Surgical Techniques   |    
Induced Membranes—A Staged Technique of Bone-Grafting for Segmental Bone LossSurgical Technique
Keen-Wai Chong, MBBS, MRCS(Edin)MMed(Ortho)FRCS(Edin)(Ortho)1; Colin Yi-Loong Woon, MBBS, MRCS(Edin)MMed(Surg)MMed(Ortho)1; Merng-Koon Wong, MBBS, FRCS(Glasg), FAMS1
1 Department of Orthopaedic Surgery, Singapore General Hospital, 169608 Singapore. E-mail address for K.-W. Chong: keenwai@gmail.com
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DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
The original case report in which the surgical technique was presented was published in JBJS Vol. 92-A, pp. 196-201, January 2010

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2011 Mar 16;93(Supplement 1):85-91. doi: 10.2106/JBJS.J.01251
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A twenty-year-old woman was struck by an automobile, sustaining an open (Gustilo type-IIIB) diaphyseal fracture of the left tibia (AO-OTA 42-C3). There was extensive loss of the soft-tissue envelope over the medial, anterior, and posterior aspects of the leg. On admission, the wound was debrided and an external fixator was applied for temporary immobilization. Two more debridements were necessary to remove all contamination. Subsequently, the soft-tissue defect was covered with a vascularized rectus abdominis muscle flap six weeks after initial presentation. The recovery of the patient was complicated by wound infection with Klebsiella pneumoniae and Escherichia coli, for which she was treated with imipenem. Six months after the injury, she was referred to our institution for the treatment of an infected tibial nonunion. The external fixator was still in place. The muscle flap was viable, but there was persistent serous discharge from a sinus. Radiographs showed a large diaphyseal segmental bone defect in the tibia (Fig. 1). The two remaining problems were fracture site infection and a lack of skeletal continuity in an area where a severe, nearly circumferential, soft-tissue degloving injury had occurred and for which a free muscle flap had already been performed.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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