# Post-Traumatic Segmental Tibial Defects Management:
## 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, [PERSON] 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]. [PERSON] 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]. [PERSON] 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 [PERSON] 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 [PERSON] et al. [44]. The mean bone union rate for the Masquelet technique found in this review is consistent with the findings by [PERSON] et al. [44] but lower than the final union rate reported by [PERSON] 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 [PERSON] et al. [44] and [PERSON] 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. [PERSON] 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).