The small pin circular fixator for proximal tibial fractures with soft tissue compromise

We used a Monticelli-Spinelli small pin circular external fixator in five cases, in combination with closed reduction or limited open reduction internal fixation, to salvage a satisfactory result in juxtaarticular, intraarticular fractures of the proximal tibia, when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin circular fixator allows juxtaarticular placement of the small pins, enhancing stabilization of the comminuted fractures, allowing early range of motion of the joint and early patient mobilization. The small diameter pins support the soft cancellous bone fragments. This technique attempts to combine the benefits of traction, external fixation, and limited internal fixation. We recommend this method as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.     

Treatment of complex tibial periarticular fractures using percutaneous techniques

Open reduction and internal fixation typically is reserved for the treatment of patients with articular or periarticular tibia fractures, or other tibial injuries that are treated inadequately with intramedullary nailing. This approach can result in extensive dissection and tissue devitalization. By modifying the method of fixation, the plating of tibial fractures has been expanded using a percutaneous technique. Using this approach, the fracture is reduced indirectly and plates are placed through subcutaneous or submuscular tunnels through limited incisions. Between 1992 and 1998, 17 patients with tibial shaft fractures and associated severe soft tissue injury, were treated using a percutaneous plating technique. Followup was available in 14 patients. Six patients required bone grafting procedures for delayed union or nonunion, although four of these patients had significant bone loss related to their injury. There were no malunions. Three patients had superficial infections related to external fixator pin sites and one patient had osteomyelitis develop. Percutaneous plating of the tibia offers an alternative method for stabilizing complex fractures with severely compromised soft tissues, especially those injuries with periarticular extension. This technique is thought to cause no increase in the risk of infection or soft tissue damage and permits rapid mobilization of the limb and patient. When using this treatment for patients with significant bone loss, bone grafting should be considered.     

轴向动力型外固定器在胫骨Pilon骨折治疗中的应用

目的回顾分析运用轴向动力型外固定器和改良穿针技术治疗严重胫骨Pilon骨折的效果。方法研究分析2000年7月至2003年2月间14例严重Pilon骨折(Rtiedi-Allgtiwer Ⅱ型和Ⅲ型)患者,年龄20-52岁(平均38岁),采用有限内固定结合轴向动力型外固定器治疗,远端外固定针置入技术经过改良,2枚外固定针分别置入距骨和跟骨,使外固定器远端夹具旋转轴线与胫距关节旋转轴线重合。结果随访5—36个月(平均18个月),骨折愈合时间12-24周(平均14周)。最后一次随访时,ASS评分优5例,良6例,可3例。无切口裂开、皮缘坏死、表浅及深部感染、骨髓炎,无骨折移位及关节面塌陷;仅有1例近端外固定针道感染,经清创及口服抗生素治疗好转。结论经过改良的轴向动力型外固定器技术结合有限内固定是治疗严重胫骨Pilon骨折的有效方法。     

Treatment of tibial fractures with external ring fixation--I

Notwithstanding the generally known principles of therapy, indications can be enlarged by use of an annular fixator to cover the following applications: 1. stage fractures of the tibia, 2. stabilisation of fractures of polytraumatised patients with no need for anatomic reposition in the first place, 3. closed lower limb fractures with soft tissue lesions. Possible unlimited correction of primary and secondary dislocations without the need for transposition of Steinmann pins already implanted, compatibility with AO external fixation systems for supplementary use of annular fixator elements for possible management of secondary dislocations and variable placeability of pins or screws for subsequent wound debridement and muscle flap transposition are major advantages of the annular fixator. Results so far obtained from use of the annular fixator are described by clinical examples.     

Operative Therapie der distalen Radiusfraktur

Distal dislocated radius fractures are now mostly treated surgically. Closed reduction and internal fixation with Kirschner wires are increasingly giving way to internal fixation with screws or fixed-angle plates and to the use of the fixateur externe. For fractures with concomitant severe soft tissue injury treatment with a bridging external fixator and adequate soft tissue management are first necessary. External fixation is needed in addition, however, once soft tissue repair has been achieved by means of internal fixation with screws or K-wires, and the external fixator should remain in place until the fracture has started to heal. If possible preference should be given to the use of nonbridging fixators. Conservative treatment can now no longer be justified except for stable and nondislocated fractures. Arthroscopy/assisted reconstruction of the carpal articular surface is the subject of some controversy and is not yet accepted as a standard procedure.     

Behandlung der distalen Tibiafraktur

Challenges and strategies in handling distal tibial fractures are affected by the anatomical site of fracture, the impact of trauma, and soft tissue damage. Extraarticular fractures may be addressed using locking nails, sometimes supported by screws. Split fractures of the tibial plafond are reduced using limited open techniques and are fixed by screws and percutaneous locking plates. If the soft tissue envelope is compromised, or in the presence of a multifragment fracture of the tibial pilon, a second-stage procedure is recommended. The treatment of choice is closed reduction of the fracture as soon as possible and application of a spanning external fixator. Open reduction and internal fixation are done after swelling has been reduced. The clinical outcome is influenced by infection, joint stiffness, and the development of posttraumatic arthritis.     

Minimally invasive plate osteosynthesis of distal fractures of the tibia

Minimally invasive plate osteosynthesis of distal tibial fractures is technically feasible and may be advantageous in that it minimizes soft tissue compromise and devascularization of the fracture fragments. The technique involves open reduction and internal fixation of the associated fibular fracture when present, followed by temporary external fixation of the tibia until swelling has resolved. Subsequent limited, but open reduction and internal fixation of the articular fragments when displaced followed by minimally invasive plate osteosynthesis of the tibia utilizing precontoured tubular plates and percutaneously placed cortical screws is performed. The semitubular plate was chosen because it adapts more easily to the bone contours than the stiffer small fragment LC-DCP does. Twenty patients (age 25-59 years) with unstable intraarticular or open extraarticular fractures have been treated including 12 A-type, 1 B-type and 7 C-type fractures according to the AO classification. Two fractures were open (both Gustilo Type I). Closed soft tissue injury was graded according to Tscherne with 3 type C0, 7 type C1, 7 type C2 and 1 type C3. All fractures healed without the need for a second operation. Time to full weight-bearing averaged 10.7 weeks (range 8-16 weeks). Two fractures healed with > 5 degrees varus alignment and 2 fractures healed with > 10 degrees recurvatum. No patient had a deep infection. The average range of motion in the ankle for dorsiflexion was 14 degrees (range 0-30 degrees) and plantar flexion averaged 42 degrees (range 20-50 degrees). With longer follow-up and a larger number of patients, the authors feel confident that the minimally invasive technique for plate osteosynthesis for the treatment of distal tibial fractures will prove to be a feasible and worthwhile method of stabilization while avoiding the severe complications associated with the more standard methods of internal or external fixation of those fractures.     

AO external fixator for definitive treatment of an open distal tibia fracture during the COVID-19 pandemic

BackgroundThe accepted gold standard for primary treatment of long bone open fractures consists of aggressive debridement, irrigation and temporary external fixation. Removal of the external fixator followed by definite internal fixation is recommended within the first two weeks after the injury to obtain a more stable fixation, alleviate rehabilitation and to avoid pin infection.Materials & MethodsHere, we report a case of a Gustilo IIIB open tibia fracture with extended soft tissue degloving of the distal tibia. Following removal of the AO external fixator, plate fixation and soft tissue coverage with a free flap, implant loosening occurred warranting a return to external fixation. The patient did not return for follow-up due to a prolonged COVID-19-quarantine and no further treatment was installed.Results & ConclusionsThe patient returned after 6 months with the fractures and soft tissues fully healed. In specific situations, the external fixator may be used as a definitive form of treatment.     

Technique for Minimally Invasive Reduction of Calcaneal Fractures Using Small Bilateral External Fixation

Soft tissue complications are well known after extensile exposure of the calcaneus for open reduction internal fixation of fractures. A variety of recommendations have been proposed to reduce soft tissue healing issues and infection. Despite these recommendations, some surgeons believe that soft tissue complication rates have remained unacceptably high with lateral extensile incisions. Recently, interest in minimally invasive repair techniques for calcaneal fractures has increased. These techniques have been purported to avoid some of the common soft tissue problems seen with calcaneal open reduction internal fixation. The focus of the present communication is to share a minimally invasive surgical method for the reduction and fixation of calcaneal fractures. Percutaneous fixation of the posterior facet fragments can be facilitated by distraction of the fractured calcaneus using skeletal traction and a small bilateral external fixator. Final stability is achieved with a combination of the external fixator and percutaneous screws and/or wires. We present our technique and discuss recent published studies on minimally invasive repair of calcaneal fractures.     

混合式单臂外固定架骨延长术治疗感染性骨不连

目的评价混合式单臂外固定架骨延长术治疗长骨干骺端感染性骨不连的初步临床结果。方法2003年1月至2006年2月采用混合式单臂外固定架固定、局部清创和截骨延长法治疗感染性骨不连21例,男17例,女4例;年龄18～48岁,平均31.5岁。16例为开放骨折内固定术后感染,5例为闭合骨折内固定术后感染。胫骨近端12例,胫骨远端6例,股骨远端3例。12例行骨折端植骨,其中2例二次植骨。结果21例术后随访10～36个月,平均18个月。18例骨折获得初期愈合,3例骨折愈合时仍有局部窦道和渗液,2例骨折尚未完全愈合,1例行截肢术,20例感染得到控制。改良ASAMI骨评定结果为优良13例,中4例,差4例;功能评定结果为优良11例,中6例,差4例。平均骨延长5.6cm,平均愈合时间为11个月。15例发生钉道感染。结论对长骨干骺端感染性骨不连可使用混合式单臂外固定架骨延长术、骨折端开放换药的方法。该方法控制感染好,可自体修复骨缺损,供区畸形发生率低。但固定需采用HA涂层螺钉,严格控制延长速度,一般在1mm/d以内,分次进行延长,手术风险小。     

Langzeitergebnisse nach operativer Versorgung von Pilon-tibial-Frakturen Eine retrospektive Untersuchung

Background: While Pilon fractures of the tibia have been treated for decades by primary open reduction and internal fixation by plate osteosynthesis, during the last 10 years differential treatment was developped: After primary open reduction nowadays patients are treated with (according to type of fracture and tissue damage). As well as primary open reduction and internal fixation a two-step treatment (primary external fixator and delayed ORIF) or consolidation by external fixator combined with minimal invasive osteosynthesis (cannulated screws and K-wires) has been implemented. Furthermore, the significance of primary bone grafting in comminuted fractures to prevent aseptic pseudarthrosis has been acknowledged. Methods: Of 151 patients with 160 pilon fractures treated from January 1979 to May 1995, 107 patients (113 fractures) were evaluated. Only the results of C2 and C3 fractures could be compared, as only in these groups were all three types of treatment used. Results: Over 75% of the treated fractures were closed fractures, most of them being fractures with a soft tissue damage grade 2 of the Oestern and Tscherne classification. In the open fractures we found mainly grade 3 fractures according to the Gustilo and Anderson classification. In 54.9% of all pilon tibial fractures we observed an uncomplicated course of healing. Early complications (25.7%) were mainly soft tissue infections, whereas we found pseudarthrosis to be the most frequent late complication. Highest infection rate (55.5%) was in the two-step treatment group (primary external fixator and delayed ORIF) and lowest in the primary internal stabilization group, although especially in the C2 and C3 fractures best clinical late results were obtained with the two-step procedure. Conclusion: The complication rate in the treatment of pilon fractures depends mainly on the type of fracture, the soft tissue damage and the type of treatment. The results of primary ORIF varied. In the case of low-grade soft tissue damage, good to excellent results were accomplished. In the case of higher-grade soft tissue damage, the problem of soft tissue coverage and reconstruction of the joint surface could be solved with good results by the two-step treatment. Herewith it is important to use limited open reduction of displaced fragments and fixation by cannulated screws and K-wires. We consider ORIF of the fibula necessary as stabilization of the second column of the ankle joint.     

Tibial pilon fractures

Tibial pilon fractures are severe injuries to the distal articular surface of the tibia. Such injuries frequently result from high-energy axial impact and are often associated with extended soft tissue injury. Various treatment methods are available, depending not only on the fracture type but mostly on the extent of the soft tissue injury; one of the most frequent procedures is a two-stage surgery: the initial closed reduction of the fracture via primary placement of an ankle joint-spanning external fixator, if possible in conjunction with open reduction and internal fixation of the fractured fibula followed by a secondary procedure after soft tissue recovery by open reduction and internal fixation of the tibial plafond. By now, new types of low-profile and locking plates are available for internal fixation allowing the anatomical reconstruction of the fractured articular surface while sparing the soft tissue. Nonetheless, the treatment of tibial pilon fractures is technically demanding because of their potential for severe complications.     

B、C型桡骨远端骨折的治疗

目的 探讨AO分类B、C型桡骨远端骨折的治疗方法。方法 对93例B、C型桡骨远端骨折采用手法复位石膏固定、闭合性复位经皮克氏针内固定及切开复位钢板螺钉内固定。结果 全部病例均随访2年以上。优良率：手法复位石膏固定组为82．05％，经皮克氏针内固定组为81．82％，切开复位钢板螺钉内固定组为80．95％。结论 手法复位能达到解剖或近似解剖复位并经石膏固定可达到良好固定者应采用非手术治疗；Bl、B3、C1型中的Colles骨折应采用闭合性复位经皮克氏针内固定；B2、Cl、C2型中的Simth骨折应采用切开复位钢板螺钉内固定；C3型骨折因干骺端粉碎应采用松质骨移植恢复桡骨的长度；伴有严重的骨质疏松的患者避免用内固定治疗。     

Stabilizing the open fracture with the external fixator]

External fixation plays a major role in contemporary trauma care. Indications are not limited to the obviously open fracture but also to cases with severe "closed" soft tissue injuries (contusions, burns etc.). The technique is reviewed and importance of pin placement, fixator geometry, minimal internal fixation and staged fixator removal are stressed. The modern external fixation techniques may be used to obtain bony union or they may be used temporarily switching to definitive internal fixation upon obtention of soft tissue healing.     

The A-O external skeletal fixator in the treatment of severe tibia fractures

A series of 33 cases of Grade II and III open tibia fractures were treated with local wound care followed by application of the A-O external fixator. Two transfixing Steinmann pins were usually used above and two below the fracture site. In six cases one Steinmann pin and one anteroposterior Schanz half pin above and below the fracture were combined with a triangulated frame. Additionally, minimal internal fixation with lag screws was used in five cases. Union was achieved in 83% of tibiae in an average time of 9.9 months. Union occurred faster when the fixator was removed in less than 3.5 months but then the incidence of malunion tended to rise. Three patients required early amputation. Eleven tibiae developed deep wound infections. Knee function was well preserved but ankle function was often impaired. The A-O fixator performed as a useful, simple, stable, light weight and versatile system in the care of these Grade II and III fractures. However, many problems intrinsic to the open tibia fracture remain.     

有限内固定联合外固定支架治疗Schatzker Ⅴ、Ⅵ型胫骨平台骨折

目的探讨有限内固定联合外固定支架治疗SchatzkerⅤ、Ⅵ型胫骨平台骨折的临床疗效。方法手术治疗55例SchatzkerⅤ型(31例)和Ⅵ型(24例)胫骨平台骨折患者。术中先透视下闭合复位或辅以小切口复位胫骨平台内外侧髁,并给予螺钉固定,再应用外固定支架固定,对塌陷骨折撬拨复位人工骨填充。结果骨折解剖复位39例,近解剖复位16例。患者均获得随访,时间12~54个月。骨折愈合时间4~7个月。末次随访膝关节功能按Rasmussen评分标准:优32例,良15例,可7例,差1例,优良率85.5%。切口并发症7例(12.7%):其中切口浅表感染2例,钉道感染5例,未发生深部感染,骨髓炎及骨不连。结论有限内固定联合外固定支架治疗SchatzkerⅤ、Ⅵ型胫骨平台骨折可获得满意临床疗效,具有创伤小、并发症发生率低、骨折愈合快等优点。     

Fixation technique influences osteogenesis of comminuted fractures

Comminuted fractures most often are associated with compromised soft tissue conditions and diminished vascularization leading to a reduced osteogenesis. In contrast to stable fixation by compression plating with lag screws, the less stable but also less invasive techniques of external fixation, unreamed nailing, or bridging plates have become increasingly popular. The aim of this study was to compare the bone healing and osteogenesis of these fixation techniques. A triple wedge osteotomy of the sheep tibia was used as a bone healing model. Internal compression plate fixation of all fragments with lag screws was used in one group. In the other three groups, only the main proximal and distal fragments were fixed by external fixation, unreamed interlocking nail, or bridging plate. The sheep with compression plate fixation and lag screws showed the worst results after 12 weeks. The periosteal and endosteal osteogenesis and the apparent density of the newly formed bone in the fracture gaps were significantly lower than those seen in the sheep in the other three technique groups. The best results were found for the bridging plate and external fixator. From these results, it can be concluded that compression plate fixation should be avoided for treatment of comminuted fractures.     

Modulation of the soft tissue reactions to percutaneous orthopaedic implants.

To evaluate soft tissue reactions and biofilm formation on percutaneous external fixator screws coated with diamond-like carbon (DLC) and hydroxyapatite (HA) coatings on stainless-steel (SS) pins in an ovine loaded osteotomy model, an Orthofix external fixator was used to stabilize a 3-mm tibial midshaft osteotomy with six tapered pins inserted into the right tibia of 32 skeletally mature Friesland ewes. Animals were divided into four groups; SS, fully coated HA, DLC, and HA-coated threads. At 10 weeks, specimens were harvested and the pins were removed en bloc to examine the interfaces between the surface coatings and the tissues. Fully coated HA pins had a significantly higher percentage of dermal contact with the pin surface than HA-coated threads (p=0.028). The presence of a biofilm was evident on all pin surfaces except DLC-coated pins. Significantly greater numbers of bacteria were present on fully coated HA and plain stainless-steel pins compared with DLC. The surface of DLC-coated pins had a significantly lower number of bacterial colonies compared to SS (p=0.028) and fully coated HA pins (p=0.005). Fully coated HA pins have greater dermal attachment to the pin surface than the other pin coatings investigated. DLC-coated pins have the potential to prevent biofilm formation and bacterial colonization that may reduce infection and consequent pin loosening. An external fixator pin that is partially coated with HA to encourage bone and soft tissue integration and with DLC to reduce biofilm formation is advocated.     

Modified hybrid fixator for high-energy Schatzker V and VI tibial plateau fractures

High-energy tibial plateau fractures associated with severe soft tissue injury are difficult to manage. The risk of wound complications following open reduction and internal fixation is notably high owing to extensive soft tissue dissection. Alternatively, application of hybrid external fixator minimizes soft tissue dissection and provides adequate fracture stabilization to allow early range of motion and correction of any mal-alignment. With this technique, soft tissue complications particularly surgical site infections are expected to be significantly reduced. This prospective study aims to determine the effectiveness of a modified hybrid external fixator in the management of high-energy tibial plateau fractures. Thirty-three patients with high-energy Schatzker V and VI tibial plateau fracture with severe soft tissue injury precluding formal open reduction were enrolled into the study. The fixator was a construct combining the Ilizarov ring with a monolateral external fixator. The results—bony union, range of motion, and associated complications of the treatment—were assessed. All fractures united within an average time of 14 weeks. Neither loss of reduction nor surgical site wound breakdown/osteomyelitis was noted. Eight patients developed superficial pin track infection and one septic arthritis of the knee joint. Hybrid external fixation is a safe option for complex high-energy tibial plateau fractures by simultaneously providing adequate fracture stabilization and protection of soft tissue healing to achieve bony union. The complication is mainly related to pin tract infection.     

The treatment of pilon fractures

Soft tissue complications, skin slough, and superficial infection lead to deeper infection and amputation. By avoiding these complications, it is expected that better results can be obtained. Two techniques are available to do this. The first is to limit incisions and use external fixation to obtain stability. Even in these cases, care must be taken with the soft tissues. The second is a staged reconstruction, whereby stage one allows soft tissue stabilization. To this end, the fibula is plated, and transarticular external fixation is performed; this maintains anatomic length, preventing soft tissue contraction and permitting edema resolution. The second stage, formal tibial open reduction and internal fixation, is performed with plates and screws when operative intervention is safe. These methods appear to be equally effective in reducing major soft tissue complications. Surgeons should treat these complex fractures with the method with which they are most comfortable. Surgeons who feel comfortable with techniques of internal fixation are best qualified to perform open reductions. Surgeons who have experience with percutaneous fixation and hybrid external fixator application should use this method. Surgeons with limited or minimal experience with pilon fractures should consider fibula fixation and transarticular external fixation followed by transfer to an orthopedic trauma surgeon for definitive management.