Abstract
PurposeAs the monolateral external fixator is increasingly used in trauma-control and definitive management for high-energy long bone fractures, timing the fixator removal remains a challenge for surgeons. The purpose of this study was to determine the feasibility and effectiveness of the bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo as a guide to removing a monolateral external fixator safely.MethodsA total of 131 patients with tibial shaft fractures treated by the monolateral external fixator in our institution were collected from January 2013 to July 2019. In group I, the fixators were removed based on the clinical and radiological assessment only by the treating surgeon. As for group II, the axial load-share (LS) ratio test was accomplished by another medical team without the knowledge of the clinical results. The external fixator was removed when the mechanical test outcome (LS ratio < 10%) was consistent with the conclusion drawn from the clinical and radiological assessment (bone union achieved) by the treating surgeon.ResultsThere was no statistical significance in demographic data between the two groups (P > 0.05). In group I, four patients suffered refracture (the refracture rate was 7.7%) after fixator removal and were successfully treated by an intramedullary nail. In group II, 71 patients underwent fixator removal after the first mechanical test, and another eight patients terminated the external fixation after the second test. None of the 79 patients in group II suffered refracture (the refracture rate was 0%). There was statistical significance in the refracture rate between the two groups (P < 0.05).ConclusionThe bony callus stiffness indirectly evaluated by the axial load-share ratio in vivo using the additional circular frame components is an effectively quantitative indicator to complement the clinical assessment of fracture healing in a monolateral external fixation treatment. Removal of the monolateral external fixator is safe when the axial load-share ratio dropped below 10%.
Highlights
Materials and methodsThe external fixation acts a crucial role in the management of infected bone nonunion, complex extremity deformity, bone defects caused by various injuries, and high-energy fractures where internal fixation is impossible [1,2,3,4,5]
The purpose of this study was to show the feasibility and effectiveness of the bony callus stiffness indirectly evaluated by an axial load-share ratio in vivo for assessing the fracture healing, and to determine if the load-share (LS) ratio dropped below 10% could be used as a safe limit to remove a monolateral external fixator
Statistical significance was observed in the refracture rate between the two groups (P < 0.05)
Summary
The external fixation acts a crucial role in the management of infected bone nonunion, complex extremity deformity, bone defects caused by various injuries, and high-energy fractures where internal fixation is impossible [1,2,3,4,5]. External fixators are wished to be removed as early as possible for most patients due to the discomfort in wearing. Removal of the external fixator introduces the risk of deformation or refracture, but complications are increased if removal is delayed. The fracture union is generally defined as the reconstruction of the bony biomechanical characteristic. The bone union is traditionally evaluated using imaging modalities, such as conventional radiographs in two planes, dual-energy X-ray absorptiometry (DEXA), computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) [6,7,8,9,10,11]. It is challenging to determine the original biomechanical feature is achieved at the fracture site
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