Is Staged Surgery Always Necessary for Schatzker Type IV-VI Tibial Plateau Fractures? A Comparison Study.

AIMS: This study aims to compare the outcomes of immediate (followed by closed-incision negative-pressure therapy use) versus delayed ORIF in patients with Schatzker type IV-VI TPFs. PATIENTS AND METHODS: A prospective study of patients undergoing ORIF between January 2018 and December 2019 was performed. The inclusion criteria were patients (>18 years) with a closed fracture sent to the emergency room (ER) within 24 h of injury. All the patients underwent preoperative image evaluation. Two senior orthopedic trauma surgeons evaluated the soft tissue condition in the ER by 5P's of the compartment syndrome, judging the timing of the operation of definitive ORIF. Group 1 (n = 16) received delayed ORIF. Group 2 (n = 16) received immediate ORIF and ciNPT use. Patient follow-up occurred after 2 and 6 weeks and 3, 6, and 12 months after surgery. The assessments included the time to definitive fixation, the length of hospital stay, the time to bone union, surgical site complications, and reoperation within 12 months. A universal goniometer was used to measure the postoperative 3 m, 6 m, and 12 m ROM. RESULTS: The patient demographics were similar between the groups (p > 0.05). Group 2 displayed significantly a shorter time to definitive fixation (5.94 ± 2.02 vs. 0.61 ± 0.28, p < 0.0001) and hospital stay (14.90 ± 8/78 vs. 10.30 ± 6.78, p = 0.0016). No significant difference was observed in the time to bone union, surgical site complication incidence, and reoperation rates (p > 0.05). Flexion and flexion-extension knee ROM were demonstrated to be significantly improved in Group 2, 3, 6, and 12 months postoperatively (p < 0.0001). CONCLUSIONS: In this study, early ORIF and ciNPT use resulted in a shorter hospital length of stay, a reduced time to early active motion of the knee, and improved knee ROM. These results suggest that early ORIF with ciNPT for Schatzker type IV-VI TPFs is safe and effective in some patients. However, further research to confirm these findings across larger and more diverse populations is needed.

Temporary Stabilization of Tibia Fractures: Does External Fixation or Temporary Plate Fixation Result in Better Outcomes?

Background: Provisional stabilization of high-energy tibia fractures using temporary plate fixation (TPF) or external fixation (ex-fix) prior to definitive medullary nailing (MN) is a strategy common in damage control orthopaedics. There is a lack of comprehensive data evaluating outcomes between these methods. This study compares outcomes of patients stabilized with either TPF or ex-fix, and with early definitive MN only, assessing complications including nonunion and deep infection. Methods: A retrospective review was performed on adult patients with tibia fractures treated with MN followed until fracture union (≥3 months) at a single level-1 trauma center from 2014 to 2022. Medical records were evaluated for nonunion and deep infection. Demographics, injury characteristics, and fixation methods were recorded. Significance between patients who underwent TPF and ex-fix was compared with a matched cohort of early MN using Pearson's exact tests, independent t-tests, and one-way ANOVA, depending on the appropriate variable. Results: 81 patients were included; 27 were temporized with TPF (n = 12) or ex-fix (n = 15). 54 early MN cases defined the matched cohort. All groups had similar patient and fracture characteristics. The difference in rates of nonunion between groups was significant, with TPF, ex-fix, and early MN groups at 17, 40, and 11% respectively (p = 0.027). Early MN had lower rates of nonunion (11% vs. 40%, p = 0.017) and deep infection (13% vs. 40%, p = 0.028) compared to ex-fix. Conclusion: Temporary ex-fix followed by staged MN was associated with higher rates of nonunion and deep infection. There was no difference in complication rates between TPF and early definitive MN. These data suggest that ex-fix followed by MN of tibia fractures should be avoided in favor of early definitive MN when possible. If temporization is needed, TPF may be a better option than ex-fix. Level of Evidence: IV.

Hand-Specific External Fixation for Treatment of Complex Proximal Interphalangeal Joint Injuries.

Background: Complex proximal interphalangeal joint (PIPJ) fractures are challenging injuries to treat. There are multiple established treatment methods available for these injuries, including dynamic external fixation. This study reports the outcomes of complex PIPJ fractures treated with a hand-specific external fixation device. Methods: Twenty-five fingers in 25 patients were treated with the DigiFix external fixator device for treatment of a PIPJ dorsal fracture dislocation (n = 16) or pilon fracture (n = 9). There were 16 males and 9 females with a mean age of 40 years (range: 14-75 years) at the time of injury. The median time from injury to surgery was 10 days (interquartile range [IQR]: 5; range: 3-49). Chart and radiographic data were reviewed retrospectively. Results: The average duration of external fixation was 41 days (range: 26-62 days). At a mean follow-up of 28 weeks (range: 12-105 weeks), the mean PIPJ flexion was 82 (range: 30-105 degrees), extension was -10° (range: -30 to 0 degrees), and flexion/extension arc of motion was 72 degrees (range: 30-95 degrees). Final mean Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 21.5 (range: 0-65.8). There were zero major complications and six (24%) minor complications, including superficial cellulitis (4) and stiffness (2). Conclusion: Dynamic external fixation for the treatment of complex PIPJ injuries allows for early range of motion and leads to favorable outcomes. This hand-specific external fixator has a reproducible technique which results in predictable and reliable PIPJ distraction.

Nomogram construction and validation of axial deviation in patients with tibial defects treated with the Ilizarov bone transport technique.

INTRODUCTION: The Ilizarov bone transport technique is widely recognised as an effective method for treating large segment bone defects in clinical practice. However, axial deviation is a common complication in the treatment of tibial large segment bone defects, which can have a serious impact on the clinical efficacy of bone transport. Our study aims to construct and validate a nomogram for predicting axial deviation of tibial bone transport. METHOD: This study retrospectively collected data from 363 patients who underwent the tibial Ilizarov technique for bone transport. Univariate and multivariate logistic regression analyses were performed to determine the independent risk factors for axial deviation, which were later used to construct a nomogram. The nomogram was evaluated using the decision curve analysis (DCA), the calibration curve, and the area under the receiver operating characteristic curve (AUC). RESULTS: Of the 363 patients who underwent Ilizarov tibial bone transport, 31.7% (115/363) experienced axial deviation. Multivariate logistic regression analysis showed that gender, height, defect site, and external fixation index were important risk factors for axial deviation. The AUC value of the nomogram model was 0.705. The calibration curve and the decision curve analysis showed a good consistency between the actual axial deviation and the predicted probability. CONCLUSION: The model assigns a quantitative risk score to each variable, which can be used to predict the risk of axial deviation during tibial bone transport.

Potential of Titanium Pins Coated with Fibroblast Growth Factor-2-Calcium Phosphate Composite Layers to Reduce the Risk of Impaired Bone-Pin Interface Strength in the External Fixation of Distal Radius Fractures.

Background: The risk of impaired bone-pin interface strength in titanium (Ti) pins coated with fibroblast growth factor (FGF)-calcium phosphate (CP) composite layers is yet to be evaluated in a clinical study. This retrospective study used Weibull plot analysis to evaluate bone-pin interface strength in Ti pins coated with FGF-CP layers for external distal radius fracture fixation. Methods: The distal radial fractures were treated with external fixation. The FGF-CP group comprised five patients (all women, aged 70.4 ± 5.9 (range: 62-77) years), and the uncoated pin group comprised ten patients (eight women and two men, aged 64.4 ± 11.7 (range: 43-83) years). The pins were removed after six weeks. The insertion and extraction peak torques were measured. The extraction peak torque was evaluated using Weibull plot analysis. Results: We compared the extraction torque of the two groups at or below 506 Nmm for a fair comparison using Weibull plot analysis. The Weibull plots were linear for both the FGF-CP and uncoated pin groups. The slope of the regression line was significantly higher in the FGF-CP group (1.7343) than in the uncoated pin group (1.5670) (p = 0.011). The intercept of the regression line was significantly lower in the FGF-CP group (-9.847) than in the uncoated pin group (-8.708) (p = 0.002). Thus, the two regression lines significantly differed. Conclusions: Ti pins coated with FGF-CP layers exhibit the potential to reduce the risk of impaired bone-pin interface strength in the external fixation of distal radius fractures.

Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort.

PURPOSE: Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. METHODS: A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. RESULTS: The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). CONCLUSION: Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.

Limb Salvage by Means of Hindfoot Arthrodesis Utilizing Bulk Allograft and External Fixation.

FORMAT: Retrospective Review. LENGTH OF FOLLOW-UP: 18 months. CLASSIFICATION: Rearfoot and Ankle Reconstruction. METHODOLOGY: Level 4 Retrospective Review. PROCEDURES: A retrospective review was performed of 6 patients who had undergone limb salvage procedures between January 2016 and April 2019. Patients underwent surgery due to severe limb-threatening diagnosis including Charcot and/or osteomyelitis. Salvage arthrodesis was performed with bulk femoral head allograft incorporation using a hexapod external fixation system. The external fixation was retained for an average of 16 weeks. All patients were followed for a postoperative period of 16 months. RESULTS: Successful rearfoot arthrodesis and limb salvage was achieved in ⅚ (83%) of patients. DISCUSSION: This review demonstrates that limb salvage and arthrodesis are possible using femoral head allograft incorporation by external fixation alone. The involved patients had resolution of the osteomyelitis and Charcot deformity, salvage arthrodesis of the rearfoot and avoidance of a major limb amputation. LEVELS OF EVIDENCE: IV.

Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review.

Introduction: External fixation devices are commonly used in orthopaedic surgery to manage a range of pathologies. In this patient population, there is currently no consensus on optimal rehabilitation techniques. There exists a large variation in practice, with a limited understanding of how these affect treatment outcomes. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review was conducted of Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PEDro, and COCHRANE databases, grey literature sources and forward and backward searching of included articles. Studies were selected following rigorous screening with predefined inclusion criteria. Data quality was assessed using validated appraisal tools. Articles were synthesised by rehabilitation type and descriptive analysis was subsequently performed. Results: From 1,156 articles identified, 18 were eligible for inclusion. The overall quality was low, with clinical commentaries and case studies being the most common study type. Studies were synthesised by rehabilitation type, the most common themes being gait re-education, strengthening, therapy-assisted, active exercises and weight-bearing exercises. Conclusion: There is a lack of high-quality evidence to support meaningful recommendations and guide rehabilitation practices for this patient cohort. Further research for patients being treated in external fixation, especially related to the potential effects of physical rehabilitation on bone healing, return of strength, mobility and independent function is likely to have transferability within wider orthopaedic populations. Clinical significance: This systematic review is unable to provide clinical recommendations due to the poor quality of the available literature. However, it is hoped this paper will provide a foundation for further research to improve rehabilitation for patients being treated with external fixation. How to cite this article: Pawson JR, Church D, Fletcher J, et al. Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review. Strategies Trauma Limb Reconstr 2024;19(1):45-55.

Immediate management of a stable patient with unstable pelvis.

The diagnosis of a traumatic unstable pelvis in a stable patient is a temporary concept depending on when we see the patient, as all patients presenting with hemorrhagic shock have hemodynamic stability until they become unstable. As a rule, the more unstable the pelvic fracture is, the higher the risk of bleeding and hemodynamic instability it has. Therefore, in unstable pelvic fractures, hemodynamic stability should be a diagnosis by exclusion. For bleeding detection in stable patients, an immediate one-stage contrast-enhanced CT scan is the appropriate diagnosis test; however, since CT scan radiation is always an issue, X-rays should be considered in those cases of hemodynamically stable patients in whom there is a reasonable suspicion that no unsafe bleeding is going on. Pelvic fracture classification is essential as usually there is an association between the injury mechanism, the fracture displacement, and the hemodynamic stability. Anteroposterior and, particularly, vertical traumatisms have much more proclivity to provoke major pelvic displacement and bleeding. The use of a pelvic binder, as early as possible including pre-hospital management, should be standard in high-impact blunt trauma patients independently of the trauma mechanisms. External fixation is the preferred method of stabilization in case of open fractures, and, in closed ones, when the schedule for definite osteosynthesis prolongs because of the patient's general condition. If possible, immediate percutaneous sacroiliac screw insertion for unstable pelvic fractures produce excellent results even in open fractures.

[Risk of postoperative morbidity and mortality after conversion of osteosynthesis in patients with polytrauma]. / Opredelenie riskov posleoperatsionnykh oslozhnenii i letal'nogo iskhoda posle konversionnogo osteosinteza u patsientov s politravmoi.

OBJECTIVE: To reduce the incidence of postoperative complications and mortality after conversion of external fixation device into various types of submerged osteosynthesis in patients with polytrauma. MATERIAL AND METHODS: A retrospective and prospective analysis of treatment outcomes in 351 patients with polytrauma was divided into 2 stages. At the first stage, we analyzed significant predictors of complications after conversion of osteosynthesis in the 1st group (retrospective analysis). At the second stage, we estimated the efficacy of the developed scale for assessing the risk of complications after conversion of osteosynthesis in a prospective group of patients. RESULTS: According to the complication risk assessment scale for conversion of osteosynthesis, analysis of time to surgical treatment depending on objective criteria in patients with polytrauma can significantly reduce the incidence of postoperative complications by 14% and mortality rate by 1.7%. CONCLUSION: The complication risk assessment scale after conversion of osteosynthesis will personalize the approach to timing and methods of conversion. This measure will eliminate the «second hit¼ in damage control orthopedics and improve the results of treatment.

Factors Associated With Pelvic Infection After Pre-Peritoneal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures.

Background: Preperitoneal pelvic packing (PPP) and external fixation has led to improved mortality after devastating pelvic trauma. However, there is limited literature on infection after this intervention. We aim to study the risk factors associated with pelvic infection after PPP. Patients and Methods: A retrospective review of patients who underwent PPP at a single level 1 trauma center was performed. Results: Over the 18-year study period, 222 patients were identified. Twenty-three percent of patients had an open fracture. Pelvic angiography was performed in 24% of patients with 16% requiring angioembolization (AE). The average time to packing removal was two (one to two days) days, although 10% of patients had their pelvis re-packed. Overall infection rate was 14% (n = 31); if pelvic re-packing was performed, the infection rate increased to 45%. Twenty-two of the patients with an infection required additional procedures for their infection, and ultimately hardware removal occurred in eight patients. On univariable analysis, patients with pelvic infections had more open fractures (55% vs. 17%; p < 0.01), underwent AE more frequently (29% vs. 14%; p = 0.04), were more likely to undergo repacking (32% vs. 6%; p < 0.01), and had packing in place for longer (2 [1,2] vs. 2 [2,3]; p = 0.01). On logistic multivariable regression analysis, open fracture (odds ratio [OR], 5.8; 95% confidence interval [CI], 2.4-14.1) and pelvic re-packing (OR, 4.7; 95% CI, 1.2-18.5) were independent risk factors for pelvic infection. Conclusions: Pelvic infection after PPP is a serious complication independently associated with open fracture and re-packing of the pelvis. Re-intervention was required in most patients with infection.

Brodie's abscess as a late complication of external fixation of the distal radius: A case report.

CASE: A 41-year-old male presented with an insidious onset of pain and swelling about the dorsal wrist, and was found to have a Brodie's abscess in the distal radius. The patient had a history of a distal radius fracture, treated with external fixation, nineteen years prior, which we believe contributed to the infection. The patient was treated surgically with abscess irrigation, debridement, bony curettage, bioactive glass S53P4 allograft, with concurrent antibiotic therapy. CONCLUSION: Brodie's abscesses can have atypical presentations, and a thorough history must be obtained from patients to identify any potential sources of infection.

Pantarsal arthrodesis stabilized with circular external skeletal fixators in 8 dogs (2010-2022).

OBJECTIVE: To report the surgical technique, complications, and outcomes of 8 dogs that underwent a unilateral pantarsal arthrodesis stabilized using a circular external skeletal fixator (CESF) construct for the treatment of uni- or multilevel tarsal instability. ANIMALS: 8 dogs. CLINICAL PRESENTATION: Medical records from 2010 to 2023 from 2 small animal hospitals were retrospectively reviewed for dogs undergoing pantarsal arthrodeses stabilized with CESF. Data collected for each dog included signalment, injury etiology, construct configuration, radiographic imaging, antimicrobial use, complications, length of time until construct removal, and outcome based on clinical evaluation by the owner and veterinary surgeon. RESULTS: 8 dogs met the requirements of inclusion for the study. Dogs had a mean age of 5.5 years (range, 0.42 to 13 years) and weight of 15.1 kg (range, 2.5 to 26.4 kg). Angulated 3- and 4-ring constructs were used in 5 and 3 dogs, respectively, with or without hybridization. Tarsi were stabilized with a mean angle of extension of 124.8° (range, 111.5° to 136.5°). Fixator removal was performed at a mean time of 11.3 weeks (range, 6 to 16 weeks). Complications developed in 4 dogs, 2 of which had poor clinical outcomes despite additional interventions, including recurrent digit trauma and poor limb use postoperatively. Six dogs had excellent outcomes. CLINICAL RELEVANCE: A CESF may be considered as an alternative to plate stabilization when performing a pantarsal arthrodesis. This fixation requires rigorous postoperative care but obviates the need for supplemental postoperative coaptation.

Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges.

PURPOSE: Determine if anterior internal versus supra-acetabular external fixation of unstable pelvic fractures is associated with care needs or discharge. METHODS: A retrospective cohort study was performed at two tertiary trauma referral centers. Adults with unstable pelvis fractures (AO/OTA 61B/61C) who received operative fixation of the anterior and posterior pelvic ring by two orthopedic trauma surgeons from October 2020 to November 2022 were included. The primary outcome was discharge destination. Secondary outcomes included intensive care unit (ICU) or ventilator days, length of stay, and hospital charges. RESULTS: Eighty-three eligible patients were 38.6% female, with a mean age of 47.2 ± 20.3 years and BMI 28.1 ± 6.4 kg/m2. Fifty-nine patients (71.1%) received anterior pelvis internal fixation and 24 (28.9%) received external fixation. External fixation was associated with weight-bearing restrictions (91.7% versus 49.2%, p = 0.01). No differences in demographic, functional status, insurance type, fracture classification, or injury severity measures were observed by treatment. Internal versus external anterior pelvic fixation was not associated with discharge to home (49.2% versus 29.2%, p = 0.10), median ICU days (3.0 [interquartile range (IQR) 7.8 versus 5.5 [IQR 4.3], p = 0.14, ventilator days (0 [IQR 6.0] versus 0 [IQR 2.8], p = 0.51), length of stay (13.0 [IQR 13.0] versus 17.5 (IQR 20.5), p = 0.38), or total hospital charges (US dollars 180,311 [IQR 219,061.75] versus 243,622 [IQR 187,111], p = 0.14). CONCLUSIONS: Anterior internal versus supra-acetabular external fixation of unstable pelvis fractures was not significantly associated with discharge destination, critical care, hospital length of stay, or hospital charges. This sample may be underpowered to detect differences between groups. LEVEL OF EVIDENCE: Therapeutic Level IV.

Comparing internal and external stabilization for traumatic elbow instability: a systematic review.

Background: Despite surgical reestablishment of the supporting structures, instability may often persist in traumatic elbow injury. In these cases, a temporary internal or external fixator may be indicated to unload the repaired structures and maintain joint concentricity. Aggregate data are needed to characterize the risk of complication between external fixation (ExFix) and the internal joint stabilizer (IJS) when used for traumatic elbow instability. Our objective was to review the literature to compare the complication profile between external fixation and the IJS. Methods: A database query was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Population, Intervention, Comparison and Outcome characteristics for eligibility were the following: for patients over 18 years clinical outcomes were compared between an ExFix or the IJS for acute or chronic elbow instability. The Cochran risk of bias in nonrandomized studies of interventions and grades of recommendation, assessment, development, and evaluation framework were compiled for risk of bias and quality assessment. Results: The rate of recurrent instability was 4.1% in the IJS group (N = 171) and 7.0% in the ExFix group (N = 435), with an odds ratio of 1.93 (95% confidence interval 0.88-4.23). The rate of device failure was 4.4% in the IJS group and 4.1% in the ExFix group. Pin-related complications occurred in 14.6% of ExFix cases. Complications in the IJS group were the following: 1 case of inflammatory reaction, 4 cases of post removal surgical site infection, and 5 symptomatic removals. Discussion: The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. Although not statistically significant, the higher rate of recurrent instability following external fixation may be clinically important. The high rate of pin-related complications with external fixation is notable.

Innovative Hip Distraction Approaches for Total Hip Arthroplasty in Crowe IV Developmental Dysplasia or Similar High-Riding Patients.

BACKGROUND: Total hip arthroplasty (THA) for dislocated hips (Crowe IV dysplasia) presents unique challenges. Conventional approaches involve subtrochanteric osteotomies, but are complex with additional fixation and potentially lead to limb length discrepancies, nerve palsies, and other complications. An alternative strategy is a staged approach, where the femoral head (or remnant) is gradually lowered (distraction technique) to align with the true acetabulum over a period of time, followed by a second-stage anatomically acetabular-positioned THA. External fixation distraction and telescoping internal lengthening devices have been utilized to achieve preoperative alignment. We evaluated these techniques, including the types, time, and amount of distraction needed, as well as outcomes and complication rates. METHODS: In this retrospective case series, 14 patients (9 women, 5 men), who had a mean age of 32 years (range, 16 to 67), underwent staged surgical interventions using hip distraction using external fixators or internal lengthening devices for hip dysplasia and other pathologies (Perthes disease, osteonecrosis) in preparation for a second-stage anatomically placed THA. The mean follow-up duration for external-fixation patients was 10 years (range, 6.5 to 13.4). RESULTS: Staged treatment involved external fixators (n = 8) or internal lengthening devices (n = 6) with a device placement mean of 48 days (range, 42 to 71). The amount of distraction ranged from 6 to 12 cm. There were 2 patients who required uncomplicated revision of the internal lengthening devices, and another patient had a temporary peroneal nerve palsy. There was 1 patient who underwent an acetabular revision at 7 years. CONCLUSIONS: We focused on a challenging patient cohort that emphasizes the efficacy of staged interventions in managing Crowe Type IV dysplasia and similar cases. Favorable outcomes were found with the immediate transition to THA after device removal that effectively addressed soft-tissue contractures and femoral migration. Despite the need for further validation via larger, prospective studies, this innovative approach may pave the way toward optimizing this strategy for these difficult hip pathologies.

Comparative Analysis of Complication Rates in Tibial Shaft Fractures: Intramedullary Nail vs. Ilizarov External Fixation Method.

Background: The external fixation (EF) Ilizarov method, shown to offer efficacy and relative safety, has unique biomechanical properties. Intramedullary nail fixation (IMN) is an advantageous alternative, offering biomechanical stability and a minimally invasive procedure. The aim of this study was to assess outcomes in patients undergoing tibia fracture fixation, comparing the Ilizarov EF and IMN methods in an early phase of IMN implementation in Serbia. Methods: This was a retrospective study including patients with radiologically confirmed closed and open (Gustilo and Anderson type I) tibial diaphysis fractures treated at the Institute for Orthopedic Surgery "Banjica'' from January 2013 to June 2017. The following demographic and clinical data were retrieved: age, sex, chronic disease diagnoses, length of hospital stay, surgical wait times, surgery length, type of anesthesia used, fracture, prophylaxis, mechanism of injury, postsurgical complications, time to recovery, and pain reduction. Pain intensity was measured by the Visual Analog Scale (VAS), a self-reported scale ranging from 0 to 100 mm. Results: A total of 58 IMN patients were compared to 74 patients who underwent Ilizarov EF. Study groups differed in time to recovery (p < 0.001), length of hospitalization (p = 0.007), pain intensity at the fracture site (p < 0.001), and frequency of general anesthesia in favor of intramedullary fixation (p < 0.001). A shorter surgery time (p < 0.001) and less antibiotic use (p < 0.001) were observed when EF was used. Additionally, we identified that the intramedullary fixation was a significant predictor of pain intensity. Conclusions: The IMN method offers faster recovery and reduced pain intensity in comparison to EF, while the length of surgery predicted the occurrence of any complication.

The Clinical Application of Double Taylor Spatial Frame in Segmental Tibial Fracture.

OBJECTIVES: Multi-planar external fixation has been used for the management of segmental tibial fractures with severe soft tissue injuries. However, fewer specialized studies have been reported. The primary aim of this study was to describe our experience of treating fractures of this type using the Taylor Spatial Frame and Ilizarov external fixation methods. METHODS: We retrospectively analyzed 33 patients with segmental tibial fracture treated at our institution between January 2016 and December 2020. The patients were divided into double Taylor Spatial Frame (D-TSF) and Ilizarov groups based on the external fixation structure. Baseline demographic data included sex, age, injury side and cause, open or closed fracture, time from injury to surgery, complications, and external frame removal and fracture healing time. The hip-knee-ankle angle (HKA) was measured from preoperative, immediate postoperative, and final follow-up full-length X-rays of bilateral lower limbs. We determined the degree of deviation in the HKA by calculating the difference between the measured angle and the ideal value of 180°; the absolute value was used to assess recovery of the lower limb force line. At the final follow-up, Johner-Wruhs tibial fracture outcome criteria (J-W TFOC) were used to classify the postoperative function of the affected limb as excellent, good, moderate, or poor. Count data were analyzed with the chi-square test or Fisher's exact test; the Mann-Whitney U test was used for rank data. RESULTS: No statistically significant differences were observed between the two groups in terms of sex, age, side of injury, cause of injury, closed or open fracture, or time between injury and surgery, which indicates that the groups were comparable (p > 0.05). A statistically significant difference was observed in external frame removal and fracture healing time between the D-TSF and Ilizarov groups (36.24 ± 8.34 vs 45.42 ± 10.21 weeks, p = 0.009; 33.33 ± 8.21 vs 42.00 ± 9.78 weeks, p = 0.011). The Johner-Wruhs criteria were used to assess the function of the affected limb, the D-TSF group performed better in correcting the lower limb force line than the Ilizarov group. A statistically significant difference in terms of excellent ratings was observed between the two groups (18/2/1/0 vs 5/5/1/1, p = 0.010). Postoperative follow-up X-rays demonstrated a significant improvement in the HKA in both groups immediately after surgery and at the final follow-up compared to the angle before surgery. At the final follow-up, a statistically significant difference was observed in the degree of deviation in the HKA between the two groups (1.58° ± 0.84° vs 2.37° ± 1.00°, p = 0.023). CONCLUSION: The D-TSF treatment is associated with minimal secondary damage to soft tissue, a straightforward and minimally invasive procedure, multiplanar stable fracture fixation, and optimization of fracture alignment and lower limb force lines, therefore, it is highly effective therapeutic option for segmental tibial fracture.

Addition of a Second Calcaneal Pin for Spanning Ankle External Fixation.

Spanning ankle external fixation is a commonly used technique for the treatment of fractures of the lower extremity. Traditionally, a single pin is placed in the safe zone of the calcaneus to provide a point of traction for fracture reduction and stabilization. Complications include infection and pin loosening with subsequent loss of fracture reduction. We aim to highlight the benefits and techniques of adding a second calcaneal pin to reduce the likelihood of infection, pin loosening, and possible loss of fracture reduction. Using the standard medial-to-lateral placement technique, two centrally threaded Schanz pins were placed within the safe zone of the calcaneus approximately 2 cm apart and were connected by clamps and a short carbon fiber rod. The remainder of the external fixation apparatus is assembled using a standard technique after obtaining fracture reduction. There is an increased incidence of infection and pin loosening with decreased bone quality and a longer duration within an external fixator. The addition of a second calcaneal pin can be used to reduce the incidence of pin loosening and associated sequela, especially in patients with decreased bone quality, thus improving outcomes for patients undergoing spanning ankle external fixation.

Is fracture management merely a physical process? Exploring the psychological effects of internal and external fixation.

BACKGROUND: Internal and external fixation are common surgical procedures for treating fractures. However, the impact of different surgical approaches (including internal and external fixations) on patients' psychological status and Quality of Life (QoL) is rarely examined. Herein, we aimed to investigate the effects of internal and external fixation on anxiety, depression, insomnia, and overall mental and physical health in Distal Radius Fractures (DRF) patients. METHODS: We performed a retrospective study on 96 fracture patients who underwent internal fixation (57 patients) or external fixation (39 patients). The Visual Analog Scale (VAS), the Hospital Anxiety and Depression Scale (HADS), the Athens Insomnia Scale (AIS), and the Medical Outcomes Study Short Form 36 (SF-36) questionnaire were used to assess the patients' pain, anxiety, depression, sleep, and QoL before surgery and at seven days, one month, and three months post-surgery. RESULTS: The VAS scores were significantly lower in the Internal Fixation Group (IFG) than in the External Fixation Group (EFG) on the seventh day and one month postoperatively (P < 0.05). Although both groups showed no significant anxiety, depression, or insomnia before surgery (P > 0.05), the EFG showed significantly higher HADS-A, HADS-D, and AIS scores than the IFG at seven days and one and three months postoperatively (P < 0.05). Additionally, changes in HADS-A, HADS-D, and AIS scores were most significant at day seven post-surgery in the EFG (P < 0.05). Furthermore, no significant difference was found between the two groups in the average Physical Component Summary (PCS) and Mental Component Summary (MCS) scores before surgery (P > 0.05). However, both groups showed positive changes in PCS and MCS scores at postoperative day seven and one and three months postoperatively, with the IFG having significantly higher average PCS and MCS scores compared to the EFG (P < 0.05). CONCLUSION: Compared to external fixation, internal fixation did not significantly impact patients' emotions regarding anxiety and depression in the early postoperative period, and physical and mental health recovery was better during the postoperative rehabilitation period. Furthermore, when there are no absolute indications, the impact on patients' psychological well-being should be considered as one of the key factors in the treatment plan during surgical approach selection.