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. 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. Results:. 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. Discussion:. Both Gigli saw and DeBastiani corticotomy techniques result in good bone formation following distraction osteogenesis. The anterior tibial cortex consolidates more slowly than the other cortices in both groups. This is likely due to deficient soft tissue cover and direct periosteal damage at time of osteotomy

The battle of revision TKA is won or lost with safe, effective, and minimally bony-destructive implant removal, protecting all ligamentous stabilisers of the knee and, most importantly, the extensor mechanism. For exposure, incisions should be long and generous to allow adequate access. A standard medial parapatellar capsular arthrotomy is preferred. A synovectomy is performed followed by debridement of all scar tissue, especially in the medial and lateral gutters. All peripatellar scar tissue is excised followed by release of scar tissue within the patellar tendon, allowing for displacement or everting of the patella. As patellar tendon avulsion at any time of knee surgery yields disastrous results, the surgeon should be continuously evaluating the patellar tendon integrity, especially while displacing/everting the patella and bringing the knee into flexion. If displacement/eversion is difficult, consider rectis-snip, V-Y quadricepsplasty, or tibial tubercle osteotomy. The long-held requisite for patellar eversion prior to component removal is inaccurate. In most cases simple lateral patellar subluxation will provide adequate exposure. If a modular tibial system is involved, removal of the tibial polyethylene will decompress the knee, allowing for easier access to patellar, femoral, and tibial components. For patellar component removal, first identify the border of the patella, then carefully clean and debride the interface, preferably with electrocautery. If the tibial component is cemented all-polyethylene, remove using an oscillating saw at the prosthetic-bone interface. Debride the remaining cement with hand tools, ultrasonic tools, or burrs. Remove the remaining peg using a low-speed burr. If the tibial component is metal-backed, then utilise a thin saw blade or reciprocating saw to negotiate the undersurface of the component between the pegs. If pegs are peripherally located, cut with a diamond disc circular cutting tool. Use a trephine to remove the pegs. For femoral component removal, identify the prosthetic-bone/prosthetic-cement interface then remove soft tissue from the interface, preferably with electrocautery. Disrupt the interface around all aspects of the component, using any of following: Gigli saw for cementless components only, micro saw, standard oscillating saw, reciprocating saw, a series of thin osteotomes, or ultrasonic equipment. If the femoral component is stemmed, remove the component in two segments using an appropriate screwdriver to remove the screw locking the stem to the component. Remove the femoral component with a retrodriver or femoral component extractor. Debride cement with hand tools or burr, using care to avoid bone fracture. If a stem is present, then remove with the appropriate extraction device. If “mismatch” exists, where femoral (or likewise, tibial) boss is smaller in diameter than the stem, creating a cement block prohibiting stem removal, remove the cement with hand tools or burr. If the stem is cemented, use hand tools, ultrasonic tools, or a burr to debride the cement. Curette and clean the canals. For tibial component removal, disrupt the prosthetic-cement/prosthetic-bone interface using an oscillating or reciprocating saw. Gently remove the tibial component with a retrodriver or tibial extractor. If stem extensions are utilised, disengage and debride all proximal cement prior to removing the stem. If stem is present, then remove stem with appropriate extraction device. If stem is grit-blasted and well-fixed, create 8mm burr holes 1.5 to 2.5cm distal to tibial tray on medial aspect and a small divot using burr, then drive implant proximally with Anspach punch. Alternatively, a tibial tubercle osteotomy may be performed. If the stem is cemented, use hand tools, ultrasonic tools or burr to debride cement

Introduction & Discussion: From an experience of over 250 Salter osteotomies, 148 of which have been reviewed at skeletal maturity, certain technical tips merit discussion:-. Preoperative positioning and the incision. Psoas tenotomy, capsular exposure and the capsulotomy. Facilitation of the Gigli saw osteotomy. Sizing and procurement of the graft. Displacement and fixation of the osteotomy. Application of the hip spica. Some questions are worthy of debate:-. Can the osteotomy be safely combined with open reduction of the high dislocation?. Should the osteotomy be fixed before reducing the femoral head?. Are there alternatives to autogenous bone graft and K-wire fixation?. Is minimally invasive surgery an option?. Are the contraindications and alternatives to the Salter osteotomy fully appreciated?

We reported a case of the acetabular depression fracture in conjunction with a central fracture dislocation of the hip that was treated with a unique surgical technique. CASE REPORT:. A 76-year-old man suffered a left acetabular fracture with severe left hip joint pain and walking disability. Acetabular fracture was not apparent on the initial radiographs including anteroposterior and oblique views of the pelvis. However, computed tomography (CT) scanning showed displaced acetabular depression fracture (a third fracture fragment) in the center of the weight-bearing area with fracture of the ilium and spontaneous reposition of central dislocation of the hip (Fig. 1, 2). It seemed that this fracture fragment created incongruity of the acetabular articular surface and the potential for hip joint instability. Therefore, the patient was treated with open reduction and internal fixation. SURGICAL TECHNIQUE:. To perform the procedure, the patient was placed in the lateral decubitus position. A direct lateral approach to the hip was used for exposure. The vastus lateralis was released 1 cm distal from its origin, trochanteric osteotomy was done by the Gigli saw. To observe the hip articular surface and to identify the fracture fragment, the femoral head was posterior dislocated with excision of teres ligamentum after T-shaped capsulotomy. The depressed fragment in the acetabulum was identified under direct vision but could not be reduced. Therefore, the outer cortex of the ilium was fenestrated in a size of 2 × 2 cm so that a 1-cm-wide levator was inserted to the depressed fragment at 2 cm proximal from the hip articular surface through the fenestrated window (Fig. 3). Subsequently, the displaced bone fragment was pushed down by using the levator to the adequate articular joint level. The fragment was stabilized with packed cancellous bone graft harvested from the osteotomized greater trochanter. The removed outer cortex of the ilium from fenestrated site was repositioned and fixed by a reconstruction plate and screws. The osteotomized greater trochanter was reattached and fixed with two cannulated cancellous hip screws. RESULTS:. At 9-month follow-up, he was pain-free and continued to function well without the use of external supports. The acetabular depression fracture was completely reduced and healed in the CT scanning evaluation. The patient had no signs of posttraumatic osteoarthritis in radiographs. DISCUSSION and CONCLUSION:. In acetabular fracture dislocations of the hip joint, the precise pathological anatomy is not easily demonstrated by routine radiographs with classification of acetabular fractures. In our case, however, details of acetabular fracture were not well visible on conventional radiographs. It has been shown that computed tomography is useful method in precise evaluation of the fracture type with bone damage and integrity of joint configuration. Concerning approach to the fracture fragment which existed in the center of the weight bearing area of acetabulum, we performed to fenestrate on the intact bony cortex of the ilium just proximal to the fracture site. It was convenient and useful to gain good reduction of the central acetabular depression fracture, although there was no report on such a ‘fenestration’ method

Aims

The outcomes of patients with unexpected positive cultures (UPCs) during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unknown. The objectives of this study were to establish the prevalence and infection-free implant survival in UPCs during presumed aseptic single-stage revision THA and TKA at mid-term follow-up.

Aims

Ilium is the most common site of pelvic Ewing’s sarcoma (ES). Resection of the ilium and iliosacral joint causes pelvic disruption. However, the outcomes of resection and reconstruction are not well described. In this study, we report patients’ outcomes after resection of the ilium and iliosacral ES and reconstruction with a tibial strut allograft.

Aims

Fracture-related infection (FRI) is commonly classified based on the time of onset of symptoms. Early infections (< two weeks) are treated with debridement, antibiotics, and implant retention (DAIR). For late infections (> ten weeks), guidelines recommend implant removal due to tolerant biofilms. For delayed infections (two to ten weeks), recommendations are unclear. In this study we compared infection clearance and bone healing in early and delayed FRI treated with DAIR in a rabbit model.

The result of the revision TKRA relies upon the causes of failure, method of operation and surgical skill of the surgeon. For the success of the revision, surgeon should do his best from surgical planning to rehabilitation program. I have experienced more than 100 cases of revision TKRA and here I would like to share my surgical techniques of revision surgery in aseptic failure of the primary TKRA. An approach, implant selection, bony reconstruction and fixation methods used are just the same with the principles of other surgeons. I will describe my surgical tips in removal of the implant, preservation of the joint line and morselized bone graft application. For removal of implants, I used microsaw instead of Gigli saw. This is because microsaw has advantages of preserving the bone by easy approach to notch and posterior condylar area and less contamination risk. After partial separation of bone and implant interface by microsaw, I would not remove the implant immediately. Instead I will tap medial and lateral condylar portion alternately with mallet repeatedly until I can see the movement of the prosthesis, and then I will gently remove the prosthesis. By this maneuver, the prosthesis is easily removed with less bony defect. Before removal of femoral prosthesis, for joint line preservation, I will mark 5–6 cm proximal to the joint line on the femoral metaphyseal area with drill bit. In most revision cases, as the height of femoral prosthesis is maintained, this mark can be good landmark for the joint line insert of the trial prosthesis later at that level, thus the joint line can be preserved. I also have special tips in morselized cancellous graft. After impaction of morselized bone, the bony fragments are easily dispersed and to prevent this phenomenon, some surgeons apply temporary cement coating over the bone. However, when using cement, the cement can intervene between bony fragment resulting in delay or failure of incorporation. Another disadvantage of cement coating is that the surface may be irregular and interfere with tight fitting of the prosthesis. My methods is by using haematoma to coat on the morselized bone followed by inserting the trial prosthesis in situ, and with knee deflate the torniquette. In most of the revision operation, 2 torniquette times is needed. It means that I deflate the torniquette a little earlier than 1st torniquette time. I do not irrigate for 10 ~ 15 min. After inflation of torniquette, gently remove the trial prosthesis and you can see beautiful shape of morselized graft which is well aggregated with haematoma. In this state, we do not need cement precoating on the morselized graft until the real prosthesis is implanted

Purpose: Surgery offers a remarkable means for modifying the physical appearance of people desiring more acceptable conformity with aesthetic standards. Height is a qualifying element for each individual. Society sometimes views persons with a short stature as different. Leg lengthening surgery to improve one’s appearance has thus become a common request. We report our experience to demonstrate that the objective is both possible to achieve and useful. Material and methods: From 1985 to 2000, we operated 54 patients (32 men and 22 women). Mean follow-up was five years three months (16 years – 1 year). For these patients, we found a valid justification for the request for increased height, while surgery was declined for 82 other patients. Mean age at surgery was 5.8 years (range 18–47) (28.1 years for men and 23.6 years for women). Mean height was 153 cm (159 for men and 147 for women). Patients were given psychological support. We performed simultaneous bilateral leg lengthening because of the better tolerance compared with the femur. The standard device had three rings and a proximal semi-ring. A two-level lengthening system was used, requiring double osteotomy, a proximal tibial metaphyseal osteotomy and a distal metaphyseal osteotomy. Seven days after trepan osteotomy and twelve days after Gigli saw osteotomy, we initiated the lengthening procedure with 1/4 turn (1/4 mm) three times a day. Achilles tendon lengthening was associated for 19 patients. For three patients (4 limbs) the regenerated bone collapsed requiring insertion of a new device. Results: Mean lengthening was 7 cm (11- 5 cm). Mean duration of treatment was eight months ten days. Aesthetic outcome was considered excellent by 92% of patients and good by 8%. Discussion: The patient’s desire for greater height must be well motivated and associated with good knowledge of possible risks (detailed informed consent). Using the circular device for leg lengthening allows correction of associated moderate alignment anomalies. Conclusion: If the patient has a valid psychological justification and an objective height below the mean of the local population, leg lengthening procedures can be performed for aesthetic purposes with reasonable risk and satisfactory results

Background The complex ranges from mild epispadias to devastating cloacalexstrophy. Affected babies require multidisciplinary care. The orthopaedic surgeon may assist either directly, in releasing the midline by pelvic osteotomies or indirectly, by advice and treatment of musculoskeletal symptoms related to disturbed mechanics or deformity in the spine, pelvis and lower limbs. Traditional osteotomies are posterior or horizontal. A technique of an oblique osteotomy from the sciatic notch to the iliac crest has been developed at Great Ormond Street since 1996, along with a system of external fixation. It is undertaken concurrently with urological reconstruction. The system of external fixation is relatively simple compared with other published work. Methods We reviewed the results of 45 oblique osteotomies performed in conjunction with genito-urinary repair of classical and cloacal bladder exstrophy. Average follow-up was 37 months. Clinical outcome measures were pain, function, continence and normal gait. All radiographs were reviewed and the pubic intersym-physeal diastasis was recorded pre-operatively and on the latest post-operative x-ray. Children were grouped according to the age at the time of osteotomy. Also children with classical exstrophy were divided into 4 groups on the basis of continence. The mean post-operative percent reduction in the amount of the original diastasis was determined for all age groups. Comparison of pubic approximation was made between the two types of post-operative immobilisation. Results The majority of patients (42) reported no pain or functional disability. Six cases had a waddling gait pattern and 2 had residual external rotation. All the wounds healed and every osteotomy united. The average improvement in pubic approximation was 37% for the whole series. Chidren who were older at the time of surgery (18–60 months) were found to maintain better correction over time (76%). Children immobilised with an external fixator maintained better closure of the pelvis than those treated with plaster cast alone. (51% and 12.2% respectively). Maintenance of pubic approximation was associated with a higher level of bladder continence. Complications included 3 cases of infection and loosening of the external fixator requiring early removal. There were no neurovascular complications. Conclusion Oblique pelvic osteotomy is an effective part of the reconstruction bladder exstrophy and compares well with other types of osteotomy. It is a reliable operation and the technique is applicable to all age groups. Technique of Oblique Pelvic Osteotomy Oblique pelvic osteotomy is performed by first placing the patient in the supine position, preparing and draping the lower part of the body from the costal margin to the mid-thigh. Intravenous antibiotic prophylaxis is administered and continued for a 24-hour period. Initially the Urologist will make an infra-umbilical incision then identify and mobilise the anatomical structures intended for their subsequent reconstruction and repair. This wound is then temporarily closed. The Orthopaedic surgeon will then approach the ilial crest through bilateral oblique incisions made inferior to the anterior superior ilial spine as described for the Salter osteotomy. The interval is developed distal to the anterior superior ilial spine after identification and protection of the lateral femoral cutaneous nerve which is taken medially. After the interval between sartorious and tensa fascia lata are identified the iliac apophysis is split and reflected off the inner and outer ilial crests. The exposure may be improved by also developing the interval between rectus femorus and gluteus medius. Each side of the pelvis is exposed sub-periosteally from the iliac crest extending into the sciatic notch. A Gigli saw is then passed through the sciatic notch. The line of the osteotomy is from the posterior part of the sciatic notch extending anteriorly and superiorly to exit the iliac crest 2cm posterior to the anterior superior iliac spine (figure 2). The most anterior 1.5cm of iliac crest from the distal pelvic fragment is trimmed to allow closure of the iliac apophysis after rotation. The size of the half pin utilised is determined by the age of the patient. A baby under 18 months old will have a 3.5mm pin from the AO wrist external fixator frame and an older child over 2 years, a 4.5mm half pin. One half pin is inserted on each side of the pelvis. The half pin is placed in the distal fragment from anterior and lateral to posterior and medial with the tip of the screw just exiting the cortical bone of the medial aspect of the sciatic notch (figure 3a). Consideration of pin placement must take into account rotation of the distal fragment and preventive skin pressure areas. The iliac apophysis is repaired and the skin wounds are closed. The Urologist completes the reconstruction procedure planned via their infra-umbilical approach. The final stage involves the medial and superior rotation of both distal pelvic fragments and subsequent closure of the symphyseal diastasis. This position is maintained with the application of an anterior A-shaped frame from the wrist, AO fixation set in the younger infant or the AO pelvic fixator in the older child (figure 3b). Symphyseal approximation is confirmed intra operatively by palpatation. Bilateral above knee front slabs casts are applied to prevent kicking the hips or knees. The post-operative management involves pin site care on alternate days. The front slab casts are removed at 3 weeks and the anterior A-frame is removed at 6 weeks after union is confirmed on a pelvic radiograph. Depending on the social situation the children may go home during the post-operative period

Aims

Little is known about the effect of haemorrhagic shock and resuscitation on fracture healing. This study used a rabbit model with a femoral osteotomy and fixation to examine this relationship.

Objectives

The purpose of this study was to compare the results and complications of tibial lengthening over an intramedullary nail with treatment using the traditional Ilizarov method.

Objectives

Healing in cancellous metaphyseal bone might be different from midshaft fracture healing due to different access to mesenchymal stem cells, and because metaphyseal bone often heals without a cartilaginous phase. Inflammation plays an important role in the healing of a shaft fracture, but if metaphyseal injury is different, it is important to clarify if the role of inflammation is also different. The biology of fracture healing is also influenced by the degree of mechanical stability. It is unclear if inflammation interacts with stability-related factors.