Introduction. The recent introduction of Chatbots has provided an interactive medium to answer patient questions. The accuracy of responses with these programs in limb lengthening and reconstruction surgery has not previously been determined. Therefore, the purpose of this study was to assess the accuracy of answers from 3 free AI chatbot platforms to 23 common questions regarding treatment for limb lengthening and reconstruction. Method. We generated a list of 23 common questions asked by parents before their child's limb lengthening and reconstruction surgery. Each question was posed to three different AI chatbots (ChatGPT 3.5 [OpenAI], Google Bard, and Microsoft Copilot [Bing!]) by three different answer retrievers on separate computers between November 17 and November 18, 2023. Responses were only asked one time to each chatbot by each answer retriever. Nine answers (3 answer retrievers × 3 chatbots) were randomized and platform-blinded prior to rating by three orthopedic surgeons. The 4-point rating system reported by Mika et al. was used to grade all responses. Result. ChatGPT had the best response accuracy score (RAS) with a mean score of 1.73 ± 0.88 across all three raters (range of means for all three raters – 1.62 – 1.81) and a median score of 2. The mean response accuracy scores for Google Bard and Microsoft Copilot were 2.32 ± 0.97 and 3.14 ± 0.82, respectively. This ranged from 2.10 – 2.48 and 2.86 – 3.54 for Google Bard and Microsoft Copilot, respectively. The differences between the mean RAS scores were statistically significant (p < 0.0001). The median scores for Google Bard and Microsoft Copilot were 2 and 3, respectively. Conclusion. Using the Response Accuracy Score, the responses from ChatGPT were determined to be satisfactory, requiring minimal clarification, while the responses from Microsoft Copilot were either satisfactory, requiring moderate clarification, or unsatisfactory, requiring substantial clarification

Aims. Patients undergoing limb reconstruction surgery often face a challenging and lengthy process to complete their treatment journey. The majority of existing outcome measures do not adequately capture the patient-reported outcomes relevant to this patient group in a single measure. Following a previous systematic review, the Stanmore Limb Reconstruction Score (SLRS) was designed with the intent to address this need for an effective instrument to measure patient-reported outcomes in limb reconstruction patients. We aim to assess the face validity of this score in a pilot study. Methods. The SLRS was designed following structured interviews with several groups including patients who have undergone limb reconstruction surgery, limb reconstruction surgeons, specialist nurses, and physiotherapists. This has subsequently undergone further adjustment for language and clarity. The score was then trialled on ten patients who had undergone limb reconstruction surgery, with subsequent structured questioning to understand the perceived suitability of the score. Results. Ten patients completed the score and the subsequent structured interview. Considering the tool as a whole, 100% of respondents felt the score to be comprehensible, relevant, and comprehensive regarding the areas that were important to a patient undergoing limb reconstruction surgery. For individual questions, on a five-point Likert scale, importance/relevance was reported as a mean of 4.78 (4.3 to 5.0), with ability to understand rated as 4.92 (4.7 to 5.0) suggesting high levels of relevance and comprehension. Flesch-Kincaid reading grade level was calculated as 5.2 (10 to 11 years old). Conclusion. The current SLRS has been shown to have acceptable scores from a patient sample regarding relevance, comprehensibility, and comprehensiveness. This suggests face validity, however further testing required and is ongoing in a larger cohort of patients to determine the reliability, responsiveness, precision, and criterion validity of the score in this patient group. Cite this article: Bone Jt Open 2021;2(9):705–709

Introduction. Continuous compression implants (CCIs) are small memory alloy bone staples that can provide continuous compression across a fracture site, which change shape due to temperature changes. Reviews of CCIs in orthopaedics have documented their use in mainly foot and ankle surgery, with very limited descriptions in trauma. They could be beneficial in the management of complex or open injuries due to their low profile and quick insertion time. The aim of this case series were to clarify the use of CCIs in modern day limb reconstruction practice. Materials & Methods. This was a single centred study looking retrospectively at prospective data for patients who were treated for an acute fracture or non-union with a CCI between September 2019 and May 2023. Primary outcome was to determine the function and indication of the CCI as judged retrospectively and secondary outcomes investigated unplanned returns to theatre for infection or CCI failure. Results. Sixty patients were eligible with a mean age of 44.2 (range 8–89). Fifty-one patients were treated for acute fractures, nine for non-unions; and almost half (27 patients) had open injuries. There were seven different sites for treatment with a CCI, the most common being tibia (25 patients) and humerus (14 patients). Of the 122 CCIs used, 80 were used as adjuncts for fixation in 48 patients. Their indication as an adjunct fell into three distrinct categories – reduction of fracture (39 CCIs), fixation of key fragments (38 CCIs) and compression (3 CCIs). Of these 48 patients, 4 patients had a frame fixation, 19 had a nail fixation, 24 patients had a plate fixation. Forty-two CCIs were used in isolation as definitive fixation, all were for midfoot dislocations expect an open iliac wing fixation from a machete attack and an isolated paediatric medial malleolus fixation. Two patients returned to theatre for infection and two due to CCI failure. Conclusions. This series has demonstrated the versality of CCIs across multiple sites of the body and for a large variety of injuries. It has identified, when not used in isolation, three main indications to support traditional orthopaedic fixations. Given the unpredictability in limb reconstruction surgery, the diversity and potential of CCIs could form part of the staple diet in the modern-day practice

Aim

Bone infections often manifest with soft tissue complications such as severe scarring, fistulas, or ulcerations. Ideally, their management involves thorough debridement of infected bone and associated soft tissues, along with achieving stable bone structure, substantial tissue coverage, and long-term antibiotic therapy. The formation of a multidisciplinary team comprising orthopedic surgeons, plastic surgeons, and infectious disease specialists is essential in addressing the most complex cases.

Introduction. To report our early experience and suitability over unicortical fixation system to reduce and hold the bone fragments in position during a CHAOS procedure of the femur or tibia during lower limb reconstruction surgery. Materials and Methods. We report a case series of the first consecutive 10 patients (11 bones) for which this CHAOS technique was used between May 2017 and October 2019 by the same surgeon. The novel aspect of the procedure was the use of a unicortical device, Galaxy UNYCO (Orthofix, Verona, Italy), which eliminate the need for any change of fixation during the procedure. It also means the intramedullary canal was left free for the intramedullary nailing. Results. We treated 4 femurs and 7 tibias with this technique without any loss or failure of the construct. We treated uniplanar and multiplanar deformities with the angulations between 8 degrees of valgus to 15 degrees of varus and from 0 to 8 mm translation in the AP view, from 20 degrees procurvatum to 15 degrees recurvatum and 0 to 2 mm translation on the lateral view and from 20 degrees internal rotation to 5 degrees external rotation and 0 to 10 mm translation on axial view. Conclusions. The construct was able to deal with the total tension in the system both in the correction phase and the additional stress applied during insertion of a nail such as reaming and impacting the nail to the canal. The potential advantage also included the possibility of intramedullary nailing without interference with the external fixation device

Introduction

Limb deformity is usually assessed clinically assisted by long leg alignment radiographs and further imaging modalities (MRI and CT). Often decisions are made based on static imaging and simple gait interpretation in clinic. We have assessed the value of gait lab analysis in surgical decision making comparing surgical planning pre and post gait lab assessment.

Introduction and Aims: Fibular hemimelia presents a problem with leg length discrepancy and equinovalgus foot deformity. Our protocol is to simultaneously treat both problems, with the goals of equalising limb length and achieving a plantigrade painless functional foot. Method: Seventy-eight patients with fibular hemimelia underwent 92 lengthenings and foot deformity correction. Equinovalgus foot deformity was corrected by four different methods in 67 cases: distraction, soft tissue release, release plus supramalleolar and/or subtalar osteotomy, and fibular transport. Results: Goals of lengthening and foot deformity correction were achieved in all cases. Foot deformity recurred in 19 patients and was retreated: 9/16 (56%) distraction cases, 4/18 (22%) soft tissue release cases, 2/28 (7%) release plus osteotomy cases, and 4/5 (80%) fibular transport cases. Genu valgum developed in many cases with no or partial anlage resection. Genu valgum did not develop in any cases with complete anlage resection. Final results based on functional and radiographic evaluation: 46 excellent, 28 good, 18 fair. Final result did not correlate with number of rays in foot. Conclusion: Limb length discrepancy and foot deformity can be successfully treated by simultaneous lengthening and foot deformity correction. Soft tissue release plus osteotomy and complete anlage resection yielded best results. Lengthening reconstruction surgery is an excellent alternative to ablative surgery and prosthetic fitting for patients with all severities of fibular hemimelia

Purpose: This study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap. Materials and Method: Sixty-eight patients (72 breasts) had this operation between September 1999 and June 2002. fifty-four patients (58 breasts) were assessed. The average age was 50 year (range 30 – 66 year). Average follow up was 38 month (range 24 – 54 month). DASH and Constant-Murley were used for clinical assessment. Results: Twenty-nine (50%) shoulders found to have a normal function; whereas, 11 (19%) shoulders had mild disability, 10 (17%) shoulders had moderate disability and 8 (14%) shoulders had severe disability. Only 6 (10%) patients reported being unsatisfied with their outcome; these were, from a shoulder function point view, 4 patients with sever disability, 1 patient with moderate disability and 1 patient with normal shoulder function. However, all these 6 patients were not satisfied with their breast reconstruction outcome. Conclusion: This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients

The purpose of this study was to assess shoulder function after breast reconstruction surgery using latissimus dorsi flap. Sixty-eight patients (72 breasts) had this operation. Average follow up was 38 months (range 24 to 54 months). DASH and Constant-Murley were used for clinical assessment. Twenty-nine shoulders found to have a normal function; whereas, 11 shoulders had mild disability, 10 shoulders had moderate disability and 8 shoulders had severe disability. However, only 6 patients reported being unsatisfied with their outcome. Furthermore, all these 6 patients were not satisfied with their breast reconstruction outcome. This study confirms that following breast reconstruction surgery using latissimus dorsi flap, there is a considerable deterioration of shoulder function of varying degrees. Nevertheless, shoulder function is not the main concern of this group of patients

Purpose: To alert the Orthopaedic fraternity that smoking needs to be considered in the Paediatric population and highlight it’s adverse effect on bone healing index. Method: During assessment of Paediatric patients who had undergone limb reconstruction surgery, a sub-population was found to have a prolonged time to consolidation of the regenerate to norm. Screening for contributing factors, we were surprised to learn that this subgroup were active smokers. Revisiting their radiographs, it was felt that the quality of the regenerate appeared to differ from non-smokers. Results: We identified 12 patients who were active smokers. 2 also had parents who smoked. They all exhibited a prolonged time to regenerate consolidation. We calculated their bone healing indices to compare with non smokers and found significant differences. Conclusion: Smoking has adverse effects on bone healing in children as well as adults. We have drawn up an advise sheet to make patients and their parents aware of the adverse effects of active and passive smoking on bone healing

Human recombinant Osteogenic Protein 1 or rhBMP-7 is licensed for use in tibial non-union where autologous bone grafting has failed. Through its osteoconductive and osteoinductive properties, its application may be more widely applied. We audited our use of rhBMP-7 and present the largest series currently reported in the literature. We reviewed 107 consecutive patients on whom rhBMP-7 was used over a 5-year period (2002–2007). Demographic and clinical details (e.g indication, site, use of adjuncts, previous surgery, smoking status, time to union, mean follow up etc) were entered into an electronic spreadsheet. RhBMP-7 was used in 112 sites on 107 patients (65 male, 42 female). Ages ranged from 16yrs to 89yrs (mean 47.6). Non-union was the main indication for surgery (82 cases). RhBMP-7 was used alone in 39 cases and with autologous bone graft (56 cases). In other cases demineralised bone matrix, USS and bone allograft were used as adjuncts. Tibia (42 cases), femur (29 cases), humerus (21 cases) were the most common sites of administration. Mean number of operations prior to use of rhBMP-7 was 1.6 (range 1–20). In all cases, union was achieved in 65% (73/112) with a mean union time 5.8 months. The ‘rhBMP-7 alone’ subgroup demonstrated union in 83% (30/36), mean union time 5.15 months. 68% (56/82) of cases treated for nonunion subsequently united with rhBMP-7. Our results suggest rhBMP-7 is useful in the management of fracture non-union and limb reconstruction surgery irrespective of site. It promotes bone healing of non-unions subjected to multiple operations previously. It may be indicated in those patients in whom autologous bone graft harvest is undesirable or not possible or as an adjunct to bone grafting. Moreover we did not detect any adverse reactions specific to the administration of rhBMP-7

Purpose of study: The aim of this study was to look at the clinical outcome of PLC interference screws in knee ligament reconstruction surgery. Materials & Results: We prospectively followed up 60 patients who underwent primary anterior cruciate ligament (ACL) reconstructions using PLC (Calaxo; Smith & Nephew) screws to secure the graft in the tibial tunnel. [(35 male patients & 25 female). Average age 33.72 years]. In addition to the ACL, PLC screws were used to reconstruct the posterior cruciate ligament in one case and posterior cruciate ligament with the posterolateral corner in another three patients. Hamstring autografts were routinely preferred except in multiple ligament reconstructions, when allografts were also used. 25 (41.67%) patients presented with complications (synovitis in 10 patients, prominent tibial swelling in 21 patients and both in 7 patients). In comparison, no complications were noted in 60 other age and sex matched patients in whom PLLA (Bio RCI; Smith & Nephew) screws were used by the same surgeon. The symptoms in the PLC screw group often settled conservatively and did not affect knee stability. 6 patients underwent exploration of the tibial tunnel site. A sterile white cheesy substance was noted which was removed, leaving an empty tibial tunnel. The ACL graft was found to be well attached to tibial tunnel in all cases. The PLC screw size did not have any correlation to the occurrence of complications. 2 patients required multiple washouts, one of whom developed a deep infection. Conclusion: The degradation of PLC screws does not follow the gradual and controlled pattern demonstrated in the ovine model [Walsh WR et all, Arthroscopy. 2007 Jul;23(7):757–65. Comparison of PLLA and PLC interference screws in an ovine ACL reconstruction model.]. The unpredictable screw resorption, and the reaction to it can lead to serious clinical consequences

As the number of patients being offered multifocal procedures in limb reconstruction surgery has increased a study was performed to compare single stage and staged procedures. A retrospective analysis of all multifocal procedures (more than two sites) performed between 1988 and 1997 was carried out looking at treatment times, results and complication rates. A total of 51 multifocal procedures were performed. The mean number of sites operated on was 3.8 per patient for single stage and 4 per patient for staged. There were 18 single stage and 33 staged operations. There were 29 performed on the paediatric age group for indications such as achondroplasia and short stature. The rest were in adults where the main indications were related to complex trauma management and their complications. External Fixation was the principle method of treatment. The total hospital stay averaged 18 days for single stage procedures and 29 days for staged. Of the single stage cases 12 had one operation with a mean of 1.33 operations (including surgery for complications) compared to staged procedures which had an average of 2.8 operations (range 2–5 ). In addition, the total treatment time (time of first surgery to discharge) was more for staged surgery, 5 years compared to 3.6 years. In the single stage group 9 patients (50%) had at least one significant post operative complication (2 severe, 7 moderate) and in the staged group 19 (57%) had significant complications (3 severe, 16 moderate). There was no detectable difference in the final clinical result obtained between the groups. From this study we would conclude that single stage procedures carry no increased risk and are of benefit to patients because of the shorter hospitalisation, reduction in the number of operations and general anaesthetics and the reduced time to final outcome

The use of cervical pedicle screws as anchors in posterior reconstruction surgery has not been widely accepted due to the neurological or vascular injury. We thus sought to investigate the accuracy of free-handed pedicle screw placement in the cervical and upper thoracic spine at the early stage of clinical application. Eight patients (five males and three females) were included in this study. Mean age was 63 years (31 to 78 years). There were three patients with rheumatoid arthritis, three with cervical fracture-dislocation, and two with spinal metastasis. Twenty-four pedicle screws (3.5 mm diameter: Vertex, Medtronic Sofamordanek) were placed into the pedicle from C2 to T2 level by free-handed technique2). Grade of breaching of pedicle cortex was divided into four groups (Grade 0–3). In addition, screw axis angle (SAA) were calculated from the horizontal and sagittal CT images and compared with pedicle transverse angle (PTA). Furthermore, perioperative complications were also examined. Our free-handed pedicle screw placement with carving technique is as follows: A longitudinal gutter was created at the lamina-lateral mass junction and then transverse gutter perpendicular to the longitudinal gutter was made at the lateral notch of lateral mass. The entry point of the pedicle screw was on the midline of lateral mass. Medial pedicle cortex through the ventral lamina was identified using the probes to create the hole within the pedicle. The hole was tapped and the screw was gently introduced into the pedicle to ensure the sagittal trajectory using fluoroscopy. In the transverse direction, 22 out of 24 screws (92%) were entirely contained within the pedicle (Grade 0). In contrast, only teo screws (8%) produced breaches less than half the screw diameter (Grade 1). In the sagittal direction, all screws were within the pedicle (Grade 0). Screw trajectories were not consistent with anatomical pedicle axis angle; the mean SAA were smaller than the mean PTA at all levels. The pedicle diameter ranged from 3.9 to 9.2 mm. The mean value gradually increased toward the caudal level. There were no neurological and vascular complications related to screw placement

Aim

The demand for a synthetic bone substitute that can build bone and at the same time kill bacteria is high. The aim of this study was to compare the elution of gentamicin from a new synthetic bone substitute in vitro with the performance in clinical applications.

Background

Referral to centres with a pelvic service is standard practice for the management of displaced acetabular fractures.

Introduction

Medial calcaneal displacement osteotomy with an FDL tendon transfer is a common method of correcting pes planus deformity secondary to grade II tibialis posterior dysfunction. There is currently no evidence that calcaneal displacement alters the centre of pressure in the foot from a medial to a more central position as the normal shape is reconstituted.

The Taylor Spatial Frame is a new external ring fixation system for correction of multi-planar deformities of the extremities. We report the first 100 consecutive cases treated with this system at the Bristol Limb Reconstruction Unit from November 1999.

The Taylor Spatial Frame incorporates the technology of a virtual hinge and a Stewart Gough Platform. With the use of computer software it is capable of adjustments to within 1 degree and 0.5mm accuracy. Deformities are measured on plain radiographs. Required corrections over any period of time are calculated and a printed prescriptiion of daily adjustments is given to the patients to perform themselves at home.

The following conditions were treated: Non-union (44), malunion (16), Leg length discrepancy (14), limb deformity (13), and acute fractures (13). The aims of frame treatment were non-union treatment (28), bone transport (12), acute fracture healing (12), correction of deformity (28), leg lengthening (15), and arthrodesis (5). Most cases involved the tibia (77) but the frame was also used on the femur (13), knee (3), ankle (4), humerus (2), and forearm (1).

Complete correction of deformity was achieved in all but 7 patients. Union was achieved in 99 cases. All non unions united without bone graft. Mean transport of 46mm and lengthening of 38mm was achieved. 1 arthrodesis failed to unite. All fractures united without any residual deformity. Mean treatment time was 169 days (range 43 to 401). There was 100% compliance with patients performing adjustments themselves. Minor pin site problems were common (34 patients) but only 3 required debridement. Other problems included wire breakage (10), pain (3), peroneal nerve palsy (1) and DVT (1). 15 knees and 11 ankles developed stiffness which resolved.

This study demonstrates the role of the Taylor Spatial Frame as an extremely versatile, accurate and safe new tool at the orthopaedic surgeon’s disposal in limb reconstruction and trauma surgery.

In an era where the survival rates of oncologic patients are improving, biologic reconstruction is the treatment of choice, however, it has its complications and fortunately we have the solutions.

Biological reconstruction was performed on 52 patients with a mean age of 11.3 (1.5–16) after malignant bone tumor resection in our institution between 1991 and 2008. Patients were followed up for a mean period of 49 months (3–216). Twenty-nine patients were diagnosed with osteosarcoma, 22 with Ewing sarcoma and 1 with adamantinoma. A wide range of vascular and nonvascular autografts, allografts, fibular transposition, bone regeneration and bone recycling techniques were utilised alone or in combination for reconstruction. Crucial anatomical parts (epiphyses, apophyses, triradiate cartilage, glenoid) were preserved in 41 patients while maintaining safe surgical margins.

Wound problem was the most common early complication. The most common late complications were nonunion, limb length discrepancy, limitation of range of motion (ROM), deformity, implant or external fixator failure and fibular graft fracture. Local recurrence was seen in only 2 patients. Patients underwent a mean of 0.8 (1–10) additional surgical interventions for treatment of complications. Thirty-one out of 43 lower extremity patients became ambulatory with full weight bearing and near full ROM while 4 died of disease and 2 were disarticulated prior to healing or treating of complications. Six patients with reconstructions around the glenohumeral joint had functional outcomes varying from excellent to poor with defect pseudoarthrosis. Two patients with successful pelvic reconstructions suffered from co-morbidities and disease itself. Implants and fixators, orthoses, physiotherapy and antibiotherapy were used as necessary for treatment of complications.

Biologic reconstruction yields good functional outcomes and allows more flexibility while treating complications since it preserves bone stock and epiphyses.

Purpose of the study: The latissimus dorsi free flap is widely used for reconstruction of large tissue defects. It is always difficult however to explain the procedure to the patient, particularly the potential sequelae. The purpose of this work was to assess sequelae affecting shoulder function and the esthetic aspect of the harvesting site.

Material and methods: We reviewed 16 patients (17 harvestings) aged 37.8 years on average (range 22–62 years), twelve men and four women, at mean follow-up of 4.5 years. All flaps had been harvested to reconstruct tissue defects of the lower limb. Eleven were semi-emergency procedures, four for chronic defects or reconstruction after tumor resection. We assessed the esthetic aspect of the harvesting zone and shoulder function suing Cybex 6000 (comparative isokinetic tests of the two shoulders). The Dash score was noted.

Results: Functional impairment was minimum in all patients. The Dash score was 17.5%. (compared with the opposite side was: 27% abduction, 22% extension and 10% rotation. Adduction, flexion and external rotation were preserved. The esthetic aspect was acceptable but not negligible. Obesity appeared to accentuate disgraceful scars.

Discussion and conclusion: The latissimus dorsi free flap is often indicated for reconstruction of significant tissue defect. Shoulder function is largely preserved. Patients should be informed about the major scar. The side to be harvested should be discussed with the patient, even in the emergency situation.