Management of paediatric tibial fractures using two types of circular external fixator: Taylor spatial frame and Ilizarov circular fixator

Background

The use of circular fixators for the treatment of tibial fractures is well established in the literature. The aim of this study was to compare the Ilizarov circular fixator (ICF) with the Taylor spatial frame (TSF) in terms of treatment results in consecutive patients with tibial fractures that required operative management.

Method

A retrospective analysis of patient records and radiographs was performed to obtain patient data, information on injury sustained, the operative technique used, time duration in frame, healing time and complications of treatment. The minimum follow-up was 24 months.

Results

Ten patients were treated with ICF between 2000 and 2005, while 15 patients have been treated with TSF since 2005. Two of the 10 treated with ICF and 5 of the 15 treated with TSF were open fractures. All patients went on to achieve complete union. Mean duration in the frame was 12.7 weeks for ICF and 14.8 weeks for the TSF group. Two patients in the TSF group had delayed union and required additional procedures including adjustment of fixator and bone grafting. There was one malunion in the TSF group that required osteotomy and reapplication of frame. There were seven and nine pin-site infections in the ICF and TSF groups, respectively, all of which responded to antibiotics. There were no refractures in either group.

Conclusion

In an appropriate patient, both types of circular fixator are equally effective but have different characteristics, with TSF allowing for postoperative deformity correction. Of concern are the two cases of delayed union in the TSF group, all in patients with high-energy injuries. We feel another larger study is required to provide further clarity in this matter.

Level of evidence

Level II—comparative study.     

Accuracy of complex lower-limb deformity correction with external fixation: a comparison of the Taylor Spatial Frame with the Ilizarov ring fixator

Purpose Circular external fixators have several advantages over other surgical options in the treatment of limb length discrepancy and axial deformity. The innovative Taylor Spatial Frame (TSF) combines a rigid hexapod fixation system with the support of a web-based software program, and thus offers the possibility of simultaneous corrections of multidirectional deformities. Whilst there is still some scepticism of many Ilizarov device users about the advantages of the TSF, the purpose of the study was to perform a comparison between the TSF and the Ilizarov ring fixator (IRF) with regard to the accuracy of deformity correction in the lower limb. Methods Two hundred and eight consecutive deformity corrections in 155 patients were retrospectively evaluated. There were 79 cases treated with the IRF and 129 cases treated with the TSF. The mean age of the patients at the time of surgery was 13.2 years (range; 2–49 years). Standing anteroposterior and lateral radiographs were evaluated preoperatively and immediately after removal of the frames. The final result was compared to the preoperatively defined aim of the deformity correction. According to the treated count of dimensions, we differentiated four types of deformity corrections. The results were graded into four groups based on the persisting axial deviation after removal of the frame. Results The aim of the deformity correction was achieved in a total of 90.7% in the TSF group, compared to 55.7% in the IRF group. On the basis of the count of dimensions, the TSF achieved obviously higher percentages of excellent results (one dimension: TSF 100%; IRF 79.3%; two dimensions: TSF 91.8%; IRF 48.6%; three dimensions: TSF 91.1%; IRF 28.6%; four dimensions: TSF 66.7%; IRF 0%). In addition, the degree of the persisting deformity increased with the number of planes of the deformity correction. Conclusions The TSF allowed for much higher precision in deformity correction compared to the IRF. In two-, three- and four-dimensional deformity corrections in particular, the TSF showed clear advantages. This may derive from the TSF-specific combination of a hexapod fixator with the support of an Internet-based software program, enabling precise simultaneous multiplanar deformity corrections.     

Severe radius shortening and deformity secondary to epiphyseal arrest corrected by Ilizarov fixator: a case report

Abstract Authors discuss a case in which radius shorthening (about 55 mm) and the associated deformity (about 48 degrees), secondary to epiphyseal arrest, were particularly severe. The patient was treated by the Ilizarov fixator frame and the whole treatment lasted 229 days, from surgical operation to beginning of rehabilitation. An adequate clinical and radiographical correction was obtained. During the treatment the patient did not suffer from any major complications. The case presented shows how severe deformity and shortening of the radius secondary to epiphyseal arrest can be very adequately treated by using the Ilizarov frame but a careful technique and a prolonged outpatient treatment, with frequent clinical controls, are necessary.     

组合式外固定器治疗合并患肢短缩的足踝部畸形

背景：传统的足踝部畸形的矫正需要通过手术来完成,术后需要“静态”的维持。Ilizarov技术遵循的“张力-应力法则”和“牵拉组织再生技术”,在一定程度上打破了传统的矫形模式。目的：探讨Ilizarov技术治疗合并患肢短缩的足踝部畸形的临床疗效。方法：回顾分析2006年8月至2012年10月采用Ilizarov技术治疗的17例下肢及足踝部畸形患者的临床资料。其中男10例,女7例,年龄20~37岁,平均27.5岁。脊髓灰质炎后遗症导致患肢短缩合并足踝负重位外翻畸形患者5例,先天性马蹄内翻足合并患肢短缩7例,高弓足合并患肢短缩3例,跟腱挛缩、仰趾畸形合并患肢短缩2例。所有患者在有限手术重建足踝部软组织平衡或者截骨矫正畸形后安装Ilizarov组合式外固定支架,同时做胫骨的延长。结果：17例患者佩戴Ilizarov支架的时间是16~44周,足踝部矫形支架在3~6个月矫形满意、骨融合确实后单独拆除,骨延长支架根据需要继续佩戴。所有患者都获得随访,随访时间6~48个月,患肢延长2~6 cm,延长段骨矿化满意,足踝部矫形满意。足踝功能参照AOFAS评分：术前（43±5.1）分,术后（76±7.2）分。结论：对于各种原因导致的合并下肢短缩的足踝部畸形的矫治,Ilizarov技术灵活的器械组合可同时完成多方向的畸形矫正,在矫正畸形的同时实施骨延长术。     

Ilizarov外固定架治疗创伤性马蹄足

目的探讨应用Ilizarov外固定支架治疗创伤性马蹄足的疗效。方法2003年2月～2005年8月应用Ilizarov外固定架治疗17例创伤所致马蹄足患者。将组装好的Ilizarov外固定架按照Ilizarov的穿针固定原则安装在患侧小腿和足部。术后3d开始转动螺纹杆上的螺母,第1周旋转螺母2～4圈/d,4次/d;1周后旋转螺母1～2圈/d,4次/d,分别逐渐缩短和延长前、后螺纹杆,矫正马蹄足畸形。用伊氏架将踝关节固定在中立位2～3个月。去除外固定架后让患者逐渐增加负重量直至完全负重。不负重时穿戴支具保持踝关节处于中立位至少3个月。结果17例患者均得到随访,平均随访10个月(7～14个月)。术后4～6周踝关节恢复到中立位。平均带外固定架14.5周(10～16周)。无血管、神经损伤。3例各1处针道轻度感染,对症处理后感染消失。1例诉矫正过程中疼痛,术后10周去除外固定架,去除外固定架后6周时僵直在跖屈20°。1例去除外固定架4个月后僵直在跖屈10°。1例小腿前后肌群损伤严重合并胫骨骨缺损重建术后踝关节矫正到中立位后1.5个月行踝关节融合术,融合术后3个月去除外固定架。其余14例达到0°全足负重,行走时无明显足下垂。2例负重时疼痛。踝关节背伸肌群功能存在的患者,踝关节可主动背伸10°。结论Ilizarov外固定架是治疗创伤性马蹄足的微创技术。     

Clinical value of the Taylor Spatial Frame: a comparison with the Ilizarov and Orthofix fixators

Purpose  

Evaluation of the advantages and limitations of the Taylor Spatial Frame (TSF) with regard to the healing index (HI), distraction–consolidation time (DCT), accuracy of correction complications, and cost of the device.     

Ilizarov principles of deformity correction

Ilizarov frames provide a versatile fixation system for the management of bony deformities, fractures and their complications. The frames give stability, soft tissue preservation, adjustability and functionality allowing bone to realise its full osteogenic potential. It is important that we have a clear and concise understanding of the Ilizarov principles of deformity correction to best make use of this fixation system. In this review article, the history of Ilizarov frame, the basic sciences behind it, the mechanical principles governing its use and the clinical use of the fixation system are discussed.     

Clinical outcomes in pediatric tibial lengthening and deformity correction: a comparison of the Taylor Spatial Frame with the Orthex Hexapod System

PurposeComparison of two hexapod frame systems in paediatric tibial deformity correction; the Taylor Spatial Frame (TSF) and Orthex Hexapod System.MethodsPaediatric patients with congenital and acquired tibial deformities treated with either TSF (between 2014 and 2016) or Orthex (between 2017 and 2019) frames were included in a retrospective comparative study. Outcome measures were healing index, pin infection rate, regenerate quality and density, software residual rate, deformity correction accuracy, strut exchanges and quality of life (QoL).ResultsThe TSF group had 17 patients (18 frames) and the Orthex group had 21 patients (25 frames). The most common indications for tibial deformity correction were fibular hemimelia (14) and septic or traumatic growth arrest (8). The median time in frame was 230 days (TSF) versus 203 days (Orthex) (p= 0.06). The mean lengthening achieved was 54 mm (TSF) and 51 mm (Orthex) (p = 0.41). The healing index was 41 days/cm (TSF) versus 43 days/cm (Orthex) (p = 0.70). Pin site infections occurred more in the TSF cohort (40%) than in the Orthex cohort (18%) (p < 0.001). The regenerate in the Orthex group showed higher density at three months (p = 0.029) and was more homogenous (p = 0.023) at six months after frame application. Strut exchanges were less frequent with the Orthex system (p < 0.0001). QoL measures were similar in both cohorts (p = 0.92).ConclusionsThis is the first study to compare two hexapod designs in paediatric orthopaedics. The Orthex system showed superiority in regenerate quality and a significant reduction in pin site infection rates. Both systems delivered predictable and accurate limb deformity correction.Level of evidenceIII     

A Novel technique of three-ring Ilizarov fixator frame in gap non-union of tibia

IntroductionGap non-union of tibia occurring mostly after trauma and many times complicated by infection, is a difficult problem to treat. The study aimed to assess the outcome of the three-ring construct of the Ilizarov fixator frame in the management of gap non-union of the tibia.MethodsThis retrospective study included 30 patients of gap non-union of tibia operated from April 2016 to March 2019 with a three-ring Ilizarov fixator frame and follow-up done till March 2021. The mean age was 39.27 (range 10–66) years. The results were assessed by the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. MPTA, PPTA, and LDTA after removal of the frame were also measured.ResultsOut of the total 30 cases, all the patients showed complete union. The Ilizarov fixator was kept for an average period of 11.43 months and the mean defect size was 7.17 (range 2–12) cm. All patients were followed up for an average period of 39.36 (range 24–54) months. According to the ASAMI score bone/radiological results, 27 were classified as excellent, 2 as good, and 1 as poor. Functionally 28 were graded as excellent and the remainder as good. The normal ranges of MPTA, LDTA & PPTA were also achieved in a majority (80%) of patients.ConclusionOur results after using only a three-ring Ilizarov fixator frame are almost equivalent to earlier studies and have advantages such as less weight, better patient compliance, superior radiographic visualization, easy mobilization, and reduced costs. Ilizarov ring fixator remains an excellent treatment modality for tibial non-union with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.     

The Ilizarov fixator in trauma: a 10-year experience

We reviewed the clinical results of 332 fractures treated with the Ilizarov external fixator between 1984 and 1993. The locations of the involved bones were: tibia, 247 (including 28 with tibial pylons); femur, 47; humerus, 21; forearm, 12 and calcaneus, 5. The clinical outcomes of this series were retrospectively evaluated by radiological and clinical rating systems. In the tibial fractures, results in 71.1% were categorized as excellent or good, without deep infection; 63.3% of the tibial pylon fractures, mostly open, also showed excellent or good results. In the femoral fractures, which were mostly localized at the metaphysis or distal epiphysis, 72% showed excellent or good results, but the patients com-monly complained of knee stiffness. Limitations of range of movement (ROM) in the elbow and the wrist were common in patients with forearm fracture, but ROM was regained after physical therapy. According to the clinical results of the present study, we believed that Ilizarov external fixation was best indicated for tibial fractures, because of its advantage of allowing early weight-bearing. Ilizarov external fixation was also best indicated for: (1) open fractures, (2) comminuted fractures, (3) intra-articular fractures, and (4) fractures with bony defect. Received for publication on Oct. 12, 1998; accepted on Sept. 7, 1999     

Versatility of Ilizarov external fixator in management of foot and ankle deformity

Abstract Traditional methods of correcting foot deformities may be difficult to apply in some conditions, especially in presence of other lower limb problems. This study discusses the versatility of Ilizarov external fixator (IEF) in such cases. It was performed in 34 foot deformities in 33 patients, treated with IEF between 1997 and 1999. The average age of the patients was 15 years. The aetiology of foot deformity was recurrent congenital talipes equinovarus (n=10), neglected congenital talipes equinovarus (n=3), poliomyelitis (n=9), post-traumatic deformity (n=6), post-burn deformity (n=1), arthrogryposis multiplex congenita (n=2), and cerebral palsy, fibular hemimelia and tibial hemimelia (1 case each). Unconstrained IEF was applied for the foot in all cases. The leg construct was applied according to the target: foot deformity alone or associated with other leg problems. IEF construct was extended to the femur in cases with flexion knee deformity and hinges were added. Follow-up continued until overcorrection was maintained for the same period of correction followed by an appropriate cast for 8 weeks. The mean time for deformity correction and Ilizarov stabilisation was 16 weeks, and follow-up period was 23.1 months. The results were good in 31, fair in 2 and bad in 1. Additional procedures were performed, most often in the same operating time. Primary arthrodesis was done for 5 feet and for one revision of failed previous arthrodesis. Open corrective osteotomy for arthrodesis was performed in 2 cases. Two females were treated for flexion knee with bloodless technique. Wire-site infections, wire cut-through a calcaneum and metatarsals and fracture post-IEF removal were observed. Although it is technically difficult, IEF can be considered an effective and versatile way of treating foot and other associated lower limb problems through one-reconstruction attack.     

Treatment of a fibular autograft non-union with a resulting deformity by stabilization, progressive correction and callotasis using an Ilizarov fixator: a case study

Bone tumours present a challenge to reconstructive surgery when the tumour breaches the physeal and periphyseal region of the growing bone. Though a host of options are available, these are not without complications. We report one such case of osteosarcoma of the tibia treated initially with wide resection of the tumour and intercalary fibular strut grafting using plate and screws. The operation was complicated by a non-union at the proximal tibio-fibular autograft junction. This leads to a multiplanar deformity with severe procurvatum at the proximal tibio-fibular graft junction, which was successfully treated by callotasis using an Ilizarov fixator. Appropriate consent was obtained from the patient and parents to publish this case report.     

High tibial osteotomy in medial compartment osteoarthritis and varus deformity using the Taylor spatial frame: early results

We report the early results of high tibial osteotomy (HTO) in medial compartment osteoarthritis (OA) and varus deformity using the Taylor spatial frame (TSF). Between October 2005 and April 2007, 9 patients with medial compartment OA and varus deformity underwent TSF application and medial opening wedge HTO. Pre- and post-operative Oxford knee scores, SF-12 and visual analogue pain scores were recorded along with radiographic outcomes. Median follow-up was 19 months (range 15–35). Mean age at operation was 49 years (range 37–59). The median time spent in the frame was 18 weeks (range 12–37). The mean preoperative Oxford knee score was 28.7. This improved to a mean of 35.4 post-operatively (P = 0.0142). 6 (67%) patients had a documented pin-site infection. With TKR as an end point, the survival rate of HTOs was 88.9% at a median of 19 months follow-up. This study demonstrates that in selected patients the TSF provides a viable treatment option for performing HTO in medial compartment OA with varus deformity.     

泰勒空间外架技术结合足部“U”形截骨治疗创伤后马蹄内翻足畸形

目的 探讨泰勒空间外架（Taylor spatial frame,TSF）技术结合足部“U”形截骨治疗创伤后马蹄内翻足的临床疗效。方法 回顾性分析2016年7月至2019年7月应急总医院收治的42例创伤后马蹄内翻足病人的临床资料,其中男31例,女11例,平均年龄为24.3岁。马蹄足畸形平均跖屈70°。术前测量畸形参数。术中依据Ilizarov穿针原则安装TSF,足部“U”形截骨同期行微创软组织松解术。术后根据处方调整TSF,行康复训练。截骨处愈合后去除外固定架,佩戴支具。定期门诊复查,记录疼痛视觉模拟量表（visual analogue scale, VAS）评分及美国足踝外科医师协会（American Orthopaedic Foot and Ankle Society,AOFAS）踝与后足功能评分。结果 本组平均手术时间为85.6 min（60~110 min）,术中平均出血量为15.5 mL（10~20 mL）。42例病人均获随访,平均随访时间为18个月（12~24个月）。术后平均40.7 d（26~80 d）踝关节恢复背伸5°~10°;佩戴外支架行走时间平均为12.7周（10~16周）。5例病人6处针道轻度感染。1例发生近端半针断裂。所有病人无血管、神经损伤。3例患足复发跖屈畸形,约10°。随访结束时所有病人均可达到不扶拐步行状态。末次复诊时AOFAS评分,优18例,良18例,可4例,差2例,优良率为85.7%;AOFAS评分为（89.4±8.0）分,较术前（52.7±1.0）分显著增加,差异有统计学意义（t=-6.085,P=0.010）。VAS评分为（2.8±1.3）分,较术前的（6.7±1.4）分明显降低,差异有统计学意义（t=0.464,P=0.025）。结论 TSF结合足部“U”形截骨是治疗创伤后马蹄内翻足畸形的有效方法。     

Preliminary experience with motorized distraction for tibial lengthening

Limb lengthening by callus distraction is commonly performed with the use of external fixation. Lengthening is routinely performed by the patient through small increments throughout the course of a day. Ilizarov has shown that both the rate and frequency of distraction are important factors in the quality of osteogenesis. We report the effect of motorized high frequency distraction for tibial lengthening in comparison with manual low-frequency distraction at the same rate. Manual distraction (0.25 mm four times a day) in a group containing 43 tibiae was compared with motorized distraction (1/1,440 mm 1,400 times a day) in a group containing 27 tibiae. There was no significant difference in time to union or in the incidence of complications.     

Botulinum toxin type A for lower limb lengthening and deformity correction: A systematic review and meta-analysis

BackgroundBotulinum toxin type A (BTX-A) is the most popular therapeutic agent for muscle relaxation and pain control. Lately, BTX-A injection received great interest as a part of multimodal pain management for lower limb lengthening and deformity correction. This systematic review aimed to determine the role of BTX-A injection in pain management for during lower limb lengthening and/or deformity correction.MethodsWe searched Medline, Embase, and CENTRAL. We included randomized controlled trials (RCTs) that compared the BTX-A injection to placebo for individuals undergoing lower limb lengthening and/or deformity correction. We sought to evaluate the following outcomes: pain on visual analogue scale (VAS), range of motion parameters, average opioid consumption, and adverse events. The standardized mean difference (SMD) was used to represent continuous outcomes while risk ratio (RR) was used to represent dichotomous outcomes.ResultsA total of 4 RCTs that enrolled 257 participants (337 limbs) deemed eligible. Adjuvant BTX-A injection showed a significant reduction in post-operative pain compared to placebo (SMD = −0.28, 95% CI –0.53 to −0.04). No difference was found between BTX-A injection and placebo in terms of range of motion parameters, average opioid consumption, or adverse events after surgical limb lengthening and/or deformity correction (RR = 0.77, 95% CI –0.58 to 1.03).ConclusionsAdjuvant BTX-A injection conferred a discernible reduction in post-operative pain during surgical limb lengthening and/or deformity without increasing the risk of adverse events.Prospero registration numberCRD42021271580.