Evidence Based Medicine in Spine Surgery

STUDY DESIGN: A review of literature regarding evidence-based medicine in spinal surgery. OBJECTIVES: To understand the philosophy of evidence-based medicine (EBM) in order to support clinical decision making. SUMMARY OF LITERATURE REVIEW: Evidence-based medicine is a commonplace phrase representing the hallmark of excellence in clinical practice. However, there has been misunderstanding and indiscriminate use of the concept of EBM in clinical practice. It is necessary to understand true philosophy of EBM. MATERIALS AND METHODS: Narrative and review of the literature. RESULTS: EBM is not for research to supplant individual clinical experience and the patients' informed preference but to integrate these factors with the best available research. CONCLUSIONS: Treatment recommendations are no longer based on level of evidence, but also the risk benefit ratio and cost effectiveness.

Reliability of Triggered EMG for Prediction of Safety during Pedicle Screw Placement in Adolescent Idiopathic Scoliosis Surgery

STUDY DESIGN: We performed a prospective study to evaluate the reliability of using triggered electromyography (EMG) for predicting pedicle wall breakthrough during the placement of pedicle screw in adolescent idiopathic scoliosis surgery. PURPOSE: We wanted to correlate pedicle wall breakthrough with the triggered EMG threshold of stimulation and the postoperative computed tomography (CT) findings. OVERVIEW OF LITERATURE: Pedicle wall breakthrough has been reported to be difficult to evaluate by radiographs. Triggered EMG had been found to be a more sensitive test to detect this breakthrough. METHODS: Seven patients who underwent the insertion of 103 pedicle screws were evaluated. The triggered EMG activity was recorded from several muscles depending on the level of screw placement. The postoperative CT scans were read by a spine surgeon who was a senior fellow in orthopedics, and a musculoskeletal radiologist. RESULTS: The mean age at surgery was 12.6 years (range, 11 to 17 years). The preoperative mean Cobb angle was 54.7degrees (range, 45 to 65degrees). There were 80 thoracic screws and 23 lumbar screws. All the screws had stimulation thresholds of > or = 6 mA, except 3 screws with the stimulation threshold of or = 6 mA were safe, with 90.3% reliability, as was assessed on the postoperative CT scans.

Traumatic Atlantoaxial Unifacetal Joint Dislocation Associated with Fractures of Ipsilateral C2 Body and Contralateral Pars / 대한정형외과학회잡지

The traumatic C1-C2 unifacetal joint dislocation associated with oblique fractures of the C2 body and arch is a rare injury that can be effectively treated with gentle closed reduction under fluoroscopic guidance followed by halo vest immobilization. To our knowledge, however, there are only a few reported cases of this injury. Recognition of associated conditions including vertebral artery compromise, concomitant cervical spine fractures, and life-threatening injuries is paramount to the successful treatment of these patients. A 29-year-old patient, who presented a unifacetal dislocation at C1-C2 with associated oblique fractures of the C2 body and arch, is reported. Closed reduction with Gardner-Wells tong and halo vest application was performed. After 3 months of application of halo vest, the fractures of C2 body and arch had the complete union and the C1-2 dislocation had the good reduction. He had no pain and discomfort in his neck for about 2 years after halo vest removal.

The Long Term Efficacy of Microdebrider Assisted versus Coblation Assisted Inferior Turbinoplasty / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The study aimed to evaluate the long term efficacy of micro-debrider assisted inferior turbinoplasty (MAIT) compared to coblation assisted inferior turbinoplasty (CAIT) for hypertrophic inferior turbinates. SUBJECTS AND METHOD: From January 2008 to December 2008 inclusively, 96 patients with persistent hypertrophic inferior turbinates mucosa refractory to medical therapy were enrolled into this study. All patients were suffering from nasal obstruction and related symptoms. Overall, 56 patients were treated with microdebrider assisted inferior turbinoplasty (MAIT group) and 40 patients were treated with coblation assisted inferior turbinoplasty (CAIT group). Postoperative changes in degree of nasal obstruction, sneezing, rhinorrhea, minimal cross sectional area (MCA), and nasal volume from the nostril to 7 cm posteriorly (V7), operation time, duration of crust formation, intraoperative bleeding and delayed bleeding were compared between the two surgical methods prospectively in the 1st and 6 months, and in the 1st and 2nd years after the procedure. Also patient's satisfaction with procedure was evaluated. RESULTS: The nasal obstruction and related nasal symptoms improved significantly in MAIT group and persisted within the periods of 2 years after surgery, while in CAIT group the significant improvements took place in the 1st and 6th months after surgery but no significant improvements from 1 to 2 years after were noted. Nasal patency (MCA and V7) also showed more improvement and persistence in MAIT group than CAIT group. There were no significant differences in operation time and intraoperative bleeding and delayed bleeding but the duration of crust formation was significantly shorter in MAIT group. And patient satisfaction in the MAIT group was higher than that in the CAIT group. CONCLUSION: From the analysis of this study, it can be said that MAIT is more effective and satisfactory for the long term relief of nasal obstruction, related nasal symptoms and reduction of hypertrophic inferior turbinate mucosa than CAIT.

Spondylodiscitis with Epidural Abscess Caused by Klebsiella pneumoniae / 대한정형외과학회잡지

Spondylodiscitis is very rare complication caused by Klebsiella pneumoniae. Among those, few cases of spondylodiscitis concomitant with epidural abscess due to Klebsiella pneumoniae have been reported. We present a case of lumbar pyogenic spondylodiscitis with epidural abscess caused by Klebsiella pneumoniae that successfully treated with administration of cefotaxime, surgical drainage and intermittent closed continuous saline irrigation.

Staged Minimally Invasive Plate Osteosynthesis of Distal Tibial Fractures

PURPOSE: To assess the result of staged minimally invasive plate osteosynthesis (MIPO) for distal tibial fracture with an open wound or injured soft tissue. MATERIALS AND METHODS: In 20 patients (mean age, 47.8 year-old) with distal tibial fractures, there were 4 type A fractures and 16 type C fractures based on the AO classification system. Eight of the 20 patients had open fractures. MIPO was performed on average 23.9 days after bridging external fixation. At the final follow-up, we assessed the radiological results of bone union and alignment. Functional results were also evaluated by measuring the degrees of ankle motion and the American Orthopedic Foot & Ankle Society (AOFAS) scores. RESULTS: Seventeen of 20 cases (85%) achieved primary union at an average of 21.3 weeks. There were 3 cases of nonunion requiring a bone graft. The mean AOFAS score was 88.5 (range, 67~92) and the average range of ankle motion was 49.2degrees (plantarflexion: 37.4degrees, dorsiflexion: 11.8degrees). Complication included 2 cases of minor mal-alignment, 1 case of claw toe and 1 case of peroneal neuropathy. Patients over the age of 60 had lower functional results. Additional factors did not affect the final results. CONCLUSION: Staged MIPO may achieve satisfactory results in distal tibial fractures with soft tissue compromise, decreasing deep infections and soft tissue complications.

Crescent Fracture-dislocation of Sacroiliac Joint: Affecting Factors of Operative Results

PURPOSE: To assess the affecting factors of results after the operation of Crescent fracture-dislocation in sacro-iliac joint. MATERIALS AND METHODS: In 19 patients (mean age, 47.4 year-old) of open reduction and internal fixation for Crescent fracture-dislocation, there were seven type I, 9 type II, and 3 type III fractures according to Day's classification. We assessed affecting factors of radiological and functional results, such as patients' ages, surgical approaches, the fixation extent of pelvic ring, and fracture patterns. RESULTS: Seventeen of 19 cases united at 14.5 weeks in average, and 2 non-unions occurred with the fixation failure of posterior ring. Satisfactory results were 14 and 15 in radiological and functional evaluation, respectively. In complications, three cases of leg length discrepancy were from an imperfect reduction and two fixation failures. Surgical approach did not show any difference of results, but all cases of unsatisfactory reduction occurred from posterior ring fixation through the anterior approach. Fixation of both rings seemed to have satisfactory results, comparing to posterior ring only. Older patients over 60 year-old had more complications and a tendency to show an unsatisfactory result. CONCLUSION: In operative treatment of Crescent fracture-dislocation of sacro-iliac joint, it is better to fix both anterior and posterior rings. But, caution is needed to prevent complications in old-aged patients.

Staged Minimally Invasive Plate Osteosynthesis of Proximal Tibial Fracture

PURPOSE: To assess the results of staged MIPO (Minimally Invasive Plate Osteosynthesis) for proximal tibial fractures with compromised soft tissue. MATERIALS AND METHODS: Eighteen proximal tibial fractures (AO 41:9 cases, AO 42:9 cases) included this study. Ten were open fractures. After temporary external fixation until soft tissue healed (mean 27.3 days), MIPO was performed secondarily without bone graft. We assessed the bony union and knee function, and affecting factors of the results were investigated. RESULTS: All fractures united at 20 weeks (range, 11~32) except 1 case. Mean range of knee flexion was 134.4degrees and mean IOWA knee score was 89.1. There were 2 superficial and 2 delayed deep infections from open fractures (grade II:1 case, grade III:3 cases), although they healed after implant removal. Open fractures seem to influence the infection rate. Otherwise, there was no related factor affecting the results. CONCLUSION: MIPO after temporary external fixation can provide favorable results in proximal tibial fractures with soft tissue injuries, but attention of delayed infection should be paid in open fractures.

Bone Transport Over the Intramedullary Nail for Defects of Long Bone

PURPOSE: To evaluate the results of bone transport using external fixator over an intramedullary nail for defects of long bone. MATERIALS AND METHODS: We treated 14 cases of bone defect after chronic osteomyelitis or trauma of tibia (12 cases) and femur (2 cases) using this method. The mean age of index procedure was 46.9 years, and all of them had follow-up study for a mean of 3 years. After the corticotomy and insertion of intramedullary nail, bone transport was done by external fixators. Then, the segment was moved and bone graft was done at docking site. RESULTS: The mean transported amount was 5.8 cm, and the external fixator was removed after 141 days. The mean external fixation index was 25.6 days/cm. Primary union of distraction and docking site was achieved in all, but one had failure in union of docking site. According to the Mekhail's functional criteria, there were 5 excellent, 6 good, and 3 fair results. Among 15 complications, there were 2 major complications with residual sequelae, and they were 1 recurred osteomyelitis and 1 flexion contracture of knee. CONCLUSION: Bone transport using external fixator over an intramedullary nail, can successfully solve defects of long bone. Since this method can remove external fixators earlier than the conventional method, it has fewer complications and makes patients to return to daily life earlier.

Protective effects of fustin, a flavonoid from Rhus verniciflua tokes, on 6-hydroxydopamine-induced neuronal cell death

6-Hydroxydopamine (6-OHDA) is a neurotoxin and is commonly used to generate experimental models of Parkinson's disease (PD). In this study, we investigated the signaling molecules involved in the 6-OHDA-induced cell death using a neuronal catecholaminergic cell line (SK-N-SH cells), and the protective effect of fustin, a flavonoid from Rhus verniciflua Stokes, on 6-OHDA-induced neuronal death. 6-OHDA significantly increased levels of reactive oxygen species (ROS), intracellular Ca2+ ([Ca2+](i)), and p38 phosphorylation. In addition, this ROS increase by 6-OHDA was reduced by pretreatment with N-acetylcysteine (NAC), a free radical scavenger, but not by bis-(o-aminophenoxy)-ethane-N,N,N,N-tetraacetic acid (BAPTA), a Ca2+ chelator. However, the [Ca2+](i) increase induced by 6-OHDA was suppressed by NAC. Moreover, pretreatment with NAC or BAPTA significantly prevented the 6-OHDA-induced increases in p38 phosphorylation, Bax/Bcl-2 ratio, and caspase-3 activity. Although 6-OHDA-increased phosphorylation of p38 was prevented by NAC or BAPTA, inhibition of p38 by SB203580 did not suppress ROS, Bax/Bcl-2 ratio, or caspase-3 activity increases, and only partially prevented 6-OHDA-induced cell death, thus demonstrating that p38 activation is a component of a signaling pathway leading to the initiation of 6-OHDA-induced cell death, which acts in parallel with an ROS-Ca2+ -Bcl-2-caspase-3 pathway. Moreover, fustin not only suppressed 6-OHDA-induced cell death in a concentration-dependent manner but also blocked 6-OHDA-induced increases in ROS, [Ca2+](i), Bax/Bcl-2 ratio, caspase-3 activity, and p38 phosphorylation. These results suggest that fustin exerts neuroprotection against 6-OHDA-induced cell death.

Comparison of Operative Methods between Retrograde and Antegrade Nailing for Ipsilateral Femoral Shaft and Neck Fracture

PURPOSE: To compare retrospectively the antegrade and retrograde nailing in the management of ipsilateral femoral neck and shaft fractures. MATERIALS AND METHODS: Thirty-two patients (thirty-three injuries) were included in this study. Mean age of patients was 38 years-old in the antegrade nailing group (16 injuries) and 44 years-old in the retrograde nailing group (17 injuries). We compared the union of fractures and complications between two groups, and investigated the influencing factors. RESULTS: Femoral shaft fracture was united in 10 cases (63%) of antegrade group and 12 cases (71%) of retrograde group, at 28.2 and 27.3 weeks respectively. Nonunion was more prevalent in Winquist-Hansen III and IV (5 in antegrade nailing, 3 in retrograde nailing) than I and II. Femoral neck fracture was united with 1 case of nonunion in each group. Nonunion developed from Garden stage IV, but fractures of Garden stage I and II united regardless of methods. CONCLUSION: In ipsilateral femoral neck and shaft fractures, the kinds of methods did not affect the results of shaft fractures. Minimally displaced neck fractures also were not influenced by kinds of methods, but retrograde nailing may have a benefit in fixing the displaced neck fractures

Anterior Plating and Ilio-sacral Screwing for Unstable Pelvic Injury / 대한정형외과학회잡지

PURPOSE: To evaluate the effectiveness of iliosacral screw fixation with anterior plating in the management of an unstable pelvic ring injury. MATERIALS AND METHODS: Nineteen patients with an unstable pelvic ring injury were enrolled in this retrospective study. All patients were followed up for at least 1 year. The mean age of the patients was 43 years. According to the AO-OTA classification, there were five B2 injuries, 11 C1 injuries, and 3 C2 injuries. After anterior fixation by plating, ilio-sacral screw fixation was performed percutaneously under the C-arm guide. RESULTS: All cases united except for 1 case of nonunion at the pubic ramus. The radiology results showed 9, 7, 2 and 1 case of anatomic, nearly anatomic, moderate and poor reduction, respectively. Sixteen out of 19 patients had a good or excellent functional result. Two moderate and one poor result were from an unsatisfactory reduction in a type C injury with the residual neurological signs. Screw misplacement with neurological compromise occurred in one patient but there were no adverse sequelae after its removal. Regarding the complications, there were two cases of screw loosening, two cases of anterior metal failures, and 1 case of a deep infection. CONCLUSION: Percutaneous ilio-sacral screwing with anterior plating may be a useful method for treating unstable pelvic ring injuries, and the reduction quality and neurological signs are important.

Minimally Invasive Plate Osteosynthesis to Prevent or Treat the Deformity after Distraction Osteogenesis / 대한정형외과학회잡지

PURPOSE: To determine the efficacy of minimally invasive plate osteosynthesis (MIPO) for distraction callus after a lengthening procedure with an external fixator. MATERIALS AND METHODS: Distraction osteogenesis were performed using an external fixator for growth arrest (7 cases), congenital pseudoarthrosis of tibia (2 cases), and congenital leg length discrepancy (2 cases). MIPO was performed using a locking compression plate over the distraction callus. The mean age of the index procedure was 11 years, and mean amount of distraction was 5.4 cm. Eight were treated earlier to remove the external fixator after achieving of the target length, and 3 were treated as a salvage operation of fractures after removal. RESULTS: In all patients, the distraction callus healed with its length or correction into the original alignment maintained. The mean external fixation index was 34.3 days/cm and the mean healing index was 52.6 days/cm. In 8 patients with the early removal of the external fixator, the mean external fixation index was 26.9 days/cm. No patient developed a deep infection or implant failure. All patients recovered their preoperative joint motion and were satisfied with their function. CONCLUSION: MIPO can prevent or correct a deformity after distraction osteogenesis, and allow patients to return to their daily life earlier.

Retrograde Intramedullary Nailing for the Treatment of Ipsilateral Femoral Shaft and Neck Fracture / 대한정형외과학회잡지

PURPOSE: To evaluate the results of the operative method for ipsilateral femoral shaft and neck fractures using retrograde nailing technique. MATERIALS AND METHODS: Seventeen fractures (sixteen patients), followed-up more than 1 year, were included in this study. There were 14 men and 2 women, and the mean age was 44 years-old. According to the Winquist-Hansen classification, type II was most common with 11 cases. In femoral neck fractures, type B was most common with 13 cases according to AO-OTA classification and 6 of them were type II in Garden stage. After retrograde nailing of femoral shaft fractures, neck fractures were fixed by cannulated screw or dynamic hip screw. RESULTS: The average time for union of shaft fractures was 27.3 (14-60) weeks. Nonunion occurred in five patients, who required bone grafts or changes of fixation. The average time for union of neck fractures was 11 (8-12) weeks. All united, except for one case of nonunion with avascuar necrosis, which was a Garden stage IV fracture. Functional results using Friedman-Wyman criteria were good in 16 cases, and fair in one. The only fair result was nonunion of the femoral neck, which had the joint arthroplasty. CONCLUSION: Although the union rate of femoral shaft must be improved, retrograde nailing can provide an easy fixation and a favorable result for ipsilateral femoral neck fractures.

Results of Recurrent Patellar Instability after Trauma According to Anatomical Predisposing Factors

PURPOSE: We analyzed the results of lateral retinacular release(LRR) and proximal realignment for recurrent patellar instability after trauma according to the anatomical predisposing factors. MATERIALS AND METHODS: Twelve patients of fifteen cases of recurrent patellar instability had been evaluated. Clinical assessment were performed by Q-angle, apprehension test, passive patellar tilt test and general joint laxity. The anatomical predisposing factors assessed by plain radiographs included patella alta, sulcus angle, femoral trochlear dysplasia, genu valgum and patellar dysplasia. Clinical results were assessed by Kujala scoring system. Radiographic results were assessed by congruence angle. The results were analyzed according to the predisposing factors. RESULTS: Patella alta was observed in eight, increased sulcus angle in six, trochlear dysplasia in twelve, genu valgum in five and patella dysplasia in four cases. The result of treatment (Kujala score / congruence angle) was 85.8 / 9.7degrees in group A(predisposing factors > or = 3) and 91.4 / -5.3degrees in group B (predisposing factors<3)(p=0.036). We had 4 cases of recurrence after operation and genu valgum was related with recurrence rate. CONCLUSION: The clinical results of LRR and proximal realignment for recurrent patellar instability developed after trauma were worse in cases with more anatomical predisposing factors.

Factors Influencing the Result of Transverse Acetabular Fractures / 대한정형외과학회잡지

PURPOSE: To review the results and factors affecting the surgical treatment of transverse acetabular fractures. MATERIALS AND METHODS: Among 15 cases of transverse fractures with an average follow-up period of 43 months (mean age, 46.6 years), there were 8 cases with and 7 cases without posterior wall fractures. Seven cases included those with a comminution of the weight-bearing dome. The post-operative radiographic results were evaluated using Matta's criteria. The final clinical results were evaluated using a modified Merle d'Aubigne scoring system. RESULTS: All the fractures united. The average time for fracture healing was 17.5 weeks. The post-operative radiology results revealed 6 cases with an anatomic reduction, 5 cases with an imperfect reduction, and 4 cases with a poor reduction. The clinical results showed nine cases with satisfactory results but 6 cases with unsatisfactory results. Regarding complications, there were 4 cases with traumatic osteoarthritis and 3 cases with heterotropic ossification. The cases of an anatomic reduction showed a higher rate of satisfactory results. The comminution of the transverse fracture appeared to have an adverse influence on the radiological results after surgery, and also appeared to correlate with the development of traumatic arthritis. CONCLUSION: Transverse acetabular fractures, if not reduced anatomically, may have a tendency toward traumatic osteoarthritis and a poor clinical outcome. Comminution of the dome may produce a poor outcome.

Minimally Invasive Percutaneous Plating of Pediatric Femoral Fractures / 대한정형외과학회잡지

PURPOSE: To determine the efficacy of percutaneous plating for pediatric femoral fractures. MATERIALS AND METHODS: Fourteen children (mean age, 9.1 years-old) with a femoral fracture were treated with minimally invasive percutaneous plating. After a temporary reduction by manual traction or flexible nailing, a plate was inserted into the submuscular plane through proximal or distal incisions of 2-3 cm. Screws were then fixed with the control of the fracture alignment under fluoroscopic guidance. All procedures were carried out without opening the fracture site. The locations of the fracture are as follows: 10 in the middle, 2 in the subtrochanteric, 1 in the proximal, and 1 in the distal area. Seven had a comminution in the fracture, and nine had associated injuries or fractures. According to Flynns criteria, the patients were evaluated after a minimum of 1 year (mean, 2.1 years). RESULTS: All the fractures united without the need for a bone graft. The mean radiographic healing time was 11.1 weeks (range, 1014 weeks). No residual radiographic frontal or sagittal plane angulation >10 or a leg length discrepancy >5 mm was observed in any patient. No patient showed any limitation in the joint, limping, or implant related problems. All the patients showed excellent final results. CONCLUSION: Minimally invasive percutaneous plating is a safe and acceptable surgical option for the treatment of pediatric femoral fractures.

A Biomechanical Advantage of the Lengthening with an External Fixator Over an Intramedullary Nail: An Experimental Study in Saw Bones and Cadeveric Bones

PURPOSE: To know biomechanical differences in methods of limb lengthening between using monolateral external fixator and using external fixator over an intramedullary nail. MATERIALS AND METHODS: In acryl rods, saw-bone, and cadeveric bone, we created two lengthening models of using monolateral external fixator and using external fixator over an intramedullary nail. The axial compression test was done on the site of osteotomy for lengthening. To fix the models, half pins of 5 mm in diameter and nails of 9 mm in diameter were used. Using MTS (Material Test System) machine, we evaluated the differences of axial stiffness according to the presence of an intramedullary nail or the numbers of half-pins which were fixed at each side of osteotomy. RESULTS: Lengthening over an intramedullary nail, comparing to monolateral external fixator only, increased the axial stiffness by 1.1~1.2 times in acryl rods, 1.2~1.6 times in saw bones, and 15.6~15.9 times in cadeveric bones when the same numbers of half-pins were used. In saw bone and cadaveric bone, the group of two half pins in lengthening over an intramedullary nail was stiffer than the group of three pins in lengthening with monolateral external fixator. CONCLUSION: In the distraction of the limb, the addition of an intramedullary nail may increase the axial stiffness of the frame of monolateral external fixator. In lengthening over an intramedullary nail, it is enough to distract the bone with fixing two half pins at each sides of osteotomy.

Double Plating of Proximal Tibial Fractures Using Minimally Invasive Percutaneous Osteosynthesis Technique

OBJECTIVES: To evaluate the results and its efficacy of double plating for proximal tibial fractures using minimally invasive percutaneous osteosynthesis (MIPO) technique. MATERIAL & METHODS: Twenty-three fractures, followed-up more than 1 year, were included in this retrospective study. There were 18 men and 5 women, and the mean age was 53.5 years-old. According to the AO-OTA classification, five were 41A, 13 were 41C, and 5 were 42. There were four open fractures (grade I- three, grade III A-one case). The plates were fixed on the medial and lateral sides of tibia with MIPO technique. Functional and radiographic results were evaluated by the modified Rasmussen system. RESULTS: All fractures healed without bone graft, and the mean period for fracture healing was 19.3 weeks (range, 10~32 weeks). All other patients had excellent or good clinical or radiological results, except for two patients of a fair clinical result after a combined injury. Complications included one case of shortening (1 cm) and two cases of mal-alignments (varus less than 10 degrees). There was one case of superficial infection, but no patient showed deep infection. CONCLUSION: Double plating using MIPO technique can provide favorable results in the treatment of proximal tibial fractures.

Internal Bone Transport in the Management of Tibial Bone Defects

PURPOSE: To retrospectively review the results of internal bone transport in the management of tibial bone defect using ilizarov fixator. MATERIALS AND METHODS: We treated 39 cases of tibial bone defect (16 of traumatic bone loss, 23 after treatment of osteomyelitis). The mean age of index procedure was 33.8 years (range, 13~66 years), and all of them had follow-up study for a mean of 3.5 years (range, 1.6~8 years). The mean transported amount was 6.3 cm (range, 2.7~20 cm), and the external fixator was removed after 345 days (range, 120~700 days). The mean external fixation index was 60.3 days/cm (range, 13.1~121.3 days/cm). RESULTS: Primary union of distraction and docking site was achieved in all, but two patients had failure in union of docking site. Functional results showed 6 excellent, 19 good, 10 fair, and 4 fair. The patients under age 20 showed better functional outcomes than the others. Among 73 complications (incidence, 1.87 cases/ patient), 27 of major complications with residual sequelae occurred in 20 patients. The residual sequelae were more common in the patients who had the concomitant injuries in the same leg. CONCLUSION: Internal bone transport can solve the large amount of tibial bone defect. However, the complications are not uncommon, which might be related to the concomitant injures in the same leg.