Removal Of Fixators Research Articles

New strategy for shortening the consolidation period in distraction lengthening of phalanges or metacarpal bone

Distraction lengthening of digits enhances hand function in patients with congenital phalangeal defects or traumatic hand amputations. Although callotasis is a useful distraction lengthening method, it is challenging and often results in various complications and prolonged fixation. Based on our experiences, we attempted to develop innovations to reduce the fixation period. We included 12 digits from nine patients with digital bone defects; lengthening was performed on seven proximal phalanges and five metacarpal bones using an Ilizarov mini-fixator device. In three digits, cancellous bone grafting within the cavity of the distraction callus, concomitant with internal fixation using an intramedullary screw, was performed to shorten the Healing Index. The mean achieved lengthening was 24mm for proximal phalanges and 22mm for metacarpal bones, with a Healing Index of 37.9 and 42.6 days/cm, respectively. Additionally, the Healing Index was significantly shorter in the three digits treated with cancellous bone grafting and internal fixation (mean 27.0 days/cm) than in the nine with no bone grafting (mean 44.1 days/cm). Major complications included early bone union, insufficient fingertip skin, and callus fractures during the consolidation period, affecting two, two, and one patient, respectively. Bone grafting within the distraction callus cavity promotes rapid bone formation, while internal fixation enables earlier removal of external fixators, thereby shortening the Healing Index.

Repair of Bone Defect of the Talus with Calcaneus Autograft and Autologous Matrix-Induced Chondrogenesis: A Case Report

Background. The question of choosing a treatment strategy for full-thickness osteochondral defects of the tarsal bone remains relevant. When choosing a treatment strategy, two key points should be considered: restoring the architecture of the tarsal bone and achieving long-term restoration of cartilage-like coverage in the area of the osteochondral defect.
 Case report. A 34-year-old physically active patient sustained an ankle injury in 2011 and was treated conservatively. In 2020, he complained of pain and reduced activity. Initial assessment scores were: VAS (Visual Analog Scale) — 6 points, AOFAS-AHS (American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score) — 49 points, FAAM (Foot and Ankle Ability Measure) — 55 points. An MRI revealed an osteochondral defect in the medial part of the tarsal bone dome, measuring 16.4×9.4 mm and with a depth of 20.8 mm. The patient underwent the replacement of the bone defect with an autograft taken from the heel bone, using autologus matrix induced chondrogenesis (AMIC) procedure. After 6 months, a follow-up examination was performed, including ankle arthroscopy and removal of metal fixators. Arthroscopic findings showed that the chondroplasty area was almost identical to intact joint cartilage. One year after chondroplasty, the patient returned to his previous level of physical activity. Assessment scores were: VAS — 1 point, AOFAS-AHS — 94 points, FAAM — 83 points.
 Conclusion. The proposed method allows for the restoration of the architecture of the tarsal bone along with the cartilage surface. The use of a bone autograft helps to fill the tarsal bone defect, and covering the autograft with a collagen membrane contributes to the formation of hyaline-like cartilage tissue in the defect area.

Penthrox® (Methoxyflurane) as an Analgesic for Removal of Circular External Fixators and Minor Procedures during the COVID-19 Pandemic.

Methoxyflurane has excellent analgesic properties and is approved for use in the United Kingdom and Ireland since 2015. It is currently used in emergency departments for analgesia during fracture reductions. During the COVID-19 pandemic, with theatre access severely restricted, Penthrox® had the potential to provide adequate pain relief to aid frame and wire removal in the clinic setting. Patients presenting to the limb reconstruction service elective clinic and requiring frame removal or minor procedures were included in the study. Patients with renal, cardiac or hepatic disease, a history of sensitivity to fluorinated anaesthetic agents and those on any nephrotoxic or enzyme-inducing drugs were excluded. All procedures were performed in an appropriate isolated room in the clinic. Patient demographics, procedure details, visual analogue score, Richmond Agitation Scale and patient satisfaction were recorded. A total of 39 patients were included in the study of which 17 had Ilizarov frames removed, 10 had hexapod removals, nine had heel rings removed and three had an external fixator removed. Eleven patients received additional pain relief in the form of oral analgesia. All patients were satisfied or very satisfied with the experience. One patient required a general anaesthetic for the removal of a wire that could not be removed in the clinic due to bony overgrowth. Patient satisfaction was very high (>95%), and it was possible to perform frame removals and minor procedures in the clinic environment during the COVID-19 pandemic. We see potential for regular use of Penthrox® in the future for the removal of external fixation outside of the operating theatre. Penthrox as an analgesic for frame adjustments and removals is safe and has the potential for significant financial savings for the National Health Service (NHS). Debuka E, Birkenhead P, Shah S, et al. Penthrox® (Methoxyflurane) as an Analgesic for Removal of Circular External Fixators and Minor Procedures during the COVID-19 Pandemic. Strategies Trauma Limb Reconstr 2023;18(2):82-86.

External fixators usage in two hospitals in Delta State south-south Nigeria

Objective: To present our experience in the use of various types of external fixators in two government owned hospitals in Delta State, Nigeria.Methods: A retrospective review of patients managed with external fixators over a period of 8 years – January 2012 to December 2019, in two government owned hospitals in Delta State, Nigeria. Relevant information including bio-data, indications for external fixation, types of external fixator applied, length of time fixators were applied, etc were collected and analysed using IBM SPSS version 22.Results: A total of 94 patients (56 males and 38 females) were included in this study giving a male: female ratio of 1.5 : 1. The mean age of patients was 33.7+ 15.9 years. Four types / designs of external fixators were used, the mono-planar AO design were the ones most commonly used (67.7%), followed by the linear rail system (LRS) type (17.2%). The most common indication for external fixator application was open fractures in 67.7% of cases, followed by bone gaps resulting from bone loss (11.1%). External fixators were used as adjunct to other treatment modalities in 59 applications (59.6%) and as the definitive treatment method in 40 applications (40.4%). The commonest solution used for pin site care was Povidone iodine in 53 patients (56.4%). The mean length of time patients were on external fixators was 124.8 days (17.8 weeks). Pin tract infection was the commonest complication encountered (26.6%). The commonest indication for removal of external fixators was the healing of the wounds in open fractures with conversion to other forms of treatment, commonly cast application (42.6%). The initial aim of applying the external fixator was achieved in 75% of cases.Conclusion: External fixators have become indispensable tools in the armamentarium of modern day Orthopaedic and trauma care. Our health facilities have also effectively keyed into this.

Removal of Metal Fixators after Consolidation of Bone Fractures: To Do or Not to Do? (Literature Review)

Summary. Removal of metal fixators today is one of the most common surgical interventions in developed countries. According to many European researchers, surgeries performed to remove metal fixators account for almost 30% of all planned surgical interventions and 15% of the total number of surgeries performed in trauma departments. This certainly indicates the great social significance of the problem. An analytical review of the literature has shown that the surgery of removing metal fixators in the consolidation of bone fractures is not a routine procedure; it requires experience and training of the surgeon. The problem of removal of metal fixators in some individual cases and localizations is not completely solved and requires further clinical and experimental studies.

ОСОБЕННОСТИ ЭНДОПРОТЕЗИРОВАНИЯ ТАЗОБЕДРЕННОГО СУСТАВА У ПАЦИЕНТОВ ПОСЛЕ ОСТЕОСИНТЕЗА ПЕРЕЛОМОВ ВЕРТЛУЖНОЙ ВПАДИНЫ

Objective. To analyze the late complications after osteosynthesis of the acetabular fractures that led to reoperations; to determine the features of surgical intervention and the choice of the acetabular component during endoprosthetics in these patients. Methods. From 2009 to 2015, the results of endoprosthetics in patients (n=35) who underwent primary osteosynthesis of the acetabulum and subsequently hip arthroplasty were evaluated at the Orthopedic and Trauma Center of Kiev Regional Clinical Hospital. To assess damage volume, the Letournel-Judet classification was used. 5 years after the endoprosthetics to evaluate functional outcomes the the Harris Hip Scale (HHS) and radiographic method have been used. Results. The initial preoperative assessment in 35 patients using Harris Hip Scale showed results: 64 (58-71) Ме (LQ; UQ) points. A year after endoprosthetics when examining 33 (94.3%) patients the Harris scale improved the results to 81 (74-88) points (p<sub>0-1</sub><0.001). 5 years after arthroplasty the Harris scale was 85 (77-92) points (p<sub>0-5</sub><0.001). After 5 years in 31 (88.6%) patients a radiographic evaluation showed stable integration of the acetabular component without any signs of attenuation in 1-3 zones according to the De Lee and Charnley classification. Conclusion. The most effective way to treat the recent acetabular fractures with fragment displacement is considered to be the early osteosynthesis with anatomical reposition of fragments, which with the development of degenerative changes in the operated joint, makes it possible to perform endoprosthetics using a full-fledged bone mass for immersion of the acetabular component. Careful planning of the operation, preliminary removal of metal fixators, which can affect the placement of the acetabular component, as well as increase the risk of postoperative complications, allows achieving good results. What this paper adds For the first time the late complications after osteosynthesis of the acetabular fractures, which led to reoperations, have been analyzed; the features of surgical intervention and the choice of the acetabular component during endoprosthetics in such patients have been determined. The most effective method for treating recent acetabular fractures with fragment displacement has been studied in detail - early osteosynthesis with anatomical reposition of fragments, which, with the development of degenerative changes in the operated joint, makes possible to perform endoprosthetics using full bone mass for immersion of the acetabular component.

Cure of recurring Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae septic shock episodes due to complicated soft tissue infection using a ceftazidime and avibactam-based regimen: a case report

BackgroundInfections caused by multidrug-resistant Enterobacteriaceae are hard to treat and life-threatening due to reduced therapeutic options. Systemic infections caused by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae strains have increased in many European regions, becoming frequent in many clinical settings, and are associated with high mortality. The co-formulation of ceftazidime, a third-generation cephalosporin, with avibactam, a new suicide inhibitor beta-lactamase inhibitor able to block most Klebsiella pneumoniae carbapenemases, has been recently licensed, with promising results in patients with limited or absent therapeutic options. Little is known, however, as to the efficacy of such a combination in patients with soft tissue infections caused by multidrug-resistant Klebsiella pneumoniae carbapenemase-producing strains of Klebsiella pneumoniae.Case presentationA Caucasian 53-year-old man with paraplegia suffered multiple vertebral fractures due to a car crash. He was treated with external fixators that became infected early after insertion and were repeatedly and inefficiently treated with multiple antibiotics. He suffered repeated septic episodes caused by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae strains with a multidrug-resistant profile. Meropenem, tigecycline, and colistin combinations allowed only temporary improvements, but septic shock episodes recurred, in spite of removal of infected external fixators. After approval of pre-marketing prescription by our local Ethics Committee, full clinical resolution was obtained with a compassionate treatment using meropenem and ceftazidime/avibactam in combination for 16 days.ConclusionsOur experience provides additional evidence that ceftazidime/avibactam, possibly in combination with meropenem rescued by avibactam, may be an efficacious treatment option also for complicated skin and soft tissue infections caused by multidrug-resistant strains of Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae.

A Model for Sustained Collaboration to Address the Unmet Global Burden of Bladder Exstrophy-Epispadias Complex and Penopubic Epispadias

International collaboration to alleviate the massive burden of surgical disease is recognized by World Health Organization as an urgent need, yet the surgical mission model to treat reconstructive surgical challenges is often constrained in ensuring adequate patient follow-up, optimal outcomes, and sustainability. To determine whether a collaboration predicated on long-term commitment by surgeons returning to the same institution annually combined with an experienced host surgical team and infrastructure to ensure sustained patient follow-up could provide surgical care with acceptable outcomes to treat bladder exstrophy-epispadias complex (BE) and penopubic epispadias (PE). In this prospective, observational study, long-term collaboration was created and based at a public hospital in Ahmedabad, India, between January 2009 and January 2015. The entire postoperative cohort was recalled in January 2016 for comprehensive examination, measurement of continence outcomes, and assessment of surgical complications. Seventy-six percent of patients (n = 57) who underwent complete primary repair of exstrophy during the study interval returned for annual follow-up in 2016 and formed the study cohort: 23 patients with primary BE, 19 patients with redo BE, and 11 patients with PE repair. Demographics, operative techniques, and perioperative complications were recorded. A postoperative protocol outlining procedures to ensure monitoring of study participants was followed including removal of ureteral stents, urethral catheter, external fixators, imaging, and patient discharge. Of the 57 patients, 4 were excluded because they underwent ureterosigmoidostomy. Median age at time of surgery was 3 years (primary BE), 7 years (redo BE), and 10 years (PE), with median follow-up of 3 years, 5 years and 3 years, respectively; boys made up more than 70% of each cohort (n = 17 for primary BE, n = 15 for redo BE, and n = 9 for PE). All BE and 3 PE repairs (27%) were completed with concurrent anterior pubic osteotomies. Seventeen of 53 patients (32%) experienced complications. Only 1 patient with BE (4%) had a bladder dehiscence and was repaired the following year. A unique surgical mission model consisting of an international collaborative focused on treating the complex diagnoses of BE and PE offers outcomes comparable with those in high-income countries, demonstrating a significant patient retention rate and an opportunity to rigorously study outcomes over an accelerated interval owing to the high burden of disease in India. Postoperative care following a systematized algorithm and rigorous follow-up is mandatory to ensure safety and optimal outcomes.

Removal of fixation construct could mitigate adjacent segment stress after lumbosacral fusion: A finite element analysis

Background dataCombined usage of posterior lumbar interbody fusion and transpedicular fixation has been extensively used to treat the various lumbar degenerative disc diseases. The transpedicular fixator aims to increase stability and enhance the fusion rate. However, how the fused disc and bridged vertebrae respectively affect adjacent-segment diseases progression is not yet clear. MethodsUsing a validated lumbosacral finite-element model, three variations at the L4–L5 segment were analyzed: 1) moderate disc degeneration, 2) instrumented with a stand-alone cage and pedicle screw fixators, and 3) with the cage only after fusion. The intersegmental angles, disc stresses, and facet loads were examined. Four motion tests, flexion, extension, bending, and twisting, were also simulated. FindingsThe adjacent-segment disease was more severe at the cephalic segment than the caudal segment. After solid fusion and fixation, the increase in intersegmental angles, disc stresses and facet loads of the adjacent segments were about 57.6%, 47.3%, and 59.6%, respectively. However, these changes were reduced to 30.1%, 22.7%, and 27.0% after removal of the fixators. This was attributed to the differences between the biomechanical characteristics of the fusion and fixation mechanisms. InterpretationFixation superimposes a stiffer constraint on the mobility of the bridged segment than fusion. The current study suggested that the removal of spinal fixators after complete fusion could decrease the stress at adjacent segments. Through a minimally invasive procedure, we could reduce secondary damage to the paraspinal structures while removing the fixators, which is of utmost concern to surgeons.

Staged Procedures after Failing Ring Fixators of Lower Limb? Series of 15 Cases Abstract

Background: Failure of the fixators is a challenging, especially in the presence of osteoporosis, bone defect, pin track infection and joint stiffness. This study aims at evaluating the functional outcomes of the lower limb proposed two-stage management of non-union after failed ring external fixation. Patients and Methods: 15 patients (six females) with age range 22-65 years enrolled in this study. Four had femoral fractures and eleven with tibial fractures. All were due to high-energy trauma and all were open ones (3 grade (I), 8 grade (II) and 4 grade (III)). Categorised AO classification, 5 type (A), 4 type (B) and 6 type (C). They initially treated by ring external fixators and had radiological signs of non-union. Treatment involved removal of external fixators, pin track and blood tests until no active infection. Non-union managed by refreshing the fracture ends, opening the medullary canal, packing the non-union with autogenous bone grafts then realigning the fracture properly and stabilizing it with locked plate or interlocking nail. Results: Average duration of nonunion 9.8 months. Average delay prior to osteosynthesis after removal of external fixation 15 days. All non-unions healed on an average 5.2 months. According to the Karlstrom-Olerud scores, final functional outcome score was excellent 7cases, good 5 cases, accepted 2 cases and poor one case. Conclusions: Two-stage treatment of non-union of long bone after ring fixation is an effective tool and may be a favorable option with low risk of complications and a high level of functional outcomes.

Implant removal in children.

Implant removal in children is still a standard procedure. Implants may disturb function, and some theoretical long-term risks like growth disturbance, foreign body reaction, chronic infection and corrosion are used as arguments for removal. Implant migration or interference with any other orthopaedic treatment over the later course of life is also a matter of debate. On the other hand, the difficulty in removing single implants as well as possible perioperative complications has induced discussion about the retention of implants in childhood. The current procedures are exposed and the available literature on implant removal in children reviewed. Actually, a clear recommendation does not exist. The current line of action still includes routine removal, as it is preferred by some authors, whereas others argue for a selective procedure. K-wires as well as intramedullary nails are usually removed because the ends may interfere with the surrounding tissue. Screws and plates can be retained if there are no local problems. The removal of external fixators is non-controversial. Benefits have to outweigh the risks and complications in the individual case and the procedure should not require a more extensive procedure than insertion. It has to be an individual decision in view of the lack of evidence to support routine removal as well as to refute it.

Causes for kyphosis after removal of internal fixators for thoracolumbar vertebrae burst fractures

Objective To retrospectively analyze whether the kyphosis exists after removal of the internal fixators for thoracolumabar vertebrae fractures. Methods A total of 18 patients (35-68 years old) with thoracolumabar vertebrae fractures (T11-L2 ) were fixed with short segment pedical screw. The fixators were removed one year postoperatively to observe the changes of the Cobb' s angle and trauma vertebra'height. Results All the patients were followed up for 6-24 months ( average 18.7 months),which showed no intraoperative or postoperative complication, breakage or loosening of the screws. Compared to the Cobb angle and the vertebra height before removal of the internal fixators, the average loss of the Cobb angle was 0.7° and that of the vertebra height was 0.8 mm six months after removal of the fixators, 1.9° and 1.1 mm respectively one year after removal of the fixators, and 2.4° and 1.3 mm respectively two years after removal of the fixators in 16 patients without osteoporosis (P ＞0. 05). Among two patients with osteoporosis, the average loss of the Cobb angle and the vertebra height was 6° and 8°respectively and 3 mm and 5 mm respectively six months after removal of the fixators; 13° and 17° respectively and 5 mm and 7 mm respectively one year after removal of the fixators; 15° and 19° respectively and 6 mm and 7.5 mm two years after removal of the fixators. Conclusions After the internal fixation for thoracolumbar vertebrae burst fractures, kyphosis develops mildly, with insignificant change of the vertebral height. While the kyphosis becomes worse after removal of the fixators for thoracolumbar vertebrae burst fractures in patients with osteoporosis. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae

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.

Submuscular plating after distraction osteogenesis in children

Although distraction osteogenesis has solved limb length discrepancies, many complications are inevitable from long duration of external fixation. Use of intramedullary nails for early removal of fixators has its own challenges especially in pediatric age group. To facilitate early removal of external fixators in children, we tried a novel method of submuscular plating over the distraction callus, which is described, and the results and complications of this technique are presented. In eight children (four girls and four boys), of limb lengthening (four cases) and bone transport (four cases) done in three femurs and five tibiae with external fixators (five Ilizarov ring fixators and three monofixators), submuscular plating was done over the distraction callus. The causes of limb length discrepancy included traumatic and septic growth arrest, congenital pseudoarthrosis of tibia, fibular hemimelia, tumor salvage, and Perthes' disease. The purpose of plating was to remove the external fixator earlier after achieving the target length. Mean age of plating procedure was 11.62 years, and mean amount of distraction was 5.47 cm. In all patients, the distraction callus healed on maintaining its length or correcting into the original alignment. The mean external fixation index was 26.93 days/cm and healing index was 52.01 days/cm. One complication of superficial pin-track infection occurred, which resolved completely with conservative treatment. None of the patients developed deep infection or implant failures. The mean follow-up after plating was 28 months (range, 18-62 months). Submuscular plating over the distraction callus may be a successful method that permits early removal of fixator with fewer complications. This method can be a useful alternative in children or when nailing is difficult.

Routine Removal of External Fixators Without Anesthesia

To examine the degree of discomfort experienced by patients with routine removal of all external fixators without anesthesia. Retrospective review. Outpatient clinic and hospital. A total of 106 consecutive patients for whom removal of external fixators was indicated. External fixators were removed without anesthesia. Visual Analog Pain Scale (VAS) following external fixator removal and patients' reported willingness to repeat the procedure without anesthesia. Patients with pin site inflammation had a significantly higher VAS (4.82 vs. 2.92, P < 0.0001). The chi test revealed that pin site inflammation was less common with wrist spanning fixators than with lower extremity and pelvic fixators. No correlation existed between age, site of fixator, closed head injury, use of olive wires, or the duration of fixation and VAS. In all, 95 of 106 patients (89.6%) responded yes when asked if they would undergo removal of their fixator again without anesthesia. Despite the association between inflamed pin sites and a higher VAS, in 84% (37/44) of the cases with inflamed pin sites, the patient would choose to undergo fixator removal without anesthesia again. Removal of external fixators without anesthesia is well tolerated by the great majority of patients. Inflammation at pin sites is associated with a higher degree of discomfort during external fixator removal. Despite the higher pain score, most patients with pin-site inflammation report that they would repeat the procedure without anesthesia.

Treatment of displaced intra-articular fractures of the calcaneus using a small lateral incision approach

目的 观察外侧小切口治疗关节面移位的跟骨骨折的疗效.方法 2004年10月～2006年4月采用腓骨尖至第4跖骨基底的外侧小切口显露、复位后空心螺钉内固定治疗31例(32侧)关节面移位的跟骨骨折患者.骨折根据Sanders分型:Ⅱ型21侧,Ⅲ型11侧.术后第2天首次换药,拔除引流片的同时尽量驱除伤口内的残留淤血,患肢垫棉垫加压包扎.结果 31例患者术后获3～18个月(平均10.5个月)随访.32侧跟骨关节面复位良好,跟骨外形恢复满意.术前B(o)hler角为6.84°±9.36°,术后为32.06°±6.87°;术前Gissane角为106.04°±12.03°,术后为115.81°±9.48°,手术前、后差异均有极显著性意义(P＜0.01).根据美国骨科足髁外科学会(AOFAS)的踝-后足评分标准评分:60～70分2侧,70～80分9侧,80～90分16侧,90～100分5侧.结论跟骨外侧小切口对软组织的损伤较外侧延长切口小、骨折显露清晰、且便于后期内固定的取出和距下关节融合术的实施,是治疗关节面移位的跟骨骨折的一种较好切口选择。

Management of tibial fractures with Orthofix axial external skeletal fixator in 15 dogs

In the present study, the applicability of fixator, surgical time, time to weightbearing, the healing time and complications of tibial fractures in dogs after fixation with Orthofix axial external skeletal fixator were evaluated. The study was performed on 15 cases which were presented to the Clinics of Small Animal Surgery. After the determination of the fracture type, fracture location, appropriate screw diameter and the location of the first screw on the fragment according to preoperative radiographs, the dogs were placed under general anaesthesia and the fixator was applied with cranio-medial approach to the tibia. Clinical and radiological examinations were continued until the removal of the external skeletal fixators at three different times (at approx. days 45, 60 and 75) according to the clinical and radiological fracture healing. The treatment results were determined by the Modified Hannover Veterinary Medicine Faculty Small Animal Fracture Evaluation Scale. The results were excellent in eight cases (53.3%), good in four cases (26.7%), fair in one case (6.7%) and poor in two cases (13.3%). Based on this study, the use of external skeletal fixation with Orthofix axial external skeletal fixator can be recommended for dogs with tibial fractures as long as careful pin tract management is performed. Further investigation is needed to determine the use of Orthofix axial external skeletal fixator for the management of other long bone fractures.

A Simple Technique of Outpatient Clinic Removal of External Fixators Using a Topical Cryorefrigerant Anesthetic

The purpose of our study was to assess patient satisfaction with office removal of external fixators using a topical cryorefrigerant anesthetic spray. Twenty-two subjects were selected in a non-randomized fashion and twenty-one subjects completed the study. After IRB approval, a prospective study was performed of patients presenting to the orthopaedic clinic for removal of an external fixator. Informed consent was obtained and patients completed a visual analogue score and simple questionnaire which included anticipated pain both before removal, pain experienced after fixator removal, and overall patient satisfaction. A topical anesthetic spray was used at the pin-skin junction prior to removal of the half-pins. There were 17 males and 4 females, average age 38.3 years, whose fixators had been in place for 6.6 weeks (range, 3.5 to 20 weeks) for the following injuries: distal radius fractures (11), pelvic ring injuries (4), tibial plateau fractures (2), pilon fracture (1), tibia-fibula fracture (1), elbow fracture (1), and mid-foot injury (1). The average time it took to remove the fixator was 7.7 minutes. Twenty-nine percent of patients anticipated no pain at all from fixator removal. The average pain score after fixator removal was 42 % of maximum. Thirty-three percent had no pain from fixator removal. Eighty-nine percent of patients were satisfied with the procedure. External fixators can be comfortably and safely removed in the outpatient clinic using a topical cryorefrigerant anesthetic spray.

Biomechanical and densitometric bone properties after callus distraction in sheep.

Assessment of biomechanical stability of diaphyseal bone lengthened by callus distraction is an unsolved problem. A middiaphyseal corticotomy was performed in the left tibia of 24 sheep. After 7 days, callus distraction was begun at a rate of 0.5 mm every 12 hours for 30 days using a standard unilateral fixator system. Animals were euthanized 4, 8, or 12 weeks after the end of distraction. The lengthened tibia and the contralateral control tibia from each animal were evaluated by radiographic, densitometric (dual energy xray absorptiometry, quantitative computed tomography), and biomechanical (axial compression testing, torsion testing to failure) methods. The bone mineral density and maximum torque for the lengthened tibia were significantly greater in the 8-week group than in the 4-week group. However, the values in the 12-week group were significantly smaller than in the 8-week group. In the lengthened tibias, there was a correlation between the maximum torque and the bone mineral density, and between the maximum torque and the bone density. Bone density measurements are useful prognosticators for the safe removal of external fixators after leg lengthening procedures. By using these methods, clinical fractures after leg lengthening could be avoided in the future.