Distal tibial fractures treated with hybrid external fixation

Comparative Outcome of Hybrid External Fixator Versus Primary Ilizarov Fixator in the Treatment of Open Distal Tibia Extra-Articular Fractures

Introduction

Because one-third of the tibia is subcutaneous throughout most of its length and its location, it is more prone to open fractures. Open distal tibia fractures are mostly due to RTA and sports injuries. The goal of treatment is to obtain a healed, well-aligned fracture; pain-free weight-bearing; and functional range of motion of the knee and ankle.

Materials and Methods

33 patients of the 18-60-year age group with open distal tibia extra-articular fractures (without vascular injury), less than 3 weeks old trauma were included in the prospective study for 1 year period (1st June 2019 to 31st May 2020). 17 cases were treated with the Hybrid external fixator (HEF) and 16 cases were treated with the Ilizarov fixator (IF).

Results

Significantly (P < 0.05), the mean duration of surgery was less in the HEF group (67.6 min), faster union of open type-II fractures in the HEF group (16.4 weeks), and also a higher AOFAS score at 6 months in open type-II fractures in the HEF group (84.4). There were two cases of equinus deformity in the IF group and one case of valgus deformity in the HEF group.

Conclusion

HEF and IF are both equally effective in the treatment of open distal tibia extra-articular fractures with the advantage of stable fracture fixation, early weight-bearing, preserving soft tissue, minimal periosteal stripping, and providing one-staged definitive intervention. However, HEF is preferred over IF in terms of less operating time, faster union, and a better functional outcome with minimal complications.

Tibial pilon fractures treated with a periarticular external fixator: Retrospective study of 47 cases

INTRODUCTION

Tibial pilon fractures are a treatment challenge, since there is no true gold standard treatment, and because of potential skin complications. Periarticular external fixation (PAEF) appears to produce good results, but the outcomes with the TL-HEX Trauma™ (Orthofix®, Verona, Italy) have not yet been evaluated. We performed a study with the following objectives: 1) evaluate time to union and union rate; 2) determine clinical and radiological results; 3) detect complications.

HYPOTHESIS

PAEF will produce comparable fracture union to other external fixator techniques for tibial pilon fractures.

METHODS

A single center, retrospective study, was done between June 2016 and December 2018. Patients who had a tibial pilon fracture operated with a PAEF were included if they had a minimum of 12 months' follow-up. Forty-seven patients were included; the mean follow-up was 2.45 years (1.2-3.7). The primary endpoint was the time to union and union rate at the final assessment. The secondary endpoints were the joint range of motion, residual pain (VAS), functional scores (AOFAS and SF12) and complication rate.

RESULTS

The union rate was 70% (33/47) and the mean time to union was 201±79 days (89-369). The range of motion was significantly reduced relative to the contralateral side. Twenty patients had residual pain that averaged 2.9 (1-6) on the VAS. The mean AOFAS score was 74 points (51-95). Twenty patients (43%) suffered at least one complication.

DISCUSSION

While a PAEF helps to avoid skin complications, in our study, it was associated with a lower union rate and longer time to union than in other published studies. This difference is likely due to a higher rate of open fractures and high-energy trauma in our study, different protocol for return to weightbearing and a different external fixator than other studies. This is the first study reporting the results of the TL-HEX Trauma in this indication.

LEVEL OF EVIDENCE

IV, retrospective study.

Effects and Anti-rotation Stabilization of the Non-bridging External Fixation for Pronation-Abduction Stage III Ankle Fracture: A Cadaveric Study

Objective

This study is aimed at providing a nonbridging external fixation technique with pinning fixation for the pronation-abduction stage III ankle fracture. The secondary purpose was to evaluate its effect on anatomic reduction and fracture fragment stability against cadaveric models' rotation.

Method

A paired design study was conducted using 14 pairs of the cadaveric model which had been modeled for pronation-abduction stage III ankle fracture. One fracture model from each pair was randomly allocated to receive an open reduction and internal fixation, while the other was reduced and stabilized with the external fixation technique. After the surgery, the antirotational stability tests were performed with external rotation torques of 10 nm, 15 nm, and 20 nm applied, respectively. The postoperation reduction rate and ankle parameters were recorded in anteroposterior and lateral radiographs before and after the antirotational stability experiment.

Result

The outcomes were assessed according to Burwell-Charnley's radiographic criteria of reduction. It showed no statistically significant differences in reduction between the two groups (P < 0.05). The displacement of lateral fragment following a reduction in the external fixation group was significantly larger than that of the internal fixation group (3.14 ± 0.56 vs. 1.49 ± 0.39, P < 0.05). After applying rotational torques of 10 nm, 15 nm, and 20 nm, the results of other parameters showed no significant differences between the two groups.

Conclusion

This nonbridging external fixation method with pin fixation of fracture fragments might have the same effect as that of internal fixation on the reduction rate of pronation-abduction stage III ankle fracture.

Hybrid external fixation in the treatment of tibial pilon fractures: A retrospective analysis of 162 fractures

OBJECTIVES

To determine the efficacy of hybrid external fixation in the treatment of tibial pilon fractures.

DESIGN

Retrospective, multicentre study.

PATIENTS/PARTICIPANTS

Adult patients with tibial pilon fractures treated with hybrid external fixation.

INTERVENTION

Fracture reduction with ligamentotaxis and fixation with XCaliber hybrid external fixator.

MAIN OUTCOME MEASUREMENTS

Fracture union, complications, functional outcome (Mazur Ankle Score).

RESULTS

Union was obtained in 159 fractures at an average of 125days; there were three delayed unions and three non-unions. The most frequent complication was superficial pin-track infections (48), all of which responded to local wound care and antibiotics. There were no deep infections and no DVT. Only one fracture had loss of reduction that required frame revision. The overall functional scores were 91 (excellent) for AO/OTA type A fractures, 89 (good) for type B fractures, and 75 (satisfactory) for type C fractures.

CONCLUSIONS

Hybrid external fixation is an effective method of stabilising tibial pilon fractures, particularly those with marked comminution. The minimally-invasive technique and stable fixation enable early mobilisation, with good functional results and minimal complications.

LEVEL OF EVIDENCE

Level IV Case series.

Comparison of 3 Minimally Invasive Methods for Distal Tibia Fractures

This study compared the results of external fixation combined with limited open reduction and internal fixation (EF + LORIF), minimally invasive percutaneous plate osteosynthesis (MIPPO), and intramedullary nailing (IMN) for distal tibia fractures. A total of 84 patients with distal tibia shaft fractures were randomized to operative stabilization using EF + LORIF (28 cases), MIPPO (28 cases), or IMN (28 cases). The 3 groups were comparable with respect to patient demographics. Data were collected on operative time and radiation time, union time, complications, time of recovery to work, secondary operations, and measured joint function using the American Orthopaedic Foot and Ankle Society (AOFAS) score. There was no significant difference in time to union, incidence of union status, time of recovery to work, and AOFAS scores among the 3 groups (P>.05). Mean operative time and radiation time in the MIPPO group were longer than those in the IMN or EF + LORIF groups (P<.05). Wound complications after MIPPO were more common compared with IMN or EF + LORIF (P<.05). Anterior knee pain occurred frequently after IMN (32.1%), and irritation symptoms were encountered more frequently after MIPPO (46.4%). Although EF + LORIF was associated with fewer secondary procedures vs MIPPO or IMN, it was related with more pin-tract infections (14.3%). Findings indicated that EF + LORIF, MIPPO, and IMN all achieved similar good functional results. However, EF + LORIF had some advantages over MIPPO and IMN in reducing operative and radiation times, postoperative complications, and reoperation rate. [Orthopedics. 2016; 39(4):e627-e633.].

Hybrid External Fixation for Arbeitsgemeinschaft für Osteosynthesefragen (AO) 43-C Tibial Plafond Fractures

Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p = .256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence.

External fixation of tibial fractures

External fixation for definitive or initial management of tibial fractures has a long history, with pin-to-bar external fixation being the standard of care for definitive management of tibial fractures. However, the use of this method lessened because of the increased popularity of intramedullary nailing and drawbacks associated with external fixation. This method is still commonly in use in the military environment and can be used for temporary stabilization of tibial fractures, especially in the setting of periarticular injuries. These fixators also may be useful for salvage of open and/or infected fractures that are unsuitable for internal fixation.

A randomised prospective study of two different combined internal and external fixation techniques for distal tibia shaft fractures

BACKGROUND

External fixation combined with limited open reduction and internal fixation (EF + LORIF) is a well-accepted and effective method for distal tibia shaft fractures, but it was also related to complications. The objective of this study was to compare external fixation combined with closed reduction and internal fixation (EF + CRIF) with EF + LORIF in the treatment of distal tibia shaft fractures, and explore the benefits and defects of these two techniques.

METHODS

Fifty-six patients were randomised to operative stabilisation either by an external fixator combined with two closed titanium elastic nails or by external fixation combined with limited open reduction and internal fixation. Pre-operative variables included the patients’ age, sex, the affected side, cause of injury, Tscherne classification of soft tissue injury, fracture pattern, and time from injury to surgery. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems and other complications, union time, time of recovery to work, the functional American Orthopaedic Foot and Ankle surgery (AOFAS) score.

RESULTS

There was no significant difference in the mean operating time (72.6 ± 11.5 vs. 78.5 ± 16.4 min, P = 0.125), the time to union (21.2 ± 11.0 vs. 22.5 ± 12.3 weeks, P = 0.678), the time of recovery to work (25.0 ± 14.5 vs. 26.4 ± 13.6 weeks, P = 0.711), pin track infection (3/28 vs. 4/28, P = 1.000), delayed union (2/28 vs. 3/28, P = 1.000), pain (38.3 ± 1.6 vs. 38.7 ± 1.5, P = 0.339), function (44.4 ± 6.0 vs. 45.0 ± 5.5, P = 0.698), and total AOFAS scores (91.5 ± 7.4 vs. 93.4 ± 6.8, P = 0.322) between the two groups. However, the mean radiation time was longer in the EF + CRIF group than in the EF + LORIF group (2.0 ± 1.2 vs. 0.3 ± 0.1 min, P < 0.01). The EF + CRIF group had no wound complications while the EF + LORIF group had five wound complications, though the difference was not statistically significant (P = 0.052). Acceptable alignment was obtained in 50 patients (22 in EF + CRIF vs. 28 in EF + LORIF, P = 0.023). Two cases with EF + CRIF had a 6 degrees of recurvatum deformity and four had 6–9 degrees of valgus deformity.

CONCLUSION

Our results indicated that both EF + CRIF and EF + LORIF were reliable methods in treatment of distal tibia shaft fractures. EF + CRIF had fewer wound complications and broader indications while EF + LORIF had lower radiation exposure and better alignment.

Biomechanical analysis and clinical effects of bridge combined fixation system for femoral fractures

This work aimed to compare the stress distribution and mechanical properties of our bridge combined fixation system and commonly used metal locking plate screw system by finite element analysis and by using the Zwick/Z100 testing machine. In addition, we also investigated the clinical outcome of our bridge combined fixation system for femoral fractures in 59 patients from June 2005 to January 2013. As a result, the stress distribution in the bone plate and screws of metal locking plate screw system during walking and climbing stairs was significantly lower than that of metal locking plate screw system. No significant difference in the displacement was observed between two systems. The equivalent bending stiffness of bridge combined fixation system was significantly lower than that of metal locking plate screw system. There were no significant differences in the bending strength, yield load, and maximum force between two systems. All the cases were followed up for 12-24 months (average 18 months). The X-ray showed bone callus was formed in most patients after 3 months, and the fracture line was faint and disappeared at 6-9 months postoperatively. No serious complications, such as implant breakage and wound infection, occurred postoperatively. According to self-developed standard for bone healing, clinical outcomes were rated as excellent or good in 55 out of 59 patients (success rate: 93.2%). Therefore, our findings suggest that our bridge combined fixation system may be a promising approach for treatment of long-bone fractures.

Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes

BACKGROUND AND PURPOSE

Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures.

PATIENTS AND METHODS

A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables.

RESULTS

27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03-0.57) and for malalignment it was 0.10 (95% CI: 0.02-0.42). Both values were statistically significant.

INTERPRETATION

This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings.

Biomechanical comparison of strategies to adjust axial stiffness of a hybrid fixator

OBJECTIVES

To evaluate strategies for increasing the axial stiffness of a hybrid external bone fixator.

MATERIALS AND METHODS

Type Ia hybrid fixators, consisting of a uniplanar linear component connected to a circular ring, were tested in displacement controlled loading in axial compression. The basic hybrid construct was modified to explore strategies considered to increase fixator stiffness including: decreasing ring diameter, increasing ring thickness, adding pins to the ring fixation, and adding struts between the ring and vertical post components of the device. Stiffness in the initial phase of loading was compared between the groups.

RESULTS

The addition of a single diagonal bar between the ring and linear connecting rail did not significantly improve the stiffness of constructs. However, the addition of two half-pins to the ring, the addition of two struts between the ring and linear connecting rail, or decreasing the internal ring diameter from 115 to 85 mm progressively increased the stiffness of the frame. The most effective strategy consisted of increasing the thickness of the ring from 6 to 12 mm, thereby increasing the stiffness of the control frame by 335%.

CLINICAL SIGNIFICANCE

Modulating the ring thickness, adding two struts between the ring and linear connecting rail, and reducing the ring diameter appear to be the most effective, simple, and clinically versatile ways to increase axial stiffness, most likely due to their impact on reducing ring bending.

Posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury

The treatment of distal tibial fractures with anterior soft tissue injury is relatively difficult. The aim of this study was to explore the efficacy and safety of the posteromedial anatomical plate for such fractures. Between February 2006 and January 2009, twenty-six cases of distal tibial fracture with anterior soft tissue injury were treated with posteromedial anatomical plates designed by our traumatic orthopedic center. Of the 26 cases, 12 were open fractures (4 Gustilo-Anderson type I, 5 type II, 2 type IIIA, and 1 type IIIB), and 14 were closed fractures (3 Tscherne-Oestern type I, 9 type II, 2 type III). Operation time, intraoperative blood loss, fracture healing time, American Orthopaedic Foot and Ankle Society (AOFAS) ankle score, and complications were recorded to evaluate treatment effects.Mean operation time was 72.5 ± 15.8 minutes (range, 45-105 minutes) with a mean intraoperative blood loss volume of 86.4 ± 17.3 mL (range, 50-150 mL). All 26 patients had good postoperative fracture healing. Mean union time was 19.2 ± 4.4 weeks (range, 13-30 weeks). Average AOFAS ankle score was 87.3 ± 9.2 (range, 68-99). No malunion, nonunion, limb-shortening deformity, or neurovascular injury occurred. Our results suggest that the posteromedial anatomical plate for the treatment of distal tibial fractures with anterior soft tissue injury is effective and results in no severe complications.

Flexible fixation and fracture healing: do locked plating 'internal fixators' resemble external fixators?

External and internal fixators use bone screws that are locked to a plate or bar to prevent periosteal compression and associated impairment of blood supply. Both osteosynthesis techniques rely on secondary bone healing with callus formation with the exception of compression plating of simple, noncomminuted fractures. External fixation uses external bars for stabilization, whereas internal fixation is realized by subcutaneous placement of locking plates. Both of these "biologic" osteosynthesis methods allow a minimally invasive approach and do not compromise fracture hematoma and periosteal blood supply. Despite these similarities, differences between the two fixation methods prevail. Locked plating "internal fixators" allow a combination of biomechanical principles such as buttressing and dynamic compression. Periarticular locking plates are anatomically contoured to facilitate fixation of articular fractures. They allow for subchondral stabilization using small-diameter angular stable screws as well as buttressing of the joint and the metaphyseal component of a fracture. Biomechanically, they can be far stiffer than external fixators, because subcutaneous plates are located much closer to the bone surface than external fixator bars. External fixators have the advantage of being less expensive, highly flexible, and technically less demanding. They remain an integral part of orthopaedic surgery for emergent stabilization, for pediatric fractures, for definitive osteosynthesis in certain indications such as distal radius fractures, and for callus distraction.

Tibial pilon fractures: which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.