Abstract
Transarticular and periarticular external skeletal fixation devices may be used interchangeably in open joint multisystem injuries about the knee and the ankle. The aim of this study is to compare results by using both. Twenty four patients with twenty six major open joint injuries of the knee and the ankle were admitted in our institution during the past nine years. During the first six years period only transarticular external fixation frames were used in the management of multisystem joint injuries. In the second three years period our previous choice was replaced by periarticular frames.
Eight injuries to the knee and eight to the ankle were managed in a transarticular frame and eight similar injuries to the knee and two to the ankle were treated by means of periarticular systems.
The results were evaluated by our ability to mobilize local or distant flaps, which was the same on either form of treatment; the facilitation for perfoming vascular surgery in the course of the management, although only in ten patients vascular surgery was undertaken; the fracture healing and the residual pseudarthrosis noticed in only one patient and deformity in four patients noticed in transarticular fixation;
the efficacy of the frames on the affected joints which were superior in periarticular fixation. In this series the use of hybrid forms of periarticular fixators have prooved themselves beneficial in the management of local problems and final results most predictable.
Open major joint injuries of the lower extremities, especially in polytrauma patients, consist a challenge for the fracture surgeon either because of the intricacies imposed by local problems or their contribution in the severity of the general condition (1). All these are more emphatic in the presence of multisystem injuries of the extremities and vascular compromise (2).
From a mechanical point of view two major concepts for achieving stability are in question when dealing with these problems.
The transarticular mountings that is external skeletal fixation systems crossing the joint and periarticular ones, in which the system elements remain in one side of the joint, with preservation of some joint movements. A comparative study of the mechanical and biological behaviour of these systems is attempted in similar open joint injuries of the knee and the ankle in polytrauma patients.
ΥΛΙΚΟ και ΜΕΘΟΔΟΣ Material and methods.
Twenty four patients with twenty six major open joint injuries of the knee and the ankle were admitted in our institution from May 1987 to December 1995.
They are separated and reviewed in two periods. During the first period from May 1987 to December 1992 in all cases only transarticular external fixation frames were used with or without minimal internal fixation at the fracture site for holding back fracture fragments especially parts of the articular cartilage and the adjacent part of subchondral bone.
During the last period only periarticular devices were used in similar injuries with internal fixation implants at the periarticular fracture sites.
The patients' ages ranged from 15 to 62 years (average 35 years) and they were 17 men and 7 women. The injuries in 16 cases located around the knee and in 10 cases around the ankle.
All patients were polytrauma ones either from the severity of the musculoskeletal injury or the coexistence of injuries elsewhere in the body (ISS>18) (3).
All patients were thought to sustain a vascular injury because of the severity of the soft tissue damage, although in only 10 cases were IIIC ones that is injuries with terminal arterial damage of the popliteal and its branches or the posterior tibial artery in knee and ankle injuries respectively requiring immediate repair (4). Since the injuries were high velocity ones, external skeletal fixation was used liberally, taking on account the severity of general and local condition and accepting a slight amount of articular depression or incongruency in general (5).
The injuries were classified according to AO (6) as tables I and II show.
Knee injuries
| Transarticular fixation | Periarticular fixation | 1. | 3.3.A.2.2 | 1. | 3.3.A.3.2 | 2. | 4.1.C.3.3 | 2. | 4.1.C.1.2 | 3. | 3.3.C.3.3 | 3. | 4.1.C.3.3 | 4. | 4.3.C.3.3 | 4. | 4.1.A.2.1 | 5. | 3.3.C.3.3 | 5. | 4.1.A.2.3 | 6. | 4.1.A.1.3 | 6. | 4.1.A.3.3 | 7. | 4.1.A.2.2 | 7. | 4.1.A.3.3 | 8. | 4.1.A.2.3 | 8. | 4.3.A.3.2 |
|---|
Table II.
Ankle injuries
| Transarticular fixation | Periarticular fixation | 1. | 4.3.B.2.2 | 1. | 4.3.B.2.3 | 2. | 4.3.B.2.3 | 2. | 4.3.A.3.1 | 3. | 4.3.C.3.3 |
|---|---|---|---|
| 4. | 4.3.C.3.3 | ||
| 5. | 4.3.B.3.2 | ||
| 6. | 4.3.C.1.2 | ||
| 7. | 4.3.A.3.2 | ||
| 8. | 4.3.A.3.2 | ||
ΑΠΟΤΕΛΕΣΜΑΤΑ, Results
Nonetheless, the use of external skeletal fixation devices facilitated ampulation and nursing in all cases and provided safety permitting continuous reassessment of the injured tissues (8). In comparing the results between the use of transarticular and periarticular mountings in similar injuries we took into account the following parameters.
1. Our ability to mobilize local or distant flaps for covering sensitive less viable tissues by either application.
2. The facilitation for perfoming vascular surgery in the course of the initial management or the probability for it.
3. The residual inflammation after the initial course of treatment.
4. The fracture healing and the residual pseudarthrosis and deformity.
5. The efficacy of the frames in the stability and mobility of the affected joints.
6. The necessity for performing reoperations.
Having these in mind as it comes to knee injuries either transarticular and periarticular fixations permitted mobilization of local and distant flaps. The transaricular fixation prooved itself more confortable for performing cross leg flaps in two cases, while in one similar periarticular fixation transformation of the initial frame was attempted in order to facilitate the aforementioned choice.
On the other hand vascular surgeons expect from the fracture surgeon an absolute stability especially when repairing vessels crossing major joints that seem to be mostly achievable with transarticular fixators. In five of our cases stong transarticular frames retained immobile the affected joints to protect vascular vascular surgery.
In tree similar cases around the knee and one about the ankle periarticular frames did so without conversion to another mounting.
Either around the knee or about the ankle both frames were equally capable in avoiding deep persistent inflammation. In four similar IIIB and IIIC converted in IIIB injuries treated in a transarticular frame when compared to two treated in a periarticular one the ability for controlling inflammation was about the same.
In all cases fractura healing was achieved even after prolongation of time required vastly because of the severity of the injuries.
Only in one patient treated by means of a periarticular frame a hypertrophic pseudarthrosis was noticed, and managed in turn by applying the distraction osteogenesis concept. It is obvious that the main cause for using periarticular frames is the prompt mobilization of affected joints with maximum stability of the fracture fragments.
Although in all the cases managed by means of a transarticular frame the residual stiffness was well affordable while when using periarticular ones the joint mobility was mostly predictable during the various phases of treatment. All of our patients managed by either way needed to be reoperated upon for plastic surgery, correction of residual deformity, joint instability or implant removal.
ΣΥΖΗΤΗΣΗ - ΣΥΜΠΕΡΑΣΜΑΤΑ Discussion
Despite the prediction for articulated external fixation frames from the beggining of the century (7) the periarticular fixator was not widely accepted since recent hybrid forms were introduced and developed (5,9,10) . The concept of ring external fixators and the evaluation of their efficacy in holding periarticular injuries as well as their minimal requirements in bone stock above the joint space and its simplification in most recent types seem to introduce them as first choice in the management of open injuries around joints.
The principles of AO as it comes to maintain joint mobility from the initial stages of treatment when applying periarticular fixation came into its own (11). In addition, all advantages of early application of an external skeletal fixation device are magnified in the presence of a periarticular or articulated devices (12).
As it comes to multisystem injuries crossing major joints absolute immobilization of jointed bones in many cases is strongly recommended (13). In our cases there is no significant difference in explaining the results between articular and periarticular external fixation in the course of treatment of vascular injuries.
There is not much reference in the literature about the difference between transarticular and periarticular fixation in open major joint injuries (9,10,14). In our cases the use of hybrid forms of external fixators prooved itself beneficial in the management of local problems and the ambulation of the severely injured patient from the beggining.
Transarticular and periarticular external skeletal fixation devices may be used interchangeably in open joint multisystem injuries about the knee and the ankle. The aim of this study is to compare results by using both. Twenty four patients with twenty six major open joint injuries of the knee and the ankle were admitted in our institution during the past nine years. During the first six years period only transarticular external fixation frames were used in the management of multisystem joint injuries. In the second three years period our previous choice was replaced by periarticular frames.
Eight injuries to the knee and eight to the ankle were managed in a transarticular frame and eight similar injuries to the knee and two to the ankle were treated by means of periarticular systems.
The results were evaluated by our ability to mobilize local or distant flaps, which was the same on either form of treatment; the facilitation for perfoming vascular surgery in the course of the management, although only in ten patients vascular surgery was undertaken; the fracture healing and the residual pseudarthrosis noticed in only one patient and deformity in four patients noticed in transarticular fixation;
the efficacy of the frames on the affected joints which were superior in periarticular fixation. In this series the use of hybrid forms of periarticular fixators have prooved themselves beneficial in the management of local problems and final results most predictable.
ΒΙΒΛΙΟΓΡΑΦΙΑ REFERENCES
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ΚΑΤΑΛΟΓΟΣ ΕΡΓΑΣΙΩΝ