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.

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.

Aim. This study assessed quality of life (QoL) in patients having external fixation for treatment of osteomyelitis and fracture-related infection (OM/FRI). Method. Patients who had surgery for OM/FRI and who completed the EuroQoL EQ-5D-5L or EQ-5D- 3L questionnaires, were identified between 2010 and 2020. Patients were followed-up for 2 years after surgery. QoL was compared between patients who had either an Ilizarov frame or a monolateral external fixator with those who did not receive external fixation. Results. 165 patients were included. Of these, 37 (22.4%) underwent application of external fixation which included 23 circular frames and 14 monolateral external fixators. Patients in the frame group had more BACH ‘Complex’ infections (34/37; 91.9%), compared to non-frame patients (57/81; 70.3%). Pre-operatively, the mean EQ-index score for patients planned to receive a frame (0.278 SD 0.427) was worse compared to other treatments (0.453 SD 0.338, p=0.083). At 6 weeks after surgery, the EQ-index score remained significantly lower in frame patients compared to non-frame patients (frame: 0.379 SD 0.363; no frame: 0.608 SD 0.326, p=0.016). By 6 months, 26/37 patients had undergone frame removal. The patients who had frames in situ at 6 months had lower EQ-index scores when compared to patients who had their frames removed (frame in situ: 0.187 SD 0.213; frame removed 0.674 SD 0.206, p=0.076). At one year, 36/37 (97.3%) patients had their frame removed. QoL had greatly improved, to levels similar to non-frame patients (no frame: 0.652 SD 0.357; frame removed: 0.657 SD 0.247, p=0.949). Conclusions. Frame treatment leads to significant improvement in Quality of Life in patients suffering from osteomyelitis, with similar results in EQ5D scores after 1 year compared to patients who did not need an external fixator. These effects cannot be felt until after the frame has been removed with impaired QoL during frame treatment, especially in those patients with frames in situ for more than 6 months. This underlines the need for close and professional patient support during frame treatment for bone infection

We present the results of the surgical correction of lower-limb deformities caused by metabolic bone disease. Our series consisted of 17 patients with a diagnosis of hypophosphataemic rickets and two with renal osteodystrophy; their mean age was 25.6 years (14 to 57). In all, 43 lower-limb segments (27 femora and 16 tibiae) were osteotomised and the deformity corrected using a monolateral external fixator. The segment was then stabilised with locked intramedullary nailing. In addition, six femora in three patients were subsequently lengthened by distraction osteogenesis. The mean follow-up was 60 months (18 to 120). The frontal alignment parameters (the mechanical axis deviation, the lateral distal femoral angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior distal femoral angle and the posterior proximal tibial angle) improved post-operatively. The external fixator was removed either at the end of surgery or at the end of the lengthening period, allowing for early mobilisation and weight-bearing. We encountered five problems and four obstacles in the programme of treatment. The use of intramedullary nails prevented recurrence of deformity and refracture

We describe a technique of ‘cross-hip distraction’ to reduce a dislocated hip with subsequent reconstruction of the joint for septic arthritis with extensive femoral osteomyelitis. A 27-year-old woman presented with a dislocated, collapsed femoral head and chronic osteomyelitis of the femur. Examination revealed a leg-length discrepancy of 7 cm and an irritable hip. A staged technique was used with primary clearance of osteomyelitis and secondary reconstruction of the hip. A cross-hip monolateral external fixator was used to establish normal anatomy followed by an arthroplasty. A good functional outcome was achieved. The use of cross-hip distraction avoids soft-tissue and nerve damage and achieved improved abductor function before arthroplasty

Nonunion of the humerus with bone loss and shortening due to osteomyelitis is rare but difficult to treat. We describe our experience with a callus distraction technique using a monolateral external fixator for the treatment of this condition. Between October 1994 and January 2004, 11 patients were treated. There were seven males and four females, with a mean age of 14 years (10 to 17). The mean bone loss was 1.9 cm (1 to 2.7) and the mean length discrepancy in the upper limb was 5.6 cm (3.5 to 8.0). The mean follow-up was for 106 months (54 to 166). The mean external fixation index was 34.8 days/cm (29.8 to 40.5). The mean lengthening was 9.5 cm (5.5 to 13.4). There were seven excellent results, three good and one poor. There were nine excellent functional results and two good. The treatment of humeral nonunion with bone loss and shortening due to osteomyelitis by callus distraction is a safe and effective means of improving function and cosmesis

We present our experience of forearm lengthening in children with various conditions performed by a single surgeon between 1995 and 2009. A total of 19 children with a mean age of 9.8 years (2.1 to 15.9) at the time of surgery had 22 forearm lengthenings using either an Ilizarov/spatial and Ilizarov circular frame or a monolateral external fixator. The patients were divided into two groups: group A, in whom the purpose of treatment was to restore the relationship between the radius and the ulna, and group B, in whom the objective was to gain forearm length. The mean follow-up after removal of the frame was 26 months (13 to 53). There were ten patients (11 forearms) in group A with a mean radioulnar discrepancy of 2.4 cm (1.5 to 3.3) and nine patients (11 forearms) in group B. In group A, the mean lengthening achieved was 2.7 cm (1.0 to 5.5), with a lengthening index of 11.1 weeks/cm. Equalisation or overcorrection of the discrepancy was achieved in seven of 11 forearms, but lengthening was only partially successful at preventing subluxation or dislocation of the radial head. In group B, the mean lengthening achieved was 3.8 cm (1.9 to 6.8), with a lengthening index of 7.25 weeks/cm. Common complications in both groups were pin-site infection and poor regenerate formation. Forearm lengthening by distraction osteogenesis is a worthwhile procedure in children that can improve cosmesis and function, particularly in patients with shortening of both radius and ulna

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

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”

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

The aim of this paper is to describe the technique and evaluate the effectiveness of the RIA system in the first cases of bone loss treated by the authors with this technique. Between January 2010 and January 2011, ten patients were treated with an average age of fourty six years, with infected bone loss as a result of open fractures in various bone segments, with multiple failed treatment attempts, including three humeri, four femurs and three tibiae. The average size of the initial bone loss was 4 cm, varying from 1 to 8 cm. In 4 patients it was used simultaneously a Ilizarov apparatus with acute compression of the focus, in two patients a Ender pin and monolateral external fixator, three other cases with a SAFE nail with core with antibiotics and in one case an osteosynthesis with a plate and screws. The RIA was introduced with a percutaneous technique with a one pass drilling. The graft thus collected was mixed with appropriate antibiotics and aplied at the defect. The volume of the harvested graft, complications of the donor and recipient and the final results was recorded. The review showed that the average volume of graft was 60 cc, from 20 to 90 cc. In two female patients older than 70 years with osteoporosis, insufficient bone of poor quality was obtained. Problems included a case of iatrogenic fracture of the donor site, due to poor surgical technique and a case of relapse of the nonunion. Regarding the effectiveness of grafts extracted with the RIA system, 90% of the cases achieved consolidation in average of 5 months after grafting, range 3–9 months. This short experience with the RIA system showed that it is an attractive method allowing a rapid removal of a large volume of bone graft with a minimally invasive approach and a short learning curve. It is not indicated in elderly patients with osteoporosis and those with a narrow medullar canal less than 11 mm. Special attention must be done to the need to choose a drill no larger than 1 mm of the diameter of the isthmus, to do a single entry point and with only one drill passage to prevent the weakening of the donor site

Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with mean age 15 years (9 to 23) and mean follow-up 21 months (8 to 51). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with torticollis, congenital myopathy and Noonans syndrome and obstetric brachial plexus injury. Mean length gained was 31 mm (15 to 41) which represens an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263) and mean external fixation index was 56 days/cm. Two patients required internal fixation following fixator removal to consolidate union and one required additional internal fixation for atrophic regenerate. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin site infections. Clavicular lengthening by distraction osteogenesis for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury following acute correction. It has the potential to improve shoulder pain, function, range of movement and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union

We performed limb lengthening and correction of deformity of nine long bones of the lower limb in six children (mean age, 14.7 years) with osteogenesis imperfecta (OI). All had femoral lengthening and three also had ipsilateral tibial lengthening. Angular deformities were corrected simultaneously. Five limb segments were treated using a monolateral external fixator and four with the Ilizarov frame. In three children, lengthening was done over previously inserted femoral intramedullary rods. The mean lengthening achieved was 6.26 cm (mean healing index, 33.25 days/cm). Significant complications included one deep infection, one fracture of the femur and one anterior angulation deformity of the tibia. The abnormal bone of OI tolerated the external fixators throughout the period of lengthening without any episodes of migration of wires or pins through the soft bone. The regenerate bone formed within the time which is normally expected in limb-lengthening procedures performed for other conditions. We conclude that despite the abnormal bone characteristics, distraction osteogenesis to correct limb-length discrepancy and angular deformity can be performed safely in children with OI

Objective: To compare the mechanical stability of fixation of bicondylar tibial plateau fractures using available internal and external fixation techniques. Method: A bicondylar tibial plateau fracture was simulated on a uniform synthetic bone and tested with loading to failure. Following power calculations, seven tibias were used for each fixation method; five types of fixation were tested: 1) Dual plating. 2) Ring Fixator with inter-fragmentary screws. 3) Hybrid fixator (Ring-Bar) with interfragmentary screws. 4) Lateral plate and medial monolateral external fixator. 5) Lateral plate and medial interfragmentary screws. The specimens were tested in compression to failure. The vertical subsidence in either medial or lateral plateau was measured using an electrical transducer. Results: In all cases the mode of failure was consistent with collapse occurring in the medial plateau. There was no significant difference in the ultimate strength between dual plating and the ring fixator [4218N, 4184N respectively; P=0.28, t test]. Failure was seen at lower loads with the other fixation systems (Table). Conclusion: The Ring Fixator and dual plating demonstrated a greater strength and the most stable fixation, choice may depend on tissue viability and surgeon preference. Furthermore mobilisation of the patient may be undertaken earlier with more confidence using these two methods rather than less stable techniques

The correction of axial deviation of the lower limbs in paediatric patients requires complete patient history and clinical examination. The correct approach to the deformity must consider:radiology,evolution,associated joint damage, neurologic diseases and surgical planning. Timing and choice of operation (osteotomy, assimetric epiphyseal distraction, hemiepiphysodesis, epiphysiodesis) are critical. Thirty-four paediatric patients with an average age of 10 years (range 2–18) were treated with a monolateral external fixator: 16 femoral osteotomies (nine post-traumatic, four congenital, one after radiotherapy for neoplastic diesease, one Ollier’s disease, one multiple exostosis) and 18 tibial osteotomies (eight congential, four post-traumatic, two multiple exostosis, two osteogenesis imperfecta, one neoplasm, one Ollier’s disease) were performed. The knowledge of normal physiologic values, angles and anatomical and mechanical axes are fundamentally important. In choosing which operation to perfom in patients with post-traumatic deviation, the controlateral limb, functional necessity, symptoms and possible compensation must be considered. External fixation appears to be necessary in the correction of lower limb deformities because of patient comfort in the femur, because it allows osteotomy in the apex of the deformity and because it is possible to perform lengthening and correction when necessary. We suggest performing lengthening and correction osteotomy at the same level when it is possible, whereas it is dangerous to perform it at the distal metaphyseal femur and distal third of the tibia

Introduction and Aims: The hypothesis that ‘utilisation of gradual distraction and soft tissue correction by external fixation improves outcomes in hand and wrist deformity’ was analysed in 29 extremities in 24 patients, to define the indications for gradual soft tissue correction of congenital and acquired deformity and distraction osteogenesis in hypoplastic digits. Method: This retrospective review of 29 extremities in 24 patients evaluated the role of monolateral external fixators with uniplanar (n=20) and multiplanar (n=9) correction capability (Orthofix, International). Evaluation included an assessment of complications, patient satisfaction, functional outcome, and impact on health-related quality of life. Results: The devices were successfully used to correct radial longitudinal deficiency of the radius (radial club hand) (n=9); digital hypoplasia (n=15) and wrist flexion contracture secondary to spasticity (n=5). There were no significant complications related to the devices. Pin track irritation and drainage occurred in two of 108 pins. One pin became loose and needed to be replaced, and one fixator required two intraoperative adjustments. Multiplanar fixators used for correction of radial club hands and wrist flexion contracture improved soft tissue position in allowing secondary bony procedures and/or tendon transfers. Distraction osteogenesis of metacarpals and phalanges (included seven previously transferred extraperiostial toe phalanges) was successful with an average lengthening of 2.1 centimetres. Conclusion: Gradual distraction and soft tissue correction improves outcomes in congential and acquired hand and wrist deformity in children and adolescents. Mono-lateral fixation devices allow correction with hinges or gears, enhance correction of complex deformity, and is well tolerated by patients and caregivers

Aim: Adequate length is an important prerequisite for a functional digit. Over the last 20 years small external fixators have been developed allowing the principles of distraction osteogenesis to be applied to the small bones of the hand. We present our experience in digital lengthening with the contemporary designs of external fixators. Methods: From 1998 to 2001, 14 patients (15 rays) were treated with metacarpal or phalangeal lengthening through distraction osteogenesis using a monolateral frame with two half-pins on each site of the osteotomy. The mean age of the patients was 21 years (7–48) and the indications were traumatic amputation in 8 and congenital amputation (transverse deficiency, brachydactyly, constriction band syndrome) in 6. The mean distraction period was 3 weeks and the mean consolidation period 7 weeks. No protective splinting or additional bone grafting was necessary. Results: The distraction callus consolidated in all patients. The mean total length gained was 17, 5 mm (68% of the original length). The mean treatment time was 2, 8 days for every mm of length gained. One patient suffered angulation at the distraction site due to hardware failure and the fixator had to be revised and in another bony prominence was noted necessitating trimming. No infection, fracture or half pin loosening were observed. Conclusions: Callotasis using contemporary monolateral external fixators is a reliable technique for digital ray lengthening. Meticulous preoperative planning and surgical technique and close observation of the patient during the distraction phase are necessary in order to avoid complications. Over 2 cm of lengthening can be achieved without bone grafting

Introduction: We present preliminary short term results of medial opening wedge high tibial osteotomy with hemicallotasis using a monolateral external fixator, combined with microfracturing, in younger active patients with established Grade IV medial compartment osteoarthritis. Methods: Prospectively collected data was analysed for 28 consecutive knees in 27 patients undergoing this procedure. Mean age was 47 years (range 28 to 64), follow up was 23 months (range 7 to 61). Results: Mean Lysholm scores improved from 63.6 before surgery (range 42 to 85) to 81.6 at latest follow-up (range 46.5–100) (p< 0.001). Similarly, the mean Tegner activity scale improved from 1.7 (range 1 – 4) to 3.3 (range 1 – 6) (p< 0.001). Average IKDC score at last follow-up was 68 (range 35.6 – 100). Mean pain score (visual analogue scale 0 to 10) improved from 5.5 pre-operatively (range 1 – 9), to 3.5 at latest follow-up (range 0 – 8) (p< 0.001). All but 4 patients reported improved pain scores. Superficial pin site infection occurred in 6 patients (21.4%) and settled with oral antiobiotics in all cases. One patient had persistent patellofemoral (PF) pain. Discussion: The use of hemicallotasis for high tibial osteotomy (HTO) in association with extensive microfracturing of the medial compartment provides a viable, minimally invasive method for management of the young active patient with medial compartment osteoarthritis, without the risk of serious complications. In the short term even with advanced full thickness cartilage damage, this provides effective pain relief, helps put off more major arthroplasty alternatives and improves activity levels

Introduction: We present preliminary short term results of medial opening wedge high tibial osteotomy with hemicallotasis using a monolateral external fixator, combined with microfracturing, in younger active patients with established Grade IV medial compartment osteoarthritis. Methods: Prospectively collected data was analysed for 28 consecutive knees in 27 patients undergoing this procedure. Mean age was 47 years (range 28 to 64); follow up was 23 months (range 7 to 61). Results: Mean Lysholm scores improved from 63.6 before surgery (range 42 to 85) to 81.6 at latest follow-up (range 46.5–100) (p< 0.001). Similarly, the mean Tegner activity scale improved from 1.7 (range 1–4) to 3.3 (range 1–6) (p< 0.001). Average IKDC score at last follow-up was 68 (range 35.6–100). Mean pain score (visual analogue scale 0 to 10) improved from 5.5 pre-operatively (range 1–9), to 3.5 at latest follow-up (range 0–8) (p< 0.001). All but 4 patients reported improved pain scores, one of whom had patellofemoral pain. Superficial pin site infection occurred in 6 patients (21.4%) and settled with oral antibiotics in all cases. Discussion: The use of hemicallotasis for high tibial osteotomy in association with extensive microfracturing of medial compartment provides a viable, minimally invasive method for management of the young active patient with medial compartment osteoarthritis, without the risk of serious complications. In the short term even with advanced full thickness damage, this provides effective pain relief, helps put off more major arthroplasty alternatives and allows patients an improved activity level. The external fixator provides a very stable functional stabilization, superior to other available methods of internal fixation