Introduction and Aims: I was presented with a Land-mine victim with closed fracture of right talus, compound injury to left lower limb, and defect in heelpad. Distal third of tibia and most of hindfoot were missing. Left foot neurovascularly intact and he was able to move his toes. Aim: reconstruct left distal tibia to enable full weight-bearing.

Method: Lower leg debrided. LRS applied, using proximal ring with Sheffield clamp and two rings around foot. Corticotomy of proximal tibia. Bone transport, 10 days later. Heel debridement, to clear necrotic bone. Two months later transported bone was 2cm from ankle. Sepsis controlled. Distal tibia beveled, bone transport continued.

Docking procedure performed. Ex-fix adjusted, attaining compression of hindfoot and midfoot. Distal tibia and foot transported 4cm, to correct disproportion. Osteoset used for bone growth. During the following two years, length discrepancy resolved, sepsis manageable. X-rays showed two cortices between proximal tibia and transported tibia. Fixator removed two months later. Received orthotic boot.

Results: In September 2003 the patient came for follow-up. There was no evidence of sepsis in the leg. He was full weight-bearing using an orthotic shoe and rocker bottom sole. There was no pain. He had left the army and was now working as a builder in his country of origin and putting in a whole day’s work. The length of the transported segment is approximately 14cm. It is now fully consolidated and four cortices are visible on x-ray. The fusion of the distal tibia into the foot is solid and no pain is experienced from that.

Conclusion: Big defects in the distal tibia can be managed with a straight rail reconstruction system, using unifocal bone transport with proximal corticotomy.

Introduction and Aims: Severe tibial plateau fractures are generally considered high-energy injuries, requiring ORIF. Bone grafting at time of surgery is generally advocated and the most devastating complication is deep infection. Our aim was to see whether we could avoid a bone graft and prevent deep infections by using a ring fixator.

Method: From 1997 to date, we treated 46 patients with Schatzker V & VI fractures, 41 males, five females, average age 43.2 years (range 30 –71). Follow-up ranged from 18 to 72 months. Forty fractures, closed or grade I compound and six grade II compound.

Reduction was by Bohler’s method. When indicated, fixation was supplemented by internal fixation. Three or four proximal wires were placed 15mm distal to the joint. Surgery was within 24 hours post-admission, irrespective of date of injury or swelling. No weight-bearing was allowed for the first six weeks. Thereafter gradual increments in weight bearing.

Results: All fractures united. No bonegrafting was required. No deep, i.e. grade III, sepsis. Osteoporosis is not a contra-indication. Pain at 4 years: Grade 0 to I - 30, grade II - 12, grade III - 4. Mean range of movement at 6 months was 5° to 115° of flexion.

Complications: Grade I pin tract sepsis - 24 patients. Grade II pin tract sepsis - 10 patients. Grade III – 0 patients.

Treatment consisted of mechanical cleansing of the pins. Added to that were antibiotics for grade II sepsis, and in 2 cases we had to re-site one of the proximal wires in order to prevent a deep infection.

Conclusion: A ring fixator can be used up to 10 days post-injury, irrespective of severity of swelling. No deep-seated infection, most likely due to minimal interference with soft tissue envelope around the proximal tibia. No bone grafting required, BMP’s stay in fracture hematoma. Follow-up now at six years.

Between 1997 and 2000, 25 Schatzker type-V and VI tibial plateau fractures were treated at our hospitals with the Ortho-fix ring fixator and followed up for between 10 months and four years. We chose this form of treatment for three reasons. First, because these are usually high-energy injuries, open reduction and internal fixation has to be done on admission or when the swelling has reduced, which can take up to three weeks. Secondly, internal fixation usually requires bone grafting at the same time. Thirdly, there is a high incidence of sepsis following conventional treatment with double plate and bone graft.

There were 20 closed or grade-I compound fractures and five grade-II compound fractures. The mean age of the 22 men and three women was 45.3 years (30 to 71). One patient had a head injury. There were ipsilateral femoral fractures in two patients, one of whom also had a comminuted distal radial fracture on the contralateral side, and one patient had a contralateral tibial plafond fracture. We routinely placed patients on a traction table and reduced the fracture, using Bohler’s method of traction and elastic bandaging. If necessary we made a limited incision and held the fragment with a large fragment screw under C-arm control. Using three or ideally four proximal wires, we made sure that the most proximal went through the fibular head. With local patients the frame was applied within 24 hours of admission. In patients who were referred from other parts of Africa, the frame was applied up to 10 days after the accident, irrespective of the amount of swelling. Continuous passive motion from 0° to 90° was started immediately postoperatively and maintained for a minimum of five days. Patients were then given crutches and mobilised touch weight-bearing in the frame. When the frame was removed, patients were fitted with a DonJoy hinged knee brace with no limitation of knee flexion or extension. All but two patients attained 90° of flexion within 10 days of application of the frame. Four patients failed to achieve full extension. Grade-I pin-tract sepsis developed in 12 patients and grade-II in four. All infections settled with treatment. One proximal wire needed to be resited. The mean time to removal of the frame was 4.5 months. No bone grafting was required.

We concluded that the amount of swelling is not a critical issue and that the ring fixator can be applied within 10 days of the injury. Probably because there was minimal interference with soft tissues, deep-seated sepsis did not occur. Even in osteoporotic bone, wire fixation gives excellent stability. There is still uncertainty about long-term follow-up, development of post-traumatic osteoarthritis and the possibility of sepsis if total knee arthroplasty is undertaken later.