Effectiveness of Ilizarov external fixation in elderly patients with pilon fractures

The successful treatment of a Gustilo-Anderson type IIIc distal leg injury with a large bone defect in elderly patient with severe osteoporosis: a case report

BACKGROUND

Gustilo-Anderson type IIIc tibial open fracture with large bone defects in elderly patients with severe osteoporosis is a rare injury that may be a challenging clinical scenario.

CASE PRESENTATION

This study presents the case of a 68-year-old Japanese man who sustained a Gustilo-Anderson type IIIc open tibial fracture with a large bone defect. The patient had severe osteoporosis and the bone was contaminated; therefore, we determined that the bone could not be returned to the tibia. The patient underwent acute limb shortening and gradual lengthening with an Ilizarov external fixator combined with low-intensity pulsed ultrasound and teriparatide administration for limb reconstruction, which allowed immediate full weight-bearing capacity. The fixator was removed at 12 months postoperatively, and by this time, the fracture had completely healed. At the most recent 5-year follow-up after the injury, the patient reported full weight-bearing capacity without walking aids and had full knee and ankle range of motion.

CONCLUSIONS

To the best of our knowledge, this is the first study to report the use of combined Ilizarov technique, low-intensity pulsed ultrasound, and teriparatide for limb reconstruction of Gustilo-Anderson type IIIc open tibial fractures with large bone defects in elderly patients with severe osteoporosis.

Medial malleolar window approach for varus-type tibial pilon fractures: a retrospective study

PURPOSE

Choosing a suitable surgical approach is crucial and challenging for type C pilon fractures. This article aims to explore the clinical efficacy of the medial malleolar window approach for varus-type tibial pilon fractures.

METHODS

A retrospective analysis was conducted on 38 patients with type C varus-type pilon fractures treated between May 2018 and June 2021. In total, 16 cases underwent surgical treatment through the medial malleolar window approach and 22 cases were treated with the traditional anteromedial approach combined with a posterior approach. The operation time, hospitalization time, fracture healing time, the American Orthopedic Foot and Ankle score, Visual Analogue Scale, and complications were recorded to comprehensively evaluate the clinical efficacy of the technique. Fracture reduction quality was evaluated using the criteria proposed by Burwell and Charnley.

RESULTS

All patients were followed up. No patients presented delayed union or nonunion. Compared with the conventional approach, the medial malleolar window approach had the advantage of better clinical effect recovery and better fracture reduction (P < 0.05). Meanwhile, the medial malleolar window approach had a shorter operation time, although the statistics suggest no significant difference with the control group. No implant exposure or infection occurred. There was good wound healing at two weeks after surgery in all but two cases. Local wound edge necrosis developed in one case in the medial malleolar window approach group, and the wound could not be closed at one stage in another case in the conventional group because of excessive tension, requiring secondary closure.

CONCLUSION

The medial malleolar window approach provides excellent exposure to type C pilon fractures, allowing for satisfactory fracture reduction and functional rehabilitation. The medial window approach is recommended for varus-type pilon fractures, which can effectively avoid a posterior incision and reduce the operation time.

Combined limited internal fixation and multiplanar external fixation for immediate weight bearing of fractures around the foot and ankle

Treatment of fractures around the foot and ankle can be challenging in patients who are unable to remain non weight bearing on their lower extremity. Traditional implants are not sufficient to resist loads incurred during weight bearing and can also lead to complications related to wound healing and infection. We describe a technique for fracture fixation of the foot and ankle that uses low profile implants to minimize soft tissue insult combined with multiplanar external fixation to allow for immediate weight bearing.

A Novel Approach Combined with MIPO Technique for the Treatment of Type C Pilon Fractures

Objective

Type C fracture is a complete intra-articular fracture, and the mainstay of treatment remains open reduction and internal fixation. The purpose of the study is to observe the clinical effect of an anterior ankle C approach (ankle-C) combined with minimal invasive plate osteosystems (MIPO) for tibial pilon fractures (AO/OTA 43C, combined with fibula fractures).

Methods

A retrospective comparative analysis was performed on the clinical data of 33 patients with C-type pilon fractures (combined fibula fractures) admitted to our department from July 2018 to July 2021, including 12 cases treated with ankle-C (a-C) approach and 21 cases with conventional approach (including combined approach). All patients were followed up for over 6 months. Visual Analogue Scale (VAS), AOFAS Ankle-Hindfoot Scale (AOFAS-AHS), wound healing time, fracture healing time, and complications were used to evaluate the clinical efficacy.

Results

The scores of VAS and AOFAS in the a-C group scored better than the conventional group (P < 0.05), especially in the extent of limited range of motion (LROM) of ankle dorsiflexion-plantarflexion in 1 month after operation and at the last follow-up (P < 0.01). Bone healing was achieved in both groups 6 months after operation, with no implant exposure or infection. Among them, 4 cases in the conventional approach group had wound healing time exceeding 2 weeks.

Conclusions

For type C pilon fractures (combined with fibula fractures), ankle-C approach combined with MIPO technique has certain advantages in ankle function recovery and soft tissue repair, which provides an alternative for the treatment of type C pilon fractures.

Influence of parameter deviation on the closeness of the tibial limb and external fixator based on a novel collision detection algorithm

The Ortho-SUV frame (OSF) is a hexapod external fixator widely applied in orthopedics deformity correction. The possibility of collision between OSF's struts and the soft tissue is an essential but overlooked issue. To avoid the issue, a novel collision detection algorithm is established based on a cone-cylinder model of the tibial limb-strut interaction for detecting the closeness of the tibial limb and external fixator. The algorithm is constructed using the vector analysis based on the model of the minimum distance between the truncated cone generatrix and the cylinder axis. The motion simulation is performed on the overall alignment through the Solidworks-motion module to verify the feasibility of the algorithm. Subsequently, the installation parameter deviations of the bone-fixator system are described to investigate the influence of orientation and position deviation on the closeness of the tibial limb and external fixator through the numerical method. The investigation results show that the orientation deviation γ (around the z-axis), the position deviation τ₁ and τ₂ (along the x and y-axes, respectively) have greater sensitivity to closeness and the influence of multiple deviations on the closeness has the property of superposition. The proposed algorithm can assist clinicians to strictly design and appraise frame configurations prior to their application to avoid the collision between the external fixator and the limbs during the correction. It has great application significance in the development of computer-aided correction software.

Effectiveness of circular hexapod external fixation with soft tissue reconstruction in treating severe knee dislocation due to burn scarring: a case report

Background

Severe varus deformity and soft tissue injury caused by a burn around a complex knee dislocation is a rare injury. Soft tissue reconstruction and deformity correction with circular hexapod external fixation of the knee and hinged total knee arthroplasty (TKA) are challenging and can lead to major complications if not performed appropriately. We present a case in which a combination of soft tissue reconstruction, circular hexapod external fixation, and TKA was used treat severe knee dislocation due to burn scarring.

Case presentation

We report the case of a 58-year-old woman who presented for knee surgery with soft tissue reconstruction, deformity correction with circular hexapod external fixation, and hinged TKA for a severe complex deformity and soft tissue injury caused by a burn injury at 6 months of age. The left leg was shorter by 35 mm in terms of functional leg length discrepancy. She walked with a limp, with a marked varus deformity of the left knee during the stance phase of walking. After a 3-stage repair, the patient was able to walk without assistance, confirming improvement of mobility.

Conclusion

The treatment method was an effective use of a combination of soft tissue reconstruction, circular hexapod external fixation, and rehearsal surgery using a 3D printed bone model of the modular rotating hinge component of TKA, which was successfully used to treat a severe knee dislocation due to burn scarring. This staged surgery maintained the leg length and ultimately achieved a satisfactory alignment.

Effectiveness of circular external fixator in periprosthetic fractures around the knee

Background

The incidence of periprosthetic fractures after total joint arthroplasty (TJA) is rising due to an increasing number of TJAs performed annually and the growing elderly population. In many elderly patients with periprosthetic fractures, the bone strength is lowered due to the deterioration of bone quality and a decrease in bone quantity; rigid fixation of the fracture is difficult. It is a challenging operation for orthopedic surgeons. The usefulness of circular external fixation for periprosthetic fractures has been reported in several case studies. The aim of this study was to investigate the rate of union and complications associated with circular external fixation in periprosthetic fractures around the knee.

Methods

We included 19 patients with periprosthetic femur and tibial fractures who underwent osteosynthesis using a circular external fixator and had at least 2 years of follow-up. All patients had comorbidities and high risks associated with anesthesia. Tourniquets were not used in any of the patients. There were no cases in which the skin incision was placed, and the closed reduction technique was used in all cases.

Results

A 100% union rate was achieved with no serious complications. All fractures healed after a mean time of 14.3 ± 5.2 weeks (range, 8–38 weeks). The walking ability was the same level as before the injury in 13 cases.

Discussion

There are many comorbidities associated with periprosthetic fractures in elderly patients. Double-plate or revision surgery were largely invasive and had high risks associated with anesthesia. Circular external fixation is a feasible and effective treatment option because it provides stable fixation, prompt postoperative mobilization, and has no major complications, especially in elderly patients who are treated for periprosthetic fractures.

Conclusion

Circular external fixation is a safe and reliable method for periprosthetic fractures around the knee in elderly patients.

Level of evidence

Level IV, retrospective case series.