Advertisement for orthosearch.org.uk
Results 1 - 20 of 36
Results per page:
Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_6 | Pages 30 - 30
1 May 2021
Shah I Brennan C Nayagam S
Full Access

Introduction

To determine the advantages and risks of plating after lengthening (PAL) of tibia in children and adolescents

Materials and Methods

35 consecutive tibial lengthenings were done for limb length discrepancy (LLD) in 26 patients. Gradual lengthening by an external fixator from a tibial (usually diaphyseal) osteotomy was followed by internal fixation with a lateral tibial submuscular plate. The mean age at the time of the lengthening was 10.3 years (4.8 – 16.8 years). The aetiology for LLD was congenital in 21, acquired in 3, and developmental in 2 patients. The mean follow-up was 4.3 years (8 months – 9.9 years).


Orthopaedic Proceedings
Vol. 103-B, Issue SUPP_6 | Pages 12 - 12
1 May 2021
Elsheikh A Elsayed A Kandel W Nayagam S
Full Access

Introduction

Femoral shaft fractures in children is a serious injury that needs hospitalization, with a high prevalence in the age group 6–8 years old. Various treatment options are available and with a comparable weight of evidence. Submuscular plating provides a dependable solution, especially in length-unstable fractures and heavier kids. We present a novel technique to facilitate and control the reduction intraoperatively, which would allow for easier submuscular plate application.

Materials and Methods

We have retrospectively reviewed four boys and three girls; all were operated in one centre. Polyaxial clamps and rods were applied to the sagittally-oriented bone screws, the reduction was done manually, and the clamps were tightened after achieving the proper alignment in the anteroposterior and lateral fluoroscopy views. The submuscular plate was applied as described, then clamps and bone screws were removed.


Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_8 | Pages 21 - 21
1 May 2018
Peterson N Dodd S Thorpe P Giotakis N Nayagam S Narayan B
Full Access

Background

The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications.

Aim

To compare outcomes for AO/OTA 42C2 and 42C3 fractures treated using IMN with those treated using EF in a University Teaching Hospital.


Orthopaedic Proceedings
Vol. 99-B, Issue SUPP_13 | Pages 12 - 12
1 Jun 2017
Patel D Howard N Nayagam S
Full Access

Background

Temporary hemiepiphysiodesis using 8 plate guided growth has gained widespread acceptance for the treatment of paediatric angular deformities. This study aims to look at outcomes of coronal lower limb deformities corrected using temporary hemiepiphysiodesis over an extended period of follow up.

Methods

A retrospective analysis was undertaken of 56 children (92 legs) with coronal plane deformities around the knee which were treated with an extraperiosteal 2 holed titanium plate and screws between 2007 and 2015. Pre and post-op long leg radiographs and clinic letters were reviewed.


The Bone & Joint Journal
Vol. 99-B, Issue 4 | Pages 494 - 502
1 Apr 2017
Simpson AHRW Keenan G Nayagam S Atkins RM Marsh D Clement ND

Aims

The aim of this double-blind prospective randomised controlled trial was to assess whether low intensity pulsed ultrasound (LIPUS) accelerated or enhanced the rate of bone healing in adult patients undergoing distraction osteogenesis.

Patients and Methods

A total of 62 adult patients undergoing limb lengthening or bone transport by distraction osteogenesis were randomised to treatment with either an active (n = 32) or a placebo (n = 30) ultrasound device. A standardised corticotomy was performed in the proximal tibial metaphysis and a circular Ilizarov frame was used in all patients. The rate of distraction was also standardised. The primary outcome measure was the time to removal of the frame after adjusting for the length of distraction in days/cm for both the per protocol (PP) and the intention-to-treat (ITT) groups. The assessor was blinded to the form of treatment. A secondary outcome was to identify covariates affecting the time to removal of the frame.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_5 | Pages 18 - 18
1 May 2015
Chan Y Selvaratnam V James L Nayagam S
Full Access

Background:

The outcomes of open tibial fractures in a paediatric population are reported.

Methods:

A retrospective analysis of consecutive cases, classified by the Gustilo-Anderson system, over the last 8 years was undertaken. The outcomes recorded were time to union, non-union, infection rates and re-operation rates.


Orthopaedic Proceedings
Vol. 97-B, Issue SUPP_5 | Pages 11 - 11
1 May 2015
Simpson A Clement N Keenan G Nayagam S Atkins R Marsh D
Full Access

Objective:

To assess efficacy of pulsed ultrasound for accelerating regenerate consolidation.

Design:

A multicentre two arm patient and assessor double blind RCT


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_10 | Pages 16 - 16
1 Jul 2014
Tang L Harrison W Holt N Narayan B Nayagam S Giotakis N
Full Access

Calcium sulphate (CaSO4) is a recognised form of delivery of antibiotic for the treatment of bone infection. Complications inherent in the rapid reabsorption are well recognised (predominantly that of wound breakdown and leakage). There is little data on the frequency of these complications. The purpose of this study was to quantify the incidence of wound leakage from CaSO4 and the service impact in orthopaedic surgery.

Infective limb reconstruction cases managed with gentamicin impregnated CaSO4 between 2004–2012 were identified. Co-morbidities and factors influencing wound leakage were recorded. Medical and wound care notes were analysed. Episodes of delayed discharge and unscheduled clinic attendance due to wound leakage were recorded.

80 patients (18 female, 62 male), with a mean age of 45 years (18–80 years, median 46 years) underwent 84 procedures utilising CaSO4. 47 were in the tibia, 14 in the femur, 10 in the humerus. A mean of 36 mL (4–150 mL, median 22 ml, unknown in 18 cases) was used.

31 cases (37%) had post-operative wound leakage, the majority from the tibia(55%) and femur(25%). 21 cases (25%) leaked within the first week. Each 10 ml rise in CaSO4 volume lead to a 50% rise in leakage incidence. Leak duration ranged from 4 days–10 months. The majority leaked between 1–4 months before ceasing spontaneously and without specific treatment.

14 cases (17%) required a cumulative 32 unscheduled clinic appointments for leakage. Further surgery was required for infection in 7 cases (8.3%). Delayed discharge was not clearly attributable to CaSO4. The mode of skin closure and cultured organism did not affect leakage.

CaSO4 has unpredictable leakage, but is present in 1/3 of patients. Volume of CaSO4 impacts on leakage. Leakage usually self-resolves and does not clearly impact on final outcomes. The cost impact of ongoing wound care and additional clinic appointments may be substantial.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_10 | Pages 29 - 29
1 Jul 2014
Pinto R Harrison W Huson S Graham K Nayagam S
Full Access

The purpose of this study is to report a unique overgrowth syndrome and discuss the insights into the complex orthopaedic management.

Written consent to report this case was granted. The patient's condition, wrongly diagnosed as Proteus syndrome, is characterised by a genetic mutation in PIK3CA, a critical regulator of cell growth. This lead to unregulated cellular division of fibroblasts isolated to the lower limbs. The legs weighed 117 kg, with a circumference of >110 cm. In addition to lower limb overgrowth, numerous musculoskeletal and organ pathologies have been encountered since birth requiring treatment from a wide variety of healthcare specialists and basic scientists. At 32 years, the patient developed septicaemia secondary to an infected foot ulcer. Amputation had been discussed in the elective setting, however the presence of sepsis expedited surgery. The above knee amputation took 9 hours and four assistants including a plastic surgeon. A difficult dissection revealed a deep subcutaneous fatty layer that integrated with deep muscle, massive hypertrophy of cutaneous nerves and the sciatic nerve and ossification within the distal quarter of the quadriceps muscles requiring osteotomy. The lower limb osteology was grossly aberrant. The size of the amputated limb did not permit use of a tourniquet and cell salvage reintroduced 10.5 litres of blood with a further 6 units of red cells intra-operatively. The leg stump successfully took to a split-skin graft. A unique phenomenon was witnessed post-operatively whereby the stump continued to grow due to upregulation of fibroblasts secondary to trauma. Targeted genetic therapies have been successfully developed to suppress this stump growth.

This unique and unclassified overgrowth syndrome was caused by a mutation in the PIK3CA gene. Orthopaedic management of the oversized limb was complex requiring multiple surgeons and prolonged general anesthetic. A multi-disciplinary approach to this condition is required for optimizing outcomes in these patients.


Orthopaedic Proceedings
Vol. 96-B, Issue SUPP_10 | Pages 13 - 13
1 Jul 2014
Grewal I Borbora A Giotakis N Nayagam S Vinjamuri S Narayan B
Full Access

The purpose of this study was to investigate the usefulness of PET-CT in the diagnosis and treatment of long bone infections following trauma.

All patients referred to the limb reconstruction service for management of non-unions were treated by the same protocol. PET-CT with FDG was performed in all patients to assess if the non-union site was infected and if so, the extent of the infection. Those requiring operative management were treated in a 2-stage manner. Initially with debridement based on PET-CT; sampling for microbiology and histology; and then Teicoplanin and Ciprofloxacin. If samples were positive then the patients were treated for a total of 6 weeks with antibiotics based on microbiology advice before undergoing definitive fixation. The sensitivity, specificity, PPV, and NPV were then calculated for PET-CTs ability to predict presence of infection using extended cultures and histology as the gold standard.

38 consecutive patients underwent surgery, 24 male and 14 female. 24 were deemed infected on extended culture or histology. PET-CT was anecdotally found to be extremely useful at determining the extent of infection to plan debridement.

PPV 0.83

NPV 0.89

Sensitivity 0.96

Specificity 0.61

As well as providing unique ability to demarcate areas of bony infection in the presence of metalwork, the ability to detect or exclude infection was exceptional.

This is a test, however, which is operator dependent and requires a skilled Nuclear Radiology Consultant to accurately interpret images. In our relatively small pilot study the accuracy improved noticeably over one year.

PET-CT has potential to be a powerful tool in the diagnosis and treatment of long bone infection following trauma and certainly warrants further investigation.


The Bone & Joint Journal
Vol. 96-B, Issue 1 | Pages 137 - 142
1 Jan 2014
Nayagam S Davis B Thevendran G Roche AJ

We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures.

A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate.

Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy.

Cite this article: Bone Joint J 2014;96-B:137–42.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_23 | Pages 17 - 17
1 May 2013
Peterson ND Mahmood A Nayagam S
Full Access

Statement of purpose

To determine whether the amount of fibula resection in fibula osteotomy influences outcome in deformity correction surgery.

Methods

Retrospective case note and imaging review was performed on a cohort of 45 patients from November 2005 to July 2009 treated with lengthening and/or correction for leg deformity in either an adult or paediatric limb reconstruction centre. Method, extent and level of original fibular resection was recorded, as well as type of fixator, distraction regime and total gap at osteotomy site after distraction. Outcome was measured as premature, expected or non-union and subsequent need for reintervention.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_7 | Pages 13 - 13
1 Feb 2013
Foster P Maitra I Grewal I Nayagam S
Full Access

Purposes of the study

To assess safety, lengths gained, frame time and perform cost analysis of the technique of submuscular plating to the femur and tibia following distraction osteogenesis.

Introduction

Since 2005 we have performed submuscular plating to the femur and tibia after distraction osteogenesis in order to shorten time in external fixator.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 144 - 144
1 Jan 2013
Elamin S Ballal M Bruce C Nayagam S
Full Access

Background

Tension band epiphysiodesis for lower limb length discrepancy in children Planned physeal growth arrest (epiphysiodesis) for the treatment of limb length discrepancy (LLD) in growing children is a well described treatment modality in the literature. We describe our experience of temporary epiphysiodesis using a tension band technique with the “8-plate” in the treatment of LLD in growing children.

Aim

The main objective of this study was to confirm whether bilateral 8-plates achieve an epiphysiodesis or not?


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 228 - 228
1 Jan 2013
Foster P Maitra I Gorva A Nayagam S
Full Access

Aims

Since 2005 we have performed submuscular plating to the femur and tibia after distraction osteogenesis in selected cases in order to shorten the time in external fixator. The aim was to assess safety, lengths gained, frame time and perform cost analysis

Methods

Retrospective analysis using notes and digital radiographs, with cost codes for 2011 prices. 23 patients (14 male), mean age 11 (range 4 to 17) were analysed. 14 were diagnosed as congenital longitudinal deficiency. Total 37 bones lengthened (14 femur and tibia, 7 tibia only, 2 femur only). Ilizarov fixator most commonly used for tibia, LRS fixator for femur.


Orthopaedic Proceedings
Vol. 95-B, Issue SUPP_1 | Pages 229 - 229
1 Jan 2013
Prasad S Kumar G Nayayan B Nayagam S
Full Access

Aim

The purpose of the study was to assess the outcomes of the surgical management of humeral shaft non-unions.

Method

Between 2002 and 2010, 23 patients with humeral shaft non-unions underwent revision surgery. Nine were initially treated non-operatively, 11 with a plate, 1 with screws and 2 with an intramedullary nail.

In previously operated patients with aseptic non-unions single stage revision was performed, while septic non-unions underwent a two stage revision. Revision stabilisation was by single or double plate fixation +/− external fixator, depending on bone loss and bone quality. Augmentation of fixation was with iliac crest bone graft in all cases.

Data collected from the case notes and radiographs included: smoking habits, type and site of non-union, bone loss, infected or not, organism isolated, definitive stabilisation, augmentation used, post operative complications, further surgical interventions and time to radiological union.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 50 - 50
1 Sep 2012
Roche A Selvaratnam V Mukhopadhaya S Unnikrishnan N Abiddin Z Narayan B Giotakis N Aniq H Nayagam S
Full Access

Introduction

The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis.

Methods

A retrospective review of cases treated consecutively from 2006 to 2010 was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36).


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIV | Pages 17 - 17
1 Jul 2012
Roche A Selvaratnam V Mukhopadhaya S Unnikrishnan N Abiddin Z Narayan B Giotakis N Aniq H Nayagam S
Full Access

The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis.

A retrospective review of cases treated consecutively from 2006 to 2010 in the Royal Liverpool University Hospital was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36).

There were 31 patients (22 male, 9 female). The mean age was 47 years (20-67). Twenty-five cases were post-surgery (6 open fractures) and 6 were haematogenous in origin. The median duration of osteomyelitis was 1.6yrs. The bones affected were 42% femur, 45% tibia, 3% radius and 10% humerus. 11 cases had diffuse as well as intramedullary involvement. 9 cases underwent segment resection and bone transport. We identified Staphylococcus Aureus in 16 and Coagulase Negative Staphylococcus in 6 cases. The median follow-up was 1.7 years (0.5-5.6). The median scores attained were: AOFAS-78, DASH-32, IOWA-71, Oxford-32. There were two recurrences.

Dead space management of intramedullary infections is difficult. We describe a method for delivery of local antibiotics and provide early evidence to its efficacy. The treatment success to date is 93%.

Bioabsorbable carriers of antibiotics are efficacious adjuncts to surgical treatment of intramedullary osteomyelitis.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXIV | Pages 6 - 6
1 May 2012
Wright D Sampath J Nayagam S Bass A
Full Access

The aim of this retrospective study was to review the outcome of patients treated with Fassier-Duval (FD) rods and highlight some of the complications found during treatment.

Between April 2006 and August 2010 we inserted 24 FD rods in 13 patients. 17 rods for osteogenesis imperfecta (OI), 2 for fractures and deformity associated with cerebral palsy, 1 for fracture associated with muscular dystrophy, 1 for fibrous dysplasia and 3 for centralisation of single bone forearms.

In the upper limb one patient required revision for proximal migration of the male component and another patient is waiting for revision for the same problem.

In the lower limb, a tibial nail was revised because of proximal migration of the male component. A femoral nail was adjusted because of loss of the proximal fixation. One of the OI patients fell, fractured the femur and bent a femoral nail. This awaits revision at a later date. A second OI patient fell on 2 separate occasions bending both a tibial and a femoral nail respectively. These were both revised to trigen intramedullary nails.

In all the other cases there were no complications.

In summary the Fassier Duval system provides a versatile way of providing intramedullary stabilisation for growing bones through a single entry point. However in our experience we have a 33% complication rate most notably bending of the rods. We advocate careful patient selection and using as high a diameter nail as is feasible.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_III | Pages 78 - 78
1 Feb 2012
Verma G Gilbody J Nayagam S
Full Access

The threshold for decompression in acute compartment syndrome is quoted as a pressure difference between the compartment and diastolic blood pressure of less than 30mmHg. This study reports the findings of continuous compartment pressure monitoring in children who underwent tibial osteotomies.

In this prospective observational study, twenty seven children who underwent tibial osteotomies had anterior compartment pressures monitored using a transducer-tipped probe for a minimum of 72 hours following surgery. Pressure data were collected hourly together with evidence of clinical signs, symptoms and patterns of analgesic use. Patients were also reviewed for late sequelae of compartment syndrome.

One case of compartment syndrome were encountered. Pressure differences (diastolic BP - compartment pressure) were found to vary widely, with many children exceeding the threshold for decompression but without manifesting other signs of compartment syndrome. Fasciotomies were not performed in view of the conflicting evidence and subsequent review confirmed the absence of late sequelae. In these children, low diastolic blood pressures were a common but normal feature. The prevalence of compartment syndrome was 3.7% (1/27). The positive predictive value of using the adult threshold was 7.1%; the negative predictive value was 100%.

We conclude that the threshold for decompression as applied to adults is unsuitable for use in children inasmuch as a positive result would lead to a correct diagnosis in only 7.1% of children. A negative test is more useful in correctly excluding compartment syndrome in 100% of the children studied.