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PubMed1978

External fixation. Classification and indications.

The conclusion from the above clinical and experimental presentation is that stabilization by using external fixation in problematic cases is the method of choice because the risk of infection is better than by using the standard methods of plating and nailing. Using external fixation based on the tubular system of ASIF we can achieve rigid stability. Correct application allows early mobilization ensuring alignment even in bone defects. This method of treatment also facilitates the care of wounds. Our experimental and clinical information provides us with the opportunity to offer a systematic classification of each individual type of external fixation and its merits, as described above in types I, II, and III and its application in different situations. Our clinical experience also shows that external fixation has greatly reduced the risk of amputation in these problematic cases, but it has not solved all the problems associated with the primary injury. The advantage of the three-dimensional external fixation type III can also be seen in the case of arthrodesis of the knee joint. Here there is a better neutralization of the bending moment, than by using type II. Finally we would like to emphasize that the external fixation is not the panacea for every problematic case and each surgeon should be well aware of its methodical and correct application, as abuse of external fixation may lead to secondary complications.

Biomechanical Phenomena↗
PubMed2004

External fixation with or without supplementary intramedullary Kirschner wires in the treatment of distal radial fractures.

OBJECTIVES: To determine radiographic outcomes in the fracture of distal radius treated by close reduction and external fixation, with or without supplementary intramedullary Kirschner wires.. METHODS: At the Orthopedic Department of National Taiwan University Hospital, we carried out a retrospective study of distal radial fractures treated with close reduction and external fixation. A consecutive series of 20 fractures were treated (from March 1995 to June 1998) with external fixation only; later (from January 1999 to December 2001), 36 distal radius fractures were treated with external fixation supplemented with intramedullary wires. The fractures were evaluated via good-quality posteroanterior and lateral radiographs. In both groups, the radial height, radial inclination and volar tilting were measured on initial (preoperative) and immediate postoperative radiographs and on others taken immediately after the removal of external fixation. Overall results were based on objective radiographic and functional data as well as on subjective assessments with demerit-point scoring. Data were analyzed with a 2-tailed t test. RESULTS: Radial height and radial inclination improved significantly immediately after surgery, but volar tilting of distal-radius deformity was little improved by treatment with external fixation alone. When external fixation was supplemented with intramedullary Kirschner wires, improvement in all 3 measurements was statistically significant. Clinical examination likewise found significantly better functional results in patients treated with the Kirschner wires. CONCLUSION: External fixation is a popular method too reduce osseous deformity of the distal radius, but can not assure maintenance of the reduction. Supplementing external fixation with intramedullary Kirschner wires can improve retention of fracture reduction during healing, resulting in better functional results.

Bone Wires↗
PubMedDate not supplied

Biomechanical comparison of flexible stainless steel and titanium nails with external fixation using a femur fracture model.

There are several options available for surgical stabilization of pediatric femoral shaft fractures. The purpose of this study was to compare the stability afforded by Ender stainless steel nails, titanium elastic nails, and one-plane unilateral external fixators for the fixation using a synthetic adolescent midshaft femur fracture model. The anterior-posterior (sagittal plane) bending, lateral (coronal plane) bending, torsional, and axial stiffness values were calculated using 6 different fixation configurations. These included pairs of 3.5-mm-diameter Ender nails with and without distal locking, 3.5- and 4.0-mm-diameter titanium elastic nails as well as single- and double-stacked monolateral external fixators. Eight synthetic femur models, 4 each with simulated transverse and comminuted fracture patterns, were sequentially tested for stability afforded by the various fracture fixation configurations. External fixation exhibited significantly greater control of anterior-posterior angulation compared with all flexible-nailing systems. Although Ender nails were slightly superior to titanium nails in control of sagittal plane angulation, this was not statistically significant. Compared with the external fixation constructs, all 4 flexible nail constructs demonstrated higher torsional stability. For prevention of axial shortening, all fixation methods were similar for the transverse fracture pattern, whereas external fixation was superior to flexible nails in the comminuted fracture model. No significant benefit was demonstrated with double stacking of external fixators. These findings may help guide clinicians choose the optimal fixation method for treatment of pediatric femoral shaft fractures.

Biomechanical Phenomena↗
PubMed1997

Femoral lengthening: callotasis with Ilizarov external fixator alone and with intramedullary locking nail.

Callus distraction (callotasis) has improved the results of limb lengthening and has decreased complication rates. Unfortunately, this technique requires a long time in an external fixator device to allow bone regeneration and consolidation, especially in adults. We retrospectively compared the results and complications of two groups of patients who underwent femoral lengthening by means of callotasis with the Ilizarov external fixator. Group I underwent callotasis alone, and group II underwent callotasis with an intramedullary locking nail. Group I consisted of 14 patients, with a median age at surgery of 24.3 years. Group I etiologies were trauma in seven patients, congenital disorders in four and sequelae of poliomyelitis in three. Group II consisted of seven patients, with a median age at surgery of 22.4 years. The etiologies in group II were trauma in five patients and congenital disorders in two. In group I, the median gain in length was 4 cm. The median time in the external fixator was 218 days. The median time index of external fixation was 50 days/cm. Complications included four pin tract infections, one incomplete corticotomy, one refracture and one flexion contracture after removal of the external fixator. In group II, the median gain in length was 4.8 cm, and the median time in the external fixator was 70 days. The median time index of external fixation was 14 days/cm. There were no major complications except one distal screw backout, which did not impair the final outcome. We conclude that femoral lengthening by callotasis with combined Ilizarov external fixator and intramedullary locking nail can significantly shorten the treatment in the external fixator period, with good results and low complication rates in adults.

Adolescent↗
PubMed1992

Remanipulation or external fixation after slipped Colles' fractures? An anatomical study.

A series of 50 consecutive patients with Colles' fractures which redisplaced after reduction underwent either remanipulation and a plaster cast or remanipulation and external fixation. The external fixator group achieved a significantly better anatomical result than simple remanipulation and replastering. Where plaster immobilization has failed, external fixation gives a better anatomical result than remanipulation and replastering.

Adult↗
PubMed1989

External fixation of femoral fractures. Indications and limitations.

The role of external fixation in the management of femoral shaft fractures is reviewed based on a study of 24 femoral fractures managed by either an AO or a Wagner external fixator during 1983-1986. Indications included open fractures with soft-tissue injury (13 patients), comminuted shaft fractures (six patients), and unstable operative candidates (five patients). In 14 patients, external fixation was a temporary method (Group I), while in ten patients it was the definitive method of stabilization (Group II). Twenty-one patients achieved solid union, two developed a delayed union, and one had a nonunion. Three patients developed pin-tract infections, and one developed osteomyelitis after intramedullary fixation in Group I. Two patients in Group II developed shortening (2.1 cm and 3.2 cm). Loss of motion occurred in 11 patients, averaging 56 degrees. It is suggested that external fixation be considered in the following types of femoral fractures: open fractures for aggressive management of soft-tissue injuries; closed fractures in severely traumatized, burn, or head injury patients; fractures about the knee resulting in floating knees; and infected femoral nonunions and pseudarthroses.

Adolescent↗
PubMed2004

[A comparison between the use of a monolateral external fixator and the Ilizarov technique for pelvic support osteotomies].

OBJECTIVES: We compared the results of monolateral external fixator and the Ilizarov technique for pelvic support osteotomies in the treatment of neglected congenital hip dislocation. METHODS: Seventeen female patients with congenital dislocation of the hip underwent pelvic support osteotomy using a monolateral external fixator (MEF) (n=7; mean age 23.2 years; range 17 to 39 years) or the hybrid advanced Ilizarov method (HAIM) (n=10; mean age 25.9 years; range 17 to 36 years). The mean leg discrepancies, durations of the external fixator, and follow up-periods in the MEF and HAIM groups were as follows, respectively: 5.5 cm and 5.2 cm; 201.5 days (range 185 to 241 days) and 197 days (164 to 248 days); 30.4 months (23 to 39 months) and 40.5 months (21 to 65 months). The two groups were compared with respect to patients' discomfort related to the use of external fixators and pin tract infections classified according to the Paley criteria. RESULTS: Overall, six pins required removal because of grade 3 pin track infections (5 in the HAIM group, 1 in the MEF group). The number of patients who reported extreme discomfort for the use of external fixator was three in the HAIM group and one in the MEF group. Although the range of motion of the knee was similar in both groups (p>0.05), clinically, patients treated with MEF exhibited a more comfortable range of motion of the knee with external fixation and, after removal of the fixator, reached a knee flexion of 90 degrees in a shorter time (36 days versus 47 days). CONCLUSION: The use of MEF for pelvic support osteotomies seems to be preferable because it is associated with a lower rate of pin tract infections and a higher degree of patient comfort.

Adolescent↗
PubMed2001

Easily removed drill guide for pin insertion during external fixation.

A new guide for tissue protection while drilling and inserting screws in external fixation without taking down the system is presented. It can be used for pin insertion in both unilateral and ring-type external fixators. The external fixator is used as a template guide, and pin insertion can be easily performed with the fixator in place. With its use, operative time is decreased, and tissue protection is achieved for all pin insertions in any part of the musculoskeletal system.

Bone Nails↗
PubMedDate not supplied

Relative stiffness and stress of type I and type II external fixators: acrylic versus stainless-steel connecting bars--a theoretical approach.

OBJECTIVE: To compare the stiffness and pin stresses of three sizes of external fixator systems with stainless-steel and acrylic connecting bars. STUDY DESIGN: Finite element analysis. METHODS: Small, medium, and large external fixator systems of type I and type II configurations were modeled for finite element analysis. Each model was evaluated with a standard stainless-steel and three different diameters of acrylic connecting bar. Displacements and stresses were calculated for the loading modes of axial compression, medio-lateral bending, cranio-caudal bending, and torsion. The location of the pin experiencing maximum stress was determined for all configurations and loading modes. RESULTS: Acrylic column diameters of 9.53 mm for the small external fixator system and 15.9 mm for the medium external fixator system provide equivalent stiffness and maximum pin stresses to those provided by the standard stainless-steel connecting bars (3.2- and 4.8-mm diameter, respectively). The largest diameter acrylic column tested (31.75-mm) produced lower stiffness and higher maximum pin stresses than the standard stainless-steel connecting bar (11.1-mm diameter). CONCLUSIONS: When applying a small or medium external fixator, an acrylic column of 9.53-mm or 15.9-mm diameter, respectively, can be used. For a large external fixator system, an acrylic column of diameter >31.75 mm is required. CLINICAL RELEVANCE: The sizes of acrylic connecting bars for use in small and medium external fixator systems have been determined. Large systems should incorporate the standard stainless-steel connecting bar.

Acrylic Resins↗
PubMed2006

External fixation versus conversion to intramedullary nailing for definitive management of closed fractures of the femoral and tibial shaft.

External fixation for definitive therapy of closed diaphyseal femur and tibia fractures is the preferred method of treatment only in the pediatric population. In adult injuries, in particular open battle wounds, the timing of conversion of an external fixator to an intramedullary nail is determined by the condition of the soft tissues and the overall stability of the patient. In the tibia, conversion to an intramedullary nail is accomplished as expeditiously as possible. Early (< 2 weeks) conversion to an intramedullary implant may be accomplished safely. Increased infection rates have been documented when conversion is done after 2 weeks of external fixation. In the femur, conversion from external fixation to nailing is done as the patient's overall physical condition and soft tissues allow. Acute conversion to an intramedullary device in a single procedure is preferred in patients without evidence of pin-tract infection. Staged conversion to an intramedullary nail often requires a prolonged period of bed rest with skeletal traction to maintain fracture stability and patient comfort, with the attendant risks of pneumonia, decubiti, and thromboembolic events. Treatment of closed femoral and tibial diaphyseal fractures with external fixation, either definitively or as a bridge to intramedullary nailing, is a viable option in the patient with gross physiologic instability or an ipsilateral dysvascular limb. The decision to use definitive external fixation versus conversion to an intramedullary device should be made on a case-by-case basis. Additional prospective clinical studies are warranted to further delineate risks and benefits of these treatment modalities.

Bone Nails↗
PubMed2004

The magnetic attraction of lower extremity external fixators in an MRI suite.

OBJECTIVES: To determine the magnetic attraction of 10 currently available lower extremity external fixators in the MRI suite and to test fixators with minimal or no magnetic attraction for the presence of temperature elevation during a 30-minute MRI scan. DESIGN: Consecutive testing of selected tibial external fixation models in an identical manner. SETTING: Level 1 trauma center. CONSTRUCTS: Ten commercially available external fixators used for lower extremity injuries applied to saw bone tibia. INTERVENTION: External fixators suspended in testing apparatus were placed at three locations in the MRI suite for magnetic testing. Fixators with minimal attraction were scanned for 30 minutes. MAIN OUTCOME MEASUREMENTS: Magnetic attraction was measured with a digital scale, and temperature measurements were obtained with a digital thermometer and thermocouple. RESULTS: The Ilizarov with carbon fiber rings, Richards Hex-Fix, and Large Synthes External Fixator had <1 kg of magnetic attraction at all three locations. No component of these fixators experienced >2 degrees of temperature elevation after a 30-minute MRI scan. The EBI Dynafix with Ankle Clamp, EBI Dynafix, and EBI Dynafix Hybrid along with the Hoffman II, Hoffman II Hybrid, Ilizarov with stainless steel rings, and Synthes Hybrid had >1 kg of magnetic attraction at all three locations. CONCLUSIONS: Many commercially available external fixators have components and spring clamps that have significant magnetic attraction to the MRI scanner. Fixators that have <1 kg of attraction do not experience significant heating during MRI.

Equipment Design↗
PubMedDate not supplied

Treatment of posttraumatic cubitus varus in the pediatric population with humeral osteotomy and external fixation.

Cubitus varus may occur after supracondylar humerus fractures. Poor fixation, however, complicates operative treatment of cubitus varus. We discuss the use of external fixation in the treatment of cubitus varus. Five patients had humeral osteotomies with external fixation. The preoperative humeroulnar angle (HUA) averaged -24.2 degrees. The immediate postoperative HUA averaged 12 degrees, and the final angle averaged 13 degrees. Duration of external fixation averaged 8.9 weeks. Complications were one transient radial neurapraxia, one superficial pin infection, and one keloid. No loss of correction or motion occurred with external fixation; we recommend external fixation as safe and effective.

Adolescent↗
PubMed1997

Open fractures of the humerus treated with external fixation.

Twenty-three patients with open fractures of the humerus who had been treated with immediate external fixation were reviewed retrospectively. Eighteen patients had adequate followup and were included in this study. Four patients (22%) had Gustilo and Anderson Grade I injury; 1 (5%), Grade II; and 13 (72%), Grade III (1 IIIA, 2 IIIB, and 10 IIIC). Fourteen patients (78%) had associated neurologic injury, of which 9 involved multiple nerves. A unilateral external fixation frame with half pins proximal and distal to the fracture site was used in all but 1 case. In 8 patients (44%) with distal humerus fractures, the external fixator crossed the elbow joint. All upper extremities in this series were salvaged. The duration of external fixation averaged 11 weeks. Complications included 3 malunions, 1 delayed union, 8 (44%) pin tract infections, 2 pin tract sequestrum formation, and 2 late fractures after removal of the external fixator. At followup (average, 34 months), function was rated as good or excellent in 12 patients (70%). There were 1 fair and 4 poor results. External fixation of complicated fractures of the humerus allowed associated injuries to the nerves, arteries, and soft tissues to be treated adequately while maintaining skeletal stability.

Adolescent↗
PubMed1999

Axial preload in external fixator half-pins: a preliminary mechanical study of an experimental bone anchorage system.

OBJECTIVE: To demonstrate the effect of axial preload achieved with an experimental external fixator pin prototype on the initial stability of the pin-bone interface. DESIGN: An in vitro mechanical study comparing pin stability of an axially-preloaded experimental pin and a radially-preloaded conventional external fixation pin. BACKGROUND: The most common problem in clinical practice of external fixation is pin site failure. An experimental external fixator half-pin has been designed introducing axial preload as an alternative method of achieving a stable pin-bone interface. METHODS: Standardized measurements of pin insertion and removal torque comparing the experimental pin prototype and a conventional external fixator pin in a synthetic composite material and ovine tibial cortical bone. RESULTS: There is a positive correlation between axial preload and torque resistance of the coaxial experimental half-pin as well as significantly increased torque resistance of the axially-preloaded experimental pin over the conventional pin tested. In addition, significantly lower insertion torque of the experimental pin was observed with the applied insertion technique. CONCLUSIONS: 'Axial preload' achieved with appropriately-designed half pins might represent an effective biology-sparing method of increasing the mechanical stability of the pin-bone interface in unilateral external fixator frames. RELEVANCE: Several aspects of the current external fixator pin design and insertion technique have been implicated for the significant incidence of failure at the pin-bone interface manifested as pin loosening, pin track infection or even osteomyelitis. An axially-preloaded bone fastener system may be mechanically and biologically superior and therefore clinically advantageous.

Animals↗
PubMed2004

External fixators in the treatment of fractures in children.

New properties are being modified in the external fixator instrumentation that are leading to the more indicated use of this type of fixation especially in children's lower limb fractures. Dynamization, the ability to lengthen the limb and easy wound care are among the new properties of the monoplane external fixator, along with greater stability than older models. These new properties are now making the external fixator an indication rather than a choice in many cases. We have retrospectively studied 21 children with lower limb fractures treated by 28 external fixators. The results of this study show advantages such as lower infection rate, consolidation without the need of reoperation, easy physiotherapy, easy wound care and the ability to perform shortening and lengthening in the same set. Disadvantages are mostly complications that are due to the external fixation such as iatrogenic vascular lesions, pins tract infections and iatrogenic fractures.

Accidental Falls↗
PubMed2002

Hydroxyapatite-coated Schanz pins in external fixators used for distraction osteogenesis : a randomized, controlled trial.

BACKGROUND: Complications of external fixation include loosening of the fixation pins and pin-track infection. Laboratory studies and clinical trials have suggested that hydroxyapatite coating improves the osteointegration of various orthopaedic implants. The purpose of this study was to determine whether the prevalence of pin-related complications can be reduced by the use of hydroxyapatite-coated pins in fixators applied for distraction osteogenesis. METHODS: Forty-six consecutive patients undergoing segmental transport or lengthening of the tibia were randomized to the use of either standard titanium Schanz pins or hydroxyapatite-coated stainless-steel Schanz pins. The fixators were used for an average of thirty-eight weeks (range, fourteen to seventy-two weeks). All patients were closely monitored for pin loosening and infection, and digitized radiographs were assessed for bone resorption around all pins. When the external fixator was removed, the torque required to extract the pins was determined with use of an electronic torque wrench. RESULTS: In the control group (titanium pins), twenty-two pins (13%) loosened and an infection occurred at the site of twenty pins. An extensive infection of the canal developed in one patient. Twenty-two pins were removed or replaced because of these complications. In the hydroxyapatite group, no clinical or radiographic signs of pin loosening or infection were observed and no pins required early removal or exchange. The mean torque (and standard deviation) required to remove the hydroxyapatite-coated pins was 0.43 0.18 N-m compared with 0.10 0.09 N-m for the uncoated pins (p < 0.001). CONCLUSION: Coating pins with hydroxyapatite increases their fixation to bone and reduces the rate of infection and loosening during external fixation for distraction osteogenesis. Use of hydroxyapatite-coated pins should be considered in clinical situations requiring prolonged external fixation.

Adolescent↗
PubMed1992

[External fixation of the tibial with primary full weightbearing].

The external fixation of open fractures of the tibia has many advantages. Nevertheless by many surgeons it is used only as a temporary emergency fixation. There are two main problems to be solved: delayed fracture healing and pin-track infections. It is widely known that physiological weight-bearing leads to a better fracture healing. Weight-bearing needs stability. For transverse and even short oblique fractures of the tibia correct reduction and a good external fixation gives enough stability to stand on the leg completely. 27 patients with such fractures have been externally fixated during the last 5 years. With immediate weight-bearing the healing time was only 12 weeks on an average.

External Fixators↗
PubMed2001

Extra-articular deformity in distal radial fractures treated by external fixation.

OBJECTIVE: To determine the radiographic outcome in fractures of the distal radius treated with closed reduction and external fixation. DESIGN: A retrospective study. SETTING: The orthopedic department of National Taiwan University Hospital. PATIENTS: Eighty-five consecutive patients (36 female, 49 male), average age 48 years, with fractures of the distal radius seen between March 1995 and June 1998. INTERVENTIONS: Closed reduction and external fixation of fractures, followed up by good-quality posteroanterior and lateral radiographs to evaluate healing. MAIN OUTCOME MEASURES: Radial height, radial inclination and volar tilt were measured on radiographs obtained initially, immediately postoperatively and at the time of removal of external fixation. Data were analyzed by the t-test. RESULTS: Immediately after reduction and fixation, there was a significant improvement in the measurements of radial height and radial inclination. This improvement was gradually lost and height and inclination were significantly decreased at the time the external fixation device was removed. External fixation did not improve the volar tilt. CONCLUSION: External fixation is a popular method to improve the reduction of osseous deformity but cannot effectively protect comminuted distal radial fractures from loss of reduction, which may be associated with shortening and redisplacement.

Congenital Abnormalities↗