Internal Osteosynthesis Research Articles

Distal humerus nonunions after failed internal fixation: Treatment with Ilizarov external fixator

Introduction/Objective. Nonunions of distal humerus after unsuccessful surgical treatment represents challenging surgical problem. The complexity of this condition is increased by bone atrophy, scar tissue, poorly vascularized bone fragment, limited elbow mobility, osteomyelitis and local neurological damage. The advantages of using Ilizarov external fixation method are stable fixation, adequate fracture reduction and fragment compression accompanied by minimal soft tissue trauma, with the possibility of early elbow mobilization. This aim of this paper is to present the treatment results of 19 patients with nonunion of distal humerus after internal osteosynthesis managed by Ilizarov external fixation method. Methods. nineteen consecutive patients were treated with the Ilizarov external fixator. The study group includes 11 male and 8 female patients with an average age of 42 years. Surgical technique consisted of approaching the nonunion, removing loose fixation material, making resection and debridement of bone fragments, after which Ilizarov fixator was placed. Rehabilitation of the elbow started in early postoperative period. The functional status of the arm was evaluated using the DASH score (Disabilities of the Arm, Shoulder and Head). Results. All patients achieved solid bony union after average 7 months from application of external fixator. In 17 patients radiographic analysis indicated the preservation of joint space, while two showed degenerative changes. All patients showed improvement in elbow range of motion and significantly better DASH score with postoperative value of 21. Conclusion. As treatment of distal humerus nonunion, Ilizarov external fixation method provides successful healing and increased range of motion in the elbow.

Fast-resorbable antibiotic-loaded hydrogel coating to reduce postsurgical infection after internal osteosynthesis: A multicenter randomized controlled trial

Introduction Infection is one of the main reasons for failure of orthopedic implants. Antibacterial coatings may prevent bacterial adhesion and biofilm formation, according to various preclinical studies. The aim of the present study is to report the first clinical trial on an antibiotic loaded fast-resorbable hydrogel coating (Defensive Antibacterial Coating, DAC) to prevent surgical site infection, in patients undergoing internal osteosynthesis for closed fractures. Materiel et methodes In this multicenter randomized controlled prospective study, a total of 256 patients in five European orthopedic centers who were scheduled to receive osteosynthesis for a closed fracture were randomly assigned to receive antibiotic-loaded DAC or to a control group (without coating). Pre and postoperative assessment of laboratory tests, wound healing, clinical scores and X-rays were performed at fixed time intervals. Resultats Overall, 253 patients were available with a mean follow-up of 18.1 ± 4.5 months (range: 12–30). On average, wound healing, clinical scores, laboratory tests and radiographic findings did not show any significant difference between the two groups. Six surgical site infections (4.6%) were observed in the control group compared to none in the treated group (P.03). No local or systemic side effects related to the DAC hydrogel product were observed and no detectable interference with bone healing was noted. Discussion This is the first clinical trial reporting on the efficacy and safety of DAC coating for internal osteosynthesis. Concerning efficacy, this study shows that the studied antibiotic-loaded hydrogel coating is able to significantly reduce early surgical site infection after osteosynthesis, at an average 18-month follow-up. This finding is in agreement with earlier in vivo studies and with the results of a multicenter clinical trial on the use of DAC coating in total hip and knee cementless or hybrid total joint replacement. Conclusion The use of a fast-resorbable antibiotic-loaded hydrogel implant coating provides a reduced rate of postsurgical site infections after internal osteosynthesis for closed fractures, without any detectable adverse event or side-effects. Ease of use, versatility and lack of side effects may open the way to an affordable wide application of antibacterial implants protection for large scale applications.

MINIMALLY INVASIVE LUMBOPELVIC FIXATION FOR STABILIZATION OF THE POSTERIOR PELVIC RING IN VICTIMS WITH POLYTRAUMA

Objective. To evaluate the use of minimally invasive lumbopelvic fixation (LPF) in the acute period of traumatic disease in patients with vertically unstable pelvic injuries. Material and Methods . Three patients with vertically unstable injuries of the pelvic ring were operated on using LPF technique. Fixation of pelvic fractures was performed by a minimally invasive procedure with a system of transpedicular and iliosacral screws. The choice of the lumbopelvic system configuration depended on the sacral injury morphology. Results . The average length of hospital stay was 22.7 ± 7.5 days. Assessment of the functional status of the pelvis using Majeed scale was 92.0 ± 5.3 points. Before surgery, the neurological status was assessed by Gibbons scale, all victims received 1 point: decompression of sacral neural structures was not indicated. All the victims returned to the previous level of physical and professional activity in the period from 6 to 18 months. At the same time, control SCT of the pelvis was performed, which confirmed the union of pelvic fractures and the stability of instrumentation. Conclusion . Successful restoration of the pelvic ring anatomy with subsequent stable fixation using minimally invasive internal osteosynthesis in the acute period of traumatic disease including lumbopelvic transpedicular stabilization allowed obtaining good anatomical and functional outcomes in patients with vertically unstable injuries of the pelvic ring.

Fast-resorbable antibiotic-loaded hydrogel coating to reduce post-surgical infection after internal osteosynthesis: a multicenter randomized controlled trial

BackgroundInfection is one of the main reasons for failure of orthopedic implants. Antibacterial coatings may prevent bacterial adhesion and biofilm formation, according to various preclinical studies. The aim of the present study is to report the first clinical trial on an antibiotic-loaded fast-resorbable hydrogel coating (Defensive Antibacterial Coating, DAC®) to prevent surgical site infection, in patients undergoing internal osteosynthesis for closed fractures.Materials and methodsIn this multicenter randomized controlled prospective study, a total of 256 patients in five European orthopedic centers who were scheduled to receive osteosynthesis for a closed fracture, were randomly assigned to receive antibiotic-loaded DAC or to a control group (without coating). Pre- and postoperative assessment of laboratory tests, wound healing, clinical scores and X-rays were performed at fixed time intervals.ResultsOverall, 253 patients were available with a mean follow-up of 18.1 ± 4.5 months (range 12–30). On average, wound healing, clinical scores, laboratory tests and radiographic findings did not show any significant difference between the two groups. Six surgical site infections (4.6%) were observed in the control group compared to none in the treated group (P < 0.03). No local or systemic side-effects related to the DAC hydrogel product were observed and no detectable interference with bone healing was noted.ConclusionsThe use of a fast-resorbable antibiotic-loaded hydrogel implant coating provides a reduced rate of post-surgical site infections after internal osteosynthesis for closed fractures, without any detectable adverse event or side-effects.Level of evidence2.

Intramedullary Fibula with Rigid Osteosynthesis in Revision of Neglected and Multiple times Operated Non Union of Long Bones

Background: Plates with Intramedullary Fibula as Strut graft(IFSG) in Non- union of long bone fractures provides most stable construct overall as fibula acts as second implant, screws have better anchorage and very high pull out strength due to penetration of four cortices and osteogenic property of the fibula is most helpful. The aim of this paper is to re-focus the importance of non-vascularised intramedullary fibula as a second internal biologic stable splint along with rigid osteosynthesis for the treatment of difficult and neglected non -union of long bones. Methods and Material: 15 cases (13 :2,males: females) of revision surgery for the neglected and multiply operated non-union of the long bones were treated with the debridement, decortication and shingling of the fracture site with addition of the trimmed fibula (as intramedullary strut). Liberal cancellous bone graft was added subperiosteally with stable and rigid internal osteosynthesis by using LCP. DASH Score was used for upper limb and VAS for lower limb for assessment. Results: Union was achieved in all patients in 12 months (range 9-12 months). Preoperative DASH score averaged 40.86(range 42.6-52.6). DASH score at the last follow-up averaged 20.38 points (range 16.4-24.2).difference was significant. (p=0.0001) Conclusions: Intra medullary fibula almost works mimicking double plate and adds in the stability as it works as second plate. Its osteogenic property helps in the healing, not only at the fracture site but proximal and distal to it. This prevents slow union at the ends of bone which are usually avascular because of the lysis. Screws have a better hold around osteoporotic bones due to four cortices hold in presence of fibula. Strong bony union can be successfully achieved in almost all cases with rigid compression at the fracture site &amp; additional extensive cancellous bone grafting. Keywords: Intra- medullary Fibula ,revision non union, rigid osteosynthesis.

Diaphyseal fractures of the humerus. How to treat conservatively and when needed surgery?

According to the Kharkiv interdistrict MSEK (2012) using of in­ternal osteosynthesis results into high incidence of nonunion of the humeral fractures — 24 % 4 months after plating. Purpose: to justify treatment guidelines of diaphysial humeral fractures using 30-years scientific and practical experience for presenting an improved method of treatment and to present achieved re­sults. Methods: To evaluate the results of treatment in 73 patients with humeral fractures treated from 2006 to 2014. Functional conservative treatment with orthosis — 39 people, external fixa­tion device (EFD) — 16 (13 after closed reduction, open 3). In 18 patients applied internal osteosynthesis. Clinical material is analyzed since 1984 (104 cases).Results: main features that in­fluence the choice of treatment method such as the displacement of the bone fragments in the initial radiograph, fracture level, other damage, limiting the mobility of the injured, the condition of the radial nerve are distinguished and characterized. Details of functional treatment of fractures of the humerus with the cast and pin EFD are presented. Conclusion: in a case monolocal diaphyseal fractures of the humerus one should choose a con­servative functional treatment method — the safest in case of complications, providing fusion of fragments in a short time, well-tolerated by patients and requiring low material costs. For a fixed displacement of fragments greater than the diameter of the bone, and associated lesions, excluding or significantly limiting the vertical position of the patient, it is advisable to use EFD. Open reduction is required for the displacement of bone fragments in the full width, irremovable hanging shoulder posi­tion within 2–5 days. Revision of the radial nerve is indicated with considerable fixation and displacement of bone fragments.

Current management of open fractures: results from an online survey.

Open fractures are orthopaedic emergencies that carry a high risk for infection, non-union and soft tissue complications. Evidence-based treatment is impeded by the lack of high-quality evidence-based studies. The aim of this investigation was to elucidate the current practice of open fracture management in Germany and to determine major differences in treatment. Surgeons were asked to complete an online questionnaire consisting of 45 items developed by an expert consensus. The first part covered questions on general principles of open fracture management. The second part included questions on soft tissue management, the preferred method of initial surgical stabilisation, microbiological testing, employment of pulsatile lavage and local antibiotics, antibiotic regimen, second-look operations, and blood testing. Of 653 respondents, 364 (65%) completed the first part and 314 (48%) completed the second part of the online survey. 55% answered that a standard operating procedure for the diagnosis and treatment of patients with open fractures exists in their hospital. Only 25% leave pre-hospitalisation applied dressings intact until arrival of the patient in the operating room, and 40% make this decision depending on information provided by pre-hospitalisation emergency personnel. 84% participants exclude the use of antibiotic-coated implants in the treatment of open fractures. The favoured stabilisation method in Gustilo type I fractures is definitive internal osteosynthesis and primary wound closure for 61% of respondents. In Gustilo type II (74%) and type III fractures (93%), temporary external fixation is preferred. High-pressure pulsatile lavage is used by 22% responding surgeons in Gustilo type I fractures, 53% for type II fractures and 67% for type III fractures. Open fracture management differs considerably among surgeons in Germany. Further studies are needed to deliver high-quality evidence concerning primary fracture stabilisation, soft tissue management and second-look operations. Existing evidence-based recommendations for general treatment, antibiotic prophylaxis and soft tissue management should be followed more strictly in clinical practice.

Use of Cannulated Screws in Pelvic Injury Surgery

Osteosynthesis with cannulated screws is one of low invasive osteosynthesis techniques that does not aggravate the condition of polytraumatized patients and can be used at the early stages of treatment. The purpose of the study was to determine the peculiarities of cannulated screws application in pelvic ring and acetabular injuries. Cannulated screws were used at surgical treatment of 368 patients, aged 14–77 years, with pelvic injuries. The overwhelming majority of patients were with severe polytrauma (17 and more points by ISS score). Pelvic ring injuries (61st segment) were diagnosed in 259 (70.4%) patients, acetabular fractures (62nd segment) — in 75 (20.4%), pelvic ring injuries associated with acetabular fractures (61st and 62nd segments) — 34 (9.2%) patients. The screws were mainly used as the basic treatment technique, rarely — in combination with internal plate osteosynthesis and more rarely — in combination with external fixation device. Analysis of the results and complications was performed. Treatment results by Majeed pelvic score at terms 1 to 3 years were studied in 207 patients. Poor results were observed in 15 (7.2%) cases. Pelvic fracture osteosynthesis with cannulated screws has a number of advantages and can be referred to as one of the basic surgical techniques for pelvic fractures.

Clinical features and outcome of bone and joint infections with streptococcal involvement: 5-year experience of interregional reference centres in the south of France.

Streptococcal bone and joint infections are less common than staphylococcal cases. Few studies have reported the cases with well-identified Streptococcus species. Their clinical features and prognosis are not clearly known to date. Moreover, no treatment regimen has yet been clarified. We reviewed the streptococcal bone and joint infection cases managed in our centres from January 2009 to December 2013. We described the epidemiology, clinical and microbiologic characteristics, treatment approach and outcome. Among the 93 cases, 83% of patients were men with a median age of 60 years, and 90% of patients had comorbidities or risk factors. Bacteraemia occurred in 14% of cases. Serious complications occurred in six patients, including severe sepsis (two cases) and infective endocarditis (two cases). Orthopaedic device infections were observed in 35% of cases, including 17 patients with internal osteosynthesis device infection, 14 with prosthetic joint infection and three with vertebral osteosynthesis device infection. The median time between orthopaedic device implantation and onset of infection was 447 days. Fourteen species of Streptococcus were identified, including 97 isolates using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry and three isolates using molecular identification. The five most represented species included S. agalactiae (37%), S. dysgalactiae (12%), S. anginosus (11%), S. constellatus (10%) and S. pneumoniae (9%). Streptococci isolates were susceptible to amoxicillin, with the exception of one S. mitis isolate. Remission 1 year after the end of treatment was recorded in 83%. One patient died of infection; eight patients had infections that failed to respond to treatment; and seven patients experienced relapse. Twenty patients (22%) had an unfavourable functional outcome, including 19 amputations and one arthrodesis. Five significant prognostic factors associated with an unfavourable clinical outcome were identified, including peripheral neuropathy (p 0.009), peripheral arterial disease (p 0.019), diabetes mellitus (p 0.031), location in the femur (p 0.0036), location in the foot (p 0.0475), osteitis without an orthopaedic device (p 0.041) and infection caused by S. dysgalactiae (p 0.020). The rate of poor outcomes remains high despite the low number of Streptococcus isolates resistant to antibiotics. Some prognostic factors, such as the presence of S. dysgalactiae, are associated with an unfavourable clinical outcome. Antibiotic regimens of streptococcal bone and joint infections are not standardized and need to be further investigated.

Fratture esposte metaepifisarie distali di tibia

The meta-epiphyseal fractures of the distal tibia commonly called tibial pilon fractures seem to have one based frequency, about 1% of all lower limb fractures. They are mostly high-energy fractures that determine burst fractures with comminution and exposure of the fragments. Muller’s AO classification divides them into three types: A (extra-articular), $B$ (partial articular), and $C$ (articular complete). Gustilo’s classification divided fractures into three types, depending on the degree of exposure of the bone. The treatment of meta-epiphyseal open fractures of distal tibia provides for an initial time of debridement of the affected tissue and then a stabilization with external fixators, which may be permanent or followed by a second internal osteosynthesis.

Immediate results of treatment periprosthetic femoral fractures after hip replacement

Periprosthetic fractures are one of the most serious complications after hip replacement. Nineteen periprosthetic femoral fractures operated on during the period 2011-2015 were followed-up retrospectively. Periprosthetic fractures were classified according to the Vancouver classification. The functional results were evaluated using Harrison scale. Bone healing and implant stability were evaluated clinically, on plain radiographs and computed tomography. The periprosthetic fractures in all patients occurred in the postoperative period. Time from operation until fracture varied from 2 weeks to 11 years. A wedge-shaped cemented or cementless stems were implanted during the first surgery: Versys ET, Spotorno, CPT (Zimmer, США): cementless fixation was performed in 16 (84,2%) patients, hybrid -in 2 (10,5%) and cemented fixation - in 1 (5,3%) patient. The fractures of greater trochanter were diagnosed in all patients with type A periprosthetic fractures. In type B1 periprosthetic fracture (8 patients) open reduction, cerclage wiring and internal plate osteosynthesis were applied. Loosening stems in 3 patients with type B2 fractures were replaced with Wagner cementless revision component (Wagner SL Revision Stem). Angle-stable plate osteosynthesis and cerclage wiring were also performed. Closed reduction and internal minimal invasive plate osteosynthesis were performed in patients with type C periprosthetic fractures. Bone consolidation was achieved in 18 (94,7%) patients, the average term was 14,3±5,2 weeks. The average Harris hip score in all patients 3 months after treatment was 64,9±16,7 points, and in 12 patients (63,2%) after a year - 86,5±15,9. Femoral periprosthetic fractures require a specialized approach to choosing the treatment tactic depending on the fracture type and quality of bone tissue. It is necessary to evaluate the femoral component stability, especially in differential diagnosis of type B1 and B2 periprosthetic fractures. Computed tomography is one of the necessary methods of diagnosis.

Postoperative infection in patients undergoing inspection of orthopedic damage due to external fixation

ObjectiveTo conduct a retrospective analysis on cases undergoing inspection of orthopedic damage, at an orthopedic emergency service in a teaching hospital, with the aim of evaluating patients with postoperative infection after conversion to internal osteosynthesis. MethodsThis was a retrospective analysis covering the period from June 2012 to June 2013, on patients who underwent inspection of orthopedic damage due to external fixation and subsequently were converted to definitive osteosynthesis using a nail or plate. ResultsWe found an infection rate of 13.3% in our sample and, furthermore, found that there had been technical errors in setting up the fixator in 60.4% of the cases. ConclusionWe found an infection rate that we considered high, along with inadequacies in constructing the external fixator. We emphasize that this procedure is not risk-free and that training for physicians who perform this procedure should be mandatory.

Potentialities of Minimally Invasive Osteosynthesis in Treatment of Malleolus Fractures

Treatment results for 71 patients with malleolus fractures are presented. In 32 patients (comparative group) surgery was performed by AO/ASIF technique after edema resolution. Thirty nine patients from the main group were operated on by our minimally invasive technique using V-shaped pins and threaded pins on the next day after admission independently on the presence of edema in the ankle joint region. All patients were operated on at terms from 1 to 3 weeks after injury. Duration of hospitalization averaged 16 and 10 days, restoration of joint function made up 6 and 2 weeks for the patients from the comparative and main group, respectively. Complications were observed only in patients from the comparative group, i.e. marginal skin necrosis in 8 (25%), inflammatory complications in 5 (15.6%), metal fixator migration in 1 (3.1%) and fracture nonunion in 4 (12.5%) patients. Outcomes were assessed by AOFAS Ankle- Hindfoot Scale. Mean point made up 90.3 in the main group and 88.6 in the comparative jnt. In the experimental part of the study the strength (tensile and shear) of 3 types of osteosynthesis for medial malleolus fracture were compared: with either 2 cannulated screws, V-shaped pin or 2 biodegradable screws of glycolized lactic acid was compared. Although the osteosynthesis of medial malleolus with V-shaped pin was the least strong it met the requirements of internal osteosynthesis.

Potentialities of Minimally Invasive Osteosynthesis in Treatment of Malleolus Fractures

Treatment results for 71 patients with malleolus fractures are presented. In 32 patients (comparative group) surgery was performed by AO/ASIF technique after edema resolution. Thirty nine patients from the main group were operated on by our minimally invasive technique using V-shaped pins and threaded pins on the next day after admission independently on the presence of edema in the ankle joint region. All patients were operated on at terms from 1 to 3 weeks after injury. Duration of hospitalization averaged 16 and 10 days, restoration of joint function made up 6 and 2 weeks for the patients from the comparative and main group, respectively. Complications were observed only in patients from the comparative group, i.e. marginal skin necrosis in 8 (25%), inflammatory complications in 5 (15.6%), metal fixator migration in 1 (3.1%) and fracture nonunion in 4 (12.5%) patients. Outcomes were assessed by AOFAS Ankle- Hindfoot Scale. Mean point made up 90.3 in the main group and 88.6 in the comparative jnt. In the experimental part of the study the strength (tensile and shear) of 3 types of osteosynthesis for medial malleolus fracture were compared: with either 2 cannulated screws, V-shaped pin or 2 biodegradable screws of glycolized lactic acid was compared. Although the osteosynthesis of medial malleolus with V-shaped pin was the least strong it met the requirements of internal osteosynthesis.

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Purpose. To study the efficiency of using the military-field rod kit for osteosynthesis of gunshot limb bone fractures. Materials and Methods. We studied the results of treating 117 wounded persons with isolated gunshot fractures of limb bones. Damage control approach, as well as consecutive osteosynthesis of fragments was used in the tactics of the wounded managing. The results of using the device of the military-field rod kit (MFRK) were compared in 54 wounded persons, as well as those of using another rod device in 63 wounded persons at the first stage of multistage surgical treatment. Results. The results demonstrated MFRK device potential to provide external fixation of long bone fragments faster and more efficiently. Conclusion. The use of MFRK at the first stage allows early switching to internal osteosynthesis, as well as obtaining good functional and anatomical outcomes.

Infecção pós‐operatória nos pacientes submetidos ao controle de danos ortopédicos pela fixação externa

ObjectiveTo conduct a retrospective analysis on cases undergoing inspection of orthopedic damage, at an orthopedic emergency service in a teaching hospital, with the aim of evaluating patients with postoperative infection after conversion to internal osteosynthesis. MethodsThis was a retrospective analysis covering the period from June 2012 to June 2013, on patients who underwent inspection of orthopedic damage due to external fixation and subsequently were converted to definitive osteosynthesis using a nail or plate. ResultsWe found an infection rate of 13.3% in our sample and, furthermore, found that there had been technical errors in setting up the fixator in 60.4% of the cases. ConclusionWe found an infection rate that we considered high, along with inadequacies in constructing the external fixator. We emphasize that this procedure is not risk‐free and that training for physicians who perform this procedure should be mandatory.

Staphylococcus caprae bone and joint infections: a re-emerging infection?

Staphylococcus caprae has been recently classified as a human pathogen, but the incidence of S. caprae in human bone and joint infections (BJIs) is under-reported. In this study, we report 25 cases of S. caprae BJI, and we review the 31 cases published in the literature. Molecular techniques and matrix-assisted laser desorption ionization time-of-flight mass spectrometry improved the identification of clinically relevant S. caprae strains. In this study, 96% of S. caprae BJIs were localized to the lower limbs, and 88% of the cases involved orthopaedic device infections. S. caprae joint prosthesis infections (JPIs), internal osteosynthesis device infections (I-ODIs) and BJIs without orthopaedic device infections were recorded in 60%, 28% and 12% of cases, respectively. Ten (40%) S. caprae BJIs were polymicrobial infections. These infections were associated with past histories of malignancy (p 0.024). Of the 14 bacterial species related to S. caprae BJI, 57% were staphylococci. I-ODIs were significantly associated with polymicrobial infections (p 0.0068), unlike JPIs, which were monomicrobial infections (p 0.0344). Treatment with rifampicin and fluoroquinolone was recorded in 40% of cases. Surgical treatment was performed in 76% of cases, e.g. prosthesis removal (36%), osteosynthesis device removal (24%), and surgical debridement (16%). Thirty per cent of cases were not treated. Relapses were observed mainly in the patients treated by surgical debridement only (p 0.033). In summary, S. caprae BJI is an underestimated hospital-acquired emerging infection. S. caprae BJI is correlated with infections in orthopaedic devices, which must be removed to control the infection.

Efficacy of a compliant semicircular Ilizarov pin fixator module for treating infected nonunion of the femoral diaphysis.

Percutaneous transosseous Ilizarov wiring, whilst preferred in the tibia because of its unique properties, carries a high risk of complications in the femur. The aim of this work was to evaluate the efficacy of a more patient-friendly semicircular pin external fixator module built up from parts of the Ilizarov fixator components and its use in managing diaphyseal femoral nonunions. A group of 20 patients with infected diaphyseal nonunions of the femur after internal osteosynthesis were included in this study. The mean age of the patients at the time of surgery was 46 years (range 16–60, SD 15.6). The mean morbidity time since the original trauma was 10.2 months (range 6–15, SD 2.5). All the cases were fixed by the described external fixator module. Bony union with resolution of infection occurred in 18 (94.7 %) out of 19 cases after a mean period in the fixator of 11.2 months (range 8–18 SD 2.9). After a mean follow-up period of 3.5 years (range 2–9, SD 2.6), there were 14 excellent, 3 good, 1 fair and 1 poor results from radiological evaluation and 10 excellent, 7 good, 1 fair and 1 poor results from functional assessment. In conclusion, the described semi-circular pin fixator module is patient-friendly and effective in managing infected nonunions of the femoral diaphysis.

External fixators and sudden-onset disasters: Médecins Sans Frontières experience

Carrying out osteosynthesis is challenging, and controlling for results and complications is necessary to define the limits of acceptable complications. Within the context of sudden-onset disasters, comparing internal with external osteosynthesis remains controversial. The most recent and significant Médecins Sans Frontières (MSF) experience with osteosynthesis was following the earthquake in Haiti in 2010: 353 external fixators were used in the 12 months following the catastrophe, 62 of which were used in the first month. Carrying out internal osteosynthesis was possible two weeks following the earthquake. The most common indication for open tibial fracture was Gustillo grade 2 or 3. Conversion rate from external to internal osteosynthesis remains anecdotal for several practical reasons. Advantages and drawbacks of external fixators are discussed in the context of precarious situations frequently encountered by MSF. External osteosynthesis as a primary and definitive treatment for open fractures, especially of the leg, remains the most frequently used and best-adapted procedure in the context of sudden-onset disasters, even though not ideal.

Treatment of bone fragments nonunion after dyaphiseal fracture

According to the Kharkiv interregional MSEC occurrences of nonunion fractures requiring additional surgical treatment ranges from 12.5 to 26 %. Treatment of such complication appeared requires weighed approach which might take into consideration its causes and clinical features in order to repeated surgery to be the last one.Purpose: to evaluate clinical, radiological, morphological and mechanical features of the regenerate in patients with nonunion diaphyseal fractures, and to substantiate choice of their treatment and methods of stimulation of bone regeneration.Methods: an experience of treatment of 73 patients with nonunion diaphyseal fractures of the extremities is presented. Among them 14 patients have had femur nonunion, 39 – shin bones nonunion, 14 – humerus nonunion, and 6 patients have had forearm bones nonunion. Terms passed after trauma or surgery amounted from 4 to 23 months. Nonunions was determined in 56 % patients after open reduction of bone fragments and internal osteosynthesis, in 33 % patients after extrafocal osteosynthesis with different apparatus of external fixation, and in 11 % patients after conservative treatment. Patients were subdivided into clinical groups based on the assessment of regenerate deformation: 1st — 16 patients with bone-cartilagenous healing; 2nd — 22 patients with free mobility of bone fragments sometimes combining with angular deformation, restriction of adjacent joint function, and considerable violation of the support function of the segment; 3rd — 35 patients with nonunion due to failure of internal fixation device.Results: indications for using of closed compression osteosynthesis as well as of various types of plastic materials (small cancellous autologous bone grafts alone and in combination with platelet-rich plasma, autologous fibrin gel and other drugs containing fibrin) were clarified. Original external fixation devices allowing functional loading of the extremity were used for juxtapositioning of bone fragments. Positive outcomes were obtained in 95 % of cases.Conclusions: deformation of soft-tissue regenerate in cases of nonunions was determined by its tissue structure. Forcible deformation is typical for bone-cartilagenous regenerate, and free one is typical for regenerate with prevalence of connective tissue. In case of dense bone-cartilagenous regenerate there were recommended creation of correct axial loading after closed elimination of its angular deformity by the external fixation device. It is a necessary to resect fibula fragment. Functional plaster dressing may be used in some cases. In case of nonunion with free type of deformation treatment has to be added with open surgery including decortication and removal of connective tissue from interfragmental area. Forming defect and subperiosteal area has to be filled with cancellous autologous bone grafts, autologous fibrin or fibrin-containing products. In case of nonunion diaphyseal fractures the use of the external fixation device is biomechanically substantiated. It allows dosage correction of the position of the fragments and thereby maintains axial vector of tension of the regenerate.