Temporary bridging external fixation in distal tibial fracture

Preoperative temporary fixation for fractures around the ankle using a simple extensible external fixator significantly improves patient comfort

BACKGROUND

The authors developed a simple extensible external fixator, which has the advantages of easy application and inexpensiveness. The present study aimed to make a comparison between this external fixator and calcaneal traction in preoperative temporary fixation for malaligned ankle fractures and pilon fractures.

METHODS

From May 2020 to February 2022, patients with malaligned ankle fractures or Rüedi-Allgöwer type 2 or 3 pilon fractures with obvious soft tissue swelling were retrospectively reviewed and divided into the calcaneal traction group and the external fixation group. The two groups of patients were matched 1:1 before making comparisons.

RESULTS

A total of 38 patients were included. Higher General Comfort Questionnaire score and lower visual analog scale score were noticed in the external fixation group during hospitalization (p < 0.05), while the operation latency time, total cost, patient satisfaction, and functional outcomes one year after surgery were not significantly different between the two groups. No wound complications were observed.

CONCLUSION

Preoperative temporary fixation for fractures around the ankle using this simple extensible external fixator significantly improves patient comfort when compared to calcaneal traction.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Comparison of temporary external and percutaneous k-wire fixations for treatment of ankle fracture-dislocations

PURPOSE

Ankle fracture-dislocations are among the most severe injuries, and the use of an external fixator as a recommended fixation method has some disadvantages. The aim of this study was to compare the clinical outcomes and complication rates of external and K-wire fixations in the treatment of ankle fracture dislocations.

METHODS

A total of 67 patients with ankle fracture-dislocations requiring temporary external or percutaneous K-wire fixation were included. The exclusion criteria were pilon fractures, open fractures, and those who required acute open reduction internal fixation (ORIF). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 10-point visual analog scale (VAS) score (range 0-10), and complications before and after the definitive surgery were recorded.

RESULTS

A significant difference between the two groups was not observed for age, sex, affected side, fracture type, smoking status, or diabetes. The average AOFAS scores were 83.2 and 83.3, the median VAS scores were 3 and 3, and the complication rates were 32.4% and 6.7% in the external and K-wire fixation groups, respectively (p = 0.010). However, skin necrosis, re-dislocation of the ankle, surgical wound infection, and posttraumatic ankle osteoarthritis frequency were not significantly different between the groups, except for pin-sites infection (p = 0.036).

CONCLUSION

Ankle fracture-dislocations using percutaneous k-wire fixation showed a low rate of complications and favorable clinical outcomes. This method could be a good alternative treatment option for ankle fracture-dislocations.

A case report of circular external fixator with low-profile mini-fragment plate fixation: A combination of two methods for a tibial pilon fracture

Tibial pilon fractures are difficult to treat. These fractures are associated with a high frequency of soft tissue complications. Therefore, two-stage surgery and less invasive surgical strategies using external fixation have been reported. The patient was a 79-year-old man. The right tibial pilon fracture was diagnosed as AO/OTA 43C3.1, Rüedi and Allgöwer type 2. He was treated with a low-profile mini-fragment plate and circular (Ilizarov type) external fixation. Herein, we report on a combination of these two methods: circular external fixator with low-profile mini-fragment plate fixation. At 18 months postoperatively, the American Orthopaedic Foot & Ankle Society Ankle-Hindfoot score was a perfect score of 100. Radiographs taken in the loading position showed no narrowing of the joint fissure. There were no soft tissue infections, no plate breakage, no bone fusion, no symptoms of plate irritation, and no need for nail extraction.

Temporary circular external fixation for spanning the traumatised ankle joint: A cohort comparison study

BACKGROUND

Temporary spanning fixation aims to provide bony stability whilst allowing access and resuscitation of the traumatised soft-tissue envelope. Conventional monolateral fixators are prone to half-pin morbidity in feet, variation in construct stability and limited weight-bearing potential. This study compares traditional delta-frame monolateral external fixators to ankle spanning circular fixators.

METHODS

Two cohorts were matched for demographics and fracture patterns. The quality of initial reduction and the maintenance of reduction until definitive surgery was assessed by two authors and categorised into four domains. Secondary measures included fixator costs, time to definitive surgery and complications.

RESULTS

Fifty-five delta-frames and 51 circular fixators were statistically matched for demographics and fracture pattern. "Excellent" and "Good" initial reduction was achieved in 50 (91%) delta-frames and 51 (100%) circular fixators (p = 0.027). Deterioration of initial reduction quality was seen in 12 (22%) delta-frames and two (4%) circular fixators (p < 0.001). Post-fixator dislocation occurred in five (9%) delta-frames and one (2%) circular fixator (p = 0.147). Median duration in spanned fixation was 11 days in both groups (p = 0.114). Three (5%) delta-frames and 13 (25%) circular fixators were used as definitive fixation. The mean implant cost was 4,307 USD for delta-frames and 3747 USD for circular fixators.

CONCLUSION

Temporary spanning circular fixation offers superior intra-operative reduction and maintenance of reduction and provides more opportunity to be used as definitive fixation. Circular fixation implants also proved to be less expensive and protected against further scheduled or unscheduled returns to theatre.

LEVEL OF EVIDENCE

IV, retrospective cohort study.

Concentrations of co-administered vancomycin and meropenem in the internal dead space of a cannulated screw and in cancellous bone adjacent to the screw - Evaluated by microdialysis in a porcine model

BACKGROUND

Cannulated screws are often used in the management of open lower extremity fractures. These fractures exhibit broad contamination profiles, necessitating empirical Gram-positive and Gram-negative antibiotic coverage. To ensure full antibiotic protection of the cannulated screw and the bone tissue, it is generally accepted that target tissue antibiotic concentrations, as a minimum, reach and remain above relevant epidemiological cut-off minimal inhibitory concentrations (T>MIC) for a sufficient amount of time.

METHODS

8 female pigs were included. Microdialysis catheters were placed in the internal dead space of a cannulated screw placed in tibial cancellous bone, in tibial cancellous bone adjacent to the screw (mean distance to the screw: 3 mm), and in cancellous bone on the contralateral tibia. Following single-dose simultaneous intravenous administrations of vancomycin (1000 mg) and meropenem (1000 mg), microdialysates and plasma were dynamically sampled over 8 h. The applied MIC targets ranged from 1 to 4 µg/mL for vancomycin and 0.125-2 µg/mL for meropenem RESULTS: For both drugs, and for all MIC targets investigated (except for the high vancomycin target: 4 µg/mL), the internal dead space of the cannulated screw had the shortest T>MIC. At the low MIC targets T>MIC ranged between 88 and 449 min across sampling sites for vancomycin (1 µg/mL), and 148-406 min for meropenem (0.125 µg/mL). For the high MIC targets, T>MIC ranged between 3 and 446 min for vancomycin (4 μg/mL) and 17-181 min for meropenem (2 μg/mL). Vancomycin displayed longer T>MIC (2 and 4 μg/mL), higher area under the concentration time curve (AUC_0-last) and peak drug concentration in the proximal tibial cancellous bone without a screw nearby. For meropenem, only the cancellous bone AUC_0-last was significantly higher on the side with no screw.

CONCLUSION

We found short T>MIC, particularly for the high MIC targets for vancomycin and meropenem, both inside the cannulated screw and in cancellous bone adjacent to the screw. The presence of a cannulated screw impaired the penetration of especially vancomycin into cancellous bone adjacent to the screw. More aggressive or different vancomycin and meropenem approaches may be considered to encompass contaminating differences and to ensure a theoretically more sufficient antibiotic protection of cannulated screws when used in the management of open lower extremity fractures.

Open versus closed pilon fractures: Comparison of management, outcomes, and complications

BACKGROUND

Despite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high complication rate and long recovery times presents a challenge for surgeons and patients. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in outcomes and complications between open and closed pilon fractures, and between patients treated by open reduction internal fixation (ORIF) or fine wire fixator (FWF) for open and closed fracture subgroups.

METHODS

This retrospective study was conducted at a major trauma centre including 135 patients over a 6-year period. Primary outcome was AOFAS score at 3, 6, and 12-months post-injury. Secondary outcomes included time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, and complications during the follow-up time. AO/OTA classification was used (43A: n = 23, 43B: n = 30, 43C: n = 82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807).

RESULTS

Higher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p = 0.003) and in 43B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively). The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. Statistically significant differences were seen in the following cases: ORIF-treated 43B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p = 0.017, respectively), ORIF-treated 43C closed fractures had shorter time to union (p = 0.005). Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (24%), superficial infection (21%). All occurred more frequently in FWF-treated patients.

CONCLUSION

Most ORIF-treated subgroups in either open or closed pilon fractures showed better primary and secondary outcomes than FWF-treated subgroups, yet few were statistically significant. Overall, our use of a two-staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.

Minimally Invasive Reduction and Fixation Techniques of Pilon Fractures Based on the Preoperative CT Findings

Tibial plafond fractures are often associated with significant articular cartilage and soft tissue damage. The presence of co-morbidities has been associated with an increased risk of surgical site complications. With improved in surgical techniques and implants, complication rates have declined; however, the overall prognosis often remains poor. The aims of this study were to evaluate the results of innovative minimally invasive reduction and fixation techniques in tibial plafond fractures based on a CT classification and to compare the difference between short and long-term outcomes. Based on preoperative CT findings, fractures were classified into varus, valgus, anterior, posterior, and neutral types. The minimally invasive reduction and fixation techniques depend on type of fracture, size and location of the intraarticular fragments, and degree of comminution of the extra-articular component. Ninety-one pilon fractures (90 patients) underwent minimally invasive reduction and fixation, of which 7 fractures (7.69%), required open reduction because of intraoperative failure to achieve anatomic reduction. Of the 84 fractures that underwent successful minimally invasive reduction and fixation reported, 35 fractures (41.7%) with excellent outcomes, 40 fractures (47.6%) with good outcomes, 6 fractures (7,1%) with fair outcomes, and 3 fractures (3.6%) had poor outcomes for the long-term American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score (follow-up ≥ 60 months). These results prove that minimally invasive treatment is an effective and durable treatment option for intra-articular pilon fractures. We encourage future clinical studies to further refine minimally invasive techniques for pilon fractures to improve outcomes.

Adding a First Metatarsal Pin to An Ankle Tubular External Fixator Does Not Reduce the Incidence of Early Reduction Loss

External fixation with a bilateral frame configuration (delta frame, DF) is a routine approach for treating ankle fractures and dislocations with severe soft tissue damage. The purpose of this study was to evaluate to what extent adding a first metatarsal fixation contributes to the stability of the fixation as evidenced by reduced frequency of early loss of reduction. A retrospective study was performed to compare the rate of early reduction loss in patients treated with a bilateral frame external fixation as part of a 2-stage treatment protocol for periarticular ankle fractures, in a level one trauma center between 2006 and 2016. The cohort was divided into 2 groups according to the frame configuration that had been used: DF only and DF with first metatarsal fixation (DF+1MT). A multivariate analysis assessing risk factors for postoperative loss of reduction was conducted. A total of 67 patients were included in the study, of which 30 underwent fixation by DF and 37 by DF+1MT. Early loss of reduction was recorded in 13 (19.4%) patients, 6 (20%) in the DF group and 7 (18.9%) in the DF+1MT group (p = .576). None of the assessed risk factors reached statistical significance. To conclude, the addition of a first metatarsal pin as an enhancement of external fixation with a delta frame configuration did not reduce the incidence of early loss of reduction. There is no evidence to support the claim that adding this pin contributes to the stability of the fixation in a clinically relevant manner.

Comparison Between the Modified External Fixation and Calcaneal Traction in Ruedi-Allgower Type II/III Pilon Fractures

Background

To compare the effect of modified external fixation and calcaneal traction in a staged management of Ruedi-Allgower type II/III tibial pilon fractures.

Material/Methods

The data of 62 patients with Ruedi-Allgower type II/III tibial pilon fractures who were treated in Liuzhou People’s hospital from January 2017 to December 2018 were extracted in this retrospective analysis. There were 32 patients in the temporary external fixation (TEF) group and 30 patients in calcaneal traction (CT) group. Outcomes, including the duration of the surgical procedure, pin track infection, degree of limb swelling, time to second-stage operation, postoperative comfort score, and visual analog scale (VAS) score, were compared.

Results

The effective rate of swelling reduction after treatment was 85% in the TEF group and 60% in the CT group; the average time to the second-stage operation was 8.34±1.29 days in the TEF group and 10.60±2.27 days in the CT group; the postoperative comfort scores were 70.1±3.2 and 61.3±3.5 in the TEF group and CT group, respectively; the postoperative VAS scores at 24 h, 48 h, and 7 days were 7.90±1.06, 4.88±0.83, 2.72±1.14 in TEF group, and 8.50±0.86, 6.27±1.36, 3.57±1.19 in CT group, respectively. There were 1 case of pin tract infection identified in the TEF group and 4 in the CT group. All differences were statistically significant (P<0.05).

Conclusions

The modified external fixation is more effective than calcaneal traction in treatment of Ruedi-Allgower type II/III tibial pilon fractures in the first-stage of combined management.

Risk factors for infection in fixation of distal tibia fractures

BACKGROUND

The aim of this study is to evaluate risk factors for infection as well as infection rates after open reduction and internal fixation for distal tibia fractures with a distal tibia locking plate and/or isolated screws.

METHODS

This is a retrospective and descriptive study based on 55 patients treated in our Major Trauma Centre from January 2009 to December 2016. All patients were classified by age, sex, open or closed fracture, injury mechanism, comorbidities, fixation and time from injury to surgery. 22 extraarticular fractures AO/OTA 43-A and 33 intraarticular (14 cases 43-B and 19 43-C) were recorded. High energy trauma was related in 27 patients, while open fractures were observed in 10 patients. Splint until surgery was applied routinely while temporary external fixation (EF) was performed in 21 patients (7 extraarticular and 14 intraarticular). Patients were treated by 5 different consultant surgeons performing isolated screws (SC) in 20% of the surgeries, antero-medial locking distal tibia plate (AM) and anterolateral (AL) were used in 47% and 33% of the patients respectively. After assessing normality and homogeneity of the subgroups, statistical contrast tests were performed.

RESULTS

Infection rate was 31.5%, mainly caused by S. aureus. We obtained a statistically significant correlation between greater age and infection rate. In the same way, a positive statistical trend between infection and AL plating was found. The use of EF followed by ORIF was not observed as a risk factor for infection compared with splint followed by internal fixation, however, the group of patients in which a splint was used, a positive relationship was found between the infection rate and shorter time until the definitive fixation. No statistically significant associations were found between extra/intraarticular fracture pattern, use of corticosteroids or open fractures and infection rate.

CONCLUSION

Greater age was a predisposing factor for infection. The use of external fixation before definitive ORIF seems to be a safe procedure regarding risk infection, and if an external fixation is not used, we recommend longer waiting time until definitive ORIF. Screw fixation or antero-medial plates, if allowed by fracture pattern, can be an option to avoid infection.

Prevention of postoperative surgical wound complications in ankle and distal tibia fractures: results of Incisional Negative Pressure Wound Therapy

BACKGROUND AND AIM OF THE WORK

complications in surgical wound healing represent the main postoperative complication in ankle and distal tibia fractures. Whereas the use of Incisional Negative Pressure Wound Therapy (INPWT) is recognized to have a role in wound complications prevention in prosthetic surgery, literature about its use in trauma surgery is scarce. The aim of this study was to compare the effectiveness of INWPT with a conventional dressing in order to prevent surgical wound complications in ankle and distal tibia fractures.

METHODS

The study population included patients over 65 years as well as patients under 65 years considered at risk for wound complications (smokers, obese, affected by diabetes), who underwent ORIF for bi/tri-malleolar ankle fractures or distal tibia (pilon) fractures. After surgery, patients were randomized to receive a conventional dressing or INPWT. Complications in surgical wound healing were classified in major (requiring surgical intervention) and minor complications.

RESULTS

65 patients were included in the study. The rate of minor and major complications between the two groups was not significantly different, although a positive trend towards a lower minor complications rate was noted in the INPWT group (12.6% vs 34.7%). No complications or complaints were reported for the INPWT device.

CONCLUSIONS

INPWT proved to be safe, well-tolerated and showed promising results in preventing surgical wound complications in ankle and distal tibia fractures.

Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how?

INTRODUCTION

In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe.

MATERIALS AND METHODS

A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty.

RESULTS

The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was ±1.38 months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C.

CONCLUSIONS

One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.

Efficacy of non-bridging external fixation in treating distal radius fractures

Objective

To investigate the efficacy of non‐bridging external fixation in treating distal radius fractures (DRF) and its effect on wrist joint function.

Methods

The medical records of 207 patients who were treated for DRF between May 2008 and April 2017 in our hospital (age, 18.0–70.0 years; 99 males and 108 females) were retrospectively analyzed. All patients had evident wrist trauma and the diagnosis of DRF was confirmed by imaging tests. A total of 101 patients received bridging external fixation (control group), whereas another 106 received non‐bridging external fixation (study group). At 12 weeks after the procedure, the treatment effect was measured using the Dienst scoring system (rating scale: ≤3 points, excellent; 4–7 points, good; 8–11 points, fair; >12 points, poor), and the wrist joint function was evaluated by Gartland and Werley classification (rating scale: 0–2 points, excellent; 3–8 points, good; 9–20 points, fair; >21 points, poor); meanwhile, the radial length, radial inclination, and palmar tilt were examined by X‐ray. Follow‐up visits were conducted once every 2 weeks for 6 months, and the incidences of complications in the two groups within 6 months after operation were recorded, including incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis.

Results

There were no differences in the sex ratio, mean age, mean injury period, Arbeitsgemeinschaft fur osteosynthesefragen classification, and cause of fracture between the two groups (all P > 0.05). In terms of the treatment effects, the study group had a higher percentage of excellent results (P < 0.001) and lower percentages of fair and poor results (P = 0.002, P = 0.001) than the control group 12 weeks after treatment, while both groups had similar percentages of good results (P = 0.109). In terms of the score of the wrist joint function, the study group had a higher proportion of excellent result than the control group 12 weeks after treatment (P = 0.029), whereas no intergroup differences in the proportion of good, fair, and poor results were observed (all P > 0.05). After follow‐up for 6 months, the incidences of incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis, as well as the total complication rate were found to be similar between the two groups (all P > 0.05).

Conclusions

Using non‐bridging external fixation for treating DRF allows some level of wrist movement during the early stage of fixation, effectively maintains the radial length, radial inclination, and palmar tilt, and achieves better outcomes than bridging external fixation.

Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures

BACKGROUND

Soft tissues (wound dehiscence, skin necrosis) and septic (wound infection, osteomyelitis) complications have been historically recognized as the most frequent complications in surgical treatment of high-energy proximal tibia fractures (PTFs). Staged management with a temporary external fixator is a commonly accepted strategy to prevent these complications. Nonetheless, there is a lack of evidence about when and how definitive external or internal definitive fixation should be chosen, and which variables are more relevant in determining soft tissues and septic complications risk. The aim of the present study is to retrospectively evaluate at midterm follow-up the results of a staged management protocol applied in a single trauma center for selective PTFs.

METHODS

The study population included 24 cases of high-energy PTFs treated with spanning external fixation followed by delayed internal fixation. Severity of soft tissues damage and fracture type, timing of definitive treatment, clinical (ROM, knee stability, WOMAC and IOWA scores) and radiographic results as well as complications were recorded.

RESULTS AND CONCLUSION

Complex fracture patterns were prevalent (AO C3 58.3%, Schatzker V-VI 79.1%), with severe soft tissues damage in 50% of cases. Mean time to definitive internal fixation was 6 days, with double-plate fixation mostly chosen. Clinical results were highly satisfying, with mean WOMAC and IOWA scores as 21.3 and 82.5, respectively. Soft tissue complication incidence was very low, with a single case of wound superficial infection (4.3%) and no cases (0%) of deep infection, skin necrosis or osteomyelitis. Staged management of high-energy PTFs leads to satisfying clinical and radiographic results with few complications in selected patients.

Two-Stage Surgery for the Malleolar Fracture-Dislocation With Severe Soft Tissue Injuries Does Not Affect the Functional Results

Soft tissue injuries associated with malleolar fracture-dislocations may increase postoperative rates of wound complication. Ankle-spanning frame plays a fundamental role in the local damage control orthopedics while gaining time for definitive surgery. The objective of this study was to evaluate the effect of a 2-stage surgery for the unstable malleolar fracture-dislocations with severe soft tissue injuries compared to a 1-stage surgery in terms of the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle and Olerud-Molander ankle scores (OMAS). We analyzed 45 patients who met our study criteria. The patients were divided into 2 groups according to staged surgeries. Demographic data of patients, comorbidities, alcohol and tobacco use, Tscherne soft tissue injury scores, the AOFAS hindfoot-ankle and OMAS, postoperative complications, total hospitalization times, waiting time between stages, and waiting time from admission to surgery times were investigated. There was a statistically significant difference between the groups in terms of the mean total hospitalization times (p = .007), waiting time from admission to surgery (p < .001), gender (p = .005), and Tscherne soft tissue injury scores (p < .001). The mean AOFAS hindfoot-ankle and OMAS of the groups did not differ statistically at a minimum of 12 months of the follow-up period (p = .094 and p = .126, respectively). A 2-stage surgery can be performed safely in the carefully selected patients with the unstable malleolar fracture-dislocations with Tscherne grades 2 and 3 soft tissue injuries, and this surgery does not affect the postoperative AOFAS hindfoot-ankle and OMAS statistically compared to a 1-stage surgery at a minimum of 12 months of the follow-up period.

External fixation of the lower extremities: Biomechanical perspective and recent innovations

The concept of supporting fractured long bones externally with mechanical fixation has been evidentially applied for over 2000 years, and since been expanded on in the mid-19th century by percutaneous bone fixation. Surgical techniques, external fixator systems, and materials have made continued progress since. The benefits of traditional external fixation have been enhanced in recent years with the introduction of hexapod-style fixators, innovative configurations, and pin modifications, among other things. It is generally agreed upon that biomechanical testing of advancements in external fixation must be inclusive of transverse or torsional loading to simulate construct behaviour in realistic scenarios. Biomechanical studies indicate that hexapod-style fixators show comparable axial stiffness to Ilizarov-style systems and improved performance under torsional and transverse forces. The addition of configuration elements to fixators, inclusion of certain carbon fibre chemical compositions, and techniques intended to augment ring thickness have also been investigated, in hopes of increasing construct stiffness under loading. Novel external fixators attempt to broaden their applications by rethinking bone mounting mechanisms and either expanding on or simplifying the implementation of 3D bone segment transport for corrective osteotomy. Older and seemingly unconventional fixation techniques are being rediscovered and evolved further in order to increase patient comfort by improving everyday usability. The development of new pin coatings can potentially enhance the pin-bone interface while lowering infection rates typically expected at thicker soft tissue envelopes. Although complication, malunion, and nonunion rates have decreased over the past 50 years, the clinical results of external fixation today can still be optimized. Unsatisfactory healing in the lower extremities has especially been reported at locations such as the distal tibia; however, advancements such as osteoinductive growth hormone treatment may provide improved results. With the current progression of technology and digitization, it is only a matter of time before 'smart', partly-autonomous external fixation systems enter the market. This review article will provide a versatile overview of biomechanically proven fixator configurations and some carefully selected innovative systems and techniques that have emerged or been established in the past two decades.

Biomechanical comparison of a novel monocortical and two common bicortical external fixation systems regarding rigidity and dynamic stability

Aim:

To biomechanically compare a monocortical single frame external fixator (Orthofix UNYCO) with two bicortical fixator systems (dual frame: Stryker Hoffmann and single frame: Synthes LEF) with respect to system rigidity and stability under cyclic loading.

Methods:

The fixator systems were assessed for axial rigidity under loads which would occur clinically during fixator application and dynamic stability (cyclic fatigue) under loads which would occur in the first week postoperatively. Tests were performed on porcine tibiae (n>5 per group) with characteristic frame configurations. Loads were applied with an electrodynamic material testing machine and pin and frame deformations were continuously monitored with a marker based motion capturing system.

Results:

The bicortical single frame fixator revealed the largest rigidity (276±55) N/mm and was 20% (p=0.116) stiffer compared to the bicortical dual frame configuration and 39% (p=0.003) stiffer compared to the monocortical system. All systems survived 4000 cycles of loading, with the smallest vertical displacement (2.44±0.54 mm) observed for the bicortical dual frame system, followed by the monocortical single frame (3±0.55 mm, p=0.85) and bicortical single frame (3.25±0.96 mm, p=0.215).

Conclusion:

The monocortical fixation system performed comparably to the bicortical systems for its intended use as a temporary treatment before a definitive fracture osteosynthesis by plating or nailing.

Complete Reduction for Pilon Fracture Can Make Complete Failure

The surgical management of distal intra-articular comminuted fracture of the tibia (pilon fracture) is difficult because complications frequently develop. The minimally invasive plate osteosynthesis technique is generally accepted for this type of fracture. In this study, complications developed after open reduction and internal fixation using multiple miniplates for accurate reduction of small fracture fragments. Therefore, when we use this technique, we need to pay attention to the development of complications such as nonunion, avascular necrosis, and osteomyelitis by the disruption of both endosteal blood supply by fracture and periosteal blood supply during approach or reduction.

Omnidirectional Internal Fixation by Double Approaches for Treating Rüedi-Allgöwer Type III Pilon Fractures

In the present study, we explored the effectiveness and complications of omnidirectional internal fixation using a double approach for treating Rüedi-Allgöwer type III pilon fractures. A retrospective analysis was performed of 19 cases of Rüedi-Allgöwer type III unilateral closed pilon fracture. With preoperative preparation and correct surgical timing, the reduction was performed using anteromedial and posterolateral approaches, and the fracture fragments were fixed by omnidirectional internal fixation. Imaging evaluation was performed using the Burwell-Charnley scoring system. The Johner-Wruhs scoring system was used to assess the functional status of the patients. A comprehensive evaluation of efficacy was performed using a 5-point Likert score. The complications were also recorded and analyzed. All patients were followed up for an average of 16.2 months. The operative incisions of 15 cases healed by primary intent and with delayed healing in 4. All patients had achieved bony union at an average of 16 weeks postoperatively. No deep infection, broken nail or withdrawn nail, exposed plate, or skin flap necrosis occurred. The Burwell-Charnley imaging evaluation showed that 14 patients had anatomic reduction of the articular surface and 5 had acceptable reduction. Using the Johner-Wruhs scoring system, the results were excellent for 8, good for 7, fair for 2, and poor for 2 patients; the combined rate of excellent and good results was 78.9%. The Likert score of efficacy self-reported by the patients was 3 to 4 points for 12 patients, 2 points for 4 patients, and 0 to 1 point for 3 patients. The Likert score of therapeutic efficacy reported by the physicians was 3 to 4 points for 10 patients, 2 points for 5 patients, and 0 to 1 point for 4 patients. Omnidirectional internal fixation using double approaches was an effective method to treat Rüedi-Allgöwer type III pilon fractures with satisfactory reduction and rigid fixation, good joint function recovery, and few complications.

Medium-Long-Term Radiographic and Clinical Outcomes after Surgical Treatment of Intra-Articular Tibial Pilon Fractures by Three Different Techniques

Introduction

The goal of this retrospective, observational, case series study was to evaluate the medium-long-term clinical and radiographic results of the three most common surgical osteosynthesis techniques used for the treatment of articular tibial pilon fractures: ORIF, MIPO, and EF.

Materials and Methods

A consecutive series of patients with articular pilon fractures who underwent surgery at our institution were enrolled in this study. Fractures were classified according to the Müller AO classification system. Overall outcomes took the following into account: radiographic quality of reduction, evaluated using Ovadia and Beals' criteria; clinical assessment, evaluated using the AOFAS questionnaire; and general health, evaluated with the SF36-v2 Health Survey.

Results

A total of 94 articular pilon fractures (34 type 43-B and 60 43-C) were evaluated with a mean follow-up of 56.34 months (range 33–101). The techniques used were ORIF, MIPO, and EF in 63 (67%), 17 (18.9%), and 14 cases (14.1%), respectively. According to Ovadia and Beals' criteria, good, fair, and poor results were reported in 61 (64.89%), 26 (27.66%), and 7 (7.45%) cases, respectively. The mean AOFAS score was 82.41 for MIPO, 79.83 for ORIF, and 50.57 for EF, respectively. Thirty-nine patients (41.49%) presented early and/or late complications.

Conclusion

Satisfactory outcomes using the three different techniques were reported. In particular, the radiographic outcomes were inversely proportional to the fracture comminutions and statistically different between internal and external osteosynthesis, but comparable between ORIF and MIPO techniques. On the other hand, the clinical outcomes were closely related to the soft tissue conditions and the anatomical reconstruction of the joint.

A new approach to local DCO in ankle fracture dislocations: external fixation with diaphyseal unicortical screws applied by local anaesthesia

PURPOSE

Ankle fracture dislocations represent a great threat for soft tissue viability and articular instability. The use of a temporary ankle bridging ExFix plays a fundamental role in the local damage control orthopaedics while waiting for definitive synthesis.

METHODS

For this prospective research, we have developed a full application protocol of innovative diaphyseal monocortical screws fixator (Unyco-Orthofix^TM) exclusively under local anaesthesia. Rigid selection criteria allowed us to collect nine patients during a period of almost 2 years. VAS score was analysed for the feasibility of the procedure, and a thorough radiologic evaluation was performed.

RESULTS

Results pointed out that the calcaneus pin insertion (VAS: 3.44) followed by the local anaesthetics injection (VAS: 3.22) was the most painful, without precluding to continue the procedure; fracture temporary stability was achieved in all the cases.

CONCLUSIONS

The procedure of monocortical diaphyseal application in bridging external fixation is comparable to the conventional transcalcaneal traction maintaining the advantage in terms of speediness, independence from anaesthetists and feasibility within few minutes from hospital admittance even in patients under anticoagulants therapy, but increasing the stability of the reduction and improving the quality of nursing (so-called portable traction).

Minimally invasive posteromedial percutaneous plate osteosynthesis for diaphyseal tibial fractures: technique description

PURPOSE

The aim of this study was to evaluate the feasibility of performing minimally-invasive plate osteosynthesis (MIPO) in tibial fractures using two posteromedial incisions, and to measure the distance between the plate and neurovascular structures.

MATERIALS AND METHODS

We performed nine dissections of specimens that were submitted to tibial MIPO with two posteromedial incisions. One locking compression plate (LCP) of 14 to 16 holes was inserted into the submuscular tunnel in a retrograde manner. Incisions were linked to evaluate the distance between neurovascular structures and the plate.

RESULTS

During the proximal incision, a blunt dissection between semitendinosus and medial gastrocnemius tendons, as well as their lateral shift, helped to protect the main local neurovascular structures. In its distal portion, the submuscular plate tunnel insertion and its direction to the proximal incision prevented direct contact and possible damage to neurovascular structures. Moreover, we obtained successful results from a patient submitted to this procedure.

CONCLUSION

Posteromedial MIPO represents a safe and attractive alternative for tibial fractures, particularly if there are damaged soft tissues in the anterior and medial side, or when access to intramedullary osteosynthesis is blocked.

Intra-articular fractures of the distal tibia: Current concepts of management

Results of the treatment of intra-articular fractures of the distal tibia have improved significantly during the last two decades.Recognition of the role of soft tissues has led to the development of a staged treatment strategy. At the first stage, joint-bridging external fixation and fibular fixation are performed. This leads to partial reduction of the distal tibial fracture and allows time for the healing of soft tissues and detailed surgical planning.Definitive open reduction and internal fixation of the tibial fracture is performed at a second stage, when the condition of the soft tissues is safe. The preferred surgical approach(es) is chosen based on the fracture morphology as determined from standard radiographic views and computed tomography.Meticulous atraumatic soft-tissue handling and the use of modern fixation techniques for the metaphyseal component such as minimally invasive plate osteosynthesis further facilitate healing. Cite this article: EFORT Open Rev 2017;2:352-361. DOI: 10.1302/2058-5241.2.150047.

Distal tibial nonunion using a contralateral anterior L-shaped locking compression plate through a posterior-lateral approach: A retrospective case series

BACKGROUND

Distal tibial nonunion is usually due to severe open distal tibial fractures with high energy injury. The best surgical treatment is not well established because of the poor soft tissue condition. We retrospectively analyzed a series of patients with distal tibial nonunion after severe open distal tibial fractures; our purpose was to introduce a treatment using a contralateral anterior L-shaped locking compression plate through a posterior-lateral approach with Iliac crest bone graft and evaluate the outcomes of patients.

METHODS

All patients with distal tibial nonunion who received a contralateral anterior L-shaped locking compression plate fixation through the posterior-lateral approach with Iliac crest bone graft by a single surgeon from 2014 to 2016 were reviewed. 9 patients met the criteria. Five of nine patients had varus deformities (range, 9-40°) and 4 patients had valgus deformities (range, 5-30°). Postoperative radiographs, Postoperative complications, limb alignment and limb functional outcome information of AOFAS ankle-hindfoot score were recorded.

RESULTS

All patients were followed up for at least 8 months (range, 8-16 months). Union was achieved in all patients after the index surgery without postoperative wound complications while one patient came up with checkrein deformity. Average time to radiographic union was 16 weeks (range, 12-24 weeks). All patients had correction to neutral alignment in both coronal and sagittal planes. The average AOFAS ankle-hindfoot score was 90 (range, 77-100) at the last follow-up of patients.

CONCLUSIONS

Using a contralateral anterior L-shaped locking compression plate fixation through a posterior-lateral approach with Iliac crest bone graft to reconstruct the distal tibial nonunion is a safe and reliable method that can successfully treat patients with poor soft tissue condition of anterior portion of leg because of its adequate exposure, both tibia and fibula rigid fixation and plenty of bone graft. We believe the application of this method resulting in a high union and low complication rate.

Standards of external fixation in prolonged applications to allow safe conversion to definitive extremity surgery: the Aachen algorithm for acute ex fix conversion

External fixation has become an important tool in orthopedic surgery. Technology has improved the design and material as well as the construct of the fixator. As most patients are converted from external fixation to definite stabilization during later clinical course, prevention of complications such as infection is of high importance. Based on the current literature, principles of temporary external fixation were summarized. We focused on minimizing the risk of infection and introduce a standardized algorithm how to proceed when converting from external to internal fixation, which also was examined for effectiveness.

Pin-site care: can we reduce the incidence of infections?

BACKGROUND

This study was conducted to determine the pin-site care protocols currently in use and to analyse their effectiveness and outcomes.

METHODS

PubMed, the Cochrane Library and Embase databases were screened for manuscripts that described comparative studies of different methods of pin-site care and referred to complications related to any kind of external fixator application.

RESULTS

A total of 369 manuscripts were screened and only 13 of these met the inclusion criteria evaluating different protocols of pin-site care. This review is based on a total of 574 patients. Infection rates were very variable depending on the type of implant used and the protocol of pin-site care applied.

CONCLUSIONS

None of the different protocols of pin-site care that were evaluated in this study were associated with a 0% infection rate. There is currently no consensus in the international literature about which protocol should be applied universally. Meticulous surgical technique during pin insertion and implementation of one of the existing protocols of pin-site care are the mainstay of prevention and/or reduction of the incidence of pin-site infections.