The state of art of the reimplantation of extruding long bone trauma. What is new? A systematic review

Traumatic extrusion of long bone segments during open fractures represents a rare but highly challenging scenario in orthopaedic trauma. The decision to reimplant a contaminated bone fragment remains controversial due to infection risk, uncertain biological viability, and the absence of standardized sterilization protocols. In particular, management becomes even more complex when large osteoarticular segments are involved. The objective of this systematic review was to critically evaluate the available evidence on long bone segment reimplantation, focusing on surgical timing, sterilization techniques, preservation strategies, and reported clinical outcomes. A structured literature search was performed in PubMed, MEDLINE, and the Cochrane Library in accordance with PRISMA principles. Studies reporting clinical cases of long bone fragment reimplantation were eligible for inclusion. Extracted variables included patient demographics, mechanism of injury, fragment size and location, decontamination method, storage protocol, timing of reimplantation, and postoperative outcomes. Only full-text articles published in indexed journals in English were considered. Fifty-five records were initially identified, and 31 studies comprising 50 patients met the inclusion criteria. The majority of cases involved young adult males sustaining high-energy trauma. The average fragment length was 11.6 cm, with most cases involving segments greater than 5 cm. Considerable heterogeneity was observed in sterilization approaches, including mechanical cleansing, chemical disinfection, autoclaving, gamma irradiation, and cryopreservation. Immediate reimplantation (within 12 hours) was reported in approximately two-thirds of cases, whereas delayed strategies were adopted in selected situations. Functional outcomes were generally described as satisfactory; however, reporting methods were inconsistent across studies. Reimplantation of extruded long bone segments may represent a limb-preserving option in carefully selected patients. Nevertheless, current evidence is limited to case reports and small series, precluding definitive recommendations regarding optimal sterilization or timing. The lack of standardized outcome measures highlights the need for collaborative multicenter investigations to establish evidence-based treatment algorithms.