In severe trauma of the lower limb, acute management needs to refer to Damage Control Orthopaedics (DCO). When additional bone, loss is encountered, surgeons face more challenging situations and decision about treatment of the bone loss is difficult. Critical size defects are those exceeding 5 cm and they cannot be treated by conventional bone grafting due to graft resorption and additional procedures needs for complete fusion. The induced membrane technique, so-called Masquelet technique, is dedicated to treat very huge bone defects up to 25 cm, using a two-stage procedure with a cement spacer insertion for six to eight weeks then filling the chamber created around by autologous cancellous morcelized bone graft. Ilizarov techniques can be used either by immediate shortening, acute shortening followed by compression-distraction techniques, or bone transport. Advantages and pitfalls include difficulty for shortening over 3 cm, length of external fixation with infection pin sites, docking site non-union, and extrusion of transferred bone due to retraction of soft tissue in the defect. Free vascularized fibula transfer is the last option for acute reconstruction for traumatic bone loss in case of femoral bone loss with a double-barreled technique or tibial defect over 12 cm. Tissue engineering will modify solutions by combining mesenchymal stem cells, specific scaffolds, and growth factors such as bone morphogenetic proteins (BMP).
