Taylor spatial frame-software-controlled fixator for deformity correction-the early Indian experience

Background:

Complex deformity correction and fracture treatment with the Ilizarov method needs extensive preoperative analysis and laborious postoperative fixator alterations, which are error-prone. We report our initial experience in treating the first 22 patients having fractures and complex deformities and shortening with software-controlled Taylor spatial frame (TSF) external fixator, for its ease of use and accuracy in achieving fracture reduction and complex deformity correction.

Settings and Design:

The struts of the TSF fixator have multiplane hinges at both ends and the six struts allow correction in all six axes. Hence the same struts act to correct either angulation or translation or rotation. With a single construct assembled during surgery all the desired axis corrections can be performed without a change of the montage as is needed with the Ilizarov fixator.

Materials and Methods:

Twenty-seven limb segments were operated with the TSF fixator. There were 23 tibiae, two femora, one knee joint and one ankle joint. Seven patients had comminuted fractures. Ten patients who had 13 deformed segments achieved full correction. Eight patients had lengthening in 10 tibiae. (Five of these also had simultaneous correction of deformities). One patient each had correction of knee and ankle deformities. Accurate reduction of fractures and correction of deformities and length could be achieved in all of our patients with minimum postoperative fixator alterations as compared to the Ilizarov system. The X-ray visualization of the osteotomy or lengthening site due to the six crossing struts and added bulk of the fixator rings which made positioning in bed and walking slightly more difficult as compared to the Ilizarov fixator.

Conclusions:

The TSF external fixator allows accurate fracture reduction and deformity correction without tedious analysis and postoperative frame alterations. The high cost of the fixator is a deterrent. The need for an internet connection and special X-rays to operate the fixator add to its complexity.     

Nonunited humerus shaft fractures treated by external fixator augmented by intramedullary rod

Background:

Nonunion of humeral shaft fractures after previously failed surgical treatment presents a challenging therapeutic problem especially in the presence of osteoporosis, bone defect, and joint stiffness. It would be beneficial to combine the use of external fixation technique and intramedullary rod in the treatment of such cases. The present study evaluates the results of using external fixator augmented by intramedullary rod and autogenous iliac crest bone grafting (ICBG) for the treatment of humerus shaft nonunion following previously failed surgical treatment.

Materials and Methods:

Eighteen patients with atrophic nonunion of the humeral shaft following previous implant surgery with no active infection were included in the present study. The procedure included exploration of the nonunion, insertion of intramedullary rod (IM rod), autogenous ICBG and application of external fixator for compression. Ilizarov fixator was used in eight cases and monolateral fixator in ten cases. The monolateral fixator was preferred for females and obese patients to avoid abutment against the breast or chest wall following the use of Ilizarov fixator. The fixator was removed after clinical and radiological healing of the nonunion, but the IM rod was left indefinitely. The evaluation of results included both bone results (union rate, angular deformity and limb shortening) and functional outcome using the University of California, Los Angeles (UCLA) rating scale.

Results:

The mean follow-up was 35 months (range 24 to 52 months). Bone union was obtained in all cases. The functional outcome was satisfactory in 15 cases (83%) and unsatisfactory in 3 cases (17%) due to joint stiffness. The time to bone healing averaged 4.2 months (range 3 to 7 months). The external fixator time averaged 4.5 months (range 3.2 to 8 months). Superficial pin tract infection occurred in 39% (28/72) of the pins. No cases of nerve palsy, refracture, or deep infection were encountered.

Conclusion:

The proposed technique is effective in treating humeral nonunion especially in the presence of osteoporosis and short bone segments. The inclusion of intramedullary rod as internal splint improves stability of fixation and prevents refracture after fixator removal.     

Outcome of rail fixator system in reconstructing bone gap

Background:

Bone loss following open fracture or infected gap nonunion is a difficult situation to manage. There are many modes of treatment such as bone grafting, vascularized bone grafting and bone transport by illizarov and monolateral fixator. We evaluated the outcome of rail fixator treatment in reconstructing bone and limb function. We felt that due to problems such as heavy apparatus, persistent pain, deformity of joints and discomfort caused by an Ilizarov ring fixator, rail fixator is a good alternative to treat bone gaps.

Materials and Methods:

20 patients (17 males and 3 females with mean age 30.5 years) who suffered bone loss due to open fracture and chronic osteomyelitis leading to infected gap nonunion. Ten patients suffered an open fracture (Gustilo type II and type III) and 10 patients suffered bone gap following excision of necrotic bone after infected nonunion. There were 19 cases of tibia and one case of humerus. All patients were treated with debridement and stabilization of fracture with a rail fixator. Further treatment involved reconstructing bone defect by corticotomy at an appropriate level and distraction by rail fixator.

Result:

We achieved union in all cases. The average bone gap reconstructed was 7.72 cm (range 3.5-15.5 cm) in 9 months (range 6-14 months). Normal range of motion in nearby joint was achieved in 80% cases. We had excellent to good limb function in 85% of cases as per the association for the study and application of the method of ilizarov scoring system[ASAMI] score.

Conclusion:

All patients well tolerated rail fixator with good functional results and gap reconstruction. Easy application of rail fixator and comfortable distraction procedure suggest rail fixator a good alternative for gap reconstruction of limbs.     

Incidence of infection after early intramedullary nailing of open tibial shaft fractures stabilized with pinless external fixators

Background:

A major drawback of conventional fixator system is the penetration of fixator pins into the medullary canal. The pins create a direct link between the medullary cavity and outer environment, leading to higher infection rates on conversion to intramedullary nailing. This disadvantage is overcome by the AO pinless fixator, in which the trocar points are clamped onto the outer cortex without penetrating it. This study was designed to evaluate the role of AO pinless fixators in primary stabilization of open diaphyseal tibial fractures that received staged treatment because of delayed presentation or poor general condition. We also analyzed the rate of infection on early conversion to intramedullary nail.

Materials and Methods:

This study is a retrospective review of 30 open diaphyseal fractures of tibia, which were managed with primary stabilization with pinless fixator and early exchange nailing. Outcome was evaluated in terms of fracture union and rate of residual infection. The data were compared with that available in the literature.

Results:

All the cases were followed up for a period of 2 years. The study includes Gustilo type 1 (n=10), 14 Gustilo type 2 (n=14), and type3 (n=6) cases. 6 cases (20%) had clamp site infection, 2 cases (6.7%) had deep infection, and in 28 cases (93%) the fracture healed and consolidated well.

Conclusion:

This study has highlighted the valuable role of pinless external fixator in the management of open tibial fractures in terms of safety and ease of application as well as the advantage of early conversion to intramedullary implant without the risk of deep infection.     

Ensuring precision in lower limb deformity correction through a combination of temporary external fixation followed by internal fixation: Results of a retrospective study

Background:

It is important to plan preoperatively when contemplating internal fixation following deformity correction. Surgeons often find it difficult to retain the achieved correction till the end of internal fixation. To maintain precise correction we used hybrid technique which uses both external and internal fixation. The objective of the study was to evaluate the effectiveness of this hybrid technique in achieving and retaining desired correction.

Materials and Methods:

In this retrospective study, we evaluated the magnitude of deformity with radiological parameters. We compared correction which was planned and correction which was achieved. The technique was used during surgery for corrective osteotomies. Before carrying out the osteotomy, rail fixator with two swivel clamps was applied. After osteotomy swivel clamps were loosened. Desired correction was achieved. While fixator held the fragments in corrected position, definitive internal fixation was carried out. External fixator was removed after completion of internal fixation. Position of mechanical axis ratio, mechanical lateral distal femoral angle and mechanical medial proximal tibial angle were measured before and 12 weeks after surgery. Student t-test was used to analyze the difference between correction which was planned and correction which was achieved.

Results:

There was no statistical difference between the desired correction and the correction achieved.

Conclusions:

Temporary use of external fixator while correcting angular deformities of lower limb allows to achieve accurate correction.     

Ilizarov��s method for treatment of nonunion of diaphyseal fractures of the humerus

Background:

Nonunion in diaphyseal fractures of the humerus can be treated by various modalities like plating and bone grafting, exchange nailing, fibular strut grafting and Ilizarov’s method of ring fixation. To achieve union in infected nonunion in which multiple surgeries have already been done is further challenging. We conducted a prospective study wherein the outcome of the treatment of nonunion of diaphyseal fractures of the humerus by Ilizarov’s method was analyzed.

Materials and Methods:

Nineteen patients with diaphyseal nonunion of the humerus were treated by Ilizarov’s external fixator. These included nonunion after plating (n=11), intramedullary nailing (n=1) or conservative methods (n=7). In post-surgical infected nonunion (n=6), the implants were removed, debridement done, bone fragments were docked followed by application of ring fixator and compression. In aseptic nonunion (n=13), distraction for three weeks followed by compression was the protocol. Early shoulder and elbow physiotherapy was instituted. The apparatus was removed after clinical and radiological union and the results were assessed for bone healing and functional status.

Results:

Fracture union was achieved in all the 19 cases. Pin site infection was seen in 2 cases (10.52%). The bone healing results were excellent in eighteen cases (94.73%) and good in one case (5.26%).The functional results were found to be excellent in fourteen cases (73.68%), good in four (21.05%) and fair in one case (5.26%).

Conclusion:

Ilizarov’s method is an excellent option for treatment of septic and aseptic non union of diaphyseal fractures of the humerus as it addresses all the problems associated with non union of the humerus like infection, deformity and joint stiffness.     

Modified Girdlestone arthroplasty and hip arthrodesis using the Ilizarov external fixator as a salvage method in the management of severely infected total hip replacement

Background:

Resection arthroplasty or hip arthrodesis after total hip replacement (THR) can be used to salvage the limb in case with deep infection and severe bone loss. The Ilizarov fixator provides stability, axial correction, weight-bearing and good fusion rates.

Materials and Methods:

We retrospectively assessed the outcomes of 37 patients with severe periprosthetic infection after THR treated between 1999 and 2011. The treatment included implant removal, debridement and a modified Girdestone arthroplasty (29 cases) or hip arthrodesis (seven cases) using the Ilizarov fixator. The Ilizarov fixation continued from 45 to 50 days in the modified arthroplasty group and 90 days in the arthrodesis group. One case was treated using the conventional resection arthroplasty bilaterally.

Results:

Eighteen months after treatment, infection control was seen in 97.3% cases. Six hips were fused as one patient died in this group. Limb length discrepancy (LLD) averaged 5.5 cm. The Harris hip score ranged from 35 to 92 points. Hip joint motion ranged from 10° to 30° in the modified arthroplasty group. All subjects could walk independently or using support aids. No subluxation or LLD progression was observed.

Conclusion:

The modified Girdlestone arthroplasty and hip arthrodesis using the Ilizarov apparatus results in sufficient ability for ambulation and good infection control in cases of failed THR associated with severe infection.     

Management of open fractures of the tibial shaft in multiple trauma

Background:

The work presents the assessment of the results of treatment of open tibial shaft fractures in polytrauma patients.

Materials and Methods:

The study group comprised 28 patients who underwent surgical treatment of open fractures of the tibial shaft with locked intramedullary nailing. The mean age of the patients was 43 years (range from 19 to 64 years). The criterion for including the patients in the study was concomitant multiple trauma. For the assessment of open tibial fractures, Gustilo classification was used. The most common concomitant multiple trauma included craniocerebral injuries, which were diagnosed in 12 patients. In 14 patients, the surgery was performed within 24 h after the injury. In 14 patients, the surgery was delayed and was performed 8–10 days after the trauma.

Results:

The assessment of the results at 12 months after the surgery included the following features: time span between the trauma and the surgery and complications in the form of osteomyelitis and delayed union. The efficacy of gait, muscular atrophy, edema of the operated limb and possible disturbances of its axis were also taken under consideration. In patients operated emergently within 24 h after the injury, infected nonunion was observed in three (10.8%) males. These patients had grade III open fractures of the tibial shaft according to Gustilo classification. No infectious complications were observed in patients who underwent a delayed operation.

Conclusion:

Evaluation of patients with open fractures of the tibial shaft in multiple trauma showed that delayed intramedullary nailing performed 8–10 days after the trauma, resulted in good outcome and avoided development of delayed union and infected nonunion. This approach gives time for stabilization of general condition of the patient and identification of pathogens from wound culture.     

Ilizarov methodology for infected non union of the Tibia: Classic circular transfixion wire assembly vs. hybrid assembly

Introduction:

Conventional wire fixation of Ilizarov rings often fails to provide 90-90 configuration because of vital structures, which is essential for optimum stability. Hybrid assembly with half pins is an alternative. The aim of this study is to compare the results of Hybrid assembly with that of conventional classic circular transfixion wire Ilizarov assembly in 50 cases of infected nonunion of tibia between 1994 and 2003.

Materials and Methods:

This study includes two groups with 25 patients in each group: Group (A) conventional Ilizarov assembly and Group (B) hybrid Ilizarov assembly. Thirty-five cases developed infected nonunion following road traffic accidents while others after fall (6) bullet injury (4), infected osteosynthesis (3) and assault (2). There were 45 males and five females with mean age (18 to 56 years). All active cases (n=28) were treated by debridement including removal of implants in infected osteosynthesis. Twenty out of 22 cases in the quiescent group (non draining for last three consecutive months) were treated without open debridement; only two cases required open debridement for various reasons. All the cases were finally treated as atrophic aseptic nonunion with bone defect and were classified according to ASAMI.Type B1: length of the limb maintained with bone gap (14 cases in both Group A and B) and Type B3: combined shortening with defect (five and seven cases in Group A and B respectively), were treated by bifocal osteosynthesis. Only one case in the B3 group was treated by trifocal osteosynthesis to shorten the time. Type B2: segments in contact with limb shortening (total nine cases; five and four cases in Group A and B respectively) with shortening up to 2 cm (total five cases) were treated with monofocal osteosynthesis while shortening up to 5 cm and beyond (total four cases) were treated with bifocal osteosynthesis.

Results:

The cases were followed up for two to six years and the results were evaluated by Paley criteria of bony results (union, infection, deformity and leg-length discrepancy) and Functional Results (significant limp, equinus rigidity of the ankle, soft-tissue dystrophy, pain and inactivity). In both the groups, 24 cases out of 25, had excellent to good bony result with Group B having twice more excellent result than Group A. Functional results were found to be similar in both the groups. Although persistence of infection and Grade III pin tract infection (PTI) were slightly higher in Group B, complications like delayed consolidation of regenerate, refracture, deformity and aneurysm of vessel were less in this group.

Discussion and Conclusion:

Ilizarov methodology produced a satisfactory result in infected nonunion of the tibia. Hybrid assembly was a fruitful advancement in the Ilizarov armamentarium. The results were comparable to Conventional assembly in terms of docking site problems, corticotomy site problems, PTIs and other problems.     

Resistant clubfoot deformities managed by Ilizarov distraction histogenesis

Background:

Resistant clubfoot deformities of the foot and ankle remain a difficult problem even for the most experienced surgeon. We report a series of neglected resistant clubfoot deformities treated by limited surgery and Ilizarov distraction histogenesis.

Materials and Methods:

Twenty one patients with 27 feet having resistant clubfoot deformities were managed by Ilizarov distraction histogenesis from April 2005 to May 2008. The mean age was 12 years (range 8–20 years). A limited soft tissue dissection like percutaneous Achilles sheath tenotomy and plantar fasciotomy were done. Progressive correction of the deformities was achieved through the standard and simple Ilizarov frame construct setting. After removal of Ilizarov frame, a short leg walking cast was used for an additional 6 weeks, followed by an ankle foot orthrosis for 3 months.

Results:

The mean followup period was 18.7 months (range 20-36 months). The mean duration of fixator application was 3.6 months (range 3–5 months). At the time of removal of the fixator, a plantigrade foot was achieved in 25 feet and gait was improved in all patients. There was residual varus hind foot deformity in two patients. Out of 27 feet, 3 (11.11%) were rated as excellent, 17 (62.96%) as good, 5 (18.51%) as fair, and 2 (7.40%) as poor according to Reinkerand Carpenter scale. Excellent and good results (74.07%) were considered satisfactory, while fair and poor results (25.92%) were considered unsatisfactory.

Conclusion:

The short term clinical and functional results of resistant clubfoot deformities with Ilizarov''s external fixator is promising and apparently a good option.     

Dynamic osteosynthesis by modified Kuntscher nail for the treatment of tibial diaphyseal fractures

Background:

We evaluated a series of diaphyseal fractures of the tibia using low-cost, Indian-made modified Kuntscher nail (Daga nail) with the provision of distal locking screw for the management of the tibial diaphyseal fractures.

Materials and Methods:

One hundred and fifty one consecutive patients with diaphyseal fractures of tibia with 151 fractures who were treated by Daga nail were enrolled. One of the patients who had died because of cancer, and the two patients who were lost to follow-up at 3 months were excluded from the study.Therefore data of 148 patients with one hundred and fortyeight fractures is described. One hundred twenty closed fractures, 20 open Grade I fractures, and eight open Grade II fractures as per Gustilo and Anderson classification were included in this study. One hundred fourteen men and 34 women, with a mean age of 38.4 years, were studied. The result were analysed for Surgical time, duration of hospitalisation, union time, union rate, complication rate, functional recovery and crutch walking time. The fractures were followed at least until the time of solid union.

Results:

The follow-up period averaged 15 months (range, 6–26 months). Union occurred in 140 cases (94.6%). The mean time to union was 13 weeks for closed fractures,17.8 weeks for Grade I open fractures, and 21.6 weeks for Grade II open fractures. Compartment syndrome occurred in two patients. Superficial infection occurred in five cases of Grade I and II compound fractures. Three closed fractures and one case of Grade I compound fracture required bone grafting for delayed union. Two cases of Grade II compound fracture with nonunion required revision surgery and bone grafting. Twelve cases resulted in acceptable malalignment due to operative technical error. In four cases, the distal screw breakage was seen, but none of these complications interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury.

Conclusion:

Unreamed distally locked dynamic tibial nailing (modified Kuntscher nail/Daga nail) can produce excellent clinical results for diaphyseal tibial fractures. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.     

Taylor spatial frame in the treatment of open tibial shaft fractures

Background:

The Taylor spatial frame (TSF) is a modern multiplanar external fixator that combines the ease of application and computer accuracy in the reduction of fractures. A retrospective review of our prospective TSF database for the use of this device for treating open tibial fractures in pediatric, adolescent, and adult patients was carried out to determine the effectiveness and complications of TSF in the treatment of these fractures.

Materials and Methods:

Nineteen male patients with open tibial fractures were included. Of these fractures, 10 were Gustilo Type II, five were Gustilo Type IIIA (two had delayed primary closure and three had split thickness skin grafting), and four were Gustilo Type IIIB (all had rotational flaps). Twelve of our patients presented immediately to the emergency room, and the remaining seven cases presented at a mean of 3 months (range, 2.2-4.5 months) after the initial injury. The fractures were located in proximal third (n=1), proximal/middle junction (n=2), middle third (n=3), middle/distal junction (n=8), distal third (n=3), and segmental fractures (n=2). Patients were of an average age of 26 years (range, 6-45years). Mean duration of follow-up was 3.5 years.

Results:

All fractures healed over a mean of 25 weeks (range, 9-46 weeks). All were able to participate in the activities of daily living without any difficulty and most were involved in sports during the last follow-up. Postoperative complications included pin tract infection in 12 patients.

Conclusion:

The TSF is an effective definitive method of open tibial fracture care with the advantage of early mobilization, ease of soft tissue management through gradual fracture reduction, and the ability to postoperatively manipulate the fracture into excellent alignment.     

Percutaneous autologus bone marrow injection in the treatment of delayed or nonunion

Background:

Bone marrow is a source of osteoprogenitor cells that are key elements in the process of bone formation and fracture healing. The purpose of the study was to ascertain the osteogenic potential of autologous bone marrow grafting and its effectiveness in the management of delayed union and nonunion.

Materials and Methods:

Twenty-eight patients with delayed union and three with nonunion of fracture of the long bones were treated with this procedure. Of these 28 cases, two patients had fracture shaft femur, one had fracture shaft ulna and 25 patients had tibial shaft fractures. The average time duration between procedure and injury was 25 weeks (range 14-53 weeks). The bone marrow was aspirated from the anterior iliac crest and injected percutaneously at the fracture site. The procedure was carried out as an outpatient procedure. All but five cases required one injection of bone marrow.

Results:

Union was observed in 23 cases. The average time of healing after the procedure was 12 weeks (range 7-18 weeks).

Conclusion:

The technique of percutaneous autologous bone marrow injection provides a very safe, easy and reliable alternative to open bone grafting, especially for early intervention in fracture healing process.     

Acute treatment of segmental tibial fractures with the Ilizarov method

Objectives

We evaluated the results of acute application of the Ilizarov external fixator for segmental tibial fractures and also examined the experience with these special type fractures.

Methods

Twenty-four patients (19 males, 5 females) with a mean age of 37.8 years (range 22-66) with segmental tibial fractures were treated with the use of an Ilizarov type circular fixator. According to the categorisation of Melis et al., the fractures were types I, II, III and IV in seven, nine, five and three patients, respectively. Seven fractures were closed and 17 were open (9 grade IIIa, 5 grade IIIb, 2 grade II, 1 grade I according to the Gustilo classification). The mean time from the injury to surgery was 14 h (range 4-36). Eight patients with partial-thickness soft-tissue defects with no bone exposure were managed by split thickness skin grafting. Flap procedures were performed in four patients. All patients had good lower leg viability with a MESS score 6 and below. No patients had bone defects of 3 cm or more at the fracture level. Functional and bone results were made using the criteria proposed by ASAMI. The mean follow-up 28 months (range 12-70).

Results

We obtained excellent results in 20 and good results in 4 patients in terms of bone assessment. Functional results were excellent in 19 and good in 5 patients. All radiological evaluations showed normal alignment except in two patients. Both united with a residual procurvatum deformity. No rotational deformity was seen. Bone grafting was performed in one patient with a distal fracture. Complete union was achieved in all patients. None of the patients required amputation. There were no refractures after frame removal. Pin-tract infection occurred in 13 of the 24 patients. There were no incidents of chronic osteomyelitis secondary to pin-tract infection. The mean time for proximal fracture union was 36.4 weeks (range 10-78) and 39.8 weeks (range 12-80) for the distal fractures (p > 0.05). Callus and consolidation occurred earlier posterolaterally. There were no implant failures.

Conclusion

Ilizarov external fixator is a successful method in the acute management of segmental tibial fractures. This method is particularly effective in the treatment of distal segmental fractures of the tibia when the distal segment is short. This method allows for control of complications by decreasing the need for new operations even in the presence of infection.     

Outcome of complex tibial plateau fractures treated with external fixator

Background:

Tibial plateau fractures are usually associated with communition and soft tissue injury. Percutaneous treatment of these complex fractures is intended to reduce soft issue complications and postoperative stiffness of the knee joint. We assessed the complications, clinical outcome scores, and postoperative knee range of movements, after fluoroscopic assisted closed reduction and external fixator application.

Materials and Methods:

Seventy eight complex tibial plateau fractures in 78 patients were included in the study. All fractures were managed with closed reduction and external fixator application. In 28 cases with intraarticular split, we used percutaneous cancellous screw fixation for reduction and fixation of condylar parts. In nine open fractures, immediate debridement was done. In 16 cases, elevation of depressed segment and bone grafting was required, which was done from a very small incision. All patients were clinically and radiographically evaluated at a mean followup of 26.16 months (range 6–60 months).

Results:

Clinical results were evaluated according to the Rasmussen''s criteria. Average healing time was 13.69 weeks (range 12– 28 weeks). Mean knee range of motion was 122.60° (range 110°–130°). Forty seven results were scored as excellent, 25 good, 2 fair, and 1 as poor.

Conclusion:

We believe that minimally invasive treatment by percutaneous techniques and external fixation is a fairly reasonable treatment alternative, if near anatomical reduction of joint surface can be confirmed on fluoroscopy.     

Immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: A multivariate analysis of factors affecting deep infection and fracture healing

Background:

The purpose of this study was to evaluate contributing factors affecting deep infection and fracture healing of open tibia fractures treated with locked intramedullary nailing (IMN) by multivariate analysis.

Materials and Methods:

We examined 99 open tibial fractures (98 patients) treated with immediate or delayed locked IMN in static fashion from 1991 to 2002. Multivariate analyses following univariate analyses were derived to determine predictors of deep infection, nonunion, and healing time to union. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type, fracture grade by AO type, fracture location, timing or method of IMN, reamed or unreamed nailing, debridement time (≤6 h or >6 h), method of soft-tissue management, skin closure time (≤1 week or >1 week), existence of polytrauma (ISS< 18 or ISS≥18), existence of floating knee injury, and existence of superficial/pin site infection. The predictive variables of nonunion selected for analysis was the same as those for deep infection, with the addition of deep infection for exchange of pin site infection. The predictive variables of union time selected for analysis was the same as those for nonunion, excluding of location, debridement time, and existence of floating knee and superficial infection.

Results:

Six (6.1%; type II Gustilo n=1, type IIIB Gustilo n=5) of the 99 open tibial fractures developed deep infections. Multivariate analysis revealed that timing or method of IMN, debridement time, method of soft-tissue management, and existence of superficial or pin site infection significantly correlated with the occurrence of deep infection (P< 0.0001). In the immediate nailing group alone, the deep infection rate in type IIIB + IIIC was significantly higher than those in type I + II and IIIA (P = 0.016). Nonunion occurred in 17 fractures (20.3%, 17/84). Multivariate analysis revealed that Gustilo type, skin closure time, and existence of deep infection significantly correlated with occurrence of nonunion (P < 0.05). Gustilo type and existence of deep infection were significantly correlated with healing time to union on multivariate analysis (r² = 0.263, P = 0.0001).

Conclusion:

Multivariate analyses for open tibial fractures treated with IMN showed that IMN after EF (especially in existence of pin site infection) was at high risk of deep infection, and that debridement within 6 h and appropriate soft-tissue managements were also important factor in preventing deep infections. These analyses postulated that both the Gustilo type and the existence of deep infection is related with fracture healing in open fractures treated with IMN. In addition, immediate IMN for type IIIB and IIIC is potentially risky, and canal reaming did not increase the risk of complication for open tibial fractures treated with IMN.     

A new treatment for avulsion fracture of the calcaneus using an Ilizarov external fixator

Introduction

In the treatment of avulsion fractures of the posterior calcaneal tuberosity, open reduction and internal fixation are prone to several complications. We describe a new treatment using an Ilizarov external fixator, which can minimise the complications and achieve sufficient stability of the displaced fragment.

Case presentation

A 55-year-old woman sustained an avulsion fracture of the calcaneus. Examination revealed the development of bruising with extremely taut skin over the posterior prominence of the displaced bone. Radiographs demonstrated grossly proximal displacement of the tuberosity fragment. Surgery was exclusively percutaneous using an Ilizarov external fixator. The displaced fragment was adequately reduced and stabilised. Progressive weight bearing in the equinus position was initiated at the third week after surgery and the external fixator was removed at the seventh week. There was no skin necrosis or loss of reduction while the fixator was maintained. Postoperative follow-up for 2 years revealed full recovery.

Discussion

Major postoperative complications after conventional open reduction and internal fixation include skin necrosis, skin irritation by metal implants and re-displacement of the reduced fragment. Our method of using an external fixator may decrease the incidence of these three complications.Skin incision and the risk of skin necrosis are inevitable during internal fixation. On the other hand, the use of an external fixator reduces or eliminates skin necrosis, as it is applied percutaneously for reduction and stabilisation of the fragment. External fixation is mostly recommended in cases of poor vascularity or bruising. In addition, skin irritation can be avoided upon removal of the external fixator.Re-displacement occurs occasionally as a serious complication in lag screw fixation, particularly in cases with poor purchase of the osteoporotic bone. Tension band wiring and application of an Ilizarov external fixator in avulsion fractures of the calcaneus can neutralise tension on the Achilles tendon during the healing process. Thus, both these methods are believed to provide sufficient mechanical stability to fix the fragment.

Conclusion

This new method, involving application of an Ilizarov external fixator, is recommended when the avulsion fragment is large enough to accommodate Ilizarov wires, especially in cases of circulatory problems or bruising.     

Anterior tibial plateau fracture: An often missed injury

Background:

In most classifications of tibial plateau fractures, including one used most widely-Schatzker classification, fractures are described as a combination of medial and lateral condyle, primarily in the sagittal plane. Coronal component of these fractures, affecting the posterior tibial condyle is now well recognized. What is not described is anterior coronal component of the fracture, what we are calling “anterior tibial condyle fracture”. These fractures are often missed on routine antero-posterior and lateral knee X-rays due to an overlap between the fracture and the normal bone.

Materials and Methods:

Eight cases of anterior tibial condyle fractures with posterior subluxation of the tibia, six of which were missed by the initial surgeon and two referred to us early, are described. Two of the six late cases and both the early ones were operated. Reconstruction of the anterior condyle and posterior cruciate ligament reconstruction was done. Primary outcome measures such as union of the fracture, residual flexion deformity, range of motion and stability were studied at the end of 6 months.

Results:

All operated fractures united. There was no posterior sag in any. In those presenting late and were operated, the flexion deformity got corrected in all (average from 15° to 0°) and mean flexion achieved was 100° (range: 80-120°). In those presenting early and were operated, there was no flexion deformity at 6 months and a mean flexion achieved was 115° (range: 100-130°). None of the operated patients had instability.

Conclusion:

This article attempts to highlight that this injury is often missed. They should be suspected, diagnosed early and treated by reconstruction of anterior condyle, posterior cruciate ligament reconstruction.     

Fracture healing following high energy tibial trauma: Ilizarov versus Taylor Spatial Frame

Introduction

The optimal treatment of high energy tibial fractures remains controversial and a challenging orthopaedic problem. The role of external fixators for all these tibial fractures has been shown to be crucial.

Methods

A five-year consecutive series was reviewed retrospectively, identifying two treatment groups: Ilizarov and Taylor Spatial Frame (TSF; Smith & Nephew, Memphis, TN, US). Fracture healing time was the primary outcome measure.

Results

A total of 112 patients (85 Ilizarov, 37 TSF) were identified for the review with a mean age of 45 years. This was higher in women (57 years) than in men (41 years). There was no significant difference between frame types (p=0.83). The median healing time was 163 days in both groups. There was no significant difference in healing time between smokers and non-smokers (180 vs 165 days respectively, p=0.07), open or closed fractures (p=0.13) or age and healing time (Spearman''s r=0.12, p=0.18). There was no incidence of non-union or re-fracture following frame removal in either group.

Conclusions

Despite the assumption of the rigid construct of the TSF, the median time to union was similar to that of the Ilizarov frame and the TSF therefore can play a significant role in complex tibial fractures.     

Our experience in the management of segmental bone defects caused by gunshots

Purpose

Bone and soft-tissue defects in the leg can be caused by high-energy trauma. One of the causes of extensive bone defects are gunshot injuries. The incidence of these has been noticeably increasing in recent years in countries with political instabilities due to the random availability of weapons. The aim of this study is to focus on the essentials of treatment of post-gunshot tibial bone loss using the Ilizarov concept.

Methods

In the period between June 2011 and July 2013, 30 patients with open tibial fractures after gunshots comprised the present study with an average follow-up of 18 months. The bone defect was associated with soft-tissue loss in 18 cases. All cases were subjected to extensive debridement of all devitalized tissues back to the healthy bone with viable soft tissue coverage. All cases were treated by the Ilizarov external fixator using the bifocal bone transport technique.

Results

The overall bone results were satisfactory in 28 cases (93.3 %). The overall functional results were satisfactory in 22 cases (73.3 %). The bone end results were significantly affected by age and smoking, while the functional end results were significantly affected by smoking, the presence of infection at the time of presentation, and complications during the procedure.

Conclusions

Bone transport is a reliable method in the treatment of gunshot bone defects of the tibia after extensive debridement of all the devitalized tissues. The Ilizarov external fixator allows the functional use of the limb throughout the course of treatment, preventing disuse osteoporosis and increasing patient satisfaction.