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The Ilizarov external fixator can be safely applied if the surgeon is alert to the "danger areas" where the transfixion wires might penetrate a neurovascular structure. The basic principle of frame assembly and application require that the wires are never bent to reach the support rings; instead, the Ilizarov hardware is used to build up to the wires from the rings. The wires are then tensioned axially.
The authors report their results in 59 cases of external fixation with A.L.J. type devices inserted from November, 1984, to November, 1988, in 57 patients (2 cases of bilateral injuries). These included 49 cases of "recent" traumatology, 4 cases of "second-hand" traumatology, and 6 orthopaedic cases (tibiotarsal arthrodesis for degenerative lesions). Among the recent traumatic injuries, 38 were fractures, most often compound fractures (stages II and III), and 11 serious soft tissue lesions, for which the external fixation was used temporarily for stabilization until the wound was healed. The older traumatological lesions were 4 infected pseudarthroses. The results based on 52 cases (6 were lost to follow-up and 1 is a peculiar case) include 45 healed injuries (ie. 86.5%) and 7 failures. The soft-tissue lesions have all healed within 2 to 4 months. Among the bony lesions, some knit primarily without an additional graft (20 of 37 cases, ie 54 percent), the others after 1, 2 or 3 grafts (10 of 37 cases, ie. 27 percent). The union also occurred without any problem for all 6 tibiotarsal arthrodeses. The 7 failures occurred in cases where no additional bone graft had been performed. The discussion evidences the advantages and drawbacks of the A.L.J.
OBJECTIVE: To determine how the mechanical environment of a tibial fracture is influenced by unlocking an external fixator frame. DESIGN: A clinical study examined 10 consecutive patients fixed with the Orthofix DAF. BACKGROUND: It has been claimed that the healing of diaphyseal tibial fractures is assisted by unlocking external fixators to allow free axial movement, but the influence on the mechanical environment at the fracture has not been established. METHODS: A transducer attached to bone screws measured dynamic interfragmentary displacement during walking both before and immediately after unlocking the fixator at 6 weeks in 10 subjects. Four subjects were monitored over the first hour after unlocking to measure interfragmentary gap shortening. RESULTS: Mean peak amplitudes of cyclical axial and angular displacement before unlocking were 0.46 mm (SD 0.27) and 0.37 degrees (SD 0.30), and after were 0.42 mm (SD 0.19) and 0.34 degrees (SD 0.28). Mean peak torsional and transverse shear displacements were 0.21 degrees (SD 0.11) and 0.30 mm (SD 0.17) before unlocking, and after were 0.42 degrees (SD 0.39) and 0.51 mm (SD 0.60). Gaps shortened permanently by unrecoverable axial translations of between 0.2 and 1.4 mm; the mean was 0.69 mm. CONCLUSIONS: Unlocking was found more often to reduce both axial and angular motion, but to increase shear. Overall, this may reduce maximum longitudinal strains in the external callus. The reduced motion may arise from gap shortening.
Factors that affect wire tension were examined using external mechanical testing units as well as in-line load cells. The circular external fixator with wires supported at each end exhibits a self-stiffening effect such that wire stiffness increases with wire deflection. Mechanical slippage between wire and fixation bolt is the primary reason for loss of wire tension. Slippage can be avoided by adequate torque on the fixation nut (20 N.m). Guidelines are presented for proper and safe tensioning techniques to achieve clinically indicated tensions without risk of breakage.
The performance of a new external fixator was assessed in 50 cases of various types of fractures of the tibia. The fixator comprises an adjustable single outrigger bearing offset pins which offers considerable versatility in its use. The angle at which the pins are offset gives the device considerable torsional and angulatory stability, but its compressive strength is low, allowing axial loading of the fracture during weight bearing. The incidence of complications such as non-union, malunion, and pin-track infection was low. The time to bony union was shorter in cases in which the fixator was applied without exposure of the fracture, compared with those in which the fracture was reduced under direct vision. The time to bony union was also slightly shorter in cases where external fixation was the primary form of treatment, compared with those receiving preliminary os calcis traction.
This paper deals with the stabilization of the tibia by means of the external fixator in special problematic cases. Indication, surgical technique and postoperative care are presented as the result of theoretical investigations and the clinical experience of several years. It is pointed out that the external fixator is a supplementary method to the standard surgical technique.
A group of fractures of the distal radius are inherently unstable and cannot be treated by closed reduction and cast or external fixation. These fractures are high-energy motor vehicle accidents often seen in young adults but possible in nearly every age group. They are not typical Colles's fractures because they are intra-articular with displacement of the joint articular surfaces. The goals of treatment are to obtain an anatomic reduction and then to proceed with treatment techniques to maintain the reduction by whatever methods are available or necessary within the experience of the treating surgeon. Previous admonitions that Colles's fractures should not be treated by open reduction are incorrect. Like other intra-articular fractures, the goal is anatomic alignment. Limited open reduction or newer arthroscopic techniques may be sufficient. A more aggressive approach of open reduction, internal and external fixation, and autogenous bone grafting is now indicated in most high-energy distal radius fractures to achieve the treatment goals defined earlier: anatomic joint surface reduction, restoration of radial length, and correction of dorsal malangulation.
Combined kinematic analysis and graphic models of two unilateral external fixators are presented to simulate and visualize the correction of bone fracture deformities through systematic adjustments of the fixator joints. The models were developed as rigid linkage systems, and the analysis utilized the 4x4 transformation matrices and the kinematic chain theory to obtain the necessary rotations and translations at each joint of the fixator to correct bone deformities at the fracture site. Three-dimensional malalignments with fracture gaps were simulated to correct the deformities. Due to the redundant pair variables in the fixator joints and other problems in obtaining unique solutions, an optimization technique was used to solve the governing linkage loop equations. For each adjustment solution, the bone correction paths were infinite but a unique and optimal reduction path was obtained by applying corrections to all joints simultaneously and in small increments. When the deformity exceeded a certain range, no admissible solution could be obtained, partially due to the limitation of the unilateral fixator configuration and partially due to the restricted joint rotation and translation in the fixator design. The present models and analysis technique can be used to investigate a fixator's adjustability to correct a 3-D bone deformity at a fracture or lengthening site facilitating patient care planning and medical personnel training.
Forty-two children (44 femur fractures) were treated by primary external fixation and early weightbearing (1984-1989). The fractures were reduced anatomically when possible. Average age at fracture was 9 years 7 months (range, 2 years 5 months to 17 years 8 months). Duration of external fixation averaged 70 days (range 42-117 days). Of 176 pins, 15 (8.5%) were inflamed and five (2.8%) required intravenous antibiotics; none resulted in osteomyelitis. Most patients returned to school by 4 weeks, and all had full knee motion 6 weeks after fixator removal. Of 16 patients with documented follow-up of at least 18 months, only six (38%) had overgrowth from 2 to 10 mm (average 5.8 mm).
More than 75% of all injuries in modern wars are localized on the extremities, and more than one-third of these injuries are accompanied by bone fracture. Application of an external fixator is one of the basic procedures in the treatment of war fractures. In this article, we present an external fixator for war purposes of our own construction called the CMC (Croatian Medical Corps) fixator. Although designed as a transport fixator, because of good biomechanical properties it has been widely used for definitive osteosynthesis of war injuries. The CMC fixator is manufactured as a sterile set, ready to use, with all necessary parts for application. On the battlefields of Croatia and Bosnia and Herzegovina during the war from 1991 to 1995, more than 2,500 CMC fixators were applied. The fixator has satisfied all required conditions and considerably contributed to diminishing the consequences of war fractures.
BACKGROUND: Between 1 January 2001 and 30 June 2003, 31 patients with dislocated ankle fractures were primarily treated with an external fixator in our clinic. The aim of the present study was to investigate whether such a concept would determine the overall outcome or influence single parameters such as mobility, dystrophy, pain, arthritis, and complications. METHODS: Of the 31 patients, 25 aged 18-84 years at the time of the accident were followed up for 6-23 months to assess range of motion, clinical scores, radiological findings, and complications. An isolated injury was present in 23 patients and 3 were open injuries of second to third degree. Between two and five operations were necessary 4-27 days after trauma. The duration of primary hospital care required ranged from 10 to 43 days. RESULTS: The Olerud and Molander score (9 criteria with 100 max points) was 80 points at the follow-up investigation (rated "good"). "Excellent" results (>90 points) were observed in four cases. In the range of motion there was only an average loss in plantar flexion of 12.4 degrees compared to the healthy side in the patients followed up. CONCLUSIONS: The treatment result in the study population was compared to the results of prospective studies investigating dislocated ankle joint fractures as well as with our own random sample (n=7) of patients with secondarily treated ankle joint fractures that were initially treated with a cast. Initial external fixation seems to be justified and leads to acceptable results. The main functional lesions are not correlated to the specific treatment selected.
Sixty-eight fractures of the distal extremity of the radius, mostly unstable, homogeneously treated by Hoffmann's radio-metacarpal external fixation, were reviewed in terms of functional, objective and radiological criteria. Mean follow-up was 4 years, with a range of 6 months to 10 years. Overall, this treatment achieved 56% of satisfactory results, 26% moderate results and 18% poor results. Open and comminuted fractures give the worst overall results, mostly in terms of functional parameters. From this study, it is clear that external fixation is effective for the treatment of unstable fractures, as it provides good restitution of anatomical integrity of the radius, ensures better stabilization and allows immediate physiotherapy, leading to restoration of a good range of movement. Moreover, compliance with certain technical aspects such as minimal distraction, limits the disadvantages of this technique.
The authors show 30 cases of recent tibial fractures treated by external fixation. They study the different types of fractures, the models of external fixation employed, the complications occurring during the treatment and the ultimate results obtained.
Excision of 1 or more central rays of the foot may complicate soft tissue coverage because large defects may result. The authors presents a technique in which an Ilizarov external fixator was used to narrow the forefoot after resection of the central rays in a patient with diabetes. After external fixator application for 8 weeks, the central defect healed uneventfully and has not shown any recurrence of ulceration after 4 years of follow-up.
We present a retrospective study of 21 patients treated with an external fixator for comminuted fractures of the distal radius from May 1993 until May 1994. Mean follow-up was 14.5 months after operation. The 21 patients were on average 59 years old. The distal radius fractures were classified according to the AO: Type A2 (four times), Type A3 (two times), Type C1 (one time), C2 (nine times), C3 (five times). We mounted the external fixator generally in a static way. After two weeks it was dynamized. The fixator was removed after four to at least six weeks. An additional osteosynthesis with Kirschner wires was performed in twenty cases. Three times we added a primary cancellous bone graft, in one case an implantation of Endobone was used.
Femoral fractures in children can be treated effectively and with a low complication rate by using external fixation. However, as with most treatment modalities there is a learning curve to be considered. The aim of this paper is to report "tricks" and different considerations that we have learned to be of value based on experience gained during a prospective and consecutive study of 98 femoral fractures in children aged 3-15 years. Our experience is based on the use of a unilateral fixator with the option to apply axial dynamisation. Traction prior to operation is not needed if the child is operated on within 24h. During surgery a traction table will prevent significant malrotation and facilitate reduction prior to insertion of the pins. Four 4 or 5mm pins are sufficient for adequate stability in children. Transverse skin incisions are preferable for pin insertion as the scars become smaller and the soft tissue irritation during activity is less when compared with longitudinal incisions. Unrestricted weight-bearing can be allowed. A nihilistic approach to pin site care with daily showers is as effective as more aggressive treatment with local antiseptics. Pin infections can occur but are mild and can be treated locally or with a short period of antibiotics taken orally. Pin-loosening and deep infections are very uncommon. By using external fixation, malunion, overgrowth or delayed union can almost be avoided completely. Re-fractures are rare and occur only after significant trauma. Treatment time is relatively short. No physiotherapy or further protection of the leg is necessary during or after healing.
At our institution, the small AO external fixator has been utilized on the wrist and hand on over 200 patients since 1979. Disregarding fractures of the distal radius, the main indications were fracture dislocations of the wrist, Kienböck's disease, combined injuries with bone defects of the wrist and metacarpals, and basilar fractures of the thumb metacarpal. In this paper, five well-established applications will be described with respect to treatment concept, indication, technique, and personal results. Furthermore, recommendations and reservations are listed to help in the prevention of the most frequent complications.
External fixation arthrodesis provides a tremendous salvage alternative to previously unsalvageable complex ankle and hindfoot pathology. Options for bone transport and soft tissue correction add versatility to the procedure while reducing risk and increasing the potential for healing without complications. Judicious use of an experienced plastic surgeon is not only helpful, but recommended. Primary or revision complex arthrodesis surgery should only be performed by a surgeon experienced in dealing with these problems and possessing the capability to implement some or all of the principles detailed in this section.