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ORIGINAL ARTICLE
Year : 2016  |  Volume : 29  |  Issue : 3  |  Page : 680-684

Management of segmental tibial fractures by an Ilizarov external fixator


Orthopedic Surgery Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission01-Apr-2015
Date of Acceptance22-Jun-2015
Date of Web Publication23-Jan-2017

Correspondence Address:
Ahmad Samy
Kwesna, 32631
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.198754

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  Abstract 

Objectives
This study aimed to evaluate the treatment of patients with segmental tibial fractures using an Ilizarov external fixator.
Background
Segmental fractures of the tibial shaft often occur after a high-energy direct trauma with consecutive severe soft-tissue injury and a high rate of open fractures. The blood supply of the intermediate bone fragment can be severely disturbed, and therefore operative treatment is demanding.
Materials and methods
This prospective study included 30 patients with segmental tibial fractures. All were fixed by an Ilizarov external fixator.
Results
The bone results were excellent in 15 patients (50%), good in six patients (20%), fair in seven patients (23.4%), and poor in two patients (6.6%). The functional results were excellent in 15 patients (50%), good in 10 patients (33.4%), fair in three patients (10%), and poor in two patients (6.6%).
Conclusion
Ilizarov external fixator is a successful method in the acute management of segmental tibial fractures. This method allows for control of complications by decreasing the need for new operations even in the presence of infection.

Keywords: bone results, distal union, functional results, Ilizarov external fixator, proximal union, segmental tibial fractures


How to cite this article:
Abdelsatar T, Elsawy M, Zayda A, Samy A. Management of segmental tibial fractures by an Ilizarov external fixator. Menoufia Med J 2016;29:680-4

How to cite this URL:
Abdelsatar T, Elsawy M, Zayda A, Samy A. Management of segmental tibial fractures by an Ilizarov external fixator. Menoufia Med J [serial online] 2016 [cited 2020 Apr 3];29:680-4. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/680/198754


  Introduction Top


Tibial diaphyseal fractures are the most common long-bone fractures. The most common cause of tibial diaphyseal fractures in most areas is road-traffic accidents, and the most difficult tibial fractures occur in motorcyclists [1] .

A segmental diaphyseal fracture occurs when a long bone is fractured at two levels, forming an intermediate fragment. Although an extensive amount of literature on tibial fractures exists, little attention is paid to segmental fractures [2] .

Open tibial fractures are more susceptible to be followed by complications even with the universally accepted lines of treatment. The basic cause is the severity of injury, the method of treatment at the first place, and the patient's general condition before injury [3] .

Complications of open tibial fracture often develop because of infection or inappropriate mechanical or biological environment. The usually confronted complications are combinations of infection, nonunion, malunion, and bone and soft-tissue loss [3] .

Fixation of segmental tibial fractures by nailing is favored; however, the reduction is frequently difficult because of the unstable nature of the intercalary segment and that may require additional plates or blocking screws [2] .

External fixation has been used for the management of fractures for a long period of time. Good fixation, mild blood loss, and early ambulation are always the main advantages of this technique. Its other advantages are that it is simple, quick, inexpensive, and causes minimal surgical trauma [4] .

The application of an external fixator enables almost perfect control of the fracture, owing to a possibility of intraoperative and postoperative reduction of the fracture [5] .

During the healing of a fracture treated by the external fixation method, there is a possibility of adapting biomechanical condition of healing-dynamization of the external fixator [5] .

The external fixation method enables early postoperative rehabilitation and functioning of extremities, which reduces the time of treatment and provides good results [5] .

This study aimed to evaluate the use of the Ilizarov external fixator in segmental tibial fractures.


  Materials and methods Top


This study  included 30 patients who presented with segmental tibial fractures, their ages ranging from 13 to 69 years, with a mean age of 33.47 years. All the patients were male. Twenty-five cases were open fractures and five were closed fractures. The number of segments ranged from three to five segments. The time between injury and operation ranged from 1 to 7 days and the duration of Ilizarov ranged from 4 to 7 months.

The cause of injury was road traffic accidents in 27 patients, motor-cycle accidents in 21 cases (70%), and car accidents in seven cases (23.3%), whereas falling from a height was the cause in two  cases (6.7%).

Twenty-five patients (83.3%) presented with open fractures and five patients (16.7%) with closed fractures.

Regarding the Gustillo classification, the most often encountered grades of open fracture were grades IIA and  IIIA. There were nine patients (30%) who presented with grade I open fracture, 13 patients (43.3%) with grade II, and eight patients (8%) with grade III fractures.

The Ilizarov fixator was used for all patients, and the results were analyzed according to the protocol of the Association for the Study and Application of the Method of Ilizarov (ASAMI).


  Results Top


The time of operation ranged from 1 to 7 days from the onset of trauma, and the duration of application of the Ilizarov fixator ranged from 4 to 7 months.

Twenty-eight patients (93.3%) had complete union, whereas two patients had nonunion and needed other lines of treatment and bone graft was performed in three cases.

Proximal callus formation ranged from 2 to 6 weeks, with a mean of 2.87 and an SD of 0.87. However, distal callus formation ranged from 3 to 8 weeks, with mean of 4.40 and an SD of 1.22.

The bone results were excellent in 15 patients (50%), good in six patients (20%), fair in seven patients (23.4%), and poor in two patients (6.6%) ([Table 1]).
Table 1 Bone results of the studded patients


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Out of the six cases that were considered to have good results, one patient had residual varus deformity of more than 7°, one had residual valgus deformity of more than 7°, two patients had residual shortening of more than 2.5 cm, and two patients had infection.

In the seven patients with fair bone results, five patients had shortness of the limp with additional infection and one patient had shortness of the limp with associated valgus deformity more than 7°.

Two patients were considered to have poor bone results due to nonunion and infection.

The functional results were excellent in 15 patients (50%), good in 10 patients (33.4%), fair in three patients (10%), and poor in two patients (6.6%) ([Table 2]).
Table 2 Functional results of the studded patients


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Three out of the 10 patients who were considered to have good results had limp with associated ankle pain: two patients had knee pain and extension deficit more than 15° and one patient had pain in the ankle with loss of 15° of the ankle dorsiflexion compared with the other side. One patient had limp and ankle dorsiflexion deficit, one patient had knee extension deficit only, one patient had limp only, and the last patient with good functional results had only ankle pain, and the pain was temporary and relieved with physiotherapy.

In the three patients with fair functional results, two patients had limp with knee pain and knee extension deficit and one patient had limp with knee pain and ankle dorsiflexion deficit.

Two patients were considered to have poor functional results due to inactivity as they could not perform their previous level of daily  work.

Proximal callus formation ranged from 2 to 6 weeks, with a mean of 2.87 and an SD of 0.87. However, distal callus formation ranged from 3 to 8 weeks, with a mean of 4.40 and an SD of 1.22 ([Table 3]).
Table 3 Time of proximal and distal union


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  Discussion Top


Segmental tibial fractures are among the most difficult types of fractures. Usually, they occur in traffic accidents due to the effect of direct violent forces. Segmental tibial fractures are rarely isolated injuries and are frequently encountered in polytraumatized patients [6] .

Treatment of segmental tibial fractures is a very complex problem. In general, the treatment of segmental tibial fractures can be nonoperative or operative. Segmental fractures are rarely suitable for nonoperative treatment, except for fractures with minimal dislocation [7] .

Severe soft-tissue injury compromises the blood flow to the segmental fragment, leading to increased risk of poor fracture healing; hence, optimum fixation of the fracture should minimize additional damage to the soft tissues and bone, preserve the remaining circulation, and provide a mechanical environment that stimulates periosteal and endosteal responses favorable to bone healing. Taking all these into consideration, the Ilizarov type fixator is the perfect method to achieve all these [8] .

There was a significant relationship between the final bone results and the original fractures. All patients in this study who had closed fractures in the original trauma had excellent bone results. In patients with open fracture, eight had excellent bone results, eight patients had good bone results, and nine patients had fair and poor results.

There was a significant relationship between the final bone results and the grade of the open fracture. None of the patients with grade IIIA open fractures had excellent bone results.

There was a significant relationship between the final functional results and the original fractures. All patients in this study who had closed fractures in the original trauma had excellent functional results. In patients with open fracture, 10 had excellent functional results, 10 patients had good functional results, and five patients had fair and poor results.

Oztόrkmen et al. [9] obtained excellent results in 20 and good results in four patients in terms of bone assessment. Functional results were excellent in 19 and good in five patients. All radiological evaluations showed normal alignment, except in two patients. No rotational deformity was seen. Bone grafting was performed in one patient with a distal fracture. Complete union was achieved in all patients. Pin-tract infection occurred in 13 of the 24 patients. There were no incidents of chronic osteomyelitis secondary to pin-tract infection. The mean time for union was 36.4 weeks (range = 10-78 weeks) for proximal fracture and 39.8 weeks (range = 12-80 weeks) for distal fractures (P > 0.05). There were no implant failures.

In our study, we noticed that the distal union takes longer time to be formed than the proximal union, with a range of 2-6 months for the proximal union and 3-8 months for distal union.

According to Audige × et al. [10] , the distal fracture is the most unstable. The natural tendency to slow union of all fractures of the distal third tibia is a well-known phenomenon. In this site, therefore, the fixation has to be as firm as possible. This is not usually possible with intramedullary fixation.

Giotakis et al. [11] present their treatment of 20 patients with segmental tibial fractures, who were treated between 2000 and in 2006 with a circular external fixator. The mean time to union was 21.7 weeks (range = 12.8-31 weeks), with no difference being observed between the proximal and the distal levels of the fracture.

Woll and Duwellius [12] used external fixators in 20 patients, but eight of these patients developed a nonunion. However, their fixators were also not Ilizarov type and they were probably monolateral fixators.

In our study, three patients showed no evidence of callus formation for 6 months, which was considered as delayed union. These patients underwent alternative gradual compression/distraction osteogenesis for 2 months; this induced callus formation, but malunion developed in one case with residual valgus deformity of more than 7°. This may be related to multiplicity of segments of the original fracture.

There were 25 patients with open fractures and five patients had closed fractures. We find that the five patients with closed fractures had final excellent bone results and excellent functional results.

We encountered 11 cases with wound infection, which ranged from minor pin-site infection to osteomyelitis (in two cases). The patients who developed osteomyelitis were further treated by removal of the Ilizarov apparatus, followed by insertion of locked  plate.

This agrees with the results of Sen et al. [13] , who stated that the major problems of the Ilizarov method are pin-tract infections and patient intolerance, but these pin-tract infections are always responsive to oral antibiotics. When the Ilizarov technique is well applied, rapid fracture healing is possible, and so the external fixation time may also be decreased to improve patient tolerance. Wire-tract infection may lead to its loosening with associated bony infection or osteolysis. Sepsis and loosening cause frame instability, which results in interference with the ability to walk and therefore slows ossification. Therefore, the control of infection in the wire tract is vital.

Inan et al. [14] stated that post-traumatic shortening and rotational or angular malalignment can be corrected at any time during the fracture-healing period. This advantage of the Ilizarov fixator decreases the risk of deformity; we encountered only one case with significant varus deformity and two cases with significant valgus deformity.

Five patients developed significant knee extension deficit and three patients developed significant ankle dorsiflexion deficit. This deformity was improved by physiotherapy in the form of passive stretching exercises of the affected muscle groups, active exercises, and electrical stimulation to stimulate muscle regeneration.

Giannoudis et al. [15] report a very important finding  that '66.6% of segmental tibial fractures require more than one surgical intervention'. It is therefore extremely vital to plan ahead so that should subsequent surgical interventions become necessary, the surgeon is well prepared for it. This planning ahead implies realigning the medullary cavity from the  start ([Figure 1] and [Figure 2]).
Figure 1: Case no. 1: segmental tibial fracture with good bone results and excellent functional results.

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Figure 2: Case no. 2: segmental tibial fracture with excellent bone results and good functional results.

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  Conclusion Top


This retrospective assessment of segmental tibial fractures has shown circular external fixation to be a reasonable method of treatment, which leaves a small biological 'footprint' and can achieve multilevel stability. There is a good mean time to union, a low rate of reoperations, and good functional and general health-status outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Miller NC, Askew AE. Tibia fractures. An overview of evaluation and treatment. Orthop Nurs 2007; 26 :216-223.  Back to cited text no. 1
    
2.
P Reynders. Open acute segmental tibial fracture fixation using the less invasive stabilization system (LISS): study of 23 consecutive cases. Injury 2009; 40 :449-454.  Back to cited text no. 2
    
3.
El Rosasy MA. Appraisal of the role of external skeletal fixation in the management of sequelae of open tibial fractures. Indian J Orthop 2008; 42 :420-425.  Back to cited text no. 3
    
4.
Elmowafy H, Abdelsattar T, Darwish A, Elrweny M. Management of intertrochanteric fracture in elderly high-risk patients using simple external fixation. MMJ 2014; 27 :249-254.  Back to cited text no. 4
    
5.
Stojkoviæ B, Milenkoviæ S, Radenkoviæ M. Tibial shaft fractures treated by the external fixation method. Facta Universitatis 2006; 13 :145-147.  Back to cited text no. 5
    
6.
Oçgüder DA, Ozer H, Solak S, Onem RY, Aðaoðlu S. Functional results of the Ilizarov circular external fixator in the treatment of open tibial fractures. Acta Orthop Traumatol Turc 2005; 39 :156-162.  Back to cited text no. 6
    
7.
Claes L, Augat P, Schorlemmer S, Konrads C, Ignatius A. Temporary distraction and compression of a diaphyseal osteotomy accelerates bone healing. J Orthop Res 2008; 26 :772-777.  Back to cited text no. 7
    
8.
French B, TornettaIII P. High-energy tibial shaft fractures. Orthop Clin North Am 2002; 33 :211-230.  Back to cited text no. 8
    
9.
Oztürkmen Y, Karamehmetoðlu M, Karadeniz H, Azboy I, Caniklioðlu M. Acute treatment of segmental tibial fractures with the Ilizarov method. Injury 2009; 40 :321-326.  Back to cited text no. 9
    
10.
AudigexL, Griffin B, Bhandari M. Path analysis of factors for delayed healing and nonunion in 416 operatively treated tibial shaft fractures. Clin Orthop Relat Res 2005; 438 :221-232.  Back to cited text no. 10
    
11.
Giotakis N, Panchani SK, Narayan B, Larkin JJ, Maskari S. Segmental fractures of the tibia treated by circular external fixation. J Bone Joint Surg Br 2010; 92 :687-692.  Back to cited text no. 11
    
12.
Woll TS, Duwellius PJ. The segmental tibial fracture. Clin Orthop Relat Res 1992; 281 :104-107.  Back to cited text no. 12
    
13.
Sen C, Kocaoglu M, Eralp L. Bifocal compression/distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss. A report of 24 cases. J Orthop Trauma 2004; 18 :150-157.  Back to cited text no. 13
    
14.
Inan M, Karaog¢lu S, Cilli F. Treatment of femoral nonunions by using cyclic compression and distraction. Clin Orthop Relat Res 2005; 436 :222-228.  Back to cited text no. 14
    
15.
Giannoudis PV, Robertson A, Matthews SJ. Maintaining reduction during unreamed nailing of a segmental tibial fracture: the use of a Farabeuf clamp. Injury 2003; 34 :389-391.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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