Removal Of External Fixator Research Articles

Folded free vascularized fibular grafts for the treatment of subtrochanteric fractures complicated with segmental bone defects

Subtrochanteric fractures of the femur complicated with segmental bone defects are uncommon injuries and challenging to manage. We evaluated the effect of reconstructing extensive bone defect in the subtrochanteric area (mean, 6.9 cm) with folded free vascularized fibular graft (FVFG). Between 2001 and 2007, 14 cases of subtrochanteric fractures complicated with huge bone defects treated by folded FVFG transfer in our hospital were retrospectively reviewed. The defect was reconstructed by folded FVFG transfer and locking plate stabilization in 10 patients with no sign of infection at admission (group 1). In the other four patients presented with infections (group 2), the defect was reconstructed by folded FVFG transfer and external fixator fixation. The average follow-up period was 67.4 months. Bone union was achieved in all of the cases at an average of 5.4 months (range, 4-6 months). Primarily, bone union was achieved in all of the cases in group 1, but one stress fracture occurred in group 2. The full weight bearing time was 5.4 months (range, 5-6 months) in group 1 and 8.5 months (range, 8-9 months) in group 2. Seven patients in group 1 had the locking plate removed in an average of 27 months (range, 18-38 months). In group 2, the external fixator removal time was 13 months (range, 10-18 months). There was no varus deformity at the final follow-up in group 1. The neck-shaft angle measured during the postoperative period and at final follow-up was 129.6 degrees and 129.4 degrees, respectively. In group 2, the neck-shaft angle at the final follow-up was significantly less than the angle measured at the postoperative period (115.5 vs. 129.5 degree, p = 0.021). The range of motion of the hip and knee joint (extend and flex) was 100 degrees or more in all patients at the final follow-up. The results of this study showed that huge subtrochanteric bone defects reconstructed by folded FVFG and locking plate were highly successful in achieving bone union, reducing risks of postoperative stress fracture and preventing malunion. When huge bone defects in the subtrochanteric area complicated with acute or chronic infections, the technique of external fixator offers an alternative to reconstruct the stability of the proximal femur after folded FVFG. However, because of the inadequate stabilization, the risks of varus malunion and postoperative stress fracture could be increased after external fixator fixation. V, therapeutic study.

Free vascularized fibular grafts in Type 3 open tibia fractures

The aim of this study was to evaluate the results and complications of free vascularized fibular grafting (FVFG) for the reconstruction of bone defects in Gustilo Type 3 open tibia fractures. Free vascularized fibular grafting was performed on open tibia fractures with a bone defect of an average of 10 (range: 6 to 18) cm in 21 patients (19 males, 2 females; mean age: 32 years; range: 16 to 47 years). Primary FVFG was performed for 15 patients with open fractures and secondary FVFG in 6 patients with osteomyelitis due to open fractures or defective nonunions. Bony unions were evaluated retrospectively. At a mean follow-up time of 74 (range: 18 to 216) months, 18 patients were examined for malalignment, shortness, and range of motion. Quality of life was evaluated using the Short Form 36 (SF-36). Mean bony union times for the proximal and distal fibula were 19 (range: 16 to 24) weeks and 20 (range: 16 to 28) weeks, respectively. Proximal nonunion was detected in three patients. Mean external fixation removal time was 6.3 (range: 3 to 14) months. Stress fractures occurred in 15 patients following fixator removal. Malalignment of over 5 degrees was detected in 7 patients and shortness over 2 cm was detected in 4 patients. SF-36 scores were significantly lower in the domains of physical functioning, role limitation due to physical problems, bodily pain, general perception of health, social function, and role limitation due to emotional problems. Mental health, energy and vitality were similar to the healthy reference group. Free vascularized fibular grafting appears to be a reliable and effective method for reconstructing bone defects and soft tissue defects in a single session in open tibia fractures.

Return to Running and Sports Participation After Limb Salvage

The ability to return to running and sports participation after lower extremity limb salvage has not been well documented previously. Although the ability to ambulate without pain or assistive devices is generally a criteria for a good limb salvage outcome, many patients at our institution have expressed a desire to return to a more athletic lifestyle to include running and sports participation. The purpose of this study was to investigate the types of athletic endeavors our high-energy lower extremity trauma patients were able to pursue after limb salvage. We retrospectively analyzed lower extremity limb salvage patients who were at least 12 weeks status after external fixation removal and participated in our limb salvage return-to-running clinical pathway. Patients were rehabilitated to their highest functional level through a sports medicine-based approach. A custom energy-storing ankle-foot orthosis was implemented to help augment plantarflexion strength in conjunction with running gait retraining. The first 10 patients to complete the clinical pathway were identified. All patients were treated at the same institution by the same orthopedic surgeon and physical therapist. Eight patients have returned to running, and 10 patients have returned to weight-lifting. Seven patients have returned to cycling, three have returned to golf, three to basketball, and two to softball. Two patients have completed a mini-triathlon. Aggressive rehabilitation, an energy-storing ankle-foot orthosis, and running gait retraining can restore an active recreational lifestyle to patients who have undergone lower extremity limb salvage.

A NEW METHOD FOR QUANTIFICATION OF REGENERATED BONE TISSUE ON X-RAY IMAGES OF ELONGATED BONES

A new method for quantification of bone regenerate on the basis of computer-aided analysis of digitized Xray images is presented and its applicability in bone lengthening using Ilizarov method is demonstrated. In contrary to classical methods the internal part of the bone image is taken into consideration instead of the bone edges. Theoretical background of this concept is presented and experimentally verified. Experimental results show that the method proposed allows us for assessment of the bone regenerate, precise choice of the moment of external fixator removal as well as prediction of abnormalities in the osteogenesis process (excluding overall decalcification). However, the rules of interpretation of the results are not discussed in details.

Correction of complex equino cavo varus foot deformity in skeletally mature patients by Ilizarov external fixation versus staged external–internal fixation

Complex foot deformity is a multi-planar foot deformity with many etiologic factors. Different corrective procedures using Ilizarov external fixation have been described which include, soft tissue release, V-osteotomy, multiple osteotomies and triple fusion. In this study we compare the results of two groups of skeletally mature patients with complex foot deformity who were treated by two different protocols. The first group (27 patients, 29 feet) was treated by triple fusion fixed by Ilizarov external fixator until union. The second group (29 patients, 30 feet), was treated by triple fusion with initial fixation by Ilizarov external fixation until correction of the deformity was achieved clinically, and then the Ilizarov fixation was replaced by internal fixation using percutaneous screws. Both groups were compared as regard the surgical outcome and the incidence of complications. There was statistically significant difference between the two groups regarding duration of external fixation and duration of casting with shorter duration in the group 2. Also there was statistically significant difference between both groups regarding pin tract infection with less incidence in group 2. Early removal of Ilizarov external fixation after correction of the deformity and percutaneous internal fixation using 6.5 cannulated screws can shorten the duration of treatment and be more comfortable for the patient with a low risk of recurrence or infection.

Evaluation of Ligamentotaxis in Management of Comminuted Intra-articular Fractures of Distal Radius Using Spanning Naseer–Awais (NA) External Fixator

Abstract Background: Comminuted intra-articular distal ra-dius fractures are the most common amongst the frac-tures of the upper limb. There are various methods of management of comminuted intra-articular fractures of distal radius published in the orthopaedic literature, these are closed reduction and plaster cast application, closed reduction and percutaneous pin fixation, closed reduction percutaneous pin fixation with plaster cast application, ligamentotaxis with application of exter-nal fixation across the wrist joint and open reduction and internal fixation. Objective: Objectives of this study were to evaluate the ligamentotaxis for the treatment of comminuted intra-articular fractures of distal radius and compare the prescribed data for comparison with similar series in the orthopaedic literature. Methodology: During this study 30 skeletally mature patients with comminuted intra-articular fractures of distal radius attending outpatient department or ortho-paedic emergency of Lahore General Hospital, Lahore, with less than one week duration were admitted in the hospital. They were examined clinically. Radiographs were taken and diagnosis was confirmed. Patients with open fractures or with multiple injuries were excluded from the study. Patients were administered general anesthesia. Skin distal to the elbow was prepared with antiseptic iodine solution and draping was done. Clo-sed reduction of the fracture was done and N. A exter-nal fixator was applied across the wrist joint. Distrac-tion force was applied across the fracture site by elon-gation of threaded rod of external fixator. This distrac-tion force was maintained till union of the fracture according to the principle of ligamentotaxis. All the patients were examined in outpatient department at regular intervals. Data of this study was recorded for comparison of similar series in recent orthopaedic lite-rature. Results: There were no serious complications in our study. Six patients (20%) developed mild pin tract in-fections these were treated by oral antibiotic therapy. One patient (3.3%) developed aseptic loosening of external fixator after three weeks. In this patient exter-nal fixator was replaced by plaster cast. One patient (3.3%) lost the reduction in which revision of external fixation was carried out. After removal of external fixator / plaster cast, a supervised programme of phy-siotherapy was started for restoration of the wrist and hand functions. Twenty two (73.3%) patients required physiotherapy for 1 week, 5 (16.7%) required for 2 weeks and 3 patient (10%) did not require it at all. Conclusion: We conclude that ligamentotaxis is an excellent method for the management of comminuted intraarticular fractures of distal end of radius. It obvi-ates the need of plaster cast application or open reduc-tion and internal fixation of the fracture and result of this study are comparable with similar series published in the orthopaedic literature. Keywords: Ligmaentotaxis distal radius fracture.

Evaluation of Reduction in Relapse and Enhancement of Patient Compliance with Hybrid Technique of Maxillary Distraction Osteogenesis: A Long-term Study

ABSTRACTIntroduction and objectivesHybrid technique of maxillary distraction osteogenesis is the latest advance introduced to correct maxillary hypoplasia in cleft lip and palate patients. The objectives of this study was to clinically and cephalometrically evaluate the stability of advanced maxilla over a period of 3 years, after maxillary advancement with hybrid technique of distraction osteogenesis in cleft lip and palate patients, and to asses the patient compliance during the procedure.Materials and methodsTen cleft lip and palate patients having severe maxillary hypoplasia underwent surgical correction of maxillary hypoplasia using hybrid technique of distraction osteogenesis where the rigid external distraction device was immediately removed after the active distraction period, and the advanced maxilla was fixed with rigid internal fixation. Clinical and cephalometrical analyses of the craniofacial skeleton were done at the predistraction, after active distraction and 3 years postdistraction period.ResultsThe results of the clinical and cephalometrical evaluation indicated that there was an effective horizontal advancement of maxilla, increase in the length of the maxilla and a positive correction of overjet all together esthetically improving the facial profile. Three years post distraction evaluation of both the hard and soft tissue profiles indicated a very minimal relapse. All the patients had greater level of compliance after the removal of rigid external distractor and fixation of the distracted maxilla.ConclusionThis study concluded that hybrid technique of maxillary distraction osteogenesis in cleft lip and palate patients gave esthetically acceptable facial profile with minimal relapse after 3 years of follow-up and an increased level of patient compliance during the procedure.

Subsidence of callotasis zone in distraction osteogenesis after external fixator removal, measured by RSA

Background and purpose In clinical practice, achieved lengthening of a callotasis zone should be maintained after the external fixator has been removed. The common understanding has been that the regenerated bone may subside. To investigate this, we used high-resolution radiostereometric analysis (RSA) with accurate measurement of the lengthening zone.Patients and methods We assessed the longitudinal subsidence of a callotasis zone after removal of the external fixator in distraction osteogenesis in 16 patients who underwent 17 segmental lengthening operations on the tibia (n = 9) or femur (n = 8). Median lengthening was 32 (6–80) mm. RSA was performed at the end of the consolidation period before the external fixation device was removed, and this was later repeated at a median time of 11 (4–32) weeks after frame removal.Results A minimal median longitudinal change of 0.01 (–0.28 to 0.60) mm across the lengthening zone occurred in uncomplicated cases.Interpretation Our results indicate that no subsidence of clinical interest occurs after external frame removal.

Assessment of distraction callus in rabbits by monitoring of the electrical impedance of bone

Background and purpose Evaluation of distraction callus is important for determination of the optimal time for removal of external fixation. We attempted to determine whether there might be a relationship between the electrical impedance of bone and callus maturation, with a view to using impedance as a way of knowing when to remove a fixator.Methods We applied an external lengthener to the right tibia of 24 rabbits and performed distraction at 1 mm/day for 10 days. Radiographs were taken and measurement of overall impedance between fixation pins was performed weekly after distraction. At weeks 2, 4, 6, and 8 after distraction (n = 6 each), resistivity of the bone to electrical conductivity was measured before killing. Cross-sectional area of the conduction pathway in callus and maximum bending stress were measured after excision of the tibia.Results The overall impedance increased statistically significantly from 1 to 6 weeks after completion of distraction. The resistivity of bone decreased over 4 weeks and the cross-sectional area of callus decreased significantly over 6 weeks, while the maximum bending stress increased significantly over the same time. We observed a negative correlation between the cross-sectional area of callus and maximum bending stress.Interpretation The impedance values, which are related to changes in electrical conductivity and the conduction pathway, increased due to the changes in the cross-sectional area of callus, despite the reduction in bone resistivity. Since the cross-sectional area of callus was correlated with maximum bending stress and the impedance values increased with the callus-remodeling process, we suggest that temporal increases in overall impedance reflect callus maturation.

Ollier's disease limb lenghtening: Should intramedullary nailing be combined with circular external fixation?

During progressive lower limb lengthening in the management of Ollier's disease, the mean bone-healing index usually reported in the literature stands around 35 days/cm. One of the therapeutic objectives is to reduce the duration of the external fixation. The use of an elastic stable intramedullary nailing system (ESIN) combined with a circular external fixator significantly reduces the healing index. Two groups of patients were compared. In group I, seven patients were operated on for progressive limb lengthening using a circular external fixator associated with an ESIN system: four monosegmental femoral lengthenings, one monosegmental tibial lengthening and two polysegmental femorotibial lengthenings. Nailing was performed via two intramedullary nails already used in traumatology. The date of external fixator removal coincided with that of radiographic healing. The nails were left in place. Group II included 37 patients who underwent limb lengthening by means of an external fixator only. The healing index was calculated and complications were analysed in both groups. The mean healing index (HI) values were: in group I: 23.3 days/cm for the femur, 22.4 days/cm for the tibia and 11.6 days/cm for polysegmental lengthenings ; in group II: 31.6 days/cm for the femur, 35.7 days/cm for the tibia and 19.9 days/cm for polysegmental lengthenings. Group I demonstrated a statistically significant decrease in the HI for monosegmental femoral lengthenings. A substantially reduced duration of external fixation, limited postoperative complications and prevention of later pathologic fractures are the reported advantages of the associated use of a circular external fixator with an ESIN system in the management of Ollier's disease. Level III, comparative retrospective study.

Prolonged Unilateral Disuse Osteopenia 14 Years Post External Fixator Removal: A Case History and Critical Review

Disuse osteopenia is a complication of immobilisation, with reversal generally noted upon remobilisation. This case report focuses on a patient who was seen 18 years following a road traffic collision when multiple fractures were sustained. The patient had an external fixator fitted for a tibia and fibula fracture, which remained in situ for a period of 4 years. Following removal, the patient was mobilised but, still required a single crutch to aid walking. Fourteen years post removal of the fixator, the patient had a DXA scan which, demonstrated a T-score 2.5 SD lower on the affected hip. This places the patient at an increased risk of hip fracture on this side, which requires monitoring. There appear to be no current studies investigating prolonged disuse-osteopenia in patients following removal of long-term external fixators. Further research is required to quantify unilateral long-term effects to bone health and fracture risk in this population.

SIGN Interlocking Nail for the Treatment of Infected Nonunion

Summary: Chronic infection of bone with nonunion and/or bone defects is traditionally treated by a 2-stage procedure involving initial debridement and antibiotic delivery for control of infection and then definitive internal fixation for fracture stabilization. The external fixators have been used to provide stability in the presence of active infection. A technique of Surgical Implant Generation Network (SIGN) solid interlocking nail is used in the femur and tibia bones after thorough irrigation and debridement at the same stage. Although not most suitable for all infected nonunions and/or segmental bone defects, this technique is particularly useful for patients who are poor and hence cannot afford multiple surgeries and are not ideal candidates for external fixation and for those who do not want to have an external fixator applied. This technique was used in a series of 250 patients from multiple centers. The goal of control of infection and bony union was achieved in 213 (85%) cases, 165 cases after a single operation, and 48 cases after additional interventions. In the remaining 37 (15%) patients, the goal of control of infection was achieved with stable nonunion, which were taken care of by standard procedure of bone grafting after control of active infection. Four patients needed exchange nailing to another thicker SIGN nail for continued infection and implant loosening. Subsequently complete control of infection could be achieved in these cases. From the total, 14 fractures went on bone healing despite persistent infection, with or without sinuses. Early removal of nail after union and thorough debridement made them free from infection. But 7 cases are still coming at follow-up with infection but pain-free functional limb, that is, persistent infection even after fracture union. In summary, control of infection and stability to promote union has traditionally been provided by 2 separate procedures, which have proved to be efficacious in the past. However, both these goals can be achieved with 1 surgical procedure in a variety of scenarios in our limited circumstances, using the technique of SIGN solid intramedullary nail. This 1-step surgical procedure eliminates the complications that can occur secondary to the use of external fixation and bone transport. It may also reduce the morbidity of 2 surgical procedures and inpatient admissions required for the two-stage procedures or for the application and removal of external fixators to that of a single procedure and inpatient admission. Additional procedures may be required with both treatment methods for achieving control of infection, bony union, or soft tissue coverage.

Objective Guidelines for Removing an External Fixator after Tibial Lengthening Using Pixel Value Ratio: A Pilot Study

During limb lengthening over an intramedullary nail, decisions regarding external fixator removal and weightbearing depend on the amount of callus seen at the lengthening area on radiographs. However, this method is subjective and objective evaluation of the amount of callus likely would minimize nail or interlocking screw breakage and refracture after fixator removal. We asked how many cortices with full corticalization of the newly formed bone at the lengthening area are needed to allow fixator removal and full weightbearing and how to radiographically determine the stage of corticalization. We retrospectively reviewed 17 patients (34 lengthenings) who underwent bilateral tibial lengthenings over an intramedullary nail. The average gain in length was 7.2 +/- 3.4 cm. We determined the pixel value ratio (ratio of pixel value of regenerate versus the mean pixel value of adjacent bone) of the lengthened area on radiographs. There were no nail or screw breakage and refracture. Partial weightbearing with crutches was permitted when the pixel value ratio was 1 in two cortices and full weightbearing without crutches was permitted when the pixel value ratio was 1 in three cortices. The pixel value ratio on radiographs can be an objective parameter for callus measurement and may provide guidelines for the timing of external fixator removal. We cannot determine from our limited data the minimum pixel value in how many cortices would suggest safe removal, but we can say our criteria were not associated with subsequent refracture.

Femoral lengthening over elastic stable intramedullary nailing in children using the monolateral external fixator

The authors report preliminary results of femoral lengthening performed with monolateral external fixation over elastic stable intramedullary nailing in children. Seven femoral lengthenings were performed in six patients, at a mean age at surgery of 6.6 years (range 1.5-12 years). All lengthenings were performed due to limb length discrepancy (congenital hypoplasia in four patients, growth arrest secondary to neonatal infective osteoarthritis in one, type II sacral agenesis in one). In six cases the elastic nails realised a bipolar ascending construct, in one case a descending construct. Cases were reviewed at a mean time from removal of external fixator of 34.2 months (range 15-75 months). The mean lengthening obtained was 4.8 cm (range 3.8-6.0 cm). Mean consolidation index was 42.9 days/cm. No case of axial deviation requiring surgery and no case of deep infection were recorded. No case of fracture of the regenerate occurred after removal of the external fixator. There were two premature consolidations requiring mobilisation under general anaesthesia, and a case of failure of consolidation requiring surgery. The technique reported provides indisputable biomechanical advantages, particularly increasing stability at the site of osteotomy. The characteristics of implants make this method ideal for lengthenings in children.

Management of bone defect of tibia and soft tissue loss with bone transport

Objective To probe into the role of bone transport on managing tibial bone defect accompanied by anterior-medial soft tissue loss. Methods Orthofix external fixator of lower limb reconstruction system were applied to the medial or anterior-medial side of 57 injured legs. The average tibial defect is 11 (5-20) cm, the largest skin loss area on the anterior-medial side of the leg is 20 cm×8 cm, the smallest area is 5 cm×4 cm. Twelve cases underwent subperiosteal osteotomy in the primary stage; remaining 45 cases underwent secondary osteotomy 2-6 weeks after debridement. The bone segments were transported 10-14 days following osteotomy and proceeded at a rate of 0.25 mm every 6 hour. In case of soft tissue obstruction, docking site mismatch or limited contact, infection and non-union at the docking site, bone grafting, manipulation and realignment and resection were required. Results The average time of treatment which is from debfidement to removal of external fixator is 21 (11-32) months. A good tibial hone reconstruction was atmined in 56 cases, poor bone formation was observed in one case that healed with bone grafting. Limb length discrepancy is less than 4 ram. All wounds were repaired without flaps. Two patients needed plastic surgery. 26% of cases had their docking site healed spontaneously, 1 patient who had a fistula at the docking site had no infection for over 6 months after debridement. Four patients complained pain around knee joint, 11 complained pain at the legs. Six patients had equinus-varus. Five patients had mild knee flexion deformity, and 4 of them recovered. Conclusion Bone transport is effective and satisfactory for managing tibial bone defect accompanied by anterior-medial soft tissue loss. Key words: Tibia; Wounds and injuries; External fixators

Measurement of bone electrical impedance in fracture healing

BackgroundAlthough external fixation is widely used for fractures and limb lengthening, evaluation of the time for removing the external fixator is dependent upon radiographic examinations and clinical findings, and a useful method has yet to be established clinically. This study aimed to measure the bone electrical impedance (Z values) non-invasively by using external fixation pins as electrodes, and clarify the relationship with bone union. MethodsThirty rabbits received the external fixation at the right tibia and were assigned to a control group (group C; n = 5) and a fractured group (group F; n = 25). Z values were measured once a week following surgery. The animals of group F were assigned to 5 groups (weeks 2, 3, 4, 5, and 6 after osteotomy, each n = 5). The resistivity (Ρ) of the electrical property between electrodes was measured prior to euthanasia, and fracture cross-sectional area (FrA) of the conduction pathway and maximum bending stress (Bmax) were measured following excision of the tibia. ResultsAlthough Z values in group F increased through 5 weeks after surgery, Z values in group C remained constant at 3 weeks, and significant differences were observed between groups at 4, 5, and 6 weeks. The Ρ values and FrA in group F decreased through 5 weeks; while Bmax increased, reaching a plateau at 5 weeks. ConclusionsNarrowing of conduction pathway due to the decrease in the contour of fracture area accompanying bone remodeling resulted in an increase of Z values. Both Z values and Bmax in group F reached a peak at 5 weeks, this was believed to be the optimal time for removal of external fixation. These results suggest that measurement of Z values makes it possible to evaluate bone union.

Quantification of Fracture Healing from Radiographs Using the Maximum Callus Index

Callus formation and growth are an essential part of secondary fracture healing. Callus growth can be observed radiographically and measured using the "Callus Index," which is defined as the maximum diameter of the callus divided by the diameter of the bone. We compared three groups of patients with tibial fractures treated by external fixation, intramedullary nailing, and casting to assess the validity of using serial measurements of callus index as a measure of fracture healing. When callus index was plotted against time for each patient, the point at which the fracture began to remodel, indicated by the highest point of the curve, was observed as a consistent feature regardless of fixation method. This occurred on average at 2(1/2) weeks after plaster cast removal (14 weeks post injury), 5 weeks after external fixator removal (22 weeks post injury), and 27 weeks post injury for the intramedullary nailed fractures. Because remodeling only occurs once the fracture is stable, a peak in callus index is a reliable sign that the fracture has united. Serial measurements of callus index would therefore appear to offer a simple method of quantifying secondary fracture healing regardless of the treatment method used. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Applications of external fixation for management of complications associated with musculoskeletal tumors and related surgery

We evaluated the results of, and the course of treatment with, external fixation (EF) in treating complications associated with bone tumors and related surgery. Eighteen patients (9 males, 9 females; mean age 19 years; range 6 to 35 years) who were treated with EF were evaluated in three groups. Histologic diagnoses were osteosarcoma (n=3), Ewing's sarcoma (n=3), hereditary multiple exostosis (n=3), chondrosarcoma (n=2), synovial sarcoma (n=2), Ollier's disease, giant cell tumor of bone, desmoid fibroma, chondromyxoid fibroma, and enchondroma. Complications secondary to bone tumors (n=4) and occurring following limb salvage surgery (n=14) were treated with Ilizarov circular EF in nine patients, unilateral EF in six patients, and both in three patients. The first group included eight patients who were treated with EF for infection and nonunion or deformity following surgery. The mean shortening was 10.6 cm, the mean lengthening was 9.7 cm, and the mean external fixator index was 48.8 days/cm. One patient developed fracture of the free vascularized fibula graft after EF removal, and amputation was required in two patients. The second group consisted of six patients who had shortening secondary to tumor surgery. The mean shortening was 7.5 cm, the mean lengthening was 6.5 cm, and the mean external fixator index was 28 days/cm. In this group, the major complications were implant failure and knee stiffness. The third group included four patients with deformity and shortening secondary to multiple exostosis (n=3) and Ollier's disease. The mean shortening was 7.5 cm, the mean lengthening was 6.5 cm, and the mean external fixator index was 57.2 days/cm. One patient developed ulnar shortening of 2 cm after growth. The use of EF in the management of complications associated with bone tumors and related surgery yields successful results especially in young patients.

Acute Invaginating Docking for Infected Nonunions of the Humerus

To assess the efficacy of acute invaginating docking for infected non-unions of the humerus. Eight men and 3 women aged 17 to 59 years with infected non-unions of the humerus underwent acute invaginating docking with shortening and Ilizarov fixation. The mean shortening was 2.9 cm owing to additional debridement. The mean time to external fixator removal was 14.9 (range, 8-28) weeks. The final bone result was excellent in 1, good in 8, and fair in 2. The functional result was excellent in 7 and good in 4. This modality enables simultaneous treatment of infected non-unions, axial alignment, vascularity, stability, and function.

Treatment of Distal Radius Fractures with a Wrist-Bridging External Fixation: The Value of Alternating Electric Current Stimulation

The radiological and functional outcomes of two groups of comminuted intraarticular fractures of the distal radius that were treated with wrist-bridging external fixation, with or without an alternating electric current stimulation (EF + ES or EF group, respectively), were compared. The radial length, radial inclination and palmar tilt were measured on radiographs taken immediately after removal of wrist external fixator and also after bone union had occurred. Furthermore, active range of motion was compared at the final consultation. Bridging callus was observed earlier postoperatively in the EF + ES group than in the EF group. The radial length and palmar tilt were significantly larger, and the loss of radial length and radial inclination significantly smaller, in the EF + ES group. We believe that callus maturation is enhanced by alternating electric current stimulation, which enables the early removal of external fixator.