Knee dislocations, vascular injuries and floating knee injuries can be initially managed by a external fixator. Fixator design constructs include the AO pattern and the Diamond pattern. However, these traditional constructs do not adhere to basic principles of external fixation. The Manchester pattern knee-spanning external fixator is a new construct pattern, which uses beam loading and multiplanar fixation. There is no data on any construct pattern. This study compares the stability of these designs. Hoffman III (Stryker, USA) external fixation constructs were applied to articulated models of the lower limb, spanning the knee with a diamond pattern and a Manchester pattern. The stiffness was loaded both statically and cyclically with a Bose 3510 Electroforce mechanical testing jig (TA Instruments). A ramp to load test was performed initially and cyclical loading for measurement of stiffness over the test period. The results were analysed with a paired t-test and ANOVA.Introduction
Materials & Methods
The viability of any surgical practice relies on the income that practice generates for the parent NHS Trust. The OPCS codes are a key determinant of an NHS trust's tariff for an admission. These contribute to the HRG codes - the means the NHS uses to determine the value of a patient's treatment, including operations. The clinical knowledge of coders may not differentiate specialist practice, including circular frames. The OPCS and HRG codes generated by patient spells in one NHS trust were examined and reviewed retrospectively. The appropriateness of these codes were determined, and potential loss of income from inappropriate codes was calculated.Background
Methods
Medical grade Calcium Sulphate can be used as a delivery vehicle for antibiotics. We use these for treating patients with established osteomyelitis, but also use it prophylactic for contaminated war injuries, to fill voids in bone with osteo conductve filler that delivers local antibiotics, and can integrate with bone. Although antibiotic loaded calcium sulphate is increasingly used, there is little data to demonstrate that systemic levels generated by local release of antibiotics are safe. For this reason, we routinely assay systemic levels of antibiotics. To determine if systemic toxicity occurs after the use of antibiotic loaded calcium sulphate in the treatment of bone and soft tissue infectionBackground
Objectives
This study evaluates the need for limb reconstruction surgery in Syria and gives examples of how this service has been delivered by UK surgeons. The conflict in Syria has resulted in over 500,000 deaths and 1.2 million injured. There is not yet a centre for limb reconstruction surgery in the country. Injuries from gunshots and shrapnel were not common prior to the civil war resulting in a paucity of experience. The senior author spent two weeks in Syria to perform limb reconstruction surgery, to help to train local surgeons and assess the capacity of the facilities available to cope with the limb reconstruction workload.Introduction
Methods
To determine if systemic toxicity occurs after the use of antibiotic loaded calcium sulphate in the treatment (1) of bone and soft tissue infection. Although antibiotic loaded calcium sulphate is increasingly used for the local treatment of bone and soft tissue infection, there is little data to demonstrate that systemic levels generated by local release of antibiotics are safe. For this reason, we routinely assay systemic levels of antibiotics. Patients with osteomyelitis or soft tissue infection underwent surgical debridement and lavage of the infected tissue in routine fashion. Patients with osteomyelitis were graded with the Cierny-Mader classification. Bone cavities and soft tissue dead spaces were packed with antibiotic loaded calcium sulphate (10–40 cc) loaded with Vancomycin (1–4 g) and Gentamicin (240–960 mg). The wounds were closed over the antibiotic loaded calcium sulphate. Patients underwent serial assays of Vancomycin and Gentamicin levels on the day of surgery and the first two post-operative days. Renal function was also measured.Aim
Methods
To compare the functional outcome of Distal Tibial Metaphyseal fracture treated with Circular frame compared vs. Locking Plate Distal Tibial Metaphyseal fractures were retrospectively identified over an 18 month period. Each fracture was assessed individually using radiographs. All paediatric, compound, tibial plateau and intra-articular fractures were excluded from the study. Other methods of fixation including intramedullary nailing were also excluded. The remaining fractures were assigned to either the circular frame fixation or the locking plate intervention group. Outcomes were assessed using radiographs for union dates and microbiology results for evidence of infection. Patients were followed up by postal questionnaires, which included a modified American Orthopaedic Foot and Ankle Score (AOFAS), the Olerud and Molander Score (O&M) and a custom questionnaire. The custom questionnaire asked about co-morbidities, smoking status and work days lost following surgery. After exclusions, 30 patients (Frame=15, Plate=15), were sent out questionnaires via post. We received completed questionnaires from 21 patients (Frame=11, Plate=10) giving us a response rate of 70%. Results show no difference in infection rates, skin necrosis, non-union or re-operation rates. There was also no significant difference in patient AOFAS and O&M scores at follow up.Statement of Purpose
Methods and Results
Taylor Spatial Frame (TSF) is a six axis deformity correction frame and accuracy of correction depend on the accuracy of parameters input in to the web based software. There are various methods of obtaining frame and deformity parameters (13 in total) including the use of dedicated software known as SpatialCAD™. We tested the accuracy of SpatialCAD™ using a saw bone two ring frame construct of known parameters. We mounted a two-ring (155mm) frame on a saw bone tibia and fibula unit and worked out the accurate mounting and deformity parameters. Then we obtained orthogonal and nonorthogonal antero-posterior and lateral images of frame using a metallic sphere of known dimensions placed at the level of the bone, to aid calibration of x-ray images. We also obtained orthogonal and non-orthogonal images without a calibrating sphere. We then uploaded the images in to SpatialCAD™ software and obtained the mounting and deformity parameters and compared with the real parameters. SpatialCAD™ is capable of yielding measurements within 1–2mm of actual measurements when Calibrated orthogonal images were used. The software was inaccurate when frame hardware of known dimensions was used for calibration because the hardware was not in the same plane as the bone
Limb lengthening with external fixators has many complications, like pin track infection, joint stiffness, severe pain and stress fracture after removal of external fixator. Prolonged period in external fixator interferes with rehabilitation and activities of daily living. We describe our results with ISKD (intramedullary skeletal kinetic distractor) system, an internal limb lengthening device, activated with rotations of 3 degrees. In this retrospective cohort we performed lengthening with the use of ISKD in 12 patients from March 2006 to date. Ten patients were included in this study as two patients had not completed the stage of consolidation. There were 7 male and 3 female patients. Their average age was 44 years (range 23–63). The mean follow up period was 16 months (range 12–24 months). Two patients had tibial lengthening and eight patients had femoral lengthening. The average lengthening desired was 42.5 mm (range 2.5 mm–75 mm). The average lengthening achieved was 38 mm. Mean hospital stay was 7 days (range 5–11 days). The distraction index was 1.2 mm/day. The average time to full weight bearing was 6 months (range 4 to 10 months). Mean healing time was 10.25 months. The mean healing index was 90.7 days/cm. If we remove two patients who took long time to heal, the mean healing index drops to 61 days/cm. Two patients needed bone grafting at the distraction site. None of the patients had infection, non-union of the distraction site or breakage of the nail. None of the patients had joint stiffness. All patients were completely satisfied with the treatment and had excellent functional results. We conclude that the low rate of complications, higher patient acceptability and avoidance of external fixation make ISKD a very attractive option for limb lengthening.
Morton's Neuroma is routinely treated by excision of the interdigital nerve. Traditional surgery works by denervation, but the results are variable, and recurrence is common. Multiple Morton's Neuromas present a difficult clinical challenge. MR and ultrasound often demonstrate a normal nerve or an interdigital bursa. Some experts advise division of the intermetatarsal ligament rather than excision. This case series evaluates an alternative method of treatment. Patients with a clinical diagnosis of Morton's Neuroma, with symptoms only on weight bearing, were treated with division of the intermetatarsal ligaments and Weil's osteotomies. The nerve was not excised. Patients wore a postoperative shoe for six weeks. If radiographs were satisfactory, they returned to weight bearing in a normal shoe. They were evaluated at 12 weeks with AOFAS scoring, as part of the routine clinical pathway.Introduction
Methods
Various rehabilitation shoes are prescribed to protect the forefoot following surgery. Patients often complain of discomfort in other areas as a result of the postoperative shoe, including the knee, hip and lower back. This has never been quantified. This study aims to establish the effect on other joints using gait analysis. Methods: 11 healthy volunteers were investigated using various common types of postoperative shoe. They were studied with gait analysis equipment and the joint motion assessed with commercial software. The effect of commercial devices designed to minimise gait changes by lifting the There was a reduction in knee flexion and extension compared to the Introduction
Results
Nice guidelines recommend VTE prophylaxis to patients in below knee casts following foot and ankle surgery following risk assessment. The guidelines are controversial and BOFAS recommendations reiterate the risk factors but highlight poor evidence to support these guidelines. Implementation has been variable dependent on interpretation. 58 patients who underwent hindfoot procedures and were immobilised in a cast were identified. These patients were under the care of two consultants, one of whom anticoagulates with daily enoxaparin and one who does not, providing a de facto case-control design. The patients were followed up to identify those who subsequently suffered a DVT or PE, and the clinical circumstances. 2 cases of VTE events were noted in 58 patients undergoing foot and ankle surgery. Both were elective cases managed postoperatively in cast and treated with prophylaxic enoxaparin. Both of these presented to hospital with signs of VTE greater than 6 weeks following surgery after cast removal and discontinuation of enoxaparin. No patients were considered high risk according to NICE guidelines. None of the patients who received no thromboprophylaxis had a clinical DVT. Within our study group we found that VTE thromboprophylaxis does not influence clinically evident VTE rates. Patients who developed VTE were not considered high risk by definition of NICE guidelines but only at increased risk due to their immobility. The VTE events were initiated while the patients were receiving thromboprophylaxis. The effectiveness of the guidelines in predicting patients who would benefit from chemoprophylaxis is questionable from this study. NICE guidelines on VTE thromboprophylaxis have been received with some concerns. Although this investigation studied only a relatively small number of patients, it raises issues about the clinical effectiveness of the guidelines in foot and ankle patients.
The treatment of very distal tibial fractures and pilon fractures is difficult. There is a wide variation in the severity of injury and the options for surgical management. Plates and external fixation each have their advantages. This retrospective study looks at complications and technical tips for anterolateral plating. 35 consecutive distal There were 32 anterolateral platings and 3 medial platings. The union rate was 95%. There were two deep infections which required surgical treatment. There were two wound breakdowns, one of which required plastic surgical intervention. Two patients had prominent metalwork, requiring removal. Other complications included deep The complication rate found was similar to that reported in the literature. The few complications were however very significant for the patient and also for the surgeon as they required bone transport. Complications other than infection occurred in the few cases performed by surgeons low on their learning curve. We present technical tips for surgery. The presence of callus only after mobilisation indicates that union is slow. Anterolateral plating is a viable option for distal
Fracture non-union poses a significant challenge to treating orthopaedic surgeons. These patients often require multiple surgical procedures. The incidence of complications after Autologous Bone Graft (ABG) harvesting has been reported up to 44%. These complications include persistent severe donor site pain, infection, heterotopic ossification and antalgic gait. We retrospectively compared the use of BMP-7 alone in long bone fracture Non-union, with patients in whom BMP-7 was used in combination with the Autologous Bone Graft (ABG). The databases of our dedicated Limb Reconstruction Unit were searched for patient with three common long bone fractures Non-unions (Tibia, Femur and Humerus). The patients who had intra-operative use of Bone Morphogenetic Protein (BMP-7) alone and in combination with ABG were evaluated. 53 Patients had combined use of ABG and BMP-7, and 65 patients had BMP-7 alone.Objectives
Material and Methods
The Mini C-arm has been heralded as a safer means of fluoroscopy. No clinical data on the use of the mini C-arm is available in the literature. The purpose of this study is to compare the exposure in clinical practice between the conventional C-arm and the mini C-arm, and to scrutinize the patterns of radiation exposure. All operations using the mini C-arm were reviewed. A control group of patients undergoing the identical surgical procedure using the conventional C-arm was used. The Sign test was used to detect the number of exposures taken and the radiation exposure documented. There were 16 surgical procedures where a valid control was available. The number of exposures performed with the mini C-arm was significantly greater than the conventional C-arm (p=0.05), but the emitted dose of radiation was significantly smaller for the mini C-arm (p 0.001). The authors conclude that the mini C-arm is a safer device for use in extremity surgery, but that the Surgeon should still be careful to avoid repeated excessive exposures.
The aim of this study was to determine if the exposure to patient and surgeon was decreased with use of the mini C arm.
Introduction: Haemophilus influenzae type B has been the pathogen responsible for a significant proportion of cases of septic arthritis in children in the past. Vaccination was introduced in the United Kingdom in October, 1992 in order to combat meningitis and epiglottitis. This study looks at the effects of vaccination on childhood septic arthritis in Wales. Methods: Data was collected prospectively from 1988 by the Public Health Laboratory Service in Wales. Data was analysed with a two-sample t-test. Results: There were 17 cases in children in which 16 were attributed to type B. 14 cases occurred in the 5 years before mass immunisation. Only 2 cases occurred in the 8 years following immunisation. The incidence of Haemophilus influenzae septic arthritis in children has fallen significantly since the introduction of immunization (P=0.009). Discussion: Vaccination has resulted in a significant fall in the incidence of Haemophilus influenzae type B septic arthritis in children in Wales. This may have consequences on guidelines for the empirical treatment of septic arthritis. If a child if found to have Haemophilus influenzae septic arthritis, this is suspicious of immunocompromise, or an alternate type infection. The novel way in which infection has been controlled may be one which can be used in future to control multi-resistant bacterial infection in orthopaedic surgery.
