Aims. Both the femoral and tibial component are usually cemented at revision total knee arthroplasty (rTKA), while stems can be added with either cemented or press-fit (hybrid) fixation. The aim of this study was to compare the long-term stability of rTKA with cemented and press-fitted stems, using radiostereometric analysis (RSA). Methods. This is a follow-up of a randomized controlled trial, initially involving 32 patients, of whom 19 (nine cemented, ten hybrid) were available for follow-up ten years postoperatively, when further RSA measurements were made. Micromotion of the femoral and tibial components was assessed using model-based RSA software (RSAcore). The clinical outcome was evaluated using the Knee Society Score (KSS), the Knee injury and Osteoarthritis Outcome Score (KOOS), and visual analogue scale (pain and satisfaction). Results. The median total femoral translation and rotation at ten years were 0.39 mm (interquartile range (IQR) 0.20 to 0.54) and 0.59° (IQR 0.46° to 0.73°) for the cemented group and 0.70 mm (IQR 0.15 to 0.77) and 0.78° (IQR 0.47° to 1.43°) for the hybrid group. For the tibial components this was 0.38 mm (IQR 0.33 to 0.85) and 0.98° (IQR 0.38° to 1.34°) for the cemented group and 0.42 mm (IQR 0.30 to 0.52) and 0.72° (IQR 0.62° to 0.82°) for the hybrid group. None of these values were significantly different between the two groups and there were no significant differences between the clinical scores in the two groups at this time. There was only one re-revision, in the hybrid group, for infection and not for aseptic loosening. Conclusion. These results show good long-term fixation with no difference in micromotion and clinical outcome between fully cemented and hybrid fixation in rTKA, which builds on earlier short- to mid-term results. The patients all had type I or II osseous defects, which may in part explain the good results. Cite this article: Bone Joint J 2022;104-B(7):875–883

Hybrid fixation is now an established modality of treatment for articular fractures of the proximal and distal tibia. However, there is a lack of consensus over the management of non-articular metaphyseal fractures extending into the diaphysis. Despite sophisticated techniques, intramedullary nailing remains difficult and has relatively high rates of malunion and nonunion. Plate fixation may produce satisfactory results, but its use is limited where there is major extension into the diaphysis or where the soft tissues are compromised. Since 1995, we have used hybrid external fixation in the treatment of such fractures in 24 male and 16 female patients of mean age 54 years (15 to 92). Mostly sustained in road traffic accidents, there were 26 closed and 14 open fractures, seven of which were Gustillo type IIIB. There were 26 distal tibial, seven proximal and seven tibial shaft fractures. Metaphyseal fixation consisted of two rings with tension wires, diaphyseal fixation of screws. We used additional rings in segmental diaphyseal fractures or used olive compression wires across the fracture when additional stability was required. Hybrid fixation was the primary procedure in 25 patients and a secondary procedure, performed within eight weeks of injury, in 15. All patients went on to union in a mean of 45 weeks, but 10 required additional procedures such as bone-grafting, additional insertion of olive wire and soft-tissue procedures. Residual malunion in six patients required adjustment with frame fixation, with minimal clinical significance. We had three pin-tract infections and one deep infection, which resolved after sequestrectomy. When choosing a fixation system, it must be taken into account that high-energy tibial fractures may be slow to unite and that deep infection is related to the degree of soft-tissue injury. We believe hybrid fixation is a safe and minimally invasive treatment option. Careful attention to reduction and soft-tissue management, followed by early functional rehabilitation, can reduce healing times

Fibular plating comprises a major component in the treatment of Pilon fractures with open reduction and internal fixation. However, its necessity when Pilon fractures are treated by hybrid fixation has been questioned. A retrospective clinical study with 65 high energy pilon fractures treated by circular fixators between 1996 and 2001 was undertaken, in order to clarify this technical detail. The mean age was 35 years (range 21 to 69 years). The fractures were classified according to the systems of Ruedi -Allgower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Hybrid fixation (tension wire fixation at the fracture site augmented by screws) was performed in 39 fractures. The lateral malleolus was internally fixed in 39(60%) patients. In 48(74%) patients the fixation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in five fractures. Clinical and radiological results were evaluated. Mean follow up was 3 years (range 1 to 10 years). On the basis of Ruedi-Allgower system, there was a negative correlation between the end result and fibular fixation in all the fractures types (p< 0.001). However, if Ovadia Beals system was used, fibular fixation was associated with better results in type II and III, but with inferior results in type IV and V. We conclude that in fractures with metaphyseal defect, fibular fixation does not allow acute shortening and makes bone transport more difficult leading to poor results. Ovadia – Beals classification considers the metaphyseal defect and the fracture comminution and should be chosen for the selection of the technique. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V

Purpose: To assess the function of the knee joint and the development of knee arthrosis, at seven years postoperatively, in patients in whom a high energy tibial plateau fracture had been treated with minimal internal fixation augmented by small wire external fixation frames. Material and Methods: Between October 1989 and November 1999, one hundred twenty nine high energy tibial plateau fractures were treated with hybrid fixation including small wire circular or hybrid frames, minimum internal fixation and occasionally provisional extension of the external fixation to the distal femur. The average patient age was 39 years. There were 69 (53%) C1 fractures, 19 (15%) C2 and 41 (32%) C3 fractures and 49 (38%) fractures were open. Complex injury according to Tscherne-Lobenhoffer classification was recorded in 87 (67%) patients. Clinical, subjective, objective and radiographic results were evaluated after an average follow up of 84 months. Results: Results were assessed according to the criteria of Honkonen–Jarvinen. Excellent or good functional result was recorded in 98 (76%) patients. However, only 74 (57.5%) patients retained an excellent or good radiographic result at the final follow up. Compared with the radiographic appearance of the post-traumatic arthritis after an average of 48 months, there was found no statistically significant deterioration of the knee arthrosis (p< 0,05). No reconstruction operations were performed after the completion of the index procedure. Conclusion: A high percentage of radiographic post-traumatic arthritis should be expected, after high energy tibial plateau fractures had been treated with minimal internal fixation augmented by small wire external fixation frames. However, because all the objectives of the fracture treatment can be obtained, the functional results remain satisfactory over time

Introduction: High energy tibial pilon fractures are usually associated with a significant bone loss in the metaphyseal area of the tibia. This study evaluates three different treatment options for the management of the metaphyseal bone loss. Materials and Methods: Betwwen 1996 and 2007, 85 high energy pilon fractures- Ovadia Beals type IV: 39 and V: 46- were treated and reviewed in our institution. Twenty four fractures were open, and fifty one closed fractures had soft tissue lesion grade1 or 2 according to Tscherne classification. To restore the bone continuity in tibia metaphyseal area bone graft substitutes were used in 53 fractures, acute shortening and proximal lengthening in 18 fractures and bone transport in 14 fractures. Evaluation was carried out according to the Ovadia-Beals evaluation system. Results: The mean average follow up was 6 years. Thirty seven fractures (70%) treated with bone graft substitutes achieved an excellent or good result. Eleven fractures (61%) treated with proximal tibia lengthening achieved an excellent or good result, whereas only eight fractures (57%) treated with bone transport achieved an excellent or good. Bone infection was recorded in 6 fractures, all in the group of the patients treated with bone graft substitutes. Conclusion: The management of the metaphyseal bone loss in the high energy tibial pilon fractures is a basic priority to achieve a satisfactory result. Hybrid external fixation with the use of bone graft substitutes seems to be a more suitable technique to these devastating injuries. However bone infection remains a major concern for these devastating injuries

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

Introduction

The number of revisions of total knee replacements (TKR) increases annually. Because of reduced bone stock, stable fixation of the implant is important. The femoral and tibial components are usually cemented whereas stems can be placed either cemented or press-fit (hybrid construct). To assess the stability of revision TKR with either cemented or hybrid places implants a randomized controlled trial (RCT) was executed, by using radiostereometric analysis (RSA). The short-term results of this RCT showed no differences between the two groups in stability and clinical outcomes. Although there were no clinical or radiological signs of loosening, both groups showed implants micromotion > 1 mm or degree. These findings might indicate the possibility of loosening later in time; therefore, the current study investigated the stability of cemented versus hybrid-placed revision TKR 6.5 years after surgery. Additionally, clinical results were evaluated.

Aims: Fibular plating comprises a major component in the treatment of Pilon fractures with ORIF. However its necessity in fractures treated by EX.FIX has been questioned. In order to clarify this technical detail we carried out a retrospective study with Pilon fractures treated by circular þxators. Methods: Between 1992–2001, 65 pilon fractures were treated with circular þxators. Fractures were classiþed according to the systems of Ruedi Ð All-gower (9 II, 56 III) and Ovadia-Beals (9 II, 21 III, 13 IV, 22 V). Tension wire þxation at the fracture site was augmented by screws in 39 fractures. The lateral malleolus was internally þxed in 39(60%) patients. In 48(74%) patients the þxation was extended to the calcaneus for 6 weeks. The metaphyseal defect (25 fractures, 38.5%) was treated by grafting in fourteen, acute shortening in six, and bone transport in þve fractures. Clinical and radiological results were evaluated. Results: Mean follow up was 3 years (1 to 10 years). On the basis of Ruedi-All-gower system, there was found negative correlation of the end result and þbular þxation in all the fractures types. However if Ovadia Beals system was used, þbular þxation was associated with better results in types II and III, but with inferior results in types IV and V. Conclusions: Ovadia Ð Beals classiþcation considers the metaphyseal defect and fracture comminution and should be chosen for the selection of the technique. In fractures with metaphyseal defect, þbular þxation does not allow acute shortening and makes bone transport more difþcult leading to poor results. Fibular plating is desirable for types II and III but it should be avoided or at least not preceded for types IV and V.

Background

The circular Ilizarov frame is a well-established method of external fixation used in the acute treatment of fractures. In our unit, based on our experience, we have changed practice from an all-wire construct to a hybrid, incorporating one 5mm titanium half-pin in the distal reference construct. We were able to compare the all-wire construct against this hybrid in terms of time to union and complications.

Aims: To evaluate the functional recovery of the complex tibial plateau fractures Schatzker type V and VI treated with hybrid ex. fix. Methods: Twenty-eight patients with intra-articular fractures of the proximal tibia were treated with hybrid external fixation in a three years period (1998–2001).The mean age was 35 years (17–76). According to Schatzker classification, there were 11(39.3%) fractures type V and 17(60.7) type VI, whereas 5(17.8%) fractures were open. Complex injury was recorded in 15(53.5%) patients. Closed reduction and hybrid external fixation was achieved in 21 (75%) fractures. Additional limited internal fixation was performed in 9(32%) cases. Open reduction was necessary in 7(25%) patients. Mobilization of the injured articulation was started at the 3rd postoperative day. Results: Mean follow up period was 18 months. All fractures but one united at an average of 13.5 weeks (range from 11 to 18 weeks). The results were assessed according to the criteria of Honkonen and Jarvinen. An overall 22(78%) excellent and good results was recorded at the final follow up. Complications included one axial deformity, one septic pseudarthrosis, one peronial palsy and five pin tract infections. Conclusions: The use of hybrid external fixation in the comminuted tibial plateau fractures (Schatzker V,VI), insure good restraining and early union, avoid major soft tissue complications and allow early mobilization and functional recovery of the knee joint

The upper and lower thirds of the tibia are areas of peculiar anatomy and pose a lot of problems in their treatment. Purpose We present a method of hybrid external fixation used in a wide variety of these fractures. Material and method: Between 2000 and 2004, 29 patients with fractures of the tibia (16 fractures of the lower third and 13 fractures of the upper third) were treated with hybrid external fixation ORTHOFIX. Most of the fractures involved the adjacent joints, 12 fractures of the tibial condyles and 9 pilon fractures. Among the patients, 5 had septic non-union 2 of who were submitted to bone transport with the attachment of a lengthening system. All patients were called for monthly follow up till union. Results: In all cases except one (septic non-union – bone transport of the lower third) there was successful union by 3 to 7 months postoperatively. There was no malalignment, no deep infection or other major complication. Conclusion: The rational use of the hybrid external fixation offers a valuable solution in the treatment of the complex fractures in the upper and lower third of the tibia

The purpose of this study is to determine the indications and effectiveness of hybrid external fixation in the treatment of tibial plateau fractures and to evaluate the patient’s functional recovery. Twenty-seven patients with 28 intra-articular fractures of the proximal tibia were surgically treated with hybrid external fixation in a two years period (1999–2001). There were 25 patients (19 men and 6 women) available for the last follow up evaluation. The mean age was 35 years (17–76). According to Schatzker classification, there were 6 fractures type V and 22 type VI. Three of them were open fractures. The method included, indirect reduction based on ligamentotaxis and compression of the fractured segments with olive pins, in most patients. Additional limited internal fixation with free screws was also performed in 5 cases. Open reduction was necessary in 6 patients. Mobilization of the injured articulation was started at the third postoperative day, while full weight bearing was allowed after three months. The fixator was removed in average 12th week. Final evaluation was done according subjective, functional, clinical and radiological criteria. Mean follow up period was 14 months. All fractures except one united at an average time of 13, 5 weeks. Twenty-two patients (77.6%) graded as excellent and good, hi detail, subjective results were acceptable in 72%, functional in 84%, clinical in 70% and radiological in 80%. Complications included one axial deformity, one septic pseudarthrosis, one peronial palsy and superficial pin path infections. The use of hybrid external fixation in the comminuted tibial plateau fractures (Schatzker V, VI), insure good restraining and early union, avoid major soft tissue complications and allow quick mobilization and functional recovery of the knee joint. Moreover it is an application rather atraumatic because, only occasionally requires open reduction

Purpose: Fractures of the distal tibia are high energy fractures, associated with marked soft-tissue trauma. Management of these fractures is challenging. The purpose of this study is to present our experience on the treatment of these fractures using hybrid external fixation, with or without open reduction and minimal internal fixation of the fibular fracture. Patients and Methods: Forty eight patients with a distal tibial fracture were admitted to the authors’ institution since 2005. There were 33 men and 15 women. According to AO there were 24 A, 10 B and 14 C fractures. The mean age of the patients was 45.6 years. Eight patients had an open pilon fracture; according to the Gustilo classification, 1 patient had a grade I, 5 patients had a grade II, and 2 patients had a grade III open fracture. In all patients, the pilon fracture was treated using hybrid external fixation; in 18 patients, open reduction and minimal internal fixation of the fibular fracture using plate and screws was also done. Results: Mean follow-up was 14 months (range, 9 to 36 months). In all patients, the mean duration of the application of the external fixation was 2.85 months, followed by the application of a below-knee cast. In 42 patients, radiographic evidence of union was observed at 3,6 months (range, 3 to 9 months). Time for union was different between patients with closed and grade I open fractures compared to patients with grade II and grade III open fractures (union at 3.5 and 6 months, respectively). There were 5 non-unions (10,4%) with 3 of them septic (6,25%). All three deep infections were low grade and occurred in open fractures.Delayed union was observed in 3 patients; in these patients, solid union of the fracture was observed at 7 months (range, 6 to 9 months). Pin track infection was observed in 7 patients (14.6%). Conclusion: Based on the present study, hybrid external is associated with satisfactory results for the management of distal tibial fractures with acceptable complications

Periarticular fractures of the proximal tibia are some of the most difficult fractures to manage as open reduction and internal fixation of the fractures is plagued with complications such as non-union, delayed union, infection and post-traumatic osteoarthritis. We evaluated the results of 16 consecutive periarticular tibial fractures stabilised with the AO hybrid fixator using the Oxford Knee Score, American Orthopaedic Foot and Ankle Score (AOFAS) and X-rays of the tibia. Two patients were lost to follow up and 1 patient refused to take part in the study whose latest radiographs showed grade 4 degenerative changes. The mean follow up was 34 months (range 12 to 57 months) and the mean age was 50 years. All fractures were closed and were graded as either Schatzker 5 or 6. The fixator was applied for an average of 12 weeks. The mean Oxford Knee score was 27.2/60 (mild to moderate knee arthritis) and the mean AOFAS was 71.9/100. There was no significant malunion however 37.5% had developed radiological evidence of grade 3 or 4 post-traumatic osteoarthritis with one requiring a total knee replacement. Forty four percent of patients developed a complication with pin site infection being the commonest complication and 25% required further surgery. There were 2 nonunions with one requiring a fibular osteotomy, which subsequently united. Eighty eight percent of patients were satisfied with the procedure while 80% would recommend the procedure if required in future. From our study we feel that hybrid fixation of proximal periarticular tibial fractures is satisfactory however preoperative counselling regarding complications and the possible need for further surgery must be emphasised to the patient prior to embarking on this type of fixation

As the number of younger and more active patients treated with total knee arthroplasty (TKA) continues to increase, consideration of better fixation as a means of improving implant longevity is required. Cemented TKA remains the reference standard with the largest body of evidence and the longest follow-up to support its use. However, cementless TKA, may offer the opportunity of a more bone-sparing procedure with long lasting biological fixation to the bone. We undertook a review of the literature examining advances of cementless TKA and the reported results.

Cite this article: Bone Joint J 2016;98-B:867–73.

Purpose: The retrospective evaluation of the results of the application of the ring and hybrid systems of external fixation for the management of the high energy injuries of the talus. Material and Methods: Between 1990–2001, seventeen patients with complex injuries of the talus were treated with the application of ring or hybrid fixators. Eleven patients were males and six females. Isolated fracture of the talus was recorded in five patients, fracture- dislocation in four and pantalar dislocation in eight. The injury was open in twelve patients. Six patients had multiple injuries. To classify the talar injury we used the systems of Hawkins and Marti/Weber. Tension wire fixation with the use of either Ilizarov or hybrid frames was applied in all fractures. Additional internal fixation was performed in eleven fractures. The fixation was extended at the forefoot in all fractures. Results were assessed using Kiel’s evaluation system. Results: The mean follow up was 42 months (range, 25 to 96). We had no cases with deep infection, wound break down, osteomyelitis, or septic arthritis. We had five excellent, eight good, three fair and one poor result. The final radiographic appearance was not satisfactory in six fractures. Avascular necrosis of the talus was diagnosed in four fractures (23.5%). Conclusions: Using the ring and hybrid external fixation systems a satisfactory reduction of the high energy fractures and dislocations of the talus with the maximum respect of the anatomical architecture of the adjacent tissues can be achieved. The method offers an excellent stability of the fracture, diminishes the rate of the postoperative infection, and reduces significantly the risk of talus avascular necrosis

Fractures of the distal metaphysis of the tibia represent 7–10% of tibial fractures and less than 1% of the lower limb fractures.

Their treatment is difficult and presents a high percentage of bad results because of comminution of the metaphyseal bone fragments, articular involvement, poor circulation in the distal third of the leg. Until few years ago, in presence of a comminuted fracture, the only surgical possibility was the use of plate and screws. The external fixation represented a temporaneous treatment in case of open fracture or severe soft tissue damage. The recent technology applicated to external fixation has transformed the external fixator in synthesis device less uncomfortable, to increase the compliance of the patient, and more stable, to be used in the definitive treatment of this fractures. Recently we change the external fixator with double ring in a monolateral external fixator with single ring, in the “hybrid frame”.

Aims: In the present study we evaluated short-term outcome of complex proximal tibial fractures treated with hybrid external þxation. Methods: A retrospective evaluation of 33 tibiae in 31 patients treated with hybrid external þxation; 9 (27.2%) AO type A metaphyseal and 24 (72.8%) type C bicondylar intraarticular proximal tibial fractures. Majority of the fractures (58.1%) were due to high-energy trauma and open fractures constituted 18.2% of all fractures. Percutaneous pinning combined with indirect reduction techniques was used in 14 (42.4%) cases. Mini-open clamp reduction and screw þxation was applied in 12 (36.4%) operations. Open reduction, reconstruction of articular surface, bone-grafting and screw þxation combined with the hybrid frame was used in 7 (21.2%) patients. Results: Uneventful consolidation without complications occurred in 13 (39.4%) patients. The mean time to bony fusion was 18 ± 6.6 weeks. However, in 21.2% of the patients the fracture had not consolidated by 24 weeks. There were 5 (20.8%) primary re-operations due to malreduction of a type C fracture. In addition 3 (33.3%) type A metaphyseal fractures were re-operated upon due to non-union by 24 weeks. Two (6.1%) fractures united in axial malalignment and required an osteotomy. Conclusions: Our þndings suggest that due to high rate of unsatisfactory reductions, hybrid external þxation may not be the method-of-choice in þxation of displaced intra-articular proximal tibial fractures. It may be indicated in þxation of high energy metaphyseal fractures, but includes a signiþcant risk of delayed consolidation.

Aims: To evaluate the functional recovery of the complex tibial plateau fractures Schatzker type V and VI treated with hybrid ex. þx. Methods: Twenty-eight patients with intra-articular fractures of the proximal tibia were treated with hybrid external þxation in a three years period (1998–2001). The mean age was 35 years (17–76). According to Schatzker classiþcation, there were 11(39.3%) fractures type V and 17(60.7) type VI, whereas 5(17.8%) fractures were open. Complex injury was recorded in 15(53.5%) patients. Closed reduction and hybrid external þxation was achieved in 21 (75%) fractures. Additional limited internal þxation was performed in 9(32%) cases. Open reduction was necessary in 7(25%) patients. Mobilization of the injured articulation was started at the 3rd postoperative day. Results: Mean follow up period was 18 months. All fractures but one united at an average of 13.5 weeks (range from 11 to 18 weeks). The results were assessed according to the criteria of Honkonen and Jarvinen. An overall 22(78%) excellent and good results was recorded at the þnal follow up. Complications included one axial deformity, one septic pseudarthrosis, one peronial palsy and þve pin tract infections. Conclusions: The use of hybrid external þxation in the comminuted tibial plateau fractures (Schatzker V, VI), insure good restraining and early union, avoid major soft tissue complications and allow early mobilization and functional recovery of the knee joint.

Aims: The evaluation of indications and results of the treatment of C fractures (according to AO) of the distal tibia with hybrid external þxation. Method: Between 1998–2001 thirty-one patients (22 men and 9 women), all available to follow-up, with 31 tibial pilon fractures were managed with hybrid external þxation. Mean follow-up time was 18 months and mean age 35 years (17–76). Seven were open fractures. Closed reduction (ligamentotaxis) and application of hybrid external þxation was done in 22 cases, while in 9 patients minimal open reduction, use of autologous bone grafts and minimal additional internal þxation was necessary. Mobilization of the ankle started at the 3rd postoperative day. The average time of healing was 4.2 months. Final evaluation was done according to evaluation criteria proposed by P. Tornetta III. Results: Fourteen patients (87%) had good and excellent, 2 (6.4%) fair and 2 (6.4%) poor. Complications were 1 valgus deformity > 8û, 1 nonunion, and 4 pin tract infections treated with p.o. antibiotics. Conclusions: Use of hybrid external þxation in C fractures allows anatomic reduction of the fragments with minimal invasion and immediate mobilization of the ankle join and early weight bearing. Open reduction is minimal and seldom needed. Pin site infection could occur.