Aims and Objective: To determine the
clinical effectiveness of Ilizarov external fixation for the
acute treatment of the supracondylar femur, tibial plateau,
upper fourth and distal fourth tibial fractures.
Study Design: Descriptive Study.
Setting: A tertiary care hospital.
Patients and Methods: 55 grade IIIB fractures of 20
distal fourth femur C3 (14), C2 (6), 12 distal fourth tibia of
C1.1 (6), C1.3 (6), 12 upper fourth Tibia of A2 (8) and A3
(4) fractures according to AO classification and 11 Tibial
plateau fractures of Schatzker type VI (5) , V(5), IV(1)
followed up to 12-52 months were studied.
Intervention- Ilizarov hybrid external fixator till sound union
Main Outcome measure-Clinical and functional outcome at > 52
Results: Supracondylar fracture united at 39.00±9.15,
distal fourth tibial fractures 31.1667±8.3046, upper fourth
tibia 24.00±5.2915 and Tibial plateau tooks 15.545±4.160 weeks
to unite and were significantly different (p-0.00). The
extensor lag of 5°to 10° (12.222±3.49) and ROM at knee in type
C2 (110°±10°), (72.85°±36.38°) in type C3 supracondylar fracture
of femur, in type IV tibial platue 130°±00, type V 124°±8.94° ,
type VI 125°±7.0711°, distal fourth fracture tibia of type C1.1
(50°±0.00), type C1.3 (43° ±5.7755) and in the upper fourth
tibial were no restriction of movement.
Conclusion: Functional results were better in upper
fourth, distal fourth tibial fractures but in only type VI
tibial platue fractures and 50% cases of only type C3
Key words: Ilizarov hybrid external fixator,
supracondylar, tibial plateau, upper fourth and distal fourth
fracture, Clinical and Functional outcome.
The use of
circular external fixator for acute trauma of the upper and
lower extremities is common in Russia and part of Western Europe
and increasing in North America.1 Metaphysical fractures may
have extension into the articular and diaphyseal regions,
greatly increases the complexity of their management. 2 The
presence of Gustilo type I or II open wound does not alter basic
treatment guidelines. However, a type III wound, especially III
B, favors stabilization with an external fixator. Less exposure
is needed if performing a limited open reduction and external
fixation, decreasing the amount of soft tissue dissection and
limiting local vascular injury. Stabilization of short
periarticular fragments is possible with a circular external
fixator. Because the wires are tensioned and supported
circumferentially, a “trampoline” of fixation is provided.2
Fixation is rigid enough to allow early motion and partial
weight bearing. The comminuted fractures are one the most
difficult to treat with open reduction and internal fixation.
The distal fragment is usually small and many times fragmented.
This versatile external fixator is an excellent tool for these
fractures. Skin conditions are bad and more complicated when the
fracture is open as in many cases. Open reduction and
stabilization are very difficult or impossible. This ring
fixator with its inherent advantage is useful. The spectrum of
injuries to the tibial plateau is so great that no single method
of treatment has proven uniformly successful. Despite
improvement in imaging technique and less invasive surgical
methods, the management of tibial plateau fractures remains
controversial.3 The purpose of this study is to clinical and
functional assessment of patients after application of ilizarov
external fixator in acute trauma.
Material and Methods :
Total 55 open grade IIIB fractures of age
between 18 to 58 years (36.9±10.76), of 24 male and 6 female, 20
cases of distal fourth fractures of femur of fourteen type C3,
six type C2 , 12 distal fourth fracture of tibia and fibula
of six C1.1 and six C1.3 and 12 upper fourth Tibia and
fibula of A2 eight and A3 four, according to AO
classification, 11 Tibial plateau fractures of Schatzker type VI
five, type V five, one type IV fractures were treated at BPKIHS,
Dharan, NEPAL during August 2000 to August 2004 and followed up
to 12-52 months, were studied. INCLUSION CRITERIA-All open grade
IIIB tibial plateau fracture, upper fourth, lower fourth and
supracondylar fracture of femurs with intraarticular extension,
EXCLUSION CRITERIA-All fractures with extensive soft tissue loss
excluded from study. Initial resuscitation, splintage and
primary care for the wound was provided in the emergency room.
Any bony fragments that were protruding out were covered with
sterile dressing. The patients were then taken to the operating
room and treated by pulse lavage and debridement of wound and
fixation of fracture accordingly. All tibial pleatue, all
proximal fourth fractures and all lower fourth fractures of
tibia and fibula (Reversed Hybrid), treated with Ilizarov hybrid
fixator using two Ilizarov 5/8 rings and AO External fixator and
all supracondylar of femur treated with two ring in lower
fragments using 5/8 ring in lower most and in proximal fragments
using one 5/8 ring and proximal most using Italian arc at
required distance and connected with threaded rods. We were used
schanz pin in proximal fragments of supracondylar fracture.
Acute shortening were done in supracondylar and distal fourth
fractures after removal of loose detached small fragments. Acute
shortening were helped in primary and delayed primary closure of
wound. In all cases we used image intensifier for accuracy of
reduction. Every attempt was made to cover the exposed part of
bone with soft tissue; however flap coverage was not needed in
any cases. Initial first 48 hours we teach the patients and
patient attendant how to clean the wire and rings. Usually we
teach them pin tract cleaning minimum twice a day regularly with
betadine solution or sprit. All patients were made to stand with
support after 48 hours, in all cases of Tibial plateau fractures
knee mobilization started within heels of pain and partial
weight bearing after 3 months and full weight bearing after 6
months after clinicoradiological assessment, in all cases of
upper fourth and lower fourth tibial fractures toe touching were
permitted as per the stability of the fixation diagnosed
radiologically. Partial weight bearing with support was started
within 2 weeks of fixation and for supracondylar fracture of
femur knee mobilization started within heels of pain and weight
bearing (either partial or full) started according to
clinicoradiological assement. Wounds were inspected at the
interval of 48 –72 hours and repeat debridement was done
whenever required. Split thickness grafting was performed within
3 weeks of primary surgery. We did secondary bone grafting in
all cases of supracondylar fractures. Clinical and radiological
feature assessed the progress of bony union at 6 weeks interval
till union was sound. The radiological assessment of bony union
by good evidence of bridging periosteal and endosteal callus
formation as seen by the obliteration of the fracture line. The
clinical assessments of the union were mainly based on complete
absence of pain and tenderness at the fracture site.
Satisfactory wound healing and good amount of endosteal and
periosteal callus formation were taken as the criteria for
removal of fixator. Clinical and functional assessments were
done after union by asking the question, ever have you pain on
walking, getting out of chair, going up, going down, pain at
rest and needs support of cane and stability was checked by
physician. Our aim was to determine the clinical effectiveness
and safety of Ilizarov external fixation for the acute treatment
of severely comminuted extra-articular tibial fractures, tibial
plateau and supracondylar fractures of the distal femur.
Time to union was significantly different
between fracture types (p-0.00). Supracondylar fracture united
at 39.00±9.15 weeks whereas distal fourth tibial fractures took
31.1667±8.3046 weeks to unite. Fractures of upper fourth tibia
united at 24.00±5.2915 and Tibial plateau took 15.545±4.160
weeks to unite.
The extensor lag of 5°to 10° (12.222±3.49)
were seen only in supracondylar fractures. The ranges of
movement at knee in C2 type supracondylar fracture were
(110°±10°) and (72.85°±36.38°) in type C3. Knee movements in
type IV tibial platue were 130°±00, type V 124°±8.94° and type
VI 125°±7.0711°.Range of movement of distal fourth fracture
tibia of type C1.1 (50°±0.00), type C1.3 (43° ±5.7755) and in
the upper fourth tibial fractures there was no restriction of
40% of supracondylar fractures had 4 cm and
40% had 1.5 cm shortening and in distal fourth tibial fracture
30% had 1cm of shortening. They are managing to walk with shoes
rising. One patient of type VI tibial plateau had pin tract
dermatitis that was successfully treated by dermatologist. One
case of distal fourth tibia develops 10º of equines she is
managing to walk with high heel sandal. Despite of pin tract
infection nothing alters our results.
In the type VI tibial platue fractures pain
on walking only in 20% of cases, whereas type IV and V it was in
above 80% of cases. There was no different seen in walking with
support, getting out of chair, going up but in going down again
there was no problem in type VI but 100% problem in type IV and
V fractures. Pain at rest was observed in one out of five cases
in type V fractures.
In supracondylar fractures of femur problems
in 100% of cases in all type of function was observed in C2 type
of fractures.50% cases of C3 fractures had problem in pain on
walking, walking with support and pain at rest, whereas no cases
had any problem in getting out of chair, going up and going
In (33%) fracture of distal fourth of tibia
of C1.1 type had pain on walking. In none of the other cases
were problems in any function.
In upper fourth of tibia only A2 type
fractures were treated in which 8 out of 12 had pain on walking?
No other functions were compromised.
The Ilizarov method of fixation device can be
used to correct limb length discrepancies, manage open and
closed fractures, nonunion, and bony or soft tissue
deformities. Early aggressive debridement of nonviable tissues,
stabilization with an Ilizarov external fixator, and either
primary or delayed primary closure followed by early
mobilization and weight bearing is an alternative treatment
method of these injuries.4Acute shortening, using the Ilizarov
technique followed by progressive lengthening, is one of the
methods used to deal with complex fractures combined with severe
soft tissue injuries.5 Despite technical difficulties and
problems associated with pin-tract infections, the Ilizarov
external fixator may be the preferred technique in open tibial
fractures because of high union rates, the use of thin K-wires
with minimal traumatic effect, and more successful functional
results.6 The most frequent complication was pin-tract
infections. This study suggests that the hybrid external fixator
in standard configuration have stiffness characteristics similar
to those of the conventional Ilizarov fixator when used to treat
metaphyseal and shaft fractures of the tibia.7 Functional result
were better in upper fourth and distal fourth tibial fractures
and in type VI tibial platue fractures only. Kumar A, Whittle AP
compared with other series, and they believed it is appropriate
for treatment of these complex tibial fractures (Schatzker Type
VI) especially those with a poor soft-tissue envelope.8 Roberts
CS, Dodds JC et al showed that most dramatic improvements in the
stability of hybrid frames used for proximal tibial fractures
result from addition of an anterior, proximal half-pin.9 This
hybrid frame is easy to apply, versatile, and significantly less
expensive than other commercially available adaptors and
frames.10 This hybrid frame allows immediate functional
stabilization of tibial diaphyseal fractures and postoperatively
allows ease of fracture gap closure and compression. For
optimum fixator stiffness in hybrid fixators, at least three
femoral arches and four half-pins must be used. However, it
should be remembered that, hybrid fixator models had less axial
and bending stiffness than standard Ilizarov fixator model.
According to Arazi M et al mean range of
flexion of the knee in supracondylar fracture of femur, at the
final follow-up were 105 degrees (35 to 130º) with compared to
our study ranges of movement at knee in C2 type supracondylar
fracture were type (110°±10°) and (72.85°±36.38°) in type C3.11
50% of cases of only type C3 supracondylar of femur will give
good functional result. Application of the Ilizarov external
fixator is slightly more complicated than traditional large pin
fixator and requires more attention to detail intraoperatively
and postoperatively, but can be a versatile tool in the
management of complex tibial shaft fractures.12
Using this technique, we found some
advantages. First, there is no need for free and local flaps.5
Second, it permits definitive treatment using an external
fixator device, enabling the possibility of early functional
loading. Third, Functional results were better in upper fourth
and distal fourth tibial fractures but in only type VI tibial
platue fractures and 50% cases of only type C3 supracondylar
fractures were better in terms functional results. On the basis
of our experience, we suggest adopting this method for
functional limb salvage after extensive complex high-energy
injuries. This fixator is safe and versatile, effective in
providing stability and allowing early rehabilitation, although
the indications for its use are very–very specific.13
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