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Background Temporary fixation with an external fixator is used for numerous indications in orthopedic trauma surgery. It is unclear whether primary wound healing or secondary open-wound healing after removal of the external fixator should be advocated for the pin site. This study compares primary wound closure with secondary wound healing for the pin site. The primary aim is to compare pin-site infection rates. The secondary aim is to compare time to wound healing and esthetic outcome. The hypothesis was that primary wound closure does not lead to more infections than secondary wound healing. Methods and design This is a prospective, randomized controlled, blinded, monocenter study based on a non-inferiority design. To obtain an equal patient population and groups, all pin-entry sites of the patients are treated alternately at the time of removal of the external fixator with primary wound closure and secondary wound healing. Patients are randomized according to whether the proximal pin-entry site is treated with wound closure or by secondary open-wound healing, from which the further sequence develops. The pre- and postoperative protocol is standardized for all pin-entry sites. A photo documentation of the pin-entry sites takes place 2 and 52 weeks postoperatively during the routine clinical follow-up visits. Further controls take place at 6, 12 and 26 weeks after pin removal. The primary outcome was to demonstrate the non-inferiority of primary wound closure compared to secondary wound healing in terms of postoperative wound infections according to the Center of Disease Control and Prevention (CDC) definitions. The secondary outcomes are time to complete wound healing (days) and esthetical outcome (subjective preference of patients and Vancouver Scar Scale score). Discussion This study aims to answer how to deal with the pin site after removal of the external fixator. To date, no routine and generally accepted protocol exists for the management of pin sites after removal of the external fixator. This prospective, randomized controlled, blinded monocenter trial should determine whether primary wound closure or secondary wound healing should be advocated after removal of the external fixator. Trial registration ClinicalTrials.gov , ID: NCT03842956 . Registered retrospectively on 13 February 2019.

Background The purpose of the study was to assess and compare the clinical efficacy of bone transport with either circular or unilateral external fixators over an intramedullary nail in the treatment of tibial bone defects caused by infection. Methods Between May 2010 and January 2019, clinical and radiographic data were collected and analyzed for patients with bone defects caused by infection. Thirteen patients underwent bone transport using a unilateral external fixator over an intramedullary nail (Group A), while 12 patients were treated with a circular external fixator over an intramedullary nail (Group B). The bone and functional outcomes of both groups were assessed and compared using the Association for the Study and Application of the Method of the Ilizarov criteria, and postoperative complications were evaluated according to the Paley classification. Results A total of 25 patients were successfully treated with bone transport using external fixators over an intramedullary nail, with a mean follow-up time of 31.63 ± 5.88 months. There were no significant statistical differences in age, gender, previous surgery per patient, duration of infection, defect size, and follow-up time between Group A and Group B ( P  > 0.05). However, statistically significant differences were observed in operation time (187.13 ± 21.88 min vs. 255.76 ± 36.42 min, P  = 0.002), intraoperative blood loss (39.26 ± 7.33 mL vs. 53.74 ± 10.69 mL, P  < 0.001), external fixation time (2.02 ± 0.31 month vs. 2.57 ± 0.38 month, P  = 0.045), external fixation index (0.27 ± 0.08 month/cm vs. 0.44 ± 0.09 month/cm, P  = 0.042), and bone union time (8.37 ± 2.30 month vs. 9.07 ± 3.12, P  = 0.032) between Group A and Group B. The excellent and good rate of bone and functional results were higher in Group A compared to Group B (76.9% vs. 75% and 84.6% vs. 58.3%). Statistically significant differences were observed in functional results (excellent/good/fair/poor, 5/6/2/0 vs. 2/5/4/1, P  = 0.013) and complication per patient (0.38 vs. 1.16, P  = 0.012) between Group A and Group B. Conclusions Bone transport using a combined technique of external fixators over an intramedullary nail proved to be an effective method in treating tibial bone defects caused by infection. In comparison to circular external fixators, bone transport utilizing a unilateral external fixator over an intramedullary nail resulted in less external fixation time, fewer complications, and better functional outcomes.

Introduction Proximal humerus fractures are usually treated with rigid angle-stable plates or nails. As an alternative, semi-rigid, minimally invasive systems have been developed for supportive fixation. A new system uses this principle with 2.5 mm partially threaded pins and external fixation. Aim This study aimed to compare the fracture stability of the fixator with an angular stable plate about whether the mechanical stability is sufficient for early postoperative mobilisation. Materials and methods Human proximal humeri (paired, female, age ≥ 60, n  = 8) were cut to a 3-part fracture and treated with an external fixator (Galaxy Shoulder, Orthofix) or an angular stable plate (Philos, DePuy Synthes). A physiological load was simulated in vitro based on a 45° abduction motion. The load level was continuously increased from 10 to 320 N within 10,000 cycles simulating the loads during rehabilitation. This was followed by another 10,000 cycles at 320 N for fatigue testing. Fracture motion was recorded with a 3D camera. Fracture stability was evaluated at a partial load of 160 N and 240 N (simulating loads during early mobilisation). Results The fracture motion at the lateral aspect was significantly ( p  < 0.034) larger for the fixator compared to the plate both for axial and for shear movements, while at the medial aspects fracture motions were similar. Both fixation systems adequately stabilized the lateral tubercle fragment with no significant differences between fixation techniques. The migration of the fixator pins (1.1 ± 1.0 mm) and valgus rotation of the head fragment were minimal (3.1 ± 2.0°). The maximum load level of 320 N was reached by all plate constructs and 3 fixator constructs. Conclusion Our results suggest that the external fixator system allows early but gentle postoperative mobilisation. More aggressive rehabilitation measures should be postponed after the healing of the fracture.

To compare the biomechanical properties of several anterior pelvic ring external fixators with two new configurations in the treatment of Tile C pelvic fractures, in order to evaluate the effectiveness of the new configurations and provide a reference for their clinical application. A finite element model of a Tile C pelvic ring injury (unilateral longitudinal sacral fracture and ipsilateral pubic fracture) was constructed. The pelvis was fixed with iliac crest external fixator (IC), anterior inferior iliac spine external fixator (AIIS), combination of IC and AIIS, combination of anterior superior iliac spine external fixator (ASIS) and AIIS, and S1 sacroiliac screw in 5 types of models. The stability indices of the anterior and posterior pelvic rings under vertical longitudinal load, left–right compression load and anterior–posterior shear load were quantified and compared. In the simulated bipedal standing position, the results of the vertical displacement of the midpoint on the upper surface of the sacrum are consistent with the displacement of the posterior rotation angle, and the order from largest to smallest is IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. The longitudinal displacement of IC is greater than that of the other models. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter is smaller. In the simulated semi-recumbent position, the vertical displacement and posterior rotation angle displacement of the midpoint on the upper surface of the sacrum are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Under the simulated left–right compression load state, the lateral displacements of the highest point of the lateral sacral fracture end are consistent with the highest point of the lateral pubic fracture end, and the order from large to small is S1 screw, IC, AIIS, ASIS + AIIS and IC + AIIS, among which the displacements of S1 screw and IC are larger, and the displacements of ASIS + AIIS and IC + AIIS are similar and smaller than those of other models. The displacements of IC + AIIS are smaller than those of ASIS + AIIS. Under the simulated anterior–posterior shear load condition, the posterior displacements of the highest point of the lateral sacral fracture end and the highest point of the lateral pubic fracture end are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Among them, the displacements of IC and AIIS are larger. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter are smaller. For the unstable pelvic injury represented by Tile C pelvic fracture, the biomechanical various stabilities of the combination of IC and AIIS are superior to those of the external fixators of conventional configurations. The biomechanical stabilities of the combination of ASIS and AIIS are also better than those of the external fixators of conventional configurations, and slightly worse than those of the combination of IC and AIIS. Compared with sacroiliac screw and conventional external fixators, the lateral stabilities of IC + AIIS and ASIS + AIIS are particularly prominent.

Background The purpose of this study was to report the outcomes of single-level bone transport with a unilateral external fixator for treatment of proximal, intermediate and distal tibial bone defects caused by fracture-related infection (FRI) and compare their complications. Methods The clinical records and consecutive X-ray photographs of patients with tibial bone defects treated by single-level bone transport using a unilateral external fixator (Orthofix Limb Reconstruction System) were analyzed retrospectively, from January 2012 to December 2018. Patients were divided into the proximal group (P, n = 19), intermediate group (I, n = 25), and distal group (D, n = 18) according to the location of the tibial bone defect. The Association for the Study and Application of the Method of Ilizarov (ASAMI) standard was applied to assess the bone and functional outcomes and postoperative complications evaluated by the Paley classification. Results A total of 62 participants were included in this study, with a median age of 36 ± 7.14 years. S ixty patients with tibial bone defects caused by FRI were successfully treated by single-level bone transport using a unilateral external fixator, with a mean bone union time (BUT) of 7.3 ± 1.71 months. According to the ASAMI criteria, there were statistical differences in bone and function results between the three groups (P vs. I vs. D, P  < 0.001). The excellent and good rate of bone result in the intermediate group was higher than the other (P vs. I vs. D, 73.6% vs. 84% vs. 66.7%), and the excellent and good rate of function result in the proximal group was the highest (P vs. I vs. D, 84.2% vs. 80% vs. 73.3%). Complications were observed in 29 out of 62 patients (46.7%), with pin tract infection being the most common (14.8%), followed by axial deviation (14.8%), muscle contractures (12.7%), joint stiffness (12.7%), and soft tissue incarceration (12.7%). Other complications included delayed consolidation (12.7%), delayed union (6.3%), nonunion (4.2%), and neurological injury (8.5%). Two patients (3.2%) required below-knee amputation due to uncontrollable infection and previous surgery failure. Conclusions Pin tract infection was the most common complication in tibial bone transport using an external fixator. Complications of distal tibial bone transport are more severe and occur at a higher rate than in other parts. Axial deviation mostly occurred in the intermediate tibial bone transport.

Closed reduction with external fixation (CREF) and percutaneous pinning (CRPP) are commonly used surgical interventions to treat distal radius fractures. However, there is no consensus regarding the optimal management of these types of fractures. Therefore, this study aimed to compare these treatments’ clinical and radiological outcomes in two subgroups of distal radius fractures. The patients who were ≥ 18 and were referred for the diagnosis of type I and III (Fernandez) distal radius fractures were treated with one of these two methods, which have been evaluated through a retrospective analysis of the medical records. A total of 244 patients were divided into CREF treatment ( n  = 122) and control treatment ( n  = 122). These patients’ radiological, clinical, functional, and incidence rates of complications (over-distraction, radial neuropathy, and deep or superficial infection) were compared to analyze each method’s positive and negative aspects. This study showed that patients in the PP group reported significantly less pain than those in the EF group (P-value < 0.05). The PP group scored lower in the specific and general activities categories, significantly reducing Patient-Rated Wrist Evaluation (PRWE). Although the CREF group had greater radius shortening, the difference was not statistically significant. Notably, the CREF group exhibited a significantly higher incidence of complications. Percutaneous pinning proved to be a more effective method for treating distal radius type I and III fractures. Compared to those treated with external fixation, patients experienced fewer post-treatment complications, lower pain levels, and less difficulty in daily activities.

Proximal phalanx (P1) fractures in horses are relatively common, and present significant treatment challenges, especially when the fractures are comminuted or infected. An innovative treatment approach includes attaching an external fixator to the third metacarpal bone (MC III), the healthy bone above fracture, to offload the injured P1 and protect it from load–bearing forces, particularly during post–surgical standing up. This study aims to develop the favourable mathematical and numerical models for screws configuration in this external fixator. Nine configurations (I-IX), varying in screw alignment and number, were investigated based on the experimental data from computed tomography and simulations of compression tests. Cortical and trabecular tissues were modelled as a nonlinear viscoelastic continuum, with material constants identified through uniaxial compression and stress relaxation tests. The best attachment of the external fixator was analysed in terms of stresses and strains in both trabecular and cortical bone, as well as stresses in screws. Configuration II (1 diaphysis screw, 4 distal metaphysis screws at 7°) and III (1 diaphysis screw, 4 distal metaphysis screws at 14°) were identified as mostly biomechanically favourable. This external stabilization approach could potentially reduce the rate of post–surgical failure often leading to horse euthanasia.

Background This study evaluated the clinical effects of the use of a temporary bi-frame fixator in conjunction with minimally invasive percutaneous plate osteosynthesis (MIPPO) for treating AO/OTA 41B3 and 41C tibial plateau fractures (TPFs). Methods This was a retrospective analysis of 30 patients with TPFs affected by vertical compression seen from October 2019 to October 2020. All patients were treated with a bi-frame fixator to correct the vertical shortening deformity, with the MIPPO technique used after reduction. All patients underwent routine examinations at 1, 3, 6, 12 and 24months postoperatively and then annually. Clinical parameters assessed included the Hospital for Special Surgery score (HSS), number of assistants, intraoperative hemorrhage, intraoperative fluoroscopy frequency, length of hospital stay, and time to fracture healing. Radiographic findings were assessed using Rasmussen scores. Results All patients had satisfactory fracture reduction on postoperative imaging. The average operating time was 112.03 ± 20.9 min, with 15.79 ± 3.45 fluoroscopic exposures; the average blood loss was 66.63 ± 10.88 mL, the average length of hospital stay was 12.86 ± 5.11 days, and the average fracture healing time was 10.33 ± 1.48 weeks. The mean follow-up time was 23.18 ± 2.59 months. At the last follow-up, the Rasmussen anatomical score was excellent in 22 (75.3%) patients, good in 5 (16.7%), and fair in 3 (10%). The average HSS was 65.7 ± 3.26, 82.26 ± 2.28, and 87.66 ± 2.4 after 1, 6, and 12 months, respectively, and it was 92.56 ± 2.96 at the last follow-up (F = 1073.073, P <  0.001). No complications occurred in any patient during follow-up. Conclusion For AO/OTA 41B3 and 41C fractures of the tibial plateau, the use of a temporary bi-frame fixator combined with the MIPPO technique can correct the compressed displacement, reduce soft tissue damage, and facilitate surgical reduction, which aid the recovery of joint function.

Background External fixators have been extensively applied in the treatment of open tibiofibular fractures and have yielded positive outcomes. The stability of an external fixator primarily hinges on its structure. Employing additional external fixation components can undoubtedly enhance stability. However, there is scant research on the topic of achieving superior stability with fewer external fixation components. Methods Utilizing 3D modeling software, constructed three different external fixation models in middle tibial fractures in Group A, constructed four external fixation models in proximal tibial fractures in Group B, and constructed four external fixation models in distal tibial fractures in Group C.Simulate the load under the assistance of a walker to stand up, obtain the displacement of fractures and the stress of the external fixator for each group. Analyze and compare the results of each model. Results In a mid-tibial fracture, the stability of the crossbar increases by 21% with each 2 cm closer to the tibia. Model B3 achieves superior stability with the use of more fixed clamps and connecting rods in the “H” shaped model. Although the triangular cross-bar structure used in Model B4 is less stable than that of Model B3, it has achieved 83.2% of the stability of Model B3, despite using fewer components. The stability of Model C4 has increased by 73.44% compared to Model C3. Conclusions The external fixator should be configured to keep the crossbar as close to the skin as possible. For proximal tibial fractures, to minimize the use of external fixation components, the triangular cross-bar structure of Model B4 can be employed. In the case of distal tibial fractures, while the triangular cross-bar structure of Model C4 offers good stability, the risk of displacement is greater. Therefore, it is advisable to use an H-shaped fixation method with additional external fixation components, such as those found in Model C3.

IntroductionVascular injuries after traumatic knee dislocation pose a potential limb threat for the patient. The benefits of external fixation have been described by many authors. However, the usefulness of the external fixator during acute management of knee dislocations with vascular injuries is a controversial aspect that has no consensus in the literature. The purpose of the present study was to provide data from the current literature on the utility of the external fixator and to investigate the percentage of knee dislocations with vascular injuries treated with an external fixator, the timing between external fixator and vascular repair, and the total time of external fixator.Material and methodsThe present systematic review was conducted according to the PRISMA checklist. MEDLINE (Pubmed), Web of Science, and SCOPUS databases were searched for articles from 1 January 2000 to 6 February 2019. Studies reporting outcomes of treatment of knee dislocations with vascular injuries were included. Exclusion criteria included studies investigating chronic knee dislocations, knee arthroplasties, editorials, case reports, and expert opinions. Two authors independently extracted data and appraised the quality of evidence and risk of bias using the Methodological quality and synthesis of case series and case reports.ResultsDescriptive statistics were used to report the outcome of our findings. Seven studies related to the usefulness of the external fixator during acute management of knee dislocations with vascular injuries were included. The external fixator had been used in the majority of knee dislocations with vascular lesions (72%). Timing between external fixator and vascular repair was reported on four studies (57%), two studies performed external fixation before vascular repair, and two studies performed external fixation after vascular repair. Total time of external fixator was only reported on three studies, ranging from 3 weeks to 3 months. These studies reported acute management, without referring to long-term results and without comparative groups.ConclusionsExternal fixator was used in the majority of knee dislocations with vascular injuries but the justification for its use remained unclear. Larger studies are needed to fully understand the merit of the external fixator in knee dislocations with vascular injuries. Joint protocols between vascular surgeons and trauma surgeons are necessary to agree on the aspects related to the management of knee dislocations with vascular injuries.Level of evidenceIV.