The treatment of bone loss resulting from acute trauma has traditionally been a complex surgical problem. Numerous procedures have been devised to reconstitute bone stock, obtain fracture union, and provide a stable functional limb. Traditional internal bone transport has been used successfully for bony reconstruction for both acute and reconstructive bone loss. Potential complications are primarily related to the complexity of the external device, prolonged time in the frame, and nonunion of the docking and regenerate segments. Recent advances in fixator and pin design have reduced the complexity of these devices as well as the incidence of pin- and frame-related complications. Gradual shortening, rapid distraction using autodistractors, transporting over intramedullary devices, and using orthobiologic and adjuvant techniques to assist in the consolidation of regenerate and docking sites are now being combined to decrease the morbidity and excessive frame time required to complete these reconstructions.