Citation Information :
Naude J, Manjra M, Birkholtz FF, Barnard A, Glatt V, Tetsworth K, Hohmann E. Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex. 2019; 14 (3):142-147.
Aim: The purpose of this study was to compare the functional and radiological outcomes of complex tibia fractures treated with two different hexapod fixators. Material and methods: This is a retrospective comparative study of patients treated for complex tibial fractures between 2010 and 2015. Inclusion criteria was patients between 18 years and 60 years of age, who sustained a complex comminuted open or closed tibial fracture with or without bone loss, who had a minimum of 12 months’ follow-up, and who have been treated definitively using either Taylor Spatial Frame (TSF) or TrueLok-Hexapod System (TL-HEX). The outcome measures were Association for the Study and Application of the Method of Ilizarov (ASAMI) score, foot function index (FFI), EQ5-D, four-step square test (FSST), and timed up and go (TUG) test. Descriptive statistics were used to assess patient demographic information. Categorical variables (ASAMI and EQ5D-5L) were analysed using the χ2 test. Continuous variables (FFI, functional tests, and radiographic outcomes) were analysed with two-tailed Student\'s t tests. Results: In all, 24 patients were treated with the TL-HEX and 21 with the TSF. The mean time for external fixation was 219 ± 107 days (TL-HEX) and 222 ± 98 days (TSF). Union occurred in 92% (TL-HEX) and 100% (TSF). The mean follow-up was 777 ± 278 days (TL-HEX) and 1211 ± 388 days (TSF). Using the ASAMI scores, there were 17 excellent and 6 good results for the TL-HEX and 10 excellent and 11 good results for the TSF (p = 0.33). The FFI was 30 ± 28.7 (TL-HEX) and 26.1+23.9 (TSF) (p = 0.55). The EQ5D was 0.67 ± 0.3 (TL-HEX) and 0.73 ± 0.2 (TSF) (p = 0.43). The mean TUG and FSST were 9.2 ± 3.2 and 10 ± 2.9 seconds (TL-HEX) and 8.4 ± 2.3 and 9.6 ± 3.1 seconds (TSF) (p = 0.34 and 0.69). Conclusion: The results of this study suggest that both hexapod external fixation devices have comparable clinical, functional, and radiographic outcomes. Either fixator can be used for the treatment of complex tibial fractures, anticipating good and excellent clinical outcomes in approximately 80% patients. Level of evidence: Therapeutic level III
Court-Brown CM, Wheelwright EF, Christie J, et al. External fixation for type III open tibial fractures. J Bone Joint Surg Br 1990;72(5):801–804. DOI: 10.1302/0301-620X.72B5.2211760.
Dickson DR, Moulder E, Hadland Y, et al. Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature. Injury 2015;46(4):751–758. DOI: 10.1016/j.injury.2015.01.025.
Webb LX, Bosse MJ, Castillo RC, et al. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. J Bone Joint Surg Am 2007;89A(5):923–928. DOI: 10.2106/JBJS.F.00776.
Henderson D, Barron E, Hadland Y, et al. Functional outcomes after tibial shaft fractures treated using the Taylor spatial frame. J Orthop Trauma 2015;29(2):54–59. DOI: 10.1097/BOT.0000000000000192.
Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res 1989;238(238):249–281. DOI: 10.1097/00003086-198901000-00038.
Gasser B, Boman B, Wyder D, et al. Stiffness characteristics of the circular Ilizarov device as opposed to conventional external fixators. J Biomech Eng 1990;112(1):15–21. DOI: 10.1115/1.2891120.
Hasler C, Krieg A. Current concepts on leg lengthening. J Child Orthop 2012;6(2):89–401. DOI: 10.1007/s11832-012-0391-5.
Ferreira N, Birkholtz F. Radiographic analysis of hexapod external fixators: fundamental differences between the Taylor spatial frame and truelok-hex. J Med Engin Technol 2015;39(3):173–176. DOI: 10.3109/03091902.2015.1025993.
Dammerer D, Kirschbichler K, Donnan L, et al. Clinical value of the Taylor spatial frame: a comparison with the Ilizarov and orthofix fixators. J Child Orthop 2011;5(5):343–349. DOI: 10.1007/s11832-011-0361-3.
Wani N, Baba A, Kangoo K, et al. Role of early Ilizarov ring fixator in the definitive management of type II, IIIA and IIIB open tibial shaft fractures. Int Orthop 2011;35(6):15–23. DOI: 10.1007/s00264-010-1023-7.
Quinnan SM. Definitive management of distal tibia and simple plafond fractures with circular external fixation. J Orthop Trauma 2016;30:S26–S32. DOI: 10.1097/BOT.0000000000000694.
Hohmann E, Birkholtz F, Glatt V, et al. The “Road to Union” protocol for the reconstruction of isolated complex high-energy tibial trauma. Injury 2017;48(6):1211–1216. DOI: 10.1016/j.injury.2017.03.018.
Menakaya CU, Rigby AS, Hadland Y, et al. Fracture healing following high energy tibial trauma: Ilizarov versus Taylor spatial frame. Ann R Coll Surg Engl 2014;96(2):106–110. DOI: 10.1308/003588414X13824511650335.
Giotakis N, Panchani SK, Narayan B, et al. Segmental fractures of the tibia treated by circular external fixation. J Bone Joint Surg Br 2010;92(5):687–692. DOI: 10.1302/0301-620X.92B5.22514.
Paley D. History and science behind the six-axis correction external fixation devices in orthopaedic surgery. Op Techn Orthop 2011;21(2):125–128. DOI: 10.1053/j.oto.2011.01.011126.
Pesenti S, Iobst CA, Launay F. Evaluation of the external fixator TrueLok hexapod system for tibial deformity correction in children. Orthop Traum Surg Res 2017;103(5):761–764. DOI: 10.1016/j.otsr.2017.03.015.
Kanellopoulos AD, Mavrogenis AF, Kanellopoulos ND, et al. A guide frame for the Taylor spatial frame. J Orthop Trauma 2009;23(7): 537–540. DOI: 10.1097/BOT.0b013e3181a24021.
Iobst CA. New trends in ring fixators. J Pediatr Orthop 2017;37(Suppl 2):S18–S21. DOI: 10.1097/BPO.0000000000001026.
Manner H, Heubl M, Radler C, et al. Accuracy of complex lower-limb deformity correction with external fixation: a comparison of the Taylor spatial frame with the Ilizarov ring fixator. J Child Orthop 2006;1(1):55–61. DOI: 10.1007/s11832-006-0005-1.
Van Niekerk AH, Birkholtz FF, de Lange P, et al. Circular external fixation and cemented PMMA spacers for the treatment of complex tibial fractures and infected nonunions with segmental bone loss. J Orthop Surg 2017;25(2):2309499017716242. DOI: 10.1177/2309499017716242.
Fischgrund J, Paley D, Sutter C. Variables affecting time to bone healing during limb lengthening. Clin Orth Rel Res 1994;301(301): 31–37. DOI: 10.1097/00003086-199404000-00006.
Hammer R, Hammerby S, Lindholm B. Accuracy of radiological assessment of tibial shaft union in humans. Clin Orth Relat Res 1985;199:233–238.
Paley D, Catagni MA, Argnani F, et al. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop 1989;241(241):146–165. DOI: 10.1097/00003086-198904000-00017.
Budiman-Mak E, Conrad KJ, Roach KE. The foot function index: A measure of foot pain and disability. J Clin Epidemiol 1991;44(6): 561–570. DOI: 10.1016/0895-4356(91)90220-4.
EuroQol Group. EuroQol–a new facility for the measurement of health related quality of life. Health Policy 1990;16(3):199–208. DOI: 10.1016/0168-8510(90)90421-9.
Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arc Phys Med Rehabil 2002;83(11):1566–1571. DOI: 10.1053/apmr.2002. 35469.
Blennerhassett JM, Jayalath VM. The four square step test is a feasible and valid clinical test of dynamic standing balance for use in ambulant people post stroke. Arch Phys Med Rehabil 2008;89(11):2156–2161. DOI: 10.1016/j.apmr.2008.05.012.
Wall JC, Bell C, Campbell S, et al. The timed get-up-and-go test revisited: measurement of the component tasks. J Rehabil Res Dev 2000;37(1):109–113.
Whitaker AT, Gesheff MG, Jauregui JJ, et al. Comparison of PACS and bone ninja mobile application for assessment of lower extremity limb length discrepancy and alignment. J Child Orthop 2016;10(5):439–443. DOI: 10.1007/s11832-016-0761-5.
Molepo M, Barnard AC, Birkholtz F, et al. Functional outcomes of the failed plate fixation in distal tibial fractures. Europ J Orthop Surg Traumatol 2018;28(8):1617–1624. DOI: 10.1007/s00590-018-2231-x.
Ganger R, Radler C, Speigner B, et al. Correction of post-traumatic lower limb deformities using the Taylor spatial frame. Int Orth 2010;34(5):723–730. DOI: 10.1007/s00264-009-0839-5.
Nieuwoudt L, Ferreira N, Marais LC. Short-term results of grade III open tibia fractures treated with circular fixators. SA Orthop J 2016;15(3):20–26. DOI: 10.17159/2309-8309/2016/v15n3a2.
Gaskill T, Schweitzer K, Nunley J. Comparison of surgical outcomes of intra-articular calcaneal fractures by age. J Bone Joint Surg Am 2010;92(18):2884–2889. DOI: 10.2106/JBJS.J.00089.
Landorf K, Radford JA. Minimal important difference: values for the foot health status questionnaire, foot function index and visual analogue scale. Foot 2008;18(1):15–19. DOI: 10.1016/j.foot.2007. 06.006.
SooHoo NF, Samimi DB, Vyas RM, et al. Evaluation of the foot function index in measuring outcomes in patients with foot and ankle disorders. Foot Ankle Int 2006;27(1):38–42. DOI: 10.1177/107110070602700107.
Bohannon RW. Reference values for the timed up and go test: a descriptive meta-analysis. J Geriatr Phys Ther 2006;29(2):64–68. DOI: 10.1519/00139143-200608000-00004.
Moore M, Barker K. The validity and reliability of the four square step test in different adult populations: a systematic review. Syst Rev 2017;6(1):187. DOI: 10.1186/s13643-017-0577-5.
Langford Z. The four square step test. J Physiotherapy 2015;61(3):162. DOI: 10.1016/j.jphys.2015.03.005.
van der Merwe L, Birkholtz F, Tetsworth K, et al. Functional and psychological outcomes of delayed lower limb amputation following failed lower limb reconstruction. Injury 2016;47(8):1756–1760. DOI: 10.1016/j.injury.2016.05.027.
Ramos T, Ekholm C, Eriksson BI, et al. The Ilizarov external fixator – a useful alternative for the treatment of proximal tibial fractures. A prospective observational study of 30 consecutive patients. BMC Musculoskelet Disord 2013;14(1):11. DOI: 10.1186/1471-2474-14-11.
Ramos T, Karlsson J, Eriksson BI, et al. Treatment of distal tibial fractures with the Ilizarov external fixator – a prospective observational study in 39 consecutive patients. BMC Musculoskelet Disord 2013;14(1):30. DOI: 10.1186/1471-2474-14-30.