External fixation by Hoffmann-Vidal-Adrey osteotaxis for severe tibial fractures. Treatment scheme and technical criticism.

In addition to the many advantages of external fixation, e.g., Hoffmann's osteotaxis technique, in the treatment of severe, open tibial fractures (grades II and III), some disadvantages result from both technical factors and the nature of the bone injury. Risk of delayed union or nonunion and secondary bone atrophy is due not only to the severity, comminution, soft tissue injury, and/or infection of the fracture site but also to the prolonged use of the external fixation equipment and the long nonweight-bearing time. In addition, a small distraction between the main fragments is often present after an otherwise successful reduction of an unstable comminuted fracture. The use of compression rods in an attempt to remove the distraction often leads to loss of the reduction result (sliding effect). The necessary compression effect between the tibial fragments in early weight-bearing is further prevented by the usual early union of the fibular fracture, which enhances the danger of delayed union or nonunion in the tibia, especially in older persons. To prevent the ossification disturbances mentioned, the authors treated 79 patients during the period from 1971 to 1978 by osteotaxis consisting of (1) a relatively short fixation time (less than or equal to 10 weeks); (2) correspondingly early graded weight-bearing in a cast; and (3) prophylactic fibulectomy in patients with the distraction phenomenon of comminuted tibial fractures. These patients have been followed up for an average of more than five years. This treatment scheme used during the early phase of treatment is often effective in producing union of tibial fractures without bone grafting. However, during later phases closed intramedullary nailing (Küntscher nail) can be used as a reliable method to treat the few severe cases that are resistant to the measures mentioned.