complications occurred in the 408 patients, including 17 studies (Table 5). The average number of complications per patient ranged from 0.3 to 2.9, with a mean of 1 complication per patient treated with D.O. Among the 415 complications, 170 (41%) were major, and 245 (59%) were minor. Major complications are those that heavily impact the quality of life of the patient. They usually require additional surgeries, and they might predispose the patient to the development of further comorbidities. Minor complications, on the other hand, can either be easily treated or do not impact the quality of life to an extent that would justify additional surgical procedures. The different types of major complications can be seen in Table 6. Among the 170 major complications, there were 83 (48.8%) delayed unions or nonunions, 29 (17.1%) angular deformities > 5°, 12 (7.1%) refractures, 9 (5.3%) deep, persistent, or recurrent infections, 12 (7.1%) leg-length discrepancies >2.5 cm, and 25 (14.7%) other major complications. The different types of minor complications can be seen in Table 7. Among the 245 minor complications, there were 102 (41.6%) pin tract infections, 60 (24.5%) joint-related complications, 23 (9.4%) leg-length discrepancies <2.5 cm, and 60 (24.5%) other minor complications. Table 8 shows the descriptive characteristics of the included studies for the Masquelet technique. One hundred thirteen patients were included (86 males, 19 females, and 8 patients for which the sex was not individually mentioned in the article). The number of patients in each study ranged from 6 to 32, with a mean of 13. The age of patients ranged from 16 to 85, with a mean age of 38. The follow-up time ranged from 12 to 69 months, with a mean follow-up time of 23.3 months. The outcomes and the complications of the included studies for the Masquelet technique can be seen in Table 9. The size of the bone defects ranged from 0.9 to 15 cm, with a mean bone defect size of 5.8 cm. The bone union rate ranged from 41.7% to 96.9%. Out of the 113 included patients, 96 reached bone union, resulting in an overall bone union rate of 85%. The time to union was reported in five studies and ranged from 4 to 18 months, with a mean time to union of 10 months. The delay from injury to treatment with the Masquelet technique was reported in six studies and ranged from 0.1 to 100 months, with a mean delay of 10.3 months. The number of previous operative procedures before treatment with the Masquelet technique was reported in three studies and ranged from 0 to 12, with a mean of 3.7 previous procedures. Fifty-seven complications occurred among the 113 patients included. The average number of complications per patient ranged from 0.1 to 1.3, with a mean of 0.5 per patient treated with the Masquelet technique. Among the 57 complications, there were 17 (29.8%) nonunions, 20 (35.1%) infections, 4 (7%) amputations, and 16 (28.1%) other complications. The mean bone union rates for D.O. (79.4%) and the Masquelet technique (85%) are similar. The average number of complications per patient, however, is higher for D.O. compared to the Masquelet technique. Meanwhile, for D.O., there was, on average, one complication per patient; with the Masquelet technique, there were 0.5 complications per patient. For the Masquelet technique, the two most common complications were infection, affecting 17.7% of patients, and nonunion, affecting 15% of patients. For DO, the two most common complications were pin tract infection, affecting 25% of patients, and delayed union or nonunion, affecting 20.3% of patients. The angular deformation rate among patients was higher for the DO technique (7.1% of patients affected) and lower for the Masquelet technique (0.9% of patients affected). While joint-related problems were quite common among patients treated with the DO technique (14.7% of patients affected), they were rare in patients treated with the Masquelet technique (5.3% of patients affected). Amputation was only reported using the Masquelet technique. A total of 4 (3.5%) out of the 113 patients treated with this technique proceeded to amputation. On the other hand, refractures were only reported in patients treated with the DO technique (2.9% of patients affected), as were leg-length discrepancies > 2.5cm (2.9% of patients affected). Among the patients treated with D.O., 2.2% developed a deep, recurrent, or persistent infection. The percentages of satisfactory bone results (Excellent + Good) and satisfactory functional results according to the ASAMI scoring system were almost the same at 87.3% and 88%.

4. Discussion

D.O. and the Masquelet technique are the two main treatment options for segmental tibial defects [44]. This systematic review aimed to answer whether D.O. (external fixator; transport nail) or the Masquelet technique is preferable for treating post-traumatic segmental tibial defects. After analyzing the results of the systematic review, the somewhat higher union rate and the lower rate of complications suggest that the Masquelet technique is the preferable treatment option for post-traumatic segmental tibial defects. It should be kept in mind, however, that amputation was only reported with the Masquelet technique, suggesting that after additional procedures (e.g., bone grafting at the docking site or hardware changes), limb salvage is more often achieved with D.O. In their review of 27 studies comprising a total of 619 patients treated with D.O. for critical-sized tibial bone defects, Aktuglu et al. found a mean bone union rate of 90.2% (range 77–100%) and a mean external fixation time of 10.8 months [45]. The most common complications were pin tract infection (46.6%), joint stiffness (25%), malunion (8.4%), infectious recurrence (4.6%), refracture (4%), and amputation (1%) [45]. Benulic et al. conducted a review of seven studies reporting on a total of 87 patients with acute bone loss after open tibia fracture that were treated with DO or the Masquelet technique [44]. For D.O., they found a union rate of 92–100% and an infection rate of 0–4% [44]. For the Masquelet technique, they found a union rate of 42–100% and an infection rate of 12–43% [44]. Hsu et al. performed a systematic review of 11 studies with a total of 115 patients who were treated with the Masquelet technique because of a post-traumatic bone defect or nonunion in the tibia [46]. Despite eleven patients (9.6%) requiring further surgeries with bone grafting to achieve union, they found a final union rate of 90.4% and an infection rate of 24.3% (including superficial surgical site infections and pin tract infections) [46].
The mean bone union rate for D.O. found in this systematic review is lower than that reported in the literature. This might be because this systematic review concerned the initial union rate and not the final one after additional surgical procedures. The percentage of patients affected by pin tract infections, angular deformity, or joint-related problems was lower in this systematic review than in the review by Aktuglu et al. [45]. The percentage of patients treated with D.O. affected by either deep, recurrent, or persistent infection is in line with the findings by Benulic et al. [44]. The mean bone union rate for the Masquelet technique found in this review is consistent with the findings by Benulic et al. [44] but lower than the final union rate reported by Hsu et al. [46]. Again, this might be because this systematic review concerned the initial union rate before additional surgical procedures were performed. The percentage of patients found in this review who were treated with the Masquelet technique and developed infection is consistent with the findings by Benulic et al. [44] and Hsu et al. [46]. The low number of systematic reviews published reflects the general gap in the literature regarding studies on post-traumatic segmental defects in the tibia. Numerous studies focus on infected tibial nonunions that develop at some point in the aftermath of a trauma, but studies focusing on acute segmental bone loss after a trauma are comparatively rare. Many authors report results with D.O. or the Masquelet technique but do not differentiate between bone defects in the femur and bone defects in the tibia. Adamczyk et al. points out, “segmental defects of the femur often present favorable soft tissue environment with spontaneous healing reported in segmental defects measuring as much as 6 to 15 cm in length” [9] (p. 2). This stands in stark contrast to the tibia, where bone defects as small as 1 cm in length, involving more than half the circumference of the cortical bone, may fail to heal spontaneously, leading to suboptimal outcomes [9]. Results obtained with D.O. or the Masquelet technique for post-traumatic segmental bone defects in the femur are not generalizable to the tibia, where the conditions that influence bone healing are different. D.O. is more established than the Masquelet technique for treating segmental bone defects. Since its development by Ilizarov in the 1950s, it has been improved and refined multiple times. On the other hand, many aspects concerning the Masquelet technique, such as the optimal spacer material, the role of adjunctive local antibiotics, the ideal timing for the second stage, and the best fixation method, are still under discussion [44]. Surgeons might choose to treat a patient by D.O. because it seems to be the safer option. As a result, more studies have been published on the outcomes of D.O. compared to those on the Masquelet technique. This trend is evident in the present systematic review, which includes twice as many studies on D.O. as on the Masquelet technique.

5. Limitations

The most important limitation of this systematic review is the low number of studies included that report on results obtained with the Masquelet technique. Another limitation is that the reviewed articles only included single-modality treatment studies, where authors did not compare the outcomes of both treatment techniques, as they were either using one or the other. While for D.O., the bone and functional results were always reported according to ASAMI scores, there was no uniform reporting system for bone and functional results in the studies on the Masquelet technique. Furthermore, the overall methodological quality of the included studies was only moderate. Only four prospective studies were among the 27 included studies, and no randomized controlled trials reported on findings obtained with D.O. and the Masquelet technique for treating post-traumatic segmental tibial defects. Lastly, only a limited number of studies provided detailed information on individual patient status and comorbidities, making it impossible to include these factors in the systematic review.

6. Conclusions

Keeping in mind the low number of studies on the Masquelet technique that could be included in this review, we reached the following conclusion: both techniques achieve comparable bone union rates, but the Masquelet technique is associated with a lower rate of complications. Notably, in contrast to D.O., the Masquelet technique is not complicated by many pin tract infections, and it showed a lower incidence of angular deformities and joint-related complications. However, the risk of amputation was higher with the Masquelet technique. The choice of treatment technique should be tailored to the individual patient’s condition, considering factors such as defect size, patient compliance, and comorbidities. Further high-quality comparative studies are needed to establish clear guidelines and optimize treatment strategies for post-traumatic segmental tibial defects.

Author Contributions

Conceptualization, D.L. and B.Z.; methodology, B.Z.; software, V.D.S.; validation, G.M. and V.D.S.; formal analysis, G.M. and P.R.; investigation, P.R.; resources, I.S.; data curation, L.L.; writing—original draft preparation, V.D.S.; writing—review and editing, B.Z.; visualization, D.L. and M.N.; supervision, I.S.; project administration, D.L. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

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Applsci 15 00064 g001
Figure 1. PRISMA flow chart of the literature search.
Figure 1. PRISMA flow chart of the literature search.
Applsci 15 00064 g001
Table 1. Inclusion and exclusion criteria for this study.
Table 1. Inclusion and exclusion criteria for this study.
Inclusion Criteria: Exclusion Criteria:
Post-traumatic segmental tibial defectsDefects following infection
Age ≥ 16 yearsDefects following bone tumor
More than 5 casesDefects following pseudoarthrosis
Mean follow-up ≥ 1 yearDefects in bones other than the tibia
Distraction osteogenesis and/or Masquelet technique
Language: English
Clinical studies
Outcomes of interest:
-
Primary outcome: union rate
-
Secondary outcomes: infection rate, type and rate of other complications, clinical and radiological outcome
Table 2. ASAMI criteria for bone outcome and for functional outcome.
Table 2. ASAMI criteria for bone outcome and for functional outcome.
Bone ResultsDescription
ExcellentUnion, no infection, deformity < 7°, limb-length discrepancy < 2.5 cm
GoodUnion + any two of the following: absence of infection, deformity < 7°, limb-length discrepancy < 2.5 cm
FairUnion + only one of the following: absence of infection, deformity < 7°, limb-length discrepancy < 2.5 cm
PoorNonunion/re-fracture/union + infection + deformity > 7° + limb-length discrepancy > 2.5 cm
Functional ResultsDescription
ExcellentActive, no limp, minimum stiffness (loss of <15° knee extension/<15° ankle dorsiflexion), no reflex sympathetic dystrophy, insignificant pain
GoodActive with one or two of the following: limp, stiffness, reflex sympathetic dystrophy, significant pain
FairActive with at least three of the following: limp, stiffness, reflex sympathetic dystrophy, significant pain
PoorInactive (unemployment or inability to return to daily activities because of injury)
Source: Adapted from [15].
Table 3. MINORS scores of included studies.
Table 3. MINORS scores of included studies.
Study:Year:Design:Technique:MINORS:
Abula et al. [17]2020RSDistraction Osteogenesis10
Ajmera et al. [18]2015PSDistraction Osteogenesis12
Azzam et al. [19]2016RSDistraction Osteogenesis10
Babar et al. [20]2013PSDistraction Osteogenesis12
Bernstein et al. [21]2015RSDistraction Osteogenesis10
Cao et al. [22]2023RSDistraction Osteogenesis10
Chand et al. [23]2024RSDistraction Osteogenesis10
Chen et al. [24]2022RSDistraction Osteogenesis10
Chloros et al. [25]2022RSMasquelet11
El-Alfy et al. [26]2018CSMasquelet10
Gupta et al. [27]2016PSMasquelet11
Hu et al. [28]2013CSDistraction Osteogenesis10
Kang et al. [29]2020CSMasquelet10
Krappinger et al. [30]2013PSDistraction Osteogenesis12
Li et al. [31]2020RSDistraction Osteogenesis10
Li et al. [32]2021RSDistraction Osteogenesis10
Lu et al. [33]2020RSDistraction Osteogenesis10
Mathieu et al. [34]2020RSMasquelet10
Mathieu et al. [35]2020RSMasquelet10
Morris et al. [36]2017RSMasquelet9
Özpolat et al. [37]2022RSMasquelet10
Sahibzada et al. [38]2005CSDistraction Osteogenesis10
Selim [39]2013CSDistraction Osteogenesis10
Xu et al. [40]2017RSDistraction Osteogenesis10
Xu et al. [41]2021RSDistraction Osteogenesis10
Yoon et al. [42]2022RSMasquelet10
Zhang et al. [43]2018RSDistraction Osteogenesis10
Table 4. Descriptive characteristics of included studies (distraction osteogenesis).
Table 4. Descriptive characteristics of included studies (distraction osteogenesis).
Author/sYearTreatment PeriodPatientsMean Age (Range)M/F RatioMean Follow-Up (Range) (Months)
Abula et al. [17]20202010–20171435.5 (18–54)8/629.9 (24–36)
Ajmera et al. [18]20152009–20122532.5 (20–48)23/215 (12–19)
Azzam et al. [19]20162011–20133032 (18–52)30/018 (10–32)
Babar et al. [20]20132009–20113231.6 (18–52)25/7N.A. (12–N.A.)
Bernstein et al. [21]20152006–20125845 (19–61)39/1936 (12–96)
Cao et al. [22]20232014–20203533.2 (N.A.)18/1732 (24–40)
Chand et al. [23]20242013–20221327.4 (18–48)11/2103.4 (36–144)
Chen et al. [24]20222014–20191140.6 (29–58)7/441.1 (25–75)
Hu et al. [28]20132006–20081631.5 (18–56)14/230.2 (19–48)
Krappinger et al. [30]20132004–20091532 (16–61)11/417.3 (8–36)
Li et al. [31]20202010–20172640.4 (22–56)20/628.5 (13–38)
Li et al. [32]20212012–201840N.A. (16–65)27/1328.2 (18–60)
Lu et al. [33]20202013–20171245 (20–65)10/225.8 (12–48)
Sahibzada et al. [38]20051997–200220N.A. (20–50)14/624 (N.A.)
Selim [39]20132010–20111030 (22–40)10/028.8 (24–36)
Xu et al. [40]20172007–20121841.2 (28–52)13/538.8 (25–52)
Xu et al. [41]20212009–20163133.4 (18–58)27/432 (12–96)
Zhang et al. [43]20182010–20151639.1 (16–65)9/729.5 (12–36)
N.A. not available.
Table 5. Outcomes of included studies and complications (distraction osteogenesis).
Table 5. Outcomes of included studies and complications (distraction osteogenesis).
Author/sYearMean Bone Defect Size (Range) (cm)Bone Union Rate (%)External Fixation Time (Range) (Months)Bone Results ASAMI (Excellent/Good/Fair/Poor)Functional Results (ASAMI)
(Excellent/Good/Fair/Poor)		Patients (Complications)Minor ComplicationsMajor ComplicationsComplications per Patient
Abula et al. [17]20207 (4–12.5)71.46.9 (5.5–7.7)8/6/0/08/6/0/0N.A.N.A.N.A.N.A.
Ajmera et al. [18]20155.5 (4–9)9210.1 (5.5–11.7)19/3/1/221/2/2/0251360.7 (19/25)
Azzam et al. [19]20167.4 (3–12)1007.5 (4.5–11.5)22/6/1/113/9/7/13036151.7 (51/30)
Babar et al. [20]20135.4 (4.2–6.5)84.46 (N.A.)24/3/4/119/7/5/1321550.6 (20/32)
Bernstein et al. [21]20155.3 (1.6–13)72.49.2 (1.2–19.3)47/8/0/051/2/0/15821270.8 (48/58)
Cao et al. [22]20236.7 (N.A.)91.4%19.2 (N.A.)19/13/3/019/11/5/035730.3 (10/35)
Chand et al. [23]20247.7 (5–13)61.5%8.5 (N.A.)8/4/1/06/7/0/013450.7 (9/13)
Chen et al. [24]20225.6 (4–7)90.98.8 (6–14)10/0/0/10/7/4/0111191.8 (20/11)
Hu et al. [28]20138.7 (7–10)87.512.9 (12–15.2)14/2/0/013/2/1/016540.6 (9/16)
Krappinger et al. [30]20136.6 (3–14.7)8013.2 (7–25)7/6/2/06/7/2/01527172.9 (44/15)
Li et al. [31]20209 (5.8–15)76.915.4 (9.5–20) 20/0/0/622/4/0/026760.5 (13/26)
Li et al. [32]20218.3 (4–18)8012.8 (10–24)N.A.24/10/4/24012210.8 (33/40)
Lu et al. [33]20206.7 (4–9.2)1003.7 (2–5.2)12/0/0/08/4/0/012400.3 (4/12)
Sahibzada et al. [38]20057 (5–N.A.)85%6.8 (4–8)12/2/3/37/8/4/12012151.4 (27/20)
Selim [39]20139 (6–12) 802.6 (2–3)7/3/0/07/3/0/010430.7 (7/10)
Xu et al. [40]20174.5 (2–6)2211.4 (7–20)N.A.N.A.189141.3 (23/18)
Xu et al. [41]202111.9 (8.2–18.2)67.722.7 (14–37)6/14/8/38/15/5/33131141.5 (45/31)
Zhang et al. [43]201810.9 (6–20)81.312 (5–18)10/0/0/612/4/0/0162762.1 (33/16)
N.A. not available.
Table 6. Major complications (distraction osteogenesis).
Table 6. Major complications (distraction osteogenesis).
Author/sYearPtsDU or NUAD
>5°		Deep, Persistent, or Recurrent InfectionRefractureLLD > 2.5 cmOther Major Complications
Ajmera et al. [18]20152520202N.A.
Azzam et al. [19]201630N.A.81114 Angulation more than 7° (corrected with hinges)
Babar et al. [20]2013325N.A.N.A.N.A.N.A.N.A.
Bernstein et al. [21]20155816603N.A.1 Osteomyelitis
1 Septic Knee
Cao et al. [22]2023353N.A.N.A.0N.A.N.A.
Chand et al. [23]2024135N.A.N.A.0N.A.N.A.
Chen et al. [24]2022111N.A.1N.A.N.A.6 Post-traumatic arthritis
1 Elongated callus curvature
Hu et al. [28]20131622N.A.N.A.N.A.N.A.
Krappinger et al. [30]201315372N.A.32 Late bending of the regenerated bone after frame removal
Li et al. [31]2020266N.A.N.A.N.A.N.A.N.A.
Li et al. [32]2021408N.A.02110 Severe nail tunnel reaction or mechanical axis deviation
Lu et al. [33]2020120000N.A.N.A.
Sahibzada et al. [38]20052036N.A.15N.A.
Selim [39]20131020N.A.10N.A.
Xu et al. [40]201718140N.A.N.A.0N.A.
Xu et al. [41]20213110N.A.31N.A.N.A.
Zhang et al. [43]20181630N.A.3N.A.N.A.
AD, angular deformity; DU, delayed union; LLD, leg-length discrepancy; N.A., not available; NU, nonunion; Pts, patients.
Table 7. Minor complications (distraction osteogenesis).
Table 7. Minor complications (distraction osteogenesis).
Author/sYearPtsPin Tract Infection LLD < 2.5 cmJoint Related ComplicationsOther Minor Complications
Ajmera et al. [18]2015254 N.A.62 Aseptic pin loosening
1 Skin reaction after fixator application
Azzam et al. [19]20163016 N.A.143 Poor quality of the regeneration
2 Skin invagination at the docking site
1 Translation at the planned docking site
Babar et al. [20]20133212N.A.N.A.3 Wire re-tension
Bernstein et al. [21]20155810 N.A.15 Equinus contracture
4 Entrapment of overlying skin
1 Failure of the fibula to separate
Cao et al. [22]2023353N.A.N.A.1 Pin loosening
3 Soft tissue incarceration
Chand et al. [23]2024134N.A.N.A.N.A.
Chen et al. [24]2022113N.A.62 Superficial wound infection
Hu et al. [28]201316113N.A.
Krappinger et al. [30]2013159126N.A.
Li et al. [31]2020267N.A.N.A.N.A.
Li et al. [32]202140N.A.48N.A.
Lu et al. [33]2020124N.A.0N.A.
Sahibzada et al. [38]2005208N.A.N.A.4 Foot equinus
Selim [39]2013101012 Equinus deformity
Xu et al. [40]201718500 4 Mild contractures of the Achilles tendon during bone transport
Xu et al. [41]20213123129 Muscle contraction
4 Axial deviation, which disappeared after adjusting the frame
1 K-wire cut out
Zhang et al. [43]2018161333 8 Soft tissues cut by the wires
LLD, leg-length discrepancy; N.A., not available; Pts, patients.
Table 8. Descriptive characteristics of included studies (Masquelet).
Table 8. Descriptive characteristics of included studies (Masquelet).
Author/sYearTreatment PeriodPatientsMean Age (Range)M/F RatioMean Follow-Up (Range) (Months)
Chloros et al. [25]20222016–2020736.1 (22–67)6/1N.A. (12–N.A.)
El-Alfy et al. [26]20182013–2017629.7 (20–37)4/2N.A. (15–N.A.)
Gupta et al. [27]20162010–2013735.5 (18–55)5/221.5 (18–24)
Kang et al. [29]20202018–20191546.5 (19–72)11/4N.A. (12–24)
Mathieu et al. [34]20202009–20181539 (26–61)12/333 (12–69)
Mathieu et al. [35]20202007–2012834.3 (22–71)N.A.14.9 (12–22)
Morris et al. [36]20172010–20151236 (16–62)9/322.5 (13–32)
Özpolat et al. [37]20222016–20191140.7 (25–63)11/024.6 (13–40)
Yoon et al. [42]20222014–20193243.9 (28–85)28/4N.A. (12–N.A.)
N.A. not available.
Table 9. Outcomes of included studies and complications (Masquelet).
Table 9. Outcomes of included studies and complications (Masquelet).
Author/sYearMean Bone Defect Size (Range) (cm)Bone Union Rate (%)Time to Union (Range) (Months) Mean Delay from Injury to Masquelet (Range) (Months)Mean Previous Operative Procedures (Range)Pts (Complications)NonunionInfectionAmputationOther ComplicationsComplications per Patient
Chloros et al. [25]20226.9 (5–8)85.7%8.7 (6–18)4.4 (4–5)N.A.71001 Soft tissue irritation0.3 (2/7)
El-Alfy et al. [26]20186.3 (5–9)83.3%5.6 (5–8)N.A.N.A.611000.3 (2/6)
Gupta et al. [27]20165.2 (3.3–8.5)85.710.5 (8–13)9.2 (0.8–24)1.7 (0–3)71 N.A.N.A.5 LLD < 2.5cm0.9 (6/7)
Kang et al. [29]20205.8 (4–11)93.3%N.A. (4–7)N.A.N.A.1511000.1 (2/15)
Mathieu et al. [34]20207.7 (3–15)86.7%10.1 (8–12)0.7 (0–2)6.7 (5–12)152105 Ankle dorsiflexion inferior to 5°0.5 (8/15)
Mathieu et al. [35]20204.8 (2–11)87.5%N.A.1.1 (0.5–1.6)N.A.813000.5 (4/8)
Morris et al. [36]20175.8 (2–15)41.7N.A.1.3 (0.1–11)N.A.1275 21 Plate breakage
1 Minimal callus		1.3 (16/12)
Özpolat et al. [37]20225.1 (2.5–9.8)81.8N.A.44.8 (18–100)2.8 (1–6)112311 Bone (graft) resorption at the defect site at 18-month follow-up after a trauma0.6 (7/11)
Yoon et al. [42]20224.4 (0.9–10)96.99.4 (4–16)N.A.N.A.321611 Angular deformity 10°
1 Joint Stiffness		0.3 (10/32)
N.A. not available.
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Marrara, G.; Zampogna, B.; Schick, V.D.; Larizza, L.; Rizzo, P.; Sanzarello, I.; Nanni, M.; Leonetti, D. Post-Traumatic Segmental Tibial Defects Management: A Systematic Review of the Literature. Appl. Sci. 2025, 15, 64. https://doi.org/10.3390/app15010064

AMA Style

Marrara G, Zampogna B, Schick VD, Larizza L, Rizzo P, Sanzarello I, Nanni M, Leonetti D. Post-Traumatic Segmental Tibial Defects Management: A Systematic Review of the Literature. Applied Sciences. 2025; 15(1):64. https://doi.org/10.3390/app15010064

Chicago/Turabian Style

Marrara, Giovanni, Biagio Zampogna, Viktor Dietrich Schick, Leone Larizza, Paolo Rizzo, Ilaria Sanzarello, Matteo Nanni, and Danilo Leonetti. 2025. "Post-Traumatic Segmental Tibial Defects Management: A Systematic Review of the Literature" Applied Sciences 15, no. 1: 64. https://doi.org/10.3390/app15010064

APA Style

Marrara, G., Zampogna, B., Schick, V. D., Larizza, L., Rizzo, P., Sanzarello, I., Nanni, M., & Leonetti, D. (2025). Post-Traumatic Segmental Tibial Defects Management: A Systematic Review of the Literature. Applied Sciences, 15(1), 64. https://doi.org/10.3390/app15010064

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