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 internal fixator versus a femoral distractor and external fixation for sacroiliac joint compression and single stance gait testing: a mechanical study in synthetic bone

Purpose

The purpose of this study was to evaluate the biomechanical stability and compressive forces across the sacroiliac (SI) joint of an anterior internal fixator compared to the femoral distractor and external fixator for vertically unstable pelvic fractures.

Methods

Five composite pelvises with a simulated APC type III injury fixed with a femoral distractor, external fixator, or anterior internal fixator were tested. A pressure-sensitive film (Tekscan) was placed in the disrupted SI joint recording the magnitude of force. Then, in a single-leg stance model (Instron machine), a load was applied through the sacrum. We recorded displacement at the pubic symphysis and SI joint using high-speed video. Peak load and displacement were measured, and axial stiffness was calculated. Values were compared using a Student’s t-test (p < 0.05).

Results

The SI joint was compressed significantly (p < 0.001) more using the anterior internal fixator (18.9 N) and femoral distractor (18.6 N) than the two-pin external fixator (2.5 N). There was no significant difference between the anterior internal fixator and the femoral distractor in displacement at the SI joint. The pubic symphysis displaced less with the femoral distractor than the anterior internal fixator (5.5 mm vs. 4.1 mm; p < 0.05).

Conclusions

The anterior pedicle screw internal fixator allows for indirect compression across the sacroiliac joint that is superior to two-pin external fixation and comparable to the femoral distractor. The anterior internal fixator may be an option for temporary anterior pelvic fixation in situations where external fixation or the femoral distractor have otherwise been used.     

Temporary and definitive external fixation of war injuries: use of a French dedicated fixator

Purpose

External fixation is the recommended stabilization method for both open and closed fractures of long bones in forward surgical hospitals. Specific combat surgical tactics are best performed using dedicated external fixators. The Percy Fx© (Biomet) fixator was developed for this reason by the French Army Medical Service, and has been used in various theatres of operations for more than ten years.

Methods

The tactics of Percy Fx© (Biomet) fixator use were analysed in two different situations: for the treatment of French soldiers wounded on several battlefields and then evacuated to France and for the management of local nationals in forward medical treatment facilities in Afghanistan and Chad.

Results

Overall 48 externals fixators were implanted on 37 French casualties; 28 frames were temporary and converted to definitive rigid frames or internal fixation after medical evacuation. The 77 Afghan patients totalled 85 external fixators, including 13 temporary frames applied in Forward Surgical Teams (FSTs) prior to their arrival at the Kabul combat support hospital. All of the 47 Chadian patients were treated in a FST with primary definitive frames because of delayed surgical management and absence of higher level of care in Chad.

Conclusion

Temporary frames were mostly used for French soldiers to facilitate strategic air medical evacuation following trauma damage control orthopaedic principles. Definitive rigid frames permitted achieving treatment of all types of war extremity injuries, even in poor conditions.     

Treatment of intertrochanteric fractures in elderly highrisk patients: Dynamic hip screw vs. external fixation

Introduction

Although the use of a dynamic hip screw (DHS) is considered to be the preferred treatment for intertrochanteric fractures, the external fixation device could produce clinical outcomes comparable to the outcomes obtained with conventional treatment. Furthermore, because external fixation is minimally invasive, we expected a lower rate of morbidity. Therefore, we compared the two treatments in a clinical trial of elderly patients with intertrochanteric fracture.

Methods

60 elderly high-risk patients with an average age of 78 years were treated for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to treatment. In Group A the patients were treated with DHS, while in Group B were treated with external fixator.

Results

The fixator was well accepted and no patient had significant difficulties while sitting or lying. The average intraoperative time was 73 min in Group A and 15 min in Group B (p < 0.05). 27 patients of Group A need blood transfusion postoperatively and none in Group B (p < 0.05). The mean duration of hospitalization in Group A and Group B was 8.4 and 2.2 days, respectively (p < 0.05). 9 of patients Group B had pin-track infection grade 2 that all were treated by oral antibiotics. There were no differences in comorbidities, quality of reduction, screw cut out, bed sore and HHS between the two groups.

Conclusion

Treatment with external fixator is an effective treatment for intertrochanteric fractures in elderly highrisk patients. The advantages include quick and simple application, minimal blood loss, less radiation exposure, adequate fixation, pain reduction, early discharge from hospital, low costs and favourable functional outcomes.     

External wire-frame fixation of digital skin grafts: A non-invasive alternative to the K-wire insertion method

Background and Aim

The current skin graft fixation methods for digits, including the Kirschner wire insertion technique, can be limited by inadequate or excessive fixation and complications such as infection or secondary injuries. Therefore, the external wire-frame fixation method was invented and used for skin grafting of digits. This study aimed to investigate external wire-frame fixation of digital skin grafts as a non-invasive alternative to the K-wire insertion method.

Methods

In 2005–2012, 15 patients with burn scar contractures on the hand digits received a skin graft that was then fixed with an external wire frame. The intra-operative time needed to make the wire frame, the postoperative time to frame and suture removal, the graft survival rate, the effect of contracture release and the complications were recorded.

Results

In all cases, the contracture release was 100%. The complete graft survival rate was 98.6%. Four patients had epithelial necrosis in <5% of the total area. There were no other complications such as pressure ulcer or hypoxia of fingers.

Conclusions

External wire-frame fixation is simple, minimally invasive and a custom-made technique for skin grafting of the fingers. It was designed for its potential benefits and the decreased risk it poses to patients with scar contractures on their fingers. It can be implemented in three phases of grafting, does not affect the epiphyseal line or subsequent finger growth and is suitable for children with multi-digit involvement.     

Salvage of infected total knee arthroplasty with Ilizarov external fixator

Background:

Knee arthrodesis may be the only option of treatment in cases of chronic infected total knee arthroplasty (TKA) with concomitant irreparable extensor mechanism disruption, extensive bone loss or severe systemic morbidities. Circular external fixation offers possible progressive adjustment to stimulate the bony fusion and to make corrections in alignment. We evaluated the results of knee arthrodesis with one or two stage circular external fixator for infected TKA.

Materials and Methods:

16 cases of femoro-tibial fusion were retrospectively evaluated. Male-to-female ratio was 10:6. Mean age of the patients was 62.2 years. Cierney-Mader classification was used for anatomical and physiological evaluation while the bone stock deficiency was classified into mild, moderate and severe. Surgical technique involved either single or two stage arthrodesis using circular external fixator.

Results:

Union was achieved in 15 patients (93.75%). The mean duration for union (frame application time) in these patients was 28.33 weeks (range 22 to 36 weeks). Analysis showed that in the group with frame application time of less than 28 weeks, the incidence of mild to moderate bone deficiency was 83.33%, while in the frame application time more than 28 weeks group the incidence was 20% (P-value 0.034). Similarly the incidence of Cierney-Mader 4B (Bl, Bs, Bls) was found to be 33.33% in the group of frame application time of less than 28 weeks, while it was 90% in the group with frame application time more than 28 weeks (P-value 0.035).

Conclusion:

Circular external fixator is a safe and reliable method to achieve knee arthrodesis in cases of deep infection following TKA. Severe bone stock deficiency and Cierney- Mader type B host are likely risk factors for prolonged frame application time. We recommend a two-stage procedure especially when there is compromised host or severe bone loss.     

Emergency stabilization of the pelvic ring: Clinical comparison between three different techniques

Background

Emergency devices for pelvic ring stabilization include circumferential sheets, pelvic binders, and c-clamps. Our knowledge of the outcome of these techniques is currently based on limited information.

Methods

Using the dataset of the German Pelvic Trauma Registry, demographic and injury-associated characteristics as well as the outcome of pelvic fracture patients after sheet, binder, and c-clamp treatment was compared. Outcome parameters included transfusion requirement of packed red blood cells, length of hospital stay, mortality, and incidence of lethal pelvic bleeding.

Results

Two hundred seven of 6137 (3.4%) patients documented in the German Pelvic Trauma Registry between April 30th 2004 and January 19th 2012 were treated by sheets, binders, or c-clamps. In most cases, c-clamps (69%) were used, followed by sheets (16%), and binders (15%). The median age was significantly lower in patients treated with binders than in patients treated with sheets or c-clamps (26 vs. 47 vs. 42 years, p = 0.01). Sheet wrapping was associated with a significantly higher incidence of lethal pelvic bleeding compared to binder or c-clamp stabilization (23% vs. 4% vs. 8%). No significant differences between the study groups were found in sex, fracture type, blood haemoglobin concentration, arterial blood pressure, Injury Severity Score, the incidence of additional pelvic packing and arterial embolization, need of red blood cell transfusion, length of hospitalisation, and mortality.

Conclusions

The data suggest that emergency stabilization of the pelvic ring by binders and c-clamps is associated with a lower incidence of lethal pelvic bleeding compared to sheet wrapping.

Level of evidence

Level III.     

Perioperative management of external fixation in staged protocols: an international survey

Introduction

Despite the frequent use of external fixation, various regimes of antibiotic prophylaxis, surgical technique and postoperative pin care exist and underline the lack of current evidence. The aim of the study was to assess the variability or consensus in perioperative protocols to prevent implant-associated infections for temporary external fixation in closed fractures of the extremities.

Materials and methods

A 26-question survey was sent to 170 members of the Traumaplatform. The survey included questions concerning demographics, level of training, type of training and perioperative protocols as: antibiotic prophylaxis, intraoperative management, disinfection and postoperative pin site care. All responses were statistically analysed, and intraoperative measures rated on a 5-point Likert scale.

Results

The responses of fifty orthopaedic trauma and general surgeons (response rate, 29.4%) were analysed. The level of experience was more than 5 years in 92% (n = 46) with up to 50 closed fractures of the extremities annually treated with external fixation in 80% (n = 40). Highest consensus could be identified in the following perioperative measures: preoperative antibiotic prophylaxis with a second-generation cephalosporin (86%, n = 43), changing gloves if manipulation of the external fixator is necessary during surgery (86%, n = 43; 4.12 points on the Likert scale), avoid overlapping of the pin sites with the definitive implant site (94%, n = 47; 4.12 points on the Likert scale) and soft tissue protection with a drill sleeve (83.6%, n = 41).

Conclusion

Our survey could identify some general principles, which were rated as important by a majority of the respondents. Futures studies’ focus should elucidate the role of perioperative antibiotics and different disinfection protocols on implant-associated infections after temporary external fixation in staged protocols.

Level of evidence

This study provides Level IV evidence according to Oxford centre for evidence-based medicine.

     

Metaphyseal locking compression plate as an external fixator for the distal tibia

Purpose

Recently we coined the term supercutaneous plating using a locking compression plate (LCP) as an external fixator. The use of this technique in peri-articular areas is facilitated by the development of anatomical plates with various screw sizes. The purpose of this report is to describe our results using the metaphyseal locking plate (LCP) as an external fixator in the treatment of infected post-traumatic problems of the distal tibia.

Methods

Between August 2008 and January 2012 a total of seven patients underwent external plating (“supercutaneous plating”) of the distal tibia using a metaphyseal locking plate. Average age was 43 years (range 20–79). Six out of seven patients had a documented infection at the time of external plate application. All patients in this cohort were followed prospectively at regular intervals by the senior author (PK).

Results

The plate was in situ for an average of 17.5 weeks (range 6–60). There were no clinically significant pin site infections. In four patients the plate was kept in place until there was complete consolidation. In three patients the external plate was exchanged for formal internal fixation once the infection had subsided. At the latest follow-up (average 12.8 months, range 4–31), all patients were fully weight bearing with a fully healed tibia. All patients were infection-free with well-healed wounds.

Conclusion

Infection of the distal tibia after treatment of traumatic and post-traumatic problems is a challenging problem. It is common practice that after initial debridement and hardware removal, temporary bony stabilisation is provided by external fixation. Most external frames for the lower leg are bulky and cumbersome, causing significant problems for the patient. To circumvent these issues, we have successfully used an anatomically-contoured metaphyseal locking compression plate as external fixator in a series of seven patients for acute or post-traumatic problems of the tibia.     

Novel technique of reduction of a chronic atlantoaxial rotatory fixation using a temporary transverse transatlantal rod

Background context

Chronic atlantoaxial rotatory fixation (AARF) is uncommon as acute AARF is easily reduced either spontaneously or by conservative methods. Various anterior and posterior surgical approaches for a chronic AARF have been reported because of the difficulty encountered in obtaining reduction.

Purpose

To describe a novel technique of reduction of a chronic AARF using a temporary transverse transatlantal rod.

Study design

Technical report.

Methods

A 13-year-old girl presented with an 8-month-old chronic AARF with typical torticollis and “cock-robin” posture of the head with a normal neurology. As closed reduction with skull traction for 2 weeks failed to reduce the deformity, the patient underwent C1–C2 fusion. C1 lateral mass and C2 pedicle screws were inserted under computer navigation. A temporary transverse rod across the atlas and axis was placed to secure a three-column fixation to derotate the subluxed atlas into anatomical alignment. Rods were then connected between the C1 lateral masses and the C2 pedicle screws and fusion obtained with autologous iliac crest grafts.

Result

Anatomic reduction of the atlantoaxial region was obtained without neural compromise, and satisfactory fusion was observed at 6-months follow-up.

Conclusion

A temporary transatlantal rod provides a secure anchor point for easy maneuverability for reduction of a chronic AARF and has the advantage of being used even in the absence of the posterior arch of the atlas.     

Static monolateral external fixation for the Rolando fracture: a simple solution for a complex fracture

INTRODUCTION

Rolando fractures are often difficult to manage because of their inherent instability. We describe a simple technique for the treatment of this fracture using the principle of ligamentotaxis, with a static, two-pin external fixator spanning the trapeziometacarpal joint, and present the results of a single-surgeon case series.

METHODS

Eight consecutive patients (mean age: 32.8 years) with Rolando fractures were treated using a Hoffmann II® Micro small bone external fixator using blunt ended 2.0mm half pins, inserted into the trapezium and diaphysis of the first metacarpal. Functional outcome was assessed with the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at a mean time of 2.7 years following the fracture (range: 4 months – 6.0 years). The mean time to frame removal was 28 days.

RESULTS

There were three cases of superficial pin site infection. Follow-up x-rays at four months did not demonstrate significant joint incongruity or malunion in any case. The mean QuickDASH score was 7.95 and all patients returned to their previous levels of activity.

CONCLUSIONS

Although external fixation risks pin site infection, the results of this study support the use of spanning trapeziometacarpal external fixation for Rolando fractures as it reliably gives excellent functional outcomes.     

Joint distraction and early mobilization using a new dynamic external finger fixator for the treatment of fracture-dislocations of the proximal interphalangeal joint

Background

Dynamic external fixation is a useful treatment option for unstable fracture-dislocations of the proximal interphalangeal (PIP) joint, because it simultaneously reduces axial pressure load on the joint surface, maintains congruent joint reduction, and permits early joint motion. However, most current devices are large, hindering finger movement, and unstable. To address these problems, we developed a dynamic external finger fixator, named the Micro Ortho Fixator^®. The purpose of this study was to review the results of using the new external finger fixator to treat unstable fracture-dislocations of the PIP joint.

Expert surgeon's quiet eye and slowing down: expertise differences in performance and quiet eye duration during identification and dissection of the recurrent laryngeal nerve

Background

Long quiet eye (QE) duration is central to expertise in sports, while cognitive “slowing down” has been identified as a perceptual skill possessed by skilled surgeons. Eye-tracking evidence is lacking about the relationship of QE duration to slowing down in surgeons. The aim of this study was to examine QE duration, hand movement time (MT), fixation location, and fixation duration in highly experienced (HE) and less experienced (LE) surgeons.

Methods

A mobile eye tracker and camera recorded coupled gaze and hand movements. Performance was quantified by blinded review.

Results

HE surgeons were rated higher than LE surgeons but did not differ in operating time or MT. HE and LE surgeons differed in fixation duration on the ligament of Berry during phases 1 and 2 and QE duration on the recurrent laryngeal nerve in phase 2.

Conclusions

Long-duration fixation on the ligament of Berry and long-duration QE on the recurrent laryngeal nerve combined with no significant differences in MT provide empirical evidence that HE surgeons cognitively slow down more than LE surgeons during critical phases of the operation.     

Crossover external fixator for acetabular fractures: a cadaver study

Background

Dislocated acetabular fractures in polytraumatized patients are very challenging cases to deal with. Temporary stabilization by skeletal traction is difficult in these patients. A more effective solution can be an external fixation.

Objective

The authors designed a new crossover external fixation frame for acetabular fracture. The aim of this study is the biomechanical testing of this frame on human cadavers.

Methods

This study is an experiment on ten human cadavers. The acetabular fracture C2.2 was created. The stabilization effect of external fixation was compared with stabilization by large distractor. Femoral heads’ shifts caused by standardized manipulation with the cadaver were obtained from X-ray pictures.

Results

The mean total shift in stabilization technique by external fixation was 2.56 (1–4) mm. In stabilization by large distractor, the mean of the total shift after cadaver manipulation was 5.11 (0–10) mm. No significant differences were found between stabilization by external fixation and by large distractor (p = 0.066).

Conclusions

The stabilization of acetabular fracture C2.2 by a crossover external fixator is as effective as large distractor. The crossover external fixation could be a suitable solution for the temporary stabilization of acetabular fractures in polytraumatized patients. Subsequent studies including clinical trials are necessary to confirm the authors’ suggestion.     

Acromioclavicular joint reconstruction by coracoid process transfer augmented with hook plate

Background

Various techniques have been reported for the treatment of chronic acromioclavicular (AC) joint separation. The purpose of this study was to evaluate the results of surgical construction of coracoclavicular ligament using coracoid process transfer augmented with a hook plate fixation.

Materials and methods

Twenty-one patients treated with coracoid process transfer augmented with a hook plate fixation for chronic type III and V AC injuries were retrospectively analysed in 2003–2009. The age of the patients ranged from 23 to 58 years with an average age of 41.6 years. The patients were followed up clinically and radiographically, with an average of 33.0 months. Functional status and the ability to return to work were recorded during follow-up. Constant score and visual analogue scale (VAS) for pain were measured.

Results

The mean Constant score has increased from 70.9 points preoperatively to 90.7 points at follow-up. The mean VAS score has decreased from 4.7 preoperatively to 1.2 at follow-up. The average abduction was 172°, forward flexion was 170° and external rotation was 56°. There were 10 excellent results, 10 good results and one fair result. All patients had resumed their job or returned to original sport activity at mean 3.7 months postoperatively. No reduction loss was observed after plate removal and the final follow-up.

Conclusions

Despite retrospective nature of the study, the outcomes of surgical construction with process transfer augmented with hook plate fixation are promising for chronic type III and V AC injuries.

Level of evidence

Therapeutic level IV. Retrospective case series, treatment study.     

A comparison of external fixation and locked intramedullary nailing in the treatment of femoral diaphysis fractures from gunshot injuries

Introduction

We studied the safety and incidence of complications from the treatment of gunshot-induced femur diaphysis fractures with locked intramedullary nailing in comparison to external fixation.

Methods

Patients who had femoral diaphysis fracture operations due to gunshot injuries (107 femurs of 99 patients) between 2003 and 2014 were retrospectively reviewed, and 66 femurs of 60 patients were place into two groups (Group A: intramedullary nailing—38 femurs of the 36 patients; Group B: external fixator—28 femurs of 24 patients). The mean follow-up was 76.3 months (22–131). The study outcomes were patient complications, infection rate, union time, need for secondary surgery, functional assessment with lower extremity functional scale, and radiological evaluation with orthoroentgenograms.

Results

The mean age of the patients was 37.3 ± 7.4 years in Group A and 39 ± 6.1 years in Group B. There was no significant difference between the two groups in age, gender or follow-up. There were two deep infections (5.2%) in Group A and one deep infection (3.5%) in Group B. Delayed union was observed in four patients (10.5%) in Group A and in two patients (7.1%) in Group B. There was one non-union (2.6%) and one non-union (3.5%) in Group A and Group B, respectively. There was no significant difference between the two groups in incidence of union, delayed union or deep infection. The mean union time was 3.1 ± 2.5 months in Group A and 5.8 ± 1.4 months in Group B. The union time was significantly lower in the intramedullary nailing group (p = 0.023). There were no significant differences between the two groups in regards to radiological and functional evaluation.

Discussion

This study showed similar complication rates and functional results both for external fixator and intramedullary nailing for the treatment of femoral diaphysis fractures due to gunshot injuries.

Level of evidence

Level 3 retrospective comparative clinical study.

     

Pelvic and lower extremity immobilization for cloacal exstrophy bladder and abdominal closure in neonates and older children

Introduction

Successful bladder closure in cloacal exstrophy (CE) is best accomplished through a multidisciplinary team and attention to pre- and postoperative technique. This study from a high volume exstrophy center investigates outcomes and complications of primary and reoperative bladder closures in patients immobilized with spica cast or patients with external fixation (EF) and skin traction.

Fractures of the posterior wall of the acetabulum: Treatment using internal fixation of two parallel reconstruction plates

Objectives

Our aim was to evaluate the efficacy of the treatment method using internal fixation of parallel reconstruction plates for the posterior wall of the acetabulum fractures.

Design

Randomised, prospective.

Setting

Level I trauma centre. Patients/participants: 57 patients with posterior wall fractures of the acetabulum in our department from 2007 to 2010 were treated operatively using this technique. Intervention: internal fixation of two parallel reconstruction plates was used in this study. One of the plates was near the border of acetabulum. The other was parallel to the former one and was located to stress concentrated area. Main outcome measurements: The clinical outcome was evaluated using the clinical grading system and radiological outcome was evaluated according to the criteria described by Matta. In addition, complications were researched in this study.

Results

The percentages of the clinical excellent-to-good and fair-to-poor results were 93.0% and 7%, respectively. We found that clinical outcome had no correlation with age, operation time from injury to operation, nor had correlation with hip dislocation, comminuted fracture condition and marginal compression fracture. Anatomical reduction was significantly correlated with excellent-to-good clinical outcome. Necrosis of the femoral head and heterotopic ossification were prone to decline the outcome of acetabular fractures despite good fracture reduction.

Conclusions

the internal fixation of two parallel reconstruction plates facilitated rigid fixation and avoided fracture fragment injury, was an effective and reliable alternative method to treat fractures of the posterior wall of the acetabulum.