Ilizarov external fixator for open fractures of the tibial shaft

Mid to Long-Term Outcomes of Grade III-B Open Tibial Fractures Definitively Managed With a Circular Frame: A 13-Year Prospective Database Study at a Major Trauma Center

OBJECTIVES

The aim of this study was to report experience of a major trauma center utilizing circular frames as definitive fixation in patients sustaining Gustilo-Anderson 3B open tibial fractures.

METHODS

DESIGN

A prospectively maintained database was retrospectively interrogated.

SETTING

Single major trauma center in the United Kingdom.

PATIENT SELECTION CRITERIA

All patients over the age of 16 sustaining an open tibial fracture with initial debridement performed at the study center. All patients also received orthoplastic care for a soft tissue defect (via skeletal deformation or a soft tissue cover procedure) and subsequent definitive management using an Ilizarov ring fixator. Patients who received primary debridement at another center, had preexisting infection, sustained a periarticular fracture, or those who did not afford a minimum of 12-month follow-up were excluded. Case notes and radiographs were reviewed to collate patient demographics and injury factors.

OUTCOME MEASURES AND COMPARISONS

The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions.

RESULTS

Two hundred twenty-five patients met inclusion criteria. Mean age was 43.2 year old, with 72% males, 34% smokers, and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Eight (3.5%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-nine (35.1%) patients had a secondary intervention, of which 8 comprised debridement of deep infection, 29 bony procedures, 8 soft tissue operations, 30 frame adjustments, and 4 patients requiring a combination of soft tissue and bony procedures. Bony union was achieved in 221 cases (98.2%), 195 (86.7%) achieved union in a single frame without the need for secondary intervention, 26 required frame adjustments to achieve union. Autologous bone grafts were used in 10 cases.

CONCLUSIONS

Orthoplastic care including circular frame fixation for Gustilo-Anderson-3B fractures of the tibia resulted in a low rate of deep infection (3.5%) and achieved excellent union rates (98.2%).

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Use of the Ilizarov Fixator for the Treatment of Open and Closed Tibial Shaft and Distal Tibial Fractures in Patients with Complex Cases

INTRODUCTION

Open and closed fractures of the tibial shaft or distal tibia can be challenging for surgeons to treat if the fractures are accompanied by aggravating conditions, such as various accompanying diseases, pronounced soft tissue injuries, osteomyelitis, and/or noncompliance. The aim of this retrospective study was to present our approach and results with the Ilizarov fixator as a treatment option for such individually complex cases.

MATERIALS AND METHODS

Between 2005 and 2018, 20 patients were treated with the Ilizarov fixator for fractures of the tibial shaft/distal tibia. The indication for this was a 2nd- to 3rd-degree open fracture in 10 patients, a 1st-degree open fracture in one patient, and closed fractures in 9 patients. Aggravating conditions included soft tissue injuries, osteomyelitis, leg deformities, multiple traumas, smoking, alcohol/drug abuse, and obesity (BMI > 60). In addition to demographic data, the time of fixator treatment, complications, and the endpoint of consolidation were evaluated retrospectively.

RESULTS

The mean time of fixator treatment was 29 (range 15-65) weeks. Complete fracture consolidation was achieved in 13 patients (65%) with the Ilizarov fixator. The mean follow-up period after fixator removal was 36 (range 2-186) months in 14 patients. Five patients with complete consolidation were lost to further follow-up. One patient was amputated. In six patients without union, internal osteosynthesis was carried out.

CONCLUSION

The use of the Ilizarov fixator is a treatment option for individual high-risk patients with complicating courses but should be seen as a salvage procedure due to the high complication rate and long treatment process.

Neglected war injuries: Reconstruction versus amputation

INTRODUCTION

War injuries are remarkably different situations with profound severity and significant contamination compared to civilian injuries. Delayed definitive management makes the situation much more complicated. This study aimed to report the outcomes of limb reconstruction of neglected war injuries with a previous decision of amputation.

PATIENTS AND METHODS

From 2010 to 2021, 1104 patients with war-related fractures from conflict-zone countries were referred to our center including 589 open tibial fractures. Of these tibial fractures, amputation had already been decided in 54 cases, and the patients were looking for a trial of reconstruction and avoiding amputation. These cases were included in the current study. The treatment approach was a single-stage procedure with bone and soft tissue reconstruction.

RESULTS

This study included 54 male patients with a mean age of 26.3 years. Infection was the predominant feature in 43 cases (79.6 %). CT angiography revealed a one-vessel limb in 17 patients. Peripheral nerve injuries affected 15 patients. The mean time from injury to presentation was 8.5 weeks. The bone gap (2-13 cm) was evident in 44 cases. In four cases, the contralateral limb was amputated below the knee. There were associated injuries in nine cases. Rotational flap coverage was done in the same setting for 19 legs. Gastrocnemius flap was done in two cases. The mean follow-up duration was 45.1 months. The treatment methods included bifocal management (33 cases), trifocal management (17 cases), fibular transfer (two cases), and a mono-focal approach in two cases. All fractures healed successfully. The mean external fixation period was 7.6 months. Recurrence of infection occurred in three patients. A non-displaced refracture developed in one case. Five cases had a residual angular deformity. Eventually, the ASAMI bone and functional results were good in all cases.

CONCLUSIONS

Neglected war injuries constitute a complex problem where amputation may be indicated. Our approach includes one-stage limb reconstruction with the corticotomy-first technique, conservative debridement of the docking site, concomitant osteoplastic procedure, and gradual distraction to tackle all the aspects of the problem. The good results obtained in the presented series make it a valid approach to avoid amputation in neglected war injuries.

Updated Meta-Analysis of Randomized Controlled Trials Comparing External Fixation to Intramedullary Nailing in the Treatment of Open Tibial Fractures

Background: The purpose of this study was to collect all available randomized controlled trials (RCT) on the treatment of open tibial fractures with an external fixator (EF) and intramedullary nailing (IMN) for meta-analysis to provide reliable evidence-based data for clinical decision-making. Material and methods: The systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and AMSTAR (Assessing the Methodological Quality of Systematic Review). An electronic search of PubMed, Cochrane Library, and Web of Science was performed until 1 March 2023 to identify RCTs which compared either IMN or EF to fix the open tibial fracture. Outcome measures were: postoperative superficial and deep infection, time to union, delayed union, malunion, nonunion and hardware failure. In addition, pain and health-related quality of life were evaluated after 3 and 12 months of follow-up. Results: Sixteen publications comprising 1011 patients were included in the meta-analysis. The pooled results suggested that the IMN technique had a lower postoperative superficial infection and malunion rate (RR = 3.56, 95%CI = 2.56-4.95 and RR = 1.96, 95%CI = 1.12-3.44, respectively), but higher hardware failure occurrence in contrast to EF (RR = 0.30; 95%CI = 0.13-0.69). No significant differences were found in the union time, delayed union or nonunion rate, and postoperative deep infection rate between the treatments. Lower levels of pain were found in the EF group (RR = 0.05, 95%CI = 0.02-0.17, p < 0.001). A difference in quality of life favoring IMN after 3 months was found (RR = -0.04, 95%CI = -0.05-0.03, p < 0.001), however, no statistical difference was found after 12 months (RR = 0.03, 95%CI = -0.05-0.11, p = 0.44). Conclusions: Meta-analysis presented reduced incidence rates of superficial infection, malunion, and health-related quality of life 3 months after treatment in IMN. However, EF led to a significant reduction in pain and incidence rate of hardware failure. Postoperative deep infection, delayed union, nonunion and health-related quality of life 12 months following therapy were similar between groups. More high-quality RCTs should be conducted to provide reliable evidence-based data for clinical decision-making.

A comparative evaluation of the time to frame removal for tibia fractures treated with hexapod and Ilizarov circular frames

INTRODUCTION

Traditional Ilizarov and hexapod frames have different biomechanical properties and there is limited literature regarding their effect on time to fracture union or time to frame removal.

METHODS

Tibial fractures managed with a circular frame at a tertiary limb reconstruction referral centre between 2011 and 2018 were retrospectively identified from a prospectively maintained database. They were classified into three treatment groups; Ilizarov style, Taylor Spatial Frame (TSF) and TrueLok Hex (TL-Hex). Data were extracted from electronic patient records and digital radiographs. The primary outcome was time to frame removal, which was seen as an indicator of clinical and radiological fracture union. Odds ratios were calculated with the clinical significance set at 30 days.

RESULTS

274 patients (median age 49 years, 36% female) were included in the analysis. 8.4% Ilizarov, 10.5% TSF and 13.5% TL-Hex frames required further surgery to aid fracture healing (p = 0.38). 30% of patients had open fractures. Median time to removal for Ilizarov, TSF & TL Hex frames was 167, 198 and 185 days respectively. There was a significant difference between Ilizarov and hexapod frames. Both TSF (OR 2.2, p<0.003) and TL-Hex (OR 1.8, p<0.04) had a significantly increased time to removal of 30 days or more compared with Ilizarov frames.The time to frame removal in metaphyseal fractures was significantly shorter for Ilizarov frame fixation than hexapod frames (p = 0.04). Open fractures were significantly more likely to require at least 30 days extra time to removal than closed fractures (OR 3.3, p<0.001). There was no significant difference in the time to frame removal between fracture location, age or sex.

CONCLUSION

Ilizarov frames have demonstrated a reduced time to frame removal in the management of tibial fractures than hexapod frames. Differences in the time to frame removal, an indicator of time to fracture union, may be due to the different mechanical properties of the frame, or early disruption of the fracture haematoma through secondary frame manipulation and fracture reduction, increased proportion of metaphyseal fractures treated with Ilizarov, or patient selection. The healing time was comparable across the tibia. Pooled meta-analyses may be able to further quantify these associations.

Comparing external fixators and intramedullary nailing for treating open tibia fractures: a meta-analysis of randomized controlled trials

BACKGROUND

External fixators (EFs) and intramedullary nailing (IMN) are two effective methods for open tibial fractures. However, both methods have advantages and disadvantages, and the optimal surgical approach remains controversial. Thus, we performed a meta-analysis of randomized controlled trials (RCTs) to compare EF with IMN to evaluate their efficacy and safety.

METHODS

A systematic study of the literature was conducted in relevant studies published in PubMed, Embase, the Cochrane Library, Web of Science, CNKI, CBM, Wanfang and Weipu from database inception to April 2022. All eligible literature was critically appraised for methodological quality via the Cochrane's collaboration tool. The primary outcome measurements included postoperative superficial infection, postoperative deep infection, union time, delayed union, malunion, nonunion, and hardware failure.

RESULTS

Nine RCTs involving 733 cases were included in the current meta-analysis. The pooled results suggested that cases in the IMN group had a significantly lower postoperative superficial infection rate [risk ratio (RR) = 2.84; 95% confidence interval (CI) = 1.83 to 4.39; P < 0.00001)] and malunion rate (RR = 3.05; 95% CI = 2.06 to 4.52; P < 0.00001) versus EF, but IMN had a significantly higher hardware failure occurrence versus EF (RR = 0.38; 95% CI = 0.17 to 0.83; P = 0.02). There were no significant differences in the postoperative deep infection rate, union time, delayed union rate or nonunion rate between the two groups (p > 0.05).

CONCLUSIONS

Compared to EF, IMN had a significantly lower risk of postoperative superficial infection and malunion in patients with open tibial fractures. Meanwhile, IMN did not prolong the union time and increased the risk of the deep infection rate, delayed union rate and nonunion rate but had a higher hardware failure rate. The reanalysis of union time showed that it was significantly shorter in the IMN group than in the EF group after excluding the study with significant heterogeneity during sensitivity analysis. Therefore, IMN is recommended as a preferred method of fracture fixation for patients with open tibial fractures, but more attention should be given to the problem of hardware failure.

Study on the relationship between the timing of conversion from external fixation to internal fixation and infection in the treatment of open fractures of extremities

Objective

To investigate the relationship between the infection rate and the timing of replacement of temporary external fixators with internal fixation, and the timing of immediate or delayed internal fixation after removal of temporary external fixation in the staging treatment modality of open fractures of extremities.

Methods

A retrospective analysis was performed on 122 cases of open fractures of extremities. External fixators were applied at the early stage and replaced with internal fixation when the condition of soft tissues improved and inflammatory indexes dropped to the normal range or showed a steady downward trend. Depending on the carrying time of external fixators after wound closure or healing, the patients were divided into three groups; the carrying time of groups A, B, and C was ≤ 14 days, 15–28 days, and > 28 days, respectively. Depending on the immediate or delayed internal fixation after removal of external fixator, patients were divided into group a (immediate internal fixation after removal of external fixator) and group b (delayed internal fixation after removal of external fixator, 5–7 days later).

Results

The infection rates of groups A, B, and C were 6.5%, 5.9%, and 23.3%, respectively. The differences among the three groups were statistically significant (P < 0.05). The infection rates of different Gustilo–Anderson fractures were as follows: no cases of infection out of 10 cases with type I fracture (0%); two cases of infection out of 35 cases with type II fracture (5.7%); three cases of infection out of 36 cases with IIIa fracture (8.3%); five cases of infection out of 28 cases with IIIB fracture (17.9%); and five cases of infection out of 13 cases with IIIC fracture (38.5%). The differences among the five groups were statistically significant.

Conclusions

The occurrence of infection of open fractures of extremities is associated with the fracture severity (Gustilo classification). For open fractures of Gustilo types I and II, the final internal fixation should be placed as soon as possible when the recovery of general and local conditions is good and the infection is controlled.

Masquelet technique for reconstructing bone defects in open lower limb fracture: Analysis of the relationship between bone defect and bone graft

OBJECTIVE

The aim of this study was to retrospectively analyze the experience of treating long segmental bone defects. Bone union was used as the criteria for the assessment of the quantitative relationship between tibial bone defects and bone grafts, which could help reduce the complication incidence in patients.

METHODS

A total of 45 patients with tibial bone defects treated with the Masquelet technique at the Ninth People's Hospital of Wuxi Affiliated to Soochow University between February 2013 and December 2017 were recruited. The age, sex, body mass index (BMI), complications, site of bone defect, length of bone defect, time from the first to the second stage of operation, and postoperative complications (including deep infection, absorption of bone graft, and bone union) were assessed.

RESULTS

Forty-two patients, including 17 males (40.5%) and 25 females (59.5%), with segmental bone defect, met the inclusion criteria. The mean age of the patients was 38.5 years (22-55 years). Nineteen patients (45.2%) underwent multiple traumas. The mean length of the bone defect was 6.3 cm. Six patients experienced complications, resulting in the incidence of complications of 14.3%. The relationship between the length of bone defect and volume of bone grafts was Y = 7.210 + 6.954 × X in patients treated with steel plates; Y = 10.962 + 5.029 × X for patients treated with intramedullary nails, and Y = 11.498 + 5.474 × X regardless of methods of internal fixation.

CONCLUSION

Masquelet technique is effective and safe for the treatment of long segmental tibial bone defects. The present study revealed the quantitative relationship between the size of bone defects and bone grafts, thus providing evidence for the selection of treatment strategies for long segmental bone defects in clinical practices, as well as helping to reduce the incidence of complications in Masquelet technique.

Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how?

INTRODUCTION

In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe.

MATERIALS AND METHODS

A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty.

RESULTS

The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was ±1.38 months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C.

CONCLUSIONS

One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.

Outcome evaluation of new calcium titanate schanz-screws for external fixators. First clinical results and cadaver studies

OBJECTIVE

External fixators are important for correcting length discrepancies and axis deformities in pediatric or trauma orthopedic surgery. Pin loosening is a common pitfall during therapy that can lead to pain, infection, and necessary revisions. This study aims to present clinical data using calcium titanate (CaTiO₃) Schanz screws and to measure the fixation strength.

PATIENTS AND METHODS

22 titanate screws were used for external fixators in 4 pediatric patients. Therapy was initiated to lengthen or correct axial deformities after congenital abnormalities. The maximum tightening torque was measured during implantation, and the loosening torque was measured during explantation. In addition, screws of the same type were used in a cadaver study and compared with stainless steel and hydroxyapatite-coated screws. 12 screws of each type were inserted in four tibias, and the loosening and tightening torque was documented.

RESULTS

The fixation index in the in vivo measurement showed a significant increase between screw insertion and extraction in three of the four patients. The pins were in situ for 91 to 150 days, and the torque increased significantly (P = 0.0004) from insertion to extraction. The cadaveric study showed lower extraction torques than insertion torques, as expected in this setting. The calculated fixation index was significantly higher in the CaTiO₃ group than in the other groups (P = 0.0208 vs. HA and P < 0.0001 vs. steel) and in the HA group vs. plain steel group (P = 0.0448).

CONCLUSION

The calcium titanate screws showed favorable fixation strength compared to HA and stainless steel screws and should be considered in long-term therapy of external fixation.

Outcome of application of primary versus secondary Illizarov's fixator in open tibial shaft fractures

BACKGROUND

The present study aimed to compare outcome of primary and secondary Illizarov's fixator application as a treatment method for type III open tibial fractures in terms of non-union and wound infection.

METHODS

This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarov's apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarov's application, primary (n=28) and secondary (n=20).

RESULTS

In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were significantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group.

CONCLUSION

Primary wound closure and Illizarov's fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarov's fixation, mostly due to a significantly less number of patients with a bone defect in the primary group.

Early Conversion of External Fixation to Interlocked Nailing in Open Fractures of Both Bone Leg Assisted with Vacuum Closure (VAC) - Final Outcome

INTRODUCTION

Management of compound grade III fractures of both bone leg includes external stabilization for long period, followed by various soft tissue coverage procedures. Primary interlocking of tibia had been also done with variable results. External fixation for long time without any bone loss often leads to infected nonunion, loss of reduction, pin tract infection and failure of fixation, primary interlocking in compound grade III fractures had shown high medullary infection rate. We managed all cases of compound grade III A/B fractures with primary external fixation, simultaneous wound management using vacuum assisted closure (VAC) followed by early conversion to interlocking within 2 weeks of fixator application.

AIM

To determine the effectiveness of vacuum assisted closure (VAC) for the early conversion of external fixator to definitive interlocking in open fractures of the both bone leg.

MATERIALS AND METHODS

In current study we selected 84 cases of compound grade IIIA/B diaphyseal fractures of both bone leg during period of May 2010 to September 2013. We managed these cases by immediate debridement and application of external fixation followed by repeated debridement, application of vacuum assisted closure (VAC) and conversion to interlocking within two weeks.

RESULTS

Out of 84 cases union was achieved in 80(95%) of cases with definitive tibial interlocking. Excellent to good result were obtained in 77(91.8%) of cases and fair to poor result seen in rest of 7(8.2%) of cases according to modified Ketenjian's criteria. 5 out of these 7 poor result group cases were from Compound Grade III B group to start with. Deep infection rate in our series were 7% i.e. total 6 cases and 4 out of these were from compound Grade III B group to start with.

CONCLUSION

Vacuum assisted closure (VAC) give a good help for rapid closure of the wound and help in early conversion to definitive intramedullary nailing. Reamed nail could well be used in compound grade IIIA/B fractures without increasing the risk of infection. It gives better stability to fracture site and lessen the risk of implant failure.

Pin-site care: can we reduce the incidence of infections?

BACKGROUND

This study was conducted to determine the pin-site care protocols currently in use and to analyse their effectiveness and outcomes.

METHODS

PubMed, the Cochrane Library and Embase databases were screened for manuscripts that described comparative studies of different methods of pin-site care and referred to complications related to any kind of external fixator application.

RESULTS

A total of 369 manuscripts were screened and only 13 of these met the inclusion criteria evaluating different protocols of pin-site care. This review is based on a total of 574 patients. Infection rates were very variable depending on the type of implant used and the protocol of pin-site care applied.

CONCLUSIONS

None of the different protocols of pin-site care that were evaluated in this study were associated with a 0% infection rate. There is currently no consensus in the international literature about which protocol should be applied universally. Meticulous surgical technique during pin insertion and implementation of one of the existing protocols of pin-site care are the mainstay of prevention and/or reduction of the incidence of pin-site infections.

The effects of tibial fracture and Ilizarov osteosynthesis on the structural reorganization of sciatic and tibial nerves during the bone consolidation phase and after fixator removal

Reactive and adaptive changes in mechanically uninjured nerves during fracture healing have not been studied previously although the status of innervation is important for bone union and functional recovery. This study explores whether subclinical nerve fibre degeneration occurs in mechanically uninjured nerves in an animal fracture model and to quantify its extent and functional significance. Twenty-four dogs were deeply anaesthetized and subjected to experimental tibial shaft fracture and Ilizarov osteosynthesis. Before fracture and during the experiment, electromyography was performed. In 7, 14, 20, 35–37 and 50 days of fixation and 30, 60–90 and 120 days after fixator removal, the dogs were euthanized. Samples from sciatic, peroneal and tibial nerves were processed for semithin section histology and morphometry. On the 37th postoperative day, M-response amplitudes in leg muscles were 70 % lower than preoperative ones. After fixator removal, these increased but were not restored to normal values. There were no signs of nerve injuries from bone fragments or wires from the fixator. The incidence of degenerated myelin fibres (MFs) was less than 12 %. Reorganization of Remak bundles (Group C nerve fibres—principally sensory) led to a temporal increase in numerical nerve fibre densities. Besides axonal atrophy, the peroneal nerve was characterized with demyelination–remyelination, while tibial nerve with hypermyelination. There were changes in endoneural vessel densities. In spite of minor acute MF degeneration, sustained axonal atrophy, dismyelination and retrograde changes did not resolve until 120 days after fracture healing. Correlations of morphometric parameters of degenerated MF with M-response amplitudes from electromyography underlie the subclinical neurologic changes in functional outcomes after tibial fractures even when nerves are mechanically uninjured.

Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature

We report on the surgical and functional outcome of 22 patients with Grade 3 open tibial fractures treated with circular frame. All cases united and there were no re-fractures or amputations. All patients were assessed at a minimum of 1-year post frame removal. Assessment included clinical examination, IOWA ankle and knee scores, Olerud and Molander ankle score and EuroQol EQ-5D. Clinical scores were either good or excellent in over half of the patients in all knee and ankle scores. There was a significant positive correlation between functional outcomes and the EQ-5D score. The EQ-5D mean health state visual analogue score was comparable to the general UK population despite patients scoring less than the average UK population in three of the five domains. 36% reported some difficulties in walking and 41% had problems with pain. 14% had difficulties with self-care and 46% had difficulties with their usual activities. 14% had problems with anxiety or depression. Systematic review of the literature suggests, in the management of open tibial fractures, circular frames provide equivalent or superior surgical outcomes in comparison with other techniques. Our study finds the application of a circular frame also results in a good functional outcome in the majority of cases.

Ilizarov external fixation versus plate osteosynthesis in the management of extra-articular fractures of the distal tibia

PURPOSE

The purpose of this study was to evaluate the outcome of Ilizarov external fixation (IE) versus dynamic compression plate (PO) in the management of extra-articular distal tibial fractures.

METHODS

Between 2010 and 2011, extra-articular distal tibial fractures in 40 consecutive patients met the inclusion criteria. They were classified according to AO classification fracture type A (A1, A2, and A3). In a randomized method, two equal groups were managed using either IE or PO. PO was performed using open reduction and internal fixation (ORIF) and DCP through anterolateral approach. IE was done using Ilizarov frame. For the PO group, non-weight bearing ambulation was permitted on the second postoperative day but partial weight bearing was permitted according to the progression in union criteria clinically and radiologically. For the IE group, weight bearing started as tolerated from the first postoperative day. Physiotherapy and pin-site care was performed by the patient themselves.

RESULTS

Modified Mazur ankle score was applied to IE (excellent 10, good 10) and in PO (excellent 2, good 8, poor 6). Data were statically analysed using (Mann-Whitney test). The rate of healing in the IE group (average 130) was higher than the PO (average 196.5); plus, there were no cases of delayed union or nonunion in the IE group (p value 0.003).

CONCLUSION

It was found that IE compared with PO provides provision of immediate weight bearing as tolerated following postoperative recovery, irrespective of radiological or clinical healing with no infection, deformity or non-union.

Bone healing by using Ilizarov external fixation combined with flexible intramedullary nailing versus Ilizarov external fixation alone in the repair of tibial shaft fractures: experimental study

Purpose. Our research was aimed at studying the radiographic and histological outcomes of using flexible intramedullary nailing (FIN) combined with Ilizarov external fixation (IEF) versus Ilizarov external fixation alone on a canine model of an open tibial shaft fracture. Materials and Methods. Transverse diaphyseal tibial fractures were modelled in twenty dogs. Fractures in the dogs of group 1 (n = 10) were stabilized with the Ilizarov apparatus while it was combined with FIN in group 2 (n = 10). Results. On day 14, a bone tissue envelope started developing round the FIN wires. Histologically, we revealed only endosteal bone union in group 1 while in group 2 the radiographs revealed complete bone union on day 28. At the same time-point, the areas of cancellous and mature lamellar bone tissues were observed in the intermediary area in group 2. The periosteal layers were formed of the trabeculae net of lamellar structure and united the bone fragments. The frame was removed at 30 days after the fracture in group 2 and after 45 days in group 1 according to bone regeneration. Conclusion. The combination of the Ilizarov apparatus and FIN accelerates bone repair and augments stabilization of tibial shaft fractures as compared with the use of the Ilizarov fixation alone.

Principles of tibial fracture management with circular external fixation

There is a growing mass of literature to suggest that circular external fixation for high-energy tibial fractures has advantages over traditional internal fixation, with potential improved rates of union, decreased incidence of posttraumatic osteomyelitis, and decreased soft tissue problems. To further advance our understanding of the role of circular external fixation in the management of these tibial fractures, randomized controlled trials should be implemented. In addition to complication rates and radiographic outcomes, validated functional outcome tools and cost analysis of this method should be compared with open reduction with internal fixation.

Ilizarov fixator pin site care: the role of crusts in the prevention of infection

Pin site infection is one of the most common local complications after procedures using the Ilizarov fine wire fixator. In this study, the rate of infection was investigated in two groups of patients, representing two consecutive case series, undergoing fracture stabilisation or lower limb reconstruction using an Ilizarov fine wire fixator. Both groups received identical Russian-style pin site care, except in the first Group A where the crusts of dried exudate were removed at the time of pin site cleaning; while in the subsequent Group B, the adherent crusts were retained during cleaning. Pin site infection was diagnosed if the site was painful and inflamed or discharging. The first infected pin site while the fixator remained in situ was considered the outcome of interest. Group A consisted of 59 patients and Group B of 33 patients. A lower proportion of patients in Group B (12/33 - 36%) developed a pin site infection compared to Group A (36/59 - 61%) (p=0.023). However, once infection had developed, a greater proportion of patients in Group B required more than one course of antibiotics to treat the infection when compared to patients in Group A (p=0.005). No patient required hospitalisation for intravenous antibiotics or wire change in Group B (0/33), whereas 3/59 patients required hospitalisation in Group A; but this did not reach statistical significance (Chi-squared test, p=0.18). Retention of adherent crusts during Ilizarov fixator pin site care significantly protects against the development of pin site infection, but renders subsequently infected pin sites more refractory to treatment. This study therefore suggests that crusts should be retained as long as a pin site remains uninfected. Retained crusts may act as a physical barrier to bacterial contamination ('biological dressing').

Histomorphometric analysis of knee synovial membrane in dogs undergoing leg lengthening by classic Ilizarov method and rapid automatic distraction

PURPOSE

This pilot study aimed to test the theory that different lengthening methods affect the microscopic structure of knee joint synovium in diverse ways.

METHODS

This was a descriptive and analytical cross-sectional study of synovium carried out in two experimental models of canine leg lengthening using the Ilizarov fixator. Group 1 (n = 6) used manual gradual distraction most commonly used in clinical practice at one millimetre/day divided into four equal increments, 0.25 mm at each increment. Group 2 (n = 7) used an increased rate of automatic distraction at three millimetres/day divided in 120 increments, 0.025 mm at each increment. At the end of distraction and after fixator removal, the animals were euthanised. Control was via intact dogs. The thickness of the synovial lining layer, number of synovial cell rows, and numerical density of subsynovial microvessels were assessed in digital images for semiautomated computerised analysis of semi-thin sections stained with toluidine blue and methylene blue-basic fuchsin. Comparison of synovitis manifestation was made with grading scale. The vascular and nerve changes in the subsynovial layer were also compared.

RESULTS

Group 1 developed marked synovitis, synovium hypervascularisation, degeneration of the nerve fibres in subsynovial nerves with the tendency to regeneration. Group 2 had moderate to mild degree of synovitis with progressive degenerative changes in subsynovial vessels and nerves.

CONCLUSION

Both methods used are unfavourable for the state of the joint synovium, but modify it in different ways.

The Ilizarov paradigm: thirty years with the Ilizarov method, current concerns and future research

The Ilizarov method of bone lengthening, reconstruction and osteosynthesis has developed immensely since its introduction by G.A. Ilizarov in the Soviet Union in the 1960s and in the Western countries in the early 1980s. It has become an integral part of the arsenal used by the orthopaedic community worldwide. The evolutionary development of the method and its current role has considerably improved the quality of life for millions of people around the whole world. Despite the great versatility of its possible applications for bone injuries and diseases, the Ilizarov method could not and cannot be the alternative to a range of other methods that are applied for some specific bone conditions, but rather is a method of choice. Its combination with the current methods of internal fixation or the means of internal fixation that use the biological principles that were laid down by G.A. Ilizarov have demonstrated the importance of tension stress, blood supply, functional loading, and fragment control during bone treatment. The objective of this study was to present an overview of the current state and concerns in the application of the Ilizarov method and define the prospective research trends aimed at regeneration stimulation, better control of treatment, infection barriers and patient comfort.

Ilizarov Versus AO External Fixator for the Treatment of Tibia Open Fractures

BACKGROUND

In developing countries, Ilizarov or AO external fixator is usually used for treatment of tibial open fractures. The purpose of this study was to compare the efficacy of these two methods for treatment of tibial open fractures.

METHODS

From April 2002 to April 2010, 120 patients with open tibial fractures admitted to the Department of Orthopedics of Babol University of Medical Sciences entered this study. In each arm, 60 subjects randomly received Ilizarov or AO external fixator. All patients were followed at least for one year. These two groups were compared regarding non-union, malunion and cure rates.

RESULTS

The mean age of the patients in Ilizarov group was 32.35±11.28 and for AO were 31.3±10.99 years. Mean time for union in Ilizarov group was 5.25±1.85 and for AO external fixator was 5.85±2.13 months. Nonunion rate in Ilizarov group was 10% and for AO external fixator was 11.7%. Malunion rate in Ilizarov group was 10% and for AO external fixator was 18.3%. Totally, efficacy of treatment in the Ilizarov group was 81.7% and in AO external fixator was 65%.

CONCLUSION

The efficacy of treatment in Ilizarov was higher than that AO external fixator in treatment of open tibial fractures.

Role of early Ilizarov ring fixator in the definitive management of type II, IIIA and IIIB open tibial shaft fractures

We evaluated the results of patients with Gustilo types II, IIIA and IIIB open tibial fractures managed early with the Ilizarov external fixator (IEF). Sixty patients (51 males, nine females; age range 20-62 years; mean age 32.8 years) with type II (11 patients), type IIIA (13) and type IIIB (36) tibial diaphyseal fractures underwent emergency debridement and minimal bone fixation (with external fixator), followed by definite fixation with the IEF after three to five days. Average duration of the hospital stay was 8.6 days. All fractures united with an average union time of 21.1 weeks (standard deviation [SD] 3.18) in type II, 21.7 weeks (SD 3.57) in IIIA and 24. 9 weeks (SD 5.14) in IIIB fractures. The difference between union time in type II and IIIA was not significant (p > 0.05), but that between IIIA (and also type II) and IIIB was significant (p < 0.05). The healing index in patients who underwent lengthening was 1.5 months/cm. The wounds in 27 patients were managed by delayed primary closure, in 19 patients with second intent (all IIIB), in 11 patients with skin grafting (mostly type IIIB fractures) and in three patients with musculocutaneous flaps. The most common complications of the procedure were pin tract infection and pain at the fracture site. Most of the patients were able to achieve good knee and ankle range of motion. Early application of the Ilizarov fixator constitutes an excellent management of open tibial fractures, especially types II, IIIA and IIIB, due to good functional and radiological results. Despite the technical difficulties and some complications (which are mostly minor) IEF may be the preferred method in open tibial fractures, especially types II and III.

Staged external and internal less-invasive stabilisation system plating for open proximal tibial fractures

High-energy proximal tibial fractures are complex injuries that may lead to significant complications. Staged treatment of these injuries using a spanning external fixator across the knee joint in the acute setting decreases the incidence of complications. This article is a prospective evaluation of outcomes using a two-stage procedure for treatment of 15 patients who sustained open proximal tibial fractures between April 2006 and January 2008. In the first stage, we used low profile, less-invasive stabilisation system (LISS) plates for temporary external fixation to immobilise the fractures after anatomic reduction, followed by soft-tissue reconstruction. In the second stage, we applied LISS plates for definitive internal fixation, using minimally invasive percutaneous osteosynthesis. All fractures were monitored for a mean of 20.4 months (range, 12-32 months). All fractures united at a mean of 38.6 weeks (range, 18-66 weeks). Knee motion ranged from a mean of 1 degrees (range, 0 degrees to 5 degrees ) to 125 degrees of flexion (range, 100 degrees to 145 degrees ). The reduction was scored as good in 13 patients and fair in two patients. At follow-up, 10 patients had excellent, and five had good knee scores. The complications included minor screw-track infections in three patients. In conclusion, the two-stage technique was well suited for treating these difficult injuries, and for patients who needed longer periods of external fixation. Surgeons were able to achieve gross anatomy restoration, soft-tissue reconstruction, stable fixation and high union rates. Patients obtained good-to-excellent motion, function and comfort after treatment.

Changing the treatment to reduce complication rate in open tibial fractures

Complications of open tibial fractures have been found to be very frequent after application of monotherapies (external fixator, plate, intramedullary nailing). The use of combined therapy has improved our results. We treated 658 patients for open tibial fractures over a course of 15 years. Plating was the method of treatment in the initial phase, and then external fixators and unreamed tibial nails (UTN) were used as a monotherapy. In the last ten years the option of a combined therapy was at our disposal, namely, changing the method of treatment. Monotherapy was performed in 352 cases, and 270 patients were treated in a combined manner. The rate of septic complications could be reduced with the combined therapy from 15.5% to 6.6%, the rate of bone healing disorders from 31.6% to 8.7%, and that of amputations from 4.9% to 0.7%. Elaboration of therapeutic tactics and their consistent application increases the healing potential of open tibial fractures. During this 15 year period, our therapeutic concepts have changed, whereby gradual, combined therapy models were initiated, increasing the advantages and decreasing the disadvantages of the different methods.

Combined single-stage osseous and soft tissue reconstruction of the tibia with the Ilizarov method and tissue transfer

OBJECTIVE

To determine the outcome of single-stage soft tissue and osseous reconstruction using the Ilizarov method and soft-tissue transfer.

DESIGN

A retrospective review.

SETTING

: A university-affiliated, tertiary-care center.

PATIENTS/INTERVENTION

We identified 11 patients from a retrospective review from January 1994 to July 1999 who underwent single-stage soft tissue and osseous reconstruction using the Ilizarov method. All 11 patients had an initial traumatic mechanism to their tibia and had previous operative intervention before the combined procedure. The Ilizarov procedure was performed for infected tibial nonunion (8 cases), or complex fracture with soft-tissue loss (3 cases).

MAIN OUTCOME MEASUREMENTS

Soft tissue transplant survival, union, range of motion, leg length discrepancy, the Association for the Study and Application of the Method of Ilizarov (ASAMI) score, radiographic parameters.

RESULTS

There were 8 concomitant free tissue flaps and 3 local pedicled flaps. Two patients had primary bone grafting, and 5 others had addition of an antibiotic impregnated bone substitute. There were 8 cases of elective reconstructive surgery and 3 cases of acute traumatic fracture. The mean duration of Ilizarov application was 26 weeks (range, 7 to 42). Eight tibiae united primarily, and 3 healed after delayed bone grafting. There were 2 major flap complications. Both were successfully managed with repeat surgery. One patient sustained a repeat open fracture and subsequently received an amputation. According to the ASAMI score, there were 9 excellent results, 1 good result, and 1 poor result.

CONCLUSION

Our study suggests that concomitant osseous and soft-tissue reconstruction with the Ilizarov technique and free or pedicled flaps is a viable option for patients with composite tissue defects.

Ilizarov external fixator for burst fracture of the lumbar spine: a case report

A 50-year-old man presented with severe back pain and tenderness throughout the lumbar area after falling from a ladder. He had an unstable type-B burst fracture, with a spinal canal narrowing of 36% and an anterior height loss of 65%. His lower-limb neurological function was intact. An Ilizarov external spinal fixator was used; the pedicular half pins were inserted into the bilateral T11, T12, L2, and L3 pedicles; bilateral pedicular half pins were fixed at each level with external plates and rods. Postoperatively, the patient had a lordosis of 2 degrees and was able to walk 7 days later. The external fixator was removed at 10 weeks. Six years and 10 months after surgery, the patient had a kyphosis of 19 degrees that did not affect his activities of daily living.

Treatment of type IIIA open fractures of tibial shaft with Ilizarov external fixator versus unreamed tibial nailing

INTRODUCTION

The aim of this study was to compare the radiographic results and clinical outcome of unreamed tibial nailing (UTN) and Ilizarov external fixation (IEF) for the treatment of type IIIA open fractures of the tibia.

MATERIALS AND METHODS

Sixty-one patients with open type IIIA tibial shaft fractures were treated with an IEF (n = 32) or UTN (n = 29). Both groups were compared for union time, secondary outcomes of nonunion, infections, mechanical failure of the implant, and malunion.

RESULTS

The average time-to-bone healing was 19 weeks (range 14-23 weeks) for IEF and 21 weeks (range 16-36 weeks) for UTN; it was significantly shorter in the IEF group (P = 0.039). One patient had refracture in the IEF group. Malunion occurred in four patients for each group. Posttraumatic osteomyelitis occurred in two patients in the IEF group and in three patients in the UTN group. In the IEF group, additional surgical procedures were indicated in three cases including sequestrectomy (n = 1), and pin replacement (n = 2). In the UTN group, seven patients needed additional surgery including bone grafting (n = 3), nail exchanged (n = 1), and posttraumatic osteomyelitis (n = 3).

CONCLUSION

The results of the current study showed that IEF technique had a notable incidence of pin-tract infection, joint contracture, and shorthening related to treatment of the delayed union. The UTN technique had the disadvantage of a posttraumatic osteomyelitis and delayed union requiring additional surgery. We believe that the decision to use IEF or UTN should be made on a case-by-case basis.

Pin-track infection in HIV-positive and HIV-negative patients with open fractures treated by external fixation

Patients infected with HIV presenting with an open fracture of a long bone are difficult to manage. There is an unacceptably high rate of post-operative infection after internal fixation. There are no published data on the use of external fixation in such patients. We compared the rates of pin-track infection in HIV-positive and HIV-negative patients presenting with an open fracture. There were 47 patients with 50 external fixators, 13 of whom were HIV-positive (15 fixators).

There were significantly more pin-track infections requiring pharmaceutical or surgical intervention (Checketts grade 2 or greater) in the HIV-positive group (t-test, p = 0.001). The overall rate of severe pin-track infection in the HIV-positive patients requiring removal of the external-fixator pins was 7%. This contrasts with other published data which have shown higher rates of wound infection if open fractures are treated by internal fixation.

We recommend the use of external fixation for the treatment of open fractures in HIV-positive patients.

Is staged external fixation a valuable strategy for war injuries to the limbs?

High-energy weapons or blast injuries usually result in substantial tissue damage and are serious medical and public health problems. We report our experience with staged external fixation for war injuries to the extremities. Forty-seven patients with 64 high-energy limb fractures caused by war weapons were retrospectively reviewed. The fractures were associated with severe soft tissue damage. There were 14 Gustilo-Anderson Type IIIA fractures, 40 Type IIIB fractures, and 10 Type IIIC fractures. Soft tissue débridement followed by axial realignment of the fractured bones with immediate skeletal stabilization using the AO/ASIF unilateral tubular external fixator was performed on the day of admission. The primary tubular fixators were exchanged 5 to 7 days later for Ilizarov frames. Delayed primary closure, skin grafts, or flaps were used for soft tissue coverage. The mean followup was 40 months, and the Ilizarov/hybrid external fixator was the definitive treatment in all patients. Bone union was achieved at an average of 8 months in 58 (90.6%) fractures. Three patients had nonunions and one patient required an amputation. Two patients were lost to followup. Staged external fixation is a valuable strategy for treatment of war injuries to the extremities.

LEVEL OF EVIDENCE

Therapeutic study, Level IV. See the Guidelines for Authors for a complete description of levels of evidence.

Tryptophan availability modulates serotonin release from rat hypothalamic slices

Application of a novel in vitro experimental system has allowed us to describe the relationship between tryptophan availability and serotonin release from rat hypothalamic slices. Superfusing hypothalamic slices with a physiologic medium containing l-tryptophan (1, 2, 5, or 10 microM) caused dose-dependent elevations in tissue tryptophan levels; the magnitude of the elevations produced by supplementing the medium with less than 5 microM tryptophan was within the physiologic range for rat brain tryptophan levels. Slice serotonin levels rose biphasically as the tryptophan concentration in the medium was increased. Superfusing the slices with medium supplemented with a low tryptophan concentration (1 or 2 microM) caused proportionally greater incremental changes in serotonin levels than the increases caused by further elevating the tryptophan concentration (5 or 10 microM). The spontaneous release of serotonin from the slices exhibited a dose-dependent relationship with the tryptophan concentration of the superfusion medium. Electrically evoked serotonin release, which was calcium-dependent and tetrodotoxin-sensitive, also increased in proportion to the medium tryptophan concentration. These data suggest that the rate at which serotonin is released from hypothalamic nerve terminals is coupled to brain tryptophan levels. Accelerations in hypothalamic serotonin synthesis, caused by elevating brain tryptophan levels, result in proportionate increases in the rates of serotonin release during rest and with membrane depolarization.