Technical Report: Two-stage Approach for Limb Reconstruction in Open Tibial Fractures with Bone Loss or Infection Using Soft Tissue Flap Coverage, Bone Resection, and Frame-guided Mono- or Bifocal Corticotomy-based Bone Transport, Including Video Demonstration

Abstract

Aim and background

Orthopaedic surgeons face a complex challenge in managing open fractures of the lower leg or infected bones with significant segmental bone loss. The aim of this technical guide and video demonstration is to describe and standardise a two-stage approach, combining bone resection, soft tissue reconstruction and bone transport using a Taylor spatial frame (TSF), as management for such injuries.

Technique

We describe a two-stage surgical technique: In the first stage, all infected, potentially infected, or necrotic bone is meticulously resected, and soft tissue coverage is provided using either local or free flaps. After soft tissue recovery and infection/contamination eradication, a TSF is applied with uni- or bifocal corticotomies to facilitate bone transport for reconstructing segmental bone loss. Bone transport is guided by frame-specific software that instructs daily micro-adjustments, carried out by the patient in their home setting. Regular follow-up and radiographic imaging allow for re-adjustment of software parameters, if required. Technical considerations, indications and limitations of the approach are also discussed.

Conclusion

This technical guide outlines a detailed description of a staged reconstructive surgical approach to address open fractures of the lower leg with significant segmental tibial bone loss. Use of the TSF system allows multiplanar adjustment and reduced risk of mal- or non-union. The technique requires careful pre-operative planning and significant patient compliance and engagement due to the prolonged treatment duration.

Clinical significance

This guide and video demonstration highlight an effective surgical technique for the management of open tibial fractures that utilises precision and advanced technology-guided frame adjustments.

Introduction

Segmental bone loss in open lower leg fractures, particularly with contamination or infection, poses a significant challenge. The Taylor spatial frame (TSF) has become a preferred management method for these patients, allowing simultaneous deformity correction and bone transport. Its precision in distraction osteogenesis facilitates the gradual regeneration of bone while maintaining alignment, making it effective for large tibial defects.^1,2

As a tertiary care centre specialising in limb reconstruction, we have managed 22 of these cases using TSFs in 2023, 41 in 2024, and 19 in early 2025. These cases have contributed to the refinement and standardisation of our peri-operative management strategy and surgical technique.

Management of contaminated/infected bone often requires a staged approach that combines debridement, soft tissue coverage, and bone transport. Southam and Archdeacon³ emphasised the importance of thorough debridement in high-energy open tibial fractures to prevent complications. Salcedo Cánovas et al.⁴ demonstrated successful outcomes using a two-stage distraction osteogenesis protocol in infected lower limb defects. Comparative studies have shown that TSF offers superior accuracy and flexibility to traditional circular fixators for bone transport in large segmental defects.⁵

The objective of this report is to provide a detailed technical guide of our two-stage approach involving bone resection, soft tissue flap coverage, TSF-assisted bone alignment correction and transport for managing segmental tibial bone loss with or without infection. We additionally discuss indications, benefits and limitations of this approach.

Indications

The outlined surgical approach is most relevant for large segmental tibial bone defects, with additional complexity added by multiplanar deformity, the need for bone transport, or the presence of severe soft-tissue compromise or osteomyelitis.

Relevant indications for a TSF system include:

• Open tibial or pilon fractures with severe segmental bone loss and extensive soft tissue damage.

• Chronic osteomyelitis requiring bone resection, where internal metalwork is undesirable due to infection risk or further soft tissue compromise.

• Failed previous fixation with established bone loss.

• Infected non-union necessitating bone and soft tissue reconstruction

• Fractures with multiple large bone segments requiring independent control of each segment.

Conversely, a TSF system may not provide significant benefit to manage smaller bone defects, minimal deformity or closed fractures. Alternative approaches, including intramedullary nailing, Ilizarov frames or bone grafting, should be considered instead.

Relevant Surgical Anatomy

The anteromedial surface of the tibia has minimal soft tissue, making it vulnerable to open fractures and bone loss. The nutrient artery supplies the diaphysis, and preserving the periosteum is vital for bone regeneration. Soft tissue coverage is essential for healing in segmental bone loss. The patient illustrated in this report suffered a high-energy injury to the tibia resulting in an open comminuted tibia and fibula fracture. No relevant previous interventions at the injury site had taken place.

Surgical Technique

Stage 1: Bone resection and soft tissue reconstruction

• Preoperative planning: Resection margins are determined using X-ray (Fig. 1) and magnetic resonance (MRI) imaging.

• Patient positioning: Supine with the leg elevated; a tourniquet may be used.

• Debridement and resection: Thorough removal of necrotic/infected tissue is essential. The transverse bone cuts optimise contact at the docking site. Intraoperative microbiological sampling (five Ballotini and two sterile container samples using separate instruments and the no-touch technique) is mandatory before applying antibiotic beads in infected cases (vancomycin 1gm, gentamicin 240 mg/5 mL Stimulan®).⁶

• Flap coverage: Local muscle flaps are preferred; larger defects may require free flaps (e.g. anterolateral thigh). The coverage must be tension-free and well vascularised. Interim external fixation is applied until frame placement (Figs 2 and 3).

• Antibiotic therapy: Postoperatively, patients receive culture-directed intravenous or oral antibiotics for 6–12 weeks. Suppressive oral antibiotics may be considered in chronic cases. In all cases, antibiotic treatment is guided by an infectious disease consultant.

Figs 1A and B.

Preoperative X-ray of an open comminuted distal tibia and fibula fracture directly after the accident. (A) Anteroposterior X-ray of the right distal lower leg; (B) Lateral X-ray of the right distal lower leg

Figs 2A to J.

Intraoperative image intensifier during surgical bone and soft tissue debridement and coverage and application of antibiotic-loaded beads (1 gm of vancomycin and 240 mg of gentamicin in 5 mL of Stimulan®) and an external fixator for interim fixation. (A) Anteroposterior view of the right distal lower leg after bone and soft tissue debridement; (B) Lateral view of the right distal lower leg for calcaneus Steinmann pin application; (C) Anteroposterior view of the right proximal lower leg after proximal pin application; (D) Lateral view of the right distal lower leg after transverse bone resection and the application of antibiotic beads; (E) Anteroposterior view of the right distal lower leg after transverse bone resection and the application of antibiotic beads; (F) Anteroposterior view of the right distal lower leg and foot after transverse bone resection, and the application of antibiotic beads and the calcaneal Steinmann pin; (G to J) Postoperative X-ray imaging after surgical bone and soft tissue debridement and application of an external fixator as an interim fixation agent until the TSF is performed. Note the divergent placement of Steinmann pins to enhance stability; (G) Anteroposterior view of the right distal lower leg; (H) Anteroposterior view of the right proximal lower leg; (I) Lateral view of the right distal lower leg; (J) Lateral view of the right proximal lower leg

Figs 3A to D.

Intraoperative image intensifier during the TSF application and double corticotomy. (A) Anteroposterior view of the right distal lower leg after application of three olive wire bayonets through the talus; (B) Anteroposterior view of the right proximal lower leg after proximal corticotomy was performed; (C) Lateral view of the right proximal lower leg after proximal corticotomy was performed; (D) Anteroposterior view of the right lower leg shaft segment after distal corticotomy was performed

Stage 2: Application of TSF and corticotomy

• Timing: The interval between debridement and frame application depends on infection severity, soft tissue healing, and overall patient condition. Stage 2 commences only after soft tissue recovery and appropriate infection treatment, although no formal guidelines exist.

• Frame application: A fine-wire frame is applied. In unifocal corticotomies, bayonet tip olive-wires with two rings may be used, whereas in bifocal corticotomies, Schanz screws may also be used for greater stability and to prevent apex anterior deformity. Accurate frame mounting in the anterior-posterior and lateral views prevents malalignment during bone transport (Fig. 3). Docking site alignment is corrected postoperatively using the frame guided by TSF software. This reduces operating time and radiation dosage for patients and surgeons.

• Corticotomy: To facilitate bone transport, one or two percutaneous corticotomies are performed using the De Bastiani technique. These are not necessarily restricted to the metaphyseal area (Fig. 3).^7–9

• Bone transport: Distraction osteogenesis begins at one millimetre per day for a single corticotomy, and at one and two millimetres per day for double corticotomies—¼ mm 4 times per day at the near corticotomy site and ½ mm 4 times per day near the docking site—provided that the rings for both segments are on the same threaded bar (Fig. 4). We must ensure that each corticotomy progresses at least ¼ mm four times per day in any configuration of the frame. This gradual process forms new bone while advancing the segment. Patients are reviewed fortnightly with radiographs; alignment for the docking site is refined as needed via updated SMART TSF prescription software.¹⁰ Adjustments are made daily by the patient (Fig. 5).

• Docking site: Upon docking, we avoid bone end freshening, grafts, or implants. In cases of non-union or post-frame-removal fracture, we utilise intramedullary tibial nailing or retrograde tibiotalocalcaneal nailing, based on the docking site location (Fig. 6).

• Frame removal: The TSF remains until bone healing is confirmed by computed tomography, typically 4–6 months post-transport. Full weight-bearing and early mobilisation are encouraged to support regeneration and recovery.

Fig. 4.

Visual presentation of unifocal and bifocal corticotomy approaches using a fine wire frame for bone transport. The unifocal approach involves the use of telescopic struts to facilitate movement of the middle bone segment distally along threaded bars. In the bifocal approach, two middle segments are created. The distal bone segment is transported at twice the rate as the proximal segment to allow increased bone growth between these segments providing movement of each corticotomy ¼ mm four times per day. ¾ Rings are also known as ‘C-rings’ and are used proximally to facilitate full or near full flexion of the knee and distally to facilitate full or near full dorsiflexion of the ankle. Schematic created using GoodNotes 6 software¹¹

Figs 5A to E.

X-rays one day postoperative after Taylor-spatial frame application for frame prescription. (A) Anteroposterior view of the right distal lower leg; (B) Anteroposterior view of the right proximal lower leg; (C) Lateral view of the right lower leg shaft segment; (D) Lateral view of the right proximal lower leg; (E) Lateral view of the right distal lower leg

Figs 6A to G.

X-rays and photographic imaging 6 months post-TSF application after bone transport with the bifocal corticotomy approach was completed. (A) Anteroposterior view of the right distal and midshaft sides of the lower leg; (B) Anteroposterior view of the right distal and ankle joints of the right distal lower leg showing the completed docking procedure; (C) Anteroposterior view of the right proximal lower leg showing the bone regenerate of the proximal callus distraction; (D) Lateral view of the right proximal lower leg showing the bone regenerate of the proximal and distal callus distraction; (E) Lateral view of the right distal lower leg and shaft showing the bone regenerate of the distal callus distraction and docking site; (F) Lateral photographic view of the right lower leg; (G) Anterior photographic view of the right lower leg

Discussion

The benefit of TSF-guided bone transport over conventional surgical methods such as intramedullary nailing or simpler circular external frames lies in its minimal invasiveness and high-precision deformity correction. Taylor spatial frame-assisted bone transport and multiplanar deformity correction through software-guided post-operative strut adjustments additionally reduce the need for additional operative frame modifications and adjustments, as seen more commonly with conventional frames. However, alternative surgical methods may be more appropriate in smaller bone defects, closed fractures or fractures with minimal deformity. Risks and benefits need to be assessed on an individual basis.

Comprehensive pre-operative planning is needed, utilising X-ray, computed tomography (CT) and MRI to assess bone loss, infection extent and soft-tissue viability. Additionally, close collaboration with plastic surgeons and microbiologists is necessary for successful outcomes. Due to the infection risk in open fractures, a two-step approach is crucial to ensure aggressive and adequate management of infected-contaminated bone and soft tissue, before placement of any long-term surgical hardware. Minimal interim external fixation is applied away from the site of injury, if possible. Beyond aggressive initial debridement, plastic surgeon expertise is needed to ensure viable soft tissue coverage, which will provide a safe and favourable environment for bone healing.¹²

Aforementioned pre-operative planning is key to ensuring accurate frame placement; hence, further fluoroscopy is used intraoperatively to facilitate precise positioning of the frame construct and avoid malalignment. Patients are encouraged to weight-bear throughout the bone transport phase to aid bone regeneration and functional recovery.¹³ However, pain and discomfort can impair this; hence, adequate analgesia is critical not only to improve functional outcomes but also to reduce the psychosocial impact of the prolonged treatment phase, which can range from 12 to 18 months.¹⁴ Additionally, patients must be educated on pin-site hygiene adherence and on identifying signs of infection. Potential post-treatment complications may include residual stiffness or minor limb-length discrepancy.

Technical Pitfalls and Limitations

Relevant surgical expertise is necessary to achieve accurate frame mounting. Inaccurate placement can compromise the bone transport capability of the frame and may require a return to theatres for frame adjustments. Crucially, this treatment approach comes with a significant patient burden, necessitating daily frame adjustments, adequate pin-site care, engagement with follow-up services and tolerance of a significant psychosocial burden. Therefore, patient selection is key and requires individuals with high compliance, engagement and resilience. Regular follow-up and imaging are needed to ensure accurate deformity correction, adequate pain control and management of pin-site infection. Non-compliance can compromise alignment, union or may even necessitate revision surgical intervention.

Conclusion

We present a two-staged approach for the management of open segmental tibial fractures. Stage 1 involves bone and tissue resection with soft tissue coverage and interim external fixation, followed by culture-guided antibiotic treatment and infection eradication. Following this, a TSF is applied that allows high-precision, software-guided bone transport of bone segments created by uni- or bifocal corticotomies, at a rate of 1–2 mm/day. This approach is particularly useful in large tibial bone defects, further complicated by significant deformity and soft tissue compromise. It requires meticulous surgical planning, multidisciplinary collaboration and careful patient selection.

Clinical Significance

This report offers a detailed technical reference and video guide for surgeons performing TSF-assisted bone transport in complex tibial reconstruction. It discusses intricacies of the procedure, including frame configuration, corticotomy approach, postoperative adjustment protocols and indications and limitations of the treatment approach.

Limitations of Study

This manuscript is intended as a technical report only and does not present a formal clinical outcomes analysis. Any unsupported clinical statements made are based on observations and perceptions and may not have been statistically verified.

Ethical Approval

This is a technical report describing a surgical technique and therefore no ethical approval was required.

Informed Consent

Written informed patient consent was obtained for medical photography/videography and publication of these in this report.

AI Disclosure

Language tools were used to improve readability and grammar in a few occurrences.

Acknowledgements

The authors would like to acknowledge Christopher De Carvalho, who kindly narrated the demonstration video.

Authors' Contributions

MK conceived and supervised the project. TV and JM collected relevant images and wrote the first draft of the surgical description. SI revised and adapted the manuscript to journal requirements. SI edited and scripted the complementary video. All authors reviewed and approved the final manuscript before submission.

Supplementary Material

The supplementary video is available on its journal website https://www.stlrjournal.com/¹⁵

Orcid

Sander V Ianniello https://orcid.org/0009-0003-6898-8844

Thylane E Vancastell https://orcid.org/0009-0004-4426-3205

Joseph Muscat https://orcid.org/0000-0002-6954-9937

Matija Krkovic https://orcid.org/0000-0003-2172-2849

Data Availability

No datasets were involved or analysed. Any further information not included in the above manuscript can be shared on request.