A single centre, prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation. Surgical management of all patients followed a protocol of the senior author (PBMT), with regard to technique and fracture reduction. Operations were performed by several different surgeons including the senior author. A definitive fixator was used as a reduction tool in 34 cases, and a separate fracture reduction device was used in 162 patients. Follow-up was in a dedicated external fixator clinic by the senior author until one year post-fracture healing. Fracture healing was determined by fracture stiffness measurements. 196 tibial fractures in 196 patients, average age 29 (range 12-80). 111 right sided and 85 left sided. 166 male and 30 female. 116 fractures due to low energy and 80 due to high energy.

In a novel external fixation system for tibial fractures accurate reduction is achieved with a complex temporary device (Staffordshire Orthopaedic Reduction Machine: STORM) following which the reduced fracture is fixed using a simple titanium bar fixator (IOS). With the fracture reduced, the external fixator screws may be placed in the optimum position. The fixator is designed to allow controlled bending to optimise movement at the fracture site for callus growth. With no need for adjustable elements, the fixator is small and short enough for epicentric placement in the commonest fracture of the middle and distal thirds. Optimum mechanical properties are approached: elastic return is to the reduced position; epicentric placement minimises shear and distraction on weightbearing. Integral healing assessment measures bending stiffness. The device is single-use.

In 40 tibial fractures (closed or grade I compound) the mean healing time was 15 weeks with a healing endpoint of bending stiffness of 15Nm/deg in two orthogonal axes and full weightbearing on fixator removal with no subsequent creep or refracture. Good reduction, defined as less than 5 deg of maximum angulation and less than 3mm of maximum translation, was achieved and maintained. The incidence of pin site complications was extremely low and there were no deep infections.

This new device thus far has had few of the drawbacks commonly associated with external fixation. The infection rate is low, healing time is comparable to other methods and there have been no malunions. We feel our strict adherence to fracture reduction and pin site hygiene are the most important factors in producing these excellent results.

Introduction: We present a prospective comparative study of 200 consecutive patients of closed tibial shaft fractures treated by external fixation using two different fracture reduction methods. Factors affecting fracture healing, including the effect of quality of reduction, was studied.

Methods: The healing time for all these fractures was determined by a combination of clinical, radiological and fracture stiffness measurements. The effect of smoking, AO classification type, associated fractures, initial and final angulation and translation on healing time was evaluated using nonparametric tests and regression analysis.

Results: Healing time was affected most by presence of Compartment syndrome followed by smoking status and final translation at fracture site. Having a compartment syndrome significantly increased fracture healing time (mean 286.7 days versus 139.2 days). There was no difference in healing times between the two different reduction machines. Angulation was found not to affect healing time, but translation did. Both initial and final translation were better using STORM (Staffordshire Orthopaedic Reduction Machine). The amount of axial shortening was also reduced by using STORM.

Conclusion: Healing time is affected by translation at fracture site, which is a factor under the control of the surgeon. The second reduction method using STORM, helps achieve better reduction.

Single centre prospective study of 196 closed tibial diaphyseal fractures treated by monolateral external fixation.

Methods: Surgical management of all patients followed protocol of senior author (PBMT), with regard to technique and fracture reduction.

Operations performed by several different surgeons including senior author.

Definitive fixator used as a reduction tool in 34 cases, fracture reduction device used in 162 patients – ST.O.R.M

Followed up in a dedicated external fixator clinic by the senior author until one year post fracture healing.

Fracture healing was determined by fracture stiffness measurements.

Results: 196 tibial fractures in 196 patients, average age 29 (range 12–80).

111 right sided and 85 left sided.

166 male and 30 female.

116 fractures due to low energy and 80 due to high energy.

Mechanism of injury: football 75, fall 52, RTA 49, direct blow 7, assault 4, rugby 3, crush 2, dancing 2, bowling 1, roller skating 1.

33 patients had an additional 74 injuries: 35 fractures (3 open), 7 compartment syndromes, 3 dislocations, 7 head injuries, 16 chest injuries, 9 soft tissue injuries.

According to AO classification system: 33 A1, 47 A2, 42 A3, 15 B1, 46 B2, 7 B3.

Time to # healing was 19 weeks on average (range 9–87)

X ray data: 15 patients had deformity > 5 degrees in the coronal plane and 1 of these also had deformity > 10 degrees in the saggital plane.

One patient underwent osteotomy for correction of malunion.

85 patients had a total of 279 pin site infections requiring Abx (6 with 14 pin infections requiring iv abx), and 33 pins were removed due to persistent infection. 15 patients had 32 ring sequestra which settled with debridement under GA.

7 fixators removed early due to pin site infection.

1 established osteomyelitis-lautenbach.

7 refractures, all healed(5 with pop, 2 with further fixator)

Non-union: 5 hypertrophic, 2 atrophic-all healed with further external fixation.

Malunion: 1

Conclusion: Our results show that external fixation of closed tibial fractures is a viable alternative to other treatment methods with regard to healing time and angular deformity.

Our study also uses a well validated end point to define fracture healing and does not rely on the difficulty of defining healing on clinical or radiological grounds which is known to be unreliable. This is the first time this highly repeatable methodology has been used for such fractures.

A prospective study of 196 closed tibial diaphyseal fractures treated by a monolateral external fixator is presented.

The patients were managed by a group of Surgeons including the senior author (PBMT), a definitive fixator being used in 34 patients, and a fracture reduction device in 162 patients. All the patients were followed up in an external fixator clinic by the senior author, and follow up continued for 1 year after the fractures had healed. Fracture healing was determined clinically.

There were 196 tibial fractures, with an average age of 29 years (range 12–80 years). 111 Fractures involved the right tibia, and 85 the left. There were 166 males and 30 females. 116 Fractures were deemed due to a low energy accident, and 80 due to a high energy injury. The most common mechanism of injury was football (75), a fall (52), a road vehicle accident (49), direct trauma (7), assault (4), and rugby (3). According to the AO classification system 33 were A1 fractures, 47 A2, 42 A3, 15 B1, 46 B2, and 7 B3. Time to fracture healing was 19 weeks on average (with a range from 9–87 weeks).

15 Fractures united with a deformity of more than 5⁰ in the coronal plane. One patient required a corrective osteotomy for a mal-united fracture. There were 279 pin track infections that required antibiotic treatment in 85 patients. 33 Pins had to be removed due to persistent infection. Of these patients 15 developed 32 ring sequestrae, but infection was settled by debridement under GA. 7 External fixators had to be removed early because of pin site infection. One patient developed a full blown osteomyelitis, which was treated with the Lautenbach irrigation and settled. There were 7 re-fractures, but all healed after further treatment. 5 Were treated in a POP cast and 2 were re-treated with another external fixator. There were 7 non-unions, but all eventually healed with further treatment with an external fixator.

The authors conclude that treating a closed tibial fracture with an external fixator is a viable alternative method of treatment.