Orthofix External Fixation in Trauma and Orthopaedics

633 Pages·2001·36.11 MB·English

by  A. G. Apley

Orthofix External Fixation
in Trauma and Orthopaedics
Springer
London
Berlin
Heidelberg
New York
Barcelona
Hong Kong
Milan
Paris
Singapore
Tokyo
Giovanni De Bastiani, A. Graham Apley and Anthony Goldberg (Eds)
Orthofix External
Fixation
in Trauma and Orthopaedics
Springer
\li!o1""~11
Anthony Goldberg MBBS, MPharm, FFPM
Group Medical Director, Orthofix® sri
Via delle Nazioni, 9
37012 Bussolengo (Verona), Italy
ISBN-13:978-1-4471-1178-8
British Library Cataloguing in Publication Data
Orthofix external fixation in trauma and orthopaedics
1. External skeletal fixation (Surgery)
I. De Bastiani, Giovanni II. Apley, A. Graham (Alan Graham)
III. Goldberg, Anthony
617.1'5
ISBN-13:978-1-4471-1178-8
Library of Congress Cataloging-in-Publication Data
Orthofix external fixation in trauma and orthopaedics / Giovanni De Bastiani, A. Graham Apley, and
Anthony Goldberg, eds.
p. ; cm.
Includes bibliographical reference and index.
ISBN-13:978-1-4471-1178-8 e-ISBN-13: 978-1-4471-0691-3
DOl: 10.1007/978-1-4471-0691-3
1. Fracture fixation. 2. Bone lengthening (Orthopedics) I. Title: Orthofix external fixation.
II. De Bastiani, Giovanni, 1921- III. Apley, A. Graham (Alan Graham) IV. Goldberg, A. A. J.
(Anthony Aaron Joseph)
[DNLM: 1. External Fixators. 2. Bone Lengthening-methods. 3. Fracture Fixation
methods. WE 18506152000]
RD103.E88.0782000
617.1'5-<1c21
00-020079
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Contents
Preface........................................................................ ix
List of contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. xxiii
PART I THE SCIENTIFIC BASIS OF ORTHOFIX EXTERNAL FIXATION
Section 1 Historical Background
1 A History of External Fixation
A. G. Apley and M.H. Noordeen ........................... . . . . . . . . . . . . . . . . . . . . . . 3
Section 2 Biological Considerations
2 The Biology of Fracture Repair and the Role of Dynamization
I. Kenwright and 1.B. Richardson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3 The Biology of Callus Distraction: Callotasis
N. Yasui and H. Kojimoto . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
4 The Biology of Soft Tissue Distraction
I. KenwrightandA.H.R. W. Simpson....................... ... ................... 25
5 The Measurement of Fracture Healing
I.B. Richardson and 1.R. W. Hardy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Section 3 Biomechanical Aspects
6 Biomechanical Performance of the Standard Orthofix External Fixator and Cortical Screws
H. T. Aro and E. Y.S. Chao. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
7 The Stability of Orthofix External Fixation: a Comparative Evaluation
A.H. Broekhuizen ...... .......... ....... .. ................................... 71
Section 4 Fixators and Fracture Repair
8 The Influence of Fixator Design on Fracture Repair: the Orthofix Pro callus
]. C.R. Scott ................................................................. 77
PART II ORTHOFIX EXTERNAL FIXATION IN TRAUMATOLOGY
Section 1 General Principles
9 Screw Selection and the Technique ofInsertion
F. Lavini ................................................................... 85
10 The Technique of Wire Insertion
M. Saleh................................................................... 90
11 Pin Track Infection and the Principles of Pin Site Care
R. G. Checketts, A. G. MacEachern and M. Otterburn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
v
vi Orthofix External Fixation
Section 2 The Upper Limb
12 Safety Corridors and Structures at Risk in External Fixation of the Upper Limb
T. Gausepohl and D. Pennig. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
13 Diaphyseal and Metaphyseal Fractures of the Humerus
F. Lavini, A. Donadelli and A. Pizzo Ii . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121
14 Fractures, Fracture Dislocations and Stiffness of the Elbow: the Elbow Fixator
D. Pennigand T. Gausepohl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 127
15 Diaphyseal Fractures of the Forearm
L. Cugolaand A.Atzei ........................................................ 145
16 The Radius: Distal Metaphyseal and Articular Fractures and Corrective Osteotomies
D. Pennig and T. Gausepohl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 152
17 The RadioLucent Wrist Fixator for Distal Radius Fractures
D.L. Nelson. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 181
18 The Orthofix Small (30.000) Fixator in Distal Radius Fractures
D.L. Nelson................................................................. 192
19 Metacarpal Fractures, Phalangeal Fractures and Reconstructive Procedures: the Pennig
MiniFixator in the Hand
D. Pennig and T. Gausepohl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 195
Section 3 The Pelvis
20 External Fixation in Pelvic Ring Injuries: the Pelvic Fixator
D. Pennig and T. Gausepohl . .. .. . .. .. .. .. . .. .. .. .. .. .. . .. .. .. . . . .. . .. . .. .. . . ... 219
Section 4 The Lower Limb
21 Proximal Femoral Fractures: the Pertrochanteric Fixator
E. Alcivar A. ................................................................ 236
22 The Impact of External Fixation of Femoral Fractures on Mortality and Morbidity in
Polytrauma Patients
E. Brug, S. Winckler, M. Pallen and W. Klein. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 244
23 Supracondylar and Intercondylar Fractures of the Femur
F.AliandM.Saleh ............................................................ 249
24 High Energy Tibial Plateau Fractures
I.L. Marsh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 256
25 Proximal Metaphyseal Fractures of the Tibia
L. Renzi Brivio .............................................................. 267
26 Diaphyseal Fractures of the Tibia: Defining the Place of External Fixation
1.R. W. Hardy and 1.B. Richardson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 275
27 Distal Tibial and Plafond Fractures
J,L. Marsh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 286
28 Hybrid External Fixation in Tibial Trauma
M. Saleh and M. El Shazley . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 299
29 Os Calcis Fractures
L. Nogarin, A. Rebeccato and B. Magnan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 308
Contents vii
30 Metatarsal Fractures, Phalangeal Fractures and Reconstructive Procedures: the Pennig
MiniFixator in the Foot
Do Pennig and Ko Mader 318
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Section 5 Fractures in Children
31 Fracture Management in Children
Jo Bennek 329
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Section 6 Acute Bone Loss Following Trauma
32 The Management of Acute Bone Loss Following Trauma
Mo Saleh 355
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Section 7 Ancillary Equipment
33 Ancillary Equipment for Fracture Management
So Salvagno 370
0000000000000000000000000000000000000000000000000000 0 0 0 0 • 0 0 0 0 0 0 0 0
34 The Fragment Fixation System in Intra-articular and Periarticular Fractures
To Gausepohl and Do Pennig 375
0 0 .. 0 0 0 0 0 .... 0 0 0 0 ............ 0 .. 0 0 0 0 0 .. 0 0 .. 0 0 ...... 0
PART III ORTHOFIX EXTERNAL FIXATION IN ORTHOPAEDICS
Introduction
Mo Saleh 399
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0
35 The Scope of Orthofix External Fixation in Lower Limb Reconstruction
Mo Saleh. 400
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Section 1 The Correction of Bony and Soft Tissue Deformity
36 The Acute Correction of Deformity by Means of Monol ateral External Fixation
Mo Saleh and So Nayagam 409
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0
37 Upper Tibial Osteotomy: A Critical Review
A. Go MacEachern andA.E. Weale 421
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
38 Upper Tibial Hemicallotasis Using a Self-Aligning Articulated Body
J.]o Elting 427
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
39 Upper Tibial Hemicallotasis Using the OF-Garches
So Toksvig-Larsen 433
000000000000000000000000000000000000000000000000. 0 0 0 0 0 0 0 0 000
40 Progressive Correction in Bone and Soft Tissue Deformity Using Monolateral Fixation
or the Sheffield Hybrid System
Mo Saleh and Mo Hashmi 440
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Section 2 Limb Lengthening
41 An Historical Perspective Prior to Callotasis
Mo To Dahl 449
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
42 The Technique of Callotasis and its Application to Monofocal Limb Lengthening
Mo Saleh and L. Donnan 458
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0 • 0 0 0 0 0 0 0 0 0 0
43 Upper Metaphyseal Lengthening of the Tibia Using the OF-Garches
-c.
Jo Pouliquen, C. Glorion and Jo Langlais 467
0 0 0 .. 0 0 ...... 0 0 0 0 0 ...... 0 .. 0 0 0 .... 0 0 0 .. 0
44 Bifocal Lengthening
No Yasui 478
000000000000000000000000000000000000000000000. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
viii Orthofix External Fixation
45 Limb Lengthening in High Risk Cases: The Importance of the Learning Curve
M. T. Dahl. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 485
46 The Complications ofLeg Lengthening
M. Saleh and B. W. Scott. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 496
Section 3 The Management of Non-Union
47 An Historical Background to the Treatment of Non-Union
R.B. Simonis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 511
48 The Principles of Non-Union Management
M. Saleh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 522
49 A Review of the Management of Non-Unions Using Orthofix External Fixation Systems
M. Saleh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 537
50 Bifocal Techniques for Non-Union and Deformity
M. SalehandA.Rees .......................................................... 541
51 The Treatment of Chronic Infected Non-Unions
S. Meletiou and I.L. Marsh .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 549
52 Infected Non-Unions with Soft Tissue Loss: the Shortening-Lengthening Technique
G. Geibel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 563
Section 4 Arthrodesis
53 External Fixation Techniques for Arthrodesis of the Knee and Ankle
M. Saleh and M. Rickman. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 568
Section 5 Articulated Distraction
Introduction
M. Saleh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 576
54 Joint Stiffness in the Upper Limb: the Arthrodiatasis Technique
D. Pennig. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 577
55 Articulated Distraction of the Hip
R.Aldegheri, G. TrivellaandM. Saleh ............................................ 605
Index .......................................................................... 613
Preface
The philosophy of external fIxation has changed dra modular attachments to the standard range of
matically over the past few decades. Wide usage in the fixators for the treatment of more complex fractures
earlier part of the last century, often for inappropriate of the long bones and the pelvis. At the same time
indications, coupled with a lack of appreciation of the they realized that the monolateral fixator could, with
biomechanics of fracture healing, served to highlight minimal modification, be used to distract and
the problems which could be associated with the tech manipulate the callus formed in response to a delib
nique when transfixing pins and multibar structures erately produced osteotomy. Suddenly it became
conferring uncompromising rigidity were employed. possible to lengthen limbs with congenital or trau
With these early systems the results frequently matic shortening and to correct deformity using
compounded the conditions they were intended to material generated within the body itself in response
treat; pin track infection, which could proceed to to an applied stimulus. The influence of the Verona
osteomyelitis, and worse still, to amputation in some school spread rapidly, fostered by regular seminars
instances, was seen as a major drawback and the inci held in Verona, and attended by surgeons from all
dence of non-union was high. This came to a head parts of the world.
with use of the then available frames during World Wide usage brought with it an abundance of ideas
War II, and led the US Surgeon General to put an from practising surgeons, many of which were tested
embargo on the use of external fIxation devices in the and subsequently incorporated within the OrthofIx
United States. range. These included fixators which could be used in
All this was to change, however, due largely to the association with fractures in and around the wrist,
vision of one man, whose training and expertise elbow, knee and ankle and which would permit early
spanned the disciplines of both physiology and ortho mobilization of the joints, and miniature fixators to
paedics. Giovanni De Bastiani knew instinctively, that treat fractures of the digits. Improvements to the orig
designed intelligently and applied appropriately, inal lengthening device with the introduction of a
external fixation could be used to complement the highly versatile modular rail construct has had a major
natural processes of fracture repair. He directed his impact on limb salvage and reconstruction, and the
energies to this end, and working with Giovanni recently developed hybrid fIxation system has
Faccioli, a precision engineer, he produced, in the late combined the best features of both monolateral and
1970s, the first prototype OrthofIx Dynamic Axial circular fixation.
fixator. This was a lightweight, monolateral device The present volume is intended as a tribute to
with tapered, non-transfixing bone screws, which Giovanni De Bastiani. It brings together, for the fIrst
could introduce micro movement and loading at the time, the in-depth experience of scientists and sur
fracture site at the correct points in the healing cycle, to geons throughout the world, whose practices in all
encourage the development and maturation of areas of orthopaedic trauma and limb reconstruction
bridging callus. The concept of "dynamization" was have been influenced and enhanced by the devices he
born. Fracture healing was expedited, and pin track conceived and made available. They have themselves,
infection appreciated as something that could be in addition, been responsible in many instances, for
controlled, if not entirely eradicated. major developments in devices and techniques based
Things did not stop here. If they had, there would upon his original ideas.
have been no need for this book. De Bastiani and his
team in Verona developed and tested a series of Anthony Goldberg
ix
Giovanni De Bastiani
Giovanni De Bastiani was born in Bari, Italy on 24 May
1921. He qualified in medicine at the University of
Padua in 1947 and in 1949 became an assistant in the
department of Human Physiology. In 1954 he was
appointed Professor of Human Physiology, and in the
same year began a clinical appointment with Professor
C. Pais in the Orthopaedic Clinic of the University of
Genoa.
In 1957 he completed specialist training in trauma
and orthopaedics, and started working with Professor
Casuccio in the Orthopaedic Department of the
University of Padua. In 1959 he was made Professor
of Orthopaedics in the University and received a
number of distinction awards over the succeeding
years for his scientific and clinical work. In 1970 he
became Head of the Department of Trauma and
Orthopaedics in the newly-built hospital of Borgo
Roma in Verona.
Possessed of an open and enquiring mind, he was the concept of "dynamization" to promote callus
always ready to explore and evaluate new methods of formation and consolidation, and culminated in the
treatment spanning a wide range of conditions. His development of the first Dynamic Axial Fixator. This
initial work in Verona centred on problems involving was designed specifically to answer many of the
the hip in children and adults, and in the design of current criticisms of external fixation and was the fore
improved forms of prostheses for both idiopathic and runner of the Orthofix range of external fixators. De
acquired forms of hip disease. During this time he also Bastiani and his group in Verona have subsequently
developed a strong interest in the factors involved in published many papers on the safe use of external fixa
fracture repair, bringing his formidable background in tion in a range of trauma indications and have had a
physiology to bear in an appreciation of the problems major influence in altering the perception of this
involved and the ways in which these might be method of treatment by the orthopaedic fraternity.
addressed. His dissatisfaction with existing forms of De Bastiani also established a firm place for external
osteosynthesis, coupled with his belief in the value fixation in many other orthopaedic indications. Many
of external fixation as a valid treatment modality, of these are a direct result of his development of the
dictated the subsequent course of his research. technique of "callotasis", or callus distraction, which
Between 1978 and 1979 he established a group with has had a major impact on the treatment oflimb length
clinical and engineering expertise to study in depth the inequality and bone loss.
problems associated with external fixation which at Giovanni De Bastiani retired in 1991, but the work
this time was still regarded as a treatment oflast resort. he initiated continues to be developed and refined in
This was a direct result of the many problems experi many parts of the world.
enced by other workers due to the biomechanical inad
equacy of existing frames and problems at the pin Lodovico Renzi Brivio
bone interface, which were associated with a high inci Director, Department of Orthopaedics and Traumatology
Carlo Poma Hospital, Mantua, Italy
dence of non-union and infection. This research led to
x