Treatment of External Fixator Pin Tract Deep Infections With an Antibiotic "Sparkler"

Pin tract infections are virtually universal complications with the use of external fixation. While most are superficial and respond to oral antibiotics and local care, septic loosening may occur at the bone-pin interface, which may lead to instability of the fixator, catastrophic failure, fracture, and long-term osteomyelitis. Classification systems and prevention protocols have been developed to address this ubiquitous complication. Treatment of severe pin tract infections often requires debridement, parenteral antibiotics, and removal of the offending pin or the entire external fixator. In cases of osteomyelitic pin tracks, a sizable cavity is often present. We describe a simple technique for treatment of deep bone pin tract infection through the use of debridement, irrigation, and an antibiotic "sparkler," which is a specially prepared percutaneous implant of antibiotic laden bone cement.Levels of Evidence: Level 5.

Safety and Complication Rate of Ring External Fixation in the Foot and Ankle

External fixation is a powerful tool for foot and ankle surgeons. Currently, there is no consensus on true complication rate. The purpose of this study was to report our institution's complication rate of ring external fixation performed by a single surgeon. We retrospectively evaluated electronic medical record of 224 patients with 238 circular frames between 2009 and 2021 at a single institution. Minor complications were defined as a frame managed without early frame removal or return to operating room. Major complications were defined as early return to operative room or early removal defined by our institution as less than 2 months. We recorded over 1642 Ilizarov wires and 278 half pins; 10% (n = 163) of wires and 7% (n = 19) of half pins had a complication. We recorded 44% (n = 104) minor complications and 9% (n = 22) major complications. Minor complications average (mean) onset was 4 weeks, 89% (n = 93) involved wires, and 73% resolved without additional care. Major complications average (mean) onset was 3.7 weeks. Of these, 32% (n = 7) went on to successful revision. This revealed a significant correlation between minor complications and history of osteomyelitis (p < .05). While minor complications do appear high, this was due to wire irritation and local erythema which resolved without additional intervention. To better assess complications with external fixation the authors believe that wire irritation and pin site erythema should be recognized as an expected outcome. A better understanding of ring external fixation in foot and ankle surgery is vital to appropriate perioperative management and patient care.

Which external fixation method is better for the treatment of tibial shaft fractures due to gunshot injury?

INTRODUCTION

The present study aimed to evaluate the functional and radiological outcomes of AO type monolateral external fixator (AO-EF) and Ilizarov type external fixator (I-EF) in definitive fixation of tibial shaft fractures due to gunshot injury.

HYPOTHESIS

Patients undergoing I-EF would have faster fracture healing with the help of early weight-bearing and the functional scores would be better compared to AO-EF.

MATERIAL AND METHODS

The study consisted of 76 (67M, 9F) patients who underwent surgery between 2010 and 2016 for tibial shaft fracture due to low-velocity gunshot injury (LVGI). The patients were divided into two groups according to the fixation method (AO-EF and I-EF) which was discussed by the surgeon team due to their experience. The average age at the time of injury was 37.8±9.8 (20 to 59 years). Groups are compared according to LEFS score, coronal-sagittal-rotational angle, Johner-Rush score, and complications such as nonunion, malunion, osteomyelitis, and pin-tract infection. The mean follow-up time 31.61±3.83 months (between 24 and 44 months).

RESULTS

No statistical difference was found between groups in terms of demographic characteristics. There was no statistical difference between groups regarding body mass index (BMI). LEFS score and operation duration were higher in the I-EF group (p=0.000 and p=0.006 respectively, p˂0.05). In the I-EF group, hospitalization period, full weight-bearing time, and healing time was shorter than the AO-EF group (p=0.001, p=0.000, and p=0.025 respectively, p˂0.05).

DISCUSSION

Although AO-EF has advantages such as ease of application and short surgery time in the definitive fixation of LVGI tibia shaft fractures, I-EF is a superior technique in terms of functional scores. However, I-EF is a surgical approach that requires relatively more experience. Therefore, the choice of fixator should be determined according to the surgeon's experience in the permanent treatment of LVGI tibial shaft fractures.

LEVEL OF EVIDENCE

IV; retrospective, case-control study.

The effectiveness of distraction lengthening in traumatic hand amputation with Ilizarov mini fixator

BACKGROUND

Bone distraction lengthening has been used for hand reconstruction. The healing process involved in this technique is affected by many factors. Here, the effectiveness and rates of healing of the phalanges and the metacarpals were evaluated in cases of traumatic finger amputation treated using an Ilizarov mini-fixator.

METHODS

Fourteen phalanges and twelve metacarpals in 15 patients (13 males and 2 females) were treated with distraction lengthening using an Ilizarov mini-fixator between 2014 and 2017. All the digits had been subjected to traumatic amputation, and shortening of the remaining digit had occurred despite successful replantation in some cases. The healing indices of phalanges and metacarpals were analyzed.

RESULTS

The mean patient age was 42.8 years. The mean lengthening of the phalanges was 13.3 mm, while that of the metacarpals was 26.5 mm. The mean consolidation times were 144.4 days for the phalanges and 154.1 days for the metacarpals. The mean healing indices of the phalanges and metacarpals were 114 days/cm and 60 days/cm, respectively. No bone grafts were needed in any of the patients.

CONCLUSIONS

Distraction lengthening of the digits after traumatic amputation is an effective procedure for hand reconstructive surgery for either the phalanges or the metacarpals and is less invasive than other techniques. The rate of healing of the metacarpals is two times faster than that of the phalanges.

Sport and physical activity after ankle arthrodesis with Ilizarov fixation and internal fixation

BACKGROUND

Severe osteoarthritis (OA) of the ankle joint constitutes an important social problem.

OBJECTIVES

We used (1) the GRIMBY scale, (2) the LOWER LIMB Activity scale, (3) the UCLA (University of California Los Angeles) activity scale, (4) the VAS (visual analogue scale) ACTIVITY scale, and (5) the FAAM (foot and ankle ability measure) SPORT scale to verify whether the type of ankle joint arthrodesis stabilization affected sports and physical activity levels.

MATERIAL AND METHODS

We carried out a prospective clinical study of 47 patients who had undergone ankle arthrodesis with Ilizarov external fixator stabilization (Group 1, n = 21) or internal stabilization with screws (Group 2, n = 26) at Orthopaedic Clinic at the Wroclaw Medical University, Poland, from 2007 to 2015. Sports and physical activity levels were measured by (1) the GRIMBY scale, (2) the LOWER LIMB Activity scale, (3) the UCLA activity scale, (4) the VAS ACTIVITY scale, and (5) the FAAM SPORT scale.

RESULTS

A comparison between the average results of Group 1 and Group 2 on the LOWER LIMB Activity scale and the GRIMBY scale before and after surgery revealed no significant differences. In Group 1, the mean scores on the VAS ACTIVITY scale and the UCLA activity scale after treatment were higher than in Group 2. In Group 1, the mean outcome in the SPORT FAAM scale after treatment was 40; in Group 2 it was 30.06.

CONCLUSIONS

Ilizarov fixation of ankle arthrodesis is associated with better scores on the FAAM SPORT, UCLA activity and VAS ACTIVITY scales after treatment than internal fixation. The scores on the GRIMBY scale and the UCLA activity scale were significantly higher after treatment than before treatment in both groups. In this study, ankle fusion with Ilizarov fixation and internal fixation was found to be effective in the treatment of ankle arthritis. The levels of sport and physical activity were satisfactory in both groups, but the outcomes after fixation with the Ilizarov apparatus were better than after internal stabilization.

Clinical evaluation of ankle arthrodesis with Ilizarov fixation and internal fixation

Background

Ankle arthrodesis may have internal or external stabilization.

We assessed whether the type of stabilization after ankle arthrodesis will affect: (1) functional outcome in Foot and Ankle Ability Measure (FAAM) scale, (2) pain level, (3) period of hospitalization, (4) rate of complications.

Methods

We retrospectively studied 47 individuals after ankle arthrodesis with Ilizarov fixation (group 1, n = 21) and internal stabilization (group 2, n = 26) at our institution in years 2007–2015. Clinical outcomes were measure by: (1) functional outcome in FAAM scale, (2) pain level, (3) period of hospitalization, (4) rate of complications.

Results

Total number of complications in Ilizarov group was 13, which corresponded to 0.62 complications per patient on average. In group 2 there were 15 complications, which corresponded to 0.58 complications per patient on average. The intergroup difference in rate of complications was not statistically significant (p = 0.066). In group 1 the mean VAS pain level before treatment was 4.69 and after treatment was 1.5 (p = 0.037). In group with internal stabilization the mean VAS pain level before treatment was 4.71 and after treatment was 2.9 (p = 0.044). In group 1 the mean period of hospitalization was 5.29 days, in group 2 was 5.71 days (p = 0.517). In group 1 the mean functional outcome in FAAM scale was 79.38, in group 2 was 70.11 (p = 0.458).

Conclusions

Ankle arthrodesis with Ilizarov stabilization is associated with lower prevalence of VAS pain level after surgery than after internal screws stabilization. Rate of complications, FAAM functional score and period of hospitalization were not statistically significant between group 1 and 2. Clinical outcome was satisfactory in group 1 and 2, but outcomes in Ilizarov group were slightly better than after internal stabilization.

Safe corridor for fibular transfixation wire in relation to common peroneal nerve: A cadaveric analysis

BACKGROUND

Peroneal nerve impalement is a recognized complication of percutaneous placement of fibular transfixation wires by palpatory method after increase use of ilizarov technique in treatment of Tibial fractures, deformity correction and limb lengthening. The purpose of this study was to identify the relationship between the Common Peroneal Nerve (CPN) and the palpable landmark, fibular head for insertion of proximal fibular transfixation wire, safe zones in proximal tibia and percentage of fibula where nerve crosses the neck.

METHODS

Standard 1.8-mm Ilizarov k- wires were inserted in the fibula head of fresh 10 un-embalmed cadaveric knees. Wires were inserted percutaneously to the fibula head by palpatory technique. The course of common peroneal nerve was dissected. Distances from wire entry point to the course of the common peroneal nerve were measured post-wire insertion.

RESULTS

The mean distance of the common peroneal nerve from the anterior aspect of the broadest point of the fibular head was 25.10 ± 4.39 mm (range 16-35 mm). Common peroneal nerve was seen to cross the neck of fibula at a mean distance of 32.3 ± 8.53 mm (range 20-50 mm). Wire placement was found to be on average, 46% of the maximal AP diameter of the fibula head and 44% of the distance from tip of fibula to the point of nerve crossing fibula neck.

CONCLUSION

We recommend Proximal fibula transfixation wires are safer to pass with in 2 cm from the tip of the styloid process of the fibula, Anterior half of the head of fibula, <8% of total fibular length, Ventral half of the anterior compartment to avoid injury to peroneal fan. The palpable landmark of fibula is a misinterpretation; it is just the prominent subcutaneous portion of fibula and not the styloid process of fibula which on dissection was located much posterior. Better to take fluoroscopic guidance in difficult cases where palpation of head of fibula is difficult.

Results of Ilizarov External Fixation in Rigid Equinus Deformity: An Experience of 30 Patients

BACKGROUND

Equinus deformity is associated with congenital disorders, trauma, infections, burns and neuromuscular diseases. Tip-toe gait resulting from equinus deformity often makes ambulation difficult. Many modalities of treatment are available but most of them are challenging due to high risk of skin and soft tissue complications. The purpose of this study was to evaluate the results of Ilizarov external fixator with or without minimal soft tissue release in patients with rigid equinus deformity.

MATERIALS AND METHODS

30 patients, with 21 (70%) males and 9 (30%) females, were included in this study. 17 (56.66%) patients had right foot, 10 (33.33%) had left foot and 3 (10%) had bilateral feet involvement. 17 (56.66%) had polio, 8 (26.66%) had cerebral palsy, 3 (10%) had posttraumatic and 2 (6.66%) had post-burn equinus deformities. Mean duration of equinus deformity was 5.1 years (range 1 to 11). The ankle range of mo-tion and radiographic lateral tibiotalar angle were assessed preoperatively and at last final follow-up. Kling et al. criteria were used to assess the morphological and functional outcome.

RESULTS

The mean preoperative rigid equinus deformity was -32° (range -40 to -20). The mean duration of Ilizarov external fixation required to correct the equinus deformity was 3.6 months (range 2-5.5 months). The mean preoperative tibiotalar angle was 150.2° (range 113° to 169°), which reduced to a mean angle of 102.8° (range 87° to 117°) at final follow-up. Mean dorsiflexion and plantar flexion at final follow-up was 15° (range -5° to 10°) and 31° (15° to 40°), respectively. 4 (13.33%) patients had superficial pin tract infection which was treated by serial dressings and oral antibiotics. 2 (6.66%) patients had a recurrence of 10° of equinus deformity. Excellent to good results were seen in 93.33% of patients whereas 6.66% had poor results.

CONCLUSION

Ilizarov external fixation being a minimal invasive procedure allows a greater degree of equinus deformity correction.

Pedobarographic analysis of body weight distribution on the lower limbs and balance after ankle arthrodesis with Ilizarov fixation and internal fixation

BACKGROUND

A number of various techniques were proposed to stabilized ankle arthrodesis, among them external and internal fixation. Appropriate balance and adequate distribution of lower limb loads determine normal biomechanics of the locomotor system. We hypothesized that various techniques used to stabilize ankle arthrodesis may exert different effects on (1) balance and (2) distribution of lower limb loads.

METHODS

Retrospective analysis included 47 patients who underwent ankle arthrodesis with external stabilization with Ilizarov fixator (group 1, n = 21) or internal stabilization with screws (group 2, n = 26) between 2007 and 2015. Balance and distribution of lower limb loads were determined with a pedobarographic platform.

RESULTS

In group 1, average load of the operated and non-operated limb amounted to 48.8% and 51.2%, respectively, and in group subjected to internal stabilization to 48.4% and 51.6%, respectively. Neither the intragroup nor the intergroup differences in the distribution of lower limb loads were statistically significant. Mean length of the center of gravity (COG) path was 137.9 cm for group 1 and 134 cm for group 2, and mean COG area amounted to 7.41 cm2 and 6.16 cm2, respectively. The latter intergroup difference was statistically significant.

CONCLUSIONS

Balance after ankle arthrodesis with Ilizarov fixation is worse than after the same procedure with internal stabilization. Despite correction of ankle deformity, musculoskeletal biomechanics still remains impaired. While ankle fusion with either Ilizarov or internal fixation provide appropriate distribution of lower limb loads, none of these procedures normalize patients' balance.

The psychological impact of external fixation using the Ilizarov or Orthofix LRS method to treat tibial osteomyelitis with a bone defect

OBJECTIVE

To examine the psychological impact of external fixation for a tibial bone defect due to osteomyelitis, and to compare the Orthofix limb reconstruction system (LRS) with the Ilizarov external fixator.

MATERIALS AND METHODS

The SCL-90-R questionnaire was administered at four different time points (before surgery, while patients wore the external fixation device, when the device was removed, and two to three months after). The scores at the four time points were compared, as were the two different methods of external fixation (Orthofix LRS vs. Ilizarov).

RESULTS

The patients experienced a significant adverse impact on their mental health, with the worst outcomes at Time 2 (while wearing the external fixator), but with some negative effects still present even several months after removal of the fixation device. Although the Orthofix LRS and Ilizarov groups showed similar mental health scores at Time 1 (preoperatively) and Time 3 (upon removal of the fixation device), the Orthofix LRS was associated with better scores, specifically in the Hostility (Time 2), Phobic Anxiety (Time 2), Psychoticism (Times 2 and 4), and Other (Time 2) sub-scores, as well as the total score (Times 2 and 4).

CONCLUSIONS

Although both Ilizarov and Orthofix LRS fixation resolved the bone defects, external fixation had a negative impact on the patients' mental health, which persisted even after removal of the devices. Although both methods led to negative effects on the patients' mental, the impact of the Orthofix LRS was less severe.

Radiological evaluation of ankle arthrodesis with Ilizarov fixation compared to internal fixation

INTRODUCTION

We asked whether the type of ankle joint arthrodesis stabilization will affect: (1) rate of union, (2) rate of adjacted-joint arthritis, (3) malalignment of the ankle joint.

MATERIAL AND METHODS

We retrospectively radiological studied 62 patients who underwent ankle arthrodesis with Ilizarov external fixator stabilization (group 1,n=29) or internal stabilization (group 2,n=33) from 2006 to 2015. Radiologic outcomes were mesure by: (1) rate of union, (2) rate of adjacent-joint arthritis, (3) malalignment of the ankle joint. The Levene's test,Mann-Whitney U test and Students t-test were used to the statistical analyses.

RESULTS

Ankle fusion was achieved in 100% of patients treated with external fixation and in 88% with internal stabilization. Desired frontal plane alignment was achieved in 100% of patients with external fixation and 76% with internal stabilization. Desired sagittal plane alignment was achieved in 100% of external fixation and 85% of internal stabilization. A total of 14 (48.3%) patients from group 1 showed a radiographic evidence of pre-existing adjacent-joint OA. The radiographic evidence of pre-existing adjacent-joint OA was also found in 27(81.8%) subjects from group 2. Alterations of adjacent joints were also found on postoperative radiograms of 19 (65.5%) patients subjected to Ilizarov fixation and in all 33 patients from group 2.

DISCUSION

Ilizarov fixation of ankle arthrodesis is associated with lower prevalence of adjacent-joint OA and ankle joint misalignment,and with higher fusion rates than after internal fixation.Although achieving a complex ankle fusion is generally challenging,radiological outcomes after fixation with the Ilizarov apparatus are better than after internal stabilization.

Evaluation of tibial condyle fractures treated with Ilizarov fixation, a prospective study

BACKGROUND

Tibial plateau fractures are associated with significant soft tissue injuries which increases the risks of complications and must be considered when managing tibial plateau fractures. Various modalities of treatment are available for treatment of these fractures but Ilizarov fixation has a special advantage over others. Review of literature shows many studies of Ilizarov fixation in the treatment of tibial plateau fractures with variable results. Aim of our study was to evaluate tibial condyle fractures treated by Ilizarov fixation.

MATERIALS AND METHODS

Study included 43 patients with Schatzker type II and above tibial plateau fractures treated by ilizarov fixation. Standard trauma evaluation, a meticulous musculoskeletal and neurologic examination was carried out. All patients underwent Ilizarov fixation by same team of surgeons. Clinicoradilogical assessment of the patients carried out at regular intervals.

RESULTS

Our study included 43 cases of tibial plateau of various types except type I. Mean time for radiological union was 24.51 wk (range 15 to 32 wk). Mean fixator period was 26.6 wk( 16-34 wk). The functional results were measured by Lyshom's and Hohl and Luck score. The mean Lyshom's score was at the end of one year was 82.16. At end of one year by Hohl and Luck grading 11 patients had fair, 23 had good and 9 had excellent results.

CONCLUSION

High energy tibial plateau fractures can be definitively treated with Ilizarov external fixation. Treatment with this method gives good union rates and less risk of infection. Closed reduction, minimal soft tissue damage and early mobilization are the key to low complications.