Tibial non-unions have always been extremely difficult to manage for surgeons. This problem becomes even more compounded in presence of infection and/or bone loss [[1], [2], [3], [4], [5], [6]]. In cases of Osteomyelitis, thorough debridement in the form of resection of the dead and infected bone is necessary to eradicate infection [7,8].

There are several treatment options available to manage patients who have tibial non-unions with bone defects in the presence or absence of infection [1,[9], [10], [11], [12], [13]]. These include cancellous bone grafting [4,[14], [15], [16]], Papineau open cancellous bone grafting [17], vascularized free-tissue transfers [[18], [19], [20]], and combined approaches with both microvascular tissue transfers and bone grafts [3]. Masquelet developed the induced membrane technique to enhance graft incorporation [21,22].

Distraction histogenesis [25,[28], [29], [30]] techniques and methods using external fixation for gradual correction have been a breakthrough in the options available for the treatment of tibial non-unions and associated bone defects [1,2,[9], [10], [11], [12],23,[31], [32], [33], [34], [35]]. Credit for development of this technique directly goes to a great surgeon from Russia, Dr Ilizarov [29,32], who has not only been successfully practicing this technique of limb salvage but has also trained innumerable surgeons in this technique of limb salvage around the world [1,2,15,16,[34], [35], [36]]. Regardless of the treatment option selected, the entire duration of the limb salvage is associated with many complications [4,[14], [15], [16],[23], [24], [25]]. Amputation may be considered a reasonable surgical alternative for those patients who want definitive procedure and predictable result [7,8,26,27].

The Ilizarov methods of limb salvage include both bone transport [1,4,5,7,[9], [10], [11], [12],34,[36], [37], [38], [39], [40], [41], [42], [43]] and acute shortening/lengthening [5,[7], [8], [9],36,[44], [45], [46], [47], [48]]. Bone transport is characterized by a corticotomy followed by gradual movement of bone and its surrounding tissues, from an adjacent healthy region into the region of bone loss [1,4,5,7,[9], [10], [11], [12],29,30,[36], [37], [38], [39], [40], [41], [42], [43]].

Acute shortening/lengthening is characterized by shortening of the limb through the region of the bone defect itself, and can be performed acutely, gradually, or as a combination [5,[9], [10], [11], [12],36,[44], [45], [46], [47], [48]]. The hallmark of acute shortening/ lengthening is the early contact at the bone ends [5,[9], [10], [11], [12],36,[44], [45], [46], [47], [48]]. Union occurs through compression of the bone ends followed by gradual lengthening of the involved limb. Broughton et al. showed acute shortening of a bone defect >7 cm may cause vascular insufficiency because of the kinking of vessels [49]. In most of the patients with tibial bone gap exceeding 4 cm, bone transport is recommended [1,15].

The purpose of this study is to evaluate the management of bone loss of 4to10cm in patients presenting with tibial non unions through monitored acute shortening and subsequent lengthening using Ilizarov ring fixator .