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. 2025 May 27;20(1):520.
doi: 10.1186/s13018-025-05948-0.

Effects of external fixator-assisted acute angulation on arterial diameter: a cadaveric model

Akif Mirioglu  1 , Kaan Ali Dalkir  2 , Hakki Can Olke  3 , Bugra Eraslan  2 , Bugra Kundakci  2 , Melih Bagir  2 , Mehmet Ali Deveci  4
Affiliations

Effects of external fixator-assisted acute angulation on arterial diameter: a cadaveric model

Akif Mirioglu et al. J Orthop Surg Res. .

Abstract

Background: Open fractures with bone and soft tissue loss pose significant challenges in orthopedic surgery. External fixator-assisted techniques, such as acute angulation and shortening, have been proposed to facilitate wound closure. However, the vascular implications of these techniques remain unclear. This cadaveric study aimed to evaluate the effect of acute angulation on arterial narrowing at the proximal tibia and distal femur, identifying angulation thresholds and comparing the vascular tolerance between these anatomical sites.

Methods: Eight lower extremities from four fresh-frozen cadavers were used. Osteotomies were performed at the distal femoral and proximal tibial metaphyses. An Ilizarov circular external fixator provided controlled angulation in varus, valgus, procurvatum, and recurvatum directions. A contrast agent was used for vascular visualization under fluoroscopy. Angulation was gradually increased until arterial narrowing was observed, and the critical angles were recorded.

Results: In the proximal tibia, the mean angulation thresholds for arterial narrowing were 45.5° in varus, 26.5° in valgus, 33.8° in procurvatum, and 13.5° in recurvatum. In the distal femur, arterial narrowing occurred at 27° in varus, 32.3° in valgus, 52° in procurvatum, and 22° in recurvatum. Varus angulation was significantly better tolerated at the tibia (p = 0.0286), while procurvatum (p = 0.0294) and recurvatum (p = 0.0286) were better tolerated at the femur. No significant difference was found in valgus angulation (p = 0.559).

Conclusions: The tibia demonstrated higher tolerance for varus angulation, while the femur allowed greater procurvatum and recurvatum before vascular compromise. Recurvatum deformities in the tibia resulted in the earliest arterial narrowing, suggesting a higher risk of vascular complications. These findings provide critical insight for surgeons performing external fixator-assisted soft tissue coverage, helping optimize angulation strategies to prevent vascular complications.

Keywords: External fixators; Fractures; Ilizarov technique; Open; Soft tissue injuries; Thrombosis.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Ethical approval for the study was obtained from the Ethics Committee of Çukurova University Faculty of Medicine with decision number 39, taken at meeting number 151 on January 3, 2025. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Pre-procedural setup of a double-ring Ilizarov external fixator with a single hinge in place (A). Completed dome osteotomy (B). Dome osteotomy with an Ilizarov external fixator attached to the bone (C). A catheter inserted into the proximal femoral artery for contrast administration (D)
Fig. 2
Fig. 2
Clinical (A) and fluoroscopic (B) images of the tibia in a neutral position after contrast administration. Clinical image of the tibia in a varus position with a goniometer for angle measurement (C), and the corresponding fluoroscopic image with an arrow indicating arterial narrowing (D)
Fig. 3
Fig. 3
Clinical (A) and fluoroscopic (B) images of the femur in a neutral position after contrast administration. Clinical image of the femur in a varus position with a goniometer for angle measurement (C), and corresponding fluoroscopic image with an arrow indicating arterial narrowing (D)
Fig. 4
Fig. 4
Box plot illustrating the distribution of angulation thresholds in all directions for both the tibial and femoral sites at which arterial narrowing occurred
See this image and copyright information in PMC

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