ExFix Group Research Articles

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. Level III, retrospective cohort study.

External Fixator vs. Locking Compression Plate in “Supracutaneous” Mode for Open Distal Tibial Fractures: A Comparison on Economics, Union, Functional Outcome and Complications

Objectives Historically, in the pre-antiseptic era, there was a great fear of open tibial factors because of high incidence of infection eventually leading to amputation and in many cases septicemia and death. Despite improvements in surgical techniques in the last century, the optimum treatment for open type IIIa and Type II tibial farcture remains controversial. Literature available on use of Ex-fix as a definitive and permanent modality is very sparse and is not encouraging. In order to maintain biology of the fracture and to expedite the healing process many institutions and surgeons are using Locking compression plate as an external fixator which is fondly called as supracutaneous plating (SCP). Material and Methods The patients who had Gustilo and Anderson type II and IIIa # of distal Tibia were enrolled in this study. They were randomized into 2 groups. In one group (Ex-Fix) external fixator was applied in and in another group SCP was done. Four general indicators, including direct cost of hospitalization, first surgery time, time to full weight bearing, and time to complete union were compared between the groups. The functional outcome of the ankle was assessed. Presence of infection, Time to union was noted in both cases. Results Mean time to fracture union was statistically less in SCP group 5.84 months as compared to 7.21 months in Ex–fix group. Also, 12 patients in Ex-fix group had to undergo a reoperation as compare to only 1 in SCP group. This led to higher cost of expenditure and higher duration of stay in Ex-fix group. AOFAS Score, Teeny and Wiss were better in SCP group as compared to Ex-fix group. Conclusion Highlighting the role Of LCP in Supracutaneous mode as a definitive and final surgery , thus reducing the financial and psychological implication of reoperations in open grade and tibial fractures which are seen in patients managed with Ex-fix in definitive mode or as an interval for secondary nailing, we recommend the use of routine use of SCP in such tibial fractures after thorough debridement and diligent handling of soft tissue.

Does Lower Extremity Fracture Fixation Technique Influence Neurologic Outcomes in Patients with Traumatic Brain Injury? The EAST Brain vs. Bone Multicenter Trial.

To determine whether lower extremity (LE) fracture fixation technique & timing (≤ 24 vs > 24 hours) impact neurologic outcomes in TBI patients. A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age ≥ 18, head abbreviated injury scale (AIS) score > 2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN) or open reduction and internal fixation (ORIF). The analysis was conducted using ANOVA, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Score (RLAS-R). Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe LE injuries (AIS 4-5) compared to the IMN group (16% vs 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix 15 [8-24] vs. ORIF 26 [12-85] vs. IMN 31[12-70], p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of LE fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (OR 1.02, 95% CI 1.002-1.03 and OR 2.37, 95% CI 1.75-3.22) and a higher GCS motor score on admission (OR 0.84, 95% CI 0.73,0.97) was associated with higher RLAS-R score at discharge. Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of LE fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. Level III (Prognostic/Epidemiological).

Is It Safe to Prep the External Fixator In Situ During Staged ORIF of Bicondylar Tibial Plateau Fractures? A Retrospective Comparative Cohort Study.

To compare the risk of deep infection and unplanned reoperation after staged open reduction internal fixation (ORIF) of bicondylar tibial plateau (BTP) fractures whether elements of the temporizing external fixator were prepped into the surgical field or completely removed before definitive fixation. Retrospective comparative cohort study. Two academic Level 1 trauma centers. One hundred forty-seven OTA/AO 41-C (Schatzker 6) BTP fractures treated with a 2-stage protocol of acute spanning ex-fix followed by definitive ORIF between 2001 and 2018. Seventy-eight fractures had retained elements of the original ex-fix prepped in situ during surgery for definitive internal fixation, and 69 had the ex-fix construct completely removed before prepping and draping. Deep infection and unplanned reoperation. Among 147 patients treated with staged ORIF, the overall deep infection rate was 26.5% and the reoperation rate was 33.3%. There were high rates of deep infection (26.9% vs. 26.1%, P = 0.909) and unplanned reoperation (30.8% vs. 36.2%, P = 0.483) in both groups, but no difference whether the ex-fix was prepped in or completely removed. Within the retained ex-fix group, there was no difference in infection with retention of the entire ex-fix compared with only the ex-fix pins (28.1% vs. 26.1%, P = 0.842). We observed high complication rates in this cohort of OTA/AO 41C BTP fractures treated with staged ORIF, but prepping in the ex-fix did not lead to a significant increase in rates of infection or reoperation. This study provides the treating surgeon with clinical data about a common practice used to facilitate definitive fixation of unstable BTP fractures. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures.

AimThis article aims to compare the outcomes between open reduction and internal fixation (ORIF) and external fixation (ExFix) in tibial plateau fractures.BackgroundOpen reduction and internal fixation and external fixation are common methods for managing tibial plateau fractures without a consensus of choice.Materials and methodsPubMed, Cochrane Library, Ovid, CINAHL®, Scopus, and Embase were searched. Clinical studies in humans comparing ExFix and ORIF for tibial plateau fractures were included. Case reports, pathological, and biomechanical studies were excluded. Two investigators reviewed the studies independently, and any discrepancies were resolved. The quality and heterogeneity of each study were assessed in addition to calculating the odds ratio (OR) of the surgical outcomes and complications at a 95% confidence interval, with p <0.05 as statistical significance.ResultsOf the 14 included studies, one was a randomised trial, one was a prospective study, and 12 were retrospective studies. The 865 fractures identified across the studies constituted 458 (52.9%) in the ExFix group and 407 (47.1%) in the ORIF group. Most studies indicated a better outcome for ORIF as compared to ExFix. Open reduction and internal fixation had a lower incidence of superficial infection and postoperative osteoarthritis, while ExFix revealed a lower proportion with heterotopic ossification (HTO).ConclusionExFix has a higher rate of superficial infections and osteoarthritis, whereas ORIF has a higher incidence of HTO. Larger studies are needed to compare outcomes and investigate the findings of this study further.Clinical significanceThis up-to-date meta-analysis on tibial plateau management will help surgeons make evidence-based decisions regarding the use of ORIF versus ExFix.How to cite this articleNaja AS, Bouji N, Eddine MN, et al. A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures. Strategies Trauma Limb Reconstr 2022;17(2):105–116.

Open Pilon Fracture Postoperative Outcomes with Definitive Surgical Management Options: A Systematic Review and Meta-analysis.

Pilon fractures represent one of the most surgically challenging fractures in orthopaedics. Different techniques exist for their management, with open reduction and internal fixation (ORIF) and External fixation (Ex-Fix) the most widely used. Whilst there is a plethora of data regarding these strategies for Pilon fractures as a whole, very limited data exists solely on the management of open Pilon fractures. This study aimed to elucidate how surgical management options can influence postoperative complications, and if this can influence future management protocols. We conducted a search in PubMed, EMBASE and CENTRAL for postoperative complications and functional outcomes in open pilon fractures in those treated with Ex-Fix vs ORIF (PROSPERO-CRD42020184213). The postoperative complications measured included non-union, mal-union, delayed union, bone grafting, amputation, osteoarthritis, deep infection and superficial infection. Functional outcomes in the form of the AOFAS score was also measured where possible. We were able to carry out a meta-analysis for both deep infections and non-unions. The search yielded 309 results and a total of 18 studies consisting of 484 patients were included. All fractures included were open, and consisted of 64 Gustilo-Anderson Type I, 148 Type II, 103 Type IIIa, 90 Type IIIb and 9 Type IIIc. 60 Type III fractures could not be further separated and 12 were ungraded. Both ORIF and Ex-Fix were found to have statistically similar AOFAS scores (P=0.682). For all included studies, the Ex-Fix group had significantly higher rates of superficial infections (P=0.001), non-unions (P=0.001), osteoarthritis (P=0.001) and bone grafting (P=0.001). The meta-analysis found no significant difference in non-union (pooled OR=0.25, 95% CI: 0.03 to 2.24, P=0.44) or deep infection rates (pooled OR=1.35, 95% CI: 0.11 to 16.69, P=0.12) between the ORIF and Ex-fix groups. Based on our study, while Ex-Fix and ORIF have similar functional outcomes, Ex-Fix appears to have a significantly higher risk of postoperative complications which must be considered by surgeons when choosing surgical management options. Further research, ideally in a randomised control trial format, is required to definitively demonstrate ORIF superiority in the management of open pilon fractures.

External Fixation in the Emergency Department for Pilon and Unstable Ankle Fractures.

Pilon and unstable ankle fractures are often treated initially with an external fixator (ex-fix). Ex-fix application in the emergency department (ED) has been described but not compared with that placed in the operating room (OR). Retrospective, case-cohort study was performed at a level-1 trauma center. Using CPT codes, we identified patients who had surgical fixation of pilon or ankle fractures with an initial ex-fix application (in the ED or the OR). Postoperative outcomes and hospital logistical data were compared between the two groups. Ninety-six patients met the inclusion criteria. The average age of patients was 47 years, and 54 (56%) of the patients were men. Thirty-three patients had the ex-fix placed in the OR, whereas 63 patients had the ex-fix placed in the ED. Postsurgical complications (prominent implant, nonunion, deep infection, deep vein thrombosis, loss of reduction) were seen in 6 of 33 patients in the ED ex-fix group and in 8 of 63 patients in the OR ex-fix group (P = 0.51). Deep infections occurred in 2 of 33 patients in the OR ex-fix group and in 5 of 63 patients in the ED ex-fix group (P = 0.71). Revision ex-fix for loss of reduction was performed in 4 of 33 patients in the OR ex-fix group and in 10 of 63 patients in the ED ex-fix group (P = 0.59). Mean length of stay was 14 days for the OR ex-fix group and 13 days for the ED ex-fix group (P = 0.35). No statistically significant differences were found in postsurgical complications (surgical or infectious) or ex-fix revision rates for the ED ex-fix group and the OR ex-fix group. Results indicate that uniplanar ex-fix may be safely applied in the ED. Level III, therapeutic.

Unreamed Intra-Medullary Nail Versus Half Pin External Fixator in Grade III [A & B] Open tibia fractures

BackgroundTibia fracture is the most common long bone fracture. The fractures of tibia are commonly open fractures due to subcutaneous position of the tibia. The choice of technique for stabilization of open tibia fractures includes - External fixation, unreamed intra-medullary nails [URTN], Reamed intra-medullary nails, ORIF with Plating. ObjectivesTo evaluate & compare the results of Unreamed Intra-Medullary Nail Versus Half Pin External Fixator in Grade III [A & B] Open tibia fractures. MethodsThis prospective clinical study [Randomized chit box] was done on 50 patients presenting to our institute within 24 h of injury. Only those who were skeletally mature with open tibia fracture Grade IIIA & IIIB [Gustilo-Anderson] were included in this study. After initial management, radiological assessment was done. Following this adequate wound debridement, skeletal stabilization with either primary URTN or external fixator was done. Inspection and debridement were repeated at 48-h intervals until the wound was considered clean. Results50 cases [25 each group] were compared in terms of - Final Alignment of the Fracture, Presence of Infection/Non-union/Mal-union, Hardware failure, Time to Bone Union, Number of Operative Procedures after index admission. Mean time to full weight bearing was 20.96 weeks in URTN group versus 24.8 weeks in Ex-fix group. 5 in URTN group required further surgery for non-union versus 11 patients in Ex-fix group. There were 6 significant pin track infection. Removal of nail was required in 1 case of deep infection. ConclusionThis study supports the use of the URTN over External fixator in the treatment of severe open tibia fractures.

External Fixation in the Emergency Department Is Equally Efficacious to Placement in the Operating Room

Category: Trauma Introduction/Purpose: Pilon and unstable ankle fractures are often treated initially with an external fixator (ex-fix) due to soft tissue concerns. Typically, the second stage involves open reduction internal fixation of the fracture as the definitive management. Ex-fix application in the emergency department (ED) has been described previously. We aimed to determine if an ex-fix applied in the ED would have any difference in rate of ex-fix revision, deep infection, and hospital length of stay when compared to an ex-fix that is applied in the operating room (OR). Methods: This is a retroscpective, case-cohort study performed at an urban, level-1 trauma center. Using CPT codes in our billing database, we identified all patients from 2011-2015 who had operative fixation of pilon (AO classification 43B or 43C) or unstable ankle fractures (AO classification 44C) and had application of an ex-fix (either ED or OR) prior to definitive fixation. Patients with open injury, those placed in ex-fix at outside institutions and those treated definitively with ex-fix were excluded. Results: Ninety-six patients met the inclusion criteria. Average age was 47 years and 54 (56%) were male. Thirty-three patients had ex-fix placed in the OR and 63 patients had ex-fix placed in the ED. Post-surgical complications (prominent implant, nonunion, deep infection, DVT, loss of reduction) were seen in 6/33 in the ED and 8/63 in the OR group (χ2=0.44, p=0.51). Deep infections occurred in 2/33 OR ex-fix and 5/63 ED ex-fix patients (χ2=0.137, p=0.71, OR= 1.4 [95% CI = 0.25 to 7.5]). Revision ex-fix for loss of reduction was performed 4/33 in the OR group and 10/63 in the ED ex-fix group (χ2=0.296, p=0.59). Mean length of stay was 14 days for the OR and 13 days for the ED group (p=0.35). Conclusion: We found no significant difference in post-surgical complications (surgical or infectious) or ex-fix revision rates for an ex-fix placed in ED compared to one placed in the OR. Total hospital days were similar in both groups. Prospective studies are needed to validate this method of provisional stabilization in the ED; however, these results indicate that the ED ex-fix is equally efficacious to an OR ex-fix.

Is external fixation a better way than plaster to supplement K-wires in non-comminuted distal radius fractures?

BackgroundDistal radius fractures represent about one-sixth of all fractures. There is still no consensus on the treatment of this fracture. We have several issues to assess and address; one of...

External fixation versus open reduction and internal fixation for tibial pilon fractures: A meta-analysis based on observational studies

PurposeTibial pilon fractures remain challenging for an orthopaedic surgeon to repair. External fixation (ExFix) and open reduction and internal fixation (ORIF) are two widely used methods for repairing tibial pilon fractures. However, conclusions of comparative studies regarding which method is superior are controversial. Our aim is to compare ORIF and ExFix and clarify which method is better in terms of reduction and union results and major complications. MethodsA computerized research of MEDLINE, EMBASE, Springer, and Cochrane Library (before December 2014) for studies of any design comparing ORIF and ExFix was conducted. Weighted mean difference (WMD), risk ratio (RR) and corresponding 95% confidence intervals (CI) were used for estimating the effects of the two methods. Statistical analyses were done using Review Manager Version 5.2. ResultsTen cohort studies and one randomized clinical trial were included in our ultimate analysis. And the analysis found no significant difference between the two methods in deep infection (p = 0.13), reduction (p = 0.11), clinical evaluation (p = 0.82), post-traumatic arthrosis (p = 0.87), and union time (p = 0.35). Besides, ExFix group was found to have a higher rate of superficial infection (p = 0.001), malunion (p = 0.01) and nonunion (p = 0.02), but have a lower risk of unplanned hardware removal (p = 0.0002). ConclusionsWe suggest that ORIF has a relatively lower incidence rate of superficial infection, malunion and nonunion, but a higher rate of unplanned hardware removal. No difference was found in deep infection, reduction, clinical evaluation, post-traumatic arthrosis and union time.

Effectiveness of antishock garment in acute management of open-book injuries of pelvic fractures in hemodynamically unstable patients

Background: Stabilizing unstable pelvic fractures with rapidly applied pelvic binder or the garment has long been a standard practice in patients suspected to be bleeding from their pelvic injuries. External fixation is believed to provide better tamponade, by decreasing the pelvic volume and, thereby, the space for blood loss. Methods: Prospective case control randomized study. A total of 30 patients were enrolled in this study. They were recruited from Suez Canal University hospital (Ismailia). They were categorized into two groups. They were selected by simple randomization method using the table of random number. Group I: patients were subjected to antishock garment (15 patients). Group II: patients were subjected to external pelvic fixation (15 patients). Results: Data analysis of the 30 patients showed that symphysis pubis diastasis was decreased from (3.2 to 2.8 cm) in binder group in comparison to (3.8 to 2.2cm) in EX-FIX group with statistically significant different (p value = P = 0.04). But there were no marked difference in the degree of shock index improvement between the two groups (p-value >0.05). Conclusions: Although EX-FIX is showing significant improvement in pelvic stability and more decreasing diastasis in comparison with binder, there was no difference in improving the haemodynamic state between both maneuvers.

Complications of pelvic ring fixation in patients requiring laparotomy

BackgroundPelvic ring disruptions in blunt trauma are rarely an isolated finding. Many individuals needing operative pelvic fixation also require laparotomy for other injuries. Pelvic fixation can be performed by open reduction and internal fixation (ORIF) or external fixation (Ex-fix). Often when a laparotomy incision is present, ORIF is performed by extending this incision. We hypothesized ORIF performed by extending the laparotomy incision would result in higher rates of ventral hernia and wound complications versus Ex-fix. MethodsAll patients admitted from 2004–June 2014 who underwent laparotomy and pelvic fixation either by ORIF through extension of a laparotomy incision (ORIF group) or definitive Ex-fix group were identified. Injury severity score, demographics, associated injuries, and complications were collected. ResultsA total of 35 patients were identified who underwent laparotomy and pelvic fixation, 21 underwent Ex-fix, whereas 14 underwent ORIF through an extended laparotomy incision. There were no differences in injury severity score, demographics, associated injuries, or rate of ventral hernia. The ORIF group had more laparotomy incision infections (50.0% versus 4.8%, P < 0.01) and pelvic abscesses (42.9% versus 9.5%, P < 0.05). They required more procedures to address their complications (13 versus 5, P < 0.05). ConclusionsIndividuals who have undergone laparotomy and pelvic fixation are a complex group of patients with multiple injuries. These data suggest that when surgical repair of a pelvic ring disruption is indicated and the patient has undergone laparotomy, careful consideration to the method of fixation should be given.

Efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography.

To assess the efficacy and safety of a patient-positioning device (EZ-FIX) for endoscopic retrograde cholangiopancreatography (ERCP). A total of 105 patients were randomized to the EZ-FIX (n = 53) or non-EZ-FIX (n = 52) group in this prospective study. Midazolam and propofol, titrated to provide an adequate level of sedation during therapeutic ERCP, were administered by trained registered nurses under endoscopist supervision. Primary outcome measures were the total dose of propofol and sedative-related complications, including hypoxia and hypotension. Secondary outcome measures were recovery time and sedation satisfaction of the endoscopist, nurses, and patients. There was no significant difference in the rate of hypoxia, but there was a statistical trend (EX-FIX group; n = 4, 7.55%, control group; n = 6, 11.53%, P = 0.06). The mean total dose of propofol was lower in the EZ-FIX group than in the non-EZ-FIX group (89.43 ± 49.8 mg vs 112.4 ± 53.8 mg, P = 0.025). In addition, the EZ-FIX group had a shorter mean recovery time (11.23 ± 4.61 mg vs 14.96 ± 5.12 mg, P < 0.001). Sedation satisfaction of the endoscopist and nurses was higher in the EX-FIX group than in the non-EZ-FIX group. Technical success rates of the procedure were 96.23% and 96.15%, respectively (P = 0.856). Procedure-related complications did not differ by group (11.32% vs 13.46%, respectively, P = 0.735). Using EZ-FIX reduced the total dose of propofol and the recovery time, and increased the satisfaction of the endoscopist and nurses.

When do anterior external or internal fixators provide additional stability in an unstable (Tile C) pelvic fracture? A biomechanical study

This study aimed at evaluating the additional stability that is provided by anterior external and internal fixators in an unstable pelvic fracture model (OTA 61-C). An unstable pelvic fracture (OTA 61-C) was created in 27 synthetic pelves by making a 5-mm gap through the sacral foramina (posterior injury) and an ipsilateral pubic rami fracture (anterior injury). The posterior injury was fixed with either a single iliosacral (IS) screw, a single trans-iliac, trans-sacral (TS) screw, or two iliosacral screws (S1S2). Two anterior fixation techniques were utilized: external fixation (Ex-Fix) and supra-acetabular external fixation and internal fixation (In-Fix); supra-acetabular pedicle screws connected with a single subcutaneous spinal rod. The specimens were tested using a nondestructive single-leg stance model. Peak-to-peak (P2P) displacement and rotation and conditioning displacement (CD) were calculated. The Ex-Fix group failed in 83.3 % of specimens with concomitant single-level posterior fixation (Total: 15/18-7 of 9 IS fixation, 8 of 9 TS fixation), and 0 % (0/9) of specimens with concomitant two-level (S1S2) posterior fixation. All specimens with the In-Fix survived testing except for two specimens treated with In-Fix combined with IS fixation. Trans-sacral fixation had higher pubic rotation and greater sacral and pubic displacement than S1S2 (p < 0.05). Rotation of the pubis and sacrum was not different between In-Fix constructs combined with single-level IS and TS fixation. In this model of an unstable pelvic fracture (OTA 61-C), anterior fixation with an In-Fix was biomechanically superior to an anterior Ex-Fix in the setting of single-level posterior fixation. There was no biomechanical difference between the In-Fix and Ex-Fix when each was combined with two levels of posterior sacral fixation.

A Retrospective Comparative Analysis of Charcot Ankle Stabilization Using an Intramedullary Rod with or without Application of Circular External Fixator—Utilization of the Retrograde Arthrodesis Intramedullary Nail Database

Brodsky type 3a Charcot destruction of the ankle is devastating to patients. The authors have surgically stabilized this deformity with the use of an intramedullary arthrodesis nail, and explore the usefulness of adjunctive application of a circular external fixator. Fifty-two patients were treated with retrograde intramedullary nail with and without circular external fixation. A comprehensive chart and radiographic review were pulled from the Retrograde Arthrodesis Intramedullary Nail database. Of these, 45 patients were treated with a nail alone (Nail group), and 7 were treated with a nail and circular external fixation augmentation (ExFix group). The primary end point was major amputation or braceable limb. The average age was 59.4 and 51.6 years in the Nail and ExFix groups, respectively (p = .0068). Chronic steroid use was statistically significantly different and was found in 3 (6.7%) and 4 (57.1%) patients in the Nail and ExFix groups, respectively (p = .0039). The rate of major amputation was 10/45 (22.2%) and 2/7 (28.6%) in the Nail and ExFix groups, respectively (p = .656), with an overall salvage rate of 40/52 limbs (75.6%). The addition of circular external fixation does not affect the overall salvage or complication rate. The authors feel that the added stability offered by external fixation may benefit patients who are at high risk for complications or require extended arthrodesis, but this was unable to be demonstrated statistically in this study. Patients with this difficult pathology can be successfully salvaged, but there is a high risk of complications.

Lower limb lengthening: is there a difference in the lengthening index and infection rates of lengthening with external fixators, external fixators with intramedullary nails or intramedullary nailing alone? A systematic review of the literature

A review of the current literature was undertaken to assess the lengthening index (LI) and infection rates found with different techniques of lower limb lengthening. We compared three methods of lengthening: external fixators, intramedullary nails and both methods used as a combined technique. Ten papers meeting the inclusion criteria were reviewed. The review found that by using either an ExFix with IMN or an IMN alone lengthening was achieved at twice the rate of ExFix alone. There were no infections recorded in the IMN group, 36.2% superficial and 2.5% deep in the ExFix group and 1.4% superficial and 5.5% deep in the ExFix + IMN group. When using LI and infection rates to compare techniques, the safest and most effective method of lower limb lengthening appears to be with IMN alone.

Intramedullary Stabilization of Extraarticular Proximal Tibial Fractures: A Biomechanical Comparison of Intramedullary and Extramedullary Implants Including a New Proximal Tibia Nail (PTN)

To determine in the laboratory whether there are or are not differences between individual geometrical designs of intramedullary and extramedullary devices used for the fixation of extraarticular proximal tibial fractures. Five devices were tested: a newly developed Proximal Tibia Nail (PTN), conventional double-plate osteosynthesis (DPO), the Less Invasive Stabilization System (LISS), an augmented Unreamed Tibial Nail with a T-stabilization-plate (UTN + TSP), and an external fixator (ExFix). A 10-mm defect osteotomy was performed on paired human tibiae, and the proximal and distal ends were potted in polymethylmethacrylate cement (PMMA). Each pair of bones was randomly stabilized with the new PTN in 1 tibia (Groups PTN1 through PTN4) and in 1 of the 4 comparative implants in the corresponding contralateral bone. A biomechanical test of the bone implant construct was then performed with a vertical axial force of 350, 600, and 900 N, a bending moment of 6 Nm and a bidirectional rotational strain of 8 Nm. Displacement of bone fragments was measured and depicted as a force-displacement diagram. For axial loading, significant differences were seen between the PTN 2 group compared to the LISS group (P = 0.016) and the PTN 4 group compared to the ExFix group (P = 0.016). No statistically significant differences were seen for the PTN 1 group compared to the DPO group (P = 0.125) and the PTN 3 group compared to the UTN + TSP group (P = 0.453). The bending stiffness of the PTN 1-4 groups was not significantly different from any of the 4 alternative implants. There was comparable torsional stiffness in all implant groups except for the UTN + TSP group, which was less stable and significantly different from the PTN 3 group (P = 0.016). Given the parameters of this investigation, the new PTN would theoretically provide the same mechanical stability as the DPO in axial loading. Higher stability in axial loading may be present when compared to the LISS or the ExFix. Further clinical investigation of this implant will determine its usefulness among proximal tibial fixation devices.