Print - Distal Tibia - Reduction & Fixation - Hybrid External Fixator - A3 - AO Surgery Reference


Distal tibia - Reduction & Fixation - Hybrid external fixator - A3 - AO Surgery Reference

Executive Editor: Peter Trafton Authors: Martin Hessmann, Sean Nork, Christoph Sommer, Bruce Twaddle

Hybrid external fixator 1 General considerations
Introduction We would like to express our thanks to Prof. Dankward Hoentzsch (Germany) for additional information. Hybrid external fixators are attached to the distal tibial epiphysis through a partial ring with tensioned wires. Proximally, the hybrid fixator is constructed conventional external fixator components from attached to the

Distal tibia 43A3 CREF Shortcuts All Preparations All Approaches All Reductions
& Fixations

diaphysis with Schanz screws. The proximal frame attaches to the distal ring with appropriate connecting clamps. Hybrid fixators may lack sufficient stability. Their instability is blamed for late loss of fracture alignment, and problems with bone healing. However, with care and attention to detail, hybrid frames may be used successfully for distal tibial fractures. Placement of pins and wires in multiple planes, and use of multiplanar cross-bracing stability. A variety of frame configurations have been proposed. Early hybrid fixators for the distal tibia were as simple as a partial ring with 2 tensioned wires for the epiphyseal region, connected to a single rod attached to two diaphyseal Schanz screws. Experienced surgeons now recommend directions with a cross-braced at least 2 or 3 pins proximal to the fracture, inserted from different frame, and at least 2 or 3 tensioned wires in the articular portion (occasionally a threaded pin is substituted for a wire.) Supplementary extensions can be used to control foot and multi-ring ankle. Hybrid fixators, unlike well-constructed may be used to increase

fixators, do not provide enough stability for weight bearing.




Wire tension can pull the olive against a bone fragment. should be added in a way that also permits wire placement.2. the possibility of septic arthritis is a concern. which extends 2 cm above the anterior joint line. typically with lag screws. . Reduction wires compression.7/15/12 Distal tibia . Wires must support rather than prevent reduction.0 44JG rnm Some wires have small beads called "olives".Hybrid external fixator .0 mlflifl . Interfragmentary fixation.. !Iong 2 Preoperative planning Placement of wires for distal tibial fixation must be carefully planned. Provisional reduction and temporary interfragmentary K-wires might be required. tB/. that cross a fracture perpendicularly may be used for https:/Iwww2. Long-term external fixation is associated with risk of pin-track infection. with complex fragment displacement.WmmO Wire selection 2 mm diameter wires are recommended. 35{} mm long Ui/:. Gapped intraarticular fracture planes should be compressed with lag screws or Indication Hybrid external fixators may be used for selected type A and C distal tibial fractures. and since external fixation wires may enter the ankle joint.aofoundation. particularly when soft tissue damage is severe.Reduction & Fixation .A3 . More complicated fracture patterns. require a separate open reduction..AO Surgery Reference Articular surface reduction By bridging from the epiphysis to the diaphysis. and thus these wires inserted and tensioned in opposite directions can produce interfragmentary 2/8 . the fixator stabilizes the metadiaphyseal reduction wires. Such wires must be inserted on the side where the olive is desired. The fracture planes must be determined. or if surgical fracture stabilization is necessary but the risks of internal fixation are considered to outweigh the benefits. region.

the offending wire must be changed. Insertion of the first wire For C-type injuries. stability is limited. the articular fracture must be satisfactorily reduced before a wire is placed across it. In addition to distal ring and tensioned wires.aofoundation.!!---. but even better is to add a third wire or a Schanz screw.--.Hybrid external fixator . and its connection to the ring. if possible. Use a small incision and spread the tissues to expose bone.. 3/8 . If a tendon is impaled. https:/Iwww2. the proximal pins and frame.- ~r~E!r~ al1d~n No conslstentlv safe zones for pin or wire insertion in the distal tibia have been identified..AO Surgery Reference Alternatively.A3 .org/wps/portal/surgery?showPage=redfix&bone=Tibia&segment=Dista . To reduce the risk of joint infection.Reduction & Fixation .7/15/12 Distal tibia . If opposed olive wires will be used for fracture compression. 3 Wire insertion Safe wire placement in the dista I tibia Many important structures surround the ankle and must not be injured by the wires. must be planned for maximal stability. their location must be planned with regard to both fracture anatomy and local structures. Maintaining an overall arc of 60-80 degrees between the wires improves stability. This may require open reduction with a small anterior incision. With only two wires. __""". Note lag screws may be placed befo re the fixato r.J~~ liiIe:rlli. Pins that are inserted less than 20 mm proximal to the tibiotalar joint may enter the joint capsule.. avoid intraarticular placement of the wires. Good knowledge of anatomy is mandatory. AFlM! rier tibiall-----. and provisional or definitive fixation. Avoid nerves and vessels.

Hybrid external fixator .) Place the wire parallel to the tibiotalar joint under image intensification until it penetrates the far cortex. Place such a clamp on either end of the wire and attach these cia m ps to the ring. Some surgeons place two wires initially and then attach the ring to . Insertion of the first wire A non-olive wire placed thro ugh the fibula to emerge from the anteromedial tibia is often a good first wire. (A split sleeve or larger diameter one will be required to allow passage of an "olive". until the wire extends an equal length on both sides of the tibia. Insert the protection sleeve until it reaches the bone. Confirm that the articular reduction is satisfactory. 4/8 . Make sure that the wire does not impale tendons or neurovascular structures.aofoundation.Reduction & Fixation .AO Surgery Reference Make a stab incision and bluntly spread to bone. 4 Attaching ring to first wire Special clamps are available to attach the wire to the ring. parallel to the ankle [olnt.. It is inserted from posterolateral (avoiding peroneal tendons) to anteromedial.A3 . The angle between the first and the second wire should be as wide as possible. 5 Additiona I wires Insertion of additional wires The ring and wire clamps may serve as guides for insertion of additional wires. keeping the wire straight. Finish wire insertion by hand.. https:/Iwww2. Tighten the clamps to the ring and then provisionally to the wire.7/15/12 Distal tibia .

a tension of lOOkg-force simultaneous is appropriate. the wire clamps on the sides opposite the olives (posteromedial and posterolateral in this illustration) are loosened. 5/8 Place an anteromedial https:/Iwww2. but must be placed so that the clamp can be added after wire . with supplementary diaphyseal pins in multiple planes. Once the required tension has been reached on both sides. Choose a . The fracture configuration must be appropriate. Advance the wire until the olive touches the bone surface. Then an anterolateral rod and cross brace will be added for mechanical stability. and the tensioners removed. 6 Placement of the first rod Placement of the first rod An anteromedial rod will be placed first. to avoid fracture displacement. Applying tension to the end of the wire opposite the olive pulls the fragment towards the tensioning device.Reduction & Fixation . If possible. using two wire tensioners. These wires cannot be inserted through a ring-clamp. First.Hybrid external fixator . Wire tensioning Flexible wires must be under tension for mechanical stability. as shown in the illustration.. the anterior clamps are tightened securely.AO Surgery Reference It is advisable to use at least 3 distal wires.aofoundation. or two with a supplementary Schanz screw. the posterior wire clamps are tightened. Generally. Opposing olive wires should be tightened symmetrically.A3 .7/15/12 Distal tibia . Reduction wires An alternative to interfragmentary lag screws is the use of reduction wires (with "olives") to compress articular fracture fragments. proximal Schanz screw first. and the tensioners applied against them. use of two tensioning devices may decrease the risk of fracture displacement during wire tightening. Then. and attached to the ring to hold the provisional reduction..

. with fracture reduction.) The last part of pin insertion should be done by hand.AO Surgery Reference rod that is long enough to connect the screw to a clamp on the medial side of the ring. insert the pin through the proximal cortex until it just begins to enter the distal cortex. length. Do not use power tools. Insert the Schanz screw until the opposite cortex is felt. insert a distal shaft Schanz screw through the rod-topin clamp. (Predrilling of the near cortex is recommended in the tibial . Place a rod-to-rod clamp on the rod. Then attach the distal end of the rod to the ring.aofoundation.Reduction & Fixation . Next.Hybrid external fixator . Insert Schanz screws bicortically. but insert the Schanz screws by hand. Note https:/Iwww2. 6/8 . Do not break through the distal cortex.A3 . Note that intraoperative placement in the opposite cortex. clamp. The use of a protective sleeve through a small incision is recommended for drilling. clamp and then a second rod-to-pin Schanz screw insertion technique Predrilling avoids heat damage to the bone and ensures that both cortices are engaged co rrectly. with a rod-to-ring approximate and rotation must each be restored. Angular alignment. xrays must be perpendicular to the Schanz screw to assess Use of self-drilling pins If self-drilling pins are used.7/15/12 Distal tibia ..

Additional pin from ring (option) A pin from the ring may be used for fixation to the distal shaft.7/15/12 Distal tibia . alignment and rotation. directed proximally..aofoundation. clamp. connect the two rods with a short cross-brace using the previously placed clamps.Reduction & Fixation .. using a rod-to-ring .AO Surgery Reference The skin incisions for the insertion of the Schanz screws should be long enough to avoid tension. towards the anteromedial tibial shaft. and reduction reconfirmed. 8 Frame completion Second and third rod Attach the anterolateral rod to the proximal Schanz screw and to the ring laterally. This is placed through a ring-to-pin clamp. 7 Reduction Loosen the rod-to-ring clamp. Check reduction clinically and with image intensification. tighten all frame clamps. Restore length. all wire and screw incisions should be inspected and enlarged if under tension.A3 . At the end of fixator application and fracture reduction. If reduction is satisfactory. A rod-torod clamp is first placed on the Once the anterolateral rod is positioned. (An alternative supplementary pin must be chosen if comminution . Reduce the segments using ring and rod as reduction handles. 7/8 https:/Iwww2.Hybrid external fixator . tighten the ring-to-rod clamp. proximal to the fracture zone. If reduction remains satisfactory.

If satisfactory.aofoundation. confirm the reduction.) Predrill if necessary for thick cortex. Place the screw. using previously described technique. and bent to avoid prominence. The sharp end can be bent into a space on the clamp.. tighten all readjust the reduction first. and tighten the clamp. the clamps.Reduction & Fixation .Hybrid external fixator . Alternatively.7/15/12 Distal tibia .A3 . If necessary.AO Surgery Reference extends too far proximally. .org/wps/portal/surgery?showPage=redfix&bone=Tibia&segment=Dista .. • [ TWllt]@ o https:/Iwww2. 8/8 . Once again. Bending the wires Cut and bend the wires. the sharp end can be covered with a protective cap.

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