Complications Of External Fixation Research Articles

A novel primary antibiotic cement-coated locking plate as a temporary fixation for the treatment of open tibial fracture

Complex lower extremity trauma reconstruction remains a challenge. This study used an internal fixation composite structure of antibiotic cement plates as a temporary fixation to treat lower extremity Grade III open fractures; thus, reducing the treatment period and complications of external fixation. We aimed to assess the safety and efficacy of this technique in the initial surgery stage. Between January 2018 and March 2021, 20 patients with Gustilo grade IIIB/C open fractures received an antibiotic cement-coated locking plate as a temporary internal fixator during initial surgery. Thorough debridement and temporary internal fixation were performed with a 3.5-mm system antibiotic cement-coated locking plate. Ten patients required free bone fragment removal, followed by bone cement packing. The final stage involved internal fixation and wound repair with a free anterolateral thigh flap. Clinical and imaging results were retrospectively analysed. The repair time ranged 1–7 days. All flaps survived. Two patients experienced wound infection, and one developed severe bone infection 3 months after three-stage bone graft surgery. Autologous cancellous bone grafting was performed on 10 patients with bone defects 6 weeks after surgery. Bone union was universally achieved after 1 year. This method proved safe and effective, successfully repairing Grade III open fractures of the lower extremity 1–7 days post-treatment.

External fixation versus open reduction and internal fixation in the treatment of Complex Tibial Plateau Fractures: A systematic review and meta-analysis.

The aim of this meta-analysis was to compare the functional outcomes and complications of external fixation (EF) versus open reduction and internal fixation (ORIF) in the treatment of complex tibial plateau fractures. Based on a comprehensive search of major databases through PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL), 19 studies comparing EF versus ORIF in treatment of complex tibial plateau fractures (Schatzker V-VI/ OTA C1, C2, and C3) were included in the studies. There was one randomized controlled trial, two prospective comparative studies, 14 retrospective comparative studies, and two conference papers. From these studies, the data regarding functional and surgical outcomes as well as complications were obtained and pooled to conduct a comparison between the two methods of treatment. 1191 tibial plateau fractures were determined by the systematic review. Of those fractures, 543 were treated using EF, and 648 were treated using ORIF with plate and screws. All the studies included the young patients with traumatic tibial plateau fractures with mean ages from 40 to 60 years. The analysis of pooled data revealed significantly better functional outcome in patients operated with EF (standard mean difference [SMD] = 0.29, 95% confidence interval [CI] = 0.04-0.55, P = 0.02, I2= 0%). However, according to categorical functional outcomes, no significant differences were found (OR 0.80, 95%CI: 0.47, 1.34, P=0.39, I2= 31%). The range of movement at the knee joint was significantly better in patients treated by EF (mean difference [MD] = 7.86, 95%CI = 3.56 -12.17, P = 0.0003). The surgical time in the EF group was significantly shorter compared to the ORIF group (MD = -52.11, 95%CI = -99.62-(-4.60), P = 0.03). Similarly, the intraoperative blood loss was significantly lesser in the EF group (MD = -341.53, 95%CI = -528.18- (-154.88), P = 0.0003). Although the superficial infection was more frequent in the EF group (odds ratio [OR] = 3.22, P = 0.0002), there were no differences in the deep infection and overall infection rates. Also, there were no differences in reoperation rate, knee stiffness, compartment syndrome, and venous thromboembolism. The radiographic osteoarthritis was more common in the EF group (OR = 1.56, P = 0.04); however, there was no difference in the need for total knee arthroplasty between the two treatment modalities. EF provides better functional outcomes and range of motion compared to ORIF in the treatment of complex tibial plateau fractures. With shorter surgical time and lesser intraoperative blood loss, EF can be considered as a definite treatment method in open injuries, polytrauma patients, and chronically morbid patients who cannot withstand prolonged surgery. Level III, Therapeutic Study.

Hip Fracture Management Using External Fixation—A Systematic Review

Patients with significant comorbidities have high general anaesthetic risks and are often thought to be undesirable candidates for general anaesthesia and, therefore, surgery. External fixation uses local or regional anaesthesia, and allows patients with significant comorbidities to avoid the risks of general anaesthesia. It has been described to be successful in the management of high-risk patients with intertrochanteric fractures. However, published data have been derived from small case series, and no published literature has attempted to analyse them in totality. This review aims to pool together these case series, and to evaluate the outcomes and complications of external fixation when performed in high-risk patients with intertrochanteric fractures. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRSIMA) guidelines. All studies that reported the outcomes of external fixation for intertrochanteric fractures of high-risk patients were included. A total of 13 publications, involving 687 patients, were included in the review. All the studies reported postoperative radiological reduction and complete fracture healing with reduction of limb length discrepancy. One study using parallel placement of proximal fixation screws showed shorter operative duration as compared to convergent placement. Another study mentioned that there was no significant difference in mortality rates between patients with stable fractures and those with unstable fractures who underwent external fixation. All the studies reported a decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. External fixation is promising and useful especially in the management of high-risk patients with intertrochanteric fractures. The procedure can help with radiological reduction of the fracture, reduction of limb length discrepancy, reduction of operative duration, decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. The procedure is versatile and seems to be able to accommodate both stable and unstable fractures. However, unstable fractures may be associated with greater postoperative morbidity, and it may be worthwhile to prognosticate based on the stability of the patients' fracture for better risk-benefit analysis preoperatively. Shorter operative times can also be achieved through parallel proximal pin placement, without impact on mortality or morbidity.

Nurses Performance Regarding Orthopedic Patients with External Fixation at Zagazig University Hospitals

Background: The external fixation device had been the gold standard for treatment of many types of fractures that cannot be treated by traction or cast. Orthopedic nurses increasingly play integral roles in all aspects of orthopedic care. The study aimed to assess nurses' performance regarding orthopedic patients with external fixation at Zagazig University Hospital. Research design: A descriptive design was used. Tools of data collection: A self-administered questionnaire and observational checklist were used to collect data. Study subjects: convenient sample of 55 nurses working at orthopedic department at Zagazig university hospitals. Results: Studied nurses’ age ranged between 28 - 58 years and all of studied nurses were females. The majority of studied nurses had a diploma degree in nursing science and hadn’t attended previous training about caring of the orthopedic patient with external fixation. About three quarter of studied nurses had unsatisfactory total knowledge and Almost half of studied nurses had inadequate total practice regarding care of patient with external fixation. The majority of the studied nurses’ performance was affected by environmental factors. A statistically significant relation was found between factors affecting nurses’ performance and their demographic characteristics at nursing qualification. Also there was a statistical relation between nurses’ total knowledge regarding external fixation and nurses total practice at care of patients’ positioning. Conclusion: Nurses had unsatisfactory level of knowledge and inadequate practice regarding care of orthopedic patient with external fixation and nurses reported that their performance was affected by environmental occupational, administrative, and psychological factors. Recommendation: Educational programs should be held periodically for such group of nurses to provide clear idea about the proper care of patient with external fixation, external fixation complications, pin site care, dressing and the factors affecting these performance.

External fixator for distal radius fracture

Unstable distal radius fractures are challenging condition for orthopedic surgeons. Among an array of options, external fixator is a valuable instrument for the reduction and stabilization of these fractures. It is either joint spanning or joint sparing types. It may be used alone or in combination with other stabilization methods. Limited open reduction, augmentation with K-wires, early range of motion, and care of complex wounds are few of the benefits of external fixation. Moderate distraction at the carpus does not induce postoperative stiffness. Complications of external fixation are usually minor but must be anticipated and treated early.

External fixators: looking beyond the hardware maze.

External fixation has a wide variety of orthopedic applications. Although external fixator frames may have a complex appearance, these constructs are formed from several basic components and can be broadly categorized into unilateral, circular, or hybrid designs. The introduction of computer-aided circular external fixation devices (hexapod frames) has simplified the treatment of multiaxial and especially rotational deformities. Serial radiography plays a central role in the evaluation of callus formation (at the level of treated fracture or nonunion as well as the regenerate and docking site with distraction osteogenesis), tailoring the rate and rhythm of distraction during distraction osteogenesis, evaluation of frame complications, and determination of the timing of frame removal. The goals of this article are to review: the components, types, and relevant terminology of external fixator constructs with special emphasis on the Taylor spatial frame, the principles and techniques of distraction osteogenesis, and complications of external fixation.

Treatment of Endoprosthetic Knee Joint Infection in the Setting of Massive Bone Loss With Fusion of Femoral and Tibial Antibiotic Rods

Chronic periprosthetic joint infection of the knee often requires staged surgical treatment combined with several weeks of intravenous antibiotic treatment. The first stage involves resection arthroplasty and placement of an antibiotic-cement spacer. A massive bone defect results from removal of a tumor-style prosthesis, introducing challenges to spacer creation and placement. This article describes a 27-year-old man who was treated 12 years prior for stage IIB osteosarcoma of the right proximal tibia with wide resection and alloprosthetic composite reconstruction. He developed chronic periprosthetic infection of the construct. Three surgical washouts and intravenous antibiotics failed to eradicate the infection, therefore 2-stage exchange arthroplasty was initiated. The first stage involved resection of all implants and allograft, and placement of a novel antibiotic-impregnated spacer. The spacer was created by locking a retrograde femoral nail and an antegrade tibial nail together at the knee joint level. This construct was then encased in antibiotic-impregnated cement to achieve fill of the massive tibial defect. After 6 weeks of intravenous antibiotic infusion, the infection was successfully eradicated and he was indicated for reimplantation arthroplasty with custom hinged knee components. Utilization of interlocked femoral and tibial nails in this manner has not been described for creating an antibiotic-laden temporary knee arthrodesis spacer as the first stage in treatment of periprosthetic joint infection. This strategy achieves stable knee fusion although avoiding violation of the hip and the complications of external fixation. Application of this technique may be particularly beneficial in the setting of massive bone loss.

Delayed methicillin-resistant Staphylococcus aureus-induced osteomyelitis of the tibia after pin tract infection: two case reports

BackgroundPin tract infection is a common complication of external fixation. It usually heals after treatment with debridement, antibiotics, and/or pin removal, only rarely developing into delayed osteomyelitis. We treated two patients with delayed methicillin-resistant Staphylococcus aureus-induced osteomyelitis of the tibia following pin tract infection.Case presentationOne patient, a diabetic 60-year-old Japanese man, underwent definitive external fixation using an Ilizarov fixator for postoperative osteomyelitis of an open fracture of his left ankle. One year after removing the external fixator, he developed methicillin-resistant Staphylococcus aureus-induced osteomyelitis of the tibial pin site. He underwent surgical debridement four times. No recurrence was seen 2 years 8 months after the last debridement. Another patient, a healthy 38-year-old Japanese man, underwent bilateral temporary external fixation for a right ankle open fracture and a comminuted fracture of the left tibial plateau. Three months after removal of the external fixator, he was diagnosed with methicillin-resistant Staphylococcus aureus-induced osteomyelitis of the bilateral tibial pin sites. He underwent surgical debridement three times, but the infection of his right tibia persisted. Finally, a gastrocnemius muscle flap was placed. No recurrence was seen 2 years after this last surgery.ConclusionsPin tract infection should not be considered a minor complication because osteomyelitis may develop, requiring treatment that is more aggressive than curettage of the pin tract. A gastrocnemius flap is a useful treatment option for refractory osteomyelitis because flap harvest causes less functional disturbance and is a relatively easy surgical technique.

Evaluation of External Fixation Results in High-risk Older Patients with Intertrochanteric Femur Fractures

Background: Intertrochanteric femur fractures are common in older people. In high-risk patients, especially American Society of Anesthesiologists (ASA) scores 3 and 4, surgery with internal fixation can cause excessive stresses. Therefore, external fixation is another option for treating these patients. Objective: To evaluate the results and complications of external fixation in elderly patients with intertrochanteric fractures. Methods: Twenty-six surgically high-risk patients with intertrochanteric fractures admitted to our clinic were treated with external fixation (January 2010- November 2011). Epidemiological and radiological data and also complications were recorded at each follow-up. Results: No complications occurred in 13 patients. The remaining 13 patients had complications after surgery: Of the patients, 10 had implant failure (6 pin migration and 4 pin cut-out) and 3 had pin tract infections. Six patients who had implant failure (2 pin migration and 4 pin cut-out) underwent revision. Unrevised complicated patients (4 pin migration) and 2 of 3 patients with pin tract infections had malunion and shortening. High risk older patients with external fixation had a high complication and morbidity rate. Conclusion: We do not recommend using pertrochanteric external fixators in high-risk patients due to the high revision rate and serious complications.

External fixation in pediatric trauma

External fixation is a vital component in the treatment of pediatric fractures. Although internal fixation is customary in the adult population, these techniques can be deleterious in the pediatric population because they may alter or compromise future growth. Therefore, methods such as external fixation that avoid injury to growth centers are required in the pediatric population. In addition, fixators can be used as temporizing stabilization in patients in extremis or in fractures with significant soft-tissue compromise. However, external fixation is not without complications, which include infection, refracture and nonunion. These indications, benefits and complications of external fixation are discussed.

External Fixation Techniques for Distal Radius Fractures

Fractures of the distal radius are common injuries. Low-energy or high-energy mechanisms may be involved. Unstable distal radius fractures present a challenge to the treating orthopaedic surgeon. External fixation is a valuable instrument for fracture reduction and stabilization. Limited open incisions, early range of motion, and treatment of complex wounds are a few of the benefits of external fixation. Fixators may be spanning or nonbridging and may be used alone or in combination with other stabilization methods to obtain and maintain distal radius fracture reduction. Augmentation with percutaneous wires allows for optimal fracture stabilization with physiologic alignment of the wrist. Moderate distraction at the carpus does not induce postoperative stiffness. The distal radioulnar joint must be assessed and may need to be stabilized. Complications of external fixation are usually minor, but must be anticipated and treated early. Level V (expert opinion).

External fixation in comminuted, displaced intra-articular fractures of the distal radius: is it sufficient?

External fixation has been extensively used to treat the intra-articular fractures of the distal radius and it has several distinct advantages over conventional POP cast and plate fixation. However, the limitation of external fixation to achieve articular congruity in the comminuted intra-articular fractures of the distal radius has been documented in the literature. This could be because external fixation alone does not expand crushed cancellous bone and cannot work without soft tissue hinges. This prospective study was conducted to look at the results of comminuted, displaced intra-articular fractures of the distal radius treated exclusively by external fixation. A 2-year follow-up of 27 patients with comminuted, displaced intra-articular fractures of distal radius that were treated exclusively by external fixation is presented. The radiological results, functional results and complications were analyzed according to the scoring system given by Jakim et al. Anatomical reduction could not be achieved in 12 patients (44%) and reduction was lost in two patients (7%). Excellent and good results were seen in 59.3%, fair results were seen in 22.2% and poor results were seen in 18.5% of the cases. Outcome scores of patients without articular step were significantly better as compared to the patients with articular step at healing. There was a positive correlation between the restoration of normal anatomy (radiological results) and the functional outcome (r=0.775). Overall nine patients (33%) had complications. We conclude that although the external fixation is reliable in maintaining the reduction in displaced comminuted intra-articular fractures, it is inadequate in restoring articular congruity in many cases. The complications of external fixation are frequent and may be potentially serious in nature.

External Fixation as a Bridge to Intramedullary Nailing for Patients with Multiple Injuries and with Femur Fractures: Damage Control Orthopedics

Background: The advantages of early fracture fixation in patients with multiple injuries have been challenged recently, particularly in patients with head injury. External fixation (EF) has been used to stabilize pelvic fractures after multiple injury. It potentially offers similar benefits to intramedullary nail (IMN) in long-bone fractures and may obviate some of the risks. We report on the use of EF as a temporary fracture fixation in a group of patients with multiple injuries and with femoral shaft fractures. Methods: Retrospective review of charts and registry data of patients admitted to our Level 1 trauma center July of 1995 to June of 1998. Forty-three patients initially treated with EF of the femur were compared to 284 patients treated with primary IMN of the femur. Results: Patients treated with EF had more severe injuries with significantly higher Injury Severity Scores (26.8 vs. 16.8) and required significantly more fluid (11.9 vs. 6.2 liters) and blood (1.5 vs. 1.0 liters) in the initial 24 hours. Glasgow Coma Scale score was lower (p < 0.01) in those treated with EF (11 vs. 14.2). Twelve patients (28%) had head injuries severe enough to require intracranial pressure monitoring. All 12 required therapy for intracranial pressure control with mannitol (100%), barbiturates (75%), and/or hyperventilation (75%). Most patients had more than one contraindication to IMN, including head injury in 46% of cases, hemodynamic instability in 65%, thoracoabdominal injuries in 51%, and/or other serious injuries in 46%, most often multiple orthopedic injuries. Median operating room time for EF was 35 minutes with estimated blood loss of 90 mL. IMN was performed in 35 of 43 patients at a mean of 4.8 days after EF. Median operating room time for IMN was 135 minutes with an estimated blood loss of 400 mL. One patient died before IMN. One other patient with a mangled extremity was treated with amputation after EF. There was one complication of EF, i.e., bleeding around a pin site, which was selflimited. Four patients in the EF group died, three from head injuries and one from acute organ failure. No death was secondary to the fracture treatment selected. One patient who had EF followed by IMN had bone infection and another had acute hardware failure. Conclusion: EF is a viable alternative to attain temporary rigid stabilization in patients with multiple injuries. It is rapid, causes negligible blood loss, and can be followed by IMN when the patient is stabilized. There were minimal orthopedic complications.

Principles of external fixation and supplementary techniques in distal radius fractures

External fixation for fractures of the distal radius has been used for almost 80 years. The main objective is to gain reduction and maintain the reduction throughout the treatment period. Several fixator concepts are available and selection is based on the complexity of the injury to be treated as well as the surgeon's experience. Periarticular application of the fixator with immediate use of the wrist joint is recommended whenever possible. For intra-articular fractures, transarticular application is advisable. External fixtion in complex fractures has to be supplemented by bone grafting, fixation wires and stabilization of the radioulnar joint. Associated injuries in distal radius fractures need to be identified and treated. The possible complications of external fixation and the means to prevent them are discussed. External fixation of the distal radius has found its place as an established method in treating certain types of this common fracture.

Treatment of unstable distal radius fractures: Methods and comparison of external distraction and ORIF versus external distraction-ORIF neutralization

Twenty-six closed unstable distal radius fractures were treated using a combination of internal fixation, external distraction (intraoperative), and, in some cases, up to 4 weeks of postoperative external fixation (neutralization). Intraoperative stability check determined the need for external neutralization. This combined technique allowed a comprehensive approach to even the most unstable fracture by merging the advantages of internal and external fixation. Up to 4 weeks of external fixation (neutralization) was not associated with the complications of external fixation usually reported.

Complications of external fixation of the wrist

Complications of external fixation of the wrist

Complications of External Fixation

External fixation is an effective method of stabilizing many fractures in veterinary orthopedics, however, it is not foolproof. Although careful attention to the principles of fixator selection and application is the optimal way to minimize complications, they do still occur. Prompt recognition of these complications and appropriate treatment, however, will minimize their effects and result in the successful outcome of fracture healing and normal limb function.

Complications in Orthopaedic Surgery

Ben Hecht once observed that Doctors have a sense for things unseen and complications unstated. Orthopedic practitioners familiar with this fine book will, without a doubt, sharpen their senses of the possibilities (both seen and unseen), prevention, problems (both stated and unstated), and treatment of the many complications of their craft. This second edition has added five new chapters to the 1978 text: Complications of External Fixation, Complications of Functional Bracing and Cast Bracing, Complications of Microvascular Surgery, Complications of Multiple Trauma, and Complications of Allograft Surgery. The old chapters have been updated, new illustrations have been added, and references have been augmented. The original format of four parts has been retained. Part 1 discusses general considerations, anesthesia, traction and appliances, external fixation, cast bracing, implants, infections, and the role of secondary gain. Part 2 covers the complications of trauma; Part 3, the complications of arthroplasty and total joint replacement;