title: The use of twin-ring Ilizarov external fixator constructs: application and biomechanical proof-of principle with possible clinical indications.
abstract: BACKGROUND
  In peri- or intra-articular fractures of the tibia or femur, the presence of short metaphyseal bone fragments may make the application of an Ilizarov external fixator (IEF) challenging. In such cases, it may be necessary to bridge the adjacent joint in order to ensure stable fixation. The twin-ring (TR) module of circular external fixation is proposed as an alternative method that avoids joint bridging, without compromising stability of fixation. The aim of this study is to present the experimental tests performed to compare the biomechanical characteristics of the single- and TR IEF modules. The clinical application of the TR module in select patients is also presented and the merits of this technique are discussed.
  
  
  METHODS
  In this experimental study, the passive stiffness and stability of the single-ring (SR) and twin-ring (TR) IEF modules were tested under axial and shear loading conditions. In each module, two perpendicular wires on the upper surface and another two wires on the lower surface of the rings were used for fixation of the rings on plastic acetal cylinders simulating long bones.
  
  
  RESULTS
  In axial loading, the main outcome measure was stiffness and the SR module proved stiffer than the TR. In shear loading, the main outcome measure was stability, the TR module proving more stable than the SR.
  
  
  CONCLUSIONS
  The TR configuration, being stiffer in shear loading, may make joint bridging unnecessary when an IEF is applied. If it is still required, TR frames allow for an earlier discontinuation of bridging; either case is in favour of a successful final outcome.
  
  
  CONCLUSIONS
  The application of the TR module has led to satisfactory clinical outcomes and should be considered as an alternative in select trauma patients treated with an IEF. Biomechanically, the TR module possesses features which enhance fracture healing and at the same time obviate the need for bridging adjacent joints, thereby significantly reducing patient morbidity.
authors.affiliation: Orthopaedic and Trauma Department, Tzanio General Hospital of Piraeus, Zanni and Afendouli 1, GR-185 36, Piraeus, Greece. tgri69@otenet.gr
authors.forename: Theodoros B
authors.initials: TB
authors.lastname: Grivas
authors.forename: Evangelos A
authors.initials: EA
authors.lastname: Magnissalis
mesh_terms: D001696:Biomechanical Phenomena; D004867:Equipment Design; D016267:External Fixators; D005264:Femoral Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D018889:Ilizarov Technique / Q000295:instrumentation*; D017063:Outcome Assessment, Health Care; D011859:Radiography; D012189:Retrospective Studies; D013314:Stress, Mechanical; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome