Title: Circular external fixation in complex tibia fractures: a case series and review of the literature

Authors: Gianluca Canton#, Emmanuele Santolini°, Luigi Sannino*, Danilo Chiapale§, Luigi Murena#, Federico Santolini*

Affiliations:

#U.C.O. Clinica Ortopedica Traumatologica - Azienda Sanitaria Universitaria Integrata – Trieste - Italy

*U.O.C. Ortopedia e Traumatologia d'Urgenza - IRCCS AOU San Martino IST - Genova – Italy

° Clinica Ortopedica Università di Genova - IRCCS AOU San Martino IST – Genova - Italy;

§ S.C. Ortopedia e Traumatologia - Ospedale San Paolo – Savona - Italy

Notes: The research project leading to realization of the present paper was possible thanks to the “Borsa di Studio SPLLOT 2014” contribute; preliminary results of the present work were presented at the 112° SPLLOT congress in Genova on September 25-26, 2015.

Corresponding author: Gianluca Canton, U.C.O. Clinica Ortopedica e Traumatologica – Azienda Sanitaria Universitaria Integrata Trieste - Ospedale Cattinara, Strada di Fiume 447, 34149 Trieste - Italy. Tel. +39 040 3994576. E-mail address: gcanton84@gmail.com

Abstract (200-250 parole, strutturato)

Objectives: To analyze indications and results of circular external fixation applied to complex tibia fracture cases in the authors' experience and in the literature. Methods: 17 cases of complex tibia fracture treated with circular external fixation in 17 patients were retrospectively evaluated to assess clinical and radiographic results. Results: There were 9/17 open fractures and 8/17 closed fractures. Union was achieved in 16 on 17 cases (94.1%), with mean union time 6.7 months (range 4-18). A septic nonunion case occurred. Malunion occurred in 3 cases. At least one unplanned surgery was necessary in 6 cases (0.6 surgeries per patient). VAS mean values were 1.6 for pain (range 0-4), 2.7 for functional impairment (range 1-8) and 8.9 for satisfaction (range 6-10). Paley scores in bone transport cases were excellent or good in most cases.

Superficial pin tract infection was common (64.7% of cases), while deep pin tract infections were not recorded. Other septic and non septic complications were recorded in 3 and 7 cases respectively. Conclusions: circular external fixation still represents a viable method to treat tibia fractures when fracture pattern is particularly complex, soft tissues are severely compromised or when acute bone or bone and soft tissue loss in present. Despite frequent complications, long treatment duration and unplanned surgeries clinical results and patients satisfaction are meanly good.

Keywords: circular external fixator, tibia fracture, tibial plateau, tibial plafond, open fracture, bone loss

Manuscript text

Introduction

Circular external fixation was introduced by Ilizarov in the 50s' in Russia and exported worldwide in the early 80s' (1). The worldwide accepted indications for this method of treatment include deformity correction, bone lengthening, bone loss reconstruction and chronic infection (2). In trauma, despite the theoretical possibility of treating any kind of bony lesion, this method is much less used for the excellent results achieved by other treatment methods (3). Moreover technical complexity, frequent complications, long length of treatment and the necessity of close follow-up make this treatment scarcely appealing for most surgeons (3). Anyway, in some clinical situations of particular complexity circular external fixation is the only treatment which can assure proper stability while respecting soft tissues, allowing bone and soft tissues healing together with early weight bearing (4, 5, 6, 7). Nonetheless, in cases of bone and soft tissues loss, it is a proven treatment method for both bone and soft tissues reconstruction in the acute setting (8, 9, 10, 11), especially when plastic surgery is contraindicated or not feasible. Because of the relatively high frequency of complex fractures, open fractures and severe soft tissues lesions, tibia fractures are the mostly suitable clinical setting for circular external fixation application (12, 13, 14). In the present paper the indications and results of circular external fixation applied to tibia fracture cases are reviewed through the authors experience and literature reports.

Materials and Methods

The cases of tibia fractures definitively treated with circular external fixation at the U.O.C. Ortopedia e Traumatologia d'Urgenza - IRCCS AOU San Martino IST - Genova (Italy) from January 2009 and December 2014 were all included in the study. Based on two of the senior authors (F.S., D.C.) indications, they included the following: complex, highly comminuted diaphyseal or meta-diaphyseal fractures with eventually compromised soft-tissues (including open fractures); high energy trauma tibial plateau and tibial plafond fractures with compromised soft tissues and/or significant metadiaphyseal extension or comminution; mangled extremities presenting as open fractures with bone loss or combined bone and soft tissue loss in which circular fixator was used as a limb salvage procedure. In all cases an Ilizarov circular fixation system (Sintea Plustek srl, Italy) was used, either with tensioned wires alone or in combination with half-pins. The circular fixator was applied in acute or after temporary stabilization with axial or polyaxial external fixation.

The population in exam counted 24 cases in 24 patients, of which 18 males and 6 females. Mean age at trauma was 47.6 years (range 19-78). From October 2014 to March 2016 patients were contacted for clinical evaluation. Of these, 2 patients moved to another country and 5 were not contactable or refused to be involved in the study. A population of 17 cases in 17 patients then resulted, of which 13 males and 4 females. Mean age at trauma was 45.6 years (range 19-78). Mean follow up was 34 months (range 6-62).

Trauma radiographic images were analyzed to classify fractures according to AO/OTA (15) classification. Soft tissues lesions were classified according to Gustilo-Anderson (16) for open fractures and according to Tscherne (17) for closed fractures. Bone loss requiring reconstructive techniques was recorded when present. For all patients union time was recorded and any nonunion and malunion noted. Fractures were considered united when full weight bearing without brace was achieved after frame removal. Any additional unplanned surgery was recorded (removal of fixator was not considered additional surgery).

At follow up clinical evaluation included evaluation of pain, functional impairment and satisfaction with a visual analogic scale (VAS). For bone transport cases both bone and functional results were specifically evaluated and rated as excellent, good, fair or poor according to Paley and Maar (2). Any septic complication was recorded. In particular, superficial pin tract infections (grade I and II according to Checketts-Otterburns (18) were recorded but not considered as septic complications, while deep pin tract infections (grade III and IV according to Checketts-Otterburns (18) were considered septic complications. Vascular, neurologic or any other complication was also recorded, including in particular knee and ankle stiffness or contracture and leg length discrepancy ≥ 1.5 cm.

Results

According to the different indications for circular external fixation, 6 cases were complex, highly comminuted diaphyseal or meta-diaphyseal fractures, with eventually compromised soft-tissues (Group A); 6 cases were high energy trauma tibial plateau (3) and tibial plafond (3) fractures with compromised soft tissues and/or significant metadiaphyseal extension or comminution (Group B); 5 cases were Gustilo IIIB-C open fractures with bone loss or combined bone and soft tissue loss (Group C). Of the latter, 3 cases presented isolated bone loss and two cases presented combined bone and soft tissue loss that was treated with bone transport or combined bone and soft tissue transport. There were 9/17 open fractures and 8/17 closed fractures, of which 4 presented Tscherne grade II-III soft tissue damage. In 13 cases a temporary external fixator was applied in the emergency department.

Union was achieved in 16 on 17 cases (94.1%), with mean union time 6.7 months (range 4-18). Mean VAS values were 1.6 for pain (range 0-4), 2.7 for functional impairment (range 1-8) and 8.9 for satisfaction (range 6-10). Bone and functional result for bone transport cases was excellent or good in most cases. Table 1 resumes clinical and radiographic data for the whole population and for the three different patients groups (Tab. 1).

Nonunion occurred in 1 case (5.9%) in the oldest patient of the population (78 years old), who suffered an AO 43 C2 / Gustilo-Anderson IIIB open fracture. Septic nonunion occurred at 11 months, requiring fixator removal and brace-protected weight bearing, in association with intravenous antibiotic therapy and hyperbaric therapy for the next 13 months (the patient refused amputation).

Malunion occurred in 3 cases (Fig 1), all of which were open Gustilo III B-C fractures with severe comminution and meta-diaphyseal extension. Table 2 resumes data about nonunion and malunion cases (Tab. 2)

At least one unplanned surgical intervention was necessary in 6 cases, with a sum of 10 unplanned surgeries in the study population and mean 0.6 additional surgeries per patient. Unplanned surgeries were performed in order to solve the following: docking site related problems, ankle and foot stiffness/contractures, soft tissues infection, soft tissue impingement with the external fixator. Data regarding unplanned surgeries are resumed in Table 3 (Tab. 3).

Superficial pin track infection was reported in 11 cases (64.7%), all of which completely resolved with oral antibiotic therapy. Deep pin track infections were not recorded. Other septic complications were recorded in 3 cases: a wound infection after docking point revision successfully treated with antibiotics; a subcutaneous abscess successfully treated with drainage; the described case of septic nonunion, which is the only case (5.9%) of deep infection.

Other complications were present in 8 cases. Data regarding septic and non septic complications are also resumed in Table 3 (Tab. 3).

Discussion

A high performance of the Ilizarov fixator in the treatment of severe tibial fractures with compromised soft tissues where more standard forms of treatment are contraindicated is demonstrated in the literature. Baskera et al (7) reviewed 48 of their patients in which the Ilizarov external fixator was used as an immediate and definitive treatment for severe tibial fractures compromised by extensive soft tissue damage. The totality of their patients stated that they were either satisfied or very satisfied with the treatment and 91% would choose the same method of treatment under similar circumstances. Dickson et al (3) reported on 22 patients treated for Gustilo-Anderson grade III open tibia fractures. There were eight Grade 3A and 14 Grade 3B fractures. Union occurred in all cases after mean 242 days (range 108–342). Their patients reached meanly good functional results and a low deep infection rate (4.5%).

Results of the present study are in line with the literature, with union occurring in 94.1% of cases at mean 6.7 months, a low bone infection rate (5.9%), good functional results and high satisfaction of patients with mean VAS values for functional impairment and patients satisfaction of 2.7/10 and 8.9/10 respectively. The unplanned surgeries and overall complications rate in the present study also resulted comparable to literature reports (3, 4, 6, 11, 12, 13, 19), with 0.6 surgeries per patient and 35.2% of patients suffering of at least one complication. Likewise, most unplanned surgeries and complications occurred in limb salvage cases.

The present authors indications for circular external fixation are based on the complexity of the fracture and the severity of soft tissues compromise, as already reported in the literature (3, 4, 5, 7, 19). In tibia fracture without articular involvement setting, circular external fixator has been used more frequently in literature for open fractures, complex fractures due to high energy trauma and metaphyseal fractures with significant shaft extension (13). In these cases, the severe soft-tissue injury compromises the blood flow to fracture fragments, thus a fixation method that minimizes additional damage is preferable (12). Moreover, the advantages of circular fixation in these complex fractures reside in the possibility to capture every segment of the fracture, to adjust fracture alignment and fragments contact after surgery and to offer circumferential control for optimal stability (6). Almedaroglu et al. (13) reported on 32 cases of complex tibia fracture, with 100% union rate after mean 20 weeks. Ozturkmen et al. (12) reported on the treatment of segmental fractures with circular external fixation. The authors treated 24 cases, of which 17 were open fractures, with a four rings construct. They reported union in all cases with good clinical results and no deep infection. Giotakis et al. (6) treated 20 adult patients with AO 42C segmental tibia fractures. There were seven open fractures, four type 3B and three type 3A according to Gustilo-Anderson. The mean time to union in their series was 21.7 weeks (range 12.8 – 31).

In the present study there were 6 patients treated for complex dyaphyseal or metadyaphyseal tibia fractures without articular involvement (Group A). Soft tissue compromise was severe in 4/6 cases, with 3 open fractures (2 Gustilo-Anderson III B and 1 Gustilo-Anderson III A) and 1 closed Tscherne II fracture. A temporary external fixator was used in 4/6 cases. Results in this group are in line with the literature, with union occurring in 100% of cases at mean 6.5 months (range 4-11). Clinical results were particularly good in this group, with mean VAS values for pain and functional impairment of 1.8/10 (range 0-4) and 1.5/10 (range 0-5) respectively. Patients were meanly very satisfied of treatment results (mean VAS 9.2, range 8-10).

In tibial plateau and tibial plafond fracture setting, circular external fixation (with or without limited internal fixation) has been applied in the literature for fractures associated with severe soft-tissue injury or swelling, predominantly metaphyseal-diaphyseal comminution and displacement, fracture extension into the tibial shaft, and less severe intra-articular fracture displacement (4, 5, 19). With respect to hybrid external fixation, which can be successfully used in proximal tibia fractures, circular fixation assures better stability especially in fractures with severe meta-diaphyseal extension (5). Several authors demonstrated the value of temporary spanning fixation on high energy trauma proximal and distal tibia fractures (20, 21, 22), allowing for delayed internal fixation with few soft-tissues related complications. On the other hand, in certain cases soft tissue compromise is too severe to be solved with the latter strategy. In this scenario, circular external fixation could be considered the treatment of choice (4-5-19). Moreover, circular fixation allows for knee or ankle spanning that is indicated for very comminuted articular fractures allowing at the same time to mobilize the joint using appropriately oriented hinges. 

Catagni et al (4) reported on 59 consecutive complex proximal tibia fractures. Among the 59 cases, 39 (66.10%) fractures were isolated to the tibial plateau and 12 (20.34%) extended beyond to the metaphysis, diaphysis, and tibial pilon. Five fractures (8.47%) were open. All fractures healed, with an average time of treatment with the frame of 115 days (range 65–153). In 46 cases (77.96%) patients regained functional use of the limb, full range of motion and good axis without pain or instability at mean 11 months follow up. The patients satisfaction was significantly related with the functional results. El Barbary et al (23) reported on 30 Schatzker type VI tibial plateau fractures in 29 patients. There were 21 closed and 9 open fractures. All fractures united, except one with varus malunion, at mean 16.3 weeks. At mean 27 months follow up 27 patients with 28 fractures were evaluated, with result rated as excellent in 18, good in 7, fair in 1 and poor in 1 case according to the Knee Society clinical rating system. The authors stated that magnitude of soft-tissue injury negatively influenced the final outcome. Lovisetti et al. (19) reported on 30 tibial pilon, 29 of which were 43 C patterns (C1: 11, C2: 9, C3: 10). Eight fractures were open (Gustilo-Anderson I in 4 cases and II in 4 cases). In their series, there were no cases of nonunion or deep infection. The mean union time was 21.4 weeks. Fadel et al (24) compared circular external fixation to open reduction and plate fixation for the treatment of extrarticular distal tibia fractures in a prospective randomized comparative study on 40 consecutive patients.  The authors concluded circular external fixation to be recommended over plate osteosynthesis, in particular because it allows for immediate weight bearing without need for secondary surgical interference for management of non-union, mal-union or infection.

In the present study there were 6 patients treated for high energy tibial plateau (3 cases) and tibial plafond (3 cases) fractures (Group B). Indication for circular external fixation was due to significant metadiaphyseal extension and comminution of the fracture in 3 cases (Fig. 2) and to severe soft tissue compromise in 3 cases. Of the latter, 2 were closed Tscherne III fractures and 1 was an open Gustilo IIIC fracture. A temporary external fixator was used in 4/6 cases. Results in this group are also in line with the literature, with union occurring in 100% of cases at mean 4.3 months (range 4-11). Clinical results and patients satisfaction were also very good, with mean VAS values for pain, functional impairment and satisfaction of 1.5/10 (range 0-3), 2.7/10 (range 1-5) and 8.8/10 (range 7-10) respectively.

Although a precise definition remains elusive, any extremity sustaining sufficiently severe injury to a combination of vascular, bony, soft tissue and/or nerve structures that results in subsequent concern for viability of the limb should be considered a mangled extremity. Mangled extremities almost by definition involve Gustilo type III B or III C injuries (25). These injuries occur most frequently at the leg because of the unique anatomy of the tibia with its associated soft tissues and their vulnerability to severe injury (14). These injuries are associated with signi'cant morbidity due to an increased risk of infection, nonunion, and amputation. They require soft tissue coverage of the open fracture (26). Free 'ap reconstruction allows overall improved outcomes in Gustilo grade IIIB/C injuries by providing well-vascularized soft tissue coverage. Despite 'ap coverage, the tibial bone injury can impair the formation of a functional limb with reported rates of non-union of 11%–50% and late amputation of 4%–12% (27). Moreover, patients might not be candidate for a flap because of unavailability of local soft tissue, poor potential vascular supply to a free tissue transfer or medical comorbidities (11). The problem becomes magnified in severe injuries with significant bony defects and concomitant soft tissue loss. Ilizarov's method of distraction osteogenesis has been shown to be particularly effective in the reconstruction of fractures with significant osseous deficit (26). The unique abilities of circular 'xators to manipulate bone segments have been innovatively described by a number of authors to de'nitively address the problems associated with signi'cant open limb injuries and tissue defects without recourse to free tissue transfer in the de'nitive management of tissue loss. (9). They include acute shortening with primary soft tissue closure, monofocal/monolocal shortening and subsequent lengthening, bifocal/bilocal shortening with subsequent lengthening, gradual shortening, acute malreduction with delayed correction (9) and combined bone and soft tissue transport (2, 8, 28). Sen et al (10) reported on 24 cases of open Gustilo-Anderson III A-B tibia fractures with bone and soft-tissue loss managed by bifocal compression-distraction osteogenesis. The mean bone defect was 5 cm (range 3–8.5). The mean soft tissue defect was 2.5 × 3.5 cm. Acute shortening was performed in defects up to 3cm in length and gradual shortening in larger defects. Mean bone healing time was 7.5 months (range 4–11). At mean 30 months of follow-up bone results were excellent in 21 and good in 3 patients and functional results were excellent in 19, good in 4, and fair in 1 patient according to Paley and Maar criteria (2). Rozbruch et al (11) treated twenty-five patients with bone and soft tissue defects associated with tibial fractures. The average soft-tissue and bone defect after debridement was 10.1 (range, 2–25) cm and 6 (range, 2–14) cm respectively. Ilizarov fixators and Taylor Spatial Frames were used to gradually close the bone and soft-tissue defects simultaneously by using monofocal shortening or bifocal or trifocal bone transport. The average time of compression and distraction was 19.7 (range, 5–70) weeks, and time to soft-tissue closure was 14.7 (range, 3–41) weeks. Lengthening at another site was performed in 15 patients. The average amount of bone lengthening was 5.6 (range, 2–11) cm. Bony union occurred in 24 patients (96%) with closure of soft tissues in all cases. El Alfy et al (28) reported on 11 cases with composite bone and soft tissue defects treated by distraction osteogenesis with a circular fixator. The causes of bone and soft tissue defects were trauma in six of the 11 cases. Mean bone loss was 7 cm. Acute shortening with subsequent lengthening at a distant corticotomy site was done in two cases. In the remaining cases the exposed bone ends were resected till they became covered by the soft tissue, then bone and soft tissue transport was carried out. All bone and soft tissue defects healed without the need for plastic surgery except in one case after mean 10.9 months of treatment. The authors claimed that the bone ends must be buried under the soft tissue when bone transport is started to allow for optimal bone and soft tissue healing.

In the present study there were 5 cases of mangled extremities presenting as Gustilo IIIB-C open fractures with bone loss or combined bone and soft tissue loss (Group C). In detail, 4 cases were Gustilo III B and one Gustilo III C, with mean bone loss of 7 cm (range 4 - 14). Soft tissue loss was present in 2 cases (5 and 14 cm respectively), both treated with combined bone and soft tissue transport (Fig 3). One of the latter cases received autologous skin graft at the end of the transport. A temporary external fixator was used in all cases. As can be expected due to the severity of the initial injury, results in this group are worse than in the other two groups of present study. Union occurred in 80 % of cases (4/5) at mean 10.7 months. Mean VAS value for functional impairment was 4.2/10 (range 1-8). On the other hand, mean VAS values for pain (1.4, range 0-4) and most importantly for patient satisfaction (8.6, range 6-10) were comparable to other groups. According to Paley and Marr (2), bone results were excellent in 3 cases, fair in 1 case and poor in 1 case while functional results were excellent in 1 case, good in 3 cases and poor in 1 case. The case rated as poor for both bone and functional results was the septic nonunion case. These results are in line with the literature related to limb salvage cases, to confirm the high capability of circular external fixation to solve extremely severe lesions leading to high satisfaction of patients despite residual pain and/or functional impairment.

Complications are common in circular external fixation practice, both for the characteristics of the frame and the severity of injuries it is used for. According to the literature, the complications of fine wire external fixation include pin track infection, joint stiffness or contracture, frame element/pin breakage, deep infection due to neglect of pin track infections, neurovascular injuries, delayed union at docking sites and fracture of bone regenerate (9). Pin track infection is by far the most common complication, with a widely variable incidence reported (5-75%). In most cases pin track infections are superficial (Checketts-Outterburn I-II) and can be successfully managed by local care and oral antibiotic therapy (12, 13, 29). Thus pin track infection is considered a minor complication, rarely influencing the final outcome. Results of the present study are in line with the literature, with 64.7% superficial pin track infections, all successfully treated conservatively. Deep pin track infection (Checketts-Outterburn III-IV) is by far less common, with literature reporting rates of 5-15% of all pin track infections (12, 13, 29). In the present study no deep pin track infections were noted. Nonetheless, 3 cases of other septic complication occurred in the present study, one of which (5.9%) resulted in deep infection. Literature reports a deep infection incidence in severely open fractures ranging from 4 to 56% of cases (3, 30), with highest rate in limb salvage cases. Therefore deep infection rate in the present study results in line with the literature. Adjacent joint stiffness or contracture is also a common complication, occasionally requiring additional surgery. Incidence reported in literature widely varies, with highest rate in limb salvage and bone transport cases. Likewise, in the present study there were two cases of ankle stiffness, the first occurring together with an en griffe deformity of toes in a Gustilo III C distal tibia fracture, the second occurring in the case with the widest bone defect requiring bone transport in the study population. In the first case toes deformity required metatarsal corrective osteotomy while ankle stiffness was well tolerated and did not require surgical treatment. In the second case, Achilles tendon lengthening was necessary. On the other hand, there were no cases of knee stiffness in the population, which is a very satisfying result especially in tibial plateau fracture setting. Delayed union at the docking site in bone transport cases is a common problem. The eventuality of primary docking point bone grafting at the end of transport in every case is a debated topic in the literature (31). In the present study there was no case of delayed union at the docking site, however the authors opted for primary bone grafting in 3/5 bone transport cases. On the basis of the present study results and literature reports no definite indications can be given on this topic. Fracture of the regenerate bone is not common and should be prevented by careful examination of clinical and x-ray appearance of the distraction gap and by sequential removal of the frame to allow for progressive mechanical stimulation of bone (32). Literature demonstrate that quality of regenerate bone and size of the distraction gap both correlate with the risk of fracture (32). In case of regenerate fracture cast immobilization, reapplication of the frame or internal fixation might be indicated. Likely, one case of fracture with valgus tibia deformity occurred in the present study 1 month after frame removal (19 months after trauma) in a 8 cm bone loss case. The regenerate fracture was succesfully treated with plate and screw fixation.   

Conclusions

Circular external fixation represents a viable method to treat tibia fractures when fracture pattern is particularly severe, soft tissues are compromised or when acute bone and soft tissue loss in present. Despite frequent complications, long duration of treatment and common unplanned surgeries, clinical results are meanly good and patients satisfaction is usually high.

Table 1

Tab.1: Clinical and radiographic data for the whole population and for the three different patients groups (Group A: fractures without articular involvement; Group B: fractures with articular involvement; Group C: bone transport cases). VAS: visual analogic scale; C-O: Checketts-Otterburn classification 

Table 2

Tab. 2: Nonunion and malunion cases in the study population

Table 3

Tab. 3: Complications and unplanned surgeries in the study population

 Fig. 1. A 29 y.o. male (Patient n°3, Group A) sustained a motorbike accident, resulting in an open Gustilo III B AO 41 A3 / 42 C3 fracture: a) Radiographic examination at trauma after temporary external fixation (AP and Lateral view); b) Treatment with circular external fixator, 4 rings construct. Radiographic examination at two months (AP and Lateral view); c) Follow-up radiographic examination at 30 months showing varus/recurvatum malunion

Fig 2. A 54 y.o. male (Patient n° 10, Group B) sustained a fall from a 3 meters high ladder, resulting in a close Tscherne I AO 41 C2 / 42 C3 fracture. a) Radiographic examination at trauma after temporary external fixation (AP and Lateral view); b) Treatment with circular external fixator, 4 rings construct. Radiographic examination at 6 weeks (AP and Lateral view); c) Follow-up radiographic examination at 21 months showing fracture healing; d) Clinical result at follow up

Fig. 3. A 58 y.o. male (Patient n° 13, Group C) sustaining a haunting accident (shotgun wound), resulting in an open Gustilo III B AO 43 C3 fracture. a) Clinical picture of soft tissue defect, temporary external fixator in situ; b) Radiographic examination at trauma after temporary external fixation (AP and Lateral view), showing bone defect; c) Radiographic examination at 5 months after bone and soft tissue transport with circular external fixator and subsequent modification of the frame for tibio-talar arthrodesis (AP and Lateral view); d,e) Clinical and radiographic result at 10 months follow up 

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