Introduction. Knee dislocations, vascular injuries and floating knee injuries can be initially managed by a external fixator. Fixator design constructs include the AO pattern and the Diamond pattern. However, these traditional constructs do not adhere to basic principles of external fixation. The Manchester pattern knee-spanning external fixator is a new construct pattern, which uses beam loading and multiplanar fixation. There is no data on any construct pattern. This study compares the stability of these designs. Materials & Methods. Hoffman III (Stryker, USA) external fixation constructs were applied to articulated models of the lower limb, spanning the knee with a diamond pattern and a Manchester pattern. The stiffness was loaded both statically and cyclically with a Bose 3510 Electroforce mechanical testing jig (TA Instruments). A ramp to load test was performed initially and cyclical loading for measurement of stiffness over the test period. The results were analysed with a paired t-test and ANOVA. Results. The mean stiffness with the diamond pattern fixator was significantly less stiff than the Manchester pattern fixator – by a factor of 3 (40N/mm vs 115N/mm). Displacement increased in all patterns over simulated loading equating to six weeks. The diamond pattern demonstrated a 50%% increase in displacement over time. The Manchester pattern demonstrated only 20% increase in displacement over time. These are all statistically significant (p<0.01). Conclusions. The aim of an external fixator in knee dislocations and vascular injuries is to provide stability, prevent displacement and protect repairs. Vascular injuries often require fixation for several weeks to protect a repair. The Manchester pattern, applying the principles of external fixation, provides a stiffer construct and also confers greater stability over the time a fixator may be required. We commend this more informed design for the management of knee dislocations and vascular injuries

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Introduction. The various problems that are managed with circular external fixation (e.g. deformity, complex fractures) also typically require serial plain x-ray imaging. One of the challenges here is that the relatively radio-opaque components of the circular external fixator (e.g. the rings) can obscure the view of the area of interest (e.g. osteotomy site, fracture site). In this presentation we describe how the geometry of the x-ray beam affects the produced image and how we can use knowledge of this to our advantage. Whilst this can be applied to any long bone, we have focused on the tibia, given that it's the most common long bone that is treated by circular external fixation. Materials & Methods. In the first part of the presentation we describe the known attributes (geometry) of the x-ray beam and postulate what effect it would have when we x-ray a long bone that is surrounded by a circular external fixator. In the second part we demonstrate this in practice using a tibia and a 3 ring circular external fixator. Differing x-ray beam orientations are used to demonstrate both how the geometry of the beam affects the produced image and how we can use this to our advantage to better visualise part of the bone. Results. The practical part of the study confirmed the theoretical part. Conclusions. Knowledge of the beam geometry can be used to minimise the obscuring nature of the circular fixator. This technique is simple and can be easily taught to the radiographer. It is a useful adjunct for the limb reconstruction surgeon

Introduction. External fixators are attached to bones with percutaneous pins and wires inserted through soft tissues and bone increasing the risk of infections. Such infections compromise patient outcomes e.g., through pin loosening or loss, failure of fixator to stabilise the fracture, additional surgery, increased pain, and delayed mobilisation. These infections also impact the healthcare system for example, increased OPD visits, hospitalisations, treatments, surgeries and costs. Nurses have a responsibility in the care and management of patients with external fixators and ultimately in the prevention of pin-site infection. Yet, evidence on best practices in the prevention of pin-site infection is limited and variation in pin-site management practices is evident. Various strategies are used for the prevention of pin-site infection including the use of different types of non-medicated and medicated wound dressings. The aim of this retrospective study was to investigate the use of dry gauze or iodine tulle dressings for the prevention of pin-site infections in patients with lower limb external fixators. Methodology. A retrospective study of patients with lower limb external fixators who attended the research site between 2015–2022. Setting & Sample: The setting was the outpatient's (OPD) orthopaedic clinic in a University Teaching Hospital in Dublin, Ireland. Eligibility Criteria:. Over the age of 16, treated with an Ilizarov, Taylor Spatial frame (TSF) or Limb Reconstruction System (LRS) external fixators on lower limbs,. Pin-sites dressed with dry gauze or iodine tulle,. Those with pre-existing infected wounds close to the pin site and/or were on long term antibiotics were excluded. Follow Up Period: From time of external fixator application to first pin-site infection or removal of external fixator. Outcome Assessment: The primary outcome was pin-site infection, secondary outcomes included but were not limited to frequency of pin-site infection according to types of bone fixation, frequency of pin/wire removal and hospitalisation due to infection. Data analysis: IBM SPSS Version 25 was used for statistical analysis. Descriptive and inferential statistics were conducted as appropriate. Categorical data were analysed by counting the frequencies (number and percentages) of participants with an event as opposed to counting the number of episodes for each event. Differences between groups were analysed using Chi-square test or Fisher's exact test, where appropriate. Continuous variables were reported using mean and standard deviations and difference analysed using a two-sample independent t-test or non-parametric test (Mann-Whitney), where appropriate. Using Kaplan-Meier, survival analysis explored time to development of infection. Ethical approval: granted by local institute Research Ethics Committee on 12th March 2018. Results. During the study period, 97 lower limb external fixators were applied with 43 patients meeting the study eligibility criteria. The mean age was 38 (SD 14.1; median 37) and the majority male (n=32, 74%). At least 50% (n=25) of participants had an IIizarov fixator, with 56% (n=24) of all fixators applied to the tibia and fibula. Pin/wire sites were dressed using iodine (n=26, 61%) or dry gauze dressings (n=15, 35%). The mean age of participants in the iodine group was significantly higher than the dry gauze group (p=.012). The only significant difference between the iodine and dry gauze dressing groups at baseline was age. A total of 30 (70%) participants developed a pin-site infection with 26% (n=11) classified as grade 2 infection. Clinical presentation included redness (n=18, 42%), discharge (n=16, 37%) and pain (n=15, 35%). Over half of participants were prescribed oral antibiotics (n=28, 65%); one required intravenous antibiotics and hospitalization due to pin-site infection. Ten (23%) participants required removal of pin/wires; two due to pin-site infection. There was no association between baseline data and pin-site infection. The median time to developing an infection was 7 weeks (95%, CI 2.7 to 11.29). Overall, there were 21 (81%, n=26) pin-site infections in the iodine group and nine (60%, n=15) in the dry gauze group, difference in proportion and relative risk between the dressing groups were not statistically significant (RR 1.35, 95% CI 0.86–2.12; p= .272). There was no association between baseline data, pin-site infection, and type of dressing. Conclusions. At the research site, patients are referred to the OPD orthopaedic clinic from internal and external clinical sites e.g., from Hospital Consultants, General Practitioners and occasionally from multidisciplinary teams, throughout Ireland. Our retrospective observation study found that 97 lower limb external fixators were applied over a seven-year period which is lower than that reported in the literature. However, the study period included the COVID pandemic years (2020 and 2021) which saw a lower number of external fixators applied due to lack of theatre availability, cancelled admissions and social/travel restrictions that resulted in fewer accidents and lower limb trauma cases requiring external fixator application. The study highlighted a high infection rate with 70% of participants developing pin-site infection which is in keeping with findings reporting in other studies. Our study showed that neither an iodine nor dry gauze dressing was successful in preventing pin-site infection. In the iodine group 81% of participants developed infection compared to 60% in the dry gauze group. Given the lack of difference between the two groups consideration needs to be given to the continued use of iodine dressings in the prevention of pin-site infection. Pin-site infections result in a high portion of participants being prescribed antibiotics and, in an era, that stresses the importance of antimicrobial stewardship there is a need to implement effective infection prevention and control strategies that minimise infection. Further research is therefore needed to investigate more innovative medicated dressings such as those that contain anti-microbial or anti-bacterial agents

Introduction. External fixators are common surgical orthopaedic treatments for the management of complex fractures and in particular, the use of circular frame fixation within patients requiring limb reconstruction. It is well known that common complications relating to muscle length and patient function without rehabilitation can occur. Despite this there remains a lack of high-quality clinical trials in this area investigating the role of physiotherapy or rehabilitation in the management of these patients. We aim to complete a systematic review of rehabilitation techniques for patients undergoing external fixator treatment for Limb Reconstruction of the lower limb. Materials & Methods. A comprehensive search of AMED, CINAHL, MEDLINE and COCHRANE databases was conducted to identify relevant articles for inclusion, using a search strategy developed in collaboration with a research librarian. Inclusion criteria consisted of adults aged 18 years and over who have experienced leg trauma (open fracture, soft tissue damage), elective leg deformity corrective surgery, bone infection or fracture non-union who have been treated with the use of an external fixator for fixation. Specific exclusion criteria were patients below the age of 18 years old, patients with cancer, treatment of the injury with internal nail, patients who underwent amputation, the use of external fixators for soft tissue contracture management, editorials, comment papers, review papers, conference proceedings and non-English papers. Titles, abstracts, and full texts were screened for suitability by pairs of reviewers according to the inclusion and exclusion criteria using Rayyan QCRI online software. Any conflicts were resolved through discussion with three independent specialist senior reviewers. Following full text screening, references lists of included articles were manually searched to ensure that all relevant studies were identified. Due to lack of evidence, forward searching was also completed for studies included in the review. Data quality was assessed using the mixed methods appraisal tool and the CERT assessment tool was utilised to look at completeness of reporting of exercise interventions. Results. A total number of 832 articles were initially retrieved from our search once duplicate articles removed. After title and abstract screening, 45 articles remained for full text screening. Of these, 11 articles met our inclusion criteria and included for data extraction. Conclusions. We expect high variability of results due to our inclusion criteria and therefore plan to conduct a narrative synthesis to summarise the findings whilst measing against the mixed methods appraisal tool and CERT assessment scores to assess the data quality. We anticipate lower assessment scores within the fewer articles found and therefore poorer-quality data. We currently are in the process of finalising this data extraction. This will be completed ready for submission and potential presentation at the BLRS conference in March 2023

Introduction. This study aims to evaluate the effect of using different types of fixator on the quality of callus and complications during distraction osteogenesis in patients with achondroplasia. Materials and Methods. Forty-nine achondroplasia patients with a minimum follow-up of 36 months who underwent limb lengthening between 2005 and 2017 with external fixator only were included. Thirty-three of the patients underwent lengthening using classical Ilizarov frame, while spatial frame used for sixteen. Regenerate quality is evaluated according to the Li classification on the X-ray taken one month after the end of the distraction. Complications were noted in the follow-up period. Results. The mean age at the time of surgery was 8,6 years. The mean external fixation index (EFI) was 34,3 and 30,1 day/cm for spatial frame and Ilizarov frame respectively. Mean follow-up period of 161,62 months and mean fixator period of 257 days. Amount of lengthening was 7,2 cm for Ilizarov frame, and 7,5 cm for spatial frame. Rate of callus with good morphological quality seen at consolidation was 72,4% and 50% for Ilizarov and spatial frames respectively. Two groups show similar results of complication rates in terms of pin site infection, premature fibular consolidation, regenerate fracture, plastic deformation, knee contracture. However fibular nonunion rates were higher for Ilizarov-type fixator. Conclusions. Although spatial frame with computer assistance brings easier follow-up for deformity correction, Ilizarov-type external fixator show slightly higher rates of good quality callus during consolidation for patients with achondroplasia

Standard external fixators have always caused difficulties in visualising fracture fragments radiologically in both planes; for this reason multiple shots are often required, exposing patients and surgeons to high X-ray levels. Radiolucent external fixator X-calibre is composed of a new thermoplastic material reinforced by carbon fibres (PEEK-CA 30). The aim of this study is to evaluate the first 30 tibial fractures treated with this device. Thirty external fixators X-calibre were used to treat 30 patients with tibial fractures with an average age of 40.4 years (range 21–60). According to the AO classification we have treated nine type A, 13 type B, and eight C fractures. Five were open fractures. The average follow-up was of 18 months. The time of healing was the same as seen using the standard fixator and the average time was 115 days (range 85 to 190). One tibial plafond fracture healed with 8° valgus deformity and persistence of pain during walking. There was loss of reduction on the third day after surgery due to erroneous evaluation of the fracture, which presented a butterfly fragment. This new radiolucent fixator showed the following advantages: single use, sterile package, radiolucency, less X-ray exposure for patients and surgeons, deal mechanical performance for each use, reduced storage and sterilisation costs, less instrumentation, less weight and increased comfort for the patient, average healing time and results comparable to the existing radio-opaque system

Objectives. External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF). Methods. A fracture gap model was created to simulate comminuted mid-shaft tibia fractures using synthetic composite bones. Fifteen constructs were stabilised with ET-LCP, ESS-LCP or UEF (five constructs each). The constructs were loaded under both axial and torsional directions to determine construct stiffness. Results. The mean axial stiffness was very similar for UEF (528 N/mm) and ESS-LCP (525 N/mm), while it was slightly lower for ET-LCP (469 N/mm). One-way analysis of variance (ANOVA) testing in all three groups demonstrated no significant difference (F(2,12) = 2.057, p = 0.171). There was a significant difference in mean torsional stiffness between the UEF (0.512 Nm/degree), the ESS-LCP (0.686 Nm/degree) and the ET-LCP (0.639 Nm/degree), as determined by one-way ANOVA (F(2,12) = 6.204, p = 0.014). A Tukey post hoc test revealed that the torsional stiffness of the ESS-LCP was statistically higher than that of the UEF by 0.174 Nm/degree (p = 0.013). No catastrophic failures were observed. Conclusion. Using the LCP as an external fixator may provide a viable and attractive alternative to the traditional UEF as its lower profile makes it more acceptable to patients, while not compromising on axial and torsional stiffness. Cite this article: B. F. H. Ang, J. Y. Chen, A. K. S. Yew, S. K. Chua, S. M. Chou, S. L. Chia, J. S. B. Koh, T. S. Howe. Externalised locking compression plate as an alternative to the unilateral external fixator: a biomechanical comparative study of axial and torsional stiffness. Bone Joint Res 2017;6:216–223. DOI: 10.1302/2046-3758.64.2000470

Aim. External fixator knee arthrodesis is a salvage procedure mainly used in cases of end-stage infected total knee replacement (iTKR). A stable fixation combined with bone-ends compression is basic to achieve knee fusion in such a scenario but providing enough stability can be challenging in the presence of severe bone loss after multiple previous procedures. Compared with monoplanar configuration, a biplanar frame achieves improved coronal stiffness, while providing the advantages of good access to the wound and allowance of early ambulation. Our primary hypothesis stated that a biplanar frame would achieve higher and quicker fusion rate than a monolateral configuration. Method. We conducted a retrospective cohort study examining patients managed with biplanar external fixator knee fusion due to non-revisable iTKR between 2014 and 2018. We compared this group of patients with a historical cohort-control patient who had been previously published by our unit in 2013, since we switched from a monoplanar to a biplanar configuration for the management of this kind of complex end-stage iTKR. Primary end-points were fusion rate, time to achieve bone fusion and infection eradication rate. Limb-length discrepancy, pain level, patient satisfaction, and health-related quality of life were also evaluated. Results. A total of 29 cases were finally included; 8 patients were managed with a bilateral external fixator and 21 patients were managed with a monoplanar external fixator. In the biplanar configuration group, infection was eradicated in 100% of the patients, and fusion was achieved in all cases after 5.24 months on average. In comparison, in the monolateral configuration group, infection was eradicated in 18 (86%) out of 21, whereas fusion was achieved in 17 (81%) of the patients after a mean of 10.3 months (range, 4–16). Such difference was statistically significant (p<0.05). In both groups, postoperative pain was mild (VAS score 2,25 and 3,4, respectively) and patients expressed a high degree of satisfaction once fusion was achieved. Conclusions. External fixation knee fusion is a useful limb-salvage procedure in end-stage cases of knee PJI. According to our data, the use of a biplanar configuration allows us to reduce in half (10.3 vs 5.2 months, p<0.05) the time needed to achieve the solid bone fusion in such a complex scenario. In this cohort of previously multi-operated patients, the satisfaction is high, and the level of pain is low if a solid bone fusion free of infection is achieved

Background. External fixation for a fracture-dislocation to a joint like the elbow, while maintaining joint mobility is currently done after identifying the center of rotation under X-ray guidance, when applying either a mono-lateral or a circular fixator. Current treatment. using the galaxy fixation system by Orthofix, the surgeon needs to correctly identify the center of rotation of the elbow under X-ray guidance on lateral views. If the center of rotation of the fixator is not aligned with that of the elbow joint, the assembly will not work, i.e. the elbow will be disrupted on trying to achieve flexion or extension movements. Figures (A, B, C and D) summarize the critical steps in identifying the centre of rotation (Courtesy of Orthofix Orthopedics International). New design. This new idea aims to propagate the principle of sliding external fixation applied on the extensor side of a joint, with the limbs of the fixator being able to slide in and out during joint extension and flexion respectively, without hindering the joint movement. Taking the ulno-humeral joint as an example, it is enough to apply the sliding external fixator in line with the subcutaneous border of the ulna, and the pins in the sagital plane, without the need to use x-ray guidance to identify the center of rotation, which simplifies the procedure, and makes it less technically demanding. The sliding external fixator over the elbow involves two bars which accommodate half pins fixation with headless grip screws to hold the pins, identical to the Rancho cubes technique by Smith & Nephew, these slide snugly into sleeves, those sleeves linked together through a hinge behind the elbow, and the bars are spring loaded to the hinge through the inside of the sleeves, which means they will slid into the sleeves in extension and out in flexion. Length of the sleeve should prevent the bars from dislodgement, and the cross section of both the bars and the sleeves have to correspond to each other for the sleeves to accommodate the bars within them and to prevent rotational instability within the construct itself. Summary. Applying an external fixator on the extensor surface is an idea could lead to major changes in external fixation product design, the ulno-humeral joint is taken as an example, and other joints could also be addressed taking in consideration joint size and anatomical structures at risk. The sliding technique makes the application easier, without the need to X-ray guided identification of the center of rotation

Purpose of study. Pin tract infection is a common complication with the use of circular external fixators. HIV infection itself is frequently quoted as a relative contra-indication for the use of circular external fixators for complex trauma and limb reconstruction in HIV seropositive individuals. Methods. Between July 2008 and December 2012, 286 patients were treated with circular external fixators at our tertiary level government hospital. A retrospective review was undertaken to compare the rate and severity of pin tract sepsis in HIV seropositive and seronegative patients. Results. Two-hundred and twenty-three patients met the inclusion and exclusion criteria. Pin tract sepsis was found in 51 patients overall (22.8%). The incidences of pin tract sepsis in the seropositive group, seronegative group, and the unknown group are 22.5%, 22.8% and 23.8% respectively, and the differences were not statistically significant. The severity of pin tract sepsis in the individual groups was also similar. Conclusion. Pin tract sepsis is a common complication with the use of circular external fixators. The incidence and severity of pin tract infection is not influenced by HIV infection, and should not in itself deter from the use of circular external fixators for complex trauma and limb reconstruction in HIV seropositive individuals. NO DISCLOSURES

Introduction. The objective of this study is to report the first cases of femoral lengthening in children using Ilizarov fixator. Materials and Methods. We carried out a retrospective study about the cases of femoral lengthening done in 2010 to 2020 in our BARI-ILIZAROV Orthopaedic centre Dhaka. Results. 48 lengthening were done during this period using Ilizarov fixator. The procedure was done incongenital bone diseases in 20 cases and after a distal femoral epiphysiodesis in 10 cases. The mean age at surgery was 12.8 years. Lengthening was required in all patients and an axis correction was required in 16 of 26 cases. The mean lengthening was 5.9 cm. The healing index was 45.5 day/cm (25.5–62). We noticed 8 knee stiffness and 5 broken wires. Knee Stiffness were corrected by Judet'squadricepsplasty and 6 broken wires were replaced by new wires. The goal of lengthening was reached in all cases. The goal of axis correction was reached in 98.5% of cases. Conclusions. Ilizarov technique allows to do accurate lengthening and axis correction and it is a unique reliable external fixator for femoral lengthening in children

A retrospective study was performed in 18 patients with achondroplasia, who underwent bilateral humeral lengthening between 2001 and 2013, using monorail external fixators. The mean age was ten years (six to 15) and the mean follow-up was 40 months (12 to 104). . The mean disabilities of the arm, shoulder and hand (DASH) score fell from 32.3 (20 to 40) pre-operatively to 9.4 (6 to 14) post-operatively (p = 0.037). A mean lengthening of 60% (40% to 95%) was required to reach the goal of independent perineal hygiene. One patient developed early consolidation, and fractures occurred in the regenerate bone of four humeri in three patients. There were three transient radial nerve palsies. Humeral lengthening increases the independence of people with achondroplasia and is not just a cosmetic procedure. Cite this article: Bone Joint J 2015;97-B:1577–81

Vascularized bone grafts (VFG) have brought great benefits in the field of reconstruction of the lower extremity. However, complications such as fracture of the grafted fibula and delayed union are sometimes seen. Not only to prevent these complications but also for stability after fracture of the grafted fibula, the Ilizarov external fixator is a very useful option. We report here the clinical results of cases treated by VFG combined with Ilizarov external fixator for reconstruction of the lower extremity. We have performed 53 vascularized fibula transfers to reconstruct lower extremities. An Ilizarov external fixator was used for the initial immobilization in 7 (2 femur, 5 tibia) and for delayed union or fracture of the grafted fibula in 2 cases of congenital pseudoarthrosis of the tibia. All patients achieved good bone reconstruction. All are able to walk without a brace except for one congenital case. The average period to achieve bony fusion was 13 months in femur cases, 6 months in adult tibia cases and 2 months in congenital cases. The average periods to walk without a brace were 14 months, 8 months and 10 months respectively. However, it took 9 months and 28 months to achieve bony union in the cases with delayed union or fracture of the grafted fibula. In the reconstruction of the lower extremities using VFG, the determining factor in method selection is whether sufficient mechanical support is available. An Ilizarov external fixator for immobilization permits the patient to walk as soon as possible. Dynamization from this semi-rigid external fixator causes bone hypertrophy and improved incorporation of the graft

Long-term survival and favourable outcome of implant use are determined by bone-implant osseointegration and absence of infection near the implants. As with most diseases, prevention is the preferred approach. Silver ion doped calcium phosphate based ceramic coating (Silveron®) for implant coating has been shown previously to be a potent antimicrobial agent as indicated by in vitro testing. The present study reports on clinical experience using silver ion doped calcium phosphate based ceramic coated external fixator pins as surgical treatment in the management of chronic osteomyelitis and open fractures. Ten patients had external fixators: six for open fractures of ankle, three for chronic osteomyelitis of the femur, one for tibia pseudoarthrosis. The electrospray method was used for coating the external fixator pins with silver ion doped calcium phosphate-based ceramics. A radiofrequency energy source was used to sinter the coated pins. Microbiological, roentgenographic, toxic and biochemical analyzes of patients were carried out. Wound debridement, and subsequent wound care resulted in control of the infection in three chronic osteomyelitis and in healing of seven fractures after follow-up ranging from three to six months. In total 67 pins were used in 10 patients but only one pin was positive microbiologically in one patient. Collectively, these data clearly illustrate that the toxic effects of silver were not observed at the doses used. Silver ion doped calcium phosphate based ceramic coating (Silveron®) can be used to prevent infection associated with the implant

Purpose of the study: These fractures, and the patients, are generally unstable. Mortality associated with these fractures remains high. It is mainly due to the haemorrhagic risk of the presacral venous plexus and the iliac system. Different techniques have been described to control the haemorrhage: pelvic girdle, embolisation, ligature of the iliac arteries, pelvic packing, pelvis clamp or external fixator. Our objective was to analyse our series of fractures of this type in order to optimise patient outcome. Material and methods: A prospective study was undertaken from January 2003 to December 2006. Among 450 multiple injury patients, 68 presented an unstable fracture of the pelvis, type B or C. The 38 patients included in this series were haemodynamically unstable. The mean ISS for these patients was 53, mean age 38.6 years (range 24–51). Fractures were diagnosed on plain x-rays of the pelvis, ap view, completed by a total body scan. Results: All patients were victims of high-energy traffic accidents and were managed using the ATLS protocol. Five patients died early despite intensive care. The patients were divided into three groups: group X: 19 patients treated with a first-intention external fixator, with or without arteriography, 18 patients survived, 94%; group Y: 8 patients treated with a first-intention external fixator with arteriography and followed by laparotomy, 7 patients survived, 87%; group Z: 6 patients had laparotomy without an external fixator, 6 patients died, 100% mortality. Conclusion: In our experience, the best way to control bleeding associated with unstable fractures of the pelvis is as follows: pelvic girdle at the scene of the accident to the emergency room, emergency external fixation followed by laparotomy if the ultrasound is positive. False positives occur due to suffusion of the retroperitoneal haematoma. Emergency laparotomy without prior external fixation of the pelvis lead to 100% mortality in our series. Similarly pelvic packing or the retroperitoneal approach cannot be proposed without exploration

Purpose of the study: In the spastic quadriplegic non-ambulatory child, hip dislocation with severe adduction is a painful situation compromising perineal hygiene and local care as well as positioning in bed or wheel chair. We describe a method of treatment using Castle’s femoral resection-interposition arthroplasty and an external fixator to prevent proximal migration of the remnant femur. Description: Resection of the proximal femur with articulated distraction of the hip using an external fixator was performed in eight children (11 hips) with cerebral palsy. All patients (five boys, three girls, mean age 15 years) had painful neurological disorders with chronic hip dislocation incompatible with the sitting position and compromising perineal hygiene. The operation, described by Castle, consisted in subtrochanteric resection and suture of the quadriceps muscle around the femoral cut. The capsule detacted from the femur was closed around the acetabulum. The abductors were sutured between the shaft and the acetabulum in order to ensure interposition of enough soft tissue. An external fixator (Orthofix®) was installed for 90 days. This method has the advantage of producing the necessary distraction while allowing immediate mobility (hip extension flexion) and good balance in the sitting position as well as better perineal hygiene compared with the preoperative situation. At six months, there was a clear clinical improvement in terms of pain relief, tolerance to the sitting position, and perineal hygiene with a significant increase in joint motion (flexion, extension, abduction). Proximal migration of the femur was observed in one case after removing the external fixator. There were no cases of recurrent adduction deformity, stiffness or bone hypertrophy. Conclusion: Proximal resection of the femur with capsular interposition arthroplasty and articulated distraction with an external fixator decreases the pain of the dislocated spastic hip. This method is a reliable salvage alternative for painful hip dislocation in cerebral palsy children. Use of an articulated external fixator for the distraction enables immediate postoperative mobilization and the sitting position in a wheel chair, improving patient comfort compared with the classical Russell also described by Castle

Objective: The main treatment for unstable distal radius fracture in Québec consists in pinning and cast, with secondary shortening and displacement responsible for lack of motion. The goal of the study is to compare clinical and radiological results after treatment with non-bridging external fixator compared to pinning and cast, with restoration of grip strength as main clinical outcome. Method: Between June 2003 and June 2005, 120 consecutive patients admitted for unstable extra-articular distal radius fracture were randomized in the 2 groups. Early mobilisation was allowed in the group with external fixator, and patients in the other group had pins and cast for 6 weeks. Follow-up was completed after 6 months with determination of clinical and radiological data for the both wrists. 110 patients completed the study, with 2 comparative groups for epidemiologic and radiological criteria (n = 63 for pins and 57 for external fixator). Results: Grip strength was significantly better in the fixator group at 3 months (68,36%;p< 0,001) and 6 months (98,26%;p< 0,001). Active ROM was better and obtained earlier in the fixator group in all directions (p< 0,001). Fixator prevent shortening and secondary displacement in a highly significant way (p< 0,001). No difference in pain medication, but fixator group could begin occupation earlier (p< 0,001). Conclusion: Non-bridging external fixator is a treatment of choice for unstable extra-articular distal radius fractures. The immediate stability allows in all patients (without influence of age, bone quality or fracture displacement) early mobilisation, prevent secondary displacement, and gives earlier and better functional results

Management of compound fractures of the tibial diaphysis forms a large proportion of the trauma workload at Tygerberg Hospital. This prompted a prospective study to compare external fixation with unreamed intramedullary nailing in the treatment of grade-I, II, IIIA and IIIB compound fractures of the tibial diaphysis. For a year we followed up 18 skeletally mature patients. External fixation was used in eight patients, four of whom had grade II fractures, two grade IIIA and two grade IIIB. Ten fractures (two grade-I, one grade-II, two grade IIIA and five grade IIIA) were stabilised with an unreamed intramedullary nail. Except for the method of fixation, fracture care was the same: all patients received antibiotics on admission, primary fracture debridement occurred within 24 hours and redebridement within 48 to 72 hours of injury. Definitive fixation by external fixator or intramedullary nailing, with wound closure, skin graft and/or myofasciocutaneous flapping was done within a week of injury. We assessed rates of infection, hardware failure, mal-union, additional procedures, hospital stay and time to union. There were no cases of wound infection in either group, but a progression of fracture gap in one patient treated by intramedullary nailing may suggest sub-clinical infection. All patients treated with external fixators developed pin-tract infection, and in five patients the external fixator had to be removed before union. One external fixator pin failed and was re-inserted under anaesthetic. There were two intramedullary nail locking screw failures, but they required no intervention. Additional procedures required in the group treated by external fixator far outnumbered those needed in the intramedullary nailing group. Fracture alignment appeared more anatomical in the patients treated by intramedullary nailing. We found no significant difference in healing rates or length of hospital stay. Our results suggest that intramedullary nailing is the more efficient method of fracture stabilisation

The use of the Dynastab K external fixator in the treatment of the tibial plateau fractures. The aim of the study was the assessment of the clinical use of Dynastab K (knee) external fixator in the treatment of intraarticular fractures of the proximal tibia. The study was conducted in the Department of Orthopaedics and Rehabilitation Warsaw Medical University. Between November 2004 and December 2007, 29 patients were included in the study (12 females and 17 males). In the experimental group, consisting of 15 patients (7 females and 8 males) open reduction and fixation of the fracture was performed. After that Dynastab K external fixator was implanted to the femur and tibia with the use of pins. On the second day after the surgery rehabilitation of the knee joint was started. Fixator was being held on the lower limb for 6 – 8 week. In the control group (14 patients – 5 females and 9 males) after open reduction and fixation of the fracture, knee orthosis was applied. Orthosis was set up in 15 degrees flexion. After that time the rehabilitation was started. The final follow up visit was performed about 34 weeks after the surgery. The amount of articular depression, the range of motion of the knee joint, the amount of pain and the condition of soft tissues around pins were assessed during the study. The clinical and radiological outcomes were determined according to Rasmussen’s system and the condition of soft tissues with the use of Dahl’s scale. Resnick and Niwoyama criteria were used for grading of post-traumatic osteoarthrosis and Visual Analogue Scale for pain intensity. Subjective evaluation of knee function was performed by the self-made scale. There were no statistically important differences in the amount of articular depression before the operation, after reduction and on the last follow-up visit, between the experimental and control group. The mean range of motion of the knee joint was 127,5 degrees in the experimental group and 118,3 degrees in the control group. In the experimental group the amount of pain around the knee was gradually diminished after the operation, whereas in the control group the amount of pain was sharply reduced, but after unblocking the orthosis rised significantly. There were not noticed any pin site infection. 10 patients (66,7%) from the experimental group and 7 (50%) from the control group achieved very good results in the radiological scale. The results in the clinical scale were very good at 6 patients (40,0%) from the experimental group and at 3 patients (21,4%) from the control group. During the last follow-up visit the subjective evaluation of the knee joint function was 0,64 points better in the group treated with the Dynastab K external fixator

Background:. Recurrent or late presenting Tibia Vara is a complex clinical problem. In addition to the multiplanar deformity the disorder is often accompanied by obesity. Simple re-alignment osteotomy with acute correction is effective early in the disease. Its use in recurrent or severe deformities is limited by geometric constraints (mechanical axis translation), difficult fixation and the risk of compartment syndrome. Gradual correction with external fixation devices is a well-accepted technique in these cases. It has been shown to obtain accurate correction and provides stable fixation. This allows early weight bearing which facilitate consolidation and rehabilitation. Hexapod fixators are technically less demanding than standard Ilizarov techniques. The TLHex is a relatively new hexapod fixator available in South Africa. Frame pre-assembly allows easier mounting on a limb with complex deformity. The software allows for non-orthogonal mounting, which simplifies frame-mounting assessment. Double telescoping struts allow greater strut excursion and the outside mounting of struts on the ring increases mounting options for fixation elements. This is the first report on its use in Blount's disease. Purpose:. Evaluation of the result of gradual correction with the TLHex external fixator in Blount's disease in terms accuracy of correction, union and complications. Illustration of key hardware and software features. Methods:. A retrospective chart and X-ray review of 7 patients (9 legs) treated by gradual correction with the TLHex external fixator was performed. The degree of correction of varus and procurvatum was assessed on pre-operative and post-correction X-rays. Internal rotation deformity correction was assessed clinically. Complications such as neurovascular compromise, minor and major pin tract infection and hardware complications were documented. The pre-operative planning, surgical technique and post-operative treatment protocol is reviewed. Results:. Mean varus was corrected from 21° (17° to 45°) to 1°(−2° to 4°). Mean procurvatum was corrected from 8° (0° to 25°) to 0° (0° to 8°). Internal rotation was corrected to between 5° to 10° of external rotation in all patients. The mean time in the frame was 112 days. Three patients needed one additional program to correct residual deformity (one over-corrected coronal aligment, one under-corrected saggital alignment and one rotational over-correction). Three patients required oral antibiotics for minor pin tract infection. One patient required intravenous antibiotics and wire removal for major pin tract infection. One patient required frame adjustment after correction for soft tissue impingement. One strut loosened after consolidation prior to frame removal. Conclusion:. Gradual correction of Tibia Vara with the TLHex external fixator is a safe and effective treatment method

Callus distraction over an intramedullary nail is a rarely used technique for the reconstruction of intercalary defects of the femur and tibia after radical debridement of chronic osteomyelitic foci. The aim of this study was to summarize our experience of distraction osteogenesis with an external fixator combined with an intramedullary nail for the treatment of bone defects and limb shortening produced as a result of radical debridement of chronic osteomyelitis. Sixteen patients aged 16 to 63 years underwent radical debridement to treat nonunion associated with chronic osteomyelitis of 8 tibias and 8 femurs. The lesions were staged as Cierny and Mader type IVA (10) and IVB (6). The resulting segmental defects and any limb length discrepancy were then reconstructed by distraction osteogenesis over an intramedullary nail. A monolateral frame was used for the femur, and a ring type external fixator for the tibia. Two patients required local gastrocnemius flaps. Free non-vascularised fibula grafts were added to the regenerate for augmentation of a femoral defect at the time of external fixator removal and locking of the nail. At the latest follow-up, functional and radiographic results were evaluated using the Paley’s criteria. In the femur, the mean defect was 10 centimeters (range 6 to 13 centimeters), while in the tibia it was 8.4 centimeters (range 5 to 11 centimeters). The mean external fixator index was 13.5 days per centimeter, the consolidation index was 36 days per centimeter and the mean time to union at the docking site was 9 (range 5–16) months. The average follow-up was 31.3 months. We obtained 81.25% (13 of 16) excellent results in terms of both bone and functional assessment. There were two recurrences of infection necessitating nail removal. These patients underwent revision with an Ilizarov fixator. Subsequently, infection was controlled and the non-unions healed. This combined method may prove to be an improvement on the classic techniques for the treatment of long bone nonunions associated with chronic osteomyelitis, in terms of external fixation period and consolidation index. These appears to be no increase in the risk of complications, and the earlier removal of the external fixator is associated with patient comfort, decreases the complication rate and facilitates convenient and quick rehabilitation

Objectives. The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures. Methods. Two types of fixation systems were selected for finite element analysis and a dual cohort study. Two fixation systems were simulated to fix the fracture in a finite element model. The relative displacement and stress distribution were analysed and compared. A total of 71 consecutive patients with closed Sanders type 2 calcaneal fractures were enrolled and divided into two groups according to the treatment to which they chose: the EFLIF group and the ORIF group. The radiological and clinical outcomes were evaluated and compared. Results. The relative displacement of the EFLIF was less than that of the plate (0.1363 mm to 0.1808 mm). The highest von Mises stress value on the plate was 33% higher than that on the EFLIF. A normal restoration of the Böhler angle was achieved in both groups. No significant difference was found in the clinical outcome on the American Orthopedic Foot and Ankle Society Ankle Hindfoot Scale, or on the Visual Analogue Scale between the two groups (p > 0.05). Wound complications were more common in those who were treated with ORIF (p = 0.028). Conclusions. Both EFLIF and ORIF systems were tested to 160 N without failure, showing the new construct to be mechanically safe to use. Both EFLIF and ORIF could be effective in treating Sanders type 2 calcaneal fractures. The EFLIF may be superior to ORIF in achieving biomechanical stability and less blood loss, shorter surgical time and hospital stay, and fewer wound complications. Cite this article: M. Pan, L. Chai, F. Xue, L. Ding, G. Tang, B. Lv. Comparisons of external fixator combined with limited internal fixation and open reduction and internal fixation for Sanders type 2 calcaneal fractures: Finite element analysis and clinical outcome. Bone Joint Res 2017;6:433–438. DOI: 10.1302/2046-3758.67.2000640

Introduction. Segmental bone defect is a challenging problem. We report our experience of bone transport by hexapod external fixator in patients with segmental defects if the tibia. Method. We report herein 15 patients with segmental bone defect of tibia who completed their treatment protocol. All patients were treated had bone transport with Taylor Spatial Frame from 2012 to 2017. All were treated by the senior author NH. Parameters measured included age, sex, diabetes, smoking, diagnosis, method of fixation prior to treatment use of a free flap, bone defect size, frame-time, external fixation index. Results. Mean age at the time of frame application was 42.7 years. Mean follow-up after frame removal was 23.7 months. Three were diabetic, one smoked and one quit smoking during treatment. Seven had Gustilo-Anderson 3B (47%) and 5 Gustilo-Anderson 3A (33%) open fractures. Three (20%) had closed fractures. Nine (60%) had internal fixation with plate in eight and IM nail in one. Ten patients (67%) had soft tissue defect that required a free flap in seven, local flap in two and skin graft in one. Mean transport was 62 mm. Mean external fixator time and latency were 350.1 and 12 days, respectively. Mean External fixator, distraction and maturation indices were 2.1, 0.52 and 1.43 month per centimeter, respectively. Ten Extra- procedures were required in 7 patients. There were no docking site procedures, non-union of regenerate, adjunctive stabilization after frame removal, recurrence of bone infection and recurrence of deformity. Conclusions. Segmental resection and transport by TSF is an effective method to achieve length, alignment and eradicate infection. Although our cohort had longer external fixator indices than similar studies, the complication rate was low

We report the results of limb salvage for non-metastatic osteosarcoma of the distal tibia using resection arthrodesis, autogenous fibular graft and fixation by an Ilizarov external fixator. In six patients with primary osteosarcoma of the distal tibia who refused amputation, treatment with wide en bloc resection and tibiotalar arthrodesis was undertaken. The defect was reconstructed using non-vascularised free autogenous fibular strut graft in three patients and a vascularised pedicular fibular graft in three, all supplemented with iliac cancellous graft at the graft-host junction. An Ilizarov external fixator was used for stabilisation of the reconstruction. In five patients sound fusion occurred at a mean of 13.2 months (8 to 20) with no evidence of local recurrence or deep infection at final follow-up. The mean post-operative functional score was 70% (63% to 73%) according to the Musculoskeletal Tumour Society scoring system. All five patients showed graft hypertrophy. Union of the graft was faster in cases reconstructed by vascularised fibular grafts. One patient who had a poor response to pre-operative chemotherapy developed local tumour recurrence at one year post-operatively and required subsequent amputation

Introduction: To determine the stiffness characteristics of a new proposed hybrid fixator in comparison with more commonly used hybrid external fixators. Methods: A prospective laboratory investigation was used to evaluate the null hypothesis that there are no differences in the mechanical stiffness between the new proposed hybrid fixator and the Ace-Fischer, DePuy-ACE, Warsaw, IN; Hoffmann II, Stryker Howmedica Osteonics, Rutherford, NJ; Synthes Hybrid, Synthes USA, Paoli, PA; EBI DynaFix®, EBI, Parsippany, NJ. Identical composite tibiae, after modeling OTA 41 – A 2.3 fracture, were fixed with the above fixators. Load-deformation behavior was compared between the different configurations under identical conditions of central-compression, medial compression-bending, posterior compression-bending, posterior-medial compression-bending and torsional loading. Stiffness values were calculated from the load deformation and the torque angle curves. Results: The new proposed hybrid external fixator was stiffer than all the other fixators tested in all modes of testing, except for torsion. The Hoffman II, DePuyACE, EBI, and Synthes fixators were essentially equivalent in stiffness in all five modes of testing. Conclusions: Decreasing the distance of the side bar to the center of the bone effectively shortens the length of the half-pins, which decreases their deflection during bending, and thus increases stiffness. We think that a better stiffness of new fixator than of others is due to a shorter distance between the bone surface and points of fixation of wires and half-pins. The proposed hybrid fixator corresponds to the contemporary requirements for external fixation: possibility to control the stiffness, easy to apply, comfortable for the patient (being light and simple)

Purpose: Use of six-axis analysis and computer assisted deformity correction via a circular external fixator is a new method for deformity correction. We investigated its accuracy and safety in reconstruction of femoral deformity in children and young adults. Method: We retrospectively reviewed all cases including the indications for use and the methodology of application of the computer assisted six-axis analysis and circular external fixator for reconstruction of 22 femora in 20 patients. Twelve patients were female, and 8 were male. The average age was 13.9 (range, 5.9–24.6). Etiology included traumatic (7), idiopathic (6), multiple enchondromatosis (2), rickets (2), congenital femoral deficiency (2), spondyloepiphyseal dysplasia (1), congenital pseudohypoparathyroidisim (1), and multifocal osteomyelitis (1). Clinical and radiographic data were analyzed. Results: Average follow-up was 14.4 months (range, 4.5–32). Average time in frame was 6.2 months (range, 2.6–19). Bone lengthening of 3.9 cm (range, 1–8.5) was performed in 12 femora. In genu valgum patients, the mLDFA improved from a mean of 73.7° to a mean of 89°. In genu varum patients, the mLDFA improved from a mean of 99.8° to a mean of 89.5°. Complications included pin tract infection in 6, knee stiffness in 3, delayed union in 2, skin irritation in 1, posterior knee subluxation in 2, both of which had stable knees preoperatively. One patient was lost to follow-up and returned back with deformity. No complications occurred in 8 patients. Conclusion: Computer assisted femoral deformity correction with six-axis analysis and application of circular external fixator is a useful technique with the advantage of managing multiplanar deformities in children and young adults. It has the potential complications of the use of any external fixator. Close follow-up is necessary to avoid subluxation of the knee joint even in patients with stable knees. Accurate and safe correction can be achieved in almost all patients

Purpose: The main treatment for unstable distal radius fracture in Québec consists in pinning and cast, with secondary shortening and displacement responsible for lack of motion. The goal of the study is to compare clinical and radiological results after treatment with non-bridging external fixator compared to pinning and cast, with restoration of grip strength as main clinical outcome. Method: Between June 2003 and June 2005, 120 consecutive patients admitted for unstable extra-articular distal radius fracture were randomized in the 2 groups. Early mobilisation was allowed in the group with external fixator, and patients in the other group had pins and cast for 6 weeks. Follow-up was completed after 6 months with determination of clinical and radiological data for the both wrists. 110 patients completed the study, with 2 comparative groups for epidemiologic and radiological criteria (n = 63 for pins and 57 for external fixator). Results: Grip strength was significantly better in the fixator group at 3 months (68,36%;p< 0,001) and 6 months (98,26%;p< 0,001). Active ROM was better and obtained earlier in the fixator group in all directions (p< 0,001). Fixator prevent shortening and secondary displacement in a highly significant way (p< 0,001). No difference in pain medication, but fixator group could begin occupation earlier (p< 0,001). Conclusion: Non-bridging external fixator is a treatment of choice for unstable extra-articular distal radius fractures. The immediate stability allows in all patients (without influence of age, bone quality or fracture displacement) early mobilisation, prevent secondary displacement, and gives earlier and better functional results

Purpose: Femoral torsion is traditionally treated by a proximal osteotomy. At this level, a significant exposure is required. Furthermore, internal fixation is typically removed by additional surgery at twelve months. We propose to demonstrate the efficacy of the AO external fixator to maintain osteotomies in the distal femur for torsional correction. Method: Between September 1994 and April 2001, supracondylar osteotomies were performed on 38 femora in 21 children with torsional and angular deformities. The average age at presentation was 10 years. Twenty-three femora had excessive anteversion and 15, retroversion. The technique required the lateral placement of three 4.0 mm end-threaded Schanz pins parallel to the distal growth plate. Three similar pins were inserted more proximally in line with the femoral shaft. A transverse osteotomy was performed through a limited lateral approach. After correction of the deformities, each pin was linked to all others by clamps and carbon fiber rods. Results: Lower extremity alignment was restored in all patients. Genu valgum was addressed in eighteen osteotomies. Five extension osteotomies were performed for fixed knee flexion deformities. The external fixators were removed at an average of ten weeks. One child had a superficial pin tract infection requiring intravenous antibiotics. All osteotomies united without complications. No postoperative femur fractures occurred. Conclusion: Osteotomy at the distal femur has the advantage of correcting both torsional and angular deformities. The exposure required is limited. The AO external fixator provides precise control of the osteotomy and allows for subsequent adjustability. This method effectively controls supracondylar osteotomies and avoids a second procedure for hardware removal

Background. Tibial pilon fractures lead to complicated therapeutic problem. Application in these cases of external fixators which are composed of an active articulated joint hinge imitating movement in the region of upper ankle joint, which allows plantar and dorsal flexion, leads to functional treatment of distal tibia fractures. Aim. The aim of the study was to present the four year experience with an evaluating biomechanical parameters, medical properties and clinical usefulness of the external fixator Dynastab-S in the treatment of tibial pilon fractures. Material. Observations were based on patients hospitalized in Orthopedic and Rehabilitation Department of Medical University of Warsaw in a period from March 2000 to August 2004. The average period of observations was 29 months. Inclusion criteria were based on the algorithm which was created in our department. Results. The assessment of biomechanical parameters of bone-fixator arrangement proved usefulness and safeness of the external fixator Dynastab-S. The positive results of clinical examinations, X-ray examinations and subjective opinion of the patients encourages to wide use of the external fixator Dynastab-S in the treatment of tibial pilon fractures

Introduction. Application of an external fixator for type B and C pelvic fractures can be life saving. Anteriorly the fixator half pins can be placed in the long and thick corridor of bone in the supra-acetabular region often referred to as the low anterior ex-fix. Pins in this location are favoured as they are more stable biomechanically. The bone tunnel for the low anterior ex-fix can be visualised with an iliac oblique projection intra-operatively. In some cases despite being outside the articular surface it may still be low enough to pass through the capsular attachment of the hip joint on the anterior inferior iliac spine. We aim to provide radiological markers for the most superior fibres of the capsule to help accurate extra-capsular pin placement within the supra-acetabular bone tunnel. Materials and Methods. Thirteen cadaveric pelves, embalmed with the method of Thiel, were used for this study. An image intensifier was positioned to acquire an iliac oblique outlet view, such that the supra acetabular bone tunnel was visualised. This was achieved by positioning the beam 30 degrees cephalad and 20 degrees medial. Both left and right hemipelves were examined in this way. A standard size metallic disc was included in all images with in the acetabulum to allow for image calibration. The proximal most fibres of the hip joint capsule were marked with a K-wire so that their relation to the bone tunnel could be clearly seen on the images. Once all images were acquired they were calibrated and analysed using ImageJ Software to estimate the height and maximum width of the bone tunnel as seen on the images and the vertical distance of the superior most fibres of the capsule from the dome of the acetabulum. Results. The mean height of the bone tunnel was 24.9 mm (SD 4.3 mm, Range 18.9–33.2 mm) and the maximum width of the tunnel was 11.7 mm (SD 2.6 mm, Range 7.6–16.3 mm). The inferior margin of the bone tunnel was on average 7.4 mm (SD 3.4 mm, Range 1.1–14.4 mm) superior to the acetabular dome and the most proximal fibres of the capsule were on average 9.2 mm (SD 2.4 mm, Range 4.7–16.1 mm) superior to the acetabular dome. This meant that on average 3.6 mm (SD 2.1 mm, Range 0.3–8.9 mm) of the inferior portion of the tunnel is within the joint. There was no statistically significant difference between the left and right sides. Conclusion. There is adequate space for two long external fixator pins within the described tunnel. These should be placed in the upper half of the anterior inferior iliac spine. Below this level there is risk of being intra-capsular which can lead to septic arthritis. For this reason we recommend that supra-acetabular pins should be placed at least 16 mm superior to the acetabular dome as visualised on the iliac oblique outlet view

Our purpose was to evaluate the use of indirect and closed reduction with Ilizarov external fixator in intraarticular calcaneal fractures. In a period of 3 years, 16 patients with 18 intraarticular fractures of calcaneus (eleven type III and seven type IV according to Sanders classification) were treated with the Ilizarov fixator. Twelve patients were male and four female. The average age was 42 years (range 25 – 63 years). Three fractures were open. Fractures were evaluated by preoperative radiographs and CT scans. Restoration of the calcaneal bone anatomy was obtained by closed means using minimally invasive reduction technique by Ilizarov fixator. Arthrodiatasis and ligamento-taxis, and closed reduction of the subtalar joint were performed in 14 cases. In 4 cases the depressed posterior calcaneal facet was elevated by small lateral incision and stabilized in frame by wires. Postoperatively, partial, early weight bearing was encouraged in all patients. The mean follow-up period was 1,5 years (range 1 – 3 years). The AOFAS Ankle – Hindfoot Score, and physical examination were used in functional evaluation. The average score was 79,8 (range 72 – 90). Six patients had limited degenerative radiological findings of osteoarthrosis about the subtalar joint and three of them had painful subtalar movement. One of the patients complained of heel pad pain. Nine (6.25%) grade II pin tract infections were detected from a total of 144 wires. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. Indirect closed reduction of calcaneal bone anatomy and arthrodiatasis of subtalar joint with Ilizarov external fixator is a viable surgical alternative for intraarticular calcaneal fractures

Purpose: We assess the results of the surgical treatment of intra-articular fractures of the calcaneus using the Ilizarov external fixator. Materials and Methods: During the period of January 2004 to June 2009 we treated 72 intra-articular calcaneus fractures in 68 patients, 51 male and 17 female with a mean age of 34 (range 18–56). The mean follow –up period was 2 years and 10 months (range 3 months to 4 years). All patients received preoperative CT-scan to facilitate classification and pre-operative planning. Of the 72 fractures, 37 (51.4%) were Sanders type II, 30 (41.6%) were type III and 5 (7%) were type IV. The Ilizarov fixator used consisted of 2 rings positioned above the ankle joint and a foot plate. 1.5 and 1.8 mm wires were used, as well as 1.8 mm wires with an olive for the reduction of displaced fragments. Under image intensification and distraction the fracture was reduced and the articular surface was restored as close as possible. Results: The clinical outcome was excellent in 29 patients (40.4%), good in 32 (44.4%), moderate in 7 (9.7%) and poor in 4 (5.5%). As far as the complications are concerned, we had 17 cases of pin track infection treated with the removal of the pins, ankle joint stiffness in 12 patients treated with physiotherapy, 2 patients developed reflex sympathetic algodystrophy, 2 malunion, 8 developed post-traumatic osteoarthritis and 1 of them underwent subtalar arthrodesis. Conclusion: The use of the Ilizarov external fixator for the treatment of intra-articular calcanear fractures has proved itself to be an alternative method to O.R.I.F with similarly good results. Given the fact that the learning curve is relatively steep, it has proven, from our experience, to be a safe and valuable tool for the treatment of these challenging fractures

Background. Although minimally invasive plate osteosynthesis (MIPO) has become popular option for humeral shaft fractures, indirect reduction and its maintenance are technically challenging. The purpose of this study is to describe a reproducible technique utilizing an external fixator during MIPO and to assess its outcomes. Methods. Twenty-nine cases with a mean age of 37.1 years were included. There were 7 simple (type A) and 22 comminuted (type B or C) fractures. Indirect reduction was achieved and maintained by a monolateral external fixator on the lateral aspect of humeral shaft, and MIPO was performed on the anterior surface. Union, alignment, complications, and functional results of the shoulder and elbow were assessed. Results. Twenty-eight of 29 fractures were united with a mean of 19.1 weeks including 3 delayed unions. The mean follow-up period was 20.8 months. There was one hypertrophic nonunion, which was healed after fixing two additional screws. None had angulation greater than 10 degrees in the coronal and sagittal planes. Mean constant shoulder score and mean Mayo elbow performance score were 89.1 and 95.5, respectively. There was no direct damage to nerves related to the pin of external fixator, while two cases of radial neuropraxia developed, which recovered within 2 months after operation. Conclusion. Assisted by the preliminary external fixation, MIPO may achieve successful outcomes for humeral shaft fractures

There is a growing trend towards using pre-clinical models of atrophic non-union. This study investigated different fixation devices, by comparing the mechanical stability at the fracture site of tibia bone fixed by either intramedullary nail, compression plate or external fixator. 40 tibias from adult male Wistar rats' cadavers were osteotomised at the mid-shaft and a gap of 1 mm was created and maintained at the fracture site to simulate criteria of atrophic non-union model. These were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with external fixator. Tibia was harvested by leg disarticulation from the knee and ankle joints, the soft tissues were carefully removed from the leg, and tibias were kept hydrated throughout the experiment. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4). Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. Axial load to failure data and stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices, however there was no statistically significant difference axially between the nail thicknesses. In bending, load to failure revealed that 18G nails are significantly stronger than 20G. We concluded that 18G nail is superior to the other fixation devices, therefore it has been used for in-vivo experiments to create a novel model of atrophic non-union with stable fixation

We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries. The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor. External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries

Purposes of the Study. To study the incidence of delayed consolidation of regenerate in children undergoing correction or lengthening of lower limb deformities using an external fixator. Methods and Results. Between 2006 and 2011, 150 patients with lower limb deformities (excluding feet) were treated in our unit using external fixators. A retrospective review of our prospective database was carried out to identify patients with poor regenerate formation requiring bone grafting. Patients with acute fractures, pseudarthrosis of the tibia due to neurofibromatosis and those above the age of eighteen were excluded. An independent observer reviewed the medical records and radiographs. Eleven patients with ages ranging from 2 years 5 months to 17 years 5 months (mean average 9 years 9 months) formed the basis of our study – 3 males and 8 females. Factors that were associated with this complication include age greater than twelve years (10 patients), lack of weight bearing (6 patients), previous fixator (5 patients) and smoking (5 patients). The regenerate was deficient in nine tibial segments and two femoral segments. Six of the deficient tibial regenerates were at a proximal site whilst three were distal. There was no significant difference in length gained between these sites (p < 0.5). The mean time to regenerate bone grafting was 7 months. Time to healing following bone grafting was 2.5 months. Conclusion. Delayed consolidation of regenerate in children undergoing treatment of lower limb deformities, though recognised, is under reported. We believe this report will serve as a guide in the consenting process for children undergoing treatment using external fixators

In a prospective, randomised study we have compared the pertrochanteric external fixator (PF) with the sliding hip screw (SHS) in 100 consecutive patients who were allocated randomly to the two methods of treatment. Details of the patients and the patterns of fracture were similar in both groups. Follow-up was for six months. Use of the PF was associated with significantly less blood loss, a shorter operating time, reduced postoperative pain, shorter hospitalisation (p < 0.001), earlier mobilisation (p < 0.001) and a reduced rate of mechanical complications (p < 0.01). Superficial infection was significantly more common with the PF (p < 0.01), but without long-term adverse consequences. There were no differences in the healing of the fracture, mortality or final functional outcome. Our results indicate that the external fixator is an effective and safe device for treating pertrochanteric fractures and should be considered as a useful alternative to conventional fixation with the sliding hip screw

Our Purpose is to present the results of treatment of 35 (thirty five) comminuted fractures of the diaphyses of Tibia and Fibula with combination of Orthofix External Fixator and Sarmiento Brace. In Syros General Hospital, during the last 8 (eight) years, 35 (thirty five) comminuted fractures of the Diaphyses of Tibia and Fibula were treated. Twenty were closed and 15 (fifteen) compound. Five were type 1, 8 (eight) type 2 and 2 type 3 Gustilo. Our Method : After a good surgical cleaning all fractures were reduced and stabilized with Orthofix External Fixator. We used two pins above and two pins below the fracture. According to the union of the fracture, we allowed partial weight bearing with dynamization. In three months the External Fixator was removed and a Sarmiento Brace was put. With the Brace we allowed full weight bearing until the fracture was united. Results: All fractures united. It took five months for the close and six months for the compound. There was no displacement in any fracture. In four fractures we had pin infection that was cured with antibiotics and lack of weight bearing for 15 days. Conclusion : Comminuted fractures of Tibia are a challenge for every Orthopaedic Surgeon. We believe that the combination of those two methods that are simple and safe solve the treatment of those difficult fractures

The definite treatment of closed or compound fractures of the long bones in polytrauma patients, who had been treated by bridging external fixation during the damage control phase is challenging, especially if it is performed delayed when the risk of infection is increased. In such cases the use of ring type external fixators seems to be a good choice. During the last two years (mean FU 16 months), 22 Polytrauma patients with fractures of the long bones were treated with the use of ring type external fixators as the definite method. Multiplanar reduction at the fracture site could be achieved with this method. 14 patients had a high ISS score in the emergency department. 14 had sustained fracture of the femur while the remaining 8 patients had suffered a tibial fracture. In all but one patient the bone union was achieved in a mean time of 19 months. In a patient with a tibial fracture where a bone defect the bone union was accomplished with bone grafting and the use of growth factors. No complications or loss of reduction were seen, while local signs of infection at the site of half pins insertion in three patients were subsided with administration of local antibiotics. The definite treatment with ring type external fixators of long bone fractures in polytrauma patients seems to be a very good choice. Bone consolidation with no evidence of bone infection was achieved in all patients. while low rate of complications were seen

Introduction. No published work exists regarding deep vein thrombosis (DVT) and pulmonary embolism (PE) incidence with the elective use of external fixators. The aim of this work was to establish the rate of DVT and PE in such cases to help inform whether thromboprophylaxis guided by risk factors is adequate or if a more aggressive approach is required. Patients and methods. Information from a prospectively maintained electronic database and case notes were examined for consecutive patients from March 2005 to June 2011. Occurrence of DVT and PE, detected by ultrasound or CT angiogram, were recorded. Risk factors for thromboembolism, age, weight, height, surgical indications, type of surgery and operative time were recorded. As recommended by the National Institute for Health and Clinical Excellence (NICE) thromboprophylaxis use is guided by risks of thromboembolism and bleeding. For adults and older adolescent patients contralateral leg compression stockings and an intraoperative calf pump were used. Mobilisation began the morning after surgery and the majority of cases permitted to bear weight fully. Results. Two hundred and seven (207) individuals underwent 255 primary applications of Ilizarov, Taylor Spatial Frame (TSF) or monolateral fixator, 173 tibial, 63 femoral and 19 to other bones. Case notes were obtained for 182 individuals (88%), representing 214 operations (84%). One DVT and one PE were recorded, an overall incidence of 2/214 (0.9%) (excluding those under 16 years old 2/143 (1.4%)). In both cases mechanical and chemical prophylaxis had been used as guided by risk assessment. The PE was sustained by a person of notably high risk, surgery involving excision of tibial adamantinoma and a high body mass index (45). He had also recently travelled from overseas (a travel time of over 3 hours). Conclusions. The rate of DVT/PE for elective application of external fixators is low with risk assessment guiding prophylaxis

Background: The Ilizarov external fixator has theoretical advantages over conventional revision surgery for the treatment of recurrent clubfoot deformity where scarred tissue planes, abnormal anatomy and impairment of local blood supply are common. Objective: To assess the outcome of treatment of recurrent club-foot deformity using this device. Patients/Methods: The study evaluated Ilizarov external fixator correction of 40 feet in 31 patients. Deformity was idiopathic in 29 patients, associated with constriction bands in 6 patients and was syndromic or associated with a defined neuromuscular disorder in 6 patients. Patients were reviewed clinically and completed questionnaires documenting pain, function and satisfaction before and after treatment at a mean follow-up of 44 months (range 14–131). All patient’s notes and radiographs were examined. Results: Pain and function scores after treatment improved in 67% and 72% of cases respectively. A subjective increase in stiffness was noted in 46%. Patient satisfaction with outcome was 61%, correlating with improved pain and function scores. Pain and function scores were not significantly different in stiff versus non-stiff feet. The overall recurrence rate was 44%, and was highest in the idiopathic group (59%) compared with the constriction band group (17%) and the neuromuscular/syndromic group (0%). Feet with recurrent deformity had been treated with the Ilizarov fixator at a younger mean age (7.8 years) than those feet which did not recur (mean age 12.6 years). 71% of recurrences experienced significant pain post treatment, compared with only 36% of those feet where deformity did not recur. Functional ability was, however, similar in the two groups. Further surgical treatment has been necessary in 6 patients, including 4 further Ilizarov frames. Complications included almost universal minor pin-site infections, flexion contractures of the toes in 5 feet and skin ulceration in 2 feet, 1 requiring a muscle flap. Conclusions: Treatment of relapsed clubfoot with the Ilizarov fixator can improve the appearance of the foot, correlating with improvement in pain, function and patient satisfaction. This must be balanced however against a high recurrence rate, particularly in young idiopathic feet, an increase in stiffness of the ankle, which has implications for future surgery, and the risk of complications inherent in the technique

The Orthopaedic Unit at The Alfred has been using an external fixator in a novel configuration for protecting lower limb wounds after free flap surgery (sometimes even in the absence of a concomitant bony injury). This soft-tissue frame allows the limb to be elevated without contact so that there is no pressure on the flap and its pedicle. Thus, optimising the arteriovenous circulation. We report our initial experience with these soft tissue frames. The soft tissue frame is not necessarily applied for definitive fracture care, but constructed or modified to optimise elevation of the leg, remove direct pressure from the soft tissues, and stabilise the muscles adjacent to the flap. All ankle-spanning frames held the foot in a plantargrade position to optimise blood flow and recovery (prevent equinus), and minimise intra-compartmental pressure. During 2007, the Plastic Surgery Unit performed 23 free flaps to the lower limbs of 22 patients. Five of these patients had a soft-tissue frame constructed. One patient had a frame applied purely to manage the soft tissue injury, and the other four, who required an external fixator for a bony injury, had their frame modified. Four of the five patients study patients were injured in motor vehicle accidents and one was injured in a simple fall. All five free flaps survived and none required any further surgery. No patients suffered complications (such as bleeding, pin-track infections, or osteomyelitis) related to the soft tissue frame. We strongly recommend considering an external fixator in a modified configuration after lower limb free flap surgery. Constructing a soft tissue frame has no added risks if the fixator is already required. In the case where there is no bony injury, a soft tissue frame has the benefits of providing optimal flap conditions and maintaining anatomical joint alignment. However, this must be balanced against the small risk associated with the insertion of pins (such as infection) and the need for an extra procedure to remove the frame. As always, treatment must be tailored to the individual patient

To assess the outcome of bicondylar tibial fractures, treated prospectively with fine wire fixation in the Limb Reconstruction Service. Twenty patients with mean age 56 years with bicondylar tibial plateau fractures, were treated at the author’s institution with fine wire fixation over a three-year period. Ten followed road traffic accidents and four followed high-energy falls; The remainder mainly in the elderly resulted from a simple fall. There were four Schatzeker type V, and sixteen type VI. Four were open fractures (Gustilo grade III); Seven patients sustained associated fractures at the same time. They were treated according to a prospective protocol and were followed up for an average of thirty months, (11 – 51). The protocol included CT Scan Guided planning, closed reduction if possible and percutaneous interfragmentary screw fixation to reconstruct the articular surface, under image intensifier control; The external fixator was applied in neutralization. Mobilization and full weight bearing was encouraged as early as possible. Ten patients started full weight bearing between four and six weeks post operatively, in nine cases with other injuries weight bearing was delayed. All patients healed with an average time in the fixator of eighteen weeks, (9–25). Fifteen patients had a range of movement from Zero to at least 120 degrees flexion. Using Rasmussen’s functional and radiological scoring system, fifteen out of twenty scored good or excellent. Complications included deep vein thrombosis in one patient, loss of fracture reduction in three, superficial pin tract infection which resolved with local pin care and a short courses of antibiotic in five patients, there was no deep infection. The Sheffield hybrid external fixator is strong, permits early fracture recovery and weight bearing and may have significantly contributed to the high rate of good results in this group, of which more than 50% were over sixty years old. This technique is recommended for treatment of this difficult fracture

Introduction: Currently used small animal models of a critical size defect do not sufficiently simulate the biologically unreactive situation in an atrophic non-union. Furthermore, models using intramedullary nails are of little, and poorly standardised, biomechanical stability. This is a characteristic known to promote callus formation though, rather leading to a hypertrophic non-union. The aim of this study was to establish an atrophic non-union model in the rat femur under well defined biomechanical conditions and with minimised interactions between the processes in the healing zone and the implant by using external fixation. MATERIALS AND METHODS: 80 male Sprague Dawley rats were randomly divided into two groups (non-union vs. control). All animals received an osteotomy (app. 0.5 mm gap) of the left femur, stabilised with a custom made external fixator. In the non-union group the periosteum was cauterised 2mm distal and proximal of the osteotomy, and the bone marrow was removed. X-rays were performed once weekly. Animals were sacrificed at 14 or 56 days post-operation. At both time points the femurs of 16 animals of each group underwent histological/histomorphometrical and immunhis-tochemical analyses (PMMA or paraffin embedding). Additionally at 56 days 8 animals of each group were tested biomechanically. The maximum torsional failure moment and the torsional stiffness were determined in relation to the intact femur. Post-mortem x-rays were evaluated in a descriptive manner. RESULTS: At 14 days the histology and radiology showed considerable mineralised periosteal callus in the control group, while the non-union group only showed very little periosteal callus, distant to the osteotomy. At 56 days the control group was completely, or at least partially, bridged by mineralised callus. The non-union group did not show a bridging of the osteotomy gap in any of the animals, moreover the bone ends were resorbed and the gap widened. The relative mean torsional stiffness was significantly larger (p< 0.001) in the control group compared to the non-union group (136.2±34.5% vs. 2.3±1.2%). In the non-union group no maximal torsional failure moment could be detected for the osteotomised femurs. In the control group it was 134.2±79.1%, relative to the intact femur. DISCUSSION: The cauterisation of the periosteum and the removal of the bone marrow, in combination with a high stiffness of the external fixator may create an atrophic non-union under well defined biomechanical conditions and with minimised interactions between the healing zone and the implant. This model will allow better standardised investigations on the subject of atrophic non-unions

Purpose: We report our experience with ankle arthrodesis using Ilizarov External fixator in 18 patients with extensive damage of the ankle joint, mainly with post traumatic osteoarthrosis, during the last 7 years. Materials and Methods: The mean age of the patients was 36 years (range 21–54 years). 14 Pts had posttraumatic arthrosis following complicated intraarticular fractures, 3 Pts had extensive osteochondritis dissecance and 1 had failure of union after RAF arthrodesis of ankle. No cases of osteomyelitis of ankle were included in this seria. All procedures were done with open arthrotomy, 6 through lateral approach and 12 through anterior approach. Bone grafting was used in 3 cases due to extensive damage of talar bone. Temporary fixation by Steinman pin was done in all cases after open alignment of ankle joint, and then Ilizarov external fixator was applied, followed by removal of the temporary fixation. Full weight bearing was allowed from the 3. rd. or 4th postoperative day. Time in fixator ranged from 6 to 14 weeks (average 9,5 weeks). Results: Solid arthrodesis was achieved in all cases. 15 patients were free of pain, 2 patients continued to complain of pain due to degenerative changes in subtalar joint which presented before surgery. 1 patient developed RSD and was treated successfully by analgesics and physiotherapy. 5 cases of superficial pin tract infection were observed and treated with antibiotics. There were no cases of deep wound infection in this series. Conclusions: This method has been proven useful for primary arthrodesis of ankle joint, mainly for complicated cases after multiple surgeries, or in patients with advanced post-taumatic changes

Background. The usefulness of arthroscopic reduction for the intra-articular fracture of the distal radius has been reported, although it is technically difficult. Hypothesis. Our hypothesis is that the reduction using the external fixator is useful as equivalent to the arthroscopic reduction for the intra-articular fracture of the distal radius fracture in the fixation with the volar locking plate. Materials & Methods. The surgery was performed in both methods randomly for 40 patients; average age 64(24 to 92) years, 11 male, 29 female. Image evaluations were performed at 24 weeks after surgery. Ulnar variance, Radial inclination, Volar tilt in the X-ray image, and gap and step in the computed tomogram were evaluated. Clinical evaluation was performed at 6, 12, 24 weeks after surgery. Objective evaluations were ranges of motion and grip strength. Subjective evaluations were disabilities of the arm, shoulder, and hand (DASH). Results. The results of image and objective evaluation had no significant difference between the two groups. DASH in arthroscopic group was significantly inferior at 24 weeks because of minor complications. Discussion & Conclusion. The external fixator and the arthroscopy are equally valuable in reduction of articular surface

Ring frames have the advantage of allowing progressive correction. However, the available frames for complex deformities are heavy and bulky leading to poor compliance by patients. Also, the mounting procedure requires considerable expertise and skill. On the other hand, a unilateral external fixator has the advantages of less bulk and a lighter weight. Thus, it causes less disability and can achieve better patient compliance even with bilateral application. However, previous unilateral fixators have had various limitations with respect to deformity correction, such as restricted placement of hinges, restricted correction planes, and a limited range of correction angles. In addition, it was impossible to achieve progressive correction while fixation was maintained. To overcome these disadvantages of existing unilateral fixators, we developed a new fixator for gradual correction of multi-plane deformities including translational and rotation deformities. This unilateral external fixator is equipped with a universal bar link system. The link is constructed from three dials and two splines that are connecting the dials. The pin clamps are able to vary the direction of a pin cluster in the three dimensional planes. The system allows us to correct angulation, translation, rotation, and the combination of the above. In addition, open or closed hinge technique is available because the correction hinge can be placed right on the center of rotational angulation (CORA), or at any desired location, by adjusting the length of the link spline. By increasing the spline length, the virtual hinge can also be set far from the fixator. Gradual correction can be performed by rotating the three dials using a worm gear goniometer that is temporarily attached. A 3D reconstructed image of the bone is generated preoperatively. Preoperative planning can be done using this image. Mounting parameters are determined by postoperative AP and lateral computed radiography images. These postoperative images are matched with the pre-operative 3D CT image by 2D and 3D image registration. Then, the fixator can be virtually fixed to the bone. By performing virtual correction, it is possible to plan the correction procedure. The fixator is manipulated by rotating each of the three dials to the predetermined angles calculated by the software. Static load testing disclosed that the fixator could bear a load of 1700 N. No breakage or deformation of the fixator itself was recognized. Mechanical testing demonstrated that this new fixator has sufficient strength for full weight bearing, as well as sufficient fatigue resistance for repeated or prolonged use. The results of clinical application in patients with multi-plane femoral deformities were excellent, and correction with very small residual deformity was achieved in each plane

Open phalangeal and metacarpal fractures of the hand were stabilised using an improvised external fixator. This was in the field hospital in Iraq and on military personnel evacuated to the UK. The fixator was improvised from K-wires and a syringe, both of which are readily available in the field hospital. It is a unilateral frame, sufficiently stable to maintain fracture reduction but not too rigid so as to allow micro-motion for fracture healing. We describe our method and recommend this simple method as a quick and easy form of initial or definitive fracture stabilisation in the hand. In the hostile environment of the field hospital we found this method simple, cost effective and relatively safe

There is a growing trend towards using pre-clinical models of atrophic non-union. This study investigated different fixation devices, by comparing the mechanical stability at the fracture site of tibia bone fixed by either intramedullary nail, compression plate or external fixator. 40 tibias from adult male Wistar rats' cadavers were osteotomised at the mid-shaft and a gap of 1 mm was created and maintained at the fracture site to simulate criteria of atrophic non-union model. These were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with external fixator. Tibia was harvested by leg disarticulation from the knee and ankle joints, the soft tissues were carefully removed from the leg, and tibias were kept hydrated throughout the experiment. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4). Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. Axial load to failure data and stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices, however there was no statistically significant difference axially between the nail thicknesses. In bending, load to failure revealed that 18G nails are significantly stronger than 20G. We concluded that 18G nail is superior to the other fixation devices, therefore it has been used for in-vivo experiments to create a novel model of atrophic non-union with stable fixation

Purpose of study: The UMEX frame was developed from the Joshi external fixator, being first used in the UK in 2004. It corrects deformity by gradual distraction and manipulation. We report the outcomes of a two centre combined experience of the UMEX frame for the treatment of complex congenital foot deformities. Method: The frame was used in the management of 27 complex foot disorders, the majority of which were resistant club feet. All patients had at least 18 month follow up. Results: Good deformity correction was achieved in all cases, with a plantigrade foot immediately post-treatment. However, minor degrees of relapse have been noted when the strict postoperative regimen was not followed. Conclusions: The application of external fixators for the correction of foot deformities can be a complex procedure for the surgeon, and cumbersome for the patient. This frame is simple to apply and manage and allows multi-planar deformity correction in one stage. Our experience and patient outcome data suggest that this technique is a useful surgical option for the Paediatric Orthopaedic surgeon dealing with a relapsed club foot and other complex foot deformities

The use of external fixation in the management of long bone fractures has long been recognised. The aim of this study was to compare 3 differing constructs of Hoffman-2 and Hoffman-3 External Fixator systems to assess which potentially withstood the greatest load. Three different constructs (2, 3 and 4-bar) of Hoffman 2 and 3 External Fixation systems were tested. A UHMWPE tube was utilised as a bone substitute to construct a biomechanically reproducible model which could be tested on an MTS testing jig. Each construct was loaded to 3, 5, 8, 12 and 15mm of displacement at the fracture gap. Each construct was cyclically loaded 200 times for each test and repeated 5 times. The results demonstrate that the Hoffman-3 configurations withstood a load of at least twice that of the Hoffman 2 configurations across all displacements. Using a 2-way ANOVA test at all displacements the 2-bar configuration withstood greater load than the 3 bar (P<0.0001). With Hoffman 2 the 2-bar configuration withstood a greater load than the 4 bar diamond configuration. These results demonstrate that Hoffman-3 External Fixation Device has a greater axial loading capacity than its Hoffman-2 predecessor

Background:. External fixators are not as well tolerated around the femur when compared to the tibia. Lengthening with an intramedullary device is therefore attractive. Method:. We reviewed all cases of femoral lengthening performed at our unit from 2007 to 2014. Cases of non-unions, concurrent deformities, congenital limb deficiencies and lengthening with an unstable hip were excluded. This left 33 cases for review. Healing index, implant tolerance and complications were compared. Results and Discussion:. In 20 cases the Precice lengthening nail was used and in 13 cases the LRS external fixator system. The desired length was achieved in all cases in the Precice group and in 12 of 13 cases in the LRS group. The Precice group had a more rapid return to full weight bearing. The mean healing index was 31.3 days/cm in the Precice and 47.1 days/cm in the LRS group. There was an increased incidence of complications with LRS lengthening, including pin site infections and regenerate deformity. Implant tolerance and the patients' perception of the cosmetic result were better with the Precice treatment. Conclusion:. We conclude excellent functional results with fewer complications and greater patient satisfaction in femoral lengthening with a Precice intramedullary nail

Aim: Complex tibial plateau fractures, Shatzker type VI, rare in the past, became more common nowadays because of high energy injuries. These complex fractures usually accompanied by compromised skin and soft tissue envelope requires deliberate planning as treatment in the past invite a high rate of complications. Materials and method: During a period of 24 months, 16 fractures of tibial plateau, Shatzker VI, were treated in 16 patients, all regarding vehicle accidents.11 patients were men and 5 women with a mean age of 42 years old (27–67).There were 2 open and 14 closed fractures (3 type I, 8 type II and 3 type III according to Tscherne’s classification).All cases were treated with circular external fixators (hybrid), whereas 9 of them needed additional mini internal fixation (one or two screws). Results: 14 patients were evaluated with a mean period of follow up 1.9 years. Healing was achieved in all 14 cases with a mean period of 16 weeks (12–24).Fixator removal was performed when bone healing was completed. There was no deep infection. 12 patients at the end of treatment had a range of motion between 0° – 120°. 3 fractures developed a malunion (1 valgus deformity, 2 anterior angular deformity). Radiographic evidence of arthritis appeared in 2 patients during follow up. Pin tract infection occurred in one case, treated with antibiotics. Conclusion: The use of circular external fixators (three olive wires to tibial plateau) obtains good stabilization while allows early joint motion, protects soft tissue envelope and in combination with minimal internal fixation achieves satisfactory reduction of comminuted fractures making the technique promising for the management of these complex fractures

Introduction: External fixation is used widely in the management of fractures, despite a relatively high incidence of complication, arising from pin loosening and infection. Diamond like carbon (DLC) is a low surface energy coating that can be applied to external fixator pins and may reduce biofilm formation and infection resulting in a lower incidence of pin loosening. Hydroxyapatite (HA) is well established as a coating to enhance fixation of external fixator pins. This study tests the hypothesis that HA and DLC coatings on stainless steel (SS) external fixator pin shafts modify integration of the implant with soft/hard tissues. Materials and Methods: An Orthofix external fixator was used to stabilise a tibial osteotomy with 6 self-drilling/tapping 6mm pins in 32 skeletally mature Friesland ewes. Animals were divided into four groups; SS, DLC, HA partially coated (threads only) and HA fully coated (threads and pin shaft). Pin insertion torque was measured using a torque wrench and extraction torque similarly obtained at 10 weeks when animals underwent euthanasia. Pin performance indices (PPI) were calculated as a ratio of extraction to insertion torque x100%. Pin site 2 was preserved for hard grade resin histology and subsequent pin tissue integration analysis. Pin site 3 was used for analysis of the soft tissue pin shaft interface using transmission electron microscopy. Pin site 5 was examined for the presence of biofilm formation using scanning electron microscopy. Pin site 6 was swabbed for microbiological analysis. Results: SS and DLC pins achieved significantly higher insertion torques compared to HA partially coated pins (p=0.001, 0.002). Both groups of HA coated pins demonstrated a significantly higher, extraction torque and therefore PPI for all pin site positions compared to SS and DLC (p< 0.001– 0.025). The epithelium was found not to be in contact with the pin shaft in all cases. No significant differences were found between the different pin groups for epidermal down growth and dermal contact. Both groups of HA coated pins showed a significantly higher percentage of new bone in direct contact with the embedded threads compared to SS and DLC pins (p< 0.001, p=0.004). The proportion of soft tissue in contact and within the thread, of fully coated HA pins was significantly lower compared to stainless steel (p=0.003, p=0.017), DLC (p=0.004, p=0.002) and HA partially coated pins (p=0.006, p=0.02). Biofilms were evident on all pins except those coated with DLC. More bacteria were observed on the fully HA coated pins. DLC had significantly lower number of bacterial colonies in culture compared to SS (p=0.028) and fully coated HA pins (p=0.005). Discussion: Coatings of DLC and HA do have a significant affect on hard/soft tissue reactions. However coatings do not have a significant effect on epidermal down growth or dermal attachment to the pin shaft surface. DLC coated pins had the cleanest surface with no bio-film present and significantly lower numbers of bacteria present. Fully HA coated pins despite evidence of bio-film formation, bacteria and high microbiological counts had significantly higher PPI. In addition fully coated HA pins demonstrated significantly reduced amounts of soft tissue at the pin bone interface. Therefore soft tissue reactions may affect bone integration

Introduction. Pin-tract infections are a common problem in orthopaedic surgery, which limits the time an external fixator or Taylor spatial frame can be applied to a patient. The purpose of our study is to evaluate the ability of a novel implant surface coating — cationic steroid antibiotic (CSA)-44 — to delay or prevent the onset of these infections. This coating mimics endogenous antimicrobial peptides of the innate immune system and has been shown to effectively eradicate biofilms as well as prevent infection and stimulate healing of open, contaminated fractures. Methods. Surgeries were performed on 20 animals (outbred; Sprague-Dawley strain rats). Each animal received both CSA-coated and standard-of-care titanium pins, with pins randomized to the fifth or sixth vertebrae prior to surgeries. Animals were also randomized to either “Imaging” (imaging analysis) or “Infection” (microbiological analysis) cohorts. Surgeons were blinded to pin types and analyses cohorts. Digital images of pin sites were collected weekly over 12 weeks, and then graded by two orthopaedic surgery residents according to an established Likert scale. Graders were blinded to animal numbers, pin types, and timepoints (Figure 1). For the infection analysis cohort, four specimens per site were subjected to microbiological analysis from each site (i.e. pin, superficial skin swab, deep skin swab, sonicated bone). Each specimen was processed on three different microbiological plates (i.e. BAP, CAN, MAC) using standardized techniques. Imaging analysis was performed by dissecting vertebrae en bloc with pin retained, followed by fixation in 10% neutral buffered formalin for 72 hours. Following a graded ethanol series and storage in 70% ethanol, specimens were scanned with microcomputed tomography (µCT). Statistical analyses were performed to compare pin site appearance (chi-square testing) as well as total bacterial colony counts within each plate cohort and imaging data (Kruskal-Wallis testing); for all tests, significance was set at α=0.05. Results. Weekly digital images of each pin site were collected, graded, and then averaged (Figure 2). Statistical analysis showed no significant difference in pin appearance between the control and CSA pin cohorts at any timepoints. For the infection analysis cohort, bacterial colonies were counted on BAP, CAN, and MAC plates, followed by bacteria species identification (Figure3). Statistical analysis showed no significant difference in total bacterial colony counts between the control and CSA pin cohorts in any of the plate groups. For the imaging cohort, post-processing and subsequent data and statistical analyses are ongoing. Discussion. No significant differences were found between the control and CSA pin cohorts, with respect to pin appearance during the 12-week study or total bacterial colony counts on three plates, indicating that the control and CSA pins performed equivalently. Imaging analysis is ongoing. Although the environmentally-acquired infection model in an outbred rat strain was used to replicate the onset of pin tract infections in human populations, many animals showed Grade 1 or 2 pin site appearances at the 12-week endpoint. A follow-on study is underway using a direct bacterial seeding model. For any figures or tables, please contact the authors directly

In arthritis of the varus knee, a high tibial osteotomy (HTO) redistributes load from the diseased medial compartment to the unaffected lateral compartment. We report the outcome of 36 patients (33 men and three women) with 42 varus, arthritic knees who underwent HTO and dynamic correction using a Garches external fixator until they felt that normal alignment had been restored. The mean age of the patients was 54.11 years (34 to 68). Normal alignment was achieved at a mean 5.5 weeks (3 to 10) post-operatively. Radiographs, gait analysis and visual analogue scores for pain were measured pre- and post-operatively, at one year and at medium-term follow-up (mean six years; 2 to 10). Failure was defined as conversion to knee arthroplasty. . Pre-operative gait analysis divided the 42 knees into two equal groups with high (17 patients) or low (19 patients) adductor moments. After correction, a statistically significant (p < 0.001, t-test,) change in adductor moment was achieved and maintained in both groups, with a rate of failure of three knees (7.1%), and 89% (95% confidence interval (CI) 84.9 to 94.7) survivorship at medium-term follow-up. At final follow-up, after a mean of 15.9 years (12 to 20), there was a survivorship of 59% (95% CI 59.6 to 68.9) irrespective of adductor moment group, with a mean time to conversion to knee arthroplasty of 9.5 years (3 to 18; 95% confidence interval ± 2.5). . HTO remains a useful option in the medium-term for the treatment of medial compartment osteoarthritis of the knee but does not last in the long-term. . Cite this article: Bone Joint J 2016;98-B:601–7

In the treatment of acute elbow dislocation promising clinical results have been reported on articulated external fixation and surgical reconstruction of major joint stabilizers. However, it remains unclear whether or not surgical reconstruction of the major joint stabilizers sufficiently stabilizes the elbow joint or if augmentation by a hinged elbow fixator is beneficial to provide early stability and motion capacity. The aim of the present study was to compare the stabilizing potential of surgical reconstruction versus augmentation by a hinged external elbow in a model of sequentially induced intability of the elbow. Materials and Methods: 8 unpreserved human upper extremities were mounted to a testing apparatus which was integrated within a material testing machine. In a first series, varus and valgus moments were induced to the intact elbow joint at full extension, as well as at 30°, 60°, 90° and 120° of flexion and the mean angular displacement at 2.5, 5, an 7.5 Nm was calculated. Instability was then induced by sequentially dissecting the lateral and the medial collateral ligament, the radial head, and the posterior capsule. The elbow joint was then sequentially restabilized by osteosynthesis of the radial head and refixation of the lateral and medial collateral ligament using bone anchors. In each sequence, elbow stability was tested with and without augmentation by a hinged external fixator according to the first testing series described above. Biomechanical data of surgical reconstruction alone and surgical reconstruction augmented by external fixation were compared using an analysis of variance. Results: In the intact elbow, varus-valgus displacement with 7.5 Nm ranged from 8,3 ± 2,4° (0°) to 11,4 ± 4,2° (90°). With the fixator applied, varus-valgus displacement was significantly lower and ranged from 4,2 ± 1,3° (0°) to 5,3 ± 2,2° (90°). After complete destabilization of the elbow joint, maximum varus-valgus displacement ranged from 17,4 ± 5,3° (0°) to 23,6 ± 6,4° (90°). Subsequent reconstruction of the collateral ligaments, the posterior capsule, and the radial head proved to stabilize the elbow joint compared with the unstable situation, however, mean varus-valgus displacement remained significantly higher when compared to the intact elbow joint. During each sequence of instability, the hinged external fixator provided constant stability not significantly different to the intact elbow joint while guiding the elbow through the entire range of motion. Conclusion: The stabilizing potential of surgical reconstruction alone is inferior to augmentation of a hinged external elbow fixator. In order to proved primary stability and early motion capacity, augmentation of a hinged external elbow fixator in the treatment of acute dislocation of the elbow is recommended

We tested the hypothesis that it is possible to accelerate fracture healing by changing the mechanical environment used in current methods i.e., from initial rigidity or micromovement followed by dynamisation to initial macromovement followed by rigidity (micro-movement). It is accepted that callus formation requires movement at the fracture site and this callus response is limited to the first few weeks after fracture. Logically, early macromovement at the fracture site would be beneficial for callus formation. Additional callus is not produced by further movement. Indeed, it may be counter-productive, just as continuing movement around two ends of a wooden stick bonded with glue will retard and even prevent “union”. We postulate that continuing movement at the fracture site after the callus response has ceased will also delay union. As a result, rigidity rather than dynamisation is required in the later stage of fracture healing. After testing an animal model, we built an external fixator which allowed 5 mm of axial movement without “self-locking” and could be compressed at a later date in order to prevent further movement. A trial containing 15 patients with unilateral tibial shaft fractures (closed or grade 1 open) was undertaken after permission was obtained from the Helsinki Ethical Committee. So far, 13 patients have been entered into the trial. They have completed therapy and are at least one year post-fracture (12 months to 22 months). Age range is from 20 to 49. The group is composed of nine males and one female. Under general anaesthetic, an external fixator was applied and the fracture reduced. The patients started ankle exercises (active and passive) the following day, with as much weight-bearing on the fractured leg as possible on the day after. The patients were seen every two weeks and AP and lateral radiographs were taken. The fracture was compressed two to six weeks later. The percentage of body weight that the patient was able to tolerate through the fractured limb was measured by using the scales of Meggit’s step test. The fixators were removed when there was radiographic union and the patient could take at least 80% of body weight through the fractured limb. Mean time duration up to removal of the fixator was 10.8 weeks (range 7 to 15.4 weeks). We conclude that it is possible to increase the speed of bone healing by changing the mechanical environment to initial macromovement followed by elimination of movement

Aims

To fully verify the reliability and reproducibility of an experimental method in generating standardized micromotion for the rat femur fracture model.

The management of carpal dislocation after a late diagnosis is difficult. Open reduction is the usual treatment but collapse of the carpus may be hard to overcome without extensive dissection and consequent damage to the blood supply, ligaments and articular cartilage. A technique of distraction by an external fixator followed by semi-closed reduction is described and its successful use is reported in two cases

We have treated 16 patients with recurrent complex elbow instability using a hinged external fixator. All patients had instability, dislocation or subluxation of the ulnohumeral joint. The injuries were open in eight patients and were associated with 20 other fractures and five peripheral nerve injuries. Two patients had received initial treatment from us; 14 had previously had a mean of 2.1 unsuccessful surgical procedures (1 to 6). The fixator was applied at a mean of 4.8 weeks (0 to 9) after the injury and remained on the elbow for a mean of 8.5 weeks (6 to 11). After treatment we found the mean range of flexion-extension to be 105° (65 to 140). At a final follow-up of 23 months (14 to 40), the mean Morrey score was 84 (49 to 96): this translated into one poor, three fair, ten good and two excellent results. Complications included one fractured humeral pin, one temporary palsy of the radial nerve, one recurrent instability, one wound infection, one severe pin-track infection and one patient with reflex sympathetic dystrophy. Although technically demanding, the use of the fixator is an important advance in the management of recurrent complex elbow instability after failure of conventional treatment

In polytrauma patients invasive surgeries can potentiate the posttraumatic systemic inflammation thus increasing the risk of multi organ dysfunction. Therefore, fractures are initially treated by external fixators, which later are replaced by intramedullary nails. We showed that a severe trauma impaired the healing of fractures stabilized by external fixation. Here we studied, whether the conversion to an intramedullary nail increases posttraumatic inflammation and leads to further impairment of healing. 44 rats received a femur osteotomy stabilized by an external fixator (FixEx). Half of the rats underwent a thoracic trauma (TXT) at the same time. After 4 days the fixator was replaced by an intramedullary nail (IMN) in half of the rats of each group. The rats were killed after 40 and 47 days. C5a serum levels were measured 0, 6, 24, and 72h after the 1st as well as the 2nd surgery. The calli were evaluated by three-point-bending test, μCT and histomorphometry. The TXT significantly increased serum C5a levels after the 2nd surgical intervention. After 40 days the switch from FixEx to IMN significantly decreased bending stiffness in rats with and without TXT. After 47 days flexural rigidity in rats subjected to conversion was significantly decreased compared to rats treated only with a FixEx, particularly in combination with TXT. This study showed that after a severe trauma the conversion of the fixation could provoke a second hit and contribute to delayed fracture healing

Aim and Purpose of the study. The authors evaluate the efficacy of athrodiatasis as possible alternative to arthrodesis or arthroplasty in the treatment of ankle arthritis in young patients. They present the long term results (average 19 years) of a small series of patients (10 cases) treated with a monolateral transarticular external fixator associated to different open or athroscopic procedures. Material and Methodology. The patients have been revaluated with the Kitaoka scoring scale associated to the x-ray evaluation. The authors will compare these results with those reported for the same series at an early evaluation (2,5 y of follow up) and with those published in literature. Discussion. Arthrodiatasis of the ankle with distraction and movement of the joint under weightbearing can guarantee an intermittent Hydrostatic pressure that has a trophyc effect on residual cartilage. In 1995 a new interest in ankle distraction was promoted by a very active Duch group which in few years demonstrated that there was still space for this indication as alternative to the arthrodesis in very young and active patients because the functional and physical impairment, the pain and mobility of this joint can be improved also after the first year of follow up. Our good results with the same approach seems to confirm their conclusions after a long term follow –up even if there is no correlation between the functional and radiological findings. It is important to underline that frequently is necessary to associate to arthrodiatasis other ancillary arthroscopic or open procedures in order to optimise the results. Conclusion. Arthodiatasis as possible alternative to arthrodesis or arthroplasty in the treatment of ankle arthritis is still a valid option in selected cases because can guarantee good functional results even at a long term follow-up

To evaluate the operative treatment of Blount disease using the TSF external fixator and to evaluate the system. During January 2004 and August 2008, 8 males and 2 females with Blount disease (16 limbs) were treated using TSF system. For the radiological assessment we obtained standard long-leg standing radiographs and we measured the anatomic medial proximal tibial angle (aMPTA), the diaphyseal-metaphyseal tibial angle (Drennan), and the femoro-tibial angle. The mean follow-up was 29 months (15 to 45). No patient had pain around the knee, medial or lateral instability. The range motion of the knee immediately after frame removal was 10° to 90° of flexion in two patients while in the other it was from 0° to 110°. The mean leg-length discrepancy was reduced postoperatively from mean 1,9 cm (1,7–3,2) to 0,9 cm (0− +1,5). The aMPTA angle increased from mean 73° (59°– 83°) to 94° (107°–90°), Drennan angle from 17° (14°–22°) to 3° (0°–7°), and femoro-tibial angle from 17° (10°–30°) varus to 7° (2°–10°) valgus. The frame was removed at mean 9 weeks (7–14). Two patients had delayed union, two presented with loss of correction (due to dissociation of struts and secondary to medial physeal bar), two patients had pin track infection. No neurologic complications were referred. Accurate corrections of multiplanar deformities as varus, internal rotation and shortening of the limb that coexist in Blount disease may be accomplished using TSF system

Background: The treatment of extensive soft tissue injury with bony involvement due to orthopaedic trauma or other pathologic conditions has undergone great improvement in the last decade. The main fields that assisted with that progress are: the ability to transfer autogenous vascularized soft and/or bony tissues to the injured areas and the possibility to apply external fixation either statistically for acute stabilization of a limb or using dynamic frames to correct late occurring contractures or deformities. Objectives: To present our experience in treating young patients with severe, post traumatic or tumor resection soft tissue and bony injuries including bone loss and late joint contractures. That was treated by a combination of free vascularized flaps and static or dynamic circular external fixation with special emphasis on preplanning and technical issues critical for the success of such complex procedures. Methods: Seven patients were included in the study; six post traumatic patients who received free vascularized myocutaneous latissimum dorsi or fasciocutaneous anterolateral thigh flaps to the calf and foot. All six patients had an Ilizarov frame for initial stabilization; two of them needed late dynamic correction of equines with the frame. The seventh patient had surgery for removal of osteosarcoma and received a vascularized osteocutaneous fibula flap with fixation by Ilizarov frame, this patient also needed late dynamic frame application for equines correction. Results: The mean age at surgery was 11.6 years (range 7–14 years); mean follow up was 1.8 years (range 2 months – 3.4 years). All microvascular flaps but one survived where the patient with the failed latissimus dorsi flap had the second muscle transferred at the next day. One patient needed 2 vascular revisions. All bone flap showed solid union at 3 months post operatively. Four patients achieved plantigrade foot initially. The three patients with dynamic correction achieved plantigrade foot at frame removal. Complications: Equinus contracture of the ankle in three patients, injury to the vascular anastomosis in one patient. Pin tract infection in all patients that responded well to antibiotics. Conclusions: The circular external fixator is a reliable method for initial fixation of injured limb. It is advised to apply the fixator before the transfer of the free flap. Position of the fixation pins should be discussed before hand with the plastic surgeons to allow free access to the microvascular anastomosis site. Free flaps allow the coverage of large soft tissue defects while the external fixators maintain anatomical position of the limb. Late occurring contractures after the incorporation of the flap can be safely corrected gradually with the circular frame. It is of paramount importance to include the foot in the frame and maintain neutral position of the ankle joint to prevent equines contractures

The most common indication for knee arthrodesis is pain and instability in an unreconstructable knee following an infected knee arthroplasty. In this study, we compare the use of the Mayday arthrodesis nail (Ortho-dynamics, Christchurch, UK) versus external fixation, Orthofix (Berkshire UK) and Stryker Hoffman II (County Cork, Ireland). All patients in this study underwent arthrodesis between 1995 and 2006 at Conquest Hospital, Hastings. In group A, 11 patients underwent arthrodesis with a Mayday nail. In all cases, the indications were infected total knee replacements (TKR). Three of these patients previously had failed attempts at arthrodesis with external fixation devices. In group B, seven patients underwent arthrodesis using external fixation. In six patients, the indication was infected TKRs. Results were reviewed retrospectively, with union assessed both clinically and radiologically. The mean inpatient stay for the Mayday nail group was 23 days (range 8 – 45 days) compared with 76 days (range 34 – 122) for the external fixation group (p< 0.01, CI 95). Ten patients in group A went on to confirmed primary arthrodesis. One patient underwent revision arthrodesis with a Mayday nail and subsequently united. In group B only two patients achieved union. The rate of union was significantly greater in the Mayday nail group than the external fixation group (91% vs 29%, p< 0.01). Of those patients that achieved union, there was no difference in the time to fusion between groups. Our study supported the existing literature and found that the Mayday nail appeared more effective than monoaxial external fixators for arthrodesis in the management of infected total knee replacements

Purpose of study: Aim was to evaluate the functional outcome of External fixation supplemented by K-wire fixation in communited fractures of lower end radius and compare the outcome in closed and open fractures treated by this method. Methods: External fixation along with K-wire fixation was done in 25 consecutive patients (mean age-41.9 years; range-20 to 72 years). According to Frykman’s classification, there were 3 Type VII fractures and 22 Type VIII fractures. 15 fractures were closed type, 4 were Open grade I, 4 were Open grade II and 2 were Open grade III according to Gustilo and Anderson classification. The mean follow-up period was 14.1 months (range- 6 to 25 months). Results: The mean union time was 7 weeks (range-5 to 8 weeks). Mean dorsiflexion was 37.6 degrees, mean palmar flexion was 44.4 degrees, mean ulnar deviation was 16.2 degrees, mean radial deviation was 14.2 degrees, mean supination was 73 degrees and mean pronation was 79 degrees. Comparison of union time, dorsiflexion, palmarflexion, ulnar deviation, radial deviation, supination and pronation between closed, Open grade I, Open grade II and Open grade III fractures revealed no significant difference. Significant radial shortening was observed in patients with open fractures (P=0.004). 1 patient developed schanz pin tract infection and late distal radioulnar joint subluxation was seen in 4 patients. Conclusion: Supplementation of External fixator with K-wires is an effective method for treating both closed and open fractures of distal end radius however; radial shortening is seen in some cases with open fractures

Introduction The purpose of this study was to compare the time to union following acute shortening and subsequent lengthening versus Bone Transport using the Ilizarov external fixator. Methods Eighteen patients with tibial non-unions (age range 26 to 63 years) were recruited between March 1995 and September 2001. Three subgroups of six patients each, were formed. Group 1 underwent Acute Shortening and subsequent Lengthening, whereas Group 2 underwent Bone Transport. Group 3 patients had defects < 1 cms but were still high energy injuries, therefore underwent application of a frame. This group was used as a comparison group. A proximal corticotomy was used for distraction osteogenesis. Bone grafting at the fracture or regenerate site was used if required to aid healing. All patients were followed-up to union. All three groups were similar for age, pre-injury health status including cigarette smoking. Ten infected non-unions were present. Most patients had at least two conventional operative interventions prior to referral to us for Ilizarov surgery. The mean bone resection in the Acute Shortening group (Group 1) was 4.6 cms and in the Bone Transport group (Group 2) was 5.9 cms. Patients in Group 2 had more procedures done before union was achieved. This included adjustment of frame/ reinsertion of wires to align transport segment for optimal docking and bone grafting at the docking/regenerate site. Four patients in Group 2 required bone grafting at the docking site compared to none in Group 1. Results Eradication of infection and union was achieved in all patients with average time in frame being 12.1 months in the Acute Shortening group, 17.2 months in the Bone Transport group and 8.0 months in the Frame stabilisation group. Using Paley’s bone result evaluation system, an excellent result was achieved in all patients of all groups. However, patients in the Acute Shortening group had a shorter time to union and needed fewer procedures. Conclusions We recommended that where feasible, acute shortening and lengthening is preferable to bone transport due to shorter union time and fewer procedures undertaken to achieve union. If this is not possible due to large defects, then a combination of acute shortening with transport to bridge the gap should be considered

External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such as necrotising fasciitis (NF) and toxic shock syndrome (TSS) may occur.

We retrospectively reviewed all patients who underwent external fixation between 1997 and 2012 in our limb lengthening and reconstruction programme. A total of eight patients (seven female and one male) with a mean age of 20 years (5 to 45) in which pin/wire track infections became limb- or life-threatening were identified. Of these, four were due to TSS and four to NF. Their management is described. A satisfactory outcome was obtained with early diagnosis and aggressive medical and surgical treatment.

Clinicians caring for patients who have external fixation and in whom infection has developed should be aware of the possibility of these more serious complications. Early diagnosis and aggressive treatment are required in order to obtain a satisfactory outcome.

Cite this article: Bone Joint J 2015;97-B:1296–1300.

Introduction

External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting.

Aims. Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy. Methods. Zucker rats, WT and homozygous for leptin receptor mutation (ZDF), were fed a moderately high-fat diet to induce T2DM only in the ZDF animals. At ten weeks of age, open femoral fractures were simulated using a unilateral osteotomy stabilized with an external fixator. At three weeks post-surgery, the fractured femur from each animal was retrieved for analysis. Callus formation and the extent of healing were assessed by radiograph and histology. Bone tissue was processed for total RNA extraction and messenger RNA (mRNA) sequencing (mRNA-Seq). Results. Radiographs and histology demonstrated impaired fracture healing in ZDF rats with incomplete bony bridge formation and an influx of intramedullary inflammatory tissue. In comparison, near-complete bridging between cortices was observed in Sham WT animals. Of 13,160 genes, mRNA-Seq analysis identified 13 that were differentially expressed in ZDF rat callus, using a false discovery rate (FDR) threshold of 10%. Seven genes were upregulated with high confidence (FDR = 0.05) in ZDF fracture callus, most with known roles in inflammation. Conclusion. These findings suggest that elevated or prolonged inflammation contributes to delayed fracture healing in T2DM. The identified genes may be used as biomarkers to monitor and treat delayed fracture healing in diabetic patients. Cite this article: Bone Joint Res 2023;12(10):657–666

Tibial nonunion represents a spectrum of conditions which are challenging to treat, and optimal management remains unclear despite its high rate of incidence. We present 44 consecutive patients with 46 stiff tibial nonunions, treated with hexapod external fixators and distraction to achieve union and gradual deformity correction. There were 31 men and 13 women with a mean age of 35 years (18 to 68) and a mean follow-up of 12 months (6 to 40). No tibial osteotomies or bone graft procedures were performed. Bony union was achieved after the initial surgery in 41 (89.1%) tibias. Four persistent nonunions united after repeat treatment with closed hexapod distraction, resulting in bony union in 45 (97.8%) patients. The mean time to union was 23 weeks (11 to 49). Leg-length was restored to within 1 cm of the contralateral side in all tibias. Mechanical alignment was restored to within 5° of normal in 42 (91.3%) tibias. Closed distraction of stiff tibial nonunions can predictably lead to union without further surgery or bone graft. In addition to generating the required distraction to achieve union, hexapod circular external fixators can accurately correct concurrent deformities and limb-length discrepancies.

Cite this article: Bone Joint J 2015;97-B:1417–22.

External fixation is useful for the treatment of selected injuries to the hand. Some authors have suggested that external fixation of a phalanx may tether the extensor hood, thereby hindering active movements and predisposing to permanent adhesions. There is no consensus as to the best site for placement of the pin to minimise these problems. This study was performed on cadaver specimens to investigate the influence of the pin site on the range of simulated active movement of the interphalangeal joint. The dorsal midline position produces least interference with the extensor mechanism; radial and ulnar to this, interdigitating oblique fibres prevent a clean longitudinal split in the direction of gliding thus limiting movement of the extensor hood. At the proximal phalanx, positioning of the pin just off the midline avoids the thickening of the proximal median hood, whereas at the middle phalanx, a true midline position utilises the bare area at its base.

The aim of the study was to test the biomechanical effectiveness of the radiolucent fixator “X-caliber”. For this reason, care was taken to include a heterogeneous group of leg fractures capable of treatment with external fixation. A multi-centre study was organized to taste the biomechanical effectiveness of the radiolucent synthesis device. Our centre was equipped with this external fix-ator, which is preassembled and completely radiolucent.

The fixator is manufactured from a carbon fibre composite, with stainless steel cams and locking nuts, and aluminium alloy bushes.

The fixator types comprise standard fixators, fixators with a periarticular ring attachment, and fixators with a swivel clamp for ankles. Between December 2000 and May 2002 the authors tasted the biomechanical effectiveness of the new fixators in 13 patients with leg fractures. After a follow up of 6 months, analysing the results of other centres the authors retook the utilization of the radiolucent fixator and, in this paper, relate their total experience until April 2004 in 42 patients with leg fractures.

Our clinical experience in treating lower limb deformities by external fixation started in 1982 by applying an Ilizarov external fixation frame. Correcting lower limb deformity by gaining the proper length and the optimal mechanical performance is of the outmost importance and essential for valid restoration of the articular function. We treated 145 patients: 25 patients affected by post-traumatic deformities; 12 patients affected by axial deviation of the knee; 82 patients affected by limb shortening and associated limb deformities; eight patients with lower limb deformities and shortening following pathological hip alterations; and 18 patients affected by severe foot deformities.

It is important to stress that in congenital lower limb deformities both axial deviation and limb shortening contribute to the final picture of the deformity. Combined (hybrid) external fixation provides an adequate correction of the mechanical axis and a proper lengthening of the shorter limb by a corticotomy followed by a gradual distraction.

Aims: To treat posttraumatic stiffness of elbow by distraction arthrodiastasis and mobilisation. Standard operative procedures were combined for 4 patients with bony blocks due to myositis ossiþcans. Methods: We reviewed 8 patients, 5:M, 3:F aged 20–42 years. 3 x 2.5mm k-wires were passed in lower-third humerus from lateral to medial side and 3 x 2.5mm k-wires in proximal ulna. Distractors were applied on anterior and posterior aspect of elbow and hinge-joint at the level of elbow-joint. Elbow was gradually distracted to achieve arthro-diastatic state of joint. Maintaining arthrodiastatic state now elbow deformity is gradually corrected by distracting anterior distractors. Than distractors and hinge are locked for tissue reaction to subside over 2–3 weeks followed by dynamic mobilization. Movement gradually improves over 2–3weeks (sometimes prolonged in severe cases). Than þxator is removed and appropriate dynamic splint is applied to maintain correction while allowing mobility. In 4cases bone block was removed surgically and followed by distraction arthrodiastatic procedure. No steroid in any form was used in any stage of treatment. Results: Average follow-up: 2years (maximum 4years). All elbows were stable and extension increased by 30û and ßexion increased by 50û. One case had minor pin-tract infection, responded to basic treatment. No neurovascular deþcit was not seen post procedure in any patients. Conclusion: This technique may be considered before arthrolysis is undertaken for stiff elbow.

Purpose We describe a simple method of dressing pin sites, based on the principles developed in the Ilizarov Institute, that can be easily used in British operating theatres.

Method There are a wide variety of protocols for pin site care but infection rates of up to 80% are reported. The Russian Ilizarov Institute claim low infection rates which may be influenced by their dressing technique. Pin sites are dressed with gauze sponges held against the skin with specifically manufactured rubber stoppers passed over the wires. These provide pressure at the pin site. Plastic syringes consist of a barrel and a plunger with a rubber bung. The rubber bung from a 5ml syringe plunger can be easily removed and slid over the end of a half-pin or both ends of a fine wire. This must be done before the frame is attached and we recommend applying the bungs each time a pin is inserted. At the end of the procedure a cut piece of gauze is applied around the pin site and held in place by the rubber bung, providing a secure non-bulky dressing. A dressing protocol developed by the senior author, based on “The Russian Protocol”, was audited and found to have made a significant impact on the incidence on pin track infection. The bungs can be slid back up the pin when the dressings are changed and left up if the pin site is to remain uncovered. Should the pin site begin to discharge the bung can again be used to hold the dressings securely.

Conclusion We have found this to be a simple, quick, inexpensive and reliable method of pin site dressing that can be readily used in everyday practice, and, reduces the pin track infection incidence.

Aim: The role of external þxation in the deþnite management of open tibial fractures is reviewd based on a study of 180 tibial fractures during 1992– 2001. Method: From the 180 patients, 70 fulþlled the criteria (anatomical or acceptable reduction, optimal fragmemts contact, high rik for infection, technical difþculties for internal þxation) and was included to the study. Fractures were stabilized with a unilateral frame, or with V or delta frame. In sixty-one cases, bony consolidation in optimal aligment occurred. In the remaining nine patients, external þxation was removed because of major pin tract infection, loss of reduction or in delayed union. Results: Sixty-one patients achieved union with the external þxation in a mean time of 4,5 months (3 to 6 months). There was no malunion. Minor pin track infection was seen in 32/280 pin sites (11.4%). No remarkable shortening of the injured leg observed. After consolidation, 44 (72.1%) fractures had a very good or good functional recovery. An acceptable result was achieved in 16 patients (26.3%), and one (1.6%) had bad function of the injured leg. Conclusion : Given the stringent adherence to the important principles of þxator application, attentive choice of the patient and the type of the fracture, and well supervised follow up, we believe that deþnitive, successful management of open tibial fractures can be obtained with external þxation.

Arthrolysis and dynamic splinting have been used in the treatment of elbow contractures, but there is no standardised protocol for treatment of severe contractures with an arc of flexion < 30°. We present our results of radical arthrolysis with twin incisions with the use of a monolateral hinged fixator to treat very severe extra-articular contracture of the elbow. This retrospective study included 26 patients (15 males and 11 females) with a mean age of 30 years (12 to 60). The mean duration of stiffness was 9.1 months (5.4 to 18) with mean follow-up of 5.2 years (3.5 to 9.4). The mean pre-operative arc of movement was 15.6° (0° to 30°), with mean pre-operative flexion of 64.1° (30° to 120°) and mean pre-operative extension of 52.1° (10° to 90°). Post-operatively the mean arc improved to 102.4° (60° to 135°), the mean flexion improved to 119.1° (90° to 140°) and mean extension improved to 16.8° (0° to 30°) (p < 0.001). The Mayo elbow score improved from a mean of 45 (30 to 65) to 89 (75 to 100) points, and 13 had excellent, nine had good, three had fair and one had a poor result. We had one case of severe instability and one wound dehiscence which responded well to treatment. One case had deep infection with poor results which responded well to treatment.

Our findings indicate that this method is very effective in the treatment of severe elbow contracture; however, a randomised controlled study is necessary for further evaluation.

Introduction: The accepted treatment for unstable displaced tibial shaft fractures in adults is primary closed reduction and intramedullary nailing. However, this method poses a problem when treating young adolescents whose epiphyseal plates have not yet closed. We used the Ilizarov external fixation as an alternative method of treatment for these patients.

Patients and Methods: 13 patients with displaced unstable tibial shaft fractures (11 boys, 2 girls; age 13 to 16 yrs), of which 5 were open (Gustilo I–II), were treated by this method from 1995–2000. The Ilizarov frame was applied to 3 patients within the first 2 days of injury, a further 6 during the 1st week and 4 on the 2nd week or later.

All patients were allowed to weight bear from the first postoperative week. Physiotherapy was started immediately after operation and continued until normal knee and ankle function was regained. Dynamization was done in all cases 2 weeks before removal of frame. Following removal, the patients were advised to use crutches for an additional two weeks.

Results: A good or excellent alignment with full ROM in the ankle and knee joints was obtained in all patients. There were no cases of delayed or non-union. No cases of contractures or nerve injuries were reported. Superficial pin tract infection was seen in 6 patients, treated by antibiotics and local care. No cases of osteomyelitis or deep infection occurred. Length of fixation was 8–15 weeks (mean 11 weeks).

Conclusions: This method permits fixation without danger of injury to the epiphysis in growing adolescents. The stability of the fixator allows early weight bearing and leaves the adjacent joints mobile. There is no necessity for POP after removal of frame. Due to early weight bearing and an unrestricted joint movement less muscle wasting occurs. The healing time is relatively shorter than in other methods of the treatment and the complications rate was low in the presented series.

We studied the effectiveness of treatment with AO-Mini external þxator in complete articular fractures of distal radius, type 23-C. Mat. and meth.: we were reviued 474 distal radius complete articular fractures treated with AO-Mini external þxator during 10 years. All of fractures were documented by de AOI sheets. We used de Classiþcation of long bones from M.E.MŸller because itñs a global system of classiþcation. Results: in 474 fractures, 246 are females and 228 males. The age are between 15 to 94 years, and the age average 51ñ59 years (63ñ14 females, 38ñ84 males).212 fractures are located in the right wrist, and 262 in the left wrist. 14% (66 cases) were open fractures. Etiology: 19% Work,23% Trafþc,8% Sports,30% Home, 20% Others. The 15% of cases had pathological antecedents previously, 27% had local injuries associated and 28% had general injuries associated. 68% were operated for a Senior Surgeon, 61% with loco-regional anaesthesia, 33% were treated with antithrombotic prophilaxis, and 25% with antibiotic treatment. The 46% of cases needed some other implant, and 15% needed surgery for collateral injuries. Complications: 4% local acute complications and 1% of general acute complications. In the late follow-up, 18% of cases were local late complications and 2% general late complications.

At the end of the follow-up, in 81% of cases the use of extremity was better than 75%, and 83% of patients were pain free.

X-Ray: 10% had Distrophy, and 56% had some articular alterations.

Four month post-operative, 54% were recovered, and at the end of the follow-up 68%, of cases the þnal disability is < 25%. The final evaluation: is good/excellent in the 75% of cases.

Aims: To evaluate the clinical outcome of the treatment of severe high-energy war injuries to limbs using circular external þxation frames. Metods: 43 patients after war injuries with 57 high-energy fractures were treated. According to Gustilo and Anderson all fractures were open grade 3B and 3C. There was other major organ trauma in 52,8% of patients. On admission, the fractured bones were stabilized with an AO tubular external þxation frame followed by thorough extensive soft tissue debridement, vascular reconstruction if needed. After 5 to 7 days the tubular þxator is exchanged for a circular frame that allows receiving stability, sufþcient for full weight bearing by minimal invasive þxation and freeing the previously bridged joints, in order to preserve their range of movement. Closed reduction of fractures was performed in most patients by successful implementation of ligamentotaxis and use thin wires with olives. In patients with high-energy Ç ßoating joint È injuries the circular devices were connected by hinges to permit early initiation of joint motions and functional treatment. In patients with upper limb injuries a separate bone þxation was used to allow early ßexion/ extension and pronation/supination motions. Results: In all patients the circular external þxation was the deþnitive treatment. Bone grafting was not necessary in any patient because of compression-distraction possibility. Fracture union was achieved at median time of 8 months (range 3 60). Throughout the period of fracture healing the patients were ambulatory, living at home. Conclusion: The circular þxation frame allows perform successful skeletal stabilization and functional restoration of limbs in patients with extensive bone and soft tissue loss, even in limbs of the risk.

Aim: Our purpose was to evaluate the use of indirect and closed reduction with Ilizarov external fixator in intra-articular calcaneal fractures. Materials and Methods: In a period of 5 years (2004–2008), 26 patients with 29 intra-articular fractures of calcaneus (eighteen type III and eleven type IV according to Sanders classification) were treated with the Ilizarov fixator. Twenty-one patients were male and five female. The average age was 45 years (range 22 – 67 years). Five fractures were open. Fractures were evaluated by preoperative radiographs and CT scans. Restoration of the calcaneal bone anatomy was obtained by closed means using minimally invasive reduction technique by Ilizarov fixator. Arthrodiatasis and ligamentotaxis, and closed reduction of the subtalar joint were performed in 24 cases. In 5 cases the depressed posterior calcaneal facet was elevated by small lateral incision and stabilized in frame by wires. Postoperatively, partial, early weight bearing was encouraged in all patients. Results: The mean follow-up period was 2,1 years (range 1 – 4 years). The AOFAS Ankle – Hindfoot Score, and physical examination were used in functional evaluation. The average score was 77,4 (range 70–90). Seven patients had limited degenerative radiological findings of osteoarthrosis about the subtalar joint and three of them had painful subtalar movement. Two of the patients complained of heel pad pain. Nine patients had grade II pin tract infections and were detected from a total of 258 wires. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. Conclusion: Indirect closed reduction of calcaneal bone anatomy and arthrodiatasis of subtalar joint with Ilizarov external fixator is a viable surgical alternative for intra-articular calcaneal fractures

Background: The Ilizarov external fixation is considered to be a unique technique in limb surgery for mal-nonunion and limb deformities with or without length discrepancy. The theory suggests that the tension stress and the subsequent distraction osteogenesis, “opens a window” over hypervascularized- hypertrophic non-union for consolidation, and stimulates vascularization and osteogenesis in the avascular nonunion. Also, post traumatic bone deformities and axial deviations can be corrected by using special hinges incorporated in the device for uniplanar or multiplanar deformities. Recently, there are encouraging reports of high rate of consolidation using a non-bone grafting technique even in atrophic nonunions. However, the bifocal treatment is still preferable.

In our study we will review 28 patients suffering from mal- nonunion, whom were treated by an Ilizarov external fixation, and the results of the treatment concerning radiological alignment and consolidation rate.

Methods: Twenty-eight patients have been operated in our department during the last eight years due to mal-union (19 patients), mal- nonunion (3 patients) and non-union (6 patients) of fractures.

Malunions were treated either with acute or gradual correction of the deformity, following low energy osteotomy. For hypertrophic nonunion and mal-nonunion in general only distraction compression technique (mono-focal) was used. Atrophic and infected nonunion were treated with a bifocal technique (so-called bone transport), except for one case treated with monofocal technique only.

Results: The average age of the patients at operation was 31 years old (12–71), six female and 22 males. The average time in the device was 4 months (2–8) and average rate of consolidation was 3.6 mo. (2–7.5). All fractures and osteotomies healed thoroughly. Still, three cases of the mal unions remained suffering from residual deformity. Two patients had fracture of the regenerate after minimal trauma just after removal of device and treated with IMN. The most prevalent complication was pin tract infection, 24 out of 28 patients, all managed with P.O. antibiotics besides two patients who needed to be admitted for intravenous antibiotics. Two cases of lateral compartment muscle herniation of the leg appeared after fibular osteotomies, treated later by large fasciotomy.

Conclusions: The treatment of the different types of nonunion and malunion following fractures is a real challenge for the orthopedic surgeon. Many times the nonunions are the result of poor vascular supply to the involved limb. While the surgeon is facing old scars and poor nourishment of the entire limb, the Ilizarov external fixation, in most of the cases, enables us to deal with these difficult cases with minimal surgical exposure. In case of malunions, Ilizarov technique enables to achieve accurate angular correction of the deformities.

Aims: To correct cubitus varus deformity by wedge resection and compression by external þxator for rapid osteogenesis. Methods: We treated 6patients with cubitus varus deformity secondary to malunited supra-condylar fracture of humerus. 4:M, 2:F aged between 8–14years. Duration between injury and surgery averaged 20months (1.4–2.4years). Preoperative humeroulna angle on x-ray averaged Ð18.5¡ (−12¡ to −28¡) and on contralateral limb averaged 12.4¡ (8¡−18¡). All patients had full elbow movements preoperatively. 2x2mm k-wires passed in lower humeral metaphysis parallel to joint line and 2x2mm k-wires passed in lower diaphysis perpendicular to humeral shaft. Laterally based bone wedge equivalent to preoperatively calculated template including 5¡ of over-correction was removed in between the wires. A compression distraction rod was applied to close the wedge by compression. Elbow was mobilized after postoperative pain relief in þrst week with dynamic elastic sling. Fixator was removed at 6weeks. Results: All patients achieved full elbow movements and complete cosmetic correction. Osteotomy united faster under compression. No neurovascular complication was seen. One patient had minor pin tract infection, subsided on treatment. Conclusions: Any residual corrections postoperatively are fully adjustable. Literature reports poor results of up to 30% due to loss off or inadequate correction. Stability achieved by þxator allowed early postoperative elbow mobilization. Extremely reliable, ßexible and fully controlled method.

Aims: The purpose of this presentation is to report our protocol for staged exchange nailing of delayed-unions and non-unions of the tibia complicated by multifocal osteomyelitis from infected pin tracts. Methods: Twenty-four patients with delayed or non-union of the tibia initially treated by external þxation were retrospectively reviewed. Fifteen males and 9 females with an average age of 40 years (range 20–74) and at least 1 year of follow up (range 1–7). External þxation was maintained until the soft tissues healed. External þxation time averaged 116 days (range 28–288). Multiple gross pin tract infection developed in all the casesl. Non-unions and delayed-unions were treated by exchange reamed intramedullary nailing. The exchange protocol consisted in the removal of the external þxator, debridement and culture of bone from the pin sites, cast immobilization, speciþc IV antibiotics for 6 weeks, and a negative post-antibiotics biopsy. Outcome measurements included recurrence of infection and healing of the delayed union or non-union. Results: Twenty-three of the fractures healed at the þrst nailing attempt on an average time of 4 months (range 2–7). One case required re-nailing at 4 months and þnally healed at 6 months from the initial procedure. No recurrence of deep infection was identiþed. Two patients developed superþcial infections, suppressive antibiotics were used until complete bone healing and subsequent nail removal. Discussion: By using our staged protocol we were able to perform exchange nailing for non-unions and delayed unions of the tibia complicated by multiple foci osteomyelitis from infected pin tracts with a considerable rate of success.

Introduction The purpose of this paper is to describe our management of complex fractures of the distal radius and ulna using a combined type of stabilization, external with a Pennig fixator, internal with radial augmentation with plate. The patient have substained a several general trauma or an high energy scheletral trauma upper limbs. Treatment In a period from 24 july 2002 to today 8 october 2004 (26 months) we have treated surgically 93 wrists with distal radial fractures in 85 patient. 4 patients bilaterally, 3 patients have substained a secondary reprease for lacking the initial reduction and 2 in two programmed timing. 46 wrists with radial internal fixation single or double plate (in one case trhee plate). 12 plate with pin or single screw in augmentation. 3 cases with only screw artroscopically assisted. 14 cases with only external fixator with or without pin. 18 wrist with a combination of radial internal fixation (plate) and external fixation with Pennig, in complex distal radial-ulna fracture (2 exposed). In 5 wrists there were associated and treated navicular fracture or intracarpal ligaments injury. 1 pazient have sustained an ipsilateral forearm fracture, epiphiseal distal radial fracture, trans scapho-lunate dislocation and controlateral transcapho-lunate dislocation. 1 patient have sustained ipsilateral navicular-fisrt metacarpal-radial and ulna fracture. The most patients (...) have been treated from the first Author. The patients were controlled from minimum of 6 month up a maximum of 39 months. We have adapted in our evaluation the Dash score system. The main problem, in the follow up results is a lack of prono-supination that stresses the importance of a perfect reduction of distal radio-ulnar joint to begin early a phisiotherapy. Clinical results In conclusion our experince in timing of treatment indicate that is important fixate the lesions earlier, whenever the priority of treatment on severly injured pazients are respected. We believe that a combination of the two fixation system allow an optimal external stabilization in the first week (So the terapist can move the patients in intensive care room). Secondary the internal fixator allows an anatomical reduction with a stable fixation in the secondary kinesiterapeutic time protocol of high energy trauma to distal forearm, in particular in politraumatized patients is:. - closed reduction and short cast or external fixator if exposed or severe instable, on the day of injury during or just following generally stabilization. - if possible e Tc 3D dimensional scan (our patients have substained a lot of tc scan for other trauma). - internal reduction and stabilitation a fews days later when the local swelling or skin damage and general condition allow it (from 2 to 7). - removal of external fixator between 3–4 week and begin a complete fkt

The main weakness of the classical external þxator is the penetration of the bone, this conducting to the entrance of the pathogenic germs by their migration toward the pins.

Despite the fact that the centromedullary synthesis is done after several weeks after the removal of the external þxator the risk of infection after the operation remains signiþcantly high. Considering these theoretical assumptions and experiencing in our current practice such complications we have started to use 3 years ago the pinless external þxator for the stabilization of the tibia fractures.

Between 1999–2002 there were hospitalized and operated 213 patients with open tibia fractures, 28 being treated using the pinless external þxator.

From those cases PEF was used for 9 patients with type II lesions, 8 patients with type IIIA lesions and 3 patients with type IIIB lesions.

After resolving the soft tissue injuries (approx. 2 weeks) the external stabilization was converted to internal centromedullar solid stabilization, without the risks associated with the use of the classical external þxator.

Our conclusion was that the external pinless þxator is less invasive, stable and realize a good adherence to the bone. This guarantees the centromedullary conversion of the osteosynthesis with minimal risks, as it doesnñt expose the medullar cavity of the shaft.

We would like to present this case series of 10 adolescent patients with displaced, closed diaphyseal tibial fractures managed using the Taylor Spatial Frame.

Management options for these injuries include non-operative treatment, antegrade nailing, flexible nailing systems, plating and external circular fixation. External circular fixation allows anatomical reduction avoiding potential complications such as growth arrest associated with antegrade nailing and retained metal work with plating. Flexible nailing system and cast immobilisation are unreliable for precise anatomical reduction. With limited evidence as to the extent of post-traumatic deformity that is acceptable, combined with the limited remodeling potential that this patient group possess, the precision of percutaneous fixation with the Taylor Spatial Frame system has clear advantages.

This is a retrospective analysis of 10 adolescent patients with a mean age of 14.5 years (range 13 to 16 years). Data collected includes fracture configuration, deformity both pre and post operatively compared to post frame removal, length of time in frame and complications. The data was gathered using the patient case notes and the Picture Archiving and Communications System. The mean time in frame was 15.5 weeks (range 11 to 22 weeks). One non-union in a cigarette smoker was successfully managed with a second Taylor Spatial Frame episode.

Our conclusion was that with careful patient selection the Taylor Spatial Frame allows successful treatment of closed tibial fractures in adolescents, avoiding complications such as growth arrest and post-traumatic deformity as well as avoiding retained metalwork.

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: The purpose of this paper is to describe our management of complex fractures of the distal radius and ulna using a combined type of stabilization, external with a Pennig fixator, internal with radial augmentation with plate. The patient have sustained a several general trauma or an high energy scheletral trauma upper limbs.

Treatment: In a period from 24 July 2002 to today 8 October 2004 (26 months) we have treated surgically 93 wrists with distal radial fractures in 85 patient.

The main problem, in the follow up results is a lack of pronosupination that stresses the importance of a perfect reduction of distal radioulnar joint to begin early a phisiotherapy

Clinical results: In conclusion our experience in timing of treatment indicate that is important fixate the lesions earlier, whenever the priority of treatment on severely injured patients are respected

We believe that a combination of the two fixation system allow an optimal external stabilization in the first week (So the therapist can move the patients in intensive care room). Secondary the internal fixator allows an anatomical reduction with a stable fixation in the secondary kinesiterapeutic time.

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

Introduction. Motorised intramedullary lengthening nails are considered more expensive than external fixators for limb lengthening. This research aims to compare the cost of femoral lengthening in children using the PRECICE magnetic lengthening nail with external fixation. Materials and Methods. Patients: Retrospective analysis of 50 children who underwent femoral lengthening. One group included patients who were treated with PRECICE lengthening nails, the other group included patients who had lengthening with external fixation. Each group included 25 patients aged between 11–17 years. The patients in both groups were matched for age. Cost analysis was performed following micro-costing and analysis of the used resources during the different phases of the treatments. Results. : Each group's mean patient age was 14.7 years. Lengthening nails were associated with longer operative times compared to external fixators, both for implantation and removal surgery (P-value 0.007 and <0.0001 respectively). Length of stay following the implantation surgery, frequency of radiographs, frequency of outpatient department appointments were all more favourable with lengthening nails. The overall cost of lengthening nails was £1393 more than external fixators, although this difference was not statistically significant (P-value 0.088). Conclusions. The cost of femoral lengthening with lengthening nails was not significantly higher than the external fixators’ cost. Further research to review the effectiveness of the devices and the quality of life during the lengthening process is crucial for robust health economic evaluation

Aims. We aimed to evaluate the health-related quality of life (HRQoL) in children with supracondylar humeral fractures (SCHFs), who were treated following the recommendations of the Paediatric Comprehensive AO Classification, and to assess if HRQoL was associated with AO fracture classification, or fixation with a lateral external fixator compared with closed reduction and percutaneous pinning (CRPP). Methods. We were able to follow-up on 775 patients (395 girls, 380 boys) who sustained a SCHF from 2004 to 2017. Patients completed questionnaires including the Quick Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH; primary outcome), and the Pediatric Quality of Life Inventory (PedsQL). Results. An AO type I SCHF was most frequent (327 children; type II: 143; type III: 150; type IV: 155 children). All children with type I fractures were treated nonoperatively. Two children with a type II fracture, 136 with a type III fracture, and 141 children with a type IV fracture underwent CRPP. In the remaining 27 children with type III or IV fractures, a lateral external fixator was necessary for closed reduction. There were no open reductions. After a mean follow-up of 6.3 years (SD 3.7), patients with a type I fracture had a mean QuickDASH of 2.0 (SD 5.2), at a scale of 0 to 100, with lower values representing better HRQoL (type II: 2.8 (SD 10.7); type III: 3.3 (SD 8.0); type IV: 1.8 (SD 4.6)). The mean function score of the PedsQL ranged from 97.4 (SD 8.0) for type I to 96.1 (SD 9.1) for type III fractures, at a scale of 0 to 100, with higher values representing better HRQoL. Conclusion. In this cohort of 775 patients in whom nonoperative treatment was chosen for AO type I and II fractures and CRPP or a lateral external fixator was used in AO type III and IV fractures, there was equally excellent mid- and long-term HRQoL when assessed by the QuickDASH and PedsQL. These results indicate that the treatment protocol followed in this study is unambiguous, avoids open reductions, and is associated with excellent treatment outcomes. Cite this article: Bone Joint J 2020;102-B(6):755–765

Abstract. Congenital posteromedial bowing of tibia (CPMBT) progresses with decreasing deformity and increasing shortening. Lengthening in CPMBT has not been studied extensively. Our series compares duration and complications of lengthening in younger vs older children. Methods. 28 tibial lengthenings (23 patients) by a single surgeon, divided into two equal groups of 14 segments: group-A ≤ 5 years, Group-B > 5 years. Lengthening was done in all with external fixators. We measured preoperative (bo) and postoperative (po) deformities, initial limb length discrepancy (LLD), LLD at maturity (LLDm), % LLD, amount of lengthening (AmtL) and %L, external fixator duration (EFD) and external fixator index (EFI). We graded complications by Lascombes' criteria, results by ASAMI Bone score. Results. Mean age was 8.8 ± 7.1 years. Follow-up was 7.9 years. Group-A had significantly greater preoperative deformities. LLD was similar in both. Expected LLD at maturity (LLDM) using the multiplier method was greater than previously reported (group-A: 4.4 – 9.5 cm; group-B: 2.5 – 9.7 cm).%L was 24% in group-A and 15.7% in group-B (p=0.002). EFD and EFI were lesser in group-A than group-B. Lascombes' triple contract was fulfilled in 11/14 lengthenings in group-A vs. 3/14 in group-B. ASAMI bone score was good and excellent in both groups. Conclusions. In our large series of CPMBT lenghtenings, we found younger children presenting with large deformities and LLDm could be safely lengthened with lesser EFD and complications than older children

The external fixator is an invaluable device when treating acute complex trauma and in limb reconstruction. It is therefore important to ensure its efficient and safe application to avoid complications. A lot of research has been done to evaluate the factors around external fixator stability, pin site infections and more is still being done to understand pin loosening. The purpose of this study was to evaluate other factors that may contribute in external fixator pin loosening. The aim was to evaluate if the different Schanz pin insertion techniques contribute to pin loosening. Two tibia diaphyses from two cadavers were each divided into three sections. Three different drilling techniques were repeated in each of the sections. A total of 36 Schanz pins were inserted and a section cut out of the bone in front of the pins was done allowing visual inspection of the pin hole for features of thread stripping. These features were predefined as thread pattern disruption, smoothening and shallow imprint on the cortex. Evidence of pin thread stripping was seen in all of the pin insertion techniques. The first method where the hole was pre-drilled and pin inserted with the drill showed 100% thread stripping. The second method of pre-drilling and hand insertion showed the least amount with 16.7% of pin stripping noted and 66.7% pin thread stripping was observed when inserting the pin with power without pre-drilling the pilot hole using the third method. Different pin insertion techniques result in varying amounts of pin thread stripping. The most amount of thread stripping occurs when a Schanz pin is inserted with power after pre-drilling. This finding, although not measured scientifically, supports the current recommendation of pre-drilling and manual insertion of the pin. In future, more scientific measurement are necessary to quantify these findings and assess their clinical significance