New concept in external fixation

A new concept in external skeletal fixation is presented. A 3D unilateral system developed by Mitkovic has widely been investigated biomechanically in AO institute in Davos (Switzerland). Consists of three components only providing extremely simple application and dynamic fixation of bones and different joints. This simple external fixator functions as an accurate reduction device at the same time, minimizing need for fluoroscopy. Clinically this system has been applied to mere then 13 thousand patients in 43 clinics. This paper presents the results of its application for treatment of open fractures, war wounds with fractures and for comminuted and intraarticular closed fractures in the series of 597 patients. Overall average time for union time was 3.2 months. Overall success of fracture healing was 96.8% including open and closed fractures. Our study suggests that the use of this 3D unilateral system is suitable for routine use.     

External fixation of the foot and ankle. Elective indications and techniques for external fixation in the midfoot

Although external fixation is widely used for treatment of fractures, limb deformities, and bone lengthening; use of external devices is still evolving. Elective cases for treatment of the midfoot and published research on external fixation specifically for surgical treatment of midfoot pain and deformity are scarce. Indications for elective external fixation in the midfoot are limited because rigid internal fixation in this area is relatively easy and successful. This article discusses podiatric conditions that can be treated advantageously by external fixation when elective surgery is done. The article also describes methods of external fixation appropriate for podiatric surgical reconstruction in patients with these conditions.     

Electrically-induced osteogenesis in external fixation treatment

This animal model experiment is performed to evaluate how bipolar direct current of 20 microamp. affects osteogenesis once external fixation treatment is applied in different forms: stabilization, distraction, and compression. In all cases a secondary healing, typical of external fixation treatment, was found; but a more mineralized callus and an increase in osteoprogenitor cell proliferation and differentiation were obtained through the use of electrical stimulation especially in the compression group.     

Two-plate fixation in the treatment of

A series of 34 tibial shaft fractures treated by the application of 2 plates is presented. A high degree of rigidity was achieved and allowed early unsplinted weight bearing. The technique is suggested as a method for limited use in severe fractures, particularly in the elderly or multiply injured. The technique also has a useful place in the treatment of non-union, especially if previous surgery has failed.     

Fragment-specific internal fixation of distal radius fractures

The treatment of complex, intra-articular distal radius fractures can be challenging. Goals of treatment include the restoration of articular congruity and maintenance of a stable reduction to allow for early range-of-motion, prevention of arthrosis, and ultimately return of upper extremity function. Proper understanding of individual fracture patterns is paramount in achieving these goals and avoiding complications. Through the use of limited surgical incisions and low-profile,anatomically contoured implants, fragment-specific internal fixation provides a rational approach to the treatment of these complex injuries.     

Simple external fixation of open and complicated fractures

Thirty patients were managed with the use of a simple means of external fixation. Ten of these patients had multiple injuries. In 18 the fractures were open. Five cases had loss of bone length and infected wounds when first seen and were treated with the aid of microvascular surgical procedures. Eight cases required skin grafting. One case required a vein graft to the popliteal artery. The method described is simple to use. It requires little previous experience and is cost effective. We recommend its use in the initial treatment of grade 2 and 3 open fractures. It may also be used on closed unstable fractures, and will maintain limb length in severe injuries with loss of bone substance while further treatment is considered or performed.     

Posterior cervical plate-screw fixation

Posterior cervical plate-screw fixation is a safe, effective, and versatile fixation technique. It offers clear advantagesover other posterior cervical fixation techniques in the treatment of traumatic, neoplastic, or degenerative disorders in which the spinous processes, laminae, or facets are fractured, deficient, or absent. Because the occiput, C2 pedicles, C3-C7 lateral masses, C6-T4 pedicles, and T1-T4 transverse processes represent potential sites for screw fixation, it is particularly useful when fixation across multiple levels or across the occipitocervical or cervicothoracic junction is required. Familiarity with the bony anatomy of the potential sites for screw fixation and the relationship of this anatomy to the anatomy of adjacent neural and vascular structures is essential for safe, biomechanically effective fixation. With careful preoperative planning and meticulous performance of the surgical procedure, arthrodesis rates of approximately 90% to 100% without substantial loss of alignment may be expected. The small but finite incidence of clinically significant screw malposition (approximately 0.8%/screw) even in the hands of surgeons familiar with the technique suggests that its use should not supplant the use of posterior cervical wire techniques unless a specific indication for its use exists.     

External fixation of complex open humeral fractures

Seven cases of complex open humeral fractures treated by external fixation are reported. The external fixation allowed the associated injuries to nerves, arteries and soft tissues to be adequately treated. Four cases developed non-union and of these, three cases treated by bone-grafting and plating united, but the one case treated by intramedullary nail without bone-graft did not unite. Frame construction and pin placement are discussed. The recommended plan for treatment of these fractures is initial external fixation until adequate soft tissue healing is achieved and sepsis controlled. Then early bone-grafting and plating is advocated if there is no progressive fracture healing. The problems and advantages encountered in the use of external fixation are also described.     

Open reduction and internal fixation of vertical shear pelvic fractures

The goal in the treatment of vertical shear fractures of the pelvis is to achieve and maintain an accurate reduction of the displaced hemipelvis. Open reduction and internal fixation of the posterior pelvic ring injury along with either internal or external fixation of the anterior pelvic ring injury was used in 12 vertical shear fractures in 11 patients. The posterior fixation was aided by accurate definition of the injury pattern, use of preoperative traction, early surgical treatment, use of flexible instruments, and identification of the posterior sacral foramina, which were used as a guide to allow accurate screw placement into the sacrum and avoid nerve root injury. The procedure was not associated with an increased rate of infection or neural injury. In the ten patients followed more than 1 year there were no late displacements of the hemipelvis and all of the fractures healed.     

Treatment of unstable closed tibial shaft fractures by external fixation

The fracture of tibia shaft is one of the most common fracture of long bones. The authors bring out the results of the treatment of 90 patients with unstable closed tibial shaft fractures treated by the use of Mitkovic external fixation systems. Within the analayzed group there were 66 (73%) male and 24 (27%) female. The average patients age was 43.9 years (range 15 to 82). Excellent result in treatment of unstable closed tibial shaft fractures with external fixation were achieved in 15 (16,7%) patients, very good in 38 (42,2%) patients, good in 24 (26,7%), poor in 9 (10%) and bad in 4 (4,4%) patients. With 4 (4,4%) patients pseudoarthrosis was formed. Additional treatment of patients with pseudoarthrosis (spongioplastic and placing of CD device) led to pseudoarthrosis healing. Within the analyzed group in all patients treated with extenal fixation there were no registered cases of postoperative osteitis. External fixation by the use of Mitkovic external fixation is one of the method of choose in the treatment of unstable closed tibial fractures, providing dynamic and balanced biomehanical conditions for fracture healing.     

Damper osteosynthesis using an external perosseous fixation device

The authors substantiate the expediency of improving osteosynthesis with apparatuses of perosseous external fixation on the basis of electromechanical principles making use of statistically reliable results of 58 chronic experiments on animals, 27 stand studies on the tibia of cadavers and 207 dynamic clinical observations employing quantitative results of clinical, roentgenomorphometric, electrophysiologic, biomechanical and histomorphological studies. Optimal parameters of the rigidity of fixation for early restoration of the properties of elasticity and strength of the injured bone are determined. Dampered external osteosynthesis in the treatment of open comminuted fractures of the bones of the crus reduced the mean periods of in-patient treatment and consolidation of the fractures by 27-34. 5% and the frequency of complications and unsatisfactory outcomes by 75%.     

Trans-sacral fixation for failed posterior fixation of the pelvic ring

Introduction: In the treatment of certain pelvic ring pathologies (non-unions and failure of ilio-sacral screw fixation) trans-sacral fixation (i.e. fixation from iliac wing to the other traversing the body of S1) may be necessary. The purpose of our study was to describe our early experience and describe the surgical technique. Materials and methods: Seven cases of trans-sacral fixation were identified with a mean patient age of 49-years-old with four females and three males. The diagnosis at the time of trans-sacral fixation was failure of posterior ring fixation in four (three of which had vertical sacral fractures), mal-position of iliosacral (IS) screw in one, failure of fusion of sacroiliac (SI) joint in two. All these cases were augmented with a 4.5 mm reconstruction plate placed in tension posteriorly. Results: At average follow up of 39 months (range 24–75), all patients achieved union. There were no neurological or vascular complications. Two patients required reoperations prior to union. Our current use for this technique is with a 8.0 mm screw (16 mm thread). Conclusions: Initial experience with trans-sacral fixation has proven to be very effective technique to solve the most difficult problems in posterior pelvic ring fixation. We reserve its use to the following indications: nonunion/malunion of the pelvic ring, and sacral fractures.     

Mandibular reconstruction: open reduction and internal fixation of mandibular fractures

Open reduction and internal fixation of mandibular fractures by intraosseous wiring in conjunction with intermaxillary fixation remains the mainstay of mandibular fracture treatment despite the availability of newer methods. The principles of treatment are reviewed, including indications for use of this technique and its advantages and disadvantages. Various surgical techniques are also reviewed and key points in their application emphasized.     

External fixation in multiply injured children

External fixation treatment for selected fractures can be as readily applied to children as to adults, although only a small percentage of pediatric fractures require this method. The best situations for the use of external fixation in children are in cases of multiple organ system injuries and in fractures associated with skin loss or large wounds. In these situations, while the child's other problems are being treated, external fixation provides excellent temporary stabilization to facilitate fracture management.     

External fixation of Charcot arthropathy

Deformity, instability, and ulceration are present in a high percentage of patients who have Charcot arthropathy. Traditional treatment of these conditions has consisted of debridement, antibiotics, and immobilization with limited weight bearing. These measures are followed by long-term use of various foot and ankle bracing devices, such as the CROW walker, double metal upright, and the lined clam shell AFO with accommodative footwear either incorporated or attached. Sometimes these conservative measures fail and surgery is indicated for foot and ankle deformities with: (1) unbraceable deformity; (2) recurrent ulceration secondary to deformity, instability, or both; and (3) Charcot arthropathy with pain that is unresponsive to conservative measures. Certain acute traumatic situations with impending deformity also may benefit from early surgical stabilization. High deep infection rates (25%) have been reported in surgical reconstruction of feet that have a history of ulceration. The high rates of infection with internal fixation techniques and improved external fixation devices have led surgeons to consider external fixation as a viable alternative for: (1) singlestage correction of a limb with recent or current ulceration; (2) revision or salvage of previously reconstructed limbs; and (3) acute treatment of insufficiency type fractures (impending Charcot arthropathy) in the diabetic who has severe peripheral neuropathy with or without adjuvant internal fixation.     

Retrograde Herbert screw fixation for treatment of proximal pole scaphoid nonunions

Most nonunions of the carpal scaphoid bone can be treated with a high rate of success by use of conventional bone grafting techniques. However, fractures with a small proximal pole fragment may be difficult to treat by use of these techniques. Nine patients with nonunion and three patients with unstable proximal pole fractures were treated with retrograde dorsal Herbert screw fixation and adjunctive bone grafting. Follow-up averaged 25 months. Of the 12 patients, the fracture healed in 11 and one fracture remained ununited. This technique has been successful in our practice and should be considered in the treatment of small proximal pole nonunions and displaced proximal pole fractures.     

Biomechanics and biology of external fixation of distal radius fractures

External fixation is a versatile and useful tool for management of complex fractures. There is little to choose between the various types of commercially available fixators, and it is important to use one that allows the surgeon adequate versatility and follows sound biomechanical principles. Ligamentotaxis can be used effectively to reduce the most difficult fractures; however, over-distraction and prolonged traction are harmful and should be avoided. Certain types of fractures do not respond to treatment with ligamentotaxis alone and require adjunctive treatment, such as limited internal fixation. A single K-wire significantly adds to the stability of fixation and should be considered in all cases. Understanding the basic mechanical principles and respect for pin-bone biology allow for successful use of external fixation with minimal complications.     

A new technique of diaphragmatic patch fixation in extrapleural pneumonectomy

Extrapleural pneumonectomy (EPP) is an established surgical treatment for malignant mesothelioma; this operation is, however, burdened by a high rate of perioperative morbidity, mostly related to the surgical procedure. Diaphragmatic patch dehiscence is a potentially serious complication often related to the difficulty in placement of the fixing stitches, especially in the costo-phrenic angle. We present our experience with the use of titanium-plate support for an easy and safe positioning of the diaphragmatic patch.     

External fixation in the management of Charcot neuroarthropathy

Charcot neuroarthropathy is a complex sequela of neuropathies associated with diabetes mellitus, syringomyelia, alcoholism, and other disorders. The treatment of deformities associated with Charcot neuroarthropathy is evolving from a passive approach to one in which an earlier recognition of the emergence of the event permits an avoidance of deformity. As the understanding of the etiology and natural history of Charcot neuroarthropathy deepens, it has become apparent that many of the deformities that do develop may be reconstructed expeditiously by the surgeon with a thorough understanding of the diabetic foot and experience in the use of external fixation.     

The fixation of pelvic ring fractures

Summary Because of the increase in fast traffic and dangerous new sports, in the last few years there has been a dramatic increase in the number of severe pelvic injuries. In 1988, we treated 125 patients with such pelvic injuries. We use Tile's classification method to stage injuries of the pelvic ring type A, type B (B1, B2, B3) and type C. More than 60% of our patients had multiple injuries. In this paper we discuss making the diagnosis, operative procedures, and treatment management.