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The aims of this study were to describe the epidemiology of metacarpal shaft fractures (MSFs), assess variation in treatment and complications following standard care, document hospital resource use, and explore factors associated with treatment modality.

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To investigate the risk factors for unsuccessful radial head reduction (RHR) in children with chronic Monteggia fractures (CMFs) treated surgically.

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Given the possible radiation damage and inaccuracy of radiological investigations, particularly in children, ultrasound and superb microvascular imaging (SMI) may offer alternative methods of evaluating new bone formation when limb lengthening is undertaken in paediatric patients. The aim of this study was to assess the use of ultrasound combined with SMI in monitoring new bone formation during limb lengthening in children.

Introduction. Tibial Pilon fractures are potentially limb threatening, yet standards of care are lacking from BOFAS and the BOA. The mantra of “span, scan, plan” describes staged management with external fixation to allow soft tissue resuscitation, followed by a planning CT-scan. Our aim was to evaluate how Tibial Pilon fractures are acutely managed. Methods. ENFORCE was a multi-centre retrospective observational study of the acute management of partial and complete articular Tibial Pilon fractures over a three-year period. Mechanism, imaging, fracture classification, time to fracture reduction and cast, and soft tissue damage control details were determined. Results. 656 patients (670 fractures) across 27 centres were reported. AO fracture classifications were: partial articular (n=294) and complete articular (n=376). Initial diagnostic imaging mobilities were: plain radiographs (n=602) and CT-scan (n=54), with all but 38 cases having a planning CT-scan. 526 fractures had a cast applied in the Emergency Department (91 before radiological diagnosis), with the times taken to obtain post cast imaging being: mean 2.7 hours, median 2.3 hours, range 28 mins – 14 hours). 35% (102/294) of partial articular and 57% (216/376) of complete articular (length unstable) fractures had an external fixator applied, all of which underwent a planning CT-scan. Definitive management consisted of: open reduction internal fixation (n=495), fine wire frame (n=86), spanning external fixator (n=25), intramedullary nail (n=25), other (n=18). Conclusion. The management of Tibial Pilon fractures is variable, with prolonged delays in obtaining post cast reduction radiographs, and just over half of length unstable complete articular fractures being managed with the gold standard “span, scan, plan” staged soft tissue resuscitation. A BOFAS endorsed BOAST (British Orthopaedic Association Standard for Trauma) for Tibial Pilon fractures is suggested for standardisation of the acute management of these potentially limb threatening injuries, together with setting them apart from more straightforward ankle fractures

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The aim of this study was to determine the fracture haematoma (fxH) proteome after multiple trauma using label-free proteomics, comparing two different fracture treatment strategies.

Introduction. Knee arthrodesis is a useful limb salvage technique to maintain function in patients with complex and infected total knee arthroplasties (TKA). There are a number of commonly used external fixators, but no consensus on which of these are optimal. The aim of this study was to synthesise the current literature to guide clinical decision making and improve patient outcomes. We systematically review the literature to compare outcomes of external fixators in arthrodesis following infected TKA. Materials & Methods. A systematic review of the literature of primary research articles investigating the use of external fixators for knee arthrodesis after an infected TKA was conducted. Relevant articles were identified with a search strategy on online databases (EMBASE and Medline) and reviewed by two independent reviewers. Clinical outcome measures were independently extracted by two reviewers which included union rate, infection eradication rate, complication rate, time to fusion, and time in frame. Results. Circular frames were more likely to result in union compared to biplanar (OR 1.40 p=0.456) and monoplanar frames (OR 2.28 p=0.018). Infection recurrence was least likely in those treated by circular frames when compared to monoplanar (OR 0.12 p=0.005) and biplanar external fixators (0.41 P=0.331). Complication rates were highest in the circular fixator group, followed by the monoplanar fixator group and biplanar fixator group at 34%, 31% and 11% respectively. Conclusions. Analysis of the available literature suggests higher union and infection eradication rates with circular frames over the other two fixation methods despite a higher complication rate. There is a paucity in the literature and therefore, no firm conclusions can be drawn. Further research investigating the variations and biomechanical properties between different external fixation methods for knee arthrodesis is necessary. Further clarity in reporting and pooled data would be useful for future analysis

Introduction. 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. Materials & Methods. 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. Results. The mean stiffness with the diamond pattern fixator was significantly less stiff than the Manchester pattern fixator – by a factor of 3 (40N/mm vs 115N/mm). Displacement increased in all patterns over simulated loading equating to six weeks. The diamond pattern demonstrated a 50%% increase in displacement over time. The Manchester pattern demonstrated only 20% increase in displacement over time. These are all statistically significant (p<0.01). Conclusions. The aim of an external fixator in knee dislocations and vascular injuries is to provide stability, prevent displacement and protect repairs. Vascular injuries often require fixation for several weeks to protect a repair. The Manchester pattern, applying the principles of external fixation, provides a stiffer construct and also confers greater stability over the time a fixator may be required. We commend this more informed design for the management of knee dislocations and vascular injuries

Introduction. Sheffield Children's Hospital specialises in limb lengthening for children. Soft tissue contracture and loss of range of motion at the knee and ankle are common complications. This review aims to look at therapeutic techniques used by the therapy team to manage these issues. Materials & Methods. A retrospective case review of therapy notes was performed of femoral and tibial lengthening's over the last 3 years. Included were children having long bone lengthening with an iIntramedullary nail, circular frame or mono-lateral rail. Patients excluded were any external fixators crossing the knee/ankle joints. Results. 20 tibial and 25 femoral lengthening's met the inclusion criteria. Pathologies included, complex fractures, limb deficiency, post septic necrosis and other congenital conditions leading to growth disturbance. All patients had issues with loss of motion at some point during the lengthening process. The knee and foot/ankle were equally affected. Numerous risk factors were identified across the cohort. Treatment provided included splinting, serial casting, bolt on shoes, exercise therapy, electrical muscle stimulation and passive stretching. Conclusions. Loss of motion in lower limb joints was common. Patients at higher risk were those with abnormal anatomy, larger target lengthening's, poor compliance or lack of access to local services. Therapy played a significant role in managing joint motion during treatment. However, limitations were noted. No one treatment option gave preferential outcomes, selection of treatment needed to be patient specific. Future research should look at guidelines to aid timely input and avoid secondary complications

The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

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Children with spinal dysraphism can develop various musculoskeletal deformities, necessitating a range of orthopaedic interventions, causing significant morbidity, and making considerable demands on resources. This systematic review aimed to identify what outcome measures have been reported in the literature for children with spinal dysraphism who undergo orthopaedic interventions involving the lower limbs.

Aims. As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. Methods. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30). Results. A median tibial distraction of 44 mm (IQR 31 to 49) was achieved with a mean distraction index of 0.5 mm/day (standard deviation 0.13) and median consolidation index of 41.2 days/cm (IQR 34 to 51). Accuracy, precision, and reliability were 91%, 92%, and 97%, respectively. New temporary range of motion limitations occurred in 51% of segments (34/67). Distraction-related equinus deformity treated by Achilles tendon lengthening was the most common major complication recorded in 16% of segments (11/67). In 95% of patients (55/58) the distraction goal was achieved with 42% unplanned additional interventions per segment (28/67). The median postoperative LD-SRS-30 score was 4.0 (IQR 3.6 to 4.3). Conclusion. Tibial distraction osteogenesis using motorized ILNs inserted via an antegrade approach appears to be a reliable and precise procedure. Temporary joint stiffness of the knee or ankle should be expected in up to every second patient. A high rate and wide range of complications of variable severity should be anticipated. Cite this article: Bone Joint J 2024;106-B(3):293–302

Aims

Acute and chronic injuries of the interosseus membrane can result in longitudinal instability of the forearm. Reconstruction of the central band of the interosseus membrane can help to restore biomechanical stability. Different methods have been used to reconstruct the central band, including tendon grafts, bone-ligament-bone grafts, and synthetic grafts. This Idea, Development, Exploration, Assessment, and Long-term (IDEAL) phase 1 study aims to review the clinical results of reconstruction using a synthetic braided cross-linked graft secured at either end with an Endobutton to restore the force balance between the bones of the forearm.

The February 2024 Foot & Ankle Roundup³⁶⁰ looks at: Survival of revision ankle arthroplasty; Tibiotalocalcaneal nail for the management of open ankle fractures in the elderly patient; Accuracy of a patient-specific total ankle arthroplasty instrumentation; Fusion after failed primary ankle arthroplasty: can it work?; Treatment options for osteochondral lesions of the talus; Managing hair tourniquet syndrome of toe: a rare emergency; Ultrasound-guided collagenase therapy for recurrent plantar fibromatosis: a promising line of therapy?.

Secondary bone healing is impacted by the extent of interfragmentary motion at the fracture site. It provides mechanical stimulus that is required for the formation of fracture callus. In clinical settings, interfragmentary motion is induced by physiological loading of the broken bone – for example, by weight-bearing. However, there is no consensus about when mechanical stimuli should be applied to achieve fast and robust healing response. Therefore, this study aims to identify the effect of the immediate and delayed application of mechanical stimuli on secondary bone healing. A partial tibial osteotomy was created in twelve Swiss White Alpine sheep and stabilized using an active external fixator that induced well-controlled interfragmentary motion in form of a strain gradient. Animals were randomly assigned into two groups which mimicked early (immediate group) and late (delayed group) weight-bearing. The immediate group received daily stimulation (1000 cycles/day) from the first day post-op and the delayed group from the 22nd day post-op. Healing progression was evaluated by measurements of the stiffness of the repair tissue during mechanical stimulation and by quantifying callus area on weekly radiographs. At the end of the five weeks period, callus volume was measured on the post-mortem high-resolution computer tomography (HRCT) scan. Stiffness of the repair tissue (p<0.05) and callus progression (p<0.01) on weekly radiographs were significantly larger for the immediate group compared to the delayed group. The callus volume measured on the HRCT was nearly 3.2 times larger for the immediate group than for the delayed group (p<0.01). This study demonstrates that the absence of immediate mechanical stimuli delays callus formation, and that mechanical stimulation already applied in the early post-op phase promotes bone healing

Healing after bone fracture is assessed by frequent radiographs, which expose patients to radiation and lacks behind biological healing. This study aimed to investigate whether the electrical impedance using electrical impedance spectroscopy correlated to quantitative scores of bone healing obtained from micro-CT and mechanical bending test. Eighteen rabbits were subjected to tibial fracture that was stabilized with external fixator. Two electrodes were positioned, one electrode placed within the medullary cavity and the other on the lateral cortex, both three millimeters from the fracture site. Impedance was measured daily across the fracture site at a frequency range of 5 Hz to 1 MHz. The animals were divided into three groups with different follow-up time: 1, 3 and 6 weeks for micro-CT (Bone volume/tissue volume (BV/TV, %)) and mechanical testing (maximum stress (MPa), failure energy (kJ/cm3), young modulus (Mpa)). There was a statistically significant correlation between last measured impedance at 5 Hz frequency immediately prior to euthanasia and BV/TV of callus (−0.68, 95%CI: (−0.87; −0.31)). Considering the mechanical testing with three-point bending, no significant correlation was found between last measured impedance at 5 Hz frequency immediately prior to euthanasia and maximum stress (−0.35, 95%CI: (−0.70; 0.14)), failure energy (−0.23, 95%CI: (−0.63; 0.26)), or young modulus (−0.28, 95%CI: (−0.66; 0.22)). The significant negative correlation between impedance and BV/TV might indicate that impedances correlate with the relative bone volume in the callus site. The lack of correlation between impedance and mechanical parameters when at the same time observing a correlation between impedance and days since operation (0-42 days), might indicate that the impedance can measure biological changes at an earlier time point than rough mechanical testing

Aim. This study assessed quality of life (QoL) in patients having external fixation for treatment of osteomyelitis and fracture-related infection (OM/FRI). Method. Patients who had surgery for OM/FRI and who completed the EuroQoL EQ-5D-5L or EQ-5D- 3L questionnaires, were identified between 2010 and 2020. Patients were followed-up for 2 years after surgery. QoL was compared between patients who had either an Ilizarov frame or a monolateral external fixator with those who did not receive external fixation. Results. 165 patients were included. Of these, 37 (22.4%) underwent application of external fixation which included 23 circular frames and 14 monolateral external fixators. Patients in the frame group had more BACH ‘Complex’ infections (34/37; 91.9%), compared to non-frame patients (57/81; 70.3%). Pre-operatively, the mean EQ-index score for patients planned to receive a frame (0.278 SD 0.427) was worse compared to other treatments (0.453 SD 0.338, p=0.083). At 6 weeks after surgery, the EQ-index score remained significantly lower in frame patients compared to non-frame patients (frame: 0.379 SD 0.363; no frame: 0.608 SD 0.326, p=0.016). By 6 months, 26/37 patients had undergone frame removal. The patients who had frames in situ at 6 months had lower EQ-index scores when compared to patients who had their frames removed (frame in situ: 0.187 SD 0.213; frame removed 0.674 SD 0.206, p=0.076). At one year, 36/37 (97.3%) patients had their frame removed. QoL had greatly improved, to levels similar to non-frame patients (no frame: 0.652 SD 0.357; frame removed: 0.657 SD 0.247, p=0.949). Conclusions. Frame treatment leads to significant improvement in Quality of Life in patients suffering from osteomyelitis, with similar results in EQ5D scores after 1 year compared to patients who did not need an external fixator. These effects cannot be felt until after the frame has been removed with impaired QoL during frame treatment, especially in those patients with frames in situ for more than 6 months. This underlines the need for close and professional patient support during frame treatment for bone infection

Aim. infected segmental bone defect (ISBD) is frequent in developing countries. The aim of this study was to assess the efficacy of the Masquelet technique in the treatment of ISBD in a low-resource setting. Patients and Method. We performed a prospective cohort study during the period from 2018 to 2022. Patients with infected bone defect of long bones were included. Management protocol consisted of two stages in all patients. The first stage consisted in debridement, tissues biopsy for microbiological culture, stabilization with external fixator and defect filling with gentamicin cement spacer. The second stage consisted of reconstruction using a cancellous bone autograft alone, or a mixture of autograft with allograft (demineralized bone matrix + tricalcium phosphate) and 1 gram of vancomycin powder. All patients were followed-up for at least one year. The results were assessed based on both objective (clinical and radiographic evaluation) and subjective (limb function and patient satisfaction) criteria. Main outcomes were bone union, reoperation and failure rates, union time, and limb function. Results. We included 31 patients in this study (80.6% men), with a median age of 35 [9 – 80] years. The tibia was affected in 12 cases and the femur in 15 cases. The median size of bone defect was 4 [1.5 – 12] cm. The most prevalent microorganisms were Klebsiella pneumoniae and Staphylococcus aureus. The mean interval between both stages was 14 (8 – 36) weeks and the median follow-up period after the second stage was 20 [12-62] months. External fixation was used in both stages in 25(80%) cases. Bone union was achieved in 26 (83.8%) patients of whom 24 without recurrence of infection, over a median time of 9 [6 – 16] months. All patients with a mixed graft (allograft and autograft) impregnated with local antibiotics achieved bone union. Two patients needed reoperation for relapse of infection between both stages, and subsequently achieved bone union without recurrence of infection. There were three cases of failure related to persistent infection or insufficient fixation stability in the second stage. Conclusions. Masquelet technique is a reliable procedure that can be safely performed in limited resources settings with satisfactory results. The mixture of autograft and allograft when available, all mixed with vancomycin seems to give promising results

Aim. Pin site infection (PSI) is a common complication of external fixators. PSI usually presents as a superficial infection which is treated conservatively. This study investigated those rare cases of PSI requiring surgery due to persistent osteomyelitis (OM), after pin removal. Method. In this retrospective cohort study we identified patients who required surgery for an OM after PSI (Checketts-Otterburn Classification Grade 6) between 2011 and 2021. We investigated patient demographics, aetiology of the OM, pathogen and histology, treatment strategies and complications. Infection was confirmed using the 2018 FRI Consensus Definition. Successful outcome was defined as an infection-free interval of at least 24 months following surgery, which was defined as minimum follow-up. Results. Twenty-seven patients were treated due to a pin site infection with an osteomyelitis (22 tibias, 2 humeri, 2 calcanei, 1 radius). 85% identified as male and the median age was 53.9 years. Eighteen infections followed external fixation of fractures, with 4 cases after Ilizarov deformity correction, 2 cases followed ankle fusion and 3 after traction pin insertion. Fifteen patients were classified as BACH Uncomplicated and 12 were BACH Complex. The median follow-up was 3.99 years (2.00–8.05 years). Staphylococci were the most common pathogens (16 MSSA, 2 MRSA, 2 CNS). Polymicrobial infections were present in 5 cases (19%). All surgery was performed in a single stage following the same protocol at one institution. This included deep sampling, debridement, implantation of local antibiotics, culture-specific systemic antibiotics and soft tissue closure. Seven patients required flap coverage (6 local, 1 free flap), which was performed in the same operation. 25 (93%) patients had a successful outcome after one surgery. Two had recurrence of infection which was successfully treated by repeat of the protocol. One patient suffered a fracture through the operated site after a fall. This healed without infection recurrence. Wound leakage after local antibiotic treatment was seen in 3/27 (11%) of cases. All resolved without treatment. After a minimum of 2 years follow up, all patients were infection free at the site of the former osteomyelitis. Conclusions. OM after PSI is uncommon but has major implications for the patient as 7 out of 27 patients needed flap coverage. This reinforces the need for careful pin placement and pin site care to prevent deep infection. These infections require appropriate surgery, not just curettage. All patients in our cohort were infection-free after a minimum follow-up of 2 years suggesting that this protocol is effective

The external fixator is an invaluable device when treating acute complex trauma and in limb reconstruction. It is therefore important to ensure its efficient and safe application to avoid complications. A lot of research has been done to evaluate the factors around external fixator stability, pin site infections and more is still being done to understand pin loosening. The purpose of this study was to evaluate other factors that may contribute in external fixator pin loosening. The aim was to evaluate if the different Schanz pin insertion techniques contribute to pin loosening. Two tibia diaphyses from two cadavers were each divided into three sections. Three different drilling techniques were repeated in each of the sections. A total of 36 Schanz pins were inserted and a section cut out of the bone in front of the pins was done allowing visual inspection of the pin hole for features of thread stripping. These features were predefined as thread pattern disruption, smoothening and shallow imprint on the cortex. Evidence of pin thread stripping was seen in all of the pin insertion techniques. The first method where the hole was pre-drilled and pin inserted with the drill showed 100% thread stripping. The second method of pre-drilling and hand insertion showed the least amount with 16.7% of pin stripping noted and 66.7% pin thread stripping was observed when inserting the pin with power without pre-drilling the pilot hole using the third method. Different pin insertion techniques result in varying amounts of pin thread stripping. The most amount of thread stripping occurs when a Schanz pin is inserted with power after pre-drilling. This finding, although not measured scientifically, supports the current recommendation of pre-drilling and manual insertion of the pin. In future, more scientific measurement are necessary to quantify these findings and assess their clinical significance