Static External Fixation Research Articles

“No Care Pin Care” Following Charcot Reconstruction With Static External Fixation

Charcot reconstruction with static external fixation provides stability in deformity correction. Concern for pin site health remains forefront to prevent premature fixator removal should infection develop. While previous investigations examined a spectrum of pin care protocol with a similar variation in outcomes, this study assesses results following a “no care pin care” routine. A retrospective analysis of patients with Charcot neuroarthropathy treated with static external fixation was performed where all pin sites were dressed using a chlorhexidine-soaked sponge without postoperative maintenance. Demographics, reconstruction-specific, and postoperative variables including pin site irritation, pin site infection, and pin tract infection were collected through frame removal. A comparison between uncomplicated and complicated pin sites was made. Statistical significance was set as p ≤ .05. Among 85 patients and their respective pin holes that posed potential spots of infection, 6 (7%) experienced pin site irritation and 5 (6%) experienced pin site infection. Moreover, 2 (2%) experienced a pin tract infection requiring removal. Out of the 768 wires/half-pins 2 (0.3%) were removed. There existed no statistically significant predictors of pin site irritation/infection other than age (p = .03). “No care pin care” proves an effective means at pin site care following static external fixation in Charcot reconstruction. Limited maintenance reduces the postoperative burden on providers and patients.

A prospective study of functional evaluation of distal radius fracture by external fixator using the principle of ligamentotaxis

Background: Preservation of the articular congruity is the principal prerequisite for successful recovery following distal radius fractures. The best method of obtaining and maintaining an accurate restoration of articular anatomy however, remains a topic of considerable controversy. External fixation as a method of treatment for distal end of radius fracture has more than 60 years of documented clinical experience. The main aim of the study is to evaluate the results obtained by treatment of distal end radius fractures by external fixation using the principle of ligamentotaxis. Methods: In a prospective controlled study, 30 cases of distal end radius fractures with intra articular extension were treated with uniplanar bridging type of external fixation using the principle of ligamentotaxis. Mean age of the patients was 40.2 years, external fixator was applied for a mean duration of 6 weeks. Results: In this study there were 8 patients with excellent results comprising 27%, 14 patients with good results comprising 47%, 7 patients with fair results comprising 23%, 1 patient with poor results comprising 3%. Conclusions: In a prospective investigation, static external fixators were applied to 30 intra-articular fractures of the distal end of the radius. Fixator was kept up for a total of six weeks. The results were 8 excellent, 14 good, 7 fair, and 1 poor. Only one complication, pin loosening (10%), occurred. This series concludes that ligamentotaxis by external fixation consistently produces a good result in the management of intra-articular distal end of radius fractures in younger age groups (50 years).

Biomechanical comparison of elbow stability constructs.

Despite surgical stabilization of complex elbow trauma, additional fixation to maintain joint congruity and stability may be required. Multiple biomechanical constructs include a static external fixator (SEF), a hinged external fixator (HEF), an internal joint stabilizer (IJS), and a hinged elbow orthosis (HEO). The optimal adjunct fixation to surgical reduction is yet to be determined. Eight matched cadaveric upper extremities were tested in a biomechanical model. Anteroposterior stress radiographs were obtained of the elbow in full supination at 0° and 45° of elbow flexion with the weight of the hand serving as a varus load as the baseline. A 360° capsuloligamentous soft-tissue release was performed around the elbow. The biomechanical constructs were applied in the same sequential order: SEF, HEF, IJS, and HEO. For each construct, 0 kg (0-lb) and 2.3 kg (5-lb) of weight were applied to the distal arm. At both weights, radiographs were obtained with the elbow at 0° and 45° of flexion, with subsequent measurement of displacement, congruence at the ulnohumeral joint, and the ulnohumeral opening angle. Statistical analysis was performed to quantify the strength and stability of each construct. Compared with the control group at 0° with and without 2.3 kg (5-lb) of varus force and at 45° with and without 2.3 kg (5-lb) of varus force, no difference was noted in the medial ulnohumeral joint space, lateral ulnohumeral joint space, or ulnohumeral opening angle between the SEF, HEF, and IJS. The gap change after exertion of a 2.3-kg (5-lb) force between the control condition and application of each construct demonstrated no difference between the SEF, HEF, and IJS. Comparison among destabilized elbows showed no significant difference between the SEF, HEF, and IJS. The HEO catastrophically failed in each position at 0 kg (0-lb) of weight. The SEF, HEF, and IJS are neither superior nor inferior at maintaining elbow congruity with the weight of the arm and 2.3 kg (5-lb) of varus stress. The HEO did not provide additional stability to the unstable elbow.

Syringe needle-cap use as novel, static, uni-planar or bi-planar, mini-external fixator for treatment of intra-condylar phalangeal fractures

Background: Comminuted intra-articular phalanx fractures are complicated injuries often treated with external fixation. Syringe needle- cap can be an excellent mini-external fixators because they are radiolucent, readily available, inexpensive, simple, safe and easy to use. Our cases received a novel treatment in the form a syringe needle-cap/mini external fixator that was originally placed in static mode for 3 weeks and then later removed in OPD visit to a dynamic-mode of ROM to allow rehabilitation of the PIPJ/DIPJ. Our cases illustrates the power and utility of this ‘static’ uniplanar or biplanar stable technique to treat intra-condylar phalanx fractures and achieved good functional recovery of finger.Methods: This was a prospective case study covering period from January 2021 to May 2022 at department of plastic surgery, Command Hospital, Chandimandir, Panchkula, Haryana, India. 10 young male patients were presented with intra-articular fractures of phalanx. All patients had undergone pre-operative and post procedure X-rays for evaluation. A static external fixator consisting of a uniplanar or biplanar 2 ml syringe needle-cap and 0.8mm small size (3-4 cm) Kirschner wires as an optimal fixator across the fractured joint. K-wires were removed in OPD visit after 3 weeks to dynamize the ROM of affected joint of finger post-operatively.Results: 10 male patients were studied with average age of 28 years. 06 of them are intra-condylar fractures at PIP joints and rest are intra-articular fractures. After 3 weeks, we removed this fixator device and started controlled physiotherapy. End results notified in our study were achievement of good functional recovery of finger ROM at 3 months follow up.Conclusions: Syringe needle-cap use as mini-external fixation should be considered as a novel tool in the treatment of comminuted intra-articular phalangeal fracture.

Safety of Tibial Half Pins With Circular External Fixation for Foot and Ankle Reconstruction in Patients With Peripheral Neuropathy

The primary aim of the study was to evaluate the rate of tibial fracture with half pin placement in conjunction with tensioned wires in Ilizarov static external fixator in patients with peripheral neuropathy. Concentric visualization through a rancho cube and careful identification of anterior, posterior, medial, and lateral borders of the tibia, the “perfect circle” technique was used to ensure avoidance of cortical breach. Bivariate analysis was performed comparing the rates of tibia fractures in those who did and did not employ the “perfect circle” technique for placement of tibial half pins; evaluating for demographics, rationale for external fixation use, and postoperative amputation and complication rates. Tibial stress fractures, and early removal of pin/wires from external fixator secondary to breakage both occurred at statistically significant higher rates in patients in which the “perfect circle” technique was not employed (p < .001 and p = .03 respectively). The overall rate of tibia stress fractures was 2.08% (2/96), 0% (0/85) when “perfect circle” technique was used, compared to 18.18% (2/11) when it was not used. This study demonstrates a substantially low rate of tibia stress fractures with half pin use, in contrast to prior literature and should provide foot and ankle surgeons confidence, particularly when appropriate placement is observed in this high-risk population.

Case report: Open reduction and extension block pinning with volar plate reconstruction for 1 month PIP joint dislocation

Proximal interphalangeal (PIP) fracture-dislocation is a common injury that results from “jamming” a finger. It can be classified according to displacement of proximal phalanx over middle phalanx. For simple dislocation treatment can be closed reduction and splinting. For old cases open reduction is usually required. Following open reduction stability of the joint is checked and accordingly augmentation of stability is done. For unstable injuries, a variety of surgical interventions have been described including extension block pinning, open reduction internal fixation, volar plate arthroplasty, static or dynamic external fixation, and hemi-hamate reconstruction. For fracture dislocation treatment varies with the degree of articular surface involvement, which determines stability of the joint. We present the case of an unstable, subacute middle finger PIP dorsal fracture dislocation in a young female for which attempts of closed reduction were given elsewhere but it could not be reduced. With volar approach we reduced the joint and for augmentation of the stability we did volar plate reconstruction using z-plasty of A3 pully. For additional stability we did extension block pinning.

Internal joint stabilizer for varus posteromedial rotatory instability of the elbow.

Management of varus posteromedial rotatory instability (VPMRI) of the elbow presents a challenging problem, sometimes requiring supplemental external fixation or ulnohumeral cross-pinning. A relatively new treatment adjunct for posterolateral rotatory instability of the elbow has become available with the development of the internal joint stabilizer (IJS) implant. However, this has not been studied for VPMRI because the implant is thought to be ineffective at treating this instability when placed in the usual manner on the lateral side of the elbow. We hypothesize that modifying the IJS technique to place the implant medially will make it as effective as external fixation at preventing VPMRI. Nine whole-arm cadaveric specimens were tested on a rig that allowed for gravity stress of the elbow at 60° of abduction. Intact specimens (INT) were tested to find the baseline stability with all structures intact. Then, O'Driscoll type 2-subtype III coronoid fractures were created with a microsagittal saw, and these same specimens were again tested without any fixation (WAF), with a static lateral external fixator (SLEF), and with a medially placed IJS (MIJS). The method for medial IJS placement is detailed within. The WAF specimens were significantly more unstable than the INT, SLEF, and MIJS groups (P < .001). There was no difference in stability between the INT and the SLEF (P = .59) or MIJS group (P = .21). In this cadaveric model, a medially placed IJS was as effective as an SLEF at maintaining elbow stability in a coronoid-deficient elbow. This technique allows for early elbow range of motion, with no external hardware, and may eliminate the complications associated with external fixation or ulnohumeral cross-pinning.

Static and Dynamic External Fixation are Equally Effective for Unstable Elbow Fracture-Dislocations.

To compare the clinical outcomes of static versus dynamic external fixation for elbow fracture-dislocations with persistent instability after surgical management. Comparative, retrospective review. Two tertiary referral upper-extremity centers. Twenty-four elbows requiring external fixation for persistent elbow instability within 90 days of surgical management of an elbow fracture-dislocation. Static and dynamic external fixation was used in 16 and 8 patients, respectively, for a median of 39 days (interquartile range, 33-48 days). Elbow range of motion, complications, and revision surgeries. Immediately after static and dynamic external fixation removal, there was no difference in elbow extension [33 degrees ± 16 degrees vs. 41 degrees ± 13 degrees, mean difference (MD) 7 degrees, 95% confidence interval (CI) -6 degrees-22 degrees] or flexion (114 degrees ± 35 degrees vs. 118 degrees ± 11 degrees, MD 4 degrees, 95% CI -23 degrees-132 degrees), respectively. At last follow-up, static and dynamic external fixation groups had no difference in elbow extension (27 degrees ± 13 degrees vs. 24 degrees ± 10 degrees, MD -3 degrees, 95% CI -15 degrees-7 degrees) or flexion (129 degrees ± 12 degrees vs. 128 degrees ± 14 degrees, MD -1 degree, 95% CI -13 degrees-10 degrees), respectively. Static and dynamic external fixation groups had no difference in complications [7 (44%) vs. 5 (63%), difference 19%, 95% CI -23%-54%] or revision surgeries [6 (38%) vs. 4 (50%), difference 13%, 95% CI -27%-49%]. No difference in range of motion, complications, and revision surgeries was detected after static versus dynamic external fixation of persistently unstable elbow fracture-dislocations. Due to ease of application, static external fixation is our preferred treatment for these injuries. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Une simple fixation externe à bas prix pour les fractures luxations de la main

Fracture dislocation is one of the most common and challenging problems in hand surgery. Pin fixation is the most common fixation device in the hand but sometimes we need to use external fixators in hand fractures and diseases. Commercial hand external fixators are expensive and sometimes they are not available. Since it has been presented some alternative solutions for this technique to overcome these problems, like Suzuki technique, Pin stabilizing with syringe or orthopedic cement and so on. We introduce a new alternative for this treatment, which is simple, available and with low price. Pi frame can be used as static or dynamic external fixator. From June 2016 to February 2018, 24 patients with hand and finger problems and trauma underwent external fixation stabilizing with Pi frame, including 8 phalangeal fracture, 6 PIP fracture dislocations, 7 metacarpal fracture and 3 congenital diseases. Eighteen cases as static and 6 cases as dynamic fixator. Technique For static external fixator we inserted the 1–1.5 mm pins at proper sites for example perpendicular to fracture lines and bent them to be caught with electric strip terminal block (Venus industrial group, Iran). For dynamic type, the proximal pin inserted parallel to articular surface and in the center of rotation of the adjacent joint. The pin bent 90 degrees and attached to the distal pins with a strip terminal block. We had one patient with delayed union, 6 patients with different degrees of limitation of joint motion. We had not seen any cases with pin tract infection, hyper-sensibility to the frame pin loosening or complaint of the appearances of the device. Fracture dislocation in hand is difficult to manage. Ilizarov and other external fixators has been evolved to overcome this problem but they are expensive and they are not available in some centers. Strip terminal block is a low price device available in all electrical stores. As a temporary external fixator it needs no bio-compatible studies. It is suitable everywhere but specially in area with lower outcomes and economic sanction. Pi mini external fixator is an available, simple with low price device with almost satisfactory results in difficult hand problems.

The use of static external fixation for chronic instability of the elbow

Chronic elbow instability after trauma is a challenging problem. Clinical results of external elbow fixation in this setting are limited, with most studies focusing on hinged external fixation. A static fixator is an alternative for maintaining joint reduction. Advantages of a static frame include ease of application, decreased need for special instrumentation, and more secure maintenance of a concentrically reduced joint in the setting of bone or soft tissue instability. The primary limitation of static fixation is the potential for stiffness. This retrospective review represents the largest reported cohort evaluating the use of static elbow external fixation for the treatment of chronic elbow instability. Twenty-seven cases treated by a single surgeon between 2004 and 2015 were identified. Twenty patients were available for a clinical evaluation, including radiographs and a physical examination at a mean follow-up of 5.8 years (range, 1.4-12.4 years). Of note, 19 of 20 were clinically obese or overweight. At final evaluation, range of motion averaged from 20° ± 13° of extension to 134° ± 9° of flexion. All patients had stable elbows, except 1 patient who had valgus and varus laxity on stress examination. Radiographs of this patient showed an incongruous joint. Eight patients required an additional operation after external fixator removal, 3 for infection and 5 for stiffness. At almost 6 years of follow-up, static elbow external fixator resulted in a congruous joint with adequate functional and clinical outcomes in 95% of patients.

Repair and augmentation of the lateral collateral ligament complex using internal bracing in dislocations and fracture dislocations of the elbow restores stability and allows early rehabilitation.

Most elbow dislocations can be treated conservatively, with surgery indicated in special circumstances. Surgical options, apart from fracture fixation, range from repair or reconstruction of the damaged ligaments to static external fixation, usually entailing either a long period of immobilization followed by carefully monitored initiation of movement or dynamic external fixation. In general, no consensus regarding surgical treatment has been reached. A new method of open ligament repair and augmentation of the lateral ulnar collateral ligament using a non-absorbable suture tape in cases of acute and subacute elbow instability following dislocations has been described here, which allows an early, brace-free initiation of the full range of motion. This is the first description of the technique of internal bracing of the lateral elbow with preliminary patient outcome parameters for acute treatment of posterolateral rotatory instability. Seventeen patients (14 males and 3 females) with acute or subacute posterolateral elbow instability as a result of dislocation or fracture dislocation were treated in our centre (Sporthopaedicum, Straubing, Regensburg, Germany) from 2014 to 2015 with open LUCL re-fixation and non-absorbable suture tape augmentation. The elbows were actively mobilized immediately after the operation and a maximum bracing period of 3days. At 10month median follow-up, none of the patients showed clinically apparent signs of instability or suffered subluxation or re-dislocation. One patient required re-operation for heterotopic ossification. The median range of motion was from 10° (0-40) to 130° (90-50) and median Oxford, Mayo Elbow Performance score, Simple Elbow Value, and DASH Scores were 41(29-48), 100 (70-100), 83% (60-95), and 18.5 (1.6-66), respectively. All patients reported a complete return to pre-injury level of activity. Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion. IV.

Telesurveillance: Exploring the Use of Mobile Phone Imaging in the Follow-Up of Orthopedic Patients with Hand Trauma.

Background:Intra-articular phalangeal fractures involving the proximal interphalangeal joint (PIPJ) are notoriously difficult injuries to treat and often require regular follow-up to assess progress, guide treatment, and determine outcomes. Some patients often have to travel long distances for follow-up care. The aim of our study was to assess the clinical outcomes of intra-articular fractures of the PIPJ through use of clinical pictures sent through a mobile phone.Methods:A retrospective study was conducted of a consecutive group of patients treated with a static external fixator (Micro Hoffman-2 Stryker®) between 2006 and 2016 for an intra-articular fracture of the PIPJ. Range of motion (ROM) at the PIPJ was assessed through clinical pictures taken on a mobile phone.Results:Clinical images were received from 15 patients with a mean age of 31.9 years (range 15-51), of which 73.3% of patients were male. Mean length of follow-up was 39 months. Around 73.3% of injuries occurred while playing a sport. Mean PIPJ ROM assessed through the clinical images was 67°.Conclusion:Our study shows that it was possible to assess ROM at the PIPJ through the use of clinical pictures taken by mobile phone. The use of mobile phones to take images provided a simple, easy, and convenient means of assessing outcome in this cohort of patients. We describe a method of follow-up that may have a greater role in the future.

Treatment of complex Charcot foot by single stage surgery with static circular fixation. Case series report

ObjectiveWe present a case series report of patients with Charcot foot treated by single-stage surgery with static circular fixation. Material and methodRetrospective review of 10 cases treated with static circular external fixation since 2016, with the following inclusion criteria: (1) Deformity with any of the following: ulcers, osteoporosis, osteomyelitis or instability; (2) peripheral neuropathy; (3) failed orthopaedic treatment. Exclusion criteria: (1) peripheral vascular obstruction without revascularization; (2) inability to comply with treatment; (3) non-ambulatory patients; (4) medical contraindication for surgery. Of the 10 patients, 7 men and 3 women, 6 had involvement of the left foot and 4 of the right one. The average age of our patients was 58 years (range 39–71). We also evaluated Eichenholtz and Brodsky classification, presence of ulcers, osteomyelitis and instability. All were treated with circular external fixation with a medium follow up of 17 months (11–24 months). Postoperatively we evaluated limb salvation, ulcer healing, stability and re-ulcerations. ResultsIn all patients a functional plantigrade foot was achieved, cutaneous ulcer healed without recurrence. Four cases presented superficial pin infection, solved with local wound care. We had wire ruptures in 2 cases, which did not require replacement. We had a traumatic tibial fracture after frame removal, orthopedically solved. All patients were satisfied and would opt for the same technique, if necessary. ConclusionsThe objectives of the study in Charcot foot are to avoid amputation and achieve a functional plantigrade foot, without ulcer.Single-stage surgery with static circular external fixation is reproducible in our country, and also a valid technique for those cases in which internal fixation may not be the best option.

Tratamiento del pie de Charcot complejo mediante cirugía en un solo tiempo con fijador circular estático. Serie de casos

ObjectiveWe present a case series report of patients with Charcot foot treated by single-stage surgery with static circular fixation. Material and methodRetrospective review of 10 cases treated with static circular external fixation since 2016, with the following inclusion criteria: 1) Deformity with any of the following: ulcers, osteoporosis, osteomyelitis or instability 2) peripheral neuropathy, 3) failed orthopaedic treatment. Exclusion criteria: 1) peripheral vascular obstruction without revascularization, 2) inability to comply with treatment, 3) non-ambulatory patients, 4) medical contraindication for surgery. Of the 10patients, 7men and 3women, 6had involvement of the left foot and 4of the right one. The average age of our patients was 58 years (range 39-71). We also evaluated Eichenholtz and Brodsky classification, presence of ulcers, osteomyelitis and instability. All were treated with circular external fixation with a medium follow up of 17 months (11-24 months). Postoperatively we evaluated limb salvation, ulcer healing, stability and re-ulcerations. ResultsIn all patients a functional plantigrade foot was achieved, cutaneous ulcer healed without recurrence. Four cases presented superficial pin infection, solved with local wound care. We had wire ruptures in 2 cases, which did not require replacement. We had a traumatic tibial fracture after frame removal, orthopedically solved. All patients were satisfied and would opt for the same technique, if necessary. Conclusionsof the study In Charcot foot, the objectives are to avoid amputation and achieve a functional plantigrade foot, without ulcer.Single-stage surgery with static circular external fixation is reproducible in our country, and also a valid technique for those cases in which internal fixation may not be the best option.

Simple low cost static external fixators for phalangeal fractures of hand

Introduction: Fractures of phalanges are the most common fractures with Incidence of 2.9% every year. They are more common in the young to middle-aged males. The phalangeal fractures are usually considered as simple injuries. Such kind of injuries may results into deformity, if not addressed properly at beginning. Phalangeal fractures with unacceptable angulation and rotations in any plane require operative fixation. There are numbers of external fixators which are versatile in the designs but needs thorough expertise to use. We describe a simple, low cost, ‘easy to construct and easy to use’ external fixator which can be used for a variety of hand fractures, particularly in an emergency setting as well as definitive fixation. Method: There were 27 patients with different types of fracture of phalanges of hand in our study. Among them 19 male and 8 female patients [mean age -31.85 yrs]. There were 7 open fractures and 20 closed fractures. Out of 27 patients, 15 had fractures of proximal phalanx & 12 patients had fracture of middle phalanx. Our technique is to treat with k wire and plastic cap of spinal needle cap as a static external fixator device. One patient with tendon injury and one with skin loss which was treated by plastic surgical intervention. Result: At the end of 3 months of follow up, range of movements and TAM score out of 27 patients 19 had an excellent result (range 220-260), 5 patients had a good result (range 180-219)and 3 with fair result (range 130-179). Conclusion: This technique is simple, low cost, reproducible, easy applicabilty in the management of fractures involving the small bones of the fingers where complex fixators are not available or costly or needed expertise. Complex Unstable fractures can be converted into stable fractures by this robust and reproducible method. We recommend this simple, low cost, ‘easy to construct and easy to use’ fixator in the management of fractures involving the small bones of the fingers.

Deformity and Clinical Outcomes Following Operative Correction of Charcot Foot: A New Classification With Implications for Treatment.

The historic treatment of Charcot foot arthropathy has been immobilization during the active phase of the disease process, followed by accommodative bracing of the acquired deformity. Evidence derived from modern patient-reported outcomes investigations has convinced many surgeons to attempt operative correction of the acquired deformity with a goal of improving quality of life. Over a 12-year period, 214 patients (9 bilateral) underwent reconstruction of the acquired deformity associated with midtarsal Charcot foot arthropathy. Over time, 3 patterns of deformity were observed based on weight-bearing pattern, relationship of the forefoot to the hindfoot, and integrity of the talocalcaneal joint. A valgus deformity pattern was present in 138, varus in 48, and dislocation of the talocalcaneal joint in 37. A consistent operative strategy was employed. Surgery included percutaneous tendon-Achilles lengthening, resection of infection when present, attempted correction of the structural deformity by wedge resection at the apex of the deformity, and immobilization with a 3-level static circular external fixator. Additional deformity pattern-specific procedures were added over time. Clinical outcomes were based on the historic metrics of limb salvage and resolution of infection and the functional metric of the ability to walk with commercially available therapeutic footwear. Seven patients died within a year of surgery, and 15 underwent partial- or whole-foot amputation. Overall, 173 of 223 feet (77.6%) achieved a favorable clinical outcome. Patients with a valgus deformity pattern were most likely to achieve a favorable clinical outcome (120 of 138, 87.0%). Patients with a dislocation pattern were less likely to achieve a favorable clinical outcome (26 of 37, 70.3%), and those with a varus deformity pattern were least likely to achieve a favorable clinical outcome (27 of 48, 56.3%). Operative correction of the acquired deformity of Charcot foot arthropathy was performed with a goal of improving quality of life. Stratification of patients by deformity pattern allowed alterations of the basic surgery to afford improved outcomes. In addition to achieving historic goals of resolution of infection and limb salvage, almost 80% of the patients were able to achieve the functional goal of independent ambulation with commercially available therapeutic footwear. The clinical outcomes achieved in this retrospective case series appear to support the modern paradigm of operative correction of deformity in this complex patient population. This realistic appreciation of outcome expectations should both be helpful in counseling patients on the risk-benefit ratio associated with surgery and provide a benchmark to measure newer strategies of treatment. Level IV, retrospective case series.

Deformity and Clinical Outcomes Following Surgical Correction of Charcot Foot

Category: Diabetes Introduction/Purpose: There is growing acceptance that the historic accommodative treatment of the acquired deformity associated with Charcot Foot arthropathy leads to very poor patient reported outcomes. Surgical correction of the acquired deformity is now advised with the goals of improving ambulation and quality of life. Methods: Over a twelve-year period, 214 consecutive patients (9 bilateral) underwent surgi-cal reconstruction of the acquired deformity associated with symptomatic midtarsal dia-betes- associated Charcot Foot arthropathy. The patterns of midtarsal deformity were ar-bitrarily stratified into three clinical groups based on observed weight bearing pattern, radiographic relationship of the forefoot to the hindfoot and integrity of the talo-calcaneal joint. All patients were followed for a minimum of one year. All had weight bearing radiographs before surgery and at a minimum of one year following surgery. A VALGUS deformity pattern was present in 138, VARUS in 48 and DISLOCATION of the talo-calcaneal joint in 37. Surgery included tendon-Achilles lengthening and an attempt at bony correction of the non-plantigrade clinical deformity. Immobilization in all cases was accomplished with a three level static circular external fixator. Clinical outcomes were based on suc-cessfu1 resolution of infection and the ability to resume independent walking with com-mercially-available therapeutic footwear. Results: Seven patients died within a year of surgery. Overall, 173 of 216 feet (80.1%) achieved a favorable clinical outcome rating. The VALGUS deformity pattern was the most common, with 120 of 138 patients (89.6%) achieving a favorable clinical outcome rating. There were two transtibial and one transmetatarsal amputations in this group. Twenty-seven of the 48 patients (58.7%) with a VARUS deformity pattern achieved a favorable clinical outcome rating, with seven undergoing transtibial, one Syme’s and one transmetatarsal amputation. There were thirty- seven patients with a valgus deformity pattern characterized by loss of integrity, i.e. DISLOCATION, of the talo-calcaneal joint. Correction of deformity and a favorable clinical outcome rating was achieved in twenty-six (72.2%), with one knee disarticulation and two transtibial amputations. Conclusion: Overall, 176 of 223 (77.6%) patients, many with severe structural deformity and osteomyelitis, achieved a favorable clinical outcome. Patients with a VARUS deformity pattern, or loss of integrity of the talocalcaneal joint, were less likely to achieve a favora-ble clinical outcome rating. This retrospective case series suggests a reasonably good probability of improving clinical outcomes in this complex patient population. This de-formity stratification should be helpful going forward when counseling patients with non-plantigrade diabetes- associated Charcot Foot deformity on the risk-benefit ratio associat-ed with surgical correction of their acquired deformity.

Fratture di radio distale

This paper compares treatment methods about fractures of the distal radius. In particular, the advantages and drawbacks of external fixation (EF) and internal fixation techniques, such as volar plates (VP) procedures are presented and discussed. The evaluation and comments reported in this work unveil that the choice between external and internal fixations is not so straightforward, although there seems to be a slight preference towards EF treatment, taking into account the following motivations: the relative ease of application, minimal surgical exposure and reduced surgical trauma, along with postoperative complications, which may be easily treated through medical and physiotherapy solutions. Hence, EF is an effective means of treatment, featuring good functional outcomes. The key role played by immediate postoperative movement must be highlighted, which privilege dynamic over static EF.

Pin Tract Infection Following Correction of Charcot Foot With Static Circular Fixation.

The traditional nonsurgical accommodative treatment for diabetes-associated Charcot foot arthropathy has been unsuccessful in improving the quality of life in affected individuals. This has led to the growing interest in surgical correction of the acquired deformity with either "super construct" internal fixation implants or fine-wire static circular external fixation. The use of static circular external fixation without implants has been demonstrated to achieve high rates of deformity correction with low complication rates. The goal of this investigation was to assess the risk of pin site infection in this high-risk patient population. Over an 11-year period, 283 consecutive diabetic patients underwent single-stage correction of Charcot foot deformity with static fine-wire circular external fixation and no internal fixation devices. Pin care was minimal. Fifty-nine (20.8%) patients developed clinical signs of pin tract infection in at least 1 pin site. Forty-nine occurred in patients undergoing surgical correction of deformity in the foot. Eight occurred in patients undergoing surgical correction at the ankle level and 2 in patients undergoing complex reconstruction for combined foot and ankle deformity. Higher rates of pin site infections were observed in patients with osteomyelitis present at the time of surgery (25.6%) as compared with patients without evidence of infection (17.8%), although the difference was not statistically significant (P = .1184). There was no correlation between body mass index and pin site infection (P = .288). There was a statistically significant trend (P < .05) for higher rates of pin site infection in patients with elevated hemoglobin A1C levels. Erythema and drainage resolved in all patients with local pin care and empiric oral antibiotic therapy. None of the wires were removed prematurely, and all infections resolved following removal of the circular external fixator at the scheduled time for removal. Pin site infection was common following surgical correction of the acquired deformity associated with Charcot foot. These acquired pin site infections were a nuisance but did not appear to add permanent morbidity or require additional surgery to resolve. Level IV, retrospective case series.

Meta analysis of dynamic or static external fixation for distal radius fracture

Objective To compare the clinical effect of dynamic and static external fixation of distal radius fracture.Methods MEDLINE (1966.01-2012.12) and Cochrane Library (Issue 4,2012) were searched for randomized controlled trials (RCTs) describing dynamic versus static external fixation of distal radius fracture.Two reviewers independently screened the studies,extracted data and evaluated the methodological quality.Meta analysis of the data was performed with RevMan 5.0 software.Results Seven RCTs were included.In comparison with static external fixation,dynamic external fixation was superior in wrist pronation (MD =0.25,95％ CI 0.08-4.92,P ＜ 0.05),radial length (MD =1.50,95％CI0.75-2.26,P＜0.01) and volartilt (MD=4.31,95％CI2.13-6.49,P＜0.01) at one year follow-up period.No between-group difference was observed with regard to upper extremity functional score,grip strength of the injured side,movement of the injured wrist except for pronation,infection rate and incidence of reflex sympathetic dystrophy (RSD).Conclusion Either dynamic or static external fixation is effective in treatment of distal radius fracture,but the dynamic external fixation can provide better radiographic anatomical alignment at one year follow-up period. Key words: Colles' fracture; External fixators ; Radius fractures ; Meta-analysis