In 13 patients (18 fingers) we used two types of external fixator as progressive static splints for the preoperative correction of the deformities of severe Dupuytren’s disease before conventional fasciectomy. The duration of treatment was from one to four weeks. At a mean follow-up of 18 months the mean total fixed flexion deficit had been reduced from 138° to 39° and the mean proximal interphalangeal joint contracture from 80° to 29°. The mean total active range of movement had increased from 123° to 175°. These preliminary results are promising, but continued follow-up is needed since recurrence is common

Congenital or acquired shortness of a metatarsal may cause pain in adjacent metatarsals. From 1983 to 1990, we performed nine metatarsal lengthenings in seven adolescent patients by metaphyseal osteotomy followed by gradual distraction of callus (callotasis). Two patients required bone grafts after the lengthening. We used a rigid, unilateral external fixator designed for use in the hand and foot. At follow-up, from three to ten years later, healing had been achieved in all with an average healing index of 50 days/cm, and metatarsalgia had been relieved by the restoration of correct metatarsal length

Deformity of the forearm is common in patients with hereditary multiple exostoses, producing cosmetic and functional impairment in which shortening of the ulna is a significant factor. The results of ulnar lengthening in 10 forearms of eight patients are reported. Lengthening was performed by osteotomy of the shaft followed immediately by a bone graft and internal fixation, or by gradual distraction with an external fixator. In all patients the appearance was improved and the range of radial deviation at the wrist was increased. In most patients forearm movement and radial head stability were improved. Partial recurrence of the deformity was seen during the follow-up of skeletally immature patients, but in general ulnar lengthening was found to be a useful operation

Pain, stiffness, instability and degenerative arthritis are common sequelae of complex fracture-dislocations of the proximal interphalangeal (PIP) joint. Operations were carried out to obtain stability, followed by application of a dynamic external fixator in 20 patients with a mean age of 29 years. This provided stability and distraction, and allowed controlled passive movement. Most (70%) of the patients had a chronic lesion and the mean time from injury to surgery was 215 days (3 to 1953). The final mean range of movement was 12 to 86°. Complications included redislocation and septic arthritis, which affected the outcome. Four pin-track infections and two breakages of the hinge did not influence the result. The PIP Compass hinge is a useful adjunct to surgical reconstruction of the injured PIP joint

We present a prospective study of the treatment of 32 unstable Colles’ fractures by external fixation and cancellous grafting with minimal exposure. We inserted an external fixator between the radius and the second metacarpal, and maintained ligamentotaxis for five weeks. In 27 patients the result was good or excellent, but five fractures healed with malunion. All patients made a satisfactory functional recovery. At a mean follow-up of three years (1 to 5) after injury none had pain in the wrist and all were satisfied with the result. The average grip strength was 95% of normal. Seven patients had algodystrophy with mild impairment of finger movements in four. We conclude that the combination of cancellous grafting and external fixation is effective for the treatment of unstable Colles’ fractures

Two consecutive cases of chronic dislocation of the head of the radius after missed Bado type-I Monteggia lesions are presented. Reduction was successfully achieved in both patients after ulnar corticotomy, gradual lengthening and angulation of the ulna using an external fixator. Open reduction or reconstruction of the radio-ulnar capitellar joint was not undertaken. The age at injury was seven years in the older and two years in the younger patient. The time from injury to treatment was five years in the older and three months in the younger child. At follow-up, nine years after completion of treatment in the older and eight months in the younger patient, both show satisfactory movement, function of the forearm and reduction of the head of the radius. This technique may be considered in missed Monteggia lesions before open procedures on the radio-ulnar capitellar joint are undertaken

We used the Ilizarov circular external fixator to treat 16 patients with persistent nonunion of the diaphysis of the humerus despite surgical treatment. All patients had pain and severe functional impairment of the affected arm. In ten, nonunion followed intramedullary nailing. We successfully treated these by a closed technique. The nail was left in place and the fracture compressed over it. The fractures of the other six patients had previously been fixed by various methods. We explored these nonunions, removed the fixation devices and excised fibrous tissue and dead bone before stabilising with the Ilizarov fixator. In five patients union was achieved. Bone grafting was not required. In the single patient in whom treatment failed, there had been a severely comminuted open fracture. All except one patient had reduction of pain, and all reported an improvement in function

We report the results of a prospective randomised controlled trial of the management of 101 Colles' fractures in patients over the age of 55 years. Within two weeks of initial reduction 43 fractures had displaced with either more than 10 degrees dorsal angulation or more than 5 mm radial shortening. These patients were randomly divided into two groups: 21 were remanipulated and held by an external fixator; in the control group of 22 patients, the redisplacement was accepted and conservative treatment was continued. Patients treated with external fixation had a good anatomical result, but their function was no better than that of the control group. We found no correlation between final anatomical and functional outcome, and concluded that the severity of the original soft-tissue injury and its complications are the major determinants of functional end result

The conventional treatment of comminuted fractures in the distal radius has been unsatisfactory. We therefore made a prospective study using the principle of ligamentotoxis and primary cancellous bone grafting as the uniform method of treatment. Ligamentotaxis was maintained by using an external fixator for three weeks only, after which a carefully monitored programme of rehabilitation was given. We have reviewed 72 consecutive distal radial fractures after a follow-up of 7 to 40 months (average 11 months). Reduction had been maintained during healing and over 80% of patients regained full range of movement in hands, wrists and forearms with strong and pain-free wrist function. Complications were infrequent and gave no real problems. We conclude that distraction, external fixation and bone grafting appears to be an excellent method of treating comminuted fractures of the distal radius

We have studied the progression of healing in 103 unstable fractures of the tibia. In 76 patients we removed the external fixator once the stiffness had reached 15 Nm/° in the sagittal plane. Deformity at the site of the fracture subsequently occurred in four patients. In a further 27, we measured stiffness in several planes and removed the fixator only when the stiffness reached 15 Nm/° in each. We found that stiffness in two orthogonal planes may differ widely (maximum difference 9.0 Nm/°, mean 4.1 Nm/°). There were no failures in the second group. We advocate that fracture stiffness be measured in two orthogonal planes when assessing tibial healing and suggest that values above 15 Nm/° in two planes give an indication that it is safe to remove the fixator

In a series of 150 consecutive patients with unstable fractures of the pelvis, angiography was performed in 23 (15%) who had uncontrolled hypotension. There were three anteroposterior compression (APC), eight lateral compression (LC) and 12 vertical shear (VS) injuries. Arterial sources of haemorrhage were identified in 18 (78%) patients and embolisation was performed. Angiography was required in 28% of VS injuries. The morphology of the fracture was not a reliable guide to the associated vascular injury. Ten (43%) patients died, of whom six had had angiography as the first therapeutic intervention. Five of these had a fracture which was associated with an increase in pelvic volume (APC or VS) which could have been stabilised by an external fixator. Based on our findings we recommend skeletal stabilisation and, if indicated, laparotomy to deal with sources of intraperitoneal blood loss before pelvic angiography. Embolisation of pelvic arterial bleeding is a worthwhile procedure in patients with hypotension which is unresponsive to these interventions

The Roger Anderson external fixator was used in the treatment of unstable fractures of the distal radius in 52 patients, and the results evaluated after a follow-up averaging 58 months. The indications for its use were failure to maintain adequate closed reduction using plaster, and instability of the fracture as determined by the initial radiographs. Our radiological criteria for instability included dorsal angulation of more than 20 degrees, fractures involving the joint, radial shortening of more than 10 mm, and severe dorsal comminution. Using the Lucas modification of the Sarmiento demerit point-rating system, we found that 46 patients (89%) had good or excellent results and six (11%) were classified as fair. There were no poor results. Seven patients (14%) developed complications. None of these affected the long-term results except in one elderly woman where the pins loosened and had to be removed

In the assessment of fracture healing by monitoring stiffness with vibrational analysis or instrumented external fixators, it has been assumed that there is a workable correlation between stiffness and strength. We used four-point bending tests to study time-related changes in stiffness and strength in healing tibial fractures in sheep. We aimed to test the validity of the measurement of stiffness to assess fracture strength. At each duration of healing examined, we found marked variations in stiffness and strength. Stiffness was shown to be load-dependent: measurements at higher loads reflected ultimate strength more accurately. There was a biphasic relationship between stiffness and strength: at first there was a strong correlation regardless of loading conditions, but in the second phase, which included the period of ‘clinical healing’, stiffness and strength were not significantly correlated. We conclude that the monitoring of stiffness is useful primarily in assessing progress towards union but is inherently limited as an assessment of strength at the time of clinical union. Any interpretation of stiffness must take into account the load conditions

Aims

In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method.

We review the results of a modified quadricepsplasty in five children who developed stiffness of the knee after femoral lengthening for congenital short femur using an Ilizarov external fixator which spanned the knee. All had a full range of movement of the knee before lengthening was undertaken. Unifocal lengthening was carried out in the distal metaphysiodiaphyseal region of the distal femur with a mean gain of 6.5 cm. The mean percentage lengthening was 24%. At the end of one year after removal of the Ilizarov frame and despite intensive physiotherapy all patients had stiffness. Physiotherapy was continued after the quadricepsplasty and, at the latest follow-up (mean 27 months), the mean active flexion was 102° (80 to 130). The gain in movement ranged from 50° to 100°. One patient had a superficial wound infection which settled after a course of oral antibiotics. None developed an increased extension lag after surgery and all were very satisfied with the results. Quadricepsplasty is a useful procedure for stiffness of the knee after femoral lengthening which has not responded to physiotherapy

Over 200 high-velocity missile injuries treated in a low-technology environment were audited under the aegis of the International Committee of the Red Cross Hospitals in Afghanistan and Northern Kenya. Femoral fractures were treated either by traction or external fixation using a uniaxial frame. The results showed that patients treated by external fixation remained in hospital longer than those treated on traction. The positional outcome was identical in both groups. In tibial fractures the external fixator was only of extra benefit in those of the lower third when compared with simple plaster slabs unless more complex procedures such as flaps or vascular repair were to be performed. In complex humeral fractures, external fixation resulted in long stays in hospital and a large number of interventions when compared with simple treatment in a sling. We conclude therefore that in an environment where facilities are limited and surgeons have only general experience very careful initial wound excision is the most important factor determining outcome. The application of complex holding techniques was generally inappropriate

We reviewed 36 cases of forearm deformity caused by multiple osteochondromas in 30 patients and classified them into three types: Type I showed a combination of ulnar shortening and bowing of the radius secondary to osteochondromas of the distal ulna (22 forearms). Type II showed dislocation of the radial head, either with osteochondromas of the proximal radius (Type IIa, two forearms) or secondary to more distal involvement (Type IIb, five forearms). Type III had relative radial shortening due to osteochrondromas at the distal radius (seven forearms). Operations were performed on 16 forearms in 13 patients, with 92% of satisfactory results. For Type I deformity, excision of osteochondromas, immediate ulnar lengthening and corrective osteotomy of the radius are recommended. For Type IIa, excision of the radial head is necessary, and for Type IIb, we advise gradual lengthening of the ulna using an external fixator. Excision of osteochondromas alone gave good results in Type III deformity. Our classification gives a reliable indication of the prognosis and is a guide to the choice of surgical treatment

Twenty consecutive patients treated by arthrodesis for failed knee arthroplasty are reviewed. Eight hinged, five stabilised and seven compartmental prostheses were removed, for infection (15 cases), loosening (4) and instability (1). One patient refused a second-stage operation but the remainder gained sound fusion. Infected knees had a two-stage procedure with temporary insertion of gentamicin-loaded beads after removal of the prosthesis; all infections healed. Six arthrodeses using a Hoffmann-Vidal external fixator resulted in two temporary failures. One Ace-Fischer external fixation was successful. Of 10 primary attempts at arthrodesis with an intramedullary Kuntscher nail, nine were successful; the tenth fused after two more attempts by the same method. The two failures of external fixation and two failures after Charnley single-frame compression done elsewhere were successfully fused with intramedullary nails. Delayed union in three cases fused after prolonged fixation and repeated bone grafts. The indications for and methods of arthrodesis after failed knee arthroplasty are discussed