Definitive External Fixation Research Articles

Staged treatment of pilon fractures

AimTo evaluate outcomes following staged anterolateral plating of pilon fractures. MethodsOver a 5 year period, patients with pilon fractures received four treatment regimens (staged anterolateral plating, staged medial plating, definitive external fixation, early total care). We defined five outcomes (reduction, soft tissue complications, infection, non-union, malunion) and assessed the outcome of fractures treated by these interventions. ResultsStaged anterolateral plating or staged medial plating achieved comparable reduction and soft tissue complications. Staged medial plating had higher infection rates, malunion and non-union rates. ConclusionsStaged anterolateral plating is superior to staged medial plating in the management of pilon fractures.

External fixation of distal femoral fractures in adults’ multicentre retrospective study of 43 patients

BackgroundA multicenter cohort of 43 adults with distal femoral fractures (DFFs) managed with external fixation was evaluated to determine the potential of this treatment. Patients and methodsThe patients were young adults (mean age: 39.6 years) with high-energy trauma; 12 had polytrauma and 41 multiple fractures. Most patients (38/43) had compound DFFs. Fracture types were A in 3 patients, B in 3 patients, and C in 37 patients. A tibio-femoral construct was required in 11 patients and a femoro-femoral construct in 32 patients. ResultsThe normal femoral axis was restored within 5° in the coronal plane in 34 (79%) patients and in the sagittal plane in 22 (51%) patients. Axis restoration within 5° in both planes was achieved in 19 (44.7%) patients. After femoro-femoral external fixation, mean malalignment was 4.2° in the coronal plane and 8.6° in the sagittal plane; corresponding values after tibio-femoral external fixation were 1.3° and 8.6°. In 23 patients (of whom 1 was lost to follow-up), external fixation was intended as the only and definitive treatment; among them, 1 required amputation after a failed revascularization procedure, 10 achieved fracture healing within a mean of 21.2 weeks, 6 required conversion to another technique, and 5 underwent non-conservative procedures (total knee arthroplasty in 3 and arthrodesis in 2). In the remaining 20 patients, conversion to internal fixation was intended initially and performed within a mean of 4.7 weeks; 1 of these patients required amputation for ischemia, 3 did not achieve fracture healing, 12 achieved primary fracture healing, and 4 achieved fracture healing after repeated grafting (n=3) or osteotomy (n=1). At last follow-up (at least 1 year), the mean International Knee Society (IKS) Function Score was 67.3 and an IKS Knee Score of 68.5. Range of active flexion was 85.75° overall, 62.3° in the group with intended definitive external fixation and 101° in the group with intended conversion to internal fixation. Healing without complications was achieved in 10 (43%) in the former group and 12 (60%) in the latter group. ConclusionOur data support provisional external fixation followed by early conversion to internal fixation in patients with extensively compounded DFFs; patients with multiple fractures requiring several surgical procedures; and polytrauma patients awaiting hemodynamic, respiratory, or neurological stabilization. Level of evidenceIV, retrospective study.

Le fratture della tibia prossimale: la fissazione esterna

Proximal tibia fractures are often caused by high energy trauma. In these cases external fixation may be applied as a temporary osteosynthesis waiting for improvement of the patient’s local and general conditions or as a method for definitive treatment. In selected cases, definitive external fixation allows a stable fixation with a minimally invasive approach, both in terms of reduced skin incisions but especially in terms of respect of the fracture site’s biology.

Temporary and definitive external fixation of war injuries: use of a French dedicated fixator

External fixation is the recommended stabilization method for both open and closed fractures of long bones in forward surgical hospitals. Specific combat surgical tactics are best performed using dedicated external fixators. The Percy Fx (Biomet) fixator was developed for this reason by the French Army Medical Service, and has been used in various theatres of operations for more than ten years. The tactics of Percy Fx (Biomet) fixator use were analysed in two different situations: for the treatment of French soldiers wounded on several battlefields and then evacuated to France and for the management of local nationals in forward medical treatment facilities in Afghanistan and Chad. Overall 48 externals fixators were implanted on 37 French casualties; 28 frames were temporary and converted to definitive rigid frames or internal fixation after medical evacuation. The 77 Afghan patients totalled 85 external fixators, including 13 temporary frames applied in Forward Surgical Teams (FSTs) prior to their arrival at the Kabul combat support hospital. All of the 47 Chadian patients were treated in a FST with primary definitive frames because of delayed surgical management and absence of higher level of care in Chad. Temporary frames were mostly used for French soldiers to facilitate strategic air medical evacuation following trauma damage control orthopaedic principles. Definitive rigid frames permitted achieving treatment of all types of war extremity injuries, even in poor conditions.

External Fixation Versus ORIF for Distal Intra-articular Tibia Fractures

Tibia plafond fractures have historically demonstrated high complication rates. The purpose of this study was to assess the outcomes of tibia plafond fractures following treatment with definitive external fixation vs delayed open reduction and internal fixation (ORIF). Sixty patients were enrolled in a prospective cohort trial at 1 Level I trauma center. No differences were noted between the 2 treatment groups in terms of age, smoking history, presence of comorbidities, mechanism of injury, incidence of open fractures, or Orthopaedic Trauma Association fracture classification. Complete 12-month follow-up was available for 18 patients in the definitive external fixation group and 27 patients in the ORIF group. No difference was noted in articular reduction between the groups at 6 and 12 months postoperatively. Delayed union or non-union occurred in 4 (22.2%) of 18 patients in the external fixation group and 1 (3.7%) of 27 patients in the ORIF group (P=.05). Deep infection was equally likely in either group (P=.33). The ORIF group had improved Iowa Ankle Scores at 6 (23.6 ± 12.1 vs 11.1 ± 7.7; P<.05) and 12 months (5.5 ± 2.2 vs 3.1 ± 1.7; P<.05) postopertively and improved Short Form-36 Physical Function scores at 6 months (49.7 ± 30.1 vs 25.5 ± 8.0; P<.05) postoperatively compared with the external fixation group.External fixation and ORIF can attain bony union with adequate articular reduction and similar infection rates. Patients treated with ORIF appeared to have improved union rates and early outcomes with ankle function and Short Form-36 Physical Function scores.

Fracture of the pelvic ring: a retrospective review of 224 patients treated at a single institution

Pelvic ring fracture presents with a wide spectrum of clinical status and fracture type that requires multimodal treatment strategy. We report our experience in the treatment of 224 pelvic ring fractures in terms of clinical and radiological findings, mode of treatment, surgical data, and functional outcome at final follow-up. The study subjects were 140 men and 84 women (mean age 58 years, range 8–94). Surgery was conducted in 63 patients, while 161 were treated conservatively. The average follow-up period was 7.1 years (range 1–15). AO-Orthopaedic Trauma Association classification of fracture type, Injury Severity score rating, Rommens and Hessmann’s ambulatory and pain assessment, and radiographic studies were conducted. Conservative treatment was provided in 161 (73%) patients, including simple bed rest with definitive external fixation, skeletal traction, and/or pelvic sling. Of these, 148 patients achieved excellent/good results, but the remaining 13 cases complained of severe pain at the sacroiliac joints caused by malunion or fibrous union of the joint. All 63 (27%) patients who were treated surgically, using most frequently a combination of anterior extraperitoneal and Pfannenstiel approaches, showed excellent/good clinical and radiographic results. Treatment of unstable pelvic ring fracture should be urgent and based on biomechanical and anatomic reconstructive strategy, paying utmost care to associated injuries. A combination of open stabilization of posterior sacroiliac area and anterior fixation of pubic rami and symphysis pubis is recommended for unstable anteroposterior compression, lateral compression, vertical instability, and unilateral or bilateral posterior injuries to the pelvic ring.

Tibial pilon fractures: Which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

A retrospective analysis of comminuted intra-articular fractures of the tibial plafond: Open reduction and internal fixation versus external Ilizarov fixation

Intra-articular fractures of the tibial plafond are complex injuries which continue to challenge orthopaedic surgeons in achieving anatomic reduction, while allowing early weight bearing and return to activity. Although a wide range of treatment options has been described for fixation of pilon fractures, the unique characteristic of each injury makes it difficult to advocate a general method of choice. We have attempted to compare a subset of AO/OTA type C pilon fractures treated either by a staged procedure of external fixation and conversion to open reduction and internal fixation (ORIF) versus definitive external Ilizarov fixation. Between 1998 and 2004, 42 patients admitted to our level 1 trauma centre underwent either procedure and were followed prospectively. Twenty-eight patients were treated with ORIF and 14 were treated by Ilizarov ring fixator. The outcome measures included time to union, as well as the rates of union, nonunion, malunion and infection. Although the ORIF group had a longer time to heal, the rates of nonunion, malunion and infection were lower compared to the Ilizarov group. However, these differences between the groups were not statistically significant. Thus, based on these results, no clinical recommendation can be made as to which procedure is better and safer for the patient. Future prospective randomised trials are required to determine with more scientific accuracy the optimal treatment strategy for these challenging injuries.

External Fixation Versus Conversion to Intramedullary Nailing for Definitive Management of Closed Fractures of the Femoral and Tibial Shaft

External fixation for definitive therapy of closed diaphyseal femur and tibia fractures is the preferred method of treatment only in the pediatric population. In adult injuries, in particular open battle wounds, the timing of conversion of an external fixator to an intramedullary nail is determined by the condition of the soft tissues and the overall stability of the patient. In the tibia, conversion to an intramedullary nail is accomplished as expeditiously as possible. Early (< 2 weeks) conversion to an intramedullary implant may be accomplished safely. Increased infection rates have been documented when conversion is done after 2 weeks of external fixation. In the femur, conversion from external fixation to nailing is done as the patient's overall physical condition and soft tissues allow. Acute conversion to an intramedullary device in a single procedure is preferred in patients without evidence of pin-tract infection. Staged conversion to an intramedullary nail often requires a prolonged period of bed rest with skeletal traction to maintain fracture stability and patient comfort, with the attendant risks of pneumonia, decubiti, and thromboembolic events. Treatment of closed femoral and tibial diaphyseal fractures with external fixation, either definitively or as a bridge to intramedullary nailing, is a viable option in the patient with gross physiologic instability or an ipsilateral dysvascular limb. The decision to use definitive external fixation versus conversion to an intramedullary device should be made on a case-by-case basis. Additional prospective clinical studies are warranted to further delineate risks and benefits of these treatment modalities.

External fixation of complex femoral shaft fractures

Conversion of temporary external fixation to an intramedullary nail within the first 2 weeks after a femoral shaft fracture is standard practice. However, due to financial constraints, in large parts of the world external fixation of femoral shaft fractures is often the definitive treatment. Out of 60 fractures, 47 were followed-up for a minimum period of 39 weeks. The average follow-up time was 75 weeks. Fourteen fractures were closed, and 33 open. Forty-four fractures united at an average of 31 weeks. There were four non-unions, three of them infected. Secondary surgical procedures were performed for four non-unions and in eight cases of delayed union. One re-fracture occurred, which was successfully treated with repeat external fixation. Only six patients regained full range of motion. The average flexion was 72 degrees . Pin tract infections occurred in 26 patients, leading to loosening of four pins. Satisfactory results can be obtained with definitive external fixation of femoral shaft fractures. Pin tract infections, although a common occurrence, are not a major problem and can be treated by local wound care and antibiotic therapy. The most common problem is significant decrease in the range of motion of the knee.

High-Energy Tibial Plateau Fractures

The severity of a tibial plateau fracture and the complexity of its treatment depend on the energy imparted to the limb. Low-energy injuries typically cause unilateral depression-type fractures, whereas high-energy injuries can lead to comminuted fractures with significant osseous, soft-tissue, and neurovascular injury. Evaluation includes appropriate radiographs and careful clinical assessment of the soft-tissue envelope. Treatment is directed at safeguarding tissue vascularity and emphasizes restoration of joint congruity and the mechanical axis of the limb. Temporary joint-spanning external fixation facilitates soft-tissue recovery, whereas minimally invasive techniques and anatomically contoured plates can limit damage to the soft tissues and provide stable fixation. Alternatively, the use of limited internal fixation and definitive external fixation can minimize soft-tissue disruption, avoid complications, and allow fracture union. Complications, including infection, loss of fixation, and malalignment, are best avoided by following these biologically respectful treatment principles.

Complications of Temporary and Definitive External Fixation of Pelvic Ring Injuries

Complications of Temporary and Definitive External Fixation of Pelvic Ring Injuries

Complications of temporary and definitive external fixation of pelvic ring injuries

To determine the incidence of complications of external fixation in pelvic ring injuries, comparing fixator use for temporary and definitive treatment. Retrospective case-note review. A regional centre for pelvic trauma in the UK. 100 consecutive patients. All patients were treated with pelvic external fixation for a pelvic ring injury. In 52 patients, external fixation was intended for use as the definitive treatment of the pelvic ring injury and was maintained for a mean duration of 60 days (17-113). In 48 patients, it was used temporarily for a mean duration of 8 days (1-20) before internal fixation of the pelvic ring. The complication rate for definitive and temporary fixators was 62 and 21%, respectively. Pin-site infection occurred in 50% of definitive fixators and 13% of temporary fixators but rarely led to more serious complications. In five patients, the definitive management was changed as a result of a complication of the external fixator. The commonest cause for revision of either fixator was aseptic pin loosening. Revision for loose pins in eight patients was associated with the use of two pins in each iliac crest rather than three. The temporary use of external fixation is safe and effective, but use for definitive treatment is associated with a high rate of infection and aseptic pin loosening.

Management of femoral diaphyseal infected nonunion with antibiotic beads local therapy, external skeletal fixation, and staged bone grafting.

Fifteen patients with femoral shaft fractures complicated by infected nonunions were treated with a two-stage protocol. In the first stage, radical debridement was performed along with antibiotic bead chains local therapy and external skeletal fixation. In the second stage, the debrided nonunion site was repaired with bone grafting and the external skeletal fixator was used until bony union was achieved. The time between the first and second stages of treatment was 2 to 6 weeks. The debrided bone defects ranged from 0.5 to 15 cm. Autogenous iliac cancellous bone grafting was performed in 11 patients, and microvascularized osteoseptocutaneous fibular transfer was performed in 4 patients. Wound healing and bone union were achieved in all 15 cases. The duration of external fixation of these patients ranged from 7 to 15 months, with an average of 9 months. Minor pin-track infection was seen in seven patients. Postoperative infection after the second-stage bone grafting occurred in three patients. These three infections were arrested by limited debridement along with 2 to 4 weeks of parenteral antibiotic therapy. In one case, stress fracture occurred at 11 months after microvascularized fibular transfer; this was managed with another 5 months of external skeletal fixation. With an aggressive physical therapy program, 10 patients achieved nearly full range of knee motion and 5 patients had relevant knee flexion deficits. The follow-up averaged 58 months (range, 40-76 months); no recurrence of osteomyelitis was observed even at 76 months. We have found that our two-stage treatment with antibiotic beads local therapy, definitive external skeletal fixation, and staged bone grafting is an acceptable treatment protocol for the management of femoral diaphyseal infected nonunion. It results in rapid recovery from osteomyelitis and a predictable recovery from nonunion.

External Fixation of Open Femoral Shaft Fractures

To determine whether external fixation proves to be a sensible technique for definitive stabilization in open femoral fractures. Retrospective clinical study. From 1985 to 1989, 18 patients (mean ISS 25.4) with open femoral fractures (type II 11%, type III 89%) were treated by primary and definitive external fixation. After failure of closed reduction procedures, open reduction via debrided soft tissue wounds was employed in 72%. Supplemental internal fixation of large wedge fragments was required in 66%. External fixators were removed after a mean of 166 days. Early deep infections developed in 11%. Additional cast, brace, or traction were not required. After a mean follow-up period of 58 months, 88% of the surviving 17 patients were clinically and radiologically evaluated and 12% were interviewed by telephone. Eleven percent developed late deep infection of the femur concerned. Eighty percent have had full or slightly restricted knee motion. The mean knee flexion amounted to 130 degrees. Relevant shortening of the femur was diagnosed in 7%. Nonunions or relevant malunions were not observed in our series. These morphologic and functional results compare with those published for alternative stabilization techniques of femoral fractures. For special indications, external fixation is considered to be a sensible technique for primary and definitive treatment of open femoral fractures.