Joint-spanning External Fixation Research Articles

Patient Safety in MRI with the Use of a Joint-Spanning External Fixator for Knee Dislocation: A Critical Analysis Review.

» Universal safety guidelines for the use of a knee-spanning external fixator in magnetic resonance imaging (MRI) are unlikely to be established considering the high variability in device construct configurations.» Per the US Food and Drug Administration, manufacturers are to provide parameters for safe MRI scanning for "MR Conditional" devices; however, such labeling may be limited in detail. Physicians should reference manufacturer labels as a starting point while making an educated clinical decision.» Scanning of a knee-spanning external fixator inside the MR bore has been safely demonstrated in previous studies, although with small sample sizes.» When considering MRI in a patient treated with a knee-spanning external fixator, physicians should use all available resources and coordinate with their medical team to make a clinically reasonable decision contrasting patient benefit vs. potential harm.

Use of the External Fixator Calcaneus Pin: Using the TRIMANO to Its Full Potential

Joint-spanning external fixation in acute ankle trauma is a means to provide temporary stability and restoration of length, alignment, and articular congruency. This allows for soft-tissue consolidation before definitive fixation to decrease the risk of wound complications. Traction is commonly used during definitive fixation to aid in fracture reduction and to maintain reduction during placement of internal hardware. Ankle arthroscopy for ankle fractures is also becoming increasingly popular to identify and treat intra-articular injury and uses traction for visual assistance and increased working space for instruments. We present a technique that uses a previously placed calcaneus external fixation pin and the TRIMANO (Arthrex, Naples, FL) external positioning arm to apply skeletal traction during arthroscopic and open definitive fixation procedures. This technique is extremely simple, can be used in both the supine and prone positions, and can be used during arthroscopic and open procedures.

Spanning External Fixation for Pilon Fractures: Steering Wheel and Kickstands.

High-energy pilon fractures are challenging for patients and surgeons. Joint-spanning external fixation can be used successfully as temporary stabilization in a staged fashion. Despite this common strategy, there are varying types of external fixator applications. The authors present an efficient and easily reproducible modification to the classic delta frame configuration, which may afford improved fracture reduction and prevent decubitus lesions. [Orthopedics. 2020;43(3):e187-e190.].

Limited internal fixation combined with a joint-spanning external fixator in the treatment of Midfoot injuries in children.

The aim of this study was to explore the clinical features and surgical treatment methods of unstable midfoot injuries in children. Eleven children with severe unstable midfoot injuries admitted to Jishuitan Hospital, Beijing, from June 2009 to October 2016 were enrolled, including seven patients with Lisfranc injuries and four patients with Chopart injuries. All Lisfranc injuries had radiographic data from the healthy sides, and radiographs of the affected sides showed that all injured Lisfranc joints separated more than 3 mm compared with the healthy sides. The treatment methods employed a joint-spanning external fixator to distract and maintain the length of the medial and lateral columns, combined with joint-preserving trans-joint locking plate fixation or trans-articular cannulated screw and Kirschner wire fixation that passed through the joint. The patients were followed up for 53.7 months (17-110 months). The average operation time was 95.1 minutes, and the average intraoperative blood loss was 83.3 ml. Nine of the 11 patients were treated with an external fixator to distract and fix the medial or lateral column. Bone healing was achieved in all patients, and none of the patients complained of chronic pain in the midfoot. Flatfoot and valgus deformity were corrected after the surgery in the child with old fracture, and the pain in the calcaneocuboid joint disappeared. The average American Orthopedic Foot and Ankle Society mid-foot score at the last follow-up was 93.4, of which nine cases were greater than 90 and two cases were between 75 and 89. Children's midfoot injury is characterized by fracture-dislocation. Simple joint capsule tear or ligament rupture is rare and often accompanied by severe cuboid compression fracture. The treatment should be focused on restoring the stability of the bony structure and the length of the medial and lateral columns. The use of a joint-spanning external fixator helps maintain reduction and restore the length of the medial and lateral columns.

Surgical Technique: Achieving Reduction With Temporizing, Knee-Spanning External Fixation

Peri- and intra-articular fractures about the knee are frequently managed with joint-spanning external fixation before definitive treatment. With a systematic approach, a near-anatomic reduction with respect to length, alignment, and rotation can be obtained. This video highlights 2 clinical cases: a bicondylar tibial plateau fracture-dislocation and a distal femur fracture, both of which were treated with temporizing, knee-spanning external fixation. The indications, principles, and biomechanics of knee-spanning external fixation are presented. In addition, we demonstrate a systematic approach to applying knee-spanning external fixation. Temporizing, joint-spanning external fixation is a critical treatment modality in the orthopaedic armamentarium for managing fractures about the knee. With a systematic approach, it is possible to obtain a near-anatomic reduction with respect to length, alignment, and rotation.

Temporary bridging external fixation in distal tibial fracture

Fractures that involve the distal area of the tibia are associated with a high percentage of complications. Soft tissue oedema, swelling, blisters, skin abrasions and open wounds could compromise the outcome of these lesions. The waiting time before surgery with ORIF is mostly due to soft tissue conditions. Early application of a simple joint-spanning external fixator would achieve the initial goal of stability and the respect of soft tissue, thereby decreasing the time necessary for definitive treatment.A total of 40 consecutive patients (22 male and 18 female) with a mean age of 52 years (range 17–82 years) with distal tibial fracture treated between January 2010 and January 2013 were evaluated. Early temporary external fixation was the first treatment step. Twenty patients had pilon fractures, characterised by the intra-articular involvement of the distal tibia with metaphyseal extension, and 20 patients had malleolar fracture-dislocation.Patients were divided into two groups, A and B. Group A comprised 10 patients with ankle fracture-dislocation and bone fragmentation, who were treated with a temporary bridging external fixation that was maintained after ORIF to exploit ligamentotaxis during the first phases of bone healing.In Group B (30 patients), the external fixation was removed after ORIF.The results of the study are in line with the recent literature: temporary external fixation in high-energy trauma and fracture-dislocation of the ankle enables soft tissue to be restored, which facilitates postoperative assessment of bone fragments by CT scan. The complication rate in this study was 5% in patients with malleolar fractures and 20% in patients with pilon fractures.The maintenance of temporary external fixation after ORIF synthesis during the entire first stage of bone healing seems to be a good method of treatment that has a low rate of soft tissue complications.

Therapie der Sprunggelenksluxationsfrakturen vom Pronationstyp

Early reduction of the dislocation and anatomic reconstruction of axial alignment, ankle mortise and articular congruity with special focus on syndesmotic stability. Fracture-dislocations resulting from pronation injuries to the ankle with a highly incongruent and unstable mortise and either considerable internal pressure on the soft tissues by the displaced fragments or open soft tissue damage. General contraindications to surgery: closed reduction and cast immobilization or external fixation. Early preoperative closed reduction of complete dislocations is achieved through longitudinal traction and movements contrary to the original fracture mechanism. A cast or joint-spanning external fixator is applied temporarily. Ideally, definite anatomic reduction of the posterior tibial fragment, the distal fibula and medial malleolus and stable internal fixation is achieved within the first hours after the injury. Congruity of the ankle mortise and syndesmotic stability is controlled intraoperatively and a syndesmotic screw is inserted if necessary. In these cases, the correct positioning of the distal fibula within the tibial incisura is verified with three-dimensional fluoroscopy or postoperative computed tomography scanning. Early range of motion exercises of the ankle and subtalar joints are initiated the second postoperative day or after soft tissue consolidation and removal of the external fixation. Patients are mobilized with partial weight bearing (20 kg) in a cast or special boot for 6 weeks postoperatively. The syndesmotic screw is then removed in most cases and weight-bearing is rapidly increased. The presence of a dislocation at the time of injury represents a negative prognostic factor in malleolar fractures. Higher rates of posttraumatic arthritis are also observed with trimalleolar fracures, especially fractures of the posterior tibial rim, cartilage damage, and syndesmotic disruption. Irrespective of the fracture classsification, good to excellent results can be obtained in 75-89% of cases with anatomic reconstruction of the ankle mortise and the articular surfaces. Proper reduction of the distal fibula into the tibial incisura is of utmost importance in cases of frank syndesmotic diastasis.

Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures: a staged protocol

This study determined outcomes after temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures. A retrospective case analysis was done of all patients who were treated between 2000 and 2008 in 3 level I trauma centers with temporary joint-spanning external fixation before internal fixation of an open intra-articular distal humeral fracture. Healing rates, complications, Disabilities of Arm, Shoulder and Hand (DASH), and Smith and Cooney outcome scores were documented. The study included 16 patients. Mean follow-up was 35.2 months. Fractures united after an average of 5.2 months. No complications specifically related to the external fixation occurred. The DASH outcome score averaged 15.1. Although complications occurred in 12 patients (9 patients requiring surgery), 10 of 16 had an excellent/good outcome score. Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures is a safe adjunct.

The Sequential Recovery of Health Status After Tibial Plafond Fractures

To assess the recovery of ankle function and general health status at multiple time points during the first 24 months after an isolated tibial plafond fracture treated with joint-spanning external fixation and to determine factors that affect a rapid versus a slow recovery and factors that influence patient outcome at a minimum of 2 years after injury. Prospective observational study. Two Level I trauma centers. Forty-three patients (mean age, 42 years; range, 20-60 years) with unilateral fractures of the tibial plafond were prospectively assessed. These 43 patients had a 24 month follow up and were seen for at least three additional scheduled visits before the 24-month follow up. Spanning articulated external fixator and follow ups at defined time intervals after injury to track the progress of the outcome measures over time. The Short Form Health Survey (SF-36) Medical Outcomes Study (MOS) version 2 Physical Component Summary Score (PCS) and Mental Component Summary Score (MCS) and the Ankle Osteoarthritis (AOS) Pain and Disability Scales. Early after injury, the MCS was not as negatively affected as the PCS. By 6 months after injury, the MCS had improved to be equivalent to age-matched norms and remained there at 2 years after injury. The PCS was more severely compromised and did not level off until the 12-month clinic visit. At 2 years, the PCS remained on average one standard deviation below age-matched normal. Although not statistically significant, both the average pain and disability AOS scales deteriorated between 6 and 12 months, suggesting some patients actually perceived their ankle as being worse as they begin walking on their injured ankle. Between 12 and 24 months, they trended toward improvement in both the pain and function scales. However, their ankle continued to have dramatically increased pain and decreased function compared with population-based norms. In patients recovering from a tibial plafond fracture that was treated with joint-spanning external fixation, the MCS improves quickly and completely, whereas the PCS often takes 1 full year or longer to reach maximal improvement and does not completely recover, because it remains on average one standard deviation below normal at 2 years after injury. Changes in the AOS pain and disability scales between 6 and 12 months after injury were not significantly different but at all time points, the patient's ankle pain and function remains dramatically different than the normal population. These results can be used in future studies for comparison with patients treated with alternate treatment techniques and to assess the effect of important treatment variables such as stabilization techniques and quality of reduction.

Temporizing External Fixation of the Lower Extremity: A Survey of the Orthopaedic Trauma Association Membership

This study examined the opinions of practicing traumatologists to aid in the initial treatment of complicated lower extremity fractures in accordance with current staged protocols. A 40-question online survey of the Orthopaedic Trauma Association (OTA) membership was administered from November 2008 to February 2009. The survey investigated surgeons' preferences regarding general principles and routine management of joint-spanning lower extremity external fixators, as well as favored knee- and ankle-spanning constructs and conditions of definitive surgical reconstruction. Data were collected using a 5-point Likert scale ranging from strongly agree (5) to strongly disagree (1). Responses were given numerical weight in descending order (scoring 5-1) and were reported as straight percentages and with a weighted mean called the rating average.Responses were received from half of the OTA membership. Among the strongest preferences (rating average >4) were for obtaining a computed tomography (CT) scan as part of prereconstruction planning (4.8) and obtaining that CT scan after joint-spanning external fixation was applied (4.6). Restoration of length as the most important part of limb realignment at the time of temporizing external fixator application (4.3), the use of soft tissue protection during pin application (4.4), and avoiding overlap of pin sites with a plate at the time of reconstruction (4.3) were highly favored. Survey respondents treated a sizable volume of periarticular lower extremity injuries with temporizing external fixation and staged reconstruction. This consolidation of trends and preferences for constructing and using temporizing external fixation for complex lower extremity injuries hopefully will aid in the treatment of these difficult fractures.

Adult Trauma

It is now recognized that the treatment of many orthopaedic injuries can be, and in many cases should be, deferred until a later date. For example, surgical repair of most fractures of the proximal and distal tibia is now delayed until soft-tissue healing has occurred. Acute treatment involves only provisionally reducing and stabilizing such fractures using a joint-spanning external fixator. However, situations occur in the emergency department in which emergency treatment, even if it is just temporizing in nature, must be done immediately. Often, such treatment is outside the comfort zone of the responsible orthopaedic surgeon, even physicians with training and experience in orthopaedic trauma. Orthopaedic surgeons will benefit from updated information on current methods for the emergency management of limb- and/or life-threatening injuries in adults. Such treatment is often provisional in nature, treating only the urgent component of the injury (such as a compartment syndrome associated with a complex tibial plateau fracture). It is important for orthopaedic surgeons to understand how to get "through the night" so that later appropriate definitive care is facilitated to optimize patient outcomes.

Positional Effects of the Knee and Ankle on the Ends of Acute Achilles Tendon Ruptures

Conservative management of acute Achilles tendon ruptures in a plantarflexed short leg cast or functional brace is a viable alternative to surgery. The ideal plantarflexion angle to allow the free ends of the tendon to oppose one another has not been clearly defined. The purpose of this cadaveric study was to define a plantarflexion angle where the free Achilles tendon ends reliably oppose one another. Ten cadaveric legs amputated at the distal femur were obtained. A laceration of the Achilles tendon was made 4 cm above the calcaneal insertion. A joint-spanning external fixator was placed across the knee. With differing degrees of knee flexion (0, 45, and 90 degrees), the diastasis between the free ends of the Achilles tendon was measured as the ankle was moved from 20 degrees of dorsiflexion to 30 degrees of plantarflexion (-20, -10, neutral, 10, 20, and 30 degrees). Regardless of knee flexion angle, the ankle plantarflexion angle where the free ends of the Achilles tendon opposed one another was 28.0 (95% confidence interval: 25.0-33.6) degrees. The ideal ankle angle in which to immobilize patients appears tightly clustered around 28 degrees of plantarflexion.

Incidence of Deep Venous Thrombosis After Temporary Joint Spanning External Fixation for Complex Lower Extremity Injuries

The purpose of this study was to determine the incidence of deep venous thrombosis (DVT) in a prospective protocol of early spanning external fixation with the concurrent use of low-molecular weight heparin (LMWH) in patients with high-energy lower extremity trauma. Three level I trauma centers. Prospective observational study. One hundred thirty-six consecutive patients with 151 complex lower extremity injuries were treated with a protocol of immediate joint spanning external fixation application and LMWH administration within 24 hours of admission. A total of 143 external fixators were applied. Early patient mobilization was encouraged and possible due to the skeletal stability provided by the external fixator. There were 87 men and 49 women with a mean age of 43 years. There were 62 proximal tibia fractures (Orthopaedic Trauma Association [OTA] Fracture Classification 41), 4 tibial shaft fractures (OTA 42), 49 distal tibia-fibula fractures (OTA 43, 44), 14 femur fractures (OTA 32, 33), 8 calcaneus fractures (OTA 73), 10 knee dislocations, and 4 talus fracture dislocations. Forty-eight injuries (32%) were open. Temporary joint spanning external fixator placement, LMWH administration, and early mobilization within 24 hours of admission. Duplex ultrasonography of the bilateral lower extremities within 1 day to 3 days before fixator removal and definitive fixation procedure. Presence of DVT on duplex ultrasound examination. Duplex ultrasonography was negative for DVT in all but three patients for an incidence of 2.1% (3 of 143 fixators). There were no bleeding complications secondary to the use of LMWH while the temporary external fixator was in place. The incidence of DVT in patients treated with a protocol of early joint spanning external fixation and LMWH administration does not exceed historical controls. The early restoration of limb length, alignment, and stability allows early mobilization, which may contribute to the prevention of DVT.

Controversies in the Treatment of Knee Dislocations and Multiligament Reconstruction

A systematic approach to evaluation and treatment is needed for the patient with knee dislocation. There is a paucity of high-level evidence on which to base treatment decisions. Reported controversies related to the treatment of the multiligament-injured knee include the selective use of arteriography for vascular assessment, serial physical examination with the ankle-brachial index, acute surgical treatment of all damaged structures, the selective application of preoperative and postoperative joint-spanning external fixation, arthroscopic reconstruction of the anterior cruciate ligament and posterior cruciate ligament, simultaneous open reconstruction with repair of the posterolateral corner, reconstruction and/or repair of the posteromedial corner, and the use of allograft tissue.

High-Energy Tibial Plateau Fractures

The severity of a tibial plateau fracture and the complexity of its treatment depend on the energy imparted to the limb. Low-energy injuries typically cause unilateral depression-type fractures, whereas high-energy injuries can lead to comminuted fractures with significant osseous, soft-tissue, and neurovascular injury. Evaluation includes appropriate radiographs and careful clinical assessment of the soft-tissue envelope. Treatment is directed at safeguarding tissue vascularity and emphasizes restoration of joint congruity and the mechanical axis of the limb. Temporary joint-spanning external fixation facilitates soft-tissue recovery, whereas minimally invasive techniques and anatomically contoured plates can limit damage to the soft tissues and provide stable fixation. Alternatively, the use of limited internal fixation and definitive external fixation can minimize soft-tissue disruption, avoid complications, and allow fracture union. Complications, including infection, loss of fixation, and malalignment, are best avoided by following these biologically respectful treatment principles.

Nonarticular proximal tibia fractures: treatment options and decision making.

Nonarticular proximal-third fractures account for 5% to 11% of tibial shaft injuries and occur as a result of a variety of mechanisms. Treatment is more challenging than for more distal fractures, and the rates of compartment syndrome and arterial injury are higher, especially for displaced fractures. Closed management often leads to varus malunion, especially when the fibula is intact. Closed treatment should therefore be reserved for nondisplaced or minimally displaced fractures with little soft-tissue injury. Plating of the proximal tibia has become a less popular alternative because of the high incidence of infection and fixation failure. However, judicious use of lateral plates as an adjunct to medial external fixation in comminuted fractures can be effective. External fixation remains the most versatile method. It is indicated for fractures with short proximal fragments and in cases of extensive soft-tissue injury that would preclude use of other surgical techniques. Temporary joint-spanning external fixation has a role in the initial management of certain fracture patterns, particularly when accompanied by severe soft-tissue injury. Although intramedullary nailing can lead to valgus malunion in a sizable percentage of patients with this injury, it can be useful for stabilizing fractures with proximal fragments longer than 5 to 6 cm. Placing the entry portal more proximal and lateral, locking in extension, and using specific techniques, such as blocking screws, can improve alignment after nailing. Use of an algorithm that takes into account the severity of soft-tissue injury, the length of the fracture fragment, and the degree of fracture stability allows effective decision making among current treatment techniques.