Sl

External fixation using simple pin fixators

A.A.FemBndez Dell’Oca, M.D. British Hospital Montevideo, Uruguay

might not be stable enough to withstand the high stresses often involved in the situations in which we use them.

Introduction We would like to present ten years of experience using simple pin fiiators, having applied more than 1000 external frames in this time. During the first five years, the majority of frames used were of type I (for classification, see below); in the last five years, the frames used were mostly modular which means they were assembled using to create standard components a multiplicity of configurations. We shall refer both to fracture cases and to reconstructive procedures. The majority of external fixator systems currently available require a number of different elements of different sizes to cope with the multiplicity of external fixation indications. A large inventory of instruments and implants must be available. Often complex frames must be used. The whole frame must be assembled as part of the preoperative planning to ensure that there are no missing components and that the length of the operation will be kept to a minimum. For our procedures, this was not the case. Instead, we have stuck to Prof. Allgijwer’s adage: “simplicity is the rule of the game”. We have only used two sizes (large and small), a few simple frames and a very simple insertion technique to perform all our operations. The operation time for these frames is almost always less than 20 minutes and often less than 10 minutes. Our approach to the subject of external fixation may not be exactly the classic one and we do not claim to be right or wrong, but we wish to report our experience and present it as a basis for discussion. , Note: The simple pin fixators we used were all original Swiss AO/ASlF implants and instruments in every case. As a large fixator: As a small fixator:

the AO-tubular system the A0 small fixator

Carbon fibre rods were only used for type IA and type IB frames. Modular frames were always constructed using stainless steel tubes. It is our opinion that modular frames constructed using the currently available carbon fibre rods

Should we choose external or internal fixation ? What are the respective advantages and disadvantages of these two bone fixation systems ? - Advantages Some recent papers have stressed the importance of the preservation of bone vascularity: low contact plating (Perren et al., 1990), and bio-logical plating (Mast et al., 1989; Ganz et al., 1991). External fixation is the least harmful fixation system currently available in respect to bone vascular@. This is true providing that atraumatic bone reduction techniques are used and it requires a system adapted to all fracture types (Burny, 197’8) (see chapter 2). The main advantages of a system which does not disturb bone vascularity have been shown to be that no necrotic layer of bone close to the implant should occur, healing is stronger and quicker, and the risk of infection is lower. Since it causes almost no vascular disturbance when using atraumatic techniques and since there are almost no implants inside the body (only the tips of the Schanz screws), external fixation has always been recognised as a very good bone fixation system especially when there is a high risk of infection or when infection is already present (Mears, 1983). The main advantages infection are:

of external

fixation

in terms

of

-

there is less risk that an infection will develop

-

if an infection occurs, the situation is always much better when working with an external fixator than with any of the internal fixation devices

These are the reasons why external fixation has been used for a long time in the treatment of open fractures and infected pseudarthrosis. In our experience, the risk of infection seems to be lower when using external fixation in the treatment of closed fractures and osteotomies after closed or minimally open reduction than when performing open reduction and

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internal fixation. This lower infection risk is particularly important when operations must be carried out in theatres which are far from ideal and under circumstances in which aggressive surgery and classical internal fixation procedures may be highly susceptible to infection. A further advantage of external fixation is that the set of instruments and implants required is much smaller than that required to perform nailing or plating with screw fixation. This calls for a significantly lower financial investment. The range of indications for external fixation is very wide and the modular system has an even broader range of indications than standard nailing, even broader than locked nailing. When the fracture line lies close to the bone ends, fixation may be out of the reach of locked nailing but it may still be possible to insert a couple of Schanz screws into the remaining, small fragment (Fig. 1).

be plated, it can still be fixed with the modular external fixator. A system which allows us to manage a very wide spectrum of fractures and requiring a much lower financial investment may be a definite advantage in some situations (see chapters 11 and 12). - Disadvantages The disadvantages of external fixation as compared with internal fixation are mainly related to the insertion of pins which enter the bone from the outside through the skin and to a lack of stiffness which prohibits early, painless mobilisation. The insertion of external fixator pins risks injury to vessels and nerves and the impalement of muscles and tendons. This risk is lower when only Schanz screws are used instead of transfixion pins. It is even lower if a system is used which permits total freedom of pin placement. However, some bones are hard to reach from the skin because they lie deep to the muscles and are surrounded by tendons, nerves and vessels, e.g. the proximal radius or the femur. External fixators using pins which penetrate the skin and muscles certainly restrict painless joint movement in the postoperative period. This disadvantage is not so apparent when using fixators on more superficial bones, such as the tibia and ulna.

Fig. 1: a: A proximal tibia1 fracture can be fixed by means of locked nailing. b: Even if the fracture is too high to be nailed, it can still be fixed with the modular external fiator. The range of indications for external fixation may even be wider than for plates and screws. Severely comminuted epiphyseal fractures may not be easy to fix with plates and screws but may be managed by ligamentotaxis using external fixation (Iakob and Femandez, 1982) (Fig. 2).

Pin track complications such as infection and pin loosening are often seen with external fixation, whereas they are not present when using internal fixation. They are a clear disadvantage to the use of the external fixator. We hope that a new screw design will reduce the rate of pm track infection in the future, but at present these factors can be a problem, especially in long-term placement. These pin track complications may force the surgeon to replace the pins and the use of simple pin fiiators for which pin replacement is easy, is then a definite advantage. Taking the above-mentioned advantages and disadvantages into account as well as the special features of the patient and hi environment, we will choose the most appropriate of the two systems.

2. Classificationof extmal fixatorsand frames We differentiate between ring fixators and pin fixators. Amongst the pin fixatom, we differentiate between simple pin fixators and modular pin fixators (Fig. 3). Simple pin fixators are those with more freedom of pm placement, but which lack bone reduction possibilities. Modular pin fiiators are those with total bone reduction possibilities, but which lack freedom of pin placement (Behrens, 1982). With the simple pin fixator, we can construct the following different types of frames: Type I:

Unilateral frames IA: unilateral uniplanar frames IB: unilateral biplanar frames

Type II:

Bilateral frames

Type III:

Bilateral 3D frames (Fig. 4) (Hierholzer 1985).

A Fig. 2: a: A distal radial fracture with three fragments can be plated. b: Even when the fracture is too comminuted to

et al.,

Femiindez:

s3

Simple pin fixa ton

Type IB frames, unilateral biplanar frames

*Kin): I;inators. (A)

Fig. 3: Classification

of external fixators

These are the most stable of the unilateral frames and well-suited to the treatment of tibia1 fractures since this is the only bone with more than 90” of its surface covered only by skin. This means that we can insert the Schanz screws at many angles without going through muscles, tendons, nerves or vessels. This is a very elegant way to achieve an extremely stable fixation of the tibia whilst retaining great freedom of pin placement. We tend to choose this frame when we foresee a long period of external fixation or when there is bone loss or severe soft tissue damage. There is reasonable scope for reduction using this frame as long as only two pins are inserted into each main fragment (we refer to this as the “plastic stage” of the unilateral biplanar frame). The frame is quite stable and can be left like this for some days. Once the X-rays show that bone reduction is correct, the fifth and sixth screws can be added (the third screw in each of the main fragments). Once these screws have been inserted the frame is complete and bone reduction cannot be improved. There is then -

a first stage fixation and malalignment

with only four screws, the freedom to correct

a fairly stable any reduction

-

a second stage with six screws completing the frame and no further freedom to correct bone reduction (Fig. 6).

Modular frames There is another type of frame which has not been included in this classification, namely the modular frame erected using simple pm fixators (Femfindez, 1989).

Fig. 4: a: Type IA, unilateral uniplanar frame (Behrens’ frame); b: Type IB, unilateral biplanar frame; c: Type II, bilateral frame; d: Type III, bilateral biplanar frame. We only use type II and type III frames for ankle and knee arthrodesis. In all other situations, we prefer to use frames without Steinmann transfiiion pins. We use frames erected using only Schanz screws. We will be talking mainly about type I unilateral frames, TypeIAfmmes,unilateraluniplanarfmmes(B&mns’ frame) This is a very simple, fairly stable frame, well-suited to the treatment of open fractures when there is little comminution of the bone and where we can be sure that the bone reduction achieved at operation will be perfect. There is freedom of pm placement but there is almost no possibility of improving reduction alignment after frame completion. We will demonstrate the use of these frames mainly on special cases of open fracture, limb lengthening, bone transport and correction osteotomy (Behrens et al., 1983) (Fig. 5).

If we use a short tube as a clamp to handle each of the main fragments, we have a modular concept - a modular fixator erected using a simple pin fixator. In this way, freedom of pin placement of the simple pm fiiators is retained, combined with all the bone reduction possibiities of the modular frames: the best of both worlds. We began experimenting with this idea in 1987 after developing a new clamp, a tube-to-tube clamp, which was not available as a standard item for the simple pin fiiators for large bones at that time but necessary for the construction of modular frames. After operating on more than 500 cases using this system, we have found that we can rely on its total freedom of pin placement and its bone reduction possibilities. However, we have also learnt that these frames are so stable in their most simple configuration (just three tubes and four pins) that we can trust them to cope with even the most challenging situations in clinical practice (femoral fractures or hip arthrodesis in adults, for example) (Fig. 7).

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Fig. 5: Insertion technique for type IA frames. a: First two Schanz screws are Inserted. b: One tube and four simple clamps are attached. c: At this stage, correction of reduction is still ossible but the fixation is not yet stable. d: The frame is completed. Fixation is stable. rs o further correction is possible.

Fi . 6: Insertion technique for a Type IB frame. a: %irst four pins are inserted, b: The frame is built, including the empty clamps to take the remaining screws which will be inserted later on. At this “plastic stage” (4 pin frame) there is stable fixation; c: At this stage reduction corrections, except rotational ones, are easy to perform; d: After insertion of the two remaining screws, the frame is complete. Stiff fixation has been achieved. No further alterations are possible.

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Femiindez: Simple pin fixatoxs

Fig. 7: Modular technique. a: Total freedom of pin placement b: The “handles” have been inserted. c: After use of the handles to reduce the fracture bone forceps required), the frame is completed. d: Example of an upper tibia1 fracture.

(no

It has been exciting to see the effect of this modular fiiation concept on the evolution of the external fixation techniques we use to treat distal radial fractures. Our wrist fracture cases treated before 1986 using the small simple pin fiiators (everything needed to build modular frames was already in the set) were all fixed with type I frames. Once the modular concept had been fully developed for the large simple pin fiiators (1986), all our wrist fracture cases were fixed using modular frames. It is not only essential to have a good new clamp (which was already there in the small external fiiator set) but also a modular concept Just think modular ! With modular we achieve:

external

fixation using simple pin fiiators

1.

Total freedom of pm placement. There are no limitations as to where the pins can be inserted in each of the main bone fragments.

2.

Total bone important fixation of of a closed

reduction possibilities. This is a particularly feature for atraumatic insertion in the open fractures and when external fixation fracture is required (Fig. 8) @my, 1978).

Fig. 8: Total bone reduction possibiities versus restricted zones. Most of the unilateral fixatom allow us some restricted bone reduction. a and b: Demonstrations of bone reduction possibiities of unilateral systems are usually made after the frame has been mounted on an intact model bone before the bone has been cut. c: Minor rotational corrections can be made when using some unilateral fixators. d: Reduction possibilities of these unilateral fixators are restricted to within a 3D path. If we start from x, we will be able to reach any point within the path (y for example), but we will be unable to reach z. As long as we start from a frame mounted on a reduced bone, we will be able to enjoy all the reduction possibiities of the system in the workshop and be able to return to our starting position, namely the reduced bone. e: If we start from a frame mounted over an unreduced fracture (this is the main difference between the OR and the demonstration room), it is highly likely that we will be unable to correct malalignment.

56

A system with path restricted bone reduction prevents easy insertion with atraumatic easy handling

insertion techniques

of closed fractures

finding the ideal position for joint fixation 3.

Stable fixation with the most simple frame (three tubes and four pins) with which fractures of all the long bones can be fixed and every one of the major joints of the body bridged.

4.

A frame which is easy to convert to a sliding frame.

5.

A single clamp frame which means that pins can easily be added or replaced as necessary with absolutely no loss of fixation. There are clip on clamps available through which new screws can be added. There is no need to loosen the clamp causing momentary loss of fixation, as is the case with conventional modular systems.

6.

As with conventional modular pm systems, the possibility of treating a multiple stage injury (two level fracture, or fracture and adjacent joint injury, for example) (Fig. 9).

7.

As a modular system, one of the modules can be a lengthening module which is a useful feature when performing complex combined procedures (Fig. 10, see also Fig. 36).

Fig. 10: When required, one of the modules can be a limb lengthening module. The idea of a modular system using simple pm fixatom is a very old idea. It is none other than the Roger Anderson system. What we feel the new idea is: -

being able to use elementary units to build the same simple frame and retaining maximum freedom of pin placement and total bone reduction possibilities.

-

having components which are strong enough to maintain stability even in high stress situations by application of the simplest frame without having to resort to complex “meccano” frames (Fig. 11).

3.

Biomehanical analysisof extemalfixationframes

A.Femsndez,

E.Deri, JLantero,

B.Melissari

A great deal has been written about the biomechanics of external fixation and a lot has changed in this area over the last few years. Disturbance of bone healing due to a too rigid external fiiator has often been reported but not often demonstrated (Mears, 1983). Many of the reports of high rates of delayed healing can probably be put down to vascular disturbance due to the trauma itself rather than to the stiffness of the frame. In most investigative series, external fixation was used to treat severe open fractures. A high rate of delayed healing is not surprising in these fractures because the trauma itself causes massive vascular damage (Mears, 1983). In a series in which external fixation was used to treat closed fractures, the healing rates were quite good and certainly comparable to those achieved by any other therapeutic protocol (Burny, 1978). Thus, it seems logical to ask whether delayed healing associated with the use of external fixation is due more to vascular damage to the bone than to excessive stiffness of the external fixator frame (Mears, 1983).

Fig. 9: Three modules can be used to fix a two level fracture, or a fracture and an adjacent joint; use even more than three if required and retain total reduction possibilities for each fracture focus/joint.

Recent work by Pen-en et al. has shown that most of the adverse effects on bone healing usually attributed to too rigid a fixation may be caused mainly by a disturbed blood supply to the bone under the plate. This work has shown rapid and sound healing even with very stiff internal fixation when there is no vascular disturbance, for example, when using limited contact plates (Pen-en et al., 1990, Perren, 1992). The external fixator is probably one of the fixation systems which causes relatively little vascular disturbance, provided atraumatic techniques are used, as was reported by Burny almost ten years ago. Atraumatic procedures rely upon the availability of total reduction apparatus.

Fern&&z:

Simple pi” ha tots

Fig. 11: 26-year-old man. Open proximal humeral fracture which was fixed in casualty using a Behrens’ frame. a: Poor reduction. b: Patient’s aspect was striking the fracture was wrongly fixed in a marked internal rotation deformity. The frame was removed and a modular frame inserted. c: We made use of the modular frame pin placement for freedom to insert the screws in the optimal place. Bone reduction possibilities allowed us to manipulate the limb to achieve good reduction. The Behrens’ frame can only be used when we are certain that reduction is very good. If this is not the case, it is very difficult to improve it later. This is why we chose a modular frame in this case. On the same subject, Ganz and Mast have presented marvellous results achieved by using bio-logical techniques (internal fixation with maximum respect for bone vascularity) (Mast et al., 1989; Ganz et al., 1991). Whatistherealimportanceofframesbffness?

-

In femur, hip, shoulder and knee fractures in adult patients optimal stiffness is a difficult target to reach. In the past, complex “meccano” frames were often used in order to fix the bone externally in these high stress areas.

-

This is not the case in the upper limb, tibia and ankle, or in external fixation in children. The frames currently available can easily achieve the minimum required stiffness in these areas.

Frame stiffness How stiff does an external fixator frame have to be ? This is still an open question and we feel that something really quite clear is often misunderstood: Weneedaframestiffenoughtocontrolpain,tostimulate soft tissue healing and to control infection in open fractures. The minimum stiffness required to avoid frame failure and total reduction loss is not always easy to achieve (Fig. 12).

c

It seems clear that we need a frame stable enough to avoid failure and to control pain in the early stages of treatment.

Should we leave the external fixator in situ until bone healing or should we let the frame slide to encourage bone healing ? Should we pmgressively dismantle the frame before total removal of the fiiator or should we switch to an internal fixation device after a while ? These are not easy questions and there will not be one valid answer to cover every situation (see chapters 6 and 7). How stiff are the external fixator frames which are currently on the market ? How can we interpret the laboratory test results on external fixator frame stiffness ?

Fig. 12: Frame failure. If the fmme is not stiff enough, will fail and total reduction may be lost.

it

Over the last 10 years, we have performed multiplanar tests on different external fixator frames in the lab, trying to avoid machine induced stiffness (built-in stiffness) and to apply stresses similar to those seen in clinical practice (in limbs externally fixed as opposed to levels during normal gait). Our results show:

-

It is possible to construct very stiff frames Schanz screws and avoiding transfixion pins. Since 1982, we have only used type III frames for ankle and knee arthrodesis 1985).

using only Steinmann II and type (Ferngndez,

-

The increase in the overall stiffness of unilateral uniplanar frames type IA (Behrens’ frame) achieved by the addition of a second longitudinal tube is usually lower than 5 %. Experience in the operating room and workshop trials have shown that double stacked longitudinal type IA frames are extremely difficult to insert. For this reason, we strongly advise against the use of two longitudinal tubes on unilateral type IA frames (Behrens’ frames).

-

The stiffness of a unilateral biplanar frame type IB in the “plastic stage” (two pins in each plane) is markedly lower than the stiffness of a type IA frame (Behrens’ frame)

-

The stiffness of a three-tube frame (modular frame) erected using simple pin fixatom (when four pins are inserted in the same plane) is similar to the stiffness of a type IA frame (Behrens’ frame).

We analysed the mechanical behaviour of different external fiiators under physiological loading, trying to avoid built-in stiffness from the testing machine itself. Striking differences were found between the mechanical behaviour patterns of the different limb lengthening devices, although similar bone regeneration results have been reported for all of them. We do not know the real effect of the me&an&l properties of a limb lengthening device on bone IegenemtiorL

4.

The type of fracture, i.e. whether it is an isolated injury or one of multiple injuries, where and when this patient must be treated, the training of the surgeon and the techniques available at that particular time and place will determine which is the best therapeutic approach for this patient at this time and in this place.

5. Modular&mnal thAion: Specialcase open fractures Third degree open tibial fractures are a classic indication for external fixation although unreamed nailing is rapidly infiltmting this area as the treatment of choice (Holbrook et al., 1989). Extensive personal experience using external fixation on open fractures has shown that this procedure is very gentle to the bone, the atraumatic reduction technique is simple and straightforward to perform and perfectly suits all types of fracture. It is an expeditious procedure and easily managed by a resident with little experience. During revision surgery any necrotic bone must be removed. This can easily be done even if one screw has been inserted into dead bone. It is very simple to replace this screw and remove the dead bone with the screw inserted in it It is hard for us to imagine how this could be done with ease if unreamed nailing has been the primary treatment of the fracture. We have often been forced to dismantle the whole frame during revision procedures in order to check the condition of muscles severely contused during the accident and now hidden by the reduced bone. The condition of these hidden muscles has often led to an amputation. The ability to check the hidden muscles has not uncommonly been a life-saving feature of the fiiator.

Currentindicationsfor edmnal fixation

Classic indications for external fixation are severe open fractures and infected pseudarthmses. Nowadays, there is a certain amount of pressure to move towards primary unreamed nailing even for the most severe open fractures on the one hand, and on the other hand to broaden the indications for external fixation to include many closed fractures. In our opinion, it is impossible to talk about indications for external fixation in general. The choice of external fixation as a treatment method depends not only on the type of fracture (single or polytrauma) but also on when, where and by whom this patient will be treated. It may be preferable to treat a comminuted closed femoral fracture in a polytraumatised patient by means of locked nailing, but it cannot be taken for granted that all theatres throughout the world will have access to the equipment and expertise required for locked nailing as an emergency procedure. Temporary external fixation with subsequent conversion to locked nailing as the definitive treatment may be the best option if stabilisation cannot be delayed. The alternative is to choose modular external fixation as the definitive treatment.

If primary unreamed nailing has been performed, will it be possible to check the condition of the hidden muscles or must it be assumed that their condition is good ? We are not yet entirely convinced that unreamed nailing is a good choice in the treatment of severe open third degree tibia1 fractures. The situation is completely different if we are treating third degree open fractures of the femur or upper limb. The condition of contused muscle is rarely as important here as it is in the lower leg, bone vascularity is usually better preserved and necrotic bone resection is seldom necessary during revision. Primary internal fiiation may then be the treatment of choice.

cla3edfIactuIes Classic indications for the use of external fiiation treatment of closed fractures are:

in the

-

polytrauma

-

poor skin coverage

-

as a stress shielding device to protect internal fixation

Femrindez:

s9

Simple pin fixa toxs

The indications

for modular external fixation may broaden

-

when theatre conditions

are not ideal

-

when there is an increased reason

-

when sets of internal fixation instruments implants are not available or incomplete

-

when there are no trained surgeons who the complex internal fixation techniques

risk of infection,

for any

and

Knee and ankle arthrodesis are classic indications for external fixation and we have nothing to add on this subject, but we also use the modular frame for shoulder and hip arthrodeses. In our hospital, modular external fiiation is the elective procedure to fix a shoulder or hip arthrodesis. wlistandhandsurgery For many commin uted distal radial fractures, e.g. severe hand injuries, modular frames constructed using small simple pin f&atom have led to some very rewarding results. This is a clear indication for external fixation (Jakob et al., 1982). surgery

Limb lengthening bone transport osteotomies may also be good indications tion.

and correction for external fixa-

5.1 Extemalfixationof the shoulderand humetus Modular external fixation of the shoulder and humerus makes use of total pin placement freedom to permit placement of the pins in the scapula or in a small, proximal humeral fragment when required - a task not always easy to perform using other external fixation methods. On the humerus, the abiity to insert proximal pins laterally and distal pins posteriorly is also an advantageous feature of this system. shoulder

arthrodesis

We have found modular fixation to be especially useful for performing shoulder arthrodesis. Arthrodesis of the shoulder is a complex procedure and it is essential to position the limb well. It is of utmost importance to fix the shoulder in the ideal position because the patient must be able to hold his arm next to his body when standing and be able to reach his face with his hand. This means that the position must be correct with regard to - external or internal rotation - flexion or extension - abduction.

-

We insert two or three Schanz screws into the scapula and two or three Schanz screws into the humerus.

-

After frame completion,

-

Now, we clinically check the range of motion of the limb at the level between the tip of the scapula and the thorax.

-

If it is not perfect, all we need to do is loosen two nuts, correct for external rotation or flexion or whatever is suboptimal and retighten the same two nuts.

-

The shoulder is now fixed again position ready to be tested again.

-

If it is not perfect, the whole procedure can be repeated again until we are satisfied with the range of movement.

command

Arthmdesis

Reconstnlctive

This is not an easy task There are no reliable landmarks during surgery. With the modular frame we proceed as follows:

the shoulder is fixed.

in

the

corrected

This trial and error procedure, performed on average three to four times for each patient, required only a few minutes and we were able to use this simple, unobtrusive frame to achieve stable shoulder fixation in the ideal position. This surmounts many of the difficulties associated with the final position of the fixed shoulder (Figs 13-15).

5.2 Exteml fWion of the dbow and forearm Modular external fixation has been used mainly on severe open fractures of the elbow and the forearm. Conventional pins were used in the humerus, 4.Q3.0 mm Schanz screws on the ulna, and small external fixator frames to fix forearm fractures (Figs 16 and 17).

5.3 Extemalfixationof the wrist and hand A.Femgndez,

R.Mangarelli,

R.Masliah

Initially, external fixation was used for open distal radial fractures. In the small pin fixator set we had everything required to perform modular fixation but we had not developed the concept at that time. All our early cases of wrist fracture were treated using type IA unilateral frames. However, ever since we discovered (using the large fiator) how to erect simple pin fiiator modular frames, all our cases have been treated using modular frames (Figs B-20). It does not help to have everything you need in the set, you have to think modular. There are striking advantages to the use of modular frames erected with simple pin fiiators in the treatment of wrist and hand injuries, in particular, pin placement freedom, stable fixation and total bone reduction possibilities. Initially, only open fractures were stabilised by means of external fixation, nowadays it is frequently used for closed comminuted distal radial fractures. Our method is to insert two pins in the radius and two pins in the second metacarpal bone. Then, we manually reduce the fracture and fix everything in the desired position using a simple three-bar frame. A.p. and lateral X-ray views using the Xray image intensifier can be carried out without exposing

s 10 anyone to radiation. Nobody has to stay and hold the reduction, the fracture is fixed and stable. If the X-rays show imperfect reduction, we loosen two nuts, improve tighten the nuts again and repeat this reduction, procedure as often as necessary. On average, three or four attempts are made before the result is satisfactory. It is a user-friendly system without X-ray hazards for the surgical team and is a very simple, elegant, stable fmme. If necessary, three modules are used.

5.4 Extemalfixationof the peivisand hip We would like to present some of our cases of pelvic injury treated using the modular system of external fixation (Fig. 21). It is nothing more than an anterior frame. It is not the solution for every kind of pelvic injury, but is a good pelvic anterior frame, strong enough to be used as a device to stop bleeding and relieve pain. The feature of pin placement freedom comes into its own when trying to insert screws into the iliac wing. Inserting pins into the iliac wing is never a simple procedure, but the modular system with total pin placement liberty can be useful if you are planning to erect an anterior frame on the pelvis. In cases of complex, unstable injury, we prefer to use internal fixation and to add an anterior frame as a stress shielding device.

5.5 Extemalfixationof the femur A.FemBndez,

J.Lasa

External fixation in the treatment of closed femoral fractures in the adult may be applicable as a transient fixation device in polytraumatised patients. On the femur, we prefer to switch to locked nailing as soon as possible. Sometimes long-term treatment using external fixation may prove unavoidable, but it is uncomfortable for the patient and pin track complications am not infrequent. The situation is not comparable with that of the tibia.

out of 19 fractures healed. Unfortunately, there were two pseudarthmses, one which healed after secondary nailing and another which has not been resolved yet The final functional

seriesandmethods From January, 1987 to November 1989, 24 consecutive femoral fractures in 22 patients were externally fixed using modular frames. Three patients died, one went on to early amputation leaving 19 fiied fractures in 18 patients for follow-up. Twelve of these fractures were open, seven closed. Nine of the patients had severe multiple injuries. In all these cases, external fixation was maintained until bone healing if possible. Early bone grafting was performed in nine of the 19 fractures treated. The external fiator was left in situ for 8-28 weeks (on average 19 weeks). Reduction loss while the external fixator was in place only occurred once (a poor quality tubeto-tube clamp prototype was used for the fit patient). 17

14 good, 2 fair and 2

These are not bad results for an injury which is very difficult to treat. Today, we prefer to convert to secondary nailing whenever possible. In any case, our results may be useful in places where locked nailing is not yet available as a technique. The external fixation of femoral fractures in children was usually performed in cases of closed fracture in polytrauma&d patients. In all cases, we left the fiiator in place for four or five weeks and then switched to a hip spica cast The results were so good that we are planning to use it in the treatment of isolated femur fractures in children as well Adult femoral fracture fixation was one of the most challenging situations for our modular fixator, but every single fracture could be managed with the most simple frame consisting of just three tubes without any additional “meccano” frame construction. Additional tubes did not increase the stiffness of the system used (Figs 22-28).

5.6 Exkrnalhation of ihe knee Knee bridges using the modular system consist of a couple of screws in the femur and a couple more in the tibia. This method has been used to treat joint injuries, distal femoral fractures, proximal tibia1 fractures, and also as a fixation method in the early postoperative period of knee ligament reconstruction procedures. The frame is very easy to apply (Figs 26 and 27).

5.7 Exhmal fixationof the tibia A.Fernandez,

In open fractures of the femur, it is not so easy to convert to locked nailing because treatment of the wound may take some time. Often, while we wait, pin track complications arise making secondary nailing a high infection risk (Maurer et al., 1989). In most of our cases of severe open femoral fractures, we were forced to keep the external fixator as the definitive method of treatment. We would like to report a small series of externally fixed femoral fractures.

results were

poor.

R.Masliah

We have extensive experience in the treatment of open tibia1 injuries The first cases were operated on using the unilateral biplanar frame (type IB), but most cases are fixed using modular frames now (Figs 28-30). We have had quite good results when using modular fixation on closed fractures in polytraumatised patients and we are now using the system to fix isolated closed tibia1 fractures in situations in which locked nailing would be impossible and in hospitals in which this technique is still not available. The external fiiator is usually left in place on the tibia until bone healing. Early bone grafting is carried out when necessary and the frame transformed to a sliding frame to encourage weight-bearing as soon as circumstances allow.

5.8 Extemalfixationof the ankleand foot A.Femandez,

R.Masliah

For ankle fixation, one Schanz screw is inserted into the calcaneus, another into the fit metatarsal bone and two into the tibia. The frame has been used for transient fixation of swollen limbs until open reduction and internal fiiation (ORIF) could be carried out. It has also been used

Femtidez:

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Simple pin fixators

as a stress shielding device following internal fixation. In the foot, the small external fixator has been successfully applied (Figs 31-33).

5.9 Modular extemalf&ration in the ttdment eongenitalnbial ps-sis A.Femandez,

of

MSchirnchak

Schimchak has performed a vascularised contralateral fibular graft to treat ten cases of congenital tibia1 pseudarthrosis (Gilbert, 1979). All of them healed - eight after primary operation and two following a secondary procedure. Fem6ndez has developed a special fixation system for use in cases like the above and it has been used in the last seven of the above-mentioned ten cases. The fixation system had to be: -

gentle to the vascular&y of the fibular graft

-

permit all necessary

-

be capable of various pin placements in order to adapt the insertion of the screws to the often very small, residual, distal tibia1 fragment.

grafting intra-articular procedures with or without subtrochanteric osteotomy, internal or external fixation or the use of a spica cast only. A variety of pelvic osteotomies have been used in an attempt to increase the contact area between femoral head and pelvis. The main difficulties reported in relation to hip arthrodesis are a high rate of nonunion and difficulty in achieving access and in maintaining the correct arthrodesis position until bone healing (O” abduction, 0” rotation, 20-30” hip flexion). Subtrochanteric osteotomy has been advocated by many authors mainly for two reasons: the ability to choose the position which will ensure optimal femoral head-pelvis contact independent of the final hip position, and the lowering of stress at the arthrodesis zone until it has healed. Arthrodesis techniques reported using external fixation are very complicated using very complex external fixator frames (Mears, 1983). Having achieved good results using simple modular external fixator frames on different parts of the body, we decided to try it for hip arthrodesis too. Series and methods

improvements

in bone reduction

We developed a three-tube modular frame based on the small A0 external fixator and combined it with minimal internal fixation by means of mini lag screws. The results with this frame have been rewarding. In only one of these seven cases was the reduction imperfect after initial operation. In the other six, alignment was very good. In none of the seven cases could reduction loss be detected. In all cases, the bones healed in the position achieved at operation. The fixator was left in place for two to three months and then replaced by a plaster cast. The frame was stable enough not to require a supplementary cast. It was so stable that it was a real problem to stop the children from walking and putting full weight on the operated limb. To achieve stable fixation with the modular frame, just loosen two nuts and improve bone reduction under X-ray control. Fix the frame again by retightening the two nuts and check again by X-ray. Repeat this procedure as often as necessary within a few minutes and correct bone alignment is attained (as was the case in 6 out of 7 patients). Freedom of pin placement was a very useful feature here, especially in cases with only a short distal tibia1 stump. It is now difficult for us to imagine how we could have managed these cases with any other external fixation system (Fig. 34).

5.10 Extemal fixation in hip arthmdesk A.Femandez,

M.Schimchak,

.A.Cagnoli

H’rp arthmdesis still seems to be the procedure of choice in many patients, despite the availability of different osteotomy and hip replacement techniques currently available for the treatment of children and young adults (Bradama et al., 1976, Mowery et al., 1986, Root et al., 1986). Since early thii century, many methods of performing this operation have been described, for example, extra-articular

From April, 1990 to August, 1991 we performed five hip arthrodeses in five patients aged 11, 14, 15, 19 and 25. The indications were: three cases of painful hip after pyogenie osteoarthritis in early childhood, one case of degenerated dislocated hip in cerebral palsy, and one case of late segmental collapse of the femoral head. In all cases, the modular system was used with the most simple of frames, namely, the three-tube frame with 2-3 Schanz screws in the iliac wing and two Schanz screws in the femur. After femoral head dislocation, femur and acetabulum were denuded of cartilage. A subtrochanteric was performed and interfragmentary osteotomy compression screws inserted from the femoral head to the pelvis. It is important to insert the Schanz screws correctly into the pelvis. These screws must be firmly anchored in the bone or else the whole assembly will lack stiffness. Once the frame is completed, we tighten the nuts of the tube-to-tube clamps. The hip is fixed and we can now clinically assess hip position in an easy and reliable way. Holding the contralateral femur considerably flexed, we can check the flexion of the operated hip, assess rotation with both iliac crests visible, and check the abduction of the operated hip. If there are any doubts, a plain X-ray is then taken. If the hip position is not entirely satisfactory, we only have to loosen two nuts and the frame is mobile. Hip position can be improved, the nuts retightened and another X-ray taken. This simple procedure can be repeated as many times as necessary until the ideal hip position has been achieved. In the postoperative period, the patients were allowed to turn over in bed and to walk on crutches without weightbearing the day after operation. The external fixator was kept in place for between 12 and 23 weeks on an outpatient basis and after its removal a hip spica cast was used for one month. Weight-bearing on the operated limb was encouraged two months after operation provided that X-rays showed good evolution. Results Hip position remained unchanged during the period of external fiation. No change in hip flexion, abduction or

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rotation was detected while the external fiiator was in place. For the five cases of hip fusion and subtrochanteric osteotomy, the hip healed in the position chosen at operation. In one case, an adduction deformity gradually developed after removal of the external fixator. At the osteotomy site, the distal femoral fragment was displaced sideways by 50 ‘I& of the shaft width in one case, more than 100 Sg (total disassembly) in one case, and not at all in three cases. In the case of total disassembly (cerebral palsy with severe spastic dystonia), the patient had to be reoperated on to remove 1 cm of bone in order to decrease the tension at the osteotomy site. It still slid by 50 % but the assembly was now stable and the patient went on to uneventful recovery. The osteotomy healed slowly and an adduction deformity gradually developed which we plan to correct in the near future. There were no major problems with any of the pin sites. Discussion From a conventional biomechanical point of view, the approach we have just presented looks very attractive. The femoral head can be fixed to the pelvic bone by lag screws. Siiultaneously, the stress to which the joint is subjected can be significantly reduced by performing subtrochanteric osteotomy. This seems to create an ideal environment for successful hip fusion. The external fixator enables us to place the hip in the ideal position for fusion and thus avoid having to use a postoperative hip spica cast. The osteotomy can be fixed in such a way that lack of rigidity encourages rapid periosteal bone healing. For the surgeon, this is quite a simple procedure and takes away the nightmare of how to achieve correct position for hip fusion. For the patient, the postoperative period is reasonably comfortable. Our patients had no great postoperative pain and were happier with the external fixator than with the hip spica cast. It remains to be seen whether the healing rate at both the hip and the osteotomy site will be good enough. To resolve this issue, we intend to perform this technique on a large series of patients. One disadvantage of this technique is that it is far from ideal to have external fiiator pins connecting the skin with the bone, especially if we are intending to carry out a total hip replacement some years later. Difficulties may also arise if the osteotomy heals with an inward slide of the distal femur, which is of particular importance, if total hip replacement is planned at a later date. It is not unusual to have a short femur on the same side as the hip arthrodesis. Our external fiiator system facilitates simultaneous procedures for hip fusion and limb lengthening. This was undertaken in two of our five cases (Figs 35 and 36).

5.11 Extmal fixationin bladderexstmphy A.Fern&ndez, A.Cagnoli,

A.Nogueira, JPereira

Bonasso

Posterior bilateral iliac osteotomy is widely accepted as a way to facilitate the midline mapproximation of soft tissues without tension in order to achieve primary healing of the reconstructed bladder and abdominal wall in the treatment of bladder exstrophy (Lloyd Roberts et al., 195% Aadalen et al., 1980). The main problem seems to be how to stabiie the pelvis

after osteotomy so that the pubes are maintained close to the midline until soft tissue healing. A number of procedures have been reported including pubic suture using heavy nylon or wires, Bryant’s traction, body cast, and a variety of different external fixation devices (Mears, 1983). In our experience, a simple anterior external fiiator frame provided a stable pelvic configuration. Here, we wiIl report the results of three children treated with our frame. casesandmethods Three children aged 1% 2 and 14 were operated on for bladder exstrophy. They alI presented with large abdominal wall defects. For the 14 year old boy, this was the fit attempt at closure; the two other cases had been operated on previously without pelvic osteotomy and in both cases the anterior defect had failed to close. All three were operated on using the same technique which was only one surgical procedure. First, perform bilateral vertical, slightly oblique iliac osteotomies, lateral to the sacroiliac joints down to the sciatic notch with the patient in the prone position. The aim is to keep some of the anterior cortex and anterior periosteum intact to act as a hinge, making sure at the same time that the bone cut was sufficient to ensure ample and free mobility at the osteotomy site. Finally, closure and dressing of the wound. The patient is then placed in the supine position and the surgical area prepared and draped. With the patient in this position, two Schanz screws are inserted percutaneously into each iliac wing. The urologists then dissect the soft tissue flaps and, before bladder and abdominal wall closure are attempted, both iliac wings are approximated by erecting a modular frame over the existing Schanz screws. In this way, a good approximation of the pubic bones is obtained and soft tissue closure can be carried out without undue tension. Neither wire nor nylon sutures were used to fix the pubic bones for fear of injuring the freshly constructed soft tissue structures. Pelvic bone stability was maintained solely by the modular external fiator. After pelvic stabilisation and approximation of the pubic bones, the urologists closed the soft tissue defects without tension. From the fit day after operation, the patients were placed on their sides in the bed in order to give access and care for the posterior wounds. They were able to stand beside the bed a week later and were allowed to walk as soon as they could do so without pain, usually two weeks after operation. The external fixator was removed once the soft tissue had healed and once they could bear full weight without pain, further treatment being on an out-patient basis. In these three cases, we used modular frames erected using simple pin fixators: 2.5 mm pins in one case, narrow tip 5 mm in another, and standard 5 mm pins in the third. Results X-ray analysis: Preoperative X-rays had shown a very large pubic gap in all cases. Postoperative correction was good in all cases. No reduction loss was detected with the fixator in place. Partial late reduction loss could be seen in the follow-up X-ray in one case. No vertical displacement at the osteotomy site could be detected. They all behaved like an open book pelvic injury with an intact posterior

Femhdez:

Simple pin fixatars

hinge. In all cases, soft tissue healing was normal. The external fiiator was well-tolerated. Apart from serous dicharge at some of the pin sites which could easily be treat& no complicatio& related to the external f&ator used were observed.

Pelvic osteotomy seems to be satisfactory for the treatment of bladder exstrophy in children older than a year. There is no agreement on how to maintain pubic approximation after Pelvic osteotomy. Bryant’s traction or a body cast have been used widely in the past but may not be as effective as the fixation systems available now. Heavy nylon sutures or wires to hold the pubic bones have been reported but this involves the risk of injury to the freshly reconstructed bladder neck or urethra and may not be very stable anyway. External fixation seems to be the treatment of choice for Pelvic stab&ration after innominate osteotomy in children The application of different external fiiation devices has been reported to achieve this end. We found that modular frames erected using simple pin fixators performed very well, We were able to achieve a very stable assembly which allowed us to turn the patient onto his side without causing pain on the day after operation. A week later, it was possible for the patient to stand up and be discharged from the hospital. It was useful-to have access to pins of different sizes so that the most suitable could be used for children of different ages. The total freedom of pin placement (no geometrical restriction when inserting the pins) facilitated insertion of the external fixator (Fig. 37). It is a tremendous advantage to be able to use a standard external fiiator for this unusual operation in an underdeveloped country such as Uruguay, since special equipment may not be available or may be beyond our purchasing power. A recently published technique for anterior pelvic osteotomy does not seem to have any advantages over ours. It is very easy to turn the patient from the prone to the supine Position. If to avoid this, the surgical procedure has to be mom complicated and the external fixator less stable, then we do not think it is justifiable (Sponseller et al., 1991).

5.12 Exknal fixationin limb rrplantation Limb replantation is a very unusual indication for external fixation. The classical indication for limb replantation is a clean cut. Neither of our cases was ideal. In both of them, the therapeutic approach involved making a cylindrical resection of both segments of the partially amputated stumps in order to remove most of the dirty, destroyed muscular mass, to shorten the limb, and to make it easier to suture the vessels and nerves. It is not easy to perform osteosynthesis when izying to replant a limb as there is no soft tissue link between the segments. Modular external fixation whereby one module is inserted into each of the free segments and the frame completed by a third bar to hold everything together, rendered bone fixation much easier. After two cases of limb replantation using the modular technique and minimal internal fixation, we hope to have found a fairly straightforward method of dealing with a difficult and unusual situation. Free choice of pm placement, total bone reduction possibilities and the stability of the fixation achieved by using a simple,

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unobtrusive

frame were a great help in these cases (Fig.

38).

5.13 Extemd finlion in polyimma paticnls It has been clearly stated that early bone fixation is very important in improving the vital prognosis of the polytraumatised patient (Loder, 1987; Bone et al., 1986). It has also been clearly stated that the surgical aggression involved in internal fixation of the polytmumatised bone is a small price to pay for a marked improvement in the general state of the patient brought about by early bone fixation. However, our anaesthetists will not usually allow us to operate for a long duration with great blood loss on a severely injured patient. They cannot guarantee that the severely injured patient can be kept alive long enough to perform the multiple open reduction and internal fixation procedures required for aggressive early fixation. For this reason, we have developed a therapeutic protocol for polytmumatised patients which we refer to as “early nonaggressive multiple bone fixation” (Claudi and Mooney, 1982; Femandez, 1992). In only a few minutes (on average 15 minutes for each frame), the major fractures of the long bones and joints can be fied using modular external fixation frames. Modular frames can be inserted using closed atmumatic techniques (Hijntzsch, 1989). Always using the same simple frame makes it relatively easy for a less experienced surgeon to achieve stable bone and joint fixation of multiple fractures without too much loss of blood. We have carried out this procedure in a few cases and feel that it is a satisfactory solution for the early management of highly complex injuries in both children and adults (pig. 39).

5.14 ltdmal fhalion in cldkh Initially, we only used external fixation in children for the treatment of open fractures. Later, we introduced external fixation for closed femoral fractures in polytraumatised children. Now we have started treating isolated closed femoral fractures in children using external fixation. The modular system has proved a very good tool in the treatment of fractures in children. Having a system with a completely free choice of pin placement is very useful Schanz screw insertion can be adapted to the fracture pattern and damage to cartilage growth is avoided. The total bone reduction possibilities of the system permit easy reduction of closed fractures using the fixator as a handle. We have been forced by circumstances to fii most of the closed femoral fractures in severely injured children in the emergency room, often without X-ray facilities. Nonetheless, this technique was easily and successfully performed in every case. In children and in adults, the current trend is towards non-aggressive bone fixation in polytraumatised patients. As mentioned in earlier chapters, we have also used external fixation for reconstructive surgery in children (Figs 40 and 41).

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Fig. 13: B-year-old man. First degree open proximal fracture of the humerus treated by modular external fixation. Freedom of pin placement was important in insertion of the screws into the very small proximal fragment Full reduction permitted the use of atraumatic insertion techniques. Extensive bone exposure was not required in order to achieve reduction. Good final result

Fig. 14: 62-year-old woman. Shoulder arthrodesis for rheumatoid arthritis was performed. A standard modular frame was erected and stable bone fixation achieved. The shoulder healed well and the position was very satisfactory.

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Fig. 15: lZyear-old boy. Closed distal fracture of the humerus with a large, aspect of the shoulder. His fracture was treated by closed insertion of a modular a and b: Good use of freedom of pin placement was made in order to insert the allowed. Bone reduction manoeuvres were useful to achieve atraumatic closed fracture. c: Quite good reduction was obtained. Good final result

dirty wound on the anterior frame. Schanz screws as the fracture reduction of this spiral distal

Fig. 16: 55-year-old man. Open Monteggia injury. A three-module frame was erected to stabilise the ulnar fracture and the elbow joint We exploited total pin placement freedom to facilitate frame insertion. After four weeks the elbow was freed and active joint mobilisation had begun. Good final result Note the 4.0/3.0 mm Schanz screws used in the ulna.

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Fig. 17: 56-year-old man. Closed distal humeral fracture, two level ulnar fracture (the dis laced ulnar fracture was open, the un-displaced one was closed), closed radial diaphyseal fracture and a high Py cornminuted distal radial fracture. On the distal humeral fracture, we erformed open reduction and internal fixation using lag screws. Both ulnar fractures, the diaphyseal radia P fracture and the cornminuted distal radial fracture were treated using modular fixation. Minimal open reduction was performed on both displaced diaphyseal forearm bones. Cancellous bone grafting was performed on both diaphyseal bones two weeks after the accident Good final

a: First degree open cornminuted distal radial fracture. Treated in emergency using a modular external fixator. b: Fair reduction was achieved, 1 mm step at the joint because of a die unch fragment c: A necrotising fasciitis developed, the patient was in a very poor con CE ‘tion, he was no longer receiving any treatment for the wrist fracture, amputation had been suggested. His general condition improved and the fixator was able to maintain reduction. d: 10 weeks later the bone had healed, no reduction loss, the joint line was far from perfect but the final functional result was good.

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Fig. 19: M-year-old man. Third degree open distal radial fracture markedly displaced. At emergency debridement and modular external fixation was performed. We used a three-module frame; one of the modules was inserted in the small distal radial fragment We made use of pin placement freedom to build his frame. Final bone healing with no loss of reduction was achieved. Good final result

Fig. 20: 26-year-old woman, professional racing driver. Open, displaced, distal radial fracture. Internal fixation using a lag screw was performed and a modular external fiiator as a stress shielding device was inserted. Four weeks of external fixator plus two more weeks of plaster cast Full function, she is racing professionally again.

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Fig. 21: lo-year-old girl. Open pelvic injury, abdominal injury requiring a colostomy, severe skin lesions. Pelvic fixation using a modular frame was performed. Pin placement freedom was very useful to insert the ood enough. The screws into the iliac wing. The reduction obtained was not perfect but was considered frame stiffness allowed the girl early postoperative walking on her externally fixed pelvis. 8 ood final result

Fig. 22: 94-year-old woman. Closed femoral fracture treated by plaster cast Inside the plaster the fracture displaced and the proximal bone fragment cut through the skin. It was treated by resection of the end of the bone fragment protruding through the wound and external fixation with a modular frame. It was an open fracture in a patient whose general state was very bad. A few days later it was converted to a locked nail. Good final result

Femkdez:

Simple pin fixa kors

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Fig. 23: 39-year-old man. Severe polytraumatised patient with bilateral femoral fractures: left closed, right open. a: Emergency modular external fixation was the only therapeutic option available at that moment Left, closed fracture was treated by closed application of the fiiator, but the reduction obtained was poor. Right, the open fracture was easy to reduce correctly and atraumatically. b and c: Reductions obtained at operation, good at the open fracture side, very poor at the closed fracture side. d: Reduction obtained at operation was maintained until bone healing. Bone healing was quickest at his open fracture. Sometimes it may be better to make a small opening to improve reduction than to fii the bone closed in a poorly reduced state. The external fiiator was kept in place for 20 weeks, followed by four weeks with a double hip spica cast Very high stresses were involved, but no reduction loss was detected. e: X-ray at 3 years. Fair final result

Fi . 24: 16-year-old man. Cornminuted closed femoral fracture and ipsilateral open tibia1 fracture. a: % 0th fractures were treated by external fixation as there was no other therapeutic option for the femur at that hospital. It was a challenging situation with high stresses involved. b, c and &The reduction obtained rimarily was kept without reduction loss until bone healing, The fixator was ke t in place until bone hea Ping. e: Good f?nal result

Femrindez: Simple pin fixators

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Fi . 25: 30-year-old man. Severely injured patient with a closed comminuted femoral fracture. a: % mergency closed application of a modular frame. was performed. b: Two weeks later, after a marked improvement of his general condition, conversion to locked nailing was undertaken. c and d: Uneventful bone healing was achieved. Good final result.

Fi . 26: 74-year-old man. Three week old distal comminuted closed femoral fracture. II ighly comminuted distal femoral fracture in an osteoporotic bone. i Closed insertion of a long modular knee bridge without Schanz screws in the small distal femoral fragment Good alignment c: The X-ray at 46 weeks shows that the bone has healed in a good position. d: Clinical aspect Ender nailing was performed years before on the contralateral femur because of a proximal femur fracture; this is his troublesome knee today, the knee treated by modular fixation is actually his good knee. Good final result

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Fig. 27: 35-year-old man. a: Closed avulsion fracture of the proximal tibia. b: Open reduction and internal fixation was performed using lag screws and cerclage wires. A modular knee bridge was erected to supplement this unstable internal fixation and was left in place for four months. c: X-ray at one year. The bone has healed without reduction loss. Current ranee of movement at the knee: from total extension to 90” flexion. Normal painless walking ability. Fair final re<

Fig. 28: 29-year-old man. Closed tibia1 fracture. Locked nailing might have been the ideal indication for this fracture but was not available. Closed modular fixation was performed. A good result was achieved by a simple operation. Perhaps rt is not the best therapeutic option but for many places it may often be the best one available.

Femtidez:

Simple pin fixa tots

523

Fig. 29: 27-year-old man. Cornminuted, displaced, closed distal tibia1 fracture. Biological plating might have been a good indication here. Modular external fixation, applied closed, may also be an elegant solution. Note how useful pin placement eration was performed freedom was, when inserting the Schanz screws into the small distal fragment ot: one healing. shortly before the time of writing and it is planned to leave the fixator in place until

Fig. 30: S&year-old man. Segmental closed leg fracture. a: Closed locked nailing might have been a good therapeutic approach for this case, even if the proximal fracture is a little bit high, However, it was not available. Therefore, modular external fixation was performed. b: A mistake is evident, a Schanz screw was mistakenly inserted at the proximal fracture focus. c: It was easily replaced as can be seen by the screw scar. Good final result This may be a good therapeutic approach for closed tibia1 fractures at two levels.

S24

Fig. 31: %&year-old man. Displaced pilon fracture treated by open reduction and internal fixation. Even after extensive internal fixation, the assembly was totally unstable, so modular external fixation was added and kept in place for four weeks. This patient was still in rehabilitation at the time of writing.

Fig. 32: 3%year-old man. Displaced pilon fracture. Open reduction and internal fixation, atraumatic techni ue, bio-logical plating. As internal fixation was not stable enough a modular frame was applied and ke t in p? ace for four weeks followed by two weeks of plaster cast The patient was still in rehabrlitation at tI e time of writing.

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Simple pin fixaton

s2.5

Fig. 33: 35-year-old man. Open fracture of the first metacarpal bone, closed fractures of the other four metacarpal bones. Modular external fixation of the fracture of the first digit was done in emergency. Uneventful bone healing was achieved

Fig. 34: S-year-old boy. Congenital tibia1 pseudarthrosis. a: Preoperative X-ray. b and c: This was treated by a contralateral vascularised fibular graft fixed by lag screws and a modular frame. It is interesting to note how freedom of pin placement allowed us to position the two distal screws very well in a very short tibia1 stump The screws were inserted to form an angle of almost 90” with one above and one below the growth carhla e. It is hard for any other external fiiator system available nowada s to match these screw placement possi%ilities. Total bone reduction ability allowed us to choose a goo J alignment between the remaining proximal and distal tibia1 fragments; the hxator was kept until bone healing. d: X-ray at 44 weeks. Good final result

52.6

Fi . 35: 24-year-old man. Arthrodesis was indicated because of post-traumatic femoral head segmental coPlapse. a: Postop. X-ray. Note the lag screws, the subtrochanteric osteotomy, and the modular external frame. b: Note on the X-ray 32 weeks after operation that the subtrocanteric osteotomy and the hip healed in the same position that was chosen. Good final result

Fig. 36: 19-year-old man. Arthrodesis performed because of late sequelae of infected osteoarthritis of the hip in childhood. Painful hip and limb shortenin . It was decided to perform hip arthrodesis an % femoral lengthening. a: Note at sur ery how both handles have been inserted: one long handle is used to fix the distal femoral osteotomy afready performed ready for lengthening, the second one has been inserted into the iliac wing. Correct hip flexion position is assessed and after frame completion the hip will be fixed in the chosen osition. b: F ostoperative X-ray. Note the lag screws, the modular frame, and the subtrochanteric osteotomy, which is hardly visible.

Femlindez: Simple pin fixaton

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Fi . 36 contd: c: % -ray at 20 weeks. Note the satisfactory callus formation present after 5 cm of femoral lengthening. d: Full wei ht-bearin good limb equalisation. e and f: J! -ray at 49 weeks. Note hip and subtrochanteric osteotomy and lengthening zone healed. No reduction loss. Note the slightly enlarged screw hole scars on the distal femur, indicating that a minor degree of pin loosening was present at external fixator removal. Good final result

Fig. 37: Zyear-old girl. Multiply operated bladder exstrophy. a: Preoperative X-ray. b: Appearance after an anterior modular frame using the small external fiiator was inserted. The abdominal wall defect could be easily closed without undue tension. There is a striking improvement in the X-ray a pearance of the pelvis. c: 8 ote the satisfactory condition of the pelvis on the X-ray 4 years postop. especially compared to the preoperative X-ray. Good final result

Fig. 38: 21-year-old man. Amputation at the distal forearm, no clean edges; it was not a clean cut Amputation was performed at both stump ends, resecting dirty muscles. Limb shortening of 4-5 cm resulted. Modular external fixation was performed between radius and second metacarpal bone. Minimal fixation at the radius and a short plate at the ulna were inserted after completion of the modular frame. Good final functional result

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Fig. 39: 48-year-old man. Severe polytrauma patient Open fracture of the femur and open fracture of the tibia. a: Emer ency modular fixation of both bones. en&, 10 screws were inserted with free b: Two g chanz screws were inserted into each one of the 5 bone fra choice of pin placement There were no restrictions as to where 8”e screws could be inserted, except those imposed by the fracture pattern and the condition of the soft tissues, the external fixation system itself imposes no limitations. c: Five handles were erected, one for each fragment to manipulate the bone fragments and achieve reduction. The frames were then completed. d: Good reduction has been obtained, an inter-fragmentary screw was added at the femoral fracture to increase the stiffness of the assembly. Bone healing after closed bone grafting was good. e and f: There was no loss of reduction and a good final functional result was achieved, the external fiiators were left in place until bone healing.

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Fig. 40: 9-year-old boy. Closed femoral fracture in a polytrauma patient with a severe brain injury. Assisted mechanical ventilation. The modular external fixator was inserted closed in the emergency unit Pin placement freedom is an especially useful feature to make fixator insertion easier m difficult situations like this. Total bone reduction possibilities allowed us to insert.the fixator without X-ray control (it was not available) and to achieve good reduction anyway. Early stabilisation of the fractured femur made nursing the atient easier while in the intensive care unit Soon after external fixation had been erformed, the patient : ecame less restless and did not need so many sedatives. A few hours later, he could 1 e disconnected from the respirator. Good final result

Fig. 41: S-year-old boy. Polytraumatised child. Open tibial, closed femoral and closed humeral fractures. Emergency external fixation of the three fractures was performed. A Behrens’ frame was used for fixation of the open tibia and modular frames (inserted closed) for fixation of the closed femoral and humeral fractures. a and b: Preoperative X-rays. c: Pins were inserted making use of the total free choice of pin placement with this system.

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Fig. 41 contd: d and e: Using the fixator modules as handles, closed atraumatic reduction was achieved. After frame completion, fixation is stable. f: Postoperative aspect After surgery the patient lay comfortably in bed and could turn on his side because the fractures were firm1 fixed. g and h: The reduction o4:tained was not perfect, but it was considered good enough for a child of this age. The small external fixator was used for the humerus, the large external fixator for the tibia and femur using narrow tip Schanz screws for the tibia and standard screws for the femur. i - I: Uneventful recovery, good final result

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6.Andaftmatanrtfixation1 External fixation has often been described as a temporary bone fixation system &Killer et aL, 1991). Some authors contend that as soon as we insert an external fixation frame, we should think about when it will be replaced and which internal fixation device we will be using. The most popular option nowadays is unreamed nailing (Claudi, 1991). This is a very expeditious approach to fracture treatment, but not the only one. First of all, we must be careful not to put everything into the same bag. The answer to what is to be done after external fixation may be different for a tibia1 or femoral fracture, for a third degree open or closed fracture, or for an adult or a child’s fracture. Secondly, it is not always possible to convert external fixation to locked nailing. In many operating rooms around the world, the technique of locked nailing is not available. In addition, many orthopaedic surgeons are already in the best equipped hospital or clinic which means there is nowhere better to transfer the patient to. Often the only available option is to leave the external fixator in place until bone healing or until removal of the external fiator and treatment with a plaster cast. We will offer a few answers to the question of what should follow external fixation but of course, this is only a report on how we proceed and why, and not a recommendation for procedures around the world. Tibia

a bone defect, we bone graft early. In the forearm, we do the same or switch to internal fixation as soon as the soft tissues have healed. In children, we always keep the external fixator on for three to four weeks. As soon as pin track complications develop, we switch to a plaster cast which stays on until bone healing. The question “What follows external fixation ?’ may be met by a chorus of replies. The answer will depend on which bone we are talking about, what type of fracture, what type of Patient, who is the attending surgeon, where will he treat the patient, what techniques are available to him at that place and which techniques can he safely master.

7. sliding fhpbon AFern6ndez, R.Masliah Altering the frame so that it can slide, thus encouraging weight-bearing, avoiding the by-pass of stress, increasing bone-to-bone stress transfer and lowering pin-bone stress is a well-known technique. It has been suggested that this so-called “dynamic fixation” encourages bone healing and lowers the pin track complication rate. In accordance with the ideas of Prof. Allg6wer and Mr. Sequin on how to make a tubular frame into a sliding frame, we developed a very simple system to transform a three-tube modular frame into a sliding frame (Allg6wer et al., 1987) (Fig. 42).

If we are dealing with an open fracture with a bone defect and/or significant vascular disturbance of the bone ends, then early bone grafting is advised. If this is not the case or if it is a closed fracture, we encourage weightbearing after conversion of the external fiiator to a sliding frame. In the tibia, we usually leave the external fixator in situ until bone healing. After fixator removal, we use a cast for three weeks. Our results have been quite good with this therapeutic protocol. External fixatom are usually welltolerated on the tibia. We have almost never converted to internal fixation for tibia1 fractures. Femur For femoral fractures, we aim to convert to locked nailing as soon as possible, the idea being to perform nailing before pin track complications can set in. However, this is not always easy in severe open fractures where it may take some time to gain control of the wound situation. If we cannot make a safe transition to nailing we prefer to keep the external fiiator in place until bone healing rather than risk a deep postoperative infection. Long-term external fixation is not usually well-tolerated and pin track infection is frequent, mainly at the proximal pins. For these reasons, we prefer to convert to locked nailing early when the risk of infection is low. If the external fiiator must be left in place until bone healing, we try to do bone grafting fairly early. upperarm In the humerus, the external fixator is usually left in place until bone healing. If there is a severe open wound and/or

Fig. 42: Sliding frames. a: Modular frames, providing that at least one of the “handles” is roughly parallel to the bone axis, can easily be transformed into sliding frames according to AllgowerSequin. b: Only a second short tube and two simple clamps have to be inserted, both tubes connected, and a couple of nuts loosened. The frame is now ready to bear weight In a closed tibia1 fracture or a first degree open fracture without bone loss, we have often transformed the frame into a sliding frame and encouraged weight-bearing with the fiiator in place. This was done relatively early for

s 33

Femrindez: Simple pin &atom

transverse fractures and somewhat later for spiral, longitudinal or oblique fractures. Our series is not yet large enough to draw conclusions from it. We are not entirely convinced that dynamic fixation is terribly important but it is not harmful and the patients usually feel better when walking on a sliding frame than on a static one. It is easy to make a simple pin fixator into a sliding frame as the need arises.

-

a simple unilateral external fiiator can be used

-

postoperative follow-up is much easier (see chapter 9.1)

The main disadvantages -

highest Possible risk of neurovascular

-

there is no easy way to improve the result after operation. If the limb is not Perfectly aligned, a new s=y procedure would be necessary to improve this

-

very careful preoperative planning is imperative.

8. Correctionosteotomicrin the haiment of limb ddonniticr A.Fern&ndez, MSchimchak,

A.Cagnoli

Osteotomy or corticotomy (Arrien et aL, 1990) in the treatment of limb deformity may be combined with limb lengthening according to the circumstances. There are two main approaches

to this subject:

1. After osteotomy/corticotomy deformity.

progressively

2.

Perform a single stage surgical wedge resection of bone (Fig. 43).

correct

correction

the

through

of the second approach are: injuries

Our clinical experience has mainly been with the second approach, Le. using a simple unilateral frame. In only one case did major neurological disturbances occur which forced us to loosen the external fiator and reproduce the original deformity. In a few cases, there were some minor neurological problems. We did not observe vascular problems in any of our cases despite some very large corrections. In our experience, the neurovascular complications arising after a single stage limb deformity correction, even if it is a major correction, have not been a great problem providing care was taken at operation to avoid soft tissue tension, even shortening the limb a little if this was necessary. If limb lengthening is required, it is carried out at a later stage, after a few days interval. At this stage, we are undertaking simple limb lengthening of an already straight limb. An external fixator can be used which is simple and easy to apply for the surgeon and comfortable for the patient to wear. Furthermore, it proved difficult to assess the exact state of the limb while the fiator was in place. It was difficult even with the help of X-ray examination to give a reliable answer to such questions as: Is it perfectly corrected ? Is there a remaining deformity which needs a little more correction ? Have we over corrected the initial deformity ?

B Fig. 43: Top: Angular deformity in a short limb, gradually corrected using a ring fixator after corticotomy. Bottom: The same case corrected using a 3D wedge resection osteotomy, fixed using a type IA frame, followed by simple limb lengthening.

On the other hand, in those cases in which we performed a single stage surgical correction based on careful preoperative planning, the final limb shape was good. At present, this seems to be the safest procedure to achieve the correct final shape of a deformed limb.

The main advantages

PreopemtivePlanning

of the fimt approach are:

-

there is a lower risk of neurovascular

-

we can push and pull achieve the perfect shape.

The main disadvantages

the

of the fit

injury

limb progressively

to

approach are:

-

a very complex ring fixator is needed to perform different types and different magnitudes of 3D malalignment correction

-

it requires an extremely careful clinical and postoperative X-ray control to tune the external fixator perfectly enough to achieve the desired final result_

The main advantages

of the second approach are:

Our method for correction osteotomy begins with very careful preoperative planning. At this stage, the elementary deformities of each of the limb segments is assessed clinically and radiologically. Attention must be paid to limb position when taking X-rays which will be used for preoperative planning. In the most severely crooked limbs it is not always easy to recognise what is a.p. and what is lateraL Once the deformity of each limb segment has been precisely determined, the angle and plane of correction and the exact point of osteotomy is meticulously planned. For each limb segment, we carefully determine deformity in the a.p. plane, deformity in the lateral plane, and rotational deformity. The preoperative planning must be followed through by the surgeon who will operate. He must go to the X-ray department himself and assess limb

S34

position on the basis of each of the X-rays. Even when preoperative planning has been completed, we see the patient again a few days later and check again just in case a mistake has been made in the planning stage.

operation so that the healing process can begin and then traction at a rate of 1 mm/day to lengthen the limb (Cafiadell, 1986, Mezhenina et al, 1984, De Bastiani et aL, 1986). The same lengthening device can then be used with different lengthening techniques.

Surgical technique Surgical procedure has always been quite straightforward providing we keep to the path decided by the preoperative planning. We begin by inserting two Schanz screws as far as possible away from the osteotomy site and assign information to these screws. This means that we insert them with a rotational misfit equal to the amount of rotation we plan to correct After osteotomy and rotation of the limb, these two Schanz screws should be in the same plane. These two screws are inserted at an angle which ensures that they will be parallel once the osteotomy and correction of the angular deformity in one plane has been completed. This means that we know that if the one plane deformity and the rotational malalignment have been corrected exactly according to our preoperative planning then the screws must be parallel. This method of fixation is simple, stable, easy and quick to insert and facilitates the osteotomy. The latter is especially important in the case of 3D corrections. Having inserted the fit two Schanz screws, performed the osteotomy and corrected the limb deformity, we then mount the tube and insert the two remaining Schanz screws. What we now have is a four screw unilateral single tube frame. Surgery is over and the wound can be closed (Figs 44-48). We advise against the use of two longitudiial tubes since our laboratory has confirmed that the second tube adds very little to overall frame stiffness. Its attachment during surgery is also extremely difficult. It detracts from the elegance and simplicity of the frame and is unnecessary. When using a unilateml tube one.

frame, always

use a single

When limb lengthening is required, a second longitudinal tube may be added later. It may be a tricky and time-consuming procedure because the screws are unlikely to be in the same plane, but it is an out-patient procedure and painless.

9. Simple limb lcngth~ng A.Fern&ndez, MSchimchak,

Today, most authors agree that femoral, simple tibia1 and humeral lengthening should best be performed using unilateral systems. Ring fiiators seem to be the best choice for tibia1 lengthening associated with marked foot deformities. We will report our experience with a very simple, unilateral external fixator. We erect a very simple, unilateral, uniplanar, single tube frame on the short limb. Once the frame is in place, the tube is removed in order to perform the osteotomy, then the tube is reapplied. In this way, the bone is exactly as it was before, cut and stab&red. After wound closure, the surgical procedure is over and has lasted no more than twenty-five minutes. We strongly advise against the insertion of two parallel tubes at operation because this forces us to insert all our Schanz screws in one plane and the bone may not lie in this plane. It may also be difficult to insert the screws pmperly. We recommend using only one tube frames at operation in order to maintain maximal pin placement freedom and to be able to insert the screws into sound bone. It must be remembered that a well inserted screw is imperative if we hope to succeed in any procedure involving long-term external fixation. For this reason, we only use single tube frames. A few days after operation, when limb lengthening is about to begin, we mount the second longitudinal parallel tube. This may be a tricky and time-consuming procedure if the Schanz screws are not in the same plane, but it is an out-patient, painless procedure. We carry out lengthening using a standard compressiondistraction threaded device at a rate of 0.25 mm four times a day. The compression-distraction device has to be replaced each week which is not a problem because these patients attend the hospital on a weekly basis anyway. Once the target length has been reached, the second tube can be removed and the single tube unilateral frame originally applied is left in place until the bone is strong enough for fixator removal. If at a later stage, we wish to transform the frame into a sliding frame, allowing a controlled l4 mm axial displacement, this will be quite a simple procedure. If we use a frame erected using radiolucent carbon fibre rods, we can easily get beautifully clear, lateral X-rays.

A.Cagnoli

This chapter deals exclusively with simple limb lengthening which is not associated with any other limb deformity. Simple limb lengthening as a way to treat limb length discrepancies is a well-known procedure. It is important to differentiate between external fiiators and limb lengthening techniques and be sure to choose the most appropriate. For example, the Wagner apparatus is used in accordance with a very well-defied protocol. Wagner recommended distraction at operation followed by traction at a rate of 1.5 mm/day until the required length was reached, then conversion to internal fiiation (Wagner, 1978). The same Wagner external fiiator device has been used by other authors as is true of the Ilizamv and De Bastiani fixators. Here, there is an interval of a few days after

For us, this is a second to none, no nonsense, limb lengthening system, similar to most of the currently available unilateral fiiators, and in our opinion, better than ring fixators for most situations. Another advantage of these simple pin fixatom is the ease with which a screw can be replaced or added. This may be an important feature when a pin becomes loose in the bone half-way through the procedure. In this case, it would be difficult to remove the fixator or switch to a cast or internal fixation without taking a risk In such a case, it is a definite advantage to be able to add or replace pins easily (Figs 49 and 50). From the biomechanical point of view, bone growth at the osteotomy site was quite good and very similar to the results reported using other devices with totally different

Femhdez:

s 35

Simple pin fixatoxs

biomechanical features. We would also like to refer the reader to the chapter written by our friends and colleagues in Malaga who have had considerably more experience with limb lengthening than we have using a similar system.

9.1Thcwaga

In the two Turner’s syndromes both tibiae were always elongated in order to avoid unequal growth. In the cases of polio sequelae, three tibiae and two femora were elongated. The cases of congenital malformation were one congenital coxa vara, one thalidomide foetopathy with a 10.8 cm femoral shortening, one congenital femoral pseudarthrosis, and three of unknown origin.

cxpwi~usingthesystcm

F.Luna, E.Queipo de Llano We had been familiar with the use of simple pin fiiators for fracture treatment for some time, but only after our fit contact with Dr. Femandez in Montevideo did we begin to use the same sliding system that he uses and obtained very satisfactory results. The simplicity of the technique and the comfort of the patient were the two criteria which convinced us to try the system for limb lengthening and bone transport. Treatments up to that moment were undertaken using ring fixatom. Our experience with ring fixators has been that the results are good but follow-up is a problem and the fiiator is not well-tolerated by the patient. As Dr. Femandez has said: “The idea of this technique is to make surgery as simple as possible for the most simple cases and for those we have to treat most often and to be able to use the same instruments and implants we use for everyday emergency work, in such a way that simple limb lengthening can be done by an average orthopaedic surgeon and does not require special complex equipment”.

The cases of post-traumatic shortening were one sequel to pelvic fracture with neurological involvement and one growth arrest at the distal tibii after a Salter type IV injury. In the first case, tibia1 shortening second case 5.3 cm

uniplanar

Behrens’

frames

with

We usually insert two 5 mm Schanz screws above and below our planned osteotomy site. We have sometimes used an additional fifth screw. On the tibia, we used carbon fibre rods and on the femur, stainless steel tubes. We are always careful to allow enough room at the osteotomy site for the lengthening device to be inserted. Before beginning lengthening, we loosen the required nuts to let the frame slide.

11.5 cm, in the

The degree of lengthening obtained was 10.8 cm for the femur in the thalidomide case, 15 cm for the femur in the congenital pseudarthrosis, 5.3 cm for the tibia in growth arrest and 12 cm for the tibia in Turner’s syndrome. surgical technique All cases technique.

were

Depending Perform:

on the bone segment

performed

with

the

same

surgical

to be lengthened,

we

Tibii: 1.

Achilles tendon lengthening

2.

Fibular fixation

3.

External fixator insertion

4.

Proximal tibia metaphyseal osteotomy

5.

Plaster cast long leg splint

Frames We used unilateral, double tubes.

was

distal

osteotomy

and

tibia-fibular

screw

Femur: Adductors and tensor fasciae latae muscles are cut

ClbiCdCaseS

External fixator insertion

We have operated on 15 patients using this system. In two cases bilateral lengthenings were performed, in 13 cases unilateral lengthenings.

Proximal or distal femoral osteotomy depending upon whether the problem is at the knee or the hip.

The average age was 15.3 years. There were 7 men and 8 women. The underlying diseases were: Turner’s syndrome (2 cases) Polio sequelae (5 cases) Congenital malformation Post-traumatic

shortenings

(5 cases) (2 cases)

For us, it is very important to perform soft tissue release during initial surgery to avoid the early onset of lengthening complications. Here, we are referring to ankle equinus deformity during leg lengthening, and hip adduction and varisation of the femur during femoral lengthening. When performing large lengthenings, these complications may arise even when initial soft tissue release has been done. This issue will be dealt with in “Complications”. Sometimes we have had to perform additional surgical procedures during the initial operation, for example: hip

S36

Ischi&ibial muscle retraction: 1 case.

a&rod&, growth arrest through staples at the knee; and one triple arthrodesis of the foot. Hip arthrodesis was required in a patient with an unstable hip. It was achieved using the same fiiator. Stapling was done in a patient with significant valgus of the knee in order to arrest excessive growth of the medial femoral condyle, triple arthrodesis was done for equinus of the foot using the same fixator.

In these 3 cases tendon release had been done previously as stated above. c. Nerves and vessels

Minor transient neurological involvement: one case. Nerve disruption: no cases

Poetop. Two weeks after operation we removed the stitches and mserted the distraction device. We carried out limb lengthening at a rate of 1 mm/day once a day. Patients do not weight-bear for the entire duration of lengthening whether it is a femoral or tibia1 lengthening.

Vein disruption: no cases Artery disruption: no cases 2. Bone and joint complications a.

Pin loosening: 3 cases.

For the femur, we authorise knee mobilisation up to 30@ flexion. In the tibia, we retain the plaster splint for the duration of lengthening. We consider this very important to avoid flexion of the knee.

b. c.

Joint stiffness: 2 cases

After lengthening of the tibia has been completed, we remove the tibia-fibular screw under local anaesthesia and encourage ankle mobilisation.

d.

Knee subluxation: in one femoral lengthening.

e.

Reduction loss: one femoral lengthening

At this stage, in both the femur and the tibia, we reinsert the nuts previously removed when we began lengthening transforming the fiiator into a static conventional frame. From now on we encourage weight-bearing fit partial and then full. Once cortical&&ion of the new bone is evident, we alter the fixator to let it function as a dynamic fixator, inserting a stop clamp which permits regulation of the amount of slide. External fixator removal has generally been done when the number of months of fixator implantation is equal to the number of cm lengthened. Subsequently, we insert a functional plaster treatment, author-i&g full weight-bearing only after the second month. complications We must differentiate between soft tissue complications, bone and joint complications, and general complications. 1. Soft tissue complications a. Skin _

Bad tolerance of the pinsz This is the most frequent complication with serous discharge, though not purulen~ at the pins. We have seen it in 90 % of pin tracks at some point during evolution. Superficial infection: 10 % of cases.

Callus fracture: 2 cases, both after external fiiator WllOVd

3. General complications We had 3 disturbance.

cases

of anorexia

and

2

of emotional

Treatment of complications Intolerance and pin track infections were always treated using Riphocyn at the pin track exit points. The three tendon retractions forced us to undertake tendon lengthening. Where a neurological paresis appeared, we stopped lengthening until total neurological recovery, we then continued lengthening. Whenever there were loose pins, we replaced them. This was an easy task because of the special features of this system. Both cases of callus fracture after external fiiator removal were treated by plaster cast In neither of them was the lengthening previously obtained lost Joint stiffness was treated by mobilisation under general anaesthesia followed by rehabijitation treatment Knee subluxation was treated by lengthening the ischiotibia1muscles and with a plaster cast One patient whose femur deformed corrected and recovery was uneventfuL

in varus

was

Final results

Deep infection: no cases. b. Muscles and tendons Achilles tendon retraction: 2 cases.

We assessed the results from both an objective and a subjective point of view. Objective assessment

s 37

Fem tidez: Simple pin fixatars

We evaluated:

10.Bonetnnrport

- residual deformity,

Bone transport as a method for treating large segmental bone defects has been described by Prof. Ilizarov. Our first case of bone transport in Uruguay was carried out in accordance with the ideas of llizarov using a unilateral simple pin fiiator frame in July, 1985. We are now in a position to present the results of our first five consecutive cases of bone transport performed using these types of frames. First and foremost, we disagree with the concept that “it doesn’t matter how much bone I St, I can solve the bone defect by bone transport later”. We believe that all the dead and infected bone must be removed, but we must be very careful not to resect any healthy, living bone at all.

- joint mobility, - pain, - walking ability. We assessed each of those items from 0 to 10 and we considered a result as excellent when the sum was between 30 and 40, good 20 to 30 and bad under 20. Objective results: - excellent cases

10

-goodcases

6

- bad cases

1

Subjective results The results of the patient’s own assessment were: excellent:

13 cases

good:

4cases

bad:

no cases

Here we see that the subjective results are better than the objective ones. This shows how well the system is tolerated by the patients (Figs 51 and 52). C!onCluaiorrs Our experience of limb lengthening using simple pin fiiatars has been very positive, mainly for two reasons. 1. Ease of pin replacement. Not infrequently pin loosening or pin track infection appears during limb lengthening. The unilateral fiiators currently in use have very little pin placement freedom, pins must be inserted a fixed distance apart in order to attach them to the clamps of the fiiator. This makes it very difficult to treat pin loosening or pin track infection if it occurs. Using the simple pin fiiator this point is not important, since we can replace screws as often as required, without taking these distances or parallelism into account 2. Ease of technique and stiffness of the frame. Because of the very few elements used, (just screws, tubes and clamps), fiator insertion is simple, universal and can be done by any orthopaedic surgeon. We must also say that the stiffness of the frame was able to cope with the high bending stresses produced when using any unilateral fiator while limbs are lengthened. Note: Original Swiss made tubular AO/ASIF instruments and implants were used in every case.

Bone translx~ can be used as a means to treat large bone defects, however, the larger the defect, the higher the complication rate, the lengthier the procedure will be and the more discomfort the patient will suffer. For this reason, the surgeon should not be too reckless with reprd to bone resection. We prefer to use a unilateral frame rather than a ring fiiator for bone transport in the lower leg. We have no experience of bone transport in the femur nor for defects due to tumour resection. We are sure that there must be procedures other than bone transport which are more comfortable for the patient and which have a similar success rate in cases in which a very long procedure is required, especially if it is not a case of an infected defect due to tomour resection operation, for example. We also feel that there must be therapeutic options better suited to the treatment of large femoral bone defects where there is a thick muscular cuff surrounding the bone defect (Jupiter et al., 1987). For us then, bone transport is a technique at present limited to bone defects more than 4 cm long in the tibia when there is a high risk of infection, e.g. tibiil defects after infected internal fition or after severe open fracture. The use of unilateral simple pin fiiators requiring only Schanz screws as opposed to transfiiion pins is advantageous. Initially, we d double tube unilateral frames for bone transport, but we experienced pt difficulty with insertion. As a result, we went over to using a single tube IA frame in the last three cases. The second longitudiil tube is only used during transportation. This tube is not inserted at operation but later on. This means that we have considerable freedom during operation when inserting the Schanz screws. It is important to note that bone transport using simple pin fiitors permitted us to correct the direction of hansport in both planes as required. We are unaware of any other unilateml bone device capable of correctly aiming the mobile fragment. This feature is essential to ensure good docking of the mobile fragment at the end of bone transport. We will now present a small series of bone transport cases bated in Uruguay. caseaandlnethods From July, 1985 to Sept, 1990 we performed five consecutive bone tmnsport procedures to treat tibia1 defects. The patients were all men with an average age of

34 years (20-49 years) and all of them were treated using unilateral uniplanar frames erected as simple pm fixators using only Schanz screws and no transfiiion pins. The segmental bone defects were between 3 and 12 cm long (6.6 cm on average). In four cases, the bone defect was in the lower tibia and the osteotomy was performed on the upper tibia. In one case, the bone defect was in the upper tibia and the osteotomy performed on the lower tibia. All these cases had been seriously considered for amputation which all patients refused to accept Four cases were the result of severe open fractures, the fifth the result of an infected plating. In our first two cases, we used double stacked longitudinal tubes inserted at operation and threaded bars inside the hollow tubes of the fixator. Mounting the frame was extremely cumbersome and so we altered our procedure. In the last three cases, we used a single tube unilateral frame completed during operation, we reframed from using the threaded bars inside the tubes and we mounted a second tube later on as an out-patient procedure. We observed an interval of one week between operation and the start of bone transport. The rate of transport was 0.25 mm four times a day in every case. The wounds were all left wide open at operation and free skin grafts were used to close the soft tissue defect. In all except one case, cancellous bone grafting was carried out after bone contact had been achieved. Weightbearing in the sense of floor contact only was authorised throughout Once there was bone contact, weight-bearing was encouraged. In the last two cases, the frame was converted to a sliding frame and weight-bearing encouraged as soon as a good image of callus at the osteotomy site was evident. After removal of the external fiiator, a long leg plaster was applied. Patients were in hospital for about half the period during which they wore the fiiator. As out-patients they were seen once a week The fiiator was left in place for 24 to 55 weeks (40 weeks on average), and the total treatment time was between 58 and 82 weeks (68 weeks on average). Bone regeneration at the osteotomy site was good in all cases. Bone healing within the defect was slow and required bone grafting in 4 out of 5 cases. Final bone healing at both the osteotomy site and in the defect was achieved in all five cases. The range of knee movement was good except in one case in which the patient had an associated @lateral femoral fracture. The range of ankle movement was normal in two cases but very limited in one patient who had no remaining ankle extensor muscles. An ankle arthrodesis was performed on the remaining two patients because of a pre-existent equinus contracture. We achieved fair functional results in 4 out of 5 patients. No late amputations were performed. Complications In one case, there was a refracture at the bone defect site which was treated with a long leg plaster cast until healing. There were no refmctures at the osteotomy site and no need to replace any of the Schanz screws due to pin loosening. There were no infections of the bone at the osteotomy or the bone defect site and no reduction losr whilst the fiator was in place, except in one case clearly related to pin loosening.

Discus&on Bone transport is not the only nor the best way to treat large defects of the tibia. It is just one more therapeutic option. Our five patients were selected from a total of 300 patients treated for open tibia1 fractures with an external fixator between 1985 and 1990. In our opinion, we have so few large tibia1 defects amongst so many cases of severe open fracture because we are extremely careful in cases of bone infection For non-infected bone defects, upper limb and femoral defects we prefer alternative therapeutic approaches. In an infected environment such as the tibia, bone transport seems an appropriate therapeutic approach: no large flaps are required and no vascular sutures must be placed in an already injured limb. It is a traumatic surgical procedure and has the disadvantages that it is long-term and uncomfortable for the patient. In our opinion, non transfixion pins are a great advantage. To discuss the importance of corticotomy or the biomechanical aspects of ring fixators seems a little old-fashioned. We do not feel that it is important to use a special frame for bone transport but rather the standard fixation system which we are familiar with from its use for more common indications. There are two main options available nowadays transport:,

for bone

-

an apparatus for every possible correction (which is also an apparatus for every possible mistake). Most ring fiiators fail into this category.

-

an apparatus that allows no correction, unilateral fiiators.

such as most

The first group of fixators allow transportation of the bone segment to the docking site with as many adjustments as necessary throughout the entire procedure. This makes patient assessment very complex. The second group of fixatom demands precise insertion of the frame or the transport segment may never reach the docking site (no correction is possible using most unilateral fiiators). On the other hand, if the frame is well positioned, there may be no need for repeated patient scrutiny throughout the whole procedure. With the unilateral fixators, pin replacement would be easy if it were required. All our patients healed and no residual osteitis was reported, but the treatment is a long one (more than one year on average) and the final functional result depends on the concomitant soft tissue lesions (Figs 53-55). Amputation may still be a valid option.

11. Thirdworldcounties and extemalfixalion External fixation is usually a very important tool in third world countries. In countries such as Uruguay, the operating environment is often far from ideal. The infection risk for open reduction and internal fixation is usually high. It cannot be assumed that a full set of the necessary instruments and implants is available. This means that external fixation is often a valid therapeutic option. The procedure is less demanding and the risk of infection lower.

Femtidez:

Simple pin fixaton

Cheap external fiuators are often presented as the correct way to meet the demands of the third world countries. The simplest fixator consisting only of a piece of soft material through which to insert the Schanz screws has been presented as the best and cheapest solution for our poor countries. Our modest thought is: “The cheaper, the betted. Nonetheless, the cheap fiiator must fulfil some basic needs: It must be versatile to facilitate full bone reduction so that it can be used to treat closed fractures and be inserted using atmumatic techniques. It must be strong and stable enough to deal with an adult femoral fracture.

s 39

buying good quality original items. We have had a lot of good experience using top quality external fixatom because they are strong, stable, well-constructed and applicable to a variety of indications. In many situations, we are able to substitute complex and expensive internal fixation devices with external fiuators thereby lowering the risk of infection. In summary, we feel that the third world only needs a cheap fixator if it meets the demands listed above. It would be a very expensive “saving” if the quality and versatility of the fiiator were greatly reduced.

12. Extmal fixation in catastmphe and wr A.Femandez, JLasa

It should be possible to convert it to a sliding fiiator which we may need to leave in place until final bone healing. It must be able to cope with limb lengthening, bone transport and correction osteotomies. Probably the most complex and striking deformities and the worst sequelae of neglected fractures are to be found in the third world countries. (I have listened to many lectures of fit world surgeons on external fixation and the most striking cases they present of limb deformity are those they encountered when tmvelling in the third world.) In our humble opinion, open, aggressive operation to reduce a fracture in order to insert a cheap fiiator is more expensive than atraumatic operation to apply an expensive fiiator. In the former case, the postoperative infection rate, the malreduction rate and the number of nonunions will be much higher, the treatment of which will be more expensive than the cost of buying a more expensive, better, first world fixator. We do not believe in the real savings involved in purchasing poor quality, cheap, third world fixatom. Our experience over ten years has been that, by reusing the good quality external fiuators mom than 20 times with very few rejects due to damage to components, we are able to reduce the cost of the fiiator per patient dramatically. There are first world surgeons who believe that reuse of fixators is not possible in the third world because these people never go back to the same doctor to have the fiiator removed and because they would sell the thing to someone anyway. This has not been our experience. We have a very high retrieval rate of the external fixators we insert. This is actually a question of organ&&on. We have trained, salaried personnel who contact the patients every week after they have left the hospital right up to implant removal. This is not only in the interests of retrieving the fiuator but also to avoid mistakes in the follow-up of these patients by the interference of well-meaning but unskilled local doctors. In our experience, contact can always be maintained by visits, by phone and with the help of the police or army when necessary. I should like to world countries should invest is us that buying

draw attention to the fact that in third the decision of how and in what we an important one. Experience has taught cheap replicas is more expensive than

The medical situation in catastrophe or war is much the same. There is a sudden rush of severely injured patients, overloading available facilities. These patients have to be treated in casualty on arrival by young inexperienced surgeons in far from ideal conditions. What should we use, external or internal fixation ? In such a situation, it will seldom be possible to keep tmck of all the instruments and implants required for open reduction and internal fixation. It will not be easy to achieve optimal OR conditions to reduce postoperative infection risks, nor will it be possible to find highly skilled surgeons at short notice to perform complex operations under difficult conditions. A simple, user-friendly external fixator frame consisting of only a few elements and being quick and easy to insert is almost certainly to be preferred to conventional internal fixation techniques in situations of catastrophe and war (Femandez and Lasa, 1990). The main advantages of such a system in these situations would be: -

a minimum of components (only some clamps, screws and tubes)

-

minimal infection risk related to bone fixation

-

minimal training for surgeons

-

wide range of indications (with regard to fracture type, joint injury, size and age of the patient).

In war, the surgeon must operate on the most severely injured patient first, whether this is a civilian, a soldier, a child or an adult. Therefore, the system must be versatile enough to accommodate children (we use the same size fiiator for the adult upper limb and the child’s lower limb). The external fixation system will enable less trained surgeons to fu multiple fractures quickly and atraumatitally. The external fixation system is simple, using only a few elements, can be adapted to fix both open and closed fractures and stable fiuation can be achieved using the most simple of frames. A system with total bone reduction possibilities is a must in these situation. In an emergency, it does not matter whether the fuator is temporary or permanent That is an issue which can be resolved later. There is some confusion about what a war fuator should

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be. A fixator with a very small frame in a neat package to fit into a soldier’s pocket has been presented as the ideal war external fixator. We do not see the soldier carrying his own fixator, his antibiotics and saline solution for wound lavage and his pain killers in his pocket ready for external fixator insertion. It is not realistic to envisage the soldier being externally fixed in the field with his pocket fiiator by his best friend ! There will always be facilities of a sort, including X-my and anaesthesia, available at the field hospital where an external fixator can be inserted. A hand drill can also be provided by the hospital and a small stock of fixators kept there. We feel that an extfnnal fixator for use in these situations must be strong enough to stabilise the most challenging injuries, such as injury to the adult femur. It must be capable of total bone reduction to allow for the treatment of closed fractures and atmumatic insertion in open fractures. It may also be important to use a system which can be left in place until bone healing, i.e. as the definitive treatment, even in femoral fmctures. Sometimes there will be nowhere to send the patients for secondary nailing (for example, after an earthquake in a third world country). In Uruguay, we have often been forced over the last 10 years to insert external fixators in very primitive environments, sometimes without even standard X-ray facilities which is similar to the situation in war or disaster. Our experience using the modular frames described earlier, applied with simple pin fixators, has been rewarding. Seeing young residents at ease using the system reaffirms our beliefs. We would like to suggest a system like the one we have presented here as a valid option in war and catastrophe external fixation.

For limb lengthening, we found that this system was second to none. Our results are quite good and the results of our friends and colleagues in Malaga are even better (see chapter 9.1). The simplicity of its insertion and the facility to replace or add pins as necessary are worthwhile features of this simple, limb lengthening system. For correction osteotomies, we were more than satisfied with the results we obtained and with the ease of the surgical procedure in very complex cases. We hope that the cases we describe are a good demonstration of what we are trying to express. In bone transport, we feel that our system is the best unilateral system available today and it is the only one which allows smooth correction in both planes of the direction of our mobile fragment. For the treatment of wrist fractures, it has proved a simple, elegant and very effective system for dealing with complex, highly comminuted distal radial fractures. In the treatment of the severely injured hand, the external fixator has been a very powerful tool, the use of which is easy to learn. It is successful and attractive for the treatment of hip and shoulder arthrodeses. For us today, this Swiss army external fixator concept is totally valid because it is advantageous to have only one tool for so many different tasks and because we feel it is amongst the best tools currently available for each of the tasks listed above (Fig. 56).

13. me swh army exhmal fixatorconcept We have shown that we use an external fixator for fracture treatment in adults and children limb lengthening bone transport correction osteotomies wrist fractures hand injuries arthrodesis as an elective procedure in the hip and shoulder The principle is very similar to that of the Swiss army knife. You have one system which you use frequently and are familiar with. If you can adhere to the “keep it simple rule” and if the system consists of only a few different elements and you always build the same frames, then this is even better. Of course, this is only a valid approach as long as the external fiiator is the best tool to perform all the different t&S.

For the treatment of the indications described here, in children and in adults, we feel that this procedure is the best choice available to us today.

Fig. 56: Swiss Army External Fixator Concept. One tool for all tasks.

14. PithUs and bad nrulis We were generally satisfied with the results achieved using the external fiiator systems, however, there were difficulties, mistakes and bad results. There were wrong indications, badly applied frames and cases in which we thought all was well but we still had bad results. We will show a few examples (Figs 57 and 58).

Femhdez:

Simple pi” fka tors

s 41

Fi . 44: 12- ear-old ‘rl. Renal rickets. Marked complex 3D deformity of both limbs. 1 cluuca and X-ray assessment of the deformity, a three level osteotomy on each side was At! er carea.*7 lanned. %or example, it was planned to perform the left distal femoral osteotomy as a 30” valgus deformity, 20’ extension, and 30” external rotation wedge resection osteotomy. Similar carefully planned corrections were designed for each of the other two tibia1 osteotomies. Then 3 complex 3D corrections were performed on both sides. a: Preoperative condition. b: Clinical as ect after the left limb had been corrected and fixed using a single tube unilateral uniplanar frame on d!le tibia and another one on the femur. One week later the right limb was operated on. c: Final view once all the osteotomies had healed. Good final result

Fig. 45: 21-year-old woman. Lobstein’s disease, marked deformity of both femora and both tibiae. She had been unable to walk since she was 6 years old. a, b and c: Preoperative condition.

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Fig. 45 contd: After careful preoperative lannin a one stage femoral osteotomy, and a two stage tibia1 osteotomy were performed on the left lim! and 8x ed with external fixators. A simple 30” extension wedge resection osteotomy was done on the femur and 30’ varisation and 30” extension resection wedge osteotomies were performed at each tibia1 level. 30” of external rotation were added at the lower tibia1 osteotomy. Thus, 3 complex, wedge resection osteotomies with high correction angles were performed on the left limb as a one sta e single operation. d: 8 ood postoperative reduction. e: Clinical aspect after the left limb had been operated on and fixed using type IA frames. f: Postoperattve X-ray after a similar rotocol had been followed on the nght tibia. It was considered too great a risk to operate on the right Pemur. g and h: Note the lateral clinical view of both legs before and after correction. 1 and j: Final X-rays at 29 and 45 weeks after operation showing both tibiae healed and good alignment in both planes. k The patient is now be ‘nning walking rehabilitation after 15 years of being unable to bear any weight on her lower limbs. Fair cYinical result

Femiindez: Simple pi” fixatars

s 43

Fig. 46: lo-year-old girl. Renal rickets. She had already been operated once before but the deformity recurred. She had a complex 3D deformity and a three level osteotomy on each side was planned. a: Preoperative X-ray. b: Clinical condition after both limbs have been operated on and fixed using single tube unilateral uniplanar frames. Complex 3D corrections were performed on the distal femur and distal tibia and a simple wedge one plane correction was performed on the upper tibia on each side. c and d: X-ray at 14 weeks. Both tibiae and femora after correction and progressive adual lengthenin of 2 cm at each one of the six osteotomy sites. Three lengthenings were pel-f? ormed on each Prmb simultaneously. e: Final X-ray at 60 weeks. All osteotomies healed; good limb alignment was achieved and all the lengthening zones healed. 6 cm of lengthening was obtained for each limb. Good final result

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Fig. 47: 11-year-old boy. Marked proximal humeral deformity of unknown origin. An upper humeral osteotomy was planned with the idea of correcting a 90“ varus deformity and a 60” internal rotation at this level. The osteotomy was performed according to preoperative planning and fixed with a modular frame in order to redisplace the osteotomy should neurological complications appear. Postoperative healing was uneventful and the bone healed in the corrected position. a: Strrking preo erauve view of the limb. b: Preoperative R -ray c: X-ray at 5 weeks. Note the healed, corrected bone. d and e: Marked difference between preop. and postop. views of the limb. Good final result

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Fig. 48: 8- ear-old girl, Post-traumatic pseudarthrosis and a very short limb. a and b: %reoperatrve view of the limb. afting, combined with an ulnar lengthening c: Modular external fixation of the pseudarthrosis and bone erformed at an up er ulnar osteotomy. The small external fE ator was used. d: R-ray at 10 weeks. R ote the satisfactory bone regeneration and the healed pseudarthrosis. e and f: Limb lengthening g: X-ray at 16 weeks. Note good corticalisation at the lengthening site and healed bone at the pseudarthrosis site. h: Final view of the limb. Good final result

546

Fig. 49: Type IA frame inserted for limb lengthening. a: At surgery a sin le tube frame was inserted, keeping pin lacement freedom. b: As long as len P ening is being performed, the second tu! e is used.

Fi . 50: 19-year-old man. Post-traumatic femoral shortening. Simple limb lengthening was performed. a: B reoperative views of both limbs. b: Postoperative X-ray. Osteotomy can hardly be seen between the second and third Schanz screws. c: Lateral X-ray at 5 weeks. It is useful to be able to achieve such a clear lateral X-ray view of the knee joint whilst performing a femoral lengthening, as is possible with this system.

Femiindez:

Simple pin fiiators

Fig. 50 contd: d: Lateral X-ray view of the knee treated using ring fixators. This emphasizes the simplicity of our system. e: Good callus formation is present after 7 cm of lengthening, seen on the X-ray at 23 weeks. f: After limb length equalisation, the second tube was removed, and a single tube type IA frame remained. g: Healed bone after external fixator removal can be seen on the X-ray at 27 weeks. Good final result

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S48

Fia 51: Turner’s _ _syndrome. 21-year-old female. 12 cm bilateral tibia1 lengthening. a: Preoperative clinical view. Height 137 cm. b: X-ray at 1 month c: X-rays at 3 and 4 months d: X-rays at 7 and 10 months e: X-ra at 12 months f: Fina Y clinical condition. Height 149 cm.

Femhdez:

Simple pin fixators

Fig. 52: Proximal femoral congenital disease in a lo-year-old boy. 13 cm left femoral lengthening. a: Clinical aspect, 10 cm shortening. b: Preop. X-ray c: Intraop. and X-ray at 1 month. d: X-rays at 2 and 4 months e: Clinical condition 5 months after operation. Limb equalisation has been attained. f: X-ray at 12 months

Fig. 53: Type IA frame inserted for bone transport a: At operation, a single tube frame was inserted, keeping pin placement freedom. b: As long as bone transport is being performed, the second tube is used.

Fig. 54: 49-year-old man. 8 cm bone defect in the distal tibia after severe open fracture. a and b: Soft tissue defect existed when bone transport began. Note the single tube type IA frame inserted at 0 eration. c: J ote the 8 cm bone defect and the large third fragment detached when performing the upper tibia1 osteotomy. It forced us to insert a third proximal screw in order to have good purchase on the proximal tibia. d: The second longitudinal tube was inserted one week later, as an out-patient procedure, and only used while the transport was taking place. e: Note the advance of the mobile fragment, its good docking, and the satisfactory bone regeneration. f: After good distal bone contact had been achieved, the second tube was removed, and a single tube frame remained. g: Two years later, the X-ray shows the healed bone. Good alignment, no shortening. Good final result

Femhdez:

Simple pin fixatars

s 51

Fig. 55: 25-year-old man. 9 cm bone defect in the upper tibia after a shotgun injury. a: Arteriography showed that there were no vessels available for a vascularised transfer. Bone transport was performed from the bottom up. ent will not hit the proximal tibia fragment It is wrongly b: Note that a mistake was made. The mobile fra directed. Usually this is not easy to correct wi 8” most unilateral fixators used for bone transport. However, it was very simple using this fixator. The procedure was painless, required no anaesthesia, and was erformed in the X-ray room. c: ! he direction of the mobile fragment was totally corrected. Now it is facing perfectly towards the upper tibia1 fragment d: Good callus regeneration after 9 cm of bone transport, very good docking has been achieved in spite of the initial mistake in bone alignment No bone grafting was performed. e: The bone healed without shortening, with quite good alignment Note the slight tilting of the proximal tibia1 fragment because of pin loosening shown by the enlarged Schanz screw hole scars.

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Fi . 57: 7-year-old boy. Congenital limb malformation. Marked shortening of the femur and tibia. a: 8: emoral lengthening was decided upon and was successfully performed. b: X-ray at 13 weeks. Pin loosening at the distal fragment is evident even when the Schanz screws have already been replaced, as can be deduced from the scars of the previous screws. At 15 weeks the external fixator was removed, the callus was thought to be strong enough, but a fracture at the callus level occurred and the femur bent forward, healing wrth a 90” deformity, as can be noted in the final X-ray. c: The patient is awaiting corrective surgery for this deformity. Very bad result

Fig. 58: lo-year-old boy. Congenital tibia1 pseudarthrosis. Previously operated on many times, marked limb shortenin . a and b: # reoperative view of the limb. Homolateral vascularised fibular graft was performed. In the same surgical procedure, an upper tibia1 osteotomy for limb lengthenin was carried out c: Two weeks after operation, Pimb lengthening is taking place

Ferhndez: Simple pin fixa ton

s 53

Fig. 58 contd: _ _ d and e: Four weeks atter operation, correct length has been achieved and the orientation of the limb is correct f: Both distal fractures healed but the proximal osteotomy where the limb lengthening was performed went on to pseudarthosis which is still present Very bad result

Aadalen R, Harvey E, Chisholm T, MC Parland F, Sweetser T (1980) Exstrophy of the bladder. Clin. Orthop. 151:193200 Allgower M, Sequin F (1987) Dynamisation of the AO/ASIF Tubular External Fixator. AO/ASIF Dialogue 1:12-15 Arrien A, de Pablos J (1990) The importance of the technique and level of osteotomy in bone Lengthening. In: Bone lengthening. Current Trends and Controversies. Ed, by de Pablos J, Cafiadell J. Facultad de Medicina de la Universidad de Navarra. Pamplona. Behrens F (1982) A classification of external fixators In: Uhthoff HK (ed) Current concepts of external fixation of fractures. Springer Verlag, Heidelberg Behrens F, Comfort T, Searls K, Denis F, Young T (1983) Unilateral external fixation for severe open tibia1 fractures. Clin. Orthop. 178:111-120 Bone L, Bucholz R (1986) The management of fractures in the patient with multiple trauma. J. Bone and Joint Surg. 68 A:6 Bradama R, Abraham E, Ray R (1976) Hip fusion utilizing the cobra head plate. J. Bone and Joint Surg. 58A:541-544 Burny F (1978) Elastic external fixation of tibia1 fractures: Study of 1421 cases. In: Brooker A, Edwards C (eds) External fixation. The current state of the art. Williams and Wilkins, Baltimore London

Cafiadell J (1986) Sobre el aumento de versatilidad y ampliacion de las posibiidades de un fijador extemo monolateral en traumatologfa y ortopedia. Rev de Ortop y traumatologia 30 (IB):477-480 Claudi 8, Mooney V. (1982) The use of external fixatom in the polytraumatized patient. In: Uhthoff HK (ed) Current concepts of external fixation of fractures. Springer Verlag Heidelberg Claudi B. (1991) Clinical testing of unreamed medullary nailing in the tibia. Hands on Course, Davos. Pers. communication De Bastiani G, Aldegheri R, Renzi L, Trivella G (1986) Limb lengthening by distraction of the epiphyseal plate. J. Bone Joint Surg. 688545549 De Bastiani G, Aldegheri R, Renzi Brivio L, Trivella G (1986) Chondrodiatasis-contlled symmetrical distraction of the epiphyseal plate. J. Bone and Joint Surg. 68B(4):550556 Femandez Dell’Oca AA (1985) External fixation in the leg using unilateral biplanar frames. Arch. Orthop. Trauma Surg. 104:182-X% Femandez Dell’Oca AA (1989) Modular external fixation in with the A.O. tubular system. Intergraf, emergency Montevideo.

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Femandez A, Lasa J (1990) Actual state of military external fixation. Medical Corps International 5:3040 Femandez Dell’Oca AA (1992) External fixation of fractures with a new frame in managing patients with multiple trauma. J. of Trauma 32 (2):X6-174 Ganz R, Mast J, Weber BG, Pen-en SM (1991) Clinical aspects of “bio-logical” plating. Injury 22 Supp 1:45 Gilbert A (1979) Vascularized transfer of the fibular shaft. Int’l J. of Microsurg. 1(2):100-102 Hierholzer G, Riiedi Th, Allgower M, Schatzker J (1985) Manual on the AO/ASIF tubular external fixator. Springer Verlag, Heidelberg Holbrook J, Swiontkowski M, Sanders R (1989) Treatment of open fractures of the tibia1 shaft: Ender nailing versus external fixation. J. Bone and Joint Surg. 71-A(8):1231-1238 Hontzsch D (1989) Erleichterung der Repositionmantiver besonders am Oberschenkel mit dem Fixateur exteme. Tempo& angeklemmte lange Griffe bei der 3 Rohr modular Technik mit dem A0 Rohrsystem. Akt. Traum. 6:305 Jakob R, Femandez D fractures with the small Uhthoff HK (ed) Current fractures. Springer Verlag,

(1982) The treatment of wrist A0 external fixation device. In: concepts of external fixation of Heidelberg

Jupiter J, Bour Ch, May J (1987) The reconstruction of defects in the femoral shaft with vascularized transfers of fibular bone. J. Bone and Joint Surg. 69A365-374 Lloyd Roberts G, Williams D, Braddock G (1959) Pelvic osteotomy in the treatment of ectopia vesicae. J. Bone and Joint Surg. 41-B:754-757 Loder RT (1987) Pediatric polytrauma: orthopaedic and hospital course. J. Orthop. Trauma 148

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Mast J, Jakob R, Ganz R (1989) Planning and reduction technique in fracture surgery. Springer Verlag, Heidelberg Maurer D, Merkow R, Gustilo R (1989) Infection after intmmedullary nailing of severe open tibia1 fractures initially treated with external fiiation. J. Bone and Joint Surg. 71-A(6):835-838 Mears DC (1983) External skeletal Wilkins, Baltimore, London

fixation.

Williams

and

Mezhenina E, Roulla E, Pechersky A, Babich V, Shadrina E, Mizhevich T (1984) Methods of limb elongation with congenital inequality in children J. Pediatric Orthop. 4(2):2Ol-287 Mower-y CA, Houkom JA, Roach JW, Sutherland DH (1986) A simple method of hip arthrodesis. J. of Ped. Orthop. 6:7-10. Miiller M, Allgower M, Schneider R, Wiienegger H (1991) Manual of internal fixation. Springer Verlag, Heidelberg

Perren SM, Klaue K Pohler 0, Predieri M, Steinemann S, Gautier E (1990) The limited contact dynamic compression plate (LC-DCP) Arch. Orthop. Trauma Surg. 109304-310 Pen-en SM, (1992) Pers. communication Root L, Goss JR, Mendes J (1986) The treatment of the painful hip in cerebral palsy by total hip replacement or hip arthmdesis. J. Bone and Joint Surg. 68A (4):590-598 Sponseller P, Gearhart J, Jeffs R (1991) Anterior innominate osteotomies for failure or late closure of bladder exstrophy. J. of Urology 146:137-140 Wagner H (1978) Operative Clin. Orthop. 136:125-142

lengthening

of the

femur.

Since the postal service in Uruguay leaves a great deal to be desired, the following address should be used to correspond with the author: AO/ASIF Research Institute Mrs.J.Buchanan Clavadelerstrasse CH-7270 Davos Platz, Switzerland Or: Fax no.: 00598-2-80 96 29

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External fixation using simple pin fixators.

Sl External fixation using simple pin fixators A.A.FemBndez Dell’Oca, M.D. British Hospital Montevideo, Uruguay might not be stable enough to withs...
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