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Introduction: Traditionally, stiff hypertrophic nonunions have been managed with open preparation of the nonunion site, which is then secured with internal fixation. Alternative surgical options are available including distraction osteogenesis with an external fixator. There is currently a limited amount of literature pertaining to the use of distraction osteogenesis in the management of hypertrophic nonunion. The aim of this systematic review was to collate and assess the effectiveness of distraction osteogenesis (DO) in the management of hypertrophic nonunions and to evaluate the complications that are commonly reported in the literature. Methods: We searched for articles pertaining to the treatment of hypertrophic nonunion using distraction osteogenesis. Several electronic bibliographic databases and clinical trial registries were searched using the MeSH terms "hypertrophic non-union," "distraction osteogenesis," "stiff non-union," and "External Fixation" in various combinations to return the maximal number of studies for review. We performed a systematic review and identified a total of 11 studies eligible for review. Results: The review of the literature demonstrated that this technique is highly effective in achieving bony union with minimal complications. The most common complication is mild superficial pin site infections, usually managed with oral antibiotics and effective wound hygiene. Other complications reported were deep pin tract infections, broken hardware, and deformity recurrence due to collapse of regenerate bone. Conclusion: The use of distraction osteogenesis with external fixator devices is an effective and safe method for producing bony union in hypertrophic nonunions. There were minimal associated complications.

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Distal humeral intra-articular fractures often result in functional impairment if treated conservatively. These fractures are particularly challenging due to osteoporosis and severe comminution. A 32-year-old female with a grade three open distal humerus intra-articular fracture presented with a 5 cm x 5 cm open wound on her right elbow. The patient underwent open reduction and internal fixation (ORIF) using the BB Joshi external fixator and a local flap for skin coverage, achieving stable fixation and early mobilization. The patient regained a near-normal range of movements and adequate skin coverage of the wound at follow-up. Compared to traditional ORIF, it showed lower infection rates and comparable union rates, leading to better functional outcomes when compared with the studies reported earlier. The BB Joshi external fixator effectively treats grade three open distal humerus intra-articular fractures, minimizing complications and promoting functional recovery.

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Introduction: The induced membrane technique was initially described by Masquelet in 1986 as a treatment for tibia non-union. It then became an established method in the management of bone defects.A critical bone defect is defined by a gap larger than 25 mm, and so, has a higher probability of non-union. Many techniques have been described to resolve this problem such as segmental bone transport, free vascular fibula graft, non-vascular fibula graft, autogenous graft, or megaprothesis. Case Report: We present the case of a 37-year-old woman who presented a multi-fragmentary open fracture of the tibia and fibula bilaterally (Gustilo-Anderson III) after a high-velocity car accident. Conclusion: The aim of this article is to demonstrate that the use of a hybrid procedure combining the Masquelet technique with the Ilizarov external fixator and reamer-irrigator-aspirator can be an effective way to treat bone defect in an open tibial fracture classified as a Gustilo-Anderson III.

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OBJECTIVE: The principles of limb reconstruction are crucial for treatment success, but there is no unified standard for complex limb deformities. The aim of this study was to analyze the characteristics of the cases of post-traumatic lower limb deformity and explore the new principle of limb reconstruction. METHOD: A retrospective analysis was conducted of 148 patients with post-traumatic lower limb deformity who underwent surgery from May 1978 to December 2023; 85 were males (57.4%) and 63 were females (42.6%); 65 cases of left side (43.9%), 79 cases of right side(53.4%), and 4 cases were on both sides (2.7%), the average age was 24.64 years (5-69). There were 4 cases suffering hip deformities, 40 cases of femoral deformities, 18 cases from knee, 40 cases from tibiofibular, 93 cases of foot and ankle deformities, and some patients also had two or more types. All patients underwent surgical intervention in an average of 40.5 months (12-96) after injury. According to the evaluation of limb deformities, deformity correction and functional reconstruction with external fixation were implemented, following the principle of "one walking, two lines, and three balances." The clinical evaluation adopts the criteria of Qinsihe lower limb deformity correction and functional reconstruction. RESULT: 148 patients with post-traumatic lower limb deformities were followed up for 40.9 (12-356) months. The main surgical procedures implemented were tendon lengthening and soft tissue release (84 cases), osteotomy (93 cases), joint fusion (30 cases), and tendon transposition (16 cases); there were multiple surgical procedures in some patients. Among them, 124 cases used external fixators for stress control and 27 cases used internal fixation, while 3 cases used plaster or brace. There were 5 wire reactions postoperatively, which improved after dressing change and oral antibiotics. There were 2 pin infections, which improved by pin removing. No surgical related deep infections occurred, and no surgical related neurovascular damage occurred. At the last follow-up, all limb deformities were corrected, limb function improved, and the results of treatment was very satisfactory. According to Qinsihe evaluation criteria for lower limb deformities, 74 cases were excellent, 56 cases good, and 18 cases fair, with an excellent and good rate of 87.84%. CONCLUSION: Stress control with external fixation is effective, safe, and controllable in correcting and reconstructing post-traumatic lower limb deformities. The principle of "one walking, two lines, and three balances" plays an important role in the entire process of stress control limb reconstruction.

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Purpose: Treatment of osteomyelitis (OM) is challenging. Ilizarov bone transport is a commonly used technique for management of OM. The recently introduced limb reconstruction system (LRS) has been effectively used for management of OM. It was suggested to be easier in use and less invasive. The present retrospective study aimed to compare LRS and Ilizarov bone transport in management of femoral OM using a propensity score matched analysis. Methods: The present retrospective study included 80 consecutive patients with femoral OM. The studied patients were managed either using Ilizarov external fixator (n = 40) or Orthofix LRS (n = 40). The clinical outcome measurements included union time, limb length discrepancy, additional operative procedures, refracture and infection. Results: Patients in the LRS group were exposed to significantly higher frequency of bone transport (30.0 versus 15.0%) and lower frequency of acute compression and lengthening (10.0 versus 32.5%). Patients in Ilizarov group had significantly higher frequency of tobramycin pellets as compared to their counterparts. The studied groups were comparable regarding the operative complications including pin-tract infection, non-union at docking site and refracture. Patients in the Ilizarov had significantly shorter time to union (8.2 ± 3.2 versus 11.0 ± 5.6 months, p = 0.012). No statistically significant differences were found between the studied groups regarding the quality-of-life domains. Conclusions: Use of Ilizarov external fixator and Orthofix LRS devices proved to be effective and reliable. Their influences on patients' quality appear to be comparable.

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Introduction: Floating hip with hip dislocation is a very high-energy, devastating, and rare injury whose treatment is very challenging, and the outcome is usually poor. Case Report: A 35-year-old man presented posterior wall fracture acetabulum and dislocation of the hip with ipsilateral distal third shaft femur fracture with intra-articular extension fracture and un-displaced patella fracture. We achieved a reduction of hip dislocation by a knee-spanning external fixator followed by open reduction and internal fixation with anatomical locking plate for distal third femur fracture with intra-articular extension followed by open reduction and internal fixation for posterior wall of acetabulum with recon plate in Kocher-Langenbeck approach in stages. The patient was able to partial weight bear after 12 weeks of the injury and mobilized independently without any support after 5 months. Conclusion: Floating hip with hip dislocation is difficult to manage but reducing the hip dislocation with knee spanning external fixator and management in stages will reduce the complications and better outcome.

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OBJECTIVE: Currently, the traditional treatment of moderate-to-severe ankle arthritis is joint fusion or joint replacement. The aim of this article is to explore the clinical efficacy of distraction arthroplasty in the treatment of moderate-to-severe ankle arthritis. METHODS: A retrospective analysis was conducted with a total of 34 cases who were diagnosed with moderate-to-severe ankle arthritis and treated by distraction arthroplasty from January 2007 to November 2021. The average age was 42.3 years. The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and pain visual analog scale (VAS) were used to evaluate ankle pain and functional improvement before surgery and at the last follow-up. Based on age, the patients were divided into the ≤45-year-old group [young group, 15 cases, age (36.37 ± 4.31) years old] and the >45-year-old group [middle-aged and elderly group, 19 cases, age (53.74 ± 3.17) years old]. The analysis included comparing preoperative and postoperative AOFAS ankle-hindfoot and VAS scores and the influence of age on distraction arthroplasty. RESULTS: All 34 patients were followed up, and the follow-up time ranged from 13 to 143 months, with an average of 45.3 months. The follow-up times for the young and middle-to-elderly groups were (33.19 ± 21.37) months and (55.63 ± 29.69) months, respectively. At the last follow-up, the AOFAS ankle-hindfoot and VAS scores were significantly improved compared with the preoperative assessment (p < 0.05). According to the etiological analysis, except for Pilon fracture, which showed no differences pre- and postoperation in the AOFAS ankle-hindfoot score and VAS score (p > 0.05), all other patients showed significant differences in these two scores (p < 0.05). The difference in preoperative AOFAS ankle-hindfoot scores between the young and middle-to-elderly groups was statistically significant (t = 3.422, p = 0.021). The preoperative and postoperative comparison of preoperative VAS scores, AOFAS ankle-hindfoot scores, and VAS scores before and after surgery showed no differences (p > 0.05). The joint space width (JSW) of 10 patients who were followed up for more than 5 years was (2.9 ± 0.5) mm. Two patients who were followed up for more than 10 years showed 3.3 and 3.0 mm, respectively, JSW. CONCLUSION: Distraction arthroplasty with the Ilizarov external fixator can achieve satisfactory results in the treatment of moderate-to-severe ankle arthritis (except arthritis caused by Pilon fracture surgery). Age has no statistical impact on the efficacy of distraction arthroplasty.

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Background: Evidence concerning the complex foot trauma, especially its definitive management, is scarce. Soft tissue envelope sequalae are the primary parameters that delay or make internal fixation implausible. Stability conferred by external fixators makes them a reasonable initial treatment choice. Although AO or circular fixators can be applied around the foot, this can involve a learning curve and substantial costs, especially for the circular fixator. There is little evidence as to how well external fixators work as a definite method of fixation in patients where progression to internal fixation cannot be made. Methods: We prospectively evaluated 10 adult patients with severe and complex foot trauma who were consecutively treated at our clinic. Initial reduction and stabilization were performed with an external fixator that was initially conceived for distal radius fractures, applied during the initial procedure and mantained throughout the treatment. Results: Fracture healing was obtained in all 10 cases, and both internal and external column length was restored. One of the patients developed chronic osteomyelitis. At the 1-year follow-up visit, these patients averaged 45.6 points in the physical and 44.8 points on the mental status sections of the 12-Item Short Form Health Survey (SF-12). The Foot Function Index findings for pain, disability, and daily activities limitations were 33.3, 39, and 41.5, respectively, which suggest moderate residual impairment. Conclusion: In this relatively small case series of complex foot trauma, we found that the use of simple external fixation as definitive treatment worked reasonably well. Level of Evidence: Level III, prospective cohort study.

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Introduction: The management of hip dislocation in patients older than 9 years of age is a challenge in terms of deciding which is the best treatment course to follow since the main sequelae are as follows: pain, discrepancy in the length of the pelvic extremities and lame gait, with the consequent disability for activities of daily living. In Ho Choi, Thabet A mention limited treatment options, including total hip arthroplasty and hip arthrodesis. These options have their benefits and limitations. The pelvic support osteotomy initially indicated for the treatment of septic arthritis of the hip and performed for the first time by Bavoier in 1838 and modified in 1970 by Ilizarov aims to improve the aforementioned sequelae. These cases report showed us the functional improvement with the treatment of dislocated hip dysplasia with pelvic support osteotomy with monolateral fixator and the 2nd osteotomy 4 cm distal to the hip. This was corroborated through the application of the modified Harris test. Case Report: A series of six female Mexican adolescent patients from 11 to 17 years of age who come to the clinic due to long-standing pain symptoms in the coxofemoral joint, three patients in the right and three in the left hip when walking. All were treated with pelvic support osteotomy. The six patients continued with mild positive Trendelenburg but all of them diminished the discrepancy in the pelvic extremities, the mobility arcs were preserved and pain was suppressed in all. The modified Harris test showed increased scores (103.3%) after the surgery. There was just a minor complication in a patient, and it was resolved with surgical lavage. Conclusion: The modifications in the technique, monolateral fixator and second osteotomy 4 cm from the first one, allowed our patients to present functional improvement at the hip, which was assessed with the modified Harris scale. Patients achieved independent walking without pain and Trendelenburg less evident. The changes we found in our patients are evidence of the goodness and effectiveness of this type of osteotomy in patients older than 9 years of age, to improve the function of the hip.

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Proximal phalanx fractures of the big toe involving angulation or dislocation of the articular surface require repositioning and fixation. We treated a patient with such a fracture using a novel wire-connected external fixator, the ICHI-FIXATOR® system. A 45-year-old male sustained an injury when slipping down the stairs and impacting his left big toe. Plain radiography and computed tomography revealed a proximal phalangeal fracture of the left big toe with dislocation of the articular surface and comminution. The surgical intervention was performed using 1.1-mm diameter C-wires and an external fixator. The patient regained ambulation and resumed work immediately after surgery. Four weeks postoperatively, all wires were removed on an outpatient basis. Eight months postoperatively, the patient experienced no pain during strenuous activities or exercises. This novel wire-connected external fixator provides reliable and secure fixation, facilitating a prompt return to normal daily activities. This technique may be an effective option for managing toe fractures.

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Decision-making regarding limb amputation represents a significant clinical challenge, especially when the initial evaluation does not coincide with the criteria established in scales used worldwide, as is the case of the MESS scale. This article presents the case of a 24-year-old female patient who was transferred to a university hospital after a road traffic accident with severe and large lesions in the left lower limb. Despite a poor initial prognosis and in-hospital complications, including multiple surgical procedures and foot drop, a favorable recovery was achieved with complete anatomical salvage of the limb at risk. The multidisciplinary approach and intensive rehabilitation were instrumental in achieving a satisfactory functional recovery. This case highlights the importance of considering factors beyond amputation scale scores, as well as the need for comprehensive care to improve outcomes in patients with complex extremity injuries.

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Objective: To analyze the effectiveness of external fixator combined with Kirschner wire (EF-KW) fixation in the treatment of oblique and comminuted distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children. Methods: A clinical data of 22 children with DHMDJ fractures who met the selection criteria between April 2021 and December 2023 was retrospectively analyzed. All patients were treated with EF-KW fixation. There were 14 boys and 8 girls with an average age of 6.8 years (range, 1.5-12.0 years). The time from injury to operation was 14-38 hours (mean, 24.2 hours). There were 18 cases of comminuted fractures and 4 cases of oblique fractures; and 1 case of median nerve injury and 1 case of radial nerve injury before operation. The occurrence of postoperative complications was recorded. At last follow-up, the function of the affected elbow joint was evaluated according to the Mayo elbow joint function score, and the Baumann's angle (BA) and humero-capitellar angle (HCA) of the affected and healthy sides were recorded and compared. Results: All fractures were successfully treated with closed reduction and no complications such as nerve injury occurred. Superficial infection occurred in 4 cases after operation and healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 9-24 months (mean, 13.8 months). At last follow-up, according to the Mayo elbow joint function score, the elbow joint function was rated as excellent in 15 cases, good in 6 cases, and fair in 1 case, with an excellent and good rate of 95.5%. The neurologic injury before operation recovered gradually. X-ray films reexamination showed that all fractures healed, and the healing time of fractures ranged from 29 to 61 days, with an average of 35.6 days. At last follow-up, there was no significant difference in BA and HCA between the healthy side and the affected side ( P>0.05). During follow-up, 1 case developed mild cubitus varus, while the other patients had no serious complications. Conclusion: EF-KW fixation for oblique and comminuted DHMDJ fractures in children has the advantages of less trauma, simple operation, easy reduction, good stability after reduction, low incidence of serious complications, and good elbow functional recovery.

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Background: The treatment of displaced intra-articular calcaneal fractures (DIACF) is debated. This study compares open reduction and internal fixation (ORIF) with minimally invasive osteosynthesis (MIOS). Methods: We conducted a retrospective study on 70 patients with DIACF treated between January 2018 and September 2022, divided into ORIF (n = 50) and MIOS (n = 20) groups. Functional outcomes were assessed using the Maryland Foot Score (MFS) and the Creighton-Nebraska Health Foundation Assessment Scale (CNHFAS). Radiographic outcomes, complication rates, and reintervention rates were evaluated. A chi-square analysis examined the correlation between Sanders classification and treatment choice. Results: The chi-square analysis indicated no significant correlation between the complexity of the fracture and the type of treatment chosen (χ2 = 0.175, p = 0.916). Additionally, the Cochran-Armitage test for trend showed no significant trend in the choice of treatment based on fracture complexity (statistic = 0.048, p = 0.826). A Kaplan-Meier analysis showed a longer time to reintervention for MIOS (p = 0.029). Complication rates were similar, with specific complications varying between groups. Quality-of-life outcomes were comparable. Conclusions: ORIF is preferable for high-demand patients due to better anatomical outcomes, while MIOS suits high-risk patients by reducing reinterventions and complications. Further randomized trials are needed to confirm these findings.

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BACKGROUND: External fixation is widely used in the treatment of traumatic fractures; however, orthopedic surgeons encounter challenges in deciding the optimal time for fixator removal. The axial load-share ratio (LS) of the fixator is a quantitative index to evaluate the stiffness of callus healing. This paper introduces an innovative method for measuring the LS and assesses the method's feasibility and efficacy. Based on a novel hexapod LS-measurement system, the proposed method is to improve the convenience and precision of measuring LS in vivo, hence facilitating the safe removal of external fixators. METHODS: A novel hexapod system is introduced, including its composition, theoretical model, and method for LS measurement. We conducted a retrospective study on 82 patients with tibial fractures treated by the Taylor Spatial Frame in our hospital from September 2018 to June 2020, of which 35 took LS measurements with our novel method (Group I), and 47 were with the traditional method (Group II). The external fixator was removed when the measurement outcome (LS < 10%) was consistent with the surgeon's diagnosis based on the clinical and radiological assessment (bone union achieved). RESULTS: No significant difference was found in the fracture healing time (mean 25.3 weeks vs. 24.9 weeks, P > 0.05), frame-wearing duration (mean 25.5 weeks vs. 25.8 weeks, P > 0.05), or LS measurement frequency (mean 1.1 times vs. 1.2 times, P > 0.05). The measurement system installation time in Group I was significantly shorter compared to Group II (mean 14.8 min vs. 81.3 min, P < 0.001). The LS value of the first measurement in Group I was lower than that of Group II (mean 5.1% vs. 6.9%, P = 0.011). In Group I, the refracture rate was 0, but in Group II it was 4.3% (2/47, P > 0.05). CONCLUSION: The novel hexapod LS-measurement system and involved method demonstrated enhanced convenience and precision in measuring the LS of the external fixator in vivo. The LS measurement indicates the callus stiffness of fracture healing, and is applicable to evaluate the safety of removing the fixator. Consequently, it is highly recommended for widespread adoption in clinical practice.

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BACKGROUND: Webplasty can be conducted for complex syndactyly caused by Apert syndrome (also referred to as Apert hand) by extending the soft tissue in the lateral direction using an external fixator. This study aimed to verify the usefulness of webplasty without skin grafting. METHODS: Webplasty with lateral extension was conducted at a single institution from 2015 to 2023. The patients were four children with Apert hand aged 1-3 years. A custom-made small external fixator was used for all of the soft tissue extension. RESULTS: Webplasty without skin grafting was completed by the time all five patients were 5-6 years of age. CONCLUSION: Webplasty without skin grafting was possible with lateral extension of the soft tissue using a simple external fixator.

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Introduction: External fixation devices are commonly used in orthopaedic surgery to manage a range of pathologies. In this patient population, there is currently no consensus on optimal rehabilitation techniques. There exists a large variation in practice, with a limited understanding of how these affect treatment outcomes. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review was conducted of Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PEDro, and COCHRANE databases, grey literature sources and forward and backward searching of included articles. Studies were selected following rigorous screening with predefined inclusion criteria. Data quality was assessed using validated appraisal tools. Articles were synthesised by rehabilitation type and descriptive analysis was subsequently performed. Results: From 1,156 articles identified, 18 were eligible for inclusion. The overall quality was low, with clinical commentaries and case studies being the most common study type. Studies were synthesised by rehabilitation type, the most common themes being gait re-education, strengthening, therapy-assisted, active exercises and weight-bearing exercises. Conclusion: There is a lack of high-quality evidence to support meaningful recommendations and guide rehabilitation practices for this patient cohort. Further research for patients being treated in external fixation, especially related to the potential effects of physical rehabilitation on bone healing, return of strength, mobility and independent function is likely to have transferability within wider orthopaedic populations. Clinical significance: This systematic review is unable to provide clinical recommendations due to the poor quality of the available literature. However, it is hoped this paper will provide a foundation for further research to improve rehabilitation for patients being treated with external fixation. How to cite this article: Pawson JR, Church D, Fletcher J, et al. Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review. Strategies Trauma Limb Reconstr 2024;19(1):45-55.

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Aim: This prospective study assessed the clinical and radiological outcomes of open tibia fractures treated with a dynamic external fixator. Materials and methods: Twenty-five patients underwent surgical debridement and stabilisation with a dynamic external fixator between November 2016 and April 2022. Regular follow-up evaluated bone healing progression. Results: Favourable outcomes were demonstrated in 20 patients. However, there were three cases of non-union, two of which subsequently deformed, and two cases of pin site-related infection. There were no fracture site infections. Conclusion: This study demonstrates the use of dynamic external fixation in the treatment of open tibia fractures. The low incidence of complications suggests its effectiveness and potential. How to cite this article: Bezerra BS, Araujo TA, Cardonia GG, et al. The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment. Strategies Trauma Limb Reconstr 2024;19(1):36-39.

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Background: Despite surgical reestablishment of the supporting structures, instability may often persist in traumatic elbow injury. In these cases, a temporary internal or external fixator may be indicated to unload the repaired structures and maintain joint concentricity. Aggregate data are needed to characterize the risk of complication between external fixation (ExFix) and the internal joint stabilizer (IJS) when used for traumatic elbow instability. Our objective was to review the literature to compare the complication profile between external fixation and the IJS. Methods: A database query was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Population, Intervention, Comparison and Outcome characteristics for eligibility were the following: for patients over 18 years clinical outcomes were compared between an ExFix or the IJS for acute or chronic elbow instability. The Cochran risk of bias in nonrandomized studies of interventions and grades of recommendation, assessment, development, and evaluation framework were compiled for risk of bias and quality assessment. Results: The rate of recurrent instability was 4.1% in the IJS group (N = 171) and 7.0% in the ExFix group (N = 435), with an odds ratio of 1.93 (95% confidence interval 0.88-4.23). The rate of device failure was 4.4% in the IJS group and 4.1% in the ExFix group. Pin-related complications occurred in 14.6% of ExFix cases. Complications in the IJS group were the following: 1 case of inflammatory reaction, 4 cases of post removal surgical site infection, and 5 symptomatic removals. Discussion: The literature demonstrates a distinct difference in complication profile between external fixation and the IJS when used as treatment for traumatic elbow instability. Although not statistically significant, the higher rate of recurrent instability following external fixation may be clinically important. The high rate of pin-related complications with external fixation is notable.