Severely comminuted bicondylar tibial plateau fractures in geriatric patients: a report of 2 cases treated with open reduction and postoperative external fixation

We present 2 cases of C3-type fractures of the tibial plateau in geriatric patients. Our treatment concept--in particular the use of postoperative external fixation--is not yet described in the recent literature and includes initial external fixation, internal fixation after soft tissue consolidation using a median incision, filling of the metaphyseal comminution zone with allogenic cancellous bone obtained from a femoral head, anteromedial and anterolateral fixed-angle double plating, and external fixation postoperatively until osseous healing. The described treatment plan does not provide a valid alternative for the treatment of bicondylar fractures in younger patients. It may be an option for the treatment of C3-type fractures in geriatric patients only.     

Recent advances in the treatment of gunshot fractures of the humeral shaft

The increase in violent crime has lead to an increase in gunshot-induced fractures in the United States. Injuries to the upper extremity are common. The treatment of gunshot injuries depends on the extent of soft tissue disruption and the type and location of fracture. Most of these injuries are a result of low-energy gunshot wounds that may be treated conservatively under the appropriate conditions. Low-energy fractures that require operative stabilization may be done with predictable results for achieving union with intramedullary fixation or compression plating. Complex open fractures from gunshot wounds associated with neurovascular injuries present a therapeutic challenge to the orthopaedic surgeon. The fractures associated with these injuries often are comminuted and unstable. Bone loss is common. Soft tissue disruption plays a more important role in high-energy gunshot-induced fractures. In these cases, external fixation is the treatment of choice for stabilization. Recent advances in the use of external fixation have led to quick fracture stabilization, stability for vascular repair, and access to the wound for debridement and subsequent soft tissue surgery.     

Management of the Schatzker VI fractures with lateral locked screw plating

Complex proximal tibial plateau fractures need surgical treatment to achieve good clinical results. The treatment of this kind of fractures is often complicated either by the patient’s compromised general conditions, or by soft tissue damage. The locking plate combines the technical advantages of an angular stable plate with those of the modern biological plating technique. From December 2002 to December 2008 we treated 18 patients with complex fractures of the tibial plateau (Schatzker VI). All patients were treated with a fixed angle locking plate, 15 with the LISS (Less Invasive Stabilisation System) and 3 with ZPLT (Zimmer Periarticular Locking Plate system). Average time for full weight bearing was 16.2 weeks. In 3 cases we removed the fixation devices after healing because the patients didn’t tolerate the fixation devices. Two patients developed superficial infections that we treated with antibiotic therapy. In 2 cases the LISS plate broke because of pseudarthrosis at the diaphyseal level. To conclude, analysing the results we obtained, we consider that the LISS system is an extremely effective fixation device for the treatment of such difficult and complicated fractures as high energy tibial plateau fractures certainly are. Indirect reduction of the fracture, obtained either with an external fixator, or with traction, must precede the use of the fixation device. The failures, such as post-op malalignment or loss of reduction, are due to a wrong evaluation of the fracture morphology. In fact, comminuted fractures, dislocation and rotation of the medial tibial plateau cannot be stabilised just with lateral angular stable plates, but fixation of the medial tibial plateau must be performed first.     

Fracture treatment in the area of the tibia]

From May 1990 to March 1992 17 open and 6 closed fractures of tibia and fibula with second- to third-degree soft tissue injuries were treated by external fixation using the Ilisarov technique. In 14 patients this external fixation was used as the primary treatment. In nine cases it was used secondarily, mainly in patients transferred after stabilization with other internal or external devices. The mean duration of fixation for diaphyseal tibial fractures was 127 days and for metaphyseal fractures, 107 days. After removal of the fixation device, a brace was temporarily fitted for full weight-bearing. Disadvantages observed include less comfort for the patient and longer operation time compared to other external fixation systems. On the other hand, this method allows full weight-bearing soon after the operation and involves minimal damage of soft tissue. Furthermore, injured soft tissue was well protected during healing.     

胫腓骨多段骨折不同手术方法疗效分析

目的探讨胫腓骨多段骨折不同手术方法的临床疗效。方法对68例胫腓骨多段骨折者分别采用闭合复位三维外固定架（32例）、带锁髓内钉（17例）、加压钢板（19例）治疗,比较3种方法的疗效。结果 68例均获得随访,时间6-24（14±3）个月。加压钢板组2例出现感染及骨不连。三维外固定架组治疗胫腓骨多段骨折在手术时间、住院时间、手术切口、出血量、输液天数、住院费用、骨折愈合时间等方面均优于带锁髓内钉组和加压钢板组（P〈0.05）。参照Johner-Wruh评定标准,优良率：三维外固定架组93.75%,带锁髓内钉组88.24%,加压钢板组89.48%。结论闭合复位三维外固定架治疗胫腓骨多段骨折疗效优于带锁髓内钉和加压钢板。     

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.     

Dorsal plate osteosynthesis of the tibial shaft. Results of a collective study of the German section of the International AO (Study Group for Osteosynthesis Problems)

This collective study was conducted by the German section of AO International to work out the indications for fixation of the tibial shaft by means of dorsal plating. Primary dorsal plating was done in 70 cases. Most of the patients had second- or third-degree open fractures with severe ventral soft tissue injuries or closed fractures that could not be reduced and fixed conservatively. In 72 patients, secondary dorsal plate fixation was performed. The main reason for the dorsally positioned plate was persistent instability or axial malalignment after previous external or internal fixation, but failed conservative treatment constituted a further reason. Most of these patients had such severe damage following fractures that dorsal plating was the last chance of avoiding amputation. The high rate of complications (12 infections and 7 non-unions and breakages of implants after primary dorsal plating; 20 infections and 11 non-unions and breakages of implants after secondary dorsal plating) has to be considered in the light of the extraordinary indications for the dorsal plating of the tibial shaft in especially severe fractures or disastrous sequelae. In cases with extremely severe conditions before fixation, dorsal plating of the tibial shaft for secondary operative treatment yields adequate results.     

Our experiences with change of osteosynthesis from external fixator to internal fixation in fractures of the lower limb

INTRODUCTION: In polytrauma patients and fractures with severe soft tissue damage of the lower limb the use of external fixator is indicated. To show the possibilities and limits of change of external fixation to internal osteosynthesis we performed a retrospective analysis. PATIENTS AND METHODS: Between 1.1.1993 to 30.6.1997 671 cases were primarily treated with external fixator. After a mean of 16.5 days a change of osteosynthesis was performed in 75 cases. RESULTS: 5 infections of the pin tracks, 3 infections of the wound, two thromboses, one case of thromboembolism and one osteomyelitis were seen in these 75 cases. One patient died due to severe brain damage after head injury. No further operations were necessary, all fractures showed primary healing. Taking the severe soft tissue damages and severe multiple trauma into account only few complications were observed. CONCLUSION: The main problems and risks of internal fixation occur in the early phase of treatment, whereas complications after external fixation are more likely to occur in later stages. By a change from external fixation to internal osteosynthesis the advantages of both methods can be combined.     

External fixation of fractures using Dysnastab-S stabilizers for massive ankle fractures of tibial bone epiphyseal articulations ]

Massive ankle fractures lead to joint stiffness and resulting decrease in range of motion. This can be avoided by functional treatment. In cases where severe soft tissue trauma coexists with bone fractures surgical treatment is limited and external fixation is the method of choice. Modern external fixation technique allows for stabilisation and maintaining range of motion in the affected joint. This paper presents the results of application of the Dynastab-S external fixator. The construction of this fixator allows dorsal and plantar, reducing postraumatic joint stiffness. It also allows appropriate insight into soft tissues and debridement of devitalised tissues as well as their forthcoming surgical reconstruction. In our material (27 cases) treated with the Dynastab-S fixator for an average of 16 weeks a satisfactory bone healing process in all cases was noted. Appropriate function of the extremity was maintained, with comparable plantar flexion to the contralateral, not affected joint. Only in one case post operative treatment was complicated by algodystrophy. Our observations showed that implementation of modern external stabilisation techniques leads to appropriate fracture healing with full function of the inferior extremity.     

Tibial Fractures Treated with Hoffmann's External Fixation: A Comparative Analysis of Hoffmann Bilateral Frames and the Vidal-Adrey Double Frame Modification

The results after treatment of 50 open and comminuted tibial fractures with Hoffmann's external fixation were analysed. Half of the fractures were treated with bilateral Hoffmann frames, the other half with the Vidal-Adrey double frame modification. The groups were found to be comparable.

The results of the study confirm that Hoffmann's external fixation is a safe method for treating the bone and soft tissue lesions in such fractures. There was only one case of osteomyelitis, no definite pseudarthrosis and no leg amputation.

The considerably increased stability of the Vidal-Adrey double frame modification did not reduce the length of the healing period compared to fractures treated with bilateral Hoffmann frames. The duration of external fixation was on average 24 weeks, and the radiological healing time 27 weeks.

A slightly greater number of residual deformities were found in the group treated with bilateral Hoffmann frames. Most of the deformities were so minor, however, that they were of little practical consequence for the patients. Thus it seems that the original Hoffmann apparatus, if duplicated, is a stable enough fixation in most cases.     

跨腕关节外固定器在桡骨远端陈旧性骨折中的应用

目的 分析桡骨远端有限切开复位、跨腕关节外固定器固定治疗桡骨远端陈旧性骨折的效果.方法 2006年3月至2008年3月,应用桡骨下端切开复位、跨腕关节外固定器固定治疗桡骨远端陈旧性骨折患者16例18侧,年龄29～72岁(平均52.6岁),其中Colles骨折13例15侧,Smith骨折3例3侧.桡骨下端复位及植骨后,以外固定器协助复位及静力性固定.方果 随访时间4～30个月,平均16个月;骨折愈合时间6～12周,平均8.7周.根据Gartland与Werley腕关节评分标准评定:优11侧,良4侧,可3侧;优良率为83.3%.方论 有限切开复位、跨腕关节外固定器固定治疗桡骨陈旧性远端骨折,手术操作简单,组织损伤小,有利于术后早期功能锻炼,促进骨折愈合,是桡骨远端陈旧性骨折的一种有效治疗方法.     

弹性髓内钉固定与外固定支架治疗儿童股骨干骨折疗效比较

目的：比较弹性髓内针与外固定支架治疗儿童股骨干骨折的疗效。方法：2002年9月至2008年8月治疗儿童股骨干骨折共67例,使用弹性髓内针治疗儿童股骨干骨折36例,男23例,女13例,年龄5～11岁,平均（7.1±1.6）岁;外固定支架治疗31例,男19例,女12例,年龄3～12岁,平均（6.5±2.3）岁。所有病例均为闭合复位,对两种不同内固定术后骨折愈合时间、术后并发症进行比较分析。结果：全部病例均获随访,时间9～24个月,平均（12±3）个月。弹性随内针组治疗小儿股骨骨折在骨折临床愈合时间和骨性愈合时间均短于外固定支架组（P〈0.05）。外固定支架组,继发钉道感染5例,骨折延迟愈合3例,再骨折2例,螺钉断裂1例;弹性髓内针组钉尾激惹3例。结论：弹性髓内针治疗儿童股骨干骨折有很大优势,而对高能量骨折及多发伤的病例外固定支架则不失为一种良好的选择,股骨近端和远端骨折尽量避免使用弹性髓内针固定。     

Pilon fractures. Treatment protocol based on severity of soft tissue injury

One hundred seven pilon fractures in 107 patients were treated according to a staged prospective protocol. All pilon fractures were stabilized immediately by the application of calcaneal traction. Open fractures or fractures in patients with multiple injuries were stabilized with traveling traction that was applied in the operating room. A distraction computed tomography scan was obtained before definitive treatment. Treatment groups were based on the degree of soft tissue compromise. Forty-one patients with Tscherne Grade 0 or Grade I injuries underwent open reduction and internal fixation (open plating) using contemporary techniques and low-profile implants. Sixty-four patients with Tscherne Grade II and Grade III closed injuries and all patients with open fractures underwent definitive treatment with limited open reduction and stabilization using small wire circular external fixators. Clinical and radiographic evaluations were performed at an average 4.9 years after injury. For all fracture types (AO classification), 81% of the patients who were treated with external fixation and 75% of the patients who were treated with open plating had good or excellent results. For severe fracture patterns (Type C), patients in both groups had significantly poorer results than patients with Types A and B fractures. The patients in the open plating group had a significantly higher rate of nonunion, malunion, and severe wound complications compared with the patients who received external fixation for Type C fracture patterns. Because of the increased incidence of bony and soft tissue complications when treating open or closed Type C fractures, use of limited exposures and stabilization with small wire circular external fixators is recommended.     

双侧固定治疗复杂胫骨平台骨折

目的 探讨双侧固定治疗复杂胫骨平台骨折的疗效. 方法 选取2003年7月至2006年10月采用胫骨平台双侧固定方法治疗的43例复杂胫骨平台骨折患者,骨折按Schatzker分型:Ⅴ型26例,Ⅵ型17例.一期胫骨近端双侧钢板螺钉固定28例,单侧钢板螺钉内固定结合对侧克氏针+外固定支架固定9例.伤后急诊外固定支架临时固定,软组织条件改善后二期改用钢板螺钉固定2例;克氏针内固定+跨膝关节外固定支架固定4例. 结果 43例患者术后获12～28个月(平均18.4个月)随访.除5例感染患者外,其余38例患者骨折愈合时间平均为4.5个月,完全负重时间平均为5.5个月.术后1年时膝关节活动度平均为95°;根据膝关节HSS评分评定疗效:优29例,良8例,中6例,优良率为86.0%.术后即刻胫骨平台内翻角、胫骨平台后倾角及股胫角与术后1年比较差异均无统计学意义(P>0.05). 结论 复杂胫骨平台骨折固定方式的选择应根据软组织条件的不同而灵活掌握,但应遵循双侧固定的同时尽早解放膝关节的原则,术前对软组织损伤恢复程度的正确评估直接影响治疗的最终效果.     

Distal Tibial Fractures: Intramedullary Nailing

The tibia is an exposed bone with vulnerable soft tissue coverage and is therefore predisposed to local soft tissue problems and delayed bone healing. The objective in distal tibial fracture treatment is to achieve stable fixation patterns with a minimum of soft-tissue affection. Thus, the risk of soft tissue breakdown and bone healing complications is more likely related to open reduction and plating. Percutaneous, minimally invasive intramedullary nailing is a proven fixation mode for fracture stabilization in tibial shaft fractures. Anticipating the pitfalls, intramedullary nailing meets the requirements of the method of choice in distal tibial fracture fixation. In conclusion, intramedullary nailing of distal tibial fractures is a reliable method of fixation, possessing the advantages of closed reduction and symmetric fracture stabilization of an area with a delicate soft tissue situation, but prospective randomized trials are needed to compare modern intramedullary fracture fixation with modern plate fixation in distal tibial fractures.     

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.     

Minimally invasive osteosynthesis of distal tibial fractures using anterolateral locking plate: Evaluation of results and complications

Purpose: Soft tissue healing is of paramount importance in distal tibial fractures for a successful outcome. There is an increasing trend of using anterolateral plate due to an adequate soft tissue cover on anterolateral distal tibia. The aim of this study was to evaluate the results and complications of minimally invasive anterolateral locking plate in distal tibial fractures. Methods: This is a retrospective study of 42 patients with distal tibial fractures treated with minimally invasive anterolateral tibial plating. This study evaluates the bone and soft tissue healing along with emphasis on complications related to bone and soft tissue healing. Results: Full weight bearing was allowed in mean time period of 4.95 months (3-12 months). A major local complication of a wound which required revision surgery was seen in one case. Minor complications were identified in 9 cases which comprised 4 cases of marginal necrosis of the surgical wound, 1 case of superficial infection, 1 case of sensory disturbance over the anterolateral foot, 1 case of muscle hernia and 2 cases of delayed union. Mean distance between the posterolateral and anterolateral incision was 5.7 cm (4.5-8 cm). Conclusion: The minimally invasive distal tibial fixation with anterolateral plating is a safe method of stabilization. Distance between anterolateral and posterolateral incision can be placed less than 7 cm apart depending on fracture pattern with proper surgical timing and technique.     

微型外固定支架与钢板、克氏针内固定治疗掌指骨骨折的比较研究

目的 比较采用微型外固定支架、钢板、克氏针内固定治疗掌、指骨骨折的临床效果.方法 微型外固定支架组21例、25处骨折,术后随访4～6月,平均5个月.钢板固定治疗组病例17例、20处骨折,术后随访4～6月,平均5月.克氏针固定治疗组19例、23处骨折.术后随访5～9个月,平均7个月.以RAFS标准评价术后掌指关节及指间关节功能和术后感染及骨折愈合时间.结果 外固定支架优良率为88%(22/25),钢板固定组优良率75%(15/20),克氏针固定组优良率为70%(16/23),三组均有明显差异(P＜0.05).结论 从术后关节功能恢复的优良率、感染率以及骨折愈合时间相比,外固定支架的疗效明显优于其它两组.     

外固定与显微技术结合治疗复杂性骨折(12例报告)

目的 探讨对有感染、骨不连和/或软组织及骨缺损,并多次手术失败等复杂性骨折病人的治疗方法。方法 对12例难治性骨折病人采用外固定与显微技术结合的方法治疗。结果 12例病人伤口均Ⅰ期愈合;11例病人骨折在手术后3～8月内愈合(平均4.7月),骨愈合率为91.7％。结论 外固定与显微两项技术结合治疗复杂性骨折具有相互促进,相互弥补的作用,可获得较好的结果。     

外固定支架结合负压封闭引流在伴有软组织严重损伤的小腿开放性骨折中的应用

目的探讨外固定支架结合负压封闭引流(VSD)在伴有软组织严重损伤的小腿开放性骨折中的治疗效果。方法本组22例病例均为严重软组织损伤的开放性小腿骨折,给予外支架固定骨折,同时使用VSD处理创面。结果全部患者持续负压引流1~3次后,创面经植皮或直接缝合愈合;骨折无分离移位.外支架无松动移位断裂。结论联用外支架与VSD处理伴严重软组织损伤的开放性小腿骨折,稳定骨折迅速,封闭引流创面安全有效,伤口愈合好,并发症少。