gms | German Medical Science

Purpose: To report our experience in treatment of severely comminuted high-energy shotgun fractures with the Ilizarov external fixator.

Material and methods: From January 1994 to December 2002, 11 high-energy shotgun fractures in 11 patients complicated with infection and bone defect were treated using the Ilizarov external fixator. All these injuries caused by multiple shotgun pellets (seen on radiographs). All patients were male, with an average age of 42.6 years (range 18-52 years). There were 8 tibial fractures (1 in proximal metaphysis third and 4 in distal metaphysis) and 3 femoral fractures (2 in distal metaphysis). All the fractures were displaced and severely comminuted - type C3 (Á.Ï.), and open type III. In all patients, monolateral external fixator was used for initial fracture stabilization (8 of them in another hospital). Eight patients underwent prophylactic or acute fasciotomies and epimysiotomies for compartment syndrome during the initial fracture management The average time that elapsed from the original injury to the Ilizarov fixator application was 117.5 days (range 23 - 403 days).

Ten patients had an active infection with purulent drainage, and only one patient had active infection without drainage. The mean bone defect was 5.7 cm (range 2 -15 cm).

Adequate surgical debridement of the infected area, with minimal intervention of the damaged bone tissue as well as extensive resection of damaged soft tissue, was performed in all the patients after removal of the monolateral external fixator. In 4 patients the limb segment was partially shortened after radical surgical debridement and in seven patients the technique of acute docking was used. At this stage the Ilizarov fixator was applied.

In 3 patients with bone defect of 2 cm, monofocal method was performed, in 8 patients with larger bone defect, bifocal method was used. Secondary locked intramedullary nailing in the consolidation phase was performed in 4 patients with delayed union at the docking site. In one case, with a very distal tibial injury, an ankle arthrodesis was performed. Efficacy of treatment was determined by Paley bone and functional results, external fixation time, and time of functional rehabilitation.

Result: Average follow-up period was 3 years (range 1-7 years). Complete bony union occurred in all patients while eradication of infection was also achieved. The mean external fixation time was 281.4 days (range 98 - 630 days). Residual angular deformity of more than 7 degrees occurred in 2 cases. Ankle joint stiffness remained in 4 patients with periarticular injuries but full weight bearing ability was spared.

Conclusions: The Ilizarov method is the treatment of choice for complicated shotgun fractures of long bones. The advantages of this method include the ability to provide rigid fixation, with the potential of simultaneous correction and restoration of a broad spectrum of accomplished orthopaedic pathology.