Unilateral External Fixator Research Articles

Ulnar lengthening for children with forearm deformity from hereditary multiple exostoses: a retrospective study from a tertiary medical center

BackgroundPatients with hereditary multiple exostosis (HME) usually present with forearm deformity with or without radial head dislocation. Ulna lengthening has been proposed to address this condition. Exostosis resection plus ulna lengthening has been adopted in our hospital since 2008, and patients with this condition were retrospectively reviewed. Herein, we aimed to investigate the optimal timing and clinical outcomes of this surgical approach.MethodsIn all, thirty-five patients (40 forearms), including 22 boys and 13 girls, were enrolled in our study from July 2014 to September 2020. We divided the patients into 4 groups based on the age when they received surgery and the status of the radial head. Pronation and supination of the forearm, flexion and extension of the elbow, wrist ulnar deviation and wrist radial deviation, and radiological parameters including ulnar length (UL), ulnar variance (UV), the percentage of radial bowing (RB/RL), radio articular angle (RAA) and carpal slip (CS), were assessed and recorded.ResultsThe mean UL was significantly improved after surgery in four Groups (P<0.05). In patients with radial head dislocation, we found significant improvement in forearm, wrist function and elbow flexion (p < 0.05). For the patients with radial head dislocation, the juniors demonstrated better improvement in % RB and RAA (p<0.05, p = 0.003 and 0.031).ConclusionExostosis resection and ulna lengthening with unilateral external fixation can effectively improve the function and radiological parameters of forearm deformity in HME children. For patients with radial head dislocation, early surgery can achieve better results. For patients not associated with radial head dislocation, we recommend regular follow-up and surgical treatment after 10 years of age.

The results of femoral lengthening using domestic unilateral external fixation and then plating: the first case series in Vietnam.

This study aimed to assess the results of femoral lengthening using an external fixator and then plating. This prospective case series study enrolled 11 patients who underwent femoral lengthening and then plating (LATP) between January 2019 and April 2023. The average age of patients was 14.45 ± 7.54 years. One patient with a femur was lengthened and plated, and one tibia was lengthened over a nail simultaneously. The average femoral lengthening was 8.41 ± 1.35cm. The femoral healing result was excellent in seven femurs and good in four femurs; the functional outcome was excellent in five patients and good in six patients. Pin-track infection occurred in all patients. A limited range of motion of knee flexion occurred in eight patients. Femoral varus and procurvatum deviation occurred during distraction in four and two patients. Femoral LATP was considered an attractive alternative to intramedullary lengthening nails in a low-income country. Our research suggests that femoral LATP was an effective method. However, the most common complications were pin-site infection and extensive knee contracture. Further research should be done with a larger sample size and longer follow-up time. Level IV-prospective observational case series study.

Treatment of tibial bone defects caused by infection: a retrospective comparative study of bone transport using a combined technique of unilateral external fixation over an intramedullary nail versus circular external fixation over an intramedullary nail

BackgroundThe purpose of the study was to assess and compare the clinical efficacy of bone transport with either circular or unilateral external fixators over an intramedullary nail in the treatment of tibial bone defects caused by infection.MethodsBetween May 2010 and January 2019, clinical and radiographic data were collected and analyzed for patients with bone defects caused by infection. Thirteen patients underwent bone transport using a unilateral external fixator over an intramedullary nail (Group A), while 12 patients were treated with a circular external fixator over an intramedullary nail (Group B). The bone and functional outcomes of both groups were assessed and compared using the Association for the Study and Application of the Method of the Ilizarov criteria, and postoperative complications were evaluated according to the Paley classification.ResultsA total of 25 patients were successfully treated with bone transport using external fixators over an intramedullary nail, with a mean follow-up time of 31.63 ± 5.88 months. There were no significant statistical differences in age, gender, previous surgery per patient, duration of infection, defect size, and follow-up time between Group A and Group B (P > 0.05). However, statistically significant differences were observed in operation time (187.13 ± 21.88 min vs. 255.76 ± 36.42 min, P = 0.002), intraoperative blood loss (39.26 ± 7.33 mL vs. 53.74 ± 10.69 mL, P < 0.001), external fixation time (2.02 ± 0.31 month vs. 2.57 ± 0.38 month, P = 0.045), external fixation index (0.27 ± 0.08 month/cm vs. 0.44 ± 0.09 month/cm, P = 0.042), and bone union time (8.37 ± 2.30 month vs. 9.07 ± 3.12, P = 0.032) between Group A and Group B. The excellent and good rate of bone and functional results were higher in Group A compared to Group B (76.9% vs. 75% and 84.6% vs. 58.3%). Statistically significant differences were observed in functional results (excellent/good/fair/poor, 5/6/2/0 vs. 2/5/4/1, P = 0.013) and complication per patient (0.38 vs. 1.16, P = 0.012) between Group A and Group B.ConclusionsBone transport using a combined technique of external fixators over an intramedullary nail proved to be an effective method in treating tibial bone defects caused by infection. In comparison to circular external fixators, bone transport utilizing a unilateral external fixator over an intramedullary nail resulted in less external fixation time, fewer complications, and better functional outcomes.

A unilateral external fixator combined with bone transport and tibio-talar fusion for the treatment of severe postoperative infection of peri-ankle fractures: retrospective analysis of 32 cases

BackgroundTo investigate the clinical effects of a unilateral external fixator combined with bone transport and tibio-talar fusion in the treatment of severe postoperative infection of peri-ankle fractures.MethodsThe clinical data of 32 patients (22 men and 10 women) with severe postoperative infection of peri-ankle fractures were retrospectively analyzed. Patients’ age ranged from 26 to 62 (mean, 42 ± 9.5) years old. The types of fractures were distal tibia fracture (25 cases), distal tibia and fibula fracture (5 cases), and talus fracture (2 cases). All patients underwent treatment with unilateral external fixation combined with bone transport and tibio-talar fusion. 6 patients with severe infection received two-stage treatment involving focal debridement and external fixation, osteotomy, and bone transport. The remaining 26 patients underwent debridement, external fixation, and osteotomy simultaneously. The length of bone transport, total fixation time of the external fixator, and postoperative complications were recorded for all patients. The efficacy of the treatment was assessed using the American Association of Foot and Ankle Society (AOFAS) ankle–hindfoot score.ResultsPatients were followed up for 16–36 months, with an average follow-up time of 24 months. The length of tibia bone transport ranged from 5 to 15 cm, with a mean length of 8.5 cm. The external fixator was applied for 12–24 months, with an average duration of 16 months. One patient suffered from refracture at tibio-talar fusion site, and one patient had external fixation pin-tract infection. No complications, such as recurrent infections (especially the MRSA infection), poor mineralization, refracture, iatrogenic nerve damage or fusion failure, were found in the remaining patients. The preoperative AOFAS ankle–hindfoot function score was 40.0 ± 3.8 (range, 30–52) points, and it increased to 75.0 ± 3.0 (range, 67–78) points at the last follow-up.ConclusionA unilateral external fixator combined with bone transport and tibio-talar fusion is an effective method for treating severe postoperative infection of peri-ankle fractures. This approach is capable of reconstructing large bone defects that remain after clearing the infected lesion. Additionally, it provides stability to the ankle, enhances ankle–hindfoot function, and improves the patient’s quality of life.

Unilateral external fixator and its biomechanical effects in treating different types of femoral fracture: A finite element study with experimental validated model

Previous works had successfully demonstrated the clinical effectiveness of unilateral external fixator in treating various types of fracture, ranging from the simple type, such as oblique and transverse fractures, to complex fractures. However, literature that investigated its biomechanical analyses to further justify its efficacy is limited. Therefore, this paper aimed to analyse the stability of unilateral external fixator for treating different types of fracture, including the simple oblique, AO32C3 comminuted, and 20 mm gap transverse fracture. These fractures were reconstructed at the distal diaphysis of the femoral bone and computationally analysed through the finite element method under the stance phase condition. Findings showed a decrease in the fixation stiffness in large gap fracture (645.2 Nmm-1 for oblique and comminuted, while 23.4 Nmm-1 for the gap fracture), which resulted in higher displacement, IFM and stress distribution at the pin bone interface. These unfavourable conditions could consequently increase the risk of delayed union, pin loosening and infection, as well as implant failure. Nevertheless, the stress observed on the fracture surfaces was relatively low and in controlled amount, indicating that bone unity is still allowable in all models. Briefly, the unilateral fixation may provide desirable results in smaller fracture gap, but its usage in larger gap fracture might be alarming. These findings could serve as a guide and insight for surgeons and researchers, especially on the biomechanical stability of fixation in different fracture types and how will it affect bone unity.

External Fixation as a Primary and Definitive Treatment for Complex Tibial Diaphyseal Fractures: An Underutilized and Efficacious Approach.

External fixation is one of the most often utilized treatment options for complicated tibial diaphyseal fractures (TDF). The purpose of this study was to assess the efficacy of unilateral external fixators as primary and definitive therapy for complex TDF in a resource-limited setting. A retrospective study between June 2016 and March 2021 included 110 subjects with TDF who were treated with an external fixator as definitive fixation in hospitals affiliated with Ibb University. The patient's demographic characteristics, complications, and outcomes were gathered and analyzed. Factors associated with pin site infection were also investigated. The mean age was 42.1 ± 10.1 years, with 92.7% being male. Rural residents accounted for 22.7%. Smoking and diabetes mellitus were present in 27.3% and 30.0%, respectively. General complications occurred in 12.0%, with pulmonary embolism being the most common at 4.5%. Orthopedic complications included pin-track infections in 27.3% (30) and osteomyelitis in 1.8% (2). Pin site infections required medical treatment in 21 cases and external fixator changes in five. Two cases each needed several debridements for osteomyelitis and soft tissue. Full union occurred in 79.1% (87) over 23.1 ± 3.2 weeks and final alignment in 97.3% (107) over 34.8 ± 4.8 weeks. Malunions occurred in 1.8% (2), and one case had hypertrophic nonunion. Factors like rural residency, smoking, diabetes, open fractures, worst fracture grade (Gustilo and Anderson type C), and general complications occurrence significantly correlated with pin site infection (all p-values < 0.05). A unilateral external fixator as a primary and definitive treatment is a viable, simple, and effective option for TDF with a high success rate even in a resource-limited setting. In this study, residents in rural areas, smoking, diabetes, open fracture, worst fracture grade, and general complication occurrence were associated with pin site infection occurrence.

Ilizarov method and its combined methods in the treatment of long bone defects of the lower extremity: systematic review and meta-analysis

BackgroundIlizarov method has become one of primary methods for treating bone defects. Currently, there is growing trend in the application of modified Ilizarov methods (e.g., applying unilateral external fixators or with flap tissue) and its combined methods (e.g., Ilizarov method with antibiotic spacer or internal fixation) to manage bone defects. However, there is a lack of studies with systematical evaluation of the clinical effects of these evolving methods. This study aimed to conduct a systematic review and meta-analysis for overall evaluating the clinical effects on long bone defects of lower extremity in Ilizarov methods and its combined methods.MethodsStudies were identified in three electronic databases (Pubmed, Embase and Cochrane Library) from the earliest indexing year through November 01, 2022, and relevant data were extracted subsequently. The total number of participants, number of participants with bone unions, bone result or functional result, and related complications including pin infection, pin loosening, pain, refracture, limb discrepancy, malalignment, joint stiffness, recurrent infection, and amputation were extracted in this study. Then, union rate (defined as the proportion of patients who achieved bone unions) and specific complication incidence rate (defined as the proportion of patients who experienced specific complication) were pooled estimated respectively. Relative risk (RR) was used for comparing the clinical effects among various Ilizarov technique.ResultsSixty-eight case series studies, 29 comparative studies, and 3 randomized clinical trials were finally included. The union rate of Ilizarov methods was 99.29% (95% CI: 98.67% ~ 99.86%) in tibial defects and 98.81% (95% CI: 98.81% ~ 100.00%) in femoral defects. The union rate of Ilizarov method with antibiotic spacer and intramedullary nail in tibial defects was 99.58% (95% CI: 98.05% ~ 100.00%) and 95.02% (95% CI: 87.28% ~ 100.00%), respectively. Compared to the Ilizarov methods, the union rate of the Ilizarov method with antibiotic spacer in tibial defects increased slightly (RR = 1.02, 95% CI: 1.01 ~ 1.04). Meanwhile, compared to Ilizarov methods, we found lower excellent rate in bone result in Ilizarov method with antibiotic spacer, with the moderate to high heterogeneity. Compared to the Ilizarov method, lower rate of pin infection, higher rate of recurrent infection and amputation were observed in Ilizarov method with intramedullary nail, however, the findings about the comparison of pin infection and recurrent infection between the two groups were presented with high degree of statistical heterogeneity.ConclusionOur study confirmed the reliable treatment of Ilizarov methods and its combined technique on long bone defects, and founded there were significant differences on some complications rate between Ilizarov methods and its combined technique. However, the findings need to be confirmed by further studies.

Biomechanical comparison of three different surgical methods in the surgical treatment of distal tibial metaphyseal fractures. An animal model study.

The aim of this study is to investigate mechanical properties of minimally invasive plate osteosynthesis (MIPO), supracutaneousplating (SP), and unilateral external fixators (UEF) which can be performed for open tibial fractures. An unstable diaphysial tibia fracture was created in 60 fresh sheep tibia specimens by performing an osteotomy at the middle of bones. Specimens were divided into 3 groups. Specimens underwent fracture fixation with a standard MIPO technique, im-planting the plate 15 mm from the bone for SP group. Unilateral uniplanar external fixators were achieved for UEF group. First, thirty specimens (10 specimen for each group) were loaded vertically along the tibial axis to 1800 N. Second, other 30 preperated bones were used for cyclical loading to avoid metal fatigue. For dynamic tests, a 350 N force was applied for 10,000 cycles. In compression testing (vertical loading up to 1800 N) of the three fixation instruments; construct stiffness was highest in MIPO group when compared with SP and UEF groups. While the stiffness of the MIPO group was similar to SP group, it was statistically higher than UEF group (P=0.08 and P=0.002, respectively). SP group was significantly stiffer than UEF group (P=0.0021). The mean peak load was highest in SP group and lowest in UEF group. The peak load in SP group was similar to the MIPO group, it was statistically higher than the UEF group (P=0.743 and P=0.002, respectively). Based on the biomechanical properties from this in vitro animal model study, SP technique was biomechanically stronger than UEF and has similar biomechanical properties with MIPO in terms of axial loading.

Complications associated with single-level bone transport for the treatment of tibial bone defects caused by fracture-related infection

BackgroundThe purpose of this study was to report the outcomes of single-level bone transport with a unilateral external fixator for treatment of proximal, intermediate and distal tibial bone defects caused by fracture-related infection (FRI) and compare their complications.MethodsThe clinical records and consecutive X-ray photographs of patients with tibial bone defects treated by single-level bone transport using a unilateral external fixator (Orthofix Limb Reconstruction System) were analyzed retrospectively, from January 2012 to December 2018. Patients were divided into the proximal group (P, n = 19), intermediate group (I, n = 25), and distal group (D, n = 18) according to the location of the tibial bone defect. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes and postoperative complications evaluated by the Paley classification.ResultsA total of 62 participants were included in this study, with a median age of 36 ± 7.14 years. Sixty patients with tibial bone defects caused by FRI were successfully treated by single-level bone transport using a unilateral external fixator, with a mean bone union time (BUT) of 7.3 ± 1.71 months. According to the ASAMI criteria, there were statistical differences in bone and function results between the three groups (P vs. I vs. D, P < 0.001). The excellent and good rate of bone result in the intermediate group was higher than the other (P vs. I vs. D, 73.6% vs. 84% vs. 66.7%), and the excellent and good rate of function result in the proximal group was the highest (P vs. I vs. D, 84.2% vs. 80% vs. 73.3%). Complications were observed in 29 out of 62 patients (46.7%), with pin tract infection being the most common (14.8%), followed by axial deviation (14.8%), muscle contractures (12.7%), joint stiffness (12.7%), and soft tissue incarceration (12.7%). Other complications included delayed consolidation (12.7%), delayed union (6.3%), nonunion (4.2%), and neurological injury (8.5%). Two patients (3.2%) required below-knee amputation due to uncontrollable infection and previous surgery failure.ConclusionsPin tract infection was the most common complication in tibial bone transport using an external fixator. Complications of distal tibial bone transport are more severe and occur at a higher rate than in other parts. Axial deviation mostly occurred in the intermediate tibial bone transport.

Anatomic consideration of the radial nerve in relation to humeral length for unilateral external fixation: a retrospective study using magnetic resonance imaging findings in korean

BackgroundThis study aimed to present a safe zone for distal pin insertion for external fixation using magnetic resonance imaging (MRI) images.MethodsAll patients who took at least one upper arm MRI from June 2003 to July 2021 were searched via a clinical data warehouse. For measuring the humerus length, proximal and distal landmarks were set as the highest protruding point of the humeral head and lowermost margin of ossified bone of the lateral condyle, respectively. For children or adolescents with incomplete ossification, the uppermost and lowermost ossified margin of the ossification centers were set as proximal and distal landmarks respectively. The anterior exit point (AEP) was defined as the location of the radial nerve exiting the lateral intermuscular septum to the anterior humerus and distance between the distal margin of the humerus and AEP was measured. The proportions between the AEP and full humeral length were calculated.ResultsA total of 132 patients were enrolled for final analysis. The mean humerus length was 29.4 cm (range 12.9–34.6 cm). The mean distance between the ossified lateral condyle and AEP was 6.6 cm (range 3.0–10.6 cm). The mean ratio of the anterior exit point and humeral length was 22.5% (range 15.1–30.8%). The minimum ratio was 15.1%.ConclusionA percutaneous distal pin insertion for humeral lengthening with an external fixator may be safely done within 15% length of the distal humerus. If pin insertion is required more proximal than distal 15% of the humeral shaft, an open procedure or preoperative radiographic assessment is advised to prevent iatrogenic radial nerve injury.

A study on the outcome of open tibial fractures managed definitively by external fixator

Introduction: High energy tibial diaphyseal open fractures are a common occurrence in modern times. In a resource strapped country like India, AO unilateral external fixator is a cheap, technically easier method for the definitive management of the same. The aim of the paper is to present the results of the treatment of 33 patients with open tibia fractures, as well as the complications that accompany the treatment of these fractures. Method: An observational prospective study was undertaken including all open diaphyseal tibia fractures with Gustilo Anderson classification Type II, IIIA, IIIB and Ganga hospital open injury severity score of 6-12. Patients underwent debridement, definitive fixation with exfix, and later Patellar Tendon Bearing Cast after removal. Outcome was measured by the Association for the Study and Application of the Method of Ilizarov Group score. Results: In 81.8% cases the mechanism of injury was road traffic accident. Mean time for complete weight bearing was 19.33 weeks, mean time for union was 26.18 months. ASAMI Radiological outcome was Excellent in 45.5%, Good in 30.3%, Fair in 9.1% and Poor in 15.2% cases. ASAMI Functional outcome was Excellent in 33.3%, Good in 51.5%, Poor in 15.2% cases. Pin tract infection was found in 39.4% and malunion in 24.2%. The mean time for union (p=0.0004), incidence of non-union (p=0.014) was found to be statistically significant to the severity of initial injury. Conclusion: Thus by this study it can be expressed that external fixator is a feasible implant in the definitive management of open tibia fractures.

Risk factors of transport gap bending deformity in the treatment of critical-size bone defect after bone transport

BackgroundThe purpose of this study was to investigate the risk factors of transport gap bending deformity (TGBD) in the treatment of critical-size bone defect (CSBD) after the removal of the external fixator.MethodsFrom January 2008 to December 2019, 178 patients with bone defects of the lower extremity caused by infection were treated by bone transport using a unilateral external fixator in our medical institution. TGBD was defined as the bone callus in the distraction area with a deviation to the force line of the femur (> 10°) or tibia (> 12°) after removal of the external fixator. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes. After the data were significant by the T-test or Pearson’s Chi-square test was analyzed, odds ratios were calculated using logistic regression tests to describe factors associated with the diagnosis of TGBD.ResultsA total of 178 patients were enrolled in the study, with a mean follow-up time of 28.6 ± 3.82 months. The positive result of the bacteria isolated test was observed in 144 cases (80.9%). The rate of excellent and good in the bone outcomes (excellent/good/fair/poor/failure, 41/108/15/14/0) was 83.7%, and 92.3% in the functional results (excellent/good/fair/poor/failure, 50/98/16/14/0) according to the ASAMI criteria. TGBD after removal of external fixator occurred in twenty-two patients (12.3%), including 6 tibias, and 16 femurs. Age > 45 years, BMI > 25 kg/m2, femoral defect, diabetes, osteoporosis, glucocorticoid intake, duration of infection > 24 months, EFT > 9 months, EFI > 1.8 month/cm were associated significantly with a higher incidence of TGBD in the binary logistic regression analysis (P < 0.05). The incidence more than 50% was found in patients with femoral defect (76.1%), osteoporosis (72.7%), BMI > 25 kg/m2 (69.0%), diabetes (59.5%), glucocorticoid intake (54.7%). In the multivariate logistic regression analyses, the following factors were associated independently with TGBD, including age > 45 years, BMI > 25 kg/m2, femoral defect, diabetes, and osteoporosis.ConclusionsBone transport using a unilateral external fixator was a safe and practical method in the treatment of CSBD caused by infection. The top five risk factors of TGBD included femoral defect, BMI > 25 kg/m2, duration of bone infection > 24 months, age > 45 years, and diabetes. Age > 45 years, BMI > 25 kg/m2, femoral defect, osteoporosis, and diabetes were the independent risk factors. The higher incidence of TGBD may be associated with more risk factors.

Unilateral External Fixator Combined with Lateral Auxiliary Frame for Ultimate Treatment of Tibia and Fibula Shaft Fractures with Poor Soft Tissue Conditions.

Background For severe soft tissue damage or open fracture, unilateral external fixation is one of the treatment choices. In the current study, a unilateral external fixator combined with a lateral auxiliary frame was used to treat tibia and fibula shaft fractures with poor soft tissue conditions to verify its feasibility for the ultimate treatment. Methods We retrospectively analyzed the patients with tibia and fibula shaft fractures who underwent unilateral external fixator combined with lateral auxiliary frame between December 2018 and October 2020. The clinical outcomes were recorded. Results 31 patients with tibia and fibula shaft fractures who received unilateral external fixator combined with lateral auxiliary frame were included in the current study. Among them, 23 cases had closed fractures with poor soft tissue and 8 cases had Gastilo type I open fractures. The average duration of hospital stay was 7.3 ± 2.3 days. The causes of injury were traffic accidents in 15 cases (48.4%), fall from height in 7 cases (22.6%), crush injury in 5 cases (16.1%), and other causes in 4 cases (12.9%). During follow-up, the clinical healing time was 3.0 ± 0.85 months. Additionally, the infection rate of pin-tract and reoperation rate was 12.9% and 3.2%. Fortunately, all patients achieved fracture healing and recovered well without joint dysfunction and obvious claudication. The Johner-Wruh scores showed that 27 cases (87.1%) were “excellent” and 4 cases (12.9%) were “good.” Conclusions The unilateral external fixator combined with lateral auxiliary frame is an effective option for ultimate treatment of the tibia and fibula shaft fractures with poor soft tissue conditions.

Effect of Annular External Fixator-Assisted Bone Transport on Clinical Healing, Pain Stress and Joint Function of Traumatic Massive Bone Defect of Tibia.

Objective To investigate the effect of annular external fixator-assisted bone transport in the treatment of traumatic massive bone defect of tibia on clinical healing, pain stress, and joint function. Methods From January 2018 to November 2021, 146 patients with traumatic massive bone defect of tibia were selected as the research objects, and they were divided into observation group (annular external fixator-assisted bone transport, 71 cases) and control group (unilateral external fixator bone lengthening, 75 cases) according to different surgical methods. The therapeutic efficacy, fracture healing-related indexes, and postoperative range of motion of the knee joint were compared between the two groups. Callus healing was evaluated by Fernandez-Esteve callus score, and joint function was evaluated by Paley score, American Knee society score (AKSS), and Baird-Jackson ankle score. The changes of pain mediator (serum substance P (SP), neuropeptide Y (NPY), prostaglandin E2 (PGE2), and tumor necrosis factor-α (TNF-α)) and stress indexes (adrenocorticotropic hormone (ACTH), cortisol (COR), and nor Epinephrine (NE)) were observed before and after treatment in two groups. The incidence of postoperative complications was analyzed. Results There were no significant differences in total effective rate and bone lengthening between the two groups (P > 0.05). The bone healing time and callus formation time in the observation group were shorter than those in the control group, and the Fernandez-Esteve callus score was higher than that in the control group (P < 0.05). The levels of SP, NPY, PGE2, TNF-α, ACTH, COR, and NE in the observation group were lower than those in the control group (P < 0.05). AKSS and Baird-Jackson scores in the observation group after operation were higher than those in the control group (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05). Conclusion Annular external fixator-assisted bone transport can promote postoperative fracture healing, reduce pain stress level, and improve joint function of patients with traumatic massive bone defect of tibia.

Plating after lengthening in treating phalangeal and metacarpal deficiency: An alternative method.

Objectives This study aims to investigate whether plating after lengthening in patients with phalanges and metacarpals deficiency could significantly shorten the duration of external fixation and decrease bone healing index.Patients and methods Between February 2010 and December 2018, 11 phalanges in nine patients (6 males, 3 females; mean age: 28.4±4.4 years; range, 22 to 35 years) and nine metacarpals in six patients (2 males, 4 females; mean age: 21.0±2.9 years; range, 16 to 25 years) were lengthened at a rate of 0.25 mm in two increments. A unilateral external fixator was applied in all cases. A locking compression plate was applied at the end of the distraction period before the external fixator was removed. Removal of the plate was considered two years after the internal fixation.Results The desired length and bone consolidation were achieved in all cases. The additional lengths achieved in the phalanges and metacarpals group were 18.3 mm and 27.7 mm on average, respectively. The bone healing indexes in the phalanges and metacarpals were 1.33 and 1.44 mo/cm, respectively. No significant difference was observed in the pre- and postoperative range of motion of involved metacarpophalangeal joint of both phalangeal (95% CI: -0.469~1.014, t=0.820, p=0.432) and metacarpal (95% CI: -0.689~0.975, t=0.420, p=0.689) lengthening cases. Only one case of minor complication (track infection) occurred.Conclusion Plating after lengthening is an ideal method for phalanges and metacarpals deficiency. Its advantages include shorter duration of external fixation, lower complication rate, and early functional recovery.

Twenty Years Development of Tibial Cortex Transverse Transport Surgery in PR China.

Tibial cortex transverse transport (TTT) surgery is an extension of the Ilizarov technique. Based on the law of tension‐stress, its primary function is to rebuild microcirculation which can relieve ischemic symptoms and promote wound healing. It has received more and more scholars' attention and has experienced a series of changes for 20 years since it entered PR China. The mechanisms involved have gradually become clear, such as the reconstruction of the polarization balance of macrophages, the promotion of vascular tissue regeneration, and the mobilization and regulation of bone marrow‐derived stem cells. TTT technique is mainly used in the treatment of chronic ischemic diseases of the lower extremities. It has recently been successfully used in the treatment of primary lymphedema of the lower extremities. A series of improvements have been made in the external fixator's style, the size of skin incision and osteotomy, and distraction method. For example, the annular external fixator has been redesigned as a unilateral external fixator, and accordion technology has been introduced. For distraction methods after surgery, there was no uniform standard in the past. The technique can also be used in combination with other treatments to achieve better effects, such as interventional therapy, negative pressure sealed drainage, 3D printing technology, traditional Chinese medicine. Nevertheless, the surgery may bring some complications, such as secondary fracture, nail infection, skin necrosis at the surgical site, etc. Reports of complications and doubts about the technique have made the TTT technique controversial. In 2020, the relevant expert consensus was published with treatment and management principles, which might guide the better application and development of this technique.

A finite element study of a fractured tibia treated with a unilateral external fixator: The effects of the number of pins and cortical thickness

IntroductionIn the early stage of fracture fixation, the aim of a unilateral external fixator (UEF) to stimulate healing and maintain stability may be suppressed by using inadequate number of pins. Cortical thinning due to age or osteoporosis endangers a successful fracture fixation. Materials and methodsThis study evaluates the initial strength and stability of the fracture fixation and tissue differentiation under the influences of variable cortical thickness (5 mm to 1 mm) and variable number of pins (1 to 4 in each bone fragment). A finite element program was utilised to develop 20 three-dimensional models of simplified diaphyseal tibia with fracture callus fixed with UEF. A mechano-regulation code based on the deviatoric strain theory was written and applied to simulate tissue differentiation. The values of von Mises stress, interfragmentary strain (IFS), and fibrocartilage index (FCI) were evaluated. ResultsCortical thinning from 5 mm to 1 mm increased IFS and FCI by an average of 30.3% and 18.7%, respectively, and resulted in higher stresses in the UEF and bone. Using 1 pin in each bone fragment produced excessive IFS in the models with 1 mm, 2 mm and 3 mm cortical thickness. Inserting the second pin into the bone fragment could considerably reduce the IFS and fibrocartilaginous tissue formation in the fracture site and improve load transmission to the fixator. Whereas inserting the fourth pin could minimally affect the mechano-biological environment of healing. ConclusionsThis study suggests that initial instability due to cortical thinning can be efficiently alleviated by adding the number of pins up to 3 in a UEF; additionally, it may improve the knowledge about applying UEFs adequately stable, whilst promoting inclination toward endochondral ossification, simultaneously.

Efficacy comparison of trifocal bone transport using unilateral external fixator for femoral and tibial bone defects caused by infection

BackgroundThis study aimed to evaluate the clinical and functional outcomes of patients with femoral and tibial critical-sized bone defect (CSBD) treated by trifocal bone transport using the Ilizarov method.MethodsFrom March 2011 and January 2017, clinical and radiographic data of patients with CSBD (> 6 cm) caused by infection were documented and analyzed. Patients were divided into the femur group (n = 18) and tibia groups (n = 21) according to the location of bone transport. The bone and functional outcomes were evaluated according to the Association for the Study and Application of the Method of the Ilizarov (ASAMI) criterion, and postoperative complications were evaluated by Paley classification.ResultsA total of 39 patients were managed by the trifocal bone transport for the femur (n = 18) or tibia (n = 21) bone defects with a mean follow-up time of 26.1 months (range 17–34 months). Eighteen femurs and 21 tibias with a mean distraction regenerate length (DRL) of 8.3 cm (range 6–13 cm) and 7.5 cm (range 6–11 cm) respectively. Infection was eradicated in all patients, and the total bone union was received in all cases (100%). Statistical difference of bone grade (excellent/good/fair/poor, 3/11/3/1 vs 2/13/4/2, P < 0.05), and function grade (excellent/good/fair/poor, 3/14/1/0 vs 4/13/3/1, P < 0.05) were respectively observed between the femur group and tibia group. The excellent and good rate of bone (femur vs tibia, 77.8% vs 71.4%), and function grade (femur vs tibia, 94.4% vs 80.9%) was higher in the femur group than the tibia. The rate of complication in the femur group was lower than in the tibia (femur vs tibia, 94.4% vs 76.2%). One femur and five tibias were performed additional surgery for delayed union and axial deviation.ConclusionsThe trifocal bone transport using the unilateral external fixator was a practical method in the management of CSBD in the lower extremity. The BUT and EFI of the femur group were shorter than the tibia. Although the complications noted were more frequent on the femur, these were mostly minor.

External Fixation as a Primary and Definitive Treatment for Tibial Diaphyseal Fractures: a Retrospective Longitudinal Study

Aim:To assess the potency of unilateral external fixation as a proper cure for tibial fractures. Study design: A retrospective longitudinal study Place and duration: This study was conducted at Pakistan Institute of Medical Sciences (PIMS) Islamabad Pakistan from August 2020 to August 2021. Methodology:Treatment of 225 tibial shaft fractures was done, in which closed fractures took 22 weeks and open 26 weeks for complete fusion. All fractures were fixed with AO fixator Results:Data of 210 patients was evaluated. Treatment of 225 tibial shaft fractures was done, in which closed fractures took 22 weeks and open 26 weeks for complete fusion. A total of 17 nonunion patients were observed while there were 22 delayed fusions, 5 malunion, 59 pin infections, and 4 osteomyelitis, 43 patients went through the re-operation process. Conclusion:Four patients had fat embolism while pulmonary embolism was present in six and venous thrombosis in 15 patients. The ultimate treatment in 88.0% of patients was external fixation. If there is a no formation of callus formation, reoperation should be carried out so unilateral external fixation is the preferred treatment for tibial fractures. Keywords: External Fixation, Tibial Diaphyseal Fractures, treatment

Обґрунтування можливості використання одноплощинного шарнірного апарата зовнішньої фіксації для лікування контрактур пальців кисті

При стійких довготривалих контрактурах після травм, включаючи артрогенні, доцільне використання апаратів зовнішньої фіксації. Мета роботи: надати біомеханічне обґрунтування для використання одноплощинного шарнірного апарата зовнішньої фіксації для лікування контрактур у міжфалангових суглобах пальців кисті. Матеріали та методи. Шляхом математичного моделювання вивчалася біомеханічна робота пристрою для лікування контрактур суглобів пальців кисті однобічної одноплощинної конструкції. Результати й обговорення. У математичній моделі біомеханічну роботу даного апарата зовнішньої фіксації можна поділити на дві частини: активну механічну роботу накладної системи та пасивну роботу кістково-суглобного вузла. Суглоб у розрахунках може бути поданий у вигляді пружного шарніра. Сила, що необхідна для щоденного прикладання під час лікування, становить 21 Н, що відповідає 1 градусу повороту у хворому суглобі. Пристроєм необхідне активне зусилля розвивається й передається через два кісткові різьбові стрижні на середню чи дистальну фаланги. Аналітичні вирази дають змогу визначити поздовжні зусилля, що діють у дистальній, проксимальній пластині та поворотному механізмі в будь-який момент роботи апарата зовнішньої фіксації. Висновки. Проведене дослідження дає підстави вважати, що використання одноплощинного одностороннього апарата забезпечує умови для дозованого повороту в суглобі та подолання пружних характеристик різного ступеня вираженості.