Several low energy osteotomy techniques are described in the literature but there is limited evidence comparing healing indices. We present a retrospective review of two techniques to evaluate an optimum method. Two cohorts of patients underwent osteotomy of the tibia using a Gigli saw (n=15) or DeBastiani corticotomy (n=12) technique. Indications for surgery included limb lengthening and bone transport for defect reconstruction with a minimal distraction of 2 cm. The patient radiographs were anonymised and the regenerate assessed by the two senior authors who were blinded to the osteotomy type. Bone quality was recorded along the anterior, posterior, medial and lateral cortices, graded 1–5 from absent to full consolidation over time in frame. The time to 3 cortices healed/regenerate length was calculated. The time to consolidation of the anterior, posterior, medial and lateral cortices were compared. The mean 3 cortices index in the Gigli group was 2.0 months/cm and in the DeBastiani group 1.8 months/cm, This was not a significant difference. In both groups anterior bone formation was slower, and in 50% and 33% of the Gigli and DeBastiani groups respectively the anterior cortex did not fully heal by the time of frame removal.Method:
Results:
The Exogen Ultrasound Device is licensed for fracture non-union under NICE guideline MTG-12. Reimbursement is offered if there is no fracture union after 250 days of treatment as per manufacturer guidelines. Quoted healing rates vary between 62% and 100%: we compare our results to these. A retrospective audit of all patients who received Exogen for long bone non-union was undertaken. The indication, duration of treatment, fracture outcome and compliance with the recommended treatment pathway were recorded.Background:
Method:
External fixators are not as well tolerated around the femur when compared to the tibia. Lengthening with an intramedullary device is therefore attractive. We reviewed all cases of femoral lengthening performed at our unit from 2007 to 2014. Cases of non-unions, concurrent deformities, congenital limb deficiencies and lengthening with an unstable hip were excluded. This left 33 cases for review. Healing index, implant tolerance and complications were compared.Background:
Method:
Little is known about the forces carried by the Taylor Spatial Frame (TSF) hexapod fixator. Our aim was to measure the TSF resultant force and how this changed during the consolidation phase. Five patients undergoing correction of tibial deformities were recruited. Measurements were taken at 2, 4, 8 and 12 weeks post-correction during various activities. Instrumented struts incorporating strain gauges measuring axial force were temporarily used each time. Strut forces and lengths were used to determine frame kinetics. The resultant axial fixator forces and moments were calculated relative to sitting. Ground reaction forces (GRF) were measured using the treadmill force plates.Background:
Method:
Leg length discrepancy related to absence of the femoral head with proximal migration of the femur presents a treatment dilemma. Late sequelae of neonatal hip sepsis and chronic hip dislocation due to developmental dysplasia are the most common causes. Traditional teaching dictates that the hip is stabilised prior to limb lengthening. Reconstructive options alter the shape of the proximal femur which complicates future surgery. We retrospectively reviewed 3 cases of femoral lengthening with an ‘unstable’ hip without prior stabilization. The aetiology was neonatal hip sepsis in 2 cases and chronic hip dislocation due to developmental dysplasia in 1 case. Lengthening was performed with the use of a retrograde Precice lengthening nail.Background:
Methods:
Pin site care in external fixation remains a major challenge. The ideal dressing regime still remains controversial as does the type of dressing. We present an audit following the use of a sponge compression dressing in comparison to previously used sterile gauze. All pins and wires were inserted using a standardised technique. Dressings were applied during surgery to prevent haematoma formation. The new sponge dressing was applied to the wire or half-pin sites and compressed to the skin by either pierced tubing over the wire or clips at the end of the procedure. Dressings were changed weekly unless the pin sites were discharging serous fluid or frankly infected, when they were changed as required. The pin sites were evaluated for evidence of infection or irritation using the good, bad or ugly grading system. Each evaluation was performed by two of the authors on two separate occasions to assess the inter- and intra-observer error. The results were compared to those previously reported using sterile gauze as the pin site dressing. 1035 pin sites were assessed. 985 pin sites were graded as “good” (95.2%), 49 “bad” (4.7%) and 1 “ugly”. The kappa values demonstrated excellent inter- and intra-observer correlation, 0.892 and 0.905 respectively. The previous study using gauze reported 600 pin sites with 514 graded “good” (85.7%), 80 “bad” (13.3%) and 6 “ugly” (1%). The use of compression sponge dressing appears to reduce the rate of pin site irritation and infection. Further anecdotal evidence by patients who have undergone surgical treatment using both techniques demonstrated a preference for the sponge dressings due to ease of dressing change and general comfort once applied. We therefore would recommend this type of dressing in the use of external fixation.
This study examined the stability of two different hexapod frames at increasing strut angles and the possible use of an additional strut to aid stability. Hexapod frames have certain advantages over standard circular frames, however disadvantages include a rattle and instability at some strut angles. This could be particularly important when larger diameter rings are used over a shorter distance resulting in lower ring strut angles such as in the femur.A statement of the purposes of the study
Introduction
We present the results of a new non-invasive lengthening nail enabling accurate control of the lengthening process and joint rehabilitation. The use of intramedullary lengthening nails have gained popularity as they reduce common complications associated with external fixators, including infection, joint stiffness, bone regenerate deformity, late fracture and patient implant acceptance. Current nails however are associated with complications including implant breakage, mechanical failure, runaway nail and requiring MUA to restart or obtain segment lengthening. The Precice nail incorporates magnet technology with a hand held device allowing non-invasive lengthening. The nail is also reversible allowing shortening if required. Physiotherapy can continue throughout treatment to maintain joint range of motion without concern of uncontrolled nail runaway. The lengthening is axial reducing shear/torsional forces on the regenerate. The lengthening of 4 femora was undertaken in 3 patients, mean age 34 yrs for post-traumatic shortening and short stature. A standard technique included an Ilizarov corticotomy followed by a 6 day latent period. Patients were mobilised partial weight bearing and knee range of motion maintained. The femora were lengthened one third of a millimetre three times per day. Radiographic and clinical review was performed every 2 weeks.Introduction
Method
To see if the addition of a locking plate to FD rod fixation of osteogenesis imperfecta confers extra strength and allows earlier mobilisation. Osteogenesis imperfecta is a heterogeneous group of disorders with congenital osseous fragility. The goal of surgery is to minimise the incidence of fracture and correct deformity. The concept of multilevel osteotomies and intramedullary fixation with a non-extendable nail was popularised by Sofield and Millar in 1959. The Bailey Dubow telescoping nail was introduced in 1963. The Fassier-Duval (FD) telescoping nail is a more recent design inserted via smaller incisions, in conjunction with percutaneous osteotomies. However there are still problems. Often the medullary canal may be too narrow to harbour a nail of adequate size for the body. Furthermore they do not give significant rotational control, which is compounded by the elasticity of the soft tissues.Purpose of Study
Introduction
Fracture healing is governed by biological and mechanical factors. Circular frames are one method to fix fractures. Recently, the number of frame designs that are available has increased and these different designs may have different effects on the mechanical environment created. The senior author has been concerned by the stability of the construction when a short frame is used. This study examined the stability of different frames and the possible use of additional 7th struts to aid stability. The frame configuration was modified with increasing strut angles from 15° − 70°. Each frame was cyclically tested in compression to 200N. The Taylor Spatial Frame was retested with the addition of a seventh strut.Introduction
Method
Identification of the paediatric orthopaedic patient at high risk of venous thromboembolism (VTE) can allow a targeted approach to thromboprophylaxis. There is currently no national consensus on the correct method of risk assessment in this patient group. The Royal National Orthopaedic Hospital has developed a guideline using the evidence available to allow stratification of risk for the paediatric orthopaedic patient. A list of departments offering specialist paediatric orthopaedic surgery was obtained from the member list of the British Society of Paediatric Orthopaedic Surgeons (BSCOS). These hospitals were contacted via telephone interview to determine if they have a specific guideline or risk assessment proforma for paediatric VTE risk. A total of 74 hospitals were identified with a specialist paediatric orthopaedic practice in the United Kingdom. A response rate was gained from 100% of these hospitals. Only 3/74 of these hospitals had a guideline or protocol in place for the formal assessment of VTE risk in the paediatric patient (Royal National Orthopaedic Hospital, Stanmore; Sheffield Children's Hospital; Barts & the London NHS Trust). All three hospitals were able to provide details of their guideline. Both the RNOH and Barts & the London commented that their guideline was based on that of the Sheffield group, with adaptations for their own requirements. The majority of hospitals in the UK with a paediatric orthopaedic interest do not have guidance available for the management of VTE risk. Presented here is the outcome of using the limited evidence available, in combination with expert opinion, to develop a guideline suitable for the requirements of a paediatric unit in an orthopaedic hospital. This may be of benefit to other units producing their own guidelines, producing thought and discussion as to the specific requirements of paediatric patients undergoing orthopaedic procedures.
To investigate the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) with external fixator use and to help establish whether current guidelines are appropriate. Case notes of individuals undergoing external fixator application by the senior author (PC) from March 2005 to June 2011 were examined. In this period 207 individuals underwent 255 primary applications of Ilizarov, Taylor Spatial Frame (TSF) or monolateral fixator. Fixators applied were 173 tibial, 63 femoral and 19 to other bones. Records were obtained for 182 individuals (88%), representing 214 operations (84%).Purpose
Methods
We hypothesised that Vitamin D deficiency could be related to SUFE in children without endocrinological abnormalities. We therefore sought to examine prevalence and severity of Vitamin D insufficiency in a cross-section of SUFE patients. Vitamin D levels were tested for at time of hospital admission for operative treatment of SUFE. Seven patients, between the months of July 2011 to November 2011, presented to our institution. All were chronic, stable slips treated with in-situ screw fixation. All patients presented in the summer months and were operated on within 3 weeks of presentation.Purpose of study
Methods
Lower limb mal-alignment as a result of fracture malunion can result in knee degenerative arthritis or predispose to early arthroplasty failure due to the altered mechanical axis. The choice of corrective osteotomy is often determined by potential complications. Opening wedge osteotomy is associated with poor bone healing especially in adult diaphyseal bone. Distraction osteogenesis enables gradual deformity correction with the gap filled by regenerate bone. Bone formation however is formed less favourably in the diaphysis and metaphyseal osteotomy is advised. We present a consecutive series of adult tibial diaphyseal correction using the Taylor Spatial Frame utilising the method of distraction osteogenesis. 15 adults, 11 male and 3 female, underwent tibial deformity correction. A mid diaphyseal osteotomy was made using minimal soft tissue dissection and an osteotome. The site was determined by the centre of rotation of angulation (CORA). After a 6 day latency period distraction was undertaken by the Taylor Spatial Frame. Patients were encouraged to fully weight bear throughout the treatment process. Following regenerate consolidation the frame was removed and a below knee weight bearing cast applied for 4 weeks.Introduction
Method
No published work exists regarding deep vein thrombosis (DVT) and pulmonary embolism (PE) incidence with the elective use of external fixators. The aim of this work was to establish the rate of DVT and PE in such cases to help inform whether thromboprophylaxis guided by risk factors is adequate or if a more aggressive approach is required. Information from a prospectively maintained electronic database and case notes were examined for consecutive patients from March 2005 to June 2011. Occurrence of DVT and PE, detected by ultrasound or CT angiogram, were recorded. Risk factors for thromboembolism, age, weight, height, surgical indications, type of surgery and operative time were recorded. As recommended by the National Institute for Health and Clinical Excellence (NICE) thromboprophylaxis use is guided by risks of thromboembolism and bleeding. For adults and older adolescent patients contralateral leg compression stockings and an intraoperative calf pump were used. Mobilisation began the morning after surgery and the majority of cases permitted to bear weight fully.Introduction
Patients and methods
Patients undergoing limb reconstruction with the Taylor Spatial Frame (TSF) often perceive that their frame is loose due to the rattle they hear when mobilising. Our aim was to determine how much and where this movement is in the various frame/bone constructs currently on the market. Using standard tibial saw bones three frames (TSF, Ilizarov and Hexapod) were made in an identical fashion. Constructs were cyclically loaded 4 times to 200 N in tension and compression using the Instron MTS. This was repeated three times. A seventh strut was also placed in the TSF construct and the tests repeated. Bones were then removed and the tests repeated for the frames alone.Introduction
Method
To evaluate the results and complications of bone transport in the treatment of massive tibial bone defects, using the Ilizarov method. 15 patients underwent bone transport using the Ilizarov technique to treat massive tibial bone defects. The average age of the patients was 8.7 years (3–24 years) and the mean bone defect was 10.8 cms. Following a latent period of 1 week, distraction of the transport doughnut was commenced at 1mm/24 hours in 4 quarterly turns. A docking procedure was performed in 7 cases which involved freshening of the bone ends and autogenous bone grafting from the iliac crest. Following docking the fixator was removed once the regenerate had consolidated.Aim
Methods
To document the success rate of closed reduction and soft tissue release in the treatment of bilateral true dislocation in developmental dysplasia of the hip (DDH). Case-note review of 22 children (44 hips) with idiopathic bilateral hip dislocation referred to a tertiary centre before walking age. The management protocol was as follows:
Examination under general anaesthesia, arthrogram, closed reduction and appropriate soft tissue release (adductors/psoas), application of a ‘frog’ cast. CT scan at 2 weeks to confirm reduction. Change of cast and arthrogram at 6 weeks to confirm improving position and stability. Cast removal at 12 weeks, and application of an abduction brace for 6 weeks. Treatment failure could occur on day 1 (failure of reduction), at week 2 (failure to maintain reduction), at week 6, or after cast removal.Purpose
Methods
To investigate the effect of soft tissue release (STR) and the length of postoperative immobilisation on the long term outcomes of closed reduction (CR) of the hip for developmental dysplasia of the hip. 77 hips (72 patients) who had undergone closed reduction (CR) between 1977-2005 were studied retrospectively to review their outcome (Severin grade), identify the reasons for failure and to assess factors associated with residual dysplasia. Particular attention was paid to the use of a STR at the time of CR (to improve initial hip stability) and the duration of postoperative immobilisation.Purpose
Materials
To document the incidence and nature of complications associated with hemiepiphysiodesis using a screw and plate device (8-plate, Orthofix). We reviewed case notes and radiographs of 71 children (130 segments) with lower limb deformities treated with temporary hemiepiphyseal arrest using the 8-plate. 96% of deformities were in the coronal plane, 4% sagittal. 72% of coronal deformities demonstrated valgus malalignment. We defined three types of complications: complications Complications were related to variables of patient age, gender, diagnosis, location of deformity and associated surgery.Purpose
Methods
