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BackgroundProvisional stabilization of high-energy tibia fractures using temporary plate fixation (TPF) or external fixation (ex-fix) prior to definitive medullary nailing (MN) is a strategy common in damage control orthopaedics. There is a lack of comprehensive data evaluating outcomes between these methods. This study compares outcomes of patients stabilized with either TPF or ex-fix, and with early definitive MN only, assessing complications including nonunion and deep infection.MethodsA retrospective review was performed on adult patients with tibia fractures treated with MN followed until fracture union (≥3 months) at a single level-1 trauma center from 2014 to 2022. Medical records were evaluated for nonunion and deep infection. Demographics, injury characteristics, and fixation methods were recorded. Significance between patients who underwent TPF and ex-fix was compared with a matched cohort of early MN using Pearsons exact tests, independent t-tests, and one-way ANOVA, depending on the appropriate variable.Results81 patients were included; 27 were temporized with TPF (n = 12) or ex-fix (n = 15). 54 early MN cases defined the matched cohort. All groups had similar patient and fracture characteristics. The difference in rates of nonunion between groups was significant, with TPF, ex-fix, and early MN groups at 17, 40, and 11% respectively (p = 0.027). Early MN had lower rates of nonunion (11% vs. 40%, p = 0.017) and deep infection (13% vs. 40%, p = 0.028) compared to ex-fix.ConclusionTemporary ex-fix followed by staged MN was associated with higher rates of nonunion and deep infection. There was no difference in complication rates between TPF and early definitive MN. These data suggest that ex-fix followed by MN of tibia fractures should be avoided in favor of early definitive MN when possible. If temporization is needed, TPF may be a better option than ex-fix. Level of Evidence: IV.

Purpose: To observe the effect of the forearm rotation function reconstruction with an external fixator in treating congenital radioulnar synostosis. Methods: From July 2017 to July 2023, 6 patients (9 sides) with congenital radioulnar synostosis who underwent reconstruction of the forearm rotation with the external fixator were retrospectively analyzed. The extent of flexion and rotation, the Modified An and Morrey functional rating index, and the grade according to the classification system proposed by Failla et al. were compared before and after the operation. Results: All patients were followed up for an average of 12.00 (8.00, 38.50) months. The average range of rotation, the Modified An and Morrey functional rating index increased from 0°, 64.56 ± 1.33 points to 85.00° ± 25.86°, 83.71 ± 5.50 points, respectively. The differences were statistically significant (t = 9.86, P < 0.01, t = 11.20, P < 0.01). There was no significant difference in forearm flexion before and after the operation (Z = 1.34, P = 0.18). According to the Failla classification system, 2 forearms were classified as poor preoperatively, 6 as fair and 1 as good. 2 forearms were assessed as excellent, 6 as good and 1 as fair during the last follow-up. Conclusion: Reconstruction of the forearm rotation function with an external fixator is safe and effective for treating congenital radioulnar synostosis. This technique can restore the partial rotational function of the forearm. [ABSTRACT FROM AUTHOR]

Incomplete sacroiliac joint injuries are often associated with external rotation and extension deformities on the injured hemipelvis. To appropriately correct this deformity, an oblique reduction force from caudal to cranial and lateral to medial is helpful. These injuries are often associated with traumatic disruption of the pubic symphysis. However, in injuries without traumatic disruption to the pubic symphysis, a two-pin oblique anterior external fixator can be used to obtain and maintain reduction of the sacroiliac joint, while percutaneous fixation is subsequently placed. Through a small case series and three specific patient examples, we demonstrate that the oblique anterior external fixator frame is a simple and effective strategy with the reduction and stabilization process of these multiplanar hemipelvis deformities. [ABSTRACT FROM AUTHOR]

Background: Compound fractures of the distal tibia (with or without the middle third) represent a challenge for orthopedic and plastic surgeons because of the scarcity of available soft tissue reconstruction and the important comminution of the fractures that usually appear. Methods: The design of this study is based on the PRISMA guidelines. Databases were searched for articles published and available until the first half of 2023. Articles that presented the evolution of patients treated by combining circular external fixators with reconstructive methods were selected. Results: After searching the literature using keywords, we obtained 3355 articles, out of which 14 articles met all the inclusion criteria, with a total number of participants of 283. The bone loss varied between 0.7 and 18.2 cm, while the soft tissue defect was between 3/3 cm and 16/21 cm. The average period of fixation ranged from 4 to 22.74 months. The most used reconstruction methods were 80 free flaps and 73 pedicled flaps out of 249 interventions. Complete flap loss appeared only in 3/283 patients. Regarding the bone union, the percentage of non-union was low, and in all cases, it was achieved after reintervention. A low rate of major complications was observed. Conclusions: The orthoplastic team is the key to successfully treating the high-energy traumatism of the distal tibia (with or without a middle third). The Ilizarov external fixator can be used as a definitive limb-salvage treatment (secondary to the standard primary methods of fixation) in combination with a flap to cover the defects because it does not damage the pedicle, and it helps stabilize the soft tissues and bones around the flap to lower the complications. [ABSTRACT FROM AUTHOR]

Objective: To describe the clinical and surgical characteristics of external fixation technique to manage complex open proximal humerus fractures caused by high-energy firearm injuries at the Hospital Militar Central, Colombia. Methods: A retrospective case series of patients with open complex proximal humerus fractures (Gustilo & Anderson III A-B or Neer III and IV) caused by long range or fragmentation weapons treated with external fixation. The variables are demographic data, range of motion, consolidation measurements, and functional outcomes according to the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) functional scale. Results: Seven male patients, with high-energy injuries causing open complex proximal humerus fractures (Gustilo & Anderson III A-B or Neer III or IV) underwent surgical treatment with external fixation and arthrodiastasis. Median age was 21.0 (19–24) years, mean treatment duration was 5.6 (4–7) months, and all patients completed 15 months of follow-up. Mean postoperative active movement measurements were flexion: 80° (40°–120°), abduction 85.7° (40°–130°), external rotation: 24.7° (10°–45°), and internal rotation: 23.6° (10°–45°). Mean postoperative pain according to visual analog scale was 2.7 (1–4) and mean Quick DASH was 36.2 (15.9–58). Two patients presented postoperative complications, one case each of infection and osteitis. Conclusion: Complex open proximal humeral fractures caused by high-energy trauma treated with transarticular external fixation via arthrodiastasis show promising short-term and mid-term results with low complication rates, low levels of postoperative pain, and moderate functional results. This external fixation technique seems to be a valid option for the treatment of polytraumatic patients with humeral injuries. Longer follow ups and larger sample sizes studies must be presented to better characterize the clinical and satisfaction outcomes. [ABSTRACT FROM AUTHOR]

AbstractDistraction osteogenesis (DO) is a bone regenerative maneuver, which is conventionally done with external fixators and, more recently, with telescopic intramedullary nails. Despite the proven effectiveness, external approaches are intrusive to the patient’s life while intramedullary nailing damages the growth plates, making them unsuitable for pediatric patients. An internal DO plate fixator (IDOPF) was developed for pediatric patients to address these limitations. The objective of this study was to test the hypothesis that the IDOPF can withstand a partial weight bearing scenario and create a favorable mechanical microenvironment at the osteotomy gap for bone regeneration as the device elongates. A finite element model of a surrogated long bone diaphysis osteotomy fixation by means of the IDOPF was created and subjected to axial compression, bending and torsion. As the osteotomy gap increased from 2 mm to 20 mm, under compression, The average axial interfragmentary strains decreased from 2.33% to 0.35%. Stress increased from 179 MPa to 281 MPa at the contact interfaces of the telescopic compartments, which exceeded the endurance limit of stainless steel (270 MPa) but was below its yield limit (415 MPa). These results demonstrate, that the IDOPF can withstand a partial load bearing scenario and provide a stable biomechanical environment conductive to bone healing. However, high contact stresses at the telescopic interfaces of the device are likely to cause wear, as is frequently reported in telescopic fixators. This study is a step towards refining the IDOPF design for clinical use. [ABSTRACT FROM AUTHOR]

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

Purpose: The task faced by surgeons becomes significantly more challenging when they encounter lower extremity bone defects due to a variety of causes requiring lengthening. The most discussed and successful approach is the Illizarov technique, or lengthening over a nail (LON):distraction osteogenesis is also widely performed with monoliteral external fixators and intramedullarylengthening nails have increasingly been used in the last decade. Methods: The data were collected from PubMed, Cochrane Library, Embase, and the Web of Science for all available studies comparing the outcomes of Ilizarov technique alone and LON technique (from January 1, 1997, to November 30, 2023). The outcomes of interest encompassed the external fixation index (EFI) (month/cm), mean duration of follow-up (MFT) (month), length gained (LG) (cm), consolidation index (CIx) (month/cm), and bone healing index (BHI) (month/cm).Complications include pin tract infection rate (PTI), axial deviation rate (AD), occurrence of intramedullary infection (II), delayed consolidation rate (DC), as well as data categorized into three levels of problems, obstacles, and sequelae based on the severity of complications.Two reviewers independently assessed each study for quality and extracted data. The case–control or respective cohort studies were evaluated using the Newcastle–Ottawa scale (NOS) to determine their techniqueological rigor.The Cochrane Collaboration's risk assessment tool was employed to perform quality evaluations for randomized controlled trials. Results: This review included thirteen studies comprising a total of 629 patients.The external fixation index (month/cm) was significantly smaller in the LON technique compared to the Ilizarov technique alone [Mean Difference(MD) = -29.59, 95% CI -39.68–-19.49, P < 0.00001].In terms of the mean follow-up time(month) (MD = -0.92, 95% CI -3.49–1.65, P = 0.57), length gained (cm) (MD = -0.87, 95%CI -2.80–1.07, P = 0.38), consolidation index (month/cm) (MD = 0.66, 95% CI -3.44–4.77, P = 0.75), and bone healing index (month/cm) (MD = -3.33, 95% CI -13.07–6.41, P = 0.5), there were no significant differences observed. The LON technique exhibited a lower incidence of axial deviation [Odds Ratio(OR) = 0.06, 95%CI 0.03–0.16, P < 0.00001] and pin tract infection (OR = 0.30, 95%CI 0.18–0.50, P < 0.00001) compared to the Ilizarov technique alone.The remaining complications, such as intramedullary infection rate (OR = 0.93, 95%CI 0.42–2.06, P = 0.85) and delayed consolidation rate(OR = 0.61, 95%CI 0.20–1.86, P = 0.38), did not exhibit statistically significant differences.Our findings demonstrated that the LON technique results in lower incidences of problems (38.5%vs.58.6%) and sequelae (16.6% vs.30.9%) when compared to the Ilizarov technique alone. However, the rates of obstacles (32.4% vs.32.3%) were comparable between the two methods. Conclusions: Our findings indicate that patients treated with the LON technique experienced significantly shorter external fixation durations and a lower incidence of complications (e.g., pin tract infections and axial deviation) compared to those treated with the Ilizarov technique alone. Other outcome metrics showed no significant differences between the two techniques. However, the LON technique offers substantial benefits, including reduced external fixation times and increased comfort, which enhance patient compliance. In conclusion, the LON technique is a safe, reliable, and effective method for treating tibial and femoral defects. [ABSTRACT FROM AUTHOR]

Background Objective Methods Results Conclusion Although the specific relationship between the stress changes in the external fixator during tibial fracture treatment and the bone healing process remains unclear, it is believed that stress variations in the external fixator scaffold can, to a certain extent, reflect the progress of tibial healing.This study aims to propose a non‐invasive method for assessing the degree of fracture healing by monitoring the changes in stress transmission, the locations of stress‐sensitive points, and displacement in the external fixator‐tibia system during the healing process of tibial fractures.In this study, finite element models of tibial fractures at various healing stages were developed. Physiological conditions, including axial, torsional, and bending loads on the tibia, were simulated to evaluate stress and strain within the external scaffold‐tibia system under normal physiological loading conditions.The results indicate variations in the stress distribution between the external fixator and the tibia during different stages of healing. In the early phase of fracture healing, the external fixator plays a crucial role as the primary load‐bearing unit under all three loading conditions. As the fracture healing progresses, the stress on the tibia gradually increases, concentrating on the medial part of the tibia under axial and torsional loading, and at the upper and lower ends, as well as the central part of the anterior and posterior tibia during bending loading. The stress at the callus gradually increases, while micro‐movements decrease. The stress within the external bracket gradually decreases, with a tendency for the connecting rod to transfer stress towards the screws. Throughout the fracture healing process, the location of maximum stress in the external fixator remains unchanged. Under axial and torsional loading, the maximum stress is located at the intersection of the lowest screw and the bone cortex, while under bending loading, it is at the intersection of the second screw and the connecting rod.During the bone healing process, stress is transferred between the external fixation frame and the bone. As bone healing advances, the stress on the connecting rods and screws of the external fixation frame decreases, and the amplitude of stress changes diminishes. When complete and robust fusion is achieved, stress variations stabilize, and the location of maximum stress on the external fixation frame remains unchanged. The intersections of the lowest screw and the bone cortex, as well as the second screw and the connecting rod, can serve as sensitive points for monitoring the degree of bone healing. [ABSTRACT FROM AUTHOR]

Biomechanical and orthopaedic studies frequently encounter complex datasets that encompass both circular and linear variables. In most cases (i) the circular and linear variables are considered in isolation with dependency between variables neglected and (ii) the cyclicity of the circular variables is disregarded resulting in erroneous decision making. Given the inherent characteristics of circular variables, it is imperative to adopt methods that integrate directional statistics to achieve precise modelling. This paper is motivated by the modelling of biomechanical data, that is, the fracture displacements, that is used as a measure in external fixator comparisons. We focus on a dataset, based on an Ilizarov ring fixator, comprising of six variables. A modelling framework applicable to the six-dimensional joint distribution of circular-linear data based on vine copulas is proposed. The pair-copula decomposition concept of vine copulas represents the dependence structure as a combination of circular-linear, circular-circular and linear-linear pairs modelled by their respective copulas. This framework allows us to assess the dependencies in the joint distribution as well as account for the cyclicity of the circular variables. Thus, a new approach for accurate modelling of mechanical behaviour for Ilizarov ring fixators and other data of this nature is imparted. [ABSTRACT FROM AUTHOR]

In the clinical application of the parallel external fixator, medical practitioners are required to quantify deformity parameters to develop corrective strategies. However, manual measurement of deformity angles is a complex and time‐consuming process that is susceptible to subjective factors, resulting in nonreproducible results. Accordingly, this study proposes an automatic measurement method based on deep learning, comprising three stages: tibial segment localization, tibial contour point detection, and deformity angle calculation. First, the Faster R‐CNN object detection model, combined with ResNet50 and FPN as the backbone, was employed to achieve accurate localization of tibial segments under both occluded and nonoccluded conditions. Subsequently, a relative position constraint loss function was added, and ResNet101 was used as the backbone, resulting in an improved RTMPose keypoint detection model that achieved precise detection of tibial contour points. Ultimately, the bone axes of each tibial segment were determined based on the coordinates of the contour points, and the deformity angles were calculated. The enhanced keypoint detection model, Con_RTMPose, elevated the Percentage of Correct Keypoints (PCK) from 63.94% of the initial model to 87.17%, markedly augmenting keypoint localization precision. Compared to manual measurements conducted by medical professionals, the proposed methodology demonstrates an average error of 0.52°, a maximum error of 1.15°, and a standard deviation of 0.07, thereby satisfying the requisite accuracy standards for orthopedic assessments. The measurement time is approximately 12 s, whereas manual measurement requires about 15 min, greatly reducing the time required. Additionally, the stability of the models was verified through K‐fold cross‐validation experiments. The proposed method meets the accuracy requirements for orthopedic applications, provides objective and reproducible results, significantly reduces the workload of medical professionals, and greatly improves efficiency. [ABSTRACT FROM AUTHOR]

Background: Orthopedic fixators depend on mechanical characteristics like stiffness and firmness. The Ilizarov Apparatus (IA) is a common surgical management approach to restructure the bone fractures. IA includes two wires, specifically K-wire and olive wire, to treat the fractures. Methods: The functions of IA using K-wire and olive wire have been explored with experimental and finite element approach. To describe the stability of fixation and stiffness of olive wire and K-wire, the mechanical performance of the wires was evaluated experimentally as well as numerically by ANSYS software. Results: The results obtained from the olive wire experimental setup with applied loads of 50 to 100 N, showed stiffnesses ranging from 13.85 to 14.58 N/mm and displacements ranging from 3.61 to 6.86 mm. Also, in analytical evaluation, the obtained stiffness ranges from 14.36 to 14.34 N/mm for loads of 50–100 N with a displacement of 3.48–6.97 mm. Conclusions: A two-ring olive wire was found to be stiffer than a two-ring K-wire fixator under the same loading conditions. The goal of this study is to help orthopedic specialists assess the stiffness and stability of IA setups with olive and K-wires. [ABSTRACT FROM AUTHOR]

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

• The error model of a 5-DOF PEF is established based on the POE formula to satisfy completeness, continuity, and minimality. • An MPC-based parameter identification approach is proposed to address the challenge in the measurement of pose information. • A novel calibration method containing the POE-based error model and the MPC-based identification approach is formed. • The method makes advances in model accuracy and measurement difficulty, and can cost-effectively finish calibration tasks. Limb deformity is a common complaint in orthopedic surgery. Currently, gradual treatment using parallel external fixator (PEF) has become the preferred option for deformity correction. As the key medical apparatus with the special application properties of temporary assembly and direct utilization, the geometric errors generated during the manufacturing and assembly process of the PEF contribute to the post-correction residual and iatrogenic deformities. However, considering the complexity of clinical scenarios, there is a lack of an applicable solution to reduce the effect of the above error source of PEF. To overcome these problems, taking a 4-U P S/S P R PEF as the research object, this paper proposes a novel kinematic calibration method. First, the error model with the features of completeness, continuity, and minimality is first established based on the product of exponentials (POE) formula. Then, the identifiability analysis is conducted to eliminate the redundant error parameters and ensure the stability and accuracy of the iterative calculation in the process of parameter identification. Furthermore, a multiple plane constraint (MPC)-based parameter identification approach is introduced to the calibration task of the PEF to effectively reduce the difficulty of the pose information measurement in the current cost-effective constraint calibration method. Finally, the simulation and prototype experiments validate that the proposed calibration method (i.e., the combination of the POE-based error model and the MPC-based parameter identification approach) can accomplish the calibration tasks in clinical applications and meet the cost-effectiveness and efficiency requirements. [ABSTRACT FROM AUTHOR]

Isolated, closed, femoral shaft fractures are dangerous injuries that commonly occur in the setting of high energy trauma or among older patients with significant comorbidities. Despite their prevalence, relatively little data exists connecting patient independent risk factors to the time to 30-day mortality, unplanned reoperations and unplanned readmissions in these fractures. Using National Surgical Quality Improvement Program (NSQIP) database, isolated close femoral shaft fractures were identified using ICD-10 codes. Patient demographics, perioperative course and adverse events were identified. Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate and multivariate analysis were conducted to identify independent risk factors associated with primary outcomes. Between 2010 and 2019, 1346 closed isolated femoral shaft fracture patients with a mean age of 66.7 were identified, of whom 30.6% and 69.4% were male and female, respectively. Surgical procedures included: 915 (68.0%) intramedullary nail (IMN); 428 (31.8%) open reduction internal fixation (ORIF); and 3 (0.2%) external fixator (Ex-fix). Patients who underwent ORIF reported 3.19 (OR: 3.19; CI: 1.45–7.03; p = 0.004) and 2.12 (OR: 2.12; CI: 1.10–4.09; p = 0.024) increased odds of mortality and unplanned related readmission compared to patients who received IMN. Transfusion, DVT, and PE rates were 34.2%, 1.4%, and 1.1%, respectively. Furthermore, 50% of mortality cases occurred within 6 days of surgery. Patients requiring reintubation reported 61.8 (OR: 61.8; CI: 15.7–242.40; p < 0.001) increased odds of mortality compared to patients not requiring reintubation. Patients with femoral shaft fractures who require reintubation have increased odds of mortality than those successfully extubated. In addition to precautions prior to extubation, patients with femoral shaft fractures should also be carefully monitored for the development of DVT or PE, and they should be definitively fixed with IMN whenever possible. [ABSTRACT FROM AUTHOR]

Objective: Distraction osteogenesis (DO) has been widely used to treat bone defects as its effectiveness in bone regeneration. Currently, distraction devices for establishing DO models are mainly developed for rats or large animals. However, a mouse DO model is in great need for in-depth mechanistic investigations using various transgenic mice. The current study reports the development of a reproducible murine DO model. Methods: A mini-titanium lengthener was designed and fabricated. The mini-lengthener was applied on the murine femur with four threaded pins using a designed clamp as the drilling and insertion guide. After transverse osteotomy using a Gigli saw, and after 5 days of latency, DO procedures started at 0.3 mm/day for 10 days, and the consolidation period was left for 28 days. The bone formation was monitored by radiography and histology. Potential effects on animal locomotion during DO were also measured by behavior tests. Results: Separated bone segments maintained good alignment during the entire DO phases. New bone formation was found as early as the end of the distraction phase. Active bone remodeling was found between the separated bone segments at late distraction and early consolidation phases. At the mature consolidation phase, bone remodeling was mainly observed in the contact cortical bone. Mice underwent DO procedure did not have significant impairment in their locomotion. Conclusion: We have successfully developed a murine femoral DO model, which may be used to study the biological processes of DO. We also developed the mini-lengthener and the guide clamp to ensure the standardization and reproducibility of the mouse DO model.The translational potential of this article: Current study reports the development of a murine femoral DO model. A well-established murine DO model will facilitate further investigations of the biological mechanisms of DO in various transgenic and normal mice.

Introduction: Open extruded fractures of the talus occur in 2% of talar fractures. These fractures are challenging for surgeons due to complications such as infection, nonunion, and arthritis. The most common treatment method is talus reimplantation and osteosynthesis. Case report: A 19-year-old presented with an open extruded fracture of the talus, classified as Hawkins II, following a fall from a height. Emergency surgery involved wound debridement, talus reimplantation, osteosynthesis with modified external fixation for dynamic ankle joint fixation (Mitkovic-type), and two Kirschner wires. Fragments were repositioned under C-Arm fluoroscopy. The patient received a 14-day antibiotic regimen (Cephalosporins, Aminoglycoside, Metronidazole) and thromboembolic prophylaxis for 35 days. After 6 weeks we allowed movements in the ankle joint with physical therapy. Gradual weight-bearing was allowed after 8 weeks. The osteosynthetic material was removed after 18 weeks, with full weight-bearing achieved after 6 months. Radiographic follow-up was conducted up to 24 months postoperatively, showing excellent healing with minimal dorsiflexion restriction. Conclusions: Treating this injury is a significant challenge. External fixation can be a viable method for managing open luxation fractures of the talus.

Study Design A 2-year follow-up study. Purpose To evaluate the effectiveness of modified halo-pelvic Ilizarov distraction assembly in the management of patients with severe kyphoscoliosis. Overview of Literature Severe and rigid scoliosis curves are always a challenge for operating surgeons. Preoperative correction through halo-pelvic devices successfully minimizes the severity of the curve; however, cumbersome complications are also reported with its use. Modified assembly could be safe for these cases. Methods Patients with severe kyphoscoliosis having coronal Cobb angle >90° were applied with modified halo-pelvic Ilizarov distraction assembly preoperatively. The modified assembly consisted of a pelvic component and halo ring, and distraction was given at the rate of 2–3 mm/day for 6–12 weeks. Complete clinical assessments along with pulmonary function tests were performed, and scoliosis series X-ray images were assessed for coronal and sagittal Cobb angle and other spinopelvic parameters before applying the assembly and during 2 years of follow-up. Results Thirty-four patients (age, 9–27 years; male/female ratio of 18:16) were included. The coronal and sagittal Cobb angles were 116°±16.2° and 84°±28.3°, respectively. Correction rates obtained through modified halo-pelvic assembly were nearly 52% (p

Purpose: This systematic review aims to investigate the management and outcomes of pelvic ring fractures (PRFs) during pregnancy, emphasizing maternal and fetal mortality rates, mechanisms of injury, and treatment modalities. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a comprehensive search of databases from 2000 to 2023, identifying 33 relevant studies. Data extraction included demographics, fracture types, treatment methods, and outcomes. Risk of bias was assessed using the JBI criteria. Results: Maternal mortality stood at 9.1%, with fetal mortality at 42.4%. Maternal factors impacting mortality included head trauma and hemodynamic instability. Fetal mortality correlated with mechanisms like motor vehicle accidents and maternal vital signs. Surgical and conservative treatments were applied, with a majority of pelvic surgeries performed before delivery. External fixators proved effective in fracture stabilization. Conclusion: Pelvic ring fractures during pregnancy present significant risks to maternal and fetal health. Early stabilization and vigilant monitoring of maternal vital signs are crucial. Vaginal bleeding/discharge serves as a critical fetal risk indicator. The choice between surgical and conservative treatment minimally influenced outcomes. Multidisciplinary collaboration and tailored interventions are essential in managing these complex cases.

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

For lengthening irregular bones, such as calcaneus, there are few reports in the literature. This study aimed to introduce the treatment strategy and preliminary outcomes for calcaneus shortening using calcaneal body lengthening. From January 2017 to January 2022, calcaneal lengthening was conducted for three patients (two males and one female) who suffered from traumatic calcaneal shortening. The Achilles tendon was lengthened in one patient. After osteotomy of the calcaneus, an Ilizarov frame was used to gradually (1 mm/day) distract the calcaneal fragment. The lengthening procedure was stopped when the calcaneal height and length were restored based on radiography. The fixator was removed after bone union. The average follow‐up length was 18 months (range, 14–24 months). X‐ray was used for radiological assessments. Patients reported satisfaction using the 100‐mm visual analog scale (VAS). Clinical outcome was evaluated following the American Orthopedic Foot and Ankle score. All data were assessed by two physicians blind to clinical assessments. The wound healed primarily in three cases. The bone got solid union without refracture and malunion. The distraction time was 30 days (range, 25–45 days). The fixation time was 113.3 days (average, 80–150 days). Calcaneal lengthening was 26 mm (range, 15–43 mm). The height and length of the calcaneus were restored nearly to the same as the opposite foot. The mean preoperative calcaneal pitch angle increased from 2.6 degrees to an average of 19.0 degrees after the surgery. The AOFAS score increased from 60.0 to 86.0. One patient experienced pin infection. The infection healed after changing the dressing. Calcaneal lengthening using an Ilizarov external fixator is a preferable technique to restore the length and height of the calcaneus and can achieve satisfactory foot function. [ABSTRACT FROM AUTHOR]

The Ilizarov technique is one of the most important tools that is currently employed in bone reconstruction surgeries. Its inception dates back to the mid‐20th century and involves various bone reconstruction methodologies implemented using a circular external fixator system devised by G. A. Ilizarov. The key advantages of this approach include the generation of viable new bone via distraction osteogenesis, high union rates, and the functional utilization of the limb during the treatment process. The exploration of distraction osteogenesis phenomenon triggered by tensile stress with the Ilizarov device served as a catalyst for progress in bone reconstruction surgery. Subsequently, the original technique has been utilized alongside several adaptations resulting from the introduction of novel fixation tools and methods of their application, such as hexapod external fixators and motorized intramedullary lengthening nails. It is crucial to possess a precise comprehension of the Ilizarov principles of deformity correction in order to effectively utilize this fixation system. In this article, we will discuss the history of Ilizarov frame, the basic sciences behind it, the mechanical principles governing its use, and the clinical application of the fixation system in our daily practice. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion Surgical technique in distraction osteogenesis for the treatment of brachymetatarsia can influence the final prognosis. However, there are currently no standardized guidelines for surgical procedures and complication management. The aim of this study is to investigate the effect of bone lengthening with external fixation by minimally invasive osteotomy based on Ilizarov technique in the treatment of congenital brachymetatarsia.A retrospective study was conducted on patients with congenital brachymetatarsia treated by metatarsal lengthening, from June 2017 to December 2020. There were 11 patients with 17 shorted fourth metatarsals, including 10 females and 1 male, with age of 24.6 ± 4.5 years (16–31 years). Six patients were bilaterally involved. Orthofix external fixator mini track was installed through dorsal approach and the fourth MTP joints were temporarily fixed by Kirschner wire. Bone lengthening was performed after a minimally invasive osteotomy at the proximal metatarsals. American Orthopedic Foot and Ankle Society (AOFAS) lesser metatarsophalangeal‐interphalangeal (MTP‐IP) scores, metatarsal length, complications were recorded. Statistical comparison was performed using the paired t‐student test for pre‐ and postoperative AOFAS MTP‐IP scores.Patients were followed up for 55 ± 10.8 months. The mean length of the fourth metatarsal bone was 49.9 ± 2.9 mm preoperatively. The mean metatarsal shortage was 18.8 ± 3.1 mm. The mean lengthening achieved was 19.8 ± 3.3 mm, with a lengthening ratio of 39.7% ± 6.6%. The lengthened callus ossified completely at 3–4 months after operation. All patients were satisfied with the results of lengthening. The AOFAS scores were improved significantly from 83.7 ± 4.2 preoperatively to 93.2 ± 2.7 postoperatively (t = −10.27, p < 0.001). One patient with traumatic metatarsophalangeal joint subluxation was treated by joint reduction and Kirschner wire fixation. One patient had metatarsophalangeal joint release and Kirschner wire fixation due to flexion contracture. Pin tract infections were controlled by wound care and antibiotics in 6 patients. All patients had no nonunion, necrosis of toes, and sensory disturbance of toes.Metatarsal lengthening by minimally invasive osteotomy with external fixator had satisfactory results in the treatment of congenital brachymetatarsia. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion Distal tibial deformities can significantly impact patients if left uncorrected, often leading to pain, alterations in gait, and the eventual development of post‐traumatic arthritis. The criteria for surgical correction in these patients continues to be a subject of debate, while supramalleolar osteotomy (SMO) is an effective method for correcting distal tibial deformities. The purpose of this study was to evaluate and compare the clinical results of SMO using internal fixation or using computer‐assisted hexapod external fixator in the treatment of distal tibial deformity.A retrospective study was conducted on 290 patients who underwent SMO between June 2015 and January 2023. Forty‐four patients met the inclusion and exclusion criteria. Among the participants, 19 underwent SMO combined with a computer‐assisted hexapod external fixator, while 25 received SMO with plate and screw internal fixation. The tibial anterior surface (TAS) angle, tibial lateral surface (TLS) angle, the tibiotalar (TT) angle and the talocrural (TC) angle were assessed on weight‐bearing X‐ray films. Functional assessments were performed according to the American Orthopedic Foot and Ankle Society (AOFAS) ankle‐hindfoot score.The study followed patients for an average duration of 31.7 ± 15.3 months, with a range from 12 to 67 months. Successful bone union was achieved in all cases. For patients treated with the computer‐assisted hexapod external fixator, significant improvements were observed: the mean deviation in sagittal plane deformity parameters decreased from 14.3 ± 10.4 degrees preoperatively to 2.8 ± 3.8 degrees postoperatively (p < 0.05). Similarly, coronal plane deformity parameters showed a reduction from 25.9 ± 22.5 degrees preoperatively to 5.9 ± 11.0 degrees postoperatively (p < 0.05). The AOFAS ankle‐hindfoot score improved markedly from 66.0 ± 14.9 to 86.1 ± 11.7 points (p < 0.05). For patients undergoing internal fixation, the absolute difference in coronal plane parameters improved from 15.4 ± 12.6 degrees preoperatively to 3.7 ± 3.4 degrees postoperatively (p < 0.05). A significant enhancement in AOFAS ankle‐hindfoot score was also noted, increasing from 68.3 ± 14.3 points to 79.4 ± 13.5 points (p < 0.05). There were no significant differences in gender, side, follow‐up time, postoperative deviation of deformity, pre‐ or postoperative AOFAS between the two groups.In conclusion, comprehensive preoperative planning of SMO combined with either internal fixation or a hexapod external fixator for treating distal tibial deformities can achieve satisfactory outcomes. The utilization of a computer‐assisted hexapod external fixator facilitates a gradual and precise correction process, which proved to be an effective and relatively safe method. [ABSTRACT FROM AUTHOR]

Background: Total talus dislocation without ankle (malleoli) fracture is a very rare injury with prevalence of only 0.06% of all dislocations and only 2% of talar injuries, and are usually associated with common complications such as infection, avascular necrosis, and posttraumatic arthritis. The treatment usually involves debridement, reduction, stabilization of the ankle joint, and primary or secondary closure of the wound. Case presentation: We present the case of a 40-year-old South Asian woman who was involved in an accident. She was rushed to our hospital, whereby subsequent examination revealed an open total talus dislocation with the talus being exposed in its entirety from a contaminated wound in the medial side. Furthermore, radiograph confirmed total talus dislocation without concomitant malleoli fracture. She was immediately taken to the operating theater whereby debridement and immediate reduction was performed under anesthesia, and the ankle was stabilized with external fixator for about 6 weeks. She is now able to bear weight on the affected ankle with minimal tolerable pain and has normal range of motion of the ankle. Conclusions: Open total talus dislocation without concomitant malleoli fracture is a rare injury. Reduction of the talus in combination with complete wound debridement potentially successfully avoids infection, provides early revascularization preventing avascular necrosis, and preserves the normal ankle anatomy. [ABSTRACT FROM AUTHOR]

Objective Methods Results Conclusion Bone transport has become the gold standard for treating large segmental tibial bone defects. The technique for application the Ilizarov circular fixator (ICF) has a long learning curve and is associated with many complications. There are few clinical studies on bone transport via the Taylor spatial frame (TSF). The main purpose of this study was to compare the radiological and clinical and outcomes of bone transport by using the TSF and the ICF.There were 62 patients included in this retrospective study from June 2011 to June 2021 and distributed to two groups according to the fixation method: a TSF group consisting of 30 patients and an ICF group consisting of 32 patients. Demographic information, surgical duration, external fixation times, external fixation index, final radiographic results, complications, and clinical outcomes were recorded and examined. The clinical outcomes were assessed using the ASAMI criteria during the most recent clinical visit. Then, statistical analysis such as independent‐samples t tests or chi‐Square test was performed.The mean surgical duration in the TSF group was 93.8 ± 7.3 min, which was shorter than that in the ICF group (109.8 ± 1.4 min) (p < 0.05). Compared to the ICF group (10.2 ± 2.0 months), the TSF group (9.7 ± 1.8 months) had a shorter average external fixation time (p > 0.05). The external fixation index was 1.4 ± 0.2 m/cm and 1.5 ± 0.1 m/cm in the two groups. Moreover, there was no significant difference between the two groups. At the last follow‐up visit, the medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) in the TSF group were 88.1 ± 12.1° and 80.9 ± 1.3°, respectively. The MPTA and PPTA in the ICF group were 84.4 ± 2.4° and 76.2 ± 1.9°, respectively. There were statistically significant differences between the two groups (all p < 0.05). The complication rate was 50% in the TSF group and 75% in the ICF group. Moreover, the ASAMI score between the two groups was no statistically significant difference (p > 0.05).No statistically significant difference was found in clinical outcomes between the use of Taylor spatial frame and Ilizarov circular fixator for treating large segmental tibial bone defects. However, TSF is a shorter and simpler procedure that causes fewer complications and improves limb alignment. [ABSTRACT FROM AUTHOR]

Background: Fractures of the talus are relatively infrequently reported in small animals. Furthermore, talar neck fracture in cats seems to be very rare. This case report aims to consider the diagnosis, treatment, and a 7-month follow-up of a cat with a Hawkins type 3 talar fracture treated with a type 1b external skeletal fixator (ESF). Emphasizing on the complexity of the injury, considering treatment options and complications, and comparing them to previous reports on cats and humans. Case Description: A 4.5-year-old mixed-breed cat was diagnosed with a Hawkins type 3 talar fracture. Additionally, there were considerations related to the collateral support of the hock joint. The fracture fragment, i.e., the talar body and parts of the neck, was reduced with pointed reduction forceps through a small medial insition. The fracture was then stabilized with a trans articular type 1b ESF. Based on radiographic fracture assessment, de-staging of the frame was done 8 weeks postoperatively. While complete frame removal was at 12 weeks postoperatively. Seven months after the fracture, the cat was minimally lame when walking, and there was a reduced range of motion in the hock joint compared to the contralateral joint. Conclusion: Based on this case and the four previous cases with talar neck fractures, we cannot conclude, but ESF seems to be a good solution, especially when considering the possibility of disruption to the collateral support of the hock joint in this case. [ABSTRACT FROM AUTHOR]

Extramedullary devices are used extensively to stabilize fractures in long bones. The type of pin–bone anchorage is a determining factor in fixation properties, which differ between mono-cortical and bi-cortical stabilizations. This computational study compares the effects of mono-cortical and bi-cortical pins of a unilateral uniplanar external fixator on the construct stiffness, the early phase of bone healing, and pin loosening. Eight finite element models were established for a simple transverse tibia fracture, treated with a unilateral uniplanar external fixator with surgical variations in the pin-bone anchorage. Each model was subjected to a partial body weight, and axial stiffness was calculated. A deviatoric strain-based mechano-regulation algorithm was applied, and tissue differentiation in the callus was predicted. Finally, a strain-based failure criterion was employed to assess the risk of pin loosening. The axial stiffnesses of bi-cortical structures were slightly larger than the results of the mono-cortical sets. Regardless of the number of pins, bi-cortical systems produce a more uniform distribution of differentiated tissue than the corresponding mono-cortical constructs. Finally, both mono-cortical and bi-cortical groups held the critical strains of the pin–bone interface within the acceptable ranges and provided a protected construct against the risk of pin loosening. Based on the findings of this study, mono-cortical pins could be considered potential alternatives to bi-cortical fixations at the early stage of healing. Nevertheless, successful management of diaphyseal fracture through mono-cortical fixation needs to be assessed in further studies over the full period of healing. [ABSTRACT FROM AUTHOR]

Background/Aim. The number of pelvic traumas is increasing globally, mostly due to car accidents but also due to an increasing number of sports and recreational traumas. Tile C-type unstable pelvic trauma (TCUPT) is a kind of high-energy trauma that occurs during traffic accidents or accidents when falling from big heights. The aim of our study was to explore the application of the internal fixation (INFIX) system for the anterior pelvic ring (APR) with simultaneous application of sacroiliac screw (SS) INFIX of the posterior pelvic ring (PPR) in TCUPT. Methods. The subjects (89 of them in total) were recruited among patients with TCUPT from December 2020 to December 2023. A retrospective analysis of the subjects' data was performed, after which the subjects were divided into two groups based on different therapeutic regimens applied: group A (INFIX system for the APR + SS INFIX of the PPR, n = 46) and group B (external fixator for the APR + SS INFIX of the PPR, n = 43). Results. In comparison with group B, group A had a shorter period before the commencement of the first activity after surgery, shorter fracture healing time and joint function recovery time, as well as length of hospital stay (t = 6.623, 4.796, 7.992, and 5.227, respectively, p < 0.05). The surgery duration and bleeding volume showed no significant differences between the two groups (t = 1.433, 1.123, respectively, p > 0.05). The fracture reduction outcomes were better in group A than in group B (Z = 2.058, p < 0.05). The incidence rate of complications was lower in group A than in group B (2.17% vs. 18.60%) (2 = 4.917, p < 0.05). Conclusion. For patients with TCUPT, the INFIX system for the APR with simultaneous application of SS INFIX of the PPR achieves good fracture reduction outcomes. [ABSTRACT FROM AUTHOR]

Study Design: A 2-year follow-up study. Purpose: To evaluate the effectiveness of modified halo-pelvic Ilizarov distraction assembly in the management of patients with severe kyphoscoliosis. Overview of Literature: Severe and rigid scoliosis curves are always a challenge for operating surgeons. Preoperative correction through halo-pelvic devices successfully minimizes the severity of the curve; however, cumbersome complications are also reported with its use. Modified assembly could be safe for these cases. Methods: Patients with severe kyphoscoliosis having coronal Cobb angle >90° were applied with modified halo-pelvic Ilizarov distraction assembly preoperatively. The modified assembly consisted of a pelvic component and halo ring, and distraction was given at the rate of 2–3 mm/day for 6–12 weeks. Complete clinical assessments along with pulmonary function tests were performed, and scoliosis series X-ray images were assessed for coronal and sagittal Cobb angle and other spinopelvic parameters before applying the assembly and during 2 years of follow-up. Results: Thirty-four patients (age, 9–27 years; male/female ratio of 18:16) were included. The coronal and sagittal Cobb angles were 116°±16.2° and 84°±28.3°, respectively. Correction rates obtained through modified halo-pelvic assembly were nearly 52% (p<0.001) in coronal and 40% (p<0.001) in sagittal Cobb angles, with improvement in height (p<0.001). Apical vertebral translation and coronal balance were also improved significantly (p<0.001). Further improvements in all the parameters were obtained after definitive surgery, with improvements in the forced expiratory volume in 1 second (p=0.002) and forced vital capacity (p=0.001). Conclusions: Our modified halo-pelvic Ilizarov distraction assembly can achieve good correction in severe spinal deformities without significant risk to neurology, has fewer complications, and promotes good patient compliance. [ABSTRACT FROM AUTHOR]

Limb lengthening relies on the process of distraction osteogenesis. The active periosteal bone formation has been detected in clinical practice with a lengthening and then nail (LATN) technique but has not been confirmed by experimental studies to date. The aim of this study is to compare the tissue regeneration of the distraction regenerate during tibial lengthening in rabbits using a LATN technique. This study was performed on 54 mature rabbits of the Soviet Chinchilla breed, which were divided into three groups of 18 animals. In group 1 (control), the tibia was lengthened in an external fixator. In group 2, the LATN technique was modeled and in group 3, lengthening over nail (LON) was modeled. The total duration of the experiment was 45 days. On the 10th, 15th, 20th, 30th, and 45th day X‐ray, computed tomography and morphological studies were performed. In the experimental groups (2 and 3), a more pronounced periosteal bone formation in the area of regenerate was noted when compared to group 1. In group 2 (LATN), wide cortical plates were formed from the intermediate and periosteal areas. In this group, the maximum densitometric density values were noted. Endosteal bone formation was preserved in all groups. The LON and LATN techniques, when compared with the classical Ilizarov lengthening, do not demonstrate any deficiency in the tissue regeneration of the bone tissue at the regenerate sites. The most powerful bone structures are formed with the sequential use of the external fixation and nailing (LATN). [ABSTRACT FROM AUTHOR]

Objective: Distances and angles measured from long-leg radiographs (LLR) are important for surgical decision-making. However, projectional radiography suffers from distortion, potentially generating differences between measurement and true anatomical dimension. These phenomena are not uniform between conventional radiography (CR) digital radiography (DR) and fan-beam technology (EOS). We aimed to identify differences between these modalities in an experimental setup. Materials and methods: A hemiskeleton was stabilized using an external fixator in neutral, valgus and varus knee alignment. Ten images were acquired for each alignment and each modality: one CR setup, two different DR systems, and an EOS. A total of 1680 measurements were acquired and analyzed. Results: We observed great differences for dimensions and angles between the 4 modalities. Femoral head diameter measurements varied in the range of > 5 mm depending on the modality, with EOS being the closest to the true anatomical dimension. With functional leg length, a difference of 8.7% was observed between CR and EOS and with the EOS system being precise in the vertical dimension on physical-technical grounds, this demonstrates significant projectional magnification with CR-LLR. The horizontal distance between the medial malleoli varied by 20 mm between CR and DR, equating to 21% of the mean. Conclusions: Projectional distortion resulting in variations approaching 21% of the mean indicate, that our confidence on measurements from standing LLR may not be justified. It appears likely that among the tested equipment, EOS-generated images are closest to the true anatomical situation most of the time. [ABSTRACT FROM AUTHOR]

The elbow joint consists of the ulnohumeral joint, radiocapitellar joint and the proximal radio-ulnar joint. The osseous anatomy, static ligamentous restraints and dynamic stabilizers all contribute to maintain elbow stability. Elbow instability is a commonly encountered condition in clinical practice. There are several ways to classify elbow instability. Instability can be classified as simple or complex based on presence of an associated fracture, it could be classified based on mechanism of injury or it could be classified in a temporal fashion as acute or chronic. It is critical to understand injury patterns that can be treated non-operatively with physiotherapy and mobilization and the ones that need surgery. Surgical management of elbow instability could involve a combination of interventions addressing various ligaments like the lateral ulnar collateral ligament and medial collateral ligament; osseous structures including the radial head, coronoid and proximal ulna based on the mechanism and extent of injury. Adjunctive and salvage procedures may be necessary in delayed presentations or severe injuries. These include application of an internal joint stabilizer, external fixator, internal bracing of the ligament and bone grafting of the coronoid. The goal of treatment of instability is to provide an elbow that is stable and amenable to early active mobilization. [ABSTRACT FROM AUTHOR]

Background: Early soft tissue management is crucial in lower extremity defects, particularly those involving vital tissue exposure, bone integrity impairment or underlying instrumentation material. In the recent literature, free flaps and perforator flaps are considered as suitable options for this region. However early microsurgery planning may not be possible in every center due to the surgical experience, equipment or hospital and patient related factors. In such cases, transposition fasciocutaneous flaps emerge as a more accessible and efficient choice. Methods: All patients who underwent reconstruction with a random pattern transposition flap due to tissue defect in the lower extremity between 2019 and 2023 were retrospectively analyzed. Demographic characteristics, comorbidities, and defect mechanisms were recorded. Additionally, information regarding bone injuries, interventions performed, duration between injury and reconstruction, pre- and post-reconstruction cultures, and antibiotic treatments were documented. Post-reconstruction complications, ambulation period, and discharge time were also assessed. The limitations of microsurgery and reasons for flap planning were noted. Results: Twelve patients were included in this study. The mean age of the patients was 44 (20–67). The mechanism of defects were gunshot (6), fall (3), traffic accident (1), pressure ulcer (1), and tumor excision (1). In three patients (25%) who have previously undergone an operation for soft tissue defect, but there was exposed titanium implant or bone due to skin necrosis, a transposition flap was performed as a salvage procedure. In addition, 8 patients (73%) had multiple or comminuted bone fractures and 1 patient (8.3%) had a single bone fracture. While fixation was performed with titanium implants in 41.7% (5 patients) of the patients in the defect area, the fracture was stabilized with an external fixator in 2 patients and with a Kishner wire in 1 patient. Wound healing was observed good in 10 patients without other complex surgical intervention. Partial necrosis was observed in one patient due to infection. Partial dehiscence was observed in another patient with a pressure ulcer in the calcaneal region which was left to heal secondarily. Conclusions: Transposition fasciocutaneous flaps offers rapid planning process, easy disection and functionally and aesthetically benefits with proper planning. They should be considered as a simple option as salvage of complex soft tissue reconstruction. Level of evidence: Level IV, Therapeutic [ABSTRACT FROM AUTHOR]

Purpose: We aimed to evaluate the safety and effectiveness of three-dimensional (3D)-printed guide plates for assisting in the positioning of the rotation axis of an elbow-hinged external fixator. Methods: Terrible triad (TT) patients, who were screened using the predefined inclusion and exclusion criteria, underwent installation of a hinged external fixator on the basis of internal fixation; 3D-printed guide plates, generated from the patient's imaging data, assisted in positioning the rotation axis. All patients received the same peri-operative management and were followed up at six, 12, 24, and 48 weeks postoperatively. The duration of positioning pin placement, the number of fluoroscopies, pin placement success rate, types and incidence of post-operative complications, and the Mayo elbow performance score (MEPS) of the diseased elbow and range of motion (ROM) of both elbows were assessed. Results: In 25 patients who completed the follow-up, the average time required for positioning pin placement was 329.32 ± 42.38 s (263–443 s), the average number of fluoroscopies was 2.32 ± 0.48 times (2–3 times), and the pin placement success rate was 100%. At the last follow-up, the mean MEPS of the diseased elbow was 97.50 ± 6.92 (75–100), with an excellent and good rate of 100%, and all patients demonstrated stable concentric reduction. The average range of flexion and extension was 135.08° ± 17.10° (77–146°), while the average range of rotation was 169.21° ± 18.14° (108–180°). No significant difference was observed in the average ROM between the both elbows (P > 0.05). Eight (32%) patients developed post-operative complications, including elbow stiffness due to heterotopic ossification in three (12%) patients, all of whom did not require secondary intervention. Conclusion: Utilizing 3D-printed guide plates for positioning the rotation axis of an elbow-hinged external fixator significantly reduced intra-operative positioning pin placement time and the number of fluoroscopies with excellent positioning results. Satisfactory results were also obtained in terms of post-operative complications, elbow ROM, and functional scores. [ABSTRACT FROM AUTHOR]

Purpose: Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. Methods: A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. Results: The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1 years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). Conclusion: Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis. [ABSTRACT FROM AUTHOR]

Background: Grade III open tibial diaphyseal fractures are challenging to treat and controversy exists on whether to treat them with an intramedullary nail (IMN) or a circular frame (CF). This study aims to compare outcomes for intramedullary nail and circular frame in the treatment of open tibial diaphyseal fractures. Methodology: Retrospective study at a major trauma center of all patients admitted with a grade III open tibial diaphyseal fracture between January 2016 and January 2022. The primary outcome measures were major complications: non-union, malunion, refracture, DBI and amputation. Secondary outcome measures were time to union and reoperation rates. Results: Fifty-five patients were included in the study, 32 patients in CF group and 23 patients in IMN group. There were no significant differences in the baseline demographics of patients in both groups. Major complications were recorded in 13 limbs (54%) in IMN group and in 18 limbs (56%) in CF group which were not statistically significant (p = 0.797). Deep bone infection rates were noted in 4 (12.5%) in the CF group, compared to 1 (4%) in IMN group; however, the result was not statistically significant (p = 0.240). Amputation rates as a result of infected non-unions were seen in 1 limb (4%) in IMN group and 2 limbs (6%) in CF group (p = 0.99). Median time to union was significantly shorter in IMN group at 30 weeks compared to 30 weeks for CF group (p = 0.04). Conclusion: IMN should be the treatment of choice in the treatment of grade III open tibial diaphyseal fracture, but CF should be considered for delayed treatment and in patients with bone loss. [ABSTRACT FROM AUTHOR]

The article discusses the use of cross leg flaps as a solution for wound coverage in cases of severe leg trauma. While the frequency of cross leg flap procedures has decreased with the advancement of microsurgical techniques, it is still important to have this technique available as a last resort or in areas without microsurgical expertise. The article provides technical tips and an algorithmic approach for deciding on the type of fixation technique for maintaining the position of the two limbs during the procedure. The authors propose the use of external fixators and describe the process of creating a fixator frame specifically for cross leg flaps. The article also emphasizes the importance of patient comfort and preventing pressure sores during the postoperative period. [Extracted from the article]

Background and Purpose: Two basic methods for genu valgum correction are osteotomy and internal fixation or external fixator assited correction. External fixators have the advantage of stabilizing fragments before osteotomy allowing better control of fragments and preventing secondary displacements. The purpose of this study was to evaluate the efficacy and complications of fixator assisted correction for genu valgum and internal fixation, using the AO distal femur pediatric osteotomy plate. Materials and Methods: Thirty-six limbs in 26 patients (age 10–16 years) underwent osteotomy in the distal femur at CORA. Open lateral wedge osteotomy was done; the desired position obtained was temporarily stabilized by connecting the pins with the AO external fixator and stabilized with 90 degrees AO distal femur pediatric locking plate and gap grafted with hydroxyapatite bone granules. Results: Translation of distal fragment was required in 17 osteotomies (53.12%). Osteotomies united within 12 weeks; no non-union was observed. The range of motion was full in all patients. The mean tibiofemoral angle was corrected by 12 degrees and the mean mechanical LDFA was corrected to 87 degrees. There was no secondary deformity, either in the rotational or sagittal plane. Conclusion: This method combines the modularity of external fixator and the advantages of internal fixation. [ABSTRACT FROM AUTHOR]

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

Deep soft tissue defects next to the joints can rapidly lead to irreversible damages and have to be covered urgently and effectively. In severely burned patients the usual approach is to use a flap even though it has its limitations in regards to the extent of the burn and the general condition of the patient. A 27-year-old male was admitted at the Burn Treatment Center for a thermic burn of 72% of his BSA. At first he has benefited from several skin grafts and later on a major open right elbow had to be treated urgently to rescue the joint. After the burn, a revascularization of the donor site was noticed, sufficient to use the radial forearm pedicled flap as a cover for the elbow. This case reports an innovative approach based on the use of an irrigation and drainage system placed underneath the flap. The elbow was rigidly immobilized with an external fixator in order to facilitate an optimal healing of the flap. In this case, the choice of this flap, combined with the irrigation and drainage system and the immobilization by external fixation, provided an original and efficient treatment. Postoperatively the healing of the flap and of the donor site was complete. The functional results exceeded the expectations with a complete recovery of the joint amplitude. Thus, in case of no other therapeutic options, it is probably possible to use a variety of flaps recently healed. [ABSTRACT FROM AUTHOR]

Purpose: Healing after bone fracture is assessed by clinical examination and frequent radiographs, which expose patients to radiation and lack standardisation. This study aimed to explore electrical impedance patterns during bone healing using electrical impedance spectroscopy in 18 rabbits subjected to tibial fracture stabilised with an external fixator. Methods: Impedance was measured daily across the fracture site at a frequency range of 5 Hz to 1 MHz. Biweekly radiographs were analysed using modified anterior‐posterior (AP) radiographic union score of the tibia (RUST). The animals were divided into three groups with different follow‐up times: 1, 3 and 6 weeks for micro‐computer tomography and mechanical testing. Results: A decreasing trend in impedance was observed over time for all rabbits at lower frequencies. Impedance closest to 5 Hz showed a statistically significant decrease over time, with greatest decrease occurring during the first 7 postoperative days. At 5 Hz, a statistically significant correlation was found between impedance and the modified AP RUST score and between impedance and bone volume fraction. Conclusions: This study showed that the electrical impedance can be measured in vivo at a distance from the fracture site with a consistent change in impedance over time and revealed significant correlation between increasing radiographic union score and decreasing impedance. Level of Evidence: Not applicable. [ABSTRACT FROM AUTHOR]

Purpose: To present the technique of correction of multiplanar deformities around the knee in children and adolescents using the monolateral external fixator. Also, to evaluate the results of the technique regarding radiological correction, time to union, and possible complications. Methods: A total of 29 patients (47 limbs) were prospectively included in the study (14 males and 15 females). Their median age was 13 years (range, 7–17). All patients had at least a 2-plane deformity around the knee which was corrected using a monolateral external fixator. The primary outcome measure was deformity correction (correction of mechanical axis deviation (MAD) in both the coronal and sagittal planes with correction of rotational deformities). The secondary outcome measures included bony union, radiographic, and functional results (assessed by using the Association for the Study and Application of the Method of Ilizarov (ASAMI) score). Results: The median pre-operative MAD improved from 6.3 to 0.4 cm post-operatively. According to the ASAMI scoring system, the radiographic scoring was excellent in all cases (100%), and the functional scoring was excellent in 22 cases (89.7%) and good in three cases (10.3%). Conclusion: The simple monolateral fixator can be an effective tool for multiplanar correction of complex deformities around the knee without limb length discrepancy. [ABSTRACT FROM AUTHOR]

The Ilizarov fixator is a type of external fixator that is used to treat patients who have suffered injuries from accidents, bone shortening, or nonunion of the bone. The principle behind the Ilizarov fixator is that thin wires (called Kirschner wires) are used to support the bones and connect them to framed rings. Before being fastened to the rings, the wires are tensioned and drilled through the bones. This study suggests using a new parallel wires configuration at the same level on the same ring and two revised versions, which are divergent and convergent models, and compare them with standard wires, 60 angle wires model. All models were designed using SolidWorks, a computer-aided design (CAD) software, and then analyzed in four conditions (axial compression, medial bending, posterior bending, and torsion) with Finite Element Analysis (FEA) using Ansys Workbench 2020 R2. Mechanical testing was conducted to validate the FEA results, A simple model consisting of a single ring, two K-wires, and polylactic acid (PLA) cylinders was utilized in a tensile test. It has been concluded from the results that the parallel model and its improvement have higher stiffness to axial compression, medial bending, and torsion, but a lower posterior bending stiffness, except the divergent model with 8-hole separation which has a relatively acceptable stiffness for posterior bendin [ABSTRACT FROM AUTHOR]

ABSTRACT Flexible intramedullary nailing and external fixation have become the main methods to surgically treat femur fractures in children. This study aimed to search the current literature and evaluate the clinical and radiographic results of surgical treatment by comparing these methods and investigating their associated complications. This systematic review was carried out following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) recommendations. Searches were carried out on the PubMed, Embase, and Web of Science databases. The search for journals in these databases was carried out from January 2023 to August 2023, retrieving 695 studies. This systematic review included 11 articles, which encompassed 718 patients who underwent surgical external fixation and flexible nailing. The most frequently observed complications referred to late or malunion, superficial and deep infections, skin irritation, angular deformity, and length discrepancy between lower limbs. Both methods of stabilization of pediatric femoral fractures can provide good clinical and radiographic results. However, the choice of treatment with flexible nails is certainly more valid and has greater acceptance than external fixation. Level of Evidence III, Systematic Review .

Objective: to evaluate three methods of nasogastric tube fixation in terms of adhesion, displacement and skin integrity. Method: ex vivo study, with a sample of 30 experimental noses (10 for each type of fixation), developed with porcine skin, based on the average measurements of the human nose, in which 14-gauge polyvinyl chloride probes were inserted and 2 methods of fixation with adhesive tape (Fixation A and B) and one with an industrial device (Fixation C) were used. Each group was exposed to traction of 50, 100 and 500g sequentially over 12 and 24 hours, testing: adhesion capacity, probe displacement and skin integrity. The Chi-square test of independence was calculated for nominal variables and Student’s t-tests and analysis of variance (p< 0.05) for rational variables. Results: fixation B showed lower adhesion capacity (p

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Objective: Muscle wasting frequently occurs following joint trauma. Previous research has demonstrated that joint distraction in combination with treadmill exercise (TRE) can mitigate intra-articular inflammation and cartilage damage, consequently delaying the advancement of post-traumatic osteoarthritis (PTOA). However, the precise mechanism underlying this phenomenon remains unclear. Hence, the purpose of this study was to examine whether the mechanism by which TRE following joint distraction delays the progression of PTOA involves the activation of peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α), as well as its impact on muscle wasting. Methods: Quadriceps samples were collected from patients with osteoarthritis (OA) and normal patients with distal femoral fractures, and the expression of PGC-1α was measured. The hinged external fixator was implanted in the rabbit PTOA model. One week after surgery, a PGC-1α agonist or inhibitor was administered for 4 weeks prior to TRE. Western blot analysis was performed to detect the expression of PGC-1α and Muscle atrophy gene 1 (Atrogin-1). We employed the enzyme-linked immunosorbent assay (ELISA) technique to examine pro-inflammatory factors. Additionally, we utilized quantitative real-time polymerase chain reaction (qRT-PCR) to analyze genes associated with cartilage regeneration. Synovial inflammation and cartilage damage were evaluated through hematoxylin-eosin staining. Furthermore, we employed Masson's trichrome staining and Alcian blue staining to analyze cartilage damage. Results: The decreased expression of PGC-1α in skeletal muscle in patients with OA is correlated with the severity of OA. In the rabbit PTOA model, TRE following joint distraction inhibited the expressions of muscle wasting genes, including Atrogin-1 and muscle ring finger 1 (MuRF1), as well as inflammatory factors such as interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) in skeletal muscle, potentially through the activation of PGC-1α. Concurrently, the production of IL-1β, IL-6, TNF-α, nitric oxide (NO), and malondialdehyde (MDA) in the synovial fluid was down-regulated, while the expression of type II collagen (Col2a1), Aggrecan (AGN), SRY-box 9 (SOX9) in the cartilage, and superoxide dismutase (SOD) in the synovial fluid was up-regulated. Additionally, histological staining results demonstrated that TRE after joint distraction reduced cartilage degeneration, leading to a significant decrease in OARSI scores.TRE following joint distraction could activate PGC-1α, inhibit Atrogin-1 expression in skeletal muscle, and reduce C-telopeptides of type II collagen (CTX-II) in the blood compared to joint distraction alone. Conclusion: Following joint distraction, TRE might promote the activation of PGC-1α in skeletal muscle during PTOA progression to exert anti-inflammatory effects in skeletal muscle and joint cavity, thereby inhibiting muscle wasting and promoting cartilage regeneration, making it a potential therapeutic intervention for treating PTOA. [ABSTRACT FROM AUTHOR]

Background: Humeral shaft fractures, constituting 3–5% of musculoskeletal injuries, are commonly managed conservatively using functional braces. However, this approach may not be feasible in resource-limited settings. This study aimed to evaluate the functional outcomes of nonoperative treatment for humeral shaft fractures in adults utilizing a U-shaped slab. Methods: This prospective study was conducted from August 2021 to August 2022 involving 16-year-old and older individuals who received nonsurgical treatment for humeral shaft fractures at public tertiary hospitals in Rwanda. The assessment focused on various functional outcomes, including alignment, union rate, range of motion, return to activities of daily living, and DASH score. Results: The study included 73 participants, predominantly males (73.9%), with a median age of 33 years. The union rate was high at 89.04%, and 10.96% experienced delayed union. Radial nerve palsy occurred in 4.11% of patients, but all the patients fully recovered within three months. Despite angular deformities during healing in the majority of participants, these deformities did not significantly impact functional outcomes. According to the international classification of disabilities, 77% of participants achieved a good functional grade. Conclusion: The conservative U-shaped slab method was effective at managing humeral shaft fractures. However, optimal results necessitate careful participant selection and comprehensive rehabilitation education. Implementing these measures can improve the overall success of nonoperative management. [ABSTRACT FROM AUTHOR]