The biomechanical effects of different materials on the application of femoral external fixator: Stainless steel versus titanium alloy and healthy versus osteoporosis bone properties.

Femoral diaphysis malunion: An overview.

Reliability and validity of shoulder muscle strength measurements using portable dynamometers: A systematic review.

Treatment of infected proximal tibial metaphyseal nonunions using the Ilizarov method: A prospective clinical study.

X-ray classification and treatment of hypotrophic distraction osteogenesis in tibial bone transport

Knee dislocations (KDs) can be limb-threatening injuries that may require a temporising knee-spanning external fixator (KSEF) for stabilisation. Precise indications for this commonly utilised invasive immobilisation technique remain controversial and poorly defined. The purpose of this study was to establish consensus-driven indications for temporising KSEF use in the initial management of KDs. A working group of fellowship-trained orthopaedic surgeons generated clinical scenarios reflecting commonly debated indications for temporising KSEF application. Utilising a modified Delphi technique, 23 surgeons from the International Knee Dislocation Study Group completed two anonymous online survey rounds. Consensus was defined a priori as ≥70% agreement or disagreement. Response rates were 100% for Round 1 and 96% for Round 2. Four scenarios achieved unanimous consensus: (1) KD without post-reduction instability (100% disagreement), (2) inability to maintain tibiofemoral reduction in the sagittal/coronal plane with non-invasive knee immobilisation (NIKI) after initial reduction (i.e., redislocation/subluxation) (100% agreement), (3) tibial plateau fracture-dislocation with post-reduction subluxation (100% agreement), and (4) in bilateral closed KDs where one limb is indicated and the other is NOT, span ONLY the indicated limb (100% agreement). Two scenarios achieved strong positive consensus (90%-99.9% agreement): (1) morbid obesity (BMI ≥ 40) without NIKI of sufficient size (91.3% agreement), and (2) extensor mechanism injury with post-reduction subluxation (91.3% agreement). Four and one additional scenarios achieved positive and negative consensus, respectively. This modified Delphi study established consensus-driven indications for temporising KSEF application in the initial management of KDs, which advocate for more selective use than what is demonstrated in the literature. Level V.

BackgroundManaging large posttraumatic tibial defects presents significant challenges. External fixation is effective for distraction osteogenesis but has drawbacks, including prolonged treatment time and complications. Intramedullary lengthening nails improve patient comfort but have limitations in large bone transport. While combined techniques have been explored, to our knowledge a fully sequential approach where an external fixator is first used for distraction and then replaced by a motorized intramedullary lengthening nail continuing the lengthening has not been clearly described in the literature. This study presents a novel staged technique and a review of existing literature on limb lengthening strategies.MethodsWe report the case of a 29‐year‐old male with a 16‐cm posttraumatic tibial defect, treated with 10 cm of bone transport using an external fixator, followed by 6 cm of additional lengthening with a motorized intramedullary nail. Additionally, a literature search was conducted in PubMed, Scopus, and Embase using keywords related to limb lengthening, external fixation, and intramedullary nailing. The technique and outcomes were compared with existing literature.DiscussionThe review did not identify any studies on fully sequential limb lengthening. Most studies focus on pediatric cases or hybrid techniques where external fixation and intramedullary nailing are used simultaneously. Our sequential approach allowed for controlled distraction and successfully addressed a 16‐cm bone defect.ConclusionsThis case highlights a previously undescribed staged limb lengthening approach. Sequential conversion from external fixation to a motorized intramedullary lengthening nail may offer advantages in reducing EFI, protecting neurovascular structures, and enhancing mechanical stability. Further research is needed to evaluate long‐term outcomes.

To investigate the effectiveness of minimally invasive hemi-cortical longitudinal bone transport technique for concurrent treatment of bone and soft tissue defects in patients with tibial osteomyelitis. A retrospective analysis was conducted on 14 patients with tibial osteomyelitis accompanied by bone and skin soft tissue defects, who were admitted between January 2022 and August 2023. There were 10 males and 4 females, with an average age of 51.2 years (range, 35-75 years). Traumatic osteomyelitis was diagnosed in 11 cases, and hematogenous osteomyelitis in 3 cases. The duration of infection ranged from 0.2 to 1.9 months (mean, 1.1 months). All bone defects were rated as Orthopaedic Trauma Association (OTA) type Ⅰ. The length of bone defects ranged from 3.4 to 6.2 cm (mean, 4.8 cm); the width of defects corresponded to 1/4-1/2 of the tibial circumference. The extent of soft tissue defects ranged from 6.5 cm×2.0 cm to 7.0 cm×3.0 cm. Upon admission, primary debridement and antibiotic calcium sulfate bead filling of the medullary cavity were performed, followed by antibiotic-coated bone cement coverage for soft tissue defects. After infection control, secondary minimally invasive tibial osteotomy was performed, followed by Orthofix unilateral external fixator for upper limb use to facilitate bone tissue transport. The time required for external fixation and bone transport was recorded, and wound healing status, bone healing progress, and adjacent joint function were observed. Scoring was performed according to the Paley healing criteria. All patients completed two phases of treatment. The external fixation duration ranged from 2.1 to 6.5 months (mean, 4.5 months); bone transport duration ranged from 1.1 to 2.3 months (mean, 1.5 months); external fixation index ranged from 0.6 to 1.3 months/cm (mean, 0.98 months/cm). During bone transport, only 1 patient developed a pin tunnel reaction, with no other complications occurring. All patients were followed up 23-27 months (mean, 25.1 months). All wounds healed, with healing time ranging from 1.1 to 2.6 months (mean, 1.5 months); no infection recurrence was observed during follow-up. Imaging re-examination confirmed complete fracture healing, with healing time ranging from 2.6 to 3.5 months (mean, 3.2 months). At 3 months after discontinuation of bone transport, according to the Paley healing criteria, the bone healing in 14 patients achieved excellent; the joint function was rated as excellent in 11 patients and good in 3 patients. The minimally invasive hemi-cortical longitudinal bone transport technique demonstrates satisfactory effectiveness in the concurrent treatment of bone and soft tissue defects following tibial osteomyelitis.

To explore the surgical technique and effectiveness of limited bone and soft tissue surgery combined with Ilizarov technique in the treatment of adolescents severe cerebral palsy with flattened valgus foot and lower leg external rotation deformity. A retrospective analysis was conducted on 12 patients with severe cerebral palsy with flattened valgus foot and external rotation deformity of the lower leg, totaling 16 feet, admitted between January 2022 and January 2025. There were 5 males with 7 feet and 7 females with 9 feet, the age ranged from 12 to 18 years, with an average of 15 years. There were 10 cases on the left foot, 6 cases on the right foot, and 4 cases on both feet. The preoperative external rotation angle of the lower leg ranged from 20° to 35°, with an average of 26°. The preoperative visual analogue scale (VAS) score was 4.9±0.9, the American Orthopaedic Foot & Ankle Society (AOFAS) score was 68.7±12.0, the calcaneal tilt angle was (12.69±1.78)°, and the hindfoot angle was (18.69±3.55)°. Patients with bilateral lower leg deformities underwent surgery in two phases, with an interval of 3-6 months between surgeries. Select soft tissue surgery (Achilles tendon elongation, release or transposition of joint capsule and ligaments) and bone surgery (joint fusion, calcaneal osteotomy, medial wedge osteotomy, etc.) combined with tibiofibular internal rotation osteotomy and Ilizarov external fixation were selected according to the patient's condition. At 1 week after operation, the external fixators of the lower leg and ankle were slowly adjusted, and the deformities that were not completely solved in the three-dimensional correction operation were corrected. Postoperative pain relief and functional recovery were evaluated by VAS and AOFAS scores, and the improvement of foot deformity was evaluated by calcaneal tilt angle and hindfoot angle on radiographic data, and the postoperative effctiveness was evaluated according to the International Clubfoot Study Group (ICFSG). At 2 weeks after operation, the foot deformity of the patient was basically adjusted. All patients were followed up 6-36 months, with an average of 18 months. The incisions healed by first intention without nerve injury, infection, or other complications. At last follow-up, the patients recovered satisfactorily, the osteotomy sites healed, and the external rotation of the lower leg was corrected. The VAS score was 1.2±0.1 and AOFAS score was 86.7±6.8, which were significantly different from those before operation ( P<0.05). The calcaneal tilt angle was (18.38±1.15)° and the hindfoot angle was (10.06±2.93)°, which were significantly different from those before operation ( P<0.05). According to the ICFSG scoring standard, 13 feet were excellent and 3 feet were good, and the excellent and good rate was 100%. The combination of bone and soft tissue limited surgery and Ilizarov technique is a safe, minimally invasive, and effective method for treating severe cerebral palsy in adolescents with flattened valgus foot and external rotation deformity of the lower leg. It conforms to biological principles and follows the concept of natural bone reconstruction.

Hereditary multiple exostoses (HME) is an autosomal dominant skeletal disorder frequently associated with progressive forearm deformities, including ulnar shortening, radial bowing, and radial head dislocation. Ulnar lengthening using distraction osteogenesis has become the principal surgical strategy; however, outcomes, techniques, and complication profiles vary across studies. This systematic review and meta-analysis synthesize contemporary evidence on radiographic correction, functional outcomes, and complications following ulnar lengthening for HME-related forearm deformities. A systematic search of SciSpace, PubMed, and Google Scholar was performed to identify studies published between January 2015 and December 2025 evaluating ulnar lengthening in patients with HME. Observational studies reporting radiographic, functional, or complication outcomes were included. Data were extracted on patient characteristics, surgical techniques, radiographic parameters, functional outcomes, and complications. Study quality was assessed using the Newcastle-Ottawa Scale. Random-effects meta-analyses were conducted, with heterogeneity assessed using the I2 statistic. Thirty observational studies comprising 350 patients and 380 forearms were included, with a mean follow-up of 38.6 months. The pooled mean ulnar lengthening achieved was 33.8 mm (95% CI: 28.4-39.2; I2 = 68%). Significant improvements were observed in radial articular angle (mean difference - 6.3°, 95% CI: - 8.7 to - 3.9; I2 = 52%) and ulnar variance (mean difference - 15.4 mm, 95% CI: - 18.2 to - 12.6; I2 = 58%). Radial head reduction was achieved in 76% of affected forearms. Functional outcomes improved significantly, with DASH scores decreasing by a pooled mean of 12.7 points (p < 0.001). The overall complication rate was 18.1%, with most complications being minor and manageable. Ulnar lengthening via distraction osteogenesis provides effective radiographic correction and meaningful functional improvement in patients with HME-related forearm deformities, with acceptable complication rates. Monolateral external fixation is the most commonly employed technique and yields reliable outcomes. Despite encouraging results, the evidence base is limited to observational studies with heterogeneous reporting, underscoring the need for prospective studies with standardized outcome measures and longer follow-up.

Ballistic injuries to the mandible produce comminuted fractures with compromised vascularity and contaminated wound beds that challenge the assumptions of rigid internal fixation. External fixation, the earliest form of mandibular stabilization, preserves periosteal blood supply by avoiding open dissection, yet direct comparisons between the 2 approaches in the ballistic setting are scarce. A retrospective review was conducted of consecutive patients with gunshot-related mandibular fractures treated at a single level 1 trauma center from January 2020 to August 2024. Patients were grouped by initial fixation method: external fixation (n=10) or internal fixation (n=30). Short-term and long-term complications were assessed through 6 months. Multivariable logistic regression compared long-term complication rates. The cohort was 85% male with a median age of 35. Median operative time was shorter for external fixation (118.5 vs. 194.5min, P =0.01). Short-term complications were higher with external fixation (80% vs. 33.3%, P =0.001), reflecting greater injury severity. After final fixation, the complication rate dropped to 10% for external fixation versus 33.3% for internal fixation. On multivariable analysis, long-term complications trended toward being less likely with initial external fixation, though without reaching statistical significance [OR=0.113, 95% CI (0.004, 1.11)]. Initial external fixation was associated with shorter operative time and lower long-term complication rates compared with primary internal fixation. These findings support external fixation as a staged approach to severe ballistic mandibular injuries, preserving periosteal vascularity and allowing soft tissue recovery before definitive reconstruction.

Free fibular flaps (FFF) and pedicled fibular grafts (PFG) are established techniques for reconstructing pediatric long bone defects. While the FFF provides versatility through microvascular transfer, PFGs avoid anastomosis but are limited by anatomic constraints. Clinical questions remain regarding optimal fixation strategies, donor-site morbidity, and graft outcomes in children. This retrospective cohort study analyzed 22 pediatric patients undergoing FFF or PFG between 1994 and 2025. Outcomes included time to radiographic union, time to weight bearing, fibular regeneration, and donor-site complications. Subgroup analyses compared external fixation use, periosteal sleeve preservation, and graft type/location. The average time to radiographic union was 41 weeks. External fixation was associated with shorter radiographic union time (30.1 vs. 86.4 wk) and earlier full weight bearing on the graft-receiving limb (52.0 vs. 127.2 d), though these findings should be interpreted as exploratory given the limited sample size and inconsistent significance across statistical tests. Younger patient age correlated with faster union (r = 0.60, P = 0.004). Preservation of a periosteal sleeve at the donor site significantly promoted fibular regeneration ( P = 0.0004) and may hasten donor limb recovery. Ankle valgus deformity was associated with shorter residual distal fibula length (mean 5.6cm, P = 0.0498). All grafts showed remodeling over time. Tibial graft location and use of PFG were significantly associated with need for refixation ( P = 0.0001 and P = 0.0002, respectively). Pediatric FFF reconstruction demonstrates high union and remodeling rates with favorable functional outcomes. External fixation was found to be weakly associated with acceleration of union and weight bearing, while periosteal sleeve preservation supports fibular regeneration and potentially expedites return to weight bearing on the donor limb. PFGs may be effective in select tibial cases but showed higher reoperation rates. Preserving an adequate distal fibula segment may mitigate ankle valgus. These findings support tailored fixation strategies and highlight the importance of surgical planning to optimize outcomes and minimize donor-site morbidity in pediatric patients. Level III-therapeutic study.

The increasing demand for daily health monitoring has accelerated the development of wearable devices. However, conventional wearables, typically based on rigid materials and external fixation methods, suffer from interfacial instability during dynamic motion and heavy sweating, leading to signal distortion and device delamination. Skin-like wearable electronics and in situ fabrication strategies have emerged to improve conformability and signal stability. However, challenges remain in achieving a stable skin-device interface and reliable performance under dynamic conditions using simplified fabrication methods. Here, we present a flexible multiparameter monitoring device that integrates with the skin through a skin-electronics interface undergoing a dual-phase transition from hydrogel to liquid and subsequently to a solid state via in situ heating and photonic crosslinking. This transition forms mechanically interlocked structures that ensure robust adhesion and stable skin contact even under humid and high-acceleration conditions. Rapid curing enabled by an integrated heating layer and optical waveguide reduces the fabrication time to 1 min, allowing efficient on-demand deployment. The device achieves stable monitoring of ECG, PPG, acceleration, and temperature signals and supports Bluetooth data transmission under accelerations up to 11 g, as well as during swimming and showering. Furthermore, machine-learning-based motion recognition and individual identification models achieve 100% accuracy. This work advances in situ-fabricated wearable electronics by improving fabrication efficiency, interfacial robustness, and environmental adaptability, providing a promising platform for portable physiological monitoring.

Pain Outcomes After Severe Open Tibial Fracture: Clarifying the Role of Fixation Strategy: Commentary on an article by Henry T. Shu, MD, et al.: " Pain Outcomes Following Modern External Ring Fixation Compared with Internal Fixation for Severe Open Tibial Fractures. A Secondary Analysis of a Prospective Randomized Trial (FIXIT) ".

To determine the rate of occult vascular abnormalities in high-energy tibial plateau fractures using Computed Tomography Angiography (CTA). Prospective Cohort Study. Single Academic Level I Trauma Center. Adult subjects with a tibial plateau (OTA/AO 41) fracture, without clinical indication for CTA, that underwent knee-spanning external fixation were prospectively enrolled. Following external fixation, subjects underwent CTA to evaluate fracture morphology and the vascular tree. Fisher's exact test was utilized to determine correlations between arterial abnormalities and wound complications in patients with ≥90 days of follow-up. Twenty-six subjects with 27 high-energy tibial plateau fractures were enrolled. Subjects were predominantly male (n=16, 61.5%) with a mean age of 45.1±13.3 years. All patients had a blunt injury mechanism resulting in mostly closed (n=25, 92.6%) bicondylar (n=22, 81.5%) tibial plateau fractures. CTA demonstrated non-atherosclerosis vascular abnormalities in three patients (11.5%). Two had disrupted flow in the popliteal artery, and one had disrupted flow in the anterior tibial artery. No subjects required vascular intervention. Atherosclerosis was appreciated in six (26.9%) subjects. One of three subjects (33%) with non-atherosclerosis vascular abnormalities had wound complications. Four of 24 subjects (16.7%) without non-atherosclerosis vascular abnormalities had wound complications. There was no significant correlation between non-atherosclerosis vascular abnormalities and wound complications (abnormality present: 33.3% wound complication rate vs. no abnormality: 16.7%, p=0.47). Non-atherosclerotic vascular abnormalities on CTA were found in approximately a tenth of high-energy tibial plateau fractures. In this cohort, vascular abnormalities were not associated with wound complications. CTA is likely not necessary in tibial plateau fracture patients without clinical indications for CTA. Level II.

Repeat pelvic osteotomy improves the management of failed bladder closure in cloacal exstrophy.

The optimal surgical strategy for length-unstable pediatric femoral shaft fractures remains debated. This study compared clinical and radiologic outcomes between submuscular biological plating (SBP) and flexible intramedullary nailing augmented with external fixation (FIMN/EF). In this prospective, randomized trial, 32 children (5 to 14 years) with unstable femoral fractures (AO/OTA 32-D/5.1 or 32-D/5.2) were allocated to SBP (n=16) or FIMN/EF (n=16). Primary outcomes included operative time, fluoroscopy time, time to union, complications, and knee range of motion (ROM). Secondary outcomes included alignment, limb length discrepancy, functional scores (Flynn criteria), and implant removal characteristics. The SBP group demonstrated shorter operative time than the FIMN/EF group (mean: 73.1 vs. 88.8min, P =0.002) and reduced fluoroscopy time (mean: 51.9 vs. 74.1s, P <0.001). Time to radiologic union was comparable between groups ( P >0.05). Knee flexion at final follow-up was greater in the SBP group (mean: 108.1 vs. 100.6 degrees, P =0.015). Complication rates and limb length discrepancies (≤10mm) were similar in both groups, with no statistically significant difference. Functional outcomes were excellent or good in most patients in both groups. Both SBP and FIMN/EF appear to be effective treatment options for selected length-unstable pediatric femoral shaft fractures. SBP offers shorter surgery, reduced radiation exposure, and better early knee ROM, whereas FIMN/EF provides easier implant removal. Technique selection should be based on patient factors, fracture pattern, surgeon experience, and family preference.

Role 2 (R2) U.S. military treatment facilities (MTFs) provide forward damage control resuscitation and surgery. There are many configurations of R2 surgical teams, but each service defines external fixation (EF) as a requisite skill. To inform planning of potential future conflicts, this study describes EF utilization in recent past conflicts. The Department of Defense Trauma Registry (DoDTR) was retrospectively reviewed from 2003 to 2023. All combat casualties who underwent EF at U.S. MTFs were included. The primary outcome was the MTF level at which EF was performed. Secondary outcomes included the anatomic site of EF and population receiving EFs. Trends in these outcomes were evaluated across time and military operation. Six thousand one hundred eleven patients received 9,310 EFs; 2,600 were U.S. casualties, 1,630 foreign civilian, 275 North Atlantic Treaty Organization (NATO) military, and 1,605 non-NATO military. 19.5% of EFs were placed at R2, 67.6% at Role 3 (R3), 4.9% at Role 4 (R4), and 8.0% at R4-Continental US (R4C) MTFs. 78.0% of patients undergoing their first EF at R3 bypassed the R2. 67.5% of EFs were on the lower extremity and 19.4% were on the upper extremity. At both R2 and R3, the lower extremity was the predominant EF site (69.6% and 67.3% respectively). External pelvic fixation was rarely performed (0.3% and 0.1%). These results offer valuable insight into modern logistical concerns in the delivery of forward surgical care. First and foremost, it underscores the importance of maintaining EF capability in expeditionary surgical teams, especially at lower echelons of care. Given the increasing prevalence of EF at R2s and the logistical challenges of evacuation in future conflicts, consideration should be given to both sustaining orthopedic-trained surgeons in theater and ensuring all general surgeons have robust orthopedic capabilities.

External Fixation and Adjuvant Pins Versus Volar Locking Plates in Unstable Distal Radius Fractures: A Randomized Controlled Study with a 10-Year Follow-Up.

​ Gradual correction of genu varum using circular external fixators is well-established. Although the External Fixation Index (EFI) is widely used in linear bone lengthening, no standardized, time-normalized metric exists for angular deformity correction. This study introduces the angular External Fixation Index (aEFI) as a descriptive tool and evaluates internal consistency within a clinical cohort treated with oblique proximal tibial corticotomy (OPTC). ​ A prospective cohort study included 22 patients (30 knees) who underwent gradual genu varum correction using OPTC and circular external fixation. The aEFI was calculated as total duration of external fixation (weeks) divided by achieved angular correction (degrees). Radiographic evaluation included medial proximal tibial angle (MPTA) and hip-knee-ankle angle measured preoperatively and at final follow-up. Functional outcomes were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index, and the Stanmore Limb Reconstruction Score. At a mean follow-up of 16.5 ± 3.25 months, coronal alignment was restored in all knees. Mean fixation duration was 27.4 ± 6.2 weeks, with a mean aEFI of 1.89 ± 0.41 weeks/degree. An inverse association was observed between correction magnitude and aEFI (r = -0.88, p < 0.001), reflecting the reduced proportional effect of fixed treatment phases with larger corrections. Functional scores improved, and minor pin-tract infections occurred in 20% of knees and resolved conservatively. ​ The proposed aEFI serves as a standardized, descriptive, time-normalized metric for reporting treatment duration relative to angular correction. External validation across different constructs and deformity patterns is warranted.