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A 30-year-old male presented with A1 extra-articular fracture of the right tibia and fibula treated with conventional plate osteosynthesis (PO). A AP and lateral radiograph of post traumatic fracture of lower leg bones. B AP, oblique and lateral radiographs of postoperative fracture fixation using conventional plating. C AP, oblique and lateral radiographs at last follow up after 213 days and results were good
Source publication
The purpose of this study was to evaluate the outcome of Ilizarov external fixation (IE) versus dynamic compression plate (PO) in the management of extra-articular distal tibial fractures.
Between 2010 and 2011, extra-articular distal tibial fractures in 40 consecutive patients met the inclusion criteria. They were classified according to AO classi...
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Tibial condyle fractures become more challenging when they present with damaged soft tissue. Our aim is to evaluate such fractures with Ilizarov ring fixator along with our modified technique to give better outcome.
: Our study included 54 cases with proximal tibia fracture treated with Ilizarov by same surgeon and team from December 2017 to May 20...
Citations
... Blade plates used were as follows: 95-degree condylar in 8 of 15, adolescent 95-degree condylar in 6 of 15 patients, and a cannulated blade plate in 1 patient (all from DePuy Synthes, Amersfoort, the Netherlands). The customized blade had a median length of 40 mm (IQR, 35-40) and a median number of 9 shaft holes (IQR, [8][9][10][11][12]. ...
... One patient had a failed tibiotalar arthrodesis and 1 patient a failed supramalleolar closing-wedge osteotomy. Median duration from initial injury until index surgery was 16 months (IQR, [11][12][13][14][15][16][17][18][19][20][21][22]. (Table 1). ...
... However, the frame is considered unpleasant and pin tract infections are common. 11,28 The advantage of IMN is that it disrupts less soft tissue and provides internal bone grafting by reaming. However, in case of malalignment, correction of deformity may require Poller screws. ...
Background
Salvage surgery for a nonunion around the ankle is challenging. Poor bone stock, stiffness, scarring, previous (or persistent) infection, and a compromised soft tissue envelope are common in these patients. We describe 15 cases that underwent blade plate fixation as salvage for a nonunion around the ankle, including patient/nonunion characteristics, Nonunion Scoring System (NUSS), surgical technique, healing rate, complications, and long-term follow-up with 2 patient-reported outcome measures.
Methods
This is a retrospective case series from a level 1 trauma referral center. We included all patients that underwent blade plate fixation for a long-standing nonunion of the distal tibia, talus, or failed subtalar fusion. All patients had autogenous bone grafting, including 14 with posterior iliac crest grafts and 2 with femoral reamer irrigator aspirator grafting. Median follow-up was 24.4 months (interquartile range [IQR], 7.7-40). Main outcome measures were (time to) union, and functional outcomes using the 36-item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS), and the Foot and Ankle Outcome Score (FAOS).
Results
We included 15 adults with a median age of 58 years (IQR, 54-62). The median NUSS score at the time of index surgery was 46 (IQR, 34-54). Union was achieved after the index procedure in 11 of 15 patients. Additional surgery was performed in 4 of 15 patients. Union was achieved in all patients at a median of 4.2 months (IQR, 2.9-11). The median score for the PCS was 38 (IQR, 34-48, range 17-58, P = .009), for the MCS 52 (IQR, 45-60, range 33-62, P = .701), and for the FAOS 73 (IQR, 48-83).
Conclusion
In this series, our use of blade plate fixation with autogenous grafting was an effective method for managing a nonunion around the ankle allowing for alignment correction, stable compression and fixation, union, and fair patient-reported outcome scores.
Level of Evidence
Level IV, therapeutic.
... For calcaneal fractures, early weight bearing usually started at three to four weeks, while more traditional progression was started anywhere from six to 13 weeks [9,17]. Both studies initiated treatment with foot and ankle exercise and gradually progressed to full For tibial fractures, early weight bearing was started as soon as day one, with the delayed weight-bearing protocols initiating weight bearing at six weeks, or earlier, pending clinical examination [18][19][20]. With the earlier tibial weight-bearing progressions, there was some evidence that noise stimulation may be beneficial [19]. ...
... The non-RCTs utilized a variety of progressions. Few studies detailed weekly weight progression, and many RCTs [15,[18][19][20] and non-RCTs [13,[27][28][29][30][31] reported only early "weight bearing as tolerated" without further elaboration. These studies were included because the authors described limited weight bearing initially due to pain or assistive device use, but did not quantify the progression to full normal weight bearing, with the exception of Braun et al. [27] and Cunningham et al. [13] Further descriptions of the weight-bearing progressions can be found in Table S2 for RCTs and Table S3 for non-RCTs. ...
... Infection rate was the most reported secondary outcome: four of the RCTs [15][16][17][18] and three of the non-RCTs [21,22,25] reported an infection rate anywhere from zero to seven cases per study. Chen et al. [17] reported one infection per group, while Fadel et al. [18] had two in the plate osteosynthesis group and six in the Ilizarov fixation group. ...
The goal of this systematic review was to examine existing evidence on the effectiveness of early, progressive weight bearing on patients after traumatic lower extremity fractures and relate these findings to device/implant choice. A search of the literature in PubMed/Medline, Embase, Web of Science, and the Cochrane Library was performed through January 2022. Randomized controlled trials and non-randomized, prospective longitudinal investigations of early, progressive weight bearing in skeletally mature adults after traumatic lower extremity fracture were included in the search, with 21 publications included in the final analysis. A summary of the loading progressions used in each study, along with the primary and additional outcomes, is provided. The progression of weight bearing was variable, dependent on fracture location and hardware fixation; however, overall outcomes were good with few complications. Most studies scored “high” on the bias tools and were predominately performed without physical therapist investigators. Few studies have investigated early, progressive weight bearing in patients after traumatic lower extremity fractures. The available clinical evidence provides variable progression guidelines. Relatively few complications and improved patient function were observed in this review. More research is needed from a rehabilitation perspective to obtain graded progression recommendations, informed by basic science concepts and tissue loading principles.
... Although a recent systematic review by Malik-Tabassum et al. analysing 5 comparative studies found that the rates of non-union, malunion, infection and arthrodesis were comparable in tibial plafond fractures that were treated with ORIF or circular external fixation [15], more severe injuries were preferentially treated with circular external fixation and cases that underwent ORIF had a significantly higher incidence of unintended metalwork removal. Fadel et al., through a randomised controlled trial, also reported shorter time to fracture union and better Modified Mazur scores using Ilizarov's fixation method as opposed to ORIF with dynamic compression plate in the treatment of extra-articular distal tibial fractures in 40 patients [16]. ...
Introduction: Multi-planar external fixation is used for the management of complex distal tibia fractures. This study aims to describe our experience of treating distal tibia fractures using the Ilizarov, Taylor Spatial Frame and True-Lok Hex external fixation methods. Methodology: We conducted a retrospective analysis of clinical and radiological records of all distal tibia fractures that were managed with multi-planar external fixation over a period of 3 years. A total of 13 cases were included, of which most were high-energy injuries. Results: The average age of the patients was 44 years old. 11 (85%) cases were high-energy trauma due to road traffic accidents. 8 (62%) cases involved the revision of a previous fixation method. Most (77%) cases were AO classification Type 3, and the majority (62%) of cases were open fractures. The average duration in the external fixator frame and time to radiological union was 5 months and 6 months respectively. The average malalignment at union was 1.3 degrees and 0.5 degrees in the coronal plane and sagittal plane respectively. All fractures involving the joint line were adequately restored. There were 2 (16%) case of non-union and 2 (15%) cases of pin site infections. 1 case required a corticotomy and subsequent lengthening. Conclusion: Multi-planar circular external fixation is a reliable method to treat complex distal tibia fractures, both in the acute setting and as revision surgery. The rates of fracture union is high, with minimal malalignment. Although pin site infections are relatively common, they are uncomplicated and easily treated.
... Although a recent systematic review by Malik-Tabassum et al. analysing 5 comparative studies found that the rates of non-union, malunion, infection and arthrodesis were comparable in tibial plafond fractures that were treated with ORIF or circular external fixation [15], more severe injuries were preferentially treated with circular external fixation and cases that underwent ORIF had a significantly higher incidence of unintended metalwork removal. Fadel et al., through a randomised controlled trial, also reported shorter time to fracture union and better Modified Mazur scores using Ilizarov's fixation method as opposed to ORIF with dynamic compression plate in the treatment of extra-articular distal tibial fractures in 40 patients [16]. ...
Introduction:
Multi-planar external fixation is used for the management of complex distal tibia fractures. This study aims to describe our experience of treating distal tibia fractures using the Ilizarov, Taylor Spatial Frame and True-Lok Hex external fixation methods.
Methodology:
We conducted a retrospective analysis of clinical and radiological records of all distal tibia fractures that were managed with multi-planar external fixation over a period of 3 years. A total of 13 cases were included, of which most were high-energy injuries.
Results:
The average age of the patients was 44 years old. 11 (85%) cases were high-energy trauma due to road traffic accidents. 8 (62%) cases involved the revision of a previous fixation method. Most (77%) cases were AO classification Type 3, and the majority (62%) of cases were open fractures. The average duration in the external fixator frame and time to radiological union was 5 months and 6 months respectively. The average malalignment at union was 1.3 degrees and 0.5 degrees in the coronal plane and sagittal plane respectively. All fractures involving the joint line were adequately restored. There were 2 (16%) case of non-union and 2 (15%) cases of pin site infections. 1 case required a corticotomy and subsequent lengthening.
Conclusion:
Multi-planar circular external fixation is a reliable method to treat complex distal tibia fractures, both in the acute setting and as revision surgery. The rates of fracture union is high, with minimal malalignment. Although pin site infections are relatively common, they are uncomplicated and easily treated.
... Diğer bir tedavi seçeneği de sirküler eksternal fiksatörlerdir. Genellikle enfekte kaynamamalarda, segment çıkarma ve uzatma ve eş zamanlı defortmitelerin düzeltilmesi gereken vakalarda oldukça iyi sonuçlar bildirilmiş ancak tel dibi enfeksiyonu, hasta uyumu bu yöntemin en önemli dezavantajları olarak gösterilmiştir (15)(16)(17)(18). ...
Özet Amaç: Tibianın alt 1/3 lük kısmında gelişen kırıklarda kaynamama sık karşılaşılan bir problemdir. Bu durumua ince yumuşak doku örtüsü ve zayıf kanlanma gibi durumlar sebep olurlar. Ayrıca ayak bileğine yakınlık ve kısa distal segment gibi mekanik problemler kaynamama probleminin tedavisini oldukça güçleştirir. İntramedüller çivileme, bu soruna güçlü bir çözüm sunar. Çünkü geniş diseksiyona gerek kalmaz ve implant intraosseöz kalarak yumuşak dokular için minimum problem oluşturur. Bu çalışmanın amacı, tibianın alt 1/3 lük kısmındaki kırıklarda gelişmiş olan kaynama kusurlarının tedavisinde oyulmuş intramedüller çivinin etkinliğini belirlemektir. Gereç ve Yöntemler: Tibia alt 1/3’lük bölge kırığı sonrasında kaynamama gelişen ve sonrasında oymalı intramedüller çivi ile tedavi edilen 14 hastanın verileri retrospektif olarak incelendi. Çalışmaya tibia 1/3 distalindeki kırığı kaynamayan ve aktif enfeksiyon bulgusu olmayan tüm hastalar dahil edildi. İki hastada ilk operasyon sonrası ortaya çıkan yüzeysel enfeksiyon öyküsü vardı, ancak ameliyat sırasında hiçbir hastada aktif enfeksiyon belirtisi yoktu. Tüm hastalar oymalı kilitli intramedüller çivileme ile tedavi edildi. Bulgular: Hastaların hepsinde kaynama elde edildi. Ortalama kaynama süresi 5.7 (3-10) ay idi. Hiçbir hastada enfeksiyon gelişmedi. Sonuç: Oymalı kilitli intramedüller çivileme, tibianın alt 1/3’lük bölgesinde görülen ve tedavisi oldukça güç olan kaynamamaların tedavisinde gayet güvenilir bir yöntemdir.
... As noted earlier, there have been four trials reported since the UK FixDT trial began. 41,[45][46][47][48] In the most recent, Fang et al. 46 compared the results of external fixation combined with limited internal fixation, minimally invasive percutaneous plate fixation and IM nailing for distal tibia fractures. 46 They concluded that 'all achieved similar good functional results' but that the different surgical techniques may have different complication profiles. ...
... Other recent studies have specifically compared external fixation using 'fine-wire' Ilizarov external fixation with plate fixation. 48 This trial, although not directly relevant to the results of the UK FixDT trial, did indicate a lower complication rate with external fixation than with plate fixation. However, again, the plate fixation group of participants in this trial had an open reduction and internal fixation with the sort of non-locking plate associated with high wound complication rates. ...
Background
The best treatment for fractures of the distal tibia remains controversial. Most of these fractures require surgical fixation, but the outcomes are unpredictable and complications are common.
Objectives
To assess disability, quality of life, complications and resource use in patients treated with intramedullary (IM) nail fixation versus locking plate fixation in the 12 months following a fracture of the distal tibia.
Design
This was a multicentre randomised trial.
Setting
The trial was conducted in 28 UK acute trauma centres from April 2013 to final follow-up in February 2017.
Participants
In total, 321 adult patients were recruited. Participants were excluded if they had open fractures, fractures involving the ankle joint, contraindication to nailing or inability to complete questionnaires.
Interventions
IM nail fixation ( n = 161), in which a metal rod is inserted into the hollow centre of the tibia, versus locking plate fixation ( n = 160), in which a plate is attached to the surface of the tibia with fixed-angle screws.
Main outcome measures
The primary outcome measure was the Disability Rating Index (DRI) score, which ranges from 0 points (no disability) to 100 points (complete disability), at 6 months with a minimum clinically important difference of 8 points. The DRI score was also collected at 3 and 12 months. The secondary outcomes were the Olerud–Molander Ankle Score (OMAS), quality of life as measured using EuroQol-5 Dimensions (EQ-5D), complications such as infection, and further surgery. Resource use was collected to inform the health economic evaluation.
Results
Participants had a mean age of 45 years (standard deviation 16.2 years), were predominantly male (61%, 197/321) and had experienced traumatic injury after a fall (69%, 223/321). There was no statistically significant difference in DRI score at 6 months [IM nail fixation group, mean 29.8 points, 95% confidence interval (CI) 26.1 to 33.7 points; locking plate group, mean 33.8 points, 95% CI 29.7 to 37.9 points; adjusted difference, 4.0 points, 95% CI –1.0 to 9.0 points; p = 0.11]. There was a statistically significant difference in DRI score at 3 months in favour of IM nail fixation (IM nail fixation group, mean 44.2 points, 95% CI 40.8 to 47.6 points; locking plate group, mean 52.6 points, 95% CI 49.3 to 55.9 points; adjusted difference 8.8 points, 95% CI 4.3 to 13.2 points; p < 0.001), but not at 12 months (IM nail fixation group, mean 23.1 points, 95% CI 18.9 to 27.2 points; locking plate group, 24.0 points, 95% CI 19.7 to 28.3 points; adjusted difference 1.9 points, 95% CI –3.2 to 6.9 points; p = 0.47). Secondary outcomes showed the same pattern, including a statistically significant difference in mean OMAS and EQ-5D scores at 3 and 6 months in favour of IM nail fixation. There were no statistically significant differences in complications, including the number of postoperative infections (13% in the locking plate group and 9% in the IM nail fixation group). Further surgery was more common in the locking plate group (12% in locking plate group and 8% in IM nail fixation group at 12 months). The economic evaluation showed that IM nail fixation provided a slightly higher quality of life in the 12 months after injury and at lower cost and, therefore, it was cost-effective compared with locking plate fixation. The probability of cost-effectiveness for IM nail fixation exceeded 90%, regardless of the value of the cost-effectiveness threshold.
Limitations
As wound dressings after surgery are clearly visible, it was not possible to blind the patients to their treatment allocation. This evidence does not apply to intra-articular (pilon) fractures of the distal tibia.
Conclusions
Among adults with an acute fracture of the distal tibia who were randomised to IM nail fixation or locking plate fixation, there were similar disability ratings at 6 months. However, recovery across all outcomes was faster in the IM nail fixation group and costs were lower.
Future work
The potential benefit of IM nail fixation in several other fractures requires investigation. Research is also required into the role of adjuvant treatment and different rehabilitation strategies to accelerate recovery following a fracture of the tibia and other long-bone fractures in the lower limb. The patients in this trial will remain in longer-term follow-up.
Trial registration
Current Controlled Trials ISRCTN99771224 and UKCRN 13761.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 22, No. 25. See the NIHR Journals Library website for further project information.
... Stabilization through external osteosynthesis enables immobilization and correction of osseous fragments. This method prevents metal entering into the fracture focus, which differentiates it from internal synthesis [15]. Bodily ageing is an inextricable process. ...
... The strategy of thigh bone fracture treatment is focused on the fastest possible mobilization of a patient [14]. Shortly after an operation, therapists use walking with relief of a limb, active exercises and movement coordination exercises [15,19]. Due to the high mortality rate, operational treatment is an optional method and a fracture itself is regarded as life threatening. ...
... The most common fixation methods are intramedullary nail (IMN), plate osteosynthesis (PO), and external fixation (EF). Each surgical fixation method has its own advantages and indications [6,11,12], so it is difficult to compare methods without also considering the fracture types. Although there are many studies comparing fixation methods in distal tibia fractures [5,[13][14][15][16][17][18][19], treatment superiority has not been established, and these deal with preventing rather than treating nonunions. ...
PurposeThe purpose of this study was to examine time to union of extra-articular distal tibia nonunions based on fracture type and fixation methods: intramedullary nail (IMN), plate osteosynthesis (PO), and external fixation (EF). Methods
This retrospective chart review included all patients who presented at a Level I trauma center with AO/OTA 43A & distal third 42A-C fracture nonunions between 2008 and 2014. Fixation methods were recorded and patient course was followed until nonunion had healed clinically. ResultsThirty-three distal tibia nonunions were included, and 29 reached eventual union (88%). Five AO/OTA fracture types were present. Mean times to union from nonunion diagnosis between original fracture types were compared (p = 0.203). Comminuted fracture types had longer times to union from nonunion diagnosis compared to simple fracture types (78 vs. 46 weeks, p = 0.051) and more revision fixations (1.5 vs. 0.5, p = 0.037). Mean time to union from nonunion diagnosis was shorter when no revision fixation was done compared to revisions (15 vs. 42 weeks, p = 0.102). Times to union from nonunion diagnosis without revision fixation were: IMN (12 weeks), PO (27 weeks), and EF (13 weeks) (p = 0.202). Times to union from definitive revision fixation were: IMN (17 weeks), PO (21 weeks), and EF (66 weeks) (p = 0.009), with EF taking significantly longer than both other methods. 21 patients (64%) underwent revision fixation. Revision fail rates were: IMN (0/6, 0%), PO (2/8, 25%), and EF (15/21, 71%). Time to union was longer in revisions that changed fixation method compared to revisions that used the same method (51 vs. 18 weeks, p = 0.030). Deep infections were also associated with longer union times (81 vs. 47 weeks, p = 0.040). Conclusions
In this nonunion population, comminuted fracture types needed more time and revisions to reach union. Time to union was only clinically shorter when revision fixation was not performed, but IMN and PO were both successful fixation options with significantly shorter times to union than EF. Mean time to union increased even more when revision of fixation method was performed vs. exchange revision, as did nonunions with deep infections.
... When evaluating these papers it was noted that 30 RCTs (43%) used terms such as "superficial skin infection", "superficial wound infection", "infection in surgical margins" and "deep infection" [64][65][66][67][68][69][70][71][72][73][74][75][76]78,80,82,[84][85][86][87][88][89][90][91][92][93]102,[105][106][107]. Such terms may be suggestive of the CDC-guidelines, although this could not be confirmed in the text. ...
Introduction:
One of the most challenging musculoskeletal complications in modern trauma surgery is infection after fracture fixation (IAFF). Although infections are clinically obvious in many cases, a clear definition of the term IAFF is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions used in the scientific literature to describe infectious complications after internal fixation of fractures. The hypothesis of this study was that the majority of fracture-related literature do not define IAFF.
Material and methods:
A comprehensive search was performed in Embase, Cochrane, Google Scholar, Medline (OvidSP), PubMed publisher and Web-of-Science for randomized controlled trials (RCTs) on fracture fixation. Data were collected on the definition of infectious complications after fracture fixation used in each study. Study selection was accomplished through two phases. During the first phase, titles and abstracts were reviewed for relevance, and the full texts of relevant articles were obtained. During the second phase, full-text articles were reviewed. All definitions were literally extracted and collected in a database. Then, a classification was designed to rate the quality of the description of IAFF.
Results:
A total of 100 RCT's were identified in the search. Of 100 studies, only two (2%) cited a validated definition to describe IAFF. In 28 (28%) RCTs, the authors used a self-designed definition. In the other 70 RCTs, (70%) there was no description of a definition in the Methods section, although all of the articles described infections as an outcome parameter in the Results section.
Conclusion:
This systematic review shows that IAFF is not defined in a large majority of the fracture-related literature. To our knowledge, this is the first study conducted with the objective to explore this important issue. The lack of a consensus definition remains a problem in current orthopedic trauma research and treatment and this void should be addressed in the near future.
... Grup 2'deki hastalarda eksternal fiksasyon kalış süreleri ortalama 4 (3-5) aydı. Tüm hastaların takip süreleri ortalama 16 (12)(13)(14)(15)(16)(17)(18)(19)(20) aydı. ...
... Fadel ve ark.'nın (15) yaptığı çalışmada, distal tibia kırığı sonrası yapılan plak fiksayonunda tam yüke geçilmesi kaynama bulguları görüldüğü zaman, eksternal fiksasyon da yüklenmeye geçiş postoperatif 1 gün olarak belirtilmiştir. Çalışmamızda, Grup 1'de literatüre ek olarak kaynama bulguları ve ağrıyla doğru orantılı olarak tam yüke geçiş yaklaşık 8 haftaydı. ...
Objective: We aimed to evaluate the functional results of
patients who had minimally invasive anatomic plate or
external fixator application for the management of fractures
in the distal third of the tibia not extending to the joint.
Material and Methods: The study included 30 patients who
presented at the Emergency Department with a distal tibia
fracture type AO 42A2 between 2010 and 2013. Group 1
comprised 15 patients with Gustilo-Andersen Grade 1-2
open fracture who had undergone minimally invasive plate
application. Fifteen patients in Group 2 with closed fractures
and Grade 1-2 with open fractures had undergone
fixation with a Limb Reconstruction System (LRS) fixator
including the distal tibia. Group 1 patients had been treated
with a splint, while Group 2 patients were not. The
functional results were evaluated according to the Johner
Wrush criteria.
Results: The median age of the patients was 36 (18-65) years.
Complete bone union was achieved in all patients. The median
follow-up period was 16 (10-20) months. The median external
fixator dwell time was 4 months. The median hospital stay was
2.5 days for the patients in Group 1 and 1.5 days for Group 2
patients In Group 1, 4 patients developed pin site infection
which responded to antibiotherapy without the need for extraction
of replacement of the pin. Partial weight-bearing was
achieved at 6 weeks and full weight-bearing at 10 weeks in
Group 1. Partial weight-bearing was applied on the 3rd day
in Group 2 with external fixator application and full weightbearing
was generally permitted after Day 10 (8-14) depending
on the severity of pain. None of the patients complained
of pain following union. In both groups functional results were
perfect based on Johner Wrush criteria.
Conclusion: Both methods applied to extra-articular tibia
distal fractures in selected patients provided very good
early stage functiional results.
