Here is your April issue of Ex-Fix Quick Fix. A special thanks goes to Dr. Christopher Iobst, Miami Children’s Hospital, and Dr. Paul Freudigman, Baylor University, for the articles they provided us for this issue. Also, thanks to Dr. Robert Rozbruch for allowing us to share his case with you. I hope you enjoy!   In This Issue   External Fixation Contacts
       

      Medical Education Opportunities

       

      Chris Schnee
      Global Director, External Fixation and Orthobiologics
      901-399-6324 chris.schnee@smith-nephew.com

      Alexander Snowden
      Regional Marketing Manager, External Fixation
      901-399-5352 alexander.snowden@smith-nephew.com

        Fundamentals of the TAYLOR SPATIAL FRAME* External Fixator  
        Damage Control Orthopaedics  
        20/20 Features ILIZAROV™ System  
        Case Study    
      The Fundamentals Behind the Frame
      by Dr. Christopher Iobst

      You may know that the TAYLOR SPATIAL FRAME External Ring Fixator can be used to correct deformities as well as in acute trauma cases, but do you understand the fundamentals of how the device works and what is occurring when adjustments are made to the frame? The principles behind the TAYLOR SPATIAL FRAME system are really not too hard to understand, as long as you think of the correction in three dimensions. The six struts of the system are designed to work in concert to bring the origin and corresponding point together. The Internet-based software that goes with this system creates a specific day-by-day prescription for correcting a deformity, but by understanding the logic behind it, surgeons can use this extremely powerful tool for the final fine tuning of bone alignment in acute trauma cases. The following link, as well as the corresponding table, will give you an overview of the core concepts in deformity correction with the TAYLOR SPATIAL FRAME system.

      TAYLOR SPATIAL FRAME Intuition

          External Fixation Training Opportunities

      Advances of External Fixation
      July 6-9, 2006
      Beaver Creek, CO
      Contact: Bonnie Muse

      Applications of the ILIZAROV/ TAYLOR SPATIAL FRAME Ring Fixators to Foot and Ankle
      July 20, 2006
      San Diego, CA
      Contact: Monica Dolbi

      International External Fixation Symposium
      August 19-21, 2006
      San Antonio, TX
      Contact: Monica Dolbi

      Baltimore Limb Deformity Course
      September 2-6, 2006
      Baltimore, MD
      Contact: Monica Dolbi

      For further meeting information, visit www.orthomeetings.com or call 800-344-9672 and ask for the contact listed above.


       

       
       
      Unilateral External Fixation used in Damage Control Orthopaedics
      by Dr. Paul Freudigman

      Unilateral external fixators play a major role in Damage Control Orthopaedics (DCO), providing rapid stabilization of multiple fractures in a patient with severe physiological damage. By stabilizing fractures early, surgeons are able to limit blood loss, decrease patient pain, improve short- and long-term patient outcomes and take additional time to plan for definitive treatment.

      The implementation of such a staged approach for fracture treatment in severely traumatized patients has been shown to provide many advantages from increased patient survivor-ability to lower infection rates. In addition, a unilateral external fixator provides a stable construct that allows early mobilization of the patient and decreases the risk of hospital acquired complications, including pneumonia among others. The patient can sit up to improve pulmonary toilet and be easily transported to the OR for debridement or other areas of the hospital for diagnostic tests such as CT or MRI.

      As a general rule, we normally perform definitive treatment five to seven days later when we expect the patient is able to go through surgery without an adverse reaction. We want to ensure the patient is stable, has an acceptable anabolic state and a strong enough immune system to defend against infection. There must be no systemic or local contraindications for definitive fixation, or we delay until these resolve. The soft tissue around the injury must be healthy enough for us to make a surgical incision. We look for resolution of blisters and reduction in edema (skin wrinkles) before attempting to do definitive fixation. In addition, we want to allow time for the patientís oxygen levels to return to normal, which is approximately six days according to the research done by Dr. Tracy Watson.

      Unilateral external fixators are sometimes used as definitive treatment if a patient cannot be safely returned to the OR for definitive surgery or when massive soft tissue damage might prevent you from being able to do internal fixation. This is also a good option for some pediatric patients where growth plates preclude the use of nails. The unilateral external fixator might also be used definitively if the patient cannot have a blood transfusion, such as patients who are Jehovahís Witnesses, or if it is an elderly patient with a distal femur or proximal tibia fracture that would be better off getting a knee replacement once the fracture heals.

      A good system we often use for Damage Control Orthopaedics is the JET-X Unilateral Fixator. It works well because the product features a sliding cartridge clamp that locks in place to prevent passive release of the bar or pin while the surgeon is reducing the fracture with the frame. In addition, the JET-X fixator has a ball joint that allows up to 30ļ of angulation of each clamp. This allows a surgeon to independently place half pins in anatomic safe zones and still reduce the fracture after the fixator is applied. It also facilitates the placement of half pins in multiple planes unlike many other systems. Using pins in multiple plans improves the biomechanics of the construct and provides a stable construct using a single bar Ė a cost savings for the patient and a time saver in the OR. By placing the half-pins in different planes, the JET-X bar fixator performs more like a circular fixator and can be used for definitive treatment when other unilateral external fixators canít.

      Another advantage to the JET-X system is that its half-pins are composed of stainless steel for strength but also have a titanium nitride coating for biocompatibility. The half pins are self-drilling and self-tapping, saving time and the number of instruments required in the OR. Its tapered minor diameter provides a tight fit while still having a constant major diameter that allows surgeons to back out the half-pin in the case of over insertion without losing fixation.

      Iíve found the JET-X bar fixator very easy to use. It can be applied quickly and efficiently, saving a lot of time in the OR and minimizing blood loss for the patient. I like the fact that I can independently place the pins and still reduce the fracture after the clamps and bars have been put in place. JET-X bar fixators provide more stability for my patients, which helps reduce pain, swelling and blood loss associated with the fracture. It was designed to help achieve the goals of Damage Control Orthopaedics and to provide surgeons with a good unilateral external fixator for definitive treatment if necessary.



      A Salute to Our Troops:
      Medical Care in Iraq

      Click here for the flash presentation

      This link will take you to a powerful slide show published by The LA Times with photography by Rick Loomis. A special thanks to all of you who are involved in the treatment of our injured everyday.

      This e-mail was sent by Smith & Nephew, Inc. If you would like to be removed from this distribution list, please e-mail us at SmithNephewTrauma@smith-nephew.com. We respect your privacy.

      *Trademark of Smith & Nephew.

      ILIZAROV Frame, Dr. Robert Rozbruch Featured on 20/20

      Dr. Robert Rozbruch, director of the Institute for Limb Lengthening and Reconstruction at New York’s Hospital for Special Surgery, was recently featured in a story that aired on the ABC news program 20/20. The story was about a now 13-year-old boy who was rescued from the civil war in Sierra Leone in West Africa by another American surgeon and brought back to the United States for the medical treatment he needed to save his leg from osteomyelitis caused by infection from a snake bit that was never properly treated.

      The boy, named Lansana, was bitten by a snake while chasing a soccer ball into the bush. With his mother dead and his father missing, an uncle abandoned Lansana at a hospital in Bo, a city in the south central portion of the country. There he stayed for nearly two years until Dr. Ian Zlotolow, an oral surgeon at the Memorial Sloan-Kettering Cancer Center in New York, visited the hospital as a medical volunteer. By this time, infection had set into his tibia resulting in massive bone loss of not only his tibia but also his entire ankle joint. Doctors in his native country recommended amputation, but Dr. Zlotolow thought a specialist like Dr. Rozbruch might be able to reconstruct the leg so he attempted to bring the boy back with him to the U.S.

      After Lansana was granted a visa and allowed to return home with Dr. Zlotolow, he began to seek treatment for the boy’s leg and was referred to Dr. Rozbruch. With his right leg approximately six inches shorter than his left with a 45 degree internal rotation, Rozbruch used the Ilizarov device to gradually correct the deformity and lengthen the bone.

      “We gradually pulled that piece of bone downward, towards the ankle, to fill in the defect,” Dr. Rozbruch said. “And, in that way, we were able to use the Ilizarov method to grow him new bone and essentially reconstruct his ankle and attach what was left of his leg to his foot.”

      Dr. Rozbruch also performed a bone transport and ankle fusion to fill in the defect caused by the osteomyelitis. In all, Dr. Rozburch was able to lengthen the boy’s leg by 23cm through several stages of treatment. Lansana is doing well today with a stable ankle and the ability to run, play soccer and basketball. He has also been adopted by Dr. Zlotolow and Wendy Cohen.

      Case Study:
      Performing Closed Reduction in a Chronic Proximal Dislocation Following Total Hip Arthroplasty

      The following case study conducted by R. Allen Butler, MD, Joseph R. Hsu, MD and Robert L. Barrack, MD, was published in the February 2006 issue of The Journal of Bone and Joint Surgery. To see the article in its entirety, please visit the following site: http://www.ejbjs.org/cgi/content/full/88/2/411

      One of the major perioperative complications of total hip arthroplasty is dislocation. This complication was successfully treated in one patient with gradual closed reduction using the ILIZAROV distraction technique.

      The patient, a 46-year-old male, underwent right total hip arthroplasty with multiple dislocations postoperatively. Six years later, radiographic evaluation revealed that the total hip replacement was dislocated posteriorly, causing 10cm of shortening. The patient complained of chronic pain in the buttock and a severe Trendelenburg gait. He walked with the use of a crutch and a 7.5cm shoe lift. Treatment options discussed included resection arthroplasty, revision surgery with residual limb-length discrepancy and soft-tissue lengthening with use of an external fixator. The patient opted for the lengthening procedure.

      A spanning ILIZAROV device was placed over the right hip, and the patient was placed in the lateral decubitus position with transosseous wires proximally and half-pins distally. The patient was started on a lengthening regimen at a rapid rate of 4mm per day on the first postoperative day. The surgeons chose this rate because they were attempting to return the patient's neurovascular structures to their normal anatomic length. 

      After the ILIZAROV was removed, the patient was put in an abduction brace for three days followed by a hip pantaloon spica cast for eight weeks. He was then allowed to bear weight as tolerated and began physical therapy. During follow-up two years later, he was able to walk without assistive devices and had only a mild limp due to residual peroneal nerve palsy from his initial injury. Radiographs made at that time showed that the total hip replacement had remained reduced and his limbs were of equal length.

      Although such procedures may have complications such as pulmonary embolism and pin-tract infections, this case was treated successfully using a rapid rate of distraction. The authors suggest educating the patient on the signs of neural irritation, as neurologic compromise can occur especially towards the end of the lengthening period. If any signs of neural irritation are noted, the distraction should be slowed or temporarily halted. The authors believe that gradual distraction with an external fixator is a viable option for the treatment of chronic dislocation following total hip arthroplasty. In this case, the treatment gave the patient a much higher level of function and equal limb lengths while avoiding an open procedure.



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