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.     

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.     

A comparative study of the correction of femoral deformity between the Ilizarov apparatus and Ortho-SUV frame

Purposes

This study compared the six-axis external fixator Ortho-SUV Frame (OSF) and the Ilizarov apparatus (IA) in femoral deformity correction. Our specific questions were: (1) which of the fixators (OSF or IA) provides shorter period of femoral deformity correction, and (2) which of the fixators (OSF or IA) provides better accuracy of correction.

Methods

We retrospectively analysed 123 cases of femoral deformities (127 femora): 45 (47) treated with OSF (20 male and 27 female) and 78 (80) with IA (53 male and 27 female). The average age in the OSF group was 34.6 (range, 18–66) and in the IA group 35.8 (range, 18–76). All the deformities were categorized according to the number of planes and deformity components as simple, middle and complex deformities.

Results

Elimination of simple deformities in the IA group took 58.3 ± 21.4 days, EFI 58.8 ± 39.8 days/cm, and lengthening was 4.6 ± 1.98 cm. Middle deformities were 71.3 ± 26.2, 61.9 ± 30.3 and 4 ± 2, respectively. In complex deformities we had 105.2 ± 21.8, 79.3 ± 35.4 and 3.2 ± 1.45, respectively. Normal alignment was achieved in 55.0 % of cases in IA. In 45.0 % of cases we had residual deformity. Elimination of simple deformations in the OSF group took 55.3 ± 12.8 days, EFI 47.5 ± 23 days/cm, and lengthening 4.5 ± 1.1сm. Middle deformities were 43.6 ± 18.9, 59 ± 14.6 and 3.6 ± 2, respectively. In complex deformities we had 44.9 ± 11.5, 57.5 ± 9.4 and 3.6 ± 1.7, respectively. In the OSF group normal alignment was achieved in 85.1 %. In 14.9 % there was residual deformity.

Conclusion

Using OSF simplifies deformity correction and reduces its period by 2.3 times in complex deformities and by 1.6 times in middle deformities. Accuracy of correction with OSF was significantly higher than correction with IA.     

外固定支架治疗严重胫腓骨开放性骨折

目的探讨半环槽式外固定器治疗严重胫腓骨开放性骨折的临床疗效。方法回顾性分析自1996年1月-2006年10月收治的76例GustiloIII型严重胫腓骨开放性骨折患者，其中ⅢA型4l例，ⅢB型22例，ⅢC型13例。其中57例伤口行彻底清创后采用直接缝合、游离植皮或局部皮瓣、肌皮瓣转位，一期闭合创面；19例经抗感染、局部换药后二期闭合创面，骨折均采用半环槽式外固定器进行固定。结果随访8—56个月，平均26个月。其中创面感染15例，经抗感染、换药、皮瓣转位后治愈；针道感染9例，经换药后治愈；未并发骨髓炎。骨折愈合时间3—15个月，平均6．3个月，其中4例延迟愈合；4例骨不连和2例骨缺损患者经再次手术加压固定或结合肢体延长术后骨愈合。结论半环槽式外固定器采用多向穿针三维立体固定，治疗GustiloⅢ型严重胫腓骨开放性骨折具有操作简单、固定稳固、微创、有利于控制感染及促进骨折愈合的优点，但仍需防治针道感染、骨不连、骨缺损等并发症。     

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.     

改进植骨方式结合锁定加压钢板治疗胫骨中下段骨不连

目的：探讨改进植骨方式结合锁定加压钢板治疗胫骨中下段骨不连的方法.方法：自2011年1月至2012年12月,采用改进植骨方式结合锁定加压钢板治疗12例胫骨中下段骨不连患者,其中男8例,女4例;年龄20～69岁,平均47岁.初次外伤至此次骨不连手术时间为9个月～5年,平均1年7个月.伤后行外固定支架治疗4例,钢板内固定治疗6例,髓内钉治疗2例,其中2例来院时已出现钢板、螺钉断裂.11例为非感染性骨不连,1例为感染性骨不连.术前X线及CT检查提示全部病例有不同程度的死骨、硬化骨形成.术中记录手术时间、出血量,术后观察伤口愈合情况,并根据术后X线片复查情况评价骨愈合时间.术后10个月参照Johner-Wruhs标准对踝关节功能进行评分.结果：手术时间90～185 min,平均（125.00±20.15） min;术中出血量225～750ml,平均（415.00±120.00） ml.12例均获随访,时间10个月～2.5年,平均1.5年.术后复查X线片提示,全部病例4个月内骨断端形成骨桥样骨连接,3例6个月达到类骨板样骨愈合,其余9例术后8～12个月达到类骨板样骨愈合.术后未出现伤口感染,神经、血管损伤,钢板、螺钉断裂等手术并发症.术后10个月根据Johner-Wruhs标准进行踝关节功能评价,优10例,良1例,可1例.结论：采用改进植骨方式结合锁定加压钢板,在骨不连断端充分加压的基础上建立骨断端多点支撑,实现有效固定是治疗胫骨中下段骨不连的有效方法.     

Cigarette smoking influences the clinical and occupational outcome of patients with tibial shaft fractures

Tibial shaft fracture is one of the most common types of bone fracture in young patients. In this prospective clinical cohort study, we investigated the effects of cigarette smoking on the clinical, functional, psychosocial and occupational outcomes after isolated lower-leg fracture.We examined 85 patients, including 61 men and 24 women, with a collective mean age of 46 years (range: 18–84 years). Thirty-nine patients had never smoked (G1) and 45 patients were current or previous smokers (G2).The G2 group displayed a significantly increased risk for delayed union or nonunion (G1 = 3 patients, G2 = 18 patients; P = 0.0007) and increased time required for fracture healing (mean times: G1 = 11.9 weeks, G2 = 17.4 weeks; p = 0.003) and a markedly increased time out of work (mean times: G1 = 16.1 weeks, G2 = 21.5 weeks; p = 0.1177 (not significant)). The 18 negatively affected patients in G2 displayed a significant increase in the time required for fracture healing and time out of work (26 weeks (p = 0.02) and 31 weeks (p = 0.03), respectively). G2 group members had a 3- to 18-fold higher risk of impaired bone healing. The mean Short Form 36 (SF-36) was similar in both groups. The physical-function scores were G1 = 49.6 and G2 = 48.6; the mental scores were G1 = 52.7 and G2 = 52.8.These findings indicate that smoking significantly increases the risk of impaired fracture healing, which has clinical and occupational consequences for the affected patients. Based on our data, we developed a score to estimate the individual risk of impaired fracture healing. These types of patients must be informed and closely monitored to determine the need for timely re-intervention with additional therapy, such as BMP s or ultrasound.     

皮瓣联合外固定架治疗胫骨骨折伴小腿软组织缺损

目的 探讨小腿软组织缺损伴有胫骨骨折或骨缺损、骨髓炎的有效治疗方法。方法 对45例小腿大面积软组织缺损同时伴有胫骨骨折或骨缺损、骨髓炎的病例，采用游离皮瓣腓肠神经营养血管皮瓣和筋膜皮瓣及腓肠肌内、外侧头肌皮瓣转位等加外固定架结合的方法治疗。结果 除1例骨髓炎外，全部病例小腿创面均愈合。采用半环架与皮瓣结合治疗37例，其骨折愈合时间为6～14个月；力臂式外固定架的6例愈合时间为1年～2年8个月；组合式外固定的2例愈合时间为1年2个月。结论 半环架与皮瓣结合是治疗小腿大面积软组织缺损伴有骨折、骨缺损或骨髓炎的一种良好方法。     

外固定支架治疗胫腓骨下端波及踝关节的严重粉碎性骨折

目的 探索一种治疗胫腓骨下端波及踝关节严重粉碎性骨折较为理想的方法。方法 应用改良Bastiani单臂多功能外固定支架治疗胫腓骨下端波及踝关节的严重粉碎性骨折47例,跟骨牵引石膏外固定治疗22例,切开复位钢板螺钉内固定治疗17例,并将其术后随访的疗效进行比较。结果 术后随访6个月-3年,平均15个月。根据病人骨折愈合情况,踝关节活动度,关节面平整度及检查患者快速行走200m(100m/min),再登50级楼梯后踝关节疼痛、肿胀及其他不适的严重程度评价疗效。其优良率为：应用外固定支架治疗为74.5%,跟骨牵引石膏外固定治疗为57.1%,切开复位钢板螺钉内理想、固定较牢固、应力遮挡小、手术操作简单、病人可早期下床活动等优点,尤其适用于伴有严重皮肤软组织损伤及缺损的病人。     

胫腓骨骨折钢板内固定在西藏高原地区的应用价值及策略

胫腓骨骨折在四肢长骨骨折中最常见，也是最常见的开放性骨折。随着带锁髓内钉技术的发展，受到广大学者推崇，在胫腓骨骨折中的应用愈来愈广。但钢板固定在很多医院，尤其是基层医院是常用治疗方法，仍有较大应用价值。以往考虑到创口闭合困难及担心钢板外露等因素，把钢板置于胫骨外侧肌肉下，现仍为很多医生所沿用。     

Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame

The closure of small-to-moderate-sized soft tissue defects in open tibial fractures can be successfully achieved with acute bony shortening. In some instances, it may be possible to close soft tissue envelope defects by preserving length and intentionally creating a deformity of the limb. As the soft tissue is now able to close, this manoeuvre converts an open IIIb to IIIa fracture. This obviates the need for soft tissue reconstructive procedures such as flaps and grafts, which have the potential to cause donor-site morbidity and may fail. In this article, the authors demonstrate the technique for treating anterior medial soft tissue defects by deforming the bone at the fracture site, permitting temporary malalignment and closure of the wound. After healing of the envelope, the malalignment is gradually corrected with the use of the Taylor Spatial Frame. We present two such cases and discuss the technical indications and challenges of managing such cases.     

双矩钉髓内固定治疗胫腓骨骨折

自1998年3月-2000年12月,作者应用双矩钉(两枚矩形髓内钉)髓内固定治疗胫腓骨骨折196例计201侧,经随访180例计185侧,疗效满意,报告如下。1 临床资料 本组男129例,女67例;年龄16～80岁,平均38.9岁。骨折部位:中上1/3骨折27侧,中段骨折109侧,中下1/3骨折65侧,其中单纯胫骨骨折55例,胫腓双骨折136例,双小腿胫腓骨折5例。骨折类型:闭合性骨折115侧,开放性骨折     

小切口有限内固定结合外固定架治疗胫腓骨骨折

胫腓骨骨折在长管状骨骨折中是较为常见的一种，胫骨全长的内侧1／3面仅位于皮下而无肌肉组织保护，骨折易成为开放性，污染常较严重。对胫腓骨骨折的治疗有多种方法，我科自1998年至2005年5月对324例胫腓骨骨折中的86例应用小切口有限内固定结合外固定支架固定取得满意疗效，现报告如下。     

锁定接骨板治疗胫骨中下段关节外骨折术后延迟愈合的危险因素分析

目的:探讨锁定接骨板治疗胫骨中下段关节外骨折术后延迟愈合的危险因素。方法:回顾性分析2013年1月至2018年12月手术并获得随访的135例胫骨中下段关节外骨折病例,男85例,女50例;年龄19～80岁;所有病例使用锁定接骨板进行治疗。根据骨折愈合情况分为正常愈合组、延迟愈合组。对14项可能影响骨折愈合的因素逐一进行单因素分析,再将单因素分析结果有显著性的因素进行二元Logistic回归分析,从而明确骨折延迟愈合的危险因素。结果:135例患者中共发生骨折延迟愈合13例。单因素分析显示骨折延迟愈合与年龄、是否吸烟、复位方式、是否贫血、术前准备时间相关。回归分析显示年龄[OR=0.849,95%CI(0.755,0.954),P=0.006]、是否吸烟[OR=0.020,95%CI(0.002,0.193),P=0.001]、复位方式[OR=23.924,95%CI(2.210,258.943),P=0.009]、是否贫血[OR=0.016,95%CI(0.001,0.289),P=0.005]是骨折延迟愈合的影像因素。结论:低龄、吸烟、闭合复位、贫血是锁定接骨板治疗胫骨中下段关节外骨折术...     

应用羟基磷灰石涂层钉和外支架治疗中老年开放性胫骨、肱骨骨折

目的 总结应用外固定支架和羟基磷灰石涂层钉治疗开放性中老年胫骨、肱骨骨折的临床经验。方法 分析2002年1月～2003年7月55岁以上肱骨和胫骨开放性骨折患者18例。应用单侧外固定支架，固定钉使用螺纹上覆盖有羟基磷灰石涂层的不锈钢钉(Oahofix，Italy)，常规使用抗牛素链珠。患者均予测定骨密度并服用钙剂。部分患者应用治疗骨质疏松药物。结果 17例患者获得超过5个月以上的随访，平均随访8，2个月。16例患者在术后平均18周内(98～159d)达到临床愈合：1例ⅢA型开放性骨折有局部感染和骨不连。无支架、螺钉松动发牛。结论羟基磷灰石涂层钉应用于外固定支架治疗中老年开放性胫骨、肱骨骨折，具有稳定性好、康复早的特点，是一种恰当的治疗骨质疏松性骨折的手术方法一有必要对此进行更多病例的前瞻性研究。     

A modified technique for the treatment of intra-articular calcaneal fractures with the use of the Ilizarov apparatus

The management of intra-articular calcaneal fractures during the past years has been ranged from the nihilistic approach of no active treatment to open reduction and internal fixation (ORIF) or even to early subtalar arthrodesis. The management of such fractures with the use of circular external fixators in a closed fashion or in combination with minimal approach is demonstrated in our study. The midterm results of 36 intra-articular calcaneal fractures treated between 1996 and 2003 with the use of the Ilizarov apparatus according to our modified operative strategy are presented. In treating calcaneal fractures, the classic Essex-Lopresti classification into depression and tongue type has been proved very useful in our hands. While the depression-type fractures can be reduced through skeletal traction and the above-mentioned minimal approach, tongue-type fractures can cause difficulties in reducing and especially maintaining the reduction of the tongue fragment. Especially for these fractures, a combined technique was applied by reducing the fracture with Steinmann pins according to the Essex-Lopresti method and incorporating them into the Ilizarov apparatus. This technique appears to be a lot easier and more accurate than the alternative bent-wire technique for reducing and holding down a tongue fragment. The original Essex-Lopresti manipulation alone with plaster immobilization does not allow weight bearing and is associated with regional osteoporosis. Apart from the Essex-Lopresti classification, the material was also categorized by the widely accepted Sanders CT classification for comparison of our results to those of the literature. The SF-36 patient-oriented general health status questionnaire was utilized before, during, and after the treatment period to assess patients satisfaction levels. We propose this operative strategy as an option for the treatment of all calcaneal fractures.The authors have not received and will not receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.     

Systematic review and meta-analysis of the additional benefit of local prophylactic antibiotic therapy for infection rates in open tibia fractures treated with intramedullary nailing

Purpose

This analysis compared the rate of deep wound infections in patients with open tibia fractures, treated with intramedullary nails, receiving additional locally-delivered antibiotics to those receiving standard care.

Methods

Two systematic literature searches identified studies reporting infection rates in patients treated with intramedullary nails for tibia fractures receiving systemic antibiotics only (search one) and in patients receiving adjunctive locally-administered antibiotics peri-operatively at the tissue-implant interface (search two). After applying inclusion and exclusion criteria, 14 and seven papers from searches one and two, respectively, were included in meta-analyses.

Results

The absolute rate of infection was lower for all Gustilo-Anderson grades of tibia fractures when local antibiotics were administered as adjunctive prophylactic therapy. For severe fractures, classified as GAIII fractures, patients receiving systemic antibiotics only had an infection rate of 14.4 % [95 % CI: 10.5 %, 18.5 %]; adding local antibiotics reduced the rate to 2.4 % [0.0 %, 9.4 %], with an odds ratio of 0.17. Risk of deep wound infections increased with severity of fracture, rising to over 31 % in GIIIB&C fractures for patients receiving systematic antibiotics only, but to below 9 % with additional local antibiotics.

Conclusion

The findings support consideration of augmenting the antibiotic prophylaxis regimen to include locally-delivered antibiotics. Patients with severe fractures will obtain greatest benefit from infections avoided. No trial directly compared the two treatments for open tibia fractures, limiting the ability to attribute the differences in observed infection rates directly to the treatments themselves. A large comparative study to improve the evidence on relative effect size is merited. Level of evidence: Level III.     

外固定器治疗儿童开放性胫腓骨骨折

<正>儿童开放性胫腓骨骨折是临床上常见的儿童下肢骨折,治疗不当极易造成残疾。自2000年1月至2009年6月对开放性胫腓骨骨折的患儿行外固定器治疗,取得满意疗效,现进     

Combined use of the Ilizarov method,concentrated bone marrow aspirate (cBMA), and platelet-rich plasma (PRP) to expedite healing of bimalleolar fractures

Distal tibial and fibular fractures, particularly in patients with comorbidities, heal slowly and have a high incidence of postoperative nonunion and infection. Autologous concentrated bone marrow aspirate (cBMA) and platelet-rich plasma (PRP) increase osteogenic potential of demineralized bone matrix (DBM). The purpose of this case series was to evaluate the efficacy of cBMA, PRP, DBM in conjunction with the Ilizarov fixator as compared to DBM and the Ilizarov fixator alone in expediting fracture healing. Ten patients (mean age 52.9 years) were in the cBMA Group, and 10 patients (mean age 54 years) were in the Control Group. Comorbidities included diabetes, obesity, smoking, and renal disease. Radiographs showed a significant difference in the rate of complete healing in the cBMA Group at 16 ± 1.6 weeks post-surgery as compared to 24 ± 1.3 weeks in the Control Group (P < 0.001). No differences were observed between groups in infection rate or nonunions. We conclude that the Ilizarov fixator combined with DBM, cBMA, and PRP expedites fracture healing of the distal tibia and fibula in patients with significant comorbidities.     

闭合复位加压空心螺钉内固定治疗股骨颈骨折

自2005年至2007年应用C形臂X线机下闭合复位加压空心螺钉治疗股骨颈骨折27例,疗敬满意,报告如下。 1临床资料 木组27例,男15例,女12例;年龄23～82岁,平均54岁。其中合并高血压、心脏病5例,合并糖尿病3例。骨折按部位分型：头下型8例,经颈型10例,基底型9例、按Garden分型：Ⅱ型15例,Ⅲ型5例,Ⅳ型7例。均为新鲜骨折,1～3d内行手术治疗。