Local Soft Tissue Injury Research Articles

Changes In Serum Creatine Kinase In Patient After Total Hip Arthroplasty

Background : Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in postoperative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation.
 Objective : This article presents a literature review regarding changes in serum creatine kinase in patients after total hip arthroplasty.
 Method : Descriptive research with a qualitative approach, systematic literature review study. Researchgate, Google Scholar and ScienceDirect searches reviewed changes in serum creatine kinase in patients after total hip arthroplasty. A total of 5 studies conducted between 2019-2023 were included in this review.
 Results : A total of 42,890 titles were identified and found 5 studies that met the requirements/criteria which discussed changes in serum creatine kinase in patients after total hip arthroplasty.
 Conclusions : We analyzed biochemical markers of muscle damage in patients treated with total hip arthroplasty with minimally invasive and standard posterolateral approach to providing objective evidence of the local soft-tissue injury at the time of arthroplasty. The objective measurement of muscle damage marker provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Changes in creatine kinase serum in patient after total hip arthroplasty

Background: Some studies reported that measuring serum creatine kinase (CK) level is an objective method with which to determine the relative invasiveness of surgery. The purpose of this study was to evaluate the change in post-operative serum CK levels as a measure of whether the direct anterior approach (DAA) is less invasive than the posterior approach (PA) regarding postoperative rehabilitation. Methods: This study design was a descriptive research with a qualitative approach, systematic literature review study. ResearchGate, Google Scholar and ScienceDirect searches reviewed changes in serum creatine kinase in patients after total hip arthroplasty. A total of 5 studies conducted between 2019-2023 were included in this review to present a literature review regarding changes in serum creatine kinase in patients after total hip arthroplasty. Results: We analyzed biochemical markers of muscle damage in patients treated with total hip arthroplasty with minimally invasive and standard posterolateral approach to providing objective evidence of the local soft-tissue injury at the time of arthroplasty. A total of 42,890 titles were identified and 5 studies that met the requirements/criteria which discussed changes in serum creatine kinase in patients after total hip arthroplasty. Conclusion: The objective measurement of muscle damage markers provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Parameters of Conversion from Temporary External Fixation to Internal Fixation in Open Fractures in Adults

Background Open fractures often have extensive soft-tissue damage requiring multiple procedures such as debridement, soft-tissue coverage, and definitive fixation through the cooperative work of orthopedic and plastic surgeons. Combined treatment for both the fracture and soft-tissue. Patients obtain many benefits from early fixation. Early stabilization facilitates patient mobility and alleviates pain and discomfort. Aim of the Work Systematically reviewing available evidence from published articles to assess points of conversion from this temporary external fixation to internal fixation in open fractures. Patients and Methods We performed this systematic review and meta-analysis in accordance to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statement. PRISMA and MOOSE are reporting checklists for Authors, Editors, and Reviewers of the interventional and observational studies. According to International committee of medical journal association (ICJME), reviewers must report their findings according to each of the items listed in those checklists. Results The moderate negative correlation between CRP and duration of conversion from EF to IF is probably because the downward trend of CRP from the peak value was considered one factor in the timing of conversion to IF, Strategy to perform definitive IF as early as possible resulted in 91% of patients undergoing definitive IF within 3 weeks after injury. In addition, this strategy is described to be beneficial for early soft-tissue repair with low infection rate. Subsequent conversion to ORIF can safely be performed once the patient is hemodynamically and systemically stable and any local soft-tissue injury has resolved, union rate of 91%, an infection rate of 16% and one fixation failure. All the infections occurred in open fractures, of which 75% were Gustilo grade III. Conclusion In conclusion, temporary external fixation for open fracture of the lower limb followed by conversion to internal fixation, as early as soft tissue and general condition permit, may be a safe and effective procedure for patients with open fracture. It is not precisely known when is the best time to convert to definitive fixation without increasing the risk of infection.

Evaluation of Treatment of Unstable Distal Radial Fractures by External Fixator

Background: Distal radial fractures are very common in Orthopaedic practice but still there is no unanimity about its treatment. Objective: To evaluate the external fixator for the treatment of unstable distal radius fractures. Methods: This prospective observational study was carried out from January 2018 to December 2019 over a period of two years. Twenty-five consecutive patients of both sexes between the ages of 18 to 60 years with closed or open unstable distal radius fractures with or without intraarticular extension admitted in the Department of Orthopaedic Surgery, 250 Bedded General Hospital, Tangail & several private hospitals in Tangail & Dhaka city were selected. Patients with diabetes mellitus or chronic renal or hepatic disorder or extra-articular fractures or volar & dorsal shear injuries (Barton fractures) were excluded from this study. All the patients were evaluated thoroughly including distal neurovascular status and any associated injuries ruled out. Patients were operated as early as possible. But 4 cases were lost to follow up. Remaining 21 patients were followed up for at least 6 months and a maximum period of 12 months. Results: In this series mean age of the patient was 35.71±11.65 years and males (66.7%) were predominant than females (33.3%). In this series right side was involved in 13 patients (61.9%) and left side in 8 patients (38.1%). The mechanism of injury included road traffic accident 13 (61.9%), fall on slippery ground 7 (33.3%) and occupational accident 1 (4.8%). Six patients of this study (28.6%) had associated injury other than the local soft tissue injury. Most of the patients (66.7%) were operated on the day of admission, 2 patients (9.5%) were operated within 3 days and 5 patients (23.8%) were operated within 7 days. As per AO classification, majority (38.1%) injury was type C3 fracture followed by C1 (33.3%), C2 (14.3%), B1 (9.5%) and A3 (4.8%). According to functional outcome, satisfactory was 76.2% and according to anatomical outcome, satisfactory was 85.7%. Conclusion: According to this study finding satisfactory outcome was 76.2% (functional) and 85.7% (anatomical). J Shaheed Suhrawardy Med Coll 2021; 13(1): 20-25

Changes of the serum creatine phosphokinase in total hip arthroplasty in Vietnamese patients

BackgroundWe analyzed biochemical markers of muscle damage in patients treated with total hip arthroplasty with minimally invasive and standard posterolateral approach to providing objective evidence of the local soft-tissue injury at the time of arthroplasty. MethodsSixty-one patients in group one treated with minimally invasive total hip arthroplasty through an approach less 9 cm length and fifty-three patients in group two treated with the same procedure through an approach more than 9 cm length. Serum creatine phosphokinase (CPK) levels were measured preoperatively and on postoperative days 1, day 2 and 5. ResultsThe levels of the markers of muscle damage were increased in both group. The rise in the CPK level on postoperative day 1 in both group was 2.5–3 times higher than preoperative CPK and were slightly decreased on the next few days. There were no significant differences between the two cohorts of changes of CPK level. ConclusionsThe objective measurement of muscle damage marker provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Arthroscopic Posterior Glenoid Fracture Fixation Using Knotless Suture Anchors

Shoulder instability after a posterior glenoid rim fracture is rare and potentially difficult pathology to treat. Operative techniques often involve a large dissection to view the fragments resulting in local soft tissue injury. Internal fixation is often achieved with interfragmentary screws; however, this may not be possible with small or multifragmentary fracture patterns. We describe an arthroscopic technique for posterior glenoid rim fracture fixation using knotless suture anchors. These anchors can be inserted without cannulas allowing easier access to the posterior glenoid. This procedure is simple, safe, and offers good visualization of the glenohumeral joint whilst avoiding the detrimental effects of larger surgical dissection.

On the importance of 3D, geometrically accurate, and subject-specific finite element analysis for evaluation of in-vivo soft tissue loads

Pressure ulcers are a type of local soft tissue injury due to sustained mechanical loading and remain a common issue in patient care. People with spinal cord injury (SCI) are especially at risk of pressure ulcers due to impaired mobility and sensory perception. The development of load improving support structures relies on realistic tissue load evaluation e.g. using finite element analysis (FEA). FEA requires realistic subject-specific mechanical properties and geometries. This study focuses on the effect of geometry. MRI is used for the creation of geometrically accurate models of the human buttock for three able-bodied volunteers and three volunteers with SCI. The effect of geometry on observed internal tissue deformations for each subject is studied by comparing FEA findings for equivalent loading conditions. The large variations found between subjects confirms the importance of subject-specific FEA.

Markers of muscle damage for comparing soft tissue injury following proximal femur nail and dynamic hip screw operations for intertrochanteric hip fractures

BackgroundFemoral neck fractures are the most common fractures among the elderly. The two operative approaches used for the treatment of AO/OTA 31 intertrochanteric fractures include an intramedullary device (proximal femoral nail [PFN]) or an extramedullary device (sliding/dynamic hip screw [DHS]). The aim of this study was to provide objective evidence of local soft tissue injury by measuring serum creatine phosphokinase (CPK), a biochemical marker, to quantify muscle damage and inflammation in patients treated by the two approaches. Patients and methodsMedical data of 359 patients operated for intertrochanteric fractures with PFN (156 patients) or DHS (193 patients) were retrospectively reviewed. The fractures were classified according to AO/OTA classification. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum CPK and serum hemoglobin (Hb) levels were measured preoperatively and on postoperative day 1 (POD1). Independent predictors of elevation in the levels of markers of inflammation and muscle damage were determined by a multivariate linear regression model. ResultsThe demographics were similar for the two groups. Our study population included 64.2% female patients. Preoperative serum CPK levels were available for 89 patients and POD1 serum CPK levels were available for all patients. One-hundred and thirteen of the 193 DHS patients (58%) and 14 of the 156 PFN patients (9%) had a stable fracture (AO/OTA 31A1, p<0.0001). The DHS patients had a greater increase between pre- and postoperative CPK levels compared to the PFN patients (DHS, δ=368 versus PFN, δ=65, p<0.0002). The PFN patients had a greater decrease in both the pre- and postoperative Hb levels compared to the DHS patients (Diff_Hb 0.27g/dl). The older the patient, the greater decreases in Diff_CPK compared to the younger ones. ConclusionsImplementation of POD1 CPK blood levels as a biochemical marker of soft tissue injury provided quantitative evidence that patients whose intertrochanteric fracture was stabilized by a DHS suffered greater soft tissue injury compared to patients whose fracture was stabilized by a PFN.

Risk factors for the development of heterotopic ossification after acetabular fracture fixation.

Heterotopic ossification (HO) is a common complication of the operative treatment of acetabular fractures. Although the surgical approach has been shown to correlate with the development of ectopic bone, specific risk factors have not been elucidated. The purposes of this study were to determine specific risk factors associated with the development of severe HO and the frequency with which patients develop severe HO after acetabular fracture fixation through an isolated Kocher-Langenbeck approach. Using an institutional orthopaedic trauma database at a regional Level I trauma center, patients undergoing open treatment of acetabular fractures during the study period (January 2000 to January 2010) were identified. A review of medical records and imaging studies was performed on 508 patients who were treated by the senior author (MR) through an isolated Kocher-Langenbeck approach. During the study period, the senior author used indomethacin for HO prophylaxis in patients who had ipsilateral femur fracture treated with antegrade reamed medullary nailing or severe local soft tissue injury; 49 (10%) of the patients he treated with the Kocher-Langenbeck approach received prophylaxis, and they were excluded from this study, leaving a total of 459 patients who met inclusion criteria. Of those, 147 (29%) were lost to followup or did not have radiographs both before and at a minimum of 6 weeks (median, 1 week; range, 0-3 weeks), leaving 312 (61% of the patients treated with the Kocher-Langenbeck approach during this time) available for this analysis. Demographic data as well as information related to cause of injury, associated periacetabular findings, other system injuries, and treatment were gathered. Final followup radiographs were assessed for the presence of ectopic bone by two of the authors (TJO, AS) using the modified Brooker classification. Logistic regression was performed to identify possible predictors of development of severe ectopic bone. The only predictor we identified for the development of severe HO was the need for prolonged mechanical ventilation (odds ratio, 7.1; 95% confidence interval, 2.9-17.3; p=0.001). Injury Severity Score, sex, presence of comminution, femoral head impaction, dislocation, degloving injury, debris in the joint, number of other fractures, and head and chest Abbreviated Injury Score>2 did not correlate with severe HO. Severe HO (Brooker Class III or IV) developed in 38 of 312 patients (12%). Patients with prolonged mechanical ventilation might benefit from HO prophylaxis given the increased risk of developing severe HO in this patient population. However, future prospective studies need to be performed to verify this finding given the fact that a considerable number of patients were prophylactically treated in this study. Level IV, prognosticstudy. See Guidelines for Authors for a complete description of levels of evidence.

Application of the self-made 10％ sodium chloride solution pad ice packs in early local soft tissue injury patients

Objective To explore the effect of self-made 10％ sodium chloride solution pad ice packs on the patients with local soft tissue injury in early time.Methods Totals of 62 cases with lower limb soft tissue injury were selected and randomly divided into experimental group ( n =32 ) that received the cold compress treatment by homemade 10％ sodium chloride solution pad ice packs,and control group( n =30) that received the cold compress treatment by water pad ice packs.Then,0,0.5,1.5,2 h later,the internal temperature,the temperature between the body surface and ice bag,hardness,the surface of contact surface size,and patients' satisfaction of two groups were observed.Results In the experimental group,the initial temperature of 10％sodium chloride solution pad ice packs was ( - 18.38 ±0.81 ) ℃,temperature between ice bag and body surface was 18℃ during cold compress,half an hour later,the temperature of inside ice bag was ( -9.73 ± 0.54)℃.After one hour in the room,the second cold compress,internal temperature was ( - 2.55 ± 1.66) ℃ and the temperature between ice bag and the surface was about 22 ℃,the end of ice internal temperature was (8.5 ±1.81 )℃.Hardness of first and secondary cold compress was small,the area size of skin contact with ice was about 72％.In the control goup,for the water cotton pad ice bags were so hardness that early thermometers were not inserted and temperature can not accurate measured.And the area of skin contact with ice was 29％.Significant differences were found in the contact area between two groups in different time (t =49.32,49.32,49.32,39.64,respectively; P ＜ 0.05 ).There was no significant difference in the pain degree of patients between two groups,while after 48 h cold compress,pain rating index and the swelling score of experimental group was significantly lower than that of control group(x2 =0.017,P ＜0.05).Patients' satisfaction of experimental group was significantly higher than that of control group ( x2 =4.4,P ＜ 0.05 ).Condusions Appling the selfmade 10％ sodium chloride solution pad ice packs,for the temperature between ice bag and the surface was higher than the skin freezing temperature( -5 ℃ ) and below the basal body temperature,which can reach the objective with no cause frostbite,it has large contact area,easy fixing and shaping,and good for patients with local soft tissue injury in early stage. Key words: Soft tissue injury; Cold compress; 10％ sodium chloride solution

Comparison of Minimally Invasive Direct Anterior Versus Posterior Total Hip Arthroplasty Based on Inflammation and Muscle Damage Markers

A number of surgical approaches are utilized in total hip arthroplasty. It has been hypothesized that the anterior approach results in less muscle damage than the posterior approach. We prospectively analyzed biochemical markers of muscle damage and inflammation in patients treated with minimally invasive total hip arthroplasty with an anterior or posterior approach to provide objective evidence of the local soft-tissue injury at the time of arthroplasty. Twenty-nine patients treated with minimally invasive total hip arthroplasty through a direct anterior approach and twenty-eight patients treated with the same procedure through a posterior approach were prospectively analyzed. Perioperative and radiographic data were collected to ensure cohorts with similar characteristics. Serum creatine kinase (CK), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-1 beta (IL-1ß), and tumor necrosis factor-alpha (TNF-a) levels were measured preoperatively, in the post-anesthesia-care unit (except for the CRP level), and on postoperative days 1 and 2. The Student t test and Fisher exact test were used to make comparisons between the two groups. Independent predictors of elevation in levels of markers of inflammation and muscle damage were determined with use of multivariate logistic regression analysis. The levels of the markers of inflammation were slightly decreased in the direct-anterior-approach group as compared with those in the posterior-approach group. The rise in the CK level in the posterior-approach group was 5.5 times higher than that in the anterior-approach group in the post-anesthesia-care unit (mean difference, 150.3 units/L [95% CI, 70.4 to 230.2]; p < 0.05) and nearly twice as high cumulatively (mean difference, 305.0 units/L [95% CI, -46.7 to 656.8]; p < 0.05). We believe that the anterior total hip arthroplasty approach used in this study caused significantly less muscle damage than did the posterior surgical approach, as indicated by serum CK levels. The clinical importance of the rise in the CK level needs to be delineated by additional clinical studies. The overall physiologic burden, as demonstrated by measurement of inflammation marker levels, appears to be similar between the anterior and posterior approaches. Objective measurement of muscle damage and inflammation markers provides an unbiased way of determining the immediate effects of surgical intervention in patients treated with total hip arthroplasty.

Surgical Treatment of Acute and Chronic Anterior and Posterior Cruciate Ligament and Medial-side Injuries of the Knee

KD-IIIM knee injuries are challenging injuries that can do well when anatomic reconstruction techniques are used. This article describes the authors preferred reconstructions, timing of surgery, and rehabilitation techniques. The reconstructions are generally initiated 3 or 4 weeks after the injury when the local soft tissue injury allows and associated fractures have already been stabilized. The posterior cruciate ligament, posteromedial corner, and meniscus injuries are addressed in the initial operation. The corresponding author prefers to come back 6 weeks later and reconstruct the anterior cruciate ligament and assure that acceptable progress has been made regarding knee motion.

Functional evaluation of foot after Lisfranc injury with local soft tissue injury

Objective To evaluate the foot function after Lisfranc injury with local soft tissue in-jury. Methods From November 2000 to April 2006, 43 patients (at mean age of 32 years) with fresh Lisfranc injuries (45 sides) were managed with open reduction and internal fixation with screws, Kir-schner wires and AO plates. All patients had no joint surface damage and received no fusion surgery. Ac-cording to the Quenu-Kuss classification of Lisfranc injury, there were 14 patients with type-A injury, 21 with type-B and 10 with type-C. According to AO classification, there were 29 feet without severe soft tis-sue injury and 16 feet with severe soft tissue injury, of which 10 patients were combined with severe local soft tissue injury (one patient with Foot compartment syndrome). The period from injury to surgery was seven days. All patients received cast immobilization for 8-12 weeks and the foot function was evaluated by anteroposterior and lateral X-rays and American Orthopedic Foot and Ankle Society (AOFAS) score. Results All patients were followed up for 12-69 months (average 37 months), which showed that all pa-tients obtained anatomic reduction and 32 patients were satisfied with operative outcome. The average postoperative AOFAS score was 97 points for patients without severe soft tissue injury and 82 points for pa-tients with severe soft tissue injury (P<0.05). Conclusion After Lisfranc injury, the foot function is related to severity of both joint injury and local soft tissue injury. Key words: Wounds and injuries; Foot joints; Dislocations; Soft tissue injuries; Inter-nal fixators

Complications related to deep venous thrombosis prophylaxis in trauma: a systematic review of the literature

Deep venous thrombosis prophylaxis is essential to the appropriate management of multisystem trauma patients. Without thromboprophylaxis, the rate of venous thrombosis and subsequent pulmonary embolism is substantial. Three prophylactic modalities are common: pharmacologic anticoagulation, mechanical compression devices, and inferior vena cava filtration. A systematic review was completed using PRISMA guidelines to evaluate the potential complications of DVT prophylactic options. Level one evidence currently supports the use of low molecular weight heparins for thromboprophylaxis in the trauma patient. Unfortunately, multiple techniques are not infrequently required for complex multisystem trauma patients. Each modality has potential complications. The risks of heparin include bleeding and heparin induced thrombocytopenia. Mechanical compression devices can result in local soft tissue injury, bleeding and patient non-compliance. Inferior vena cava filters migrate, cause inferior vena cava occlusion, and penetrate the vessel wall. While the use of these techniques can be life saving, they must be appropriately utilized.

Analysis of outcomes of vascularized flap reconstruction in patients with advanced mandibular osteoradionecrosis

Objective To examine outcomes of vascularized bone flap reconstruction of end-stage osteoradionecrosis of the mandible. Study Design Case series with planned data collection. Setting Tertiary care academic hospital. Subjects Patients with end-stage radiation-induced osteoradionecrosis (ORN) refractory to conservative therapy with wound complications including chronic infections, fistula formation, and pathologic fracture were included. Results Outcomes of 33 patients were prospectively collected and analyzed, making this the largest series on this subject in the literature and the only one with planned data collection. Data on preoperative variables including radiation dose, sub-site location, treatment date, and prior therapy, along with intraoperative issues and postoperative outcomes, were tracked and are presented. ORN was seen to develop in a bimodal distribution based on the timing of interval surgical intervention. The extent of local soft tissue injury often required the use of contralateral recipient vessels. Local wound complication rates were higher than that seen in primary reconstructions. Conclusions Successful reconstruction was achieved in all of the patients in this series. Long-term resolution of infectious complication and disease resolution was seen in 91 percent of the patients in this series.

Long Bone Fractures Caused by Penetrating Injuries in Terrorists Attacks

High-energy penetrating injuries are increasingly common in the civilian setting. During the years 2000 to 2003, more than 70 suicide bombing attacks occurred in Israel. These were characterized by high numbers of casualties, primarily caused by blast injuries. Injury caused by a blast can be either a primary blast effect of acceleration-deceleration of the blast wave or a secondary effect of metal fragments deliberately placed in explosives, causing severe penetrating injuries. The latter type of injury may result in severe open limb fractures. We identified and reviewed 91 patients with 117 long bone fractures caused by penetrating terror-related injuries treated in our institution during 2000 to 2003. The patients were divided according to the mechanism of injury, i.e., either gunshot injury or blast injuries; several parameters were compared. Patients in the blast injury group included more children and elderly patients than the gunshot injury group did. This group also had a significantly higher Injury Severity Score and a higher number of associated injuries, including multiple fractures and mortality. The treatment modalities for the fractures were similar for both groups, as was the fracture final outcome. Local soft tissue injury was more severe in the gunshot injury group, as demonstrated by a higher number of type IIIC fractures, as well as more nerve injuries. Terror attacks may produce several modes of severe penetrating injuries causing high-grade open fractures. These should be aggressively treated by physicians remaining cognizant of other systemic and general implications of such a severe trauma.

Fractures of the Tibial Shaft (including Acute Compartment Syndrome)

Tibial shaft fractures are the most common diaphyseal fractures in adults. Epidemiological data from Edinburgh, UK, suggest an incidence of 2 fractures per 10,000 population per year. The most common single cause in this series was motor vehicle accidents, (which accounted for more than 50% of fractures), followed by sport (predominantly soccer). Twenty-four percent of the fractures in this series were open injuries. Whilst these figures will differ widely between centres, it is clear that tibial shaft fractures represent a wide spectrum of injury patterns. They vary from simple, low-violence fractures, which can often be reliably managed by non-surgical treatments, to violent, high-energy fractures, often associated with severe local soft tissue damage or injury to other body areas, which will require multidisciplinary surgical care (Figure 1). There are several methods of treatment for tibial shaft fractures, and controversy exists as to which (if any) is superior. The authors believe that no method of treatment is universally applicable. Each method has its merits, and a competent surgeon should be capable of applying the most suitable treatment for any particular patient. This decision should be guided by the factors listed in Figure 2, and surgeons may occasionally have to accept that a particular injury lies beyond their ability to treat, and consider seeking help from colleagues.

BIOMECHANICS AND BIOLOGY OF FRACTURE REPAIR UNDER EXTERNAL FIXATION

The major factors determining the mechanical milieu of a healing fracture under external fixation, and thereby the mechanism of union, are the rigidity of the selected fixation device, the fracture configuration, the accuracy of fracture reduction, and the amount of physiologic stresses dictated by functional activity and loading. Bone healing problems encountered in fractures stabilized externally merely reflect the severity of the local soft-tissue and periosteal injury and should not be attributed to the inherent features of the fixation modality. Although some surgeons have had reservations concerning the use of external fixation for fracture treatment, based mainly on concerns of pin-tract infection and fracture nonunion, much of the clinical experience and basic science research results have proven the reverse. Many of the potential benefits of external fixation, such as the change of fixation stiffness, are not yet fully appreciated. Additional research and well-organized clinical trials must be performed. Pin-tract problems can be controlled, but the surgeon using such a device must be familiar with the techniques and follow the established regimens during postoperative care. One common mistake is to assume that external fixators, especially those of the simpler unilateral configuration, are easy to use and do not require learning or mastering the surgical techniques until the time of application. Periodic examination and radiographic evaluations are also essential to adjust conditions of the fracture site. The importance of balancing the biomechanical properties and the biologic consequences of different external fixation modalities has been demonstrated. Understanding this knowledge and the techniques of application associated with external fixation is the prerequisite to successful treatment. Some of the basic biomechanical information related to external fixation and bone fracture union is still unknown. This lack should provide the impetus for surgeons, bioengineers, and medical scientists to continue collaborative basic and applied research. Furthermore, by recognizing the proper cell mediators and the physical means to stimulate these cellular elements, the bone fracture healing process may be modulated, regardless of the fixation technique. The result of such effort should provide new modalities to improve fracture management.