Orthopedics

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Feature Article 

Treatment of Complex Tibial Fractures in Children With the Taylor Spatial Frame

Mark Eidelman, MD; Alexander Katzman, MD

  • Orthopedics. 2008;31(10)
  • Posted October 1, 2008

Abstract

Most tibial shaft fractures in children can be treated with closed reduction and cast fixation, but some fractures need external or internal fixation. The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a relatively new external fixator that can correct 6-axis deformities with computer accuracy. This article reports our experience using the Taylor spatial frame as a rewarding treatment modality for complex tibial fractures in children and adolescents.

Most tibial shaft fractures in children and adolescents can be treated with closed reduction and cast fixation; however, some fractures, especially compound, high-energy displaced fractures and fractures with delayed union, should be treated with internal or external fixation. Although rigid intramedullary nailing is widely used with adults, its use with children is limited because of the presence of open growth plates. External fixation is the cornerstone treatment for patients with complicated tibial fractures, severe soft tissue damage, and multiple trauma. Monolateral or circular external fixators can be employed in their treatment. While monolateral fixators are easy to assemble, they are usually less stable than circular fixators, and difficult or even impossible to adjust postoperatively.1,2

The Ilizarov device is the classic example of a circular external fixator.3,4 The introduction of this device and its method dramatically changed our understanding of deformities and fractures and our ability to manage them. However, despite its obvious advantages, many surgeons experience difficulty with its application and with mastering reduction.1

The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a relatively new external fixator. This unique, stable device is able to correct 6-axis deformities with computer accuracy. This article reports our experience with using the Taylor spatial frame in the treatment of complex tibial fractures in children and adolescents.

From March 2003 to July 2006, 13 patients with complicated tibial fractures were treated using the Taylor spatial frame. The study group comprised 12 boys and 1 girl with a mean age of 11.1 years (range, 5-16 years) at the time of frame application. Nine fractures were open and 4 were closed. The 9 open fractures were graded as Gustilo grade II (4 fractures), grade IIIA (2 fractures), and grade IIIB (2 fractures). Eight patients had associated injuries (Table). There were 2 fractures of the distal tibia, 1 proximal, and 10 midshaft.

Prior to application of the Taylor spatial frame, all patients were treated with another fixation method. All patients with open fractures, except 1, initially underwent debridement and primary stabilization with a unilateral external fixator. Closed fractures were treated initially with closed reduction and cast fixation. One patient with a closed distal tibial fracture developed compartment syndrome and underwent a 4-compartment fasciotomy and application of an Ilizarov fixator. Mean time interval from fracture to Taylor spatial frame application was 31.8 days (range, 3-165 days). The indications for Taylor spatial frame exchange were unacceptable alignment in cast or external fixator in 11 patients and nonunion or delayed union in 2.

The basic principles of the Taylor spatial frame are well described.1,5-8 Deformity parameters showing relationships between origin and corresponding point were determined using the fracture method.5,6 Frame parameters reflected the relationship between ring diameters and strut length, while mounting parameters reflected distance between origin and center of the reference ring. The reference ring was applied strictly orthogonal to the reference fragment, which was either proximal or distal (Figure 1A). The second ring on the moving fragment can be applied in a nonorthogonal position relative to the fragment. Care is needed to prevent a rotary frame offset, but if offset is already present it should be accurately determined and noted in the report (Figure 1B). After frame application,…

Abstract

Most tibial shaft fractures in children can be treated with closed reduction and cast fixation, but some fractures need external or internal fixation. The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a relatively new external fixator that can correct 6-axis deformities with computer accuracy. This article reports our experience using the Taylor spatial frame as a rewarding treatment modality for complex tibial fractures in children and adolescents.

Most tibial shaft fractures in children and adolescents can be treated with closed reduction and cast fixation; however, some fractures, especially compound, high-energy displaced fractures and fractures with delayed union, should be treated with internal or external fixation. Although rigid intramedullary nailing is widely used with adults, its use with children is limited because of the presence of open growth plates. External fixation is the cornerstone treatment for patients with complicated tibial fractures, severe soft tissue damage, and multiple trauma. Monolateral or circular external fixators can be employed in their treatment. While monolateral fixators are easy to assemble, they are usually less stable than circular fixators, and difficult or even impossible to adjust postoperatively.1,2

The Ilizarov device is the classic example of a circular external fixator.3,4 The introduction of this device and its method dramatically changed our understanding of deformities and fractures and our ability to manage them. However, despite its obvious advantages, many surgeons experience difficulty with its application and with mastering reduction.1

The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a relatively new external fixator. This unique, stable device is able to correct 6-axis deformities with computer accuracy. This article reports our experience with using the Taylor spatial frame in the treatment of complex tibial fractures in children and adolescents.

Materials and Methods

From March 2003 to July 2006, 13 patients with complicated tibial fractures were treated using the Taylor spatial frame. The study group comprised 12 boys and 1 girl with a mean age of 11.1 years (range, 5-16 years) at the time of frame application. Nine fractures were open and 4 were closed. The 9 open fractures were graded as Gustilo grade II (4 fractures), grade IIIA (2 fractures), and grade IIIB (2 fractures). Eight patients had associated injuries (Table). There were 2 fractures of the distal tibia, 1 proximal, and 10 midshaft.

Table: Patient Data

Prior to application of the Taylor spatial frame, all patients were treated with another fixation method. All patients with open fractures, except 1, initially underwent debridement and primary stabilization with a unilateral external fixator. Closed fractures were treated initially with closed reduction and cast fixation. One patient with a closed distal tibial fracture developed compartment syndrome and underwent a 4-compartment fasciotomy and application of an Ilizarov fixator. Mean time interval from fracture to Taylor spatial frame application was 31.8 days (range, 3-165 days). The indications for Taylor spatial frame exchange were unacceptable alignment in cast or external fixator in 11 patients and nonunion or delayed union in 2.

Surgical Technique

The basic principles of the Taylor spatial frame are well described.1,5-8 Deformity parameters showing relationships between origin and corresponding point were determined using the fracture method.5,6 Frame parameters reflected the relationship between ring diameters and strut length, while mounting parameters reflected distance between origin and center of the reference ring. The reference ring was applied strictly orthogonal to the reference fragment, which was either proximal or distal (Figure 1A). The second ring on the moving fragment can be applied in a nonorthogonal position relative to the fragment. Care is needed to prevent a rotary frame offset, but if offset is already present it should be accurately determined and noted in the report (Figure 1B). After frame application, full-leg radiographs were taken in the operating room. For accurate determination of deformity and mounting parameters, the center of the reference ring was marked on AP and lateral views. We did not try to reduce the fracture acutely. The total residual program was employed in all patients, and correction was begun 1 day postoperatively.

Figure 1A: Fixation of the distal reference ring. Note that this ring should be strictly orthogonal to the reference fragment and parallel to the ankle joint Figure 1B: Typical pin and wire placement in a mid-diaphyseal fracture of the tibia. In this case distal reference was chosen. Note zero rotational offset Figure 2A: Figure 2: AP view of delayed union 11 weeks after open fracture of the open mid-tibia and fibulaFigure 2B: Lateral view
Figure 2C: Immediate AP postoperative radiographs Figure 2D: Lateral postoperative radiographs Figure 4B: Torsional rigidity of radial head ORIF constructsFigure 2F: Lateral radiograph after frame removal
Figure 1: Fixation of the distal reference ring. Note that this ring should be strictly orthogonal to the reference fragment and parallel to the ankle joint (A). Typical pin and wire placement in a mid-diaphyseal fracture of the tibia. In this case distal reference was chosen. Note zero rotational offset (B). Figure 2: AP view of delayed union 11 weeks after open fracture of the open mid-tibia and fibula (A). Lateral view (B). Immediate AP (C) and lateral (D) postoperative radiographs. AP (E) and lateral (F) radiographs after frame removal.

Results

All fractures except 1 were united in normal anatomical alignment and frames were removed. Mechanical axis deviation was minimal or negligible compared to the contralateral limb. At latest follow-up, mean medial proximal tibial angle was 88° (range, 85°-89°), mean posterior proximal tibial angle was 81° (range, 79°-83°), and mean lateral distal tibial angle was 90° (range, 88°-93°). Mean time of frame fixation was 11 weeks (range, 7-18 weeks). All deformities were corrected gradually (velocity correction of 1 mm daily). One patient had a mild restriction of knee movement, which resolved a few weeks after frame removal. All other patients had no significant restriction of knee and ankle movement during fixation. Complications were related to superficial pin tract infections in 5 patients, which resolved after a short course of oral antibiotics. One patient, after a lengthening of 40 mm (Figures 2, 3), developed a proximal tibial valgus 1 year after frame removal, which was addressed with medial hemiepiphysiodesis.

Discussion

Most pediatric tibial fractures can be successfully treated with closed reduction and cast fixation; however, there are several indications for surgical treatment, including tibial fractures that cannot be maintained in a reduced position in a cast, open fractures, multiple trauma (especially in older children), fractures associated with compartment syndrome, and floating knees.9

Rigid intramedullary nailing is impractical due to the presence of the growth plates and the relatively short length of the tibia in children. External fixation is the mainstay treatment of severely comminuted open fractures with soft-tissue injury and unstable tibial fractures.2,10-12 Several external fixators are available. For simple fractures, a monolateral external fixator can be a good solution, but for many complex tibial fractures, circular external fixators offer better stability and the ability to correct the deformity gradually. The Ilizarov frame is the classic option, but the reduction technique, especially when multiplanar correction is needed, is difficult to perform with the Ilizarov fixator.1

Figure 3A: Gustilo IIIB open fracture of the tibia in a 10-year-old boy Figure 3B: Clinical photographs of the leg Figure 3C: Radiographs showing a 40-mm gap after removal of all nonviable bone spikesFigure 3D: Acute shortening and posterior angulation
Figure 3E: Clinical appearance of the leg after shortening and angulation Figure 3F: AP radiograph after proximal tibial osteotomy and 40 mm lengthening Figure 3G: Lateral radiograph after proximal tibial osteotomy and 40 mm lengtheningFigure 3H: Final radiographs 18 months after removal showing proximal tibial valgus treated with medial proximal tibial hemiepiphysiodesis
Figure 3: Gustilo IIIB open fracture of the tibia in a 10-year-old boy (A). Clinical photographs of the leg (B). Radiographs showing a 40-mm gap after removal of all nonviable bone spikes (C). Acute shortening and posterior angulation (D). Clinical appearance of the leg after shortening and angulation (E). AP (F) and lateral (G) radiographs after proximal tibial osteotomy and 40 mm lengthening. Final radiographs 18 months after removal showing proximal tibial valgus treated with medial proximal tibial hemiepiphysiodesis (H).

The Taylor spatial frame is stable and possesses the unique advantage of allowing 6-axis deformity correction with computer accuracy.5 We found relatively few examples in the literature on the use of the Taylor spatial frame in fracture care.1,8,13-15 Binski1 reviewed results of fixation of acute tibial fractures in adult patients. He achieved a 93% union rate, with 96% anatomical alignment of the mechanical axis. Only 3 patients underwent a second operation due to nonunion and refracture. The author concluded that the Taylor spatial frame is an effective tool and can be used as definitive method for fracture care using an external fixator.

Only 1 article described the use of the Taylor spatial frame in the treatment of pediatric tibial fractures: Al-Sayyad13 reported the results of the treatment of 10 tibial fractures in 9 children with an average age of 12 years. He reduced all fractures acutely with “fine-tuning” a few days postoperatively.

Feldman et al14 achieved union and deformity correction in 17 of 18 patients with post-traumatic tibial malunion and nonunion.

The Taylor spatial frame’s ability to correct 6-axis deformities precludes the need for frame adjustments, which are usually needed with the Ilizarov fixator. In addition, reduction can be performed gradually at any time postoperatively and after optimal care of the soft tissues.

The majority of our patients were treated with the Taylor spatial frame after considerable delay following fracture (mean, 31.8 days; range, 3-165 days). Acute anatomical reduction in this situation is difficult and often impossible to perform. Gradual reduction in children should be performed in all cases when fracture reduction is significantly delayed, because acute reduction in such a situation will cause unnecessary pain. The Taylor spatial frame is an ideally fitted device for controlled gradual reduction to prevent neurovascular compromise and skin and soft tissue problems. The mean age of our patients was 11.1 years, when growth stimulation and remodeling potential relatively decrease.16 After the age of 10, acceptable reduction of tibial fractures is quite close to adults’ criteria, with no malrotations acceptable.

The orthogonal position of the reference ring relative to the reference fragment is important for accurate measurement of the Taylor spatial frame’s parameters. Any residual correction and fine-tuning of fracture reduction can be performed in the office without frame modification (Figure 3). The current high cost of Taylor spatial frame equipment restricts its wide use in practice, but its obvious advantages will help it become the external fixation of choice in many centers.

Conclusion

Based on our experience, we believe that the Taylor spatial frame is a fixator with outstanding stability and computer accuracy. The Taylor spatial frame is our treatment of choice for complex displaced tibial fractures in children and adolescents.

References

  1. Binski JC. Taylor spatial frame in acute fracture care. Tech Orthop. 2002; 17(2):173-184.
  2. Norman D, Peskin B, Ehrenraich A, Rosenberg N, Bar-Joseph G, Bialik V. The use of external fixators in the immobilization of pediatric fractures. Arch Orthop Trauma Surg. 2002; 122(7):379-382.
  3. Ilizarov GA. Transosseous Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue. Berlin, Germany: Springer-Verlag; 1992.
  4. Solomin LN. General Aspects of Transosseous Osteosynthesis by Ilizarov Apparatus [in Russian]. St Petersburg, Russia: Morsar; 2005.
  5. Taylor JC. Correction of general deformity with Taylor spatial frame fixator. J Charles Taylor, MD, Web site. http://www.jcharlestaylor.com/spat/00spat.html. Accessed June 2008.
  6. Taylor JC. Six-axis deformity analysis and correction. In: Paley D, ed. Principles of Deformity Correction. New York, NY: Springer-Verlag; 2002:411-436.
  7. Rozbruch SR, Fragomen AT, Ilizarov S. Correction of tibial deformity with use of the Ilizarov-Taylor spatial frame. J Bone Joint Surg Am. 2006; 88(suppl 4):156-174.
  8. Eidelman M, Bialik V, Katzman A. Correction of deformities in children using the Taylor spatial frame. J Pediatr Orthop B. 2006; 15(6):387-395.
  9. Rang M, Wenger DR, Pring ME. Rang’s Children’s Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
  10. Cramer KE, Limbird TJ, Green NE. Open fractures of the diaphysis of the lower extremity in children. Treatment, results, and complications. J Bone Joint Surg Am. 1992; 74(2):218-232.
  11. Kreder HJ, Armstrong P. A review of open tibia fractures in children. J Pediatr Orthop. 1995; 15(4):482-488.
  12. Mashru RP, Herman MJ, Pizzutillo PD. Tibial shaft fractures in children and adolescents. Am Acad Orthop Surg. 2005; 13(5):345-352.
  13. Al-Sayyad MJ. Taylor Spatial Frame in the treatment of pediatric and adolescent tibial shaft fractures. J Pediatr Orthop. 2006; 26(2):164-170.
  14. Feldman DS, Shin SS, Madan S, Koval KJ. Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor Spatial Frame. J Orthop Trauma. 2003; 17(8):549-554.
  15. Seide K, Wolter D, Kortmann HR. Fracture reduction and deformity correction with hexapod Ilizarov fixator. Clin Orthop Relat Res. 1999; (363):186-195.
  16. Von Laer L. Pediatric Fractures and Dislocations. New York, NY: Thieme Medical Publishers; 2004.

Authors

Drs Eidelman and Katzman are from the Pediatric Orthopedic Unit, Meyer Children’s Hospital, Rambam Medical Center, Haifa, Israel.

Drs Eidelman and Katzman have no relevant financial relationships to disclose.

Correspondence should be addressed to: Mark Eidelman, MD, Pediatric Orthopedic Unit, Meyer Children’s Hospital, Rambam Health Care Campus, Aalia St 6, Bat-Galim, PO Box 96092, Haifa 31096, Israel.

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