Duration Of External Fixation Research Articles

TIBIAL DIAPHYSEAL NONUNIONS AFTER EXTERNAL FIXATION TREATED WITH NONREAMED SOLID CORE NAILS

Twenty-nine patients with tibial diaphyseal fractures had external fixators applied to treat their initial fractures and underwent nonreamed solid core nailing for nonunion (> 22 weeks). Fifteen Alta, 11 Lottes, and 3 Rush nails were used. The original fracture grades were: 1 closed, 1 grade I, 7 grade II, 3 grade IIIA, and 17 grade IIIB. The duration of nonunion was 51 weeks (average: 22 to 173). The average duration of external fixation was 19 weeks (range: 9 to 47). The average interval from fixator removal to nail was 32 weeks (range: 0 to 156). Twenty-eight patients were seen at > 12 months' follow up (average: 35; range: 10 to 58) and completion of treatment. Twenty-seven patients' fractures united at an average of 14 weeks (range: 6 to 40). One patient required a reamed exchange nailing at 39 weeks and united 58 weeks post-exchange nailing. One patient had a persistent asymptomatic nonunion. One patient developed a stress fracture 49 months post nail requiring an exchange nailing. Eleven fractures had a pre-nail deformity of 10 degrees or more; 9 were corrected. Eight patients had pre-nail wound and five had pre-nail pin tract infections. Except for two cases, all of these infections were treated successfully with surgical debridement and/or antibiotics prior to nail insertion. Two patients had their nail inserted through active infections that could not be controlled with an unstable fracture. One patient healed uneventfully in 6 weeks. One required two subsequent debridements. There were no other infections. The authors conclude that nonreamed solid core nailing is an acceptable treatment for tibial diaphyseal nonunions following external fixation.

Use of an articulated external fixator for fractures of the tibial plafond.

We performed a prospective study of forty-nine displaced fractures of the tibial plafond in forty-eight patients managed, at three centers, with an articulated external fixator placed medially across the ankle joint. Forty ankles had interfragmental screw fixation of a reduced articular fracture, and fourteen ankles had bone-grafting. The average duration of external fixation was twelve weeks. All of the fractures healed (one after delayed bone-grafting). There were no infections in any of the operative or traumatic wounds over the tibia. Two wound infections over the fibula resolved with treatment. Eight patients were managed with antibiotics for a pin-site infection, and two patients had curettage and débridement of a pin site in the hindfoot after removal of the fixator. Thirty patients (thirty-one ankles) completed two-year data sheets at an average of thirty months after the injury. The average ankle score was 67 points. Twenty-one patients had grade-0 or 1 osteoarthrosis and nine had grade-2 or 3. One ankle had been treated with an arthrodesis. These data suggest that the prevalence of early complications associated with severe fractures of the tibial plafond and their treatment can be decreased with use of an articulated external fixator combined with limited internal fixation. We concluded that this technique of external fixation is a satisfactory technique for the treatment of these fractures.

Reconstruction of Compound Tibial and Soft Tissue Loss Using a Traction Histogenesis Technique

We used simultaneous bone and soft tissue transport for reconstruction of large compound tissue loss in the lower leg. We report the results and complications of a 12-patient series. The average age of the patients was 31.2 years (range 20 to 48 years). Seven patients had grade IIIB open tibial fractures, three had complications after grade II or IIIA, and two had an en-bloc resection of bone, muscle, and skin for a malignant bone tumor. Arteriography was routinely performed, and demonstrated at least one patent tibial artery. Every patient had normal sensibility of the sole. The first stage of the reconstruction was an aggressive excision of the all necrotic skin, muscle, and bone. The Ilizarov external fixator was applied and wires were secured under a tension of 100 kg, using a dynamometric tensioner. Cutaneous tissue loss was not replaced in 10 patients, when the bone was not exposed. A medial gastrocnemius flap was performed in two patients and lengthened with the bone. Corticotomy was performed 15 days after the first stage with careful respect for the periosteum. Distraction was initiated 15 days after the corticotomy. The average bone defect was 12.5 cm after initial excision. An average of 9 operative procedures and 18 months of treatment were required before bony union. The mean duration of bone transport was 6.5 months, and the mean duration of external fixation was 12 months. The final functional results were fair and only two patients returned to work. One patient had a below-knee amputation after 10 months of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

External fixation and limited internal fixation for complex fractures of the tibial plateau.

Twenty-one complex fractures of the tibial plateau in twenty patients were treated with closed reduction, interfragmental screw fixation of the articular fragments, and application of a unilateral half-pin external fixator. The average duration of external fixation was twelve weeks (range, three to twenty weeks). The fixator was left in situ until the fracture had united in all but two patients. All of the fractures healed. The complications with this technique were attributable primarily to the proximal half-pins of the external fixator. Seven patients needed antibiotics for an infection at a pin site, and two had septic arthritis that necessitated arthrotomy and débridement. The average duration of follow-up was thirty-eight months. The range of motion of nineteen of the twenty-one knees was at least a 115-degree arc. Laxity was evident in seven knees, but no patient complained of instability of the knee. Radiographs showed malalignment of more than 6 degrees in three knees compared with the normal, contralateral knee and evidence of post-traumatic osteoarthrosis in five knees. The Iowa knee score, determined for nineteen patients, averaged 87 points (range, 55 to 100 points). The SF-36 general health survey demonstrated that most patients had function close to that of age-matched controls. We concluded that external fixation with limited internal fixation is a satisfactory technique for the treatment of selected complex fractures of the tibial plateau.

Compression plating for non-union after failed external fixation of open tibial fractures.

Fifty non-unions of the tibia that were present in forty-nine patients after external fixation and immobilization in a cast for a high-energy fracture were subsequently treated by compression plating. Initially, there were forty-six open fractures and four closed fractures with a compartment syndrome. Twenty-two non-unions (44 per cent) had early soft-tissue reconstruction (thirteen rotational and nine free flaps). The duration of external fixation averaged ten weeks, and the mean time from injury to plating was eight months. None of the non-unions were infected at the time of plating. The average preoperative deformity in the sagittal (anterior-posterior) plane was 8 degrees and in the frontal (medial-lateral) plane, 9 degrees; after plate fixation, the residual angulation averaged 3 and 2 degrees. Autogenous bone graft was used in thirty-nine of the fifty non-unions. The patients were followed for an average of twenty-four months. Forty-six (92 per cent) of the non-unions united, in an average of seven months, without further intervention. In four patients (8 per cent), the plate broke, necessitating re-plating in three and external fixation in one (the latter patient had an infected non-union). A deep infection developed in three patients (6 per cent). Ultimately, forty-eight non-unions (96 per cent) healed without evidence of infection. Plate osteosynthesis is an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and immobilization in a cast.

Segmental Transport After Unreamed Intramedullary Nailing

The Ilizarov method of segmental bone transport has been shown to be an alternative to more conventional treatments of posttraumatic bony defects. After extensive clinical experience with the unreamed tibial nail in open fractures up to Grade IIIb, a new monorail fixation system for callus distraction and segmental bone transport was devised. This Monorail system is composed of an unreamed intramedullary (IM) nail and a unilateral AO distraction device. The new fixation method and the preliminary clinical experience are reported here. Four patients who previously sustained Grades II-IIIb open tibial fractures had an average bony defect of 9 cm. Two patients had previous bony infections. All patients had had serial debridements and myocutaneous flaps were required in three patients. An unreamed IM nail was inserted, and the transport device was applied. After an osteotomy, segmental transport was carried out until docking was achieved. The external fixator was removed after interlocking of the transported segment. The mean duration of external fixation was 17.9 days/cm and the mean period until roentgenographic consolidation of the distraction and nonunion site was 41.2 days/cm. There were two pin-tract infections but no IM infections. One nail broke after osseous consolidation of the regenerate at the distal interlocking site and required exchange. The goal of transport was achieved in all cases without angular or rotational deformity or length discrepancy. There were no neurovascular injuries.

External fixation of femur fractures in children.

Forty-two children (44 femur fractures) were treated by primary external fixation and early weightbearing (1984-1989). The fractures were reduced anatomically when possible. Average age at fracture was 9 years 7 months (range, 2 years 5 months to 17 years 8 months). Duration of external fixation averaged 70 days (range 42-117 days). Of 176 pins, 15 (8.5%) were inflamed and five (2.8%) required intravenous antibiotics; none resulted in osteomyelitis. Most patients returned to school by 4 weeks, and all had full knee motion 6 weeks after fixator removal. Of 16 patients with documented follow-up of at least 18 months, only six (38%) had overgrowth from 2 to 10 mm (average 5.8 mm).

小児新鮮大腿骨骨折に対する創外固定の治療成績

Various methods have been applied for the treatment of the femoral shaft fracture in childen.We used the external fixation for the treatment.Eight childen with femoral shaft fracture, aged between 6 and 12 years, were treated with the Hoffman and Wagnar external fixation apparatus from 1984 to 1990. The hospital stay was about 39 days. The average duration of external fixation was 8 weeks. The leg length discrepancy measured from 3mm to 12mm in six cases (average, 9mm). Two cases showed equal leg length. Rotational deformities were not found.We reported that the fixation method demonstrated following advantages: shortening hospital stay; earlier ambulation; increased patient comfort; easy nursing care.

External Minifixation for Treatment of Closed Fractures of the Metacarpal Bones

External minifixators were used in the treatment of 63 closed diaphyseal metacarpal bone fractures. A simple half-frame configuration was applied in all the cases. Open reduction was performed in 26%. The mean duration of external fixation was 30 days. There were no cases of nonunion. Anatomical reduction was obtained in 86.6% of the cases. There were no cases of reflex sympathetic dystrophy. The general functional results were very good or good in 96.6%. Open reduction did not significantly alter the final results. External minifixation is usually accepted as a treatment of open metacarpal fractures. Because of the excellent results obtained in our series, we believe that the indications of external minifixation could be enlarged to closed metacarpal bone fractures.

Complex Femur Fractures in Children

External fixation was used to treat complex femur fractures in 10 children. These injuries were associated with head trauma, cerebral palsy, epidermolysis bullosa, open wounds, and failed casting. The duration of external fixation averaged 8 weeks, and the mean follow-up was 5 years 8 months. At follow-up, one patient had 2.6 cm of residual shortening, and two had overgrowth. Complications included one refracture. Three children developed superficial pin site drainage. Although most femur fractures can be treated with traction or casting, external fixation may simplify overall care in children with multiple injuries and is effective in controlling unacceptable femoral shortening and angulation.

External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol.

Between 1983 and 1989, forty-one open fractures of the tibial shaft were treated with débridement and provisional external fixation, followed by delayed soft-tissue closure and subsequent intramedullary nailing with reaming. The average duration of external fixation was seventeen days (range, six to fifty-two days). The average time between removal of the fixator and intramedullary nailing was nine days (range, zero to twenty-four days). Of thirty-nine patients who had adequate follow-up, two (5 per cent) subsequently had a deep infection. Both infections healed, with retention of the nail and without chronic osteomyelitis. There were two nonunions and one delayed union. Satisfactory alignment was achieved in thirty-seven patients (95 per cent). This sequential protocol for treatment, which involved a short period of external fixation and thus minimized colonization of the pin tracks, yielded excellent results and a low rate of infection.

Reconstruction of large diaphyseal defects, without free fibular transfer, in Grade-IIIB tibial fractures.

Eight Grade-IIIB tibial fractures that were associated with large soft-tissue and segmental diaphyseal defects, averaging ten centimeters in length, were successfully reconstructed without the use of a free fibular transfer. A free tissue flap was the preferred form of soft-tissue coverage. The osseous reconstruction was accomplished by using a massive amount of autogenous cancellous bone graft. Beads that were made from polymethylmethacrylate and impregnated with two antibiotics at the time of operation were used as soft-tissue spacers to preserve the volume of the diaphyseal defect for later receipt of the cancellous bone graft. The beads prevented the soft-tissue flap from collapsing into and adhering to the site of the tibial defect. The beads also served as vehicles for local delivery of the antibiotics that they contained. When the soft-tissue flap had healed, the beads were replaced with cancellous graft. All of the tibiae healed. The time to healing averaged nine months. The average duration of external fixation was 5.5 months. One deep infection developed, but resolved after debridement and antibiotic therapy. This conservative technique is safe and reliable for patients who have sustained a high-energy tibial fracture and a large segmental diaphyseal defect.

Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation.

Twenty-four patients had a severe open fracture of the tibia that was initially treated by external fixation and subsequently by reamed intramedullary nailing. The external fixation had been maintained for an average of fifty-two days (range, seven to 230 days). The mean interval between removal of the external fixator and intramedullary nailing was sixty-five days (range, three to 360 days). In five of the seven patients who had had an infection at one or more of the pin sites, an infection later developed around the intramedullary nail. In comparison, only one of the seventeen patients who had not had a pin-site infection had an infection later around the nail (p = 0.003). An analysis of other variables, including the duration of external fixation, wound coverage, other injuries, and the type of fracture, showed that none was a predictor of infection either at the pin sites or around the intramedullary nail. We concluded that a pin-site infection that develops during external fixation is a contraindication to the subsequent use of reamed intramedullary nailing in patients who have a fracture of the tibia.

Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing.

Between 1979 and 1986, sixteen of 369 open fractures of the tibial shaft were treated by external fixation followed by intramedullary nailing. These fractures comprised one Type-I, two Type-II, and thirteen Type-III injuries. This method of treatment was the original treatment plan in nine patients (56 per cent), for delayed union while the external fixator was still in place in four patients (25 per cent), for loss of reduction in a plaster cast in two patients (13 per cent), and for osteomyelitis and a segmental defect in one patient (6 per cent). The average duration of external fixation was 8.5 weeks; the average time between removal of the external fixator and intramedullary nailing, three weeks; and the average time between injury and nailing, twelve weeks. All sixteen patients were followed until either the fracture had united (eleven patients) or there was an established non-union (five patients). At that time, seventeen additional procedures were performed, including bone-grafting, fibulectomy, and re-nailing. Only five of the sixteen fractures healed without additional surgical procedures or major complications. The five fractures that progressed to a non-union were all Type III, and all were complicated by a deep infection. Over-all, the complications included seven deep infections (an intramedullary infection in four patients, osteomyelitis in two, and a chronic draining sinus associated with a ring sequestrum in one); five minor infections during external fixation, which developed into five of the seven deep infections that occurred after the secondary intramedullary nailing; and eight non-unions, three of which progressed to union after multiple procedures. The over-all incidence of non-union was 50 per cent and that of deep infection, 44 per cent. On the basis of the high incidence of complications in both the present series and the few reports in the literature, we concluded that alternative treatment options should be carefully considered before electing this sequential method of fixation.

The role of external fixation in the treatment of posttraumatic osteomyelitis.

External skeletal fixation played a central role in the reconstruction of 30 limbs involved in posttraumatic osteomyelitis. The tibia was involved in 15, the femur in six, the ankle in five, and the foot and radius in two each. Of the thirty limbs, 27 were ununited. Positive bacteriology and/or histology was found in each case. A total of 36 frames were used with 20 unilateral half-frame constructs and 16 bilateral transfixion frames. The average duration of external fixation was 60 days. Specific procedures for soft tissue coverage were required in 21 cases and autogenous bone grafting in 26. Loosening and local infection occurred in three of 168 external fixation pins. There were no cases of pin-track osteomyelitis, fractures through pintracks, or neurovascular damage from pin insertion. Infection was controlled in 29 of 30 limbs, with one requiring a below-knee amputation. Skeletal union was achieved in all cases. At an average follow-up of 35 months, 20 of 28 lower limbs in 27 patients tolerated full weight bearing without ambulatory aides. Four used a patellar tendon-bearing polypropylene orthosis, two used a cane, and one a walker. In the 23 patients ambulating without upper-extremity aides, the average time from the start of treatment to reach this functional status was 14 months.

Hughes external fixator in treatment of tibial fractures.

The results of a prospective trial of the use of the Hughes unilateral external fixator in the management of 48 tibial diaphyseal fractures are presented. Good results were obtained in grade II and III fractures but not in closed and grade I fractures. The results and complication rates were comparable with those of other more complex external fixators. Good results were found to be dependent on the adequacy of the initial reduction and the duration of external fixation, but independent of alterations in pin angle, length and location as well as fixator location.