Treatment of Posttraumatic Deformities in Children and Adolescents by Taylor Spatial Frame

Treatment of Posttraumatic Deformities in Children and Adolescents by Taylor Spatial Frame

By Mark Eidelman, MD; Michael Zaidman, MD; Alexander Katzman, MD

The Taylor Spatial Frame provides outstanding stability and computer accuracy and is a reliable and definite method for posttraumatic deformity correction. Limb deformity may result from various traumatic sequelae. The most common cause is fracture malunion, but in growing children, shortening and angulation secondary to physis injury is also common. Correction of posttraumatic deformities can be done by various approaches. Each method has pros and cons, but a combination of limb shortening and angulation justify external fixator application. Several external fixators are available. They can be divided into 2 groups: monolateral and circular. A monolateral external fixator may be more easily tolerated, but it is less stable and forgiving compared to the circular external fixator. The Ilizarov frame is a classic example of a circular external fixator. This frame allows excellent stability but has some disadvantages, such as a long surgeon learning curve and difficulty with rotational correction.The Taylor Spatial Frame (Smith & Nephew, Memphis, Tennessee) is a computerized external fixator with a virtual hinge and the ability to correct 6-axis deformities simultaneously. In contrast with the Ilizarov frame, there is no need for hinge application, multiple frame adjustments, or change of frame configuration to correct multiple plane deformities. The purpose of this study was to determine the effectiveness of the Taylor Spatial Frame for treatment of complex posttraumatic deformities in children and adolescents. Materials and Methods Between 2003 and 2007, 18 patients with various posttraumatic deformities were treated with the Taylor Spatial Frame at our institution (Table). Average patient age at the time of frame application was 13.1 years (range, 8-17 years). There were equal numbers of proximal, mid, and distal tibial malunions; 2 patients had combined distal and proximal tibial malunions. Seven patients had deformities secondary to growth arrest: 3 patients had growth arrest of the distal femur, 3 had proximal tibial growth arrest, and 1 had distal radius deformity secondary to physis injury. Standing anteroposterior (AP) and lateral radiographs from pelvis to toes were obtained pre- and postoperatively and at final follow-up. Deformity analysis and measurements were made in all planes according to the principles described by Paley.1 Surgical technique was described in detail in several reports.1-5 All osteotomies were performed percutaneously by Gigli saw or the drilling and osteotome technique.1 All deformities were analyzed using the total residual correction program and were gradually corrected. Minimum follow-up was 2 years after frame removal. Results In all patients, restoration of the mechanical axis and length equalization was achieved with no or minimal difference compared with anatomical parameters of contralateral extremity. At last follow-up, all patients were pain free and had regained preoperative range of motion (ROM). The frame was removed after a mean 12.3 weeks (range, 8-24 weeks). Average lengthening was 17.9 mm (range, 5-80 mm). Eight patients had superficial pin tract infection, which resolved with oral antibiotics or a short course of intravenous administration. One patient had transient peroneal palsy. Another patient had delayed union and needed 2 additional cast immobilizations after fixator removal. The most serious complication was angulation of the regenerate after 40 mm of femoral lengthening (Figure 1). This complication was caused by unstable ring fixation. The fixation block was revised and angulation was successfully and gradually corrected by the total residual program. No patient had deep infection or nonunion. Figure 1: Radiographs of a 13-year-old boy with a segmented fracture of the femur and damage of the distal femoral epiphysis (A, B). AP (C) and lateral (D) radiographs before frame application (1 year after trauma) showing distal femoral valgus, recurvatum, and external rotation. AP (E) and lateral (F) radiographs during correction showing regenerate of angulation. Note the distal fragment fixed with 1 ring and only 2 half pins. Radiograph after addition of the second ring and four 1.8 Ilizarov wires (G). Radiograph of normal femoral alignment after frame removal (H). Discussion Posttraumatic deformity correction in children with open physis can be a surgical challenge. Proximity of the growth plate restricts the use of intramedullary nail fixation, while shortening and pure soft tissue coverage restrict wide use of the plating technique. The obvious advantage of external fixator application in contrast to internal fixation devices is soft tissue preservation, which can be essential in posttraumatic conditions (Figure 2). Figure 2: Photograph of 16-year-old boy with 80-mm shortening and severe varus deformity secondary to damage of the proximal and distal epiphysis (A). Note the pure soft tissue coverage of the medial side of the tibia (B). AP radiographs before (C) and after (D) correction. Clinical appearance after correction (E). Several external fixators are available. They can be divided into 2 groups: monolateral and circular. A monolateral external fixator may be better tolerated but is less stable and forgiving.6 The stability of the circular frame allows early postoperative weight bearing and ROM maintenance, which can be essential for regenerate formation.2,3 The Ilizarov circular frame is the classic choice for deformity correction and allows correction of almost all possible deformities.7,8 However, correction of multiplanar deformities requires replacement of hinges and frequent frame readjustments. Successful use of the Ilizarov technique has a long learning curve, and correction of complex—especially multiplanar and rotational—deformities remains a difficult challenge, even for surgeons experienced with this technique.3,6 Manner et al9 compared the accuracy of complex deformity correction by Taylor Spatial Frame and Ilizarov circular frame on 208 deformities in 155 patients. They reported that deformity correction was achieved in 90.7% in the Taylor Spatial Frame group vs 55.7% in the Ilizarov frame group. They concluded that the Taylor Spatial Frame has better precision in deformity correction, in 2-, 3-, and 4-dimensional deformity corrections in particular. In most cases, orthopedic surgeons deal with multiplanar posttraumatic deformities. We treated 18 patients with posttraumatic malunions. Most of our patients had multiplanar deformities and shortening. Despite complex deformities, all patients achieved precise correction of all deformities. Another choice the surgeon faces is acute vs gradual deformity correction. Matsubara et al10 retrospectively examined clinical results of acute and gradual deformity correction in 2 groups of patients treated by Ilizarov frame or Taylor Spatial Frame. They concluded that gradual correction is a better approach with the use of external fixation. We believe that gradual correction is a more forgiving and safe way to correct deformities in children. Almost all of our patients had some shortening; therefore, gradual correction with lengthening is the only way to resolve this problem, especially in children with deformities secondary to injury of the growth plate. We observed relatively few complications in this study. The most common complications were superficial pin tract infections, which were treated with oral antibiotics. There were no deep infections or osteomyelitis. In our previous report,3 the most serious complications were fractures of the regenerate due to pure dynamization in 3 patients. In this study, 1 patient had angulation of the regenerate secondary to unstable fixation of the distal femur. Currently, we use 2 rings at the distal femur with at least one 1.8 Ilizarov wire and three 6-mm half pins. References Paley D, ed. Principles of Deformity Correction. Heidelberg, Germany: Springer-Verlag; 2002. Rozbruch SR, Fragomen AT, Ilizarov S. Correction of tibial deformity with use of the Ilizarov-Taylor spatial frame. J Bone Joint Surg Am. 2006; 88(suppl 4):156-174. Eidelman M, Bialik V, Katzman A. Correction of deformities in children using the Taylor spatial frame. J Pediatr Orthop B. 2006; 15(6):387-395. Eidelman M, Katzman A. Treatment of complex tibial fractures in children with the Taylor spatial frame. Orthopedics. 2008; 31(10). pii: orthosupersite.com/view.aspx?rID=31513. Taylor JC. Correction of general deformity with Taylor spatial frame fixator. J. Charles Taylor Web site. http://www.jcharlestaylor.com/spat/00spat.html. Accessed January 2010. Binski JC. Taylor spatial frame in acute fracture care. Tech Orthop. 2002; 17(2):173-184. Ilizarov GA, ed. Transosseous Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue. Berlin, Germany: Springer-Verlag; 1992. Birch JG, Samchukov ML. Use of the Ilizarov method to correct lower limb deformities in children and adolescents. J Am Acad Orthop Surg. 2004; 12(3):144-154. Manner HM, Huebl M, Radler C, Ganger R, Petje G, Grill F. Accuracy of complex lower-limb deformity correction with external fixation: a comparison of the Taylor Spatial Frame with the Ilizarov ring fixator. J Child Orthop. 2007; 1(1):55-61. Matsubara H, Tsuchiya H, Sakurakichi K, Watanabe K, Tomita K. Deformity correction and lengthening of lower legs with an external fixator. Int Orthop. 2006; 30(6):550-554. Authors Drs Eidelman, Zaidman, and Katzman are from the Pediatric Orthopedic Unit, Meyer Children’s Hospital, Rambam Medical Center, Haifa, Israel. Drs Eidelman, Zaidman, and Katzman have no relevant financial relationships to disclose. Correspondence should be addressed to: Mark Eidelman, MD, Pediatric Orthopedic Unit, Meyer Children’s Hospital, Rambam Medical Center, PO Box 96092, Haifa, 31906 Israel (eidelmanm@gmail.com). doi: 10.3928/01477447-20100225-16