Evaluating the stability of external fixators following pelvic injury: A systematic review of biomechanical testing methods

INTRODUCTION

This systematic review aims to identify previously used techniques in biomechanics to assess pelvic instability following pelvic injury, focusing on external fixation constructs.

METHODS

A systematic literature search was conducted to include biomechanical studies and to exclude clinical trials.

RESULTS

Of an initial 4666 studies found, 38 met the inclusion criteria. 84% of the included studies were retrieved from PubMed, Scopus, and Web of Science. The studies analysed 106 postmortem specimens, 154 synthetic bones, and 103 computational models. Most specimens were male (97% synthetic, 70% postmortem specimens). Both the type of injury and the classification system employed varied across studies. About 82% of the injuries assessed were of type C. Two different fixators were tested for FFPII and type A injury, five for type B injury, and fifteen for type C injury. Large variability was observed for external fixation constructs concerning device type and configuration, pin size, and geometry. Biomechanical studies deployed various methods to assess injury displacement, deformation, stiffness, and motion. Thereby, loading protocols differed and inconsistent definitions of failure were determined. Measurement techniques applied in biomechanical test setups included strain gauges, force transducers, and motion tracking techniques.

DISCUSSION AND CONCLUSION

An ideal fixation method should be safe, stable, non-obstructive, and have low complication rates. Although biomechanical testing should ensure that the load applied during testing is representative of a physiological load, a high degree of variability was found in the current literature in both the loading and measurement equipment. The lack of a standardised test design for fixation constructs in pelvic injuries across the studies challenges comparisons between them. When interpreting the results of biomechanical studies, it seems crucial to consider the limitations in cross-study comparability, with implications on their applicability to the clinical setting.

Biomechanical comparative study on external fixators of new configurations in the treatment of Tile C pelvic injury

To compare the biomechanical properties of several anterior pelvic ring external fixators with two new configurations in the treatment of Tile C pelvic fractures, in order to evaluate the effectiveness of the new configurations and provide a reference for their clinical application. A finite element model of a Tile C pelvic ring injury (unilateral longitudinal sacral fracture and ipsilateral pubic fracture) was constructed. The pelvis was fixed with iliac crest external fixator (IC), anterior inferior iliac spine external fixator (AIIS), combination of IC and AIIS, combination of anterior superior iliac spine external fixator (ASIS) and AIIS, and S1 sacroiliac screw in 5 types of models. The stability indices of the anterior and posterior pelvic rings under vertical longitudinal load, left-right compression load and anterior-posterior shear load were quantified and compared. In the simulated bipedal standing position, the results of the vertical displacement of the midpoint on the upper surface of the sacrum are consistent with the displacement of the posterior rotation angle, and the order from largest to smallest is IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. The longitudinal displacement of IC is greater than that of the other models. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter is smaller. In the simulated semi-recumbent position, the vertical displacement and posterior rotation angle displacement of the midpoint on the upper surface of the sacrum are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Under the simulated left-right compression load state, the lateral displacements of the highest point of the lateral sacral fracture end are consistent with the highest point of the lateral pubic fracture end, and the order from large to small is S1 screw, IC, AIIS, ASIS + AIIS and IC + AIIS, among which the displacements of S1 screw and IC are larger, and the displacements of ASIS + AIIS and IC + AIIS are similar and smaller than those of other models. The displacements of IC + AIIS are smaller than those of ASIS + AIIS. Under the simulated anterior-posterior shear load condition, the posterior displacements of the highest point of the lateral sacral fracture end and the highest point of the lateral pubic fracture end are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Among them, the displacements of IC and AIIS are larger. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter are smaller. For the unstable pelvic injury represented by Tile C pelvic fracture, the biomechanical various stabilities of the combination of IC and AIIS are superior to those of the external fixators of conventional configurations. The biomechanical stabilities of the combination of ASIS and AIIS are also better than those of the external fixators of conventional configurations, and slightly worse than those of the combination of IC and AIIS. Compared with sacroiliac screw and conventional external fixators, the lateral stabilities of IC + AIIS and ASIS + AIIS are particularly prominent.

Treatment of tibial bone defects caused by infection: a retrospective comparative study of bone transport using a combined technique of unilateral external fixation over an intramedullary nail versus circular external fixation over an intramedullary nail

BACKGROUND

The purpose of the study was to assess and compare the clinical efficacy of bone transport with either circular or unilateral external fixators over an intramedullary nail in the treatment of tibial bone defects caused by infection.

METHODS

Between May 2010 and January 2019, clinical and radiographic data were collected and analyzed for patients with bone defects caused by infection. Thirteen patients underwent bone transport using a unilateral external fixator over an intramedullary nail (Group A), while 12 patients were treated with a circular external fixator over an intramedullary nail (Group B). The bone and functional outcomes of both groups were assessed and compared using the Association for the Study and Application of the Method of the Ilizarov criteria, and postoperative complications were evaluated according to the Paley classification.

RESULTS

A total of 25 patients were successfully treated with bone transport using external fixators over an intramedullary nail, with a mean follow-up time of 31.63 ± 5.88 months. There were no significant statistical differences in age, gender, previous surgery per patient, duration of infection, defect size, and follow-up time between Group A and Group B (P > 0.05). However, statistically significant differences were observed in operation time (187.13 ± 21.88 min vs. 255.76 ± 36.42 min, P = 0.002), intraoperative blood loss (39.26 ± 7.33 mL vs. 53.74 ± 10.69 mL, P < 0.001), external fixation time (2.02 ± 0.31 month vs. 2.57 ± 0.38 month, P = 0.045), external fixation index (0.27 ± 0.08 month/cm vs. 0.44 ± 0.09 month/cm, P = 0.042), and bone union time (8.37 ± 2.30 month vs. 9.07 ± 3.12, P = 0.032) between Group A and Group B. The excellent and good rate of bone and functional results were higher in Group A compared to Group B (76.9% vs. 75% and 84.6% vs. 58.3%). Statistically significant differences were observed in functional results (excellent/good/fair/poor, 5/6/2/0 vs. 2/5/4/1, P = 0.013) and complication per patient (0.38 vs. 1.16, P = 0.012) between Group A and Group B.

CONCLUSIONS

Bone transport using a combined technique of external fixators over an intramedullary nail proved to be an effective method in treating tibial bone defects caused by infection. In comparison to circular external fixators, bone transport utilizing a unilateral external fixator over an intramedullary nail resulted in less external fixation time, fewer complications, and better functional outcomes.

Magnetic resonance imaging quality in the context of a knee-spanning external fixator placed inside the MR bore: a literature review

After emergent assessment of potentially limb-threatening injuries in knee dislocation or multi-ligament knee injury patients, magnetic resonance imaging is necessary to visualize ligamentous structures and plan for soft tissue repair. However, the application of a knee-spanning external fixator may introduce artifact and reduce overall image quality, which can limit the evaluation of soft tissue injury. As a result, the utility of MRI in the context of a knee-spanning external fixator has been called into question. Signal-to-noise ratio, contrast-to-noise ratio, and qualitative scales have been used to assess image quality of MRI in the context of a knee-spanning external fixator. Despite the potential for artifact, studies have demonstrated that useful diagnostic information may be obtained from MRI in the presence of an external fixator. This review examines the general principles of anatomical assessment, magnetic field strength, device composition and design, radiofrequency coil use, and MRI sequences and artifact reduction as they pertain to MRI in the presence of a knee-spanning external fixator.

Comparative analysis of free vascularized fibula grafting and Ilizarov bone transport in management of segmental long bone defect of the lower limb: A systematic review and meta-analysis

Introduction

Reconstruction of segmental defects of long bones is a daunting task for surgeons. Bone transport with the help of Illizarov external fixator and vascularized free fibula flap are some of the most discussed and valid options for the same. Both techniques have their limitations and overlapping indications. However, there has been no objective evidence in the manner of a systematic review supporting one treatment method over the other.

Aim

This systemic review is aimed to compare the bony union, functional outcomes, and complications of Illizarov bone lengthening and free fibula flap performed for segmental bone defects of long bones of the leg.

Methods

A comprehensive search was done for all studies published before May 2023. Any observational study comparing bone transport based on Illizarov external fixator and free vascularized fibula grafting techniques for treating lower limb long bone segmental defects was entailed in this study.

Results

This systematic review comprised of five retrospective studies. A total of 96 patients were treated by the Illizarov-based bone transport technique and 72 patients were treated by the free vascularized fibula grafting technique. The free vascularized fibula grafting technique yielded a shorter mean time to union (average difference 9.3 months), relatively shorter external fixator time (average difference 5.32 months), and external fixator index (average difference 0.57 months/cm). However, there was no difference in terms of bony and functional outcomes between both techniques when used for the reconstruction of bony defects in the lower limb. Total number of complications was 68 % higher in bone transport with Illizarov external fixator. However, the rates of non-union didn't differ between the groups.

Conclusion

The free vascularized fibula grafting technique had a lesser time to bony union, shorter time for external fixator application, and lower incidence of complications. However, the functional and bony outcomes didn't differ between both techniques.

Level of evidence

Level 4.

External fixator versus Ilizarov external fixator for pediatric tibial shaft fractures: A retrospective comparative study

INTRODUCTION

External fixators (EF) are widely employed for pediatric tibial shaft fractures, being a prevalent choice in clinical practice. However, they are associated with numerous complications, such as loss of reduction, delayed union, and nonunion. An alternative approach involves the use of Ilizarov external fixators (IEF), which have been documented in the treatment of tibial shaft fractures in various studies. This study endeavors to retrospectively compare the clinical outcomes of EF and IEF in the treatment of pediatric tibial shaft fractures.

METHODS

The study retrospectively examined patients aged 5-14 years who underwent treatment for tibial shaft fractures at our institute between January 2017 and January 2023. These individuals were subsequently classified into EF and IEF groups. Exclusions comprised patients presenting with pathological fracture, neuromuscular disorder, metabolic disease, prior tibial fracture or instrumentation, and polytrauma. Additionally, individuals with a follow-up duration of more than 12 months or incomplete medical records were excluded.

RESULTS

A total of 45 patients were divided into two groups: the EF group, comprising 24 patients (18 males, 6 females), and the IEF group, consisting of 21 patients (17 males, 4 females). The two groups exhibited no statistically significant differences in terms of sex, age, body weight, time from injury to surgery, AO classification, or concomitant injuries. There were two cases of nonunion in the EF group. Radiological union occurred more rapidly in the IEF group (7.8 ± 0.4 weeks) than in the EF group (9.3 ± 1.1 weeks) (P < 0.05). The mean hospitalization duration differed significantly between the EF group (6.7 ± 3.4 days) and the IEF group (7.5 ± 1.1 days) (P > 0.05). The mean duration of the operative procedure significantly differed between the IEF group (147.8 ± 24.5 min) and the EF group (77.2 ± 43.9 min) (P < 0.001). A significant difference (P < 0.001) in weight-bearing time was observed between the IEF group (2.6 ± 0.7 weeks) and the EF group (9.9 ± 1.4 weeks). According to the Johner-Wruhs criteria, no significant differences were found between the two groups. A significant difference (P < 0.001) in hospitalization costs was observed between the IEF group (7848.0 ± 262.4 $) and the EF group (5403.0 ± 233.3 $).

CONCLUSION

EF is cheaper, quicker and simpler and we need more randomized controlled studies and that this is a pilot study only. Both types of surgery are good choices for children. Nevertheless, the IEF group demonstrates advantages such as early weight-bearing capability and faster fracture healing.

Perspectives and institutional policies on patient safety and image quality regarding the use of knee-spanning external fixators in MRI: A survey study of the Society of Skeletal Radiology

OBJECTIVE

Concerns regarding patient safety and image quality have made the use of knee-spanning external fixators in MRI a challenging clinical scenario. The purpose of our study was to poll practicing musculoskeletal radiologists on their personal experiences regarding the use of knee-spanning external fixators in MRI in an effort to consolidate practice trends for the radiologists' benefit.

METHODS

A 27-item survey was created to address the institutional use, safety, adverse events, quality, and perspectives of the radiologist related to MRI of an externally fixated knee. The survey was distributed to 1739 members of the Society of Skeletal Radiology.

RESULTS

A total of 72 members of the Society of Skeletal Radiology completed the survey. Most notably, 40 of 72 (55.56%) respondents are permitted to place a knee-spanning external fixator inside the MR bore at their institution, while19 of 72 (26.39%) respondents are not permitted to do so. Fourteen of 32 (43.75%) respondents have institutional guidelines for safely performing an MRI of an externally fixated knee. Twenty-five of 32 (78.13%) respondents are comfortable permitting an MRI of an externally fixated knee.

CONCLUSION

We found a general lack of consensus regarding the decision to scan a patient with a knee-spanning external fixator in MRI. Many institutions lack safety guidelines, and providers rely upon a heterogeneous breadth of resources for safety information. A re-examination of the FDA device labeling nomenclature and expectations of the individual manufacturers may be needed to bridge this gap and help direct management decisions placed upon the provider.

Unilateral external fixator and its biomechanical effects in treating different types of femoral fracture: A finite element study with experimental validated model

Previous works had successfully demonstrated the clinical effectiveness of unilateral external fixator in treating various types of fracture, ranging from the simple type, such as oblique and transverse fractures, to complex fractures. However, literature that investigated its biomechanical analyses to further justify its efficacy is limited. Therefore, this paper aimed to analyse the stability of unilateral external fixator for treating different types of fracture, including the simple oblique, AO32C3 comminuted, and 20 mm gap transverse fracture. These fractures were reconstructed at the distal diaphysis of the femoral bone and computationally analysed through the finite element method under the stance phase condition. Findings showed a decrease in the fixation stiffness in large gap fracture (645.2 Nmm-1 for oblique and comminuted, while 23.4 Nmm-1 for the gap fracture), which resulted in higher displacement, IFM and stress distribution at the pin bone interface. These unfavourable conditions could consequently increase the risk of delayed union, pin loosening and infection, as well as implant failure. Nevertheless, the stress observed on the fracture surfaces was relatively low and in controlled amount, indicating that bone unity is still allowable in all models. Briefly, the unilateral fixation may provide desirable results in smaller fracture gap, but its usage in larger gap fracture might be alarming. These findings could serve as a guide and insight for surgeons and researchers, especially on the biomechanical stability of fixation in different fracture types and how will it affect bone unity.

Comparing the mechanical characteristics between leg lengthening using only an Ilizarov external fixator and leg lengthening over a nail using an external fixator manufactured in Vietnam

PURPOSE

The mechanical characteristics of leg lengthening over a nail (LON) using an external fixator are not well known; specifically, the number of rings and K-wires required for this method has not been determined. This study aimed to compare the mechanical characteristics of leg LON using the simplest configuration for a domestic frame and those of leg lengthening using the Ilizarov frame alone.

METHODS

The mechanical characteristics of cow tibial samples for lengthening over an intramedullary nail in combination with a domestic external fixator (LON samples) and for lengthening with the Ilizarov frame (Ilizarov samples) were evaluated by assessing axial compression, bending load, and torsional load. The research indices were compression stiffness, bending stiffness, torsion stiffness, yield axial load, ultimate axial load, yield bending load, and ultimate bending load.

RESULTS

No statistically significant differences were observed in the compression stiffness, ultimate axial load, bending stiffness, and ultimate, yield bending forces between the Ilizarov samples and LON samples. The compressive stiffness, yield axial load, and ultimate axial load of the LON samples were 98 ± 1.31 N/mm, 915 ± 23.89 N, and 1032 ± 29.86 N, respectively. The anterior-posterior bending stiffness and lateral bending stiffness of the LON samples were 122.48 ± 2.92 N/mm and 116.34 ± 3.95 N/mm, respectively. The yield anterior-posterior bending and ultimate anterior-posterior bending forces of the LON samples were 616.4 ± 3.64 N and 753.2 ± 3.49 N, respectively. The yield lateral bending and ultimate lateral bending forces of the LON samples were 624.6 ± 4.04 N and 759.0 ± 3.39 N, respectively. The axial torsional stiffness of the LON samples was 1.73 ± 0.05 N m/°, which was significantly lower than that of the Ilizarov samples (2.63 ± 0.03 N m/°).

CONCLUSION

No statistically significant differences were observed in the mechanical fixation characteristics of axial compression and bending between the Ilizarov samples and LON samples. However, the axial torsional stiffness of the Ilizarov samples was statistically greater than that of the LON samples. We recommend using the simplest configuration for domestic frames in combination with LON for limb lengthening. Partial weight-bearing is permitted in the distraction stage.

LEVEL OF EVIDENCE

Case-control study.

External fixation in intra-articular fractures of the calcaneus: Is it a valid option as definitive treatment?

INTRODUCTION

The therapeutic management of calcaneal fractures is currently a major source of controversy in the literature. There is no consensus on the need to treat these injuries conservatively or surgically, nor on the criteria for deciding one option or the other. Although the gold standard has classically been the open approach and osteosynthesis, there are currently minimally invasive techniques that also report good results. Our objective is to present our results and experience with the MBA® Orthofix external fixator in a series of cases of calcaneal fractures.

METHODS

We performed a retrospective observational study in our center, between the years 2019 and 2021, of Sanders types II-IV calcaneal fractures operated with MBA® Orthofix external fixator. We recorded a total of 38 patients, 42 fractures. We registered demographic information, intraoperative, postoperative, radiological and functional parameters, using the American Orthopedic Foot and Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D and VAS scales.

RESULTS

A total of 26 men and 12 women were included, and the median age was 38 years. Mean follow-up was 24,4 months (6, 8-40, 1). The average time to surgery was 7 days and partial loading was started at 2.5 weeks after external fixation, which was removed at 9.2 weeks. The average Böhler angle correction was 7, 4°, Gissane - 12,2°, length 2 mm and calcaneal width was reduced by 5 mm. We recorded two superficial infections, one peroneal entrapment and three subtalar arthrodesis due to post-traumatic osteoarthritis. The AOFAS obtained was 79.1 + / - 15.7 points, MOXFQ 20.1 + / - 16.1 points, EQ-5D 0.84 + / - 0.2 and VAS 3.3 + / - 1.9.

CONCLUSION

The external fixator is an excellent surgical alternative for complex articular fractures of the calcaneus, obtaining clinical and radiological results comparable to other osteosynthesis techniques and significantly reducing soft tissue complications.

Mechanical evaluation of the effect of the rod to rod distance on the stiffness of uniplanar external fixator frames

PURPOSE

To investigate the effect of the rod-to-rod distance on the mechanical stability of single-rod and double-rod external fixator frames.

METHODS

 Four different constructs, one single-rod and three double-rod constructs with different rod-rod distances, were subjected to the axial, bending, and torsional forces. The stiffness of different configurations was calculated.

RESULTS

 Single-rod configuration had statistically the lowest stiffness when subjected to the axial, bending, and torsional forces. Maximum stiffness against the axial and anterior-posterior bending forces was achieved when the rod-rod distance was adjusted to 50 mm (halfway between the first rod and the end of the Schanz pins). There was no statistically significant difference in lateral bending stiffness among different double-rod configurations (p value: 0.435). The maximum stiffness against torsional forces was achieved when the rod-rod distance was adjusted to 100 mm (the second rod at the end of the Schanz pins).

CONCLUSION

 Double-rod uniplanar external fixator frames are significantly stiffer than the single-rod constructs, and however, the rod-rod distance can significantly affect the construct stiffness. We found that a frame with 50 mm rod-rod distance was the optimum fixator among tested configurations that allowed a balance between axial, bending, and torsional stiffness of the construct.

Miserable malalignment syndrome associated knee pain: a case for infra-tubercle tibial de-rotation osteotomy using an external fixator

INTRODUCTION

Miserable malalignment syndrome is a complex torsional lower limb deformity with limited consensus on surgical treatment. We present the outcome of de-rotation of the tibia alone using an external fixator.

METHODS

Fifteen patients (22 segments) were operated on between 2012 and 2020; 13 presented with anterior knee pain, and two presented with out-toeing. Gait analysis was done in nine patients, and CT scan rotational profile, including tibial tubercle-trochlear groove distance, femoral version, and tibial torsion, were calculated. Kujala knee pain score and visual analogue pain score (VAS) were recorded. All underwent infra-tubercular osteotomy of the tibia and midshaft osteotmy of the fibula and application of a hexapod circular frame to gradually internally rotate the tibia until the foot aligned with the patella.

RESULTS

There was no preoperative clinical or radiographic evidence for patellar instability, femoral anteversion 30° (21°-54°), and external tibial torsion 50° (37-70). The mean age at surgery was 21 years (12-37) with a mean follow-up of 20 months (9-83). All osteotomies healed, and the frames were removed at a mean of 111 days (80-168). The mean VAS score improved from 8(5-9) to 1(0-4) postoperatively (P < 0.001). The mean Kujala knee pain score increased from 53 (30-75) to 92 (54-100) postoperatively (P < 0.001). The mean preoperative foot progression angle (FPA) was 37° (20°-50°), with 13 postoperatively walking with neutral FPA. One patient walked with symmetrical + 10° and the other with - 5° FPA. All patients reported relief of knee pain and were satisfied with the alignment.

CONCLUSION

Gradual correction of severe external tibia torsion with a hexapod external fixator and an infra-tubercle tibial osteotomy could provide an optimum method to eliminate knee pain and improve limb alignment in miserable malalignment syndrome.

The treatment of a malunited posterior pilon fracture with talar dislocation: A staged surgical treatment protocol

BACKGROUND

Malunited posterior pilon fractures with talus dislocation (mPPFtd) are rare and there are no appropriate treatment strategies. The purpose of this study was to introduce a stepped strategy featuring preliminary soft tissue management according to the Ilizarov principle and delayed open reduction and internal fixation (ORIF) through a modified posteromedial approach to overcome rigid soft tissue contracture.

METHOD

From February 2015 to August 2021, 12 selected patients with mPPFtd who were treated with the staged protocol (Group A) were retrospectively analysed. The clinical and radiographic outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, the visual analogue scale (VAS) score, and the Burwell-Charnley score. Moreover, this case series was compared with some cases of fresh fracture (Group B) in patients that had the same baseline data from our previous study.

RESULTS

In Group A, the average length of time between the date of injury and the date of surgery was 4.8 ± 3.3 months. The average time to external fixator distraction, as the first-stage treatment, was 13.4 ± 1.0 days. In the second stage of ORIF, the posterosuperior dislocation of the talus was corrected with osteotomy and leverage manoeuvres. According to the Burwell-Charnley score system, the reduction quality was excellent in 9 cases and good in 3 cases. After a mean follow-up of 3.8 ± 2.1 years, there were no infections, wound healing problems, or nerve injuries in our cohort, and union was observed in all fractures without a loss of reduction. The baseline data of the two groups were not significantly different (p>0.05). The mean AOFAS score in Group A was 85.0 ± 10.5 and that in Group B was 95.4 ± 6.1 (p<0.05). The mean VAS score in Group A was 1.7 ± 1.4 and that in Group B was 0.7 ± 0.9 (p<0.05).

CONCLUSION

A staged surgical treatment strategy characterized by soft tissue management will improve the treatment of mPPFtd and produce satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

[A retrospective study on manual reduction combined with Chinese Orthopaedic ankle external fixator in the treatment of trimalleolar fracture]

OBJECTIVE

To evaluate the needle puncture safety and clinical efficacy of manual reduction combined with external fixation of ankle frame in the treatment of trimalleolar fracture under the guidance of Chinese Osteosynthesis (CO) theory.

METHODS

The clinical data of 118 patients with trimalleolar fractures admitted from December 2010 to December 2021 were retrospectively analyzed. Fifty-three patients were treated with manual reduction combined with external fixation of ankle frame(observation group). Sixty-five patients were treated with open reduction and internal fixation with plate and screws(control group). The operation time, hospitalization days, non-weight-bearing time of the affected limb, clinical healing time of fracture, incidence of complications, visual analogue scale (VAS) before and 1 month after operation, and American Orthopedic Foot and Ankle Society(AOFAS) score of ankle joint before and 1 year after operation were compared between the two groups.

RESULTS

Patients in both groups were followed up for more than 1 year. All patients were followed up, and the duration ranged from 14 to 70 months, with an average of(35.28±14.66) months. There were statistically significant in operation time, hospitalization days, non-load-bearing time of affected limbs, clinical healing time of fractures and VAS score one month after operation between the two groups. One month after operation, the VAS score of the observation group was lower than that of the control group(t=3.343, P=0.001). The operation time of the observation group was significantly shorter than that of the control group(t=9.091, P=0.000). The hospitalization days in the observation group were significantly less than those in the control group(t=5.034, P=0.000). The non-load-bearing time of the affected limb in the observation group was significantly shorter than that in the control group(t=11.960, P=0.000). The clinical healing time of fracture in the observation group was significantly shorter than that in the control group(t=4.007, P=0.000). There was no significant difference in AOFAS score between the two groups one year after operation(t=0.417, P=0.678). In the observation group, there were 2 cases of pinhole infection and 3 cases of loss of reduction less than 2 mm. There were 3 cases of surgical incision infection in the control group. There was no significant difference in the incidence of complications between the two groups(χ2=0.446, P=0.504).

CONCLUSION

Manual reduction combined with external fixation is safe and effective in the treatment of trimalleolar fracture under the guidance of CO theory, and the function of ankle joint recovers well after operation. This therapy has good clinical value.

Formation process of extension knee joint contracture following external immobilization in rats

BACKGROUND

Current research lacks a model of knee extension contracture in rats.

AIM

To elucidate the formation process of knee extension contracture.

METHODS

We developed a rat model using an aluminum external fixator. Sixty male Sprague-Dawley rats with mature bones were divided into the control group (n = 6) and groups that had the left knee immobilized with an aluminum external fixator for 1, 2, and 3 d, and 1, 2, 3, 4, 6, and 8 wk (n = 6 in each group). The passive extension range of motion, histology, and expression of fibrosis-related proteins were compared between the control group and the immobilization groups.

RESULTS

Myogenic contracture progressed very quickly during the initial 2 wk of immobilization. After 2 wk, the contracture gradually changed from myogenic to arthrogenic. The arthrogenic contracture progressed slowly during the 1^st week, rapidly progressed until the 3^rd week, and then showed a steady progression until the 4^rd week. Histological analyses confirmed that the anterior joint capsule of the extended fixed knee became increasingly thicker over time. Correspondingly, the level of transforming growth factor beta 1 (TGF-β1) and phosphorylated mothers against decapentaplegic homolog 2 (p-Smad2) in the anterior joint capsule also increased with the immobilization time. Over time, the cross-sectional area of muscle fibers gradually decreased, while the amount of intermuscular collagen and TGF-β1, p-Smad2, and p-Smad3 was increased. Unexpectedly, the amount of intermuscular collagen and TGF-β1, p-Smad2, and p-Smad3 was decreased during the late stage of immobilization (6-8 wk). The myogenic contracture was stabilized after 2 wk of immobilization, whereas the arthrogenic contracture was stabilized after 3 wk of immobilization and completely stable in 4 wk.

CONCLUSION

This rat model may be a useful tool to study the etiology of joint contracture and establish therapeutic approaches.

Immediate identification and management of an open posterior knee dislocation: Important lessons from a case report

Traumatic knee dislocation represents a rare event, contributing to less than 0.02 % of all orthopedic trauma and 0.05 % of joint dislocations, respectively. It is critically important to recognize, identify, and appropriately manage such cases as 'time' is implicated as an outcome-determining factor. Thus, such cases warrant quick consideration and appropriate management to mitigate the possibility of neurovascular damage and long-term sequelae. We report a case of a 59-year-old man struck by a motor vehicle in a remote rural community in northern Mexico managed with external fixation 16 h after the initial trauma, and later resulting in a supracondylar amputation. The authors of this case report underline the importance of timely intervention strategies when faced with such cases of knee dislocation and promote enhanced training of peripheral trauma-care providers to help improve patient outcomes.

Elbow Kinematics and Function Following Treatment with Open Arthrolysis and Hinged External Fixator

OBJECTIVE

Open arthrolysis (OA) combined with hinged external fixator (HEF) is a promising surgical option for patients with elbow stiffness. This study aimed to investigate elbow kinematics and function following a combined treatment with OA and HEF in elbow stiffness cases.

METHODS

Patients treated with OA with or without HEF due to elbow stiffness were recruited between August 2017 and July 2019. Elbow flexion-extension motion and function (Mayo elbow performance scores, MEPS) were recorded and compared between patients with and without HEF during a 1-year follow-up period. Additionally, those with HEF were assessed by dual fluoroscopy at week 6 postoperatively. Flexion-extension and varus-valgus motions, as well as ligament insertion distances of the anterior medial collateral ligament (AMCL) and lateral ulnar collateral ligament (LUCL), were compared between the surgical and intact sides.

RESULTS

This study included 42 patients, of which 12 with HEF demonstrated a similar flexion-extension angle and range of motion (ROM) and MEPS as the other patients. In patients with HEF, the surgical elbows showed limitations in flexion-extension (maximal flexion, 120.5° ± 5.3° vs 140.4° ± 6.8°; maximal extension, 13.1° ± 6.0° vs 6.4° ± 3.0°; ROM, 107.4° ± 9.9° vs 134.0° ± 6.8°; all Ps < 0.01) compared with the contralateral sides. During elbow flexion, a gradual valgus-to-varus transition of the ulna, increase in the AMCL insertion distance, and steady change in the LUCL insertion distance were observed, with no significant differences between the bilateral sides.

CONCLUSIONS

Patients treated with OA and HEF demonstrated similar elbow flexion-extension motion and function to those treated with OA alone. Although the use of HEF could not restore an intact flexion-extension ROM and might result in some minor but not significant changes in kinematics, it contributed to clinical outcomes comparable to that of the treatment with OA alone.

Internal fixator vs external fixator in the management of unstable pelvic ring injuries: A prospective comparative cohort study

BACKGROUND

Reconstruction of the pelvic ring anatomy in unstable anterior pelvic ring injuries is a significant step to reduce the mortality rate associated with these injuries efficiently. There is a debate on using either an anterior subcutaneous pelvis internal fixator (INFIX) or an anterior supra-acetabular external fixator (EXFIX) to manage an unstable anterior pelvic ring fracture.

AIM

To compare the functional and radiological outcomes and complications of INFIX vs EXFIX in managing unstable pelvic ring injuries.

METHODS

A prospective cohort study included 54 patients with unstable pelvic ring fractures. The patients were divided into two groups; the INFIX group, in which 30 cases were fixed by INFIX, and the EXFIX group, in which 24 patients were treated by EXFIX. The average age in the EXFIX group was 31.17 years (16-57 years), while in the INFIX group, it was 34.5 years (17-53 years). The study included 20 (66.7%) males and 10 (33.3%) females in the INFIX group and 10 (41.7%) males and 14 (58.3%) females in the EXFIX group. The radiological outcomes were evaluated using Matta and Tornetta's score, and the functional outcomes using the Majeed score.

RESULTS

The results revealed a statistically significant difference between both groups (P = 0.013) regarding radiological outcomes, according to Matta and Tornetta's score in favor of the INFIX group. Sitting, standing, and walking abilities were measured at a 3-mo follow-up visit using Majeed score modules. It was significantly better among the INFIX group than the EXFIX group in all three modules. At the final follow-up, both groups had no statistically significant difference according to the Majeed score; 92.35 in the INFIX group and 90.99 in the EXFIX group (P = 0.513). A lower surgical site infection rate was noticed in the INFIX group (P = 0.007).

CONCLUSION

Anterior subcutaneous pelvis INFIX is associated with better radiological outcomes and a lower infection rate than anterior supra-acetabular EXFIX in managing patients with unstable anterior pelvic ring fractures.

Ankle Distraction Arthroplasty: A Survivorship Review and Meta-Analysis

Multiple treatments exist for ankle osteoarthritis. Ankle arthrodesis is the gold standard in late-stage osteoarthritis, but sacrifices range of motion and risks nonunion. Total ankle arthroplasty is typically reserved for low-demand patients as the long-term outcomes are poor. Ankle distraction arthroplasty is a joint sparing procedure which utilizes external fixator frame to unload the joint. This promotes chondral repair and improves function. This study aimed to organize clinical data and survivorship in published papers and direct further research efforts. Thirty-one publications were evaluated and sixteen were included in the meta-analysis. The Modified Coleman Methodology Score was used to assess quality of the individual publications. Random effects models were used to estimate the failure risk after ankle distraction arthroplasty. Ankle Osteoarthritis Score (AOS), American Orthopedic Foot and Ankle Score (AOFAS), Van Valburg, and Visual Analog Scores (VAS) all improved postoperatively. Random effects model analysis revealed an overall failure ratio of 11% (95% CI: 7%-15%; p value≤0.001; I² =87.01%) after 46.68±7.17 months follow up, 9% (95% CI: 5%-12%; p value≤0.001 I²=81.59%) with less than 5 years follow up and 28% (95% CI: 16%-41%; p value≤0.001 I²=69.03%) for patients with more than 5 years follow up. Ankle Distraction Arthroplasty has promising short to intermediate term outcomes which makes this a reasonable treatment option to delay joint sacrificing surgery. The selection of the optimal candidates and consistent technique would improve research and subsequently outcomes. Based on our meta-analysis, negative prognostic factors include female sex, obesity, ROM<20 degrees, leg muscle weakness, high activity level, low preoperative pain levels, higher preoperative clinical scores, inflammatory arthritis, septic arthritis, and deformity.

Complications associated with single-level bone transport for the treatment of tibial bone defects caused by fracture-related infection

BACKGROUND

The purpose of this study was to report the outcomes of single-level bone transport with a unilateral external fixator for treatment of proximal, intermediate and distal tibial bone defects caused by fracture-related infection (FRI) and compare their complications.

METHODS

The clinical records and consecutive X-ray photographs of patients with tibial bone defects treated by single-level bone transport using a unilateral external fixator (Orthofix Limb Reconstruction System) were analyzed retrospectively, from January 2012 to December 2018. Patients were divided into the proximal group (P, n = 19), intermediate group (I, n = 25), and distal group (D, n = 18) according to the location of the tibial bone defect. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes and postoperative complications evaluated by the Paley classification.

RESULTS

A total of 62 participants were included in this study, with a median age of 36 ± 7.14 years. Sixty patients with tibial bone defects caused by FRI were successfully treated by single-level bone transport using a unilateral external fixator, with a mean bone union time (BUT) of 7.3 ± 1.71 months. According to the ASAMI criteria, there were statistical differences in bone and function results between the three groups (P vs. I vs. D, P < 0.001). The excellent and good rate of bone result in the intermediate group was higher than the other (P vs. I vs. D, 73.6% vs. 84% vs. 66.7%), and the excellent and good rate of function result in the proximal group was the highest (P vs. I vs. D, 84.2% vs. 80% vs. 73.3%). Complications were observed in 29 out of 62 patients (46.7%), with pin tract infection being the most common (14.8%), followed by axial deviation (14.8%), muscle contractures (12.7%), joint stiffness (12.7%), and soft tissue incarceration (12.7%). Other complications included delayed consolidation (12.7%), delayed union (6.3%), nonunion (4.2%), and neurological injury (8.5%). Two patients (3.2%) required below-knee amputation due to uncontrollable infection and previous surgery failure.

CONCLUSIONS

Pin tract infection was the most common complication in tibial bone transport using an external fixator. Complications of distal tibial bone transport are more severe and occur at a higher rate than in other parts. Axial deviation mostly occurred in the intermediate tibial bone transport.

Penthrox® (Methoxyflurane) as an Analgesic for Removal of Circular External Fixators and Minor Procedures during the COVID-19 Pandemic

Introduction

Methoxyflurane has excellent analgesic properties and is approved for use in the United Kingdom and Ireland since 2015. It is currently used in emergency departments for analgesia during fracture reductions. During the COVID-19 pandemic, with theatre access severely restricted, Penthrox® had the potential to provide adequate pain relief to aid frame and wire removal in the clinic setting.

Materials and methods

Patients presenting to the limb reconstruction service elective clinic and requiring frame removal or minor procedures were included in the study. Patients with renal, cardiac or hepatic disease, a history of sensitivity to fluorinated anaesthetic agents and those on any nephrotoxic or enzyme-inducing drugs were excluded. All procedures were performed in an appropriate isolated room in the clinic. Patient demographics, procedure details, visual analogue score, Richmond Agitation Scale and patient satisfaction were recorded.

Results

A total of 39 patients were included in the study of which 17 had Ilizarov frames removed, 10 had hexapod removals, nine had heel rings removed and three had an external fixator removed. Eleven patients received additional pain relief in the form of oral analgesia. All patients were satisfied or very satisfied with the experience. One patient required a general anaesthetic for the removal of a wire that could not be removed in the clinic due to bony overgrowth.

Conclusion

Patient satisfaction was very high (>95%), and it was possible to perform frame removals and minor procedures in the clinic environment during the COVID-19 pandemic. We see potential for regular use of Penthrox® in the future for the removal of external fixation outside of the operating theatre.

Clinical significance

Penthrox as an analgesic for frame adjustments and removals is safe and has the potential for significant financial savings for the National Health Service (NHS).

How to cite this article

Debuka E, Birkenhead P, Shah S, et al. Penthrox® (Methoxyflurane) as an Analgesic for Removal of Circular External Fixators and Minor Procedures during the COVID-19 Pandemic. Strategies Trauma Limb Reconstr 2023;18(2):82-86.

Functional outcomes and complications after treatment of distal radius fracture in patients sixty years and over: A systematic review and network meta-analysis

AIM

This network meta-analysis aims to compare functional outcomes and complications between conservative treatment and surgery for distal radius fractures in patients aged 60 years and over.

METHODS

We searched the PubMed, EMBASE, and Web of Science databases for randomized controlled trials (RCTs) assessing the effect of conservative treatment and surgery for distal radius fractures in patients aged 60 years and over. Primary outcomes included grip strength and overall complications. Secondary outcomes included Disabilities of the Arm, Shoulder, and Hand (DASH) scores, Patient-Rated Wrist Evaluation (PRWE) scores, wrist range of motion and forearm rotation, and radiographic assessment. All continuous outcomes were assessed using standardized mean differences (SMDs) with 95% confidence intervals (CIs), and binary outcomes were assessed using odds ratio (OR) with 95% CIs. The surface under the cumulative ranking curve (SUCRA) was used to determine a hierarchy of treatments. Cluster analysis was performed for grouping treatments based on the SUCRA values of primary outcomes.

RESULTS

Fourteen RCTs were included to compare conservative treatment, volar lockedplate (VLP), K-wires fixation, and external-fixation. VLP outperformed conservative treatment for 1-year and minimum 2-year grip strength (SMD; 0.28 [0.07 to 0.48] and 0.27 [0.02 to 0.53], respectively). VLP yielded the optimal grip strength at 1-year and minimum 2-year follow-up (SUCRA; 89.8% and 86.7%, respectively). In a subgroup analysis of patients aged 60 to 80 years old, VLP outperformed conservative treatment in DASH and PRWE scores (SMD, 0.33 [0.10, 0.56] and 0.23 [0.01, 0.45], respectively). In addition, VLP had the fewest complications (SUCRA = 84.3%). Cluster analysis suggested that VLP and K-wire fixation were more effective treatment groups.

CONCLUSION

Evidence to date demonstrates that VLP provides measurable benefits in grip strength and fewer complications to those 60 years of age and over, and that benefit is not reflected in current practice guidelines. There is a subgroup of patients where K-wire fixation outcomes are similar to those of VLP; defining this subgroup may yield substantial societal benefits.

Physiotherapy assessment and treatment of patients with tibial external fixator: a systematic scoping review

PURPOSE

To map evidence regarding physiotherapy assessment and treatment of patients with tibial external fixator (EF), and to point out literature gaps for further research.

METHODS

Systematic scoping review conducted in four databases. We included both experimental and non-experimental studies involving patients with tibial EF and outcomes of interest. We recorded study design, population, sample size, sample age, reason for EF use, type of surgery, type of EF used, instruments used for assessing function, pain, quality of life, satisfaction, psychosocial aspects, and physiotherapy treatment descriptions from included studies. We categorised data accordingly to outcomes assessed and physiotherapy treatments description.

RESULTS

Eighty-six studies were included involving 3070 patients. Causes of fixator use were traumatic conditions, acquired and congenital deformities, and non-traumatic conditions, like compartmental osteoarthritis. Function was assessed in about three-quarters of included studies, though other outcomes were not presented in most studies. Only one study described satisfactorily the physiotherapy treatment. Almost half of the studies did not provide any description of the rehabilitation process.

CONCLUSIONS

There is little evidence about the assessment of function, pain, quality of life, satisfaction, psychosocial aspects, and other outcomes in tibial EF patients. Physiotherapy treatment in these patients is poorly reported.Protocol registration: Open Science Framework: doi:10.17605/OSF.IO/UT2DAIMPLICATIONS FOR REHABILITATIONRehabilitation programmes and research should consider that most studies with tibial external fixator (EF) patients did not evaluate outcomes routinely used in physiotherapy assessment.Rehabilitation programmes should consider that the instruments used in evaluation of tibial EF patients have unknown measurement properties.Rehabilitation programmes should consider that treatment of patients with tibial EF involves different types of interventions, however, they are poorly described or not described in most studies.

Radiographic parameters associated with fracture-related infection in high energy bicondylar tibial plateau fractures managed with two-stage treatment: Identifying the bad actors

INTRODUCTION

High energy tibial plateau fractures are fraught with complications, particularly fracture-related infection (FRI). Previous studies have evaluated patient demographics, fracture classification, and injury characteristics as risk factors for FRI in patients with these injuries. This study evaluated the relationship between radiographic parameters (fracture length relative to femoral condyle width (FLF ratio), initial femoral displacement (FD ratio), and tibial widening (TW ratio)) and fracture-related infection following internal fixation in high energy bicondylar tibial plateau fractures.

METHODS

225 patients treated for bicondylar tibial plateau fractures at two level I trauma centers were retrospectively reviewed. Patient characteristics, fracture classification, and radiographic measurements were analyzed to determine association with FRI.

RESULTS

The rate of FRI was 13.8%. Increased fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were each associated with FRI on regression analysis, independent of clinical variables. Cutoff values were identified for each parameter and patients were risk stratified based on these radiographic parameters. High-risk patients had a 2.68- and 12.36-times risk of FRI compared to medium and low-risk patients, respectively.

DISCUSSION

This study is the first to examine the relationship between radiographic parameters and FRI in high energy bicondylar tibial plateau fractures. Fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were identified as radiographic parameters associated with FRI. More importantly, risk stratifying patients based on these parameters accurately identified patients at increased risk of FRI. Not all bicondylar tibial plateau fractures are created equal and radiographic parameters can be utilized to help identify the bad actors.

Clinical trial of a low-cost external fixator for global surgery use

PURPOSE

A low-cost modular external fixator for the lower limb has been developed for global surgery use. The purpose of this study is to assess outcome measures in the first clinical use of the device.

METHODS

A prospective cohort study was conducted with patients recruited in two trauma hospitals. Initial clinical procedure data were collected, and patients were followed up every two weeks until 12 weeks or definitive fixation. Follow-up assessed infection, stability, and radiographic outcomes. In addition, patient-reported outcomes and surgeons' feedback on device usability were collected by questionnaires.

RESULTS

The external fixator was used on 17 patients. Ten were mono-lateral, five were joint spanning, and two were delta configuration. One patient had a pin site infection at 12-week follow-up. All were stable when tested mechanically and using radiographic assessment, and 53% were converted to definitive fixation.

CONCLUSION

The low-cost external fixator developed is appropriate for use in global surgery trauma centres with good clinical outcomes.

PROSPECTIVE TRIAL REGISTRATION NUMBER AND DATE

SLCTR/2021/025 (06 Sep 2021).

Treatment outcomes of applying external fixator on distal radius fractures: a randomized clinical trial to compare between two directions of force exertion in parallel to radius shaft and perpendicular to the distal radius articular surface

BACKGROUND

External fixation has been one of the conventional managements of unstable distal radius fracture. The main aim of this paper is to compare two methods of applying distractive force along the radius shaft versus perpendicular to the distal radius articular surface.

DESIGN

Sixty patients with unstable distal radius fracture were included in present clinical trial and randomized in two groups, using block randomization method. In group A (first arm), distraction force was exerted parallel to the radius shaft. In group B (second arm), the external fixator was adjusted based on radial and palmar tilt of the mean population healthy wrist so that distraction was exerted perpendicular to the wrist articular surface.

METHODS

Radiological and clinical parameters were evaluated in both groups of patients pre-operatively, immediately after surgery, and 6 weeks post-operatively. We also followed up patients clinically at 12 weeks after surgery. Patient-Rated Wrist Evaluation (PRWE), Mayo wrist score, and Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires were used in order to assess patients' clinical and functional states.

RESULTS

The method used in group B resulted in better improvement of palmar tilt both immediately (P = 0.007) and at 6 weeks follow up (P = 0.013) post-operatively in comparison with patients in group A. Radius height and radial inclination were also better restored when using the proposed modified method (P = 0.001 and < 0.001, respectively). There was no difference in any of clinical results (range of motion, grip strength, PRWE, Mayo, and DASH scores) between two groups of study, 12 weeks after surgery.

CONCLUSION

Applying distractive force perpendicular to the distal radius articular surface seems to improve some radiological outcomes, probably due to better reduction maintenance, when compared with the technique of applying distraction force along distal radius shaft axis.

LEVEL OF EVIDENCE

Level I (clinical trial study).

TRIAL REGISTRATION

This study is registered at Iranian Registry of Clinical Trials (IRCT) with approval code of IRCT20200313046759N1.

[Development and principles of intramedullary and extramedullary segmental bone transport: overview and clinical results]

BACKGROUND

Segmental bone transport using intramedullary or extramedullary techniques is one of the most commonly used procedures for bone defect management in the diaphyseal region of long bones.

OBJECTIVE

The purpose of this work is to provide an overview of the historical development and general principles as well as the current status of extramedullary and intramedullary techniques of bone segment transport. In addition, own results on internal segmental bone transport are presented.

MATERIAL AND METHODS

A retrospective database analysis included all patients between May 2019 and January 2021 who underwent segmental bone transport via a fully implantable intramedullary segment transport nail system. In addition to the radiological outcome, the clinical outcome was assessed using the lower extremity functional scale (LEFS).

RESULTS

A total of 9 patients (8 male, 1 female; age 41.7 ± 3.9 years) could be included. The cause of the segmental bone defect was chronic fracture-related infection in all cases. The segmental defect size was 62 ± 10 mm. Sufficient bridging of the bone defect was achieved in all patients, with a mean distraction rate of 0.9 ± 0.1 mm per day. Bony consolidation of the regeneration was achieved after 292 ± 57 days, and final bony consolidation of the docking zone was achieved after 469 ± 116 days. At 22 ± 3 months after implantation of the segmental transport nail, the LEFS demonstrated a result of 59 ± 4 points. No recurrence of infection or regeneration failure occurred.

CONCLUSION

The aim of treating segmental bone defects, in addition to reconstructing a load-bearing bone, is to restore correct joint angles, leg length, and leg axis without torsional deviation and can be achieved via classical external segmental bone transport. In recent years, internal segmental bone transport has been developed as an alternative. It remains to be seen whether the preliminary and reproducibly good clinical and radiological results of segmental transport nails can be confirmed for widespread use in the future.

Hydroxyapatite-coated compared with stainless steel external fixation pins did not show impact in the rate of pin track infection: a multicenter prospective study

PURPOSE

Infection at the pin site remains the most common complication of external fixators (EFs). It is known that hydroxyapatite (HA)-coated pins increase bone adhesion and may lead to reduced rates of reported infections. The present study compares the rates of pin track infection associated with stainless steel and HA-coated pins.

METHODS

This is a prospective, multicenter, nonrandomized, comparative intervention study among patients undergoing surgical treatment with EFs of any type between April 2018 and October 2021. Patients were followed up until the removal of the EF, or the end of the study period (ranging from 1 to 27.6 months). The definition of pin track infection was based upon the Maz-Oxford-Nuffield (MON) pin infection grading system.

RESULTS

Overall, 132 patients undergoing external fixation surgery were included. Of these, 94 (71.2%) were male, with a mean age of 36.9 years (SD ± 18.9). Infection of any type (score > 1) was observed in 63 (47.7%) patients. Coated and uncoated-pin track-infection occurred in 45.7% and 48.5% of patients, respectively (P= 0.0887). The probability of developing infection (defined as a score ≥ 2) adjusted for comorbidities and follow-up time was not statistically higher among those who received uncoated pins compared to those who received pins coated with HA (odds ratio (OR) = 1.56, 95% confidence interval (95% CI): 0.67-3.67, p <0.05).

CONCLUSION

In the present study, the external fixator pin infection rates were similar when using HA coating and standard steel pins.

Treatment of camptodactyly with a new progressive correction device

The aim of this study was to introduce a new progressive correction device and present treatment results in camptodactyly patients. Eight patients (11 fingers) were treated for camptodactyly by an external fixator between February 2019 and April 2020. Mean follow-up was 28.7 ± 3.3 months (range, 24-35 months). Operative times and treatment complications were recorded. Pre- and post-operative flexion contracture, total active range of motion (TAM) and esthetic satisfaction were evaluated at final follow-up. Esthetic satisfaction was rated by the patient on a 1-5 point scale. Seven patients were male, and 1 female. Mean age was 21.6 ± 8.5 years (range, 15-42 years). Mean surgery time was 14.9 ± 2.4 min (range, 10-18 min). Mean preoperative flexion contracture was 85.9 ± 7° (range, 75-95°), and mean postoperative flexion contracture was 4 ± 3° (range, 0-10°). Transient proximal interphalangeal joint swelling was seen in 1 case and pin tract infection in 1. TAM was perfect in 5 fingers and good in 6. Patients were either very satisfied (n = 5) or satisfied (n = 3) with the esthetic appearance of each operated finger. Camptodactyly could be managed with a hinged external fixator simply and effectively with gratifying results in selected patients. LEVEL OF EVIDENCE: Level IV, case series.

Biomechanical study of the stiffness of the femoral locking compression plate of an external fixator for lower tibial fractures

BACKGROUND

A locking compression plate (LCP) of the distal femur is used as an external fixator for lower tibial fractures. However, in clinical practice, the technique lacks a standardized approach and a strong biomechanical basis for its stability.

METHODS

In this paper, internal tibial LCP fixator (Group IT-44), external tibial LCP fixator (Group ET-44), external distal femoral LCP fixator (Group EF-44, group EF-33, group EF-22), and conventional external fixator (Group CEF-22) frames were used to fix unstable fracture models of the lower tibial segment, and anatomical studies were performed to standardize the operation as well as to assess the biomechanical stability and adjustability of the distal femoral LCP external fixator by biomechanical experiments.

RESULTS

It was found that the torsional and flexural stiffnesses of group EF-44 and group EF-33 were higher than those of group IT-44 and group ET-44 (p < 0.05); the flexural stiffness of group EF-22 was similar to that of group IT-44 (p > 0.05); and the compressive stiffness of all three EF groups was higher than that of group ET-44 (p < 0.05). In addition, the flexural and compressive stiffnesses of the three EF groups decreased with the decrease in the number of screws (p < 0.05), while the torsional stiffness of the three groups did not differ significantly between the two adjacent groups (p > 0.05). Group CEF-22 showed the highest stiffnesses, while group ET-44 had the lowest stiffnesses (P < 0.05).

CONCLUSIONS

The study shows that the distal femoral LCP has good biomechanical stability and adjustability and is superior to the tibial LCP as an external fixator for distal tibial fractures, as long as the technique is used in a standardized manner according to the anatomical studies in this article.

Percutaneous femoral de-rotational varus osteotomy for the treatment of acetabular dysplasia: surgical technique

Pediatric acetabular dysplasia is common in orthopedic practice. Femoral de-rotational varus osteotomy (FDVO) is one of the surgical options suggested for treatment. In this article, we describe a simplified surgical technique of performing FDVO percutaneously using a pediatric Limb Reconstruction System external fixator, and we discuss the advantages and disadvantages of the technique.

Circular External Fixator Removal in the Outpatient Clinic Using Regional Anaesthesia: A Pilot Study of a Novel Approach

Introduction

External fixator (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under general anaesthesia in an operating theatre. This practice is resource-intensive and limits the amount of time available for other surgical cases in the operating theatre. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate the EF removal in an outpatient setting.

Design and methods

This prospective case series evaluated the first 50 consecutive cases of EF removal in the outpatient clinic between 10/06/22 and 03/02/23. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirements and then were asked to evaluate their experience and perceived pain using the visual analogue scale (VAS).

Results

Fifty patients were included in the study. The mean age was 46.8 years (range 21-85 years). About 54% of the patients were male patients (N = 27). Post-procedure, all patients indicated positive satisfaction ratings, each participant responded as either 'satisfied' (N = 6), 'very satisfied' (N = 24) or 'highly satisfied' (N = 20). In addition, 90% of the participants reported that they would opt for this method of EF removal again in future. The VAS for pain immediately following completion of the procedure was low, with a mean score of 0.36 (range 0-4), where a score of 0 = 'No pain', and 10 = 'worst pain possible'. The median score was 0.

Conclusion

We present the first description of outpatient EF removal using regional anaesthesia, with a prospective case series of 50 fully conscious patients from whom the EF was removed. This novel technique is likely to be cost-effective, reproducible, and safe. This technique reduces the burden of EF removal from an operating list and also improves the patient's experience when compared with other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this technique also demonstrates a method of improving environmental sustainability.

How to cite this article

Williams LM, Stamps G, Peak H, et al. Circular External Fixator Removal in the Outpatient Clinic Using Regional Anaesthesia: A Pilot Study of A Novel Approach. Strategies Trauma Limb Reconstr 2023;18(1):7-11.

Efficacy analysis of a double-Schanz screw external fixator combined with anti-rotating Kirschner wire in the treatment of proximal humerus fractures in skeletally immature patients

OBJECTIVES

The objective of this study is to evaluate the efficacy of a double-Schanz screw external fixator combined with anti-rotating Kirschner wire in the treatment of displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients.

METHODS

A retrospective analysis was performed on 22 cases of displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients who were treated with a double-Schanz screw external fixator combined with anti-rotating Kirschner wire. Patients included were the Neer-Horowitz (N-H) type 2, 3, and 4 of fracture. The basic information of the patients was recorded, fracture healing and shoulder range of motion were assessed at the last follow-up visit. The disabilities of the arm, hand (DASH) score and Constant-Murley score of the shoulder were performed to observe the occurrence of complications.

RESULTS

The mean age at the time of surgery was 12.41 years, and all patients completed a median follow-up of 18.18 months. There were two cases of N-H type 2, 12 cases of N-H type 3, and eight cases of N-H type 4 among the patients. At the last follow-up, all patients were able to achieve pain-free shoulder movement. There was no significant difference in shoulder function between the injured side and the uninjured side. The DASH score mean was 2.43 (95% CI 1.44-3.52). The constant score mean was 98.55 (95% CI 97.73-99.27). All patients returned to their pre-injury daily life and physical activities, and there was no significant difference in bilateral limb length at the last follow-up (p < 0.05). The most common complication of double-Schanz screw external fixator combined with anti-rotating Kirschner wire surgery was pin tract infection, which occurred in 5 cases (22.7%). There were no complications such as deep infections, vascular and nerve damage, failure of fixation, secondary fracture displacement, non-union of fracture, osteonecrosis of the humerus, joint stiffness, rotator cuff weakness and limb deformity.

CONCLUSION

The double-Schanz screw external fixator combined with anti-rotating Kirschner wire is a safe and effective treatment for displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients over the age of 10 years.

A comparative study of bone union and nonunion during distraction osteogenesis

BACKGROUND

The clinical characteristics of bone nonunion during distraction osteogenesis (DO) were rarely discussed. This study was employed to specify the difference between bone union and nonunion during DO.

METHODS

The patients with bone lengthening were recruited in our study. The bone union cases indicated the ones that remove the external fixator successfully, whereas the bone nonunion represented the bridging callus did not appear even after 9 months (an absence of bridging callus for at least three out of four cortices on plain radiographs) that needs autogenous bone transplantation. The differences in the pixel value ratio (PVR) growth of regenerated callus, lengthening index (LI), healing index (HI), external fixation index (EFI) and blood biochemical indexes between bone union and nonunion were analyzed.

RESULTS

A total of 8 bone nonunion and 27 bone union subjects were included in this study. The PVR growth in bone nonunion was significantly lower than that in bone union (0.19 ± 0.06 vs. 0.32 ± 0.16, P = 0.048). Interestingly, the HI and EFI in bone nonunion was significantly higher than that in bone union (62.0 ± 31.4 vs. 37.0 ± 27.4, P = 0.036; 75.0 ± 30.9 vs. 49.9 ± 16.1, P = 0.006). However, no significant difference with regard to LI was identified (0.76 ± 0.52 vs. 0.77 ± 0.32, P = 0.976). Moreover, the circulating level of urea and lymphocyte count in bone union was significantly lower than that in bone nonunion (4.31 ± 1.05 vs. 5.17 ± 1.06, P = 0.049; 2.08 ± 0.67 vs. 2.73 ± 0.54, P = 0.018). On the contrary, the circulating level of magnesium in bone union was significantly higher than that in bone nonunion (0.87 ± 0.07 vs. 0.80 ± 0.07, P = 0.014).

CONCLUSION

Compared to the bone union, the PVR growth was significantly lower, whereas the HI and EFI was significantly higher in the bone nonunion. Moreover, the circulating level of urea, magnesium and lymphocyte count was also different between these two. Therefore, the PVR, HI and EFI seems to be reliable and sensitive indicators to reflect the bone nonunion during DO, which might be considered in bone lengthening. Further prospective studies are still needed to elaborate the concerned issues.

Assessing and managing open fractures: a systematic approach

Open fractures are complex injuries strongly associated with high-energy trauma. Assessment should include the mechanism and place of injury, timing, associated injuries and comorbidities. The initial management of these fractures, whether in the prehospital setting or emergency department, must include the following in a prompt manner: administration of antibiotics and tetanus prophylaxis, photography, reduction or re-alignment, wound coverage and splintage. Imaging includes plain X-rays and a computed tomography trauma scan, as well as an angiogram if vessel damage is suspected. Collectively, the energy of the mechanism of injury, with the level of contamination, potential for compartment syndrome and vascular damage, determines the operative urgency. Operative management can be a one- or two-stage procedure, because definitive internal skeletal fixation should only be attempted if soft tissue coverage can occur during the same operation. Ideally, all open fractures should be closed within 72 hours. This article explores the evidence for current best practice.

Callus distraction for brachymetatarsia - A comparison between an internal device and the external fixator

BACKGROUND

Symptomatic patients with severe brachymetatarsia are commonly treated with callus distraction using external mini-fixator (EF) or internal device (ID). This study points out advantages and limitations of both methods comparing clinical and radiographical parameters.

METHODS

Retrospective analysis of 21 metatarsal bones in twelve patients. Twelve metatarsals were treated with ID (Genos Mini), nine with EF (MiniRail).

RESULTS

Mean lengthening distance was 17.3 mm using EF and 11.7 mm using ID (p = 0.016). Adverse results were observed in 89% of metatarsals treated with EF and in 33% treated with ID (p = 0.011). Postoperative surgical intervention was required in 33% using EF compared to 0% using ID (p = 0.031). Mean total German Foot Function Index (FFI-T) improved from 49 to 33 using EF and from 47 to 22 using ID (p < 0.001).

CONCLUSION

CD is a reliable surgical treatment for BMT. Surgeons should be aware of implant-related advantages and complications when counseling patients about treatment options.

Tibial pilon fractures treated with a periarticular external fixator: Retrospective study of 47 cases

INTRODUCTION

Tibial pilon fractures are a treatment challenge, since there is no true gold standard treatment, and because of potential skin complications. Periarticular external fixation (PAEF) appears to produce good results, but the outcomes with the TL-HEX Trauma™ (Orthofix®, Verona, Italy) have not yet been evaluated. We performed a study with the following objectives: 1) evaluate time to union and union rate; 2) determine clinical and radiological results; 3) detect complications.

HYPOTHESIS

PAEF will produce comparable fracture union to other external fixator techniques for tibial pilon fractures.

METHODS

A single center, retrospective study, was done between June 2016 and December 2018. Patients who had a tibial pilon fracture operated with a PAEF were included if they had a minimum of 12 months' follow-up. Forty-seven patients were included; the mean follow-up was 2.45 years (1.2-3.7). The primary endpoint was the time to union and union rate at the final assessment. The secondary endpoints were the joint range of motion, residual pain (VAS), functional scores (AOFAS and SF12) and complication rate.

RESULTS

The union rate was 70% (33/47) and the mean time to union was 201±79 days (89-369). The range of motion was significantly reduced relative to the contralateral side. Twenty patients had residual pain that averaged 2.9 (1-6) on the VAS. The mean AOFAS score was 74 points (51-95). Twenty patients (43%) suffered at least one complication.

DISCUSSION

While a PAEF helps to avoid skin complications, in our study, it was associated with a lower union rate and longer time to union than in other published studies. This difference is likely due to a higher rate of open fractures and high-energy trauma in our study, different protocol for return to weightbearing and a different external fixator than other studies. This is the first study reporting the results of the TL-HEX Trauma in this indication.

LEVEL OF EVIDENCE

IV, retrospective study.

[Comparative study of monolateral and circular fixator in the treatment of infectious tibial nonunion]

OBJECTIVE

To compare treatment effect of monolateral and circular external fixator in infectious tibial nonunion and to explore external fixation structure with better osteogenic ability and fewer complications.

METHODS

A retrospective analysis was performed on 150 patients with infectious tibial nonunion admitted from January 2010 to December 2014. Patients who met the inclusion and exclusion criteria were divided into monolateral fixator group and circular fixator group according to the type of external fixation. Demographic and perioperative data of the two groups were collected. New bone quality was assessed by pixels ratio, treatment effect was assessed by complications. Notes for treatment was explored by case analysis.

RESULTS

A total of 64 patients with infectious mid-tibial nonunion were included, 26 in monolateral fixator group and 38 in circular fixator group. There was no difference in demographic data between two groups. The pixel ratio of new bone between two groups was from 0.91 to 0.97 with an average of (0.94±0.03), and from 0.93 to 0.97 with an average of(0.95±0.02), respectively, with no statistical significance (P>0.05). The external fixation index was from 34.1 to 50.6 with an average of (42.3±8.3) days /cm in monolateral fixator group and from 44.5 to 56.1 with an average of (45.8±10.3) days/cm in the circular fixator group, and the difference was not statistically significant (P>0.05). There were 7 cases (26.9%) of complications in monolateral fixator group and 5 cases (13.2%) in circular fixator group, the difference was not statistically significant (P>0.05), but 5 cases of foot ptosis in monolateral fixator group and none in circular fixator group. The time of weight bearing in monolateral fixator group was later than that in circular fixator group, and the difference was statistically significant (P<0.05).

CONCLUSION

Monolateral and circular fixators can achieve equivalent bone formation in the treatment of infected tibial nonunion. Circular fixator is recommended for patients with severe osteoporosis or concomitant medical diseases requiring early weight bearing. Hydroxyapatite coated screws are recommended if a monolateral external fixator is selected when the expected enlarged length is long and the fixation time is long and close monitoring of the ankle movement is required to avoid foot droop.

Risk factors of transport gap bending deformity in the treatment of critical-size bone defect after bone transport

Background

The purpose of this study was to investigate the risk factors of transport gap bending deformity (TGBD) in the treatment of critical-size bone defect (CSBD) after the removal of the external fixator.

Methods

From January 2008 to December 2019, 178 patients with bone defects of the lower extremity caused by infection were treated by bone transport using a unilateral external fixator in our medical institution. TGBD was defined as the bone callus in the distraction area with a deviation to the force line of the femur (> 10°) or tibia (> 12°) after removal of the external fixator. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes. After the data were significant by the T-test or Pearson’s Chi-square test was analyzed, odds ratios were calculated using logistic regression tests to describe factors associated with the diagnosis of TGBD.

Results

A total of 178 patients were enrolled in the study, with a mean follow-up time of 28.6 ± 3.82 months. The positive result of the bacteria isolated test was observed in 144 cases (80.9%). The rate of excellent and good in the bone outcomes (excellent/good/fair/poor/failure, 41/108/15/14/0) was 83.7%, and 92.3% in the functional results (excellent/good/fair/poor/failure, 50/98/16/14/0) according to the ASAMI criteria. TGBD after removal of external fixator occurred in twenty-two patients (12.3%), including 6 tibias, and 16 femurs. Age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, osteoporosis, glucocorticoid intake, duration of infection > 24 months, EFT > 9 months, EFI > 1.8 month/cm were associated significantly with a higher incidence of TGBD in the binary logistic regression analysis (P < 0.05). The incidence more than 50% was found in patients with femoral defect (76.1%), osteoporosis (72.7%), BMI > 25 kg/m² (69.0%), diabetes (59.5%), glucocorticoid intake (54.7%). In the multivariate logistic regression analyses, the following factors were associated independently with TGBD, including age > 45 years, BMI > 25 kg/m², femoral defect, diabetes, and osteoporosis.

Conclusions

Bone transport using a unilateral external fixator was a safe and practical method in the treatment of CSBD caused by infection. The top five risk factors of TGBD included femoral defect, BMI > 25 kg/m², duration of bone infection > 24 months, age > 45 years, and diabetes. Age > 45 years, BMI > 25 kg/m², femoral defect, osteoporosis, and diabetes were the independent risk factors. The higher incidence of TGBD may be associated with more risk factors.

Therapeutic effect of an external fixator in the treatment of unstable pelvic fractures in children

BACKGROUND

Unstable pelvic fractures in children are serious and complex injuries, and the optimal method to manage these injuries is controversial.

HYPOTHESIS

We hypothesized that an external fixator would be a satisfactory method of treating unstable pelvic fractures in children.

PATIENTS AND METHODS

We retrospectively reviewed 40 pediatric patients with unstable pelvic fractures who were treated with an external fixator in Beijing Children's Hospital from June 2006 to June 2016. Postoperative follow-up was 12 to 108 months, with an average of 26 months. One year after the operation, fracture healing, pelvic asymmetry, and deformity index were assessed by X-ray. Pelvic function was evaluated with the Cole evaluation standard, and daily cognitive and motor functions were evaluated by weeFIM. Patient complications were recorded.

RESULTS

The average age of the 40 patients was 5.9±3.1 years (2 to 14.5), including 25 boys and 15 girls. Among these cases, 37 (92.5%) had injuries caused by traffic accidents and 3 (7.5%) had injuries caused by falling from height. Based on the Tile classification, there were 18 cases of class B (14 class B2 and 4 class B3) and 22 cases of class C (15 class C1, 6 class C2, and 1 class C3). The X-rays showed good fracture healing at the 1-year postoperative follow-up. The pelvic asymmetry was reduced from 1.13cm before the operation to 0.88cm after (p<0.05), and the deformity index was decreased from 0.09 before to 0.05 after the operation (p<0.05). At the 1-year postoperative follow-up, 36 patients had excellent Cole scores, and 4 had good Cole scores, with a good or excellent rate of 100%. According to the weeFIM, 28 patients had complete independence, 11 had basic independence, and 1 had conditional independence. Three patients (7.5%) had complications, all of which were postoperative pin-site infections.

DISCUSSION

For children with horizontally unstable pelvic fractures, an external fixator can be used alone. For children with horizontally and vertically unstable pelvic fractures, after external fixator placement and reduction, lower extremity traction can be performed to achieve better reduction and maintain stability, and the therapeutic effect is satisfactory.

LEVEL OF EVIDENCE

IV, retrospective observational cohort study.

Efficacy of Temporary Intentional Leg Shortening and Deformation for Treatment of Massive Bone and Soft Tissue Defects in Three Patients

Aim

This study describes the intentional deformation and shortening of a limb using external fixation (EF) in three patients with post-traumatic injury tibial defects and to assess the outcomes.

Case description

Three patients with infected non-unions and massive bone and soft tissue defects who were treated with temporary intentional leg shortening and deformation using a Taylor Spatial Frame (TSF) EF were retrospectively reviewed. The alignment was restored by gradual deformity correction and lengthening after a 2-week interval. No additional surgical intervention was required for soft tissue reconstruction after primary skin closure. Skin closure and good bone alignment were achieved in all patients. The functional outcomes and bone outcomes were evaluated for all cases according to the Paley criteria modified by the Association for the Study and Application of Methods of Ilizarov. All patients showed excellent bone outcomes. Two patients achieved excellent functional outcomes and one had a good outcome. The patient with a good outcome was unable to descend the stairs comfortably.

Conclusion

This technique is suitable for treating massive bone and soft tissue defects and should be considered as a treatment option.

How to cite this article

Ugaji S, Matsubara H, Aikawa T, et al. Efficacy of Temporary Intentional Leg Shortening and Deformation for Treatment of Massive Bone and Soft Tissue Defects in Three Patients. Strategies Trauma Limb Reconstr 2022;17(3):195-201.

Metatarsal Gradual Lengthening for Brachymetatarsia Using a Mini-rail External Fixator System

Aim

To describe the surgical technique for gradual lengthening of the metatarsal using the Orthofix MiniRail System (Orthofix Medical Inc., Lewisville, TX, USA).

Background

Brachymetatarsia refers to the shortening of the metatarsal bone. When indicated, metatarsal lengthening is performed to treat this deformity.

Technique

A dorsal approach to the short metatarsal is performed, protecting the neurovascular structures and the extensor tendons. The most proximal wire or screw is inserted first, followed by the most distal wire or screw. The distal wire or screw should not be inserted in the metatarsal head. The middle wires or screws are inserted thereafter. All wires or screws should be placed perpendicular to the anatomic axis of the bone. Once the MiniRail lengthener is assembled, a 1.6 mm K-wire is inserted from the tip of the toe into the metatarsal head, blocking the motion of the metatarsophalangeal joint and avoiding joint subluxation during lengthening. The osteotomy is then performed perpendicular to the metatarsal shaft, in between the middle two wires and screws.

Conclusion

The surgical technique for gradual lengthening of the metatarsal using the Orthofix MiniRail System was described in detail with accompanying step-by-step intraoperative clinical and fluoroscopic images.

Clinical significance

This surgical technique of metatarsal lengthening is simple and effective. An understanding of the surgical technique of gradual lengthening of the metatarsal bone is important when treating shorting deformities of more than 1 cm.

How to cite this article

Marwan Y, Abu Dalu K, Bernstein M, et al. Metatarsal Gradual Lengthening for Brachymetatarsia Using a Mini-rail External Fixator System. Strategies Trauma Limb Reconstr 2022;17(3):184-188.

External fixator pin placement during initial management of tibial plateau fractures: are there parameters to minimize pin-plate overlap?

PURPOSE

External fixator pin site overlap with definitive fixation implants (pin-plate overlap) has been identified as a risk factor for surgical site infection in tibial plateau fractures. Despite this, pin-plate overlap occurs in 24-38% of patients. This study sought to identify radiographic characteristics associated with pin-plate overlap to help minimize occurrences.

METHODS

283 patients at two Level I trauma centers were retrospectively reviewed. Radiographic measurements were recorded including fracture length, distance from fracture to proximal tibial pin site, and pin site distance-to-fracture (PSF) ratio.

RESULTS

70 (24.7%) cases of pin-plate overlap were identified. Pin-plate overlap was associated with increased fracture length (81.5 ± 32.1 mm vs 56.9 ± 26.1 mm, p < 0.001) and decreased distance from fracture to proximal tibial pin site (84.5 ± 37.1 mm vs 126.9 ± 35.8 mm). Pins placed greater than 100 mm and 150 mm from the fracture eliminated 36/70 (51%) and 67/70 (96%) pin-plate overlaps, respectively. Pins placed with a PSF ratio greater than 1.5 and 2.0 eliminated 47/70 (67%), and 57/70 (81%) of pin-plate overlaps, respectively.

CONCLUSIONS

Longer fractures, pins closer to the fracture, and decreased PSF ratio were associated with overlap. Placing proximal tibial pins more than 100 mm from the fracture eliminated most pin-plate overlaps.

Are external fixators as effective as volar plates in multi-fragmented radius distal intra-articular fractures (AO type C)?

INTRODUCTION

This study aimed to compare the radiological and clinical results of VP and EF applications in multi-fragmented radius distal intra-articular fractures (AO type C) in our clinic.

METHODS

We retrospectively analysed 80 patients who underwent surgery for radius distal fracture (AO type C) between 2014 and 2020. Group 1 comprised patients who were treated with VP, and Group 2 comprised patients who were treated with EF. Radiological evaluation was performed by measuring radial inclination, radial length, volar tilt, intra-articular step-off and ulnar variance by two-way radiography. The clinical findings were evaluated using the Gartland and Werley scoring system, and complications were noted.

RESULTS

There were no statistically significant differences between the two groups in terms of age, gender, side, fracture subtypes and follow-up time (p > 0.05). There were no statistically significant differences between the two groups in radiological parameters (based on cut-off values) (p > 0.05). The clinical evaluation did not reveal a statistically significant difference between the two groups (p = 0.613).

CONCLUSION

EF is as successful as VP in providing radiological cut-off values. EF treatment can be used as an effective and safe alternative method for multi-fragmented radius distal intra-articular fractures.

Cost Variation in Temporizing External Fixation of Tibial Plateau and Pilon Fractures: Is There Room to Improve?

INTRODUCTION

External fixator costs have been shown to be highly variable. Current information on external fixator costs and cost drivers is limited. The aim of this study was to examine the cost variation as well as the patient-, injury-, and surgeon-related cost drivers associated with temporizing external fixation constructs in tibial plateau and pilon fracture management.

MATERIALS AND METHODS

A retrospective review was conducted to identify isolated tibial plateau and pilon fractures treated with temporizing external fixation from 2006-2018 at a level 1 trauma center. Inclusion criteria were based on fractures managed with primary external fixation, skeletal maturity, and isolated ipsilateral fracture fixation. Fracture patterns were identified radiographically using Schatzker, Weber, and OTA classification systems. Implant costs were determined using direct purchase price from the institution. The primary outcome was the external fixator total construct cost. Clinical covariates and secondary outcomes, namely unplanned reoperations, were extracted. Factors associated with cost (i.e. cost drivers) were identified via multivariable regression analysis.

RESULTS

A total of 319 patients were included in this study (121 tibial plateau and 198 pilon fractures). Mean plateau construct cost was $5,372.12 and mean pilon construct cost was $3,938.97. Implant cost correlated poorly with demographic (r²=0.01 & r²=0.01), injury-independent (r²<0.01 & r²=0.03), and fracture pattern classifications (r²=0.03 & r²=0.02). Traumatologists produced significantly cheaper implants for pilon fractures (p=0.05) but not for plateau fractures (p=0.85). There was no difference in construct cost or components between patients that underwent unplanned reoperation and those that did not for both tibial plateau (p>0.19) and pilon (p>0.06). Clamps contributed to 69.9% and 77.3% of construct costs for tibial plateau and pilon, respectively. The most cost-efficient fixation constructs for tibial plateau and pilon fractures were the following respectively: of 5 clamps, 2 bars, and 4 pins; and of 4 clamps, 2 bars, and 3 pins.

CONCLUSIONS

There is large cost variation in temporizing external fixation management. Cost drivers included surgeon bias and implant preference as well as use of external fixator clamps. Introducing construct standardization will contain healthcare spending without sacrificing patient outcomes.

LEVEL OF EVIDENCE

Level III. Retrospective Cohort.

Pure Ankle Dislocation Without Associated Fracture: A Series of Cases and Our Clinical Experience

PURPOSE

Pure ankle dislocation without associated fracture is extremely rare. The current study reports eight cases of this type of injury, aiming to add some new material to the published data and present our clinical experience.

METHODS

Six open and two closed posteromedial tibiotalar dislocations without associated fractures treated in our department from 2015 to 2019 were retrospectively analyzed. Emergent reduction was performed for all patients followed by an average of 6 weeks of immobilization with external fixators in open cases and a short leg cast in closed cases. No patients underwent ligament or capsule repair except one case. The clinical data were recorded and analyzed.

RESULTS

At a mean follow-up of 33 months (range 13-61), the average AOFAS score was 91 (range 78-100) with five ankles rated as excellent and three rated as good. All of the eight patients returned to their prior daily life and the two closed patients with sports injuries resumed pre-injury activity level. The average range of motion (ROM) loss of the ankles was 9 degrees for plantarflexion and 3 degrees for dorsiflexion. Complications included superficial infection, moderate ankle stiffness, ankle degenerative change and residual numbness. None of the eight patients showed obvious ankle instability.

CONCLUSION

Pure ankle dislocation without associated fracture is a rare injury. Emergent reduction, appropriate wound care in open injuries and proper joint stabilisation with a cast or external fixator provide good clinical results and could be the mainstay of treatment.

Adjuvant Denosumab therapy following curettage and external fixator for a giant cell tumor of the distal radius presenting with a pathological fracture: A case report

INTRODUCTION AND IMPORTANCE

Denosumab is used as a neoadjuvant therapy for giant cell tumours (GCT) prior to surgery to improve surgical clearance and reduce the rate of recurrence. However, the use of denosumab as adjuvant therapy following an external fixator for GCT of the distal radius has not been commonly described. We describe the use of adjuvant denosumab following curettage and external fixation in a patient with GCT of the distal radius presenting with a pathological fracture.

CASE PRESENTATION

A 23-year-old male presented with a right distal radius fracture. Imaging was suggestive of a Campanacci grade 3 GCT at the distal radius with a pathological fracture. His chest X-ray was normal. He was managed with a dorsal open distal radius curettage and stabilization of the fracture with an external minifixator. Histology confirmed a GCT and adjuvant denosumab therapy was given. The response was satisfactory and the external fixator was removed at 5 months. At 42 months post-treatment, he had satisfactory function with no evidence of recurrence.

CLINICAL DISCUSSION

The extensive involvement of the distal radius and local invasion precluded the use of internal fixation after thorough curettage. Therefore, an external minifixator was applied to stabilize the fracture and started on denosumab following oncology opinion.

CONCLUSION

External fixation and adjuvant denosumab may be considered as an option in patients who are not suitable for internal fixation. However, cohort studies with long term follow up is necessary before it can be recommended in routine practice.

Matched comparative study of trifocal bone transport versus induced membrane followed by trifocal bone transport in the treatment of segmental tibial defects caused by posttraumatic osteomyelitis

Objectives

To compare the efficacy and clinical outcomes of trifocal bone transport (TBT) versus induced membrane followed by trifocal bone transport (IM + TBT) in the treatment of tibial defects > 6 cm caused by posttraumatic osteomyelitis.

Methods

A total of 69 eligible patients with tibial defects > 6 cm who were treated between January 2010 and January 2018 were retrospectively reviewed. Overall, 18 patients treated by IM + TBT and 18 treated by TBT were matched by propensity score analysis. The mean tibial defect after radical debridement was 6.97 ± 0.76 cm (range, 6.0 to 8.9 cm). The measurements, including demographic data, external fixation index (EFI), external fixation time (EFT), duration of docking union, bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated by Paley classification during follow-up were recorded.

Results

Age, gender, injury mechanism, affected side, defect size, previous operation time, and follow-up time were not significantly different between the two groups (P > 0.05). The mean EFT was 293.8 ± 12.1 days in the TBT group vs. 287.5 ± 15.3 days in the IM + TBT group. The mean EFI was 36.02 ± 2.76 days/cm vs. 34.69 ± 2.83 days/cm, respectively. The mean duration of docking union was 210.7 ± 33.6 days vs. 179.7 ± 22.9 days, respectively. There was no significant difference in postoperative bone and functional results between the two groups. Delayed union or nonunion and soft tissue incarceration were significantly reduced in the IM + TBT group compared to those in the TBT group.

Conclusion

Both TBT and IM + TBT achieved satisfactory postoperative bone and functional outcomes in patients with segmental tibial defects > 6 cm following posttraumatic osteomyelitis, while IM + TBT had a significantly lower incidence of postoperative complication in delayed union or nonunion and soft tissue incarceration, as well as faster docking union.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05501-8.

Open knee dislocation, triple intra-articular fractures and patellar tendon rupture: case report of a knee disaster treated with aggressive irrigation/debridement, early anatomic reduction and internal fixation

Background

Open knee fracture-dislocation is a rare orthopedic injury. However, the importance of its correct management could not be overstated. To the best of our knowledge, this is the fifth study reporting a case with simultaneous Hoffa fracture and knee dislocation and the 1^st study describing a patient with open plateau fracture-dislocation accompanied with Hoffa fracture, patella fracture, and patellar tendon tear. In addition, this report is noticeable as our case had no gross ligament injury unlike frequent association of knee dislocation with knee collateral ligament damage.

Case presentation

In this study, we describe a 34-year-old motorcyclist referred to our center following a motor car accident. Further work-up revealed an open irreducible posterolateral knee dislocation, type 5 Hohl and Moore plateau fracture, lateral femoral condyle Hoffa’s fracture, patellar fracture, and patellar tendon tear of his right knee. During an open reduction, it turned out that an entrapped lateral meniscus prevented the joint to be reduced by closed means. After applying a temporary external fixator, the patient was finally managed with open reduction and internal fixation.

Conclusion

Irreducible knee dislocation needs further work up to rule out any interposed soft tissue into the joint. Aggressive irrigation/ debridement, early anatomic reduction, and internal fixation may help reduce open fracture complications including infection, non-union, and stiffness.

Efficacy comparison of trifocal bone transport using unilateral external fixator for femoral and tibial bone defects caused by infection

BACKGROUND

This study aimed to evaluate the clinical and functional outcomes of patients with femoral and tibial critical-sized bone defect (CSBD) treated by trifocal bone transport using the Ilizarov method.

METHODS

From March 2011 and January 2017, clinical and radiographic data of patients with CSBD (> 6 cm) caused by infection were documented and analyzed. Patients were divided into the femur group (n = 18) and tibia groups (n = 21) according to the location of bone transport. The bone and functional outcomes were evaluated according to the Association for the Study and Application of the Method of the Ilizarov (ASAMI) criterion, and postoperative complications were evaluated by Paley classification.

RESULTS

A total of 39 patients were managed by the trifocal bone transport for the femur (n = 18) or tibia (n = 21) bone defects with a mean follow-up time of 26.1 months (range 17-34 months). Eighteen femurs and 21 tibias with a mean distraction regenerate length (DRL) of 8.3 cm (range 6-13 cm) and 7.5 cm (range 6-11 cm) respectively. Infection was eradicated in all patients, and the total bone union was received in all cases (100%). Statistical difference of bone grade (excellent/good/fair/poor, 3/11/3/1 vs 2/13/4/2, P < 0.05), and function grade (excellent/good/fair/poor, 3/14/1/0 vs 4/13/3/1, P < 0.05) were respectively observed between the femur group and tibia group. The excellent and good rate of bone (femur vs tibia, 77.8% vs 71.4%), and function grade (femur vs tibia, 94.4% vs 80.9%) was higher in the femur group than the tibia. The rate of complication in the femur group was lower than in the tibia (femur vs tibia, 94.4% vs 76.2%). One femur and five tibias were performed additional surgery for delayed union and axial deviation.

CONCLUSIONS

The trifocal bone transport using the unilateral external fixator was a practical method in the management of CSBD in the lower extremity. The BUT and EFI of the femur group were shorter than the tibia. Although the complications noted were more frequent on the femur, these were mostly minor.