Skip to main content
SpringerLink
Log in

Ball-joint versus single monolateral external fixators for definitive treatment of tibial shaft fractures

  • Original Article
  • Published:
European Journal of Orthopaedic Surgery & Traumatology Aims and scope Submit manuscript

Abstract

Purpose

To compare modular monolateral external fixators with single monolateral external fixators for the treatment of open and complex tibial shaft fractures, to determine the optimal construct for fracture union.

Materials and methods

A total of 223 tibial shaft fractures in 212 patients were treated with a monolateral external fixator from 2005 to 2011; 112 fractures were treated with a modular external fixator with ball-joints (group A), and 111 fractures were treated with a single external fixator without ball-joints (group B). The mean follow-up was 2.9 years. We retrospectively evaluated the operative time for fracture reduction with the external fixator, pain and range of motion of the knee and ankle joints, time to union, rate of malunion, reoperations and revisions of the external fixators, and complications.

Results

The time for fracture reduction was statistically higher in group B; the rate of union was statistically higher in group B; the rate of nonunion was statistically higher in group A; the mean time to union was statistically higher in group A; the rate of reoperations was statistically higher in group A; and the rate of revision of the external fixator was statistically higher in group A. Pain, range of motion of the knee and ankle joints, rates of delayed union, malunion and complications were similar.

Conclusion

Although modular external fixators are associated with faster intraoperative fracture reduction with the external fixator, single external fixators are associated with significantly better rates of union and reoperations; the rates of delayed union, malunion and complications are similar.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Has B, Jovanovic S, Wertheimer B et al (1995) External fixation as a primary and definitive treatment of open limb fractures. Injury 26:245–248

    Article  CAS  PubMed  Google Scholar 

  2. Haidukewych G (2002) Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity. J Orthop Trauma 16:678–685

    Article  PubMed  Google Scholar 

  3. Dougherty PJ, Silverton C, Yeni Y et al (2006) Conversion from temporary external fixation to definitive fixation: shaft fractures. J Am Acad Orthop Surg 14(10 Spec No.):S124–S127

    PubMed  Google Scholar 

  4. Rommens P, Broos P, Gruwez JA (1986) External fixation of tibial shaft fractures with severe soft tissue injuries by Hoffmann-Vidal-Adrey osteotaxis. Arch Orthop Trauma Surg 105(3):170–174

    Article  CAS  PubMed  Google Scholar 

  5. McGraw JM, Lim EV (1988) Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing. J Bone Joint Surg Am 70(6):900–911

    CAS  PubMed  Google Scholar 

  6. Blachut PA, Meek RN, O’Brien PJ (1990) External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol. J Bone Joint Surg Am 72(5):729–735

    CAS  PubMed  Google Scholar 

  7. Reis ND, Zinman C, Besser MI et al (1991) A philosophy of limb salvage in war: use of the fixateur externe. Mil Med 156(10):505–520

    CAS  PubMed  Google Scholar 

  8. Aro HT, Chao EY (1993) Biomechanics and biology of fracture repair under external fixation. Hand Clin 9(4):531–542

    CAS  PubMed  Google Scholar 

  9. Aro HT, Chao EYS (1993) Bone healing patterns affected by loading, fracture fragment stability, fracture type and fracture site compression. Clin Orthop Relat Res 293:8–17

    PubMed  Google Scholar 

  10. Riemer BL, Butterfield SL (1993) Comparison of reamed and nonreamed solid core nailing of the tibial diaphysis after external fixation: a preliminary report. J Orthop Trauma 7(3):279–285

    Article  CAS  PubMed  Google Scholar 

  11. Tornetta P 3rd, DeMarco C (1995) Intramedullary nailing after external fixation of the tibia. Bull Hosp Jt Dis 54(1):5–13

    PubMed  Google Scholar 

  12. Antich-Adrover P, Martí-Garin D, Murias-Alvarez J, Puente-Alonso C (1997) External fixation and secondary intramedullary nailing of open tibial fractures. A randomised, prospective trial. J Bone Joint Surg Br 79(3):433–437

    Article  CAS  PubMed  Google Scholar 

  13. Bhandari M, Zlowodzki M, Tornetta P II et al (2005) Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma 19:140–144

    Article  PubMed  Google Scholar 

  14. Klein P, Opitz M, Schell H et al (2004) Comparison of unreamed nailing and external fixation of tibial diastases–mechanical conditions during healing and biological outcome. J Orthop Res 22(5):1072–1078

    Article  CAS  PubMed  Google Scholar 

  15. Braten M, Helland P, Grontvedt T et al (2005) External fixation versus locked intramedullary nailing in tibial shaft fractures: a prospective, randomized study of 78 patients. Arch Orthop Trauma Surg 125:21–26

    Article  PubMed  Google Scholar 

  16. Lenarz C, Bledsoe G, Watson JT (2008) Circular external fixation frames with divergent half pins: a pilot biomechanical study. Clin Orthop Relat Res 466(12):2933–2939

    Article  PubMed Central  PubMed  Google Scholar 

  17. Hutchinson AJ, Frampton AE, Bhattacharya R (2012) Operative fixation for complex tibial fractures. Ann R Coll Surg Engl 94(1):34–38

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  18. Gardner TN, Evans M, Kenwright J (1997) A biomechanical study on five unilateral external fracture fixation devices. Clin Biomech (Bristol, Avon) 12(2):87–96

    Article  Google Scholar 

  19. Matsushita T, Nakamura K, Ohnishi I, Kurokawa T (1998) Sliding performance of unilateral external fixators for tibia. Med Eng Phys 20(1):66–69

    Article  CAS  PubMed  Google Scholar 

  20. Johner R, Wruhs O (1983) Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop Relat Res 178:7–25

    PubMed  Google Scholar 

  21. Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 58:453–458

    CAS  PubMed  Google Scholar 

  22. Tscherne H, Oestern HJ (1982) A new classification of soft-tissue damage in open and closed fractures (author’s transl). Unfallheilkunde 85(3):111–115

    CAS  PubMed  Google Scholar 

  23. Puno RM, Vaughan JJ, Stetten ML, Johnson JR (1991) Long-term effects of tibial angular malunion on the knee and ankle joints. J Orthop Trauma 5(3):247–254

    Article  CAS  PubMed  Google Scholar 

  24. Puno RM, Vaughan JJ, von Fraunhofer JA et al (1987) A method of determining the angular malalignments of the knee and ankle joints resulting from a tibial malunion. Clin Orthop Relat Res 223:213–219

    PubMed  Google Scholar 

  25. Tile M (1987) Fractures of the tibia. In: Schatzker J, Tile M (eds) The rationale of operative fracture care. Springer, Berlin, pp 297–341

    Chapter  Google Scholar 

  26. van der Werken C, Marti RK (1983) Post-traumatic rotational deformity of the lower leg. Injury 15(1):38–40

    Article  PubMed  Google Scholar 

  27. Hildebrand F, Giannoudis P, Kretteck C, Pape HC (2004) Damage control: extremities. Injury 35:678–689

    Article  PubMed  Google Scholar 

  28. Remiger AR, Miclau T, Neuer W (1997) A simple technique for creating hybrid fixators using a modified AO single adjustable clamp. J Orthop Trauma 11(1):54–56

    Article  CAS  PubMed  Google Scholar 

  29. Bal GK, Kuo RS, Chapman JR et al (2000) The anterior T-frame external fixator for high-energy proximal tibial fractures. Clin Orthop Relat Res 380:234–240

    Article  PubMed  Google Scholar 

  30. Watson T (2006) External fixation. In: Bucholz RW, Hechman JD, Court-Brown C (eds) Rockwood and green’s fractures in adults, 6th edn. Lippincott Williams & Wilkins, Philadelphia

    Google Scholar 

  31. Karlström G, Olerud S (1983) External fixation of severe open tibial fractures with the Hoffmann frame. Clin Orthop Relat Res 180:68–77

    PubMed  Google Scholar 

  32. Fragomen AT, Rozbruch SR (2007) The mechanics of external fixation. HSS J 3(1):13–29

    Article  PubMed Central  PubMed  Google Scholar 

  33. Brighton CT (1984) The biology of fracture repair. Instr Course Lect 33:60–82

    CAS  PubMed  Google Scholar 

  34. Williams EA, Rand JA, An KN et al (1987) The early healing of tibial osteotomies stabilized by one-plane or two-plane external fixation. J Bone Joint Surg Am 69:355–365

    CAS  PubMed  Google Scholar 

  35. Chao EY, Aro HT, Lewallen DG, Kelly PJ (1989) The effect of rigidity on fracture healing in external fixation. Clin Orthop Relat Res 241:24–35

    PubMed  Google Scholar 

  36. Emami A, Mjöberg B, Karlström G, Larsson S (1995) Treatment of closed tibial shaft fractures with unilateral external fixation. Injury 26(5):299–303

    Article  CAS  PubMed  Google Scholar 

  37. Perren SM (1992) Biomechanical basis of fracture treatment. Orthopade 21:3–10

    CAS  PubMed  Google Scholar 

  38. Goodship AE, Watkins PE, Rigby HS, Kenwright J (1993) The role of fixator frame stiffness in the control of fracture healing. An experimental study. J Biomech 26:1027–1035

    Article  CAS  PubMed  Google Scholar 

  39. Claes L, Wolf S, Augat P (2000) Mechanical modification of callus healing. Chirurge 7(1):989–994

    Article  Google Scholar 

  40. Helland P, Boe A, Molster AO et al (1996) Open tibial fractures treated with the Ex-fi-re external fixation system. Clin Orthop Relat Res 326:209–220

    Article  PubMed  Google Scholar 

  41. Noordeen MH, Lavy CB, Shergill NS et al (1995) Cyclical micromovement and fracture healing. J Bone Joint Surg Br 77(4):645–648

    CAS  PubMed  Google Scholar 

  42. Jagodzinski M, Krettek C (2007) Effect of mechanical stability on fracture healing–an update. Injury 38(Suppl 1):S3–S10

    Article  PubMed  Google Scholar 

  43. Smith-Adaline EA, Volkman SK, Ignelzi MA Jr et al (2004) Mechanical environment alters tissue formation patterns during fracture repair. J Orthop Res 22(5):1079–1085

    Article  CAS  PubMed  Google Scholar 

  44. Ilizarov GA (1992) The apparatus: components and biomechanical principles of application. In: Green S (ed) Transosseus osteosynthesis. Theoretical and clinical aspects of the regeneration and growth of tissue. Springer, Berlin, pp 63–136

    Google Scholar 

  45. Kenwright J, Richardson JB, Cunningham JL et al (1991) Axial movement and tibial fractures. A controlled randomised trial of treatment. J Bone Joint Surg Br 73:654–659

    CAS  PubMed  Google Scholar 

  46. Foxworthy M, Pringle RM (1995) Dynamization timing and its effect on bone healing when using the Orthofix Dynamic Axial Fixator. Injury 26:117–119

    Article  CAS  PubMed  Google Scholar 

  47. Yasui N, Nakase T, Kawabata H et al (2000) A technique of percutaneous multidrilling osteotomy for limb lengthening and deformity correction. J Orthop Sci 5(2):104–107

    Article  CAS  PubMed  Google Scholar 

  48. Aho AJ, Nieminen SJ, Nylamo EI (1983) External fixation by Hoffmann-Vidal-Adrey osteotaxis for severe tibial fractures. Treatment scheme and technical criticism. Clin Orthop Relat Res 181:154–164

    PubMed  Google Scholar 

  49. Rhinelander F (1974) Tibia blood flow in relation to fracture healing. Clin Orthop Relat Res 105:34–81

    Article  PubMed  Google Scholar 

  50. Edge AJ, Denham RA (1981) External fixation for complicated tibial shaft fractures. J Bone Joint Surg Br 63B:92–97

    Google Scholar 

  51. Fischer DA (1982) External fixation in the management of the open fracture. In: Gustilo RB (ed) Management of open fractures and their complications. WB Saunders, Philadelphia, p 70

    Google Scholar 

  52. Edwards CC, Simmons SC, Browner BD, Weigel MC (1988) Severe open tibial fractures. Results treating 202 injuries with external fixation. Clin Orthop Relat Res 230:98–115

    PubMed  Google Scholar 

  53. Marsh JL, Nepola JV, Wuest TK et al (1991) Unilateral external fixation until healing with the dynamic axial fixator for severe open tibial fractures. J Orthop Trauma 5:341–348

    Article  CAS  PubMed  Google Scholar 

  54. Behrens F, Searls K (1986) External fixation of the tibia. Basic concepts and prospective evaluation. J Bone Joint Surg Br 68(2):246–254

    CAS  PubMed  Google Scholar 

  55. Beltsios M, Savvidou O, Kovanis J et al (2009) External fixation as a primary and definitive treatment for tibial diaphyseal fractures. Strateg Trauma Limb Reconstr 4(2):81–87

    Article  Google Scholar 

Download references

Conflict of interest

None of the authors had any financial or personal relationships with other people or organizations that could inappropriately influence (bias) their work.

Author information

Authors and Affiliations

  1. Department of Orthopaedics, Thriasion Hospital, Elefsis, Greece

    Michail Beltsios

  2. First Department of Orthopaedics, ATTIKON University Hospital, Athens University Medical School, 41 Ventouri Street, 15562, Holargos, Athens, Greece

    Andreas F. Mavrogenis, Olga D. Savvidou, Eirineos Karamanis, Zinon T. Kokkalis & Panayiotis J. Papagelopoulos

Authors
  1. Michail Beltsios
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Andreas F. Mavrogenis
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Olga D. Savvidou
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Eirineos Karamanis
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zinon T. Kokkalis
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Panayiotis J. Papagelopoulos
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andreas F. Mavrogenis.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Beltsios, M., Mavrogenis, A.F., Savvidou, O.D. et al. Ball-joint versus single monolateral external fixators for definitive treatment of tibial shaft fractures. Eur J Orthop Surg Traumatol 24, 821–828 (2014). https://doi.org/10.1007/s00590-013-1256-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00590-013-1256-4

Keywords

Search

Navigation