title: Two-ring hybrid external fixation of distal tibial fractures: a review of 47 cases.
abstract: BACKGROUND
  The healing of a metaphyseal fracture line is a major problem in cases of distal tibial fracture treated with external fixation.
  
  
  METHODS
  Forty-seven distal tibial fractures treated with two-ring Ilizarov hybrid external fixation (16 AO/OTA type A and 31 type C, 10 open) were followed up. Fracture reduction and union time was evaluated and IOWA and RAND 36-Item Health Survey scores were used to assess functional outcome.
  
  
  RESULTS
  Thirty-five fractures united uneventfully in a median time of 20 weeks, but 12 fractures needed additional procedures because of delayed union. According to univariate analysis, the risk factors for a longer time needed for fracture union were translational displacement and current smoking, and the risk factors for reoperation because of delayed union translational displacement fibular fracture fixation, and the number of cigarettes smoked per day. In multivariate analysis, translational displacement was a risk factor for both longer time to fracture union and reoperation and fibular fracture fixation was a risk factor for reoperation. If the translational displacement was less than 3 mm, the reoperation rate was 6%, whereas if the displacement was more than 3 mm, it was 83%. Reoperation was performed on 50% of the patients who underwent fibular fixation and on 15% of the patients who did not undergo fibular fixation. There were only marginal decreases in the range of motion and arthritis scores in the AO/OTA fracture types other than type C3. There were no significant differences in RAND 36 scores between the general Finnish population aged 18 to 64 years and our patients.
  
  
  CONCLUSIONS
  Hybrid external fixation of distal tibial fractures is associated with delayed union, which is closely related to the degree of residual translational displacement after reduction. Fixation of an associated fibular fracture does not help to achieve better contact in the tibial fracture and increases the risk of delayed union.
authors.affiliation: From the Department of Orthopaedic and Trauma Surgery, University Hospital of Oulu, Oulu, Finland. jukka.ristiniemi@oulu.fi
authors.forename: Jukka
authors.initials: J
authors.lastname: Ristiniemi
authors.forename: Tapio
authors.initials: T
authors.lastname: Flinkkilä
authors.forename: Pekka
authors.initials: P
authors.lastname: Hyvönen
authors.forename: Martti
authors.initials: M
authors.lastname: Lakovaara
authors.forename: Harri
authors.initials: H
authors.lastname: Pakarinen
authors.forename: Fausto
authors.initials: F
authors.lastname: Biancari
authors.forename: Pekka
authors.initials: P
authors.lastname: Jalovaara
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016512:Ankle Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D016022:Case-Control Studies; D016267:External Fixators; D005260:Female; D005500:Follow-Up Studies; D005592:Fracture Fixation / Q000379:methods*; D017102:Fracture Healing; D005599:Fractures, Ununited / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011859:Radiography; D016059:Range of Motion, Articular; D012307:Risk Factors; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome