External Fixation Research Articles

An Improvised External Ventricular Drain Fixation Technique to Avoid Pullout-Related Complications in a Low-Resource Setting: A Descriptive Cross-Sectional Study in a Single Center of Nepal.

An external ventricular drain (EVD) placement is a commonly performed life-saving procedure. Its accidental pullout can occur in complex environments, patient care, and positioning, which leads to significant morbidity. The method of EVD fixation and pullout rates is sparsely described in the literature, and there exists a wide variation among the techniques practiced for fixation. However, some techniques require additional tools, which are expensive and unavailable in low-resource settings. We describe an improvised method of securely fixing the EVD to the scalp applicable in low-resources and describe the EVD pullout rate with the use of this technique. A retrospective review of pullout-related complications in 107 consecutive patients was performed. The EVD was fixed to the scalp using an improvised technique to loop the catheter around a soft flange and secure it with sutures. Pullout occurred in 1 patient (0.93%), who was in an alcohol withdrawal state and deliberately pulled out the catheter. There were zero nondeliberate pullouts. EVD fixation by coiling the catheter around a soft flange has a low pullout rate. Because it is secure and requires only a flange, it is suitable for low-resource settings.

Enhancement of antimicrobial properties of plasma electrolytic oxidation coatings on aluminum alloy surfaces with CuO nanoparticles

A coating containing copper oxide/cuprous oxide (CuO/Cu2O) nanoparticles with excellent antimicrobial properties was synthesized on the surface of an aluminum alloy substrate by plasma electrolytic oxidation (PEO) technology. This study focuses on the impact of incorporating CuO nanoparticles on the coating's composition, microstructure, mechanical properties, corrosion resistance, and antimicrobial efficacy. EDS and XPS analyses confirmed that the primary components of the coating are Al2O3 and Cu2O/CuO, with the Cu element predominantly located in the micropores and microcracks of the coating. The inclusion of CuO nanoparticles significantly increased the coating's thickness, hardness, and densification while reducing surface roughness. Electrochemical tests and antimicrobial experiments demonstrated that the PEO coating with added CuO nanoparticles exhibited excellent corrosion resistance, with an antimicrobial rate against Staphylococcus aureus reaching 99.06 %, compared to 45.12 % for the ordinary PEO coating. The study also investigated the effects of key process parameters (positive voltage, negative voltage, duty cycle, and CuO nanoparticle concentration) on the coating's antimicrobial rate, identifying optimal parameters for maximum antimicrobial performance. Studies have shown that the incorporation of CuO nanoparticles effectively enhances the overall performance of PEO coatings, particularly in terms of antibacterial and corrosion resistance. The process parameters mainly influence the antimicrobial properties of the coating by affecting the state and content of Cu. This coating shows promising application prospects in medical devices, such as orthopedic external fixation frames, microsurgical instruments, and prosthetic devices.

Reconstruction of bone defects around the ankle with retrograde gentamicin-coated tibial intramedullary nail (ETN PROtect™) for tibiotalocalcaneal arthrodesis: a case series.

The objective of this study was to describe the use of retrograde gentamicin-coated tibial intramedullary nail (ETN PROtect™) in patients with tibial defects who required a tibiotalocalcaneal arthrodesis (TTC). Consecutive series case review of seven men treated with TTC using retrograde PROtect™ between January 2018 and December 2023. The main outcomes evaluated were fracture union, complications, and the health-related quality of life using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L). The mean age was 45.3 8.0years. Six patients had a clinical history of chronic osteomyelitis, and one case underwent TTC for congenital pseudoarthrosis. Fracture union was achieved in 5 of 7 patients between 4 and 11months after surgery. Three patients developed complications; two patients had fistulas, and one had persistent pain. At the end of the follow-up, a median of 70 points (interquartile range: 60 to 90) on the EQ-5D-3L was reported. No complications directly attributed to the use of the PROtect™ were reported. TTC with retrograde PROtect™ is a prophylactic treatment option in patients with tibial defects treated with external fixation requiring a tibiotalar and subtalar arthrodesis. This novel use of PROtect™ allows simultaneous fixation of the tibiotalocalcaneal joint and protection of the regenerated bone, facilitating earlier rehabilitation in patients at high risk for postoperative infections.

Correction of a Golf Club Deformity of the Femur Using a Computer-Assisted Circular Ring Fixator: A Case Report.

The golf club deformity is the most notable malreduction that occurs after distal femur fracture fixation. This can lead to disruption of the patient's knee biomechanics, arthritis, and functional deterioration. There is a lack of consensus for optimal treatment of these malunions among the orthopaedic community. We present a technique that uses an osteotomy and ring external fixation with computer-assisted deformity correction and retrograde intramedullary nailing to secure correction. Our case shows a potential means to achieve a reliable and objective method of measuring, correcting, and securing the fixation of a golf club deformity.

Comparing The Efficiency and Outcome of Syringe External Fixators and K-Wire Fixation in Unstable Hand Fractures

Comparing The Efficiency and Outcome of Syringe External Fixators and K-Wire Fixation in Unstable Hand Fractures

Trace element selenium–augmented Kirschner wire with enhanced osteogenetic and antibacterial properties

The Kirschner wire (K-wire) is widely used in orthopedic external fixation due to its versatility and clinical effectiveness. However, a significant challenge associated with its use is the potential for bacterial migration, subsequent infection, and dislodgement as the wire penetrates the skin and bone. This study introduces a novel bioactive material, selenium/calcium silicate (Se/β-CS), achieved by integrating selenium—an essential trace element in the human body—into bioceramic calcium silicate. This integration was accomplished using a combined chemical co-deposition method and redox reaction. Furthermore, a uniform and controllable Se/β-CS coating was applied to the K-wire's surface using the Langmuir-Blodgett technique. This coating gradually releases active components—Si, Ca, and Se—that effectively eliminate bacterial infections and promote osteointegration. The findings of this study offer promising opportunities for the use of robust and multifunctional coating materials on implantable devices, particularly within the fields of orthopedics, transplantation, and surgery.

Salvage of a comminuted proximal tibial polymicrobial infected non-union with antibiotic loaded bio-composite and intramedullary nailing: a case report

Background. Management of open proximal metaphyseal fractures poses a significant challenge and is fraught with complications. These injuries are severe, often accompanied by extensive soft tissue and vascular damage, leading to high risks of infection and long-term disability. Case presentation. A 72-year-old male was severely injured in a road traffic accident. Plain X-rays and CT angiogram identified a comminuted proximal tibial fracture with transection of the popliteal artery and vein. Initial emergency treatment included fasciotomies, external fixation, and vascular primary repair. On the 12th day of admission, the patient underwent open reduction and internal fixation (ORIF) with dual plate fixation using a two incision technique. A plastic surgeon performed skin grafting, harvested from the patient’s thigh, to allow closure of his fasciotomy wounds immediately following ORIF. Four weeks post-operatively, the patient developed a wound breakdown over the lateral fasciotomy site, exposing the metal plates with a small defect developing on the medial fasciotomy wound in tandem. The patient’s course was further complicated by persistent polymicrobial infections. Over 6 months of antibiotic regimes, operative intervention was ultimately required. All of the infected metal implants were removed, the non-union sites were aggressively debrided. The tibial canal was reamed to prepare for a tibial nailing. An antibiotic loaded bio-composite was then inserted through the non-union sites into the canal followed by an intramedullary nail. A blocking screw was used to address the procurvatum deformity in the sagittal plane. The patient currently shows signs of recovery, mobilizing over short distances, weight-bearing with assistive aids and with healing wounds and early signs of callus formation on recent CT scans and plain X-rays. Conclusions. The management of complex tibial fractures with vascular involvement demands an aggressive multidisciplinary approach and continuous adaptability in treatment plans to address the evolving challenges of such severe injuries. This case exemplifies the utility of injectable antibiotic-loaded bio-composites in a limb-salvage setting and their ability to provide high doses of local antibiotics to an infection site which, in conjunction with appropriate stable fixation and systemic antibiotics, can aid in eradicating and treating fracture-related infections.

Distraction of longitudinally split fragments using the Ilizarov method: a series of clinical cases of treating partial bone defects

Background. The Ilizarov method is a recognized technique for treating severe skeletal injuries, allowing for a comprehensive restoration of both bone and soft tissue components. Despite the fact that bone lengthening and transport are widely known techniques, distraction of a longitudinally split fragment is still used extremely rarely. The aim of the study is to describe a series of clinical cases involving patients operated on using this technique. Methods. We present a series of observations of five patients who underwent distraction of a longitudinally split fragment using the Ilizarov method between January 2006 and December 2022. Clinical information was obtained from case histories, all surgical interventions were documented. Postoperative examination was performed using radiography. Results. A case series demonstrates the successful application of this technique for reconstruction of partial bone defects resulting from trauma or osteomyelitis. The study included five patients (4 men and 1 woman) who underwent surgery 4.8-34.0 months after trauma for a partial defect of the proximal tibia ranging from 4 to 8 cm in length. Distraction was performed in different directions along the sagittal and longitudinal axes. The time of external fixation ranged from 3.5 to 4.8 months, the external fixation index ranged from 0.49 to 1.22. The ASAMI (Association for the Study and Application of the Methods of Ilizarov) functional score at the follow-up examination was excellent in all five patients. The ASAMI bone tissue assessment showed excellent results in all patients, except for one patient with residual equinus (good result). No other complications were reported. Conclusions. The Ilizarov method provides a minimally invasive and comprehensive approach to the elimination of partial bone defects, affecting simultaneously the skeletal and soft tissue components. Due to the longitudinal splitting during fragment transport and distraction osteogenesis, this method promotes bone and tissue regeneration and helps to avoid a volumetric bone defect and more complex segmental bone transport. Moreover, the role of transverse transport of the tibial cortex increases in the treatment of peripheral arterial diseases.

History and formation of “Limb lengthening and reconstruction surgery — LLRS” as a subspecialty of orthopedic surgery

In 1998, the first meeting of members of the Association for the Study and Application of the Methods of Ilizarov (ASAMI) was held in the USA to introduce and popularize the methods developed in Kurgan by Professor G. Ilizarov and his staff. During 2005-2016, other communities worked in parallel with ASAMI, which went beyond the use of only the Ilizarov apparatus. Since 2017, the joint meetings have been called “Combined congress of the ASAMI-BR and ILLRS societies”. This actually became the basis for the definition of “Limb Lengthening and Reconstruction Surgery (LLRS)” as a subspecialty of orthopedic surgery that treats patients with nonunions, congenital and acquired long bone, large joints deformities of the upper and lower extremities. LLRS is based on the Ilizarov method and discovery (“Ilizarov effect”) with the rational use of external and internal fixation, osteotomy and soft tissue procedures. It takes at least three years for an orthopedic surgeon to become a specialist in the field of LLRS, and the education must be staged. A significant role in this is played by the ASAMI-BR ILLRS congresses, ExFix LLRS courses held in many countries, ExFix modules integrated into courses provided as part of the education of AO Trauma, as well as extensive world literature.

Functional reliability of means of fixation for complex pelvic fractures. Part 3. Experimental studies under cyclic loads

Fixation of fragments of human pelvic bones by standard and new means of osteosynthesis, in addition to clinical indicators, should have sufficiently high mechanical characteristics. In particular, the “bone with a fracture - osteosynthesis system” system must be sufficiently strong, rigid and stable during long-term treatment, which may be accompanied by certain physiological loads. Today, in traumatology and orthopedics, two methods of fixation are used to fix complex fractures of the pelvic bones caused by high-velocity wounding projectiles: parallel insertion of spongy screws (osteosynthesis of the posterior pelvic ring) and stabilization with a rod apparatus of external fixation and fixation by means of reinforced with application of extramedullary reconstructive plate (osteosynthesis of the anterior pelvic ring). The anterior pelvis is stabilized more often because this technique is simpler, does not require much time and high qualification of the surgeon. However, this method of fixation does not provide sufficient stability of the connection of the pelvic ring bone fragments. This work is devoted to the study of the processes of occurrence and development of mutual displacements of fracture points of pelvic bones under the action of long-term cyclic loads. Experimental studies were carried out under the action of bending cyclic loads, which are close to physiological ones. Calculated creep deformations and irreversible displacements of fracture points. The stiffness characteristics of pelvic fracture fixation systems were studied.

Usefulness of Platelet-rich Fibrin in Open Fractures of Tibia: A Randomised Comparative Pilot Study

Background and Aims: Platelet-rich fibrin (PRF), rich in growth factors and cytokines, found useful for bone healing in animal studies, has paucity of literature on open fractures in humans. This randomised comparative interventional study aimed to find out the role of PRF in wound healing and fracture union in open fractures of tibia. Material and Methods: Random computerised allocation of 14 open tibial shaft fractures managed with an external fixator were done into PRF and non-PRF groups. Autologous PRF injected at fracture site, with PRF gel over open wounds in the PRF group, was compared with conventional standard treatment in the non-PRF group. Wound assessment on day 3, day 7 and weekly till complete wound healing and radiographs for fracture union at 3, 6, and 12 months were done in both groups. The statistical analysis was done using an unpaired t-test (wound size assessment) and chi-squared test (fracture union), using SPSS version 25. Results: Fractures union in PRF group 7/8 (87.5%) was better than 3/6 (50%) in non-PRF group. External fixators were removed 4 weeks earlier in PRF group. Wound healing time, though not statistically significant, was faster in PRF group (36.25±3.03 days) compared to non-PRF (42±7 days), even with larger wound size in PRF group (7.87±1.43 cm 2 ) than non-PRF group (7.5±1.5 cm 2 ). Conclusions: Results of injectable PRF at fracture site and PRF gel over the wound are encouraging, found to be safe, with faster wound healing and better fracture union in the small sample size of this pilot study.

Improving surgical technical skills for emergency fixation of unstable pelvic ring fractures: an experimental study using a pelvic ring fracture simulator

BackgroundThe management of hemodynamically unstable pelvic ring injuries necessitates surgical intervention, often involving procedures such as external fixation and percutaneous screw placement. Given the infrequent performance of these procedures, regular training is imperative to ensure readiness for emergencies. Our pre- post simulation study aimed to adapt and validate a realistic simulation model for stabilizing unstable pelvic ring injuries, facilitating participants’ knowledge retention and procedural confidence enhancement.MethodsA standardized simulator of an unstable pelvic ring utilizing synthetic pelvic bones featuring complete disruption of the symphysis and sacroiliac joint was developed. Trauma surgeons of a level one academic hospital were invited to perform external fixation and emergency sacroiliac screw application under C-arm guidance. Prior to and following the simulation session, participants completed a subjective questionnaire assessing their confidence in emergency interventions on a 10-point Likert scale (10-LS). Objective parameters, such as intraoperative imaging quality, reduction accuracy, and the positioning of screws, wires, and external fixators, were also evaluated as secondary outcome measures.ResultsFifteen trauma surgeons (10 residents, 5 consultants) participated in the simulation over the course of one day. The mean total operation time was 20.34 ± 6.06 min, without significant differences between consultants and residents (p = 0.604). The confidence for emergency SI-Screw placement increased significantly after the simulator (10-LS: Before = 3.8 ± 3.08 vs. After = 5.67 ± 2.35; p = 0.002) as well as after external fixation (10-LS: Before = 3.93 ± 2.79 vs. After = 6.07 ± 2.52; p = 0.002). In addition, confidence in (intraoperative) pelvic imaging increased significantly (10-LS: Before = 4.60 ± 3.0 vs. After = 6.53 ± 2.39; p = 0.011). Overall, the model was rated as a realistic simulation of clinical practice (10-LS = 7.87 ± 1.13).ConclusionsOur unstable pelvis fracture model is a tool to practice emergency interventions such as external fixation and percutaneous techniques. Participants benefitted from this in terms of technical instrumentation as well as intraoperative imaging. Further studies are required to validate the objective benefits and improvements that participants undergo through frequent training.

Orthoplastic Reconstruction of Distal Tibia High-Energy Fractures Using a Circular External Fixator—A Systematic Review

Background: Compound fractures of the distal tibia (with or without the middle third) represent a challenge for orthopedic and plastic surgeons because of the scarcity of available soft tissue reconstruction and the important comminution of the fractures that usually appear. Methods: The design of this study is based on the PRISMA guidelines. Databases were searched for articles published and available until the first half of 2023. Articles that presented the evolution of patients treated by combining circular external fixators with reconstructive methods were selected. Results: After searching the literature using keywords, we obtained 3355 articles, out of which 14 articles met all the inclusion criteria, with a total number of participants of 283. The bone loss varied between 0.7 and 18.2 cm, while the soft tissue defect was between 3/3 cm and 16/21 cm. The average period of fixation ranged from 4 to 22.74 months. The most used reconstruction methods were 80 free flaps and 73 pedicled flaps out of 249 interventions. Complete flap loss appeared only in 3/283 patients. Regarding the bone union, the percentage of non-union was low, and in all cases, it was achieved after reintervention. A low rate of major complications was observed. Conclusions: The orthoplastic team is the key to successfully treating the high-energy traumatism of the distal tibia (with or without a middle third). The Ilizarov external fixator can be used as a definitive limb-salvage treatment (secondary to the standard primary methods of fixation) in combination with a flap to cover the defects because it does not damage the pedicle, and it helps stabilize the soft tissues and bones around the flap to lower the complications.

External fixation of an internal aortic annuloplasty device: advancing the technique.

We present a modified technique of Hemispherical Aortic Annuloplasty Reconstructive Technology (HAART) 200 annuloplasty ring implantation in bicuspid aortic valve morphology by external fixation of the looping sutures to avoid common complications associated with the original implantation technique. Preliminary results are promising and should be confirmed in subsequent multicentre studies.

Anorectal avulsion-an unusual anorectal trauma

Anorectal avulsion is a rare trauma. In this type of lesion, the anus and the sphincter complex are pulled up by a tremendous compression of the pelvic floor. Frequently, this trauma is associated with other injured organs, like pelvic bones or urethra. We report a case of a young man who was admitted with a total anorectal avulsion associated with a pelvic fracture. A multidisciplinary treatment included external fixation of the broken pelvis, suprapubic cystostomy, sigmoid loop colostomy and reimplanting the anal complex in the original position with appropriate drainage. Anorectal injuries are uncommon and represent about less than 10% of rectal trauma, but anorectal avulsion is extremely rare. These cases often require a quick decision making and multidisciplinary approaches to reduce the possibilities of morbidity and mortality.

Three-dimensional acetabular reorientation during periacetabular osteotomy: an intraoperative navigation method using an external fixator for periacetabular osteotomy.

Bernese periacetabular osteotomy (PAO) is an effective procedure for treating acetabular dysplasia. However, limited visual control of the acetabular position during surgery may result in under- or overcorrection or changes in acetabular version resulting in residual dysplasia or femoroacetabular impingement. Thus, we wanted to develop a simple and straightforward navigation method that provides information about acetabular correction in all three planes during surgery. Intraoperatively, acetabular coordinates are shown in coronal, sagittal, and transverse plane by two perpendicular tubes of an external fixator mounted onto a third tube that is fixed to the mobilized acetabular fragment with two Schanz screws. The application and fixation of the external fixator on the pelvis are demonstrated in this article. We used this analog navigation method on 27 PAOs, where we mainly performed a lateral rotational correction. The pre- and postoperative radiographs of these 27 hips were analyzed regarding the radiological hip parameters, taking into account the pelvic tilt. The mean preoperative lateral center edge angle (LCEA) of the 27 PAOs improved from 16° (+-6) to a mean of 34° (+-6°) and the mean acetabular index (AI) was corrected from 15° (+-4) to 2° (+-4). This implements highly physiologic postoperative values for lateral coverage in this population. In this case series, no postoperative acetabular retroversion was measured in any of the 27 PAOs. Three-dimensional control of the acetabular orientation during periacetabular osteotomy is important to avoid over- and undercorrection. Using a fixateur externe as an analog navigation method this three-dimensional control can be implemented intraoperatively for PAOs.

Can pin-site inflammation be detected with thermographic imaging? A cross-sectional study from the USA and Denmark of patients treated with external fixators.

Patients with external fixators are at risk of pin-site infection. A tool for objective monitoring of pin sites for evolving signs of infection is warranted. We aimed to investigate the temperature (MaxTp) difference between clean and visually inflamed pin sites using thermography and to establish the optimal cut-off value of MaxTp using thermography as a screening tool for inflammation detection. This was a cross-sectional study performed in the USA and Denmark of patients with circular external fixators. Pin sites were visually judged by a surgeon or a nurse as clean or as showing signs of inflammation. The MaxTp was obtained at the pin site by thermographic imaging using an infrared camera (FLIR T540). We included 1,970 pin sites from 83 patients. The mean MaxTp for clean pin sites (n = 1,739) was 33.1°C (95% confidence interval [CI] 32.8-33.4) and the mean MaxTp for visual inflamed pin sites (n = 231) was 34.0°C (CI 33.6-34.3). The mean difference, when adjusted for repeated observations of patients and pin sites, was statistically significant with a difference of 0.9°C (CI 0.7-1.1) (P < 0.001). The area under the receiver operating characteristic curve for MaxTp as a screening tool to detect visual signs of inflammation was 0.71 (CI 0.65-0.76). The empirically optimal cut-off value was 34.1°C with a sensitivity of 65%, a specificity of 72%, a positive predictive value of 23%, and a negative predictive value of 94%. We found a statistically significant difference in mean temperature between pin sites with and without visual signs of inflammation. Thermography could be a promising tool for future point of care technology for monitoring inflammation around pin sites.

Combined pelvic ring and acetabular fractures – strategies and sequence of surgery. State of the art

AbstractCombined injuries of the pelvic ring and the acetabulum are uncommon. Acute treatment should follow common protocols (ATLS e.g.) for pelvic ring injuries, although mechanical stabilization using pelvic binders or external fixators might be insufficient or even worsen the reduction in some combined fracture patterns. In case of mechanically connected acetabular and pelvic ring injury (MCAPI), surgical treatment might be demanding in lack of clear recommendations concerning the reduction and fixation sequence. A “pelvic ring first” sequence may be the best choice for most MCAPIs, starting with sacrum or SI-joint and symphysis pubis. An “acetabulum first” sequence should be considered in relatively stable posterior ring injuries and acetabulum fractures in younger patients, where a perfect anatomical reduction is feasible. Definitive surgical treatment should be performed as soon as possible depending on concomitant injuries, ideally within 3–7 days. Mechanical understanding of the combined fracture pattern and accurate planning are mandatory for surgical repair.

Evaluation of the utility of surgical simulation software in medical postgraduate education

BackgroundThe use of medical simulation software in medical institutions is growing to address teaching challenges. The study aims to assess the effectiveness of the Touch Surgery app, a free medical simulation software, as a supplement to the teaching methodology of unified surgery for medical students. MethodsTwenty-three postgraduate students, divided into three groups based on residency training years, and five senior orthopedic surgeons took part in the study. Each participant completed three modules within the Large External Fixators module using the Touch Surgery app. The results achieved by orthopedic specialists and postgraduates in the test module were recorded separately. The orthopedic specialists' first test module scores were used as a baseline. A Likert survey assessed the usefulness and content accuracy of the app. Statistical analysis included analysis of variance and 2-tailed t-test. ResultsThe first and second scores achieved by the postgraduates in the three groups were significantly different from the baseline of the orthopedic specialists, but the mean scores of all postgraduate's groups increased with simulator usage for learning and by the third attempt they were at the same level as the orthopedic specialists. However, no significant performance differences were observed between postgraduates with different training years. Postgraduates expressed a positive opinion of the usefulness and content of Touch Surgery in the questionnaire and their intention to continue using it in their future studies. ConclusionsThis study shows that the use of Touch Surgery improves postgraduates' performance and ultimately enables them to reach the level of orthopedic specialists in simulated surgery, and received positive ratings for the software's experience and content. Touch Surgery can be a valuable complement to traditional surgical teaching methods, bridging the gap between theoretical learning from textbooks and guided rehearsals of surgical steps and skills.

Comparison Between Surgical Techniques for Correction of Congenital Syndactyly: A Systematic Review and Meta Analysis

This review aimed to assess which surgical technique has better outcomes to correct one of the most common congenital anomalies of the upper limb: syndactyly. The following databases were used in the search: PubMed, Embase, Cochrane (CENTRAL), LILACS, SciELO, Scopus and Web of Science, on October 27, 2022. Studies that described a surgical technique for correcting syndactyly and evaluated surgical complications were included. Studies about noncongenital or foot syndactyly were excluded. The risk of bias was assessed using a specific method for case reports. For synthesis of results, the characteristics of the studies and techniques were demonstrated by a qualitative analysis. Meta-analysis models were applied for complications, functionality, and aesthetic. 73 studies were included, of which 70 were series or case reports, 27 studies did not use skin grafts and 7 studies used external fixators. To evaluate functional results, 42 studies used only the surgeon’s opinion. Meta-analyses showed a higher incidence of scar defects when using skin grafts and of infection when using external fixators. There was no difference for web creep and readmission. Few studies evaluated results using the VSS scale, showing worse scar pigmentation when skin grafts were used, but there was no difference in other parameters (PROSPERO CRD42022368930).