Use of Ilizarov Device to Gain Early Range of Motion in the Treatment of Pediatric Talus Body Fractures: A Series of Four Cases and Literature Review

BackgroundTalus fractures are rare in children but can lead to severe outcomes if untreated. The Ilizarov external fixator has been used in the treatment of a variety of lower extremity pathologies. The purpose of this study was to investigate the clinical outcomes of talus body fractures treated with the Ilizarov external fixator.Case PresentationFour male pediatric patients (age range, 5–11 years) with talus body fractures who were treated by open reduction and internal fixation combined with Ilizarov external fixator between November 2015 and April 2016 were reviewed. Mean follow‐up period was 4 years (range, 4–5). Clinical outcome was evaluated using the clinical rating scale of the American Orthopaedic Foot and Ankle Society (AOFAS). All four patients achieved good to excellent results at the last follow‐up. None of the patients developed avascular necrosis. One patient developed automatic fusion of tibiotalar joint.ConclusionUse of the Ilizarov external fixator to gain early range of motion is a valuable option for treatment of talus body fractures in children.     

Management of shotgun-induced fractures of the humerus with Ilizarov external fixator

Abstract We retrospectively reviewed 11 shotgun-induced open humeral fractures treated with immediate application of Ilizarov type ring external fixation. Eight patients had grade III A and three had grade III B open fractures. No patient had associated neurovascular injury. All fractures were stabilized with Ilizarov external fixator immediately after meticulous debridement and irrigation under emergent conditions. Complete bony union occurred in all patients in 14–44 weeks (mean, 21 weeks). One patient required a second intervention to adjust the external fixator rings. Two patients required a rotational fasciocutaneous flap to handle the soft tissue coverage problem. Superficial pin tract infection was present in eight patients; however none of them had deep infection or osteomyelitis. A good to excellent result was achieved in 10 patients according to the rating system of Smith and Cooney. Immediate Ilizarov external fixation is a safe method of obtaining a functional limb in the treatment of shotgun-induced open humeral fractures with severe soft tissue damage.     

The use of the Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss

We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight.The mean external fixation time was 309.8 days. According to Paley's grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.     

Femoral Periprosthetic Fracture in Osteoporotic Bone after a Total Knee Replacement: Treatment with Ilizarov External Fixation

We report 3 cases of periprosthetic fractures after total knee replacement treated with Ilizarov external fixator (Smith and Nephew plc, Memphis, Tenn) and a follow-up of at least 3 years. We used 2 rings in the supracondylar area distal to the fracture and 3 half pins proximally in all our cases leaving the knee free to move. In one patient apart from the 2-ring frame placed distal to the fracture site the fixator included another ring frame placed proximally just below the 3 half pins. Uncomplicated fracture healing with lower extremity excellent alignment was achieved in 12 weeks after surgery. In periprosthetic femoral fractures, especially in elderly patients, Ilizarov external fixator is a treatment option which provides stable fixation, prompt postoperative mobilization, and has no major complications.     

Ilizarov external fixation for severely comminuted supracondylar and intercondylar fractures of the distal femur

Our aim was to determine the clinical effectiveness and safety of Ilizarov external fixation for the acute treatment of severely comminuted extra-articular and intercondylar fractures of the distal femur. A total of 14 consecutive patients with complex fractures was treated. There were three type-A3, two type-C2 and nine type-C3 fractures according to the AO/ASIF system. The mean follow-up was 14 months. Most fractures (13) united primarily at a mean of 16 weeks. One patient with a type-IIIA open fracture had infection and nonunion. The mean range of flexion of the knee at the final follow-up was 105 degrees (35 to 130). We conclude that, in the treatment of comminuted fractures of the distal femur, the Ilizarov fixator is safe and effective in providing stability and allowing early rehabilitation.     

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 small pin circular fixator for distal tibial pilon fractures with soft tissue compromise

A Monticelli-Spinelli small pin circular external fixator was used in combination with closed reduction or a limited open reduction internal fixation in five cases in an attempt to salvage a satisfactory result in distal tibia pilon fractures when associated soft tissue compromise prevented standard fixation with plates and screws. The small pin fixator enhances the ability to perform a closed reduction through a technique that uses distraction with pins in the tibia and calcaneus, combined with correction of angulation by tensioning wires with a stop nut. Small pin stabilization of these comminuted fractures allows 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 technique as a salvage procedure when plates and screws are contraindicated because of poor bone and soft tissue conditions.     

Intra-articular fractures of the tibial plafond. A comparison of the results using articulated and ring external fixators

We retrospectively reviewed 60 fractures of the tibial plafond treated by either an ankle-sparing diaphyseal-epiphyseal technique using the Ilizarov ring fixator or by an ankle-spanning technique using a monolateral articulated external fixator. The Ilizarov ring fixator was applied in 24 fractures and the monolateral articulated transarticular external fixator in 20. Both techniques were combined with limited open reduction and internal fixation of the articular surface if necessary. Between three and nine years after the injury, all patients returned for clinical and radiological assessment and evaluation of ankle function using the modified Mazur score. There were no significant differences between the two groups in terms of age, gender, mechanism of injury, type of fracture or length of follow-up. The mean functional ankle score was 86 points for the Ilizarov group and 82 points for the articulated fixator group. The difference was not significant (p = 0.07). There were no significant differences between the groups with regard to the radiographic score and late complications. Patients treated with the Ilizarov ring fixator had significantly better ankle and subtalar movement. We conclude that both techniques of external fixation are satisfactory methods of treatment for fractures of the tibial plafond, but that the total arc of movement of the joint is preserved better without bridging the ankle.     

单边外固定器治疗股骨髁上髁间复杂性骨折

目的探讨应用单边外固定器治疗股骨远端复杂骨折的适应证及治疗效果。方法21例股骨髁上髁间粉碎性骨折患．先采用膝前内侧切口。行股骨髁间骨折复位，解剖复位关节面，于股骨外髁部定位直视下用特制外固定螺纹针加压固定两髁部骨折。透视下闭合牵引复位髁上骨折，并撬拨整复游离骨折片，于骨折近端定位置人外固定针。安装紧固外固定器行骨折固定。结果随访时间8～24个月。平均13．2个月。骨折在4～7个月内全部愈合，并去除外固定器。2例患外固定针道感染，经去除固定针局部换药后愈合。根据Rasumssen评分(总分30分，膝关节活动功能0～6分)评价患膝关节功能恢复情况，优良16例(76．2％)，一般4例(19％)，差1例(4．8％)。结论单边骨外固定器治疗股骨髁上髁间复杂性骨折，具有创伤小。血运破坏少。骨折复位满意，可以早期功能练习等优点。尤其适用于应用内固定难以处理的长节段股骨髁上髁间粉碎性骨折，外固定器可多向、多部位调节，对骨折起到牵引、复位和固定的作用。     

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.     

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。     

外固定支架结合有限内固定治疗儿童股骨远端骨折

目的 :探讨外固定支架结合有限内固定治疗儿童股骨远端骨折的临床疗效。方法 :自2008年1月至2014年6月,采用外固定支架结合有限内固定法治疗儿童股骨远端骨折17例,其中男12例,女5例;年龄6~13岁,平均10.2岁;病程1 h~2 d。所有患儿经X线片确诊,股骨髁上骨折11例,髁间粉碎性骨折6例。按AO/ASIF分型:A1型9例,A2型5例,C1型3例。观察并记录患者术中及术后并发症、术后放射学检查、下肢长度及膝关节活动度,并采用KSS膝关节功能评分对膝关节功能进行评分。结果:17例患者均获随访,时间6~38个月,平均24.4个月。术后均无神经血管损伤表现,出现外固定针松动1例,针道感染2例,双侧肢体不等长3例。膝关节活动度及长度测量(与健侧对比):平均屈曲受限10°(0°~20°),平均伸直受限4°(0°~10°),平均内/外翻3°(0°~5°)。末次随访时膝关节功能KSS临床评分为96.4±5.0;优16例,良1例。X线片显示所有骨折愈合,未发现骨骺早闭现象。结论:采用外固定支架结合有限内固定方法治疗儿童股骨远端骨折,具有手术操作简单、固定牢固、早期功能锻炼等优点。     

External fixation of femoral shaft fractures in children: enhanced stability with the use of an auxiliary pin.

From 1989 through 1994, we used a monolateral external fixator (Orthofix) to treat 39 femur fractures in 37 patients. The average age of the patients was 9.5 years (range, 5+11 to 18+8 years); 38 fractures were closed, and one was a grade I (Gustillo-Anderson classification) open fracture. Twenty-two fractures were treated by using the standard Orthofix pin configuration with two or three pins held in the pin clamps both above and below the fracture. We treated the remaining 16 fractures identically, except for the addition of an auxiliary pin, which was secured to the body of the fixator by using wire and methylmethacrylate. All patients were followed up to union and fixator removal at a mean of 97 days after fixator placement (range, 50-175 days). Thirty-one (84%) patients were followed up for 1 year after injury. Six of 22 femurs without an auxiliary pin required remanipulation for loss of reduction. Only one of 16 femurs treated with an auxiliary pin required remanipulation. Four of 22 femurs without an auxiliary pin went on to malunion. No femur with an auxiliary pin went on to malunion.     

Mechanical rigidity of the Ortho-SUV frame compared to the Ilizarov frame in the correction of femoral deformity

The Ortho-SUV frame (OSF) is a novel hexapod circular external fixator which draws upon the innovation of the Ilizarov method and the advantages of hexapod construction in the three-dimensional control of bone segments. Stability of fixation is critical to the success or failure of an external circular fixator for fracture or osteotomy healing. In vitro biomechanical modelling study was performed comparing the stability of the OSF under load in both original form and after dynamisation to the Ilizarov fixator in all zones of the femur utilising optimal frame configuration. A superior performance of the OSF in terms of resistance to deforming forces in both original and dynamised forms over that of the original Ilizarov fixator was found. The OSF shows higher rigidity than the Ilizarov in the control of forces acting upon the femur. This suggests better stabilisation of femoral fractures and osteotomies and thus improved healing with a reduced incidence of instability-related bone segment deformity, non-union and delayed union.     

Stabilization of supra- and intercondylar femoral fractures with retrograde interlocking nailing

Surgical Principles In patients with supracondylar fracture the closed reduction and internal fixation with a medullary pin or nail [1, 2, 4, 5, 10, 12, 13] very frequently cause a deformity of the distal end of the femur. A fixation is not possible in the presence of a short distal fragment. In these instances and in intercondylar femoral fractures an angled blade-plate, a dynamic condylar screw, a T- or Y-shaped plate, or an external fixator can be used [6–9, 11]. If there is an instability on the medial side of the fracture, additional cancellous bone grafting is indicated. In spite of adequate postoperative care the plate becomes sometimes loose and due to it a varus deformity results with decreased knee motion. To avoid these complications Henry et al. developed the GSH-nail [3]. The nail is inserted into the medullary canal of the femur through a transarticular approach. The nail has to be locked at the distal and proximal end. If the fracture is comminuted, restoration of the articular surface has to be achieved first. In 1991 we modified this method and developed an appropriate intramedullary nail and an insertion handle.     

Secondary fractures associated with external fixation in pediatric femur fractures.

Sixty-six femur fractures sustained by children ages 4-14 years and treated with external fixation were reviewed retrospectively to assess factors influencing the incidence of refracture. The total rate of secondary fracture was 12% (eight patients) including five recurrent fractures at the original fracture site and three fractures through the pin sites. After removal of the external fixator, five patients refractured at the original fracture site and one patient fractured through a pin tract. Two patients fractured at pin sites while the fixator was still in place. Multivariate linear-regression analysis showed no correlation between the incidence of refracture and fracture pattern, percentage of bone fragment contact after fixator application, type of external fixator, or dynamization. A statistically significant association (p < 0.05) was found between the number of cortices demonstrating bridging callus [on both anteroposterior (AP) and lateral views] at the time of fixator removal and the rate of refracture. Fractures showing fewer than three cortices of bridging callus had a three (33%) in nine rate of refracture, whereas fractures with three or four cortices of bridging callus had a two (4%) of 57 rate of refracture.     

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     

Management of unstable open and closed tibial fractures using the Ilizarov method.

Forty-one consecutive tibial diaphyseal fractures that required operative stabilization were treated using the external fixator and concepts of compression-distraction of Ilizarov. Eleven fractures had bone loss greater than 1 cm and were managed by simultaneously compressing the fracture gap and distracting through a corticotomy site to maintain extremity length. Thirty tibial fractures consisted of closed unstable and open fractures that were managed using the external fixator, emphasizing immediate weight bearing and gradual compression at the fracture site. Twenty-six fractures in 23 patients were available for follow-up evaluation six to 9.5 months after bone healing. There were six closed, two Grade I, eight Grade II, five Grade IIIA, and five Grade IIIB fractures. Serial wound debridements, wet-to-dry-dressing changes, wound- and fracture-site compressions (13 fractures), and split-thickness skin grafts (eight wounds) were used to accomplish wound closure. Chronic infections did not occur. All fractures healed from 12 to 47 weeks without bone grafting. Eight transosseous fixation wires are used, only two of which transfixed significant muscle. Approximately 10% of the 248 wire sites became inflamed and nine wire sites were treated for infection with antibiotics, skin release around the offending wire, or wire removal. Three wires fractured and one wire was replaced. One ring sequestrum occurred and responded to curettement. Angulation of 7 degrees-9 degrees occurred in five fractures (19%). The results were good or excellent in 25 fractures. One patient with 9 degrees varus in a distal fracture refused correction. Operative time was 60 to 90 minutes after developing a satisfactory protocol for frame application. This method allows immediate functional stabilization of tibial diaphyseal fractures and postoperatively allows ease of fracture gap closure and compression. The frame can be left in place for the duration of the fracture care. Application of the Ilizarov external fixator is slightly more complicated than traditional large pin fixators and requires more attention to detail intraoperatively and postoperatively, but can be a versatile tool in the management of complex tibial shaft fractures.     

Treatment of complicated pediatric femoral fractures with titanium elastic nail

Nonunion and major complications are not very common in pediatric fractures. No commonly accepted methods exist for the treatment of these fractures. In this study, treatment of complicated pediatric femoral fractures with titanium elastic nails was evaluated. Five girls and four boys with nine femoral fractures constituted the group. The mean age of the patients was 8.7 (5-11) years and the mean follow-up was 46.6 (24-84) months. Five of them had implant failure and nonunion, two of them had loss of position in the external fixator, one of them had incomplete union and loss of position in the external fixator and the other had femoral fracture in the lengthening segment of the femur and had loss of position and incomplete union in the spica cast. All the patients were treated with a closed or open reduction of the fracture, debridement if treated with open method and fixation of the fracture with titanium elastic nails. Complete union was achieved in all the patients within the 6-9 months. No neurovascular injury or infection was reported in the group. The result of the treatment showed that fixation of complicated pediatric femoral fractures with intramedullary titanium elastic nails is a good option.