Advertisement

A comparative evaluation of the time to frame removal for tibia fractures treated with hexapod and Ilizarov circular frames

Published:December 28, 2022DOI:https://doi.org/10.1016/j.injury.2022.12.027

      Abstract

      Introduction

      Traditional Ilizarov and hexapod frames have different biomechanical properties and there is limited literature regarding their effect on time to fracture union or time to frame removal.

      Methods

      Tibial fractures managed with a circular frame at a tertiary limb reconstruction referral centre between 2011 and 2018 were retrospectively identified from a prospectively maintained database. They were classified into three treatment groups; Ilizarov style, Taylor Spatial Frame (TSF) and TrueLok Hex (TL-Hex). Data were extracted from electronic patient records and digital radiographs. The primary outcome was time to frame removal, which was seen as an indicator of clinical and radiological fracture union. Odds ratios were calculated with the clinical significance set at 30 days.

      Results

      274 patients (median age 49 years, 36% female) were included in the analysis. 8.4% Ilizarov, 10.5% TSF and 13.5% TL-Hex frames required further surgery to aid fracture healing (p = 0.38). 30% of patients had open fractures. Median time to removal for Ilizarov, TSF & TL Hex frames was 167, 198 and 185 days respectively. There was a significant difference between Ilizarov and hexapod frames. Both TSF (OR 2.2, p<0.003) and TL-Hex (OR 1.8, p<0.04) had a significantly increased time to removal of 30 days or more compared with Ilizarov frames.The time to frame removal in metaphyseal fractures was significantly shorter for Ilizarov frame fixation than hexapod frames (p = 0.04). Open fractures were significantly more likely to require at least 30 days extra time to removal than closed fractures (OR 3.3, p<0.001). There was no significant difference in the time to frame removal between fracture location, age or sex.

      Conclusion

      Ilizarov frames have demonstrated a reduced time to frame removal in the management of tibial fractures than hexapod frames. Differences in the time to frame removal, an indicator of time to fracture union, may be due to the different mechanical properties of the frame, or early disruption of the fracture haematoma through secondary frame manipulation and fracture reduction, increased proportion of metaphyseal fractures treated with Ilizarov, or patient selection. The healing time was comparable across the tibia. Pooled meta-analyses may be able to further quantify these associations.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Court-Brown C.
        • McBirnie J.
        The epidemiology of tibial fractures.
        The Journal of bone and joint surgery British. 1995; 77: 417-421
        • Curtis E.M.
        • van der Velde R.
        • Moon R.J.
        • van den Bergh J.P.
        • Geusens P.
        • de Vries F.
        • et al.
        Epidemiology of fractures in the United Kingdom 1988-2012: variation with age, sex, geography, ethnicity and socioeconomic status.
        Bone. 2016; 87: 19-26
        • Atkins R.
        • Sudhakar J.
        • Porteous A.
        Distraction osteogenesis through high energy fractures.
        Injury. 1998; 29: 535-537
        • Borrelli Jr, J.
        • Ellis E.
        Pilon fractures: assessment and treatment.
        Orthop Clin North Am. 2002; 33: 231-245https://doi.org/10.1016/s0030-5898(03)00082-8
      1. PMID: 11832323.
        • Finkemeier C.G.
        • Schmidt A.H.
        • Kyle R.F.
        • Templeman D.C.
        • Varecka T.F.
        A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft.
        J Orthop Trauma. 2000; 14: 187-193
        • French B.
        • Tornetta P.
        High-Energy Tibial Shaft Fractures.
        Orthopedic Clinics of North America. 2002; 33: 211-230
        • Gaudinez R.F.
        • Mallik A.R.
        • Szporn M.
        Hybrid external fixation in tibial plafond fractures.
        Clinical Orthopaedics and Related Research®. 1996; 329: 223-232
        • Giannoudis P.V.
        • Hinsche A.F.
        • Cohen A.
        • Macdonald D.A.
        • Matthews S.J.
        • Smith R.M.
        Segmental tibial fractures: an assessment of procedures in 27 cases.
        Injury. 2003; 34: 756-762
        • Giotakis N.
        • Panchani S.K.
        • Narayan B.
        • Larkin J.J.
        • Al Maskari S.
        • Nayagam S
        Segmental fractures of the tibia treated by circular external fixation.
        J Bone Joint Surg Br. 2010; 92: 687-692
        • Helfet D.L.
        • Koval K.
        • Pappas J.
        • Sanders R.W.
        • DiPasquale T.
        Intraarticular" pilon" fracture of the tibia.
        Clin. Orthop. Relat. Res. 1994; : 221-228
        • Huang C.-.K.
        • Chen W.-.M.
        • Chen T.-.H.
        • Lo W.-.H.
        Segmental tibial fractures treated with interlocking nails: a retrospective study of 33 cases.
        Acta Orthop Scand. 1997; 68: 563-566
        • Kapoor S.K.
        • Kataria H.
        • Patra S.R.
        Boruah T. Capsuloligamentotaxis and definitive fixation by an ankle-spanning Ilizarov fixator in high-energy pilon fractures.
        J Bone Joint Surg Br. 2010; 92: 1100-1106
        • Sanders R.
        • Jersinovich I.
        • Anglen J.
        • DiPasquale T.
        • Herscovici Jr, D
        The treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming.
        J Orthop Trauma. 1994; 8: 504-510
        • Stegemann P.
        • Lorio M.
        • Soriano R.
        • Bone L.
        Management protocol for unreamed interlocking tibial nails for open tibial fractures.
        J Orthop Trauma. 1995; 9: 117-120
        • MJ Al-Sayyad
        Taylor spatial frame in the treatment of open tibial shaft fractures.
        Indian J Orthop. 2008; 42: 431
        • Dagher F.
        • Roukoz S.
        Compound tibial fractures with bone loss treated by the Ilizarov technique.
        The Journal of bone and joint surgery British volume. 1991; 73: 316-321
        • Edwards C.C.
        • Simmons S.
        • Browner B.
        • Weigel M.
        Severe open tibial fractures. Results treating 202 injuries with external fixation.
        Clin. Orthop. Relat. Res. 1988; : 98-115
        • Ferreira N.
        • Marais L.C.
        Aldous C. Hexapod external fixator closed distraction in the management of stiff hypertrophic tibial nonunions.
        Bone Joint J. 2015; 97-B: 1417-1422
        • Hosny G.
        • Fadel M.
        Ilizarov external fixator for open fractures of the tibial shaft.
        Int Orthop. 2003; 27: 303-306
        • Muharrem I.
        • Tuncel M.
        • Karaoglu S.
        • Halici M.
        Treatment of type II and III open tibial fractures with Ilizarov external fixation.
        Acta Orthop Traumatol Turc. 2002; 36: 390-396
        • McBride A.
        • Nicol S.
        • Monsell F.
        The programmable hexapod: historical perspective, theoretical basis and relevance to orthopaedic practice.
        Bone & Joint. 2015; 360 (4): 8-11
        • Whitehouse M.R.
        • Livingstone J.A.
        Taylor Spatial Frame application with the aid of a fine wire half frame.
        J Orthop Trauma. 2008; 22: 276-281
        • Kanellopoulos A.D.
        • Mavrogenis A.F.
        • Kanellopoulos N.D.
        • Magnissalis E.A.
        • Papagelopoulos P.J.
        A guide frame for the Taylor Spatial Frame.
        J Orthop Trauma. 2009; 23: 537-540
        • Solomin L.
        • Vilensky V.
        • Utenkin A.
        Clinical and Experimental Comparison of External Fixation Devices on the Base of Computer Navigation.
        Proceedings of the 6th SICOT/SIROT Annual International Conference, Abstract #19461. Pattaya, Thailand, 2009
        • Solomin L.N.
        • Paley D.
        • Shchepkina E.А.
        • Vilensky V.A.
        • Skomoroshko P.V.
        A comparative study of the correction of femoral deformity between the Ilizarov apparatus and Ortho-SUV Frame.
        Int Orthop. 2014; 38: 865-872
        • Marangoz S.
        • Feldman D.S.
        • Sala D.A.
        • Hyman J.E.
        • Vitale M.G.
        Femoral deformity correction in children and young adults using Taylor Spatial Frame.
        Clin Orthop Relat Res. 2008; 466: 3018-3024
        • Naqui S.Z.H.
        • Thiryayi W.
        • Foster A.
        • Tselentakis G.
        • Evans M.
        • Day J.B.
        Correction of simple and complex pediatric deformities using the Taylor-Spatial Frame.
        Journal of Pediatric Orthopaedics. 2008; 28: 640-647
        • Paloski M.
        • Taylor B.C.
        • Iobst C.
        • Pugh K.J.
        Pediatric and adolescent applications of the Taylor Spatial Frame.
        Orthopedics. 2012; 35: 518-527
        • Ferreira N.
        • Birkholtz F.
        Radiographic analysis of hexapod external fixators: fundamental differences between the Taylor Spatial Frame and TrueLok-Hex.
        J Med Eng Technol. 2015; 39: 173-176
        • Binski J.C.
        Taylor spatial frame in acute fracture care.
        Techniques in Orthopaedics. 2002; 17: 173-184
        • Menakaya C.U.
        • Rigby A.S.
        • Hadland Y.
        • Barron E.
        • Sharma H.
        Fracture healing following high energy tibial trauma: ilizarov versus Taylor Spatial Frame.
        Ann R Coll Surg Engl. 2014; 96: 106-110
        • Naude J.
        • Manjra M.
        • Birkholtz F.F.
        • Barnard A.C.
        • Glatt V.
        • Tetsworth K.
        • et al.
        Outcomes following treatment of complex tibial fractures with circular external fixation: a comparison between the Taylor Spatial Frame and TrueLok-Hex.
        Strategies Trauma Limb Reconstr. 2019; 14: 142-147
        • Rommens P.
        • Coosemans W.
        • Broos P.
        The difficult healing of segmental fractures of the tibial shaft.
        Arch Orthop Trauma Surg. 1989; 108: 238-242
        • Sarmiento A.
        • Latta L.
        Functional treatment of closed segmental fractures of the tibia.
        Acta Chir Orthop Traumatol Cech. 2008; 75: 325-331
        • Dendrinos G.K.
        • Kontos S.
        • Katsenis D.
        • Dalas A.
        Treatment of high-energy tibial plateau fractures by the Ilizarov circular fixator.
        The Journal of bone and joint surgery British volume. 1996; 78: 710-717
        • Kakar S.
        • Tornetta P.
        Segmental tibia fractures: a prospective evaluation.
        Clin Orthop Relat Res. 2007; 460: 196-201
        • Leung F.
        • Kwok H.Y.
        • Pun T.S.
        • Chow S.P.
        Limited open reduction and Ilizarov external fixation in the treatment of distal tibial fractures.
        Injury. 2004; 35: 278-283
        • McMahon S.E.
        • Little Z.E.
        • Smith T.O.
        • Trompeter A.
        • Hing C.B.
        The management of segmental tibial shaft fractures: a systematic review.
        Injury. 2016; 47: 568-573
        • Quinnan S.M.
        Definitive Management of Distal Tibia and Simple Plafond Fractures With Circular External Fixation.
        J Orthop Trauma. 2016; 30 (Suppl): S26-S32
        • Yang L.
        • Saleeh M.
        • Nayagam S.
        The effects of different wire and screw combinations on the stiffness of a hybrid external fixator.
        Proc Inst Mech Eng H. 2000; 214: 669-676https://doi.org/10.1243/0954411001535697
      2. PMID: 11201414.
        • Aro H.T.
        • Kelly P.J.
        • Lewallen D.G.
        • Chao E.
        The effects of physiologic dynamic compression on bone healing under external fixation.
        Clin. Orthop. Relat. Res. 1990; : 260-273
        • Kenwright J.
        • Richardson J.B.G.
        • A.E Evans M
        • Kelly D.J.
        • Spriggins A.J.
        • Newman J.H.
        • et al.
        Effect of controlled axial micromovement on healing of tibial fractures.
        Lancet. 1986; 22 (2(8517)): 1185-1187
        • Wu J.
        • Shyr H.
        • Chao E.
        • Kelly P.
        Comparison of osteotomy healing under external fixation devices with different stiffness characteristics.
        The Journal of bone and joint surgery. 1984; (American volume(66(8))): 1258-1264
        • Fenton C.
        • Henderson D.
        • Samchukov M.
        • Cherkashin A.
        • Sharma H.
        Comparative Stiffness Characteristics of Ilizarov- and Hexapod-type External Frame Constructs.
        Strategies Trauma Limb Reconstr. 2021; 16: 138-143
        • Henderson D.J.
        • Barron E.
        • Hadland Y.
        • Sharma H.K
        Functional outcomes after tibial shaft fractures treated using the Taylor spatial frame.
        J Orthop Trauma. 2015; 29: e54-e59
        • Teraa M.
        • Blokhuis T.J.
        • Tang L.
        • Leenen L.P.
        Segmental tibial fractures: an infrequent but demanding injury.
        Clin Orthop Relat Res. 2013; 471: 2790-2796
        • Ozturkmen Y.
        • Karamehmetoglu M.
        • Karadeniz H.
        • Azboy I.
        • Caniklioglu M.
        Acute treatment of segmental tibial fractures with the Ilizarov method.
        Injury. 2009; 40: 321-326