Results: Journal of Pediatric Orthopaedics
Taylor Spatial Frame in the Treatment of Pediatric and Adolescent Tibial Shaft
Fractures
DOI: 10.1097/01.bpo.0000218522.05868.f9ISSN: 0271-6798Accession: 01241398200603000-00003Full
Text (PDF) 608 K
Author(s):
AL-Sayyad, Mohammed J. MD, FRCSC
Issue:Volume 26(2), March/April 2006, pp 164-170
Publication Type:[Trauma: Original Article]
Publisher:(C) 2006 Lippincott Williams & Wilkins, Inc.
Institution(s):From the Department of Orthopedic Surgery, King Abdulaziz
University Hospital, Jeddah, Saudi Arabia.
None of the authors received financial support for this study.
Reprints: Mohammed J. AL-Sayyad, MD, FRCSC, Department Orthopedic Surgery,
King
Abdulaziz University Hospital, P.O. Box 1817, Jeddah, 21441, Saudi Arabia
(e-mail: abojalal@aol.com).
Keywords: external fixation, Taylor Spatial Frame, tibia fracture
---------------------------------------------Outline
Abstract
METHODS
SURGICAL TECHNIQUE
RESULTS
DISCUSSION
REFERENCES
Graphics
Figure 1
Figure 2
Table 1
1
Abstract
Abstract: The Taylor Spatial Frame (TSF) is a modern multiplanar external
fixator that combines ease of application plus computer accuracy in the
reduction of fractures. A retrospective review of our experience in using this
device for treating unstable tibia fractures in pediatric and adolescent
patients was carried out to determine the effectiveness and complications of TSF
in the treatment of these fractures. Ten tibia fractures were included. All
patients were boys with an average age of 12 years (range 8-15 years). Mean
duration of follow-up was 3.1 years. These fractures included 5 open fractures.
All fractures healed over a mean of 18 weeks. All patients were doing well and
involved in sports when last seen. Postoperative complications included pin
tract infection in 5 patients. TSF is an effective definitive method of tibia
fracture care with the advantage of early mobilization and ability to postoperatively
manipulate fracture into excellent alignment.
---------------------------------------------In the skeletally immature patient, few tibial shaft fractures require surgical
stabilization.1 These include open fractures, fractures in the multiply injured
patient, fractures associated with neurovascular injury, fractures with
significant soft tissue injury, compartment syndrome, and comminuted shaft
fractures.1-4 For these unstable tibial shaft fractures, external fixation is a
common option and historically external fixators have been reserved for the more
severe, high-energy fractures with soft tissue damage and comminution. External
fixation has been considered by some to have significant complications such as
infection, delayed union, refracture, limb overgrowth, malunion, and need for
remanipulation.1,5-11 The multiplanar circular fixator popularized by Ilizarov
provides better resistance to bending and torsion.12 One common complaint about
the circular external fixator for fracture care was the difficulty in applying
it. In addition, the methods of fracture reduction with the use of olive and
arch wires were difficult to master.12 The Taylor Spatial Frame (TSF) presented
here has answered most of these complaints. TSF provides all the advantages of
multiplanar fixation of the Ilizarov system and even exceeds it in stability. In
addition, accurate fracture reduction is now possible and easy to perform with
the aid of computer accuracy. This method of treatment allows immediate
stabilization of the fracture, facilitates access to soft tissues, and obviates
the need for immobilization.12
This is the first report in the English literature that describes the results of
using TSF in children and adolescent tibia fractures. The purpose of this
article is to determine the effectiveness and complications of the use of TSF
(Smith and Nephew Richards, Memphis, TN, USA) in the reduction and treatment of
unstable tibial shaft fractures in the abovementioned patient population.
METHODS
Over a 2-year period, the author treated 64 tibial shaft fractures in children
2
and adolescents. During the same period, 9 patients with 10 unstable tibial
fractures were treated using TSF. A retrospective review of these 9 patients was
carried out. All patients were followed until after fracture healing. No
patients were lost to follow-up. Patient charts were retrospectively reviewed
for demographic data, mechanism of injury, associated injuries, surgical data,
complications, and functional outcome. Radiographs were reviewed to asses
fracture type, location, displacement, angulation, fracture union, and final
postoperative alignment. Postoperative computed tomographic (CT) scanograms to
evaluate leg length were carried out in all 9 patients.
All patients were boys. The average age of the patients at the time of injury
was 12 years and 3 months with a range from 8 years and 2 months to 15 years and
5 months. Mean duration of follow-up was 3.1 years (range 2-4 years). The
mechanism of injury was car versus pedestrian in 4 patients, the other fractures
were sustained in a motor vehicle accident in 3 patients, an all-terrain vehicle
injury in 1 patient, and a sports injury in 1 patient. These fractures included
5 open fractures that, based on the classification by Gustillo and Anderson,
were two type 2, and three type 3A.13,14 Of the closed fractures, 2 presented
with compartment syndrome and 1 had hemorrhagic fracture blisters on presentation
to our institute 2 days after the injury. The fracture location involved the
proximal third in 1 fracture, the middle third of the tibia in 4 fractures, the
junction of the middle and distal third in 3 fractures, and the distal third in
2 fractures. The predominant fracture pattern was transverse in 4 fractures. Two
fractures were comminuted, 2 fractures were oblique, 1 was spiral, and 1 was
segmental.
Five patients had significant associated injuries including severe closed head
injury in 1 patient, significant skin loss overlying the fracture site in 1
patient, ipsilateral multiple metatarsal shaft fractures in 2 patients, and
pulmonary contusion in 1 patient.
The indication of surgery in the closed fracture patients was compartment
syndrome in 2 patients, failure of closed reduction in the patient who had the
hemorrhagic fracture blisters, and 2 patients who presented 6 weeks after the
fracture of which 1 failed closed reduction and cast immobilization and the
other after failed closed reduction and monolateral fixation done elsewhere. All
patients were treated using TSF (Smith and Nephew Richards, Memphis, TN, USA)
using the following technique.
SURGICAL TECHNIQUE
At surgery a flat-top radiolucent table was used (OSI table, Orthopedic Systems,
Union City, CA, USA). The injured limb was prepared and draped as usual, and for
open fractures, adequate irrigation and debridement was performed first. A
rolled up sheet was placed under the thigh and a second one was placed under the
heel. This provided an open access to the entire limb needed for application of
TSF. Manual traction (by a surgical assistant pulling on the foot) was used to
realign the bone ends and restore some length.
3
The "rings-first" operative method was used in all cases. The diameter of the
proximal and distal ring was selected in relation to the size of the patient's
leg, with appropriate clearance from the skin to allow for additional swelling
and local care of the soft tissue envelope. The diameter of the rings can be
different to provide for a more contoured fixator. Next, a proximal or distal
reference fragment was selected. The reference fragment was designed to be
stationary in space with the opposite moving fragment rotating around it. The
proximal and distal rings were attached to each bone segment independently. The
rings were placed in an orthogonal manner so each is perpendicular to the long
axis of its segment. A transverse 1.8-mm smooth transosseous wire or 6-mm
half-pin was next inserted in the reference fragment. The wire should be
perpendicular to the bone axis or parallel to the adjacent joint. The fixator
ring was mounted to this reference wire or screw. At least three 6-mm hydroxyapatitecoated
external screws (Orthofix, Richardson, TX, USA) were used in the diaphysis on
each side of the fracture. In the metaphyseal segment 3 or 4, 1.8-mm transosseous
wires were placed in the frontal plane and 1 or 2 external screws in the
sagittal plane. After the rings were fixed to the bone, 6 struts were attached
to the nonparallel rings and the strut length was determined by the ring
position. Best possible reduction was achieved, dressing was then applied, and
patient was kept under general anesthesia until acute strut adjustment described
below was made.
Anteroposterior and lateral radiographs were then taken. The radiographs were
analyzed for deformities present. The total residual online program (Smith and
Nephew Richards, Memphis, TN, USA) was used in all cases. To use the previously
mentioned computer program, the anatomic side involved needs to be entered, and
13 parameters that describe the fixator itself, the deformity between the bone
ends, and the position of the fixator to the bone were entered into the
computer. The deformity parameters include the 6 planes of deformity. There may
be 3 angulations and 3 translations in the frontal, sagittal, and axial planes.
These were measured in degrees and millimeters from the anteroposterior (AP) and
lateral radiographs. Before the translation of the bone ends can be measured,
the surgeon selects a point on the reference fragment (stationary fragment),
which was termed the origin [a bone edge (cortex or spike) was marked on the AP
and lateral radiographs]. On the moving fragment, a second point was chosen,
either on the same cortex or in the depression of the spike. This was termed the
corresponding point and, when repositioned to the origin, the bone ends were
reduced anatomically. The translation was calculated as the distance between the
origin and corresponding point in the 3 planes previously mentioned. The final
data that were entered by the operator were the mounting parameters. The
distance between the center of the reference fragment ring and the origin was
determined on the AP radiograph. This represents the AP frame offset. The
distance between the frame center and the origin on the lateral radiograph was
the lateral frame offset. The axial frame offset was the longitudinal distance
from the reference ring to the origin measured from the AP radiograph. A rotary
frame offset was added according to the frame position on the leg, the number of
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degrees and the direction were entered in the rotary frame offset box, and the
computer through the total residual online program generates the length to which
each strut is adjusted to gain perfect reduction. These adjustments were easy to
make and were done acutely at the time of fixator application, and if anatomic
reduction was not present on the postreduction radiographs, fine tuning using
the total residual mode again was then used over the next few days to obtain
perfect alignment, according to the adjustment schedule, which was generated by
the computer program.
Patients who had compartment syndrome underwent 4 compartment fasciotomy with
delayed skin grafting. Typically, for an isolated tibia fracture, partial weight
bearing was initiated in the first postoperative day and gradually advanced to
full weight bearing with help of crutches within 2-4 weeks. Fractures were
determined to be healed after evidence of tricortical callus and lack of
tenderness at the fracture site. TSF was removed in an outpatient surgery unit
under sedation and no postoperative immobilization was needed in all cases.
Patients were then seen after 1 week for wound check and then every 3 months.
Two case examples are shown in Figures 1 and 2.
----------------------------------------------
FIGURE 1. A, Radiographs of tibial and fibular transverse fracture in a
13-year-old boy. B, Radiographs immediately after application of TSF. C,
Radiographs after final adjustment. D, Patient in TSF with preoperative fracture
blister seen. E, Radiographs 3 months after removal of fixator, fracture
healing, and anatomic alignment are documented.
-------------------------------------------------------------------------------------------
FIGURE 2. A, Radiographs of open midshaft tibial fracture in a 9-year-old
boy. B, Radiographs immediately after application of TSF. C, Radiographs after 3
months from frame application. D, Patient in TSF with foot splint for metatarsal
fractures. E, Radiographs 12 months after removal of fixator and anatomic
alignment is observed.
---------------------------------------------RESULTS
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The total operative time averaged 122 minutes (range 110-141 minutes),
debridement time averaged 31 minutes (range 30-46 minutes), frame application
time averaged 78 minutes (range 70-92 minutes), and the postapplication
adjustment under general anesthesia took an average of 13 minutes (range 10-21
minutes). Patients were followed for a mean of 3.1 years (range 2-4.1 years).
The 10 fractures healed over a mean of 18 weeks (range 12-29 weeks), for closed
fractures the healing time was 14.6 weeks (range 12-18 weeks), and for open
fractures healing time was 22 weeks (range 18-29 weeks). Patients remained in
the external fixator for a mean of 19 weeks (range 12-33 weeks), which varied
from healing time because most of the patients were in school and delayed their
frame removal until school commitments were over, waited for the nearest time
off, and 1 waited on removal until coming back from vacation on fear of
developing trouble while abroad. All patients were doing well and involved in
sports when last seen, including patients with other significant associated
injuries. Eight patients were not experiencing any pain in their last follow-up
and 1 patient with significant skin loss had minimal pain requiring occasional
use of nonsteroidal anti-inflammatory medications. Patient's gait was examined
and all patients had normal gait. No patient was noted to be more than 5 degrees
malrotated on clinical examination. No patient had a functional leg length
discrepancy. There were no intraoperative complications. Postoperative
complications included superficial pin tract infection in 5 patients and all
resolved with oral antibiotics; no patient developed osteomyelitis, neurovascular
injury, or had a refracture. All patients had normal range of motion of their
knees and ankles on clinical examination during their last follow-up visit.
All fractures ultimately united, including 1 patient with severely comminuted
fracture, who had a preplanned autogenous iliac crest bone grafting 2 months
after the initial injury while still in the external fixator and the fracture
healed uneventfully. There were no loss of reduction or return to the operating
room for remanipulation, and no patient developed a malunion.
The mean preoperative malalignment on the anteroposterior radiograph of the
tibia was 14.5 degrees (range 4-35 degrees). The mean preoperative displacement
on the anteroposterior radiograph of the tibia was 67% (range 45-100%). The mean
preoperative malalignment on the lateral radiograph of the tibia was 9 degrees
(range 0-9 degrees). The mean preoperative displacement on the lateral
radiograph of the tibia was 63% (range 5-100%). The mean final malalignment on
the anteroposterior radiograph of the tibia was 1 degree (range 0-3 degrees).
The mean final displacement on the anteroposterior radiograph of the tibia was
0%. The mean final malalignment on the lateral radiograph of the tibia was 1
degree (range 0-3 degrees). The mean final displacement on the lateral
radiograph of the tibia was 0%. Table 1 summarizes the preoperative malalignment
and the postoperative correction achieved.
----------------------------------------------
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TABLE 1. Details of Preoperative Radiographic Malalignment and Postoperative
Correction Achieved
---------------------------------------------No leg length discrepancy was detected clinically and the postoperative computed
tomography scanogram showed a mean of 1.1 mm (range 0-4 mm) leg length
difference.
DISCUSSION
External fixation has a clear role in the management of unstable pediatric tibia
fractures, especially for high-energy injuries with extensive soft tissue
damage. The use of an external fixator for the unstable tibia fracture is well
described in the literature.5-11 The results have been satisfactory but a number
of studies reported significant complications such as infection, delayed union,
refracture, limb overgrowth, malunion, need for remanipulation, and joint
stiffness.5-11 Complications related to pin site problems have been well
described.15,16 Gordon et al 15 reported that circular external fixators should
be considered in the unstable tibial shaft fracture with comminution or oblique
fracture pattern.
Ideally, fracture care should be as minimally invasive as possible and avoiding
the presence of foreign material such as plates and intramedullary nails should
be considered desirable.12 Internal fixation has the best chance at anatomic
reduction, but it is also the most invasive form of treatment and carries a
higher risk of infection. Titanium intramedullary nails work best in diaphyseal
transverse fracture patterns but unstable oblique, spiral, and comminuted
fractures present a greater challenge for intramedullary nails.1,17,18 In this
series, excellent reduction was obtained without the need for invasive exposures
used during internal fixation.
The current study discusses a group of high-energy tibial shaft fractures in
skeletally immature patients; these fractures were unstable and could not be
treated in the usual closed fashion in a cast. This high-energy trauma caused
extensive soft tissue damage and made successful cast treatment very unlikely.
Here the author used TSF, which is a modern multiplanar external fixator that
combines ease of application, plus computer accuracy in the reduction of tibial
fractures through inputting 13 parameters into a computer online program that
provides the proper adjustments needed to reduce the fracture; indirect
reduction of the fracture is achieved by realigning 1 fracture end to the other
through a spatial point of rotation.12 This method of treatment allows immediate
stabilization of the fracture, facilitates access to soft tissues, and obviates
the need for immobilization. Basically, TSF represents the ultimate form of
indirect reduction techniques that are well documented through the corrections
7
achieved and shown in Table 1. In this series, no significant postoperative
complications occurred, only 5 patients had pin tract infections and all
resolved with oral antibiotics. No patient developed osteomyelitis, neurovascular
injury, refracture, delayed union, limb overgrowth, malunion, joint stiffness,
or need for remanipulation under general anesthesia.
Gordon et al 15 reported that patients with tibial shaft fractures who were over
12 years and were treated with a monolateral device were at a statistically
significant risk for loss of reduction. In our series, 7 fractures occurred in
patients over 12 years and excellent alignment was achieved in all without need
for remanipulation under general anesthesia or loss of reduction with the use of
TSF.
Few series discussed the use of circular external fixators in treating the
fractured tibia.5,12,15,19-21 These were even fewer in case of children tibia
fracture.5,15 Bartlett et al 5 reported on 23 open tibia fracture treated with
the use of circular external fixator, all fractures in this series healed
between 8 and 26 weeks and no refractures occurred. Gordon et al 15 reported on
the use of circular external fixator in 16 unstable tibial fracture, all
fractures healed, no patient with a circular fixator required a return to the
operating room because of loss of reduction or malunion, and no refractures were
reported. Schwartsman et al 19 reported on the use of circular external fixators
in 18 tibial fracture in adults, all healed and no refractures were reported.
Tuker et al 21 used the Ilizarov method in 41 consecutive adult tibial
diaphyseal fracture that required operative stabilization. All fractures healed
from 12 to 47 weeks without bone grafting and no refractures occurred. Shtarker
et al 20 reported on 32 open tibial fracture that were stabilized with the
Ilizarov device. All fractures healed with good anatomic alignment, except for
one with 5 degrees angulation and another with 1-cm shortening, no nonunion or
refracture was reported. Shtarker et al 20 concluded that his results show the
superiority of the Ilizarov device compared with other uniplanar external
fixators in the treatment of open tibial fractures. The above discussion
demonstrates that both adult and pediatric series of tibial shaft fractures
stabilized with circular external fixators documented excellent results and did
not show a high rate of refractures as that reported previously with monolateral
fixators. It is well documented in the literature that refractures are avoided
by using proper technique of insertion of appropriately sized half-pins, use of
a more modular multiplanar external fixator along with gradual dynamization, and
appropriate timing of fixator removal with at least 3 visible cortices as well
as postremoval protection of the fractured limb by avoiding impact, contact,
collision activity, and aggressive physiotherapy.22-25 All points mentioned here
to avoid refractures were strictly followed in the author series and no
refractures were encountered.
Our mean leg length discrepancy was 1.1 mm with a range of 0-4 mm mainly because
our patients were older with a mean age of 12 years and 3 months and has nothing
to do with the type of fixator used. Hansen et al 26 reported that accelerated
growth after tibial fractures occurs in children younger than 10 years and that
8
older children may have mild growth inhibition; Swaan and Oppers 27 also
reported that younger children have a greater chance for overgrowth than older
children. In our series, excellent reduction was achieved in all cases with full
restoration of length at the time of reduction. This could be the second
contributing factor for our reported limb length inequality. Song et al 28
studied open fractures of the tibia in children and stated that external
fixation with anatomic reduction does not seem to lead to significant limb
length inequality in the absence of an associated ipsilateral femur fracture and
reported an average leg length discrepancy of 2.5 mm, and Shannak 29 reported on
tibial fractures in children documenting an average leg length discrepancy of 4
mm and that fractures with significant shortening have more physeal growth
stimulation than fractures without shortening at union.
This is the first report in the English literature that describes the results of
using TSF in children and adolescent tibia fractures and the author suggests its
use for surgical stabilization of the pediatric and adolescent tibia in open
fractures, multiple system injuries, or multiple long bone injuries, failed
conservative management, associated compartment syndrome, associated severe soft
tissue injuries, and unstable fracture configurations. Previous pediatric series
were described using the spatial frame for correction of tibia vara 30 and in
correcting femoral shortening and deformity.31
In summary, TSF is an external fixator that can be successfully used for
definitive tibia fracture care in the pediatric and adolescent patient from
fracture reduction to healing. The technique is noninvasive to the fracture
site. The fracture site can be manipulated postoperatively over few days into
excellent alignment in outpatient bases with no need for remanipulation in the
operating room. The fixator is stable enough to allow early functional weight
bearing and active motion of adjacent joints as demonstrated in this pediatric
and adolescent patient series.
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Key Words: external fixation; Taylor Spatial Frame; tibia fracture
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