|Year : 2016 | Volume
| Issue : 3 | Page : 137-141
Monolateral frame external fixators in the definitive management of open limb fractures in North-western Nigeria
Yau Zakari Lawal1, Friday S Ejagwulu1, Sunny O Salami2, Salihu Mohammed2
1 Department of Trauma and Orthopaedic Surgery, Ahmadu Bello University, Zaria, Nigeria
2 Department of Surgery, Federal Medical Centre, Katsina, Nigeria
|Date of Submission||04-Aug-2015|
|Date of Acceptance||01-Sep-2016|
|Date of Web Publication||19-Sep-2016|
Yau Zakari Lawal
Department of Trauma and Orthopaedic Surgery, Ahmadu Bello University, Zaria
Background: The use of external fixators became popular in the last ten years in our environment with the availability and expertise to apply them being popularised by the AO foundation. They have virtually supplanted the application of casts which had high levels of complications and unpredictable outcomes in patients with open fractures. This manuscript describes its use in trauma in our environment. Aims: The aim of this study is to demonstrate that monolateral frame external fixators are a means of definitively treating open limb fractures. Materials and Methods: For a period of nine years (2006-2014), we prospectively studied the use of monoframe external fixation in one hundred and six limbs in three hospitals in the northwest of Nigeria. Gustillo II and III A, B and C patients were included in the study. External fixators from different manufacturers were used. The adherence to the principles of application, duration of application, pin track infection, union and non-union rates were observed for both groups. Results: One hundred and six limbs in were studied. Ninety four males and eleven females in the study group with five of the males being children of less than twelve years. Ninety seven cases had open tibial fractures (one lady had bilateral open tibial fractures) and four cases involved the femur. Union rate of 60% was observed. Pin tack infection rate of 80%, average duration of stay of the patient was three month; fracture union rate of 60% and reoperation rate of 2%were observed. Conclusion: Monolateral external fixators can be used successfully in the management of open diaphyseal fractures of long bones with reasonably high success rates and few complications.
Keywords: External fixators, fracture healing, open limb fractures
|How to cite this article:|
Lawal YZ, Ejagwulu FS, Salami SO, Mohammed S. Monolateral frame external fixators in the definitive management of open limb fractures in North-western Nigeria. Sub-Saharan Afr J Med 2016;3:137-41
|How to cite this URL:|
Lawal YZ, Ejagwulu FS, Salami SO, Mohammed S. Monolateral frame external fixators in the definitive management of open limb fractures in North-western Nigeria. Sub-Saharan Afr J Med [serial online] 2016 [cited 2017 Oct 20];3:137-41. Available from: http://www.ssajm.org/text.asp?2016/3/3/137/190847
| Introduction|| |
External fixation was known as early as 2400 BC. Hippocrates was said to have used a form of external fixation to treat fractures. The fathers of modern external fixation are Embser and Malgaine.  Compressive arthrodesis of the knee, which is considered a form of external fixation, was described by Charnley in the English medical literature.  There are three basic concepts that guide the application of external frames for bony trauma:
- The pins and wires should meet the mechanical demands of the patient and the injury
- They should avoid injuries to the vessels and nerves
- They should allow access to the area of injury. 
The ever-increasing use of motor vehicles and increase in conflicts between communities have led to a significant increase in injuries requiring external fixation. External fixation is the primary form of initial treatment for American and allied soldiers in battlefield hospitals. The concept of military use of external fixation is similar in the civilian population. 
Looking at Africa in general and Nigeria in particular, the use of motorcycles as a means of transport without proper regulation and the increasing incidence of communal strife have increased the prevalence of extremity injuries requiring external fixation. In our hospitals, the surgery of external fixation is often relegated to residents without supervision. This leads to inappropriate or incorrect application and therefore unwanted outcomes. It is our aim to demonstrate the effectiveness of monolateral external fixator as a definitive means of Gustillo and Anderson II to III open fracture of the extremities.
| Materials and methods|| |
This is an observational study designed to evaluate the application of external fixators as a definitive means of open fracture fixation, I and its complications. For 8 years (2006-2014), we prospectively studied the use of monoframe or monolateral external fixation in three hospitals in the northwest of Nigeria. These hospitals are National Orthopaedic Hospital, Dala-Kano, the Federal Medical Centre, Katsina, and the Ahmadu Bello University Teaching Hospital, Zaria. Inclusion criterion is an open fracture corresponding to Gustillo and Anderson Type II and III (A-C). One hundred and six patients with open limb injuries involving the tibia, femur, humerus, and the forearm bones were included in the study.
External fixators from different manufacturers were used, with 80% being Orthofix made by Synthes. The remaining 20% were external fixators made by various Indian companies determined by availability.
Patients were operated on randomly by consultants and residents alike. Intraoperative reduction plates were not used in all the patients operated upon. Seven patients had compression of the fracture at the time of operation. These seven cases had transverse compressible fractures. There were no bone grafts or bone graft substitutes used in managing all the patients. Patients with a diagnosis of nonunion at the outset were not included in the obsevations. Early movement was encouraged after surgery according to the capacity of the patient.
Duration of application was defined as the time in months the external fixator remained on the patient until union or lack thereof.
Union was defined as fracture consolidation within 3 months of application of the external fixator as evidenced by consolidated callus formation seen on X-rays and absence of demonstrable movement at the fracture site. Delayed union is healing after 3 months but not more than 6 months. Nonunion was defined as fracture union after 6 months. Re-operation is defined as the repetition of the process of fixation in its entirety. Principles guiding application were defined by the access, avoidance of neurovascular bundles, minimal soft tissue stripping, and stability of the external fixation. Outcome was defined in three terms, very good; in which there is fracture union without complications, good; in which there is one complication and acceptable in which there are two or more complications in addition to fracture union. These terminologies have been previously defined (Michail Belsios).
- Duration of application
- Time taken to union
- Pin-tract infections
However, with eventual fracture union, and poor in which there were complications such as osteomyelitis and need for reoperation due to nonunion.
Pin-tract infection was defined as positive bacterial culture of 10,000 bacteria per high-power field from exudates or swabs taken from pin site. Loosening of pins was demonstrated by vertical movement of the Schanz screws in their long axis by a reasonable pull. The primary aim of the monoframe external fixation was to allow the surgeon access to the wound to achieve skin and soft tissue cover in the presence of reasonable fracture stabilization. Secondary aim may include fracture union in some selected cases.
Eighty patients were operated under spinal anesthesia, while the remaining 24 patients had general anesthesia because they were considered unfit for spinal anesthesia (consider using American Society of Anesthesiologists classification) or have injuries in the upper limbs. There were no blood transfusions for intra-operative blood loss. Preoperative and postoperative radiographs were taken in all cases.
| Results|| |
One hundred and six patients with 107 open extremity fractures requiring external fixation were observed. There were 95 males and 11 females in the observed group accounting for 89.6% and 10.4%, respectively. Of the 95 males, five of them were children < 12 years.
Duration of Application
The shortest time the external fixator remain fixed to the patients limb was 6 weeks and the longest was 1 year. The average time, however, was 3 months. Follow-up for some patients was for 8 years.
Time Taken to Union
The mean time taken for union in the tibial and femoral fractures observed was 12 weeks with a range of 10 weeks to 36 weeks. Sixty-one limbs united primarily by monoframe external fixation accounting for 60.4% union rate. Forty patients had conversion to plate fixation or casting.
There were 86 incidences of pin-tract infections at different stages of the treatment. This corresponds to 80% of the treated patients. There were no cases of ring sequestrum or osteomyelitis. Three pins became loose leading to dislodgement of the external fixator.
Three patients had re-operation due to improper placement of pins.
There were no cases of deep vein thrombosis and no fat embolism or decubitus ulceration.
| Discussion|| |
It has become a standard practice in traumatology to use external fixation as a temporary means of treatment for severely injured patients who cannot tolerate extensive surgery such as bomb blast victims to treat their open limb injuries. It may also serves as a stop gap procedure for the heavily contaminated limb injuries. In situations where the expertise and facilities to do open reduction and internal fixation and flap cover or other appropriate soft tissue cover is made on the same sitting or at a later date. ,, The patients who need this staggered treatment protocol are those who need expeditious stabilization due to vascular injuries or those who are multiply injured. It has become a technique of evacuating army service personnel with minimal physiologic insult allowing the surgeon maximal options for definitive treatment of such fractures. There is no consensus how long an external fixator should be left on the patient before it is converted to other definitive treatment. 
In the current realms of trauma in Nigeria, the definitive options available for treating these types of patients are similar, if less complex. Although there is a fledgling health insurance scheme in Nigeria, the coverage is limited to civil servants and does not cover major orthopedic procedures. Due to limited resources, poor patient financial capacity coupled with nonexistent health insurance orthopedic urgeons, therefore, opt for definitive fracture fixation using external fixators from the time of admission at the casualty department. Frequently, the patients or their relations opt for nonorthodox fracture management despite visible open wounds. In more economically empowered nations, external fixators are kept on an average for about 7 days with a range of 1-49 days.  In one series of 39 patients with tibial fractures, initially the patients were treated with external fixators and then converted into IM nails, external fixation was used for 17 days and converted to IM nail. This series reported two nonunions and one delayed union.  These findings are in contrast to ours in which the average duration of application of external fixators is 3 months with a range of 6 weeks to 1 year. Reasons for such long period of application may be adduced to dearth of reconstructive expertise on the side of the caregivers in the region where the study was conducted and financial difficulties on the side of the patient. In a comparative study of treatment of open fractures of the tibia using traction, casting and external fixation in a Red Cross hospital similar to our hospitals in Kenya and Afghanistan, it was observed that patients treated with external fixators stayed in the hospital longer and had more complications than those with cast.  This study, however, was silent on the degree of soft tissue damage. Our patients had Gustillo II to III A and B injuries in the upper and lower limbs.
Fracture union rate of 6 out of 10 patients treated was observed in our series which was high, considering the degree of soft tissue damage in the majority of the patients studied. There was 80% rate of healing between cases operated by consultants and those operated by trainees. Fracture union rate after 6 months was found to be very high in patients who had initial external fixation followed by IM nailing, averaging 97%. 
There was a very high pin-tract infection rate of 80%. This was easily treated with antibiotics and local pin care, the absence of which might have contributed to the infection in the first place. It is our tradition to clean the bases of the Schanz screws in the morning and in the evening. This responsibility is then handed over to the patient without close monitoring. One other reason was the long stay of the external fixators encouraging colonization of the Schanz screw site. No definite case of osteomyelitis was documented.
In a study of 192 cases on the use of external fixators for temporary and definitive treatment of patients with open fractures during the Croatian war, 5 out of 8 patients with upper limb injuries developed delayed union and osteomyelitis while 4 out of 13 patients developed similar complications in cases where the injuries were in the lower limbs.  Several studies have documented the pin-site infection rates in external fixation. In a series of 191 patients with external fixation lasting for <28 days, the infection rate was 3.7%. For those patients whose external fixators lasted longer than 28 days, the infection rate was 22%.  Our study shows good union rates comparable to what has been obtained in the Nigerian literature. ,,
The re-operation rate for our series was 2%. This is considered to be low given the fact that all cases were single-frame external fixations that are known to have problems of stability and high risks of dislodgement of construct following reduction.  In a meta-analytic review of studies on reamed and unreamed IM nails versus external fixation for open tibial fractures, rates of re-operation were found to be lower in external fixation than IM nails (6.7% vs. 50%, P < 0.01).  Surgery being a psychomotor learning process, the experience of the surgeon may affect the outcome of any surgical procedure. There is a tendency for the younger surgeon to be aggressive in debridement and general tissue handling. We found overall union rates to be concordant in 80% of the cases studied in our series. [Figure 1] a severely injured patient with Gustillo III B open Femoral fracture at presentation. The same patient is seen in [Figure 2] after debridement and in [Figure 3] after monolateral frame external fixator application.
|Figure 1: A severely injured patient with Gustillo III B open femoral fracture|
Click here to view
| Conclusions|| |
This study has shown monolateral external fixation to be a procedure that is easily carried out with reasonable success and few controllable complications despite the complex nature of the injuries patients present with. External fixation as a temporary as well as definitive means of fracture care in open injuries is a well-established method in our environment now. It allows for simultaneous open wound care while the fractures heal, thus reducing the duration of hospital stay and cost for the patient and society.
Although vascular and nerve injuries are the most feared complications of application of external fixations, we did not encounter any of these in our study. This is probably fortuitous, because there were several overshooting Schanz screws in our series. Indeed, one of the operators wondered why so few of these complications are recorded.
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Conflicts of Interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]