Archives of Orthopaedic and Trauma Surgery

, Volume 124, Issue 8, pp 542–546 | Cite as

Hybrid external fixation of distal tibial fractures: new strategy to place pins and wires without penetrating the anterior compartment

  • Jong- Keon Oh
  • Jeong- Joon Lee
  • Duk- Young Jung
  • Bong- Ju Kim
  • Chang- Wug Oh
Original Article



Impalement of the anterior compartment musculature remains a problem in the hybrid external fixation of distal tibial fractures. The purposes of this study were to develop a tensioned wire configuration which does not violate the anterior compartment and to analyze the biomechanical implications of new wire configuration.

Materials and methods

Thirty-seven adult volunteers without known pathology around either tibia were recruited. Axial computed tomography of the distal tibia was performed at 5-mm slices from the plafond to the upper margin of the syndesmosis. The wire convergence angle was measured at the 1-, 2-, and 2.5-cm levels using the following landmarks: tibialis anterior tendon (TA), tibialis posterior tendon (TP), peroneus brevis tendon (PB), anterolateral border of the lateral malleolus (LM). Two straight lines were drawn by connecting TA and PB and connecting TP and LM. The wire convergence angle was defined as an acute angle between these two lines. Then the orientation of the bisector axis of the wires was measured. As a second part of this study, a validated three-dimensional hybrid external fixator model was developed using finite elements modeling to analyze the stiffness of the frames constructed according to the measured wire convergence angle and orientation. Five simulated configurations were tested. The stiffness of each frame was analyzed under four load conditions: torsion, axial compression, side bending, and anteroposterior bending.


The mean convergence angle was 30° irrespective of the level. The bisector axis was oriented towards the anterolateral direction about 20° from the coronal plane. The stiffness of the frame constructed with a wire convergence angle of 30° and an anterolateral wire orientation of 20° was 20–30% less than that of the frame constructed with 60° wires oriented in a coronal plane. The addition of an anteromedial half-pin increased the stiffness significantly.


Two tensioned wires may be placed without violating the anterior compartment by using the above four clinically identifiable landmarks. Addition of a half-pin on the anteromedial surface of the distal articular fragment makes the frame markedly stiffer than is possible using the standard wire configuration.


Distal tibial fractures Hybrid external fixation Impalement Wire convergence angle Finite elements modeling 


  1. 1.
    Anglen JO (1999) Early outcome of hybrid external fixation for fracture of the distal tibia. J Orthop Trauma 13:92–97CrossRefGoogle Scholar
  2. 2.
    Barbieri R, Schenk R, Koval K, Aurori K, Aurori B (1996) Hybrid external fixation in the treatment of tibial plafond fractures. Clin Orthop 332:16–22CrossRefPubMedGoogle Scholar
  3. 3.
    Court-Brown CM, Walker C, Garg A, McQueen MM (1999) Half-ring external fixation in the management of tibial plafond fractures. J Orthop Trauma 13:200–206CrossRefPubMedGoogle Scholar
  4. 4.
    Fleming B, Paley D, Kristiansen T (1989) A biomechanical analysis of the Ilizarov external fixator. Clin Orthop 241:95–105PubMedGoogle Scholar
  5. 5.
    Gaudinez RF, Mallik AR, Szporn M (1996) Hybrid external fixation in tibial plafond fractures. Clin Orthop 329:223–232Google Scholar
  6. 6.
    Karas EH, Weiner LS (1994) Displaced pilon fractures. An update. Orthop Clin North Am 25:651–663Google Scholar
  7. 7.
    Kummer FJ (1992) Biomechanics of the Ilizarov external fixator. Clin Orthop 280:11–14Google Scholar
  8. 8.
    Marsh JL (1999) External fixation is the treatment of choice for fractures of the tibial plafond. J Orthop Trauma 13:583–585CrossRefPubMedGoogle Scholar
  9. 9.
    Orbay GL, Frankel VH, Kummer MJ (1992) The effect of wire configuration on the stability of the Ilizarov external fixator. Clin Orthop 279:299–302Google Scholar
  10. 10.
    Roberts CS, Dodds JC, Perry K, Beck D, Seligson D, Voor MJ (2003) Hybrid external fixation of the proximal tibia: strategies to improve frame stability. J Orthop Trauma 17:415–420CrossRefPubMedGoogle Scholar
  11. 11.
    Stamer DT, Schenk R, Staggers B, Aurori K, Aurori B, Behrens FF (1994) Bicondylar tibial plateau fractures treated with a hybrid ring external fixator: a preliminary study. J Orthop Trauma 8:455–461PubMedGoogle Scholar
  12. 12.
    Tornetta P III, Weiner L, Bergman M et al (1993) Pilon fractures: treatment with combined internal and external fixation. J Orthop Trauma 7:489–496PubMedGoogle Scholar
  13. 13.
    Vives MJ, Abidi NA, Ishikawa SN, Taliwal RV, Sharkey PF (2001) Soft tissue injuries with the use of safe corridors for transfixion wire placement during external fixation of distal tibia fractures: an anatomic study. J Orthop Trauma 15:555–559CrossRefPubMedGoogle Scholar
  14. 14.
    Watson JT (1996) Tibial pilon fractures. Techn Orthop 11:150–159Google Scholar
  15. 15.
    Weiner LS, Kelley M, Yang E, Steuer J, Watnick N, Evans M, Bergman M (1995) The use of combination internal fixation and hybrid external fixation in severe proximal tibia fractures. J Orthop Trauma 9:244–250PubMedGoogle Scholar
  16. 16.
    Williams TM, Marsh JL, Nepola JV et al (1998) External fixation of tibial plafond fractures: is routine plating of the fibula necessary? J Orthop Trauma 12:16–20CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2004

Authors and Affiliations

  • Jong- Keon Oh
    • 1
  • Jeong- Joon Lee
    • 1
  • Duk- Young Jung
    • 2
  • Bong- Ju Kim
    • 3
  • Chang- Wug Oh
    • 4
  1. 1.Department of Orthopedics, Medical Research Institute, College of MedicineEwha Womans UniversitySeoulKorea
  2. 2.Institute for Frontier Medical SciencesKyoto UniversityKyotoJapan
  3. 3.Biosimulation CenterKyoto UniversityKyotoJapan
  4. 4.Department of Orthopedic SurgeryKyungpook National University HospitalDaeguKorea

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