Introduction. The purpose of this research is to compare the quality of life in children during gradual deformity correction using external fixators with intramedullary lengthening nails. Materials and Methods. Prospective analysis of children during lower limb lengthening. Group A included children who had external fixation, patients in group B had lengthening nails. Patients in each group were followed up during their limb reconstruction. CHU-9D and EQ-5DY instruments were used to measure quality of life at fixed intervals. The first assessment was during the distraction phase (1 month postop.), the second was during the early consolidation phase (3 months postop.) and the final one was late consolidation phase (6–9 months depends on the frame time). Results. Group B patients reported significantly better utility compared to Group A. This was observed during all the stages of the treatment. Group B children were less worried (P 0.004), less sad (P 0.0001), less pain (p <0.0001), less tired (P 0.0002), better school work (P0.0041), better sleep (p 0.016), more able to do sports activities (p 0.004) and, they were more independent (p <0.0001) compared to group B. QALYS was better for the nails group compared to external fixation group 0.44 compared to 0.36 for external fixators. Conclusions. Lengthening nails had the potential to improve the quality of life and utility compared to external fixation. This will help further economic evaluation to measure ICER to further explore the cost effectiveness of these devices

Introduction. A subset of patients in cast awaiting fixation of ankle fractures require conversion to delayed external fixation (dEF). We aimed to evaluate the effect of delayed versus planned external fixation (pEF), then identify objective characteristics contributing to need for conversion. Method. We extracted data from our booking system to identify all ankle external fixation procedures between 2010 to 2022. Exclusions included open fractures, the skeletally immature, and pilon or talus fractures. Fractures were classified using the AO/OTA classification, then a matched cohort was identified based on fracture classification. We compared the planned, delayed and matched cohorts for demographics, posterior malleolar fragment (PMF) ratio, and degree of displacement at presentation. Results. We identified 25 pEF, 42 dEF, and 67 matched patients. Ankles with dEF had a 3.8 day longer time to ORIF from presentation than those who had pEF, and had an infection rate of 9.5%, compared to 4% in the pEF group. Two patients in the dEF group required further operative intervention. There were no infections or reoperations required in the pEF or matched groups. The dEF group were more likely to have ≥2 reductions (OR 4.13), a PMF ratio of >0.23 (OR 5.07), and have increased displacement at time of injury on lateral (32% vs 19%) and AP (62% vs 36%) radiographs. Discussion. Our retrospective study highlights the longer time to operation and increased infection rates of patients who do not get timely external fixation. We propose a series of objective parameters that predict failure of cast treatment and guide the surgeon to consider planned external fixation in some ankle

Introduction: In the management of patients with bone neoplasm, we are confronted with various status which is difficult to treat. External fixation is useful for such status, and result in succes. The purpose of this study is to report that patients of bone neoplasms were treated with external fixation. Materials and methods: Fifteen patients with bone neoplasm who had treated by external fixation are an objective of this study, between 1989 and 2000. Clinical and pathological diagnosis is osteosarcoma in 7, giant cell tumor in 4, Ewing’s sarcoma in 1, chondrosarcoma in1, osteochondroma in 1, enchondroma in 1. Patients were divided into 4 groups depends on difference of indication of external fixation. Result. Group 1. Immobilization of pathological fracture. Two patients with osteosarcoma of femur and one patient with GCT of humerus were treated by external fixation for their pathological fracture. Group 2. Bone lengthening or correction for bone defect or deformity. We performed external fixation with Ilizarov fixator for bone lengthening following bone defect after tumor excision in 4 patients. Mean length of bone defect was 83.5 (22–150) mm. Two in 4 cases were stopped bone lengthening owing to local recurrence and progression of disease. And in 2 patients, we performed correction with external fixation for bone deformity arised by enchondroma of humerus and osteochondroma of ulna. Group 3. Stabilization for vascularized bone graft. We performed vascularized fibular graft after wide resection and stabilized with external fixator in 2 patients with humeral sarcoma. Group 4. Salvage of infected prosthesis. There were 4 patients with infected prosthesis. Three of them were treated by bone lengthening technique after removal of prosthesis. Mean length of bone defect was 264 (220–330) mm and mean term of fitting external fixator was 583.7 (442–726) days. Discussion: Advantages of treatment with external fixation for bone defect, bone deformity and pathological fracture arise from bone neoplasm are mentioned as follows. It could immobilize pathological fracture that is difficult for plaster cast immobilization. It could compensate for bone defect following tumor resection. It is useful method for salvage of the infected prosthesis. Disadvantages of using of external fixation are mentioned as follows. In case of bone lengthening, it is need to perform a complete tumor control. Treatment term is longer. It is need pin site management. Treatment with external fixation is one of the useful method for pathological fracture, bone deformity, shortening, bone defect and infected prosthesis arise from bone neoplasm

Introduction. The vast majority of orthopaedic surgeons use C-arm fluoroscopy in the operating theatre when building a circular external fixator. In the absence of previous research in this area, we hypothesised that the surgeon who builds a circular external fixator is exposed to a greater amount of radiation purely as a result of the presence of the metallic fixator in the x-ray beam. The aim of our study therefore was to investigate how the presence of a circular external fixator affects the radiation dose to the surgeon and the surgical assistant. Materials & Methods. A simulated environment was created using a radiolucent operating table, an acrylic lower limb phantom (below knee segment), various configurations of metalic circular external fixation, and a standard size C-arm image intensifier. The variables investigated were 1. the amount of metal in the beam 2. the orientation of the beam (PA vertical vs lateral) 3. the horizonal distance of the person from the beam (surgeon vs assistant) and 4. the vertical distance of the various body parts from the beam (e.g. thyroid, groin). In terms of radiation dose, we recorded two things : 1. the dose produced by the image intensifier 2. the dose rate at standardised positions in the operating theatre. The latter was done using a solid-state survey sensor. These positions represented both where the surgeon and surgical assistant typically stand plus the heights of their various body regions relative to the operating table. Results. The effect of the presence of the circular external fixator : all frame constructs tested resulted in a statistically significant greater radiation dose both produced by the image intensifier and received by the surgical team. The effect of the beam orientation : the PA (vertical) orientation resulted in a statistically significant greater radiation dose for the surgeon than did the lateral orientation, but made no difference for the assistant. The effect of horizontal distance from the beam : unsurprisingly, the surgeon (who was closer to the beam) received a statistically significant greater radiation dose than the assistant. The effect of vertical distance from the beam : for the surgeon, the dose received was highest at the level of the phantom leg / frame, whilst for the assistant there was no statistically significant difference for any level. Conclusions. To our knowledge, this is the first study investigating the radiation dose rate to the orthopaedic surgeon when building a circular external fixator. We found that the surgeon does indeed receive a ‘double whammy’ because the image intensifier puts out a greater amount of radiation plus the metalic frame scatters more of the x-ray beam. Whilst the amounts are relatively small, we think that it's important to quantify doses that orthopaedic surgeons receive to ensure optimal radiation practices

Introduction. Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt. Materials & Methods. Data of patients with complex lower limb injuries treated before, during and after the pandemic were collected from our in-house trauma database, theatre records and follow up clinics. The rationale for choosing other techniques over a circular frame, the type of alternative technique used, the cost of such alternatives, the need for soft tissue reconstruction, time to recovery, complications and amputation rates were compared among groups. Results. These data suggest comparable outcomes between circular frames and alternative techniques can be achieved. A notable reduction in the number of circular frames applied during the review period was observed. Furthermore, frame fixation was associated with more frequent outpatient review and the associated implications for resource management. Conclusions. Conclusion: The Covid-19 pandemic has posed great challenges to the Trauma and Orthopaedic community, forcing us to be flexible by adopting alternative treatment methods to traditional circular external fixation. These alternatives have proven feasible and potentially more cost effective, prompting their adoption in the post pandemic era. However, this change of practice is not without potential consequences and continued investigation is warranted

The choice of treatment for open fractures is conditioned by the care of bone and soft tissue. Grade I open fractures can be treated as closed fractures, according to the centre’s protocol. In Grade II open fractures skin wounds must be left open, and the suture should be delayed for at least a week. Most authors perform fixation by means of intramedullary nails. In our opinion, external fixation is the best choice in these cases. The skin cannot be closed in Grade III open fractures, and the basic point of treatment is adequate surgical debridement. The fixation must be done by external fixation. To achieve the treatment in an emergency situation, the device to be used must be quick and simple like a monolateral device that can be changed into a more complex one, such as an Ilizarov. The Ilizarov technique uses distractional osteogenesis that can fill bone and soft tissue loss without further bone or soft tissue grafting. Following these general guidelines, each district has its own particular approach to treating open fractures. Internal fixation by DCP plates is always indicated for forearm fractures. For a humerus fracture, simple direct shortening and external fixation can fill bone loss. Patients with fractures of the femur usually have multiple injuries. The problem is to provide a quick fixation in order to allow for easier intensive care. External fixation is the most indicated technique

The choice of treatment for open fractures is conditioned by the care of bone and soft tissue. Grade I open fractures can be treated as closed fractures, according to the centre’s protocol. In Grade II open fractures skin wounds must be left open, and the suture should be delayed for at least a week. Most authors perform fixation by means of intramedullary nails. In our opinion, external fixation is the best choice in these cases. The skin cannot be closed in Grade III open fractures, and the basic point of treatment is adequate surgical debridement. The fixation must be done by external fixation. To achieve the treatment in an emergency situation, the device to be used must be quick and simple like a monolateral device that can be changed into a more complex one, such as an Ilizarov. The Ilizarov technique uses distractional osteogenesis that can fill bone and soft tissue loss without further bone or soft tissue grafting. Following these general guidelines, each district has its own particular approach to treating open fractures. Internal fixation by DCP plates is always indicated for forearm fractures. For a humerus fracture, simple direct shortening and external fixation can fill bone loss. Patients with fractures of the femur usually have multiple injuries. The problem is to provide a quick fixation in order to allow for easier intensive care. External fixation is the most indicated technique

BACKGROUND. Most closed tibial fractures in children can be treated conservatively. On the occasions that surgical intervention is required, there are various options available to stabilise the fracture. We would like to present our experience of using monolateral external fixators in the management of closed tibial fractures. Aim. We sought to assess the time to healing, limb alignment, and complications observed in a cohort of tibial fractures treated with external fixation. METHODS. Our limb reconstruction database was used to identify patients who underwent monolateral external fixation for a closed tibial fracture between January 2008 and December 2016. Radiographs of all patients were assessed to determine the original fracture pattern. Time to union was assessed as the time when the fixator was removed and the patient allowed to mobilise independently without any further support of the limb. The presence or absence of residual deformity was assessed on final follow-up radiographs. RESULTS. 22 patients fulfilled the inclusion criteria. 78% of patients had both tibial and fibular fracture. The mean age at injury was 12 years. The mean time taken for the fracture to heal was 18 weeks. The total duration of follow-up averaged 9 months. The mean Valgus deformity at the final follow up was 4 degrees and the mean Varus deformity was 4 degrees. The mean procurvatum was 4.2 degrees and the mean recurvatum was 6 degrees. 50% of patients had pin site infection. Two patients had tibio fibular synostosis. None of them had leg length discrepancy or refractures. There were no episodes of osteomyelitis. CONCLUSIONS. Five degree of coronal plane deformity and ten degree of sagittal deformity were considered as acceptable in children due to their potential for remodeling. All our patients had acceptable levels of residual deformity. In our opinion monolateral external fixation represents a safe and effective option

Introduction. Knee arthrodesis is a useful limb salvage technique to maintain function in patients with complex and infected total knee arthroplasties (TKA). There are a number of commonly used external fixators, but no consensus on which of these are optimal. The aim of this study was to synthesise the current literature to guide clinical decision making and improve patient outcomes. We systematically review the literature to compare outcomes of external fixators in arthrodesis following infected TKA. Materials & Methods. A systematic review of the literature of primary research articles investigating the use of external fixators for knee arthrodesis after an infected TKA was conducted. Relevant articles were identified with a search strategy on online databases (EMBASE and Medline) and reviewed by two independent reviewers. Clinical outcome measures were independently extracted by two reviewers which included union rate, infection eradication rate, complication rate, time to fusion, and time in frame. Results. Circular frames were more likely to result in union compared to biplanar (OR 1.40 p=0.456) and monoplanar frames (OR 2.28 p=0.018). Infection recurrence was least likely in those treated by circular frames when compared to monoplanar (OR 0.12 p=0.005) and biplanar external fixators (0.41 P=0.331). Complication rates were highest in the circular fixator group, followed by the monoplanar fixator group and biplanar fixator group at 34%, 31% and 11% respectively. Conclusions. Analysis of the available literature suggests higher union and infection eradication rates with circular frames over the other two fixation methods despite a higher complication rate. There is a paucity in the literature and therefore, no firm conclusions can be drawn. Further research investigating the variations and biomechanical properties between different external fixation methods for knee arthrodesis is necessary. Further clarity in reporting and pooled data would be useful for future analysis

Purpose: External fixation is a popular treatment method of unstable distal radius fractures. There has been much debate and confusion however regarding the use of bridging versus non-bridging fixation. The aim of this study is to define the indications for bridging and non-bridging external fixation in the treatment of unstable distal radius fractures. The study also endeavours to evaluate the complications and pitfalls associated with this treatment and to determine if non-expert surgeons can reproduce successful outcomes. Methods: Between January 1995 and December 2000, 641 patients with fractures of the distal radius were treated at our institution with external fixation. The fractures were treated either by bridging or non-bridging external fixation. Demographic data was collected prospectively for these patients including their hospital number, date of birth, gender, age at injury, mode of injury, type of external fixator and whether the fracture was an open or closed injury. Further information was collected retrospectively from review of case notes and x-rays and included AO classification, status of the operating surgeon, duration of fixation, and complications. Results: Patients treated with bridging external fixation had significantly more mal unions in terms of dorsal angulation and shortening. The non-bridging fixators were better able to maintain and in some cases improve on the immediate post external fixation measurements. Minor pin tract infections were more common in the non-bridging group. Conclusions: Non-bridging external fixation is the treatment of choice for unstable fractures of the distal radius with sufficient space for the placement of pins in the distal fragment. A predictable outcome with low complication rate can be expected

Background. Surgical management of calcaneus fractures is demanding and has a high risk of wound complications. Traditionally these fractures are managed with splinting until swelling has subsided. We describe a novel protocol for the management of displaced intra-articular calcaneus fractures utilising a temporizing external fixator and staged conversion to plate fixation through a sinus tarsi approach. The goal of this technique is to allow for earlier treatment with open reduction and internal fixation, minimise the amount of manipulation required at the time of definitive fixation and reduce the wound complication rate seen with the extensile approach. Methods. The records of patients with displaced calcaneus fractures from 2010–2014 were retrospectively reviewed. A total of 10 patients with 12 calcaneus fractures were treated with this protocol. All patients underwent ankle-spanning medial external fixation within 48 hours of injury. Patients underwent conversion to open plate fixation through a sinus tarsi approach when skin turgor had returned to normal. Time to surgery, infection rate, wound complications, radiographic alignment, and time to radiographic union were recorded. Results. The average Bohler's angle improved from 13.2 (range −2 to 34) degrees preoperatively to 34.3 (range 26 to 42) degrees postoperatively. The average time from external fixation to conversion to internal fixation was 4.8 (range 3 to 7) days. There were no immediate post-surgical complications. The average time to weight bearing was 8.5 weeks. The average time to radiographic union was 9.5 (range 8 to 12) weeks. There were no infections or wound complications at the time of last follow-up. Conclusions. Early temporizing external fixation for the acute management of displaced calcaneus fractures is a safe and effective method to reduce and stabilise the foot and may decrease the time to definitive fixation. In our series there were no complications related to the use of the external fixator. Level of Evidence. IV Retrospective case series

The treatment of the open tibial fractures is still an orthopaedic challenge and full of complications. In many cases the use of external fixation that has been known as a non-union machine is obligatory with a high incidence of pin track infection and other complications. The aim of this study was to compare the use of external fixation as a definite method of treatment of open tibial fractures with it’s subsequent conversion to internal fixation or casting. During June 2004 to July 2006 in a randomized controlled trial 67 patients with types A and B of Arbeitsge-meinschaft fur Osteosynthesefragen (AO) open type III Gustilo tibial and fibular diaphyseal fractures were studied. Mean age of the patients was 25 years (18–40 years) and mean follow up time was 8 months. After the external fixation of the fractures, the patients were divided into three groups by drawing from the random table of numbers. Group one consisted of 20 patients were selected for delayed conversion to internal fixation after 6–8 weeks (after three weeks of removal of external fixator). Group two consisted of 25 patients in whom external fixation had continued in order to convert to Patellar Tendon Bearing (PTB) cast after developing union. The remaining 22 patients were considered as group three in whom external fixation was continued until complete union. There was a meaningful difference only in the union time (P=0.001) and superficial infection (P=0.018) between the first group and the other two groups. So, in the treatment of the open tibial fractures there is priority for method of conversion of the external fixation to internal fixation compared to the other protocols of treatment

Introduction. We present the results of the management of irreducible dislocation or fracture / dislocation of the elbow using the “Orthofix” external fixator in cases where the condition of the soft tissues was contraindicated for extensile surgical approaches or the internal fixation would not be stable enough to permit safe joint mobilization postoperatively. Materials and methods. Twelve (12) patients were treated using elbow external fixation,5 with supracondylar fracture and severe osteoporosis and 7 with fracture / dislocation of the elbow and excessive soft tissue impairment (two of them with open fracture). For the patients with fracture, we performed minimal internal fixation using small incisions and minor soft tissue detachments and then we applied the elbow external fixator for the neutralization of the fixation. This permitted the immediate active assisted joint mobilization postoperatively without interfering with the stability of the joint and of the fixation. The same happened for the patients that their elbow remained unstable after reduction of traumatic dislocation, where the external fixation maintained the reduction of the joint. Prerequisite for the safe mobilization of the joint was the application of the external fixation at the center of rotation of the elbow which is the transepicondylar axis, in order to comply with the biomechanics of the joint. Results. The fixator was applied for a mean of 10 weeks (6 – 16 weeks). All the fractures united and no instability of the joint was noted. The range of motion was between useful limits with lack of extension less than 30 degrees and flexion more than 130 degrees, pronation 60 degrees and supination 55 degrees (mean values). Pin track infection was presented in 3 patients and the treatment was local care and antibiotics. One patient had radial nerve palsy immediately after the operation, who recovered totally after four months without any treatment. Conclusions. The external fixation of the elbow provides sufficient stability permitting the immediate mobilization of the joint postoperatively and in combination with the minimal soft tissue damage during the operation prevents the postoperative stiffness. It is a safe alternative solution when the condition of soft tissues around the elbow do not permit a thorough open procedure

Background. The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications. Aim. To compare outcomes for AO/OTA 42C2 and 42C3 fractures treated using IMN with those treated using EF in a University Teaching Hospital. Methods. Retrospective case note and radiograph review of 31 segmental tibial fractures treated between 2010 and 2017. Results. There were 17 42C2 and 14 42C3 fractures. 17 patients underwent IMN and 14 EF, and were matched for age and gender. 9 fractures in each group were open. Median time to radiological union was 7 months for IMN and 8 months for EF. Revision surgery was needed for 4 IMN patients and 3 EF patients. The mean number of unplanned procedures was 1.46 for IMN and 1.1 for EF (p=0.69). Length of stay was 15.5 days for IMN and 16.2 days for EF (p=0.9). There was one compartment syndrome in each group and 2 cases of deep infection in the IMN group. There was no significant difference in coronal and sagittal plane alignment. Conclusions. Notwithstanding the small numbers and the retrospective design, the results show that the results of IMN may be equivalent to EF. Modern techniques using suprapatellar entry and blocking screws, combined with early plastic surgical coverage in open injuries are likely to have improved outcomes. Implications. Modern IM nailing techniques have produced similar clinical and radiological outcomes to that achieved by external fixation in this series

Purpose of the study: We report our experience with 59 cases of secondary nailing after external fixation of tibial fractures. Material and methods: Between 1988 and 2002, 59 tibial fractures (58 patients) were treated initially by external fixation then by secondary nailing. The AO classification was: A (n=28), B (n=20), C (n=11). The Gustilo classification was: closed (n=28), grade 1 (n=18), grade 2 (n=10), grade 3A (n=1), grade 3C (n=2). Tibiotibial or tibio-calcaneal external fixation was used initially for these lower diaphysometaphyseal fractures. The reason for using external fixation was: soft tissue damage (n=38), complex fracture (n=14), associated injuries (n=7). Associated plastic surgery procedures were: medial gastrocnemius flap (n=1), skin graft (n=3). Secondary nailing was undertaken early in 41 cases at about the sixth week because of improvement in the local or general status. For seven cases, the secondary nailing was performed at about four weeks after the multiple-fragment fracture had partially consolidated. There were three infectious complications after nailing (abscess on screw, fistula, pandiaphysistis) in patients whose initial samples of the reaming material were bacteriologically negative. Bone healing was achieved after nailing in 56 cases. Dynamizing the nail was sufficient to achieve healing in one case. Two cases of septic non-union were nailed again and finally healed. The case of pandiaphysitis was treated by removing the nail then a new external fixation which was successful in achieving bone healing. Results: The results of the secondary centromedullary nailing were satisfactory. Several operations were necessary however (removal of the fixator, nailing, dynaiztion, material removal) with considerable risk of infection. This two-stge method enables treatment of difficult situations rapidly (external fixation) and early (four weeks) revision to allow «programmed» treatment in safer conditions. This secondary nailing can also be used as a treatment in the event of late healing after initial external fixation. Contraindications are pin tract osteitis and serious local infection during the external fixation phase

Fractures of the distal radius are the most common bony injuries in the upper extremity, and many treatment Methods: have been described in the literature. External fixation remains a highly versatile method to treat many fracture types involving the distal radius. The primary indications for external fixation include reduction of unstable extra-articular fractures and most intra-articular fractures. The use of adjuvant pinning or mini open procedures can be used when external fixation inadequately reduces the joint line alone, especially with central depressions and highly comminuted injuries. The ease of use of the implants and successful track record make it an extremely versatile tool for treating complex fractures of the distal radius. Purpose: To compare 2 Methods: of surgical treatment for displaced intra-articular fractures of the distal radius: open reduction and internal fixation with dorsal plating (Pi Plate; Synthes, Paoli, PA) versus external fixation with o without K-wires. Methods: We compare a retrospective study about AO type C intra-articular distal radius fractures. The fist group (40 patients) is treated with open reduction and internal fixation with DVR plate ande the second group (65 pacients) is treated with external fixation and K-wires and mini-open reduction. Objective, subjective, and radiographic outcomes were assessed at 2 weeks, 4 to 6 weeks, 10 to 12 weeks, 6 months, and 1- and 2-year intervals. The minimum follow-up period was 6 months; the average follow-up period was 18 months. The principal outcome analyzed was Jakim store that included pain, grip strength, range of motion, complications, and radiographic parameters. The groups were equal with respect to age, gender and fracture subtype. Results: No significant difference was found in the Jakim store outcome. The volar plate group, howevwe, showed a similar complication rate when compared with the external fixator group. The plate group also had similar levels of pain at 1 year when compared with the external fixator group. The external fixator group showed an average grip strength of 92% compared with the normal side and 86% in the volar plate group. Conclusions: At midterm analysis the volar plate group showed a significantly higher complication rate compared with the external fixator group; therefore enrollment in the study was terminated. The volar plate group also showed statistically significant higher levels of pain, and weaker grip strength. Based on these results we can recommend the use of volar plates in treating complex intraarticular fractures of the distal radius

To review healing rates, complications, alignment, length and function in non-unions treated with Mono-lateral External Fixation. A cohort of 110 patients (113 segments) treated for non-union, by mono-lateral external fixation in Sheffield between 1987 and 1996 is reviewed. There were 83 males and 27 females with a mean age of 37.2 years. 67 patients had high-energy injuries and there were 56 open fractures. There were 60 tibiae, 38 femora and the rest were upper limb long bones with a mean of 3.2 previous procedures. The mean duration of non-union was 23.4 months (range 3–123). There were 64 monofocal procedures with 41 supported in neutralisation, 20 in compression and three in distraction. There were 49 bifocal procedures (33 compression distraction and 16 bone transport). 71 segments required a bone graft. The success rate using the initial fixator was 90%. Clinical and radiological union was achieved in 109 segments (96.5%) although seven required further fixation and one subsequently went on to amputation for ischamia. All five amputations were in smokers and three were directly related to vascular failure. The mean hospital stay was 21.12 days and the mean number of operations per patients was 2.55.The mean time to bony union was 12.69 months (range 2.5-64). The Length gained mean 4.5 cm (range 1.5-12 cm). Angular correction achieved 12° (range 2-39°); The bony and functional results were assessed at the end of treatment by system described by Paley & Catagni (JBJS 77A, 1995). Bony results. Excellent. 42%. Good. 50%. Fair. 0.3%. Poor. 0.0%. Amputations. 4.4%. Functional results. Excellent. 59 cases. Good. 34 cases. Fair. 03 cases. Poor. 00. Monolateral external fixation can provide stable fixation for the treatment of established non-unions. The fracture environment may be carefully controlled and angulation and length corrected simultaneously. Interestingly 11 out of 12 problem cases were in smokers

Objective: To evaluate retrospectivelly the outcome of periarticular tibial pilon fractures treated by hybrid external fixation. Method: Between 1999–2003, 44 patients(44 fractures) were treated with a combination of hybrid external fixation and minimal internal fixation(k-wires or lag-screws). There were 31 men and 13 women with a mean age of 41 years. A high energy trauma( accident or fall from a height) was the mechanism of injury for 32(73%) patients. According with A.O. clasiffication 4 fractures were A1, 5-A2, 5-A3, 8-C1, 12-C2,10-C3. All fractures were treated within a 10 days from the initial injury (10(23%) of them were open and treated immediately). The use of bone grafts reguired in 8 cases. Primary postop mobilization of adjacent joints was performed in all cases. Fourty patients were available for clinical and radiographic evaluation(using Teeny’s and Wiss ancle score). The average follow-up was 26 months. Results: There were 9(23%) excellent, 12(30%) good, 10(25%) fair, and 9(23%) poor results. Union achieved in 40(92%) cases. Overall, 12(30%) complications reported: 6 pin track infections, 2 deep infections, 4 non-unions and 1 malunion. Post-traumatic osteoarthritis noticed in 11(28%) cases. Conclusions: Hybrid external fixation permits early mobilization of the ankle joint and decrease the soft tissue trauma. Poor results associated with the presence of infection, the degree of intraarticular involvement and the inability to achieve adeguate fracture reduction

Introduction: Septic non unions are rare and often occurs after an open fracture but they might arise after an inappropriate surgical or medical treatment. Different techniques can be used for the treatment. External fixation has many advantages over other techniques particularly when bone reconstruction and/or plastic surgery are indicated although sometimes more than one surgery is necessary to restore ideal biological and mechanical conditions for healing. Material and Methods: The authors present their experience in the treatment of 38 septic non unions using a protocol which differentiates the diagnostic and therapeutic approach. External fixation can be used as a single procedure or associated to other surgical procedures in relation to the type and diffusion of the infection. Results: Bone healing and infection eradication have been obtained in 92% of the cases (35 pts). We had 3 secondary amputations (8%). In the first series of patients screw removal and replacement, for pin track infections, occurred in 40% of the cases while this percentage decreased to 4.3% when HA- coated screws were used. Conclusions: The treatment of septic non-unions needs a multidisciplinary approach to treat properly both non union and infection of bone and soft tissues. Internal fixation remains a procedure at risk because of the high rate of infection recurrence. External fixation is instead still the safer and more versatile surgical option to treat these pathologies. It nevertheless requests strict diagnostic and therapeutic protocols and a good postoperative organisation in order to shorten the healing time and to minimise the complications

Introduction: The variety of operative procedures for neglected Monteggia lesions reflect the difficulty to securely keep the radial head relocated. The amount and direction of angulation in case of an ulnar oste-otomy can only be defined intraoperatively by empirically searching for the appropriate position since the primary ulnar deformity has already partially or completely remodelled with growth in most cases. Material and Methods: Retrospective study. From Janu-ary 1998 to May 2001 14 patients with late missed Mon-teggia lesions (Bado type I) underwent an osteotomy and external fixation (Hoffmann II compact, Howmed-ica) of the ulna combined with an open reduction of the radial head but without reconstruction of the anular ligament. The average age of 7 girls and 7 boys at the time of reconstruction was 9 years (5 to 15 years), the mean interval between the primary trauma and the reconstructive procedure 21 months (2 weeks to 7 years). Removal of the external fixator:12 weeks (7 – 16 weeks). Results: In 12 patients the radial head remained located, in 2 patients it re-dislocated postoperatively. After early postoperative closed reduction in one patient and open relocation of the radial head in the other patient with modification of the external fixation, the radial head remained located. Preoperatively 7 of the 14 patients showed a decreased range of motion which improved postoperatively in most cases. Thirteen of the 14 patients had a clinical and radiological follow-up 14 months (3 – 44 months) after the reconstructive procedure. There were no complications. Conclusions: Ulnar osteotomy, external fixation and open reduction of the radial head without ligament reconstruction or transarticular wire fixation proved to be a technically simple and safe procedure. It allows early functional after treatment without plaster. In case of posttraumatic overlength of the radius, it can be combined with acute or gradual lengthening of the ulna. Radio-humeral joint reconstruction in case of incongruency of the radial head and the capitullum, as well as reconstruction in adults with longstanding dislocation of the radial head are prone to failure