Surgical outcomes of elderly patients aged more than 80 years with distal radius fracture: comparison of external fixation and locking plate

BACKGROUND

To compare the outcomes after surgical intervention, including external fixation (EF) with the optional addition of K-pins or open reduction and internal fixation (ORIF) with a volar locking plate (VLP), in patients with distal radius fracture aged > 80 years.

METHODS

We reviewed 69 patients with a distal radius fracture aged > 80 years who treated under surgical intervention from 2011 to 2017 retrospectively. Their demographic data and complications were recorded. Preoperative, postoperative, and last follow-up plain films were analyzed. The functional outcomes of wrist range of motion were also evaluated.

RESULTS

41 patients were treated with EF with the optional addition of K-pins, while 28 patients were treated with ORIF with a VLP. The radiological parameters, including ulnar variance and radial inclination, at the last follow-up were significantly more acceptable in the VLP group (p = 0.01, p = 0.03, respectively). The forearm supination was significantly better in patients treated with VLP (p = 0.002). The overall incidence of complications was lower in the VLP group (p = 0.003).

CONCLUSION

VLP provides better radiological outcomes, wrist supination and lower complication rates than EF. Therefore, although EF is still widely used because of its acceptable results and easy application, we recommend VLP as a suitable treatment option for distal radius fracture in the geriatric population aged > 80 years.

Distal radius fractures-Regional variation in treatment regimens

OBJECTIVES

After recent technical innovations of fracture surgery implants, treatment traditions are changing for distal radius fractures, the most common orthopaedic injury. The aim of this study was to determine if the choice of surgical method for treatment of distal radius fractures differ between healthcare regions in Sweden.

METHOD

The study was based on all (n = 22 378) adult patients who were registered with a surgical procedure due to a distal radius fracture during 2010-2013 in Sweden. Consecutive data was collected from the Swedish National Patient Registry.

RESULTS

The proportions of use of surgical method varied among the 21 healthcare regions between 41% and 95% for internal fixation, between 2.3% and 44% for percutaneous fixation and between 0.6% and 19% for external fixation. Differences between regions were statistically significant in all but 6 comparisons when controlled for age and gender. Incidence rates of surgical treatment of a distal radius fracture varied between 4.2 and 9.2/10 000 person-years.

CONCLUSION

We conclude that there is a large variation in operative management of distal radius fractures between Swedish healthcare regions.

Surgical versus nonsurgical management for type II odontoid fractures in the elderly population: a systematic review

BACKGROUND

Odontoid process fractures, of which type II constitute the majority, are an increasingly important cause of morbidity and mortality in the elderly population. The incidence of geriatric type II fractures is steadily increasing in line with the aging population. However, the decision between surgical and non-surgical intervention for type II fractures in the elderly remains controversial.

PURPOSE

The present study aims to synthesize the current published literature comparing outcomes following surgical and non-surgical interventions for type II odontoid fractures in the elderly population (≥65 years old).

STUDY DESIGN/SETTING

Systematic review and meta-analysis were performed.

METHODS

A systematic search of MEDLINE, MEDLINE In-Progress & Other Non-Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to identify available evidence in English language. Studies with extractable data for all type II odontoid fractures in participants aged 65 years or older and which compared surgical and non-surgical intervention were included. Methodological quality was assessed using the Downs & Black checklist. Primary outcomes were mortality at short-term follow-up (≤3 months), mortality at long-term follow-up (predetermined study endpoint or mean follow-up length), and radiological union rate. Funding was provided by The University of Edinburgh for travel expenses to present this paper at the Society of British Neurological Sciences 2016 Conference ($170).

RESULTS

Twelve studies (n=1,098), all non-randomized, met eligibility criteria. Methodological quality was particularly poor in the confounding, bias, and power domains of assessment. Substantial methodological and statistical heterogeneity allowed only a narrative synthesis of the primary outcomes. Overall, data on mortality at short-term follow-up appeared to favor neither surgical nor non-surgical intervention. A small favorable outcome in surgically managed patients over non-surgically managed patients in terms of mortality at long-term follow-up was not proven conclusive because of considerable heterogeneity in study methodologies. Inadequate reporting of the time point of union assessment introduced the potential for significant intra- and interstudy heterogeneity and precluded assessment of union rates.

CONCLUSIONS

Evidence on this controversial topic is sparse, markedly heterogeneous, and of poor quality. Well-designed prospective trials adhering to guidance published by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative are required to inform clinical practice on this contentious but growing issue. Future randomized controlled trials should include an assessment of frailty and medical comorbidities with suitable patients subsequently randomized to surgical or non-surgical treatment.

How Often Are Protocols Followed at Level I Trauma Centers?

This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers' trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol's first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol's next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols' compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109-112, 2018).

Femoral nonunion with segmental bone defect treated by distraction osteogenesis with monolateral external fixation

BACKGROUND

Currently, the common treatment for femoral nonunion with large segmental bone defect is difficult and complex. The effective surgical methods are rare, include vascularized bone grafting, Masquelet technique and Ilizarov distraction osteogenesis. The objective of this study is to investigate the outcomes of segmental femoral defects treated with monolateral external fixation using the distraction osteogenesis.

METHODS

We retrospectively analyzed patients with femoral nonunion with segmental bone defects (> 6 cm) between January 2010 and January 2014 in our single trauma center. All patients were treated by distraction osteogenesis with monolateral external fixation. All surgeries were performed by the same surgeon. Bone union, duration of distraction osteogenesis in days, time to consolidation in months, external fixation index (EFI), complications, and additional surgical interventions were recorded postoperatively. The modified Application of Methods of Illizarov (ASAMI) criteria were used to evaluate the operative effectiveness.

RESULTS

Forty-one patients were enrolled in this study for analysis. The length of the bone defect ranged from 6 to 17 cm. All patients eventually achieved healing, and no patient experienced recurrence of infection or newly developed infection. The average time needed for healing was 13 months. In terms of the incidence of complications, 3 cases axial deviations, 5 cases docking site nonunion, 23 cases pin-tract infection, 14 cases knee joint stiffness or their joint mobility declined, 2 cases osteogenesis insufficient in the distraction area,1 case refracture, and 2 cases loose external fixation pins. In terms of the evaluations of fracture healing and function, 30 patients excellent, 6 patients good, 5 patients fair, and 0 patient poor. In terms of postoperative function evaluations, 21 patients excellent, 9 patients good, 7 patients fair, and 4 patients poor.

CONCLUSION

For patients with femoral nonunion with large segmental bone defects, the monolateral external fixation can provide effective stability, improve compliance, and reduce complications.

The role of the intramedullary implant in limb lengthening

Limb lengthening is now an accepted practice in orthopaedic surgery. The principles of distraction osteogenesis have become well established with the use of external fixators, utilizing both monolateral and ring fixators. Corticotomy technique, frame stability, lengthening rate and rhythm all contribute to the formation of bone regenerate and tissues. Complications are however common including pin-site infection, soft tissue tethering from the pins and wires resulting in pain, regenerate deformity from soft tissue forces or fracture following frame removal and patient intolerance of the frames during treatment. Surgical techniques have changed to try and minimise these complications. The use of intramedullary nails have been used in conjunction with an external fixator or inserted after lengthening has been achieved, to reduce fixator time and prevent regenerate deformity. Implant innovation has led to the production of intramedullary lengthening nails. The initial devices used ratchet mechanisms with rotation of the bone fragments to achieve lengthening (Bliskunov, Albizzia and ISKD). More accurate control of lengthening and a reduction in pain, resulting from the manual rotation of the leg required to achieve the ratchet progression, was achieved by the use of a transcutaneous electrical conduit powered by external high frequency electrical energy (Fitbone). The most recent implant uses an external remote controller which contains two neodymium magnets. These are placed over the nail on the skin and rotate which in turn rotates a third magnet within the intramedullary nail (Precice). This magnet rotation is converted by a motor to extend or retract the extendible rod. There are multiple nail sizes and lengths available, and early results have shown accurate control with few complications. With such promising outcomes the use of this lengthening intramedullary nail is now recommended as the implant of choice in femoral lengthening. This article is an historical account of the intramedullary device and the impact on limb lengthening.

When Traditional Offloading is not an Option, Could an External Fixator be a Solution?: A Case Report

Offloading is a cornerstone in managing diabetic plantar foot ulcers; however, it often represents one of the most challenging aspects of treatment for clinician and patient alike. The authors present a case of a 61-year-old African American man with type 2 diabetes and a limb-threatening plantar foot ulcer that required aggressive wound and surgical management. Due to the heavy drainage and patient adherence issues, traditional offloading techniques such as total contact cast, DH Pressure Relief Walker (Össur, Foothill Ranch, CA), and wedge shoes, among others, were not viable options. Without offloading, healing will be difficult to achieve and will take a long time, carrying a higher risk of limb loss. The decision was made to apply an Ilizarov circular frame with footplate to facilitate offloading and weight bearing in tandem with negative pressure therapy. Although this is still considered an unusual use of this device, the results were positive and the wound progressed to complete reepithelialization.

The use of circular external fixators in the management of lower limb trauma in Dublin: a single surgeon's 20-year experience

INTRODUCTION

It has been estimated that approximately 520,000 injury presentations are made to Irish accident and emergency departments each year. Fractures account for 20 % of these injuries. Circular external fixators (frames) have been shown to be a safe and effective method of treatment for long bone fractures where internal fixation is impossible or in-advisable. We present the outcomes of all frames applied at our institution for stabilisation of acute fractures over a 20-year period.

METHODS AND METHODS

We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute lower limb trauma.

RESULTS

We identified 68 fractures in 63 patients. There were 11 femoral fractures and 57 tibial fractures. All fractures were classified using the AO Classification system, and most fractures were Type C fractures. We used an Ilizarov frame for 53 fractures and a Taylor Spatial Frame for 15 fractures. The mean time in frame was 365 days for a femoral fracture and 230 days for a tibial fracture. There were five tibial non-unions giving an overall union rate of 93 %. Factors associated with non-union included high-energy trauma and cigarette smoking.

CONCLUSION

The vast majority of lower limb fractures can be treated using 'conventional' methods. Complex fractures which are not amenable to open reduction and internal fixation or cast immobilisation can be treated in a frame with excellent results. The paucity of published reports regarding the use of frames for complex trauma reflects the under-utilisation of the technique.

[Locking plate external fixator for the treatment of middle and distal tibial fractures]

OBJECTIVE

To evaluate the effectiveness of locking plate external fixator in treating middle and distal tibial fractures.

METHODS

From January 2010 to January 2013,18 patients suffered from middle and distal tibial fractures were treated by locking plate external fixator,including 11 males and 7 females, with an average age of 53.5 (ranged from 13 to 80) years old,the course of disease ranged from 2 h to 3 d. According to AO classification, 4 cases were type A,11 cases were type B and 3 were type C. Among them,6 patients were open fracture, including 2 cases with type I, 3 cases with type II and 1 case with type III, according to Gustilo classification), 12 patients were close fracture. Operation time, postoperative complications were observed, and Johner-Wruhs scoring were used to evaluate clinical outcomes.

RESULTS

All patients were followed up from 6 to 15 (meaned 11) months. Two cases occurred skin necrosis (1 case occurred bone exposure), 2 cases occurred delayed union (all were open fracture), and 1 case occurred nail infection. No screw loosening or broken occurred. According to Johner-Wruhs scoring, 10 cases obtained excellent result,6 cases good,and 2 cases fine.

CONCLUSION

Locking plate external fixator for the treatment of middle and distal tibial fractures, which has advantages of lessen damage, shorter operative time, less complications and rapid functional recovery, is one of good choice.

[Updates on rickets and osteomalacia: surgical treatment for rickets/osteomalacia]

In general, surgical treatments are indicated for severe extremity deformities due to impaired bone growth and fractures due to bone fragility in rickets/osteomalacia patients. Corrective osteotomy and fixation with external fixators, Kirshner's wires, intramedullary nail, plates and casting including epiphysiodesis is performed. For tumor induced osteomalacia patients, excision of causative tumor is indispensable as definitive therapy. In this article, surgical treatments were updated especially for tumor induced osteomalacia.

[Pain intensity in patients treated by the external fixation]

One of the inherent features of the external fixation is pain occurring during the whole treatment process. The aim of this paper is evaluation of the level of pain intensity during particular stages of treatment and defining the correlation between pain intensity and type and also localization of fixator, etiology, type of treatment and patient's life activity. We analyzed 64 patients treated by external fixation of the lower limb in the age between 13 to 72 (mean 23.7). The pain intensity was evaluated four times by the NRS protocol (Numeric Rating Scale) in active and passive situation. It is stated that there is a different pain pattern in time depending on the type of treatment and personal life activity. Lengthened and patients in full time education are characterized by rapid increase in pain level in the first period of treatment. Patients with stabilization of non-union or fracture and professionally inactive had lower fluctuations of pain intensity. Localization of apparatus has influence on pain intensity level- greater pain was noted in the tibial group. Etiology influences on pain intensity. Increase of pain intensity in patients with non-union is lower in comparison to patients treated for the other indications.

[Discussion of the mechanism of using continuous traction in treating unstable distal radius fracture]

OBJECTIVE

To explore the mechanism of continuous traction in treating unstable distal radius fracture.

METHODS

Thirty patients with unstable distal radius fractures were treated by diaplastic external fixator including 4 males and 26 females with an average age of 61 years ranging from 18 to 85 years. According to AO classification, 12 cases were type A3, 3 were type B2, 8 were type C1, 4 were type C2, 3 were type C3. The distance of the processus radial malleolus and ulnar articularis were measured through X-ray examination.

RESULTS

Thirty patients were followed-up for 6 to 15 months with an average of 11.2 months. The results of distance before treatment measuring in X-ray was (0.55+/-0.22) cm, and the distance after treatment was (1.07+/-0.23) cm. The distance after treatment was higher than the distance before treatment, there were significant difference between them (P<0.01).

CONCLUSION

Continuous traction by diaplastic external fixator can explain by the theory of tendon reinforced bone and ligament restoration, or distraction osteogenesis.

The economic impact of reprocessing external fixation components

BACKGROUND

The trend toward temporizing external fixation of complex fractures has resulted in increased expenditures for these devices. Increasing pressure to reduce health-care expenditures has led to exploration of reuse of equipment intended for single use. Devices must be tested and recertified prior to redeployment in hospital stock. We report the rate of manufacturer recertification and institutional cost savings associated with a reuse program approved by the United States Food and Drug Administration.

METHODS

All Hoffmann-II external fixation components that had been removed at our institution during the study period were submitted to the manufacturer for visual inspection and mechanical testing. Pass rates for original components and previously recycled components were determined. With use of a conservative pass rate and the assumption of a maximum of three recertifications of each component, the total potential hospital savings on external fixation were calculated.

RESULTS

The first pass rate was 76%. The second pass rate (i.e., the rate for components that had already been recertified once and had been sent for a second recertification) was 83%, but that rate was derived from a limited sample. On the basis of a conservative pass-rate estimate of 75%, the predicted average number of uses of a recyclable component was 2.7. The recertified components were sold back to our hospital at 50% of the original price. Because carbon-fiber bars and half-pins are not recycled, 85% of the charges expended on a new external fixation component are spent on portions of the system that are recyclable. The potential total savings on reusable components was found to be 32%, with a total savings of 27% for the whole external fixation system. No recertified components failed in clinical use over the course of the study.

CONCLUSIONS

With the expansion of cost-control efforts, the recycling of medical devices appears inevitable. Previous data have demonstrated the safety of reuse of external fixation devices, and this study confirms that finding. Our paper demonstrates the real cost savings associated with a manufacturer-based testing and recertification program. Issues of voluntary participation in reuse programs, component ownership, and the impact of savings on patient charges are yet to be worked out by individual institutions.

The use of external fixators: a review of literature and experiences in a developing world

BACKGROUND

The introduction of external fixation devices has brought significant improvement in the management of complex open fractures. Its importance and versatility ranges from its use as temporary fixation device in fractures with soft tissue and vascular injuries to its use in definitive correction of limb length deformities and congenital malformations. It avoids extensive soft tissue damage and enhances easy management of associated soft tissue injuries.

METHOD

This was an overview of the clinical experience at the University of Calabar Teaching hospital and a review of literature.

RESULT

The paper highlight the usefulness of external fixation devices and the need to encourage its use in the developing world. It also stresses the constraints encountered in a Nigerian teaching hospital.

CONCLUSION

A call is made to all surgeons particularly those in rural areas to make use of this simple appliances after due training. Government should equip the hospitals with these tools and encourage the fabrication of such in our environment.

Efficacy of Translaminar Facet Screw Fixation in Circumferential Interbody Fusions As Compared to Pedicle Screw Fixation

OBJECTIVES

Posterior lumbar fixation with translaminar facet screws is a minimally invasive technique with good success rates. Long-term follow-ups show reduced reoperation rates, a decrease in pain scores, and few complications compared with pedicle screw fixation devices. The purpose of this study was to compare the reoperation rate of translaminar facet screw fixation with that of pedicle screw fixation in 360 degrees anterior and posterior fusions for incapacitating low back pain due to lumbar disc degeneration unresponsive to at least 6 months of aggressive nonoperative treatment.

METHODS

One hundred five patients underwent a combined circumferential lumbar fusion with posterior fixation for discogenic pain by one surgeon between August 1993 and February 2003. Seventeen patients were excluded from the study owing to their preoperative etiology for fusion or a prior instrumented posterior fusion. A retrospective chart review was done on all 88 remaining patients. Patients were followed in the office, by phone, or by mail to obtain functional outcome measures. Any subsequent operations by this surgeon or another were recorded. The comparison focused on the rate of reoperation on the region of posterior lumbar fixation.

RESULTS

Sixty-seven patients have had at least a 2-year follow-up. Twenty-four patients had a posterior fusion with pedicle screws, and 43 had translaminar facet screw fixation. Nine patients of the pedicle screw population (37.5%) had a reoperation to remove their instrumentation. Two patients of the translaminar facet screw population (4.7%) had reoperations on their lumbar spine. There was a significant association between posterior instrumentation type and reoperation (P = 0.001).

CONCLUSION

The success of translaminar facet screws in circumferential fusions is justified.

Vordere Kreuzbandplastik mit proximaler Endobutton-Fixation eines Lig.-patellae-Transplantats

BACKGROUND

Interference screw fixation in ACL reconstruction with bone-patellar tendon-bone graft (BPTB) is a potential source of intraoperative complications such as graft laceration. Further problems are artifacts on MRI and screw removal in revision surgery. These problems can be avoided by using distant fixation with the EndoButton. We designed this study to evaluate the clinical as well as the subjective outcome of ACL reconstruction with BPTB graft and femoral fixation with the EndoButton.

METHODS

A total of 51 patients (7 female, 44 male) were examined 2-5 years after ACL reconstruction with BPTB graft and femoral fixation with the EndoButton. We used the IKDC form, Lysholm score, Tegner activity score, and digital radiographs (AP, lateral, axial) for the evaluation.

RESULTS

Of all the patients included in the study, 87% showed a "normal" or "nearly normal" knee function according to the IKDC score, Lysholm score 94.2+/-7.9, Tegner score 6.4+/-1.2, and subjective IKDC 89.9+/-11.9. Radiological signs of arthritic changes could be seen in ten cases.

CONCLUSION

The clinical outcome of ACL reconstruction with EndoButton fixation is comparable to other studies on ACL reconstruction with interference screw fixation. However, since the EndoButton avoids potential problems of the interference screw fixation, we recommend this fixation technique for ACL reconstruction with BPTB graft.

[Treatment results after primary management of severely dislocated ankle fractures with external fixation and subsequent internal osteosynthesis]

BACKGROUND

Between 1 January 2001 and 30 June 2003, 31 patients with dislocated ankle fractures were primarily treated with an external fixator in our clinic. The aim of the present study was to investigate whether such a concept would determine the overall outcome or influence single parameters such as mobility, dystrophy, pain, arthritis, and complications.

METHODS

Of the 31 patients, 25 aged 18-84 years at the time of the accident were followed up for 6-23 months to assess range of motion, clinical scores, radiological findings, and complications. An isolated injury was present in 23 patients and 3 were open injuries of second to third degree. Between two and five operations were necessary 4-27 days after trauma. The duration of primary hospital care required ranged from 10 to 43 days.

RESULTS

The Olerud and Molander score (9 criteria with 100 max points) was 80 points at the follow-up investigation (rated "good"). "Excellent" results (>90 points) were observed in four cases. In the range of motion there was only an average loss in plantar flexion of 12.4 degrees compared to the healthy side in the patients followed up.

CONCLUSIONS

The treatment result in the study population was compared to the results of prospective studies investigating dislocated ankle joint fractures as well as with our own random sample (n=7) of patients with secondarily treated ankle joint fractures that were initially treated with a cast. Initial external fixation seems to be justified and leads to acceptable results. The main functional lesions are not correlated to the specific treatment selected.

[Treatment of two-part proximal humeral fractures with external fixators]

BACKGROUND

We aimed to evaluate the results of the closed manipulation or transcutaneous reduction and external fixation in the treatment of two-part fractures.

METHODS

Eight patients with two-part proximal humerus fractures who had been treated in our clinic with closed manipulation or transcutaneous reduction and external fixation between 1996-2001 were evaluated for this study. We evaluated the final functional status according to the Neer's classification system.

RESULTS

Mean age of the patients was 42 (21-75) years. The major aetiologic factor was motor vehicle accident (in 5 cases). Follow-up time was 2 to 4.5 years. Mean union time was 16 weeks (10 to 24). Nonunion and avascular necrosis of the humeral head have not been observed in none of the cases. Superficial pin tract infection was developed in three cases. All of them were treated successfully with antibiotics. Functional results according to Neer's classification were as follows: 5 good. 2 fair and 1 failed. Mean score 77, 25 (50 to 89).

CONCLUSION

External fixation of displaced two-part fractures of proximal humerus can be assessed as a reliable method with respect to satisfactory fracture reduction and stability, low rate of complications and good early functional results-obtained with this technique.

Long-Term Results of Occipitothoracic Fusion Surgery in RA Patients with Destruction of the Cervical Spine

OBJECTIVE

This is a retrospective study of the outcome of occipitothoracic fusion surgery in rheumatoid arthritis (RA) patients with destruction of the cervical spine, designed to assess the efficacy of halo vest before surgery, the postoperative outcome, and the activities-of-daily living (ADL) problems associated with surgical management. There have been no reports regarding these issues, including surgical effect on subjacent vertebrae.

METHODS

This study included 20 RA patients with destruction of the cervical spine. All patients underwent preoperative halo vest followed by occipitothoracic fusion with an average follow-up of 5 years. The long-term clinical outcomes were analyzed using a modified Ranawat classification.

RESULTS

Before halo application, the neurologic status was assessed as IIIC in 15 patients and IIIB in 5 patients. After halo application, the neurologic status improved in all patients: IIIA in 12 patients and IIIB in 8 patients. After surgery, the neurologic status did not improve in six of the eight IIIB patients but improved to IIIA in two patients. Of the 12 IIIA patients, the neurologic status improved to II in 6 patients but did not improve in the other 6 patients. Patient satisfaction was excellent for 14 patients, good for 3 patients, and fair for only 3 patients (1 had difficulty drinking, another had back pain, and the last had low back pain associated with a compression fracture of the lumbar spine).

CONCLUSIONS

We have performed occipitothoracic fusion surgery in RA patients with destruction of the cervical spine. Preoperative halo vest was very effective for improving the neurologic status, for the general condition, and for an optimal sagittal alignment. Occipitothoracic fusion using unit rods gave satisfactory long-term clinical results compared with the prognosis of patients in whom the disease follows its natural course.

The External Fixator

BACKGROUND

The selection of patients with low back pain for fusion is especially difficult when previous surgical interventions failed and/or invasive tests (discograms, facet blocks) do not allow or do not clearly identify the painful motion segment. Test fixation with an external fixator may mimic a definite internal fixation, such as a fusion, and may help select patients for a more favorable result. The purpose of the study was to clarify if temporary back pain relief by external fixation is predictive for back pain relief after final internal fixation and fusion.

METHODS

A retrospective study of 63 patients up to 6 years after evaluation of low back pain problems with an external fixator (index operation) was conducted. The data were collected from the charts based on a protocol that patients had to fill in during evaluation, and the actual state was checked during a clinical investigation at the outpatient clinic. The protocol monitored pain (Visual Analog Scale), pain medication, and work status. Based on the first two parameters, the effect of external fixation was defined as a general estimation as positive, doubtful, or negative. The same parameters were reassessed at follow-up control.

RESULTS

In 38 patients, the immobilization test did improve the pain situation, in 11 it remained unchanged, and in 14 the pain got worse. Thirty-eight patients (not identical with the above) underwent definitive fusion afterward, whereas 25 were not operated on. Twenty-one of 30 patients with a positive effect undergoing surgery showed an improved situation after fusion, and 8 of 22 patients without further operation were improved at follow-up. Nine of 12 patients with a negative immobilization test did stay in a bad situation at follow-up.

CONCLUSION

The external fixator as a tool for evaluation of patients with low back pain is an expensive measure with a considerable complication risk and only justified in selected patients when any other measure fails to assess and evaluate a patient's situation. If the test fixation reveals no benefit, the patients will remain in a bad situation whatever the therapeutic measure will be. Therefore the main value of the external fixator assessment is the selection of these patients that should not undergo surgery. A positive test fixation means a 72% chance for a satisfactory outcome at least two years after surgery, whereas without surgery the chance for some spontaneous improvement is 57% if the test immobilization did show some improvement. With respect of the "negative" selection of this group of patients (complex history, previous interventions) in our as well as in others series, the obtained results seem acceptable and the use of this invasive diagnostic measure in this group of patients seems justified. Statistical analysis did not show differences of significance as the numbers in the individual groups was too small.

Role of onlay grafting with minimal internal fixation for occipitocervical fusion in oncologic patients

The choice of fixation for occipitocervical arthrodesis remains controversial, especially in oncologic patients who need further radiographic evaluation or postoperative radiotherapy. We studied the long-term outcome of 20 patients who underwent occipitocervical fusions using onlay corticocancellous bone graft and wiring, with postoperative halo vest immobilization. Eight of these patients had postoperative radiotherapy for spinal tumors (group I), and 12 patients had occipitocervical fusions for other pathologies that did not require postoperative radiotherapy (group II). All patients had solid arthrodeses; however, there was a difference in the average time to fusion between patients who received pre- or postoperative radiotherapy and those who did not (p = 0.11). At an average follow-up of 54.5 months (range 24-92 months) 15 of 20 patients (75%) had excellent or good outcomes. A high fusion rate can be expected with reasonable intraoperative or postoperative complications.

Is there a place for external fixation in humeral shaft fractures?

There is a good indication for unilateral axial dynamic external fixation in fractures of the humeral shaft when the fracture appears in the distal third or in cases of bilateral fractures. A non-union or a posttraumatic paralysis of the radial nerve may be indications for external fixation as well as fractures associated with multiple injuries. Further indications include osteitis, infected non-union and comminuted fracture. There is maximum protection of the soft tissue with this method of treatment. External fixation combines the advantages of conservative and operative treatment by influencing callus formation by dynamizing, distraction or compression. Minimizing soft tissue damage facilitates the decision for early exploration of the radial nerve in cases of palsy. A safer positioning technique of the distal screws of the fixator is described.

External fixator for war purposes: the CMC fixator

More than 75% of all injuries in modern wars are localized on the extremities, and more than one-third of these injuries are accompanied by bone fracture. Application of an external fixator is one of the basic procedures in the treatment of war fractures. In this article, we present an external fixator for war purposes of our own construction called the CMC (Croatian Medical Corps) fixator. Although designed as a transport fixator, because of good biomechanical properties it has been widely used for definitive osteosynthesis of war injuries. The CMC fixator is manufactured as a sterile set, ready to use, with all necessary parts for application. On the battlefields of Croatia and Bosnia and Herzegovina during the war from 1991 to 1995, more than 2,500 CMC fixators were applied. The fixator has satisfied all required conditions and considerably contributed to diminishing the consequences of war fractures.

The design and performance of an experimental external fixation device with load transducers

It is becoming increasingly common that fracture healing is modelled in the laboratory with an osteotomy in the diaphysis of the ovine tibia. External fixation is often used to hold the bones in these models, presenting the problem that the loads on such devices are poorly understood. To help investigate this, a unilateral device has been developed which is capable of measuring the two components of load considered to be the most important, that of axial compression and bending in the plane of the fixator. The device was found to be a rigid system and easy to apply, with the in-vivo measurements being straightforward. The estimated limits of error of the compression transducer are +37.9 N and -21.4 N and those of the bending transducer are +3.6 Nm and -4.2 Nm. Preliminary measurements showed the maximum load during normal walking to 345 N compression and 28 Nm in-plane bending.

[Internal fixation of thoracolumbar, lumbar and lumbosacral spine with internal fixators]

The report is a review of the literature on fully implantable transpedicular fixation device known under the general name internal fixator, and designed for short (one to three segments) internal fixation of the spine in various pathologies. The implants are found in a routine clinical use throughout many European countries and have become more familiar to spine surgeons in the U.S. The authors present a general description of the fixators, indications and contraindications to their implantation, the implantation technique and possibilities of intraoperative reposition of the spine. The advantages of usage of the fixators and the history of their development are presented.

The Ilizarov technique in the treatment of osteomyelitis

Seventy-five patients with bone infection have been treated at The University of Texas Medical Branch at Galveston (UTMB) with the Ilizarov external fixator. Multiple deformities were present in many patients. Thirty-four patients had infected nonunions, 22 were short, 18 were angulated, 15 needed joint fusions, 12 had open fractures, 10 had segmental defects, 5 had knee problems and equinus deformities, 4 had rotational problems, 2 had hip problems, and 1 had a translational problem. The average number of deformities per patient was 1.71. Problems with the device include length of therapy (6.8 months average time in device), pin tract infection (superficial, 41.3%; deep, 2.7%), pain (narcotic use, 2.7 months average), and device adjustment. Successful results were obtained in a high percentage of cases. The infection was arrested in 92.0% of the patients and the deformities were corrected in 85.1%. We found that the Ilizarov fixator was effective in the reconstruction of difficult deformities that result from osteomyelitis.

Diagnostic external fixation of two carpal bones. A technical note

Ulnar midcarpal instability can be treated by ligament repair or by a partial arthrodesis between the triquetrum and the hamate. If a partial arthrodesis is planned, we perform an ultimate diagnostic test to determine whether or not a subsequent definitive partial arthrodesis would be effective in controlling the feeling of weakness and instability.