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Routine application of the pinless external fixator
s-c3
Routine application of the pinless external fixator
N. Haas I, M. Schlitz I, A. Wagenitz l, Chr. Krettek 2, N. Siidkamp * 1 Unfall- und Wiederherstellungschirurgie, Universitatsklinik Rudolf Virchow Freie Universitat Berlin, Germany (Director: Prof. Dr. Norbert Haas) 2 Unfallchirurgische Klinik, Medizinische Hochschule, Hannover, Germany (Director: Prof. Dr. Harald Tscheme)
summaryl One serious disadvantage of conventional fixator systems is the need to open the medullary space, hence creating a direct communication with the exterior. The new pinless external fixator does not have this major disadvantage, because the fixator clamps simply rest on the cortical bone without penetrating it. Clinically, this easily managed system is intended for fractures of the tibia in cases in which primary internal fixation is precluded either by precarious local or general conditions or by infrastructural problems. In such situations the new pinless fixator is an excellent device with which to achieve good stabilization of the fracture rapidly, while leaving open all options for subsequent alteration of treatment. If the surgeon decides to convert to locked intramedullary nailing, the pinless fiiator facilitates the new approach, because it can be used as a distractor and makes it unnecessary to transfer the patient to a fracture table. Keywords: Pinless external fixator, external fixator Throughout the world the external fixator finds its most frequent use in fractures of the tibia (1, 2), though widely differing models are employed. However, all fixator models in current use have one serious disadvantage, namely that they require screws or pins which penetrate the intact cortical bone and open the medullary cavity. This creates a direct communication between the medullary cavity, the
’
Abstracts in German, French, Italian, Spanish and Japanese are printed at the end of this supplement.
bone and the exterior, in other words the situation which exists in an open fracture. As personal experience has shown and numerous publications point out, after lo-14 days have elapsed there is at least latent infl ammation at the points where the pins of the fixator pass through the skin (3). In most cases this subsequently leads to pin track infection with consequent loOsening, Often necessitating a further operation to m-locate the pin. Alteration of treatment to intramedullary fixation (medullary nail), though necessary or desirable, is then no longer contraindicated.
possible
and
may
even
be
The new pinless external fixator does not have this disadvantage. Its clamps are in contact only with the exterior of the bone. It hence constitutes a logical development of the existing external fixator systems. Besides the advantage of not penetrating the bone, it has major advantages, among them ease of application without air drill and problem-free aftercorrection in all dimensions (rotation, axial, longitudinal). Thanks to these advantages, the pinless fixator has the following clinical uses: 1. Major disasters or wartime conditions. Primary stabilization of fractures portation.
2.
for
external
trans-
s-c4 3. Rapid stabilization of fractures under emergency conditions for patients in very poor general condition. 4. Primary stabilization of fractures in cases in which primary internal fixation is not feasible because of the state of the soft tissues or the fracture. 5. As a distractor for reducing fractures. 6. As an external locking system for patients undergoing internal fixation by medullary nailing. Re. 1: In major disasters and in wartime large numbers of patients have to be treated rapidly and effectively, even though the infrastructural and aseptic facilities of an operating theatre are not available. The surgeon working under such conditions will very seldom have access to an image intensifier or an air drill. One advantage of the pinless external fixator is that radiological control is not necessary for
its application. Axial alignment is checked clinically. If the axis subsequently requires correction, this can be carried out without difficulty in any desired direction without repositioning the clamps. General anaesthesia is normally not necessary for this purpose. Re. 2: In hospitals in which the facilities for the care of injured patients are limited, the pinless external fixator is useful for rapid and effective primary stabilization of tibia1 fractures so that the patient can
be transferred to a trauma centre. The pmless external fixator does not impose any constraints on the surgeon who has to choose a definitive mode of treatment for the fracture.
Re. 3: Patients with serious multiple injuries are often in poor general condition with an unstable circulation, troublesome ventilatory impairment and often grave cerebral signs, all of which preclude protracted surgical intervention. Nevertheless, any fractures left untreated will aggravate the overall situation. Primary stabilization of the fractures is absolutely imperative and in this situation the pinless external fixator offers an ideal solution. In an emergency it can also be rapidly applied in places other than an equipped operating theatre. Once the patient’s general condition has been stabilized, planned, definitive treatment of the fracture can be carried out. Provided the state of the fracture permits, the fixator should ultimately be replaced by an intramedullary nail. When this has been done the pinless fixator can be left in place to serve as a distractor and can render a fracture table unnecessary.
Case 1. The patient sustained this closed fracture of the tibia (A0 classification 12.8.1.1) in a motorcycle accident. Primary internal fixation was not practicable because of an extremely severe head injury. The fracture was therefore temporarily immobilized with a pinless fixator. On the fifth day, after the patient’s general condition and cerebral function had improved, an early change of treatment was made to an unreamed intramedullary nail.
Haas: Routine application of the pinless externalfixator Re. 4: Fractures in which primary internal fixation is impracticable because of the critical state of the soft tissues can be very effectively treated by using the pinless external fixator as an initial measure. When applying the pinless clamps care must be taken that the clamp points pierce as little soft tissue as possible and are inserted only through small stab incisions. This requirement can be met by the construction of the system, in that each of the clamps can be placed in any desired position, depending on the state of the fracture and soft tissues. In order to ensure satisfactory stability, two clamps should be inserted into each of the main fragments and should then be connected to one another by a steel or carbon fibre rod. The fracture is then reduced and the entire
s-c5 system stabilized and fixed by tightening the clamping nuts. Provided the state of the soft tissues permits or after any necessary soft tissue reconstruction has been carried out, treatment is then altered to internal fixation. Re. 5: The pinless external fixator can also be used as an aid to reducing a fracture instead of using a fracture table. When dealing with particularly severe comminuted or multiple fractures, it can be left in place, for a time at least, to provide additional external stabilization after definitive intramedullary nailing. The pinless external fixator is removed when radiological examination shows adequate consolidation of the fracture.
Case 2. A 42-year-old-man sustained a second degree compound fracture of the tibia (A0 classification 42-C3.3) together with serious multiple injuries. Primary fixation of the fracture was carried out by applying a pinless fixator with simultaneous unreamed intramedullary nailing. The pinless fixator was left in place for 8 weeks postoperatively to provide additional external stabilization.
SC6 Re. 6: The pinless external fixator can also be used as an external locking system when performing internal fixation by intramedullary nailing. This is particularly advantageous when dealing with fractures in extreme proximal or distal locations where the indications for nailing are marginal and where ordinary locking nails are not fully satisfactory or even quite unusable. When dealing intramedullary
with secondary axial deviations after nailing, this mode of external fixation
has also proved extremely valuable. While the fracture is still mobile, axial correction is carried out as a closed procedure and the pinless fixator is applied. It is sometimes necessary to remove the locked intramedullary nail to ease correction. In this situation, the pinless fixator is left in place until radiological examination shows that fracture union has reached a stage at which secondary dislocation is unlikely.
Case 3. A 55-year-old man was involved in a road traffic accident and sustained a closed fracture of the tibia with severe soft tissue injuries (Tscheme Grade III). Primary treatment with a static locked, unreamed tibia1 intramedullary nail. After weight-bearing had begun, a valgus malalignment became evident. Axial correction was carried out by applying a pinless external fixator after loosening the proximal locking screw. The pinless fixator was removed after six weeks.
Haas: Routine application
of the pinless external fixator
Conclusion The new pinless external fixator is an excellent device for rapid stabilization of tibia1 fractures in cases in which primary internal fixation is not feasible, either because of the critical state of the soft tissues or because other, more serious injuries demand priority. In hospitals lacking appropriate facilities the pinless external fixator can be used to stabilize fractures of the tibia so that the patient can be transferred to another hospital. In such cases the pinless external fixator offers an ideal solution; it is quickly and easily applied without an air drill, and when the patient has been transferred the surgeon is still free to adopt any form of internal fixation desired. If the state of the fracture permits, definitive treatment should be carried out by intramedullary nailing. In this case, the pinless fixator can be left in place and used as a distractor instead of a fracture table. The aim of fracture treatment is the same in all circumstances. Once the patient’s general condition has been brought under control and the local situation has been stabilized, treatment should be switched over from the pinless external fixator to an internal fixation method as early as possible. References 1. Behrens TL, Searls K. External fixation of the tibia. J. Bone Joint Surg. 1986;68B:246-254.
2. Heim D, Regazzoni P, Perren SM. Current use of external fixation in open fractures, Injury 1992;23(2). 3. Krettek C, Haas N, Tscheme H. Behandlungsergebnisse von 202 frischen Unterschenkelfrakturen versorgt mit einem unilateralen Fixateur exteme (Monofixateur), Unfallchirurg 1989;92:440-452.
I+ y 1994, Slcpplemen t3
s-c7
Routine application of the pinless external fixator
N. Haas I, M. Schlitz I, A. Wagenitz l, Chr. Krettek 2, N. Siidkamp * 1 Unfall- und Wiederherstellungschirurgie, Universitatsklinik Rudolf Virchow Freie Universitat Berlin, Germany (Director: Prof. Dr. Norbert Haas) 2 Unfallchirurgische Klinik, Medizinische Hochschule, Hannover, Germany (Director: Prof. Dr. Harald Tscheme)
summaryl One serious disadvantage of conventional fixator systems is the need to open the medullary space, hence creating a direct communication with the exterior. The new pinless external fixator does not have this major disadvantage, because the fixator clamps simply rest on the cortical bone without penetrating it. Clinically, this easily managed system is intended for fractures of the tibia in cases in which primary internal fixation is precluded either by precarious local or general conditions or by infrastructural problems. In such situations the new pinless fixator is an excellent device with which to achieve good stabilization of the fracture rapidly, while leaving open all options for subsequent alteration of treatment. If the surgeon decides to convert to locked intramedullary nailing, the pinless fiiator facilitates the new approach, because it can be used as a distractor and makes it unnecessary to transfer the patient to a fracture table. Keywords: Pinless external fixator, external fixator Throughout the world the external fixator finds its most frequent use in fractures of the tibia (1, 2), though widely differing models are employed. However, all fixator models in current use have one serious disadvantage, namely that they require screws or pins which penetrate the intact cortical bone and open the medullary cavity. This creates a direct communication between the medullary cavity, the
’
Abstracts in German, French, Italian, Spanish and Japanese are printed at the end of this supplement.
bone and the exterior, in other words the situation which exists in an open fracture. As personal experience has shown and numerous publications point out, after lo-14 days have elapsed there is at least latent infl ammation at the points where the pins of the fixator pass through the skin (3). In most cases this subsequently leads to pin track infection with consequent loOsening, Often necessitating a further operation to m-locate the pin. Alteration of treatment to intramedullary fixation (medullary nail), though necessary or desirable, is then no longer contraindicated.
possible
and
may
even
be
The new pinless external fixator does not have this disadvantage. Its clamps are in contact only with the exterior of the bone. It hence constitutes a logical development of the existing external fixator systems. Besides the advantage of not penetrating the bone, it has major advantages, among them ease of application without air drill and problem-free aftercorrection in all dimensions (rotation, axial, longitudinal). Thanks to these advantages, the pinless fixator has the following clinical uses: 1. Major disasters or wartime conditions. Primary stabilization of fractures portation.
2.
for
external
trans-
s-c4 3. Rapid stabilization of fractures under emergency conditions for patients in very poor general condition. 4. Primary stabilization of fractures in cases in which primary internal fixation is not feasible because of the state of the soft tissues or the fracture. 5. As a distractor for reducing fractures. 6. As an external locking system for patients undergoing internal fixation by medullary nailing. Re. 1: In major disasters and in wartime large numbers of patients have to be treated rapidly and effectively, even though the infrastructural and aseptic facilities of an operating theatre are not available. The surgeon working under such conditions will very seldom have access to an image intensifier or an air drill. One advantage of the pinless external fixator is that radiological control is not necessary for
its application. Axial alignment is checked clinically. If the axis subsequently requires correction, this can be carried out without difficulty in any desired direction without repositioning the clamps. General anaesthesia is normally not necessary for this purpose. Re. 2: In hospitals in which the facilities for the care of injured patients are limited, the pinless external fixator is useful for rapid and effective primary stabilization of tibia1 fractures so that the patient can
be transferred to a trauma centre. The pmless external fixator does not impose any constraints on the surgeon who has to choose a definitive mode of treatment for the fracture.
Re. 3: Patients with serious multiple injuries are often in poor general condition with an unstable circulation, troublesome ventilatory impairment and often grave cerebral signs, all of which preclude protracted surgical intervention. Nevertheless, any fractures left untreated will aggravate the overall situation. Primary stabilization of the fractures is absolutely imperative and in this situation the pinless external fixator offers an ideal solution. In an emergency it can also be rapidly applied in places other than an equipped operating theatre. Once the patient’s general condition has been stabilized, planned, definitive treatment of the fracture can be carried out. Provided the state of the fracture permits, the fixator should ultimately be replaced by an intramedullary nail. When this has been done the pinless fixator can be left in place to serve as a distractor and can render a fracture table unnecessary.
Case 1. The patient sustained this closed fracture of the tibia (A0 classification 12.8.1.1) in a motorcycle accident. Primary internal fixation was not practicable because of an extremely severe head injury. The fracture was therefore temporarily immobilized with a pinless fixator. On the fifth day, after the patient’s general condition and cerebral function had improved, an early change of treatment was made to an unreamed intramedullary nail.
Haas: Routine application of the pinless externalfixator Re. 4: Fractures in which primary internal fixation is impracticable because of the critical state of the soft tissues can be very effectively treated by using the pinless external fixator as an initial measure. When applying the pinless clamps care must be taken that the clamp points pierce as little soft tissue as possible and are inserted only through small stab incisions. This requirement can be met by the construction of the system, in that each of the clamps can be placed in any desired position, depending on the state of the fracture and soft tissues. In order to ensure satisfactory stability, two clamps should be inserted into each of the main fragments and should then be connected to one another by a steel or carbon fibre rod. The fracture is then reduced and the entire
s-c5 system stabilized and fixed by tightening the clamping nuts. Provided the state of the soft tissues permits or after any necessary soft tissue reconstruction has been carried out, treatment is then altered to internal fixation. Re. 5: The pinless external fixator can also be used as an aid to reducing a fracture instead of using a fracture table. When dealing with particularly severe comminuted or multiple fractures, it can be left in place, for a time at least, to provide additional external stabilization after definitive intramedullary nailing. The pinless external fixator is removed when radiological examination shows adequate consolidation of the fracture.
Case 2. A 42-year-old-man sustained a second degree compound fracture of the tibia (A0 classification 42-C3.3) together with serious multiple injuries. Primary fixation of the fracture was carried out by applying a pinless fixator with simultaneous unreamed intramedullary nailing. The pinless fixator was left in place for 8 weeks postoperatively to provide additional external stabilization.
SC6 Re. 6: The pinless external fixator can also be used as an external locking system when performing internal fixation by intramedullary nailing. This is particularly advantageous when dealing with fractures in extreme proximal or distal locations where the indications for nailing are marginal and where ordinary locking nails are not fully satisfactory or even quite unusable. When dealing intramedullary
with secondary axial deviations after nailing, this mode of external fixation
has also proved extremely valuable. While the fracture is still mobile, axial correction is carried out as a closed procedure and the pinless fixator is applied. It is sometimes necessary to remove the locked intramedullary nail to ease correction. In this situation, the pinless fixator is left in place until radiological examination shows that fracture union has reached a stage at which secondary dislocation is unlikely.
Case 3. A 55-year-old man was involved in a road traffic accident and sustained a closed fracture of the tibia with severe soft tissue injuries (Tscheme Grade III). Primary treatment with a static locked, unreamed tibia1 intramedullary nail. After weight-bearing had begun, a valgus malalignment became evident. Axial correction was carried out by applying a pinless external fixator after loosening the proximal locking screw. The pinless fixator was removed after six weeks.
Haas: Routine application
of the pinless external fixator
Conclusion The new pinless external fixator is an excellent device for rapid stabilization of tibia1 fractures in cases in which primary internal fixation is not feasible, either because of the critical state of the soft tissues or because other, more serious injuries demand priority. In hospitals lacking appropriate facilities the pinless external fixator can be used to stabilize fractures of the tibia so that the patient can be transferred to another hospital. In such cases the pinless external fixator offers an ideal solution; it is quickly and easily applied without an air drill, and when the patient has been transferred the surgeon is still free to adopt any form of internal fixation desired. If the state of the fracture permits, definitive treatment should be carried out by intramedullary nailing. In this case, the pinless fixator can be left in place and used as a distractor instead of a fracture table. The aim of fracture treatment is the same in all circumstances. Once the patient’s general condition has been brought under control and the local situation has been stabilized, treatment should be switched over from the pinless external fixator to an internal fixation method as early as possible. References 1. Behrens TL, Searls K. External fixation of the tibia. J. Bone Joint Surg. 1986;68B:246-254.
2. Heim D, Regazzoni P, Perren SM. Current use of external fixation in open fractures, Injury 1992;23(2). 3. Krettek C, Haas N, Tscheme H. Behandlungsergebnisse von 202 frischen Unterschenkelfrakturen versorgt mit einem unilateralen Fixateur exteme (Monofixateur), Unfallchirurg 1989;92:440-452.
I+ y 1994, Slcpplemen t3
s-c7