Bone transport for lower limb bone defects: circular versus monolateral external fixators

What's New in Limb Lengthening and Deformity Correction.

The Limb Lengthening and Reconstruction Society (LLRS) celebrated its 28th year as an orthopaedic subspecialty, with a combined meeting with the Pediatric Orthopaedic Society of North America (POSNA) at the 2019 American Academy of Orthopaedic Surgeons (AAOS) meeting in Las Vegas. The LLRS 28th Annual Scientific Meeting was held on July 19 and 20, 2019, in Boston, Massachusetts, featuring papers and workshops from around the world. A diverse subspecialty society, we overlap with trauma, pediatric, foot and ankle, sports, arthroplasty, and oncologic orthopaedic surgeons in the diagnosis and treatment of deformities of length, alignment, contracture, nonunion, and bone healing. The purpose of this update was to summarize the important articles with regard to these subjects published since 2018. Guided Growth The technique of temporary, asymmetric growth plate tethering continues to be a successful method of deformity correction in growing children. The concept, known as guided growth, was developed by Dr. Peter Stevens, using a small, 2-hole plate to span the growth plate on 1 side, allowing the opposite side to grow unresisted, and thereby correcting angular deformity without osteotomy. The screws within the plate provide an articulation, with the apex of the correction occurring at the perichondrial ring. A multinational retrospective study described results of guided growth in 537 children with 967 physes treated1. Distal femoral and proximal tibial correction rates were similar, averaging 0.77° per month for the distal part of the femur and 0.79° for the proximal part of the tibia, despite the commonly held opinion that the femur corrects faster than the tibia. Patients with >3 years of growth remaining had a better quality of correction. Infection was uncommon, occurring in 1.78% of patients. Seven of the 8 infections occurred at the upper medial part of the tibia. The study was unable to correlate the effect of body weight on the result, nor did it assess the incidence of rebound deformity. A modified guided growth technique has been previously advocated for only removing the metaphyseal screw and leaving the plate and epiphyseal screw in place once a correction is complete. Thus, in the event that a deformity recurs, a simpler procedure to reinsert a single screw could be performed. A study by Keshet et al. refuted this practice2, as they observed permanent bar formation in 2 of 55 cases using the technique. They also observed that only 12 of their 55 patients required reinsertion of the metaphyseal screw and that 9 of those actually required plate repositioning. Anterior guided growth of the distal part of the femur to treat fixed knee flexion contracture in cerebral palsy has been reported to have favorable results, provided that implants are placed sufficiently anterior and adequate growth remains3. Congenital Pseudarthrosis of the Tibia Congenital pseudarthrosis of the tibia remains a challenge for the orthopaedic surgeon. Richards and Anderson4 reported using bone morphogenetic protein (BMP)-2 without deleterious effects in 21 children with congenital pseudarthrosis. They applied a single sponge around an autologous cancellous bone graft with intramedullary pinning that crossed the ankle joint. This technique seemed to shorten the time to union, but did not eliminate nonunion or refracture, the latter occurring in 5 of the 16 initially healed patients. In a retrospective multicenter study of 119 patients with Crawford type-II congenital pseudarthrosis of the tibia followed to maturity, Shah et al. reported an 86% primary union rate, with 69% still united at maturity5. They did not identify specific factors influencing rates of union or refracture and recommended a larger, prospective, multicenter study. Three-Dimensional Printing Three-dimensional printing, originally known as additive manufacturing, creates models by printing layers of materials on top of one another. These models can be physically held, manipulated, and studied, providing the surgeon preoperative assessment of the specific anatomical geometry. Haleem and Javaid6 described methods to create 3-dimensional models for preparation and practice of orthopaedic procedures. Exact fit models, based on magnetic resonance imaging (MRI) or computed tomography (CT) scanning techniques, can allow for preoperative planning and mock surgical procedures and can create implants specific for complex cases. Corona et al.7 described using 3-dimensional printed titanium truss cages in conjunction with the Masquelet technique to treat massive infected posttraumatic defects. Bone Defects Nauth et al.8 described a 3-stage protocol of (1) radical debridement and resection of infected skeletal elements; (2) defect space management using antibiotic blocks, spacers, or beads, which provide a local depository of culture-specific antibiotic and develop a vascularized membrane; and (3) 8 weeks later, carefully opening the membrane and exchanging the spacer for an autologous graft. Napora et al.9 described excellent functional outcome of patients at 2 to 8 years after tibial defects were treated with bone transport using a stacked hexapod frame. Corticotomy and transport were delayed for 6 to 8 weeks in patients undergoing concurrent flap coverage. The authors noted improved ease and accuracy of the docking with hexapod frames and described a method to augment frame stability near the end of treatment. The Short Musculoskeletal Function Assessment (SMFA) score was not influenced by age, sex, or diabetic status. Seventeen of 38 patients required an additional fixation surgical procedure (plate, nail, or fixator reapplication) at some point during their treatment. Barinaga et al.10 published a case report of successful tibial bone transport combining the use of a motorized magnetic lengthening nail and a limited contact dynamic compression plate, sparing the patient adjunctive external fixation. Limb Lengthening Distraction osteogenesis is the spontaneous formation of new bone in a gradually widening osteotomy site using external fixation. The more recent development of motorized internal limb-lengthening nails has advanced the capabilities of treating patients with limb lengthening and reconstruction needs. Additional authors have reported safe and successful lengthening with motorized intramedullary devices. Iobst et al.11 reported on simultaneously performing distal femoral angular correction and insertion of a retrograde intramedullary lengthening nail, while controlling the fragments with a temporary intraoperative external fixator. Length was subsequently achieved with the motorized intramedullary lengthening nail. Acute corrections of up to 15° were possible with the technique. The authors preoperatively planned their cases using the Baumgart method of reverse planning. Magnetic lengthening nails were used with liberal application of blocking screws preventing postoperative deformity. A cost study suggested that patients undergoing intramedullary lengthening have higher initial implant costs than fixator lengthening over a nail, but the former undergo fewer procedures overall12. Reuse of a PRECICE nail (Nuvasive) was reported in a case of a femoral discrepancy after an infection in which a 3-cm lengthening was successfully performed, distal locking screws were removed, the telescopic portion of the nail was retracted, and a second corticotomy and lengthening were performed13. Radiographic evaluation of bone regenerate formation during lengthening is possible by a number of means. A radiographic pilot study by Vulcano et al.14 found that a pixel-density ratio of >0.89 (ratio of pixel density in the regenerate relative to the surrounding cortex) may correlate with osseous healing and may be the threshold for allowing full weight-bearing. In pediatric patients, Archer et al.15 also found that the most reliable radiographic assessments of regenerate were by the pixel value ratio and the Ru Li technique. The mechanical environment of distracted callus affects the quality of new bone formation. An ovine study was performed by Claes et al.16 in which lateral callus distraction was undertaken in tibiae and various cyclic loads were applied at the end of lengthening. Tibiae that underwent compressive loading had more bone formation, higher spicule height, and higher blood vessel density than those experiencing shear or distractive loading. Growth Prediction Makarov et al.17 evaluated 77 patients at their institution, comparing the predictive accuracy of the White-Menelaus, Anderson-Green, Moseley, and multiplier methods for correctly timing epiphysiodesis. Final leg-length prediction errors varied from 0.7 to 1.1 cm, with the multiplier method proving to be the least accurate. Makarov et al.18 also reported a 7% complication rate among 863 epiphysiodeses, the most common of which was incomplete arrest in 31 patients resulting in angular deformity and requiring reoperation in half of such cases. Physeal Violation A sheep model was used by Knapik et al.19 to assess the consequences of distal femoral physeal violation by a retrograde intramedullary implant, noting that violations of ≤7% of the cross-sectional area were associated with continued growth of the physis without bar formation. Congenital Limb Deficiencies A review from the Finnish Register of Congenital Malformations and Care Register for Health Care20 identified all children born with lower-limb deficiencies, comparing their hospital admissions and stays with the general pediatric population of Finland. In the 16-year study period, the authors found that children with lower-limb deficiencies (terminal, long bone, foot, and toe) had 6 times the number of hospital admissions and 10 times the number of days in the hospital per child than all of the children born without limb deficiency. Two-thirds of the patients born with congenital lower-limb deficiencies required an operation, and approximately half of those operations were orthopaedic. The ratio of the short lower extremity to the contralateral, longer lower extremity in patients with congenital deficiencies has historically been considered constant in the orthopaedic literature. Tsai et al.21 attempted to verify this concept of constant inhibition and to further elucidate the pattern of skeletal maturation in patients with fibular hemimelia. They confirmed the concept of constant inhibition, with a mean deviation ranging from 0.1% to 3.3% in the femur and 0.1% to 3% in the tibia. They also noted that the growth patterns of the lower extremities in patients with unilateral fibular hemimelia did not differ when compared with the normal population. Kowalczyk and Kuźnik-Buziewicz22 reported outcomes of rotation-plasty for unilateral proximal femoral focal deficiency, reviewing postoperative function, time to knee fusion, and complications in 8 adolescents followed for 6 to 12 years postoperatively. Intensive preoperative physical therapy was performed to maximize strength and motion, especially ankle dorsiflexion. Patients were all pain-free and were able to walk without assistive devices. The 2 patients who did not exhibit a Trendelenburg gait had undergone preoperative hip stabilization procedures. Spontaneous derotation of the foot occurred in 5 of 8 patients, necessitating a repeat surgical procedure in 2 patients. All patients reported acceptance of the limb appearance and satisfaction with the result. Radhakrishna et al.23 reviewed 6 patients with Jones type-II tibial hemimelia presenting with an absent distal part of the tibia who were treated with limb salvage. All patients were reconstructed with the following elements: gradually moving the fibula distally using an external fixator to normalize the relationship of the proximal parts of the tibia and fibula; centralizing the fibula with creation of a synostosis between the fibula and tibia; and centralizing the foot relative to the fibula distally, creating a fibular-talar fusion, using external fixation and soft-tissue releases. The mean increase in leg length was 4 cm, with a mean time of 43 days in the fixator. Each child required 2 to 4 procedures, with all patients achieving union. Walker et al.24 analyzed a group of patients with ulnar deficiency and noted that a lower-extremity deficiency was present in 55% of patients. The patients with lower-extremity deficiencies and ulnar deficiencies had less severe presentation of ulnar deficiency. The authors observed no patients with tibial hemimelia (pre-axial deficiency) associated with ulnar deficiencies (post-axial deficiency). They pointed out that the upper-limb bud forms earlier than the lower-limb bud, considering the possibility that a developing limb insult would explain the observation that more lower-extremity involvement was related to less upper-extremity involvement. Physeal Arrest and Epiphysiodesis Physeal bar formation was assessed in a rat model by Wattenbarger et al.25. They selectively induced injury by scraping and drilling the metaphyseal and epiphyseal sides of the physis. Basement plate penetration on the epiphyseal side was associated with radiographic and histologic physeal injury, whereas hypertrophic zone violation on the metaphyseal side was associated with continued growth. Arthroscopic and navigation-assisted physeal bar resection is being increasingly reported. Miyamura et al.26 reported a case with a 2-year follow-up of a distal radial bar excision and concomitant osteotomy, planned using 3-dimensional CT, patient-specific guides, and intraoperative endoscopic visualization. Foot and Ankle Ankle arthrodesis for neuropathic foot deformity is historically associated with poor union rates. A fusion technique combining an external fixator and an intramedullary nail was reported to achieve fusion in 22 of 24 patients by El-Mowafi et al.27. Neuropathic foot deformity with concurrent osteomyelitis is the subject of an article by Kliushin et al.28. Seventy-seven patients were treated for a mean time of 180 days in an external fixator, with infection eradicated in 90.9% of patients at a 1-year follow-up. The American Orthopaedic Foot & Ankle Score (AOFAS) increased marginally, which the authors attributed to the pain component of the outcome score. Brandão et al.29 discussed the management of diabetic neuropathy of the foot with both internal and external fixation techniques, with particular attention to the concept of beaming of the midfoot with axial internal fixation. This concept was described as stiff, thick, intramedullary longitudinal support from hindfoot to forefoot. Staged distraction osteogenesis and ankle arthrodesis were performed by Lou et al.30 in 12 patients with posttraumatic or infectious bone loss of the distal part of the tibia who were treated with simultaneous proximal lengthening and distal compression osteosynthesis using circular fixation to provide ankle fusion. The AOFAS improved from a mean of 37.3 to 75.3 points, and successful regenerate was formed in all, although 2 patients underwent bone-grafting. Ahmad et al.31 reported the results of the treatment of rigid equinus foot deformity with circular external fixation in an adolescent and pediatric population. They reported a mean correction angle of 47.4°. Pin-track infections occurred in 4 of the 30 patients. Equinus deformity secondary to burn contractures treated with circular external fixation was the subject of a report by Zhang et al.32. The authors described a wire technique in the foot, predominantly using hindfoot wires, recognizing the need to avoid injury to the posterior tibial neurovascular bundle. A cadaver study by Kelly et al.33 identified safe hindfoot wire insertion using an entry point one-third of the distance along a line from the posterior aspect of the calcaneus to the lateral malleolus to predictably avoid the posteromedial neurovascular bundle. Nepalese children who were 1 to 5 years of age and had neglected clubfoot deformity were treated by the Ponseti method34. Ninety-five percent of feet remained plantigrade at a minimum of 10 years. Despite some residual deformity, patient-reported outcomes were satisfactory, with a relapse rate of 3%. Trauma The role of external fixation in the management of tibial fractures was described in a number of publications. In a retrospective study, Berven et al.35 compared Ilizarov frame fixation with locking plate fixation of proximal tibial fractures between 62 patients treated at 1 center using the Ilizarov technique and 68 patients treated at a different institution using internal fixation. Time to union was considered faster in the internal fixation group. Deep infection, alignment, reoperation, and range of motion were similar in the 2 groups. Lovisetti et al.36 reported the results of circular external fixation in bicondylar tibial plateau fractures, with a mean follow-up period of 37.3 months. All 20 cases were initially managed with knee-spanning fixation. The results were measured by radiographs and Hospital for Special Surgery (HSS) score and were described as favorable when compared with other series presented in the literature. Napora et al.9 examined functional outcomes in 38 patients with infected tibial nonunion managed with stacked hexapod external fixators for the purpose of bone transport. Corticotomy and transport were delayed for 6 to 8 weeks in patients undergoing concurrent flap coverage. The study noted that, with an intact fibula, the proximal and distal portions of the frame programs must be a mirror image of each other and that if angular, translational, rotation, or additional length deformity correction is built into the frame, a fibular osteotomy is required. Patients completed an SMFA survey at the time of final follow-up. The SMFA score was not influenced by age, sex, or diabetic status. Of 38 patients, 17 required an additional fixation surgical procedure (plate, nail, or fixator reapplication) at some point during their treatment. Arsoy et al.37 reported that patients presumed to have aseptic nonunion but later determined to have positive cultures had an 84% union rate with systemic antibiotic therapy. Tumor Elalfy et al.38 determined that chemotherapy had a negative effect on bone healing and diminished bone hypertrophy when using modulated compliant compressive forces to induce osteointegration in a tumor prosthesis. The 49 patients receiving chemotherapy postoperatively had less bone formation than the 44 patients who did not receive chemotherapy. Implant survival was not affected by chemotherapy, with 10-year survival rates of 85%. Limb-salvage techniques in the management of pediatric sarcoma continue to evolve. Segmental metadiaphyseal distal femoral defects after resection can be reconstructed with a novel vascularized fibular A-frame technique, augmented with an intramedullary nail. This provides a biological reconstruction with greater cross-sectional area than a single vascularized fibula, with a segment amenable to later limb lengthening39. For patients with limb growth potential remaining who require endoprosthetic reconstruction, growing prostheses are described. These include both minimally invasive devices (requiring lengthening under fluoroscopic guidance) and noninvasive devices (driven by an external magnet), and these were compared in a survival analysis by Medellin et al.40. Prosthesis survival was demonstrated as 79% (minimally invasive) and 70% (noninvasive) at 10 years. Patients receiving noninvasive prostheses had a higher mean Musculoskeletal Tumor Society Score (27 points) compared with patients who received minimally invasive devices (24.7 points), which, although not attaining significance (p = 0.295), was attributed by the authors to higher patient satisfaction, better gait, and greater independence. A novel approach to limb salvage in sarcoma of the distal part of the tibia was also described by Lou et al.30, with 5 patients undergoing resection of tumor (including the distal part of the tibia and the talar chondral surface) and subsequent tibial bone transport to achieve tibiotalar fusion. The segment was plated 1 month following the transport phase to expedite frame removal, with mean final Musculoskeletal Tumor Society Score of 88 points.

Clinical Faceoff: The Complex Tibial Plafond Fracture: ORIF or Circular External Fixation?

Introduction: The treatment of infected non unions of long bones is one of the most challenging tasks in modern orthopaedic trauma practice. With the increasing prevalence of Road Traffic Accidents (RTAs) and associated high-energy trauma, primary fractures are often presented with gross contamination, softtissue degloving, bone loss and vascular compromise. Infected non unions of the femur are managed through debridement, external fixation, bone grafting, microvascular composite tissue transfer, bone transport via an external fixator over a nail and Ilizarov circular or monolateral fixators. Aim: To evaluate the clinical and functional outcomes in infected non unions of the femur treated with a monolateral external fixator. Materials and Methods: This study was a prospective interventional study that included 17 males and one female patient, with a mean age of 35 years, who were treated at Dr. DY Patil Tertiary Care Hospital in Pune city, Maharashtra, India with a monolateral external fixator between January 2021 and January 2024. All patients had high-energy RTAs, compound fractures and gross contamination initially. Implant removal was performed, followed by radical debridement and stabilisation with the rail fixator. The mean duration of non union was 13 months (range: 4-24 months). The mean number of previous surgical procedures was 3.4 (range: 1-4). Corticotomy and bone transport were performed in six patients who had shortening or bone loss of more than 2 cm. Distraction of the corticotomy was initiated one week later at a rate of 1 mm per day until lengthening was achieved. Monthly outpatient department follow-ups, with X-rays, were conducted and the fixator was maintained until the healing of three cortices and eradication of infection were confirmed. The average follow-up duration was 2.3 years (range: 1-4 years). A paired t-test was used for statistical analysis during follow-up. Results: Union was achieved in 17 out of 18 patients, resulting in a union rate of 94.4%. The mean time to bony union was 7±2 months (range: 4-12 months). Infection was eradicated in all but one patient, who continued to experience a discharging sinus. The mean length achieved in the corticotomy and lengthening group was 4±0.75 cm. According to Paley’s bone and functional outcome scoring, all but one patient had excellent to good results at the one-year follow-up. Significant improvement was observed in the Lower Extremity Functional Score (LEFS) and in the Physical Component Score (PCS) of the 36-Item Short Form Health Survey questionnaire (SF-36) at the one-year follow-up (p-value <0.05); however, there was no improvement in the Mental Component Score (MCS) of the SF-36. Conclusion: A monolateral external fixator can provide stable fixation for the management of infected non unions of the femur and is an effective method for eradicating infection.

A retrospective comparative study of corrective osteotomy for tibial deformities with the multiaxial correction fixator and the circular fixator

Objective To report our clinical outcomes of treating tibial defects combined with soft tissue defects using Ilizarov technique. Methods From May 2010 to February 2015, 52 patients with combined bone and soft tissue defects of the tibia were treated at our department. They were 41 males and 11 females, aged from 19 to 65 years (average, 37.7 years). By Gustilo classification, 49 cases were type ⅢB and 3 type ⅢC. The areas of soft tissue defect ranged from 7 cm×3 cm to 28 cm×15 cm, and the tibial defects ranged from 5 cm to 15 cm in length (average, 12.6 cm). The schemes of Ilizarov technique depended on the location and size of the tibial defects. Open wound dressing combined with bone transport was adopted in 21 cases, limb shortening followed by bone lengthening with compression at the fracture ends in 12 cases, and tissue flap transplantation combined with bone transport or lengthening in 19 cases. Results The follow-up time of the 52 patients ranged from 13 to 61 months (average, 27.1 months). The distance of bone transport or lengthening ranged from 5.0 cm to 13.6 cm (average, 10.8 cm); the bone transport speed averaged 0.81 mm/day. The tibiae united in all the 52 patients; the time for external fixation ranged from 13 to 21 months (average, 15.3 months); the external fixation index was 2.3 months/cm. According to the Paley functional criteria, 23 cases were excellent, 19 good, 9 fair, and one poor, yielding an excellent to good rate of 80.7%. Conclusion According to the location and size of the bone and soft tissue defects of the tibia, the 3 schemes of Ilizarov technique can be rationally chosen to obtain fine clinical outcomes. Key words: Tibia; Injury; External fixator; Ilizarov technique

Objective To investigate the therapeutic effect of chronic posttraumatic osteomyelitis of lower-extremity long bones treated by bone lengthening and bone transport with the Ilizarov method. Methods From January 2005 to December 2012, 42 cases of chronic posttraumatic osteomyelitis of lower-extremity long bones were treated using Ilizarov bone lengthening and bone transport technique, including 13 cases of femur infection and 29 cases of tibia infection. Thirty cases were treated by debridement, compression of the fracture end and bone lengthening and 12 cases by debridement and bone transport. Results All the patients received a follow-up of 12 to 48 months [(15.0 ± 4.5) months]. Infection obtained one-stage control in 38 cases, but the infection was not controlled in 4 cases until 1-3 more debridement. For the 30 cases undergoing compression-distraction, 26 healed in one-stage and 4 nonunion healed after additional autogenous bone grafting. Twelve cases treated by bone transport healed after additional surgery of fracture gap cleaning and autogenous bone grafting.Length of bone lengthening was 2.5-11.0 cm (mean, 4.5 cm). After bone healing, shortening of the lower limb compared to the normal side was less than 2.5 cm in 36 cases, 2.5-3.0 cm in 4 cases, and 3.0-4.5 cm in 2 cases. Eight cases were detected with pin-tract infection, but healed by drainage or replacement of external fixation pins. There was no further bone infection. Three cases had loosening of external fixation pin and the pins were replaced. Conclusion Ilizarov bone lengthening and bone transport technique have advantages in the treatment of chronic posttraumatic osteomyelitis of lower-extremity long bones, but postoperative active rehabilitation and close observation are needed to prevent complications of joint dysfunctions, pin tract infection and pin loosening. Key words: Osteomyelitis; Ilizarov technique; Bone transport

Category: Ankle; Other Introduction/Purpose: In the context of chronic osteomyelitis following an ankle fracture, limb salvage through treatment—ideally including infection eradication—can be an alternative to amputation. Tibiotalocalcaneal arthrodesis is perhaps the most popular procedure, widely familiar among surgeons. When performing fusion in osteomyelitis patients, external fixation is more commonly used, although there is some experience with internal fixation systems. In this study, we conducted a retrospective evaluation of three groups of consecutively treated patients undergoing tibiotalocalcaneal fusion using either circular or monoplanar external fixation or an endomedullary nail coated with antibiotic-loaded cement. Our objective was to assess the success of each procedure in terms of consolidation, infection remission, and improvement in the quality of life. Methods: A multicenter, retrospective, descriptive study of 17 patients treated with tibiotalocalcaneal fusion, divided into three groups based on the treatment performed: Group A used a retrograde endomedullary nail coated with Polymethylmethacrylate (PMMA) with antibiotic, Group B used a monoplanar LRS (Limb Reconstruction System) external fixator, and Group C used a circular external fixator; all with a minimum follow-up of 12 months. Quality and the percentage of consolidation were evaluated through tomography. Additionally, the SF-12 form was administered to assess the quality of life at the last follow-up visit. Results: 17 patients were evaluated. Group A: 6 patients stabilized with a coated nail. Average tibiotalar and subtalar consolidation rates were 66.24% and 67.06%. One patient did not achieve infection healing. SF-12 scores averaged 40 for physical and 48.13 for mental. Group B: 5 patients with an LRS fixator; 3 active smokers. Average tibiotalar and subtalar consolidation rates were 52.78% and 62.3%, respectively. All patients achieved infection remission. SF-12 scores averaged 46.7 for physical and 51.3 for mental. Group C: 6 patients stabilized with a circular external fixator; 1 diabetic and 3 were smokers. Average tibiotalar and subtalar consolidation rates were 65.9% and 65.7%. Half experienced infection recurrence. SF-12 scores averaged 36.7 for physical and 47.8 for mental. Conclusion: Patients with retrograde nails coated with PMMA and antibiotics exhibit higher consolidation rates than the rest; however, patients with circular external fixation had a higher infection recurrence rate. Establishing generalizable treatment algorithms for these patients remains challenging, but our data suggest a favorable trend toward the use of internal endomedullary fixation coated with PMMA.

ABSTRACTBACKGROUND:Complex tibial plateau fractures present significant challenges due to severe articular comminution and soft tissue complications. There is still no consensus in the current literature regarding the optimal treatment for these fractures. This study aims to evaluate the clinical and radiological outcomes of complex tibial plateau fractures treated with Ilizarov external fixation with or without minimal internal fixation.METHODS:This retrospective study analyzed 62 patients with Schatzker type V or VI tibial plateau fractures, with a minimum follow-up duration of three years. Patients were divided into two groups: one treated with circular external fixation (Ilizarov method) combined with minimal internal fixation and the other treated with circular external fixation alone. Clinical, functional, and radiological outcomes were assessed, including knee range of motion (ROM), Knee Society Score (KSS), Kujala Score, and Visual Analog Scale (VAS) score.RESULTS:At the latest follow-up, Group 1 demonstrated better functional and clinical outcomes compared to Group 2. The mean knee range of motion in Group 1 was 116.56° versus 97.83° in Group 2 (p<0.05). Group 1 also had higher KSS scores (92.43 vs. 79.06) and Kujala Scores (94.75 vs. 90.6) and lower VAS scores (1.13 vs. 3.33) (all p<0.05). Flexion contracture and extension lag were significantly less prevalent in Group 1, with fewer cases and lower severity. Circular external fixators were removed earlier in Group 1 (120.43 days) compared to Group 2 (157.06 days) (p<0.05), with a lower incidence of delayed union in Group 1. Varus malalignment was also less frequent and less severe in Group 1. No major complications, such as neurovascular injuries, septic nonunion, or deep venous thrombosis, were reported in either group. Both groups exhibited similar rates of minor complications, primarily pin tract infections, which resolved with appropriate treatment.CONCLUSION:Ilizarov external fixation, with or without minimal internal fixation, is an effective treatment method for complex tibial plateau fractures. However, patients in whom the joint was anatomically reduced demonstrated better anatomical reduction, improved range of motion, earlier weight-bearing, and enhanced functional recovery, highlighting the superiority of this approach. These findings support the recommendation of this combined technique as the preferred treatment for such challenging fractures.

The remote-controlled, motorized, intramedullary lengthening nail is a disruptive technology that has fundamentally changed the approach to limb lengthening and reconstruction surgery globally. This new paradigm for limb reconstruction, marked by a decreased need for external fixation, has ignited a fervor among limb deformity surgeons. Although the origins of the Ilizarov method of distraction osteogenesis are deeply entwined with circular external fixation, the disadvantages of external fixators are well known and include pin track infections, skin pain, soft-tissue tethering, and joint stiffness. Integrated fixation techniques were developed combining internal and external fixation such as lengthening over a nail, lengthening and then nailing, lengthening and then plating, and bone transport over a nail to minimize the treatment time in external fixation. Building on these incremental advances, bone lengthening with a fully implantable device has enabled us to entirely avoid external fixation in most cases. Early designs of the internal lengthening nail (ILN) were telescopic and lengthened through a ratchet mechanism requiring mechanical rotation of the limb. Issues with mechanical integrity and accurate control of distraction by these implants have vastly improved over the last decade with the latest remote-controlled ILN delivering a predictable outcome. The remote-controlled ILN is available in different nail types with varied mechanics, material properties, and surgical indications. One design employs an electric motor imbedded into the telescopic rod, activated by intermittent transcutaneous transmission of radiofrequency waves to an implanted antennae/receiver which converts these waves into an electrical impulse discharged via a connecting cable. The second design, now most widely used in the United States, is a telescopic rod with a magnetic drive mechanism, activated by a hand-held external electromagnetic actuator. Furthermore, in addition to the functional mechanism differences, there are nails made from titanium or from stainless steel, and these have different biomechanical properties. The indications range by bone and nail orientation. The femur can be approached antegrade through a piriformis or greater trochanteric entry or can be entered retrograde. A short residual femur after amputation can be lengthened with a specially designed nail. The tibia is approached antegrade. Although the ILNs are primarily used for distraction osteogenesis bone lengthening, the magnetic ILN can also be used for compression of nonunions. In the last several years, there has been some experience with bone transport nails but recently, a motorized magnetic bone transport nail for treatment of segmental bone defects up to 10 cm has been launched, and the early experience is currently being accumulated. Creative, off-label uses of the commercially available nails have included humerus lengthening, retrograde tibia through an ankle/subtalar arthrodesis, extramedullary lengthening with a nail, and bone transport over a plate. Additional internal lengthening designs are in development including humerus nails, ankle fusion/retrograde tibia nails, and internal lengthening plates. In the absence of angular deformity, lengthening of a long bone with the ILN is an ideal surgical indication. Rotation may be corrected over the nail. Blocking screws may be needed to prevent predictable deformities that occur during lengthening. In the presence of preoperative angular deformity, adjuvant techniques such as fixator assisted nailing and blocking screws may be utilized in many, but not all cases, to acutely correct deformity and then gradually lengthen with the ILN. With increased periosteal disruption, latency and distraction may need to be modified. In addition, a staged approach may be used where deformity correction is performed and then at a second surgery, lengthening with the ILN is done. Furthermore, a bifocal approach may be used where deformity correction is performed at one end of the bone and lengthening with the ILN is done at the other end of the bone. The ILNs have created excitement among surgeons from separate sub specialties and diverse nationalities. Both pediatric and adult patients share common pathologies that require bone lengthening and deformity correction including congenital and posttraumatic deformity and leg length discrepancy. These pathologies have inspired global collaboration between orthopedists trained in pediatrics, trauma, foot and ankle, oncology, sports, knee/hip reconstruction, or limb deformity. Through annual meetings and a common body of literature, we all come together to teach and learn from each other. The motorized ILN is an ingenious technology has encouraged us to build new paradigms for limb reconstruction surgery. Although there is continued need for external fixation in selected cases, the modern limb deformity surgeon will use the ILN when possible. The ILN is, however, not available yet in many developing countries. In this edition of Techniques in Orthopedics, dedicated to internal limb lengthening, we have gathered an international panel of experts to discuss specialized applications of this most recent evolution of the Ilizarov method.

Aim: planned to assess bone and functional outcome of Ilizarov's circular external fixator in treatment of femoral and tibial nonunion (infected and noninfected both). Material and methods: The present study is clinical prospective type of study conducted at Dr Hardas Singh Orthopaedic Hospital & Superspeciality Research Centre, Amritsar, Punjab. The present study included 15 cases, all managed with Ilizarov circular external fixator for isolated femoral or tibial nonunion after obtaining informed consent, clinical and radiological examination during a period of 24 months. After removal of frame, patient followed up regularly every month and we assessed them for bony and functional outcome. Results: The age of patients in present study was 22 to 55 years with mean age of 39.4 years. There were 3 (20%) femoral and 12 (80%) tibial nonunions that were operated with Ilizarov’s circular external fixator using ilizarov method’s. Road traffic accidents were the most common mode of injury accounting for 11 cases (73.3%). Fourteen patients had undergone fixation previously (plate osteosynthesis = 7, external fixators of the AO tubular type = 7) and one patient had been treated by traditional bonesetter bandages. According to ASAMI guidelines, bone outcome was excellent in 7 cases (46.6%), good in 5 cases (33.3%), fair in 2 (13.3%) cases and poor in 1 case (6.7%). Functional outcome was excellent in 3 cases (20%), good in 11 cases (73.3%), fair in no case and poor in 1 case (6.7%). But no patient required amputation. Conclusion: Ilizarov technique using circular external fixator is a good salvage operation for infected and noninfected nonunion of the femur and tibia both. Functional results can be improved by the early use of the Ilizarov technique.

Objective To evaluate the efficacy of acute angular shortening and delayed distraction histogenesis with an external fixator in the treatment of crural composite tissue defects. Methods From May 2009 to August 2014, 6 patients with crural composite tissue defects were treated by acute angular shortening and delayed gradual distraction histiogenesis with an external fixator. They were 5 men and one woman, from 23 to 65 years of age (average, 38.8 years). According to the Gustilo classification, 2 cases were graded as type Ⅲ A and 4 as type ⅢB. Four of them received primary treatment at our department while the other 2 were transferred to our hospital after primary management in other hospitals. Radical debridement was rapidly performed once life threatening factors were eliminated. The lower limbs were maximally bended to close the skin defects. The wounds were closed directly in 4 cases; the remnant wounds in the other 2 cases were cured by daily dressing in one and covered by skin graft in the other. Next, about 2 to 3 weeks after complete wound healing the pre-constructed circular fixators were mounted to the bended cms before they were adjusted to correct angulation deformity and reconstruct bone defects. Results All the wounds in the 6 cases healed successfully without additional microsurgical transfer of osteocutaneous flap. The regenerative skin tissue was similar to the skin in situ. The follow-ups ranged from 8 to 24 months (mean, 16.8 months). The average length of lengthened tibia was 8.0 cm and the time for Ilizarov external fixation ranged from 10 to 25 months (mean, 17.3 months). The average bone lengthening index was 2.3 months/cm. The limb functional recovery was rated as excellent in 2 cases and good in 4. The radiography revealed complete reconstruction of bone defects and restoration of mechanical alignments in all the cases. No disability was recorded during follow-up. Conclusions Acute angular shortening and delayed distraction histogenesis with an external fixator is a very effective treatment of crural bone and soft tissue defects. It can provide rapid management of acute or subacute open injury because it does not necessitate microsurgical flap transfer or bone graft, thus avoiding donor site morbidity. Key words: Fractures, open; External fixators; Bone lengthening; Ilizarov technique

Circular External Fixation for Treatment of Distal Humerus Fractures: Case Report

After surgical treatment of Charcot neuro-osteoarthropathy (CNO) complicated by plantar ulcer and midtarsal osteomyelitis, offloading is mandatory to protect the surgical site. Total contact casting is, to date, the standard-of-care to offload the foot during the postoperative period. We have compared the application of external circular fixator, to the standard of care, with regard to surgical wound healing and time to healing. During the time period from January 2020 to December 2021, 71 consecutive patients admitted to our unit with diabetes and CNO complicated by plantar ulceration and midtarsal osteomyelitis were enrolled in our study. All patients were classified as stage 2, according to the Frykberg & Sanders classification. Wifi wound stage was W2 I0 FI2 in 43 of 71 patients (60.6%) and W2 I2 FI2 in 28 of 71 patients (39.4%). In cases where critical limb ischemia occurred, we performed an endovascular procedure to obtain patency in at least one of the tibial arteries. Localization of osteomyelitis was carried out with magnetic resonance imaging studies, and the degree of deformity was assessed using plain X-ray or computed tomography. A localized ostectomy through the ulceration was carried out with a fasciocutaneous flap to cover the surgical site. In 36 patients, an external circular fixator was applied intraoperatively (exfix+ group); the remaining 35 patients received fiberglass cast in the postoperative period (exfix- group). Complete healing of the surgical site was achieved in 36 of 36 patients in the exfix+ arm and in 22 of 35 in the exfix- arm (P < .02). Time to healing was 68 ± 28 days in exfix+ and 102 ± 88 days in exfix- (P = .05). Circular external frames should be considered as an effective offloading device that enhances the healing rate and reduces time to healing after surgical treatment of midfoot osteomyelitis in subjects affected by CNO.

Despite the widespread use of the Ponseti method for treatment of clubfeet, there continue to be a significant number of patients who present with a severe, stiff clubfoot as a result of extensive intra-articular soft tissue release or lack of access to care. In such patients, circular external fixators can be utilized for deformity correction with distraction across soft tissues, joints, and osteotomies. Ilizarov or hexapod circular fixators may be utilized according to surgeon preference. Indications for soft tissue release and osteotomies to aid in correction of clubfoot deformity with Ilizarov and hexapod fixators are not standardized and are guided by patient age, joint congruity, soft tissue suppleness, and osseous deformity. Correction time varies according to clubfoot deformity severity. Following deformity correction, external fixators are left in place for several weeks to stabilize the soft tissues and allow for osteotomy healing. Complications range from relatively minor pin tract infections that resolve with oral antibiotics to tarsal tunnel syndrome, osteomyelitis, or disabling arthritis requiring revision procedures. At Scottish Rite Hospital for Children, we prefer to correct severe residual clubfoot deformity with a hexapod external fixator. Acute correction and gradual correction via distraction are considered for each segmental deformity and utilized to efficiently correct deformity while minimizing soft tissue trauma. The purpose of this article is to summarize the relevant literature related to circular external fixator treatment of recurrent clubfoot deformity and outline our approach to the segmental deformities of the foot and ankle in this patient population.