The use of articulated external fixation for complex elbow trauma treatment.

INTRODUCTION: We use external elbow joint fixator (FE-F4) for fracture and dislocation of the ulnohumeral joint to evaluate the early articular mobilization maintaining concentric reduction, protecting the osteoligamentous reconstruction and avoiding postoperative stiffness. MATERIALS AND METHODS: Thirty-two patients (13 men and 19 women) were treated with FE-F4: 7 simple dislocations (21.9%), 15 distal humerus fractures (46.9%), 4 fractures and dislocations of which 1 terrible triad (12.5%), and 6 complex dislocations (18.7%). The mean age was 64 years. The average follow-up (FU) was 47 months. We evaluated the flexion-extension and prone-supination movement arc, VAS (Visual Analogue Scale), Quick DASH (Disability of the Arm, Shoulder and Hand score), MEPI (Mayo Elbow Performance Index) and the Broberg and Morrey rating system. RESULTS: The average ROM was 125.9° for flexion-extension, 77.8° for pronation and 79.7° for supination. The average VAS was 0.56 at the FU, the MEPI score of 93.6, the Broberg and Morrey rating system of 92.4 and the Quick DASH of 8.7. No major complications were found after surgery, and no objective or subjective posterolateral or medial joint instability was found. No patients at the FU had a new surgery with arthromyolysis or elbow arthroplasty. DISCUSSION: The elbow joint stiffness is the main cause of functional inability for the patient suffering from posttraumatic outcomes. The FE-F4 allows an early mobilization, even in case of injuries or complex reconstructions, keeping the joint stable and protecting any bone synthesis and the damaged capsule-ligament structures. LEVELS OF EVIDENCE: IV.

Treatment of 103 displaced tibial diaphyseal fractures with a radiolucent unilateral external fixator.

OBJECTIVE: The authors report their experience in the treatment of the diaphyseal tibial fractures, using the unilateral radiolucent External Fixator (EF) XCaliber. DESIGN: A total of 100 patients (average age 35 years, range 16-76) with 103 displaced diaphyseal tibial fractures were treated with the XCaliber. There were 59 type A fractures, 35 type B, and 9 type C (according to the AO classification) and 35 were open fractures. MAIN OUTCOME MEASUREMENTS: During the last assessment, patients were evaluated for level of pain, ability to perform weight-bearing activities, and number of residual deformities. RESULTS: The average follow-up time was 24 months, 3 patients (4 fractures) were excluded for final assessment and 1 patient moved abroad. Of the remaining 98 fractures, 83 (84.7%) healed with a single operation in a mean 21 weeks (SD 3.97; 12-38 weeks), 10 fractures had a delayed union and 5 fractures proceeded to a non-union. There were 13 complications. Among them, a loss of reduction was observed in 3 cases due to overload of the EF, in 3 cases, deep pin track infections were observed and 2 fractures healed with more than 1 cm of shortening. CONCLUSIONS: The results are encouraging, since both complex and open fractures were included in this study. The XCaliber was shown to be a valid unilateral external fixator, combining the advantage of radiolucency during application and radioscopic follow-up with a stable and flexible fracture fixation. This represents the first report in the literature specifically examining treatment of tibial diaphyseal fractures with a radiolucent external fixator.

Internal femoral osteosynthesis after external fixation in multiple-trauma patients.

In this study the authors evaluate the results of internal synthesis of femoral fractures in polytraumatised patients initially treated by external fixation (EF). From January 2002 to December 2005, 39 femurs in 37 polytraumatised patients (average age 34.2 years, range 18-44) with closed fractures and an ISS>20 were initially treated with EF. There were three groups: Group A, 13 cases when conversion to internal osteosynthesis occurred after 4-7 days (average 5.6 days); Group B, 11 cases with a 4-6-month interval before internal osteosynthesis, and after investigation using MRI and scintigraphy with labelled leucocytes; Group C, the remaining cases treated definitively with EF. Time of healing, lower limb function, time of return to previous activities and short and long-term complications were evaluated at the follow-up. The average time of follow-up was 23 months. In Group A the time of bone healing was 123 days; there were no events of embolism but one case of pseudoarthrosis and one case of instrument failure. In Group B the time of bone healing was 274 days, with one case of pseudoarthrosis and one case of deep infection. In Group C the average healing time was 193 days, with 3 cases of screw (half-pin) osteolysis. Functional recovery was delayed by the presence of other fractures. EF is a simple, quick and safe procedure to stabilise fractures in polytraumatised patients. According to damage control orthopaedic (DCO) concepts, it is possible to replace EF with internal synthesis after an interval as this reduces the risks of internal osteosynthesis when performed in the emergency period. EF can also be maintained as definitive treatment but should a change to internal synthesis be needed, it is possible to do it safely after excluding bone infection.

External fixation for displaced intra-articular fractures of the calcaneum.

A minimally-invasive procedure using percutaneous reduction and external fixation can be carried out for Sanders' type II, III and IV fractures of the os calcis. We have treated 54 consecutive closed displaced fractures of the calcaneum involving the articular surface in 52 patients with the Orthofix Calcaneal Mini-Fixator. Patients were followed up for a mean of 49 months (27 to 94) and assessed clinically with the Maryland Foot Score and radiologically with radiographs and CT scans, evaluated according to the Score Analysis of Verona. The clinical results at follow-up were excellent or good in 49 cases (90.7%), fair in two (3.7%) and poor in three (5.6%). The mean pre-operative Böhler's angle was 6.98 degrees (5.95 degrees to 19.86 degrees), whereas after surgery the mean value was 21.94 degrees (12.58 degrees to 31.30 degrees) (p < 0.01). Excellent results on CT scanning were demonstrated in 24 cases (44.4%), good in 25 (46.3%), fair in three (5.6%) and poor in two (3.7%). Transient local osteoporosis was observed in ten patients (18.5%), superficial pin track infection in three (5.6%), and three patients (5.6%) showed thalamic displacement following unadvised early weight-bearing. The clinical results appear to be comparable with those obtainable with open reduction and internal fixation, with the advantages of reduced risk using a minimally-invasive technique.