Ilizarov external fixation in the management of bilateral, highly complex blast injuries of lower extremities: a report of two cases

Calcanisation of tibia using Ilizarov fixator in crush injuries of hindfoot: a new method

Crush injuries of the foot are one of the most difficult and challenging tasks for a trauma surgeon to manage in terms of limb salvage and provision of a painless functional foot. Injuries to the foot, especially the hindfoot, account for almost 24.6% of all the warfare injuries in Afghanistan, of which more than 70% end in amputation for various reasons. We devised a method using the principles of Ilizarov's distraction osteosynthesis to salvage limbs with bony defects in the hindfoot which otherwise were candidates for amputation. The procedure is done in two stages. Initially, the ring fixator is applied for the soft tissue reconstruction and infection control, and the next stage consists of percutaneous "inverted L"-shaped osteotomy in the posterior half of the lower tibia. The study included 32 patients with hindfoot crush injuries involving talus, calcaneum, a combination of both, or even involving the adjacent tarsal bones. All these crush injuries were classified using the Gustilo and Anderson classification. The postoperative functional assessment of the feet was done using the Maryland Foot Score system with a minimum follow-up of four years. We had good results in 53%, fair in 34% and failure in 13% of our cases. The complications of this procedure were the same as with the use of the ring fixator elsewhere in the body. This method provides a technique to salvage the foot and produce a painless, stable, fused foot in one of the most difficult settings of a hindfoot crush injury.

The Revised ???Reconstructive Ladder??? and Its Applications for High-Energy Injuries to the Extremities

In this report, we tried to evaluate the merits of the classic "reconstructive ladder" and other reconstructive tools, such as acute shortening followed by distraction osteogenesis and a vacuum-assisted closure device, for the treatment of high-energy injuries. Thirty-seven patients suffering from high-velocity injuries to the extremities caused by war weapons and blast terror attacks were treated at our institution. The fractures were initially stabilized by the Association for the Study of Internal Fixation (AO/ASIF) unilateral tubular external fixator, which was changed 2-3 days later to a circular Ilizarov frame for 19 patients. Temporary acute shortening was performed for 5 patients. Skin grafts were performed for 21 patients, local or regional flaps for 14 patients, and free flaps for 6. Vacuum-assisted closure was selected for 8 patients. The wounds were successfully closed in all the patients. Two patients with upper-limb injuries had nonunion. Motor nerve injuries recovered in 7/10 patients. Due to hypergranulating tissue, 2 patients treated with vacuum-assisted closure (VAC) had to stop treatment early. Their wounds were closed with skin graft or local flap. The classic reconstructive ladder, starting from direct closure and ending with a free flap, should be extended for limb traumas and include acute shortening with or without angulation, followed by distraction osteogenesis and the VAC system on the same step as the free flap.

Complications encountered while using thin-wire-hybrid-external fixation modular frames for fracture fixation. A retrospective clinical analysis and possible support for "Damage Control Orthopaedic Surgery"

One hundred ninety eight adult patients who had sustained long bone fractures were treated by external fixation from admission to bone healing and consolidation. Of these, 135 had sustained high-energy injuries, 39 of them had suffered multi-system injuries. Superficial pin track infection was the most common complication, occurring predominantly in pins located in the femur, upper tibia and upper humerus. There were no cases of deep infection or osteomyelitis. One patient with a femoral shaft fracture developed a DVT although he was on preventive low molecular weight heparin, i.e. sc Clexane 40 mg daily. There were no cases of PE or ARDS. External fixation systems are a minimal invasive surgical modality, which allow three-dimensional fracture fixation after closed or minimal open reduction. They require a good command of surgical anatomy, but provide an optimal preservation of the fracture's soft tissue envelope, the critical biological factor for new bone formation and fracture healing. Recent publications have suggested that in the critically ill patient, minimally invasive fracture fixation surgery may prevent the perpetuation of a reactive, life threatening inflammatory reaction (the "second hit") which may induce the development of multiple organ dysfunction (MODS).

Stabilization of a short juxta-articular bone segment with a circular external fixator

The objective of the current study was to evaluate the stabilization of a simulated juxta-articular bone segment with a circular external fixator, and to determine which method of fixation improved bending stabilization while preserving the axial dynamization of a three-wire configuration. Frames were divided into three groups: wire, half-pin and hybrid and tested in axial compression, torsion, anteroposterior bending and mediolateral bending. Hybrid frames using 4 mm half-pins improved the anteroposterior stabilization of the short bone segment while maintaining axial characteristics similar to a three-wire frame. Increasing the bending stabilization will improve bone segment alignment while permitting axial micromotion beneficial to bone healing.

Hybrid external fixation in high-energy elbow fractures: a modular system with a promising future

BACKGROUND

Severe, high-energy, periarticular elbow injuries producing a "floating joint" are a major surgical challenge. Their reconstruction and rehabilitation are not well documented. Therefore, the following reports our experience with treating such injuries caused by war wounds.

METHODS

Seven adults with compound open peri- and intra-articular elbow fractures were treated in hybrid ring tubular fixation frames. After debridement, bone stabilization, and neurovascular reconstructions, early controlled daily movements were started in the affected joint.

RESULTS

These seven patients had together seven humeral, five radial, and six ulnar fractures. All fractures united at a median time of 180 days. No deep infection developed. The functional end results assessed by the Khalfayan functional score were excellent in two, good in one, and fair in four of these severely mangled upper extremities. None was amputated.

CONCLUSIONS

The Mangled Extremity Severity Score has been shown to be unable to provide a reliable assessment for severe high-energy limb injuries surgically managed with the modular hybrid thin wire tubular external fixation system. This hybrid system is a very useful addition to the surgical armamentarium of orthopedic trauma surgeons. It both allows complex surgical reconstructions and reduces the incidence of deep infections in these heavily contaminated injuries. The hybrid circular (thin wire) external fixation system is very modular and may provide secure skeletal stabilization even in cases of severely comminuted juxta-articular fractures on both sides of the elbow joint (floating elbow) with severe damage to soft tissues. This fixation system allows individual fixation of forearm bone fractures, thus allowing the preservation of pronation-supination movements.