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

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

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

External fixation of distal tibial fractures is often associated with delayed union. We have investigated whether union can be enhanced by using recombinant bone morphogenetic protein-7 (rhBMP-7). Osteoinduction with rhBMP-7 and bovine collagen was used in 20 patients with distal tibial fractures which had been treated by external fixation (BMP group). Healing of the fracture was compared with that of 20 matched patients in whom treatment was similar except that rhBMP-7 was not used. Significantly more fractures had healed by 16 (p = 0.039) and 20 weeks (p = 0.022) in the BMP group compared with the matched group. The mean time to union (p = 0.002), the duration of absence from work (p = 0.018) and the time for which external fixation was required (p = 0.037) were significantly shorter in the BMP group than in the matched group. Secondary intervention due to delayed healing was required in two patients in the BMP group and seven in the matched group. RhBMP-7 can enhance the union of distal tibial fractures treated by external fixation

We studied the safety of external fixation during post-operative chemotherapy in 28 patients who had undergone distraction osteogenesis (17, group A) or vascularised fibular grafting (11, group B) after resection of a tumour. Four cycles of multi-agent post-operative chemotherapy were administered over a mean period of 14 weeks (6 to 27). The mean duration of external fixation for all patients was 350 days (91 to 828). In total 204 wires and 240 half pins were used. During the period of post-operative chemotherapy, 14 patients (11 in group A, 3 in group B) developed wire- and pin-track infection. A total of ten wires (4.9%) and 11 half pins (4.6%) became infected. Seven of the ten infected wires were in periarticular locations. External fixation during post-operative chemotherapy was used safely and successfully for fixation of a vascularised fibular graft and distraction osteogenesis in 27 of 28 patients. Post-operative chemotherapy for malignant bone tumours did not adversely affect the ability to achieve union or cause hypertrophy of the vascularised fibular graft and had a minimal effect on distraction osteogenesis. Only one patient developed osteomyelitis which required further surgery

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

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

An account is given of 38 patients with complicated tibial fractures who were treated by the Portsmouth method of external fixation. Twenty-one patients had multiple injuries and 30 had compound fractures of the tibia. Eighteen fractures wounds were infected, 17 cases required bone grafts and 13 had skin grafts. Thirty-four fractures united in an average time of six months; three patients underwent below-knee amputations; one with neurofibromatosis remains ununited. Those treated primarily by external fixation did better than those in whom external fixation was used after failure of another method. Most fresh fractures united with external callus; and the significance of this in relation to the rigidity of fixation is discussed. The method is easy to use, effective and economical. Improvements to permit adjustment of position and testing for union are suggested. We advise the use of this method of external fixation as the primary treatment for complicated tibial fractures where there is a significant risk of infection or non-union

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

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

We have compared the outcomes of the use of external fixation devices for spanning or sparing the ankle joint in the treatment of fractures of the tibial plafond, focusing on the complications and the rates of healing. We have devised a scoring system for the quality of reporting of clinical outcomes, to determine the reliability of the results. We conducted a search of publications in English between 1990 and 2006 using the Pubmed search engine. The key words used were pilon, pylon, plafond fractures, external fixation. A total of 15 articles, which included 465 fractures, were eligible for final evaluation. There were no statistically significant differences between spanning and sparing fixation systems regarding the rates of infection, nonunion, and the time to union. Patients treated with spanning frames had significantly greater incidence of malunion compared with patients treated with sparing frames. In both groups, the outcome reporting score was very low; 60% of reports involving infection, nonunion or malunion scored 0 points

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

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

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

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

We present a retrospective study of patients suffering from a variety of benign tumours in whom external fixators were used to treat deformity and limb-length discrepancy, and for the reconstruction of bone defects. A total of 43 limbs in 31 patients (12 male and 19 female) with a mean age of 14 years (2 to 54) were treated. The diagnosis was Ollier’s disease in 12 limbs, fibrous dysplasia in 11, osteochondroma in eight, giant cell tumour in five, osteofibrous dysplasia in five and non-ossifying fibroma in two. The lesions were treated in the tibia in 19 limbs, in the femur in 16, and in the forearm in eight. The Ilizarov frame was used in 25 limbs, the Taylor Spatial Frame in seven, the Orthofix fixator in six, the Monotube in four and the Heidelberg fixator in one. The mean follow-up was 72 months (22 to 221). The mean external fixation period was 168 days (71 to 352). The mean external fixation index was 42 days/cm (22.2 to 102.0) in the 22 patients who required limb lengthening. The mean correction angle for those with angular deformity was 23° (7° to 45°). At final follow-up all patients had returned to normal activities. Four patients required a second operation for recurrent deformity of further limb lengthening. Local recurrence occurred in one patient, requiring further surgery

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

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

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

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