Osteomyelitis is an inflammatory condition accompanied by the destruction of bone and caused by an infecting microorganism. Open contaminated fractures can lead to the development of osteomyelitis of the fractured bone in 3-25% of cases, depending on fracture type, degree of soft-tissue injury, degree of microbial contamination, and whether systemic and/or local antimicrobial therapies have been administered. Untreated, infection will ultimately lead to non-union, chronic osteomyelitis, or amputation. We report a case series of 10 patients that presented with post-operative infected non-union of the distal femur with or without prior surgery. The cases were performed at Padmashree Dr. D. Y. Patil Hospital, Nerul, Navi Mumbai, India. All the patients’ consents were taken for the study which was carried out in accordance with the Helsinki Declaration. The methodology involved patients undergoing a two-stage procedure in case of no prior implant or a three-stage procedure in case of a previous implant. Firstly, debridement and implant removal were done. The second was a definitive procedure in form of knee arthrodesis with ring fixator and finally followed by limb lengthening surgery. Arthrodesis was planned in view of infection, non-union, severe arthritic, subluxated knee, stiff knee, non-salvage knee joint, and financial constraints. After all the patients demonstrated wound healing in 3 months along with good radiographic osteogenesis at the knee arthrodesis site, limb lengthening surgeries by tibial osteotomy were done to overcome the limb length discrepancy. Distraction was started and followed up for 5 months. All 10 patients showed results with sound knee arthrodesis and good osteogenesis at the osteotomy site followed by achieving the limb length just 1-inch short from the normal side to achieve ground clearance while walking. Our case series is unique and distinctive as it shows that when patients with infected nonunion of distal femur come with the stiff and non-salvage knee with severe arthritic changes and financial constraints, we should consider knee arthrodesis with Ilizarov ring fixator followed by limb lengthening surgery

Introduction and Aims: Severe tibial plateau fractures are generally considered high-energy injuries, requiring ORIF. Bone grafting at time of surgery is generally advocated and the most devastating complication is deep infection. Our aim was to see whether we could avoid a bone graft and prevent deep infections by using a ring fixator. Method: From 1997 to date, we treated 46 patients with Schatzker V & VI fractures, 41 males, five females, average age 43.2 years (range 30 –71). Follow-up ranged from 18 to 72 months. Forty fractures, closed or grade I compound and six grade II compound. Reduction was by Bohler’s method. When indicated, fixation was supplemented by internal fixation. Three or four proximal wires were placed 15mm distal to the joint. Surgery was within 24 hours post-admission, irrespective of date of injury or swelling. No weight-bearing was allowed for the first six weeks. Thereafter gradual increments in weight bearing. Results: All fractures united. No bonegrafting was required. No deep, i.e. grade III, sepsis. Osteoporosis is not a contra-indication. Pain at 4 years: Grade 0 to I - 30, grade II - 12, grade III - 4. Mean range of movement at 6 months was 5° to 115° of flexion. Complications: Grade I pin tract sepsis - 24 patients. Grade II pin tract sepsis - 10 patients. Grade III – 0 patients. Treatment consisted of mechanical cleansing of the pins. Added to that were antibiotics for grade II sepsis, and in 2 cases we had to re-site one of the proximal wires in order to prevent a deep infection. Conclusion: A ring fixator can be used up to 10 days post-injury, irrespective of severity of swelling. No deep-seated infection, most likely due to minimal interference with soft tissue envelope around the proximal tibia. No bone grafting required, BMP’s stay in fracture hematoma. Follow-up now at six years

Between 1997 and 2000, 25 Schatzker type-V and VI tibial plateau fractures were treated at our hospitals with the Ortho-fix ring fixator and followed up for between 10 months and four years. We chose this form of treatment for three reasons. First, because these are usually high-energy injuries, open reduction and internal fixation has to be done on admission or when the swelling has reduced, which can take up to three weeks. Secondly, internal fixation usually requires bone grafting at the same time. Thirdly, there is a high incidence of sepsis following conventional treatment with double plate and bone graft. There were 20 closed or grade-I compound fractures and five grade-II compound fractures. The mean age of the 22 men and three women was 45.3 years (30 to 71). One patient had a head injury. There were ipsilateral femoral fractures in two patients, one of whom also had a comminuted distal radial fracture on the contralateral side, and one patient had a contralateral tibial plafond fracture. We routinely placed patients on a traction table and reduced the fracture, using Bohler’s method of traction and elastic bandaging. If necessary we made a limited incision and held the fragment with a large fragment screw under C-arm control. Using three or ideally four proximal wires, we made sure that the most proximal went through the fibular head. With local patients the frame was applied within 24 hours of admission. In patients who were referred from other parts of Africa, the frame was applied up to 10 days after the accident, irrespective of the amount of swelling. Continuous passive motion from 0° to 90° was started immediately postoperatively and maintained for a minimum of five days. Patients were then given crutches and mobilised touch weight-bearing in the frame. When the frame was removed, patients were fitted with a DonJoy hinged knee brace with no limitation of knee flexion or extension. All but two patients attained 90° of flexion within 10 days of application of the frame. Four patients failed to achieve full extension. Grade-I pin-tract sepsis developed in 12 patients and grade-II in four. All infections settled with treatment. One proximal wire needed to be resited. The mean time to removal of the frame was 4.5 months. No bone grafting was required. We concluded that the amount of swelling is not a critical issue and that the ring fixator can be applied within 10 days of the injury. Probably because there was minimal interference with soft tissues, deep-seated sepsis did not occur. Even in osteoporotic bone, wire fixation gives excellent stability. There is still uncertainty about long-term follow-up, development of post-traumatic osteoarthritis and the possibility of sepsis if total knee arthroplasty is undertaken later

Aim: To review the results of tibial lengthening and deformities correction in children using the Sheffield Ring Fixator. Materials and methods: We have reviewed, retrospectively, 25 patients (average 12.2 years old) who underwent predominantly lengthening of the tibia using the Sheffield Ring fixator. The average follow up was 25.7 months. For logistic regression analysis the patients were binary coded into two groups: those with a good outcome (BHI< 45 days/cm) and those with a poor outcome (BHI> 45 days/cm). Various factors which may influence the out come were then analysed. Results: The most common indication for tibial lengthening in our series was for fibular hemimelia in 6 patients and achondroplasia in 4 and growth arrest secondary to trauma in 3. The mean lengthening of 48.1 mm (25–76). The mean accuracy of lengthening achieved was 85%. 11 patients had foot plate extension, and 5 had cross knee extension for unstable knee. 10 patients had bifocal osteotomy, and 8 patients had spontaneous SLR for femoral lengthening or correction. The mean bone healing index was 49 days/cm (20–95). The mean maximum correction in any one plane was 150 (3–40), the site of the osteotomy was mainly metaphyseal at an average of 25% of the tibial length. There were 5 grade II complications, 9 grades I complications and one type III complication. Thirteen patients had grade I pin site infection, three had grade II and 12 had no pin site problems. A moderately strong relationship was identified between the BHI and a number of variables such as complications, maximum correction and pin site infection grade. The analysis of the factors which may influence the BHI suggested a correlation between increasing angular correction and poor out come BHI. Conclusion: In tibial lengthening in children there is a correlation between increasing angular correction and poor out come BHI

In five teaching hospitals, seventy-two patients with seventy-three bicondylar tibial plateau fractures were prospectively randomized by envelope to treatment either by AO methods (group A) or ring fixator methods (group B). Outcome measures included clinical and radiographic parameters, & HSS knee scores. Results: Re-intervention was necessary within six months in ten group A & seven Group B patients. Forty-three procedures were performed (thirty-three Group A-ten Group B) I& D 12- 3: STSG 3-0: Quadricepsplasty 1-0; Manipulation 2–4; Muscle flap 2–0; Above knee amputation 1–0; Revision ORIF 5–1; Revision Rings 0–1; Bone graft 2–1; Bead pouch 3-0; Synovectomy 1-0; Sequestrectomy 1-0. More patients had more septic and wound complications resulting in more need for re-intervention following ORIF. Conclusion. For bi-condylar tibial plateau fractures (OTA 41.C) six-month HSS scores are significantly higher after treatment with Ring Fixator methods. Reintervention rates for deep sepsis/wound problems are higher with AO methods. Wound and infection complications occurring after AO treatment are more severe and require multiple procedures for control. We have conducted a prospective randomized trial to determine the outcomes of treatment by. Open reduction and internal fixation or. Closed reduction and ring fixation for the treatment of bi-condylar tibial plateau fractures (OTA 41.C). We report our early findings on re-intervention rates for complications. In five teaching hospitals, seventy-two patients with seventy-three bi-condylar tibial plateau fractures were prospectively randomized by envelope to treatment either by AO methods (group A) or ring fixator methods (group B). Outcome measures included clinical and radiographic parameters, & HSS knee scores. Randomization gave the following demographics. Re-intervention was necessary within six months in ten group A & seven Group B patients. Forty-three procedures were performed (thirty-three Group A-ten Group B) I& D 12- 3: STSG 3-0: Quadricepsplasty 1-0; Manipulation 2-4; Muscle flap 2-0; Above knee amputation 1-0; Revision ORIF 5-1; Revision Rings 0-1; Bone graft 2-1; Bead pouch 3-0; Synovectomy 1-0; Sequestrectomy 1-0. More patients had more septic and wound complications resulting in more need for re-intervention following ORIF. For bi-condylar tibial plateau fractures (OTA 41.C) six-month HSS scores are significantly higher after treatment with Ring Fixator methods. Reintervention rates for deep sepsis/wound problems are higher with AO methods. Wound and infection complications occurring after AO treatment are more severe and require multiple procedures for control. Please contact author for pictures and/or diagrams

We present a series of 88 non-unions in which non-union, infection, bony alignment and length were addressed simultaneously, by using the Sheffield Ring Fixator. The mean follow up was 50 months (range 6–110) after union, which was achieved in 90.5% of the patients. The mean deformity correction was 16.80 (range 60–320), and mean length gain was 12.5 mm (range 2–40 mm). Smoking and infection had a statistical significant association with the time of healing, as healing of the non-union in over 18 months was more common in smoker and patients with infected non-union. There was no statistical difference between the functional score (SF-36) between these patients and normal population, at a follow up of minimum 2 years, but that was significant between pre operative and less than one year follow up on one side, and more than 2 years follow up on the other

To review the results of the treatment of pilon fracture with percutaneous internal fixation and extrarticular ring fixation in neutralization, twenty-two fractures in twenty-one patients were included in the study. The mean follow-up time was 5.3 years. Five fractures were classified Ruedi-Algower type I, six were Ruedi-Algower type II and eleven Ruedi-Algower type III. Six were open fractures (3 Gustilo type III) and there were 19 associated fibular fractures (five were internally fIxed). Thirteen fractures (60%) were associated with metaphysealdiaphyseal dissociation (MDD). The majority of fractures were high energy (18 out of 22). General health outcome was assessed with the use of the SF-36 and functional outcome was evaluated with AOFAS score and Bone’s criteria. The average AOFAS score for the study population was 79.4. The AOFAS scores decreased as the severity of the fracture increases and these differences were statistically significant between the Ruedi-Algower types I and III. The pilon fractures population scored lower in all SF-36 categories but mental health and energy and vitality when compared to an age matched population but statistically significant differences were only found in the categories of physical function and limitation due to health problems. 65% achieved excellent or good results according to Bone’s criteria. No significant differences were found in the union times in the MDD group (253 days) when compared to the fractures with no MDD (224 days), but this can be due to the high incidence of autograft in the MDD group (7 out of 13). All patients achieved full weight bearing at 6 weeks. Fourteen patients had superficial pin site infections (one needed screw removal) that settled with oral antibiotics. There was one case of non-union and two varus heels. Conclusion: Good results are achieved treating pilon fractures with minimal internal fixation and the Sheffield ring fixator in neutralization but quality of life and functional scores significantly worsen in the most severe Ruedi-Algower type III fractures

Aims: is to evaluate the efficiency of the Sheffield Ring Fixator (SRF) in the management of posttraumatic tibial Deformity. Introduction: Correction of tibial deformity as a consequence of malunion or injury to the growth plate is challenging. Progressive correction is usually necessary due to the low compliance of the anatomical compartments. The SRF provides an effective solution. Materials and Methods: a consecutive series of 30 patients with posttraumatic tibial deformity treated by progressive correction using the SRF between 1997 and 2000. The mean age was 33 years (range 18 to 65). Cases were analysed to ascertain the degree of deformity, treatment time, final outcome in terms of the accuracy of correction of deformity, and incidence of complications. Results: Full correction was achieved in 27 of the 30 cases: two patients had residual angular deformities of 7 and 10 degrees and one had 15mm residual shortening. Satisfactory bone formation occurred in all cases. There were no significant complications. The mean correction time was dependent on whether or not lengthening had been performed (72 and 53 days respectively). From this study the correction time can be estimated as 2 days per degree plus an extra 0.5 days per degree for every centimetre of length to be gained. Conclusion: Knowledge of the efficiency of the system will enable an estimation of treatment times to be made thereby facilitating the setting of goals for both patient and surgeon. Accuracy of correction and total treatment times were satisfactory suggesting that the fixation system was both stable and yet sufficiently elastic to permit good bone healing

The aim of this study is to evaluate the efficiency of the Sheffield Ring Fixator (SRF) in the management of tibial deformity. Tibial deformity correction is challenging and requires an efficient system with strong bony fixation.Progressive correction is usually necessary due to the low compliance of the anatomical compartments. The SRF provides an effective solution, employing a combination of wire and screw fixation for metaphyseal corrections and all screw fixation for diaphyseal corrections. We reviewed a consecutive series of 50 patients with tibial deformity treated by progressive correction using the SRF between 1997 and 2000. The mean age was 33 years (range 18 to 65). Thirty nine cases were due to post-traumatic deformity and eleven as sequelae of childhood disease. Cases were analysed to ascertain the degree of deformity, treatment time, final outcome in terms of the accuracy of correction of deformity, and incidence of complications. All patients had significant angular deformity and 12 had a rotational deformity. 21 patients had clinically significant shortening. The mean deformities were: varus 10.5, valgus 13, posterior 11.8, anterior 20.6 (giving a mean oblique plane deformity of 24° ) rotation 17° and 26mm of shortening. Full correction was achieved in 45 of the 50 cases: Three patients had residual angular deformities of 5,7 and 10 degrees and two had residual shortening (15mm& 5mm). Satisfactory bone formation occurred in all cases. There were no significant complications. The mean correction time was dependent on whether or not lengthening had been performed (72 and 53 days respectively). From this study the correction time can be estimated as 2 days per degree plus an extra 0.5 days per degree for every centimetre of length to be gained. A knowledge of the efficiency of the system will enable estimation of treatment times to be made thereby facilitating the setting of goals for both patient and surgeon. Correction and total treatment times were satisfactory suggesting that the fixation system was both stable and yet sufficiently elastic to permit good bone healing. Even when the rotation translation systems were used prescribed movements led to satisfactory corrections suggesting few if any losses in the system. The SRF provides a strong and efficient system for the accurate and controlled correction of tibial deformities

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an llizarov ring fixator. Only patients with intra-articular fracture of the tibial plafond on plain radiographs that corresponded to type III pattern of Ruedi and Allgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the Ilizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided. Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average of 6.3 months). Neither deep infection nor soft tissue complications occurred. Outcomes measured using the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire and our results compare well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an Ilizarov ring fixator. Only patients with an intra-articular fracture of the tibial plafond on plainradiographs that corresponded to type III pattern with the system of Rfiedi andAllgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the llizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided. Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average 6. 3 months). Neither deep infection nor soft tissue complications occurred. Outcome measurements included the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire. Wound and deep infections were successfully avoided and bony union was achieved in all our patients. This compares well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Aims. Infected and deformed neuropathic feet and ankles are serious challenges for surgical management. In this study we present our experience in performing ankle arthrodesis in a closed manner, without surgical preparation of the joint surfaces by cartilaginous debridement, but instead using an Ilizarov ring fixator (IRF) for deformity correction and facilitating fusion, in arthritic neuropathic ankles with associated osteomyelitis. Methods. We retrospectively reviewed all the patients who underwent closed ankle arthrodesis (CAA) in Ilizarov Scientific Centre from 2013 to 2018 (Group A) and compared them with a similar group of patients (Group B) who underwent open ankle arthrodesis (OAA). We then divided the neuropathic patients into three arthritic subgroups: Charcot joint, Charcot-Maire-Tooth disease, and post-traumatic arthritis. All arthrodeses were performed by using an Ilizarov ring fixator. All patients were followed up clinically and radiologically for a minimum of 12 months to assess union and function. Results. The union rate for Group A was 81% (17/21) while it was 84.6% (33/39) for Group B. All the nonunions in Group A underwent revision with an open technique and achieved 100% union. Mean duration of IRF was 71.5 days (59 to 82) in Group A and 69 days (64.8 to 77.7) in Group B. The American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score was similar in both groups. The postoperative hospital stay was shorter in Group A (21 days (SD 8)) than Group B (28 days (SD 9)). In the latter Group there were more problems with wound healing and greater requirement for antibiotic treatment. The mean operating time was 40 minutes (SD 9) in Group A compared to 80 minutes (SD 13) in Group B. Recurrence of infection occurred in 19% (4/21) and 15.5% (6/39) for Group A and Group B respectively. Conclusion. We found CAA using an IRF to be an effective method for ankle arthrodesis in infected neuropathic foot and ankle cases and afforded comparable results to open methods. Due to its great advantages, Ilizarov method of CAA should always be considered for neuropathic ankles in suitable patients. Cite this article: Bone Joint J 2020;102-B(4):470–477

Aims. This is a prospective randomised study which compares the radiological and functional outcomes of ring and rail fixators in patients with an infected gap (> 3 cm) nonunion of the tibia. Patients and Methods. Between May 2008 and February 2013, 70 patients were treated at our Institute for a posttraumatic osseocutaneous defect of the tibia measuring at least 3 cm. These were randomised into two groups of 35 patients using the lottery method. Group I patients were treated with a ring fixator and group II patients with a rail fixator. The mean age was 33.2 years (18 to 64) in group I and 29.3 years (18 to 65) in group II. The mean bone gap was 5.84 cm in group I and 5.78 cm in group II. The mean followup was 33.8 months in group I and 32.6 months in group II. Bone and functional results were assessed using the classification of the Association for the Study and Application of the Method of Ilizarov (ASAMI). Functional results were also assessed at six months using the short musculoskeletal functional assessment (SMFA) score. Results. The bone result was excellent, good, fair and poor in 21, 12, 0 and 2 in group I; and 14, 15, 3, and 3 in group II, respectively. The functional results were excellent, good, fair, poor and failure in 16, 17, 1, 0 and 1 in group I; and 22, 10, 0, 3 and 0 in group II, respectively. Both fixator systems achieved comparable rates of union and functional outcomes. The rate of deep pintract infection was significantly higher in the rail fixator group but patients found it more comfortable. Conclusion. We recommend the use of a ring fixator in patients with a bone gap of more than 6 cm. Patients with a bone gap up to 6 cm can be managed with either a ring or rail fixator. Cite this article: Bone Joint J 2016;98B:1399–1405

Aims

In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia.

Introduction. Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures. Materials & Methods. We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA). 137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups. Results. Mean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years. PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17). Conclusions. This pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures

We retrospectively reviewed 60 fractures of the tibial plafond treated by either an ankle-sparing diaphyseal-epiphyseal technique using the Ilizarov ring fixator or by an ankle-spanning technique using a monolateral articulated external fixator. The Ilizarov ring fixator was applied in 24 fractures and the monolateral articulated transarticular external fixator in 20. Both techniques were combined with limited open reduction and internal fixation of the articular surface if necessary. Between three and nine years after the injury, all patients returned for clinical and radiological assessment and evaluation of ankle function using the modified Mazur score. There were no significant differences between the two groups in terms of age, gender, mechanism of injury, type of fracture or length of follow-up. The mean functional ankle score was 86 points for the Ilizarov group and 82 points for the articulated fixator group. The difference was not significant (p = 0.07). There were no significant differences between the groups with regard to the radiographic score and late complications. Patients treated with the Ilizarov ring fixator had significantly better ankle and subtalar movement. We conclude that both techniques of external fixation are satisfactory methods of treatment for fractures of the tibial plafond, but that the total arc of movement of the joint is preserved better without bridging the ankle

Objective: To compare the mechanical stability of fixation of bicondylar tibial plateau fractures using available internal and external fixation techniques. Method: A bicondylar tibial plateau fracture was simulated on a uniform synthetic bone and tested with loading to failure. Following power calculations, seven tibias were used for each fixation method; five types of fixation were tested: 1) Dual plating. 2) Ring Fixator with inter-fragmentary screws. 3) Hybrid fixator (Ring-Bar) with interfragmentary screws. 4) Lateral plate and medial monolateral external fixator. 5) Lateral plate and medial interfragmentary screws. The specimens were tested in compression to failure. The vertical subsidence in either medial or lateral plateau was measured using an electrical transducer. Results: In all cases the mode of failure was consistent with collapse occurring in the medial plateau. There was no significant difference in the ultimate strength between dual plating and the ring fixator [4218N, 4184N respectively; P=0.28, t test]. Failure was seen at lower loads with the other fixation systems (Table). Conclusion: The Ring Fixator and dual plating demonstrated a greater strength and the most stable fixation, choice may depend on tissue viability and surgeon preference. Furthermore mobilisation of the patient may be undertaken earlier with more confidence using these two methods rather than less stable techniques

Introduction: The Staffordshire Orthopaedic Reduction Machine (STORM) was developed to assist in the reduction of tibial shaft fractures prior to the application of an external fixator. Its use has now been extended to fractures of the tibial plateau and plafond, where it has been utilised to gain and hold a good reduction prior to the application of various internal and external fixation techniques. Methods: The STORM was used sterile within the operative field on a standard radiolucent operating table. It was applied with two tensioned 2 mm wires: the distal through the calcaneum; the proximal through the proximal tibia for shaft and pilon fractures, and through the distal femur for plateau fractures. Controlled traction was applied through these two wires. Torsion was independently corrected and locked. Translation and angulation was corrected using two translation arms each applied to the tibia with a single unicortical screw. The STORM was removed at the end of each operation. Results: The STORM was used in 241 cases. Pilon (n=42): bridging hinge 23 (t [mean operation time in minutes]=102.9), percutaneous plate 10 (t=131.4), ring fixator 5 (t=140), screws and fibula plate 3 (t=77), other 2. Plateau (n=23): ring fixator 11 (t=129.7), LISS plate 8 (t=98.6 mins), monolateral Garches fixator 3 (t=64.4), screws only 1 (t=15). Shaft (n=176): monolateral fixator 138 (t=69.1), ring fixator 37 (t=131.2), nail 1 (t=65). Ilizarov rings up to 200 mm were accommodated. Discussion: The STORM is a safe device for reliable reduction of tibial plateau, shaft and pilon fractures which allows good access for internal or external fixation. No significant complications attributable to the use of the current design of the STORM were encountered

Introduction and Objective. Management of gap non-union of the tibia, the major weight bearing bone of the leg remains controversial. The different internal fixation techniques are often weighed down by relatively high complication rates that include fractures which fail to heal (non-union). Minimally invasive techniques with ring fixators and bone transport (distraction osteogenesis) have come into picture as an alternative allowing alignment and stabilization, avoiding a graduated approach. This study was focused on fractures that result in a gap non-union of > 6 cm. Ilizarov technique was employed for management of such non-unions in this case series. The Ilizarov apparatus consists of rings, rods and kirschner wires that encloses the limb as a cylinder and uses kirschner wires to create tension allowing early weight bearing and stimulating bone growth. Ilizarov technique works on the principle of distraction osteogenesis, that is, pulling apart of bone to stimulate new bone growth. Usually, 4–5 rings are used in the setup depending on fracture site and pattern for stable fixation. In this study, we demonstrate effective bone transport and formation of gap non-union more than 6 cm in 10 patients using only 3 rings construct Ilizarov apparatus. Materials and Methods. This case study was conducted at Dr. D. Y. Patil Medical Hospital, Navi Mumbai, Maharashtra, India. The study involved 10 patients with a non-union or gap > 6 cm after tibial fracture. 3 rings were used in the setup for the treatment of all the patients. Wires were passed percutaneously through the bone using a drill and the projecting ends of the wires were attached to the metal rings and tensioned to increase stability. The outcome of the study was measured using the Oxford Knee scoring system, Functional Mobility Scale, the American Foot and Ankle Score and Visual Analog Scale. Further, follow up of patients was done upto 2 years. Results. All the patients demonstrated good fixation as was assessed clinically and radiologically. 9 patients had a clinical score of > 65 which implied fair to excellent clinical rating. The patients showed good range of motion and were highly satisfied with the treatment as measured by different scoring parameters. Conclusions. In this case study, we demonstrate that the Ilizarov technique using 3 rings is equally effective in treating non-unions > 6 cm as when using 4–5 rings. Obtaining good clinical outcome and low complication rate in all 10 patients shows that this modified technique can be employed for patients with such difficulties in the future