SUPPLEMENT ARTICLE Preoperative Evaluation and Optimization for Reconstruction of Segmental Bone Defects of the Tibia Philip K. McClure, MD,*† Hamza M. Alrabai, MD,†‡ and Janet D. Conway, MD† Summary: Reconstruction of segmental bone defects requires a large commitment both on the part of the patient and the physician. Investing in preoperative evaluation and optimization is the only logical way to pursue such an endeavor. Unfortunately, detailed studies regarding segmental bone defects and preoperative factors are relatively lacking owing to the relatively low incidence of the problem. Fortunately, other orthopaedic pathologies (arthritis, liga- mentous injuries about the knee) have high prevalence and consistency, allowing detailed analysis of preoperative factors. We review this literature, and that directly involving segmental bone defects when available, to guide surgeons planning segmental bone defect reconstruction. Key Words: bone defect, induced membrane, distraction osteogen- esis, bone transport, preoperative (J Orthop Trauma 2017;31:S16–S19) HOST FACTORS Reconstruction of segmental bone defects of the tibia requires technical expertise, careful operative planning, and a detailed understanding of the problem at hand. However, reconstructive efforts can easily be derailed by factors outside of the surgeon’s direct control. Dedication to maximizing patient factors in the preoperative period is of paramount importance; once the reconstructive effort has begun, the risks inherent to reconstruction cannot be undone—failure to opti- mize may lead to failure to achieve a good outcome. Potential hazards may be encountered due to previous infection, host comorbidities, poor social support, and financial considera- tions. A patient’s health, willingness to comply with surgical protocols, and ability to withstand the mental stresses are critical factors in the reconstructive process. PHYSIOLOGIC STATUS Before considering reconstructive efforts for segmental bone loss, a determination must first be made as to whether reconstruction or salvage is a viable option. Multiple decision support tools and classification schemes are available to assist in this process, and a thorough review of them is beyond the scope of this setting. 1–6 For the following discussion, the assumption has been made that local host factors intrinsic to the limb have been evaluated carefully and a decision to reconstruct has been made. Reconsideration for reconstruc- tion versus amputation may be needed in light of other sys- temic factors, both internal and external to the patient. Cierny described a classification system of osteomyelitis based on systemic factors of the host (see Table 1, Supplemental Digital Content 1, http://links.lww.com/JOT/A76). Addition- ally, the MSIS classification system has been established for use in periprosthetic infection (see Table 2, Supplemental Digital Content 2, http://links.lww.com/JOT/A77). We assume a familiarity with these classifications and explore detailed data of various comorbid conditions. Reconstruction of segmental bone defects generally requires multiple surgical interventions, and each surgical procedure is associated with risk of perioperative complica- tions. Both the induced membrane technique and distraction osteogenesis have been noted to require 5 to 6 operations to achieve the desired outcome. 7,8 As such, patients require detailed optimization of comorbid conditions to limit the rate of complications and attain an optimal outcome. The use of nicotine has been known to be a risk factor for a myriad of complications associated with orthopaedic surgery. Elevated complication rates have been reported with distraction osteogenesis, particularly focused on delayed consolidation and regenerate deformity. 9 This finding has been corroborated in multiple other studies, with a suggested mechanism of un- coupled angiogenesis and osteogenesis due to nicotine expo- sure. 10–12 The presence of this modifiable risk factor in the preoperative period should prompt careful evaluation, assistance to the patient in smoking cessation, and consideration for delay- ing surgery until successful cessation has been achieved. Accepted for publication July 14, 2017. From the *University of Utah, Salt Lake City, UT; †International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hos- pital of Baltimore, Baltimore, MD; and ‡Department of Orthopedics, King Saud University, Riyadh, Saudi Arabia. J. D. Conway is a consultant for Biomet and Cerament; receives research support from Microbion, CD Diagnostics, and Acelity; receives fellow- ship support from Biocomposites; and receives royalties from University of Florida. P. K. McClure, H. M. Alrabai, and J. D. Conway have the following institutional disclosures: The following companies supported the International Center for Limb Lengthening’s nonprofit organization, which provides financial assistance to patients: CS Medical Supply, Metro Prosthetics, and Stryker. The following organizations supported the International Center for Limb Lengthening’s annual course for ortho- pedic surgeons: Baxter, DePuy Synthes, Merete Technologies, MHE Coa- lition, NuVasive Specialized Orthopedics, Orthofix, OrthoPediatrics, Smith & Nephew, Stryker, and Zimmer Biomet. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jorthotrauma.com). Reprints: Janet D. Conway, MD, International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore 2401 West Belvedere Avenue, Baltimore, MD 21215 (e-mail: jconway@ lifebridgehealth.org). Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/BOT.0000000000000983 S16 | www.jorthotrauma.com J Orthop Trauma  Volume 31, Number 10 Supplement, October 2017 Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.