The operative management of open fractures of the lower limb requires a consistent treatment to avoid soft tissue complications. Acute angular shortening of the fracture enabling primary soft tissue closure is still an uncommon operative technique because of difficulties in correcting the secondary deformity. The case of a pediatric open fracture of the lower limb (Gustilo type IIIa) is described, which was treated with acute angular shortening followed by gradual correction using the Taylor spatial frame (TSF).

Das operative Vorgehen bei offenen Unterschenkelfrakturen erfordert auf Grund des prätibial dünnen Weichteilmantels ein konsequentes Handeln, um Weichteilkomplikationen zu vermeiden. Hierbei ist das Prinzip der akuten Verkürzung im Frakturbereich zum direkten Weichteilverschluss ein selten praktiziertes Verfahren, da die Korrektur der sekundären Fehlstellung schwierig ist. Anhand einer kindlichen, offenen Unterschenkelfraktur (Gustilo-Klassifikation Grad IIIa) werden die Möglichkeiten der sekundären Korrektur nach primärer angulärer Verkürzung mit dem Taylor Spatial Frame (TSF) dargestellt.

Mit zunehmender Adipositasprävalenz wird es für Chirurgen und Krankenhäuser wichtig, mit dem operativen Management von übergewichtigen Patienten vertraut zu sein. Die genaue präoperative Evaluierung der häufig schweren Begleiterkrankungen muss ebenso bedacht werden wie spezielle peri- und postoperative Behandlungen und Anforderungen an die Krankenhauslogistik. Über die Behandlung von Patient mit morbider Adipositas mit einem BMI >50 kg/m2 ist in der Literatur noch wenig berichtet.

Background: Correction of severe tibial deformity due to a non-union of the tibia is best achieved by a slow gradual correction which allows the compromised tissue to adapt. The Taylor spatial frame (TSF) is a hexapod-based ring fixator that allows a simultaneous gradual correction of a multiplanar deformity through a virtual hinge. The aim of this study was to demonstrate the application of the TSF and the clinical outcomes of ten patients with a non-union of the tibia.Patients and Method: Ten patients with either a hypertrophic or atrophic non-union of the tibia were treated between 2003 and 2006 with the TSF. The mean age of these patients was 43 years (range: 12 - 73). There were 5 hypertrophic and 5 atrophic non-unions. Five of the ten fractures were initially open. The mean preoperative magnitude of the angulation deformity was 21.9 degrees (range: 5 - 44). In nine patients, the correction was performed in a closed manner; one patient had hardware removed prior to the frame application.Results: In all ten patients, the deformities were corrected. The average duration of time that the frame was worn was 158.5 days (range: 89-300). The mean time for gradual correction was 23.1 days (range: 5-43) with an average correction speed of 1.3 mm/day (range: 0.5 - 2). No additional bone stimulation was performed. In terms of complications, one patient had a residual valgus deformity of 5 degrees, one a pin tract infection, and one a stress fracture next to a pin hole.Conclusion: In patients with either a hypertrophic or olidgotrophic non-union of the tibia and severe deformity, the TSF is a powerful tool to correct the deformity in a closed manner which preserves the remaining viability of the nonunion.

BACKGROUND:Post-traumatic supramalleolar deformities and malunions of ankle fusion require mostly a multiplanar correction. In cases of severe soft tissue damage, external fixation and gradual correction is a definite treatment alternative.METHOD:Between 2003 and 2007 a correction of supramalleolar deformities was performed in 9 patients with the Taylor spatial frame external fixator. The mean age was 30 years (min. 12, max. 68). There were 6 patients with deformities after malunion of supramalleolar fractures and 3 patients with malunion after ankle fusion. The mean angular deformity was 30 degrees and 5 patients had a rotational malposition of 13.6 degrees (min. 5 degrees, max. 25 degrees). 5 patients needed also lengthening (min. 10 mm, max. 40 mm) of the post-traumatic deformed tibia. The mean time of the follow-up examination was 23 months (min. 12, max. 41).RESULTS:Anatomic correction could be achieved in all patients. The average correction time was 36 days (min. 10, max. 82) with an average time period of 163 days (min. 130, max. 218) until the fixator was removed. The healing index of the leg lengthening cases was 77 d/cm. There were 2 pin-tract infections, 1 prolongated callus formation and 1 insufficient callus formation.CONCLUSION:In cases of post-traumatic supramalleolar deformities with poor soft tissue and bone quality the Taylor spatial frame is a useful tool. Angular, axial, translational and rotatory deformities are corrected simultaneously without complex and time-consuming fixator reconstructions.

Die Therapie von posttraumatischen Achsabweichungen der unteren Extremität erfordert in der Regel eine mehrdimensionale Korrektur. Selten sind Achsabweichungen nur in einer Ebene lokalisiert. Aufgrund der häufig schlechten Weichteilverhältnisse sind bei ausgeprägten Fehlstellungen interne Osteosyntheseverfahren in der rekonstruktiven Chirurgie nur eingeschränkt einsetzbar. Der Taylor Spatial Frame (TSF) ist ein hexapod basierter Ringfixateur mit der Möglichkeit, dreidimensional in einem virtuellen Gelenk auch ausgeprägte Fehlstellungen kontinuierlich selbst bei schlechten Weichteilverhältnissen zu korrigieren.

Despite adequate primary treatment many ankle fractures result in post-traumatic deformities and arthrosis. Revision mostly requires a multidirectional correction whereas internal fixation procedures are often not applicable due to soft tissue damage and the extent of deformity. The Taylor spatial frame enables simultaneous correction of multidirectional deformities through a virtual hinge using the same ideas of distraction osteogenesis as the Ilizarov fixator. The presented case demonstrates minimally invasive correction of a complex deformity of the ankle with the Taylor spatial frame fixator. Orthogonal alignment was achieved and a stabilizing tibiotalar arthrodesis was performed achieving a good functional and pain-free result.

Given the rising prevalence of obesity, surgeons and hospitals must become more familiar with the treatment and operative management of obese patients. Several additional pre- and postoperative considerations must be involved such as appropriate assessment of comorbidities and requirements for special equipment. There are still very few data regarding morbidly obese patients with BMIs > 50kg/m(2). After a general literature review of operative management of obese patients, we report on fracture care of the lower limb in such patients with custom-made Ilizarov ring fixators. We found them suited to bear enormous weight-loading but that associated comborbidities can limit successful fracture care.

Introduction. Posttraumatic deformities in the lower limb are mainly multidirectional, with angulation, translation, and rotatory deformities. Acute corrections with internal fixation are often not possible due to the soft tissue damage and the extent of the deformity. The Taylor Spatial Frame (TSF) allows correction in a virtual hinge with 6 axes, thus enabling the correction of multidirectional deformities simultaneously.Methods. From February 2003 until December 2006, we applied 31 TSFs to 20 patients with a posttraumatic deformity of the tibia and hindfoot. The mean patient age was 41 years (range 12-73). 9 patients had a nonunion of the tibia with deformity, 6 had a malunion of the lower tibia and ankle, 3 had an angular deformity after ankle fusion, and 2 had malaligned Ilizarov bone segment transports. The mean follow-up time was 25.3 months (range 10-82).Results. In all 20 patients, full correction of the deformity was achieved. The mean time for correction was 29 days (range 5-82). On average, the frame was worn ( time to healing) 164.2 days (80-300) and the mean distraction rate was 1.1 mm/day (0.5-2.0). The Web-based planning was done two times per case for full deformity correction. Complications were 3 pin-site infections, 2 insufficient callus formations and 1 pinhole stress fracture.Conclusions. The main advantage of the TSF compared with other external frames is the ability to perform simultaneous correction of angular, axial, translational, and rotatory deformities. This enables a reduced correction time and increased patient comfort.

Copyright © Taylor & Francis 2008. ISSN 1745–3674. Printed in Sweden – all rights reserved. DOI 10.1080/17453670710015607 Forearm fractures are one of the most common injuries in children (Bailey et al. 1989, Kramhoft and Bodtker 1988). Growth disturbance or growth arrest of an injured physis after distal radius fractures occur in 4–7% of cases (Lee et al. 1984). The resulting deformity resembles Madelung’s deformity, and is also called pseudo-Madelung’s deformity (Figure 1). This deformity leads to ulnocarpal impaction and dorsal dislocation of the distal radioulnar joint (DRUJ). Several treatment options such as lengthening of the radius and shortening of the ulna or epiphysiodesis of the distal ulna have been described (Villa et al. 1990, Abe et al. 1996, Hove and Engesaeter 1997, Waters et al. 1997, Pennig et al. 1999). The Taylor spatial frame (TSF) is a hexapodbased external ring fixator, which is widely used to perform six-axis deformity corrections of the lower limb (Eidelman et al. 2006, Rozbruch et al. 2006). TSF planning is web-based (www.spatialframe.com), but its use is only available for the lower extremities. This technical note shows how to apply the TSF to the arms to correct pseudoMadelung deformities.

Background Fracture care in obese patients is becoming an everyday problem because the prevalence of obesity in European countries has tripled since the last 20 years. Patients and method With the use of a custom made Ilizarov ring fixator with a ring diameter of 300 to 340 mm, fracture stabilization in three morbidly obese patients was performed. The patients’ body mass index (BMI) ranged from 59 to 89. There were one proximal tibia fracture and two pilon fractures. The tibia fracture was stabilized with a 340-mm frame and the pilon fractures were stabilized by primary ankle arthrodesis with 300-mm frames. Primary ankle arthrodesis was performed because polyneuropathy and Charcot arthropathy were present in one patient and in the other patient because time from injury to referral was too long for reconstruction. Results All patients were able to fully weight bear. Frame removal after fracture correction and consolidation was performed only in the patient with the tibial fracture (patient BMI 89). The other patients died during the treatment because of decompensated comorbidities. Conclusion The Ilizarov technique is a good fixation modality for stabilizing fractures of the lower limb in morbidly obese patients. Associated medical comorbidities are the limitations of successful fracture care.

Fehlstellungskorrekturen bei posttraumatischer Weichteil- und Knochensituation mit großem Fehlstellungsausmaß erfordern eine schonende und meist graduelle Korrektur, um sekundäre Gefäß-, Nerven- oder Weichteilschäden zu vermeiden. Akutkorrekturen können nur bei guter Weichteildeckung und günstiger Korrekturrichtung durchgeführt werden. Der Ringfixateur und insbesondere der Taylor-Spatial-Frame eignen sich im Besonderen für die graduelle Korrektur von Fehlstellungen mit großem Fehlstellungsausmaß. Eine simultane Korrektur von mehrdimensionalen Fehlstellungen mit dem Taylor-Spatial-Frame ist ohne große Fixateurumbauten möglich. Die Patienten können sofort voll belasten und den Transport selbstständig durchführen.

Mit Zunahme der Adipositasprävalenz in der Bevölkerung steigt in Zukunft auch die Zahl der osteosynthetisch zu versorgenden Frakturen bei adipösen Patienten. Der Chirurg muss mit Behandlungsmöglichkeiten sowie dem prä- und postoperativen Management vertraut sein. Die Eingriffe sind technisch anspruchsvoller, Infektionen und Implantatversagen sind häufiger. Bei extremer Adipositas sind interne Implantate unterdimensioniert, und der operative Zugang ist durch den ausgedehnten Weichteilmantel erschwert. Hier stellt der Ilisarov-Ringfixateur eine weichteilschonende Osteosynthese mit hoher Stabilität dar. Peri- und postoperativ stehen bei dieser Patientengruppe die Behandlung und Komplikationen der Komorbiditäten im Vordergrund.

Severe posttraumatic deformities involving compromised soft tissue and bone demand gentle and usually gradual methods of correction so as to avoid secondary damage to the vascular system, nerves or soft tissue. Acute techniques are only possible when there is a good soft tissue mantle and the direction is safe. The Ilizarov ring fixator and the Taylor spatial frame are both known to be particularly suitable for gradual correction of severe deformities. The Taylor spatial frame allows correction of severe multiplanar deformities with no need for elaborate adaptations to it. The patients are capable of full weightbearing immediately and can be followed up as out-patients.