Objective To evaluate the effectiveness of limited internal fixation combined with a hinged external fixator in the treatment of peri-elbow bone infection. Methods The clinical data of 19 patients with peri-elbow bone infection treated with limited internal fixation combined with a hinged external fixator between May 2018 and May 2021 were retrospectively analyzed. There were 15 males and 4 females with an average age of 44.6 years (range, 28-61 years). There were 13 cases of distal humerus fractures and 6 cases of proximal ulna fractures. All the 19 cases were infected after internal fixation of fracture, and 2 cases were complicated with radial nerve injury. According to Cierny-Mader anatomical classification, 11 cases were type Ⅱ, 6 cases were type Ⅲ, and 2 cases were type Ⅳ. The duration of bone infection was 1-3 years. After primary debridement, the bone defect was (3.04±0.28) cm, and the antibiotic bone cement was implanted into the defect area, and the external fixator was installed; 3 cases were repaired with latissimus dorsi myocutaneous flap, and 2 cases were repaired with lateral brachial fascial flap. Bone defects repair and reconstruction were performed after 6-8 weeks of infection control. The wound healing was observed, and white blood cell (WBC), erythrocyte sedimentation rate (ESR), and C-reaction protein (CRP) were reexamined regularly after operation to evaluate the infection control. X-ray films of the affected limb were taken regularly after operation to observe the bone healing in the defect area. At last follow-up, the flexion and extension range of motion and the total range of motion of the elbow joint were observed and recorded, and compared with those before operation, and the function of the elbow joint was evaluated by Mayo score. Results All patients were followed up 12-34 months (mean, 26.2 months). The wounds healed in 5 cases after skin flap repair. Two cases of recurrent infection were effectively controlled by debridement again and replacement of antibiotic bone cement. The infection control rate was 89.47% (17/19) in the first stage. Two patients with radial nerve injury had poor muscle strength of the affected limb, and the muscle strength of the affected limb recovered from grade Ⅲ to about grade Ⅳ after rehabilitation exercise. During the follow-up period, there was no complication such as incision ulceration, exudation, bone nonunion, infection recurrence, or infection in the bone harvesting area. Bone healing time ranged from 16 to 37 weeks, with an average of 24.2 weeks. WBC, ESR, CRP, PCT, and elbow flexion, extension, and total range of motions significantly improved at last follow-up (P<0.05). According to Mayo elbow scoring system, the results were excellent in 14 cases, good in 3 cases, and fair in 2 cases, and the excellent and good rate was 89.47%. ConclusionLimited internal fixation combined with a hinged external fixator in the treatment of the peri-elbow bone infection can effectively control infection and restore the function of the elbow joint.
Objective To summarize the methods of ankle hinge position design in the correction of clubfoot deformity by Ilizarov method, and to explore its application value in the prevention of ankle dislocation. Methods A retrospective study was conducted including 28 patients with rigid clubfoot deformity (34 feet) who met the selection criteria and admitted between September 2021 and December 2024. There were 19 males and 9 females with an average age of 31.8 years (range, 19-47 years). According to Dimeglio classification, there were 21 feet of degree Ⅲ and 13 feet of degree Ⅳ. The causes were traumatic sequelae in 9 cases, congenital foot deformity in 15 cases, spina bifida sequelae in 1 case, peripheral neuropathy in 1 case, and cerebral palsy sequelae in 2 cases. The malformation lasted from 6 to 46 years, with an average of 29.3 years. All patients were treated with Ilizarov circular external fixator, and the hinge position of ankle joint was planned according to the standard lateral X-ray film of foot and ankle and the principle of Ilizarov limb deformity correction center of rotation angulation (CORA) before operation. The 2008 International Clubfoot Study Group (ICFSG) scoring system was used to evaluate the efficacy. ResultsThe deformity of rigid clubfoot was completely corrected in all patients, and the patients could walk with plantar weight-bearing, and the ankle weight-bearing walking significantly improved when compared with that before operation. There was no complication such as ankle dislocation, talus impact or extrusion, local skin necrosis, needle tract infection, or numbness of extremities during the correction process. All patients were followed up 5-39 months, with an average of 18.1 months. At last follow-up, according to the ICFSG scoring system, 23 feet were excellent, 10 feet were good, and 1 foot was fair, and the excellent and good rate was 97%. Conclusion Designing the position of the ankle hinge according to the principle of CORA can effectively avoid ankle dislocation, talus impingement, tibiotalar joint extrusion, and other ankle adverse events in the process of correcting clubfoot deformity, which has good application value in clinical practice.
Objective To investigate the surgical characteristics and preliminary effectiveness of Orthofix unilateral external fixator in the treatment of musculoskeletal tumors. Methods Twenty-two patients received Orthofix unilateral external fixator treatment for bone defect after tumor excision or complications after limb salvage surgery between June 2011 and March 2016. There were 11 males and 11 females with a median age of 23.5 years (range, 4-57 years). The bone defect or limb length discrepancy after tumor resection was at proximal femur in 6 cases, distal femur in 8 cases, diaphysis of femur in 3 cases, proximal tibia in 2 cases, and diaphysis of tibia in 3 cases. The external fixation was used for temporary fixation after reconstruction of bone defect in 10 cases [the length of bone defect was 6-19 cm (mean, 12.3 cm); using vascularized fibular graft in 2 cases, allograft bone and free fibular graft in 2 cases, allograft bone and autogenous bone graft in 5 cases, allograft bone reconstruction in 1 case]; bone distraction lengthening for limb length discrepancy in 5 cases [the length of shortening was 6.5-8.5 cm (mean, 7.5 cm)]; temporary fixation after open biopsy in 3 cases; bone transportation over locking plate in 1 case (the length of bone defect was 7.5 cm); fixation for preoperatively pathology fracture in 1 case; and joint distraction for dislocation after tumor ablation in 2 cases. Results All the patients were followed up 12-72 months (mean, 36 months). In 10 patients with bone defect reconstruction, the wearing external fixator time was 3-8 months (mean, 4.8 months); all got bone union with the healing time of 3-16 months (mean, 6.4 months); the Musculoskeletal Tumor Society 93 (MSTS 93) score was 73.3-93.3 (mean, 87.2); and no complication occurred during wearing external fixator. In 5 patients with bone distraction lengthening for limb length discrepancy, the wearing external fixator time was 7-15 months; 2 patients had axial deviation during distraction and2 had greenstick fracture after apparatus removal; pin site infection was observed in 2 cases with grade 1 and 1 case with grade 2 according to Checketts-Otterburn classification system; the MSTS 93 score was 80.0-96.7 (mean, 89.2). The remaining patients had no complications, the knee and ankle joint movement was normal. Conclusion Orthofix unilateral external fixator can be used in fixation for complex bone defect after tumor resection and to correct limb length discrepancy after limb salvage surgery.
Objective To evaluate the effectiveness of precise orthormorphia of tibial angulation deformity and shortening deformity by using digital technology combined with external fixator. Methods Twenty-six cases of tibial angulation deformity combined with shortening deformity were treated between June 2012 and August 2016, including 12 males and 14 females aged from 1 to 19 years with an average age of 16.5 years. There were 6 cases of congenital patella pseudoarthrosis, 1 case of fibrous dysplasia of femur and tibia, 3 cases of limb shortening deformity caused by infantile paralysis, 16 cases of fracture malunion. Limb shortening was 1.5-9.5 cm (mean, 6.2 cm) before operation. The deformity from three-dimensional perspective was analysed by digital technology, the surgical procedures of lengthening and osteotomy was simulated, the navigation templates were completed with computer aided design (CAD) and three-dimensional printing, and the external fixator was used to assist the lengthening of the tibia. X-ray films were regularly reviewed after operation to observe the new bone remolding, limb lengthening, load bearing line of lower limb, and recurrences of angulation. Results All the patients were followed up 14-48 months (mean, 18.8 months). There was only 1 case of superficial pin site infection which was cured with oral antibiotics and pin site care with mild disinfectants, and no complication such as bone nonunion, equines deformity, or vascular nerve injury occurred. The deformity of tibia and load bearing line of lower limb had been completely recovered according to postoperative X-ray films at 1 week. All the cases achieved perfect limb length as with preoperative design. The bone mineralization time was 12-20 weeks (mean, 11.6 weeks), the external fixator removal time was 18-26 weeks (mean, 14.9 weeks), and the healing index was 21-78 d/cm (mean, 63.4 d/cm). The postoperative flexion range of the injured limb was 15° less than the unaffected extremity in 1 case, and the situation was improved significantly after some physical manipulation and exercise, who completed the limb lengthening and achieved the expected effectiveness finally. Conclusion Precise orthormorphia of tibial deformity by using digital technology, and limb lengthening with the aid of external fixator can achieve good effectiveness with good reliability, invasiveness, and precision.
ObjectiveTo explore the mechanical stability of the three-dimensional (3-D) external fixator for osteoporotic fracture so as to provide the biomechanical basis for clinical application. MethodsForty-five fresh frozen adult tibial specimens were selected to rapidly prepare the extracorporal tibia osteoporotic fracture models, and were randomly divided into 3 groups (n=15). Fractures were fixed with 3-D external fixators (3-D external fixators group), intramedullary nails (intramedullary nail group), and plate (plate group) respectively. Five specimens randomly from each group were used to do axial compression test, three-point bending test, and torsion test with microcomputer control electronic universal testing machine, then the mechanical parameters were calculated. ResultsIn the axial compression test, the displacement of 3-D external fixator group and intramedullary nail group were shorter than plate group, showing significant differences (P<0.05); but no significant difference was found between 3-D external fixator group and intramedullary nail group (P>0.05). In the three-point bending test and torsion test, the deflection and the torsional angle of 3-D external fixator group and intramedullary nail group were smaller than plate group, showing significant differences (P<0.05); but no significant difference was found between 3-D external fixator group and intramedullary nail group (P>0.05). ConclusionThe 3-D external fixator can fix fracture three-dimensionally from multiple plane and it can offer strong fixing. It is biomechanically demonstrated to be suitable for osteoporotic fracture.
Objective To compare the effectiveness of suspension fixation plus hinged external fixator with double plate internal fixation in the treatment of type C humeral intercondylar fractures. Methods Between January 2014 and April 2016, 30 patients with type C (Association for the Study of Internal Fixation, AO/ASIF) humeral intercondylar fractures were treated. Kirschner wire suspension fixation plus hinged external fixator was used in 14 cases (group A), and double plate internal fixation in 16 cases (group B). There was no significant difference in gender, age, injury cause, disease duration, injury side, and type of fracture between 2 groups (P>0.05). Results There was no significant difference in operation time and hospitalization stay between 2 groups (P>0.05). But the intraoperative blood loss in group A was significantly less than that in group B (P<0.05); the visual analogue scale (VAS) score at 1 day and 3 days after operation in group A were significantly less than those in group B (P<0.05). Primary healing of incision was obtained in all patients of 2 groups, and no surgery-related complications occurred. The patients were followed up 6-24 months (mean, 12.3 months) in group A and 6-24 months (mean, 12.8 months) in group B. The self-evaluation satisfaction rate was 85.7% (12/14) in group A and was 81.2% (13/16) in group B at 3 months after operation, showing no significant difference (χ2=0.055, P=0.990). Based on the improved Gassebaum elbow performance score at 6 months after operation, excellent and good rate of the elbow function was 78.6% (excellent in 5 cases, good in 6 cases, fair in 2 cases, and poor in 1 case) in group A and was 81.2% (excellent in 6 cases, good in 7 cases, fair in 2 cases, and poor in 1 case) in group B, showing no significant difference between 2 groups (χ2=0.056, P=0.990). Heterotopic ossification occurred at 3 months after operation in 1 case of each group respectively. The X-ray films showed bony union in all cases; no loosening or breakage of screw was observed. The bone union time showed no significant difference between 2 groups (t=–0.028, P=0.978). The time of internal fixation removal, the intraoperative blood loss, and VAS score at 1 day and 3 days after operation in group A were significant better than those in group B (P<0.05). Conclusion The suspension fixation plus hinged external fixator and double plate internal fixation for the treatment of type C humeral intercondylar fractures have ideal outcome in elbow function. But the suspension fixation plus hinged external fixator is better than double plate internal fixation in intraoperative blood loss, postoperative VAS score, and time of internal fixation removal.
ObjectiveThe anatomical calcaneal external fixator was designed by measuring and calculating the morphological data of the heel.MethodsA total of 100 normal people were randomly selected to obtain 200 hind foot data, including 45 males and 55 females, with an average age of 43.9 years (range, 19-67 years). According to the principles of human engineering and local anatomy, the morphological data of the heel in the weight-bearing standing position and supine position were measured with the direct measurement mode. The heel length, heel width, heel height, medial ankle height, lateral ankle height, and calcaneal pitch angle (CPA) were measured by vernier calipers and ulnar markers in weight-bearing standing position, and the gender groups and left and right foot groups were compared; the shape of the hind foot in the supine position was measured by three-dimensional (3D) dot matrix inverse model method. According to the stereoscopic data of the comprehensive anatomical morphology of the heel, the anatomical calcaneal external fixator was designed with AutoCAD 2019 and other 3D industrial design softwares.ResultsThe measurements of shoe size, heel length, heel width, heel height, medial ankle height, lateral ankle height, and CPA in male were significantly higher than those in female (P<0.05). There was no significant difference between the left and right feet in the other indexes except that the height of the medial malleolus of the left foot was significantly lower than that of the right foot (t=−2.827, P=0.005). The measurement of 3D dot matrix inverse model in supine position showed that the heel part was non-circular arc edge, and many groups of arc edges fluctuate in a limited range. Based on the above data, an anatomical calcaneal external fixator was designed, which could fit the anatomic radian in theory, so as to be flexible in configuration. On this basis, the ordinary configuration, compression configuration, and orthodontic configuration were designed to meet the treatment needs of calcaneal fractures in different degrees. The ordinary configuration was suitable for patients with Sanders Ⅰ, ⅡA, and ⅡB calcaneal fractures with no or slight displacement of intra-articular fractures; the ordinary configuration was mainly used for simple fixing. The compression configuration was suitable for patients with Sanders ⅡC, ⅢA, and ⅢB, tongue fractures, and avulsion fractures with severe displacement of intra-articular fractures; the compression configuration used obliquely drawn console wires to fix the displaced bones. The orthodontic configuration was suitable for patients with Sanders ⅢC and Ⅳ calcaneal fractures with severe displacement of intra-articular fractures or severe calcaneal bone defects; the orthodontic configuration was a multi-module design, which took into account the stable fixation of the fracture and the arbitrary adjustment of the joint fixation angle.ConclusionThe hind foot is special for morphology, so the external fixator designed based on the vernier caliper measurement method and 3D dot matrix measuring plate measurement method is an anatomical type and its configuration can theoretically meet stable and flexible clinical needs.
Objective To evaluate the safety of conversion from external fixation to internal fixation for open tibia fractures. Methods Between January 2010 and December 2014, 94 patients (98 limbs) with open tibia fractures were initially treated with external fixators at the first stage, and the clinical data were retrospectively analyzed. In 29 cases (31 limbs), the external fixators were changed to internal fixation for discomfort, pin tract response, Schantz pin loosening, delayed union or non-union after complete wound healing and normal or close to normal levels of erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and the leucocyte count as well as the neutrophil ratio (trial group); in 65 cases (67 limbs), the external fixators were used as the ultimate treatment in the control group. There was no significant difference in gender, age, side of the limbs, interval from injury to the first debridement, initial pathogenic bacteria, the limbs that skin grafting or flap transferring for skin and soft tissue defect between the two groups ( P>0.05). The incidence of Gustilo type III fractures in the control group was significantly higher than that in the trial group (P=0.000). The overall incidence of infection was calculated respectively in the two groups. The incidence of infection according to different fracture types and whether skin grafting or flap transferring was compared between the two groups. The information of the pathogenic bacteria was recorded in the infected patients, and it was compared with the results of the initial culture. The incidence of infection in the patients of the trial group using different internal fixation instruments was recorded. Results The overall incidences of infection for the trial and control groups were 9.7% (3/31) and 9.0% (6/67) respectively, showing no significant difference (χ2=0.013, P=0.909). No infection occurred in Gustilo type I and type II patients. The incidence of infection for Gustilo type IIIA patients in the trial group and the control group were 14.3% (1/7) and 6.3% (2/32) respectively, showing no significant difference (χ2=0.509, P=0.476); the incidence of infection for type IIIB patients in the two groups were 50.0% (2/4) and 14.3% (2/14) respectively, showing no significant difference (χ2=2.168, P=0.141); and the incidence of infection for type IIIC patients in the two groups were 0 and 16.7% (2/12) respectively, showing no significant difference (χ2=0.361, P=0.548). Of all the infected limbs, only 1 limb in the trial group had the same Staphylococcus Aureus as the result of the initial culture. In the patients who underwent skin grafting or flap transferring, the incidence of infection in the trial and control groups were 33.3% (2/6) and 13.3% (2/15) respectively, showing no significant difference (χ2=1.059, P=0.303). After conversion to internal fixation, no infection occurred in the cases that fixed with nails (11 limbs), and infection occurred in 4 of 20 limbs that fixed with plates, with an incidence of infection of 20%. Conclusion Conversion from external fixation to internal fixation for open tibia fractures is safe in most cases. However, for open tibia fractures with extensive and severe soft tissue injury, especially Gustilo type III patients who achieved wound heal after flap transfer or skin grafting, the choice of secondary conversion to internal fixation should carried out cautiously. Careful pre-operative evaluation of soft tissue status, cautious choice of fixation instrument and meticulous intra-operative soft tissue protection are essential for its safety.
Objective To analyze the effectiveness comparison of external fixator combined with Kirschner wire fixation and Kirschner wire fixation in the treatment of cubitus varus deformity in children. Methods A retrospective case-control study was conducted to collect 36 children of postoperative supracondylar humerus fracture complicating cubitus varus deformity between January 2018 and July 2022. Among them, 17 cases were treated with distal humeral wedge osteotomy external fixation combined with Kirschner wire fixation (observation group), and 19 cases were treated with distal humeral wedge osteotomy and Kirschner wire fixation (control group). The baseline data including age, gender, deformity side, time from fracture to operation, carrying angle of the healthy side and preoperative carrying angle of the affected side, elbow flexion and extension range of motion, and lateral condylar prominence index (LCPI) showed no significant difference between the two groups (P>0.05). The operation time, hospitalization cost, healing time of osteotomy, postoperative complications, and the carrying angle, LCPI, and elbow flexion and extention range of motion were recorded and compared between the two groups. The elbow function was assessed by Oppenheim score at 3 months after operation and at last follow-up. Results The children in both groups were followed up 13-48 months, with an average of 26.7 months. There was 1 case of needle tract infection in the observation group and 2 cases in the control group, and no nerve injury occurred, the difference in the incidence of complication (5.88% vs 10.53%) between the two groups was not significant (χ2=0.502, P=0.593). There was no significant difference in the operation time and fracture healing time between the two groups (P>0.05); the hospitalization cost of the observation group was significantly higher than that of the control group (P<0.05). The Oppenheim score of the observation group was significantly better than that of the control group at 3 months after operation (P<0.05), but there was no significant difference in the Oppenheim score between the two groups at last follow-up (P>0.05). At last follow-up, the carrying angle of affected side significantly improved in both groups when compared with preoperative ones (P<0.05); the differences of the pre- and post-operative carrying angle of affected side and elbow flexion and extension range of motion showed no significant differences between the two groups (P>0.05), but the difference in pre- and post-operative LCPI of the observation group was significantly better than that of the control group (P<0.05). ConclusionExternal fixator combined with Kirschner wire fixation and Kirschner wire fixation both can achieve satisfactory correction of cubitus varus deformity in children, and the former can achieve better short-term functional recovery of elbow joint and reduce the incidence of humeral lateral condyle protrusion.
ObjectiveTo analyze the effectiveness of external fixator combined with Kirschner wire (EF-KW) fixation in the treatment of oblique and comminuted distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children. Methods A clinical data of 22 children with DHMDJ fractures who met the selection criteria between April 2021 and December 2023 was retrospectively analyzed. All patients were treated with EF-KW fixation. There were 14 boys and 8 girls with an average age of 6.8 years (range, 1.5-12.0 years). The time from injury to operation was 14-38 hours (mean, 24.2 hours). There were 18 cases of comminuted fractures and 4 cases of oblique fractures; and 1 case of median nerve injury and 1 case of radial nerve injury before operation. The occurrence of postoperative complications was recorded. At last follow-up, the function of the affected elbow joint was evaluated according to the Mayo elbow joint function score, and the Baumann’s angle (BA) and humero-capitellar angle (HCA) of the affected and healthy sides were recorded and compared. ResultsAll fractures were successfully treated with closed reduction and no complications such as nerve injury occurred. Superficial infection occurred in 4 cases after operation and healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 9-24 months (mean, 13.8 months). At last follow-up, according to the Mayo elbow joint function score, the elbow joint function was rated as excellent in 15 cases, good in 6 cases, and fair in 1 case, with an excellent and good rate of 95.5%. The neurologic injury before operation recovered gradually. X-ray films reexamination showed that all fractures healed, and the healing time of fractures ranged from 29 to 61 days, with an average of 35.6 days. At last follow-up, there was no significant difference in BA and HCA between the healthy side and the affected side (P>0.05). During follow-up, 1 case developed mild cubitus varus, while the other patients had no serious complications. ConclusionEF-KW fixation for oblique and comminuted DHMDJ fractures in children has the advantages of less trauma, simple operation, easy reduction, good stability after reduction, low incidence of serious complications, and good elbow functional recovery.