Between 2005 and 2010 ten consecutive children with high-energy open diaphyseal tibial fractures were treated by early reduction and application of a programmable circular external fixator. They were all male with a mean age of 11.5 years (5.2 to 15.4), and they were followed for a mean of 34.5 months (6 to 77). Full weight-bearing was allowed immediately post-operatively. The mean time from application to removal of the frame was 16 weeks (12 to 21). The mean deformity following removal of the frame was 0.15° (0° to 1.5°) of coronal angulation, 0.2° (0° to 2°) sagittal angulation, 1.1 mm (0 to 10) coronal translation, and 0.5 mm (0 to 2) sagittal translation. All patients achieved consolidated bony union and satisfactory wound healing. There were no cases of delayed or nonunion, compartment syndrome or neurovascular injury. Four patients had a mild superficial pin site infection; all settled with a single course of oral antibiotics. No patient had a deep infection or re-fracture following removal of the frame. The time to union was comparable with, or better than, other published methods of stabilisation for these injuries. The stable fixator configuration not only facilitates management of the accompanying soft-tissue injury but enables anatomical post-injury alignment, which is important in view of the limited remodelling potential of the tibia in children aged > ten years. Where appropriate expertise exists, we recommend this technique for the management of high-energy open tibial fractures in children.

Introduction: Treatment of high energy unstable lower leg fractures requires a fixation system that will provide skeletal stability, promote bone healing without residual deformity and allow wound care. The Taylor Spatial Frame is a device which provides excellent skeletal stability, allows immediate weight bearing and provides an opportunity for correction of residual deformity without return to the operating theatre.

Method: 9 patients (10 limbs), all male, mean age 12.6 (5.2–16.5 years old) were treated at Bristol Royal Hospital for Children for high energy tibial fractures between 2005 and 2008. There were 6 open fractures (3 fractures Gustilo IIIA and 3 IIIB) and 4 closed fractures. Of the 4 closed fractures, 3 required fasciotomies for compartment syndrome. The case notes and radiographs of all patients were retrospectively reviewed to assess outcomes.

Results: 2 patients were stabilized primarily with TSF, 1 had plaster backslab before applying TSF, 7 were treated primarily with unilateral external fixation prior to applying TSF. TSF was applied on average 7.3 days after initial injury. All fractures were reduced at the first visit to the operating theatre. In 6 cases malalignment developed and residual deformity corrections were performed via TSF programming, in 1 case frame was adjusted at the second visit to theatre to facilitate wound closure and then fracture reduced. Time of treatment with TSF was on average 107 days. Sound bone union and satisfactory wound healing was achieved in all cases. All tibiae were united without significant residual deformity or leg length discrepancy. There was one complication – muscle tethering at proximal fine wire fixation requiring adjustment of TSF with insertion of half pins.

Discussion: In this study group the results of TSF fixation were excellent. The commonest device used in this patient group is unilateral external fixation. Whilst this gives predictable results and allows good wound care there are limitations to the use of this technique. The TSF has two particular advantages that we believe make it more suitable than unilateral external fixation. The intrinsic stability of the ring structure allows immediate post-operative weight bearing and the programmable strut adjustments allow easy non-operative correction of residual deformity.

Achieving deep flexion after total knee replacement remains a challenge. In this study we compared the soft-tissue tension and tibiofemoral force in a mobile-bearing posterior cruciate ligament-sacrificing total knee replacement, using equal flexion and extension gaps, and with the gaps increased by 2 mm each. The tests were conducted during passive movement in five cadaver knees, and measurements of strain were made simultaneously in the collateral ligaments. The tibiofemoral force was measured using a customised mini-force plate in the tibial tray. Measurements of collateral ligament strain were not very sensitive to changes in the gap ratio, but tibiofemoral force measurements were. Tibiofemoral force was decreased by a mean of 40% (sd 10.7) after 90° of knee flexion when the flexion gap was increased by 2 mm. Increasing the extension gap by 2 mm affected the force only in full extension. Because increasing the range of flexion after total knee replacement beyond 110° is a widely-held goal, small increases in the flexion gap warrant further investigation.