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A 19-year-old morbidly obese man presented with infected nonunion of femoral shaft fracture. Patient had history of 13 failed fixation surgeries, assessment revealed 3-centimetre limb-length discrepancy with 3-centimetre gap nonunion. Wound debridement, primary compression and external fixation using a customised Ilizarov external fixation assembly were planned. A four-ring customised assembly was applied. Partial weight bearing was allowed from first postoperative day on walker. Patient was kept on a monthly follow-up. After complete union at 10 months after surgery, frame was dynamised. After 6 months of dynamisation, frame was removed, at that time patient was full weight bearing. Knee was still stiff with a range of motion of 0°–20°, and there was 6 cm of limb length discrepancy, which was managed with a shoe raise. At 9 months after frame removal, patient is mobile with fully united bone. Ilizarov external fixator can be a good managing option in such difficult and complicated cases.

To evaluate the clinical curative effect of Ilizarov external fixation and ankle arthrodesis in the treatment of elderly traumatic ankle arthritis.From June 2013 to August 2019, 72 patients with elderly traumatic ankle arthritis were treated with arthrodesis through Ilizarov external fixation technique in our institution. Conventional double-feet standing X-ray films were taken before and after operation. The tibiotalar angle on X-ray image was measured to evaluate the degree of talipes varus and valgus. The Foot and Ankle pain score of American Orthopaedics Foot and Ankle Society (AOFAS) and Visual Analog Scale (VAS) were compared by using paired t-test to evaluate the functional recovery.All of the patients acquired effective postoperative 18-49 months follow-up, with an average of 31.5 months. All patients were included in the analysis, among which 38 cases were males and 34 cases were females, with an average of 65.4 years (ranging from 60 to 74). All ankles achieved bony fusion; the clinical healing time was 12.7 weeks on average (11-18 weeks). The AOFAS score was 45.36 ± 6.43 preoperatively and 80.25 ± 9.16 at 12 months post-operation, with a statistically significant difference (p 0.0001). The VAS score was 8.56 ± 1.85 on average preoperatively and 2.72 ± 0.83 at 12 months post-operation, with a statistically significant difference (p 0.0001). The tibiotalar angle was 101.93° ± 4.12° preoperatively and 94.45° ± 2.37° at 12 months post-operation, with a statistically significant difference (p 0.0001). The results of the functional evaluation indicated that 44 patients (61.1%) had excellent results, 18 (25%) had good results, and 10 (13.9%) had fair results.Our study demonstrated that it is possible to obtain satisfactory outcome with Ilizarov external fixation and ankle arthrodesis in the treatment of elderly traumatic ankle arthritis.

To evaluate the preliminary outcomes of tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique for the treatment of distal tibial defect and describe the surgical technique.A total of 12 eligible patients with distal tibial defect6 cm caused by direct trauma or posttraumatic osteomyelitis who were admitted to our institution from January 2017 to January 2019 were treated by tetrafocal or pentafocal bone transport using Ilizarov technique. Detailed demographic data, including age, sex, etiology, defect size, number of osteotomies (three or four), external fixation time (EFT) and external fixation index (EFI), were collected, and the bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during the surgery and the follow-up period were recorded and evaluated by the Paley classification at a minimum follow-up of two years after removal of the fixator.There were 9 men and 3 women with an average age of 37.4±7.8 years. The etiology included posttraumatic osteomyelitis in 8 cases and posttraumatic bone loss in 4 cases. The mean bone defect after radical debridement was 7.1±0.6 cm. Tetrafocal bone transport was applied in 9 cases, and pentafocal bone transport was applied in 3 cases. The average EFT and EFI were 5.2±0.8 months and 0.7±0.2 months/cm, respectively. The average time of follow-up after removal of the external fixator was 28.5±3.3 months without recurrence of osteomyelitis. The bone results were good in 7 cases, fair in 4 cases, and poor in 1 case, and the functional results were good in 5 cases, fair in 6 cases, and poor in 1 case. The most common complication was pin tract infection, which occurred in all cases, but there were no major complications, such as nerve or vascular injury.Tetrafocal and pentafocal bone transport using Ilizarov technique could be an alternative treatment option in selected cases with distal tibial defect6 cm. It could shorten the distraction period, fasten regeneration, and reduce the associated complications.

The most common technique of orthopedic surgical procedure for the correction of deformities is bone lengthening by “distraction osteogenesis,” which requires periodic and ongoing bone assessment following surgery. Bone impedance is a noninvasive, quantitative method of assessing bone fracture healing. The purpose of this study was to monitor bone healing and determine when fixation devices should be removed. The left tibia of eight male New Zealand white rabbits (2.4 ± 0.4 kg) undergoing osteotomy was attached with a mini-external fixator. The bone length was increased by 1 cm one week after surgery by distracting it 1 mm per day. Before and after osteotomy, as well as every week after, bone impedance was measured in seven frequency ranges using an EVAL-AD5933EBZ board. Three orthopedic surgeons analyzed the radiographs using the Radiographic Union Scale for Tibial (RUST) score. The Kappa Fleiss coefficient was used to determine surgeon agreement, and the Spearman rank correlation coefficient was used to find out the relationship between impedance measurements and RUST scores. Finally, the device removal time was calculated by comparing the bone impedance to the preosteotomy impedance. The agreement of three orthopedic surgeons on radiographs had a Fleiss’ Kappa coefficient of 49%, indicating a moderate level of agreement. The Spearman rank correlation coefficient was 0.43, indicating that impedance and radiographic techniques have a direct relationship. Impedance is expected to be used to monitor fractured or lengthened bones in a noninvasive, low-cost, portable, and straightforward manner. Furthermore, when used in conjunction with other qualitative methods such as radiography, impedance can be useful in determining the precise time of device removal.

The aim of this study was to evaluate the clinical and radiological outcomes and complications of external fixation use in the treatment of children with displaced supracondylar femoral fractures..In this retrospective study, 14 children (6 boys, 8 girls; mean age = 7.3 years; age range = 3.9 - 10.3 years) who underwent external fixation for the treatment of a displaced supracondylar femoral fracture from 2010 to 2017 were included. Their medical records were reviewed for general information and surgery details. Postoperative information, such as time to radiographic union, time to regain walking ability, Knee Society Scores (KSS) postoperative score, and KSS functional score were collected. Radiographic images were examined for the measurement of leg length discrepancy and valgus deformity.The mean follow up was 34 (range = 24-50) months. The mean time to radiographic union was 12.3 (range = 10-16) weeks, and the mean time to regain walking ability was 11.8 (range = 11-13) weeks. Leg length discrepancies were all less than 0.8 cm, and valgus deformity was all limited in 10°. The mean KSS postoperative score was 97.5 (range = 93-100), and the mean KSS functional score was 97.1 (range = 90-100). None of the patients exhibited functional deficiency. Neither deep infection nor refracture was detected postoperatively.External fixation seems to be an acceptable alternative modality for treatingdisplaced supracondylar femoral fractures in children, with favorable clinical and radiological outcomes as well as a low complication rate.Level IV, Therapeutic Study.

INTRODUCTION: Open ankle fractures in geriatric (age > 60 years) patients are a source of significant morbidity and mortality. Surgical management includes plate and screw fixation (ORIF), retrograde hindfoot nail (HFN), definitive external fixation (ex-fix) and below knee amputation. However, each modality poses unique challenges for this population. We sought to identify predictors of unplanned OR and short-term mortality after geriatric open ankle fractures managed by our service. MATERIALS AND METHODS: In an IRB-approved protocol, we evaluated patients over 60 years of age managed for a low energy open ankle/distal tibia pilon fracture by trauma fellowship-trained surgeons from a single academic department that covers two level I trauma centers. Our primary outcome was an unplanned return to the OR. Secondary outcomes were a 90-day “event”, defined as an all-cause hospital readmission or mortality, and 1-year mortality. Differences with a p-value < 0.1 measured on univariate analysis were evaluated using a multivariable logistic regression to identify independent outcome predictors. RESULTS: A total of 113 (60 ORIF, 36 HFN, 11 ex-fix, 6 amputations) were performed. Cohort mean age was 75.2 ± 9.8 years, and 31 patients (27.4%) were male. Mean age-adjusted charlson comorbidity index was 5.5 ± 2.0. Significant independent predictors of an unplanned return to the OR were male sex (OR 4.4, 95% CI 1.3 to 15.4), Gustilo Type III open fracture (OR 4.9, 95% CI 1.5 to 17.5) and ex-fix (OR 15.6, 95% CI 2.7 to 126.3). Independent predictors of a 90-day “event” were walker/minimal ambulation (OR 3.5, 95% CI 1.3 to 10.4), surgical site infection (OR 4.8, 95% CI 1.8 to 13.8) and reduced BMI (OR 0.9, 95% CI 0.9 – 0.99), while independent predictors of 1-year mortality were age (OR 1.1, 95% CI 1.003 to 1.2), ACCI (OR 1.4, 95% CI 1.02 to 2.0) and walker/minimal ambulator (OR 7.5, 95% CI 1.7 to 53) CONCLUSIONS: Host factors, particularly pre-operative mobility, were most predictive of 90-day event and 1-year mortality. Only definitive external fixation was found to influence patient morbidity as a significant predictor of unplanned OR. However, no surgical modality had any influence on short-term readmission or survival.

Background The purpose of this study was to evaluate the outcomes of bifocal bone transport in the treatment of femoral bone defects caused by infections. Methods Clinical and radiographic data of patients with infected femoral nonunion treated by the bifocal bone transport at our hospital were analyzed retrospectively, from January 2008 to December 2019. Depending on the location of bone defects, the patients were divided into three groups (proximal, intermediate, and distal). The Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria was applied to assess the bone and functional outcomes. Postoperative complications of three groups were documented and compared. Results Seventy-six cases of infected femoral bone defects (31 cases of proximal, 19 cases of intermediate, and 26 cases of distal) were managed by bifocal bone transport successfully with a mean follow-up time of 30.8 months (range, 23 to 41 months). There were 58 men (76.3%) and 18 women (23.6%), with a mean age of 38.8 years (range, 23 to 60 years). The bone union was received in 76 cases with a mean of 6.9 months (range, 5 to 8 months). Pin tract infection was observed in twenty-nine cases (38.1%), 7 cases (9.2%) of muscle contractures, 3 cases (7.9%) of joint stiffness, 13 cases (17.1%) of axial deviation, 2 cases (2.6%) of delayed union, one case (1.3%) of nonunion, and none (0%) of transport gap re-fracture. One patient (1.3%) was scheduled for knee arthroplasty when bone transport treatment ended. Conclusions Bone transport using an external rail fixator was a practical method to treat the femoral bone defects, since the satisfactory rate of bone union and limb function recovery. Complications of distal femoral bone transport were more severe than the proximal and intermedia, but the rate of complication was the least of the three groups. Soft-tissue-related complications were more likely to occur in the intermediate bone transport.

Objective To compare the clinical efficacy of percutaneous minimally invasive reduction combined with external fixation and a tarsal sinus approach to treat Sanders type II and III intra‐articular calcaneal fractures. Methods The clinical data of 64 patients with Sanders type II and III calcaneal fractures admitted to our hospital from January 2010 to January 2016 were retrospectively analyzed; data includedage, sex, body mass index. According to the surgical method, they were divided into the percutaneous minimally invasive reduction with internal and external fixation group (30 cases) and the tarsal sinus approach group (34 cases).The two groups of patients were compared in terms of the time tosurgery, length of hospital stay, intraoperative blood loss, operative duration, complications, radiographic features, including the heel bone length, width, height, Bohlerangle, Gissane angle, and calcaneal varus angle, and clinical efficacy indicators, including the American Orthopedic Foot and Ankle Society (AOFAS) score, the visual analog scale (VAS) pain score, health survey profile (SF‐36) score and Maryland ankle function score. Results Patients in both groups were followed up for 12 to 50 months, with an average of 24.8 months.Bony union was achieved in all cases. The time to surgery, length of hospitalstay, intraoperative blood loss and incidence of incision‐related complications were significantly lower in the percutaneous minimally invasive medial external fixation group than in the tarsal sinus group (P 0.05). As measures of clinical efficacy, the AOFAS, VAS, SF‐36 and Maryland scores were 85.28 ± 8.21, 0.84 ± 1.21, 82.95 ± 3.25 and 83.56 ± 3.32, respectively, at the last follow‐up in the percutaneous minimally invasive medial external fixation group and 83.32 ± 7.69, 1.85 ± 1.32, 80.71 ± 5.42, and 81.85 ± 2.41 in the tarsal sinus group, respectively, with no significant differences between the two groups (P > 0.05). Conclusion Under the condition of a good command of surgical indications and surgical skills, the use of plastic calcaneal forceps for percutaneous minimally invasive reduction combined with medial external fixation for the treatment of Sanders type II and III intra‐articular calcaneal fractures can achieve similar clinical effects as the tarsal sinus approach. However, the use of plastic calcaneal forceps for percutaneous minimally invasive reduction combined with internal and external fixation has advantages, such as fewer complications, less bloodloss, and a shorter operation, and thus has good safety and is worthy of clinical promotion., The anatomical structure of the calcaneus was restored by applying traction and extrusion with calcaneus‐shaping forceps. On axial X‐ray, 4 nails were arranged from the subtalar joint to the calcaneal tuberosity in different planes to provide fracture surface support. Two Kirschner wires drilled from the posterior tuberosity were fixed in the talus and cuboid to correct and control calcaneal varus. On lateral X‐ray near the Gissane angle, three nails were drilled in a zigzag arrangement perpendicular to the fracture line and the lateral wall of the calcaneus. The three nails were drilled almost in an equilateral triangle or at an angle of 60 degrees to maintain the fixed fractured end. The first nail near the bottom of the calcaneal tubercle was drilled vertically to the fracture line to avoid calcaneal widening. Two Kirschner wires, one high and one low, were fixed in the talus and cuboid at an angle of approximately 45 degrees to prevent height collapse and calcaneal shortening.

To explore clinical efficacy of external placement of micro-locking plate combined with small incision reduction in treating proximal phalanx comminuted fractures.From January 2018 to December 2019, 17 patients with proximal phalanx comminuted fractures were treated with micro-locking plate combined with small incision open reduction, including 13 males and 4 females, aged from 16 to 64 years old with an average of (37.2±20.1) years old. Two patients were accompanied by soft tissue extrusion and opening injuries, which were treated with fixed treatment after the first-stage emergency debridement. Curative effect was evaluated according to total active flexion scale (TAFS) of American Hand Surgery Association at 6 months after operation;and fracture healing, nailing, local soft tissue healing, complications were observed.All patients were followed up from 6 to 12 months with an avaerge of(9.3±3.6) months. Two patients occurred delayed union, 1 occurred local skin necrosis and was treated with the second-stage skin grafting to repair wound surface. No external screw breakage or infection was reported, skin soft tissue healed favorably and reached bony union, the union time from 12 to 24 weeks with an average of (15.7±2.1) weeks. According to TAFS standard, 9 patients got excellent result, 5 good and 3 poor at 6 months after operation.External micro-locking plate combined with small incision reduction in treating proximal phalanx comminuted fracture, which has advantages of good condition of skin and soft tissue, simple operation, early functional exercise, good range of motion of interphalanx joint, and function score of recovery period is high.

To compare the clinical outcomes of external fixator + elastic stable intramedullary nail (EF+ESIN) vs. external fixator (EF) in the treatment for open tibial shaft fracture in overweight adolescents.Patients of open tibial shaft fractures younger than 14 years old with body weight over 50 Kg treated with EF + ESIN or EF at our institute from 2010 to 2018 were reviewed. Patients with Gustilo Type III open fractures, pathological fractures, previous fracture or instrumentation in the operative leg were excluded. Baseline information and clinical data were collected from the hospital database and during out-patient visits.Forty-six patients, including 27 males and 19 females, were included in the EF group, whereas 35 patients, including 18 males and 17 females, were included in the EF + ESIN group (p = 0.527). The incidence of superficial infection was higher in the EF group (26/46, 56.5%) than the EF + ESIN group (12/35, 34.3%), p 0.001. The frontal and sagittal angulation was higher in the EF group (p 0.001), but the degrees in both groups were within the acceptable range. The union time was longer in the EF group (68.0 ± 12.7, d) than the EF + ESIN group (61.9 ± 11.9), p 0.001. The retaining of EF (11.9 ± 3.2, w) was longer in the EF group than the EF +ESIN group (5.7 ± 1.2, w), p 0.001.EF+ESIN is a safe and alternative choice for selected overweight adolescents with open tibial shaft fracture.

BackgroundThe bone transport using the unilateral external fixator, one of the Ilizarov techniques, is widely practiced in lower limb reconstructive surgery. Pin tract infection (PTI), one of most common complication, has become the important postoperative problems which plague clinicians gradually.MethodsA group of 130 patients who received bone transport surgery for tibia or femur defects using the unilateral external fixation (Orthofix limb reconstruction system, Verona, Italy) and met the inclusion criteria were selected for the study from 2015 to 2019. Regular pin tract care was performed twice a day, and the conditions of the pin tract were evaluated by the same observer using clinical appearance criteria. The Saw’s classification of PTI was used to assess the condition around screws. After the data were significant by the T-test or Pearson’s Chi-square test analyzed, odds ratios were calculated using logistic regression tests to describe factors associated with the diagnosis of PTI.ResultsNinety-one males and thirty-nine females with a mean age of 43 years (range 28–58 years) were included in this cohort. 7816 observations were documented from 12 to 36 months, and 58 cases (44.6%) of PTI (thirty-nine cases in grade 1, 17 cases in grade 2, and 2 cases in grade 3). The top five risk factors were agricultural work (OR 1.86, CI 0.94–2.39), non-urban living (OR 1.75, CI 1.24–3.26), male (OR 1.71, CI 1.02–2.31), smoking (OR 1.53, CI 0.76–1.89), and diabetes (OR 1.26, CI 1.12–2.64). No long-term sequelae were observed at the latest clinical visit.ConclusionOccupation, gender, living environment (non-urban), smoking, and diabetes were the top five significant risk factors for PTI in the period of bone transport using unilateral external fixation. Awareness of predictable risk factors of PTI is beneficial to avoid or early detect the severe complications which can affect the effectiveness.

Gradual distraction with an external fixator is a widely used treatment for severe postburn ankle contracture (SPAC). However, application of external fixators is complex, and conventional two-dimensional (2D) imaging-based surgical planning is not particularly helpful due to a lack of spatial geometry. The purpose of this study was to evaluate the surgical planning process for this procedure with patient-specific three-dimension-printed models (3DPMs). In this study, patients coming from two centers were divided into two cohorts (3DPM group vs. control group) depending on whether a 3DPM was used for preoperative surgical planning. Operation duration, improvement in metatarsal-tibial angle (MTA), range of motion (ROM), the American Orthopedic Foot and Ankle Society (AOFAS) scores, complications, and patient-reported satisfaction were compared between two groups. The 3DPM group had significantly shorter operation duration than the control group ((2.0±0.3) h vs. (3.2± 0.3) h, P

To explore the clinical therapeutic strategies of refracture after Ilizarov bone transport technique in the treatment of tibial bone defect.A retrospective study was performed on 19 patients with infected tibial bone defect treated by Ilizarov bone transport technique and then refracture from August 2010 to January 2020, including 18 males and 1 female with an average age of (37.7±13.0) years old ranging from 15 to 66 years old. Cause of injury invlved falling injury in 4 cases, crashing injury 1 case, crushing injury in 1 case and without obvious injury history in 13 cases. The ipsilateral distal femoral fracture in 2 cases occurred before the external fixator of tibia was removed, and the other 17 cases had a minimum of 1 day and a maximum of 30 months after the external fixator had been removed. The site of refracture was at regenerative zone in 8 cases, at docking site in 9 cases, at ipsilateral femoral shaft in 2 cases. According to the modified Simpson classification proposed by the author, the refracture was classified. The treatment of refracture include plaster splint, traction or external fixation. Bone healing and function were evaluated according to the standards of the Association for the Study and Application of the Method of Ilizarov(ASAMI).All patients were followed up, and the duration ranged from 9 to 17 months with an average of (12.3±3.2) months. According to the modified Simpson classification, there were 3 cases of type Ⅰa, 1 case of type Ⅰb, 3 cases of type Ⅰc, 1 case of type Ⅱ, 9 cases of type Ⅲ and 2 cases of type Ⅴ. All the refractures healed without infection or malunion. The fracture healing time of conservative treatment for 6 cases were 3, 5, 3, 2, 2, 2 months fespectively;and the healing time of fracture treated by surgery for 13 cases was 2 to 6 months, with an average of(4.4±1.4) months. According to ASAMI evaluation criteria, bony results showed all patients obtained excellent results, and functional results showed 6 patients got excellent results, 13 good beacause of ankle or knee stiffness.The modified Simpson classification could contain most clinical types of refracture after bone transport, and the external fixation is a simple and effective method for refracture.

To investigate the clinical effect of NRD assisted Ilizarov technique in the treatment of infected bone and soft tissue defect of tibia.All 48 patients with infected bone and soft tissue defect of tibia were randomly divided into study group and control group from March 2013 to December 2020. There were 34 males and 14 females, aged from 24 to 55 years old with an average of (40.54±11.64) years old. There were 25 patients in the study group, including 17 males and 8 females, aged from 31 to 55 years old with an average of (41.36±9.69) years old. The study group were treated with NRD assisted with Ilizarov bone transport technique. There were 23 patients in control group, including 17 males and 6 females, aged from 24 to 53 years old with an average of(38.61±8.76) years old. The control group were treated with traditional bone transport technique. The curative rate, recurrence rate, incidence rate of pin track infection, time of using antibiotics, time of wound healing, time of carrying external fixation, time of bone transport, time of bone healing and postoperative function were used to evaluate the therapeutic effect of the two groups.The follow-up period was from 12 to 62 months with an average of (33.0±7.2) months. At the final follow-up, there was no significant difference in the curative rate between the two groups (NRD assisted Ilizarov technique can achieve satisfactory results in the treatment of infected bone and soft tissue defect of tibia and shorten the treatment period and the time of using antibiotics. It is worthy of development in clinic.

Modern external ring fixation has been hypothesized to reduce complications requiring hospital readmission compared with internal fixation when treating patients with high-energy open tibial shaft fractures. In this study, the 1-year probability of a major limb complication was compared between external and internal fixation of severe open tibial fractures.This multicenter randomized clinical trial included patients 18 to 64 years of age with severe open tibial shaft fractures randomly assigned to either modern external ring fixation (n = 127) or internal fixation (n = 133). The primary outcome was a major limb complication within 365 days after randomization; these complications included amputation, infection, a soft-tissue problem, nonunion, malunion, and a loss of reduction/implant failure.Of 260 randomized patients, 254 were included in the final analysis. Their mean age (standard deviation) was 39 (13) years; 214 (84%) were men. The probability of at least 1 major limb complication was higher for external fixation (62.1% [95% confidence interval (CI): 53.4% to 70.8%]) than internal fixation (43.7% [95% CI: 35.5% to 52.9%]), with a risk difference of 18.4% (95% CI: 5.8% to 30.4%); p = 0.005). The most notable difference was in loss of reduction/implant failure, the rate of which was higher for external fixation (risk difference: 14.4% [95% CI: 7.0% to 21.6%]; p = 0.002). There was no appreciable difference in the probability of deep infection between external fixation (26.1%) and internal fixation (29.7%) (risk difference: -3.5% [95% CI: -14.8% to 7.8%]; p = 0.54). There were also no appreciable differences in the probabilities of amputation, nonunion, soft-tissue problems, malunion, or fracture healing between the groups.These results argue against routine use of modern external ring fixation for the treatment of these severe open tibial fractures.Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background and Objectives: The purpose of this study was to compare the clinical and radiographic evolution of chronic Monteggia fractures (CMFs) treated by ulnar osteotomy and monolateral external fixators (MEFs) with or without angulation of the ulna during the distraction period. Materials and Methods: This retrospective study evaluated 20 children (14 boys and 6 girls) with CMFs. According to the strategy of ulnar lengthening, two groups of patients were identified: patients undergoing gradual lengthening with (Group A, n = 11) or without ulna angulation (Group B, n = 9). The mean age at the time of surgery was 7.7 years old (range, 5.4–12.9). The mean time from initial trauma to surgery was 26.3 months (range, 1–96), and the mean follow-up was 24.6 months (range, 5.5–45.4). Clinical outcomes were evaluated by Kim et al.’s Elbow Performance Score, while radiographic outcomes were assessed on plain radiographs. Results: Age at surgery, sex, laterality, time between trauma and surgery, and time of follow up in the two groups of patients showed no significant differences. The radial head was successfully reduced in 9 of 9 and 10 of 11 patients in Groups B and A, respectively (p = 1.00). The mean time to achieve radial head reduction was shorter in Group B (18.1 ± 5.3 days) than in Group A (39.2 ± 18.7 days; p = 0.004). The mean angulation of the ulna at the end of treatment was significantly lower in Group B (0.6° ± 1.1°) than in Group A (25.9° ± 6.3°; p < 0.0001). The average ulnar lengthening at the end of treatment in Group B (14.1 ± 5.8 mm) was, on average, 7.7 mm less than that in Group A (21.8 ± 9.7 mm; p = 0.05). The Kim et al. Elbow Performance Score at the last follow-up visit was comparable between the two groups of patients (p = 1.00). Conclusions: A shorter time to achieve radial head reduction and less deformity of the ulna can be expected in paediatric patients with CMFs undergoing intraoperative restoration of ulnar alignment and gradual lengthening without angulation postoperatively.

BackgroundMany patients with achondroplasia experience functional impairments because of rhizomelic upper extremities (proximal limb shortening). Bilateral humeral lengthening may overcome these functional limitations, but it is associated with several risks, such as radial nerve palsy and insufficient bone regeneration. Only a few studies have reported on patient satisfaction and functional outcome after humeral lengthening in patients with achondroplasia. Furthermore, the reported numbers of adverse events associated with lengthening procedures using external fixators vary widely.Questions/purposes(1) Does bilateral humeral lengthening with a monolateral external fixator in patients with achondroplasia reliably improve patient function and autonomy, and what proportion of patients achieved at least 8 cm of humeral lengthening? (2) What adverse events occur after bilateral humeral lengthening with monolateral external fixators?MethodsBetween 2011 and 2019, 44 patients underwent humeral lengthening at our institution. Humeral lengthening was performed in patients with severe shortening of the upper extremities and functional impairments. In humeri in which intramedullary devices were not applicable, lengthening was performed with monolateral external fixators in 40 patients. Eight patients were excluded because they underwent unilateral lengthening for etiologies other than achondroplasia, and another four patients did not fulfill the minimum study follow-up period of 2 years, leaving 28 patients with bilateral humeral lengthening to treat achondroplasia available for analysis in this retrospective study. The patients had a median (interquartile range) age of 8 years (8 to 10), and 50% (14 of 28) were girls. The median follow-up time was 6 years (4 to 8). The median humeral lengthening was 9 cm (9 to 10) with a median elongation of 73% (67% to 78%) from an initial median length of 12 cm (11 to 13). To determine whether this treatment reliably improved patient function and autonomy, surgeons retrospectively evaluated patient charts. An unvalidated retrospective patient-reported outcome measure questionnaire consisting of nine items (with answers of "yes" or "no" or a 5-point Likert scale) was administered to assess the patient's functional improvement in activities of daily living, physical appearance, and overall satisfaction, such that 45 points was the highest possible score. The radiographic outcome was assessed on calibrated radiographs of the humerus. To ascertain the proportion of adverse events, study surgeons performed a chart review and telephone interviews. Major complications were defined as events that resulted in unplanned revision surgery, nerve injury (either temporary or permanent), refracture of the bone regenerate, or permanent functional sequelae. Minor complications were characterized as events that resolved without further surgical interventions.ResultsOn our unvalidated assessment of patient function and independence, all patients reported improvement at their most recent follow-up compared with scores obtained before treatment (median [IQR] 24 [16 to 28] before surgery versus 44 [42 to 45] at latest follow-up, difference of medians 20 points, p < 0.001). A total of 89% (25 of 28) of patients achieved the desired 8 cm of lengthening in both arms. A total of 50% (14 of 28) of our patients experienced a major complication. Specifically, 39% (11 of 28) had an unplanned reoperation, 39% (11 of 28) had a radial nerve palsy, 18% (5 of 28) had a refracture of the regenerate, and 4% (1 of 28) concluded treatment with a severe limb length discrepancy. In addition, 82% (23 of 28) of our patients experienced minor complications that resolved without further surgery and did not involve radial nerve symptoms. Radial nerve palsy was observed immediately postoperatively in eight of 13 segments, and 1 to 7 days postoperatively in five of 13 segments. The treatment goal was not achieved because of radial nerve palsy in 5% (3 of 56) of lengthened segments, which occurred in 7% (2 of 28) of patients. Full functional recovery of the radial nerve was observed in all patients after a median (IQR) of 3 months (2 to 5). Refractures of bone regenerates were observed in 11% (6 of 56) of humeri in 18% (5 of 28) of patients. Of those refractures, 1 of 6 patients was treated nonsurgically with a hanging cast, while 5 of 6 patients underwent revision surgery with intramedullary rodding.ConclusionMost patients with achondroplasia who underwent humeral lengthening achieved the treatment goal without permanent sequelae; nonetheless, complications of treatment were common, and the road to recovery was long and often complicated, with many patients experiencing problems that were either painful (such as refracture) or bothersome (such as temporary radial nerve palsy). However, using a subjective scale, patients seemed improved after treatment; nevertheless, robust outcomes tools are not available for this condition, and so we must interpret that finding with caution. Considering our discoveries, bilateral humeral lengthening with a monolateral external fixator should only be considered in patients with severe functional impairments because of rhizomelic shortening of the upper extremities. If feasible, internal lengthening devices might be preferable, as these are generally associated with higher patient comfort and decreased complication rates compared with external fixators.Level of EvidenceLevel IV, therapeutic study.

For adolescents with severely displaced proximal humeral fracture (PHF), surgery is a good choice yielding excellent outcomes, and Kirchner wire (KW) is a cost-effective choice for fixation. Purpose of this study is to compare the clinical outcomes of external fixator (EF) and KW for the treatment of PHF in adolescents.Patients of PHF operated at our institute, from January 2008 to January 2016, were reviewed retrospectively. Demographic data, including sex, age at the time of surgery, operated side, and hardware choice, were collected from the hospital database. Preoperative radiographs were reviewed and classified according to Neer-Horwitz classification. Shoulder function was evaluated at the last follow-up using the American Shoulder and Elbow Surgeons (ASES) score. Complications, including infection, malunion, nonunion, stiffness of the shoulder joint, and failure of fixation were also recorded.Thirty-five patients, including 23 males and 12 females, were included in the EF group, whereas 40 patients, including 25 males and 15 females, were included in the KW group (P = 0.867). The average age of patients in the EF group was 13.3 ± 1.7 years, and that of KW was 13.6 ± 1.8 years (P = 0.409). Patients in both groups were followed-up for at least 12 months. The operative time in the EF group (42.4 ± 11.2 min) was significantly shorter than those in the KW group (54 ± 13.6 min) (P0.001). The frequency of fluoroscopy in the EF group (12 ± 2.4 times) was significantly less than those in the KW group (17 ± 2.8 times (P0.001). The rate of open reduction was significantly higher in KW (35%) group than those in the EF group (0%) (P0.001). There was no case of nonunion and malunion in both groups.External fixator is superior to Kirschner wire in the treatment of proximal humeral fractures in adolescents with shorter operative time and lower rate of open reduction with comparable clinical outcomes.

Refracture of the tibia after union is a challenging problem for the patients and the surgeons. The purpose of the current study is to present our experience in conservative management of such patients with refracture of infected ununited tibia after successful treatment by Ilizarov external fixator and bone transport. We reviewed the files of 812 patients with infected ununited tibia who were treated by debridement, corticotomy, and bone transport using Ilizarov methods in our institute between 1997 and 2017. Inclusion criteria were patients with refracture after union and removal of the Ilizarov apparatus. Twenty-two patients with 23 refracture tibia were included in the study. All the 23 tibias were treated conservatively by above knee cast that was converted to Sarmiento below knee cast after early callus formation, except in the case of upper tibial fracture that continued in above knee cast till union. Afterwards, a protective splint was used for additional two months. There were 19 males (86.4%) and three females (13.6%), the mean age of the patients was 38.39 years, the mean time of Ilizarov external fixator application was 10.86 months (range, 6–17), and the mean time of refracture after fixator removal was 2.33 months. Union was achieved in 19 tibias (82.6%), with a mean time of 7.2 months (range, 4–12). Complications included five cases of skin irritation that was treated by large windows in the cast and changing the casts more frequently, three cases developed DVT (deep venous thrombosis), and axial deviation occured in four tibias (17.3%). Conservative treatment of refractured tibia after removal of Ilizarov external fixator following treatment of infected non-union tibia by above knee cast is effective in achieving union. However, complications as skin irritation, DVT (deep venous thrombosis), and axial deviation can be anticipated.

Objectives: We aimed to compare the outcomes of two surgical treatment options, external fixator (EF) or open reduction and internal fixation (ORIF), in patients with bilateral distal radius fractures (DRFs). Patients and methods: Twenty-one patients (11 males 10 females; mean age: 40.0±16.0 years; range, 20 to 67 years) who underwent ORIF (n=10) or EF (n=11) due to bilateral DRF at between January 2011 and December 2019 were retrospectively analyzed. The Quick Disability of the Arm, Shoulder and Hand (Q-DASH) was used to calculate functional and symptomatic evaluation. The MAYO wrist scores were used to evaluate pain, functional status, ROM, and grip strength and the Michigan Hand Outcomes Questionnaire (MHOQ) was used to measure hand performance in daily life. Results: The operation time was statistically significantly longer in the ORIF group, compared to the EF group (p Conclusion: In bilateral DRF cases, hand functions in the first two months after treatment were better in the EF group, compared to the ORIF group. This functional difference between the two groups gradually decreased in the first year and reached similar levels. Our results demonstrate that EF can be a good alternative in the surgical treatment of bilateral DRFs owing to its acceptable results, particularly in the short-term.

Supplemental Digital Content is Available in the Text., Objectives: (1) Evaluate intentional temporary limb deformation for closure of soft-tissue defects as a reconstruction strategy in open tibia fractures and (2) analyze the deformity parameters required for such reconstruction. Design: Multicenter retrospective cohort. Setting: Level I trauma center. Patients/Participants: Nineteen patients 18 years of age and older at the time of initial trauma, with a Gustilo–Anderson type IIIB or IIIC open tibia fracture treated with hexapod external fixation and intentional bony deformity created to facilitate soft-tissue closure. Intervention: Intentional limb deformation for soft-tissue closure, followed by gradual correction with a hexapod external fixator. Outcome Measurements: Radiographic healing, radiographic assessment of limb alignment, and functional and bony Application of the Method of Ilizarov Group score. Results: The average age was 45.3 (20–70), and 79% of patients were men. The most common mechanism of injury was motor vehicle accidents. The distal 1 of 5 of the tibia was the most common fracture location, with 37% of these involving the articular surface at the plafond. After wound closure, deformity correction was initiated after 30 days on average. Varus and apex posterior were the most common initial deformity required for primary soft-tissue closure. Bony and functional Application of the Method of Ilizarov Group outcomes were good or excellent in 94% of patients. Conclusion: Intentional deformation followed by a gradual correction can be an effective strategy to obtain bone union and soft-tissue coverage in certain open fractures. This technique, in essence, converts these injuries from type IIIB to IIIA. This strategy obviates the need for flap coverage and results in satisfactory outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background Infected nonunion of the distal humerus represents a true challenge as the fragment is usually small and difficult for fixation. The aim of the present study is to assess the results of Ilizarov external fixator in management of infected nonunion of the distal third humerus. Material and methods Twenty-three patients with infected nonunion of the distal humerus were included in this study. The ages ranged from 19 to 58 years with an average of 35 years. Seventeen cases were males and 6 were females. All patients were treated by radical debridement and application of Ilizarov external fixator in one stage surgery. Results Bony union was achieved in all cases. Bone graft was required in 12 patients with hypotrophic nonunion. The external fixation time ranged from 4 to 9 months with an average of 5.6 months. Infection was controlled in all cases without recurrence during the period of follow up. The complications included pin tract infection in 7 cases, radial nerve injury in one case, elbow stiffness in 4 cases and refracture after frame removal in one case. Conclusion Ilizarov external fixator is effective in management of infected nonunion of the distal humerus. The thin tensioned wires produce good grip in the small or osteoporotic bone fragments.

To summarize and analyze the characteristics and treatment strategies of post-traumatic lower limb deformity based on QIN Sihe Orthopaedic Surgery Database.A clinical data of 837 patients with post-traumatic lower limb deformities treated by orthopaedic surgery between May 25, 1978 and December 31, 2020 in QIN Sihe Orthopaedic Surgery Database were analyzed retrospectively. The information of the patient's gender, age at the time of surgery, region of origin, cause of trauma, deformity side, orthopedic surgery related information (operation time, location, type, and fixation method after operation) were summarized and analyzed.All patients came from 32 provinces, municipalities, autonomous regions, and Taiwan in China. Among them, 551 cases (65.83%) were male and 286 cases (34.17%) were female. The age of the patients at the time of surgery was 3-84 years old, with an average of 27.6 years old, and the most patients were 16-45 years old (559 cases, 66.78%). The main cause of trauma was traffic accident injury (639 cases, 76.34%). The deformity mainly involved unilateral limbs, including 394 cases (47.07%) on the left side and 376 cases (44.92%) on the right side. The most patients were admitted between 2008 and 2017, accounting for 53.05% (444/837). All patients were operated on one or more sites (1 048 sites), among which ankle and toe surgery were the most, accounting for 48.38% (507/1 048). The patients received 1204 surgeries including tendon lengthening and soft tissue contracture release,Post-traumatic lower extremity deformity patients have a large proportion of males, with a wide geographical distribution, involving various parts of the lower extremities, and most commonly in the foot and ankle. Orthopedic surgery combined with bone external fixation (Ilizarov technique) is the main methods for correction and functional reconstruction of post-traumatic lower limb deformity.基于秦泗河矫形外科数据库中创伤后遗下肢畸形患者临床资料，总结分析该类患者特点及治疗策略。.回顾性分析秦泗河矫形外科数据库中1978年5月25日—2020年12月31日期间，接受矫形手术治疗的837例创伤后遗下肢畸形患者临床资料。对患者性别、手术时年龄、来源地区、创伤侧别、矫形手术相关信息（手术时间、部位、类型以及术后固定方式）进行归纳分析。.837例患者来自全国32个省、直辖市、自治区及台湾地区。其中，男551例（65.83%）、女286例（34.17%）；手术时年龄3～84岁，平均 27.6岁，其中16～45岁年龄段患者最多（559例，66.78%）；创伤以交通事故伤为主（639例，76.34%）。畸形主要累及单侧肢体，其中左侧394例（47.07%）、右侧376例（44.92%）。2008年—2017年手术患者最多，占53.05%（444/837）。患者均实施 1 个或多个部位手术（1048个部位），其中踝关节及足趾手术矫正最多，占48.38%（507/1048）。实施包括肌腱延长及软组织挛缩松解术等各类矫形手术1204例次。术后联合骨外固定624例（Ilizarov 外固定 467例、组合式外固定 157例），联合石膏或支具外固定213例。.创伤后遗下肢畸形患者中男性比重大，地域分布广，涉及下肢各个部位且以足踝部多见，矫形手术联合骨外固定（Ilizarov技术）是畸形矫正和功能重建的主要方式。.

Background To determine if temporizing cast immobilization is a safe alternative to external fixator (ex-fix) in ankle fracture-dislocations with delayed surgery or moderate soft-tissue injury, we analysed the early complications and re-dislocation rates of cast immobilization in relation to ex-fix in patients sustaining these injuries. Methods All skeletally mature patients with a closed ankle fracture-dislocation and a minimum 6-months follow-up treated between 2007 and 2017 were included. Baseline demographics, comorbidities, injury description, treatment history and complications were assessed. Results In 160 patients (94 female; mean age 50 years) with 162 ankle fracture-dislocations, 35 underwent primary ex-fix and 127 temporizing cast immobilizations. Loss of reduction (LOR) was observed in 25 cases (19.7%) and 19 (15.0%) were converted to ex-fix. The rate of surgical site infections (ex-fix: 11.1% vs cast: 4.6%) and skin necrosis (ex-fix: 7.4% vs cast: 6.5%) did not differ significantly between groups (p = 0.122 and p = 0.825). Temporizing cast immobilization led to an on average 2.7 days earlier definite surgery and 5.0 days shorter hospitalization when compared to ex-fix (p p Conclusion Temporizing cast immobilization was a safe option for those ankle fracture-dislocations in which immediate definite treatment was not possible. Those temporized in a cast underwent definite fixation earlier than those with a fix-ex and had a complication rate no worse than the ex-fix patients. PMF-size was an important predictor for LOR. Primary ex-fix seems appropriate for those with ≥ 22.5% PMF-size. Trial registration The study does not meet the criteria of a prospective, clinical trial. There was no registration.

Arthrodesis of the knee joint is still a salvage procedure after recurrent prosthetic joint infections (PJI) of total knee arthroplasties (TKA) with substantial bone loss and seems to be a good solution to avoid amputation. Until now, intramedullary arthrodesis has increasingly been performed; no study has yet been published to compare these techniques after septic removal of TKA in terms of functional assessment and quality of daily life. In a single-centre retrospective setting, clinical and radiographic evaluation of consecutive patients after knee arthrodesis using intramedullary and external fixation for infected knee joints was performed. All patients were evaluated clinically, with x-ray and questionnaire including analysis regarding any complications at latest follow-up of a minimum 12 months postoperatively. We included 152 patients (75 females, 77 males) in this study. The mean age of the patients at surgery was 63.6 years (range 12 to 90 years). The minimum follow-up was 12 months (mean 3.1 years, range 12 to 49 months). Arthrodesis with external fixator (83 patients, 52.2%) showed less blood loss and less peri-operative complications (1.6%) but a high rate of post-operative, pin-track infections (35.5%); loose pins (12.7%); and pin fractures (4.8%), and therefore risk factors for instability and nonunion (30.9%). Revision rate was 22.6% for arthrodesis with external fixator, and the primary union rate was 65.6%. Intramedullary arthrodesis (69 patients, 43.4%) showed a similar re-infection rate to external fixation (16.1% and 15.9%, respectively) but a significantly lower revision rate (5.4%, p

This investigation develops a predictive model for loss of alignment (LOA) following fixation of open tibia fractures.An analysis was performed of adults with diaphyseal open tibia fractures randomized to intramedullary nailing (IMN) or external fixation (EF) followed at 6, 12, 24, and 52 weeks postoperatively. Demographic data were collected at baseline. Pre-injury and follow-up EuroQol 5-Dimensions (EQ-5D) and pain score were measured. Radiographs, taken postoperatively and in follow-up, were assessed for coronal and sagittal angulation, and used to calculate the modified Radiographic Union Scale for Tibia fractures (mRUST). LOA was defined as an increase in angulation5° by one year follow-up. Fracture comminution was defined using AO/OTA classification. Putative risk factors were assessed for association with LOA using bivariate logistic regression. Adjusted associations with LOA were estimated using multivariable logistic regression and marginal analysis.Analyses included 129 patients (70 IMN, 59 EF), majority male, of mean age 33 years (range 17.7-73) and body mass index (BMI) 25.2 (range 15.5-45.1), with 48% Type A, 41% Type B, and 11% Type C fractures (AO/OTA classification). The likelihood of LOA with EF increased with greater fracture comminution; 45.21% (p0.001), 77.50% (p0.001), and 100% LOA for Type A, B, and C fractures respectively. Relative risk of LOA for EF compared to IMN was 3.87 (95% CI 1.36, 11.02), 3.75 (95% CI 1.77, 7.92), and 5.76 for Type A, B, and C fractures, respectively. Compared to patients who lost alignment, patients without LOA had improved fracture healing (p = 0.003) and higher EQ-5D scores (p = 0.03) at one year.Increasing age and BMI are associated with LOA and segmental fracture amplifies the protective effect of IMN versus EF. The importance of LOA as a surrogate outcome after operative treatment of open tibial fractures is supported by its association with inferior radiographic and functional patient outcomes.

BACKGROUND Hydroxyapatite (HA) coated flexible intramedullary nailing (FIN) stimulates osteogenic activity. The role of HA-coated intramedullary nails remains unclear in normal bone lengthening. The goal of this study was to quantify the influence of FIN on the External Fixation Index (EFI) in patients with congenital lower limb discrepancy. METHODS Patients with femoral deficiency and fibular hemimelia underwent lengthening by the combined technique of external fixation with titanium (Ti) FIN or HA coated FIN and returned for follow-up at least 12 months after frame removal. RESULTS Seventy patients (mean age of 12.6 y) were included: 19 monofocal femoral lengthenings, 35 tibial monofocal lengthenings, 16 tibial bifocal lengthenings. The mean EFI's for those treated with and without HA-coated nails were not significantly different. The Conover posthoc analysis did not reveal a significant influence of the type of FIN on EFI in any subgroup. However, 2-way analysis of variance revealed simultaneous effects of nail types and age on the EFI in tibial bifocal lengthening.Significant positive correlation between the ratio "nail diameter/medullary shaft diameter" and EFI in tibial bifocal non-HA-coated FIN lengthening, and a significant positive correlation between age and EFI for femoral non-HA-coated FIN lengthening, tibial monofocal and bifocal HA-coated FIN lengthening were revealed.There were 4 cases of fracture at lengthening site required unscheduled surgery. In the non-HA-coated group, there was a statistically significant negative correlation between nail diameter and fracture occurrence at the lengthening site after frame removal. A ratio of

OBJECTIVE To report the radiographic, surgical and postoperative features in horses with unstable oblique mandibular fractures secured with polyaxial pedicle screws (PPS) external fixation construct and intraoral wiring. ANIMALS Three client-owned horses. STUDY DESIGN Short case series. METHODS Two horses each had a unilateral fracture, which did not improve after conservative management, and one horse had bilateral fractures. Clinical and radiographic features were documented. Polyaxial pedicle screw external fixators and intraoral tension band wiring were applied in standing horses after combining sedation and regional nerve anesthesia. Intraoral wires were implanted through a lateral buccotomy between teeth (two horses) or burred through exposed crown (one horse) and then secured around the incisors. The PPS were inserted under radiographic guidance to avoid tooth roots. Healing was assessed with radiographic examination. The PPS external fixator rod and intraoral wires were removed first. The mandible was manipulated, and, if it was stable, the PPS were removed. RESULTS Implants were removed at 6, 8, or 10 weeks after the mandibles were palpably stable. Complications included broken wires in one horse, bone sequestration in one horse, and infection in one horse. Follow-up communication with the owners 12 to 18 months later confirmed complete healing without further complications of the fractured mandibles or teeth. CONCLUSION Polyaxial pedicle screw external fixation led to fracture healing and a return to function in all three horses. The complications encountered did not preclude a successful outcome. CLINICAL SIGNIFICANCE Polyaxial pedicle screw external fixation coupled with intraoral wiring provides an alternative to treat unstable equine mandibular fractures without general anesthesia.

Objectives To observe the changes in the concentrations of circulating peripheral blood mesenchymal stem cells (PBMSCs) in Sprague Dawley (SD) rats and explore the pattern of changes in PBMSCs during the process of distraction osteogenesis. Methods SD rats were randomly divided into the osteotomy with lengthening group (lengthening group), the osteotomy without lengthening group (osteotomy group), and the blank control group (control group). Each group included 24 rats. Percutaneous pinning with external fixation of the left femur was carried out in lengthening group and osteotomy group, but control group received no surgical treatment. On day 5 after operation, continuous traction was carried out at a rate of 0.25 mm/d in lengthening group, while no traction was carried out in osteotomy group. Peripheral blood was collected from all rats on days 1, 3, 7, and 16 after the start of traction. PBMSCs were isolated by density gradient centrifugation. CD105, CD34, and CD45 were selected as cell surface markers. The concentration of PBMSCs was detected by flow cytometry and compared between groups at different time points. X‐ray films were taken during and after the operation to observe whether the osteotomy end was pulled and the growth and mineralization of the new bone in the osteogenic area of the femur. Color ultrasound was used to monitor the width of the distraction space, the formation of new bone, and the blood supply of soft tissue around the distraction. Results All rats were able to tolerate the operation well, and the external fixation was firm and reliable. X‐ray showed that, in lengthening group, the distraction space of femur gradually widened and new bone gradually formed in the distraction space; after 8 weeks, the samples were taken out, which showed that the new bone tissue in the lengthened area healed well. In osteotomy group, the average healing time of osteotomy was (7.12 ± 0.78) weeks. Ultrasonic examination showed that after the end of traction, the high echo callus shadow was seen in the traction space, and the blood flow signal was obviously rich at an earlier stage. In lengthening group and osteotomy group, the average concentrations of PBMSCs (3.02% ± 0.87% vs 2.95% ± 0.74%, respectively) were significantly increased in the early stage after osteotomy, and the average concentrations of PBMSCs on days 3, 7, and 16 after the start of traction were 5.34% ± 1.13% vs 3.28% ± 1.22%; 6.41% ± 1.05% vs 3.16% ± 0.92%; and 5.94% ± 1.23% vs 1.48% ± 0.52%, respectively. The concentration of PBMSCs in peripheral blood of lengthening group and osteotomy group was the same at osteotomy stage, and the difference between the two groups was not statistically significant (P > 0.05). After that, compared with lengthening group, the concentration of PBMSCs in osteotomy group gradually decreased and maintained at a certain level; the difference between the two groups was statistically significant (P, In the rat model of femoral osteotomy, with the process of distraction osteogenesis, peripheral blood mesenchymal stem cells will have obvious aggregation changes.

Background The hexapod external fixator (HEF) is increasingly used for high-energy tibial shaft fracture care as more general orthopedic surgeons are gaining expertise of this versatile device. The purpose of this study was to evaluate the clinical effectiveness of the HEF for definitive management in patients with high-energy tibial shaft fractures. Methods The study was conducted on 34 patients with tibial shaft fractures who were admitted or referred to our institution and consented to HEF treatment from Jan 2016 to June 2019, including 27 males and 7 females with a mean age of 39 years (range 18 to 65 years). Patients' clinical and radiological data, and the final clinical outcomes at a minimum of 12 months follow-up were collected and retrospectively analyzed. All complications were documented according to Paley’s classification. The clinical outcomes were evaluated using the Association for the Study and Application of the Method of Ilizarov criteria (ASAMI) at the last clinical visit. Results All patients remained in the HEF for a mean of 26 weeks (range 15 to 52 weeks) and acquired complete bone union. The satisfactory alignment was achieved in all patients, and all the patients were able to perform daily activities with no difficulty at the last clinical visit. Complications included pin tract infection (44%), delayed union (6%), nonunion (3%), and joint stiffness (3%). The ASAMI bony result was excellent in 31 patients and good in 3. The ASAMI functional result was excellent in 27 patients, good in 6, and fair in 1. Conclusions Definitive management using the hexapod external fixator is an alternative and effective method for high-energy tibial shaft fractures, including technical advantages of early trauma-control, the versatility of achieving excellent alignment, and the continuity of device until bone union.

Background The hexapod external fixator (HEF), such as the Taylor spatial frame (TSF), offering the ability of multidirectional deformities correction without changing the structure, whereas there are so many parameters for surgeons to measure and subjective errors will occur inevitably. The purpose of this study was to evaluate the effectiveness of a new method based on computer-assisted three-dimensional (3D) reconstruction and hexapod external fixator for long bone fracture reduction and deformity correction without calculating the parameters needed by the traditional usage. Methods This retrospective study consists of 25 patients with high-energy tibial diaphyseal fractures treated by the HEF at our institution from January 2016 to June 2018, including 22 males and 3 females with a mean age of 42 years (range 14–63 years). Hexapod external fixator treatments were conducted to manage the multiplanar posttraumatic deformities with/without poor soft-tissue that were not suitable for internal fixation. Computer-assisted 3D reconstruction and trajectory planning of the reduction by Mimics were applied to perform virtual fracture reduction and deformity correction. The electronic prescription derived from the length changes of the six struts were calculated by SolidWorks. Fracture reduction was conducted by adjusting the lengths of the six struts according to the electronic prescription. Effectiveness was evaluated by the standard anteroposterior (AP) and lateral X-rays after reduction. Results All patients acquired excellent functional reduction and achieved bone union in our study. After correction, the mean translation (1.0 ± 1.1 mm) and angulation (0.8 ± 1.2°) on the coronal plane, mean translation (0.8 ± 1.0 mm) and angulation (0.3 ± 0.8°) on the sagittal plane were all less than those (6.1 ± 4.9 mm, 5.2 ± 3.2°, 4.2 ± 3.5 mm, 4.0 ± 2.5°) before correction (P Conclusions The computer-assisted three-dimensional reconstruction and hexapod external fixator-based method allows surgeons to conduct long bone fracture reduction and deformity correction without calculating the parameters needed by the traditional usage. This method is suggested to apply in those unusually complex cases with extensive soft tissue damage and where internal fixation is impossible or inadvisable.

BackgroundThe Ilizarov segmental bone transport technique can be applied in the reconstruction of the bone defects with less invasive fashion and more versatility compared to other methods, while most studies were focused on the lower extremity. The purpose of this study was to evaluate the effectiveness of the Ilizarov segmental bone transport technique in the treatment of diaphyseal forearm bone defects caused by infection.MethodsThis study included 12 patients with diaphyseal forearm bone defects caused by infection, who underwent bone transport procedures using the monolateral external fixator at our institution from January 2010 to January 2018, including 10 males and 2 females with a mean age of 39 years (range 23–57 years). Patient’s demographic data and clinical outcomes at least two years follow-up after removing the external fixator were collected and retrospectively analyzed. The functional results were evaluated by the questionnaire of Disability of Arm, Shoulder and Hand (DASH) and the modified Mayo wrist score (MWS) at the final follow-up.ResultsThere were 10 radii and 2 ulnae bone transport procedures collected. The average defect size was 5.1 cm (4-6.5 cm). All patients were successfully followed up with a mean period of 28.2 months (24 to 36 months) and achieved infection-free union. There was no recurrence of infection observed. The mean external fixation time was 232.6 days (182 to 276 days), and the mean external fixation index was 46.3 days/cm (40.9 to 61.8 days/cm). The mean DASH score was 30.6(18 to 49) preoperative, while 13.8 (5 to 26) at the final follow-up. The average modified MWS improved from 68.8 (55 to 80) pre-operatively to 83.8 (65 to 90) at the final follow-up. All the differences between the preoperative and final scores were statistically significant (p ConclusionsIlizarov segmental bone transport technique is an alternative and effective method for the treatment of diaphyseal forearm bone defects caused by infection, and this method acquired satisfactory clinical outcomes.

Background The Taylor spatial frame offered the ability of simultaneous correction of the multidirectional deformities without the need to change the frame, and it was widely used for limb lengthening, deformity correction, and fracture reduction in recent years. There are still some inherent limitations that can affect the accuracy of correction, especially for the measurement of the mounting and rotational parameters. The purpose of our study was to propose some more precise postoperative measurement of Taylor spatial frame (TSF) parameters by application of elliptic registration and three-dimensional reconstruction. Methods This retrospectively study included 28 trauma patients who suffered tibial fracture treated by the TSF at our institution from January 2016 to January 2018, including 25 males and 3 females with a mean age of 43 years (range 14-70 years). We conducted standard full-length anteroposterior and lateral X-rays of the injured extremity and the computed tomographic scans of the bilateral extremities after the operation. Elliptic registration and 3D reconstruction were used to calculate the parameters by two types of software Mimics and CorelDRAW. Correction of the deformity was conducted by adjusting the struts of the TSF according to the electronic prescription. The standard anteroposterior and lateral X-rays after correction were taken to evaluate the effectiveness. Results All patients acquired functional reduction, which was evaluated by digital radiography. The mean coronal plane translation(1.9±2.2 mm), coronal plane angulation(1.2±1.0°), sagittal plane translation(2.7±2.1 mm), and sagittal plane angulation(1.2±1.0°) after correction were all less than those(5.5±4.6 mm, 4.9±3.9°, 4.7±4.0 mm, 2.7±2.3°) before correction. Conclusions The TSF system can correct the 6-axis deformities simultaneously with the accurate parameters. Elliptic registration and three-dimensional reconstruction are alternative methods to precisely measure the parameters needed by the TSF system, especially for the mounting and rotational parameters of unusually complex cases.

Tibial pylon fractures are difficult to manage injuries due to their anatomical situation, mechanism of production, and damage to the surrounding soft tissue. Surgical treatment is the most widely used, including external fixation that can be used temporarily or permanently.To evaluate the use of external fixation in patients with tibial pylon fractures.A pre-experimental study with a level of evidence II, recommendation grade B, was carried out in 34 patients with tibial pylon fracture, treated from January 2014 to February 2020. From the statistical point of view, the distribution of absolute and relative frequencies was used for qualitative variables and for quantitative variables, the Student's t test.The general average age was 45.8 years, the male sex predominated with a ratio of 1.4 to 1 and the closed-open fractures 1.8 to 1. Type A fractures predominated according to the classification of the AO group. In relation to open fractures, 3A types predominated. Significance between a before and after was detected when applying the Olreud C and Molander H scales, from the American Ankle and Foot Society, and the Ankle Scoring System. The complications of the surgical procedure were minimal.External fixation in patients with tibial pylon fractures is an effective method that can be used immediately and definitively in patients with both open and closed fractures with few complications.Las fracturas del pilón tibial constituyen lesiones de difícil manejo por su situación anatómica, mecanismo de producción y daño de las partes blandas que la rodean. El tratamiento quirúrgico es el más empleado, la fijación externa puede utilizarse de forma transitoria o definitiva.Evaluar el uso de la fijación externa en pacientes con fracturas del pilón tibial.Se realizó un estudio con un nivel de evidencia IV, grado de recomendación B, en 34 pacientes con fractura del pilón tibial, atendidos de Enero de 2014 a Febrero de 2020. Desde el punto de vista estadístico se utilizó la distribución de frecuencias absolutas y relativas para variables cualitativas y para las cuantitativas la prueba de t Student.El promedio de edad general fue de 45.8 años, predominó el sexo masculino con una razón de 1.4 a 1 y la fractura cerrada-abierta 1.8 a 1. Predominaron las fracturas tipo A según la clasificación del grupo AO. En relación a las fracturas abiertas predominaron las de tipo 3A. Se detectó significación entre un antes y un después al aplicar las escalas Olreud C y Molander H de la Sociedad Americana del Tobillo y Pie y el Ankle Scoring System. Las complicaciones del procedimiento quirúrgico fueron mínimas.La fijación externa en pacientes con fracturas del pilón tibial es un método efectivo que puede emplearse de forma inmediata y definitiva en pacientes con fracturas abiertas y cerradas.

Despite success of the Ponseti method, a subset of patients with clubfeet experience residual deformity. Surgical release after unsuccessful serial casting can lead to residual clubfoot deformities, including a flat-top talus. We present a case of a 17-year-old boy with a dysmorphic ankle and a complete dorsal dislocation of the Chopart joint. Because of pain with activities and functional limitations, the patient underwent a staged correction of the dislocation. The deformity was corrected through a staged approach using a Taylor Spatial Frame, navicular excision, talocuneiform arthrodesis, and calcaneocuboid arthrodesis. One year postoperatively, the patient is pain free with notable functional gains.

This study aims to evaluate the efficacy of close-wedge osteotomy and monorail external fixator in the treatment of chronic Monteggia fracture.Between January 2014 and December 2021, data of a total of 22 patients (14 males, 8 females; mean age: 15.6±5.1 years; range, 6 to 25 years) who suffered from chronic Monteggia fractures were retrospectively reviewed. All the patients were treated for acute angulation of the ulna after osteotomy and gradual angulation for radial head reduction. Range of motion of the elbow and forearm, the angle between the longitudinal axis of proximal radius and the hypothesized Storen's line (RSA), Visual Analog Scale (VAS), and Mayo Elbow Performance Score (MEPS), as well as Disabilities of Arm, Shoulder and Hand (DASH) score were recorded preoperatively and at the final follow-up.Objective parameters were all significantly improved in the aspects of range of motions of the elbow and forearm, and RSA (21.4±4.5° preoperatively and 2.0±1.4° at the final follow-up, t=18.20, p0.05). The level of pain due to the chronic injury was eliminated, as the mean VAS was significantly lower at the final follow-up compared to preoperative scoring (2.8±2.0 preoperatively and 0.5±0.9 at the final follow-up, t=4.86, p0.05). The function of the elbow and upper limb was restored, which was indicated by improved MEPS (73.2±12.5 preoperatively and 96.6±6.4 at the final follow-up, t=7.70, p0.05) and DASH (28.3±6.0 preoperatively and 4.1±2.0 at the final follow-up, t=19.35, p0.05). No complication was observed.Close-wedge osteotomy and gradual lengthening with monorail external fixator in the treatment of chronic Monteggia fracture showed great efficacy. We also provided a specified osteotomy site aiming at PRUJ reconstruction.

CASE DESCRIPTION A 2-year-old intact male Mini Lop rabbit (Oryctolagus cuniculus) exhibited acute paraplegia and was suspected of having a traumatic spinal injury after leaping from the owner’s arms. CLINICAL FINDINGS In the physical examination, the patient was conscious and responsive and presented a loss of hind-limb motor function. The results of the neurologic examination indicated a T3-L3 spinal cord lesion. Vertebral column radiography and CT showed a fracture of the dorsal arch in the right caudal part of vertebra L1 and a fracture of the caudal end plate of vertebra L1 without displacement. TREATMENT AND OUTCOME The vertebral fracture was stabilized by a monolateral external fixator placed percutaneously with fluoroscopy guidance. The rabbit was discharged 48 hours after surgery. Three days later, the rabbit was able to walk with mild paraparesis, and 2 weeks after surgery, the rabbit showed full recovery of neurologic function. The follow-up performed 6 weeks after surgery showed normal gait, good alignment and complete consolidation of the fracture. The external fixator was then removed. The follow-up examination and radiographic findings showed complete recovery at 2 and 6 months after surgery. CLINICAL RELEVANCE The most common cause of traumatic posterior paralysis in rabbits is vertebral fracture. This article describes the possibility and successful outcome of stabilizing a vertebral fracture in a rabbit with an external fixator using a minimally invasive fluoroscopic technique. This technique, described to the authors’ knowledge for the first time in a rabbit, allows a fracture to be stabilized accurately without any incisions while minimizing complications and postoperative pain.

Objectives The aims of this study were to describe the type, presentation and prognostic factors of feline humeral fractures over a 10-year period and to compare three stabilisation systems for feline humeral diaphyseal fractures. Methods In total, 101 cats with humeral fractures presenting to seven UK referral centres between 2009 and 2020 were reviewed. Data collected included signalment, weight at the time of surgery, fracture aetiology, preoperative presentation, fixation method, surgical details, perioperative management and follow-up examinations. Of these cases, 57 cats with humeral diaphyseal fractures stabilised using three different fixation methods were compared, with outcome parameters including the time to radiographic healing, time to function and complication rate. Results The majority of the fractures were diaphyseal (71%), with only 10% condylar. Of the known causes of fracture, road traffic accidents (RTAs) were the most common. Neutered males were over-represented in having a fracture caused by an RTA ( P = 0.001) and diaphyseal fractures were significantly more likely to result from an RTA ( P = 0.01). Body weight had a positive correlation ( r = 0.398) with time to radiographic healing and time to acceptable function ( r = 0.315), and was significant ( P = 0.014 and P = 0.037, respectively). Of the 57 humeral diaphyseal fractures; 16 (28%) were stabilised using a plate–rod construct, 31 (54%) using external skeletal fixation and 10 (18%) using bone plating and screws only. Open diaphyseal fractures were associated with more minor complications ( P = 0.048). There was a significant difference between fixation groups in terms of overall complication rate between groups ( P = 0.012). There was no significant difference between fixation groups in time to radiographic union ( P = 0.145) or time to acceptable function ( P = 0.306). Conclusions and relevance All three fixation systems were successful in healing a wide variety of humeral diaphyseal fractures. There was a significantly higher overall complication rate with external skeletal fixators compared with bone plating; however, the clinical impact of these is likely low.

Purpose The aim of this study is to investigate the outcome of these limb-threatening injuries through external fixation treatment and to discuss the case of patients’ functional recovery after external fixation. Methods Demographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery. Results Eighty-eight patients were identified and 80 patients (90 legs) maintained a successful lower leg salvage. The mean age was 32.7 ± 10.8 years, and 81.8% were male. The primary outcomes included the following complications: pin-tract infection (8 legs), pins loosening (4 pins), wound superficial infection (7 legs), deep infection developed osteomyelitis (3 legs), bone nonunion or bone defect (17 legs) and amputation (8 legs). The average healing time of fracture was 5.6 ± 4.3 months. The maintain of external fixation average time was 5.8 ± 3.6 months. The improvement of scores of the pain, function and quality of life in our follow-up was statistically significant. Conclusion For the lower extremity fracture patients with vascular injuries, using external fixation correctly can improve clinical outcomes and produce the improvement of pain, function and the quality of life. Level of evidence Retrospective cohort, level IV.

Various external fixation systems for lower extremity long bone deformities have been used to various degrees of success, while newer mechanical lengthening nail (MLN) systems offer the potential for improved patient outcomes. Proponents of MLNs argue that they reduce the number of operations, infectious complications, and improve quality of life; however, the evidence to support these claims is scant. This systematic review aims to evaluate the optimal lengthening system for treating post-traumatic long bone deformity. The systematic review was conducted in accordance with PRISMA guidelines. PUBMED, EMBASE, CINAHL, and the Cochrane Library were searched for comparative studies of lengthening techniques among adult patients with axial deformities. Studies were screened and data extracted in duplicate. Treatment groups were pooled into external fixation (EF) alone, combined internal and external fixation (CIF), and mechanical lengthening nail (MLN). Outcomes were mean lengthening achieved, lengthening index, and reported complications. Thirteen studies with 725 patients (mean age: 29.6 years, 74% male) were included. Nearly all of the studies were either prospective or retrospective cohort studies (n = 12), with one randomized controlled trial of moderate study quality. The mean limb lengthening achieved, lengthening index, and rate of reoperation were similar among the MLN, EF, and CIF groups. The purported decreased the duration of lengthening and the risk of reoperation associated with MLNs was not demonstrated in this review. Patients with post-traumatic leg length deformities remain a challenging patient population to treat, with intervention being associated with high rates of infectious complications and need for revision operations.

Purpose To analyze the indications, radiological short-term outcomes, and complications of ankle fractures in geriatric patients treated with a triangular external fixator (AEF) until fracture healing. Furthermore, the effect of an additional osteosynthesis to AEF on the radiological outcome was investigated. Methods Retrospective analysis of ankle fractures treated in a Level I Trauma Center between 2005 and 2015 with an AEF in patients aged ≥ 65 years until fracture has healed. The combination of AEF and at least one additional osteosynthesis of a malleolus was defined as hybrid external fixator (HEF). At the time of AEF removal, a preserved ankle joint congruity was defined as good radiological outcome. Incongruity more than 2 mm was defined as poor radiologic results. Results 16 patients (13 women, 3 men) with a mean age of 74 years (SD 6.2) were treated with AEF until fracture healing, 9 with a single AEF and 7 with a HEF. Stabilization with HEF (n = 7 [100%]) showed higher rates of good radiological outcome than AEF alone (n = 4 [44%] of 9; p = 0.034). The duration of therapy did not differ between HEF and AEF (70 day vs 77 days). 4 patients (22%) required surgical revision. Conclusion It could be shown that osteosynthesis in addition to AEF leads to a better radiological short-term results than using AEF alone. Therefore, in the situation where an AEF is considered as the definitive treatment option for an ankle fracture in geriatric patients with expected or existing soft tissue problems, it should be done or completed as a HEF. Level of evidence Therapeutic level IV.

Objective The aim of this study was to assess the early operative results of a staged progressive reduction technique using a bilateral external fixator in the treatment of patients with open Lisfranc fracture dislocations. Methods In this retrospective study, 21 patients (5 women and 16 men; mean age=44.4 years; age range=24 to 69 years) with open Lisfranc fracture dislocations were included. All the patients were treated in a staged manner from 2012 to 2015. The mean follow-up was 15.4 months (range=12 to 24 months). A two-stage surgical protocol was performed for each patient. At the first stage, a bilateral spanning external fixator was applied across the injured Lisfranc joint, and the length of the disrupted columns was restored by distraction process. Vacuum-assisted closure was used if required. At the second stage, the external fixator was removed, and open reduction and internal fixation were carried out. The time interval between the first and second stages and postoperative complications were documented. To assess the functional status of the patients, the visual analog scale (VAS) and the American Orthopaedic Foot - Ankle Society (AOFAS) midfoot scale were measured at the final follow-up. Radiographic parameters indicating the alignment of the midfoot after the second operation were examined. Results Deep infection in one patient and superficial infection in 2 patients were observed. Venous thrombosis was detected in 3 patients. The mean interval between the first and second stages was 18.6 days (range=8 to 48 days). The first metatarso-cuneiform step-off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) significantly improved at the final follow-up. The mean VAS score was 2.4 (range=0-5), and the mean AOFAS score was 76.3 (range=63 to 97). Primary arthrodesis was performed in seven patients, and six of the remaining 14 patients developed post-traumatic arthritis. Conclusion With a low risk of complications, the staged progressive reduction protocol using an adjustable bilateral external fixator can be an effective treatment to achieve and maintain anatomic reduction for patients with open Lisfranc fracture dislocations in a short-time follow-up. Level of evidence Level IV, Therapeutic study.

Background: The pins and rubbers traction system is widely used to treat unstable proximal interphalangeal (PIP) joint fracture-dislocations. However, dealing with rubber bands can be difficult due to its elasticity and weakness. The purpose of this study was to report the results of an alternative dynamic external fixator technique for unstable PIP joint injuries. Methods: Thirteen patients with acute unstable PIP joint fracture-dislocation (n = 8), pilon fracture (n = 2), or comminuted shaft fractures of a middle phalanx with or without PIP joint extension (n = 3) were enrolled. The alternative fixator used a plastic syringe to maintain distraction force instead of the commonly used rubber bands. Four patients underwent combined open reduction due to unsatisfactory reduction by closed mean. The fixator was removed when there was radiographic evidence of healing. Results: At 6 months after the operation, the mean active ROM of the injured PIP joint was 89° (range, 70–104°), and the mean Quick-DASH score was 9.78 (range, 0–40.9). The mean NRS of pain before fixator removal was 1 (range, 0–4). One patient had a pin tract infection and underwent debridement and fixator removal at 33 days postoperatively. There was no loss of reduction or implant failure in the study. Conclusions: The results were comparable to other dynamic external fixation techniques used for unstable PIP joint fracture-dislocations. The main advantages of this technique were strength of the system, procedure simplicity, the compact design, and relatively low cost. In addition, this technique can also be used in pilon fractures and comminuted shaft fractures of a middle phalanx with or without PIP joint extension.

Introduction While the management of Rockwood type III injuries is still a topic of debate, high-grade Rockwood type V injuries are mostly treated surgically, to anatomically reduce the acromioclavicular (AC) joint and to restore functionality. In this case report, we present a method for non-operative reduction and stabilization of a high-grade AC joint injury. Case A 31-year-old male orthopaedic resident sustained a Rockwood type V injury during a snowboarding accident. His AC joint was reduced and stabilized with an AC joint brace for six weeks. The brace provided active clavicle depression and humeral elevation. After removal of the brace the AC joint showed a nearly anatomic reduction. Six-month follow-up weighted X-ray views showed an AC joint which had healed in a Rockwood type II position and the patient returned to full pre-injury function with a satisfying cosmetic appearance. Conclusion Non-operative reduction and stabilization of high-grade AC joint separations seems to be a valuable treatment option. A “closed reduction and external fixation” approach with the aid of a dedicated AC joint brace can reduce the AC joint and keep it in place until ligamentous consolidation occurs, thus improving AC joint stability and cosmetic appearance without surgical intervention.

The prevalence of C2 fractures has increased in recent years. The treatment of these fractures include halo-vest immobilization (HVI), rigid cervical collar, or spinal fusion. There is controversy regarding the management of these fractures with different institutions having their own protocols based on individualized experience. The volume-outcome relationship of HVI use for C2 fractures has not been studied. Evaluation of such relationships are important as they suggest that patients may benefit from referral to and treatment at high-volume institutions.To evaluate the volume-outcome relationship in HVI use for C2 fractures in New York State.Retrospective analysis of a statewide database.We queried the New York Statewide Planning and Research Cooperative System database for the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code 805.02 (closed fracture of second cervical vertebra) and procedure code 029.4 (insertion or replacement of skull tongs or halo traction device) to identify all patients who received HVI for a fracture of the second cervical vertebra between the years 2001 and 2014. Those who had isolated C2 fractures were selected.Outcomes of interest included resource utilization characteristics (hospitalization charges and length of stay), perioperative complications, comorbidities, 30-day mortality, any readmission, and any future cervical fusion surgery.The 2001 to 2014 Statewide Planning and Research Cooperative System database was used to identify patients with C2 fractures who received HVI. Our key independent variable was institution volume modeled as high- (25 halos/year), medium-, (10-25 halos/year), or low-volume (10 halos/year) based on the total number of HVI procedures reported by hospitals during the study period. We compared outcomes with respect to hospital volume. We also compared patients by age groups:40, 40 to 60, 60 to 80, and80. Multivariate logistic regressions were performed for the binary variables any complication and any readmission while controlling for covariates hospital volume, age, sex, race, insurance status, and Elixhauser comorbidity mean. Statistical significance was set at a value of p.05 for all analyses.In all, 625 patients with C2 fractures managed with HVI were included. Most patients were male (53%) and Caucasian (76%) with a mean age of 57. Patients at high-volume hospitals were younger (52 vs. 59 and 60 for medium- and low-volume, respectively; p.01) and had fewer future readmissions (40% vs. 54% and 84% for medium- and low-volume, respectively; p.01). On multivariable analysis, those with private insurance and worker's compensation had lower likelihood of future readmission compared to Medicaid patients. Patients80 had higher rates of major in-hospital complications (52% vs. 40%, 18%, and 19% for groups 60-79, 40-59, and40, respectively; p.01), mortality (14% vs. 5%, 1%, and 1% for groups 60-79, 40-59, and40, respectively; p.01), and readmissions after the initial HVI (62% vs. 50%, 54%, and 37% for groups 60-79, 40-59, and40, respectively; p.01). The annual rate of HVI use for C2 fractures decreased significantly from 2001 to 2014 (0.32 to 0.06 HVI procedures per 100,000 people; p.01) with the rate of decline being less pronounced in high-volume institutions (70% decrease vs. 85% and 90% for medium- and low-volume, respectively).Halo vest utilization for C2 fractures in New York State has been declining over the past decade, with the decline being less pronounced in high-volume hospitals. Our hospital volume analysis suggests that HVI use in high-volume institutions is associated with a lower rate of future readmissions. This finding suggests that patients with C2 fractures may benefit from treatment at high-volume institutions. Further research to help improve referral of appropriate patients and increase access to such institutions is warranted.

Chronic wounds of the lower extremity can pose several obstacles for the treating physician as well as the patient. Peroneal artery adipofascial flaps have been shown to be a reliable and durable option for reconstruction of these defects for many reasons, including ease of dissection, minimized donor site mobility, reliability of take to underlying surfaces, and cosmetically more pleasing outcome. This article discusses the current literature regarding the use of peroneal artery adipofascial flaps and our surgical technique for harvest, transfer, and postoperative course for this versatile flap.