External Fixation Period Research Articles

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

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

Bone Transport with the Taylor Spatial Frame Technique: A Case Series.

Bone transport is a beneficial reconstructive method for bone defects caused by infected non-unions or bone tumours. The Taylor Spatial Frame (TSF) is a three-dimensional corrective external fixator that can be used to achieve bone transport and correct any residual deformities easily at any time. This study reports the results of bone transport using TSF. This is a retrospective study of ten patients who underwent bone transport using the TSF. The mean age was 32.3 years; the femur was affected in one case and the lower leg in nine. Bone defects were due to infected non-unions in seven cases and bone tumours in three. The duration of external fixation, bone transport distance, distraction index (DI), alignment at the end of correction, leg length discrepancy, and complications were investigated. The average bone transport distance was 76.0 mm. The external fixation period averaged 367 days with the DI at 20.8 days/cm. Deformity at the docking site was assessed to have an average 2.6° deformity and 2.0 mm translation in the frontal view, as well as 3.3° deformity and 3.7 mm translation in the lateral view. The mean leg length discrepancy was 10.9 mm and the percentage of the mechanical axis (%MA) was 40.6%. Four patients underwent plate conversion after correction and two required additional surgery for non-union at the docking site. Bone union was achieved in all patients and there was no reaggravation of infection or tumour recurrence. The TSF allowed for the correction of deformities and translations that occurred during bone transport giving excellent results. However, as with bone transport using this or other devices, additional procedures are often needed to obtain consolidation or docking site union. Shimokawa K, Matsubara H, Hikichi T, et al. Bone Transport with the Taylor Spatial Frame Technique: A Case Series. Strategies Trauma Limb Reconstr 2023;18(2):117-122.

Treatment of Extension Knee Contractures with Ilizarov Apparatus Versus Orthopedic Hexapod Ortho-SUV Frame

Background. In case if it is impossible to eliminate the knee contracture by soft tissue release, external fixation is additionally used. Most often, the Ilizarov apparatus with a uniaxial hinge is used for this purpose. Orthopedic hexapods, unlike the Ilizarov frame, are able to reproduce the kinematics of movements in the knee joint.
 Aim of the study to evaluate the effectiveness of orthopedic hexapod for the treatment of patients with knee extension contractures in comparison with the Ilizarov apparatus.
 Methods. We analyzed 64 cases of combined treatment of extension knee contractures, which were divided into two groups. In the 1st group (31 patients) in addition to the soft tissue release, the orthopedic hexapod Ortho-SUV Frame (OSF) was used. In the 2nd group (33 patients) the Ilizarov apparatus with an uniaxial hinge was used. In a comparative analysis between groups, the number of flexion-extension cycles, the time required to complete them, and the time needed for complete knee range of motion (ROM) restoration were evaluated. Functional results were assessed using specialized scales-questionnaires KSS, Lysholm, LEFS in 2 days, 6 and 12 mon. after frame dismantling.
 Results. Comparing the total external fixation period, as well as the time needed for ROM restoration, no significant difference between groups was found (р0.05). When using the orthopedic hexapod, in comparison with the Ilizarov apparatus, fewer flexion-extension cycles were required. When assessing the amplitude of movements in 12 mon. in the first group, excellent results were found in 27 patients and good results in 4. In the second group, in all 33 patients good ROM was evaluated. On average, the ROM in the 1st group was 20 more than in the 2nd group. The knee function in 12 mon. was 16 points higher on the KSS in the 1st group, 5 points higher on the Lysholm scale, and 15 points higher on the LEFS scale than in the 2nd group. When analyzing the frequency of complications, no significant differences were found (р0.05).
 Conclusions. The results obtained indicate the effectiveness of the orthopedic hexapod in the treatment of patients with knee extension contractures.

Lower limbs lengthening over the intramedullary nail versus lengthening by Ilizarov technique

Introduction. Lengthening over the nail (LON) combines the advantages of external and internal fixations.The objective was to compare the effectiveness of the application, to assess the structure and frequency of complications in patients treated with lengthening by Ilizarov technique and lengthening over the nail.Methods and materials. We analyzed 55 LON cases and 64 cases lengthening by Ilizarov technique. The duration of the external fixation period, complications and quality of the patient life were compared.Results. The external fixation period in LON group was 4 times less than in the Ilizarov technique group. There were 25 complications (45.5 %) in LON group and 54 complications (84.4 %) in the Ilizarov technique group. Femur lengthening was associated with a greater number of complications in both groups. Pin infections were 2.5 times less frequently in the femur LON group. Knee contractures were only in Ilizarov technique group (11.4 %). Ankle joint contracture was noted with the same frequency during tibial lengthening in both groups. Disorders of the consolidation were 2 times more often in the femur LON group and 5 times more often in the tibial lengthening with Ilizarov technique. Premature fusion was observed only in the LON group. There were 2 times less fractures of the half-pins and wires in the LON group.Conclusions. A reduction of external fixation period in LON group correlates with the 2-fold decrease of complications and an increase of the treatment comfort. LON is promising for wider clinical applications.

Bone transport over the nail vs Ilizarov method in the treatment of posttraumatic defects of the femur and tibia

Relevance. From the point of view of using the advantages of both external fixation and internal osteosynthesis, the method “Bone transport over the nail” (BTON) deserves attention.Intention: To compare the effectiveness of the BTON and Ilizarov method in the treatment of patients with post-traumatic defects of the long bones of the lower extremities.Methodology. We analyzed 24 BTON cases and 47 cases of defects replacement via the Ilizarov method. The analysis included patients with segmental defects of the tibia, femur and knee joint bone defects complicated by chronic osteomyelitis.Results and Discussion. The external fixation period in BTON group was 3 times less than in the comparison group, as was the external fixation index. In case of monolocal defect replacement, the external fixation period and external fixation index in the BTON group was 4 times less than in the Ilizarov defect replacement group. With bifocal replacement of the defect, the external fixation period was 2.5 times less, and the external fixation index was 2 times less. BTON interventions were associated with complications in 31 cases (129.2 %) vs 82 cases for the Ilizarov method (174.5 %). The most pronounced decrease (3 times) was noted for cases of transosseous elements inflammation.Conclusion. The “Bone transport over the nail” technique reduces the external fixation period by an average of 3 times. This facilitates management of the outpatient phase and reduces the number of complications, especially the pin-tract infection. Cable technique combined with an orthopedic hexapod allows bifocal replacement of extended defects of the distal femur and knee joint applying the apparatus only to the lower leg. Risks of jamming the transported bone fragments by the intramedullary nail are thus excluded. To avoid breaking the traction cable, only designated devices should be used.

Is arthroplasty inevitable after Ilizarov hip reconstruction of unstable hip joints in adolescents and young adults? Long-Term Evaluation of 136 Cases

Introduction Whereas hip joint destroying trauma and diseases are difficult situations, the problem is more complex when it is complicated by hip instability. This could be a sequel of several hip affections such as trauma, septic or tuberculous arthritis, neglected developmental dysplasia of the hip, postoperative conditions, and neurologic pathologies (cerebral palsy, myelomeningocele, poliomyelitis). Purpose The purpose of this study is to evaluate long-term radiographic and clinical outcomes of the Ilizarov hip reconstruction for the treatment of painful and unstable hips in adolescents and young adults. Materials and methods The study included 136 patients with an average age of 18.3 years (range, 6 to 34 years); 75 patients were males (55.1%) and 61 females (44.9%). The primary causes of the hip instability were untreated or unsuccessfully treated cases of septic arthritis (40 cases; 29.4 %), congenital hip dislocation (28 cases; 20.6 %), paralytic hip dislocation (36 cases; 26.5 %), proximal femoral focal deficiency (14 cases; 10.3 %), neglected fracture of the femoral neck (10 cases; 7.4 %), osteoarthritis (6 cases; 4.4 %), and tuberculous hip arthritis (2 cases; 1.5 %). The intervention consisted in the performance of two osteotomies (proximal and distal) of the femur with pelviс support and placement of the Ilizarov apparatus of a specific assembly. Results The external fixation period ranged from 4 to 12 months (6.5 months on average). Patients were followed up for an average of 17.4 years (range, 5 to 27 years). Multiple clinical parameters at final follow-ups showed significant improvement, including pain relief, pain-free walking distance, lameness, hip flexion and abduction, hip contracture, and lumbar lordosis. Functionally, the mean Harris Hip Score improved with a statistically significant difference from 48 points (range, 35–65) before surgery to 83 points (range 70–90) after surgery. The pain disappeared in all patients, with the exception of six cases of pain in the early postoperative period. In all cases, supportive walking aids were no longer necessary, with the exception of two cases of persistent pain by physical activities. Walking ability and painless walking distance improved in all patients from an average of 35 m (range, 10 to 50 m) before surgery to 1,150 m (range, 1,000 to 1,500 m) after surgery, showing significant difference. Conclusion Ilizarov pelvic support osteotomy provided a multi-purpose solution to the complex challenging problem of hip instability in adolescents and young adults with variable primary etiologies. The improvements in the hip motion, mechanical axis, and correction of limb-length discrepancy lead to good functional outcomes over a long-term follow-up. This treatment modality might avoid or postpone the need for total hip arthroplasty for several years.

A New Classification for Ankle Arthrodesis When Using an External Fixator.

ABSTRACTBackgroundWe have classified ankle arthrodesis when using an external fixator into four types based on the deformity and defect. Each of the four types of technique have been evaluated retrospectively.Materials and methodsThirty-three lower limb segments in 30 patients (average age 49 years) were treated by ankle arthrodesis using an external fixator in our institution. We classified the pre-treatment problems into four types and adjusted the surgical treatment accordingly: type I—no bone defect, no or mild deformity; type II—no bone defect, severe deformity; type III—bone defect with the possibility to shorten acutely after resection of the pathological focus; and type IV—bone defect but without the ability to shorten acutely after resection of the pathological focus. Type I problems were treated with curettage of ankle cartilage and bone graft with external fixation. Type II problems were treated with mobilisation using an external fixation after performing a type I ankle arthrodesis. Type III problems were treated with ankle arthrodesis using acute shortening and distraction. Type IV problems were treated with ankle arthrodesis using bone transport.ResultsAll patients had secure ankle fusion and were able to bear total weight in walking on completion of treatment. The mean external fixation period was 96 days in type I, 181 days in type II, 231 days with lengthening in type III and IV. The complications included re-fracture in three cases, deformity at the lengthening site in one, delayed union in one, and infection at fusion site in one.ConclusionWe have strategized ankle arthrodesis procedures using an external fixator into four groups in order to align the surgical technique with the pre-treatment problem. Our classification can help decide the appropriate operative method when using an external fixator, especially for difficult cases.How to cite this articleMatsubara H, Watanabe K, Takata M, et al. A New Classification for Ankle Arthrodesis When Using an External Fixator. Strategies Trauma Limb Reconstr 2019;14(3):148–154.

Submuscular Plate Stabilisation After Lengthening: Standard and Modified Techniques.

Introduction:Submuscular plating after lengthening shortened the period of external fixation in distraction osteogenesis of the femur. In the femur, where monolateral or ring fixators had been used for the distraction, plates, could be inserted laterally, anteriorly or medially. Specific technical modification of the plate insertion, however, would be necessary to accommodate the femoral varus angular correction created at the end of the distraction, in the pelvic support osteotomy lengthening.Material and Methods:We reviewed a series of eight cases with standard and modified techniques of plating after lengthening. The amount of lengthening, the period of distraction, the external fixator index and the associated complications were assessed.Results:The mean lengthening was 5cm, with a range of 3cm to 9cm. The external fixation index, the period of external fixators in days in relation to the length of distraction in cm, was between 18 days/cm to 58 days/cm. One patient with quadriceps contracture, underwent quadriceplasty to improve knee flexion. Three patients with transient knee stiffness had resolution with aggressive physiotherapy. One patient with transient hypoesthesia recovered spontaneously. None of the patients developed joint subluxation, deep infection, re-fracture or implant failures.Conclusion:Standard and modified techniques of plating after lengthening were safe and required only a short period of external fixation. The modified technique offered an easier way of plate insertion in a deformed bone.

Paediatric infected femoral nonunion; mid-term results of a rare problem with a single-stage treatment and up to eleven and halfyears follow-up.

Nonunion of femur fractures is a devastating disabling complication which is rare in children. The purpose of this study was to report the outcomes of treating infected femur nonunions in children by the Ilizarov fixator in one stage. The study included 13 patients with unilateral infected nonunion of the femur with an average age of 9.1years. The nonunion duration averaged 10.69months. Ten cases were draining nonunions, and three patients had quiescent sinuses. Associated problems include shortening in all cases (mean 3.5cm), joint stiffness (9 cases), and angular deformity (7 cases). The quiescent cases were treated by bloodless monofocal compression-distraction. Four draining cases were treated by debridement and compression with relengthening through nonunion site. The remaining six cases were treated by bifocal technique. The mean follow-up duration was 60.15months. External fixation period averaged 5.3months. Successful union was achieved in all patients. Recurrences of infection occurred in two cases including one with refracture and another one with late pathological fracture. Other complications included pin tract infections, one delayed union, two residual angular deformities, and 6cm residual shortening in one patient. ASAMI bone results were excellent (8 patients), good (3 patients), fair (one patient), and poor (one patient). The functional results were excellent (9 cases), good (3cases), and fair (one case). The Ilizarov method provided a viable treatment option for treating paediatric infected femur nonunions in single stage of management with infection control in most cases and satisfactory outcomes.

Lower limb lengthening over an intramedullary nail: a long-term follow-up study of 28 cases

BackgroundLimb lengthening using an external fixator requires a long period of external fixation and may be associated with several complications such as axial deformity, fracture of the regenerated bone, and joint stiffness. With the goal of reducing the time of external fixation as well as some of these complications, we performed femoral or tibial lengthening over an intramedullary nail, according to Paley’s technique, in 28 patients, followed up after a mean period of 8 years.Materials and methodsTwenty-eight patients treated for lower limb discrepancy by limb lengthening over an intramedullary nail were reviewed from 5 to 11 years after healing of regenerated bone. There were 20 femurs and 8 tibiae, with average age at surgery of 14.2 years and average length inequality of 6.1 cm for femurs and 5.3 cm for tibiae.ResultsThe mean lengthening was 5.8 cm for femurs and 4.8 cm for tibiae. The mean period of radiographic consolidation of the regenerated bone was 6 months for femoral lengthening and 4.5 months for tibial lengthening. At follow-up, we observed 8 excellent results, 15 good results, 4 fair results, and 1 poor result, based on Paley’s evaluation criteria. The main complications were one deep infection, one nonunion of the distracted segment, one breakage of the distal fiche of the external fixator, and one breakage of both distal locking screws of the intramedullary nail.DiscussionWe believe that limb lengthening over an intramedullary nail still represents a good method to treat limb length discrepancy because it reduces the time of external fixation, prevents axial deformities and fractures of regenerated bone, and allows early rehabilitation. The new intramedullary lengthening nails, which theoretically are the ideal device for treating limb length inequality, are still very expensive and need longer follow-up for definitive evaluation.Level of evidence4.

Ulnar osteotomy and the ilizarov mini-fixator for pediatric chronic monteggia fracture-dislocations.

Treatment of chronic Monteggia fracture-dislocations remains controversial in skeletally immature patients. The present study aimed to review the clinical outcomes of surgical treatment with an Ilizarov mini-fixator for chronic Monteggia fracture-dislocations in children. From April 2003 to March 2014, 5 pediatric patients (4 males, 1 female) with chronic Monteggia fracture-dislocation were treated with an Ilizarov mini-fixator at our institution. The median age at the time of surgery was 9 years (range 5–14 years), median duration from injury to surgery was 31 months (range 2–125 months), and median duration of follow-up was 12 months (range 11 months–10 years). All patients underwent opening wedge osteotomy of the proximal ulna followed by the application of an Ilizarov mini-fixator. Although closed reduction was attempted after ulnar osteotomy and application of the Ilizarov mini-fixator, open reduction of the radial head was required in all patients. In 4 patients, dense scar tissue in the radiocapitellar joint was excised to enable reduction of the radial head; the remaining patient had traumatic radioulnar synostosis, and underwent separation of the synostosis followed by anconeus interposition arthroplasty. No patient received bone grafting at the ulnar osteotomy site, repair or reconstruction of the annular ligament, or temporary fixation of the radial head with transarticular wire. The median period of external fixation was 10 weeks (range 8–13 weeks). Although there were no severe complications such as deep infection and neurovascular disturbance, asymptomatic radial head subluxation occurred in 2 patients. The patient with traumatic synostosis had residual posterior subluxation with limitation of forearm rotation, and another patient with radial head enlargement had residual anterior subluxation. The median postoperative ranges of motion in pronation, supination, extension, and flexion were 90°, 90°, 0°, and 140°, respectively. The median Kim's elbow performance score was 65 (range 50–75) preoperatively, which improved to 94 (range 80–100) at final follow-up. The outcome was rated as excellent in 4 cases, and good in 1. In pediatric chronic Monteggia fracture-dislocations, ulnar osteotomy followed by the application of an Ilizarov mini-fixator is a viable option that is less invasive than plate fixation.

Ankle fusion by Ilizarov external fixator

Introduction Arthrodesis is a salvage procedure for patients with a destroyed, painful ankle joint to restore pain-free ambulation. The paper aimed to evaluate the results of ankle arthrodesis using the Ilizarov external fixator to treat end-stage tibiotalar arthritis. Patients and methods This retrospective study included 20 patients who had been treated with ankle fusion by Ilizarov fixator performed from December 2007 to January 2014. Their mean age was 44.95 years. Eight patients were females. The underlying pathology was septic ankle destruction, post-traumatic osteoarthritis, and rheumatoid arthritis. Avascular necrosis of talus was present in three cases. Seventeen patients had previous surgical procedures with a mean of 2.15 surgeries. Five patients had a failed previous arthrodesis. Six patients had associated equinus deformity. The mean preoperative American Orthopaedic Foot and Ankle Society Ankle-Hind foot score was 26. Results The mean follow-up period was 28.15 months. The mean external fixation period was 15.75 weeks. Sound fusion was achieved in all patients without additional operative procedures. Infection was controlled in all septic ankles. Pin-tract infections were observed in seven cases. In three cases, wires or half-pins needed to be removed. One ankle was fused in mild varus. One patient reported moderate daily diffuse pain. The mean postoperative American Orthopaedic Foot and Ankle Society Ankle-Hind foot score was 75.45. Patients reported functional satisfaction with the results. Conclusions The use of the Ilizarov external fixator provides a successful salvage method that offers solid bony fusion, optimal alignment, and eradication of infection in complex ankle pathology or failed previous arthrodesis.

Treatment of deformities in patients with healed congenital pseudarthrosis of the tibia

Background. Correction of deformities and lengthening of the lower extremities in patients with healed congenital pseudarthrosis of tibia (cCPT) is associated with certain characteristics, difficulties, and complications. But even the restoration of the anatomy and length of the tibia does not solve the problem of further recurrence of the deformity.
 Aim. This study aimed to evaluate the results of the correction of deformities of the tibia in patients with congenital pseudarthrosis of the tibia after achieving union by using external fixation and guided growth.
 Materials and methods. The results of treatment of 19 patients with cCPT, aged 4–15 years, which were observed in the Department of the Turner Scientific Research Institute from 2013 to 2018 years, were analyzed. We analyzed the types of deformities before the stage of correction deformities, evaluated the accuracy of the correction deformities after two-level osteotomies of the tibia, and used ortho-SUv passive computer navigation. External fixation index and number of complications were also determined. The type and number of recurrence of deformities and the timing of their detection were analyzed.
 Results. On the basis of clinical classification, patients with cCPT had complex deformities of the affected lower limb. The accuracy of the correction of deformities was 84% at the end of the correction period. The amount of elongation was 4.5 ± 1.5 cm. The IEF was 64.3 ± 40.6 days/cm. After the end of the external fixation period, deformities recurred in 100% of cases. In 17 patients, temporary hemiepiphysiodesis of the tibial bones, the second stage, was performed. The accuracy of the correction was 100%. The period of correction ranged from 12 to 14 months.
 Discussion. In the literature, we found no studies investigating the accuracy of the deformity correction, the choice of the level of osteotomies in patients with cCPT. Considering these data and the experience of the senior author of the publication, we performed two osteotomies of the tibia, outside the consolidation zone of the pseudarthrosis. High accuracy of the correction deformities was achieved in conjunction with the use of the ortho-SUv frame.
 Conclusion. The analysis showed that the deformity relapsed in 100% of children as the child grows, regardless of the accuracy of the deformity correction in children after achieving union CPT. Hemiepiphysiodesis is an effective treatment for this complication.

Infected tibial nonunion in children: Is radical debridement mandatory?

Nonunion is a devastating complication of tibial fractures with a debilitating effect. Several studies reporting tibial nonunions in adults are available; however, the reports on infected nonunions in children are scarce. The purpose of this study was to evaluate the results of treating paediatric infected tibial nonunion using Ilizarov fixator without radical resection. Materials and methodsThe study included 36 cases with infected nonunion of the tibia with 31 males and 5 females, and an average age of 11.4 years. The mean number of previous operations was 3.5. The duration before presentation averaged 10.4 months. At presentation, 24 cases were draining nonunions, while 12 patients had quiescent sinuses. Preoperative shortening was evident in 31 patients ranging from 1 to12 cm. Six cases had equinus foot deformity. Stiffness of the ankle and/or knee was present in 11 cases. Angular deformity of more than 10° was evident in 13 nonunions. The monofocal compression-distraction was used for 10 cases managed by bloodless technique, and four draining cases managed by limited debridement and compression distraction. Limited debridement and bone transport was used in the remaining cases including proximal chondrodiastasis (two cases), proximal tibial corticotomy (17 cases), and partial osteotomy (three cases). ResultsThe mean follow-up duration was 51.9 months. The external fixation period averaged 5.3 months. Delayed union occurred in three cases treated by repeating compression-distraction. Eventually, union was achieved in all cases. Two cases suffered refracture. Four cases had residual angular deformity of about 5-7°. Infection recurred in one case. ASAMI bone results were excellent in 29 patients, good in three patients, fair in two patients, and poor in two patients. The ASAMI functional results were excellent in 27 cases, good in 5 cases, fair in two cases, and poor in two cases. ConclusionThe Ilizarov method provides a viable treatment method for treating paediatric infected nonunions in a single stage of management. Limited debridement was enough to control infection and achieved good results without radical resection.

Pining Fixation Versus Canulated Screw with Open Reduction of Pediatric Lateral Condyle Humerus Fractures

Good results have been described for lateral condyle Fractures pediatrics treated by open reduction and fixation usingKirschner wires or screws.We, in our level III retrospective comparison clinical research study, retrospectively reviewed 20patients (10 K-wire, 10 screw fixation; average age 5.6 years, average follow-up 6.8 months). The clinical outcomes wereevaluated according to the criteria of Hardacre et al. There was no statistically significant difference in clinical outcomebetween these two groups. Two patients developed skin infection around K-wires, while no infection occurred in fracture withscrews. An obvious lateral prominence occurred in one patient with K-wires and none with screws. One patient with K-wiresand one patient with screws had a lack of 15° of extension of the elbow compared with the other side. With K-wires therewere two nonunions (average time to union 9.6 weeks). With screws, one nonunions (average of 6.8 weeks). Both K-wires andcannulated screw fixation are effective in treatment for lateral humeral condyle fracture. K-wires can pass through the ossificnucleus of capitulum without damaging it, but a longer period of external fixation and local skin care will be required. Screwfixation patients spent fewer days in a cast and had agreater range of motion at the last follow-up. Screw fixation is associatedwith fewer nonunions and faster time to union, but a secondary procedure for removal is required .

Salvage of failed ankle arthrodesis after posttraumatic septic arthritis by Ilizarov external fixator: mid-term results

Background: Failed septic ankle arthrodesis is a challenging problem. This study evaluated the results of salvage revision ankle arthrodesis using Ilizarov external fixation to treat nonunited arthrodesis of posttraumatic septic ankle arthritis and to analyze the functional outcome of this method. Methods: This prospective study included 14 patients with a mean age of 48 yr. Patients had already undergone a mean of 4.43 previous surgeries at a mean of 17.14 mo from primary arthrodesis. Five patients had associated deformity. The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 23.93. Meticulous debridement was done and an Ilizarov fixator was applied in compression in a one-stage procedure. Results: The mean follow up period was 41.71 mo with mean external fixation period of 17.29 wk. Successful arthrodesis in perfect alignment was achieved in 13 of 14 patients without additional procedures. One ankle did not go on to union. A chronic discharging sinus persisted in one patient. One infected loose wire was exchanged in two patients. One diabetic patient reported moderate daily diffuse pain. The mean postoperative AOFAS ankle-hindfoot score was 71.57. Patients with successful fusion were satisfied with the procedure. Conclusions: Using an Ilizarov fixator to salvage nonunited septic posttraumatic ankle arthrodesis was effective, with patients reporting a stable ankle and dramatic functional improvement with minimal complications.

Application of a customized 3D printed reduction aid after external fixation of the femur and tibia: Technical note.

To construct a fracture-specific reduction aid by means of virtual reduction technology and 3D printing to reduce malreduced, externally fixed, long bone fractures. Following application of an external fixator to a malreduced long bone fracture, we performed postoperative computed tomography to visualise the fragments and their position relative to Schanz screws. DICOM data were transferred to 3D planning software, and the fracture was then virtually reduced. Subsequently, a reduction aid was designed to cover the Schanz screws in such a way that it would maintain the position of the new fragments. Following 3D printing, the solid reduction aid could be applied onto the Schanz screws. The reduction aid fit only in the reduced position of the fracture, thus maintaining correct bone alignment. Our reduction technique can be applied during the temporary external fixation period on the preexisting external fixator or as a reduction aid during definitive treatment.

Rate of venous thromboembolism after complex lower-limb fracture surgery without pharmacological prophylaxis.

To evaluate the rate of venous thromboembolism (VTE) after complex lower-limb fracture surgery without pharmacological prophylaxis. Between July 2005 and April 2009, 11 men and 6 women (mean age, 45 years) underwent temporary external fixation followed by internal fixation for a total of 3 femoral and 20 tibial fractures. Patients were screened for VTE using contrast-enhanced computed tomography (CT) when the D-dimer value was beyond normal range. Between May 2009 and December 2012, 18 men and 4 women (mean age, 45 years) underwent temporary external fixation followed by internal fixation for a total of 8 femoral and 20 tibial fractures. Patients were routinely screened for deep vein thrombosis (DVT) using ultrasonography and for pulmonary embolism (PE) using contrast-enhanced CT (in high-risk patients with multiple injuries or pelvic and acetabular fractures). In both groups, pharmacological prophylaxis was not used; only mechanical prophylaxis was used. The 2 groups were comparable in terms of age, sex, and proportion of bilateral external fixation, open fracture, and associated injury, except that the duration of external fixation was longer in the early group (29.8±28.0 vs. 11.6±4.0 days, p=0.001). Of the 17 patients in the early group, 5 developed VTEs (3 DVTs and 2 PEs) at a mean of 13.6 (range, 6-20) days after injury; 2 of whom developed VTE during the external fixation period. Of the 22 patients in the later period, 10 developed VTEs (10 DVTs and 4 PEs) at a mean of 13 (range, 5-33) days after injury; 7 of whom developed VTE during the external fixation period. The rate of VTE was high in patients undergoing complex lower-limb fracture surgery without pharmacological prophylaxis.

Tibial lengthening with a submuscular plate in adolescents.

Lengthening over an intramedullary nail has become a common technique for reducing the period of external fixation. However, the technique presents difficulties in patients with an open physis or a small marrow canal. Lengthening using a submuscular plate offers a new substitute in such situations, but few studies have been undertaken to determine its efficacy in teenagers. A retrospective review was performed on 20 consecutive tibiae of 16 patients who underwent tibial lengthening with the aid of external fixator and submuscular plate. Charts and radiographs were reviewed for demographics, surgical details, and complications related to the technique. The average age of the 16 patients was 14.3 years (range 10-17), and the amount of lengthening averaged 4.1 cm (range 3.0-5.0 cm), which represented 12.7 % of preoperative bone length (range 9.1-15.8 %). Mean time in the fixator was 60.3 days, mean external fixation index was 14.8 days/cm (range 13.2-22.5 days/cm), and mean healing index was 49.1 days/cm (range 37-59.3 days/cm). Twenty-seven complications occurred giving an overall complication rate of 1.35. Twenty of the 27 were minor complications, but 7 were major. These major complications were resolved surgically or by a resolution period exceeding 3 months. There were 3 cases of transient angular deformity of distraction callus, 2 cases of transient peroneal nerve palsy, 1 case of clamp loosening, and 1 case of plate failure. Functional results were good or excellent with an average score of 95.6 according to modified Paley's criteria. Although complications were not uncommon, tibial lengthening with a submuscular plate proved to be a reliable technique for treating limb length discrepancy in adolescents with reduced external fixation duration. Level IV, case series.

Medial submuscular plating of the femur in a series of paediatric patients

We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures. A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate. Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy.