PRINCIPLES OF EXTERNAL

FIXATION
 OVERVIEW

• INDICATIONS
• ADVANTAGES AND DISADVANTAGES
• MECHANICS
• BIOLOGY
• COMPLICATIONS
 INDICATIONS
• DEFINITIVE FX CARE:
• MALUNION/NON
• OPEN FRACTURES
• PERI-ARTICULAR FRACTURES
UNION
• PEDIATRIC FRACTURES • ARTHRODESIS
• TEMPORARY FX CARE • OSTEOMYELITIS
• “DAMAGE CONTROL”
• LONG BONE FRACTURE
• LIMB
TEMPORIZATION DEFORMITY/LEN
• PELVIC RING INJURY GTH INEQUALITY
• PERIARTICULAR FRACTURES
• CONGENITAL
• PILON FRACTURE
• ACQUIRED
 ADVANTAGES

• MINIMALLY INVASIVE
• FLEXIBILITY (BUILD TO FIT)
• QUICK APPLICATION
Complex 3-C humerus fx
• USEFUL BOTH AS A TEMPORIZING OR DEFINITIVE
STABILIZATION DEVICE
• RECONSTRUCTIVE AND SALVAGE APPLICATIONS
 DISADVANTAGES
• MECHANICAL
• DISTRACTION OF FRACTURE SITE
• INADEQUATE IMMOBILIZATION May result in
• PIN-BONE INTERFACE FAILURE
• WEIGHT/BULK malunion/nonunion,
• REFRACTURE (PEDIATRIC FEMUR) loss of function
• BIOLOGIC
• INFECTION (PIN TRACK)
• MAY PRECLUDE CONVERSION TO IM NAILING OR
INTERNAL FIXATION
• NEUROVASCULAR INJURY
• TETHERING OF MUSCLE
• SOFT TISSUE CONTRACTURE
COMPONENTS OF THE EX-FIX

• PINS

• CLAMPS

• CONNECTING RODS
 PINS
• PRINCIPLE: THE PIN IS THE CRITICAL LINK
BETWEEN THE BONE AND THE FRAME
• PIN DIAMETER
• BENDING STIFFNESS
PROPORTIONAL TO R4
• 5MM PIN 144% STIFFER
THAN 4MM PIN
< 1/3 dia
• PIN INSERTION TECHNIQUE RESPECTING BONE AND
SOFT TISSUE
 PINS
• VARIOUS DIAMETERS,
LENGTHS, AND DESIGNS
• 2.5 MM PIN
• 4 MM SHORT THREAD PIN
• 5 MM PREDRILLED PIN
• 6 MM TAPERED OR CONICAL
PIN
• 5 MM SELF-DRILLING AND SELF
TAPPING PIN
• 5 MM CENTRALLY THREADED
PIN
• MATERIALS
• STAINLESS STEEL
• TITANIUM
• MORE BIOCOMPATIBLE
• LESS STIFF
 PIN GEOMETRY

‘BLUNT’ PINS
- STRAIGHT
- CONICAL

Self Drilling and Tapping

 PIN COATINGS
• RECENT DEVELOPMENT OF VARIOUS COATINGS
(CHLOROHEXIDINE, SILVER, HYDROXYAPATITE)
• IMPROVE FIXATION TO BONE
• DECREASE INFECTION

• MORONI, JOT, ’02

• ANIMAL STUDY, HA PIN 13X HIGHER EXTRACTION
TORQUE VS STAINLESS AND TITANIUM AND EQUAL
TO INSERTION TORQUE
• MORONI, JBJS A, ’05
• 0/50 PTS PIN INFECTION IN TX OF
PERTROCHANTERIC FX
 PIN INSERTION TECHNIQUE

1.INCISE SKIN
2.SPREAD SOFT
TISSUES TO BONE
3.USE SHARP DRILL
WITH SLEEVE
4.IRRIGATE WHILE
DRILLING
5.PLACE APPROPRIATE
PIN USING SLEEVE

Avoid soft tissue damage and bone

thermal necrosis
 PIN INSERTION

•SELF DRILLING PIN

CONSIDERATIONS
• SHORT DRILL FLUTES
• THERMAL NECROSIS
• STRIPPING OF NEAR vs.
CORTEX WITH FAR CORTEX
CONTACT
• QUICK INSERTION
• USEFUL FOR SHORT
TERM
APPLICATIONS
 PIN LENGTH
•HALF PINS
•SINGLE POINT OF ENTRY
•ENGAGE TWO CORTICES

•TRANSFIXATION PINS
•BILATERAL, UNIPLANAR
FIXATION
•LOWER STRESSES AT PIN BONE
INTERFACE
•LIMITED ANATOMIC SITES (NV
INJURY)
•TRAVELING TRACTION

Courtesy Matthew Camuso

 PIN DIAMETER GUIDELINES

•FEMUR – 5 OR 6 MM
•TIBIA – 5 OR 6 MM
•HUMERUS – 5 MM
•FOREARM – 4 MM
•HAND, FOOT – 3 MM

< 1/3 dia

Slide courtesy Matthew Camuso

 CLAMPS
• TWO GENERAL VARIETIES:
• SINGLE PIN TO BAR CLAMPS
• MULTIPLE PIN TO BAR CLAMPS
• FEATURES:
• MULTI-PLANAR ADJUSTABILITY
• OPEN VS CLOSED END
• PRINCIPLES
• MUST SECURELY HOLD
THE FRAME TO THE PIN
• CLAMPS PLACED
CLOSER TO BONE
INCREASES THE
STIFFNESS OF THE
ENTIRE FIXATOR
CONSTRUCT
 CONNECTING RODS AND/OR
FRAMES
• OPTIONS:
• MATERIALS:
• STEEL
• ALUMINUM
• CARBON FIBER
• DESIGN
• SIMPLE ROD
• ARTICULATED
• TELESCOPING

• PRINCIPLE
• INCREASED DIAMETER = INCREASED STIFFNESS AND
STRENGTH
• STACKED (2 PARALLEL BARS) = INCREASED STIFFNESS
 BARS

•STAINLESS VS CARBON FIBER

•RADIOLUCENCY
Added bar stiffness
•↑ DIAMETER = ↑ STIFFNESS ≠
•CARBON 15% STIFFER VS
increased frame stiffness
STAINLESS STEEL IN LOADING
TO FAILURE
•FRAMES WITH CARBON FIBER
ARE ONLY 85% AS STIFF ? ? ? ?
WEAK LINK IS CLAMP TO
CARBON BAR?

Kowalski M, et al, Comparative Biomechanical Evaluation of Different External Fixator Sidebars: Stainless-Steel Tubes
versus Carbon Fiber Bars, JOT 10(7): 470-475, 1996
 RING FIXATORS

• COMPONENTS:
• TENSIONED THIN WIRES
• OLIVE OR STRAIGHT
• WIRE AND HALF PIN
CLAMPS
• RINGS
• RODS
• MOTORS AND HINGES (NOT
PICTURED)
 RING FIXATORS
• PRINCIPLES:
• MULTIPLE TENSIONED THIN
WIRES (90-130 KG)
• PLACE WIRES AS CLOSE TO 90O TO
EACH OTHER
• HALF PINS ALSO EFFECTIVE
• USE FULL RINGS (MORE
DIFFICULT TO DEFORM)
• CAN MAINTAIN PURCHASE
IN METAPHYSEAL BONE
• ALLOWS DYNAMIC AXIAL
LOADING
• MAY ALLOW JOINT
MOTION
MULTIPLANAR ADJUSTABLE RING
FIXATORS
• APPLICATION WITH WIRE OR HALF
PINS
• ADJUSTABLE WITH 6 DEGREES OF
FREEDOM
• DEFORMITY CORRECTION
• ACUTE
• CHRONIC
• TYPE 3A OPEN TIBIA FRACTURE WITH BONE LOSS
• FOLLOWING FRAME ADJUSTMENT AND BONE GRAFTING
 FRAME TYPES
• UNIPLANAR
• UNILATERAL
• BILATERAL
• PIN TRANSFIXES
EXTREMITY
• BIPLANAR
• UNILATERAL
• BILATERAL
• CIRCULAR (RING
FIXATOR)
• MAY USE HALF-PINS
AND/OR TRANSFIXION
WIRES
• HYBRID Unilateral uniplanar Unilateral biplanar
• COMBINES RINGS WITH
PLANAR FRAMES
 HYBRID FIXATORS

• COMBINES THE
ADVANTAGES OF
RING FIXATORS IN
PERIARTICULAR
AREAS WITH
SIMPLICITY OF
PLANAR HALF PIN
FIXATORS IN
DIAPHYSEAL BONE
From Rockwood and Green’s, 5th Ed
 BIOMECHANICAL COMPARISON
HYBRID VS RING FRAMES
• RING FRAMES RESIST AXIAL AND BENDING DEFORMATION
BETTER THAN ANY HYBRID MODIFICATION
• ADDING 2ND PROXIMAL RING AND ANTERIOR HALF PIN
IMPROVES STABILITY OF HYBRID FRAME

Clinical application: Use full ring fixator for fx

with bone defects or expected long frame time
Pugh et al, JOT, ‘99
Yilmaz et al, Clin Biomech, 2003
Roberts et al, JOT, 2003
 FRAME TYPES

• STANDARD FRAME

• JOINT SPANNING FRAME:

• NONARTICULATED
• ARTICULATED FRAME

• DISTRACTION OR CORRECTION FRAME

 STANDARD FRAME

• STANDARD
FRAME DESIGN
• DIAPHYSEAL
REGION
• ALLOWS
ADJACENT JOINT
MOTION
• STABLE
 JOINT SPANNING FRAME
• JOINT SPANNING FRAME
• INDICATIONS:
• PERI-ARTICULAR FX
• DEFINITIVE FIXATION
THROUGH LIGAMENTOTAXIS
• TEMPORIZING
• PLACE PINS AWAY FROM
POSSIBLE ORIF INCISION
SITES
• ARTHRODESIS
• STABILIZATION OF LIMB WITH
SEVERE LIGAMENTOUS OR
VASCULAR INJURY: DAMAGE
CONTROL
 ARTICULATED FRAME
• ARTICULATING FRAME
• LIMITED INDICATIONS
• INTRA- AND PERI-ARTICULAR FRACTURES OR
LIGAMENTOUS INJURY
• MOST COMMONLY USED IN THE ANKLE, ELBOW AND
KNEE
• ALLOWS JOINT MOTION
• REQUIRES PRECISE PLACEMENT OF HINGE IN THE
AXIS OF JOINT MOTION

(Figure from: Rockwood and Green, Fractures in Adults, 4 th ed, Lippincott-Raven, 1996)
 CORRECTION OF DEFORMITY
OR DEFECTS
• MAY USE UNILATERAL OR RING FRAMES
• SIMPLE DEFORMITIES MAY USE SIMPLE FRAMES
• COMPLEX DEFORMITIES REQUIRE MORE COMPLEX FRAMES
• ALL REQUIRE CAREFUL PLANNING
• 3B TIBIA WITH SEGMENTAL BONE
LOSS, 3A PLATEAU, TEMPORARY
SPANNING EX FIX
• CONVERT TO
CIRCULAR FRAME,
ORIF PLATEAU • Corticotomy and
distraction
• CONSOLIDATION
*NOTE: DOCKING SITE BONE GRAFTED
Healed
 EXTERNAL FIXATION
BIOMECHANICS

Leave the Eiffel tower in Paris!

Understand fixator mechanics
• do not over or underbuild frame!
 FIXATOR MECHANICS:
PIN FACTORS
• LARGER PIN DIAMETER
• INCREASED PIN SPREAD
• ON THE SAME SIDE OF THE
FRACTURE
• INCREASED NUMBER OF
PINS (BOTH IN AND OUT
OF PLANE OF
CONSTRUCT)
 FIXATOR MECHANICS:
PIN FACTORS

• OBLIQUE FXS
SUBJECT TO SHEAR
• USE OBLIQUE PIN TO
COUNTER THESE
EFFECTS

Metcalfe, et al, JBJS B, 2005

Lowenberg, et al, CORR, 2008
 FIXATOR MECHANICS: ROD
FACTORS
• FRAMES PLACED IN THE SAME PLANE AS THE APPLIED
LOAD
• DECREASED DISTANCE FROM BARS TO BONE
• STACKING OF BARS

 
 FRAME MECHANICS:
BIPLANAR CONSTRUCT

• LINKAGE BETWEEN FRAMES IN

PERPENDICULAR PLANES
(DELTA)
• CONTROLS EACH PLANE OF
DEFORMATION
 FRAME MECHANICS: RING
FIXATORS
• SPREAD WIRES TO
AS CLOSE TO 90O AS
ANATOMICALLY
POSSIBLE
• USE AT LEAST 2

PLANES OF
WIRES/HALF PINS
IN EACH MAJOR
BONE SEGMENT
 MODES OF FIXATION
• COMPRESSION
• SUFFICIENT BONE STOCK
• ENHANCES STABILITY
• INTIMATE CONTACT OF BONY ENDS
• TYPICALLY USED IN ARTHRODESIS OR TO COMPLETE
UNION OF A FRACTURE
• NEUTRALIZATION
• COMMINUTION OR BONE LOSS PRESENT
• MAINTAINS LENGTH AND ALIGNMENT
• RESISTS EXTERNAL DEFORMING FORCES
• DISTRACTION
• REDUCTION THROUGH LIGAMENTOTAXIS
• TEMPORIZING DEVICE
• DISTRACTION OSTEOGENESIS
 BIOLOGY
• FRACTURE HEALING BY STABLE
YET LESS RIGID SYSTEMS

• DYNAMIZATION
• MICROMOTION
• MICROMOTION = CALLUS
FORMATION

(Figures from: Rockwood and Green,

Kenwright, CORR, 1998 Fractures in Adults, 4th ed,
Larsson, CORR, 2001 Lippincott-Raven, 1996)
 BIOLOGY
• DYNAMIZATION = LOAD-
SHARING CONSTRUCT THAT
PROMOTE MICROMOTION
AT THE FRACTURE SITE
• CONTROLLED LOAD-
SHARING HELPS TO "WORK
HARDEN" THE FRACTURE (Figures from: Rockwood and Green,
CALLUS AND ACCELERATE Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)
REMODELING
•Kenwright and Richardson, JBJS-B, ‘91
•Quicker union less refracture
•Marsh and Nepola, ’91
•96% union at 24.6 wks
 ANATOMIC CONSIDERATIONS

• FUNDAMENTAL KNOWLEDGE OF THE ANATOMY IS

CRITICAL
• AVOIDANCE OF MAJOR NERVES,VESSELS AND
ORGANS (PELVIS) IS MANDATORY
• AVOID JOINTS AND JOINT CAPSULES
• PROXIMAL TIBIAL PINS SHOULD BE PLACED 14 MM DISTAL TO
ARTICULAR SURFACE TO AVOID CAPSULAR REFLECTION

• MINIMIZE MUSCLE/TENDON IMPALEMENT

(ESPECIALLY THOSE WITH LARGE EXCURSIONS)
LOWER EXTREMITY “SAFE” SITES
14 mm

• AVOID
• NERVES
• VESSELS
• JOINT CAPSULES

• MINIMIZE
• MUSCLE TRANSFIXION
 UPPER EXTREMITY “SAFE” SITES

• HUMERUS: NARROW LANES

• PROXIMAL: AXILLARY N
• MID: RADIAL NERVE
• DISTAL: RADIAL, MEDIAN AND ULNAR N
• DISSECT TO BONE, USE SLEEVES
• ULNA: SAFE SUBCUTANEOUS BORDER, AVOID
OVERPENETRATION
• RADIUS: NARROW LANES
• PROXIMAL: AVOID BECAUSE RADIAL N AND PIN, THICK MUSCLE
SLEEVE
• MID AND DISTAL: USE DISSECTION TO AVOID SUP. RADIAL N.
 DAMAGE CONTROL AND
TEMPORARY FRAMES
• INITIAL FRAME
APPLICATION RAPID
• ENOUGH TO STABILIZE BUT
IS NOT DEFINITIVE FRAME!
• BE AWARE OF DEFINITIVE
FIXATION OPTIONS
• AVOID PINS IN SURGICAL
APPROACH SITES
• DEPENDING ON CLINICAL
SITUATION MAY CONSIDER
MINIMAL FIXATION OF
ARTICULAR SURFACE AT
INITIAL SURGERY
 CONVERSION TO INTERNAL
FIXATION
• GENERALLY SAFE WITHIN 2-3 WKS
• BHANDARI, JOT, 2005
• META ANALYSIS: 6 FEMUR, 9 TIBIA, ALL BUT ONE
RETROSPECTIVE
• INFECTION IN TIBIA AND FEMUR <4%
• RODS OR PLATES APPROPRIATE
• USE WITH CAUTION WITH SIGNS OF PIN
IRRITATION
• CONSIDER STAGED PROCEDURE
• REMOVE AND CURETTE SITES
• RETURN FOLLOWING HEALING FOR DEFINITIVE FIXATION
• EXTREME CAUTION WITH ESTABLISHED PIN TRACK INFECTION
• MAURER, ’89
• 77% DEEP INFECTION WITH H/O PIN INFECTION
 EVIDENCE
• FEMUR FX
• NOWOTARSKI, JBJS-A, ’00
• 59 FX (19 OPEN), 54 PTS,
• CONVERT AT 7 DAYS (1-49
DAYS)
• 1 INFECTED NONUNION, 1
ASEPTIC NONUNION
• SCALEA, J TRAUMA, ’00 Bilat open femur, massive
• 43 EX-FIX THEN NAILED VS compartment syndrome, ex fix
then nail
284 PRIMARY IM NAIL
• ISS 26.8 VS 16.8
• FLUIDS 11.9L VS 6.2L FIRST
24 HRS
• OR TIME 35 MIN EBL 90CC
VS 135 MIN EBL 400CC
• EX FIX GROUP 1 INFECTED
NONUNION, 1 ASEPTIC
NONUNION
 EVIDENCE

• PILON FX
• SIRKIN ET AL, JOT, 1999
• 49 FXS, 22 OPEN
• PLATING @ 12-14 DAYS,
• 5 MINOR WOUND PROBLEMS, 1 OSTEOMYELITIS
• PATTERSON & COLE, JOT, 1999
• 22 FXS
• PLATING @ 24 D (15-49)
• NO WOUND HEALING PROBLEMS
• 1 MALUNION, 1 NONUNION
 COMPLICATIONS

• PIN-TRACK INFECTION/LOOSENING
• FRAME OR PIN/WIRE FAILURE
• MALUNION
• NON-UNION
• SOFT-TISSUE IMPALEMENT
• COMPARTMENT SYNDROME
 PIN-TRACK INFECTION

• MOST COMMON
COMPLICATION
• 0 – 14.2% INCIDENCE
• 4 STAGES:
• STAGE I: SEROPURULENT
DRAINAGE
• STAGE II: SUPERFICIAL
CELLULITIS
• STAGE III: DEEP INFECTION
• STAGE IV: OSTEOMYELITIS
 PIN-TRACK INFECTION

Union Fx infection Malunion Pin Infection

Mendes, ‘81 100% 4% NA 0

Velazco, ’83 92% NA 5% 12.5%

Behrens, ’86 100% 4% 1.3% 6.9%

Steinfeld, ’88 97% 7.1% 23% 0.5%

Marsh, ‘91 95% 5% 5% 10%

Melendez, ’89 98% 22% 2% 14.2%

 PIN-TRACK INFECTION
• PREVENTION:
• PROPER PIN/WIRE INSERTION
TECHNIQUE:
• SUBCUTANEOUS BONE
BORDERS
• AWAY FROM ZONE OF INJURY
• ADEQUATE SKIN INCISION
• CANNULAE TO PREVENT SOFT
TISSUE INJURY DURING
INSERTION
• SHARP DRILL BITS AND
IRRIGATION TO PREVENT
THERMAL NECROSIS
• MANUAL PIN INSERTION
(Figures from: Rockwood and
Green, Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)
 PIN-TRACK INFECTION

• POSTOPERATIVE CARE:
• CLEAN IMPLANT/SKIN
INTERFACE
• SALINE
• GAUZE
• SHOWER
 PIN-TRACK INFECTION

• TREATMENT:
• STAGE I: AGGRESSIVE PIN-SITE CARE AND ORAL
CEPHALOSPORIN
• STAGE II: SAME AS STAGE I AND +/- PARENTERAL ABX
• STAGE III: REMOVAL/EXCHANGE OF PIN PLUS PARENTERAL
ABX
• STAGE IV: SAME AS STAGE III, CULTURE PIN SITE FOR
OFFENDING ORGANISM, SPECIFIC IV ABX FOR 10 TO 14 DAYS,
SURGICAL DEBRIDEMENT OF PIN SITE
 PIN LOOSENING

• FACTORS INFLUENCING
PIN LOOSENING:
• PIN TRACK
INFECTION/OSTEOMYELITIS
• THERMONECROSIS
• DELAYED UNION OR NON-
UNION
• BENDING PRE-LOAD
 PIN LOOSENING

• PREVENTION:
• PROPER PIN/WIRE INSERTION TECHNIQUES
• RADIAL PRELOAD
• EUTHERMIC PIN INSERTION
• ADEQUATE SOFT-TISSUE RELEASE
• BONE GRAFT EARLY
• PIN COATINGS
• TREATMENT:
• REPLACE/REMOVE LOOSE PIN
 FRAME FAILURE

• INCIDENCE: RARE
• THEORETICALLY CAN OCCUR WITH RECYCLING OF OLD
FRAMES
• HOWEVER, NO PROOF THAT FRAMES CAN NOT BE RE-USED
 MALUNION
INTRA-OPERATIVE CAUSES:
• DUE TO POOR TECHNIQUE

• PREVENTION:
• CLEAR PRE-OPERATIVE PLANNING
• PREP CONTRALATERAL LIMB FOR COMPARISON
• USE FLUOROSCOPIC AND/OR INTRA-OPERATIVE FILMS
• ADEQUATE CONSTRUCT

• TREATMENT:
• EARLY: CORRECT DEFORMITY AND ADJUST OR RE-APPLY
FRAME PRIOR TO BONY UNION
• LATE: RECONSTRUCTIVE CORRECTION OF MALUNION
 MALUNION

POST-OPERATIVE CAUSES:
• DUE TO FRAME FAILURE
• PREVENTION:
• PROPER FOLLOW-UP WITH BOTH CLINICAL AND
RADIOGRAPHIC CHECK-UPS
• ADHERENCE TO APPROPRIATE WEIGHT-BEARING
RESTRICTIONS
• CHECK AND RE-TIGHTEN FRAME AT PERIODIC INTERVALS
• TREATMENT:
• OSTEOTOMY/RECONSTRUCTION
 NON-UNION

• UNION RATES COMPARABLE TO THOSE ACHIEVED

WITH INTERNAL FIXATION DEVICES
• MINIMIZED BY:
• AVOIDING DISTRACTION AT FRACTURE SITE
• EARLY BONE GRAFTING
• STABLE/RIGID CONSTRUCT
• GOOD SURGICAL TECHNIQUE
• CONTROL INFECTIONS
• EARLY WT BEARING
• PROGRESSIVE DYNAMIZATION
 SOFT-TISSUE IMPALEMENT
• TETHERING OF SOFT TISSUES CAN
RESULT IN:
• LOSS OF MOTION
• SCARRING
• VESSEL INJURY

• PREVENTION:
• CHECK ROM INTRA-OPERATIVELY
• AVOID PIERCING MUSCLE OR TENDONS
• POSITION JOINT IN NEUTRAL
• EARLY STRETCHING AND ROM EXERCISES
 COMPARTMENT SYNDROME

• RARE
• CAUSE:
• INJURY RELATED
• PIN OR WIRE CAUSING INTRACOMPARTMENTAL BLEEDING

• PREVENTION:
• CLEAR UNDERSTANDING OF THE ANATOMY
• GOOD TECHNIQUE
• POST-OPERATIVE VIGILANCE
FUTURE AREAS OF DEVELOPMENT

• PIN COATINGS/SLEEVES
• REDUCE INFECTION
• REDUCE PIN LOOSENING

• OPTIMIZATION OF DYNAMIZATION FOR FRACTURE

HEALING
• INCREASING EASE OF USE/REDUCED COST
 CONSTRUCT TIPS
• CHOSE OPTIMAL PIN DIAMETER
• USE GOOD INSERTION TECHNIQUE
• PLACE CLAMPS AND FRAMES CLOSE TO SKIN
• FRAME IN PLANE OF DEFORMING FORCES
• STACK FRAME (2 BARS)
• RE-USE/RECYCLE COMPONENTS (REQUIRES CERTIFIED
INSPECTION).

Plan ahead!
 REFERENCES
4. KENWRIGHT J, RICHARDSON JB, CUNNINGHAM, ET AL. AXIAL MOVEMENT AND TIBIAL FRACTURES. A CONTROLLED RANDOMIZED TRIAL OF
TREATMENT, JBJS-B, 73 (4): 654-650, 1991.

5. KENWRIGHT J , GARDNER T. MECHANICAL INFLUENCES ON TIBIAL FRACTURE HEALING. CORR, 355: 179-190,1998.

6. KOWALSKI, M ET AL, COMPARATIVE BIOMECHANICAL EVALUATION OF DIFFERENT EXTERNAL FIXATOR SIDEBARS: STAINLESS-STEEL TUBES
VERSUS CARBON FIBER BARS, JOT 10(7): 470-475, 1996.

7. KUMAR R, LERSKI RA, GANDY S, CLIFT BA, ABBOUD RJ. SAFETY OF ORTHOPEDIC IMPLANTS IN MAGNETIC RESONANCE IMAGING: AN
EXPERIMENTAL VERIFICATION. J ORTHOP RES, 24 (9): 1799-1802, 2006.

8. LARSSON S, KIM W, CAJA VL, EGGER EL, INOUE N, CHAO EY. EFFECT OF EARLY AXIAL DYNAMIZATION ON TIBIAL BONE HEALING: A STUDY IN
DOGS. CORR, 388: 240-51, 2001.

9. LOWENBERG DW, NORK S, ABRUZZO FM. THE CORRELATION OF SHEARING FORCE WITH FRACTURE LINE MIGRATION FOR PROGRESSIVE
FRACTURE OBLIQUITIES STABILIZED BY EXTERNAL FIXATION IN THE TIBIAL MODEL. CORR, 466:2947–2954, 2008.

10. MARSH JL. NEPOLA JV, WUEST TK, OSTEEN D, COX K, OPPENHEIM W. UNILATERAL EXTERNAL FIXATION UNTIL HEALING WITH THE DYNAMIC
AXIAL FIXATOR FOR SEVERE OPEN TIBIAL FRACTURES. REVIEW OF TWO CONSECUTIVE SERIES , JOT, 5(3): 341-348, 1991.

11. MAURER DJ, MERKOW RL, GUSTILO RB. INFECTION AFTER INTRAMEDULLARY NAILING OF SEVERE OPEN TIBIAL FRACTURES INITIALLY
TREATED WITH EXTERNAL FIXATION. JBJS-A, 71(6), 835-838, 1989.

12. METCALFE AJ, SALEH M, YANG L. TECHNIQUES FOR IMPROVING STABILITY IN OBLIQUE FRACTURES TREATED BY CIRCULAR FIXATION WITH
PARTICULAR REFERENCE TO THE SAGITTAL PLANE. JBJS B, 87 (6): 868-872, 2005.

13. MORONI A, FALDINI C, MARCHETTI S, MANCA M, CONSOLI V, GIANNINI S. IMPROVEMENT OF THE BONE-PIN INTERFACE STRENGTH IN
OSTEOPOROTIC BONE WITH USE OF HYDROXYAPATITE-COATED TAPERED EXTERNAL-FIXATION PINS: A PROSPECTIVE, RANDOMIZED
CLINICAL STUDY OF WRIST FRACTURES . JBJS –A, 83:717-721, 2001.
14. MORONI A, FALDINI C. PEGREFFI F. HOANG-KIM A. VANNINI F. GIANNINI S. DYNAMIC HIP SCREW VERSUS EXTERNAL FIXATION FOR
TREATMENT OF OSTEOPOROTIC PERTROCHANTERIC FRACTURES, J BJS-A. 87:753-759, 2005.
15. MORONI A. FALDINI C. ROCCA M. STEA S. GIANNINI S. IMPROVEMENT OF THE BONE-SCREW INTERFACE STRENGTH WITH HYDROXYAPATITE-
COATED AND TITANIUM-COATED AO/ASIF CORTICAL SCREWS. J OT. 16(4): 257-63, 2002 .
16. NOWOTARSKI PJ, TUREN CH, BRUMBACK RJ, SCARBORO JM, CONVERSION OF EXTERNAL FIXATION TO INTRAMEDULLARY NAILING FOR
FRACTURES OF THE SHAFT OF THE FEMUR IN MULTIPLY INJURED PATIENTS, JBJS-A, 82:781-788, 2000.

17. PATTERSON MJ, COLE J. TWO-STAGED DELAYED OPEN REDUCTION AND INTERNAL FIXATION OF SEVERE PILON FRACTURES. JOT, 13(2): 85-91,
1999.

18. PUGH K.J, WOLINSKY PR, DAWSON JM, STAHLMAN GC. THE BIOMECHANICS OF HYBRID EXTERNAL FIXATION. JOT. 13(1):20-26, 1999.
 SUMMARY

• MULTIPLE APPLICATIONS
• CHOOSE COMPONENTS AND GEOMETRY SUITABLE FOR
PARTICULAR APPLICATION
• APPROPRIATE USE CAN LEAD TO EXCELLENT RESULTS
• RECOGNIZE AND CORRECT COMPLICATIONS EARLY

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