Application Of External Fixator Research Articles

Application of external fixator combined with Kirschner wire fixation for oblique and comminuted distal humeral metaphyseal-diaphyseal junction fractures in children

To analyze the effectiveness of external fixator combined with Kirschner wire (EF-KW) fixation in the treatment of oblique and comminuted distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children. A clinical data of 22 children with DHMDJ fractures who met the selection criteria between April 2021 and December 2023 was retrospectively analyzed. All patients were treated with EF-KW fixation. There were 14 boys and 8 girls with an average age of 6.8 years (range, 1.5-12.0 years). The time from injury to operation was 14-38 hours (mean, 24.2 hours). There were 18 cases of comminuted fractures and 4 cases of oblique fractures; and 1 case of median nerve injury and 1 case of radial nerve injury before operation. The occurrence of postoperative complications was recorded. At last follow-up, the function of the affected elbow joint was evaluated according to the Mayo elbow joint function score, and the Baumann's angle (BA) and humero-capitellar angle (HCA) of the affected and healthy sides were recorded and compared. All fractures were successfully treated with closed reduction and no complications such as nerve injury occurred. Superficial infection occurred in 4 cases after operation and healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 9-24 months (mean, 13.8 months). At last follow-up, according to the Mayo elbow joint function score, the elbow joint function was rated as excellent in 15 cases, good in 6 cases, and fair in 1 case, with an excellent and good rate of 95.5%. The neurologic injury before operation recovered gradually. X-ray films reexamination showed that all fractures healed, and the healing time of fractures ranged from 29 to 61 days, with an average of 35.6 days. At last follow-up, there was no significant difference in BA and HCA between the healthy side and the affected side ( P>0.05). During follow-up, 1 case developed mild cubitus varus, while the other patients had no serious complications. EF-KW fixation for oblique and comminuted DHMDJ fractures in children has the advantages of less trauma, simple operation, easy reduction, good stability after reduction, low incidence of serious complications, and good elbow functional recovery.

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.

Three-Dimensional-Printed Patient-Specific Total Cuboid Replacement for Treatment of Post-traumatic Arthritis: A Case Report.

Cuboid injuries, including fractures, are rare and infrequently occur in isolation. Often, cuboid injuries can be treated nonoperatively. However, when surgery is indicated, appropriate management is necessary for maintaining the associated biomechanics of the midfoot. Current procedures for surgical management of the cuboid include open reduction and internal fixation, application of external fixation, or primary arthrodesis of the calcaneocuboid joint. Secondary procedures for symptomatic or poor outcomes of nonoperative and operative cuboid injuries consist of corrective osteotomy, bone resection, and interpositional arthroplasty. We present a novel surgical technique using a patient-specific three-dimensional-printed total cuboid replacement. This is an alternative treatment for post-traumatic arthritis of the cuboid along with a shortened lateral column. A single case example is given as well as details and discussion of the surgical technique.

Effect of damage control strategy combining pre-hospital emergency treatment with in-hospital treatment on pelvic fracture complicated by multiple injuries

ObjectiveTo analyze the application value of damage control strategies combining pre-hospital emergency treatment with in-hospital treatment for multiple injuries in treating pelvic fracture complicated by multiple injuries. Methods120 patients with pelvic fracture complicated by multiple injuries admitted to our hospital from January 2020 to January 2023 were selected and divided into a damage control group (early temporary reduction after resuscitation, n = 60) and a control group (no reduction and resuscitation only, n = 60) by treatment methods. The control group was treated with conventional methods, while the damage control group was treated with the damage control strategy combining pre-hospital emergency treatment combined with in-hospital treatment in addition to conventional methods. The mortality rate, complication rate, fracture reduction quality, long-term efficacy, and patient satisfaction of the two groups were compared. ResultsThe mortality rate of the damage control group was lower than that of the control group, and the difference has statistical significance (P<0.05); the incidence of infection, DIC, and MODS of the damage control group were lower than that of the control group, with the difference being statistically significant (P<0.05); the incidence of ARDS in the two groups is not that different (P>0.05); the fracture reduction quality and long-term therapeutic effect of patients in the two groups were statistically different, with the damage control group outperforming the control group in both aspects; the difference between the two groups in terms of patient satisfaction was statistically significant (P<0.05), with the patient satisfaction of the damage control group being higher than that of the control group. ConclusionFor patients with pelvic fracture, the application of the damage control strategy combining pre-hospital emergency treatment and in-hospital treatment is a boon to the standardization of the treatment process, the improvement of the treatment success rate and fracture reduction quality and the reduction of complications, and therefore is worth promoting in clinical practice. the early application of external fixation has helped with the definitive reduction at a time when the patuent was stable.

Independent predictors of systemic inflammatory response syndrome for intramedullary nailing of femoral shaft fractures: Analysis of national inpatient sample database

BackgroundThe systemic inflammatory response syndrome (SIRS) is a clinical reaction that can occur due to a variety of stimuli. Reamed intramedullary femoral nailing is a common orthopedic surgery that has been shown to induce SIRS. To date, no nationwide analyses have been performed to evaluate the incidence, risk factors, and economic burdens of SIRS following intramedullary femoral nailing for femoral shaft fractures. The objective of this study is to investigate the independent predictors, incidence, post-operative, and economic burden of SIRS among patients treated with intramedullary nailing for femoral shaft fractures. MethodsWe utilized the 2016–2019 National Inpatient Sample (NIS) to identify patients who underwent intramedullary femoral nailing and were diagnosed with non-infectious SIRS (NI-SIRS) based on ICD-10-CM coding. Identified patients who underwent intramedullary femoral nailing were dichotomized into SIRS and Non-SIRS groups to assess independent predictors of SIRS development, and to compare post-operative complications and costs. ResultsA total of 65,240 patients with femur shaft fractures underwent IMFN, of which 665 (1.0 %) developed NI-SIRS. Patients with NI-SIRS had a higher incidence of laparotomy (OR = 13.97, p < 0.001), initial treatment with external fixation (OR = 1.845, p < 0.001), and late application of external fixation (OR = 4.884, p = 0.005). Routine discharge (OR = 0.491, p < 0.001) was less likely in patients with NI-SIRS. Length of stay (12.38 days vs 7.16 days, p < 0.001) and total charges ($278, 590 vs $145,118, p < 0.001) were both increased in patients with NI-SIRS. ConclusionNI-SIRS is associated with increasing injury severity and post-operative complications. Those that developed NI-SIRS experienced higher healthcare resource utilization. Risk factors associated with development of NI-SIRS warrant further investigation.

Case Report: Effectiveness of physiotherapy rehabilitation in a patient with compound grade IIIC proximal third tibia fracture along with vascular injury

The proximal metaphyseal region of the bone is thought to be the location of fractures of the proximal tibia. The surgical management of proximal tibial shaft fractures and high-energy bicondylar tibial plateau fractures is still challenging . Supra-cutaneous plating, also known as a locking compression plate, has been promoted as a crucial technique in the management of challenging reconstructive scenarios since it has shown to be adjustable, concealed, and well-accepted by patients. Physical therapy rehabilitation is critically necessary for a full recovery from a range of orthopaedic issues. Physical therapy rehabilitation is a vital step in the healing process for patients with lower limb fractures. In our study , we rehabilitated a patient with Compound grade IIIC proximal third tibia fracture right side managed with Closed reduction external fixator application and vascular repair along with proximal fibula fracture. Through this study, we developed a physiotherapy rehabilitation protocol that was very helpful for these patients, produced positive results, and served to enhance the patient's quality of life.

Use of external fixator combined with titanium elastic nails in the treatment of tibia shaft fractures in children

Tibia shaft fractures are common in all age groups. For these fractures; Conservative and surgical treatment methods are available. In surgical treatment, numerous surgical methods such as plate screw fixation, external fixator, and titanium elastic nail and K-wire fixation have been defined. The aim of the present study was to present the results of patients for whom external fixator combined with titanium elastic nails or titanium elastic nails alone were applied due to tibia shaft fractures. The study included 40 patients treated for tibia shaft fracture in our clinic between January 2016 and January 2019. Combined external fixator (EF) fixation was applied to patients who were found to be instable after Titanium elastic nail (TEN) application during the surgery. In clinical evaluation, Flynn classification, time to fracture union, fluoroscopy count, reoperation and time to full weight bearing were used. The results of patients for whom EF combined with TEN were applied were compared with the patients who had only TEN. Thirty patients were treated using TEN and 10 patients using EF combined with TEN. After 12 months of follow-ups, fracture union was achieved in all patients. There were 5% sagittal and 2.5% coronal plane angulation. Patients developed angular deformity of an average of 2.43 ± 1.9 degrees in the coronal plane and 2.65 ± 1.9 degrees in sagittal plane. Lower percentages of angular and rotational deformity were observed compared to the literature. Despite the disadvantages of using a greater number of fluoroscopy and longer operation periods in patients who underwent TEN+EF, these patients were mobilized earlier. It was concluded that combined EF application is a more feasible method in patients with pediatric tibia shaft fracture for whom stable fixation cannot be achieved with TEN.

Comparison of Joshi's external stabilization system and Kirschner wire fixation technique for extra-articular metacarpal fractures

Hand fractures, especially metacarpals and phalanges, account for 15% of emergency department admissions. Metacarpal fractures can be treated using various algorithms. Hand fractures have been treated with K wire fixation, micro plates, and external fixator application devices. A successful functional outcome requires surgical intervention with good fixation principles and a rigid system that allows early mobilization. JESS is a simple, lightweight fixation that can be used with splints or converted to dynamic mobilization units. In open fractures, JESS rigidly fixes bones. Compress, neutralize, or distract a fracture fragment to aggressively treat bone and soft tissue injuries. Moving the proximal and distal joints instantly reduces edema, capsular fibrosis, joint stiffness, and muscle atrophy. Kirschner wires are the easiest, cheapest, and most versatile hand injury treatment. They can be percutaneously introduced. It allows early movements without surgical stress This study compares intramedullary Kirschner wires and Joshi’s external fixator device for unstable extra-articular metacarpal fractures.

Radiological and Functional Outcomes and Associated Factors After Secondary Intramedullary Nailing Among Patients With Open Fractures of the Lower Limb.

Background Open fractures of the lower limb are serious injuries caused by high-energy trauma that can lead to long-term disability. Initial treatment includes wound debridement, fracture reduction, and external fixation to stabilize bone fragments. Secondary nailing, a surgical technique to provide additional stability, has been shown to promote early mobilization and improve fracture alignment. However, there is a lack of consensus on the optimal timing and technique for secondary nailing. This study aims to evaluate the functional and radiological outcomes of patients who undergo secondary nailing for open fractures of the lower limb. Methods The study was a hospital-based prospective study of 53 patients who underwent secondary nailing for open fractures of the lower limbs. Patients aged 18 years or older, with Gustilo-Anderson classification grades 1, 2, or 3 A and B, who underwent wound debridement and external fixator application, followed by conversion to secondary intramedullary nail fixation between January 2019 and December 2021 were included in the study. The primary outcome measures were functional and radiological outcomes at follow-ups, assessed using the Lower Extremity Functional Scale (LEFS) and Radiographic Union Scale for Tibia fractures (RUST) score. Data were collected prospectively and analyzed using Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY). Descriptive statistics were used to summarize patient demographics and injury characteristics, and the Student's t-test and analysis of variance (ANOVA) were used to compare continuous variables between groups. The study had a final analysis of 39 patients. Results The study reports the baseline characteristics, radiological, and functional outcomes of 39 patients who underwent secondary nailing for open fractures of the lower limb. The majority of the fractures occurred in the tibia (71.8%), with most classified as grade 3 (A and B) (69.2%). At the end of the six-month period after secondary nailing, 74.4% of the fractures had a union. Radiological and functional outcomes showed significant improvement after undergoing secondary nailing. Gender and age group did not have a significant association with the radiological outcome, while the time interval between external fixation and secondary nailing was significantly associated with the radiological outcome at six weeks and threemonths. Conclusion According to a study, secondary nailing is effective in managing lower limb open fractures with good radiological and functional outcomes. The time interval between external fixation and secondary nailing affects radiological outcomes, with longer delays leading to lower RUST scores. Orthopaedic surgeons should consider this factor when planning surgical management. Larger sample sizes and more extended follow-up periods are needed to confirm findings and evaluate the effect of other variables on the outcome.

Advanced Dupuytren Contracture: Approach to Management.

Dupuytren disease is a common pathologic condition that can be especially challenging to hand surgeons in recurrent or severe contractures. Recurrence risk may be reduced with a variety of techniques, including skin grafting, external fixator application, radiation, and many others described in this article. Management of recurrence requires special attention to anatomy at risk. Adjuvant therapy may help to prevent the progression or recurrence of severe disease.

Circular External Fixation as a New Offloading Standard of Treatment in Charcot Neuro-Osteoarthropathy Complicated by Midfoot Osteomyelitis: A Pilot, Prospective Case-Control Study.

After surgical treatment of Charcot neuro-osteoarthropathy (CNO) complicated by plantar ulcer and midtarsal osteomyelitis, offloading is mandatory to protect the surgical site. Total contact casting is, to date, the standard-of-care to offload the foot during the postoperative period. We have compared the application of external circular fixator, to the standard of care, with regard to surgical wound healing and time to healing. During the time period from January 2020 to December 2021, 71 consecutive patients admitted to our unit with diabetes and CNO complicated by plantar ulceration and midtarsal osteomyelitis were enrolled in our study. All patients were classified as stage 2, according to the Frykberg & Sanders classification. Wifi wound stage was W2 I0 FI2 in 43 of 71 patients (60.6%) and W2 I2 FI2 in 28 of 71 patients (39.4%). In cases where critical limb ischemia occurred, we performed an endovascular procedure to obtain patency in at least one of the tibial arteries. Localization of osteomyelitis was carried out with magnetic resonance imaging studies, and the degree of deformity was assessed using plain X-ray or computed tomography. A localized ostectomy through the ulceration was carried out with a fasciocutaneous flap to cover the surgical site. In 36 patients, an external circular fixator was applied intraoperatively (exfix+ group); the remaining 35 patients received fiberglass cast in the postoperative period (exfix- group). Complete healing of the surgical site was achieved in 36 of 36 patients in the exfix+ arm and in 22 of 35 in the exfix- arm (P < .02). Time to healing was 68 ± 28 days in exfix+ and 102 ± 88 days in exfix- (P = .05). Circular external frames should be considered as an effective offloading device that enhances the healing rate and reduces time to healing after surgical treatment of midfoot osteomyelitis in subjects affected by CNO.

Manoeuvring Distal Tibial Shaft Fractures with Ender’s Nailing: Case Series

Fractures of the tibial shaft are the most common fractures to occur in the human body. Number of motor vehicle high-velocity injuries has increased in recent years. Various modalities used for treatment range from immobilization with the cast to open reduction and plating, closed reduction and nailing, and external fixator application. In our study, we have preferred fixation with multiple Ender’s nails in a series of three cases with different modes of injury. We found that closed reduction along with internal fixation with Ender’s nailing is a better modality in terms of easy technique, cost-effectiveness, small incision size, no soft-tissue damage or stripping, and complication. Ender’s nailing is an excellent alternative.

Limb Salvage in Diabetic Patients With Combination of Radical Excision, Antibiotic Impregnated Bone Cement, and External Fixator Application

In patients with diabetes, foot ulceration is a major cause of morbidity and hospitalization. The combination of deep ulcers and underlying osteomyelitis in patients with diabetes frequently leads to chronic nonhealing foot ulcers. These patients have often ended up with amputation. From 2003 to 2017, 17 of 175 diabetic patients (11 males and 6 females, 37 to 82 y old) were treated for diabetic foot and presented with complaints of ulceration, osteomyelitis, and foot gangrene. Magnetic resonance imaging–guided necrotic tissue debridement was performed, after the placement of antibiotic-impregnated bone cement, and soft tissue defect reduction was performed with an external fixator. Approximately 4 weeks later, polymethylmethacrylate was removed, and then the external fixator was removed after the soft tissue defect was closed. No patients had recurrent ulceration or osteomyelitis seen on radiographs up to their latest follow-up. There was pin tract infection in 2 patients who were treated with oral antibiotics and wound dressings. All patients have a fibrous union in the metatarsophalangeal joint. Compared with other radical techniques such as amputation, amputation, and long-term wound dressings, salvage of limbs with an external fixation can be used in selected patients who have osteomyelitis and soft tissue defects after debridement. Level of Evidence: Diagnostic level III—nonrandomized controlled cohort study.

DRY GAUZE AND IODINE TULLE DRESSINGS FOR THE PREVENTION OF INFECTION IN PATIENTS WITH A LOWER LIMB EXTERNAL FIXATOR: A RETROSPECTIVE OBSERVATIONAL STUDY

DRY GAUZE AND IODINE TULLE DRESSINGS FOR THE PREVENTION OF INFECTION IN PATIENTS WITH A LOWER LIMB EXTERNAL FIXATOR: A RETROSPECTIVE OBSERVATIONAL STUDY

External fixators usage in two hospitals in Delta State south-south Nigeria

Objective: To present our experience in the use of various types of external fixators in two government owned hospitals in Delta State, Nigeria.Methods: A retrospective review of patients managed with external fixators over a period of 8 years – January 2012 to December 2019, in two government owned hospitals in Delta State, Nigeria. Relevant information including bio-data, indications for external fixation, types of external fixator applied, length of time fixators were applied, etc were collected and analysed using IBM SPSS version 22.Results: A total of 94 patients (56 males and 38 females) were included in this study giving a male: female ratio of 1.5 : 1. The mean age of patients was 33.7+ 15.9 years. Four types / designs of external fixators were used, the mono-planar AO design were the ones most commonly used (67.7%), followed by the linear rail system (LRS) type (17.2%). The most common indication for external fixator application was open fractures in 67.7% of cases, followed by bone gaps resulting from bone loss (11.1%). External fixators were used as adjunct to other treatment modalities in 59 applications (59.6%) and as the definitive treatment method in 40 applications (40.4%). The commonest solution used for pin site care was Povidone iodine in 53 patients (56.4%). The mean length of time patients were on external fixators was 124.8 days (17.8 weeks). Pin tract infection was the commonest complication encountered (26.6%). The commonest indication for removal of external fixators was the healing of the wounds in open fractures with conversion to other forms of treatment, commonly cast application (42.6%). The initial aim of applying the external fixator was achieved in 75% of cases.Conclusion: External fixators have become indispensable tools in the armamentarium of modern day Orthopaedic and trauma care. Our health facilities have also effectively keyed into this.

Surgical load in major fractures — results of a survey on the optimal quantification and timing of surgery in polytraumatized patients

PurposeIt is known that the magnitude of surgery and timing of surgical procedures represents a crucial step of care in polytraumatized patients. In contrast, it is not clear which specific factors are most critical when evaluating the surgical load (physiologic burden to the patient incurred by surgical procedures). Additionally, there is a dearth of evidence for which body region and surgical procedures are associated with high surgical burden. The aim of this study was to identify key factors and quantify the surgical load for different types of fracture fixation in multiple anatomic regions.MethodsA standardized questionnaire was developed by experts from Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT)-Trauma committee. Questions included relevance and composition of the surgical load, operational staging criteria, and stratification of operation procedures in different anatomic regions. Quantitative values according to a five-point Likert scale were chosen by the correspondents to determine the surgical load value based on their expertise. The surgical load for different surgical procedures in different body regions could be chosen in a range between “1,” defined as the surgical load equivalent to external (monolateral) fixator application, and “5,” defined as the maximal surgical load possible in that specific anatomic region.ResultsThis questionnaire was completed online by 196 trauma surgeons from 61 countries in between Jun 26, 2022, and July 16, 2022 that are members of SICOT. The surgical load (SL) overall was considered very important by 77.0% of correspondents and important by 20.9% correspondents. Intraoperative blood loss (43.2%) and soft tissue damage (29.6%) were chosen as the most significant factors by participating surgeons. The decision for staged procedures was dictated by involved body region (56.1%), followed by bleeding risk (18.9%) and fracture complexity (9.2%). Percutaneous or intramedullary procedures as well as fractures in distal anatomic regions, such as hands, ankles, and feet, were consistently ranked lower in their surgical load.ConclusionThis study demonstrates a consensus in the trauma community about the crucial relevance of the surgical load in polytrauma care. The surgical load is ranked higher with increased intraoperative bleeding and greater soft tissue damage/extent of surgical approach and depends relevantly on the anatomic region and kind of operative procedure. The experts especially consider anatomic regions and the risk of intraoperative bleeding as well as fracture complexity to guide staging protocols. Specialized guidance and teaching is required to assess both the patient’s physiological status and the estimated surgical load reliably in the preoperative decision-making and operative staging.

Venous Thromboembolism Chemoprophylaxis Compliance in the Surgical Intensive Care Unit.

Early initiation of venous thromboembolism chemoprophylaxis (VTEp) decreases VTE risk in trauma patients in the Surgical Intensive Care Unit (SICU). The frequency and variation of VTEp interruption by different surgical subspecialties in the SICU is incompletely described in the literature. The objective of this study was to examine VTEp compliance in the SICU in terms of uninterrupted VTEp following initiation, both by surgical service and time of year, to identify opportunities for improvement. This single-center quality improvement (QI) study examined all SICU patients, which are almost exclusively trauma patients, at our institution (1/2021-04/2022). Exclusions were therapeutic anticoagulation. Type of VTEp, calendar month of SICU stay, perceived indications for interruption, and primary service were collected. Of 5 434 patient days (PD), VTEp was not administered in 1879 (35%). Common reasons for VTEp interruption were ongoing bleeding (n = 964 PD, 51%) and periprocedural status (n = 651 PD, 35%). Periprocedural interruption was highest in July. Acute Care Surgery (ACS) (n = 208 PD, 32%) and Orthopedics (n = 188 PD, 29%) interrupted VTEp most often. ACS most commonly withheld VTEp for second look laparotomies while Orthopedics withheld VTEp for intramedullary nailing or external fixator application. Missed VTEp doses occurred most frequently at the beginning of the residency year, with a high percentage held for periprocedural status. Because the necessity of periprocedural VTEp holds is unclear, the appropriateness of these holds and any impact on VTE rates will be assessed as the next steps. In the interim, our findings provide targets for multidisciplinary QI endeavors.

Retrospective Evaluation of Challenging Delayed Union and Non-union Encountered in Dogs: 16 Cases (2012-2018)

This paper aims to showcase some challenging delayed union and non-union cases, explain their possible causes and the treatment processes they underwent. Most non-union cases included in this study required at least two surgical interventions, and the main reasons for the consecutive interventions were either compromised vasculature of the soft tissues due to extreme trauma or infection. The final successful procedure for cases with excessive soft tissue trauma was external fixator application in most cases. Bone plates were more successful in cases with infection or had poor owner compliance. Minimally invasive external fixator implementation seems to be efficient in preserving the compromised vasculature of the bone while bone plates show better results in cases with localized infection. Harvesting bone grafts from the iliac crest was very practicable, required little time and should be utilized in every possible non-union case given their obvious benefits.

External fixator as a safe method in the treatment of distal tibial fractures in children.

The objective of this study is to evaluate the functional and radiological results of external fixator application in the treatment of distal tibial metaphyseal diaphyseal junction (MDJ) fractures in children and to analyze differences between stable and unstable fractures. Medical records of children with distal tibial MDJ fracture confirmed by imaging from January 2015 to November 2021 were retrospectively analyzed. Patients were divided into stable and unstable groups and parameters, including clinical and imaging data and Tornetta ankle score were compared. Twenty-five children, comprising 13 with stable and 12 with unstable fractures, were included in our study. The mean age was 7 years (range, 2-13.1 years), and there were 17 males and 8 females. All children had closed reduction, and the basic clinical data of the two groups were comparable. Stable fractures showed shorter intraoperative fluoroscopy, operation, and fracture healing times than unstable fractures. No significant difference in Tornetta ankle score was observed. Twenty-two patients had excellent ankle score, and three had a good ankle score, for a combined incidence of 100%. Two patients in the stable fracture group and one in the unstable fracture group developed a pin site infection, and one patient with unstable fracture showed a length discrepancy (discrepancy<1 cm). External fixator is safe and effective for the treatment of distal tibial MDJ fractures, whether the fracture is stable or not. It has the advantages of minimally invasive, excellent ankle function score, few major complications, needless auxiliary cast fixation, and early functional exercise and weight bearing. Level IV.

Percutaneous Reduction and Provisional Pinning of the Distal Fibula: A Novel Way to Maintain Fibular Length in Temporary Stabilization.

Ankle fractures are commonly observed by orthopaedic trauma surgeons, foot and ankle surgeons, and general orthopaedists with more than 135,000 fractures surgically treated every year in the United States. 1 The soft tissue envelope surrounding the osseous anatomy of the ankle is limited and many injuries, including those that result from higher injury mechanisms and/or those occurring in hosts with vascular and metabolic comorbidities may benefit from a delay in definitive fixation; this may minimize risks of wound healing issues and fracture-related infection. 2,3 Open fractures may benefit from temporizing fixation after debridement and irrigation for the same reasons. 4-6 The benefits of temporizing external fixation in pilon fractures has been recognized for decades. 7 The use of ankle-spanning external fixation for ankle fractures and dislocations has become more frequently used to maintain coronal and sagittal alignment of the ankle mortise as a bridge to definitive fixation. 8-10 However, standard ankle-spanning external fixation techniques do not always directly restore fibular length and rotation, especially in fracture patterns with syndesmotic disruption and/or segmental fibular comminution. Some authors have advocated for limited internal fixation of fibula fractures at time of external fixation application to address this problem, 7 but this still necessitates a surgical approach through a traumatized soft tissue envelope and potentially compromises posterolateral and anterolateral approaches that could be used to address associated Volkman or Chaput fragments. Delayed distal fibular open reduction and internal fixation of shortened fractures has frustrated orthopaedic surgeons for decades and techniques such as "push-pull" screws 11 and extensive soft tissue dissection 12 are often necessary to restore anatomic fibular reduction of length and rotation. Given these challenges, the senior author began to use a technique of percutaneous reduction and buried provisional pinning of the distal fibula to the talus for fibula fractures with persistent shortening after ankle-spanning external fixation of injuries not deemed appropriate for immediate open reduction and internal fixation. We aim to report early results and describe this novel, low-cost surgical technique.