Definitive External Fixation Research Articles

Comparison of Single-Stage and Dual-Stage Approaches for Nonunion Repair in the Absence of Evident Infections

OBJECTIVE: This study aimed to determine if routine dual-stage nonunion repair (DSR) surgery lead to better outcomes than single-stage nonunion (SSR) repair surgery in fracture nonunions without evident clinical or laboratory signs of infection. METHODS: Design: Retrospective comparison study Setting: Level One Trauma Center affiliated with an academic teaching hospital Patient selection Criteria: Skeletally mature patients diagnosed with fracture nonunion between June 2013 and January 2022 were included. Patients with previous non-operative treatment, definitive external fixation, previous or current diagnosis of FRI, or less than 12 months of follow-up were excluded. Outcome measures and comparison: Patient characteristics and details of the primary and the revision surgery were recorded. Comparison of the primary outcome measures - FRI, recalcitrant nonunion, and implant failures were performed between SSR and DSR groups RESULTS: A total of 113 patients met the eligibility criteria. Eighty-six patients (mean age 44.8 years, range – 17 – 80 years, 64 percent males) underwent SSR, while 27 patients (mean age 50.8 years, range 21-77 years, 52 percent males) underwent DSR. Seventy six percent underwent SSR and 24 percent underwent DSR. Baseline characteristics were similar between groups (open fractures, p=0.918; smoking, p=0.86; lower limb fractures, p=0.238; Diabetes, p=0.503; ESR, p=0.27; CRP, p=0.11; age, p=0.11; CCI, p=0.06) except for a higher rate of DSR in cases initially treated elsewhere (p = 0.015) and in obese patients (p=0.044). Bone grafting was more frequent in DSR using plates (p = 0.030). No significant differences were observed in subsequent infections (6.97 % vs 7.41 %, p=0.939), persistent nonunion (28.2 % vs 14.81 %, p=0.169), or implant failure (19.76 % vs 22.22 %, p=0.782) between SSR and DSR. CONCLUSION: No difference was found in infection, recalcitrant nonunion, and implant failure between single stage repair and dual stage repair for nonunions without overt signs of infection. The study challenges the routine use of DSR, questions the necessity of subjecting patients to two surgical procedures, and advocates for a more judicious approach in the absence of overt FRI in a fracture nonunion. LEVEL OF EVIDENCE: Level III

External fixation as definitive treatment or external fixation followed by early fixation in open fractures of the tibial shaft: A descriptive study

IntroductionTreatment options for open tibial shaft fractures include external fixation with or without early conversion to internal fixation. ObjectivesThe aim of this study was to describe 1) early conversion to internal fixation and definitive external fixation and 2) in case of conversion, to identify risk factors for complications. MethodsSeventy-two external fixations of open fractures of the tibial shaft (Gustilo classification, 7 fractures (9.7 %) grade I, 25 fractures (34.7 %) grade II, 40 fractures (55.6 %) grade III (31 grade IIIA and 9 grade IIIB)) were included in a continuous non-randomised study. Thirty-three fractures without infection signs were converted to internal fixation at a mean time of 40.5 +/-15 days (IF group). External fixation was maintened in the remaining 39 fractures (EF group). ResultsIn the “IF” group, the union rate was 69.7 % at 6.3 +/-3.6 months (3–16). All patients had complete union at 16 months, requiring 2.8 +/-0.8 reoperations. Fixation with external fixation only (“EF” group) showed a union rate of 51.3 % at 8.9 +/-4 (5–22) months and 96 % at 16 months after 3.7 +/-0.9 reoperations. Superficial infection (12.1 %; p = 0.011) and numerous surgeries (2.76; p = 0.004) were found to be risk factors for deep infection. Time to wound closure >7 days (p = 0.049), time to reoperation >28 days (p = 0.00), numerous surgeries (2.76; p = 0.004) and deep infection (6.1 %; p = 0.027) were found to be union failure factors. ConclusionEarly conversion of external fixation to internal fixation is an effective option to achieve bone union of open tibial fractures in selected patients.

Bone union and mobility outcomes for reconstructed open tibial fractures: a plastic surgical experience from a major trauma center.

The goal in open tibial fracture management is to achieve a united tibia in an extremity that allows pain free mobilization. The objective of this study was to assess factors that lead to this functional outcome in lower limb reconstruction, from a plastic surgical perspective. The Plastic and Reconstructive Surgery lower limb database at a tertiary trauma hospital was searched for open tibial injuries from February 2015 to March 2020. The nature and severity of injury, timing and details of all operations including reconstructions were collected prospectively. Mobility including gait aids, pain, and complications were retrospectively collected. Union was assessed in two ways, depending on fracture location. Metaphyseal and diaphyseal tibial fractures were provided mRUST scores (union defined as RUST > 13) and epiphyseal tibial fractures were categorically classified as "united" or "non-union" by two independent radiologists. During the five-year study period there were 148 open leg injuries in the database. Twenty-one patients underwent a primary amputation due to severity of their initial injury. One hundred patients underwent primary limb salvage. Sixty-one patients in the limb salvage group achieved primary tibial union with a mean follow-up time of 19.4 months post injury. Twenty-three additional patients were confirmed to subsequently unite. Patient who achieved union were more likely to mobilise without gait aids. In this study definitive external fixation and soft tissue infection were both associated with higher rates of non-union. Longer times to soft tissue reconstruction was not associated with an increase in acute soft tissue complications. More importantly bone union, pain and mobility did not decline. After undertaking a primary limb salvage pathway for 100 patients, the ultimate tibial fracture union rate was 84% and the confirmed ambulation rate was 96%.

SURGICAL TREATMENT OF COMPLEX META-DIAPHYSEAL TIBIAL FRACTURES – CURRENT STATE OF THE ART AND NEW TREATMENT MODALITIES

Fractures of a meta-diaphyseal region of the tibia are still challenging in terms of safe, fast, minimal invasive, low - risk surgical treatment. The unstable meta diaphyseal tibial fractures affect proximal and distal one-third of the tibia and result from high-energy trauma, usually combined with severe soft tissue injury. Treatment strategies include mostly operative approaches with various contemporary surgical instrumentations and modern techniques for definitive fracture repair, achieving primary or secondary bone union and better quality of life for patients. In the last decade, new techniques for definitive external plate fixation have been introduced as a part of contemporary trauma armamentarium with good and excellent outcomes.

Estudio observacional retrospectivo correlacionando las fracturas traumáticas de pelvis y sus lesiones asociadas según la clasificación de Tile

IntroductionPelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification. MethodsRetrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016. ResultsA total of 42 patients were included; of those 69% (n=29) were males, mean age was 48 years. 45% (n=19) suffered traffic accidents and 26.2% (n=11) falls. There was a different proportion in pelvic injuries: Tile A (n=15, 35.7%), B (n=20, 47.6%), and C (n=7, 16.6%) of cases. 54.8% (n=23) underwent surgery, 21.4% (n=9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P=.032), and Tile B with sacral fractures (P=.033) and visceral injuries (P=.049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n=26) needed blood transfusion; 9.5% (n=4) presented hypovolemic shock. ConclusionsTile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Retrospective observational study correlating traumatic pelvic fractures and their associated injuries according to the Tile classification

IntroductionPelvic fractures due to high energy trauma present a high risk of associated injuries that compromise the functional and vital prognosis of the patients. The objective of this study was to analyze the relationship between traumatic pelvic fractures and their associated injuries according to the Tile classification. MethodsRetrospective observational study of patients who suffered traumatic pelvic fractures (Type A, B or C of the Tile classification) with concomitant associated injuries, analyzing hemoglobin levels, between 6/2013 and 1/2016. ResultsA total of 42 patients were included; of those 69% (n = 29) were males, mean age was 48 years. 45% (n = 19) suffered traffic accidents and 26.2% (n = 11) falls. There was a different proportion in pelvic injuries: Tile A (n = 15, 35.7%), B (n = 20, 47.6%), and C (n = 7, 16.6%) of cases. 54.8% (n = 23) underwent surgery, 21.4% (n = 9) needed temporary or definitive external fixation. Significant differences were found between Tile A type and scapula fractures (P = .032), and Tile B with sacral fractures (P = .033) and visceral injuries (P = .049), while there is a tendency without a statistical significal between Tile C and costal fractures. 61.9% (n = 26) needed blood transfusion; 9.5% (n = 4) presented hypovolemic shock. ConclusionsTile A pelvic fractures were associated with scapular fractures, and Tile B with transforaminal fractures of the sacrum and with visceral injuries (lungs, liver and genitourinary). The small number of Tile C prevent us to confirm an association with any pathology, although they are the ones which presnt more hemodynamically instability and thoracic injuries.

Male sex, Gustillo-Anderson type III open fracture and definitive external fixation are risk factors for a return to the or following the surgical management of geriatric low energy open ankle fractures

IntroductionOpen ankle fractures in geriatric (age > 60 years) patients are a source of significant morbidity and mortality. Surgical management includes plate and screw fixation (ORIF), retrograde hindfoot nail (HFN), definitive external fixation (ex-fix) and below knee amputation. However, each modality poses unique challenges for this population. We sought to identify predictors of unplanned OR and short-term mortality after geriatric open ankle fractures managed by our service. Materials and methodsIn an IRB-approved protocol, we evaluated patients over 60 years of age managed for a low energy open ankle/distal tibia pilon fracture by trauma fellowship-trained surgeons from a single academic department that covers two level I trauma centers. Our primary outcome was an unplanned return to the OR. Secondary outcomes were a 90-day “event”, defined as an all-cause hospital readmission or mortality, and 1-year mortality. Differences with a p-value < 0.1 measured on univariate analysis were evaluated using a multivariable logistic regression to identify independent outcome predictors. ResultsA total of 113 (60 ORIF, 36 HFN, 11 ex-fix, 6 amputations) were performed. Cohort mean age was 75.2 ± 9.8 years, and 31 patients (27.4%) were male. Mean age-adjusted charlson comorbidity index was 5.5 ± 2.0. Significant independent predictors of an unplanned return to the OR were male sex (OR 4.4, 95% CI 1.3 to 15.4), Gustilo Type III open fracture (OR 4.9, 95% CI 1.5 to 17.5) and ex-fix (OR 15.6, 95% CI 2.7 to 126.3). Independent predictors of a 90-day “event” were walker/minimal ambulation (OR 3.5, 95% CI 1.3 to 10.4), surgical site infection (OR 4.8, 95% CI 1.8 to 13.8) and reduced BMI (OR 0.9, 95% CI 0.9 – 0.99), while independent predictors of 1-year mortality were age (OR 1.1, 95% CI 1.003 to 1.2), ACCI (OR 1.4, 95% CI 1.02 to 2.0) and walker/minimal ambulator (OR 7.5, 95% CI 1.7 to 53) ConclusionsHost factors, particularly pre-operative mobility, were most predictive of 90-day event and 1-year mortality. Only definitive external fixation was found to influence patient morbidity as a significant predictor of unplanned OR. However, no surgical modality had any influence on short-term readmission or survival.

Management of Gustilo-Anderson IIIB open tibial fractures in adults-a systematic review.

Open tibial fractures are the most common open long bone fracture, despite this, the management of these complex injuries still remains a topic of discussion amongst orthopaedic surgeons. We searched the EMBASE, MEDLINE and Google Scholar and a systematic review of 7500 articles, leaving 23 after exclusion criteria were applied, in order to analyse the management of open tibial fractures. Infection was noted to be the most significant concern amongst authors, with definitive external fixation having a high rate of superficial pin-site infection and internal fixation having a high deep infection rate. It is essential to have a combined ortho-plastic approach to the management of these fractures as muscle flaps were the most common form of soft tissue coverage. A national pragmatic trial into the management of open tibial fractures is required looking at fixation methods and soft tissue coverage, with at least a 2-year follow-up in order to ascertain the most appropriate management of these fractures and patient-related outcomes.

Combined medial gastrocnemius and hemisoleus flap: a reproducible alternative for open tibial fractures complicated with large or double soft tissue defects.

Utilization of combined local muscle flaps for Gustilo type IIIB open tibial fractures has not been clearly delineated. We describe a combination of medial gastrocnemius and hemisoleus flaps for managing open tibial fractures accompanying large or double soft tissue defects. Twelve patients with Gustilo IIIB open fractures of the tibial shaft with large (9) or double (3) defects were operated on by fracture stabilization and combined medial gastrocnemius and hemisoleus flap coverage. Data were collected on types of implants, types of flaps, union time, postoperative complications, and Puno functional scores. Regarding implants for fixation, an intramedullary nail was used in three patients, plate and screws in five, combined plate and intramedullary nail in one, and definitive external fixation was used in three. Regarding soft tissue coverage, combined medial gastrocnemius and hemisoleus flaps were used in ten patients, combined hemigastrocnemius and hemisoleus in one, and combined medial gastrocnemius and reversed hemisoleus in one. All flaps survived, and all fractures were united with a mean union time of 19.7weeks (range 16-24). Tip necrosis of the hemisoleus flap occurred in two patients. Regarding Puno functional score, one was determined to be excellent, nine was good and two was fair. Combined medial gastrocnemius and hemisoleus flaps are reliable and effective for open tibial fractures complicated with large or double soft tissue defects.

Supracutaneous locking compression plate as an external fixator in compound metaphyseal and diaphyseal fractures of tibia

Background: Most of lower leg external fixation are bulky and cumbersome and provides only temporary bony stabilization. Anatomically pre-contoured supracutaneous LCP has been utilized by many authors as an external fixator in patients with metaphyseal and diaphyseal fractures of tibia. Aim: The aim of this study is to analyse the end result of Supracutaneous LCP as a definitive external fixation and its effect on rate of union in metaphyseal and diaphyseal fractures. Materials and methods: A complete of 30 patients of compound fractures of tibia underwent “supracutaneous plating” of the tibia using an LCP. Average age was 44 years. Regular screw tract dressings were done. Average period of follow-up was 13 months. Results: The plate was kept ex situ for a period of 24-30 weeks. Proximal metaphysis, diaphysis and distal metaphysis united in 14 weeks, 20 weeks and 16 weeks respectively. Total of 30 patients were operated for Supracutaneous LCP of which one complicated with Infected Non-union resulting in implant removal and other complicated with Non-union which later underwent internal fixation. Conclusion: In compound fractures of tibia supracutaneous LCP are often used as a definitive external fixator because it gives good results especially for metaphyseal fractures and fewer complication rates, with Adequate stability. Advantageous effect of LCP in facilitating wound healing, cosmetic surgery procedure. Because it does not strike the contralateral leg therefore cosmetically acceptable and functional while ambulation. Because of nonoverlapping of implants fracture healing is easily assessed on x rays.

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study.

Introduction:Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment.Material and Methods:Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes.Results:Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor.Conclusion:“Fix and Flap” in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

Strategies to minimize soft tissues and septic complications in staged management of high-energy proximal tibia fractures.

Soft tissues (wound dehiscence, skin necrosis) and septic (wound infection, osteomyelitis) complications have been historically recognized as the most frequent complications in surgical treatment of high-energy proximal tibia fractures (PTFs). Staged management with a temporary external fixator is a commonly accepted strategy to prevent these complications. Nonetheless, there is a lack of evidence about when and how definitive external or internal definitive fixation should be chosen, and which variables are more relevant in determining soft tissues and septic complications risk. The aim of the present study is to retrospectively evaluate at midterm follow-up the results of a staged management protocol applied in a single trauma center for selective PTFs. The study population included 24 cases of high-energy PTFs treated with spanning external fixation followed by delayed internal fixation. Severity of soft tissues damage and fracture type, timing of definitive treatment, clinical (ROM, knee stability, WOMAC and IOWA scores) and radiographic results as well as complications were recorded. Complex fracture patterns were prevalent (AO C3 58.3%, Schatzker V-VI 79.1%), with severe soft tissues damage in 50% of cases. Mean time to definitive internal fixation was 6days, with double-plate fixation mostly chosen. Clinical results were highly satisfying, with mean WOMAC and IOWA scores as 21.3 and 82.5, respectively. Soft tissue complication incidence was very low, with a single case of wound superficial infection (4.3%) and no cases (0%) of deep infection, skin necrosis or osteomyelitis. Staged management of high-energy PTFs leads to satisfying clinical and radiographic results with few complications in selected patients.

Definitive External Fixation for Anterior Stabilization of Combat-related Pelvic Ring Injuries, With or Without Sacroiliac Fixation.

Combat-related pelvic ring injuries frequently lead to placement of a temporizing external fixation device for early resuscitation and transport. These injuries are commonly complicated by concomitant polytrauma and extensive soft-tissue injuries, which may preclude early internal fixation and lead to prolonged use of external fixation. To date, few studies have reported on the outcomes of definitive external fixation for combat-related pelvic ring injuries. (1) In patients treated with definitive external fixation after combat-related pelvic ring injuries, how often is the quality of reduction within radiographically acceptable parameters at the end of treatment? (2) What proportion of patients demonstrate local heterotopic ossification after these injuries? (3) What patient- and treatment-related factors are associated with increased complications and pain? We retrospectively studied all patients with pelvic ring injuries treated at a tertiary military referral center from January 2003 to December 2012. In total, 114 patients were identified, 55 of whom maintained an external fixation frame throughout their treatment. During that time, the general indications for definitive external fixation were an open, contaminated pelvic ring injury with a high risk of infection or open urologic injury; confluent abdominal, perineal, and thigh wounds; or comminution of the pubic ramus that would necessitate plate fixation extending up the anterior column in patients with open abdomen or exposure-compromising abdominal wounds. Posterior fixation, either sacroiliac or lumbopelvic, was applied in patients with sacroiliac instability. Of the 55 patients with pelvic ring injuries treated with definitive external fixation (27 open and 28 closed), four underwent hemipelvectomy and construct removal for massive ascending infections and four were lost to follow-up, leaving 47 patients (85%) who were available at a minimum follow-up of 12 months (median 29 months, interquartile range 17-43 months). All 47 patients underwent serial imaging to assess their injury and reduction during treatment. External fixators were typically removed after 12 weeks, except in patients in whom pin-site irritation or infection prompted earlier removal, and all were confirmed to be grossly stable during an examination under anesthesia. Clinical union was defined as the absence of radiographically present fracture lines and stable examination findings under anesthesia when the external fixator was removed. Data on demographics, injury pattern, associated injuries, revision procedures, complications, and final functional outcomes including ambulation status, sexual function, and pain were collected. Pelvic radiographs were reviewed for the initial injury pattern, type of pelvic fixation construct, residual displacement after removal of the frame, and evidence of formation of heterotopic ossification in the pelvis or bilateral hips. Pelvic displacement and diastasis were determined by digital caliper measurement on plain images; malunion was defined as anterior diastasis of the pelvis or vertical incongruity of the hemipelvis greater than 10 mm. Radiographic malunion after construct removal occurred in eight of 24 patients with open injuries and in five of 23 patients with closed injuries. Heterotopic ossification developed in the pelvis or hips of all 24 patients with open injuries and in two of the 23 patients with closed injuries. In patients with open pelvic ring injuries, concomitant acetabular fractures were associated with pelvic pain at the final follow-up examination (risk ratio 1.9; 95% confidence interval, 1.0-3.5; p = 0.017). No treatment factor resulted in superior functional outcomes. In the closed-injury group, concomitant lower-extremity amputation was associated with improved radiographic final reduction (RR 0.4; 95% CI, 0.2-0.7; p = 0.02). There was no association between radiographic malunion and increased pain (RR 1.9; 95% CI, 0.5-7.0; p = 0.54 for the open group; RR 0.8; 95% CI, 0.7-1.0; p = 0.86 for the closed group). In this series of patients with severe combat-related pelvic ring injuries who were treated anteriorly with definitive external fixation because of a severe soft-tissue injury, high infection risk, or unacceptable physiologic cost of internal fixation, malunion and chronic pelvic pain were less common than previously observed. Prior studies primarily differ in their lack of sacroiliac or lumbopelvic stabilization for posteriorly unstable fracture patterns, likely accounting for much of these differences. There may have been important between-study differences such as extremely severe injuries, concomitant injuries, and study population. Our study also differs because we specifically analyzed a large cohort of patients who sustained open pelvic ring injuries. Future studies should prospectively investigate the ideal construct type and pin material, optimize the length of treatment and assessment of healing, and improve radiographic measures to predict long-term functional outcomes. Level IV, therapeutic study.

Bridging versus Nonbridging Dynamic External Fixation of Unstable Distal Radius Fractures in the Elderly with Polytrauma: A Randomized Study.

Background Despite the high prevalence of unstable distal radius fractures (DRFs), there is no consensus regarding the optimal method and treatment timing, especially for elderly patients with multiple associated injuries. Purpose This study aimed to compare the grip strength achieved with two different methods for definitive dynamic external fixation of DRFs in elderly patients with polytrauma operated on within the first 24 hours. Methods In this prospective randomized trial, 35 patients were assigned to undergo definitive external dynamic fixation of DRFs using the nonbridging (group A) or bridging (group B) method. The grip strength, range of motion (ROM), Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcome measure, visual analog scale (VAS) score for pain, and radiographic characteristics were evaluated at 6 and 12 months. Results At 12 months, no significant between-group difference was observed with respect to grip strength. All patients showed results in the third or fourth quartiles. The mean ROMs were 96.94 and 96.38% and the mean QuickDASH scores were 3.53 and 3.85 in groups A and B, respectively. The VAS scores were 1.60 and 1.85 in groups A and B, respectively. The overall complication rates were 13.3 and 15% in groups A and B, respectively. Initial fracture reduction was maintained in 86.67 and 95% of the patients in groups A and B, respectively. Conclusions Both bridging and nonbridging external definitive dynamic fixation proved safe and reliable for the treatment of unstable DRFs in elderly patients with polytrauma. The grip strength results in both groups predicted the restoration of ability in elderly patients to perform activities of daily living independently.

Inter-Rater Reliability of the Modified Radiographic Union Score for Diaphyseal Tibial Fractures With Bone Defects.

To evaluate inter-rater reliability of the modified Radiographic Union Score for Tibial (mRUST) fractures among patients with open, diaphyseal tibia fractures with a bone defect treated with intramedullary nails (IMNs), plates, or definitive external fixation (ex-fix). Retrospective cohort study. Fifteen-level one civilian trauma centers; 2 military treatment facilities. Patients ≥18 years old with open, diaphyseal tibia fractures with a bone defect ≥1 cm surgically treated between 2007 and 2012. Three of 6 orthopedic traumatologists reviewed and applied mRUST scoring criteria to radiographs from the last clinical visit within 13 months of injury. Inter-rater reliability was assessed using Krippendorff's alpha (KA) statistic; intraclass correlation coefficient (ICC) is presented for comparison with previous publications. Two hundred thirteen patients met inclusion criteria including 115 IMNs, 24 plates, 29 ex-fixes, and 45 cases that no longer had instrumentation at evaluation. All reviewers agreed on the pattern of scoreable cortices for 90.4% of IMNs, 88.9% of those without instrumentation, 44.8% of rings, and 20.8% of plates. Thirty-one (15%) cases, primarily plates and ex-fixes, did not contribute to KA and ICC estimates because <2 raters scored all cortices. The overall KA for the 85% that could be analyzed was 0.64 (ICC 0.71). For IMNs, plates, ex-fixes, and no instrumentation, KA (ICC) was 0.65 (0.75), 0.88 (0.90), 0.47 (0.62), and 0.48 (0.57), respectively. In tibia fractures with bone defects, the mRUST seems similarly reliable to previous work in patients treated with IMN but is less reliable in those with plates or ex-fixes, or after removal of instrumentation.

Surgical treatment of unstable pelvic ring fractures

Background/Aim. Pelvic ring fractures are complex injuries and are often associated with internal organs injuries. These injuries require rapid and accurate diagnosis and in some cases one or more surgical interventions. The aim of this retrospective study is to describe the indications and outcomes of surgical treatment of pelvic ring injuries with the emphasis on anatomical reconstruction and stable osteosynthesis as a prerequisite for early mobilization and more favorable functional outcomes. Methods. In the period from 2006 to 2012, fifty-five patients with pelvic ring injuries with or without acetabular fractures were analyzed. The average age of all patients was 36 years. Forty-one patients were treated with operational open reduction and internal fixation (ORIF) while nine of them were treated nonoperatively (bed rest, skeletal traction and external fixation). Results. All operated patients were treated within 3- 24 days with ORIF, stable osteosynthesis and early mobilization which resulted in avascular necrosis (AVN) of the femoral head in two cases. AVN of the femoral head was noted in five cases in combined and isolated pelvic ring injuries and acetabulum which were treated with skeletal traction. Neurological deficit was recorded in three patients treated with conservative methods while two patients underwent ORIF. Deep vein thrombosis (DVT) was noted in two patients and pulmonary thromboembolism appeared in one patient 23 days after surgical intervention. Two infections occurred around Steinman pins in the patients who had the definitive treatment performed with external fixator. In one patient treated with ORIF a superficial infection occurred and was treated with antibiotics. The functional results were evaluated based on Merle d'Aubign? score. The results of the radiography treatment were analyzed according to Slatis. Conclusion. Strict application of rational criteria and surgical technique with stable internal fixation with early mobilization provide significantly better outcomes of these injuries in relation to non surgical treatment or treatment with definitive external fixation.

Complications after operative treatment of femoral shaft fractures in childhood and adolescence.

Purpose of the study was to retrospectively analyze the complication rates after operatively treated femoral shaft fractures in childhood and adolescence. Retrospective evaluation of 42 children with operatively treated femoral shaft fractures between 2000 and 2014. Fractures were classified as 27 A type, 12 B type and 3 C type fractures according the OTA/AO classification. 8 (19.05%) fractures were open. Age averaged 10.2 years (3-16). Fracture treatment was recorded as temporary or definitive external fixation, ESIN, plate fixation or IMN. Complications such as wound infection, re-fractures, nonunion and malunion were analyzed. Six (14.29%) fractures were temporarily stabilized using an external fixator. In 22 (52.38%) children the femoral shaft fracture was stabilized using ESINs. 10 (23.81%) children had a plate fixation and 9 (21.43%) adolescents were treated using an IMN. ESIN treated children were significantly younger (P=0.000) and had less weight (P=0.000) than children treated with both other methods. Complications were two (4.76%) superficial and two deep (4.76%) wound infections, one (2.38%) re-fracture with the ESIN in situ, one (2.38%) nonunion and one (2.38%) malunion. Six (14.29%) children required a reoperation for a complication. Risk factors for complications were temporarily applied external fixators, open fractures, C Type fractures (P=0.031) and an increasing age (P=0.048) and weight (P=0.047) of the child. The majority of children in our study population were successfully treated using ESIN presenting a low complication rate. Complications were observed following open fractures and more complex fracture types. Furthermore we observed an increasing complication rate with increasing ages and weights of the children.

Le fratture diafisarie di femore trattate con FE

Conversion of temporary external fixation to an intramedullary nailing within the first two weeks after femoral shaft fracture is a standard practice. However, in large parts of the world, external fixation of femoral shaft fractures is often the definitive treatment. Satisfactory results can be obtained through definitive external fixation of femoral shaft fractures. Pin tract infections, in spite of being a common occurrence, are not a major problem and may be treated by local wound care and antibiotic therapy. The most common problem is a significant decrease in the range of motion of the knee.

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.

Prophylactic Postoperative Antibiotics May Not Reduce Pin Site Infections After External Fixation

Pin infection continues to be a nuisance when using definitive external fixation. Prophylactic antibiotic treatment has been proposed in an effort to decrease pin complications. We performed a prospective, randomized, single-blinded study to answer the following questions: (1) what was the effect of a 10-day course of oral prophylactic antibiotics administered immediately after external fixation surgery on the incidence of a subsequent pin infection, (2) what was the effect on the severity of a subsequent pin infection, and (3) what was the effect on the timing of a subsequent pin infection? Patients were randomized into antibiotic treatment and control groups, and incidence, severity, and time of onset of pin infection were recorded. The incidence of pin infection for the entire cohort during the 90-day observation period was 46/58 (79%) without a statistically significant difference (p = 0.106). There was no statistical difference found (p = 0.512) in pin infection severity. There was no significant difference in the time of onset of infection between the two groups from the date of surgery (p = 0.553). Our randomized data do not suggest that oral antibiotics alter the incidence, timing, or severity of pin infection. This study does not support the use of prophylactic oral antibiotics in healthy patients.