Combined External Fixation Research Articles

Use of external fixator combined with titanium elastic nails in the treatment of tibia shaft fractures in children

Tibia shaft fractures are common in all age groups. For these fractures; Conservative and surgical treatment methods are available. In surgical treatment, numerous surgical methods such as plate screw fixation, external fixator, and titanium elastic nail and K-wire fixation have been defined. The aim of the present study was to present the results of patients for whom external fixator combined with titanium elastic nails or titanium elastic nails alone were applied due to tibia shaft fractures. The study included 40 patients treated for tibia shaft fracture in our clinic between January 2016 and January 2019. Combined external fixator (EF) fixation was applied to patients who were found to be instable after Titanium elastic nail (TEN) application during the surgery. In clinical evaluation, Flynn classification, time to fracture union, fluoroscopy count, reoperation and time to full weight bearing were used. The results of patients for whom EF combined with TEN were applied were compared with the patients who had only TEN. Thirty patients were treated using TEN and 10 patients using EF combined with TEN. After 12 months of follow-ups, fracture union was achieved in all patients. There were 5% sagittal and 2.5% coronal plane angulation. Patients developed angular deformity of an average of 2.43 ± 1.9 degrees in the coronal plane and 2.65 ± 1.9 degrees in sagittal plane. Lower percentages of angular and rotational deformity were observed compared to the literature. Despite the disadvantages of using a greater number of fluoroscopy and longer operation periods in patients who underwent TEN+EF, these patients were mobilized earlier. It was concluded that combined EF application is a more feasible method in patients with pediatric tibia shaft fracture for whom stable fixation cannot be achieved with TEN.

Application of the suture anchor in the treatment of Hoffa fractures of the lateral femoral condyle

BackgroundTo evaluate the feasibility and clinical effect of the suture anchor combined with external fixation in the treatment of the lateral femoral condyle Hoffa fracture.MethodsIn this study, a retrospective study was conducted to analyze the feasibility of treating fourteen patients (eight men and six women) with Hoffa fractures admitted to our Hospital from January 2016 to October 2021 with combined external fixation using incisional reduction anchor nailing. The age of the patients ranged from 23 to 45 years, with an average of 37.5 years. According to Letenneur’s classification, there were eight cases of type I, three cases of type II, and three cases of type III. The functional assessment of Letenneur was used to measure the clinical outcome.ResultsAll patients had one-stage wound healing, and all patients were followed up for 12 to 18 months after surgery, and all fractures healed well, with normal knee flexion and extension activities, and no complications such as fracture displacement, anchor nail loosening, or fracture malunion were observed. The clinical outcome was evaluated according to the functional evaluation criteria of Letenneur et al. The clinical outcome of fourteen patients: excellent in thirteen cases and good in one case, with an overall excellent rate of 100%.ConclusionsOur study results indicate that the use of anchor nailing combined with external fixation for Hoffa fractures of the femoral condyle has some clinical reference significance because it is less invasive, has fewer complications, does not require secondary removal, and is worthy of clinical application.Trial registration: Retrospectively registered.

Clinical characteristics analysis of 22 062 patients of foot and ankle deformity from QIN Sihe Orthopaedic Surgery Database between May 25, 1978 and December 31, 2020

Based on the clinical data of patients with foot and ankle deformities in the QIN Sihe Orthopaedic Surgery Database, to analyze the characteristics and treatment strategies of foot and ankle deformities, and provide a basis for clinical decision-making. A total of 22 062 patients with foot and ankle deformities who received orthopedic surgery between May 25, 1978 and December 31, 2020 were searched in the QIN Sihe Orthopedic Surgery Database. The gender, age at operation, regional distribution, etiology, type of deformity, operation method, postoperative fixation method, and other information were collected. Among the 22 062 patients, there were 13 046 males (59.13%) and 9 016 females (40.87%); the age at operation ranged from 1 to 77 years, with a median of 17 years, and 20 026 cases (90.77%) were aged 5 to 40 years. The patients came from 32 provinces, municipalities, and autonomous regions across the China and 5 countries including India and the United States, et al. The etiology and diseases type covered 154 kinds (of which sequelae of poliomyelitis, cerebral palsy, spina bifida and tethered spinal cord, congenital equinovarus foot, post-traumatic foot and ankle deformity, and Charcot-Marie-Tooth disease accounted for the highest proportion). The types of deformities included varus foot, equinus foot, valgus foot, talipes calcaneus, equinocavus, high arched foot, claw toe, and flail foot. Surgical methods included tendon lengthening, soft tissue release, tendon transposition, osteotomy orthopedics, and ankle arthrodesis. The 36 620 operations were performed, including 11 561 cases of hip, knee, and lower leg operations to correct the foot and ankle deformities. Postoperative fixation methods included Ilizarov external fixator in 2 709 cases (12.28%), combined external fixator in 3 966 cases (17.98%), and plaster or brace fixation in 15 387 cases (69.74%). Male patients with foot and ankle deformities account for a large proportion, and the population distribution is mainly adolescents, with a wide distribution of regions, causes and diseases, and talipes equinovarus and varus foot are the main types of deformities. Foot and ankle deformities are often combined with deformities of other parts of the lower limb, which requires a holistic treatment concept. The application of foot soft tissue and bone surgery combined with Ilizarov external fixator and combined external fixators provides a guarantee for the correction of complex foot and ankle deformities.

Analysis on the characteristics of 837 patients with post-traumatic lower limb deformities from QIN Sihe Orthopaedic Surgery Database between May 25, 1978 and December 31, 2020

To summarize and analyze the characteristics and treatment strategies of post-traumatic lower limb deformity based on QIN Sihe Orthopaedic Surgery Database. A clinical data of 837 patients with post-traumatic lower limb deformities treated by orthopaedic surgery between May 25, 1978 and December 31, 2020 in QIN Sihe Orthopaedic Surgery Database were analyzed retrospectively. The information of the patient's gender, age at the time of surgery, region of origin, cause of trauma, deformity side, orthopedic surgery related information (operation time, location, type, and fixation method after operation) were summarized and analyzed. All patients came from 32 provinces, municipalities, autonomous regions, and Taiwan in China. Among them, 551 cases (65.83%) were male and 286 cases (34.17%) were female. The age of the patients at the time of surgery was 3-84 years old, with an average of 27.6 years old, and the most patients were 16-45 years old (559 cases, 66.78%). The main cause of trauma was traffic accident injury (639 cases, 76.34%). The deformity mainly involved unilateral limbs, including 394 cases (47.07%) on the left side and 376 cases (44.92%) on the right side. The most patients were admitted between 2008 and 2017, accounting for 53.05% (444/837). All patients were operated on one or more sites (1 048 sites), among which ankle and toe surgery were the most, accounting for 48.38% (507/1 048). The patients received 1204 surgeries including tendon lengthening and soft tissue contracture release, et al. Orthopedic surgery combined with bone external fixation was used in 624 cases (467 cases of Ilizarov external fixation and 157 cases of combined external fixation), and plaster or brace external fixation was used in 213 cases. Post-traumatic lower extremity deformity patients have a large proportion of males, with a wide geographical distribution, involving various parts of the lower extremities, and most commonly in the foot and ankle. Orthopedic surgery combined with bone external fixation (Ilizarov technique) is the main methods for correction and functional reconstruction of post-traumatic lower limb deformity.

Comparative Analysis of Secondary Outcomes in Treatment of Charcot Neuropathy: A Systematic Review.

Charcot neuroarthropathy (CN) is commonly associated with diabetic neuropathy and can predispose patients to amputations. Management remains a challenge, with no definitive treatment. This study examines major postoperative complications associated with open reduction with internal (intramedullary) nails, fixation, external fixation, or combined internal and external fixation for correction of the deformity. We reviewed available literature using PubMed, OvidSP, Scopus, and Cochrane and searched bibliographies of the included studies to identify additional pertinent references. After review and agreement among 4 raters, a total of 15 studies were included in this analysis. Hardware removal rates were 0.133 for intramedullary nails, 0.007 for external fixators, and 0.050 for combined fixation. Rates of hardware complication were 0.182 for intramedullary nails and 0.007 for external fixators. Wound dehiscence occurred at rates of 0.059 for intramedullary nails and 0.216 for combined fixation. The rate of deep infections was 0.031 for intramedullary nails, 0.032 for external fixators, and 0.113 for combined fixation. The rate of irrigation and debridement was 0.007 for external fixators. Rates of hardware removal (13.3%) and complications (18.2%) were high with intramedullary nails. Dehiscence (21.6%) and deep infection (11.3%) were high in combined fixation. Other complications occurred relatively rarely. Level III.

Preliminary analysis of the clinical characteristics of 1 012 patients with secondary lower limb deformity of spina bifida from QIN Sihe Orthopedic Surgery Case Data between October 12, 1986 and December 31, 2020

To analyze the characteristics of patients with secondary lower limb deformity of spina bifida based on the QIN Sihe Orthopedic Surgery Case Data, and provide the references for clinical research, diagnosis, and treatment. A clinical data of 1 012 patients with secondary lower limb deformity of spina bifida between October 12, 1986 and December 31, 2020 selected from QIN Sihe Orthopedic Surgery Case Data was retrospectively analyzed. Among them, 231 cases (22.83%) had undergone orthopedic surgery for lower extremity deformities in other hospitals. The gender, age at surgery, indicators related to spina bifida (deformity side, comorbidity, sensory disturbance level), and information related to surgery (operating time, surgical site, postoperative fixation method) were analyzed. Of the 1012 patients, 457 were males and 555 were females. The age was 3-51 years at the time of surgery, with a median of 18.0 years; among them, the 15-30 years old group had the most patients, accounting for 53.16%. Most deformities involved both lower limbs (652 cases, 64.43%). There were 111 cases of ulcers in the weight-bearing area of the foot, 265 cases of gatism, 554 cases of sensory disturbance, and 85 cases of abnormal hair on the waist. From 2010 to 2019, there were significantly more patients undergoing surgery than before 2010, reaching 61.17%. Sensory disturbances mostly occurred in the ankle and foot. A total of 1 149 sites were treated with surgery, of which the most ankle joint deformities were corrected by surgery, accounting for 84.33%. The main fixation methods after orthopedic surgery were external fixation, including Ilizarov external fixation (442 cases), combined external fixation (315 cases), and plaster fixation (189 cases). Spina bifida can be secondary to severe deformities of the lower limbs, mainly in the ankles. Common complications include ulcers in the weight-bearing area, dysfunction of urine and feces, and sensory disturbances; external fixation is the main method of fixation after surgery.

Management of Infected Charcot Neuroarthropathy due to Diabetes Mellitus with Half Pins External Fixator and Pinning: A Case Series

BACKGROUND: Charcot neuroarthropathy (CN) of the foot and ankle, which is complicated with infection, is debilitating disease and presents challenges until now. External fixation with half-pins is useful as provisional treatment.
 AIM: The purpose of this retrospective case series is to summarize the patient characteristic, type of surgical intervention, outcome, and complication of infected CN treated in our hospital.
 MATERIALS AND METHODS: This case series studied retrospectively patients with CN of the foot and ankle due to diabetes mellitus type II, complicated by infection, who required surgical treatment in a single institution, from 2018 to 2019. Diagnosis was based on chronic deformity (fracture or dislocation) as proven on X-ray and recently developed infection as shown through clinical, laboratory, and radiological evaluation.
 RESULTS: We studied seven patients with CN classified as Eichenholtz Stage 3 (100%) and Brodsky type 3A alone (n = 3) (Figure 1), and type 3A with other types (n = 4). The mean age is 44.6 years old (range, 35–60) and mean body mass index was 24.08 kg/m2 (range, 21.45–25.39). Signs of infection include leukocytosis (n = 6), soft-tissue swelling (n = 4), ulcer (n = 4), and osteomyelitis (n = 1) at presentation. Operative treatment consisted of debridement, followed by external fixation only (n = 4), combined external fixation and pinning (n = 2), and intramedullary pinning only (n = 1). The mean hospital length of stay was 4.5 days (range, 3–7). We performed short-term follow-up after a mean of 4.12 months (range, 1.3–5.3) and long-term after a mean of 15.02 months (range, 11.27–16.8), the limb salvage rate was 100% in both. One patient had revision of external fixation. As for functional outcome, at the time of long-term follow-up mean visual analogue scale was 0.75 (range, 0–2) and American Orthopaedic Foot and Ankle Score was 66.25 (range, 57–77).
 CONCLUSION: In this study, mostly external fixation with half-pins and methyl metacrylate was used based on the bone condition and patient’s compliance. Despite of its limitation, this method is effective when it is combined with strict blood glucose level and infection control.

Tarsocrural Instability in Cats: Combined Internal Repair and Transarticular External Skeletal Fixation

Abstract Objective The aim of this study was to report outcomes after combined internal repair and transarticular external skeletal fixation (TESF) for the treatment of tarsocrural joint instabilities (TCI) in cats. Materials and Methods Open reduction of the tarsal joint was performed followed by combined (1) internal repair (tibial/ fibular malleolar osteosynthesis or primary ligament suture and/or prosthetic ligament repair) and (2) temporary TESF. Stability of the tarsus was determined at short-term follow-up (4–8 weeks postoperatively). Short-term complications were evaluated and midterm outcome assessed by an owner telephone questionnaire. Results Fourteen cats were included of which nine had open TCI. Median time for frame removal was 47 days. Eleven patients had satisfactory stability of the tarsus at short-term follow-up. Catastrophic complications occurred in three cats consisting of extensive skin necrosis of the paw with subsequent hindlimb amputation in two and multiple digit amputations in one cat. Major complications occurred in one cat with persistent TCI requiring pantarsal arthrodesis. Nine cat owners indicated a ‘full or acceptable’ outcome at midterm (median, 1.5 years). Conclusion Close monitoring in the postoperative period until TESF removal is important for early identification of complications. Despite good joint stability at short-term, persistent or recurrent lameness at midterm can occur.

Does age affect the hidden blood loss of elderly intertrochanteric fracture patients fixed with combined external fixator?

Objective: To evaluate the postoperatively hidden blood loss of elderly intertrochanteric fracture patients fixed with combined external fixator, and to explore the correlation between hidden blood loss and age. Methods: A retrospective analysis was conducted on 60 elderly intertrochanteric fracture patients who were admitted to the Department of Orthopedics of Hebei Provincial Hospital from January 2016 to May 2019. All the fractures were fixed with combined external fixators. The patients were divided into two groups according to the age: there were 31 cases in group A (60-80 years old) and 29 cases in group B (≥80 years old). The Gross equation and the Nandler formula were used to evaluate the amount of hidden blood loss based on changes in hematocrit (Hct) at the day preoperatively, 3 days postoperatively and the weight. The data were compared between the two groups by independent-sample t test. Results: The decreased Hct, hemoglobin(Hb) and the dominant blood loss and hidden blood loss in group A and B was 3.4%±1.7%, (13±7) g/L, (25±6) ml, (186±7) ml and 3.8%±1.2%, (13±3) g/L, (24±8) ml, (194±7) ml, respectively. There was no significant differences in the dominant and hidden blood loss between the groups (t=0.309, 0.883, both P>0.05). Conclusion: The age doesn't affect the hidden blood loss in elderly intertrochanteric fracture patients fixed with combined external fixator, which indicated that the operation is safe and reliable for such patients.

Treatment of distal metaphyseal tibia fractures using an external fixator in children.

Introduction:Current treatment of pediatric distal metaphyseal tibial/fibular fractures is challenging due to poor skin and soft tissue coverage and limited blood supply to the distal tibia area in children. It remains unknown whether the SK combined external fixator (made by Double Medical Technology Inc., China) is effective for the treatment of distal metaphyseal tibia/fibula fractures in children.Hypothesis:We hypothesized that SK combined external fixator could achieve satisfying outcomes for pediatric distal metaphyseal tibia/fibula fractures.Patients and methods:A total of 19 pediatric patients with a median age of 6 years (range: 3.8–12.0 years), who had distal tibia/fibula metaphyseal fractures and attended our hospital between January 2017 and November 2017, were evaluated. All patients with tibia fracture had closed reduction and percutaneously fixed SK combined external fixators. Radiographs were taken at an average of every 4 weeks to evaluate the healing of the fracture. Complications were recorded, and the stability of the pin clamp and rod were also checked. Follow-up was conducted for up to 13 months. All patients provided informed consent for publication of the case.Results:All patients achieved a satisfactory clinical outcome at the final follow-up. Weight-bearing exercises were started at post-operative 2 weeks. Bone union was obtained at 8 weeks post-operation on average. No delayed healing or nonunion was observed, although one case of pin site infection and three cases of pin clamp loosening occurred.Discussion:Three-dimensional SK combined external fixators are light, easy to apply, minimally invasive, and result in low rates of complications. They provide excellent stability for pediatric distal tibia/fibula metaphyseal fractures.Level of evidence:IV.

Limited orthopaedic surgery combined with external fixation for the treatment of lower extremity sequelae of middle and old aged post-poliomyelitis

To summarize the effectiveness of limited orthopedic surgery combined with external fixation for the treatment of lower extremity sequelae of middle and old aged post-poliomyelitis, and then to explore the strategy of surgical correction and functional reconstruction method. From the database of 23 310 cases of poliomyelitis sequelae treated by QIN Sihe Orthopaedic Surgical team between September 1982 and December 2017, 629 patients over 41 years old were retrieved and the epidemiological characteristics of the patients were analyzed. Between March 2011 and June 2015, 57 patients with poliomyelitis sequelae treated with limited operation and external fixation were followed up 2-6 years, and the history of poliomyelitis sequelae was 41-67 years (mean, 47.1 years). Preoperative histopathological gait included 29 cases of quadriceps gait, 17 cases of walking with crutch, and 11 cases of claudication only. The operative methods included Achilles tendon lengthening in 52 cases, supracondylar osteotomy in 39 cases, knee flexion release in 36 cases, calcaneal arthrodesis in 27 cases, flexion and hip arthrodesis in 21 cases, tibia and fibula osteotomy in 19 cases, triple arthrodesis in 11 cases, and tendon transposition in 1 case. After operation, 18 cases were treated with combined external fixator and 39 cases with Ilizarov ring external fixator. Of the 629 cases, 481 cases were less than 50 years old (76.47%), accounting for 144 cases between 51 and 65 years old (22.89%). Among them, 495 cases (78.70%) were diagnosed after 2003. Of the 57 patients obtained complete follow-up information, 7 had slight infection of needle path during traction orthopaedics, 2 had early postoperative venous thrombosis of lower extremities, and 2 had incomplete paralysis of the common peroneal nerve. There was no complications such as skin incision infection, vascular injury, and bone nonunion. According to the evaluation standard of postoperative efficacy standard in correction of lower extremity deformities, the results were excellent in 23 cases, good in 20 cases, fair in 12 cases, and poor in 2 cases, with an excellent and good rate of 75.44%. The 2 patients with poor effectiveness were reoperated to improve their function. Limited orthopedic surgery combined with external fixation for the treatment of lower extremity sequelae of middle and old aged post-poliomyelitis can effectively correct deformities of lower limbs, improve function, delay the disability aggravated by decay, and avoid serious complications.

Исследование регионарной гемодинамики у пациентов с псевдоартрозами диафиза бедренной кости при лечении в условиях комбинированного чрескостного и интрамедуллярного остеосинтеза

Objective The purpose of the study was to explore peripheral hemodynamics in patients with femoral shaft nonunions treated with combined external fixation and intramedullary nail. Material and methods Two groups of patients were identified. Group I included 11 patients with a deformity at the apex of nonunion treated with consecutive combined osteosynthesis. Group II consisted of 15 patients with nonunions and femoral shortening treated with synchronous combined distraction-compression osteosynthesis. Methods of examination comprised duplex ultrasound of veins and paraosseous vessels at the regeneration site (HITACHI HI Vision Avius), USDG (ANGIO-PLUS, Moscow) and tetrapolar rheovasography (RVG) of lower limbs (Rheograph RGPA-6/12, Taganrog). Results and discussion Volumetric blood flow of the femur and tibia measured postoperatively with RVG showed no differences in the intact and operated limb whatever technique was applied. In all patients, major blood flow was recorded at stages of combined fixation and Ilizarov fixation, linear systolic velocity and pulsatility index were not significantly different from normal and intact limb values, hemodynamic criteria of vasoconstriction of major vessels were not identified. The steal syndrome of distal segments due to functional bypass was observed in patients with unstable metal constructs and did not aggravate after surgical treatment in Group I. Duplex ultrasound scan of the femoral shaft cortical bone showed expressed arterial and venous color map in all patients with high peripheral indices reflecting vascular tone and measuring PI = 12 ± 3.5; RI = 0.9 ± 0.1. Conclusion No significant hemodynamic changes were detected in major arteries during treatment of patients with femoral nonunions using combined techniques of external fixation and intramedullary nail. Vasodilatation of veins recorded during treatment of patients with femoral nonunions using combined techniques of external fixation and intramedullary nail was determined as a risk factor for venous thromboembolism. A local increase in the arterial and venous paraosseous blood flow was recorded at the cortical site of nonunion with combined intramedullary osteosynthesis.

Risk factors related to refracture after union of congenital pseudarthrosis of the tibia with a combined surgical

Objective To explore the risk factors related to refracture after union of congenital pseudarthrosis of the tibia with a combined surgical, and to provide an important reference for clinical treatment. Methods From April 2007 to August 2011, 40 cases of congenital pseudarthrosis of the tibia (CPT) confirmed by the use of intramedullary nail combined Ilizarov external fixator treatment of bony union were obtained for retrospective analysis. There were 27 males and 13 females, and the average age was 3.6±2.7 years (ranged from 0.8 to 11.3 years), and the follow-up time are all over 36 months. Survival analysis were applied respectively on gender, whether the merger of neurofibromatosis type 1 (NF-1) and ankle joint, operative age, fibular status and the cross-sectional area ratio of healing site. Multifactorial Cox proportional hazards regression analysis was performed on the single factor with statistical significance. Results No significant inter-group differences existed in gender or whether combined NF-1. In operative age ≥3 years group whose refracture-free survival was significantly better than those 0.05). Conclusion The major risk factors for refracture after union of congenital tibia pseudarthrosis with the use of intramedullary nail combined Ilizarov external fixator are the smaller cross-sectional area of pseudarthrosis and with fibula pseudarthrosis. Key words: Pseudarthrosis; Tibia; Fracture fixation; Risk factors

Evaluation of functional outcome of pilon fractures managed with limited internal fixation and external fixation: A prospective clinical study

IntroductionThe management of pilon fractures is controversial primarily due to the high rate of complications irrespective of the mode of treatment. Limited internal fixation with external fixation is associated with minimal soft tissue handling. This may reduce the chances of wound dehiscence and infection. This study was designed to evaluate the functional and clinical outcomes in patients treated with limited internal fixation combined with external fixation in pilon fractures. Material and methodsThis study was conducted as a prospective clinical study on 56 skeletally mature patients with closed fractures with poor skin condition, and with open grade 1 and grade 2 distal tibial intra-articular fractures. All patients were treated with combined limited internal fixation and ankle spanning external fixation. ResultsAll fractures in this series united with an average time period of union of 18.3weeks (ranging from 13 weeks to 30 weeks). There was no non-union in any case. There was malunion in 4 cases, varus malunion (>5 degree) in 2 cases and recurvatum in another 2 cases). Excellent to good functional results were observed in 88% cases based on the modified Ovadia and Beals score. The mean ankle dorsiflexion and planter flexion movements were 10.2±5.3 degrees and 27.4±7.2 degrees respectively. infections occurred in 6 patients which included 4 pin tract infections and 2 superficial wound infection, all 6 healed after removal of pin tract and with oral antibiotics. ConclusionThe technique of combined external fixation with internal fixation is safe and effective management option for intra-articular distal tibial fractures.

Pelvic Fracture - Results of Early External Fixation

Background : The behavior of pelvic ring fracture following surgical fixation has been very sparsely studied. Pelvic ring injuries, depending on their severity had been treated by variety of closed method. The purpose of the study is to assess the short-term functional outcome of pelvic ring fracture following surgical fixation. Method: Present prospective study consists of 62 patients of pelvic fracture admitted in department of orthopedics, NSCB medical college and hospital Jabalpur (M.P) during the period of Oct. 2010 to Sep. 2011. All patient of type A (stable) fracture treated by conservative method. Out of 40 patients of unstable pelvic fracture (involving pelvic ring) 14 were treated by surgical method. Out of 14 patients 4 were treated by external fixation, 8 by internal fixation, and 2 by combined external and internal fixation. Functional outcome assessment was done by Majeed Scoring System [1]. Results: Functional outcome score in surgically treated patient is excellent in 7 patients, good in 4, fair in 2, and poor in 1 patient at 3 month follow-up. Pain is the most common complaint after 3 month of surgical fixation, it is seen in 4 patients (28.57%) but only 1 patient changed his job because of this pain. Conclusion: Unstable Pelvic ring injury has poor outcome, it should be treated by operative methods for optimal functional outcome.

Evaluation of combined high tibial osteotomy and ‎ilizarov external fixator in the treatment of late-onset tibia ‎var

Purpose The purpose of this study was to evaluate the results of combined high tibial osteotomy in combination with gradual translation by ilizarov external fixator in the treatment of late-onset tibia vara. Patients and methods A total of 23 patients with a diagnosis of late-onset tibia vara, 16 (69.6%) male and seven (30.4%) female, were included in this study; in 14 (60.9%) patients the deformity was on the right side, whereas in nine (39.1%) patients the deformity was on the left side. The etiology was Blount’s disease in all patients. The mean age of the patients was 23 years, ranging from 13 to 35 years, and the mean preoperative mechanical axis deviation was 84.39 mm. The mean preoperative medial posterior tibial angle was 61.17°, whereas the mean preoperative proximal posterior tibial angle was 63.09°. Results The mean duration of external fixator application was 124.6 days, ranging from 90 to 170 days; the mean postoperative medial proximal tibial angle was 86.22°, with a P value of 0.001; the mean postoperative proximal posterior tibial angle was 79.74°, with a P value of 0.001; and the mean postoperative mechanical axis deviation was 10.7 mm, with a P value of 0.001. Residual deformity was present in three (13%) cases, ranging from 5 to 18°; no neurovascular complication was seen in both early and late postoperative periods; and limb length discrepancy was present in five (21.7%) cases, which was between 1.5 and 2.7 cm. Conclusion High tibial osteotomy in combination with gradual correction by ilizarov is safe and effective in the management of late-onset tibia vara.

Comminuted long bone fractures in children. Could combined fixation improve the results?

Comminuted diaphyseal fractures in the pediatric age group represent a major orthopedic problem. It is associated with a high incidence of complications and poor outcomes because of the instability and difficulty in treatment. The aim of this study was to evaluate the efficacy of combined external skeletal fixation and flexible intramedullary nails in reconstruction of comminuted diaphyseal fracture in skeletally immature patients. Combined external fixator and elastic stable intramedullary nails were used in the management of 27 pediatric patients (15 males and 12 females) with unstable comminuted diaphyseal fractures of the tibia and femur. There were 19 fractures of the femur and eight fractures of the tibia. The average age of the patients was 8.7 years (range 7-14 years) for the femur and 10.8 years (range 6-15 years) for the tibia. Fractures were classified according to the system of Winquist and Hansen as grade II (five cases), grade III (nine cases), and grade IV (13 cases). All cases were operated within 6 days (range 0-6 days) after injury. The mean follow-up period was 2.8 years (range 2-3.5 years). The average duration of the external fixation was 1.6 months for fractures of the tibia, whereas it was 1.4 months for fractures of the femur. The average time for tibia fracture union was 2.8 months for fractures of the tibia, whereas it was 1.9 months for fractures of the femur. Malalignment in varus less than 5° was noted in one patient. One patient had a limb-length discrepancy of 1.5 cms. There were five cases (18.5%) with pin-tract infection. According to the Association for the Study and Application of the Methods of Ilizarov evaluation system, bone results were excellent in 23 cases (85.2%), good in three cases (11.1%), and poor in one case (3.7%). Functional results were excellent in 22 (81.5%) cases and good in five (18.5%) cases. Combined use of external fixators and elastic intramedullary nails is a good method for the treatment of comminuted long bone fractures in children.

Complications after use of extracortical clamp device in combined and consecutive external and internal fixation of femoral bone

Introduction. Extracortical Clamp Device (ECD) is a tool that, unlike conventional wires and pins, does not perforate long bone cortex. Therefore, its use simplifies methods of combined and consequtive use of internal and external fixation, osteosynthesis in periprosthetic fractures and deformities. Purpose of the study - to compare the rate of complications and their structure depending on extracortical clamp device application and conventional transosseous elements in combined external fixation of femur. Materials and methods. We analyzed the complications arising in treatment of 66 patients with frames where ECD were used (group «ECD»). The results were compared with the results of treatment 29 patients, when utilizing combination of external and internal fixation, external fixation device included conventional transosseous elements only (group «W-P»). Results. In the group «ECD» inflammation of the soft tissues around fixing elements was identified in 14.8% of cases. In these patients complication arisen at 45.5% of the all used fixing elements; of them - 18.2% around ECD. In the group «W-P» pin-tract infection occurred in 29.2% cases. ECD breaking was in one case (3.7%) breaking of wires or pins in «W-P» group was diagnosed in 3 cases (13.6%). In the treatment of periprosthetic fractures and deformities with ECD soft tissues around fixing elements was in 16.7% of cases. In the treatment of similar fractures and deformities without prosthesis pin-tract infection were diagnosed in 21.5% cases. All of these complications did not affect the outcome. Other complications (neuropathy, contracture of the knee) were not depending on the application of ECD.

Resection of Comminuted Ulna Head Fragments With Soft Tissue Reconstruction When Associated With Distal Radius Fractures

Acute management of fractures involving the head and neck of the distal ulna associated with comminuted unstable fractures of the distal radius remains difficult and controversial. Fifteen consecutive such cases treated with combined external and internal fixation together with primary resection of comminuted distal ulna fracture fragments and reconstruction of the periosteal sleeve and triangular fibrocartilaginous complex are reviewed. At an average follow-up of 5.8 years, all patients were assessed for range of motion, strength, pain and function, and radiographic appearance. All had a range of motion postoperatively of at least 85% of the opposite wrist in all planes. Average grip strength was 88.6% of the contralateral wrist. Radiographic evaluation demonstrated no evidence of instability in any plane. There were no cases of subluxation of the distal ulna nor collapse of the ulnar side of the carpus. Those 7 patients studied arthrographically demonstrated an intact "water-tight" ulna-sided soft tissue sling, and all distal radius fractures healed primarily.

Protocolo combinado de fijación externa y arteriografía en fracturas de pelvis con inestabilidad hemodinámica asociada: estudio retrospectivo sobre 79 casos

Purpose Frequently pelvic fractures are associated with arterial and/or venous intrapelvic bleeding, resulting in a high mortality rate ranging between 10 and 50%. Numerous treatment protocols have been published for the early control of hemorrhage. All of them agree on the need of a determined and multi-disciplinary approach that combines various therapeutic methods. The purpose of this study is to determine the applicability, clinical evolution and results of a therapeutic diagnostic algorithm used with a group of 79 patients with a pelvis fracture and a related hemodynamic instability. Materials and methods This is a retrospective study of a series of patients with a pelvic fracture associated to hemodynamic instability, who were admitted to our hospital between 1994 and 2004. The inclusion criteria were as follows: patients with a high-energy pelvic fracture and hemodynamic instability. The criteria used to define hemodynamic instability were a systolic blood pressure < 90 mmHg on admission or transfusion needs higher than 2 units of red cell concentrate in the first 12 hours. Results External fixation was used for 45 patients (57%). 48 patients (61%) were subjected to an arteriography, which revealed active arterial intrapelvic bleeding in 44 cases (56%). Twenty-one patients required an arterography plus external fixation, one after the other. twenty-four patients underwent a laparotomy. The incidence of systemic complications was high and mortality stood at 19%. The application of the algorithm was fairly widespread, except for patients requiring a laparotomy and presenting with an open-book type fracture. This group had a high mortality rate. Conclusions The incidence of arteriography-validated arterial lesions was very high. The use of a combined external fixation and arteriography protocol, adapted to the specific health-care characteristics of each hospital makes it possible to check intrapelvic bleeding in quite a large number of cases. Indications for laparotomy should be restricted to the treatment of the hemoperitoneum and of open fractures, and should always be accompanied by some external fixation device.