[Ortho] Tibia Fx - Segmental Defect

[Roger C. Sohn]

Dear Forum,

I am taking care of a 21 y/o Marine who was shot in the leg with an
M-16 from close range.  He was on base (Camp Pendleton) when this
happened.  

The patient has a medial and lateral wounds with extensive soft
tissue injury (open grade 3C) with the Posterior Tibial Artery
repaired on the night of injury.  Fasciotomies were not necessary
because his entry and exit wounds essentially exploded medially and
laterally.  Initial debridment left him with approximately 6" of
missing bone from the mid-shaft.  I ex-fixed him and have taken him
back for a 2nd and 3rd look I and D.  It looks like soft tissue
coverage will not be too much of an issue due to his slightly
shortened position as well as the large amount of dead muscle that I
removed.  He is post-injury day #4 and now wound is improved.  I'll
be able to close his medial wound directly and place a skin graft
over his lateral wound in a couple days.           

Right now, he is stabilized in an ex-fix and I'm planning my next
step.  I have seen the previous similar cases from 2003 and was
wondering if any of you have new ideas on how to treat this segmental
defect.  I haven't seen it published, but I have seen some data out
of Ortho Indy showing good results with plating, followed by RIA
aspirate bone grafting.  I have placed an ABX spacer "log" of PMMA
with hopes of him forming a pseudomembrane.  However, I don't feel I
have burned any bridges yet and wanted some input.       

Patient is sensate with good blood flow.  He would like to salvage
the limb.  He does not smoke and is very healthy.

Thanks in advance for your input.

Sincerely,

Roger Sohn
Mission Viejo, CA