ORIGINAL ARTICLE
Taylor Spatial Frame Fixation in Patients With Multiple
Traumatic Injuries: Study of 57 Long-Bone Fractures
Francesco Sala, MD,* Yasser Elbatrawy, MD,† Ahmed M. Thabet, MD,‡ Mahmoud Zayed, MD,†
and Dario Capitani, MD*
Objective: To evaluate the Taylor spatial frame (TSF) for primary
and definitive fixation of lower limb long-bone fractures in patients
with multiple traumatic injuries.
Design: Retrospective.
Setting: Level I trauma center.
Patients: Consecutive series of 52 patients, 57 fractures (25 femoral
and 32 tibial), treated between 2005 and 2009. Forty-nine fractures
(86%) were open. Injury Severity Score $16 for all patients.
Intervention: Fifty-four fractures (95%) underwent definitive
fixation with the TSF and 3 were treated primarily within 48 hours
of injury. In 22 cases (39%), fractures were acutely reduced with the
TSF, fixed to bone and the struts in sliding mode without further
adjustment, and in 35 cases (61%), the total residual deformity
correction program was undertaken.
Main Outcome Measure: Clinical and radiological.
Results: Complete union was obtained in 52 fractures (91%) without
additional surgery at an average of 29 weeks. Four nonunions and 1
delayed union occurred. Results based on Association for the Study
and Application of the Method of Ilizarov criteria: 74% excellent, 16%
good, 4% fair, and 7% poor for bone outcomes and 35% excellent,
47% good, and 18% fair for functional outcomes. Eighty-eight percent
of patients returned to preinjury work activities.
Conclusions: Primary and definitive fixation with the TSF is
effective. Advantages include continuity of device until union, reduced
risk of infection, early mobilization, restoration of primary defect
caused by bone loss, easy and accurate application, convertibility and
versatility compared with a monolateral fixator, and improved union
Accepted for publication November 6, 2012.
From the *Department of Orthopaedic Surgery and Traumatology, Trauma Team,
Niguarda Hospital, Milan, Italy; †Department of Orthopedics and Trauma,
Elzahra’a Hospital, Al Zahra’a University Hospital, Al-Azhar University,
Abbasia, Abdou Pasha, Cairo, Egypt; and ‡Orthopedics Department, Benha
University, Benha, Egypt.
None of the authors received benefits for personal or professional use from
a commercial party related directly or indirectly to the subject of this manuscript.
The current study was approved by the Ethical Review Boards of Niguarda
Hospital and Elzahra’a Hospital.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions this article on the journal’s Web site (www.jorthotrauma.com).
Reprints: Yasser Elbatrawy, MD, Elzahra’a Hospital, Al-Azhar University,
8 Elnozha St, Saudia Buildings, Madinet Nasr, 11371 Cairo, Egypt (e-mail:
yasser@elbatrawy.com).
Copyright © 2012 by Lippincott Williams & Wilkins
442 | www.jorthotrauma.com
rate and range of motion for lower extremity long-bone fractures in
patients with multiple traumatic injuries.
Key Words: multiple trauma, tibia, femur, fracture, Taylor spatial frame
Level of Evidence: Therapeutic Level IV. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2013;27:442–450)
INTRODUCTION
External fixation plays an important role in the primary
management of complex lower limb fractures in adult patients
with multiple traumatic injuries.1,2 Damage control orthopedics
with external fixation is becoming the standard management at
many trauma centers.2,3 Skeletal traction has long been used as
a method for temporary stabilization of fractures.4 External
fixation has been used in the treatment of high-energy frac-
tures, usually multifragmentary fractures with soft-tissue
lesions, because of its many advantages compared with internal
fixation, including less disruption of the blood supply to the
bone and minimal interference with soft-tissue cover.5 Histor-
ically, definitive external fixation has been associated with
a high incidence of complications, including loss of reduction,
delayed union, malunion, nonunion, articular stiffness, and pin
site infections.2
The Taylor spatial frame (TSF) (Smith & Nephew,
Memphis, TN) is a modern multiplanar external hexapod
frame that consists of 2 rings or partial rings connected by
6 telescopic struts at special universal joints. The TSF offers
many advantages including reliability and the versatility to
simultaneously correct rotation, angulation, and translation
deformities by adjusting the strut lengths.6 The purpose of
our study was to determine the clinical effectiveness of the
TSF in primary and definitive external fixation for patients
with multiple injuries and open fractures of the lower limb.7,8
PATIENTS AND METHODS
This study was approved by our hospital’s ethical
review board. The study included a consecutive series of 52
trauma patients whose injuries were treated with the TSF.
Inclusion criteria were open fractures and polytrauma with
an Injury Severity Score (ISS) $16. At our institution, both
internal fixation and external fixation options are available.
The indications for the use of external fixation are fractures
with poor soft-tissue coverage, fractures with bone loss, com-
minuted fractures, and periarticular fractures. The decision of
J Orthop Trauma  Volume 27, Number 8, August 2013
J Orthop Trauma  Volume 27, Number 8, August 2013
whether to use internal or external fixation is based on a thor-
ough discussion among the entire medical team regarding the
best way to achieve the best possible outcome. The fractures
in this study were judged unsuitable for internal fixation
based on fracture patterns and/or soft-tissue problems. We
excluded all patients with pathological conditions of the bone
and patients who were treated initially with external fixation
then converted to internal fixation (either plating or nailing).
Forty male and 12 female patients with a mean age of 43
years (age range, 11–81 years) and a mean ISS of 23 (range,
scores of 16–34) were included in the study. Fractures included
25 femoral (44%) and 32 tibial (56%) fractures treated between
March 2005 and December 2009 (Tables, Supplemental Dig-
ital Content 1, http://links.lww.com/BOT/A88, Supplemental
Digital Content 2, http://links.lww.com/BOT/A89). Patients
were followed for a mean of 18 months (range, 13–33 months).
The same surgeon treated all included patients.
The fractures were classified according to the OTA and
Gustilo and Anderson systems for grading open fractures.9,10
Initial evaluation of these serious injuries followed the guide-
lines of the Advanced Trauma Life Support System.11
Patients with risk of infection, open fractures with soft-tissue
loss, bone loss, severe comminution, juxtaarticular fractures,
ipsilateral fractures, or Gustilo grade IIIC fractures that were
not suitable for internal fixation underwent conversion to
definitive external fixation with the TSF.
For all patients, preoperative and latest follow-up radio-
graphic measurements were reviewed for both union and lower
limb axis alignment in both the frontal and the sagittal planes.
Mechanical axis deviation (MAD) was measured on the
anteroposterior view standing radiograph; MAD was assessed
as normal within the range of 6 mm lateral to 17 mm medial
from the center of the knee.12 External fixation time, defined as
the length of time the extremity was in the TSF, was calculated.
The results were assessed by using the functional and bone
scoring systems described by Paley and Maar (Table, Supple-
mental Digital Content 3, http://links.lww.com/BOT/A90).13
FIGURE 1. Images of a 21-year-old
man with multiple traumatic injuries
(ISS = 18), including a type 33C3
grade IIIB femoral fracture (case 5 in
the femoral group), fracture of the
ipsilateral patella, and patellar tendon
rupture. A, anteroposterior and lateral
view radiographs. B, clinical photo-
graph shows patellar tendon rupture.
Ó 2012 Lippincott Williams & Wilkins
TSF Fixation in Patients with Multiple Traumatic Injuries
Complications encountered intraoperatively and during
postoperative treatment were also recorded. Difficulties that
occurred during bone transport were grouped into problems,
obstacles, and complications based on criteria presented by
Paley.14 Complications were classified as minor or major, as
determined by absence or presence of residual sequelae,
respectively. Pin site infections were classified into 6 grades,
from grade 0 to grade V (grade 0, normal; grade I, inflamed;
grade II, serous discharge; grade III, purulent discharge; grade
IV, osteolysis; and grade V, ring sequestrum).15
Surgical Technique
Surgical technique for TSF consisted of femoral and tibial
applications of TSF external fixation with the patient positioned
supine on the traction table under general anesthesia. The timing
of conversion procedures for patients who received initial damage
control orthopedics was decided based on hemodynamic stability,
local soft-tissue status, and systemic conditions. Frames were
applied under image intensifier control to ensure the accuracy of
pin insertion and the quality of orthogonal frame placement.
Accurate anatomic reduction of intraarticular fractures was
achieved by using limited open reduction and internal fixation
with cancellous screws and washers (Figs. 1 and 2). Hydroxyap-
atite-coated pins (Orthofix, McKinney, TX) were used to connect
the frames to the bone segments in all patients. The hybrid
advanced technique was used in all cases.16 This technique was
developed to achieve more frame stability by combining pins
with the conventional Ilizarov bayonet 1.8-mm-diameter
wires in a special configuration.17 A temporary knee-spanning
construct with the addition of tibial rings improved joint pro-
tection and allowed early weight bearing. Articulated distrac-
tion using hinges aligned with the joint allowed for early knee
movement (Fig. 3). The tibial rings were removed 8–12
weeks later.
In 22 cases (39%), the fractures were acutely reduced
under direct vision with the TSF fixed to the bone and the struts
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Sala et al J Orthop Trauma  Volume 27, Number 8, August 2013

FIGURE 2. Images of the same

patient shown in Figure 1. Ten days
after the damage control orthopedics
procedure was performed, the patient
was returned to the operating room
for definitive treatment with accurate
anatomic reduction of the intra-
articular fracture by using open
reduction and internal fixation with
screws and a TSF. A, Radiographs ob-
tained after the conversion procedure
show condylar osteosynthesis with
restoration of the articular surface and
the TSF device in place with 6 struts. B,
Postreduction radiographs show
excellent reduction of the fracture in
both planes, achieved by using the
total residual mode.

FIGURE 3. Images of the same patient shown in Figures 1 and 2. Standing front view obtained 16 weeks after frame application.
A, Orthoroentgenogram obtained with the pelvis leveled and the patellae forward shows accurate distal femoral fracture
realignment with a correct mechanical axis and without limb-length discrepancy. B, Clinical photograph shows the patient with
the femoral TSF in place. Tibial extension of the frame across the knee can be seen. C, Total time in the frame was 23 weeks.
Anteroposterior and lateral view radiographs show the limb at 18 months after frame removal. D, Front view of the lower limbs
shows equal limb lengths and the absence of deformity.

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J Orthop Trauma  Volume 27, Number 8, August 2013 TSF Fixation in Patients with Multiple Traumatic Injuries

in their sliding mode; no further fine adjustment was necessary.
The total residual deformity correction program was undertaken
for 35 (61%) fractures. The 6 skeletal deformity parameters and
the 4 mounting parameters were measured on the radio-
graphs. These parameters and the current strut settings were
input into a total residual deformity correction program that
returned 6 specific strut lengths for adjusting the TSF to
exactly correct the fractures. This method provided gradual
reduction that was well tolerated by the patients. The goals
of postoperative management were early active mobility and
progressive staged weight bearing. Continuous regional
anesthesia was used to control pain after intervention.
Postoperative analgesia in the patients who underwent
continuous regional anesthesia was assured with a 2%
ropivacaine solution administered at 0.2–0.35 mg/kg of
body weight per hour plus paracetamol as a rescue dose.
Patients were given continuous lumbar plexus and sciatic
nerve block for external fixation of the femur and tibia,
respectively: after surgical treatment, for physiotherapy,
and during continuous passive motion of the joints. Quadri-
ceps isometric exercises and range-of-motion exercises of
the knee were initiated shortly after surgery, followed by
progressive staged weight bearing. Standard pin care with
showering and application of dry gauze around the pins were
recommended. Orally administered antibiotics were pre-
scribed for patients with pin site infections.
Statistical Analyses
Descriptive statistics for the means, ranges, and frequency
were calculated for all continuous and categorical variables.
Statistical software used for evaluation was SPSS 13.0 (SPSS,
Inc., Chicago, IL).
RESULTS
OTA fracture classifications are shown in (Tables, Supple-
mental Digital Content 1, http://links.lww.com/BOT/A88, Sup-
plemental Digital Content 2, http://links.lww.com/BOT/A89).
According to the Gustilo and Anderson system,10 classification
of the 49 (86%) open fractures was as follows: grade I, 9 fractures;
grade II, 7 fractures; grade IIIA, 12 fractures; grade IIIB, 16
fractures; and grade IIIC, 5 fractures. Successful vascular repair
was achieved in all patients in the grade IIIC group. Motor vehi-
cle accident was the most frequent cause of injury (42 patients,
81%). Four patients had floating knee fractures and 1 had bilateral

FIGURE 4. Images of a 41-year-old man with a type 33C2 grade IIIC femoral fracture and ipsilateral type 43A3 grade I tibial fracture
(case 1 in the femoral group and case 3 in the tibial group). A, Preoperative radiographs show the displaced left supracondylar
femoral and the distal tibial fractures. Injuries included femoral superficial artery laceration. B, Postoperative anteroposterior and
lateral view computed tomographic scans show the fracture of the femur stabilized with a knee-spanning external fixator as
a damage control orthopedic procedure. C, Postoperative photograph shows the patient with external fixation of the bone injuries
and fasciotomies of the thigh and leg. D, computed tomographic scan shows the left femoral arterial prosthesis bypass.

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Sala et al
femoral fractures. The mean ISS was 23 6 4.9 (range, scores of
16–34).
Thirty-seven of the 57 fractures (65%) were primarily
treated by external fixation within 24 hours of injury (Fig. 4).
Damage control external fixation was applied to 34 fractures
(60%) by using a multiplanar or monolateral external fixator,
and TSF was initially applied to treat 3 fractures (5%).7
Twenty fractures (35%) underwent initial stabilization with
a traction pin (skeletal traction) at the time of hospital admis-
sion.18 The mean time interval between primary treatment and
secondary TSF was 5 days (range, 1–28 days). Delay in TSF
application was due to shock, physiological instability, major
thoracoabdominal injury requiring emergent therapy, substan-
tial head injury, and management of associated soft-tissue
injury (Fig. 5).
The longest time to reduction with the total residual
deformity correction program was 9 days (Figs. 2 and 5).
Continuous regional anesthesia was discontinued between
days 6 and 8 of intervention. Fifty-two of 57 fractures
(91%) healed with initial treatment. The mean time to union
was 28 weeks (range, 14–64 weeks) in the femoral group and
26 weeks (range, 12–60 weeks) in the tibial group.
Acute shortening and relengthening were performed in
4 femoral and 1 tibial fracture with bone loss, and the mean
time to healing was 32 weeks (range, 16–64 weeks). In these
5 cases, the TSF strut adjustments were used for bone length-
ening and anatomic alignment.
Bone transport procedures were performed on 1 femoral
(10 cm) and 2 tibial fractures because of large bone defects
FIGURE 5. Images of the same patient shown in Figure 4 after application of the TSF. A and B, Axial alignment in both planes has
been restored by using the total residual mode. C, The patient is shown with the TSF applied after 6-strut residual correction
performed in the office. Extension of the fixator to the foot prevents equinus and allows stable mounting.
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J Orthop Trauma  Volume 27, Number 8, August 2013
(7–10 cm). These fractures underwent bone grafting at the
docking site, and the frames were applied for 58 weeks in
the femoral case and for 58 and 60 weeks in the tibial cases,
respectively. The TSF strut adjustments allowed for correction
of the procurvatum valgus tibial deformity at the lengthening
site and mechanical axis alignment of the lower limbs after
docking site revision. Among the 57 fractures in the study, 7
(12%) underwent bone grafting. The result of MAD evaluation
was between 5 mm lateral and 15 mm medial from the center
of the knee and was within the normal range.
Functional and Bone Results
Based on the outcomes scoring system proposed by
Paley and Maar,13 bone results were excellent in 42 cases
(74%), good in 9 (16%), fair in 2 (4%), and poor in 4
(7%). Functional results were excellent in 20 cases (35%),
good in 27 (47%), and fair in 10 (18%). Eighty-nine percent
of patients returned to their preinjury work activities.
Complications
Five fractures (9%) healed after secondary surgical
procedures were performed to treat complications (Tables, Sup-
plemental Digital Content 1, http://links.lww.com/BOT/A88,
Supplemental Digital Content 2, http://links.lww.com/BOT/A89).
In our study, the incidence of nonunion (4 cases) and delayed
union (1 case) was 7% and 2%, respectively. Two infected non-
unions occurred (1 femoral and 1 tibial). One patient with a type
32B2 grade IIIB femoral fracture had an infected nonunion that
was treated with bone resection and a bifocal bone transport
Ó 2012 Lippincott Williams & Wilkins
J Orthop Trauma  Volume 27, Number 8, August 2013
technique using another new TSF (Table, Supplemental Digital
Content 1, http://links.lww.com/BOT/A88, case 4). One femoral
delayed union underwent reamer–irrigator–aspirator sys-
tem grafting with no frame removal 5 months after the
index operation (Table, Supplemental Digital Content 1,
http://links.lww.com/BOT/A88, case 12). For 1 patient with
ipsilateral type 33C2 grade IIIC femoral and type 43A3 grade
IIIA tibial fractures, a floating knee fracture and a superficial
femoral artery injury were present (Table, Supplemental Digital
Content 1, http://links.lww.com/BOT/A88, case 1, and Table, Sup-
plemental Digital Content 2, http://links.lww.com/BOT/A89,
case 3). An osteotomy of the fibula was performed after 14
weeks to gradually compress and stimulate the tibial fracture
callus. For this patient, after 32 weeks, the femoral TSF was
exchanged for a plate and iliac crest bone grafting because of
nonunion (Figs. 6 and 7).
Two tibial nonunions occurred. The first was the result
of an avascular cortical bone fragment in an open midshaft
tibial fracture (Table, Supplemental Digital Content 2,
http://links.lww.com/BOT/A89, case 1). Union was obtained
at 44 weeks and then bone resection, bifocal bone transport, and
application of a second spatial frame were performed. The second
nonunion with infection occurred in a type 42C3 grade IIIB tibial
fracture in a patient with multiple traumatic injuries including
contralateral traumatic below-knee amputation and an ipsilateral
closed femoral fracture that was treated with damage control
external fixation and intramedullary nailing (Table, Supplemen-
tal Digital Content 2, http://links.lww.com/BOT/A89 case 9).
FIGURE 6. Images of the same patient shown in Figures 4 and 5. A, Femoral nonunion was present at 32 weeks after fixation with
the TSF. B, Healing of the nonunion was obtained by using autologous bone graft and a locking plate. C, The tibial fracture healed
in the TSF. Anteroposterior and lateral view radiographs show good coronal and sagittal plane alignment. External fixation time
was 46 weeks.
Ó 2012 Lippincott Williams & Wilkins
TSF Fixation in Patients with Multiple Traumatic Injuries
Bone union was obtained at 52 weeks by distraction osteo-
genesis with a second TSF using the combined Ilizarov and
TSF technique.19,20 The TSF was newly applied frame
because of the hospital’s policy that disallows the recycling
of frames.
An additional operation, Judet quadricepsplasty, was
required for 2 patients with type 33C2 grade IIIA and type 33C3
grade IIIB fractures to treat limited knee flexion (Table, Supple-
mental Digital Content 1, http://links.lww.com/BOT/A88,
cases 2 and 17); full extension, however, was achieved in all
cases. Although TSF achieved accurate reduction of deformities
in both the frontal and the sagittal planes in all cases, ,2.5 cm
of shortening (minor complication) occurred in 2 patients
because of the presence of a femoral arteriovenous bypass
and a prosthetic femoral arterial bypass that discouraged
bone lengthening (Table, Supplemental Digital Content 1,
http://links.lww.com/BOT/A88 cases 1 and 16).
Twenty-one patients developed pin site infections: 10
patients (48%) with grade II infections treated with local care,
8 patients (38%) with grade III infections treated with orally
administered antibiotics, and 3 patients (14%) with grade IV
infections treated with wire retensioning and orally adminis-
tered antibiotics.15 Half-pin breakage occurred in 2 cases, and
half-pin loosening required early removal in 1 case.
DISCUSSION
The dilemma regarding the optimal timing and type of
definitive stabilization for open femoral and tibial fractures in
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Sala et al
FIGURE 7. Clinical follow-up images, obtained at 24 months after tibial frame removal, of the same patient shown in Figures 4
through 6. Good clinical outcomes were achieved in the femur and tibia.
patients with multiple traumatic injuries is a challenge to all trau-
ma surgeons and remains a controversial issue (Table, Supple-
mental Digital Content 4, http://links.lww.com/BOT/A91).
Early fracture stabilization with primary external fixation as
a “temporizing device” and then intramedullary nailing, plate
fixation, or conversion to definitive external fixation have been
supported as ideal management techniques for these types of
fractures.3,19,21 Although intramedullary nailing is currently con-
sidered the preferable method of treating closed femoral frac-
tures, various methods of fixation have been used in the
treatment of open femoral fractures. Giannoudis et al22 analyzed
10 relevant studies of femur fractures treated by primary and
delayed nailing (representing 525 open femoral fractures). The
overall incidence on infection was 3.3%, the rate of union was
98%, and delayed union and malunion were observed in 2% and
6.5% of the cases, respectively. Secondary surgical procedures
were performed in 13.5% of the cases.
The role of plating open femoral shaft fractures is
limited. Plates can be used as an alternative to external
fixation for treating unstable pelvis, spinal injuries, and grade
IIIC open fractures.23
Three publications24–26 reported 96 tibial nail insertions
for open fractures previously treated by external fixation.
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J Orthop Trauma  Volume 27, Number 8, August 2013
Union was achieved in 92% of the cases at a mean of 38.5
weeks. The overall rate of deep infection in those reports was
17%, with 2.5% of cases developing chronic osteomyelitis.
Bhandari et al21 reported analyzing several prospective
studies and finding that the use of reamed nails reduced the
need for reoperation compared with external fixation but did
not reduce the risks of deep infection and nonunion. McGraw
and Lim,24 in a series of 16 open tibial fractures treated with
this sequential protocol, found a high rate of complications
including deep infection in 7 cases (44%) and nonunion in 5
cases (31%). Local complications have to be considered
when judging the effectiveness of a certain type of fracture
fixation.27 Maurer et al25 found an association between pre-
vious pin site infection and the development of deep infection
after nailing.
In comparison, Bach and Hansen28 conducted a prospec-
tive randomized study to compare 30 open fractures of the
tibia treated with external fixation and 26 treated with plates
and screws. All the fractures united with the same mean heal-
ing time, but the rates of deep infection, delayed union, and
reoperation were higher in the plated group, whereas the rate
of malunion was lower. However, the results of locking plates
with radical plastic treatment for severe open fractures of the
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J Orthop Trauma  Volume 27, Number 8, August 2013
tibia by experienced plastic surgeons are encouraging.29
External fixation provides a safe and viable management
strategy for patients with multiple traumatic injuries who
are at high risk for postoperative complications, particularly
patients with head and chest injuries.3
Few articles describe the use of external fixation as
a definitive treatment of open femoral fractures.5,7,30,31 Mohr
et al30 treated 18 open fractures of the femur, and Dabezies
et al31 treated 20 cases that included 13 open fractures. The
overall rate of union reached 100%. The rate of pin site infec-
tion was 15%. Deep infection and malunion occurred in 13%
and 23%, respectively; the delayed union rate was not reported.
Range of motion of the knee resulted in loss of more than 10
degrees of joint flexion in 27%.
In our study, nonunion occurred in 4 cases (7%) and
delayed union in 1 case (2%). Two infected nonunions
occurred (1 femur and 1 tibia). Our rates of nonunion and
delayed union are lower than those currently published in the
literature.5,22,32,33 In contrast, Velazco and Fleming32 and
Giannoudis et al22 noted 24% and 13% rates of delayed union,
respectively. Has et al5 found a 10% rate of pseudoarthrosis
after treatment of open fractures by external fixation in the
long bones. No substantial angular deformity in the coronal or
sagittal plane or rotational deformity occurred in our study,
whereas Gionnoudis et al22 and Kimmel33 reported 20% and
26% rates of malunion, respectively.
Our results compare favorably with other reports. Mohr
et al30 and Dabezies et al31 found relevant shortening (.2.5 cm)
of the femur in 7% and 15% of cases, respectively, and Henley
et al34 and Holbrook et al35 reported tibial malalignment in 31%
and 36% of cases, respectively. It is possible that this difference
can be explained by the accuracy of the TSF to achieve ana-
tomic fracture reduction with the 6 strut bars and the total resid-
ual deformity correction program.6–8 External fixation in our
study provided definitive stabilization in 5 Gustilo grade IIIC
femoral fractures after vascular repair, achieving bone union.
In the current literature, the incidences of pin site
infection range from 32% to 80%, with an average 4% having
chronic osteomyelitis.21,32,33 In the current study, 21 cases
(38%) developed pin site infections that were treated with
orally administered antibiotics. We encountered no cases of
osteitis. Wire retensioning was performed in 3 of the 21 cases.
The hydroxyapatite-coated half-pins improve the strength of
fixation at the pin–bone interface and are associated with
a lower rate of pin site infection.36
The rate of reoperation in our study was 14%, with
a change of the fixation method or fixation device necessary for
3 fractures (5%). This result is similar to the rate of reoperation
of 17% reported by Mohr et al30 and contrary to the rates
reported by Velazco and Fleming32 and Giannoudis et al22 of
2% and 69%, respectively, before union was achieved.
As delineated above, our results achieved by using
external fixation with the TSF are better than the results
achieved with other methods of external fixation as reported
in previous studies in most respects. Few data are available
regarding the use of TSF for long-bone fractures in patients
with polytrauma. Sala et al7 achieved good clinical and radio-
graphic outcomes by using the TSF as definitive fixation for
12 patients with shaft and distal femoral fractures.
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TSF Fixation in Patients with Multiple Traumatic Injuries
We are satisfied with the ease of use, accuracy, and
results achieved with the TSF in our patient cohort. The
TSF is easy and quick to apply, which is especially crucial
in a trauma setting. Based on our experience, the TSF can
be applied not only for deformity correction but also for
closed fracture reduction and fixation without having to
expose the bone, thereby avoiding the disadvantages of
open surgery. In addition to offering all the advantages of
external fixation, the TSF offers the advantages of post-
operative adjustability at any time before bone consolida-
tion. One drawback of the TSF is that the high cost of the
frame limits its usage. Our results are promising in terms of
achieved union rates, axis alignment of the lower extremity,
and functional outcome. Although we cannot conduct
a quantitative analysis because of the limited number of
cases, our experience indicates that the regional anesthesia
technique improves early rehabilitation by controlling pain
during continuous passive motion and improves surgical
outcomes and patient satisfaction. We have shown that the
TSF is useful for primary and definitive external fixation for
patients with multiple injuries and open fractures of the
lower limb.
ACKNOWLEDGMENT
The authors thank Dori Kelly, MA, for professional
medical editing.
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