III COURSE ON EXTERNAL FIXATION OF

FEDERAL UNIVERSITY OF SÃO PAULO

PAULISTA SCHOOL OF MEDICINE

14 e 15 de JUNHO DE 2013
BORIS CASOY AMPHITHEATER
Rua Botucatu No. 821 1st floor

COORDENADOR: DR HILÁRIO BOATTO

SUPPORT
 BONE STRETCHING AND RECONSTRUCTION GROUP OF
PAULISTA SCHOOL OF MEDICINE - UNIFESP

Group Leader: Dr. Hilário Boatto

MEMBROS: Dr Osvaldo Clinco Jr, Dr Carlos Luiz Engelen, Dr Alexandre Rial Dias,
Dr. Marcelo Fumio Utsunomiya, Dr. Robinson Toshimitsu Kiyohara, Dr. Raul
Münch Cavalcanti, Dr Fábio de Assunção e Silva, Dr Glauber Kazuo Linhares, Dr
Thiago Amorim Bastos, Dr. Ivonir Fagundes Alves Jr, Dr. Felipe Martinez Neto, Dr.
Ronaldo Borkowski Jr

GUESTS:
DR DANIEL BALBACHEVSKY DR LUIZ CARLOS ANGELINI

DR. LUIZ FERNANDO COCCO DR. ADRIANA MACEDO DELL AQUILA

DR AYRES FERNANDO RODRIGUES

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Editors:

Dr. Hilário Boatto

Dr. Fábio de Assunção e Silva

Dr. Glauber Kazuo Linhares

Dr. Felipe Martinez Neto

Dr. Ronaldo Borkowski Jr

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Content
PRINCIPLES OF EXTERNAL FIXATIONA ................................................................. 5

EXTERNAL FIXATION IN EMERGENCYA ................................................................................................ 33

EXTERNAL FIXATION ON THE HUMERUS AND ELBOW............................................................................ 40

EXTERNAL FIXATOR ON DISTAL RADIUSL......................................................................................... 44

Tibia PestleL 50

PSEUDARTHROSES................................................................................................................................. 62
BONE DEFECTS.................................................................................................................................. 73
PELVIC FRACTURES......................................................................................................................... 83
MOST COMMON ERRORS IN EXTERNAL FIXATION......................................................................... 106

TREATMENT OF ANISOMELIA OF THE LOWER LIMBS.............................................. 119

OSTEOMYELITISE................................................................................................................................... 155
CORRECTION OF DEFORMITIES IN THE LOWER LIMBS.............................................. 162
PLANNING IN THE CORRECTION OF DEFORMITIES IN THE FEMUR....................................... 170

CORRECTION OF DEFORMITIES IN THE TIBIA................................................................................. 180

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 PRINCIPLES OF EXTERNAL FIXATION
Dr. Hilário Boatto

History of External Fixation

External fixators are defined with a group of devices, in the vast majority.
metallic, which allow to maintain the rigidity or stability of the bone structure linked to them by
means of wires and/or pins that are applied percutaneously.

The fasteners can be configured in different ways and are classified as:

A- Unilateral
B- Bilateral
C- Quadrilaterals
D- Delta
E- Semi-circular
F- Circular

Chao E.Y.S., Aro H., Lewallen D.G.: The effect of rigidity on fracture headline in external fixation. Clin Orthop 241: 24-35, 1989.

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 In relation to the frontal and sagittal planes, the fixators are defined as uniplanar and
biplanar.

Behrens F., Johnson W.: Unilateral external fixation: methods to increaseand reduce frame stiffness. Clin Orthop 241: 48-56, 1984.

The first reports regarding external fixation date back to the time of Hippocrates.
which described a method of immobilization of tibia fractures that allowed for inspection of the
wound. Strips of leather were placed above the ankle and below the knee being connected
by wooden bars.

(ROCKWOOD & GREEN'S FRACTURES IN ADULTS 7º edição 2009)

Approximately 12 years before the introduction of plaster casts to treat

fractures Jean Francoise Malgaigne (1843) used a metal clamp to stabilize a
patella fracture.

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 Chassin in 1852 modified the clamp designed by Malgaigne to fix a fracture of
clavicle with deviation.

Keetley developed a device in 1893 to stabilize fractures of the femur.

Clayton Parkhill in 1897 presented the results of treatment with external fixation.
performed on 9 patients. Considered by American literature as the father of external fixation
presented in 1894 what would effectively be the first model of external fixator that
used 2 proximal pins and 2 distal pins to the fracture, inserted in only one cortical bone and
connected to each other by a system of clamps.

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 In 1902, Albin Lambotte (Belgium) recognized that the metal pins that penetrated
the bone and externalized through the skin were well tolerated and could be connected to a
external assembly that promoted stability to the pins and consequently to the bone. This
the fixator consisted of two proximal threaded pins and two distal ones to the fracture fixed to a
cortical only and connected by screws to a metal bar.

Crile, in 1919, developed a device for femur fixation.

8
In 1934, Roger Anderson designed an external fixation device that used smooth pins.
connected to external clamps.

In 1937, Otto Stader developed an external fixator initially for veterinary use that
also used smooth pins connecting the bone tissue to the external fixator.

9
In 1938, Raoul Hoffman developed an external fixator that incorporated universal joints.
allowing the reduction of fractures beyond compression and possible elongation of the same.

Charnley in 1948 presented an external fixator that was used in compression for
knee arthrodesis.

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In 1972, Heinz Wagner presented a device designed for bone elongation.

Wagner's Longing

In 1975, Volkov & Oganesian presented a type of fixator that constituted the first joint.
artificial external, an articulated distractor for knee and elbow.

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In 1981, it was presented at the XXII AO Congress of the Italian Club by Prof. Graviil Abramovich.
Ilizarov, the circular fixer that he had been using since 1951, which consisted of rings
connected to the bone exclusively by Kirschner wires, with and without olives. This type of fixator allows for
fixation, extension and correction of complex bone deformities, which has been improved and is
used until our days.

More recently, the original circular fasteners made of steel are also manufactured in
aluminum and carbon fiber.

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Several modifications, mainly regarding the correction of deformities, have been developed.
aiming to facilitate the monitoring of the patient's treatment through software that provides
precise guidance for the necessary manipulations of the device, thus achieving accurate correction
at the end of the treatment. Among these devices, we find the Hexapod and the Taylor Spatial Frame.

Hexapod Taylor Spatial Frame

Unilateral fixators have also evolved and currently the LRS (Limb Reconstruction) system
The system presents much greater stability and rigidity compared to past fasteners.
indicated in fracture fixation, correction of deformities, and bone lengthening.

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LRS- Limb Reconstruction System LRS Advanced

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Biomechanics of External Fixation

Laboratory experiments allow for the establishment of various parameters related to

rigidity and stability of the fixator considering its resistance to bending, torsion, and deforming forces.
compression.

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Considering a unilateral and uniplanar external fixator, the closer the connecting rod ...
the closer to the bone axis, the more stable the assembly.

More stable Less stable

Regarding the arrangement of the pins inserted in each bone segment, they should be inserted starting with
if there are hairline fractures, then two pins closer to the fracture site and the third pin from
equidistant segment from the previous ones.

Greater rigidity less rigidity

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The use of conical pins provides a radial pre-load and optimal fixation in the bone tissue by
fact that they have a diameter of 6 mm at the base and 5 mm at the tip. The coating of the pins
with hydroxyapatite increases its fixation in the bone.

In our circular fixators, the load is centralized close to the bone axis (principle of the elastic bed).

Trampoline

In our unilateral fixators, the system works like a 'cantilever' – similar to a diving board.

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 Cantilever beam - diving board

In this case, the load is more concentrated in the entry cortex of the pin (cortex "Cis").

Location of highest stress in unilateral fixation: cortical Cis

Types of pins:

A- CONICS
B- CYLINDRICAL SELF-PERFORATING
C - WITH A LARGER THREAD STEP (SPONGY BONE)
D- NARROW RASPBERRY STEP (CORTICAL BONE)
E- COATED WITH HYDROXYAPATITE

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Thread characteristic:

DR = THREAD DIAMETER
DA= DIAMETER OF THE SOUL
P= STEP
ER = THICKNESS OF THE THREAD OF THE SCREW
AP = PROXIMAL ANGLE OF THE THREAD
AD= DISTAL ANGLE OF THE THREAD WIRE
RP = PROXIMAL RADIUS OF THE SCREW THREAD
RD = DISTAL RADIUS OF THE THREAD WIRE

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Correct insertion of the pin: drilling should be performed in the center of the bone

CORRECT INCORRECT

Insertion of the pins: 4 cm from the joints and 2 cm from the fracture focus, with the distance between the
pins in the same segment should be as large as possible.

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Resistance of the bone-fixator set to deforming forces

21
PIN RESISTANCE TO TENSILE STRENGTH Koranyi ET AL 1970

There is a linear relationship between the thickness of the cortical bone and tensile strength.

Pins fixed to both corticals are significantly more resistant to traction than those fixed by
points only to the input cortex.

The resistance is 17% lower in the cortical areas and 24% lower in the spongy areas.

Greater tensile strength Lower tensile strength

Hughes & Jordan 1972

They studied screws fixed to synthetic resin blocks.

The resistance to tension is greater in screws with a larger core diameter, with the resistance being
greater in steel screws, followed by Co-Cr-Mo and titanium with lower strength.

Torsion resistance: fixed to aluminum blocks and tightened until they break: the most resistant are
the ones with the biggest soul.

A larger pin diameter provides greater resistance to tensile and torsional forces.

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Pin insertion technique:

The low-speed pre-drilling, to avoid thermal necrosis of the bone tissue, must always be
performed and the pins must be inserted manually.

In the absence of prior drilling, the pin will encounter greater resistance to its progress when it reaches
the second cortex (trans). This progression will be given by the step of the existing screw in the first cortex
The greatest resistance to the progression of the pin can cause a fracture in the trans cortical or the loss of the
pin interference in the first cortex (Cis).

Bone necrosis - damage to osteocytes can occur after exposure of the bone to temperatures of 55 degrees.
for a minute or more.

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The mechanical properties of cortical bone change when exposed to temperatures greater than 50.
degrees

The best way to prevent the increase in heating is to carry out preliminary drilling with a drill.
sharpened, cooled with continuous irrigation followed by manual insertion of the pin.

Each pin is a gateway for bacteria into the bone, and thermal necrosis facilitates the focus of infection.
much more than the normal bone

(Browner: skeletal trauma, 4th ed. Chapter 11–principles and complications of external fixation Stuart
a. Green, m.d.)

Schatzker ET AL -1975

They conducted a histological analysis in the region of screw or pin fixation. The studies showed
that when there is movement at the bone-screw interface: there is intense osteoclastic activity and
proliferation of connective tissue around the screw where there is no movement there is activity
osteoblastic with deposition of new bone around the screw.

With movements bone screw No movement screw bone

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Chao at AL 1982

They showed that the increase in diameter and the number of pins promotes an increase in global stiffness and
less stress on the pins.

Chao at AL 1982

The greater separation of the bars promotes: a decrease in axial compression stiffness, an increase in bending.
Lateral in the plane of the fastener does not affect the torsional or perpendicular bending forces on the fastener.

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Chao at AL 1982

The greater the separation between the pins on the same side of the fracture, the greater the rigidity to the forces of
bending and twisting but do not affect the resistance to axial compression.

Goodbye at AL 1982

The addition of a perpendicular pin (90º) to the plane of the fastener increases the stiffness of the assembly.
especially to the anterior-posterior bending forces.

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Chao at AL 1982

The contact between bone fragments can reduce stress on the pins by 97%.

Without greater bone contact, more stress on the pins

Selingson ET AL 1984 (Study with unicortical with smooth stalk)

They concluded that the stiffness of the 5mm Schanz pins is almost double when compared to the
4 mm pins were used, both bicortical (threaded) and unicortical with a smooth stem resting on the cortex.
cis (entrance). The unicorticals are significantly stiffer than the bicorticals due to the fact that
support the smooth stem on the cortical. The rigidity is determined by the core of the pin in the threaded pins and in the
In the case of unicorticals, the rigidity is determined by the diameter (stem).

Huiskes et al. 1985

The stress between the bone and the pin is 100% greater in unilateral assemblies than in bilateral ones, with pins.
transfixing.

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Huiskes et al. 1985

Compared to bilateral mounts, the stress is 30% lower in triangular mounts and in
quadrilateral assemblies 50% smaller.

30% less stress 50% less stress

Titanium pins increase pin-bone stress by 20 to 25% compared to stainless steel pins.
More important than the material of the pin is its diameter. The decrease in the diameter of the pin results in
a significant increase in bone stress due to increased flexibility (related to the fourth
power).

Chao et al. 1989

Bilateral settings are 50% stiffer than unilateral ones. The less rigid external fixation presents
greater bone absorption and lower formation of intracortical bone. Six pins are better than 4 pins.

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Behrens 1989

The increase in the number of components (pins, wires, stems, and other elements) is less efficient than the
increase in its dimensions. The increase in dimensions can raise the bending strength to the fourth
power and the resistance to twisting to the third power. It asserts that supporting the smooth stem of the pin on the cortical of
entry (cis) doubles the pin resistance, reduces irritation of soft tissues, and decreases stress on
pino-bone interface.

Evans ET al 1990

They affirm that in the monolateral fixator stabilizing a bone subjected to axial load, the pins undergo 2
types of forces:

AXIAL - responsible for the removal of the pin-

BENDING - responsible for microfractures in the bones, especially in the inner cortical (entry).

The reduction of the thread pitch increases the resistance to axial forces. The increase in the web does not promote
significant changes in resistance to axial forces but causes a substantial increase in resistance to
bending forces.

Micromovements between the pin and the bone cause the cells that migrate between the threads of the screws to
they differentiate into osteoclasts, fibroblasts, and chondrocytes causing resorption of the newly formed bone and
release of the pins.

Halsey ET al 1992

The pin-bone interface is the area of highest stress concentration of an external fixator, being also the
weakest component of the system. The pins with smaller internal diameter are significantly more resistant.
to the tensile forces. There is no significant difference when comparing the pitch or profile of the wires of
rings. The pins with the greatest interference (difference between the outer diameter and the drill hole) are more
tensile resistant.

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Aro ET al 1993

Pre-drilling is the best way to avoid necrosis during the insertion of pins.

Hungarian ET al 1997

They performed biplanar fixation in tibial osteotomy. They used common and coated pins.
hydroxyapatite that were compared regarding insertion and removal torque.

Fixators are maintained on average for 101 days with 2 metaphyseal pins and 2 diaphyseal pins of 6.5 mm.
There is a difference in insertion torque between the two models. All conventional metaphyseal pins
they presented clinical release.

Pins coated with hydroxyapatite exhibit increased extraction torque compared to the
insertion torque.

Among the conventional diaphyseal pins, one showed clinical loosening and the others showed a
average reduction of 50% in extraction torque compared to insertion torque. Among the pins
Metaphysical covers: 19 out of 20 pins showed extraction torque greater than insertion torque.
Among the diaphyseal coated pins, 18 out of 20 pins showed increased extraction torque.
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Mercadante et al 2005

Study with monolateral external fixators:

The resistance to axial forces increases with greater separation between the Schanz pins in the same
fragment of the fracture and with the addition of a second bar. The resistance to twisting forces or torque
does not increase with the addition of a second bar, being dependent exclusively on the resistance of the
Schanz pins. The diameter of the pin's shank determines its resistance to bending.

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References

1. A.S.A.M.I. Group, Maiocchi AB, Aronson J, eds. Operative principles of Ilizarov. Baltimore:
Williams & Wilkins, 1991.
2. Aro HT, Hein TJ, Chao EYS. Mechanical performance of pin clamps in external fixators. Clin
Orthop 1989;248:246–253.
3. Behrens F. General theory and principles of external fixation. Clin Orthop 1989;241:15–23.
4. 7. Behrens F, Johnson W. Unilateral external fixation. Clin Orthop 1989;241:48–56.
5. 8. Behrens F, Searls K. External fixation of the tibia. J Bone Joint Surg 1986;68B:246–250.
6. Chao EYS, Aro HT, Lewallen DG, et al. The effect of rigidity on fracture healing in external
fixation. Clin Orthop 1989;241:24–35.
7. Green SA. Complications of external skeletal fixation. Clin Orthop 1983;180:109–116.
8. 28. Ilizarov G.A.: A method of uniting bones in fractures and an apparatus to implement this
method, U.S.S.R, Kurgan, 1952
9. Ilizarov G.A.: A new principle of osteosynthesis with the use of crossing pins and rings.
Collected Scientific Works of the Kurgan Regional Scientific Medical Society, U.S.S.R:
Kurgan; 1954:145-160.
10. Ilizarov G.A.: A decade of experience in the application of the author's apparatus for
compression osteosynthesis in traumatology and orthopedics. Problems of Rehabilitation Surgery Traumatology
Orthop 1962; 8:14.
11. Ilizarov G.A.: Arthroplasty of the major joints. Invagination Anastomoses. Compression–
Distraction Osteosynthesis, U.S.S.R: Kurgan; 1967:373-377.
12. Ilizarov G.A.: General principles of transosteal compression and distraction osteosynthesis.
Proceedings of the Scientific Session of the Institutes of Traumatology and Orthopedics, U.S.S.R:
Leningrad; 1968:35-39.
13. Ilizarov G.A.: Basic principles of transosseous compression and distraction osteosynthesis.
Orthop Traumatol Prosthet 1971; 32:7-15.
14 Ilizarov G.A.: Angular deformities with shortening. In: Coombs R., Green S., Sarmiento A.
ed. External Fixation and Functional Bracing, Frederick: MD, Aspen; 1989.
15 Ilizarov G.A.: Fractures and nonunions. In: Coombs R., Green S., Sarmiento A., ed. External
Fixation and Functional Bracing, Frederick: MD, Aspen; 1989.
16 Ilizarov G.A.: Transosseous Osteosynthesis, Heidelberg, Springer-Verlag, 1991.
17 Paley D.: Problems, obstacles and complications of limb lengthening by the Ilizarov technique.
Clin Orthop Rel Res 1990; 250:81-104
18Sisk TD. External fixation. Clin Orthop 1983; 180: 15–22.
19 Taylor J.C: The Taylor Spatial3 Frame, Memphis, Smith & Nephew Richards, 1997
20 Vidal J. External fixation. Clin Orthop 1983;180:7–14
21 Wagner H.: Surgical lengthening or shortening of the femur. In: Gschwend N., ed. Progress in
Orthopaedic Surgery, New York: Springer-Verlag; 1977.

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EXTERNAL FIXATION IN EMERGENCY
Dr. Raul Münch Cavalcanti

In recent decades, the approach to the polytraumatized patient has evolved and become
greatly developed, with the systematization of pre-hospital care and in the room of
emergencies, through protocols such as A.T.L.S., which reduce the mortality of these
individuals.
In this chapter, we will address the injuries that affect the extremities, emphasizing the
need for rapid and effective stabilization of the member in question.
In the treatment of severe limb injuries, external fixation is a
powerful and irreplaceable tool, as there is no other synthesis method with such
agility and versatility to definitively or temporarily solve the injuries of
musculoskeletal system.

WHEN IS EXTERNAL FIXATION INDICATED?

There is an infinite number of applications for the external fixator in emergencies. As a concept
basically, we can say that "whenever there is a need to stabilize a segment of the
skeleton in the urgency, and since the use of internal synthesis is not advisable, one should make use of
external fixator.
In practical criteria, we can cite as examples:

Exposed fractures with extensive soft tissue injury (where the smallest
Dissection can result in necrosis and internal synthesis methods can lead to opportunity.
elevated infection
Fractures associated with vascular injuries (where surgical stabilization
prolonged can lead to ischemia of the limb and access routes may come into conflict
with the surgical approach to vascular repair
Ligamentotaxia of severe articular fractures that do not have conditions
for adequate surgical access at the initial moment and the lack of stabilization may
to result in necrosis and suffering of the skin (tibial plateau, distal radius, tibial plateau,
elbow
Joint immobilization in peri-articular and/or floating fractures
Stabilization of multiple fractures in severely injured polytrauma patients
complexity (facilitating its movement in the bed, reducing pain and injury
additional tissue that can occur from bone fragments of a fracture not
stabilized)
Stabilization of pelvic ring fractures (potentially serious due to
to excessive bleeding)

Although the indications for external fixation are usually well defined regarding
the conduct of most trauma orthopedic doctors is often complicated by a
lack of basic concepts in the use of external fixation, both in terms of planning
from external fixation (where the concepts of 'damage control' and 'early total care' come in) as
also to the surgical technique of installing the fixator.

HOW TO USE EXTERNAL FIXATION IN EMERGENCY? (CONCEPTS

BASICS OF PLANNING

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 In his book "The Art of War", the author Sun Tzu states, "Premature strategy is \
cause of suffering". Although it may seem like an outdated and romanticized concept, often
In our clinical practice, we encounter several examples where external fixation is performed.
arbitrarily, without planning for future treatment, regardless of good technique
for the installation, results in difficulties for definitive treatment of the lesion or even in
irreversible sequelae for the patient.

A simple and quick way to avoid these complications can be done by asking-
if you are planning your fixing, the following questions:

WHAT WILL BE THE ROLE OF THE EXTERNAL FIXATOR IN THE INJURY

PRESENT? (no matter how redundant it may seem, it is common to find fixed fractures
externally, where fastening was not necessary, or even, fasteners that do not comply with the
function for which they were nominated

WILL YOUR USE BE TEMPORARY OR PERMANENT?

TEMPORARY: In this modality, the concept of

DAMAGE CONTROL or DAMAGE CONTROL, where the objective is
limit the injury only to the one that the patient presented upon admission
emergency sector. The fixing should be aimed at minimizing damage that may
occurs from movable bone fragments, joint instability or
metabolic responses resulting from trauma. Even at this moment, one does not
must lose focus on the definitive treatment that will follow, in order not to
jeopardize this future approach with its initial treatment. it should also be
consider the estimated time period to carry out the definitive treatment, of
way to perform a damage control that lasts without difficulties for this
period. A fixation that has insufficient technique or planning can
fail before the definitive treatment occurs and result in new complications
for the patient.
It is also worth adding that often other traumas may
compromise the possibility of new surgical approaches for the patient by
extended time, due to the multiple risks associated with the act
anesthetic. It is up to the competent trauma orthopedic surgeon to anticipate this possibility and
eventually carry out the fixation in a manner closer to definitive, given that
Many times, 'DAMAGE CONTROL' ends up becoming the treatment.
definitive.

DEFINITIVE: In this modality, the concept of "EARLY TOTAL CARE" is applied, or

EARLY DEFINITIVE TREATMENT, where the objective is the complete resolution of
injury directly in the first surgical act, avoiding additional procedures during the
treatment. This can be of great importance for the patient who presents themselves
excessively committed and weakened by the consequences of the trauma as mentioned in
above topic. usually this approach requires a lot of criteria regarding the injury in question,
looking for good reduction and contact of bone fragments and joints, ligament repairs and
tendinous and adequate coverage of soft parts. Normally, it is necessary that the injury
have characteristics that allow for "EARLY TOTAL CARE." Extensive injuries and
complex issues rarely can follow this type of treatment. it is also necessary
ponder whether the assembly will have stability and strength to carry the treatment until
the end, and it may also hinder some other intermediate procedure such as by
example, skin patches or grafts.

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 On the other hand, the definitive treatment of lesions through external fixation consists of
way to reduce hospital costs, length of hospitalization and number of surgical treatments
anesthetic agents, and implant materials; something valuable when it comes to public health and
medicine applied to large populations.

Questions and considerations answered, the indication will be supported by concepts.

solid and well-established, minimizing future inquiries. Enter the scene the
PRINCIPLES OF USE OF EXTERNAL FIXATORS
always remain in the memory of the trauma orthopedic surgeon. The fixator must:

It must be simple and easy to install, in order to comply with the

function to which is being indicated
Must MANDATORILY provide adequate stability
to local mechanical requests and maintain it during the period of time in which
he used
It should promote dressings, patient mobilization, allow
other interventions without the need for modification of the assembly
It must provide some degree of comfort to the patient.
In the case of provisional fixation, it should NEVER compromise the
definitive synthesis method that will be used, nor increase risks of
even, like infection, dehiscences and skin necrosis
It must have a cost compatible with the benefits established by
she.
In general terms, following these concepts, the planning of external fixation in the
Emergencies will be carried out satisfactorily. Here is a simple but common example in practice.
daily:
Both figures depict temporary fixators for damage control in a
tibial plateau fracture-dislocation. Although in both cases the stabilization seems to be
technically correct, in FIGURE-1 there is a flaw in the planning, where the pin's path
the most distal part of the tibia is within the area of definitive synthesis. The infection resulting from the
The path of this pin will increase the chances of infecting the definitive treatment method for the fracture.
(normally a plate) that will have a thin covering of soft parts due to the characteristic
of this region. In FIGURE-2, the planning respected the bed where the synthesis will be supported,
minimizing risks.

35
FIGURE- 1

36
FIGURE- 2

Now let's address the technical aspect of installing an external fastener.

37
 LINEAR EXTERNAL FIXATORS:
INSTALLATION TECHNIQUES
It is extremely common to encounter professionals in the field of trauma orthopedics who
they express doubts regarding the stability of external fixators, as well as the duration of
fixation. They often report several cases of early release or failure to achieve consolidation,
and attribute this failure directly to the method, that is, to the external fixation.

The main issue lies in viewing external fixation as a solution.

Immediate for the injury. Pin installations by drilling are frequently carried out.
directly and at high rotation and assemblies without techniques or stability parameters. These factors
lead to the loss of reduction and extremely early release of the components.

External fixation is a quick solution for the injury, but just like a plate, a
interfragmentary screw or a tension band has rules for the success of the treatment.
Whatever the function or indication of the external fixator, the most important step is the
installation of Schanz pins. This pin-bone interface is critical for stability of the
fixing segment. The correct positioning in the segment and the correct quantity of elements
The fixation elements are the key to maximizing the biomechanical qualities.
of the chosen assembly.
Special attention must be given to the conditions at the pin entry point. Fabrics
Depleted individuals are infected more easily, favoring early release.
The insertion should be made through a prior incision of the area, from 0.7cm to 1cm.
considering the diameter of the pin. Then a blunt dissection is performed with fine scissors
You pinch Kelly until the bone plane. The introduction of the soft tissue protector follows,
present in most TUBO-TUBO model fixing kits. The drilling must be done with
drill, under low rotation and high torque, usually with the drill diameter varying by 65%
75% of the diameter of the pin to be inserted, or as indicated by the manufacturer. The insertion of
the pin is manual, usually assisted by a 'T' key. The insertion of the pin should never
it should be done with the drill even with prior drilling, considering the heating resulting from
accelerated rotation can lead to thermal necrosis and subsequent early release of the pin.
Regarding the positioning in the bone, the pin should be inserted crossing the cavity.
medullary, fixed in both cortical bones, leaving the tip some
millimeters external to the output cortex.

The number of pins per fixed segment and their arrangement influences directly.
in the stability of the assembly and should be based on the fixation planning strategy.
Provisional fixations for diaphyseal fractures are usually made in a linear configuration and
We use 2 to 3 pins per segment (regions subject to the action of large and strong muscle groups)
it can require 3 pins per segment, even in provisional fixations, such as the femur
adult.
Permanent fixations can benefit from additional stability in a setup.
biplanar, where the greatest stability is achieved when the pins are angled at 90 degrees between
if on the transverse plane (maintaining parallelism in the sagittal plane). We recommend a minimum of
3 pins per segment in permanent fixations.
It is also worth noting that the farther apart they are, the greater the stability provided.
when two pins are used.

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39
EXTERNAL FIXATION ON THE HUMERUS AND ELBOW
Dr. Luiz Fernando Cocco
Dr. Felipe Martinez Neto

The External Fixator is a highly versatile resource in the treatment of humeral fractures.
mainly in the transarticular stabilizations of the elbow and in the complications of the diaphyseal region.

Your assembly follows the same general principles in the placement of external fasteners,
referring to the number of pins, the distance between them and the fracture focus, and the number of rods
associated.

They also follow the guidelines for temporary or permanent assemblies in treatment.
of these fractures. However, due to the frequent possibility of conversion to internal synthesis with great
success and the difficulties of patients in their daily lives with the use of fixators in the upper limb,
most of the setups are designed for a short period of time. Generally after the
clinical stabilization or improvement of soft tissue conditions, the external fixator is removed and the
internal osteosynthesis is performed.

The local anatomy of the arm and forearm must be taken into account for assembly.
Secure the external fixator. There is a high rate of radial nerve and deep brachial artery injury in
untimely maneuvers for reduction or improper violation of compartments by Schanz pins and
Kirchner's wires. To prevent this, we must use the so-called 'Safety Zones' (fig.
1).

Fig. 1: Safety Zone for placing pins and wires in the humerus.

In the arm, this area corresponds to the region 5cm distal to the acromion (axillary nerve) on the lateral side and
10 cm proximal to the lateral epicondyle (passage of the radial nerve from posterior to anterior).

40
The indications for the use of the fixer are numerous, both acute and in treatment of
subsequent complications. The acute indications are bilateral fractures in polytraumatized patients
and/or polyfractured, exposed fractures, loss of substance or large local burns (fig.2), fractures
complex or what is called "floating elbow".

Patients with severe traumatic brain injury (TBI) who will remain bedridden (ICU, for example) for
For a long time, they can benefit greatly from this treatment option. Even with the downgrading.
at the level of consciousness (very common in these situations) will have the member stable enough to
mobilization in bed (physiotherapy), local dressings, in a safe, stable, and painless manner. Many times,
this assembly becomes the definitive treatment until the fracture consolidates.

Fig. 2: Exposed fracture dislocation of the right elbow.

The more elaborate or even circular mountings are much less frequent in emergencies or
emergency. They are usually performed to correct congenital deformities or sequelae of
Old fractures (fig.3), requiring planning. They are performed on an elective basis.

Fig. 3.: Infected pseudoarthrosis treated with circular external fixator.

41
 Another indication for external fixator in the upper limbs is the treatment of joint stiffness.
of the elbow. An articulated device in the fixer stabilizes the lateral rotation center of the elbow for
execution of extensive joint releases (fig. 4). With this device, the patient shows safety
sufficient mechanics for early mobilization of the recently released elbow, without risk of dislocations
or instabilities.

Fig.4.: Treatment of elbow stiffness with a hinged fixator.

In summary, the external fixator for the humerus is an excellent treatment option for patients.
in conditions of urgency or emergency, it should be used with criteria in the placement technique and
selection of the assembly (provisional or definitive). Elaborate assemblies are more frequently of a character
elective or for the correction of chronic diseases.

42
43
EXTERNAL FIXATOR ON DISTAL RADIUS

Dr. Luiz Carlos Angelini

Dr. Fábio de Assunção e Silva
Dr Ronaldo Borkowski Jr

INTRODUCTION
Distal radius fracture occurs more frequently in patients
female, over 40 years old and is related to osteoporosis.
In his study, O'Neill found an incidence of fracture of 9/10,000 men and of
37/10,000 in women. Riggs, Melton, in a work published in 1995 found that patients
those over the age of 50 had an approximate risk of 40% (women) and 13% (men) of
may present spinal fractures, Colles fracture or proximal femur fracture.
Currently, 1.5 million fractures occur due to osteoporosis annually.
Of these, 250,000 affect the distal end of the radius and spend between 5 to 10 billion dollars on
your treatment.

TREATMENT

What is the best treatment method for unstable fractures that affect the
joint surface? intramedullary wires / Kirschner wires / external fixator (graft) /
DCP plates, Blocked (dorsal or volar), Orthogonal / Association with Arthroscopy?
The choice of treatment method depends on the type of fracture, the age of the patient, the
profession of the degree of use of the upper limb, of sports practices, of the experience of
doctor, about the working conditions of the traumatologist.
Fractures amenable to indirect reduction (ligamentotaxis) and complex fractures can be
treated by external fixation. However, we must consider the deviation of the fracture, involvement
from the joint, associated with ulnar fracture and ARUD lesions, assessment of bone quality
the patient's tolerance to the method.
External fixation is essential in the treatment arsenal for orthopedic trauma because it is
a simple, fast, and effective method. Moreover, it shows good immediate results and
definitive.

44
 We basically have two types of external fixation for the treatment of the distal radius:
bridge (bridging) or non-bridge (nonbridging). In the first, we have the blockage of the joint and in
according to the joint remains free.
Type bridge - 'Bridging'

Nonbridging

Fractures and Injuries of the distal radius and carpus David Slutsky, A Lee Osterman, MD
45
 In order to improve retention and accelerate recovery, we can utilize the
following methods:

1. K-styloid wire / neutralizes deformation force / m. brachioradialis

Dorsal transfixation wires - 'DTW' / increases resistance

Wolfe SW, Swigart CR, Grauer BS, et al: Augmented external fixation of distal radius
fractures: a biomechanical analysis J Hand Surg 1998;23:127-134

2. Bone graft - Improves the joint surface, accelerates fracture healing, allows
early withdrawal.

Leung KS, Shen WY, Tsang HK, et al: An effective treatment of comminuted fractures of the
distal radius . J Hand Surg 1990; 15:11-1

46
REDUCTION PARAMETERS

TECHNIQUE FOR FIXATION ON BRIDGE

With the patient previously anesthetized in the surgical center, we must proceed to
non-invasive reduction of the fracture under radioscopy. Next, the skin should be incised at the location where it will be
located the pin. A blunt dissection with a Kelly-type clamp should be performed to avoid injury.
of neurovascular structures. As we do not have a drill for this type of fixer,
Drilling must be even more careful as we will use the pin directly on the driller. This
it should be inserted on the lateral dorsal face of the radius at an angle of 45 degrees. The remaining pins
devem ser posicionados através do fixador para garantir seu posicionamento correto.
The pins in the hand are, in the vast majority of cases, positioned in the second metacarpal.
with the same tilt of the radio and taking the same precautions regarding injury to parts
Moles. Aiming for a more stable fixation, we can advance the more proximal pin to the base.
of the 3rd metacarpal.

COMPLICATIONS
Like any surgical procedure, we may have the following complications:

Infection
Neuro-vascular injury
Pseudoarthrosis
Complex Regional Pain Syndrome

SUMMARY
Be familiar with the technique and the chosen fixing agent;
Use a mini-incision to avoid iatrogenic injury to the vessels and nerves;
Use a drill and saline solution – avoid thermal necrosis of the bone;
Using DTW and radial fixations - increase the fastening strength;
Avoid skin tension on the K wires - minimize infection;
Avoid prolonged immobilization - it can result in 'regional pain syndrome'
complex
Always use bone graft whenever possible – it speeds up bone healing.

47
Bibliographic References:

1. Rockwood and Green’s. (C.A.Rockwood, Robert W., Md. Bucholz, James D., Md.
Heckman, D.P. Green) Fractures in adults. 7th edition (2010). Lippincott Williams & Wilkins
Publishers.

2. Hand Surgery. I. Green, David P. II. Wolfe, Scott W. III. Title: Operative hand
surgery. 6a ed (2011).

48
49
 Tibial Pilon
Dr. Ivonir Fagundes Alves Jr

DEFINITION
The term tibial mallet originated in 1911 with Destot referring to the analogy existing between the
tibio-tarsal joint and a shroud.
It corresponds to the metaphyseal fracture compromising the distal articular surface of the tibia.

EPIDEMIOLOGY
Tibial plateau fractures represent 1% of all fractures. They account for 7-10%
of all tibia fractures.
Most common in men between 30 and 40 years old. Generally the result of high-impact traumas.
energy, therefore associated injuries are common.

ASSOCIATED INJURIES

Associated Treatment 18
Polytrauma 12
Nervous 2
Cutaneous 27
Vascular 4
0 5 10 15 20 25 30

50
TRAUMA MECHANISM

Axial compression: usually occurs in high-energy trauma.

Presents a worse prognosis in treatment. More common in falls from height and accidents.
of traffic.

Rotational: generally low-energy traumas present a better

prognosis during treatment. More common in skiing and skating accidents.

CLINICAL EVALUATION
Tibial plateau fractures are typically associated with high-energy trauma. Therefore, a
A global assessment of the patient is necessary. The search for associated injuries is important.
There is a rapid and massive edema in the distal region of the tibia, due to being in a position with
small coverage of soft tissues. Assess skin integrity, the presence of skin necrosis
And the neurovascular integrity is essential.

51
RADIOGRAPHIC EVALUATION
To assess a fracture of the tibial plafond, X-rays are needed in the positions
anteroposterior and lateral of the tibio-tarsal joint. An ankle tomography is of great
valid for the study of the best treatment method.

52
CLASSIFICATION

Ruedi and Allgower Classification

I–INTRA-ARTICULAR WITHOUT DEVIATION

II–MODERATE DEVIATION OF THE FRAGMENTS CONTINUATION
MINIMAL OR ABSENT FROM THE ARTICULAR SURFACE
III–SEVERE CONTINUATION OF THE ARTICULAR SURFACE AND METAPHYSIS

RANKING TO

A- EXTRA-ARTICULAR
B- PARTIAL ARTICULAR FRACTURES
C- COMPLETE ARTICULAR FRACTURES

53
TREATMENT

The conservative treatment is reserved for cases where there is no displacement of the fracture, although
there is generally a loss of reduction, and for patients who cannot undergo the
surgical act.
Tibial plateau fractures are primarily treated surgically, based on several
factors such as the degree of comminution of the fracture, the condition of the soft tissues, age, and the
preexisting diseases of the patient.
The ideal time for surgery for tibial plateau osteosynthesis is up to 6 hours after the accident or
wait 6 days, as this is when the improvement of the soft tissue lesions occurs.

Since tibial plafond fractures are generally associated with high energy trauma, the
damage control with the use of the transarticular external fixator of the ankle in emergencies
improves the condition of the soft tissues more quickly, promotes a stabilization of the
fracture, restores the length and partially reduces the fracture fragments.
For assembly of the external transarticular ankle fixator, the Schanz pins must be
arranged as follows: two pins in the tibia, proximally to the fracture in the anterio-
medial, a pin in the calcaneus and a pin in the first metatarsal. After assembly and connection
Two pins with bars, the reduction of the fracture promoted by arthrodiastasis must be performed.

54
The choice of method for the definitive treatment of plafond tibia fracture depends on several
factors such as the condition of the soft tissues, the degree of comminution of the fracture, the energy of the trauma,
patient's clinical conditions, availability of implants, and surgeon's skill.
Tibial plateau fractures can be stabilized with plates or external fixators. A
mixed synthesis can be used. Whatever method is chosen for the treatment of
fracture, should have the objectives of: anatomical reconstruction of the articular surface, stabilization and
support of the metaphyseal bone and early joint movement.

55
The surgical treatment of tibial plafond fractures should follow Allgower's criteria:

– Reestablish the length

– Reestablish the joint surface
– Bone grafting in metaphyseal defects
– Neutralization of the distal metaphysis of the tibia

The treatment of tibial plafond fractures with external fixation is indicated when there is
great commitment of the soft tissues, extremely comminuted fractures, patients with
severe osteoporosis, diabetes, and with peripheral vascular insufficiency.

The reduction of the articular fragments is achieved through the ligamentotaxis promoted by
joint distraction. The olive wires can be used for compressing the fragments.

56
 The assembly of the circular external fixator for the treatment of these fractures consists of:
A proximal block with two rings attached to the tibia,
A waiting ring that allows the passage of olivated wires for compression
two articular fragments,
A semi-ring fixed on the heel.

WAITING RING

PRE-ASSEMBLY

Arthrodiastase

57
 REDUCTION OF FRAGMENTS
WITH OLIVE FIBERS

The postoperative period of treatment for tibial plafond fractures with external fixator should
to be carried out as follows:
After 4 weeks, release the mobility of the ankle using hinges.
center of rotation of the joint.
After 8 weeks, remove the component from the hindfoot, allowing for mobility.
the tibio-talar and subtalar joints. Partial load should be maintained.

COMPLICATIONS
Complications in tibial plateau fractures are relatively common, this is due to
inappropriate choice of surgical method, early approach without waiting for improvement of
conditions in the soft tissues, clinical conditions of the patients among other variables. The most
commons are:

• Vicious consolidation
• Pseudoarthroses
• Infection and dehiscence of the surgical wound
• Skin necrosis
• Joint stiffness
• Ankle osteoarthritis
Dehiscence of the surgical wound with exposure of the synthetic material

58
VICIOUS CONSOLIDATION

ROTATIONAL VARO VALGO

PSEUDARTHROSIS

POST-TRAUMATIC ARTHRITIS

59
DEHISCENCE

60
61
PSEUDARTHROSES
Dr. Glauber Kazuo Linhares

DEFINITION

Pseudarthrosis is the situation in which the fracture shows no evidence of progression in the healing process.
consolidation, which can no longer progress without intervention.

Delay in consolidation is when the consolidation is not progressing within the expected timeframe for
determined location and type of fracture.

There are discrepancies regarding the time to define what a pseudarthrosis is. Some authors mention
the period of 6 to 8 months, but there is no consensus. In order to try to standardize, the FDA defined that
there must be at least 9 months from the injury and no visible progressive signs of consolidation for 3
months to configure a pseudarthrosis. Even so, the definition of time remains
arbitrary due to various factors involved in the consolidation process such as the location of the fracture, age and
clinical conditions of the patient.

INCIDENCE

The incidence is estimated to be between 2.5 to 5% of all fractures. This number varies depending on the degree of
energy from the injury, reaching about 20% in the case of open fractures and with soft tissue injuries.

PATHOPHYSIOLOGY

Various factors are considered in the consolidation process; if there is any irregularity in any of them, the
consolidation will be harmed. Generally speaking, the factors are divided into two groups: The cause
biological occur when the organism is unable to provide a biological response to the formation of a
new bone tissue. And the mechanical causes occur when there is generally a good response
biological, however there is no stability for consolidation to occur.

Location of the fracture: Vascular irrigation at the site of the fracture is a key factor for
the consolidation will occur. Therefore, some places that have limited irrigation will have more
difficulty in consolidating a fracture. Example: scaphoid, femoral neck, and talar neck.
on the other hand, the metaphysical regions usually do not encounter difficulties in consolidation.
Grau de energia da lesão: quanto maior o grau de energia, mais desvascularização ocorrerá, o
which will hinder consolidation.
Infection: There may be consolidation in the face of an infection. However, there may be delay or even
even complete inhibition of the consolidation process. The inflammatory process resulting from the
infection is harmful to consolidation.
Nutritional and metabolic framework: any situation of malnutrition and immunosuppression can
to result in a decrease in the body's response in consolidation.
Smoking: tobacco is associated with changes in consolidation and failure in treatment of
pseudarthroses. The vasoconstrictive properties of nicotine inhibit tissue differentiation and the
angiogenic responses in the consolidation process.

62
 Diabetes: a microvascular disease associated with neuropathy and decreased immune competence
prepares the diabetic patient for pseudarthrosis.
Anti-inflammatories: by inhibiting angiogenesis, they are associated with the incidence of nonunion.
Age: studies suggest that advanced age is a risk factor for pseudoarthrosis.
Activity level: bedridden patients are more prone to develop pseudarthrosis in
relation to active patients.
Inappropriate choice of treatment: when there is an inappropriate indication of a
treatment modality for a specific fracture, the chances of bone healing
decrease.
Stability: the lack of mechanical stability does not provide a suitable situation for the
consolidation.

RANKINGS

A simple classification divides pseudarthroses according to the presence or absence of infection. So

they can be classified as septic and aseptic.

Weber and Cech divided pseudarthroses into vascular and avascular. The vascular ones are subdivided
in hypertrophic (elephant foot), normotrophic (horse hoof), and oligotrophic. The avascular are
divided into wedge of torsion, comminuted, bone failure and atrophic.

On the elephant pad (A), the fragments are viable and the callus is osteocartilaginous and occurs due to
inadequate stability. In the horse hoof (B), the fragments are also viable and the formation of the callus
Osteocartilaginous tissue is reduced compared to elephant foot. In oligotrophic conditions, there is viability.
in the fragments, however, they are diminished, with the formation of a poor bony callus.

63
In the wedge of torsion (A), the consolidation of the wedge occurs in only one of the main fragments. In
cominutiva(B) does not lead to the consolidation of smaller fragments, which are usually in the
compromised irrigation. In the bone failure (C) there is no bone contact for callus formation to occur.
In the atrophic (D), the viability of the fragments is compromised to the point of leading to reabsorption.
bone at the fracture site.

64
ILIZAROV divided pseudarthroses into two groups. The first are loose asphyxia.
an exuberant bone callus and there is a large area of bone contact. The loose ones present a callus
poor bone and there is a minimal contact area.

FIXA FROUXA

PALEY developed a classification for tibial pseudarthroses, but this classification can be
used in other long bones.

Pseudarthroses are divided into two groups:

A. With bone loss less than 1cm.

B. With bone loss greater than 1cm.

The subdivisions are:

A: < 1 cm

with movable deformity

fixed

A2-1: rigid without deformation

65
 A2-2: rigid with deformity

> 1 cm

B1: Bone defect without shortening

B2: Flawless shortening

B3: Defect and shortening

66
DIAGNOSIS

MEDICAL HISTORY

It is fundamentally important for the management of fractures that are facing problems in
consolidation. The detailed history of the injury event is important to determine the degree of energy and
estimate the risk of developing an infection.

Information about previous treatments for the fracture in question must be obtained. Comorbidities and
The medications in use are also important in the analysis of the history.

PHYSICAL EXAMINATION

The presence of pain and mobility at the fracture site are the most important elements in the evaluation of
pseudarthrosis. When associated with the presence of a fistula with purulent secretion output, it is a sign
indicative of septic pseudarthrosis.

RADIOGRAPHY

It is the simplest and most common method for evaluating fracture consolidation. It is usually observed
a callus of union that crosses the fracture. There is no consensus on the number of corticals that
they must exist in orthogonal radiographs to define complete consolidation. Studies vary from 2 to
4 corticals.

The visualization of the number of corticals, although it seems simple, often becomes subjective. The
An incorrectly performed exam hinders the orthogonal visualization of the fracture. In other cases, the
the fracture and the X-ray are not coplanar, which may conceal the presence of a gap at the focus.

Through radiographs, it is possible to obtain direct and indirect evidence of pseudarthrosis. The evidence
direct is the gap at the fracture site and the indirect appear through the signs of loosening or breaking of
synthesis material.

COMPUTED TOMOGRAPHY

Promotes better visualization of the fracture focus. It is highly sensitive (100%), but nonspecific (62%)
In the diagnosis of pseudarthrosis, what does a high number of false positives mean.

BONE SCINTIGRAPHY

It also shows high sensitivity and low specificity.

67
TREATMENT

CONSERVATIVE

Conservative treatment consists of non-surgical measures aimed at accelerating the process of

consolidation and can be divided into direct and indirect interventions.

Indirect interventions consist of measures aimed at the patient as a whole, targeting the
factors that may be contributing to the non-consolidation of the fracture. Examples include the cessation of
smoking, improvement of nutritional status, control of endocrine and metabolic disorders, control
of medications.

Direct interventions consist of applying a treatment method directly to the bone.

committed. Examples include increased load on the member, use of immobilization, stimulation
electric, ultrasound, and shock waves.

SURGICAL

There is a wide variety of surgical treatment methods for pseudarthrosis. For the choice of
The method to be used must take into account the presence or absence of infection, the condition of
local soft tissues, the etiology of pseudarthrosis and the surgeon's experience with the method.

The choice of appropriate surgical treatment depends on the diagnosis being made correctly. In the case of
pseudarthrosis resulting from mechanical failure, the treatment consists of increasing the stability of the fixation.
The focus approach is generally unnecessary. If there is angular deformity, it must be
corrected.

In the case of pseudarthrosis resulting from decreased biological potential, debridement is necessary.
from the focus to the attainment of viable bone tissue, usually associated with bone grafting.

If the pseudarthrosis is septic, the infection must be eradicated as a priority. As stated,

previously, the infection hinders the consolidation process. In addition to antibiotic therapy, it is necessary
the wide debridement of infected and necrotic soft tissues as well as the removal of bone fragments
devoid of vitality (kidnappings).

External fixation for the treatment of pseudarthroses can be used on almost any bone.
long. Provides relatively small trauma to the soft tissues and allows for the correction of
deformities in a slow and gradual manner. Another advantage is the possibility of immediate support of the
weight. In case of bone failures or infection requiring resection of a bone segment, it may
bone transport should be carried out (see chapter on bone failures).

68
FOR FIXATION WITH INTRAMEDULLARY ROD

69
STABILIZATION

FINAL

70
REFERENCES

1.C.A.Rockwood, Robert W., Md. Bucholz, James D., Md. Heckman, D.P.GreenFractures
in adults. 7th edition (2010). Lippincott Williams & Wilkins Publishers.
2. S. Terry Canale, Campbell's Orthopaedic Surgery. 11th edition
3. Ruedi et al, AO Principles of Fracture Treatment. 2nd edition

71
72
BONE DEFECTS

Dr. Fábio de Assunção e Silva

Dr. Hilário Boatto

INTRODUCTION

Despite all the advances that Medicine has achieved in recent times, bone failures continue.
being one of the most challenging themes for treatment. It is a cause of great morbidity, disability
prolonged and high costs in your treatment.

Currently, the presence of bone loss is becoming very common mainly due to
increase in the number of high-energy traumas that our society is exposed to. This is the main
cause of bone failures, with the second leading cause being infections followed by tumors and pseudo-
arthrosis.

Soft tissue injuries associated with severe fractures lead to suffering of blood supply and,
many times, the presence of devitalized bone fragments is already identified when one performs the
approach to open fracture. These fragments, when completely devitalized, must be removed.
in order to avoid the presence of a bone sequestration and consequent osteomyelitis. On the other hand
a bone defect is created that can have varying extent.

It is a pathology of difficult classification due to the numerous factors involved (soft tissue injuries,
potential for infection, affected bone region, etc.). In general, bone failures are classified as
agreement on its extent. The Orthopaedic Trauma Association divided it into 3 types:

Less than 50% of the circumference of the cortical

Greater than 50% of the circumference of the cortex

3. Loss of segment

The presence of small bone defects, up to 2 cm, could be resolved in a simpler way.
causing the acute shortening of the bone in question, but this conduct results in a shortening of the
member.

It is considered a significant bone loss when the extent of the bone defect is greater than 3 cm and several
methods have already been described for the treatment of these flaws, however many of them have proven to be
ineffective in promoting the definitive cure of the patient.

The commonly used methods are:

Bone graft

Vascularized

Non-vascularized

73
 Synthetic graft

Shortening

Arthrodesis

Bone transport

Amputation

Vascularized bone grafts have been used for the treatment of bone loss as well as
placement of cancellous cortical graft, however this is limited by the availability of bone that can
to be used for this purpose. The limitation becomes even greater when there is a local infection.
use of exposed spongy bone grafts (Papineau), biomaterials or materials associated with
local antibiotics do not solve the deformities associated with bone failure as well as shortening
of the member.

The use of external fixation meets the appeal of simultaneously correcting anisomelia and
associated deformities and the filling of the bone defect.

BONE TRANSPORT

The development of the osteogenic distraction method with the improvement of external fixation brought
a new perspective in the treatment of bone defects. Bone defects can be treated with
uniplanar and circular fixators. The circular external fixator allows full load on the affected limb, the
correction of associated deformities and provides bone lengthening in patients who present
bone failure associated with shortening. Some uniplanar fixators have characteristics
similar to the circular ones, but do not allow full load during treatment.

The transport speed is 1mm per day in the first week and 0.75mm from the second week onwards.
week. This speed can and should be adjusted to the patient's needs. But speeds of
transports larger than 1mm result in the non-formation of good quality bone tissue.

Types of bone transport

Bone transport is classified according to the number and position of its osteotomies and
also according to the way the transportation is done.

74
Bifocal Transport

Convergent Trifocal Transport

75
Trifocal Tandem Type Transport

Bone transport methods

Three types of bone transport can be performed:

1- Internal bone transport: Kirschner wires are introduced obliquely into the bone segments.
to be transported as these wires are gradually pulled leading the
bone fragment to which it is fixed towards the proximal or distal bone.

2- External bone transport: Kirschner wires and Schanz pins are inserted transversely.
the bone is connected to the rings allowing transportation and if necessary the correction of
associated deformities.

3-Combined bone transport (external-internal): kirschner wires and pins are introduced
Transverse shanz in one fragment and oblique wires in another fragment.

76
Osteotomies

Osteotomies should preferably be performed in the metaphyseal regions, especially in the presence of
For a bone defect of up to 5 cm, a single osteotomy is sufficient to promote bone transport.
Our group advocates for performing osteotomy percutaneously with a Gigli saw, but also
Your execution with the use of osteotomes and drills is correct.

In the case of an osteotomy, bone transport is called bifocal due to the presence of a focus of
pseudarthrosis is a focus of osteotomy.

If the bone defect is greater than 5 cm, two osteotomies can be performed, which accelerates the
transport reduces treatment time and promotes a better quality regenerator.
bone transport is called trifocal in tandem when the bone fragments are transported one
one after the other and convergent when the segments come together.

The segment to be transported must be large enough to be secured with three elements.

In case the proximal segment of the tibia or distal segment of the femur has a small size, which does not allow for
performing osteotomy in the mentioned metaphyseal regions, the osteotomy should be performed in the
distal tibia and proximal femur.

Proximal tibial osteotomy Distal osteotomy of the femur

Acute shortening and bone elongation

In the presence of bone defects, there is the possibility of performing the focus regularization, the
acute shortening of the bone and simultaneously performing an osteotomy for elongation. Several
authors have described tibial shortening of about 4 cm and femoral shortening of about 5 to 6 cm without having

77
found complications. With this procedure, we can say that the bone failure is filled,
but we are now left with the residual bone shortening that will be resolved with elongation.

This procedure allows for the promotion of bone contact between the fragments, which increases the
stability of the set, and leaves us with a more focused monitoring on the bone regenerated relative to
stretching. In figure 7 we can observe the distal bone failure in the tibia where it was performed
bone regularization and assembly of the circular external fixator with acute shortening, compression and
osteotomy for bone lengthening.

Fig 6- Radiographic appearance Fig 7 - Regularization of bone ends,

of bone failure acute shortening and proximal osteotomy.

Subsequently, bone elongation and compression of the pseudarthrosis focus were performed (fig 8) with
equalization of the lower limbs and bone consolidation (Fig 9).

Fig 8 - Bone stretching Fig 9 - Consolidation

78
Bone failure associated with infection

The treatment through bone transportation can be carried out even when there is an infection present.
A thorough surgical cleaning is performed with debridement of devitalized tissues, resection of
all the necrotic bone and after the assembly of the external fixator we performed the exchange of the
surgical instruments and osteotomies can be performed.

Infected pseudarthroses are difficult to treat when associated with bone defects and certainly,
in the past, many patients suffered amputations after fighting for several years against infection and
suffered multiple surgical approaches without resolution, mainly of the infectious condition.

In figure 10 we can observe the severity of the involvement of soft tissues and in figure 11 the condition.
of the bones of the leg of the patient in question.

Fig 10 - Extent of the lesion Fig 11 - Radiographic appearance

The patient underwent a latissimus dorsi graft which developed necrosis (Fig 12 and 13)

79
Fig 12 - Donor area of the graft Fig 13 - Appearance after graft necrosis

A convergent trifocal bone transport was performed (fig 14) including skin transport (fig 15) and
bone consolidation was obtained (Fig 16)

Fig 14 and 15 - Convergent trifocal transport

80
Fig 16 - Bone consolidation and clinical aspect

Conclusions

Bone defects continue to be a huge challenge for orthopedic surgeons, but they have great
ally for your treatment the bone transport method once the reconstruction through
external fixation promoted a better outlook for the salvation of members affected by major
loss of bone tissue mainly when associated with infections.

The use of external fixators, especially circular ones, allows the patient to bear full weight on the
affected member, leaves, as much as possible, adjacent joints free with conditions to perform
rehabilitation and physiotherapy being a tool that should be part of every orthopedist's arsenal that
is challenged by the serious complications of the traumas that affect the long bones.

The treatment time will obviously depend on the extent of the bone defect in question, but even still
in patients who needed to remain with the external fixator for an extended period,
maintenance of the affected member, when compared to the possibility of amputation in the most cases
graves, resulted in a high level of satisfaction among patients.

81
REFERENCES:

Sala F; Thabet AM; Castelli F; Miller AN; Capitani D; Lovisetti G; Talamonti T; Singh S

Bone transport for postinfectious segmental tibial bone defects with a combined Ilizarov/Taylor spatial
frame techniquee.Journal of Orthopaedic Trauma;25(3):162-8, March 2011.

Osteocutaneous thermal necrosis of the leg

salvaged by TSF/Ilizarov reconstruction. Report of 7 patients.Int Orthop;35(1):121-6, January 2011.

Iacobellis C; Berizzi A; Aldegheri R Bone transport using the Ilizarov method: a review of complications
in 100 consecutive cases. Strategies Trauma Limb Reconstr;5(1):17-22, 2010 Apr.

Chaddha M; Gulati D; Singh AP; Singh AP; Maini L Management of massive posttraumatic bone defects
in the lower limb with the Ilizarov techniquee. Acta Orthop Belg;76(6):811-20, December 2010.

Fragmental bone transport in conjunction with acute

shortening followed by gradual lengthening for a failed infected nonunion of the tibia.J Orthop
Sci;15(3):420-4, May 2010.

Guerreschi F; Azzam W; Camagni M; Lovisetti L; Catagni MA Tetrafocal bone transport of the tibia with
circular external fixation: a case report.J Bone Joint Surg Am;92(1):190-5, January 2010.

Smith WR; Elbatrawy YA; Andreassen GS; Philips GC; Guerreschi F; Lovisetti L; Catagni MA Treatment
of traumatic forearm bone loss with Ilizarov ring fixation and bone transportrt.International Orthopaedics;31(2):165-70,
April 2007

Paley D, Chaudray M, Pirone AM, Lentz P, Kautz D. Treatment of malunions and mal-nonunions of the
femur and tibia by detailed preoperative planning and the

Ilizarov techniques. Orthop Clin North Am 1990;21:667-91.

Motsitsi NS. Management of infected nonunion of long bones: the last decade

(1996-2006). Injury 2008; 39: 155-60.

Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov Treatment of tibial
nonunions with bone loss. Clin Orthop Relat Res. 1989;241:

146-65.

Aronson J. Limb-lengthening, skeletal reconstruction, and bone transport with the Ilizarov method.
Bone Joint Surg Am.1997;79:1243-58.

Ilizarov GA. The principles of the Ilizarov method. Bull Hosp Joint Dis Orthop Inst.

1988;48:1-11.

Catagni MA, Guerreschi F, Cattaneo R. Treatment of infected nonunion with the Ilizarov method.
Italian Journal of Orthopedics and Traumatology. 1999;24:443-51.

Keating JFSimpson AH,Robinson CM.The management of fractures with bone loss. J Bone Joint Surg
Br. 2005 Feb;87(2):142-50.

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Pelvic fractures

Dr. Daniel Balbachevsky

Dr. Ronaldo Borkowski Jr.
Pelvic fractures are rare injuries (3% of overall trauma) and severe, with up to 50% mortality. They are
high energy, generally associated with other injuries and are difficult to treat.

Fortunately, most injuries are of type A in the AO classification, which are less severe compared to
type B and C injuries.

These injuries cause hemodynamic instability and require bone stabilization.

83
The pelvis has no intrinsic stability, that is, without the ligaments it is extremely unstable. It is
It is important to remember that 80% of stability is provided by the posterior ligaments.

The source of the bleeding can be from the bone, the posterior venous plexus, or the intrapelvic viscera.

Anatomy

84
The physical examination includes inspection and maneuvers, such as anterior and lateral compression.

85
One aspect that cannot be forgotten is the research of hidden exposed fractures: we have these injuries in
20-30% of cases. We should observe the aspect of the external genitalia, as well as routinely perform the
anal and vaginal touches.

In the emergency: panoramic X-ray of pelvis from the front. Inlet/outlet/wing/obturator incidences are considered.
electives, due to being more laborious and adding little to the initial conduct, where saving a life is the
priority.

86
 15 minutes

Literature

The reliability of clinical examination in detecting pelvic fractures in blunt trauma patients: a meta-
analysis.

Sauerland et al - Acta Orthop Trauma Surg 2004

Evaluation of the accuracy of clinical examination for diagnosing pelvic injuries in victims of
closed trauma - meta-analysis

Sensitivity: 100%. It is concluded in this study that only the clinical examination would have a high
diagnostic sensitivity.

Electively, we can request special incidences and mainly, a CT.

Classifications:

Tile Classification:

TYPE A–STABLE

Fractures of the pelvis not compromising the ring;

A2: Minimally displaced stable fractures of the ring;

A3: Transverse sacrococcygeal fracture;

TYPE B - ROTATIONALLY UNSTABLE, VERTICALLY STABLE

Open Book

B2: Ipsilateral lateral compression;

B3: Contralateral lateral compression (bucket handle)

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TYPE C–ROTATIONAL AND VERTICALLY UNSTABLE

C1: Rotationally and vertically unstable;

C2: Bilaterals;

C3: Associated with an acetabular fracture;

Young's modulus

Transverse fracture of pubic rami, ipsilateral or contralateral to the posterior injury:

CL I: sacral compression on the impact side;

CL II: crescent fracture (wing of the ilium) on the impact side;

CL III: injury CL I or CL II on the impact side; contralateral injury in open book (CAP);

CAP: Diastasis of the symphysis and/or longitudinal fractures of the rami:

CAP I: slight widening of the pubic symphysis and/or SI joint; anterior and posterior ligaments
relaxed, but intact;

CAP II: SI articulation with greater widening, rupture of the anterior ligaments; ligaments
intact posterior;

CAP III: complete separation of the hemipelvis, but without vertical displacement; complete rupture of the
SI joint articulation; complete rupture of the anterior and posterior ligaments;

CV: diastasis of the symphysis or anterior vertical fracture, anterior and posterior vertical displacement,
usually through the SI joint, occasionally through the wing of the ilium and/or sacrum;

MR: Previous and/or subsequent, vertical and/or transverse components, combined with others.
lesion patterns: CL/CV or CL/CAP;

88
Müller 1990 - The comprehensive classification of fractures of long bones.

89
90
Treatment and prognosis:

It is divided into an emergency room and a surgical center.

In the emergency room, we must reduce the pelvic volume.

To avoid shock, temporary closure of the pelvis can be done with a sheet. Also tie it.
knees and legs. Pelvic bands, MAST PASG are used.

Also: pelvic clamp, tamping, exploration, angiography, and embolization.

91
Treatment with external fixator:

The supracetabular fixer is more rigid and resistant than the one placed on the iliac crest.

In Marvin Tile's 1999–CORR work, there was no injury to the lateral femoral cutaneous nerve.
in supra-acetabular fixators. Furthermore, it facilitates nursing and physiotherapy care, and
leave space for a possible laparotomy.

Literature

According to Simonian 1995–CORR, the external fixator better stabilizes the anterior region (pubic symphysis)
and the clamp stabilizes the posterior region (sacroiliac).

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Pelvic packing is the placement of dressings inside the pelvis, used in
large and difficult to control bleeding. Through a suprapubic incision (Pfannenstiel or
Modified stop, the compresses are placed in the Retzius space and in the sacroiliac joints.

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In major vessel injury, we can perform exploration and subsequent repair via open approach.

Angiography and embolization are also available techniques, more commonly used for compressive lesions.
lateral before external fixation. However, these resources are not always available.

Urgent treatment in the operating room:

Initially, we must stabilize the patient even with a temporary treatment, whether with
external fixation, pelvic clamp, tamponade, exploration, angiography or embolization.
And what about the internal fixation?

Anterior fixation can be performed during laparotomy or percutaneous fixation, with the latter
requires experience and special materials.

Below, images of previous fixation in the pubic symphysis and in the ilio-pubic rami.

94
95
Other internal osteosyntheses:

Percutaneous fixation

Sacroiliac pinning

Pinning of pubic branches

Pinning of the iliac wing

Sacroiliac dislocation and sacral fracture:

96
Retrograde technique

97
Anterograde technique

Fractures of the ilio-pubic rami

Percutaneous stabilization of the pelvis - emergency treatment

Indications: type C fractures (Malgaigne), near the greater sciatic notch, crescent fractures

98
Fractures of the iliac wing

Technique: supra-acetabular region of the anterior superior iliac spine to the posterior superior iliac spine/I

99
Summary:

The minority experiences hemodynamic instability because most are non-serious injuries, type A of
AO.

Recognize serious injuries and save the patient's life.

100
Stabilize the patient in the emergency room with sheets, MAST, PASG, tapes...

Reduce the volume of the pelvis

External fixer, clamp

Rear-end collision

101
Angiography, exploration

102
BIBLIOGRAPHIC REFERENCES

1. Balbachevsky D, Pires RES, Falopa F, Reis FB. Treatment of pelvic and acetabular fractures
through the modified Stoppa approach. Orthop Bras Act 2006; 14:190-2.

2. Blatter R, The treatment of fractures in children and adolescents In: Weber BG, Brunner CH,
Freuler F (eds). Berlin, Heidelberg, New York, Springer Verlag, 1979.

3. Cole JD, Bolhofner BR. Acetabular fracture fixation via modified Stoppa limited intrapelvic
approach: description of operative technique and preliminary treatment results. Clin Orthop
1994; 305: 112-23.

4. Committee on Trauma. American College of Surgeons (eds). Advanced Trauma Life Support
manual. Chicago, American College Surgeons, 1993.

5. De Palma. The management of fractures and dislocations. Philadelphia, Saunders, 1970.

6. Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic
fractures. Clin Orthop 1993; 297; 28-32.

7. Key JA, Conwell ME. Management of fractures dislocations and sprains. St Louis, Mosby, 1951.

8. Letournel E, Judet R, Fractures of the acetabulum 2 ed. Nova York, Springer Verlag, 1993.

9. Muller ME, Allgower M, Schneider R, Willeneger H. Manual of internal fixation. 3rd ed. Berlin,
Heidelberg. New York, Springer Verlag, 1992.

10. Quareshi AA, Archdeacon MT, Jenkins MA et al. Infrapectinal plating for acetabular fractures a
Technical adjunct to internal fixation. J Orthop Trauma 2004; 18(3): 175-8.

11. Routt MLC, Simonian PT, Mills WJ. Iliosacral screw fixation: early complication of the
percutaneous technique. J Orthop Trauma 1997; 11(8): 584-9.

12. Simonian PT, Routt Jr. ML, Harrington RM, Tencer AF. Internal fixation of the unstable anterior
pelvic ring: a biomechanical comparison of standard plating techniques and the retrograde
medullary superior pubic ramus screw. J Orthop Trauma 1994; 8(6): 476-82.

103
13. Starr AJ, Walter JC, Harris RW et al, Percutaneous screw fixation of fractures of the iliac wing
and fracture-dislocations of the sacro-iliac joint (OTA types 61-B2.2 and 61-B2.3, or Young-
Burgess 'Lateral Compression Type II' pelvic fractures). JOrthop Trauma 2002; 16(2):116-23.

14. Tile M. Pelvic fractures Orthop Clin North Am 1980; 11:423-64.

15. Fractures of the pelvis and acetabulum. 3rd ed. Philadelphia, Williams and Wilkins, 2003.

16. Wiedner U, Frealer F, Bianchini D, Gipsfibel: Common Fixations and Extenders of the
Injuries in Childhood. Berlin, Heidelberg, New York, Springer Verlag, 1976.

104
105
MOST COMMON ERRORS IN EXTERNAL FIXATION

Dr. Alexandre Rial Dias Dr. Hilário Boatto

Complications can be divided into intraoperative and postoperative.

Intraoperative complications include vascular and neurological injuries that are related to
knowledge of anatomy and consequently compartment syndromes. The use of material
inadequate as pins and external components to the skeleton as well as the inadequate reduction and
unstable mounts contribute to the emergence of complications.

They are postoperative complications:

-infection route of pins or wires;

breakage of pins or wires;

pin release;

osteolysis

pseudo-aneurysm;

vicious consolidation;

joint stiffness;

joint deformities;

-dor

The prevention of complications begins with a good knowledge of the anatomy of the area to be installed.
the external fixator, safety runners and the care in the insertion of the pins themselves.

1- Always perform drilling at low speed to avoid thermal necrosis. The temperature
Temperatures of 50 degrees Celsius for more than a minute already cause deterioration of the bone tissue leading
the necrosis.

2- In the case of no prior drilling, the so-called self-drilling and self-tapping pin, when reaching
the second cortex encounters greater resistance to its progression. As a result, the pin rotates without
appropriate progression to the thread pitch, at its entry cortex (CIS) and there is loss of the
interference in this cortical or break in the second cortical (TRANS).

106
 The use of inadequate or improvised material: Does not provide sufficient fixation and stability
leading to a bad outcome.

In the figure above, the pins are fixed to wooden bars or components secured with cement.
orthopedic

107
The inappropriate insertion of the pins: The figure below shows the fixation through pins that secures
inadequately the bone tissue in the proximal femur and intra-articular pin in the knee.

Mounting instability

With the presence of only one distal pin. Laboratory studies show that the presence of a
a third pin in each bone segment significantly increases its stability. The addition of a fourth
the fifth pin no longer increases stability much.

108
Inadequate reduction: The contact between the bone fragments can reduce the stress on the pins.
up to 97% (Chão et AL 1982)

Infection track

The exaggerated transfixation of the pins can be avoided with the use of a 'stop'.

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Superficial infection along the pathway of the pins can be caused by their release. Many times this
slippage is caused by improper insertion technique.

Pin breakage:

The point of greatest stress in the assembly is the area of the pin located in the cortical "CIS" which is the
entry cortex of the pin.

The bone pin interface is the area of greatest stress concentration of an external fixator, being also the
weakest component of the system.

Pins with a smaller inner diameter are significantly more resistant to tensile forces.

There is no significant difference when comparing the pitch or the profile of the thread wires.

The pins with greater interference (difference between the outer diameter and the drill hole) are more
tensile resistant. (False ET al 1992)

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Osteolysis: Usually caused by thermal necrosis due to the high rotation used in the insertion of the
Pine. Always perform the drilling at low speed to avoid thermal necrosis. The temperature of
50 degrees Celsius for more than one minute already causes deterioration of bone tissue leading to necrosis.

Release of the pins:

Usually related to inadequate insertion technique:

High rotation in insertion

Absence of prior drilling
Poor bone quality (porous)
Quality of the pin (conical pins have greater interference and coated pins with
hydroxyapatite has greater integration with bone tissue.

111
The presence of one or more loose pins causes local infection, and whenever it is detected that the pin is
he must be removed.

Pseudarthrosis:

The quality of the reduction is one of the factors that most contributes to its consolidation or absence in
treatment of a fracture. In external fixation, we should always aim to achieve a reduction as much as possible
anatomical possibility to avoid delay or pseudarthrosis. With the absence of contact between the fragments
As shown in the figure below, it will certainly lead to poor evolution in osteogenesis.

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 Vicious consolidation: Result of poor quality reduction

Joint stiffness, deformity in knee flexion, and even posterior subluxation of the tibia:

Most common in thigh stretches

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Avoid the transfixation of the extensor muscles by wires or pins, encourage physiotherapy, in the absence
For deformities, use a monolateral fixator, lengthening on average 15% of the femur length.

No stretching of the femur or tibia: Deformity in knee flexion

Normally associated with the absence of rehabilitation.

The prevention of complications with external fixation is directly related to the surgical technique.
correct, early and intensive physiotherapy, positioning of the limbs in the postoperative period in this way
During the surgery, it is important to avoid trapping soft tissue by not transfixing the musculature.
extender

During the bone elongation process, it is necessary for the patient to maintain the arch of
movement from 0 to 45 degrees of flexion to maintain stretching; if this does not occur, it is
it is necessary to stop the stretching or decrease its speed to intensify physical therapy and re
establish the range of motion.

To prevent complications from femur lengthening with a monolateral fixator, one should
assemble the fixture, if possible, with the knee flexed.

The mechanical axis of the femur must be elongated and for this to happen the fixator must be placed parallel.
to the mechanical axis and not parallel to the thigh.

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Complications related to osteotomy:

Incomplete

Irregulars

Associated with fractures.

Incomplete osteotomies

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IRREGULAR OSTEOTOMIES

OSTEOTOMIES ASSOCIATED WITH FRACTURES

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CURRENT TRENDS:

Reduce the resistance of soft tissues to stretching

Stretch the soft tissues and not the femur!!

Lengthening less than 15% of the length of the femur

Remove the brace prematurely to

Facilitate recovery from knee surgery.

(external fixator + intramedullary rod)

Mid-diaphyseal osteotomy

Stretch slowly (0.5 to 0.75 mm/day)

Associate muscle tendon releases (rectus femoris)

Lateral vastus, iliotibial band, ischial-tibial

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118
TREATMENT OF ANISOMELIA OF THE LIMBS
INFERIORS

DR. HILÁRIO BOATTO

DR. FÁBIO DE ASSUNÇÃO E SILVA

The difference in limb length (Anisomelia) has varied etiology and planning
strategic in the treatment should be considered individually for each etiology in question.

In addition to assessing the present shortening, we should always check for the presence of
associated deformities that alter the mechanical axis of the lower limb resulting in overloads
articulations that result in subsequent cartilage degeneration and osteoarthritis with functional consequences
incapacitating for walking.

The treatment should be planned considering the shortening that will be present in
skeletal maturity and not on the patient's current age, if there is still growth potential.
The immediate functional and mechanical effects of anisomelia are apparent, but the late effects are
less understood. Although there is a consensus on the effects of discrepancies affecting the
Between quadris and column, there is a lack of scientific studies that prove these consequences.

Compensation mechanisms:

The child who presents shortening normally compensates better than adults.
probably due to the shorter length of the segment requiring smaller forces relative to the arm
of the lever. The march is normally executed with the foot in equine position so that the heel does not touch the
only during walking.

This attitude can lead to a contraction of the triceps surae with consequent shortening of
calcaneal tendon and irreducible equinus foot deformity. In adults, the tendency is to perform a
walking supporting the heel and the toes.

It is agreed that shortening up to 2 cm would not result in changes in gait.

important. There are reports in the literature citing that shortenings above 5.5%, considering the
the extremity of greater length would increase the mechanical work of the longer member and would increase the
vertical displacement of the center of gravity with higher energy expenditure also increasing the force
impact against the ground.

Changes in the Hip: As the difference in length increases, the femoral head
on the larger side, it is suffering a loss of its coverage as the angle CE increases, which could
increase the risk of developing degenerative arthritis but there is no documentation to prove this
theory. For each centimeter of discrepancy, there is a decrease of 2.6 degrees in the CE angle.

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 Changes in the knee joint: The difference in the length of the lower limbs
it seems to increase the incidence of knee pain in athletes, however this relationship is still not well understood.
clarified.

Changes in the column: It is not yet well clarified what they would effectively be.
changes that the column would suffer due to anisomelia of the lower limbs. The development of
scoliosis and degenerative arthritis of the spine is a concern for the parents of young patients.
however, the evidence regarding this is contradictory. Some authors show that there are no changes in
orientation of the articular facets of the vertebrae in patients with limb shortening
inferior and there is no evidence that shortening may lead to scoliosis. Some authors
they studied this relationship and it was expected that scoliosis would arise on the side where there was compensation
shortening, however in 1/3 of the cases there was scoliosis on the opposite side.

Etiology:

A - Traumatic:

Sequela fractures

Physical injuries

B- Infectious:

1- With growth retardation:

Acute hematogenous osteomyelitis

Pioarthritis

2- With accelerated growth:

Chronic osteomyelitis in children

C- Paralytic:

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Polio

Myelopathies

Cerebral palsy

D- Congenital:

Congenital femoral deficiency

Fibular and tibial hemimelia

Congenital tibial pseudoarthrosis

Hemi-hypertrophy

Varus knee

Multiple exostoses

Congenital hip dislocation

Congenital bowing of the tibia

Arteriovenous fistulas

E- Tumors

Osteochondromatosis

Giant cell tumor

Neurofibromatosis

F- Others:

Legg-Calvé-Perthes disease

Radiotherapy

Proximal femoral epiphysiolysis

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Clinical Assessment

In the presence of a patient with anisomelia of the lower limbs, the detailed physical examination
it must be carried out so that it can initially determine the origin of the shortening, that is,
whether it is at the expense of the tibia, the femur, or both segments.

The Allis sign may already indicate the origin of the shortening (Fig 1)

Fig 1–Allis test: on the left tibial shortening; on the right femoral shortening

The length of the lower limbs can also be measured through

measurement of the distance between the umbilical scar and the medial malleoli (apparent shortening) and of the
anterior superior iliac spines to the medial malleoli (true shortening)

Fig 2.

122
 Fig 2- Apparent and real measurement of the lower limbs

A - Apparent discrepancy due to pelvic obliquity. The limb length is

different when measured from the umbilical scar, while the length from

the iliac spines are symmetrical.

B- Real discrepancy of the lower limbs. The length of the limbs is different.

when measured from the anterior-superior iliac crest.

Assessment of the discrepancy with block compensation

This clinical assessment is quite accurate as when we place blocks under the lower limb more
short, until the leveling of the pelvis occurs, we will be compensating the limb as a whole. This
the procedure is of great value, especially in cases of congenital etiology such as, for example, the
fibular hemimelia in which, in addition to the difference in length of the long bones, there is a difference in height of the
bones of the foot mainly with hypoplastic calcaneus. The difference in height of this bone contributes to the
total difference in limb length and would not be considered in other measurements. Fig 3.

123
 Fig 3 - Compensation through wedges with pelvic alignment

Radiographic Examination:

It is of fundamental importance to perform high-quality radiographic examinations for the

evaluation and planning of the treatment of limb length discrepancies. Many shortenings
they present associated angular deformities that can determine changes in axis alignment
mechanics of the lower limb in the frontal and sagittal planes and also rotational deformities may be
presents.

Telerradiography (panoramic X-ray of the lower limbs)

The telerradiography is currently the radiographic exam of choice for assessment and planning.
the treatment to be performed on the patient with anisomelia of the lower limbs.

This exam should be performed with the patient standing and with the discrepancy compensated with shims until the
pelvic leveling (Fig 4)

124
 Fig 4 - Compensation of anisomelia with leveling of the pelvis for telerradiography

The Rx ampoule should be centered at the center of the knee and the patella should be aligned with the X-rays.
that is, regardless of the position of the foot, the alignment of the patella is essential for the correct measurement of
deformities that may eventually be present. (Fig 5).

Fig 5 - The figure shows the incorrect position (on the left) and the correct position (on the right) in

125
 positioning of the lower limb for the performance of tele-radiography.

The tele-radiography must include from the joint surfaces of the hips to the joint surfaces.
two ankles (Fig 6)

Fig 6- Tele-radiography of lower limbs

In addition to measuring the discrepancy, the cephalometric X-ray allows for the evaluation of any possible changes that
they can be present in the mechanical axis of the lower limb as well as in the joint surfaces. (Fig
7)

126
Fig 7 - Measurement in degrees of the joint orientation angles in the lower limb:

APFL= ângulo proximal lateral do fêmur = 90 graus; ADLF= Ângulo distal lateral do fêmur = 87 graus;
APMT= Ângulo proximal medial da tíbia = 87 graus; ADLT= ângulo distal lateral do tornozelo= 90
degrees.

The mechanical axis of the lower limb is determined by a line that starts from the center of the head of
the femur extends to the center of the ankle joint and must pass through the center of the knee or deviate
no more than 10 mm to the medial side of the joint. (Fig 8). In the case of valgus deformities this
The line will pass laterally to the center of the knee, and in cases of varus deformities, it will pass medially to the center of the knee.

knee.

127
 Fig 8- Mechanical axis of the lower limb

Treatment

After the clinical and radiographic evaluation of the patient with limb anisomelia
The treatment to be performed will depend on the current shortening and the forecast of the discrepancy in
skeletal maturity. The method currently used is the one recommended by Paley–Multiplier. This
the method allows us to calculate what the shortening in skeletal maturity will be and also what will be
the height reached at the end of growth. It is a simple method, easy to apply and
immediate visibility as can be seen in table 1.

128
 Table 1-- Multiplier: for determining the discrepancy of the lower limbs at maturity
skeletal.

The calculation is very simple. We must consider different values for boys and girls, since
that the growth standard is different for both. To the left of the table is the multiplier for boys and the
to the right of the table, the multiplier for girls.

The calculation of shortening at skeletal maturity is done as follows: Consider an example of a

boy with a current age of 4 years and 6 months who shows a shortening of 5 cm. In the multiplier table,
Boys, see the value of the multiplier corresponding to the age of 4 years and 6 months. We found the value of
1.890. Multiply the current shortening (5cm) by the value of the multiplier (1.890). The result will be 9.45 cm which
it will be the shortening in the skeletal maturity of the patient in question.

The table below shows the multiplier for height where we take the patient's current height and multiply it.
by the value found in the table, corresponding to the current age. The result will be the height in maturity
skeletal. (Table 2)

Table 2 - Multiplier for calculating height at skeletal maturity

129
More recently, a multifunctional app for smartphones has become available that does the
prediction of anisomelia at skeletal maturity besides providing other facilities in the management of
anisomelias (Paley Growth)

Non-surgical treatment: Patients with shortening of up to 2 cm do not need to

treatment for equalization of the limbs.

Use of insoles and heel elevation: to compensate for discrepancies is an efficient and easy way.
resolution of the anisomelias however the maximum that the patient tolerates for internal compensation (within the
The shoe) is 1.5 cm. For differences above this value, it becomes necessary to add a sole.
external to the footwear until the alignment of the pelvis is achieved. (Fig 9)

If the patient has a shortening of 4 cm, we can compensate 1.5 internally with an insole and 2.5 cm.
with the elevation of the shoe sole. In everyday practice, we find that the biggest obstacle to the use of
the elevations of the sole are found among adolescents who do not use external compensation because they
they will feel the object of attention from colleagues. Self-esteem is negatively affected by the use of sole
external and the adherence to use by adolescents is very low.

130
 Fig 9 - raising the shoe sole to compensate for shortening

Use of prosthetic orthosis: when the discrepancy of the limb is more pronounced, the weight of a sole in
footwear overly compromises function and energy expenditure increases on a large scale. There is the alternative of the
use of a prosthetic orthosis as shown in figure 10.

Fig 10 - Orthosis-prothesis as an alternative in compensating for greater discrepancies

Lateral shortening: although it is a method described in the literature for the equalization of the limbs
we are not sympathetic to this type of resolution because there is a need for us to act in

131
healthy limb, that is, surgery would be performed on the contralateral side to the affected limb by
shortening. Moreover, if it is performed, an osteotomy for bone resection would be necessary and this
the bone must be fixed with some implant material, with the inherent risks of the surgical procedure.
Although some authors claim that shortening can be performed by 5 cm in the femur and 3 cm in the tibia.
we believe that there is a significant loss of tone and consequent loss of muscle strength caused by
acute shortening of the segment which impairs the stability and function of the limb.

Contralateral epiphysiodesis: It involves the temporary or permanent surgical blocking of the growth of a
or the extremity of long bones through the use of staples, screws or metal plates. The Staples
Blount plates are the most used and currently 8-shaped plates are available on the market to
perform the epiphysiodeses. (Fig 11 A and B).

Fig 11 A and B - Show some examples of techniques for epiphysiodesis.

Bone elongation:

The first attempts to perform bone stretching through an osteotomy they are reassembled
to the 19th century with Hopkins in 1889, being the first author to perform an osteotomy, lengthening
sharp and bone grafting placement in leg bones. Osteotomy and sudden traction were also
reported by Codivilla in 1905 and Magnuson in 1908 as a way to achieve stretching
osseous.

132
Several other authors followed with similar techniques and a high rate of complications.
leading to a discredit regarding the technique used.

In 1981, it was presented at the XXII Congress of the Italian Club from June 12 to 14, 1981, in Bellagio.
Italy or Prof. Graviil Abramovich Ilizarov, Russian doctor who developed studies on regeneration
of bone tissue and demonstrated that osteogenesis was perfectly viable as long as the
biological principles of tissues. Developed a methodology for the preservation of the periosteum and
endosteal, during the osteotomy, and a rhythm, periodicity, and stability in bone elongation,
principles that revolutionized the approach to bone elongation and the concept of
osteogenesis.

Femur stretching

In the shortening of the lower limb to the cost of the femur, with the indication of lengthening it.
bone, special attention should be given to the knee joint since the preservation of function
this articulation will allow or prevent its stretching. This means that the stretching of
the femur depends almost exclusively on how the knee will behave throughout the entire process of
bone elongation. The goal of treatment should primarily be the function of the limb. In order to
maintain a good function we must aim for, in addition to equalizing the members, to preserve the
knee movement arc. Laboratory gait studies show that the knee, during the
marching on a flat surface creates an arc of movement that goes from zero to sixty-two degrees.
If the patient does not regain mobility in this joint to at least this standard, they will present
limping during walking. To sit with a minimum of comfort, the knee must flex at least
at 90 degrees.

Due to the high risk of limiting the range of motion of the knee, related to stretching of the
femur, several preventive measures should be taken when planning stretching: stabilize the
hip and knee joints if they present any instability, correct deformities
associated and stay attentive to the movement arc of the knee to avoid functional compromise.

Thigh stretching in the absence of deformities:

When we evaluate the patient who presents anisomelia of the lower limbs, which is caused by
due to the shortening of the femur, we must evaluate in the clinical and radiographic examination if there is the presence of
angular or rotational deformities associated. In the absence of any angular deformity or in the
presence of small angular deformities subject to acute correction is the best option for
stretching is done using monolateral fixators.

133
 This type of fixation on the lateral face of the femur allows the extensor musculature to remain completely
free from any fixation with pins, thus facilitating knee mobilization (Fig 12) Moreover,
we opted for a diaphyseal or proximal osteotomy just below the lesser trochanter, with its
remote location of the knee trying to minimize the restrictive effects on the movement of this joint.

Fig 12- Monolateral external fixer for femur elongation

Surgical technique:

With the patient positioned in horizontal supine position, after preparing the surgical field,
we used the cord of the electric scalpel and with the use of the image intensifier we marked a
proximal point in the center of the head of the femur and a distal point in the center of the knee (fig 13) We traced
then a line between these two points thus drawing the mechanical axis of the femur (fig 14).

134
 Fig 13 - Finding the mechanical axis of the femur Fig 14 - Tracing the mechanical axis
of the femur

The external fixation device should be positioned parallel to this line, meaning the elongation will be
performed while maintaining the mechanical axis of the femur. (fig 15)

Fig 15 - Shows the parallelism between the mechanical axis and the external fixator.

135
 Next, the sites for pin insertion are identified, with a minimum of 3 pins being placed.
proximal (6 cortical) and 3 distal pins. In cases of adult patients with a femur of
greater length that exerts a greater lever arm, we prefer the placement of 3 pins
proximal and 4 distal pins.

The pins used are 6 mm in adults and 5 mm in children. We must always perform the drilling.
previously, with low rotation to avoid thermal necrosis, and insert the Schanz pins
manually. If the patient has a range of motion in the knee that allows for the placement of the pins
with the knee flexed at 90 degrees this position should be adopted, as it occurs with less entrapment
of soft tissues facilitating knee rehabilitation. (Fig 16).

Fig 16 - Placement of the monolateral external fixator with the knee flexed at 90 degrees.

After the connection of the components, the osteotomy is performed and the elongation should be initiated. In the
the most current trend recommends performing a stretch that corresponds to a maximum of 15% of
femur size at a speed of ¼ mm every 12 hours. With a slower stretching rate, it occurs
better adaptation of soft tissues and lower risk of joint stiffness. As the osteotomy is not performed
In the metaphysical region and indeed diaphysial, the stretching at a slower pace and speed allows for the occurrence of the
osteogenesis in the bone regenerate (fig 17).

It is very important to always perform passive mobilization of the knee after the end of the surgical procedure.
its maximum amplitude to prevent soft tissue entrapment by the pins of the external fixator
that will allow the maintenance of the mobility of the knee joint (fig 18 and 19).

136
Fig 17 - shows the bone regenerate Fig 18 - Knee extension

Fig 19 - Knee Flexion

137
Femur stretching with circular fixator

The use of circular fixators for femoral lengthening is reserved for patients who
present with anisomelia associated with angular or rotational deformities that cannot be corrected
sharply. The circular geometric configuration allows for the stretching to be carried out.
concomitant with the correction of any deformities that may be present in the limb. Generally in the
patients with congenital shortening exhibit angular deformities and/or
rotational associated requiring simultaneous corrections to elongation.

The placement of the circular fixator follows the same principles reported above for the fixator.
monoplanar, that is, elongating the mechanical axis, low-speed bone drilling, and manual insertion of the
Schanz pins.

The external fixation device consists of a proximal arch and two distal rings, with the most distal one
positioned 1.5 to 2 cm from the growth line of the distal femur. In patients with etiology
Congenital, the assembly of the fixator must always be extended to the tibia with one or two more rings to be
prevent knee flexion deformities, subluxation and/or stiffness of this joint. The blocks
femoral and tibial are connected by 2 hinges positioned at the center of rotation of the knee and one
anterior bar. During the stretching, in the rehabilitation of this patient, the anterior bar is released which
allows for the performance of active and passive exercises for the knee (fig 20 and 21).

Fig 20- Circular fixation assembly for femur lengthening, tibia inclusion and hinges in the center
of the rotation of

knee to allow the mobilization of this joint.

138
 Fig 21 - Knee flexion with circular external fixator maintaining the largest range of motion
possible.

With the use of circular fixator, the osteotomy is performed in the distal metaphyseal region of the femur between the
two distal rings and the bone elongation is gradually being carried out at a rate of 1 mm per day in the
first week and then ¼ mm every 8 hours. The pace and speed of the stretching should be
suitable for each patient, as the biological potentials for regeneration and the response of the joint
the knee extension varies individually. (Fig 22) When the desired extension is achieved,
The calcification of the regenerated bone is awaited, and the device is removed after its corticalization.
the range of motion of the knee must be preserved (Fig 23 and 24).

Fig 22 - Shows the bone regeneration during the elongation of the femur

139
 Figures 23 and 24 show the flexion and extension movement of the knee after stretching with a fixer.
circular.

Care during femur stretching

During the lengthening of the femur, various complications can arise and to minimize them the
The surgeon must strictly follow the considerations mentioned above. In addition, a special
attention must be given to the articulation of the knee, always with the aim of preserving the arch of
movement. Functional limitations of this important joint will compromise gait in the future.
During the stretching of the femur, the range of motion demonstrated by the knee must be at least
from zero to 45 degrees. If the patient loses this range during treatment, the stretching should be
interrupted and physiotherapy should be intensified. If the patient recovers the arc of 45 degrees the
stretching can be restarted. If this does not occur, stretching should be interrupted. It is
fundamental importance of physiotherapy assistance to the patient and it must cover from the pre- phase
surgery until the total rehabilitation period after the removal of the external fixator. The main
complications of femoral lengthening are related to the knee joint: deformity
in flexion, subluxation, and joint stiffness. The goal of treatment is to correct the discrepancy, but
with a joint that maintains its normal function. It should always be remembered that it is of no use
lengthen the femur and create a joint stiffness that will severely compromise function.

The pre-operative evaluation of the patient should be multidisciplinary and thorough, involving the aspect
surgical, psychological and rehabilitation. Several reasons can prevent the patient from undergoing the
appropriate rehabilitation. Difficulties in transportation, financial, social, etc.

140
Caso seja detectado qualquer fator que dificuldade o comparecimento do paciente para reabilitação a
The decision to perform bone lengthening must be very carefully considered and is often contraindicated.
since the function will be seriously compromised in carrying out infrequent physiotherapy or in
absence of the same.

Stretching of the leg bones

When we detect that the anisomelia is due to the shortening of the leg bones, this segment should
be prolonged, always with the clinical and radiographic evaluation of the patient. The cephalometric X-ray should be
performed and the presence of additional deformities to the shortening must be considered and corrected.

The tibial lengthening can be performed in cases where there is shortening due to the femur when
if there is any contraindication to the stretching of this, such as limitation of the knee's range of motion
which is usually due to previous stretching in the femur.

Leg bone elongation with unilateral fixator

We prefer the use of unilateral fixators when there are no deformities present in the
segment to be elongated or, if they exist, be subject to acute correction with subsequent fixation and
stretching.

The use of a unilateral splint is better tolerated by the patient in their daily life activities due to its
positioning on the anteromedial face of the tibia, practically without transfixing large volumes of tissues
moles.

Surgical technique

The patient is positioned in a horizontal supine position and after the usual preparations, the procedure should be performed.
fixation of the proximal and distal fibula with cannulated screws. This fixation is necessary to prevent the
migration of the fibula during the bone lengthening process.

Next, a osteotomy of the middle to distal third of the fibula is performed, followed by layered stitching and skin closure.

Using the image intensifier, a guidewire is inserted proximally and distally in the tibia, connected to
a 'template', thus facilitating the perfect alignment of the fastener with the mechanical axis of the tibia. (Fig
25)

141
 Fig 25 - Shows the guide wires that will be inserted into the tibia to guide the alignment of the
fixative.

Next, we insert a soft tissue protector, a drill guide, and after drilling, we apply the low.
rotation a first pin is manually inserted into the bone. (Fig 26 a and 26b)

Figure 26 a and 26 b show the positioning of the soft tissue protector and drill guide.

Next, the same procedure is performed distally, always taking care to do so in this
moment to align the fixator with the tibia in both the frontal and sagittal planes. A hole is created
now in the distal part of the tibia a distal pin is inserted using the same technique described above.

Once the fixer is fully aligned, the other pins are inserted and the
assembly completed (fig 27 A and B)

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 Fig 27 a e 27 b - Show the alignment and final assembly of the monolateral external fixator.

We then performed the osteotomy of the proximal tibia and the patient will begin the elongation.
waiting around seven days for the start, if the osteotomy was performed with an osteotome and 15 days
if the osteotomy was performed with a Gigli saw.

We recommend that the stretching be done 1mm per day divided into four times, being 0.25 mm each.
every 6 hours in the first week and after we confirm radiographically that the elongation is
occurring without any obstacles, we proceed to extend 0.25 mm every 8 hours, that is, 0.75 mm per day. The
bone elongation is maintained at this frequency and speed, always evaluating osteogenesis at the focus of
stretching and adjusting the speed to the patient's biology (fig 28 a and 28b). If the bone regenerated
if weakened, the stretching rhythm is reduced.

Fig 28 A and B - Beginning and progression of bone elongation

143
Special attention should be given to the articulation of the ankle, as there is a tendency towards equinus.
ankle during the stretching of the leg bones. The patient should be guided and encouraged to
maintain intense physiotherapy monitoring and to maintain the range of motion of the ankle.
Stretches up to 5 cm are well tolerated by this joint as long as an intense rehabilitation is conducted.
carried out throughout the treatment.

Upon achieving the proper stretching with the equalization of the lower limbs, the fixator device
The external device should be maintained until bone consolidation and then removed. (Fig 29 A and B).

Fig 29 A and B - Shows bone consolidation after elongation and after removal of the fixator.

During the entire treatment with the unipolar fixator, the patient will be able to walk with weight.
partial gradual using support with crutches.

Leg bone stretching with circular fixator

In the presence of anisomelias associated with severe deformities of the lower limb, the external fixator
circular allows for the desired stretching as well as the gradual correction of
angular, rotational, and translational deformities. It is also common for us to encounter serious
deformities in the feet of patients with congenital deformities where it is necessary to associate with
correction of the foot to bone elongation. A common example is fibular hemimelia. In these
situations where the use of a circular external fixator allows for elongation and simultaneous correction of the

144
associated deformities. If the necessary elongation for the equalization does not exceed 5 cm,
the assembly of the circular fixture is limited to the leg, without the need to include the foot. Intense
Physical therapy becomes necessary to prevent deformities. If stretching is required above
5 cm makes foot assembly mandatory for the prevention of deformity in horses.

Surgical Technique

With the patient positioned in horizontal dorsal decubitus, after the usual preparations, we began the
procedure with fibula osteotomy in the middle to distal third. Then, we inserted a smooth wire
1.8 mm in the proximal tibia, under fluoroscopic control, perpendicular to the axis of this bone and we centered it.
the assembly of the external fixator, composed of 3 rings, on the leg, taking care to maintain a
safe distance (around 4 cm) from the skin mainly at the back to avoid compressions
in case of severe edema. The wire is fixed to the proximal ring with wire-fixing screws. With the device
centrally we then passed a smooth wire of 1.8 mm through the distal tibia, centering the distal ring and
fixing with wire-fixing screws on the corresponding ring. Each ring will be attached to two Schanz pins.
conical, with a diameter suitable for the patient's age, and a wire of 1.8 mm. It is important to ensure that the
the wire inserted in the distal ring must be introduced into the posterolateral face of the leg towards the region
Antero medial and should fix the fibula, thus avoiding its migration during the stretching process.
osseo. The wires of each ring are tensioned. The setup for the stretching consists of 3 rings being
one proximal at the level of the head of the fibula, a second ring, distal to it at a distance of 2 cm from
focus where the metaphyseal osteotomy of the tibia will be performed and a third more distal ring on the leg. (Fig
30)

Fig 30 - Shows the configuration of the circular fixator for bone lengthening.
leg

Proximal fixation of the fibula is also necessary to prevent its migration during stretching and is
performed with the insertion of a 2.5 mm Kirschner wire which is inserted through the fibular head in
direction to the anteromedial region of the tibia, where it externalizes medially and is buried in the

145
posterolateral region. The burial of this proximal fibula wire provides greater comfort to the patient.
and does not hinder the bending movement of the knee. (Fig 31)

Fig 31- The red line shows the direction of insertion of the proximal fibular fixation wire and the white arrow
points out the burial site of the same.

After the assembly is completed, a proximal tibial osteotomy is performed for lengthening.
the technique of osteotomy is at the surgeon's discretion, and it may be performed with prior perforations and
osteotome or with gigli saw. If performed with an osteotome, the elongation should be started in
maximum in the first week after its performance. If performed with a Gigli saw the
Stretching should begin 15 days after the osteotomy is performed.

Stretching starts with ¼ mm every 6 hours in the first week. After 1 week, a check-up.
The radiographic is done and the stretching starts to be done ¼ turn every 8 hours, totaling 0.75 mm per day.
(Fig 32)

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 Fig- 32- Shows the radiographic image of the beginning of bone lengthening

After achieving the planned elongation, we await the corticalization of the regenerated bone. (Fig 33)

Fig 33 - Shows uniform and homogeneous bone regeneration after tibia elongation.

After the consolidation of the regenerated bone, the external fixator is removed, under anesthesia in the center.
surgical.

147
It is essential that the patient undergoes physiotherapy throughout the entire treatment.

Fig 34 A, B and C - Show respectively the initial discrepancy, the device in use and the equalization of
members after removal.

Complications

During bone lengthening, superficial infection along the path of the wires and pins is common, but
easily treated with proper local cleaning and the use of oral antibiotics.

The most common complications in femur extension are: knee flexion deformity,
joint stiffness and eventually joint subluxation may occur. Rehabilitation should be part of
mandatory treatment with pre- and post-operative guidance, physiotherapy should be maintained
even after the removal of the external fixator, in order to prevent deformities and maintain tone
muscular.

In the elongation of leg bones, the main complication is related to equinus deformity.
foot and in some cases deformity in knee flexion. Rehabilitation during treatment is essential
to prevent and combat these complications.

148
STRETCHING ABOUT INTERNAL IMPLANT

A form of stretching that is currently in the spotlight is bone stretching on

internal implant. For approximately 15 years, leg lengthening has been performed.
with an external fixator on an intramedullary rod, whether in the tibia or the femur. Recently, new studies
They also promote the stretching with an external fixator associated with a submuscular plate.

The external fixator is applied to the limb after the osteotomy and placement of the internal implant. The implant
the internal is fixed only at one end, usually the proximal end. After this stage, the
The fixative is applied with care to avoid contact between the wires and pins and the internal implant. (Fig )
35).

Fig 35 - Shows the elongation of the femur being performed under an intramedullary rod.

The greatest advantage of distraction over internal fixation is the reduction in the time of use of the fixator.
external, once the desired length is reached, the rod or plate is locked to the
distal fragment and thus the fixator is removed. In addition, decrease in joint stiffness of the knee,
decrease in the incidence of infection along the pin path and increase in elongation speed are
other advantages mentioned by the enthusiasts of this technique.

Intramedullary infection is the most concerning complication and occurs at an incidence that ranges from 3% to
15%. It is associated with the contact between the intramedullary rod and the wires and pins of the external fixator. The plate is
used as an alternative to reduce this complication and better indicated in patients
skeletally immature, where the use of the intramedullary rod would lead to damage to the growth plate.

Ankle equinus deformity is the most common complication and is associated with greater
stretching speed and low adherence to rehabilitation.

149
Stretching with internal implant

Since the 1970s, we have been seeking ways to promote bone elongation with implants.
intramedullary. Thus, it would be possible to reduce the complications resulting from the elongation of the
members with external fixators.

Various types of intramedullary rods have been developed for this purpose. Some use
controlled external rotation movements of the distal fragment for length gain and currently
We have motorized rods that are activated by remote control.

Recent studies suggest that these devices reduce the incidence of stiffness and joint pain and
They eliminate the infection problem in the pin path.

As complications of this type of treatment, we have system failure and distraction control.
still requires even greater care in monitoring these patients.

150
Bibliographic References:

Aronson, J., and Harp, J. H.: Mechanical forces as predictors of healing during tibial lengthening by
distraction osteogenesis.Clin.

Orthop,301:73-79,1994.

Bonnard, C; Favard, L.; Sollogoub, I.; and Glorion, B.: Limb lengthening in children using the
Uizarov method. Clin. Orthop.,293:

83-88, 1993.

Cattaneo, R.; Catagni, M.; and Johnson, E. E.: The treatment of infected nonunions and segmental
defects of the tibia by the methods of

Uizarov. Clin. Orthop., 280:143-152, 1992.

Catagni, M. A.; Bolano, L.; and Cattaneo, R.: Management of fibular hemimelia using the Ilizarov
method.Orthop. Clin. North America,

22:715-722, 1991.

Coglianese, D. B.; Herzenberg, J. E.; and Goulet, J. A.: Physical therapy management of patients
undergoing limb lengthening by distraction osteogenesis. J. Orthop. and Sports Phys. The/:,17:124-
132,1993.

Eldridge, J. C. and Bell, D. F.: Problems with substantial limb lengthening. Orthop. Clin. North
America, 22: 625-631, 1991.

Green, S. A.: Postoperative management during limb lengthening. Orthop. Clin. North America, 22:
723-734, 1991.

Green, S. A.: Ilizarov method. Clin. Orthop., 280: 2-6, 1992.

Herzenberg JE, Paley D. Tibial lengthening over nails (LON). Tech Orthop.

1997;12:250-9.

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Ilizarov, G. A.: The tension-stress effect on the genesis and growth of tissues. Part I. The influence of
stability of fixation and soft-tissue preservation. Clin. Orthop, 238: 249-281, 1989.

Ilizarov, G. A.: The tension-stress effect on the genesis and growth of tissues: Part II. The influence of
the rate and frequency of distraction. Clin. Orthop., 239: 263-285, 1989.

Ilizarov, G. A.: Clinical application of the tension-stress effect for limb lengthening. Clin. Orthop.,
250: 8-26,1990.

Bone transport using the Ilizarov method:

a review of complications in 100 consecutive cases. Strategies Trauma Limb Reconstr.

2010;5:17-22.

Morrissy, Raymond T.; Weinstein, Stuart L.

Lovell & Winter's Pediatric Orthopaedics, 6th Edition 2006 Lippincott Williams & Wilkins

Paley, D.: Current techniques of limb lengthening. /. Pediat. Orthop., 8: 73-92, 1988.

Paley, D.: Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin.
Orthop., 250: 81 -104, 1990.

Paley D.Principles of deformity correction. 1st ed, 3rd printing. Berlin: Springer-Verlag; 2005.

Paley, D., and Tetsworth, K.: Percutaneous osteotomies. Osteotome and Gigli saw techniques. Orthop.
Clin. North America, 22:613-624, 1991.

Paley, D., and Tetsworth, K.: Mechanical axis deviation of the lower limbs. Preoperative planning of
uniapical angular deformities of the tibia or femur. Clin, Orthop., 280:48-64, 1992.

Paley, D., and Tetsworth, K.: Mechanical axis deviation of the lower limbs. Preoperative planning of
multiapical frontal plane angular and bowing deformities of the femur and tibia. Clin, Orthop., 280: 65-
71,1992.

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Paley, D.; Fleming, B.; Catagni, M.; Kristiansen, T.; and Pope, M.: Mechanical evaluation of
external fixators used in limb lengthening. Clin. Orthop, 250:50-57, 1990.

Paley D, Herzenberg JE, Paremain G, Bhave A. Femoral lengthening over an

intramedullary nail. A matched-case comparison with Ilizarov femoral lengthening.

J Bone Joint Surg Am. 1997;79:1464-80.

Paterson, D.: Leg-lengthening procedures. A historical review. Clin. Orthop., 250: 27-33, 1990.

Price, C. T., and Mann, J. W.: Experience with the Orthofix device for limb lengthening. Orthop.
Clin. North America, 22: 651-661, 1991.

Simpson AH, Cole AS, Kenwright J. Leg lengthening over an intramedullary nail.

J Bone Joint Surg Br. 1999;81:1041-5.

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154
OSTEOMYELITIS
Dr. Adriana Macêdo Dell Aquila

Osteomyelitis (OM) is an important inflammatory and infectious process in the bone.

enrolled with high productivity loss and consequences with high health costs (people
young and active)
The rate of orthopedic trauma ISC ranges from 0.94% to 12.5%, with a higher probability of
resolution in the acute phase, but the chronic form may have therapeutic failure in 30 to 80%
two cases.
By definition, Chronic Osteomyelitis (COM) presents itself as a persistent infection,
even after treatment of acute condition, confirmed by radiological and surgical criteria
or anatomopathological at the end of a year after osteosynthesis, infection after trauma that
persists for more than 4 weeks after diagnosis and treatment of non-union fractures
after treatment of infection in the surgical site of orthopedic osteosynthesis.
The pathogenesis of OM occurs through the adherence of Staphylococcus aureus via receptors.
for components of the bone matrix (fibronectin, laminin, collagen, bone sialoglycoprotein).
The adhesion to collagen (fig.1) promotes bacterial survival
intracellular (osteoblasts), with the release of cytokines (IL-1β, IL-6, IL-8, TNFα) as a factor
osteolytic.

Fig.1. infection by S. aureus

In histopathology, there is deposition of fibrin, with infiltration of PMN, reabsorption.

osseous (sequestration) and formation of bone tissue (fig.2).
The most common etiological agents in OM are listed in the table below:

155
 S. aureus (sensitive or resistant to OXA) More frequent

S. Coagulase negative or Propionibacterium Associated with foreign body infection

Enterobacteriaceae or P. aeruginosa Common in Nosocomial Infections

Associated with bites, diabetic foot and ulcer

Streptococcus or Anaerobes from the supine position

Salmonella or S. pneumoniae Sickle Cell Anemia

Bartonella henselae HIV-related infection

Pasteurella multocida or Eikenella Animal or human bite

corrodens

Aspergillus, Candida albicans or Immunocompromised Patients

Mycobacterium avium

M. tuberculosis High prevalence of Tuberculosis

Whose pathology is endemic
Brucella, Coxiella brunetti or another fungus

Fig.2. Image of sequestration and bone neoformation

156
 In OM there are several classifications:

Waldvogel Classification
Hematogenous Osteomyelitis
Osteomyelitis by Contiguity
Osteomyelitis associated with
Vascular Disease
Chronic Osteomyelitis

Cierny and Mader classification (fig. 3).

Anatomical Stage
Medullary Osteomyelitis
Superficial Osteomyelitis
Localized Osteomyelitis
Diffuse Osteomyelitis
Physiological Stage
Normal Host
Systemic Commitment
or Local
C: Treatment worse than the disease

Fig.3. Cierny and Mader Classification

Roberts Classification
Type 1A - metaphyseal scoop lesion - most common
Type 1B–similar to 1A with the sclerotic cortex
Type 2 – metaphyseal bone erosion often including the cortex
Type 3 – localized cortical and periosteal reactions that resemble osteoid osteoma
Tipo 4–reações periosteais em casca de cebola
Type 5–epiphyseal erosions
Type 6 – affecting vertebral bodies

157
 For infection time
Recent: < 3 months after surgery
Perioperative
Virulent microorganisms (S. aureus, GNB)
Localized pain, erythema, edema, discharge, fever
Moderate: 3 months to 2 years after surgery
Low virulence microorganisms (SCN)
Persistent or progressive pain - signs of infections are frustrating
Late: > 2 years after the surgery
Hematogenous dissemination - skin, respiratory tract, oral cavity or urinary tract.

There are numerous risk factors for bone infection. The table below demonstrates
this information:
Use of drain (OR 2.3 IC95%= 1.3 - 3.8 p=0.004)
(OR 4.6, 95% CI = 3.8 - 6.5)

Number of surgeries (OR 3.4 IC95% = 2.0 - 6.0 p = 0.001)

(OR 9.6 IC95% = 8.2 - 11.0)

Diabetes (OR 2.1 IC95%= 1.2 - 3.8 p=0.028)

Heart Failure (OR 2.8 IC95% = 1.3 - 6.5 p = 0.026)

ASA > 2 (OR 3.9 IC95% = 1.8 - 8.8 p = 0.001)

External fixer (OR 2.9 IC95% = 1.4 - 5.9 p = 0.005)

Surgery duration > 2h (OR 2.1 IC95% = 1.5 - 4.2 p = 0.03)

Internal fixation (OR 3.8 IC95% = 2.4 - 5.2)

Location of the tibial injury (OR 2.3 IC95% = 1.3 - 4.2 p = 0.005)

Infected wound (OR 8.7 IC95% = 4.6 - 16.4 p < 0.001)

Post-implant or prosthesis (OR 35.9 IC95%= 8.3–154.6)

The laboratory tests used are ESR, PCR (rapid increase 6-8h with peak 48h
and rapid decline with a half-life of 48h), α 1 acid glycoprotein, fibrinogen, TNF,
procalcitonin and IL6.

158
 Imaging diagnosis can be done through:
Conventional radiography (X-ray)
Computed tomography (CT)
Ultrasound
Magnetic Resonance Imaging (MRI)
Nuclear Medicine
Bone scintigraphy
Positron emission tomography (PET) with Fluorine-18-fluorodeoxyglucose (FDG)

Fig. 3. MRI showing infection of the vertebral body

The treatment of OM remains undefined in a literature review of the last 30.

years. It cannot be stated which is the best antibiotic, route, and duration of treatment.
Most studies are based on personal experiences or groups, being
conducted with few patients and in a non-randomized way.
The main objective after surgical site infection in osteosynthesis is to
fracture consolidation and OMC prevention. A good surgical cleaning technique should
preserve the activity of alkaline phosphatase, formation of the bone nodule and the removal of bacteria
adhesive.

159
 Some authors suggest the following treatment regimen:

Acute Osteomyelitis in 4-6 days (IV) followed by

Children 3-4 weeks (VO)

Acute Osteomyelitis in 2-4 weeks (IV) followed

Adults from 2-4 weeks (VO)

Chronic Osteomyelitis or 2-6 weeks (IV) followed

associated with devices of therapeutic (VO) by
orthopedic duration ≥ 3 months

The administered antibiotics:

160
161
CORRECTION OF DEFORMITIES IN THE LOWER LIMBS
DR. OSVALDO CLINCO JR

Introduction

In order to understand the deformities of the lower limbs, we must first,

establish the parameters and limits of normal alignment and how to achieve them so that there is a
proper planning and a satisfactory result at the end of the correction.

Normal axis

We can determine the axis of the lower limbs in two ways: the mechanical axis and the
anatomical.

The mechanical axis that represents the load axis of the lower member is determined by 2
points interconnected by a line, being the center of the hip and ankle joints, having as
parameters the center of the femoral head and the center of the talus, passing through the knee (Figures 1 and 2).

To separately define the axis of the femur and tibia, one must determine the center of the head.
femoral and draw a line to the center of the femoral condyles. In the tibia, determine the center of the plateau.
tibial and extend it to the center of the talus.

A B C

162
 Figure 1 – References for tracing the mechanical axis of the femur: A – center of the femoral head. B -

midpoint of the line that tangents the femoral condyles. C - mechanical axis of the femur.

C D E

Figure 2 - References for tracing the mechanical axis of the tibia: C - midpoint of the line that

tangency or tibial plateau, D–midpoint of the line that tangents the distal articular surface of the tibia
(toward the center of the talus) E–mechanical axis of the tibia.

The anatomical axis is a mid-diaphyseal line of the femur and tibia. This should be measured.
separately in the tibia and the femur, being determined by the midpoint of the diaphysis of both. In the tibia the
The line starts at the midpoint of the tibial plateau and extends through a mid-diaphyseal line.
determined by midpoints on the diaphysis, whereas in the femur the line starts at the midpoint of the
piriform fossa and extends to the center of the femoral condyles, also determined by midpoint
in the diaphysis (Figures 4 and 5).

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Figure 4 - Determined by the line drawn from the midpoint of 2

medial diaphyseal levels of the femur.

Figure 5 - Determined by the line drawn from the midpoint of 2 average diaphyseal levels of the tibia.

Defined as the lines, we must obtain the angles in relation to the mechanical axis, the main ones being the
proximal lateral do fêmur 90 º (85º-95º), distal lateral do fêmur 88º (85º-90º), proximal medial da tíbia
87º (85º-90º), distal lateral of the tibia 89º (86º-92º) (Figure 6).

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Figure 6–Main angles obtained from the mechanical axis of the lower limb.

Determination of deformity through X-rays

To determine the deformity, an X-ray is needed in which we can observe the member.
lower as a whole in order to calculate the deformations and shortenings.

That radiography is defined as telerradiography of the lower limbs or panoramic radiography of the
lower limbs.

To carry out such an examination, we must follow certain parameters:

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always level the pelvis before performing the exam

the patella should be positioned at the Zenith of both members

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it must be performed in an upright position.

the distance of the patient to the tube must be 3.05m centered on the patella (recommended distance)
so that there is no change in size due to the magnitude of the examination) (Figure 9).

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Test of Poor Alignment

This test is important to initially determine if the lower limb in question presents
or not the deformity.

We determined the center of the femoral head and the center of the ankle and drew a line connecting the two.
two points. When the line crosses the center of the knee, the affected limb does not present bad
alignment (Figure 10).

Figure 10–Normal mechanical shaft without misalignment.

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 If the line projects medially to the center of the knee, we have a poor alignment in varus.
(Figure 11) and when projected laterally to the center, we have poor alignment in valgus.

Such deformities can originate from the tibia, femur, or joint, which should be defined.
later.

Figure 11–Mechanical axis altered with varus misalignment test.

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PLANNING IN THE CORRECTION OF DEFORMITIES IN THE FEMUR

Dr. Thiago Amorin Bastos

Introduction

Femur deformities lead to a change in the mechanical axis of the lower limb, thus causing
difficulty in walking, joint overload, and accelerates joint wear. In this way, the
Correction of femur deformities is of great importance for the maintenance of gait.

The main causes of deformity in the femur are: sequelae of trauma, rickets, poliomyelitis.
congenital femur deficiency, myelomeningocele and bone dystrophies.

The patient's evaluation begins with the patient's entry into the office, observing their posture and
marching of the same. After the static and dynamic inspection, specific examinations and
image, such as: actual and apparent measurement of the lower limbs, Nelaton-Galleazzi test,
escanometry and telerradiography.

A telerradiography is a radiographic examination of the entire lower limb performed on a 130 film.
cm following the premises below:

The pelvis must be aligned, using compensations if necessary;

The kneecaps should be aligned;

The film must be 130 cm;

The distance from the movie to the bulb should be 305 cm;

To be performed in profile, the patient must be angled 30 to 45 degrees with the film.

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MULTIPLIER:

The Multiplier is a tool used to assist in the planning of the correction of

deformities. The table below presents a ratio for each age and gender that should be multiplied
by the size of the discrepancy. For example, to calculate the discrepancy at the end of growth of
a male child 5 years and 6 months old with 10 cm of limb shortening
lower right: 10 X 1.740 = 17.4 cm

PLANNING:

To plan the correction of femur deformities, it is necessary to draw the mechanical axes,
anatomical and know the normal angles of the lower limb.

FRONTAL PLANE:

Mechanical axis of the lower limb: a line formed between the central point of the femoral head and the point
average of the distal articular surface of the tibia.

Mechanical axis of the femur: line formed between the central point of the femoral head and the midpoint of
intercondylar fossa.

Anatomical axis of the femur: line formed between two midpoint points of the proximal and distal femoral diaphysis.

Mechanical and anatomical axis of the tibia: line formed between the midpoint of the tibial plateau and the point
average of the distal articular surface of the tibia.

LPFA (lateral proximal femoral angle): line formed by the central point of the femoral head and the top of
greater trochanter with the mechanical axis of the femur, being 90 degrees.

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LDFA (lateral distal femoral angle): distal joint orientation line of the femur with the mechanical axis
of the femur, being 88 degrees.

MPTA (medial proximal tibial angle): line of the proximal tibial joint orientation with the mechanical axis
from the tibia, being 87 degrees.

LDTA (lateral distal tibial angle): line of distal joint orientation of the tibia with the mechanical axis of
tibia, being 89 degrees.

The difference between the anatomical and mechanical axes of the femur is 7 degrees.

Test of misalignment: after calculating the mechanical axis of the altered member, the axis should be calculated.
mechanical of the femur and tibia separately to determine the origin of the deformity.

PLANNING:

Draw the mechanical axis of the lower limb

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Perform the misalignment test to determine the source of the deformation.

The distal lateral angle of the femur is altered and the proximal medial angle of the tibia is normal.

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As the proximal angle of the tibia is normal, it can be extended to the distal femur determining the
distal mechanical axis of the same.

Draw a mid-diaphyseal line on the femur

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Draw a line parallel to this, starting from the head of the femur.

Trace the mechanical axis of the proximal femur using as a reference the

anatomical axis (difference of 7 degrees).

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Trace the line of proximal articular orientation of the femur.

Measure the proximal angle to check for any proximal deformity in the femur.

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Mark the “CORA” = Center of rotation of the angle.

11- Measure the magnitude of the deformity.

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CORRECTION OF DEFORMITIES IN THE TIBIA
Dr. Robinson Toshimitsu Kyiohara
Dr. Carlos Luiz Engelen

How to draw the lines:

In order to determine the magnitude of the deformation, we must correctly draw the lines in order to
quantify the deformity.

Determining the reference lines:

Proximal tibia

A - Frontal view - connect 2 points in the region of the subchondral bone of the tibial plateau

B - Sagittal view - connect 2 points in the region of the tibial plateau respecting the proximal tibial slope (Figure
12).

A B

Figure 12 -

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Distal tibia

A - Frontal view - connect 2 points in the region of the subchondral bone of the tibial plateau.

B - Sagittal view - connect the 2 most distal anterior and posterior points (Figure 13).

A B

Figure 13–A–Line obtained by joining 2 points of the tibial pilon in the frontal plane. B–Line obtained
by the union of 2 most distal points anterior and posterior of the tibial plateau in the sagittal plane.

Determining the axis

Frontal plan

The mechanical and anatomical axes of the tibia are practically coincident, with the anatomical axis having

a medial translation of 2 mm in relation to the mechanical axis.

The center of the knee (midpoint of the tibial spines) and the center of the ankle (point
middle of the talus) interconnecting the 2 points (Figure 14).

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Figure 14–Obtaining the mechanical and anatomical axis from the midpoint of the line drawn by the
iliac spines and by the midpoint of the talus.

Sagittal plane

In the sagittal plane, the axis is different due to the tibial slope. Let's focus only on the axis.
mechanical in which the determination of the deformity must be carried out.

Divide the line of orientation of the proximal tibia into 4 parts, locate the point of the fourth.
the anterior of the tibia and the midpoint of the distal tibial alignment line connect the 2 points. The angle
Proximally formed - proximal posterior tibial angle of 81º (77º-85º) and distally the angle
anterior distal tibia with 80o(78o-82o).

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A B C

Determining the deformity

Frontal plan

The same point at the center of the tibia and the reference line of the proximal tibia is used, a line is drawn.

perpendicular a partir deste ponto em direção a diáfise da tíbia.

The same procedure is performed regarding the distal tibia - reference line of the distal tibia point
middle of the ankle and a perpendicular is drawn towards the diaphysis of the tibia

The intersection point of the two lines determines the center of rotation of the deformity (CORA), being this
location of utmost importance, as the correction of the deformity will be based on this point.

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Sagittal plane

The point of the proximal fourth and the proximal tibial orientation line is used, and a line is drawn on
direction to the diaphysis of the tibia with an angle of 81º (proximal posterior angle of the tibia).

The same procedure is performed on the distal tibia - the midpoint of the distal tibia is located and a line is drawn.
a line towards the diaphysis of the tibia with an angle of 81º (anterior distal angle of the tibia) in relation to
the distal guiding line of the tibia. The intersection of the two lines determines the CORA.

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