It is important to be able to identify patients with an increased risk of venous thromboembolism (VTE) in order to minimise the risk of an event. We investigated the incidence and risk factors for post-operative VTE in 168 consecutive patients with a malignancy of the lower limb. The period of study included ten months before and 12 months after the introduction of chemical thromboprophylaxis. All data about the potential risk factors were identified and classified into three groups (patient-, surgery- and tumour-related). The outcome measure was a thromboembolic event within 90 days of surgery. Of the 168 patients, eight (4.8%) had a confirmed symptomatic deep-vein thrombosis and one (0.6%) a fatal pulmonary embolism. Of the 28 variables tested, age > 60 years, higher American Society of Anesthesiologists grade and metastatic tumour were independent risk factors for VTE. The overall rate of symptomatic VTE was not significantly different between patients who received chemical thromboprophylaxis and those who did not. Knowledge of these risk factors may be of value in improving the surgical outcome of patients with a malignancy of the lower limb. Cite this article: Bone Joint J 2013;95-B:558–62

Aims. The aim of this study is to develop a core set of outcome domains that should be considered and reported in all future trials of childhood limb fractures. Methods. A four-phase study was conducted to agree a set of core outcome domains. Identification of candidate outcome domains were identified through systematic review of trials, and outcome domains relevant to families were identified through semi-structured interviews with 20 families (parent-child pairing or group). Outcome domains were prioritized using an international three-round Delphi survey with 205 panellists and then condensed into a core outcome set through a consensus workshop with 30 stakeholders. Results. The systematic review and interviews identified 85 outcome domains as relevant to professionals or families. The Delphi survey prioritized 30 upper and 29 lower limb outcome domains at first round, an additional 17 upper and 18 lower limb outcomes at second round, and four additional outcomes for upper and lower limb at the third round as important domains. At the consensus workshop, the core outcome domains were agreed as: 1) pain and discomfort; 2) return to physical and recreational activities; 3) emotional and psychosocial wellbeing; 4) complications from the injury and treatment; 5) rturn to baseline activities daily living; 6) participation in learning; 7) appearance and deformity; and 8) time to union. In addition, 9a) recovery of mobility and 9b) recovery of manual dexterity was recommended as a core outcome for lower and upper limb fractures, respectively. Conclusion. This set of core outcome domains is recommended as a minimum set of outcomes to be reported in all trials. It is not an exhaustive set and further work is required to identify what outcome tools should be used to measure each of these outcomes. Adoption of this outcome set will improve the consistency of research for these children that can be combined for more meaningful meta-analyses and policy development. Cite this article: Bone Joint J 2021;103-B(12):1821–1830

Aims. Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. Methods. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy. Results. A total of 3,303 records were screened, of which 99 studies were included. Most studies were case series (77/99; 78%) and assessed one method of reconstruction (68/99; 69%). A total of 511 outcomes were reported, which were grouped into 58 distinct outcomes. Overall, 143/511 of all outcomes (28%) were provided with a clear, in-text definition, and 231 outcomes (45%) had details reported of how and when they were measured. The most commonly reported outcome was ‘recurrence of osteomyelitis’ (62; 12%). The single-most patient-reported outcome measure was ‘pain’. Conclusion. This study has highlighted significant inconsistencies in the defining, reporting, and measuring of outcomes across studies investigating surgical management for chronic osteomyelitis of the lower limb in adults. Future studies should clearly report complete details of how outcomes are defined and measured, including timing. The development of a standardized core outcome set would be of significant benefit in order to allow evidence synthesis and comparison across studies. Cite this article: Bone Jt Open 2023;4(3):146–157

Aims. The aim of this study was to report the outcomes of patients with severe open fractures of the lower limb in the five years after they took part in the Wound management for Open Lower Limb Fracture (WOLLF) trial. Methods. The WOLLF trial compared standard dressings to negative pressure wound therapy (NPWT) applied at the end of the first surgical wound debridement, and patients were followed-up for 12 months. At 12 months, 170 of the original 460 participants agreed to take part in this medium-term follow-up study. Patients reported their Disability Rating Index (DRI) (0 to 100, where 100 is total disability) and health-related quality of life (HRQoL) using the EuroQol five-dimension three-level health questionnaire (EQ-5D-3L) annually by self-reported questionnaire. Further surgical interventions related to the open fracture were also recorded. Results. There was no evidence of a difference in patient-reported disability, HRQoL, or the need for further surgery between patients treated with NPWT versus standard dressings at five years. Considering the combined results for all participants, there was a small but statistically significant change in DRI scores over time (1.6 units per year; p = 0.005), but no evidence that EQ-5D-3L scores changed significantly during years two to five (p = 0.551). Conclusion. This study shows that the high levels of disability and reduced HRQoL reported by patients 12 months after severe open fractures of the lower limb persist in the medium term, with little evidence of improvement between years two and five. Cite this article: Bone Joint J 2022;104-B(5):633–639

Evaluating musculoskeletal conditions of the lower limb and understanding the pathophysiology of complex bone kinematics is challenging. Static images do not take into account the dynamic component of relative bone motion and muscle activation. Fluoroscopy and dynamic MRI have important limitations. Dynamic CT (4D-CT) is an emerging alternative that combines high spatial and temporal resolution, with an increased availability in clinical practice. 4D-CT allows simultaneous visualization of bone morphology and joint kinematics. This unique combination makes it an ideal tool to evaluate functional disorders of the musculoskeletal system. In the lower limb, 4D-CT has been used to diagnose femoroacetabular impingement, patellofemoral, ankle and subtalar joint instability, or reduced range of motion. 4D-CT has also been used to demonstrate the effect of surgery, mainly on patellar instability. 4D-CT will need further research and validation before it can be widely used in clinical practice. We believe, however, it is here to stay, and will become a reference in the diagnosis of lower limb conditions and the evaluation of treatment options. Cite this article: Bone Joint J 2021;103-B(5):822–827

Introduction. Despite the established guidelines on lower extremity free flap reconstruction by the British Orthopaedic Association Standard for Trauma (BOAST-4) the post-operative care has yet to be standardised. There is currently no coherent evidence in the literature regarding clinical monitoring, warming, dangling and compression; the optimal regimes and their respective physiological benefits. The aim of this study is to survey all UK Major Trauma Centres (MTCs) with regards to the post-operative care of lower extremity free flaps and elucidate the current protocols for clinical monitoring, warming, dangling and compression. Materials & Methods. All UK-based adult MTCs were surveyed. We formulated a detailed questionnaire to enquire about the post-operative care of lower extremity free flap reconstructions; the number of free flap reconstructions per month and take backs per month and for which post-operative methods a protocol is used in each MTC. We asked specific questions concerning: clinical monitoring, warming, dangling and compression. This questionnaire was distributed to consultant leads in the form of multiple choice questions, with an option of free-text box for further comments, using JISC online surveys. Results were analysed in Excel and presented in percentages. Results. The 28 adult MTCs were contacted. The results showed a lack of formal regional protocols with great variability, suggesting there is no general consensus on post-operative care of lower extremity free flap reconstructions with regards to clinical monitoring, warming, dangling and compression. Conclusions. This survey of UK MTCs on the post-operative protocols for lower extremity free flap reconstruction demonstrated lack of evidence, consensus and large variability in common practice which requires standardisation

Aims. The aims of this study were to report the outcomes of patients with a complex fracture of the lower limb in the five years after they took part in the Wound Healing in Surgery for Trauma (WHIST) trial. Methods. The WHIST trial compared negative pressure wound therapy (NPWT) dressings with standard dressings applied at the end of the first operation for patients undergoing internal fixation of a complex fracture of the lower limb. Complex fractures included periarticular fractures and open fractures when the wound could be closed primarily at the end of the first debridement. A total of 1,548 patients aged ≥ 16 years completed the initial follow-up, six months after injury. In this study we report the pre-planned analysis of outcome data up to five years. Patients reported their Disability Rating Index (DRI) (0 to 100, in which 100 = total disability), and health-related quality of life, chronic pain scores and neuropathic pain scores annually, using a self-reported questionnaire. Complications, including further surgery related to the fracture, were also recorded. Results. A total of 1,015 of the original patients (66%) provided at least one set of outcome data during the five years of follow-up. There was no evidence of a difference in patient-reported disability between the two groups at five years (NPWT group mean DRI 30.0 (SD 26.5), standard dressing group mean DRI 31.5 (SD 28.8), adjusted difference -0.86 (95% CI -4.14 to 2.40; p = 0.609). There was also no evidence of a difference in the complication rates at this time. Conclusion. We found no evidence of a difference in disability ratings between NPWT compared with standard wound dressings in the five years following the surgical treatment of a complex fracture of the lower limb. Patients in both groups reported high levels of persistent disability and reduced quality of life, with little evidence of improvement during this time. Cite this article: Bone Joint J 2024;106-B(8):858–864

Introduction. Classical fixation using a circular frame involves two rings per segment and in many units this remains the norm whether using ilizarov or hexapod type frames. We present the results of two ring circular frame at King's College Hospital. Materials & Methods. A prospective database has been maintained of all frames applied since 2007. Radiographs from frames applied prior to July 2022 were examined. Clinic letters were then used to identify complications. Included: two ring hexapod for fracture, malunion, nonunion, arthrodesis or deformity correction in the lower limb. Excluded: patients under 16 years old, diabetic feet, Charcot joints, soft tissue contractures, arthrodiastasis, correction of the mid/forefoot, plate fixation augmentation, fixation off a third ring. Results. 518 two ring hexapods were identified. Mean age was 46 (16–89). 55% were for fracture, 18% for malunion, 11% for nonunion. Mean frame time was 7 months (2–29 months). All clinic letters from 384 patients showed 203 patients (52%) had at least one pin site infection, 27 nonunions (7%), 16 frame revisions (4%), 25 bone grafting procedures (7%), 5 cases of septic arthritis (1%), 3 periprosthetic fractures (0.8%),), 12 malunions (3%), 4 Amputations (1%). Conclusions. These results demonstrate the efficacy of a two ring hexapod for patients requiring reconstruction of the lower limb

Primary malignant bone and soft tissue tumours often occur in the lower extremities of active individuals including children, teenagers and young adults. Survivors routinely face long-term physical disability. Participation in sports is particularly important for active young people but the impact of sarcoma treatment is not widely recognised and clinicians may be unable to provide objective advice about returning to sports. We aimed to identify and summarise the current evidence for involvement in sports following treatment of lower limb primary malignant bone and soft tissue tumours. A comprehensive search strategy was used to identify relevant studies combining the main concepts of interest: (1) Bone/Soft Tissue Tumour, (2) Lower Limb, (3) Surgical Interventions and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors. Customised data extraction and quality assessment tools were used. 22 studies were selected, published between 1985 – 2020, and comprising 1005 patients. Fifteen studies with data on return to sports including 705 participants of which 412 (58.4%) returned to some form of sport at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing and amputation; none of these were able to identify a difference in sports participation or ability. Return to sports is important for patients treated for musculoskeletal tumours, however, there is insufficient published research to provide good information and support for patients. Future prospective studies are needed to collect better pre and post-treatment data at multiple time intervals and validated clinical and patient sports participation outcomes such as type of sports participation, level and frequency and a validated sports specific outcome score, such as UCLA assessment. In particular, more comparison between limb sparing and amputation would be welcome

Functional outcomes are important for patients with bone tumors undergoing lower extremity endoprosthetic reconstruction; however, there is limited empirical evidence evaluating function longitudinally. The objective of this study was to determine the changes in function over time in patients undergoing endoprosthetic reconstructions of the proximal femur, distal femur and proximal tibia. We conducted a secondary analysis of functional outcome data from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. Patient function was assessed with the Musculoskeletal Tumor Society Score 93 (MSTS) and the Toronto Extremity Salvage Score (TESS), which were administered preoperatively and at 3, 6 and 12 months postoperatively. Both instruments are scored from 0-100, with higher scores indicated greater function. Mean functional scores were evaluated over time and we explored for differences among patients undergoing proximal femur reconstructions (PFR), distal femur reconstructions (DFR) and proximal tibia reconstructions (PTR). The patient-importance of statistically significant differences in function was evaluated utilizing the minimally important difference (MID) of 12 for the MSTS and 11 for the TESS. We explored for differences in change scores between each time interval with paired t-tests. Differences based on endoprosthetic reconstruction undertaken were evaluated by analysis of variance and post-hoc comparisons using the Tukey test. A total of 573 patients were included. The overall mean MSTS and TESS scores were 77.1(SD±21) and 80.2(SD±20) respectively at 1-year post-surgery, demonstrating approximately a 20-point improvement from baseline for both instruments. When evaluating change scores over time by type of reconstruction, PFR patients experienced significant functional improvement during the 3-6 and 6-12 month follow-up intervals, DFR patients demonstrated significant improvements in function at each follow-up interval, and PTR patients reported a significant decrease in function from baseline to 3 months, and subsequent improvements during the 3-6 and 6-12 month intervals. On average, patients undergoing endoprosthetic reconstruction of the lower extremity experience important improvements in function from baseline within the first year. Patterns of functional recovery varied significantly based on type of reconstruction performed. The results of this study will inform both clinicians and patients about the expected rehabilitation course and functional outcomes following endoprosthetic reconstruction of the lower extremity

Aims. The standard of surgical treatment for lower limb neoplasms had been characterized by highly interventional techniques, leading to severe kinetic impairment of the patients and incidences of phantom pain. Rotationplasty had arisen as a potent limb salvage treatment option for young cancer patients with lower limb bone tumours, but its impact on the gait through comparative studies still remains unclear several years after the introduction of the procedure. The aim of this study is to assess the effect of rotationplasty on gait parameters measured by gait analysis compared to healthy individuals. Methods. The MEDLINE, Scopus, and Cochrane databases were systematically searched without time restriction until 10 January 2022 for eligible studies. Gait parameters measured by gait analysis were the outcomes of interest. Results. Three studies were eligible for analyses. Compared to healthy individuals, rotationplasty significantly decreased gait velocity (-1.45 cm/sec; 95% confidence interval (CI) -1.98 to -0.93; p < 0.001), stride length (-1.20 cm; 95% CI -2.31 to -0.09; p < 0.001), cadence (-0.83 stride/min; 95% (CI -1.29 to -0.36; p < 0.001), and non-significantly increased cycle time (0.54 sec; 95% CI -0.42 to 1.51; p = 0.184). Conclusion. Rotationplasty is a valid option for the management of lower limb bone tumours in young cancer patients. Larger studies, with high patient accrual, refined surgical techniques, and well planned rehabilitation strategies, are required to further improve the reported outcomes of this procedure. Cite this article: Bone Jt Open 2023;4(11):817–824

Introduction. External fixators are attached to bones with percutaneous pins and wires inserted through soft tissues and bone increasing the risk of infections. Such infections compromise patient outcomes e.g., through pin loosening or loss, failure of fixator to stabilise the fracture, additional surgery, increased pain, and delayed mobilisation. These infections also impact the healthcare system for example, increased OPD visits, hospitalisations, treatments, surgeries and costs. Nurses have a responsibility in the care and management of patients with external fixators and ultimately in the prevention of pin-site infection. Yet, evidence on best practices in the prevention of pin-site infection is limited and variation in pin-site management practices is evident. Various strategies are used for the prevention of pin-site infection including the use of different types of non-medicated and medicated wound dressings. The aim of this retrospective study was to investigate the use of dry gauze or iodine tulle dressings for the prevention of pin-site infections in patients with lower limb external fixators. Methodology. A retrospective study of patients with lower limb external fixators who attended the research site between 2015–2022. Setting & Sample: The setting was the outpatient's (OPD) orthopaedic clinic in a University Teaching Hospital in Dublin, Ireland. Eligibility Criteria:. Over the age of 16, treated with an Ilizarov, Taylor Spatial frame (TSF) or Limb Reconstruction System (LRS) external fixators on lower limbs,. Pin-sites dressed with dry gauze or iodine tulle,. Those with pre-existing infected wounds close to the pin site and/or were on long term antibiotics were excluded. Follow Up Period: From time of external fixator application to first pin-site infection or removal of external fixator. Outcome Assessment: The primary outcome was pin-site infection, secondary outcomes included but were not limited to frequency of pin-site infection according to types of bone fixation, frequency of pin/wire removal and hospitalisation due to infection. Data analysis: IBM SPSS Version 25 was used for statistical analysis. Descriptive and inferential statistics were conducted as appropriate. Categorical data were analysed by counting the frequencies (number and percentages) of participants with an event as opposed to counting the number of episodes for each event. Differences between groups were analysed using Chi-square test or Fisher's exact test, where appropriate. Continuous variables were reported using mean and standard deviations and difference analysed using a two-sample independent t-test or non-parametric test (Mann-Whitney), where appropriate. Using Kaplan-Meier, survival analysis explored time to development of infection. Ethical approval: granted by local institute Research Ethics Committee on 12th March 2018. Results. During the study period, 97 lower limb external fixators were applied with 43 patients meeting the study eligibility criteria. The mean age was 38 (SD 14.1; median 37) and the majority male (n=32, 74%). At least 50% (n=25) of participants had an IIizarov fixator, with 56% (n=24) of all fixators applied to the tibia and fibula. Pin/wire sites were dressed using iodine (n=26, 61%) or dry gauze dressings (n=15, 35%). The mean age of participants in the iodine group was significantly higher than the dry gauze group (p=.012). The only significant difference between the iodine and dry gauze dressing groups at baseline was age. A total of 30 (70%) participants developed a pin-site infection with 26% (n=11) classified as grade 2 infection. Clinical presentation included redness (n=18, 42%), discharge (n=16, 37%) and pain (n=15, 35%). Over half of participants were prescribed oral antibiotics (n=28, 65%); one required intravenous antibiotics and hospitalization due to pin-site infection. Ten (23%) participants required removal of pin/wires; two due to pin-site infection. There was no association between baseline data and pin-site infection. The median time to developing an infection was 7 weeks (95%, CI 2.7 to 11.29). Overall, there were 21 (81%, n=26) pin-site infections in the iodine group and nine (60%, n=15) in the dry gauze group, difference in proportion and relative risk between the dressing groups were not statistically significant (RR 1.35, 95% CI 0.86–2.12; p= .272). There was no association between baseline data, pin-site infection, and type of dressing. Conclusions. At the research site, patients are referred to the OPD orthopaedic clinic from internal and external clinical sites e.g., from Hospital Consultants, General Practitioners and occasionally from multidisciplinary teams, throughout Ireland. Our retrospective observation study found that 97 lower limb external fixators were applied over a seven-year period which is lower than that reported in the literature. However, the study period included the COVID pandemic years (2020 and 2021) which saw a lower number of external fixators applied due to lack of theatre availability, cancelled admissions and social/travel restrictions that resulted in fewer accidents and lower limb trauma cases requiring external fixator application. The study highlighted a high infection rate with 70% of participants developing pin-site infection which is in keeping with findings reporting in other studies. Our study showed that neither an iodine nor dry gauze dressing was successful in preventing pin-site infection. In the iodine group 81% of participants developed infection compared to 60% in the dry gauze group. Given the lack of difference between the two groups consideration needs to be given to the continued use of iodine dressings in the prevention of pin-site infection. Pin-site infections result in a high portion of participants being prescribed antibiotics and, in an era, that stresses the importance of antimicrobial stewardship there is a need to implement effective infection prevention and control strategies that minimise infection. Further research is therefore needed to investigate more innovative medicated dressings such as those that contain anti-microbial or anti-bacterial agents

A huge commitment is required from patients and families who undergo a limb reconstruction procedure using the hexapod frame. This includes turning the struts on the frame, pin site care and intensive rehabilitation. Montpetit et al (2009) discovered that function, participation, engagement in regular activities of daily living is severely impacted during the hexapod lengthening period. Due to the long duration and burden for families, it is imperative that healthcare professionals understand the impact that the hexapod frame has on functional abilities and health related quality of life (HRQL). This project involved a retrospective review of prospectively collected data on function and HRQL during two periods of time: (1) when the hexapod frame is applied on the child's lower extremity and (2) when the lengthening phase is completed, and the hexapod frame is removed. Data from 38 children (mean age: 12 years SD 3.8) who completed lower extremity reconstruction using the hexapod frame and completed either or both the Pediatric Quality of Life Inventory 4.0 Generic Core Scale (PedsQL) and Pediatric Outcomes data Collection Instrument (PODCI) was included. Analysis included, standardized response means, the non-parametric Wilcoxon test and effect size calculation. A Wilcoxon signed rank test for those children who completed pre and post frame PODCI’;s revealed those scores were significantly greater once the hexapod frame was removed (Md=85.10, n=10) compared to during (Md=66.50, n=10) with a large effect size, r= 1.45. Similar, the PedsQL scores improved post frame removal (Md= 66.30, n=10) compared to during treatment (Md = 53.34, n=10), with a medium size effect, r= 0.62. All subtests improved once the frame was removed. This study provides essential insights into the burden of the hexapod frame for children and provides valuable information for all allied healthcare professionals targeted interventions for health domains. This study shows that children's function improves once the hexapod frame is removed. However, this study highlights the importance for all healthcare professional to address health domains for the duration of the hexapod procedure where the child scored lower e.g. sports and physical function, pain and comfort, happiness from the PODCI. The PedsQL identified lower mean scores in physical and emotional function

A major cause of morbidity in lower limb amputees is phantom limb pain (PLP) and residual limb pain (RLP). This study aimed to determine if surgical interposition of nerve endings into adjacent muscle bellies at the time of major lower limb amputation can decrease the incidence and severity of PLP and RLP. Data was retrospectively collected from January 2015 to January 2021, including eight patients that underwent nerve interposition (NI) and 36 that received standard treatment. Primary outcomes included the 11-point Numerical Rating Scale (NRS) for pain severity, and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity, behaviour, and interference. Secondary outcome included Neuro-QoL Lower Extremity Function assessing mobility. Cumulative scores were transformed to standardised t scores. Across all primary and secondary outcomes, NI patients had lower PLP and RLP. Mean ‘worst pain’ score was 3.5 out of 10 for PLP in the NI cohort, compared to 4.89 in the control cohort (p=0.298), and 2.6 out of 10 for RLP in the NI cohort, compared to 4.44 in the control cohort (p=0.035). Mean ‘best pain’ and ‘current pain’ scores were also superior in the NI cohort for PLP (p=0.003, p=0.022), and RLP (p=0.018, p=0.134). Mean PROMIS t scores were lower for the NI cohort for RLP (40.1 vs 49.4 for pain intensity; p=0.014, 44.4 vs 48.2 for pain interference; p=0.085, 42.5 vs 49.9 for pain behaviour; p=0.025). Mean PROMIS t scores were also lower for the NI cohort for PLP (42.5 vs 52.7 for pain intensity; p=0.018); 45.0 vs 51.5 for pain interference; p=0.015, 46.3 vs 51.1 for pain behaviour; p=0.569). Mean Neuro-QoL t score was lower in NI cohort (45.4 vs 41.9;p=0.03). Surgical interposition of nerve endings during lower limb amputation is a simple yet effective way of minimising PLP and RLP, improving patients’ subsequent quality of life. Additional comparisons with targeted muscle reinnervation should be performed to determine the optimal treatment option

Introduction. Metabolic bone disease encompasses disorders of bone mineralization, abnormal matrix formation or deposition and alteration in osteoblastic and osteoclastic activity. In the paediatric cohort, patients with metabolic bone disease present with pain, fractures and deformities. The aim was to evaluate the use of lateral entry rigid intramedullary nailing in lower limbs in children and adolescents. Materials and Methods. Retrospective review was performed for an 11-year period. Lower limb rigid intramedullary nailing was performed in 27 patients with a total of 63 segments (57 femora, 6 tibiae). Majority of patients had underlying diagnoses of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright disease). Mean age at surgery was 14 years. Indications for surgery included acute fractures, prophylactic stabilisation, previous nonunion and malunion, deformity correction and lengthening via distraction osteogenesis. Results. All fractures healed. Correction of deformity was successfully achieved in all segments. Delayed union occurred in 4 segments in 1 patient and was successfully treated with nail dynamization. Other complications included prominence, cortical penetrance and loosening of locking screws. One patient who had lengthening performed had nonunion and was managed with exchange nailing and adjunctive measures. Conclusions. Rigid intramedullary nailing is very effective in stabilisation and deformity correction of long bones in adolescent patients with pathological bone disease. The technique has low complication rates. We recommend the use of this technique in paediatric units with experience in managing metabolic bone conditions

Introduction. We undertook a qualitative study to explore what is important to people with lower limb conditions requiring reconstruction (LLR) and how it impacted their quality of life (QOL), in order to develop a conceptual framework for a new patient reported outcome measure (PROM). This builds on a previous qualitative evidence synthesis of existing research to develop a preliminary conceptual framework as part of the Patient Reported Outcomes for Lower Limb Reconstruction (PROLLIT) study. Materials and Methods. Patients (n=32) and Orthopaedic staff (n=23) were interviewed (November 2020-June 2021) from three centres in England using one-to-one, semi-structured interviews. Patient interviews focused on experiences during and after LLR, including impact on QOL. Staff interviews explored important outcomes and goals for patients and how the LLR impacted QOL. Recordings were transcribed verbatim and analysed using thematic analysis. Results. The conceptual framework consists of 6 overarching factors important to patients: Pain, Identity, Work, Daily lifestyle, Emotional well-being and Support. These factors are not independent of each other, rather they're all interrelated (e.g. pain impacts identity, work, emotional well-being and daily lifestyle. Work impacts identity, pain, emotional well-being and daily lifestyle). Support from the hospital, physiotherapists and family underpins the other factors and acts as a moderator of their influence. Conclusions. This conceptual framework displays key factors important to patients after a LLR. Further research is required to map these factors onto existing PROMs to establish whether the factors we identified are captured by existing PROMs

Introduction. Patient reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction on patient's quality of life (QOL). Existing measures have not been developed to specifically capture patient experiences amongst adults with lower limb conditions that require reconstruction surgery. This systematic review of qualitative studies (qualitative evidence synthesis) aimed to identify what is important to these patients. Materials and Methods. MEDLINE, Embase, PsychINFO and Cinahl were searched from inception until November 2020. Studies were included if they employed qualitative research methods, involved patients requiring, undergoing or following lower limb reconstruction and explored patients' experiences of care, treatment, recovery and QOL. Mixed methods/population studies that did not separate the findings from each group and studies not in English were excluded. Included studies were analysed using thematic synthesis. The review followed the methodological framework published by the Cochrane Qualitative and Implementation Methods Group for qualitative evidence syntheses. Results. Nine studies met the inclusion criteria. Thematic synthesis identified two overarching themes:(1) areas of living key to QOL for lower limb reconstruction patients, with sub-themes: pain, daily functioning and lifestyle, identity, income and emotional wellbeing and (2) moving towards a new normal, with sub-themes: support, the ability to adapt and adjust and the ability to move forwards. The impact of lower limb reconstruction on QOL and recovery is complex and is influenced by a range of inter-related factors, which will affect patients to varying degrees depending on individual circumstances. Conclusions. The impact of lower limb reconstruction on patients' QOL is complex, may change over time and is strongly linked to their recovery. This review was conducted as part of the wider ‘PROLLIT' study, which will develop a conceptual framework to identify what outcomes are important to patients and should be included in a PROM. We will then map our conceptual framework onto existing PROMS to establish whether our identified factors are captured by current PROMS. Depending on the outcome of this work, a new PROM for patients following lower limb reconstruction may be developed

Introduction. LIMB-Q Kids is a new patient-reported outcome measure (PROM) for children with Lower limb differences (LLDs). The objective is to conduct an international field test study. Materials & Methods. A mixed method multiphase approach was used to develop LIMB-Q Kids. In phase one, a systematic review was conducted to identify concepts from existing PROMs used in research with children with LLDs. A preliminary conceptual framework derived from the systematic review informed an international qualitative study. The data from qualitative interviews were used to form the LIMB-Q Kids, which was further refined through multiple rounds of cognitive debriefing interviews with children. Input was obtained from parents and healthcare professionals from Australia, Canada, Ethiopia, India, UK, and the USA. LIMB-Q Kids was translated and culturally adapted into multiple languages. Results. The final field-test version consists of 11 scales (159 items) that measure appearance, physical function, symptoms (hip, knee, ankle, foot, and leg), leg-related distress, and school, social and psychological function. This version was rigorously translated into Danish and German. Translations that are in progress include Arabic, Finnish, Hindi, Swahili, Portuguese, Spanish, and Luganda. An international field-test study is underway in nine countries (15 sites with a target recruitment of 150 participants per country). At the time of abstract submission, 190 patients from seven sites have completed LIMB-Q Kids. The UK collaborative has worked on language adaption for the UK and is currently validating the score across five paediatric limb reconstruction units. Conclusions. No internationally applicable PROM exists for children with LLDs. We present the current progress in developing and validating such a score. Data from the international field-test study will be used to reduce items and perform psychometric testing of LIMB-Q Kids. The rigorous translation and cultural adaption process will provide versions of LIMB-Q Kids in different languages. Once completed, the LIMB-Q Kids will provide a common metric for outcome assessment for children with lower limb differences internationally

Introduction. There are concerns that patient-reported outcome measures (PROMs) currently used for adults requiring, undergoing or after undergoing lower limb reconstruction (LLR) are not adequately capturing the range of experiences important to these patients. The ‘Patient-Reported Outcome Measure for Lower Limb Reconstruction’ (PROLLIT) study developed a conceptual framework of outcomes identified as important and relevant by adult LLR patients. This review explored whether existing PROMs address these outcomes, and exhibit content validity in this population. Materials & Methods. A range of key PROMs was selected (n=32). Systematic and hand-searches were employed to find studies assessing content validity of these PROMs in the adult LLR population, along with PROM content and development information. A systematic review of content validity of the measures was carried out following ‘COnsensus-based Standards for the selection of health Measurement Instruments’ (COSMIN) guidance, alongside conceptual mapping of the content of the PROMs against the PROLLIT conceptual framework. Results. The searches uncovered very few content validity studies assessing the PROMs when applied in adult LLR patients. The COSMIN review found that these measures lacked content validity when applied in this population. The conceptual mapping found that PROMs did not capture all concepts identified as important and relevant in the PROLLIT framework. Conclusions. Existing PROMs applied in the adult LLR population lack content validity and fail to adequately capture relevant outcomes for this patient group. There is a need for a new, dedicated PROM designed for adult LLR patients

Biomedical imaging is essential in the diagnosis of musculoskeletal pathologies and postoperative evaluations. In this context, Cone-Beam technology-based Computed Tomography (CBCT) can make important contributions in orthopaedics. CBCT relies on divergent cone X-rays on the whole field of view and a rotating source-detector element to generate three-dimensional (3D) volumes. For the lower limb, they can allow acquisitions under real loading conditions, taking the name Weight-Bearing CBCT (WB-CBCT). Assessments at the foot, ankle, knee, and at the upper limb, can benefit from it in situations where loading is critical to understanding the interactions between anatomical structures. The present study reports 4 recent applications using WB-CBCT in an orthopaedic centre. Patient scans by WB-CBCT were collected for examinations of the lower limb in monopodal standing position. An initial volumetric reconstruction is obtained, and the DICOM file is segmented to obtain 3D bone models. A reference frame is then established on each bone model by virtual landmark palpation or principal component analysis. Based on the variance of the model point cloud, this analysis automatically calculates longitudinal, vertical and mid-lateral axes. Using the defined references, absolute or relative orientations of the bones can be calculated in 3D. In 19 diabetic patients, 3D reconstructed bone models of the foot under load were combined with plantar pressure measurement. Significant correlations were found between bone orientations, heights above the ground, and pressure values, revealing anatomic areas potentially prone to ulceration. In 4 patients enrolled for total ankle arthroplasty, preoperative 3D reconstructions were used for prosthetic design customization, allowing prosthesis-bone mismatch to be minimized. 20 knees with femoral ligament reconstruction were acquired with WB-CBCT and standard CT (in unloading). Bone reconstructions were used to assess congruency angle and patellar tilt and TT-TG. The values obtained show differences between loading and unloading, questioning what has been observed so far. Twenty flat feet were scanned before and after Grice surgery. WB-CBCT allowed characterization of the deformity and bone realignment after surgery, demonstrating the complexity and multi-planarity of the pathology. These applications show how a more complete and realistic 3D geometric characterization of the of lower limb bones is now possible in loading using WB-CBCT. This allows for more accurate diagnoses, surgical planning, and postoperative evaluations, even by automatisms. Other applications are in progress

Functional outcomes are commonly reported in studies of musculoskeletal oncology patients undergoing limb salvage surgery; however, interpretation requires knowledge of the smallest amount of improvement that is important to patients – the minimally important difference (MID). We established the MIDs for the Musculoskeletal Tumor Society Rating Scale (MSTS) and Toronto Extremity Salvage Score (TESS) in patients with bone tumors undergoing lower limb salvage surgery. This study was a secondary analysis of the recently completed PARITY (Prophylactic Antibiotic Regimens in Tumor Surgery) study. This data was used to calculate: (1) the anchor-based MIDs using an overall function scale and a receiver operating curve analysis, and (2) the distribution-based MIDs based on one-half of the standard deviation of the change scores from baseline to 12-month follow-up, for both the MSTS and TESS. There were 591 patients available for analysis. The Pearson correlation coefficients for the association between changes in MSTS and TESS scores and changes in the external anchor scores were 0.71 and 0.57, indicating “high” and “moderate” correlation. Anchor-based MIDs were 12 points and 11 points for the MSTS and TESS, respectively. Distribution-based calculations yielded MIDs of 16-17 points for the MSTS and 14 points for the TESS. The current study proposes MID scores for both the MSTS and TESS outcome measures based on 591 patients with bone tumors undergoing lower extremity endoprosthetic reconstruction. These thresholds will optimize interpretation of the magnitude of treatment effects, which will enable shared decision-making with patients in trading off desirable and undesirable outcomes of alternative management strategies. We recommend anchor-based MIDs as they are grounded in changes in functional status that are meaningful to patients

Osteoarthritis (OA) of the knee joint is a complex peripheral joint disorder with multiple risk factors. We aimed to examine the relationship between the grade of knee OA and anterior thigh length (ATL). A total of 64 geriatric patients who had no total hip or knee replacement with a BMI of ≥30 were evaluated. Patients' OA severity was determined by two independent experts from bilateral standing knee radiographs according to the Kellgren-Lawrence (KL) grade. Joint cartilage structure was assessed using ultrasonography (US). The ATL, the gastrocnemius medialis (GC), the rectus femoris (RF) and the rectus abdominis (RA) skeletal muscle thicknesses as well as the RF cross-sectional area (CSA) were measured with US. Sarcopenia was diagnosed using the handgrip strength (HGS), 5× sit-to-stand test (5xSST) and bioelectrical impedance analysis. The median (IQR) age of participants was 72 (65–88) years. Seventy-one per cent of the patients (n=46) were female. They were divided into the sarcopenic obese (31.3 %) and the non-sarcopenic obese (68.8%) groups. KL grade of all patients correlated negatively with the ATL (mm) and the thickness of GC (mm) (r= -0,517, p<0.001 and r= -0.456, p<0.001, respectively). In the sarcopenic obese and the non-sarcopenic obese groups, KL grade of the all patients was negatively correlated with ATL (mm) and thickness of GC (mm) (r= -0,986, p<0.001; r= -0.456, p=0.05 and r= -0,812, p=0.002; r= −0,427, p=0.006). KL grade negatively correlated with the RF thickness in the sarcopenic obese group (r= -0,928, p=0.008). In conclusion, OA risk may decrease as the lower extremity skeletal muscle mass increases. Acknowledgments: Feza Korkusuz MD is a member of the Turkish Academy of Sciences (TÜBA)

Introduction. Day stay surgery for anterior cruciate ligament (ACL) reconstructions is an increasingly common practice and has driven clinicians to come up with postoperative pain regimes that allow same day mobilisation and a safe and timely discharge. There is a paucity of literature surrounding the use of intraosseous (IO) ropivacaine used as a Bier's block to provide both intraoperative and postoperative analgesia in lower limb surgery. Methods. This patient blinded, pilot study randomised 15 patients undergoing ACL reconstruction to receive either IO ropivacaine 1.5 or 2.0 mg/kg; or 300 mg of ropivacaine as local infiltration (standard of care). Toxic plasma levels of ropivacaine have been defined in the literature and therefore the primary outcome for this study was arterial plasma concentration of ropivacaine as a means to determine its safety profile. Samples were taken via an arterial line at prespecified times after tourniquet deflation. Secondary outcomes that we were interested in included immediate postoperative pain scores using the visual analogue scale (VAS) and perioperative opioid equivalent consumption. Results. Participants had a mean age of 27.8 (SD 9.2) years and 87% (13/15) were male. All patients in the intervention group receiving IO ropivacaine had plasma concentrations well below the threshold for central nervous system (CNS) toxicity (0.60 µg/ml). The highest plasma concentration was achieved in the intervention group receiving 1.5 mg/kg dose of ropivacaine reaching 3.59 mg/ml. This would equate to 0.22 µg/ml of free plasma ropivacaine. There were no differences across the three groups regarding pain scores or perioperative opioid consumption. Conclusions. This study demonstrates that IO administration of 0.2% ropivacaine is both safe and effective in reducing perioperative pain in patients undergoing ACL reconstruction. There may be scope to increase the IO dose further or utilise other analgesics via the IO regional route to improve perioperative pain relief

Aims. Once knee arthritis and deformity have occurred, it is currently not known how to determine a patient’s constitutional (pre-arthritic) limb alignment. The purpose of this study was to describe and validate the arithmetic hip-knee-ankle (aHKA) algorithm as a straightforward method for preoperative planning and intraoperative restoration of the constitutional limb alignment in total knee arthroplasty (TKA). Methods. A comparative cross-sectional, radiological study was undertaken of 500 normal knees and 500 arthritic knees undergoing TKA. By definition, the aHKA algorithm subtracts the lateral distal femoral angle (LDFA) from the medial proximal tibial angle (MPTA). The mechanical HKA (mHKA) of the normal group was compared to the mHKA of the arthritic group to examine the difference, specifically related to deformity in the latter. The mHKA and aHKA were then compared in the normal group to assess for differences related to joint line convergence. Lastly, the aHKA of both the normal and arthritic groups were compared to test the hypothesis that the aHKA can estimate the constitutional alignment of the limb by sharing a similar centrality and distribution with the normal population. Results. There was a significant difference in means and distributions of the mHKA of the normal group compared to the arthritic group (mean -1.33° (SD 2.34°) vs mean -2.88° (SD 7.39°) respectively; p < 0.001). However, there was no significant difference between normal and arthritic groups using the aHKA (mean -0.87° (SD 2.54°) vs mean -0.77° (SD 2.84°) respectively; p = 0.550). There was no significant difference in the MPTA and LDFA between the normal and arthritic groups. Conclusion. The arithmetic HKA effectively estimated the constitutional alignment of the lower limb after the onset of arthritis in this cross-sectional population-based analysis. This finding is of significant importance to surgeons aiming to restore the constitutional alignment of the lower limb during TKA. Cite this article: Bone Jt Open 2021;2(5):351–358

Aims. To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes. Methods. A review of the medical records was conducted of consecutive 35 lower limbs (30 males and five females; median age 46 years (interquartile range (IQR) 40 to 61)) treated with IMT using β-TCP between 2014 and 2018. Lower Extremity Functional Score (LEFS) was examined preoperatively and at final follow-up to clarify patient-centered outcomes. Bone healing was assessed radiologically, and time from the second stage to bone healing was also evaluated. Patients were divided into ≥ 50 mm and < 50 mm defect groups and into femoral reconstruction, tibial reconstruction, and ankle arthrodesis groups. Results. There were ten and 25 defects in the femur and tibia, respectively. Median LEFS improved significantly from 8 (IQR 1.5 to 19.3) preoperatively to 63.5 (IQR 57 to 73.3) at final follow-up (p < 0.001). Bone healing was achieved in all limbs, and median time from the second stage to bone healing was six months (IQR 5 to 10). Median time to bone healing, preoperative LEFS, or postoperative LEFS did not differ significantly between the defect size groups or among the treatment groups. Conclusion. IMT using β-TCP provided satisfactory clinical and radiological outcomes for segmental bone defects in the lower limbs; surgical outcomes were not influenced by bone defect size or operated part. Cite this article: Bone Joint J 2021;103-B(3):456–461

Abstract. Objectives. Exploring the association of objective lower limb function pre and post total knee replacement (TKR). Methods. 3D gait analysis was performed on 28 non-pathological participants (NP) and 40 patients with advanced knee osteoarthritis (OA) before and approximately one year after TKR. For NP and OA patients pre/post-TKR, 12 waveforms on kinetic and kinematic variables of the operative side were chosen to perform data reduction through Principal Component (PC) Analysis. The Cardiff Classifier, a classification system based on Dempster-Shafer theory, was trained with the first 3 PCs of each variable. The 18 highest-ranking PCs classifying the biomechanical features of each participant as Belief in Healthy, Belief in OA (BOA) or Belief in Uncertainty were used to quantify biomechanical changes pre- to post-TKR. The correlation between patients’ BOA values (range: 0 to 1, 0 indicates null BOA and 1 high BOA) pre- and post-TKR was tested through Spearman's correlation coefficient. Wilcoxon matched-pair test (α<0.05) determined the significance of the change in BOA. Results. NP (57% women) had a mean age of 38 (SD=18.13), mean height and weight of 1.70 m (SD=0.09) and 68 Kg (SD=15.24), respectively. Their mean BOA was 0.05 (SD=0.08), in line with inclusion criteria. OA patients (38% women) had a mean age of 68.5 (SD=7.59), mean height and weight of 1.68 m (SD=0.10) and 92.6 Kg (SD=21.22), respectively. Their mean pre-TKR BOA was 0.81 (SD=0.18), falling to 0.64 (SD=0.26) post-TKR. The change in BOA (0.16, SD=0.19) pre- to post-TKR was significant (p=0.000). BOAs pre- and post-TKR were non-normally distributed therefore, a Spearman's rank-order correlation was run, revealing a positive, statistically significant (p=0.000), strong correlation (r. S. =0.657) between BOA pre- and post-TKR. Conclusions. This study found that worse objective pre-operative lower limb function in people with advanced knee OA was strongly correlated with poorer one-year post-TKR function (r. S. =0.657, p<0.01). Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

High energy pelvic injury poses a challenging setting for the treating surgeon. Often multiple injuries are associated, which makes the measurement of short- and long-term functional outcomes a difficult task. The purpose of this study was to determine the incidence of pelvic dysfunction and late impacts of high energy pelvic ring fractures on pelvic floor function in women, with respect to urinary, sexual and musculoskeletal function. This was compared to a similar cohort of women with lower limb fractures without pelvis involvement. The data in our study was prospectively gathered between 2010 and 2013 on 229 adult females who sustained injury between 1998 and 2012. Besides demographic and operative variables, the scores of three validated health assessment tools were tabulated: King's Health Questionnaire (KHQ), Female Sexual Function Index (FSFI) and the Short Musculoskeletal Functional Assessment (SMFA). A multivariate regression analysis was done to compare groups. The incidence of sexual dysfunction was 80.8% in the pelvis and 59.4% in the lower extremity group. A Wilcoxon rank sum test showed a significant difference in KHQ-score (p<0.01) with the pelvis group being worse. When adjusting for age, follow-up and Injury Severity Score this difference was not significant (p=0.28), as was for FSFI and SMFA score. The mean FSFI scores of both groups met the criteria for female sexual dysfunction (<26). Patients with a Tile C fracture have better FSFI scores (16.98) compared to Tile B fractures (10.12; p=0.02). Logistic regression predicting FSFI larger than 26.5 showed that older age and pelvic fractures have a higher likelihood having a form of sexual dysfunction. Sexual dysfunction after lower extremity trauma is found in patients regardless of pelvic ring involvement. Urinary function is more impaired after pelvic injuries, but more data is needed to confirm this. Older age and pelvic fracture are predictors for sexual dysfunction in women. This study is important as it could help counsel patients on the likelihood of sexual dysfunction, something that is probably under-reported and recognized during our patient follow up

Accurate evaluation of lower limb coronal alignment is essential for effective pre-operative planning of knee arthroplasty. Weightbearing hip-knee-ankle (HKA) radiographs are considered the gold standard. Mako SmartRobotics uses CT-based navigation to provide intra-operative data on lower limb coronal alignment during robotic assisted knee arthroplasty. This study aimed to compare the correlation between the two methods in assessing coronal plane alignment. Patients undergoing Mako partial (PKA) or total knee arthroplasty (TKA) were identified from our hospital database. The hospital PACS system was used to measure pre-operative coronal plane alignment on HKA radiographs. This data was correlated to the intraoperative deformity assessment during Mako PKA and TKA surgery. 443 consecutive Mako knee arthroplasties were performed between November 2019 and December 2021. Weightbearing HKA radiographs were done in 56% of cases. Data for intraoperative coronal plane alignment was available for 414 patients. 378 knees were aligned in varus, and 36 in valgus. Mean varus deformity was 7.46° (SD 3.89) on HKA vs 7.13° (SD 3.56) on Mako intraoperative assessment, with a moderate correlation (R= 0.50, p<0.0001). Intraoperative varus deformity of 0-4° correlated to HKA measured varus (within 3°) in 60% of cases, compared to 28% for 5-9°, 17% for 10-14°, and in no cases with >15° deformity. Mean valgus deformity was 6.44° (SD 4.68) on HKA vs 4.75° (SD 3.79) for Mako, with poor correlation (R=0.18, p=0.38). In this series, the correlation between weightbearing HKA radiographs and intraoperative alignment assessment using Mako SmartRobotics appears to be poor, with greater deformities having poorer correlation

Inter-subject variability is inherently present in patient anatomy and is apparent in differences in shape, size and relative alignment of the bony structures. Understanding the variability in patient anatomy is useful for distinguishing between pathologies and to assist in surgical planning. With the aim of supporting the development of stratified orthopaedic interventions, this work introduces an Articulated Statistical Shape Model (ASSM) of the lower limb. The model captures inter-subject variability and allows reconstructing ‘virtual’ knee joints of the lower limb shape while considering pose. A training dataset consisting of 173 lower limbs from CT scans of 110 subjects (77 male, 33 female) was used to construct the ASSM of the lower limb. Each bone of the lower limb was segmented using ScanIP (Simpleware Ltd., UK), reconstructed into 3D surface meshes, and a SSM of each bone was created. A series of sizing and positioning procedures were carried out to ensure all the lower limbs were in full extension, had the same femoral length and that the femora were aligned with a coincident centre. All articulated lower limbs were represented as: (femur scale factor) × (full extension articulated lower limb + relative transformation of tibia, fibula and patella to femur). Articulated lower limbs were in full extension were used to construct a statistical shape model, representing the variance of lower limb morphology. Relative transformations of the tibia, fibula and patella versus the femur were used to form a statistical pose model. Principal component analysis (PCA) was used to extract the modes of changes in the model. The first 30 modes of the shape model covered 90% of the variance in shape and the first 10 modes of the pose model covered 90% of the pose variance. The first mode captures changes of the femoral CCD angle and the varus/valgus alignment of the knee. The second mode represents the changes in the ratio of femur to tibia length. The third mode reflects change of femoral shaft diameter and patella size. The first mode characterising pose captures the medial/lateral translation between femur and tibia. The second mode represents variation in knee flexion. The third mode reflects variation in tibio-femoral joint space. An articulated statistical modelling approach was developed to characterize inter-subject variability in lower limb morphology for a set of training specimens. This model can generate large sets of lower limbs to systematically study the effect of anatomical variability on joint replacement performance. Moreover, if a series of images of the lower limb during a dynamic activity are used as training data, this method can be applied to analyse variance of lower limb motion across a population

Alcohol hand rubs, endorsed by WHO and NICE guidelines, are integral to modern surgical practices. Our objective was to assess how different scrubbing methods impact overall water usage by the surgical team, shedding light on variations among team members and their environmental implications. Over three consecutive arthroplasty lists spanning a week, water usage during scrubbing was observed for the operating team. Blinding all team members, including the anesthetist, consultant surgeon, orthopaedic registrar, orthopaedic SHO, and scrub nurse, during water usage calculations was implemented. Automated taps, using motion sensors, posed a challenge due to variable water quantity, necessitating water flow calculations per sensor movement. The senior surgeon, with over 20 years of experience, follows a traditional approach, starting with a morning prescrub and using an alcohol tub for each case, except when hands are soiled. We observed a total of 14 cases of lower limb primary arthroplasty. The cumulative water usage for scrubbing by the entire team was 193 liters, yielding a mean of 13.8 liters (±1.85) per case. The anaesthetist demonstrated the most conservative water usage, utilizing a total of 11.85 liters with a mean of 0.84 liters per case. Notably, alcohol rub was employed for half of the observed time, contributing to this efficient use. The senior operating surgeon used a total of 15.6 liters, averaging 1.1 liters per case. In contrast, the SHO and the registrar exhibited the highest water consumption, totaling 121.6 liters and yielding a mean of 5.7 liters per case. The nurses’ collective water usage for scrubbing amounted to 44.8 liters. Adopting alcohol rub, as endorsed by WHO, results in a remarkable 10-fold reduction in water usage, aligning with global health guidelines. This highlights significant potential for resource conservation in surgical procedures, presenting a practical and environmentally conscious approach to surgical scrubbing practices

Introduction. Deformity influences the weight bearing stresses on the knee joint. Correction of mechanical alignment is performed to offload the knee and slow the rate of degenerative change. Fixator assisted deformity correction facilitates accurate correction prior to internal fixation. We present our results with standard Ilizarov and UNYCO system assisted deformity correction of the lower limb. Materials and Methods. Retrospective analysis of adult surgical cases of mechanical re-alignment performed between 2010 and 2019 in a tertiary referral centre. We recorded standard demographics and operative time from the electronic patient record. We analysed digitalised radiographs to record pre- and post-operative measurements of: Mechanical axis deviation (MAD), femoral tibial angle (FTA), Medial Proximal tibial angle (MPTA) and Mechanical lateral distal femoral angle (mLDFA). The accuracy of the correction was analysed. Time to healing, secondary interventions and complications were also recorded. Results. 7 patients underwent fixator assisted deformity correction with the UNYCO system and 11 with a standard Ilizarov frame. Mean pre-op MAD was 45.8mm in the UNYCO group and 43.4mm in Ilazrov; Mean post-op MAD was 9.5mm in the UNYCO group (5–15) and 12.3 in the Ilizarov group (1–25) p=0.07. The average surgical time in the UNYCO group was 200 minutes (128–325) and 252 minutes (203–301) in the Ilizarov group p=0.07. The mean post op MPTA was 90.2 (87–96) in the UNYCO group and 87.4 (81–94) in the Ilizarov group. The mean mLDFA was 90.0(81–93.5) in the UNYCO group and 87.3(82.2–93.9) in the Ilizarov group. All the corrections involved a plate or nail fixation and mean time to union was 76.3 days in the UNYCO and 117.3 in the Ilizarov group. Conclusions. Both systems allowed accurate correction of deformity and limb alignment. In this small series we were unable to show a difference in theatre time. The application of the principles of deformity correction are as important as the surgical methods

Introduction. The regionalisation of major trauma in the UK has significantly improved outcomes for patients with severe, lower limb injuries. Chronic pain after complex lower limb injuries is well documented, but seems to remain a problem despite better clinical and radiological outcomes. We hypothesised that pain was mediated through the saphenous nerve, especially as most tibial injuries affected the soft tissues medially. As a proof of concept, we undertook adductor canal blocks to understand pain aetiology. Materials & Methods. Patients with chronic pain following complex lower limb trauma or congenital deformity correction have been selected and underwent an adductor canal block by one of our trauma anaesthetist that specialises in this procedure. Their outcomes were recorded in their clinical records and patients were contacted by phone to document their experiences. Results. 14 patients with chronic, treatment refractory lower limb pain who were being managed in our orthoplastics clinic following complex, lower limb trauma were identified. Six of those patients had required plastic coverage. Of these 14 patients, all stated their pain completely resolved after the procedure and then returned between 24 hours and 4 weeks after the procedure. Two patients underwent a saphenous nerve diversion after conduction of the blocks, reporting subsequent resolution of their complaints. Conclusions. As a proof of concept, we report that the saphenous nerve underlies chronic pain in patients with complex lower limb injuries. An adductor canal block is an effective diagnostic tool for these patients. Saphenous diversion may offer a permanent solution in patients who respond well to saphenous nerve block. A prospective study is planned to objectively measure pain and quality of life scores after treatment of complex injuries and pre and post adductor canal block

Aims. To evaluate mid-to long-term patient-reported outcome measures (PROMs) of endoprosthetic reconstruction after resection of malignant tumours arising around the knee, and to investigate the risk factors for unfavourable PROMs. Methods. The medical records of 75 patients who underwent surgery between 2000 and 2020 were retrospectively reviewed, and 44 patients who were alive and available for follow-up (at a mean of 9.7 years postoperatively) were included in the study. Leg length discrepancy was measured on whole-leg radiographs, and functional assessment was performed with PROMs (Toronto Extremity Salvage Score (TESS) and Comprehensive Outcome Measure for Musculoskeletal Oncology Lower Extremity (COMMON-LE)) with two different aspects. The thresholds for unfavourable PROMs were determined using anchor questions regarding satisfaction, and the risk factors for unfavourable PROMs were investigated. Results. The thresholds for favourable TESS and COMMON were 64.8 and 70.4 points, respectively. Multivariate analysis showed that age at surgery (p = 0.004) and postoperative leg length discrepancy (p = 0.043) were significant risk factors for unfavourable TESS results, while age at surgery (p < 0.001) was a significant risk factor for unfavourable COMMON-LE results. Following receiver operating characteristic analysis, the threshold for both TESS and COMMON-LE was 29 years of age at surgery. Additionally, a leg length discrepancy of 8.2 mm was the threshold for unfavourable TESS. Conclusion. Patients aged > 29 years at the time of surgery require appropriate preoperative counselling and adequate postoperative physical and socioemotional support. Reconstruction equivalent to the length of the resected bone can reduce the risk of functional disabilities in daily living. Cite this article: Bone Jt Open 2023;4(12):906–913

Abstract. Background. Lower limb mechanical axis has long been seen as a key to successful in lower limb surgery, including knee arthroplasty. Traditionally, coronal alignment has been assessed with weight-bearing lower limb radiographs (LLR) allowing assessment of hip-knee-ankle alignment. More recently CT scanograms (CTS) have been advocated as a possible alternative, having the potential benefits of being quicker, cheaper, requiring less specialist equipment and being non-weightbearing. Objectives. To evaluate the accuracy and comparability of lower limb alignment values derived from LLR versus CTS. Methods. We prospectively investigated patients undergoing knee arthroplasty with preoperative and postoperative LLR and CTS, analysing both preoperative and postoperative LLRs & CTS giving 140 imaging tests for direct comparison. We used two independent observers to calculate on each of imaging modalities, on both pre- and post-operative images, the: hip-knee-ankle alignment (HKA), lateral distal femoral angle (LDFA) and medial proximal tibial angle (MPTA). Results. 840 data points were captured from pre- and post-operative LLRs and CTSs. Analysis demonstrated very strong correlation in pre-operative HKA (LLR vs CTS, r = 0.917), post-operative HKAs (LLR vs CTS, 0.850) and postoperative LDFAs (LLR vs CTS, 0.850). Strong correlation was observed in pre-operative LDFAs (0.732), MPTAs (0.604), and post-operative MPTAs (0.690). Conclusion. Both pre- and post-operative LLR and CTS imaging display very strong correlation for HKA coronal alignment correlation, with strong correlation for other associated angles around the knee. Our results demonstrate that both LLR and CTS can be used interchangeably with similar results. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction and Objective. Continuous peripheral nerve blocks (cPNBs) have shown good results in pain management after orthopedic surgeries. However, the variation of performance between different subspecialities is unknown. The aim of this study is to describe our experience with cPNBs after lower limb orthopedic surgeries in different subspecialties. Materials and Methods. This prospective cohort study was performed on collected data from cPNBs after orthopedic surgeries in lower limbs. Catheters were placed by experienced anesthesiologists using sterile technique. After catheterization, the patients were examined daily, by specially educated acute pain service nurses. The characteristics of the patients, duration of catheterization, severity of the post-operative pain, need for additional opioids, and possible complications were registered. Results. We included 246 patients (=547 catheters). 115 (21%) femoral, 162 (30%) saphenous, 66 (12%) sciatic, and 204 (37%) popliteal sciatic nerve catheter were used. The median duration of a catheter was 3 days [IQR = 2 – 5]. The proportion of femoral, sciatic, saphenous, and popliteal nerve catheters with duration of more than two days was 81%, 79%, 73%, and 71% for, respectively. This proportion varied also between different subspecialties. 91% of the catheters remained in place for more than two days in amputations (n=56), 89% in pediatric surgery (n=79), 76% in trauma (n=217), 64% in foot and ankle surgery (n=129), and 59% in limb reconstructive surgery (n=66). The proportion of pain-free patients were 77 – 95% at rest, 63 – 88% at mobilization. 79 – 92% did not need increased opioid doses, and 50 – 67% did not require PRN opioid. 443 catheters (81%) were removed as planned. The cause of unplanned catheter removal was loss of efficacy in 69 (13%), dislodgement in 23 (4.2%), leakage in 8 (1.5%), and erythema in 4 catheters (0.73%). No major complication occurred. Conclusions. 81% of catheters remained in place until planned removal and opioid usage after surgery was lower than expected. Catheters were efficient in both adult and pediatric surgery; however, a variation was seen between orthopaedic subspecialities regarding duration of nerve catheter usage

Introduction. Insufficient pain control following lower extremity surgery can increase length of stay, readmission rates, and impair postoperative outcome. It has been shown that CYP2D6 genotypes predict function of the enzyme responsible for conversion of hydrocodone to hydromorphone (active metabolite) and plasma concentration of hydromorphone best predicted analgesic response. Purpose of this study was to evaluate relationship of CYP2D6 genotypes, drug-drug interactions, and plasma drug concentrations in patients undergoing lower extremity surgery. Methods. A prospective cohort of 271 orthopedic patients undergoing lower extremity surgery including TKA, THA and trauma were queried. Patients treated with hydrocodone were enrolled and tested for plasma concentrations of hydrocodone and hydromorphone. CYP2D6 genotyping was performed. Medications co-administered with hydrocodone during perioperative and postoperative periods were queried. Results. Out of 271 patients enrolled, only 41 (15%) had detectable hydromorphone (i.e. >0.5 ng/mL). 86% were extensive (normal) metabolizers, 7% were intermediate metabolizers, 5% poor metabolizers and 2% were ultra rapid metabolizers. 179 subjects were not administered any inhibitors of CYP2D6 whereas 92 were on at least one inhibitor. 33 (18%) with no pharmacological inhibitors had detectable hydromorphone, whereas only 7 (7.6%) on inhibitors had hydromorphone detected above the lower limit of quantification (0.5ng/mL), p=0.033. Diphenhydramine, fluoxetine, hydralazine, duloxetine, bupropion and sertraline, were the most common CYP2D6 inhibitors co-administered with hydrocodone in this cohort. Conclusions. Patients' home medications and selection of various drugs in the postoperative setting could impact the pharmacokinetics and pharmacodynamics of hydrocodone leading to a diminished analgesic response. We conclude that health care providers should become familiar with the inhibitors of CYP2D6 to obtain the best response with the use of hydrocodone following lower extremity surgery. Additional work is required to determine the ideal opioid for an individual patient's genotype following lower extremity orthopedic surgery. For figures, tables, or references, please contact authors directly

Aims. To our knowledge, there is currently no information available about the rate of venous thromboembolism (VTE) or recommendations regarding chemoprophylaxis for patients whose lower limb is immobilized in a plaster cast. We report a retrospective case series assessing the rate of symptomatic VTE in patients treated with a lower limb cast. Given the complex, heterogeneous nature of this group of patients, with many risk factors for VTE, we hypothesized that the rate of VTE would be higher than in the general population. Patients and Methods. Patients treated with a lower limb cast between 2006 and 2018 were identified using plaster room records. Their electronic records and radiological reports were reviewed for details about their cast, past medical history, and any VTE recorded in our hospital within a year of casting. Results. There were 136 episodes of casting in 100 patients. The mean age was 55 years (22 to 91). The mean time in a cast was 45 days (five days to eight months). A total of 76 patients had neuropathy secondary to diabetes. No patient received chemical thromboprophylaxis while in a cast. One VTE (0.7% of casting episodes) was documented. This was confirmed by Doppler scan nine days after removing the cast. Conclusion. The frequency of VTE was higher than that of the general population (0.05%); this is most likely attributable to our patients’ apparent increase in VTE risk as suggested by The National Institute for Health and Care Excellence (NICE). These findings suggest that thromboprophylaxis is not routinely indicated in patients who undergo immobilization of the lower limb in a cast, although the risks of VTE should be assessed. While the cast itself does not pose an increased risk, other pathologies, such as active cancer, mean that each individual case needs to be considered on their merit. Cite this article: Bone Joint J 2019;101-B:691–694

Aims. The aim of this study was to estimate the cost-effectiveness of negative-pressure wound therapy (NPWT) in comparison with standard wound management after initial surgical wound debridement in adults with severe open fractures of the lower limb. Patients and Methods. An economic evaluation was conducted from the perspective of the United Kingdom NHS and Personal Social Services, based on evidence from the 460 participants in the Wound Management of Open Lower Limb Fractures (WOLLF) trial. Economic outcomes were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Bivariate regression of costs (given in £, 2014 to 2015 prices) and quality-adjusted life-years (QALYs), with multiple imputation of missing data, was conducted to estimate the incremental cost per QALY gained associated with NPWT dressings. Sensitivity and subgroup analyses were undertaken to assess the impacts of uncertainty and heterogeneity, respectively, surrounding aspects of the economic evaluation. Results. The base case analysis produced an incremental cost-effectiveness ratio of £267 910 per QALY gained, reflecting higher costs on average (£678; 95% confidence interval (CI) -£1082 to £2438) and only marginally higher QALYS (0.002; 95% CI -0.054 to 0.059) in the NPWT group. The probability that NPWT is cost-effective in this patient population did not exceed 27% regardless of the value of the cost-effectiveness threshold. This result remained robust to several sensitivity and subgroup analyses. Conclusion. This trial-based economic evaluation suggests that NPWT is unlikely to be a cost-effective strategy for improving outcomes in adult patients with severe open fractures of the lower limb. Cite this article: Bone Joint J 2019;101-B:1392–1401

Introduction. External fixators are common surgical orthopaedic treatments for the management of complex fractures and in particular, the use of circular frame fixation within patients requiring limb reconstruction. It is well known that common complications relating to muscle length and patient function without rehabilitation can occur. Despite this there remains a lack of high-quality clinical trials in this area investigating the role of physiotherapy or rehabilitation in the management of these patients. We aim to complete a systematic review of rehabilitation techniques for patients undergoing external fixator treatment for Limb Reconstruction of the lower limb. Materials & Methods. A comprehensive search of AMED, CINAHL, MEDLINE and COCHRANE databases was conducted to identify relevant articles for inclusion, using a search strategy developed in collaboration with a research librarian. Inclusion criteria consisted of adults aged 18 years and over who have experienced leg trauma (open fracture, soft tissue damage), elective leg deformity corrective surgery, bone infection or fracture non-union who have been treated with the use of an external fixator for fixation. Specific exclusion criteria were patients below the age of 18 years old, patients with cancer, treatment of the injury with internal nail, patients who underwent amputation, the use of external fixators for soft tissue contracture management, editorials, comment papers, review papers, conference proceedings and non-English papers. Titles, abstracts, and full texts were screened for suitability by pairs of reviewers according to the inclusion and exclusion criteria using Rayyan QCRI online software. Any conflicts were resolved through discussion with three independent specialist senior reviewers. Following full text screening, references lists of included articles were manually searched to ensure that all relevant studies were identified. Due to lack of evidence, forward searching was also completed for studies included in the review. Data quality was assessed using the mixed methods appraisal tool and the CERT assessment tool was utilised to look at completeness of reporting of exercise interventions. Results. A total number of 832 articles were initially retrieved from our search once duplicate articles removed. After title and abstract screening, 45 articles remained for full text screening. Of these, 11 articles met our inclusion criteria and included for data extraction. Conclusions. We expect high variability of results due to our inclusion criteria and therefore plan to conduct a narrative synthesis to summarise the findings whilst measing against the mixed methods appraisal tool and CERT assessment scores to assess the data quality. We anticipate lower assessment scores within the fewer articles found and therefore poorer-quality data. We currently are in the process of finalising this data extraction. This will be completed ready for submission and potential presentation at the BLRS conference in March 2023

Aims

Robotic-assisted total knee arthroplasty (RA-TKA) is theoretically more accurate for component positioning than TKA performed with mechanical instruments (M-TKA). Furthermore, the ability to incorporate soft-tissue laxity data into the plan prior to bone resection should reduce variability between the planned polyethylene thickness and the final implanted polyethylene. The purpose of this study was to compare accuracy to plan for component positioning and precision, as demonstrated by deviation from plan for polyethylene insert thickness in measured-resection RA-TKA versus M-TKA.

A retrospective case control study of all rehabilitated patients who suffered amputations of the lower extremity by sepsis was performed in the HELIOS centre of rehabilitation for amputees, Bad Berleburg, Germany. This study examines patients who had undertaken an amputation of the lower extremity caused by severe sepsis and septic shock. Methods: Case control study. The clinical reports of 448 patients with amputations of the lower extremity clinically rehabilitated from 2010 to 2013 were systematically and statistically evaluated. Sepsis is classified in 4 categories: SIRS, sepsis, severe sepsis and septic shock. Epidemiology: The mean age of the amputees was 61.33 years, with 25 men and 11 women. Marital status: 16 patients are married (44.44%), 7 divorced, 5 widowed, 7 unmarried, 1 unknown. 24 patients are retired (66.67%). School-leaving qualifications: 22 elementary school (61.11%), 8 secondary school, 1 high school, 5 unknown. Health insurance: AOK 10 patients (27.77%), BEK 7 patients (19.44%), pension insurance 9 patients (25.0%). The medial time of hospitalization in the clinic for rehabilitation of the amputated patients suffering sepsis was 27.23 days. Results: 36 patients, – 8.03 % of all – with 39 amputations, suffered a loss of the lower extremity caused by severe sepsis and septic shock: 1 patient suffered an exarticulation of both hips, 20 patients suffered a transfemoral amputation (1 patient had a transfemoral amputation of both legs), 17 patients lost their leg by transtibial amputation (1 patient had a transtibial amputation of both legs). 13 patients presented a sepsis by MRSA (multiresistant Staph. aureus 36.11%), 8 patients with MSSA (multisensible Staph. aureus), 4 patients with multiresistant Acinetobacter (8.33%), 2 patients with MRSE (multiresistant Staph. epidermidis), 13 patients with other multiresistant germs (36.11%) such as Streptococcus B, Enterococcus faecalis, Enterobacteriaceae, Klebsiella. Mobility class of amputees at the beginning of hospitalization: class 0 (= non walkers) all 36 patients (100%). Mobility class of amputees at the end of hospitalization: class 0 (= non walkers) are 5 patients (27.78%), class 1 (= only inside walkers) are 5 patients (13.89%), class 2 (= inside and little outside walkers) are 18 patients (50.00%), class 3 (= inside and good outside walkers) are 3 patients (8.33%). Amputation of the lower extremity following severe sepsis and septic shock is not rare – in our group we found more than 8%

Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant

Purpose. While changes in lower limb alignment and pelvic inclination after total hip arthroplasty (THA) using certain surgical approaches have been studied, the effect of preserving the joint capsule is still unclear. We retrospectively investigated changes in lower limb alignment, length and pelvic inclination before and after surgery, and the risk of postoperative dislocation in patients who underwent capsule preserving THA using the anterolateral-supine (ALS) approach. Methods. Between July 2016 and March 2018, 112 hips (non-capsule preservation group: 42 hips, and capsule preservation group: 70 hips) from patients with hip osteoarthritis who underwent THA were included in this study. Patients who underwent spinal fusion and total knee arthroplasty on the same side as that of the THA were excluded. Using computed tomography, we measured lower limb elongation, external rotation of the knee, and femoral neck/stem anteversion before operation and three to five days after operation. We examined the pelvic inclination using vertical/transverse ratio of the pelvic cavity measured by X-ray of the anteroposterior pelvic region in the standing position before and six to 12 months after operation. All operations were performed using the ALS approach and taper wedge stem. Results. No dislocation was found in both groups. Lower limb elongation was 14.5±6.3 (mean±SD) mm in the non-capsule preservation group and 9.4±8.8 mm in the capsule preservation group. A significant reduction was found in the capsule preservation group (p<0.05). Changes in knee external rotation was 7.2±10.5 degrees in the non-capsule preservation group and 3.5±10.3 degrees in the capsule preservation group. A trend toward decreased knee external rotation in the capsule preservation group (p=0.07) was observed. There was no difference in femoral neck/stem anteversion and vertical/transverse ratio of the pelvic cavity between both groups. Discussion. Patients in the capsule preservation group tended to have reduced external rotation of lower limb, which might prevent postoperative anterior dislocation due to preservation of anterior structures. The capsule preservation group had significantly reduced lower limb elongation, suggesting that preservation of the hip joint capsule ligament contributes to joint stability. There was no significant difference in the pelvic inclination between both groups. Long-term changes will be assessed by regular follow up after operation

Background. Authors sought to determine the degree of lateral condylar hypoplasia of distal femur was related to degree of valgus malalignment of lower extremity in patients who underwent TKA. Authors also examined the relationships between degree of valgus malalignment and degree of femoral anteversion or tibial torsion. Methods. This retrospective study included 211 patients (422 lower extremities). Alignment of lower extremity was determined using mechanical tibiofemoral angle (mTFA) measured from standing full-limb AP radiography. mTFA was described positive value when it was valgus. Patients were divided into three groups by mTFA; more than 3 degrees of valgus (valgus group, n = 31), between 3 degrees of valgus to 3 degrees of varus (neutral group, n = 78), and more than 3 degrees of varus (varus group, n = 313). Condylar twisting angle (CTA) was used to measure degree of the lateral femoral condylar hypoplasia. CTA was defined as the angle between clinical transepicondylar axis (TEA) and posterior condylar axis (PCA). Femoral anteversion was measured by two methods. One was the angle formed between the line intersecting femoral neck and the PCA (pFeAV). The other was the angle formed between the line intersecting femoral neck and clinical TEA (tFeAV). Tibial torsion was defined as a degree of torsion of distal tibia relative to proximal tibia. It was determined by the angle formed between the line connecting posterior cortices of proximal tibial condyles and the line connecting the most prominent points of lateral and medial malleolus. Positive values represented relative external rotation. Negative values represented relative internal rotation. Results. Greater lateral femoral condylar hypoplasia was related to increased valgus alignment of lower extremity. Correlation coefficient between mTFA and CTA was 0.253 (p < 0.001). Valgus group showed increased CTA, which was 10.2° ± 1.9°. CTA was 7.4° ± 2.5° in neutral group and 6.6° ± 4.8° in varus group. There was significant positive correlation between the degree of valgus alignment and the degree of femoral anteversion (r = 0.145, p = 0.003). pFeAV was 16.7° ± 5.8° in valgus group, 12.1° ± 6.0° in neutral group and 10.9° ± 7.0° in varus group. There was no correlation between degree of valgus alignment and degree of femoral anteversion (r = 0.060, p = 0.218). In terms of tibial torsion, increased valgus malalignment was associated with increased tibial torsion (r = 0.374, p < 0.001). Valgus group showed increased tibial torsion than other groups. Tibial torsion was 32.6° ± 6.2° in valgus group, 26.3° ± 6.9° in neutral group and 22.6° ± 7.2° in varus group. Conclusions. Increased valgus alignment of lower extremity was related to greater lateral femoral condylar hypoplasia. However, increased valgus alignment was not related to degree of femoral anteversion whereas it was related to increased external tibial torsion. Our findings should be considered when determining proper rotational alignment in TKA

Background. Patients requiring lower limb reconstruction have often undergone significant trauma. In some patients this is a consequence of self-harm, others develop depression as a result of the accidental trauma that caused their injury. Little is known of the extent of the problem and how it changes over the course of their treatment. Design and Methods. Patients undergoing limb reconstruction in a major trauma centre were asked to complete an online questionnaire on the day of surgery. This included a Zung self-rating depression score, LEFS and EQ5D. They were asked to complete these again at subsequent post-operative time points. Results. Provisional results showed that all 3 outcome measures fluctuated over 6 months. Most patients triggered for at least mild depression on the Zung Self Rating Depression score at one or more time points. Not all patients had completed the questionnaire at all time points. Of those who did complete multiple time points, there was variation in the change in LEFS. Conclusion. Patients undergoing lower limb reconstruction are vulnerable to depression. There may be a correlation between mood and lower limb function. Gaining better understanding of these problems and how they change over time could help direct services to improve support for these patients

Aims. To compare the cost-utility of standard dressing with incisional negative-pressure wound therapy (iNPWT) in adults with closed surgical wounds associated with major trauma to the lower limbs. Methods. A within-trial economic evaluation was conducted from the UK NHS and personal social services (PSS) perspective based on data collected from the Wound Healing in Surgery for Trauma (WHiST) multicentre randomized clinical trial. Health resource utilization was collected over a six-month post-randomization period using trial case report forms and participant-completed questionnaires. Cost-utility was reported in terms of incremental cost per quality-adjusted life year (QALY) gained. Sensitivity analysis was conducted to test the robustness of cost-effectiveness estimates while uncertainty was handled using confidence ellipses and cost-effectiveness acceptability curves. Results. The incremental cost of standard dressing versus iNPWT over six months was £2,037 (95% confidence interval (CI) £349 to £3,724). There was an insignificant increment in QALYs gained in the iNPWT group (0.005, 95% CI -0.018 to 0.028). The probability of iNPWT being cost-effective at £20,000 per QALY was 1.9%. The results remained robust in the sensitivity analysis. Conclusion. The within-trial economic evaluation suggests that iNPWT is unlikely to be a cost-effective alternative to standard dressing in adults with closed surgical wounds to their lower limbs. Cite this article: Bone Joint J 2020;102-B(8):1072–1081

Accurate 3D pre-operative planning shows significance of improving the precision of Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA). Since CT acquisition leads to high radiation exposure to patients, it is clinically desirable to find an alternative to CT scan for planning THA or TKA such as patient-specific 2D–3D reconstruction from a limited number of 2D calibrated X-ray images acquired with much lower radiation dose e.g. EOS imaging. Feature-based 2D–3D non-rigid registration based on the construction of statistical shape model (SSM) as a priori has been applied to reconstruct the surface models of proximal femur, and also the surface reconstruction of lower extremity for TKA has been validated in a cadaveric study by Zheng et al. On the other hand, intensity-based 2D–3D non-rigid registration can reconstruct the patient-specific intensity volumes like CTs to allow an insight into lower extremity morphology such as intramedullary anatomy, which can provide more comprehensive information in routine clinical practice. In this study, we will present an atlas- based 2D–3D reconstruction method and introduce its application to reconstruct the intensity volumes of lower extremity. Moreover, we take the articulation in the knee joint into consideration so as to avoid the penetration between femur and tibia which is favourable for the pre-operative planning. The results of the experiments demonstrated the efficacy of the proposed method on reconstructing the lower extremity morphology as well as the intramedullary canal anatomy

Background. Readmission following any total joint arthroplasty has become a closely watched metric for many hospitals in the United States because financial penalties imposed by CMS for excessive readmissions occurring within thirty days of discharge has occurred since 2015. The purpose of this study was to identify both preoperative comorbidities associated with and postoperative reasons for readmission within thirty days following primary total joint arthroplasty in the lower extremity. Methods. Retrospective data was collected for patients who underwent elective primary total hip arthroplasty (CPT code 27130), total knee arthroplasty (27447), and total ankle arthroplasty (27702) from January 1, 2008, to December 31, 2013 at our institution. The sample was separated into readmitted and non-readmitted cohorts. Demographic variables, preoperative comorbidities, Charlson Comorbidities Index (CCI), operative parameters, readmission rates, and causes of readmission were compared between the groups using univariate and multivariate regression analysis. Results. There were 42 (3.4%), 28 (2.2%), and 1 (0.5%) readmissions within 30 days for THA, TKA, and TAA, respectively. The most common cause of readmission within 30 days following total joint arthroplasty in lower extremity was infection. Trauma was the second most common reason for readmission of a THA while wound dehiscence was the second most common cause for readmission following TKA. With univariate regression, there were multiple associated factors for readmission among total hip and total knee arthroplasty patients including BMI, metabolic equivalent (MET), and CCI. Multivariate regression revealed that hospital length of stay was significantly associated with 30-day readmission after THA and TKA. Conclusion. Patient co-morbidities and pre-operative functional capacity significantly affect 30-day readmission rate following total joint arthroplasty. Adjustments for these parameters should be considered when hospital penalties are calculated with regard to 30-day readmission. Level of Evidence. Level III; Retrospective cohort study

Corrective osteotomies are often planned and performed on the basis of normal anatomical proportions. We have evaluated the length and torsion of the segments of the lower limb in normal individuals, to analyse the differences between left and right sides, and to provide tolerance figures for both length and torsion. We used CT on 355 adult patients and measured length and torsion by the Ulm method. We excluded all patients with evidence of trauma, infection, tumour or any congenital disorder. The mean length of 511 femora was 46.3 ± 6.4 cm (±2. sd. ) and of 513 tibiae 36.9 ± 5.6 cm; the mean total length of 378 lower limbs was 83.2 ± 11.4 cm with a tibiofemoral ratio of 1 to 1.26 ± 0.1. The 99th percentile level for length difference in 178 paired femora was 1.2 cm, in 171 paired tibiae 1.0 cm and in 60 paired lower limbs 1.4 cm. In 505 femora the mean internal torsion was 24.1 ± 17.4°, and in 504 tibiae the mean external torsion was 34.9 ± 15.9°. For 352 lower limbs the mean external torsion was 9.8 ± 11.4°. The mean torsion angle of right and left femora in individuals did not differ significantly, but mean tibial torsion showed a significant difference between right (36.46° of external torsion) and left sides (33.07° of external torsion). For the whole legs torsion on the left was 7.5 ± 18.2° and 11.8 ± 18.8°, respectively (p < 0.001). There was a trend to greater internal torsion in femora in association with an increased external torsion in tibiae, but we found no correlation. The 99th percentile value for the difference in 172 paired femora was 13°; in 176 pairs of tibiae it was 14.3° and for 60 paired lower limbs 15.6°. These results will help to plan corrective osteotomies in the lower limbs, and we have re-evaluated the mathematical limits of differences in length and torsion

Aims

The impact of a diaphyseal femoral deformity on knee alignment varies according to its severity and localization. The aims of this study were to determine a method of assessing the impact of diaphyseal femoral deformities on knee alignment for the varus knee, and to evaluate the reliability and the reproducibility of this method in a large cohort of osteoarthritic patients.

Background. Readmission following any total joint arthroplasty has become a closely watched metric for many hospitals in the United States because financial penalties imposed by CMS for excessive readmissions occurring within thirty days of discharge will be forthcoming in 2015. The purpose of this study was to identify both preoperative comorbidities associated with and postoperative reasons for readmission within thirty days following primary total joint arthroplasty in the lower extremity. Methods. Retrospective data was collected for patients who underwent elective primary total hip arthroplasty (CPT code 27130), total knee arthroplasty (27447), and total ankle arthroplasty (27702) from January 1, 2008, to December 31, 2013 at our institution. The sample was separated into readmitted and non-readmitted cohorts. Demographic variables, preoperative comorbidities, Charlson Comorbidities Index (CCI), operative parameters, readmission rates, and causes of readmission were compared between the groups using univariate and multivariate regression analysis. Results. There were 42 (3.4%), 28 (2.2%), and 1 (0.5%) readmissions within 30 days for THA, TKA, and TAA, respectively. The most common cause of readmission within 30 days following total joint arthroplasty in lower extremity was infection. Trauma was the second most common reason for readmission of a THA while wound dehiscence was the second most common cause for readmission following TKA. With univariate regression, there were multiple associated factors for readmission among total hip and total knee arthroplasty patients including BMI, metabolic equivalent (MET), and CCI. Multivariate regression revealed that hospital length of stay was significantly associated with 30-day readmission after THA and TKA. Conclusion. Patient co-morbidities and pre-operative functional capacity significantly affect 30-day readmission rate following total joint arthroplasty. Adjustments for these parameters should be considered when hospital penalties are calculated with regard to 30-day readmission

INTRODUCTION. While computational models have been used for many years to contribute to pre-clinical, design phase iterations of total knee replacement implants, the analysis time required has limited the real-time use as required for other applications, such as in patient-specific surgical alignment in the operating room. In this environment, the impact of variation in ligament balance and implant alignment on estimated joint mechanics must be available instantaneously. As neural networks (NN) have shown the ability to appropriately represent dynamic systems, the objective of this preliminary study was to evaluate deep learning to represent the joint level kinetic and kinematic results from a validated finite element lower limb model with varied surgical alignment. METHODS. External hip and ankle boundary conditions were created for a previously-developed finite element lower limb model [1] for step down (SD), deep knee bend (DKB) and gait to best reproduce in-vivo loading conditions as measured on patients with the Innex knee (. orthoload.com. ) (Figure1). These boundary conditions were subsequently used as inputs for the model with a current fixed-bearing total knee replacement to estimate implant-specific kinetics and kinematics during activities of daily living. Implant alignments were varied, including variation of the hip-knee-ankle angle-±3°, the frontal plane joint line −7° to +5°, internal-external femoral rotation ±3°, and the tibial posterior slope 5° and 0°. Through varying these parameters a total of 2464 simulations were completed. A NN was created utilizing the NN toolbox in MATLAB. Sequence data inputs were produced from the alignment and the external boundary conditions for each activity cycle. Sequence outputs for the model were the 6 degree of freedom kinetics and kinematics, totaling 12 outputs. All data was normalized across the entire data set. Ten percent of the simulation runs were removed at random from the training set to be used for validation, leaving 2220 simulations for training and 244 for validation. A nine-layer bi-long short-term memory (LSTM) NN was created to take advantage of bi-LSTM layers ability to learn from past and future data. Training on the network was undertaken using an RMSprop solver until the root mean square error (RMSE) stopped reducing. Evaluation of NN quality was determined by the RMSE of the validation set. RESULTS. The trained NN was able to effectively estimate the validation data. Average RMSE over the kinetics of the validation data set was 140.7N/N∗m while the average RMSE over the kinematics of the validation data set was 4.47mm/deg (Figure 2,3–DKB, Gait shown). It is noted the error may be skewed by the larger magnitude kinetics and kinematics in the DKB activity as the average RMSE for just SD and gait was 85.9N/N∗m and 2.8mm/deg for the kinetics and kinematics, respectively. DISCUSSION. The accuracy of the generated NN indicates its potential for use in real-time modeling, and further work will explore additional changes in post-operative soft-tissue balance as well as scaling to patient-specific geometry

Aims. The aim of this study was to validate the Mirels score in predicting pathological fractures in metastatic disease of the lower limb. Patients and Methods. A total of 62 patients with confirmed metastatic disease met the inclusion criteria. Of the 62 patients, 32 were female and 30 were male. The mean age of patients was 65 years (35 to 89). The primary malignancy originated from the breast in 27 (44%) patients, prostate in 15 (24%) patients, kidney in seven (11%), and lung in four (6%) of patients. One patient (2%) had metastatic carcinoma from the lacrimal gland, two patients (3%) had multiple myeloma, one patient (2%) had lymphoma of bone, and five patients (8%) had metastatic carcinoma of unknown primary. Plain radiographs at the time of initial presentation were scored using Mirels system by the four authors. The radiographic components of the score (anatomical site, size, and radiographic appearance) were scored two weeks apart. Inter- and intraobserver reliability were calculated with Fleiss’ kappa test. Bland-Altman plots were created to compare the variances of the individual components of the score and the total Mirels score. Results. Kappa values for the interobserver variability of the components of the Mirels score were k = 0.554 (95% CI 0.483 to 0.626) for site, k = 0.342 (95% CI 0.285 to 0.400) for size, k = 0.443 (95% CI 0.387 to 0.499) for radiographic appearance, and k = 0.294 (95% CI 0.258 to 0.331)for the total score. Kappa values for the intra-observer reliability were k = 0.608 (95% CI 0.506 to 0.710) for site, k = 0.579 (95% CI 0.487 to 0.670) for size, k = 0.614 (95% CI 0.522 to 0.703) for radiographic appearance, and k = 0.323 (95% CI 0.266 to 0.379) for total score. Conclusion. Our study showed fair to moderate agreement between authors when using the Mirels score, and moderate to substantial agreement when authors rescored radiographs. The Mirels score is subjective and lacks reproducibility in predicting the risk of pathological fracture. Cite this article: Bone Joint J 2018;100-B:1100–5

The aim of this study was to examine the loading of the other joints of the lower limb in patients with unilateral osteoarthritis (OA) of the knee. We recruited 20 patients with no other symptoms or deformity in the lower limbs from a consecutive cohort of patients awaiting knee replacement. Gait analysis and electromyographic recordings were performed to determine moments at both knees and hips, and contraction patterns in the medial and lateral quadriceps and hamstrings bilaterally. The speed of gait was reduced in the group with OA compared with the controls, but there were only minor differences in stance times between the limbs. Patients with OA of the knee had significant increases in adduction moment impulse at both knees and the contralateral hip (adjusted p-values: affected knee: p < 0.01, unaffected knee p = 0.048, contralateral hip p = 0.03), and significantly increased muscular co-contraction bilaterally compared with controls (all comparisons for co-contraction, p < 0.01). The other major weight-bearing joints are at risk from abnormal biomechanics in patients with unilateral OA of the knee. Cite this article: Bone Joint J 2013;95-B:348–53

Aims

This study aimed to investigate the incidence of ≥ 5 mm asymmetry in lower and whole leg lengths (LLs) in patients with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH-OA) and primary hip osteoarthritis (PHOA), and the relationship between lower and whole LL asymmetries and femoral length asymmetry.

One hundred and nine children with myelodysplasia were evaluated and classified according to the level and type of paralysis and its effect on functional ability. Thirty-one per cent of the patients were paralysed at the thoracic level, 26% at the upper lumbar level, 30% at the lower lumbar level and 13% at the sacral level. Fifty-four per cent of these patients demonstrated the classic flaccid paralysis in the lower limbs with normal upper limbs; 9% were flaccid in the lower limbs, but were spastic in the upper; 24% were spastic in the lower limbs; 13% were spastic in the upper and lower limbs. Patients with spastic lower limbs required more orthopaedic procedures, more days in hospital and in casts, and were less likely to walk than those with flaccid paralysis. Patients with spastic upper limbs were less likely to be independent in activities of daily living and were more likely to require special schools than patients with normal upper limbs. In addition to the spinal cord level of the lesion, the degree of spasticity is important in the evaluation, treatment and prognosis of myelodysplastic patients

Introduction. We aimed to determine whether there are differences in patient-reported quality of life (QoL) outcome between local flap versus free flap. Materials and Methods. All patients admitted with lower limb open fractures were retrospectively reviewed. Patient notes were assessed for demographics, time to fracture union, wound healing and patient-reported QoL with EQ-5D-5L, alongside a novel flap assessment tool. Results. A total of 40 patients had flap reconstruction of their lower limb injury; 23 local flap (Group I) and 17 free flaps (Group II). The average length of follow-up was 33.8 months. Group I - 10 revisions of flaps (43.5%) and 14 surgical complications (60.9%). Fracture union was 171 days and wound healing 130 days. EQ-5D index and EQVAS scores were 0.709 and 79.3, respectively. Group II – 8 revision of flaps (47.1%) and 12 surgical complications (70.6%). Fracture union was 273 days and wound healing 213 days. EQ-5D index and EQ-VAS scores were 0.525 and 57.2, respectively. Aesthetic appeal - 48% Group I vs. 66% Group II. Significant differences were found between the two flap groups with higher scores for daily living in Group I (p–0.007) compared to higher overall flap ratings in Group II (p–0.049). Both groups were comparable in terms of complications, while flap congestion and dehiscence were more common with free flaps. statistical interrogation did not elicit significance (p > 0.05). Conclusions. Local flap and free flap techniques offer distinct advantages. Local flaps have a better surgical outcome and patient-reported QoL in the first few years post soft tissue reconstruction. Differences between local and free reconstructive techniques in terms of patient health and function are ameliorated in the longer term

Objectives. We aimed to examine the characteristics of deep venous flow in the leg in a cast and the effects of a wearable neuromuscular stimulator (geko; FirstKind Ltd) and also to explore the participants’ tolerance of the stimulator. Methods. This is an open-label physiological study on ten healthy volunteers. Duplex ultrasonography of the superficial femoral vein measured normal flow and cross-sectional area in the standing and supine positions (with the lower limb initially horizontal and then elevated). Flow measurements were repeated during activation of the geko stimulator placed over the peroneal nerve. The process was repeated after the application of a below-knee cast. Participants evaluated discomfort using a questionnaire (verbal rating score) and a scoring index (visual analogue scale). Results. The geko device was effective in significantly increasing venous blood flow in the lower limb both with a plaster cast (mean difference 11.5 cm/sec. -1. ; p = 0.001 to 0.13) and without a plaster cast (mean difference 7.7 cm/sec. -1. ; p = 0.001 to 0.75). Posture also had a significant effect on peak venous blood flow when the cast was on and the geko inactive (p = 0.003 to 0.69), although these differences were less pronounced than the effect of the geko (mean difference 3.1 cm/sec. -1. (-6.5 to 10)). The geko device was well tolerated, with participants generally reporting only mild discomfort using the device. Conclusion. The geko device increases venous blood flow in the lower limb, offering a potential mechanical thromboprolylaxis for patients in a cast. Cite this article: Bone Joint Res 2013;2:179–85

Aims. To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury. Methods. Secondary analysis of a UK multicentre randomized controlled trial (Wound Healing in Surgery for Trauma; WHiST) dataset including adults aged 16 years or over following surgery for lower limb major trauma. The trial recruited 1,547 participants from 24 trauma centres. Neuropathic pain was measured at three and six months using the Doleur Neuropathique Questionnaire (DN4); 701 participants provided a DN4 score at three months and 781 at six months. Overall, 933 participants provided DN4 for at least one time point. Physical disability (Disability Rating Index (DRI) 0 to 100) and health-related quality-of-life (EuroQol five-dimension five-level; EQ-5D-5L) were measured. Candidate predictors of neuropathic pain included sex, age, BMI, injury mechanism, concurrent injury, diabetes, smoking, alcohol, analgaesia use pre-injury, index surgery location, fixation type, Injury Severity Score, open injury, and wound care. Results. The median age of the participants was 51 years (interquartile range 35 to 64). At three and six months post-injury respectively, 32% (222/702) and 30% (234/787) had neuropathic pain, 56% (396/702) and 53% (413/787) had chronic pain without neuropathic characteristics, and the remainder were pain-free. Pain severity was higher among those with neuropathic pain. Linear regression analyses found that those with neuropathic pain at six months post-injury had more physical disability (DRI adjusted mean difference 11.49 (95% confidence interval (CI) 7.84 to 15.14; p < 0.001) and poorer quality of life (EQ-5D utility -0.15 (95% CI -0.19 to -0.11); p < 0.001) compared to those without neuropathic characteristics. Logistic regression identified that prognostic factors of younger age, current smoker, below knee fracture, concurrent injuries, and regular analgaesia pre-injury were associated with higher odds of post-injury neuropathic pain. Conclusion. Pain with neuropathic characteristics is common after lower limb fracture surgery and persists to six months post-injury. Persistent neuropathic pain is associated with substantially poorer recovery. Further attention to identify neuropathic pain post-lower limb injury, predicting patients at risk, and targeting interventions, is indicated. Cite this article: Bone Joint J 2021;103-B(6):1047–1054

Aim. Periprosthetic joint infections are a devastating complication after modular endoprosthetic reconstruction following resection of a musculoskeletal tumour. Due to long operating times, soft tissue dissection and immunosuppression, the infection rate after limb salvage is high and ranges between 8% and 15%. The aim of this retrospective single centre study was to assess the reinfection and re-reinfection rate after septic complications of megaprostheses. Method. In this retrospective study, 627 patients with a primary replacement of a musculoskeletal tumour of the lower limb and reconstruction by a megaprosthesis were recorded from 1983 – 2016. 83 out of 621 patients available for follow-up experienced an infection (13.4%). Two patients were treated with debridement and removal of the mobile parts, 61 patients with a one-stage revision, 16 patients with a two-stage revision, and 4 patients with an amputation. The mean follow up was 133 months (range: 2 – 423 months). Results. The reinfection rates after debridement, one-stage revision, two-stage revision, and amputation were 100% (CI 95%: 20 −100%), 49% (CI 95%: 36 – 62%), 38% (CI 95%: 6 – 76%), and 0%, respectively. A reinfection occurred after a mean of 38,7 months (range: 0 to 201 months). The most commonly isolated microorganisms were coagulase negative Staphylococci, followed by Staphylococcus aureus. A re-reinfection occurred in 100% after debridement, in 44% (CI 95%: 22 – 69%) after one-stage revision, in 55% (CI 95%: 31 – 91%) after two-stage revision, and 0% after amputation. Regarding two-stage revision, there was a statistically significant difference in infection rates between patients treated with complete removal of the megaprosthesis and patients with at least one retained component (Fisher's exact test, p = 0.027). Conclusions. Septic failures after megaprosthesis reconstruction of a musculoskeletal tumour of the lower limb are difficult to treat and show high reinfection and re-reinfection rates. A two-stage revision with removal of all components showed the best results among limb salvage procedures for periprosthetic megaprosthesis infection

Aims. The aim of this study was to estimate economic outcomes associated with deep surgical site infection (SSI) in patients with an open fracture of the lower limb. Patients and Methods. A total of 460 patients were recruited from 24 specialist trauma hospitals in the United Kingdom Major Trauma Network. Preference-based health-related quality-of-life outcomes, assessed using the EuroQol EQ-5D-3L and the 6-Item Short-Form Health Survey questionnaire (SF-6D), and economic costs (£, 2014/2015 prices) were measured using participant-completed questionnaires over the 12 months following injury. Descriptive statistics and multivariate regression analysis were used to explore the relationship between deep SSI and health utility scores, quality-adjusted life-years (QALYs), and health and personal social service (PSS) costs. Results. Deep SSI was associated with lower EQ-5D-3L derived QALYs (adjusted mean difference -0.102, 95% confidence interval (CI) -0.202 to 0.001, p = 0.047) and increased health and social care costs (adjusted mean difference £1950; 95% CI £1383 to £5285, p = 0.250) versus patients without deep SSI over the 12 months following injury. Conclusion. Deep SSI may lead to significantly impaired health-related quality of life and increased economic costs. Our economic estimates can be used to inform clinical and budgetary service planning and can act as reference data for future economic evaluations of preventive or treatment interventions. Cite this article: Bone Joint J 2018;100-B:1506–10

Introduction: Normal axial alignment of the lower extremity is important to surgeons who perform reconstruction surgery of the knee. The data are, however, not available for Chinese adults. Methods: The axial alignment of the lower extremity of twenty-five adult males and twenty-five adult females of southern Chinese origin was measured by using weight-bearing radiographs of the entire lower limb. The mean age of the male and female volunteers was twenty-four years and twenty-three years respectively. The axial alignment of the lower extremity was measured and the results were compared with two similar studies conducted in the United States. Results: The medial inclination of the tibial plateau in the Chinese volunteers was greater than the commonly cited 3 degrees (with a mean of 5.4 ± 2.5 degrees for females and 4.9 ± 2.3 degrees for males). The extremities in Chinese volunteers were found to have a mean of 2.2 ± 2.5 degrees varus (females) and 2.2 ± 2.7 degrees varus (males). Conclusions and Discussion: The medial inclination (knee joint obliquity) of the Chinese knee joint was significantly larger than Caucasian subjects. The higher knee joint obliquity exposes the cartilage of the Chinese knee to a higher shearing force and subsequently result in osteoarthritis. This may explain the racial difference in the ratio of knee to hip osteoarthritis. When performing total knee arthroplasty, a 5-degree, instead of the commonly cited 3-degree, external rotation of the femoral component may be required to obtain a rectangular flexion gap in total knee arthroplasty in Chinese patients

Introduction. High tibial osteotomy (HTO) is a commonly used surgical technique for treating moderate osteoarthritis (OA) of the medial compartment of the knee by shifting the center of force towards the lateral compartment. The amount of alignment correction to be performed is usually calculated prior to surgery and it's based on the patient's lower limb alignment using long-leg radiographs. While the procedure is generally effective at relieving symptoms, an accurate estimation of change in intraarticular contact pressures and contact surface area has not been developed. Using electromyography (EMG), Meyer et al. attempted to predict intraarticular contact pressures during gait patterns in a patient who had received a cruciate retaining force-measuring tibial prosthesis. Lundberg et al. used data from the Third Grand Challenge Competition to improve contact force predictions in total knee replacement. Mina et al. performed high tibial osteotomy on eight human cadaveric knees with osteochondral defects in the medial compartment. They determined that complete unloading of the medial compartment occurred at between 6° and 10° of valgus, and that contact pressure was similarly distributed between the medial and lateral compartments at alignments of 0° to 4° of valgus. In the current study, we hypothesised that it would be possible to predict the change in intra-articular pressures based on extra-articular data acquisition. Methods. Seven cadavers underwent an HTO procedure with sequential 5º valgus realignment of the leg up to 15º of correction. A previously developed stainless-steel device with integrated load cell was used to axially load the leg. Pressure-sensitive sensors were used to measure intra-articular contact pressures. Intraoperative changes in alignment were monitored in real time using computer navigation. An axial loading force was applied to the leg in the caudal-craneal direction and gradually ramped up from 0 to 550 N. Intra-articular contact pressure (kg) and contact area (mm2) data were collected. Generalised linear models were constructed to estimate the change in contact pressure based on extra-articular force and alignment data. Results. The application of an axial load results in axial angle changes and load distribution changes inside the knee joint. Preliminary analysis has shown that it is possible to predict lateral and medial compartment pressures using externally acquired data. For lateral compartment pressure estimation, the following equation had an R of 0.86: Lateral compartment pressure = −1.26*axial_force + 37.08*horizontal_force − 2.40*vertical_force − 271.66*axial_torque − 32.64*horizontal_torque + 18.98*vertical_torque − 24.97*varusvalgus_angle_change + 86.68*anterecurvature_angle_change − 17.33*axial_angle_change − 26.14. For medial compartment pressure estimation, the following equation had an R2 of 0.86: Medial compartment pressure = −2.95*axial_force −22.93*horizontal_force − 9.48*vertical_force − 34.53*axial_torque + 6.18*horizontal_torque − 127.00*vertical_torque − 110.10*varusvalgus_angle_change − 15.10*anterecurvature_angle_change + 55.00*axial_angle_change + 193.91. Discussion. The most important finding of this study was that intra-articular pressure changes in the knee could be accurately estimated given a set of extra-articular parameters. The results from this study could be helpful in developing more accurate lower limb realignment procedures. This work complements and expands on previous research by other groups aimed at predicting intra-articular pressures and identifying optimal alignment for unloading arthritic defects. A possible clinical application of these findings may involve the application of a predetermined axial force to the leg intra-operatively. Given the estimated output from the predictive equation, one could then perform the opening wedge until the desired estimated intra-articular pressure is achieved. With this method, an arthrotomy and placement of intra-articular pressure sensors would not be needed. This work is not without its limitations. This experiment was performed on cadaveric specimens. Therefore, we cannot directly predict what the pressures would be in a de-ambulating patient. However, these sort of experiments do help us understand the complex biomechanics of the knee in response to alterations in multi-planar alignment. Further in vivo research would be warranted to validate these results. Additionally, given our current experimental setup, only axial loading could be performed for testing. Further experiments involving dynamic motion of the lower limb under load would further help us understand the changes in pressure at difference flexion angles. Continued experiments would help us gather additional data to better understand the relationship between these variables and to construct a more accurate predictive model. In summary, we have established a framework for estimating the change in intra-articular contact pressures based on extra-articular, computer-navigated measurements. Quantifying the resulting changes in load distribution, alignment changes, torque generation and deflection will be essential for generating appropriate algorithms able to estimate joint alignment changes based on applied loads

The study compared thigh-shank and shank-foot coordination during gait before and after total knee arthroplasty (TKA) with controls (CTRL).

Twenty-seven patients (male=15/female=12; age=63.2±6.9 years) were evaluated one month prior to and twelve months after surgery, and compared to 27 controls (male=14/female=13; age=62.2±4.3). The participants were outfitted with a full-body marker set. Gait speed (normalized by leg length) was calculated. The time series of the thigh, shank, and foot orientation in relation to the laboratory coordinate system were extracted. The coordination between the thigh-shank and shank-foot in the sagittal plane were calculated using a vector coding technique. The coupling angles were categorized into four coordination patterns. The stance phase was divided into thirds: early, mid, and late stance. The frequency of each pattern and gait speed were compared using a one-way ANOVA with a post-hoc Bonferroni correction.

Walking speed and shank-foot coordination showed no differences between the groups. The thigh-shank showed differences. The pre-TKA group showed a more in-phase pattern compared to the CTRL group during early-stance. During mid-stance, the pre- and post-TKA presented a more in-phase pattern compared to the CTRL group. Regarding shank-foot coordination, the groups presented an in-phase and shank pattern, with more shank phase during mid-stance and more in-phase during late-stance.

The pre-TKA group showed greater differences than the post-TKA compared to the controls. The more in-phase pattern in the pre- and post-TKA groups could relate to a reduced capacity for the thigh that leads the movement. During mid-stance in normal gait, the knee is extending, where the thigh and shank movements are in opposite directions. The in-phase results in the TKA groups indicate knee stiffness during the stance phase, which may relate to a muscular deficit or a gait strategy to reduce joint stress.

Aims. The use of frozen tumour-bearing autograft combined with a vascularized fibular graft (VFG) represents a new technique for biological reconstruction of massive bone defect. We have compared the clinical outcomes between this technique and Capanna reconstruction. Methods. From June 2011 to January 2016 a retrospective study was carried out of patients with primary osteosarcoma of lower limbs who underwent combined biological intercalary reconstruction. Patients were categorized into two groups based on the reconstructive technique: frozen tumour-bearing autograft combined with concurrent VFG (Group 1) and the Capanna method (Group 2). Demographics, operating procedures, oncological outcomes, graft union, limb function, and postoperative complications were compared. Results. A total of 23 patients were identified for analysis: eight in Group 1 and 15 in Group 2. There was no difference in the demographics (age, sex, and affected site) and operating procedures (resection length, duration of surgery, and blood loss) between the two groups. No significant difference was found in local recurrence in Group 1 versus Group 2 (p = 0.585). Mean union time for the frozen autograft-host junction was 8.4 months (7.0 to 11.0), significantly earlier than for the allograft-host junction in Group 2 (mean 14.1 months (10.0 to 28.0); p < 0.001). Mean Musculoskeletal Tumor Society scores in groups 1 and 2 were 90.3% (SD 7.4%) and 88.0% (SD 9.0%), respectively, with no significant statistical difference (p = 0.535). In terms of complications, infection (n = 1, 6.7%) and delayed union (n = 2, 13.3%) occurred in Group 2, but no such complications were observed in Group 1. Conclusion. Frozen tumour-bearing autograft in combination with VFG can be used as an alternative to the Capanna reconstruction in properly selected patients with osteosarcoma. Cite this article: Bone Joint J 2020;102-B(5):646–652

Aim. The aim of this study was to determine whether the absence of periosteal reaction on plain radiographs was predictive of exchange nail failure in lower limb diaphyseal fracture non-unions. Methods. A consecutive cohort of 20 femora and 35 tibiae undergoing exchange nailing for diaphyseal aseptic (n=39) and septic (n=16) fracture non-union at a single centre from 2003 to 2010. Multiple causes of non-union were found in 29 patients (53%) with infection present in 16 cases (29.1%). Of this cohort 49 fracture non-unions had complete radiographic records (19 femora and 30 tibiae) allowing evaluation of the periosteal callus. The primary outcome was the number of number of revision procedures required to achieve union. Failure was defined was as the requirement of >two revision procedures to achieve union. Results. The absence of periosteal callus from the fracture site on all four cortices conferred a relative risk ratio (RRR) 5.00 (p=0.006) of exchange nail failure in septic fracture non-unions. Receiver operator characteristic curve analysis of number of cortices with periosteal reaction for predicting exchange nail (>two exchange nail procedures) failure in both septic and aseptic cases found an area under the curve of 0.79 (95% confidence interval 0.675–0.904, p<0.0001). The complete absence of callus within 5 mm of the fracture site had a 75% chance of requiring 3 or more exchange nails to obtain union. Conversely the presence periosteal callus on at least one cortex within 5mm of the fracture site had a 100% chance the fracture would unite following 1 or 2 exchange nail procedures. Conclusion. Careful radiographic analysis of lower limb diaphyseal non-union should be undertaken before exchange nailing. The absence of periosteal reaction on plain radiographs in septic fracture non-union is predictive of exchange nail failure

Aims. The aim of this study was to explore the patients’ experience of recovery from open fracture of the lower limb in acute care. Patients and Methods. A purposeful sample of 20 participants with a mean age of 40 years (20 to 82) (16 males, four females) were interviewed a mean of 12 days (five to 35) after their first surgical intervention took place between July 2012 and July 2013 in two National Health Service (NHS) trusts in England, United Kingdom. The qualitative interviews drew on phenomenology and analysis identified codes, which were drawn together into categories and themes. Results. The findings identify the vulnerability of the patients expressed through three themes; being emotionally fragile, being injured and living with injury. The participants felt a closeness to death and continued uncertainty regarding loss of their limb. They experienced strong emotions while also trying to contain their emotions for the benefit of others. Their sense of self changed as they became a person with visible wounds, needed intimate help, and endured pain. When ready, they imagined what it would be like to live with injury. Conclusion. Recovery activities require an increased focus on emotional wellbeing. Surgeons are aware of the need for clinical expertise and for adequate pain relief but may not be as aware that their patients require support regarding their body image and help to imagine their future life. Cite this article: Bone Joint J 2018;100-B:522–6

Introduction. Antibiotic loaded absorbable calcium sulphate beads (ALCSB) are an increasingly popular adjunct in the treatment of musculoskeletal infections including osteomyelitis and peri-prosthetic joint infections (PJI). Limited data exist regarding the clinical indications and biochemical outcomes of ALCSB in PJI cases. Aims. To determine the proportion of organisms that were sensitive to the gentamicin and vancomycin that we add to the ALCSB as a part of our treatment protocol and to determine the prevalence of postoperative hypercalcaemia when used for treatment of hip and knee DAIR (debridement and implant retention) and revision arthroplasty for PJI. Methods. A retrospective review of 160 hip and knee revisions using ALCSB performed between June 2015 and May 2018 at a tertiary unit was performed. 10–40 cc of ALCSB was used for each case containing vancomycin and gentamicin. Data recorded included patient demographics, comorbidities, indication for surgery, operative intervention, microbiological results and serum biochemistry for calcium levels. Results. The cohort consisted of 91 males and 69 females, with a mean age of 69.0 years (21.3 to 93.1) and mean BMI of 34.7(12.6 to 48.1). 56 (35%) had single-stage revision, 45 (28.1%) had first stage revision, 35 (21.9) had DAIR, 19 (11.9%) had second stage revision and 5 (3.1%) other procedures. Organisms included staphylococcus aureus (30.0%), culture-negative (27.5%), staphylococcus epidermidis (18.1%), and pseudomonas aeruginosa (3.1%). 54.3% were sensitive to both vancomycin and gentamicin, 25.0% to vancomycin only and 8.6% to gentamicin only. 11.9% (19/160) of patients had transient post-operative hypercalcaemia (normal range 2.2–2.7mmol/L), peaking at day 6–7 and resolved with hydration by day 10 postoperatively. Preoperatively, 26.9% had albumin <35 g/L and 49.3% had some degree of renal impairment with an eGFR <90 ml/min. Conclusion. The use of ALCSB allows local delivery of vancomycin and gentamicin in lower limb PJI. Organisms were sensitive to this antibiotic combination in 88% cases. Care must be taken to monitor calcium for 10 days post-operatively

Aim

Mega-endoprosthesis over the last two decades have played a significant role in management of non-neoplastic cases for limb salvage for a variety of indications involving bone loss, infection, fracture and failed revision surgery. This is a retrospective case control study comparing outcomes of Mega-Endoprosthesis (MEP) in non-neoplastic cases with periprosthetic joint infections (PJI), with previous history of PJI and aseptic revision. Failure was defined as persistence/recurrence of infection, all cause revision, and antibiotic suppression during the follow up period. Secondary aims were identification of causative organisms, resistance profile and causative factors for revision surgery.

Pre-operative planning for limb deformity correction involves detailed imaging of the lower limb to define the level, magnitude and direction of deformity. This is then used to plan the correction by defining the centre of rotational alignment (CORA). The method as described by Paley and Hertzenberg involves the use of orthogonal radiographs of the lower limbs using long cassettes (130 cm) taken from a distance of 305 cm to minimize magnification. This method requires special equipment, trained radiographers and multiple doses of radiation even when each radiograph was perfectly positioned first time every time. We present a work in progress replacing the radiographs with a “virtual 3D” CT dataset of the lower limb which we hope will improve the ability to pre-operatively plan deformity correction, but at a lower cost in terms of skill, equipment and dose. Whole limb CT is too costly in terms of time and radiation dose for this to be suitable. New multislice CT systems allow a single coherent study to include segments of unscanned data. Thus it is possible to run a single series through a lower limb to include the articular surfaces, but excluding the diaphyseal segments (gaps). This reduces the radiation exposure to the patient. Such data when entered into suitable DICOM image manipulation software allows the Radiologist or Surgeon to measure and assess the deformity with great precision. Such software is available on the diagnostic radiology workstations but is also available for personal computers, allowing the Surgeon to perform preoperative planning in a numerical modeling setting. Allowing the elements of length, rotation, translation and angulation of the deformity to be measured and corrective surgery tested on the mathematical model. We have compared the measurements taken from a deformity model using this new CT approach and compared it to standard radiographs and found that the above method is no less accurate. Rotational deformities are easier to estimate. However the advantage of our method is that the dataset can be manipulated to determine other technical aspects of deformity correction such as calculating the mounting parameters of the Talyor Spatial Frame. We present worked examples of the methodology showing how this technique improves deformity appraisal

The National Institute of Clinical Excellence (NICE) published guidance for reducing the risk of venous thromboembolism (VTE) in January 2010. This guidance has had a significant impact on the management of all inpatients. It is now mandatory to risk assess every inpatient and commence appropriate treatment if indicated. The guidelines specifically exclude outpatients although NICE recognises' that lower limb cast immobilisation is a risk factor for VTE. The purpose of our study was to establish the current practice for the management of outpatients treated with lower limb casts in England. The NHS Choices website lists 166 acute hospitals in England. A telephone audit was conducted in February 2011. A member of the on call orthopaedic team was asked: 1. Are you aware of the NICE guidelines for VTE prophylaxis? 2. In your department, outpatients treated with a lower limb cast, are they risk assessed for VTE? 3. If a patient undergoes Open Reduction Internal Fixation (ORIF) for an ankle fracture and is discharged wearing a cast, are they given VTE prophylaxis? 4. If yes - for how long are they treated?. Responses were obtained from 150 eligible hospitals (1 FY1, 28 FY2, 44 ST1-ST2, 76 ST3+, 1 Consultant). 62% of responders stated that they were aware of the NICE guidance. 40% of responders stated that outpatients were routinely risk assessed for VTE. 32% of responders stated that ankle fractures treated with an ORIF and discharged wearing a cast would receive VTE prophylaxis. The duration of treatment varied from 5 days, to 6 weeks, to removal of cast. The management of patients treated with a lower limb cast is variable and inconsistent throughout England. Although there are no national guidelines for this patient group, the routine risk assessment of outpatients was higher than anticipated by the authors. We recommend that if VTE prophylaxis is commenced as an inpatient, then it should be continued until the cast is removed

Introduction. In clinical routine surgeons depend largely on 2D x-ray radiographs and their experience to plan and evaluate surgical interventions around the knee joint. Numerous studies have shown that pure 2D x-ray radiography based measurements are not accurate due to the error in determining accurate radiography magnification and the projection characteristics of 2D radiographs. Using 2D x-ray radiographs to plan 3D knee joint surgery may lead to component misalignment in Total Knee Arthroplasty (TKA) or to over- or under-correction of the mechanical axis in Lower Extremity Osteotomy (LEO). Recently we developed a personalized X-ray reconstruction-based planning and post-operative treatment evaluation system called “iLeg” for TKA or LEO. Based on a patented X-ray image calibration cage and a unique 2D–3D reconstruction technique, iLeg can generate accurate patient-specific 3D models of a complete lower extremity from two standing X-rays for true 3D planning and evaluation of surgical interventions at the knee joint. The goal of this study is to validate the accuracy of this newly developed system using digitally reconstructed radiographs (DRRs) generated from CT data of cadavers. Methods. CT data of 12 cadavers (24 legs) were used in the study. For each leg, two DRRs, one from the antero-posterior (AP) direction and the other from the later-medial (LM) direction, were generated following clinical requirements and used as the input to the iLeg software. The 2D–3D reconstruction was then done by non-rigidly matching statistical shape models (SSMs) of both femur and tibia to the DRRs (seee Fig. 1). In order to evaluate the 2D–3D reconstruction accuracy, we conducted a semi-automatic segmentation of all CT data using the commercial software Amira (FEI Corporate, Oregon, USA). The reconstructed surface models of each leg were then compared with the surface models segmented from the associated CT data. Since the DRRs were generated from the associated CT data, the surface models were reconstructed in the local coordinate system of the CT data. Thus, we can directly compare the reconstructed surface models with the surface models segmented from the associated CT data, which we took as the ground truth. Again, we used the software Amira to compute distances from each vertex on the reconstructed surface models to the associated ground truth models. Results. When the reconstructed models were compared with the surface models segmented from the associated CT data, a mean reconstruction accuracy of 1.2±0.2mm, 1.3±0.2mm, 1.4±0.3mm and 1.3±0.2mm was found for left femur, right femur, left tibia and right tibia, respectively. When looking into the reconstruction of each subject, we found an average reconstruction accuracy in the range of 1.1mm to 1.5mm. Overall, the reconstruction accuracy was found to be 1.3±0.2mm. Discussions. We presented a cadaver study to validate the accuracy of reconstructing 3D patient-specific models of a complete lower extremity from 2D X-rays. Our experimental results demonstrate that the complete lower extremity can be reconstructed accurately from 2D X-rays. Please note that the errors we reported above include both pose and shape reconstruction errors whole most of previous studies only reported shape reconstruction errors

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

The verification of the alignment of the lower limb is critical for reconstructive surgery as well as trauma surgery in order to prevent osteoarthritis. The mechanical axis is a straight line defined by the center of the femoral head and the center of the ankle joint, ideally passing the knee joint in its center. Whereas the usual preoperative method to determine the mechanical axis of the lower limbs is still the long standing radiograph, common intra-operative methods are the use of an electrocautery cord or an X-ray grid consisting of wire lines underneath the patient. Both methods require the surgeon to bring the femoral head and the ankle joint exactly to overlay with a radiopaque line that passes through both points. The distance of the knee center from this line is defined as the mechanical axis deviation (MAD). In order to reduce the errors introduced by perspective projection effects, the joint centers must be placed in the center of the c-arm images, which definitely requires time, experience and additional radiation. We propose a computer aided X-ray stitching method that puts individual X-ray images into a panoramic image frame combining the Camera Augmented Mobile C-arm (CamC) system, which features a video camera with its optical center virtually coinciding with the origin of the X-rays, with an optical tracking marker pattern underneath the operating table. The camera image of the marker pattern is used to perform pose estimation of the C-arm, allowing the calculation of the x-ray source motion between the positions in which the individual X-rays were taken. By estimating the homography, the different X-rays can be registered into a panoramic frame, enabling perfect alignment and metric measurements. In order to reduce parallax effects that lead to axis and metric measurement errors, we applied a method requiring two constraints: The bone plane has to be roughly parallel to the planar marker pattern and the distance between the marker plane and the bone plane has to be estimated. In order to evaluate the method, we used a life-size synthetic skeleton leg. After tightening a straight wire between the centers of the hip and ankle joint, the knee joint was bent into a MAD of 55 mm, which was confirmed by measuring the distance between the knee center and the wire with a ruler. The leg phantom was then placed on a radiolucent operating table, parallel to the pattern plane 130 mm underneath. The operating table was moved through the C-arm while acquiring the three desired X-ray images. which were registered into a panoramic image frame. The centers of the femoral head, the ankle, and the knee were manually determined on the generated panoramic image by a surgeon. The mechanical axis was automatically displayed and the MAD was visualised in the image and computed as 55.23 mm. We presented a new solution to intra-operatively verify alignment of the lower extremity. When using the CamC system, only a marker pattern has to be used for tracking. No additional tracking devices and calibration procedures are needed. Furthermore, the presented method only requires three x-rays that cover the femoral head, the knee and the ankle and marking of the three spots. Due to the parallax correction, these spots do not have to be exactly in the center of the picture. For this reason, compared to using an X-ray grid or an electrocautery cord, our method allows the procedure to be much faster and reduces the number of x-ray images. However, for clinical evaluation, a patient study will be conducted in the future

Aim. To assess the efficacy of combined medical and surgical management in obtaining normal lower limb mechanical alignment in a patient cohort with genotypically similar hypophosphataemic rickets. Methods. A notes and radiograph audit was performed of all patients attending our institution with hypophosphataemic rickets: a subset with PHEX gene anomalies was studied further. Lower limb radiographs were assessed at two points during childhood and note made of treatment start, compliance; indication, timing and result of surgery. Standing leg alignment radiographs were measured at skeletal maturity or at latest review. Results. 35 patients (16 females, 18 skeletally mature) were identified. 10 commenced treatment at <12m. 11 patients (5 female) underwent 24 surgical procedures (13 for varus deformities). Surgery was bilateral in 10/11 patients. 5/14 osteotomies were performed after skeletal maturity. Malalignment was common: with NSA (neck-shaft angle) abnormalities in 20%, abnormal angles at distal femur and proximal tibia in 58% and 60% respectively and ankle abnormalities in 24%, prior to surgery. Surgical management led to normal mechanical alignment at skeletal maturity. At latest review, no patient had a leg length difference. 40% of non-operated, skeletally immature limbs have significant malalignment despite medical therapy. There was no statistical relationship between treatment onset and need for surgical correction. The relationship between non-compliance with medical treatment and surgical intervention was confounded by the changing emphasis on preferred method of surgical correction from osteotomy to guided growth. Conclusion. Even when medical treatment is commenced promptly and adhered to, significant lower limb malalignment can occur requiring surgical correction. Guided growth principles allow early deformity correction. Significance. Lower limb malalignment should not be considered a failure of medical treatment but more a consequence of the disease process. Earlier surgical intervention may encourage a more normal pattern of growth

1 . A technique for measuring venous pressure during exercise is described. 2. The findings in normal and abnormal conditions of the lower limb are recorded. 3. The mechanisms involved in the return of blood from the lower limb in various conditions are discussed, with particular reference to the post-phlebitic state. 4. The need for an objective method of assessing the results of surgical treatment of venous abnormalities in the lower limb is stressed

Limb length disparity is a frequent complication after hip surgery inducing many surgeon-patients conflicts. To date no study has been able to precisely quantify such limb length disparity. EOS® system, currently validated to measure lower limb parameters, allows from two bi-dimensional numerical orthogonal radiographies in standing position to obtain a tri-dimensional reconstruction of lower limbs. A computerized system achieves the parameters calculation. The aim of this study is to precisely measure the limb length disparities and the other hip parameters following total hip arthroplasty surgical procedure, by using a standard X-rays and using EOS® three-dimensional reconstructions. Twenty-eight patients programmed for total hip arthroplasty have been included (i.e. thirty lower limbs). Two independent performers have carried out twice the measures either on standard X-rays and using three-dimensional reconstructions of the lower limb disparities prior and after the surgical procedure. The inter and intra-observer reproducibility for the measure of the lower limb disparities have been of the EOS® measures have been respectively of 0.854 and 0.865 and for the standard X-rays of 0.717 and 0.726. Mean length disparity observed was before Total Hip Arthroplasty of −0.328 cm (0.705; −1.266/0.530) and was of 0.088 mm (1.326; −1.635/0.632) after. We are able to decrease the lower limbs disparity in 69.1% and for the average of 0,416cm. Using EOS® system has allowed assessing with greater precision the possibility to restore equal lower limb length. This assessment has permitted introducing a new planning procedure including EOS® imaging associated to the fusion of the prosthetic tri-dimensional image in order to achieve adequate lower limb length

Identification of gait deviations and compensations in patients with total hip arthroplasty (THA) is important for the management of their fall risks. To prevent collapse of the lower limbs while balancing and supporting the body, proper combinations of joint moments are necessary. However, hip muscles affected by THA may compromise the sharing of load and thus the whole body balance. The current study aimed to quantify the control of body support in patients with THA in terms of the total support moment (Ms) and contributions of individual joint moments to Ms during walking. Six patients who underwent unilateral THA via an anterolateral approach for at least six months at the time of the gait experiment, and six age- and gender-matched healthy controls were recruited. Twenty-eight infrared retro-reflected markers were placed on specific landmarks of the pelvis-leg apparatus to track the motion of the segments during walking. Kinematic and kinetic data were measured using an 8-camera motion analysis system (Vicon, Oxford Metrics, U.K.) and two force plates (AMTI, U.S.A.). The Ms of a limb was calculated as the sum of the net extensor moments at the hip, knee and ankle during stance phase. The contributions of the hip, knee and ankle to the first and second peaks of Ms (Ms1 and Ms2) were calculated by dividing the joint moment value by the corresponding peak values of Ms. Independent t-tests were performed to compare between groups at a significance level set at α=0.05 using SAS version 9.2 (SAS Institute Inc., NC, USA). No significant differences in Ms1 and Ms2 were found between the THA group and normal controls (P >0.05). However, compared to the healthy controls, significantly increased hip and ankle contributions but decreased knee contributions to Ms1, and significantly increased hip contributions but decreased ankle contributions to Ms2 were found in the THA group. Similar Ms1 and Ms2 between groups indicates that the lower limbs in the THA group were able to provide normal body supports. However, this was achieved via an altered contributions of the hip, knee and ankle. Hip and knee extensors play important roles in supporting the body when the Ms1 occurs during early stance of walking. In the THA group, greater hip and ankle contributions but lesser knee contributions for the Ms1 indicates that the function of hip extensors were not affected but compensatory mechanisms of the knee and ankle were found. For the Ms2, hip flexor and ankle plantarflexors are important for supporting the body during late stance. Decreased hip flexor (i.e., greater hip extensor contributions) and ankle plantarflexor moments in the THA patients suggests that the hip flexors and ankle plantarflexor muscles were affected by THA surgery. Hip muscles affected by the THA may compromise the sharing of load at the hip and thus the whole body balance. Further postoperative rehabilitation is suggested for the patients following THA. Further studies on the effects of different surgical approaches on the support moments is needed for improving treatment plans

We determined the efficacy of a devitalised autograft (n = 13) and allograft (n = 16) cortical strut bone graft combined with long-stem endoprosthetic reconstruction in the treatment of massive tumours of the lower limb. A total of 29 patients (18 men:11 women, mean age 20.1 years (12 to 45) with a ratio of length of resection to that of the whole prosthesis of > 50% were treated between May 2003 and May 2012. The mean follow-up was 47 months (15 to 132). The stem of the prosthesis was introduced through bone graft struts filled with cement, then cemented into the residual bone. Bone healing was achieved in 23 patients (86%). The mean Musculoskeletal Tumour Society functional score was 85% (57 to 97). The five-year survival rate of the endoprostheses was 81% (95% confidence intervals 67.3 to 92.3). The mean length of devitalised autografts and allografts was 8.6 cm (5 to 15), which increased the ratio of the the length of the stem of the prosthesis to that of the whole length of the prosthesis from a theoretical 35% to an actual 55%. . Cortical strut bone grafting and long-stem endoprosthetic reconstruction is an option for treating massive segmental defects following resection of a tumour in the lower limb. Patients can regain good function with a low incidence of aseptic loosening. The strut graft and the residual bone together serve as a satisfactory bony environment for a revision prosthesis, if required, once union is achieved. Cite this article: Bone Joint J 2015;97-B:544–9

Objective: To review the existing classifications in characterizing the pathological morphology of congenital lower limb deficiencies and their usefulness in planning limb reconstruction. Methods: Ninety-five patients undergoing limb reconstruction were classified using existing classifications. Predominantly femoral deficiencies were classified using Aitken,Amstutz,Hamanishi,Gillespie andTorode,Fixsen and Lloyd-Roberts, Kalamchi, and Pappas systems and fibular deficiencies were classified using Coventry and Johnston, Achterman and Kalamchi, and Birch systems. Results: All patients with predominantly femoral deficiencies also had associated shortening of ipsilateral tibia and fibula. Similarly, most patients with predominantly fibular deficiencies also had some associated shortening ipsilateral femur. Acetabular dysplasia, knee instability due to cruciate insufficiency and lateral femoral condylar hypoplasia were found in both femoral and fibular deficiencies. None of the existing classification systems were able to represent the complete pathologic morphology in any given patient. Due consideration of alignment, joint stability and length discrepancy of affected limb as a whole at the planning stage of reconstruction could not be ascertained using these classification systems. Instead, it was useful to characterize the morphology of the involved limb using the following method:. Acetabulum: Dysplastic/ Non-dysplastic (AC index, Sharp’s angle, CE angle). Ball (Head of femur): Present/Absent. Cervix (Neck of femur): Presence of pseudoarthrosis & neck-shaft angle. Diaphysis of femur: Length / deformity. Knee: Presence of cruciates, patellar and femoral con-dylar hypoplasia. Fibula and Tibia: Presence/ absence, length and deformity. Ankle: Normal/Ball and socket/ valgus. Heel: Presence of tarsal coalition and deformity (valgus, equinus). Ray: Number of rays present in the foot. Conclusion: Congenital longitudinal lower limb deficiency is a spectrum of disorder involving the entire lower limb. Existing classifications do not represent the complete morphology of the entire involved lower limb and therefore a systematic method of characterizing the morphology of the lower limb is more useful in planning limb reconstruction

Introduction. In prosthetic knee surgery, the axis of the lower limb is often determined only by static radiographic analysis. However, it is relevant to determine if this axis varies during walking, as this may alter the stresses on the implants. The aim of this study was to determine whether pre-operative measurement of the mechanical femorotibial axis (mFTA) varies between static and dynamic analysis in isolated medial femorotibial osteoarthritis. Methods. Twenty patients scheduled for robotic-assisted medial unicompartmental knee arthroplasty (UKA) were included in this prospective study. We compared three measurements of the coronal femorotibial axis: in a static and weightbearing position (on long leg radiographs), in a dynamic but non-weightbearing position (intra-operative acquisition during robotic-assisted UKA), and in a dynamic and weightbearing position (during walking by a gait analysis). Results. There was no significant difference in the mFTA between radiological (173.9 ± 3.3°), robotic (174.4 ± 3.4°), and gait analysis (172.9 ± 5.1°) measurements (p < 0.05). Conclusion. There is no significant variation in varus between lying, standing, and while walking in patients who are candidates for medial UKA. This study also allows us to validate the accuracy of the robotic system in varus estimation, and to rely on intra-operative planning as it also reflects the dynamic knee under load

Patients immobilised in lower limb casts are at risk of venous thrombo-embolism. We have devised a unique patient administered scoring system to provide targeted thrombo-prophylactic therapy based on a patient’s risk factors for thrombo-embolism. This study investigated completion of the risk assessment form and intra-observer error. We carried out a prospective observational study investigating completion of risk assessment forms in patients attending the fracture clinic who were immobilised in lower limb casts. Each patient completed a form at initial presentation which determined their treatment regime. The patients were asked to complete a second identical form once their plaster was removed together with a short questionnaire asking about ease of use of the risk assessment form. 92 patients were included in the study. The first form was correctly completed by 90 patients (98%) and the second by 89 patients (97%). There was an exact scoring correlation between the two forms in 82% of patients. 93% of patients found the scoring system easy to understand and complete. We propose that this unique patient administered, venous thrombo-embolism risk assessment form provides a user friendly, practical and reproducible tool for highlighting trauma patients in lower limb casts at increased risk of thromboembolic disease

Introduction

Lower limb amputation is associated with significant morbidity and mortality. Reflecting the predominance of vascular or diabetic disease as a cause for lower limb amputation, much of the available literature excludes lower limb amputation secondary to trauma in the reporting of complication rates. This paucity in the literature represents a research gap in describing the incidence of complications in lower limb amputation due to trauma, which we aim to address.

Predictions of lower limb growth are based upon historical data, collected from patients who had coexistent poliomyelitis. By utilising standardised longitudinal prospective European data, our objective was to generate superior estimates for the age and rate at which lower limb skeletal maturity is reached; thus improving the timing of epiphysiodesis, for the management of leg length discrepancy. The Avon Longitudinal Study of Parents and Children of the 90s (ALSPAC) is a longitudinal cohort study of children recruited antenatally 2. Using a previously validated Multiplier Method, a sequence of leg length multipliers were calculated for each child. 15,458 individuals were recruited to the ALSPAC study; and of those whose growth was measured, 52% were boys and 48% girls, each with an average of eight recording episodes. 25,828 leg length multiplier (LLM) values were calculated with final recordings taken at a mean age of 15.5 years. From this data, the age at which girls reach skeletal maturity (LLM=1) is 11 months later than previously calculated and for boys nearly 9 months earlier. With nearly 4000 more children recruited in this cohort than preceding studies, this study brings increased power to future leg length calculations

This is a case series of prospectively gathered data characterising the injuries, surgical treatment and outcomes of consecutive British service personnel who underwent a unilateral lower limb amputation following combat injury. Patients with primary, unilateral loss of the lower limb sustained between March 2004 and March 2010 were identified from the United Kingdom Military Trauma Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire. A total of 48 patients were identified: 21 had a trans-tibial amputation, nine had a knee disarticulation and 18 had an amputation at the trans-femoral level. The median New Injury Severity Score was 24 (mean 27.4 (9 to 75)) and the median number of procedures per residual limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were completed by 39 patients (81%) at a mean follow-up of 40 months (25 to 75). The physical component of the SF-36 varied significantly between different levels of amputation (p = 0.01). Mental component scores did not vary between amputation levels (p = 0.114). Pain (p = 0.332), use of prosthesis (p = 0.503), rate of re-admission (p = 0.228) and mobility (p = 0.087) did not vary between amputation levels. These findings illustrate the significant impact of these injuries and the considerable surgical burden associated with their treatment. Quality of life is improved with a longer residual limb, and these results support surgical attempts to maximise residual limb length. Cite this article: Bone Joint J 2013;95-B:224–9

The aim of this study was to define the incidence of venous thromboembolism (VTE) and risk factors for the development of deep-vein thrombosis (DVT) after the resection of a musculoskeletal tumour. A total of 94 patients who underwent resection of a musculoskeletal tumour between January 2003 and December 2005 were prospectively studied. There were 42 men and 52 women with a mean age of 54.4 years (18 to 86). All patients wore intermittent pneumatic compression devices and graduated compression stockings. Ultrasound examination of the lower limbs was conducted to screen for DVT between the fifth and ninth post-operative days. DVT was detected in 21 patients (22%). Of these, two were symptomatic (2%). One patient (1%) had a fatal pulmonary embolism. Patients aged ≥ 70 years had an increased risk of DVT (p = 0.004). The overall incidence of DVT (both symptomatic and asymptomatic) after resection of a musculoskeletal tumour with mechanical prophylaxis was high. It seems that both mechanical and anticoagulant prophylaxis is needed to prevent VTE in patients who have undergone the resection of a musculoskeletal tumour. Cite this article: Bone Joint J 2013;95-B:1280–4

Three-dimensional (3D) weight-bearing alignment of the lower extremity is crucial for understanding biomechanics of the normal and pathological functions at the hip, knee, and ankle joints. In addition, implant position with reference to bone is a critical factor affecting the long-term survival of artificial joints. The purpose of this study was to develop a biplanar system using a slot-scan radiography (SSR) for assessing weight-bearing alignment of the lower extremity and for assessing implant positioning with respect to bone. A SSR system (Sonial Vision Safire 17, Shimadzu, Kyoto, Japan) with a custom-made rotation table was used to capture x-ray images at 0 deg and 60 deg relative to the optical axis of an x-ray source [Fig.1]. The SSR system uses collimated fan beam x-rays synchronized with the movement of a flat-panel detector. This system allows to obtain a full length x-ray image of the body with reduced dose and small image distortion compared with conventional x-ray systems. Camera calibration was performed beforehand using an acrylic reference frame with 72 radiopaque markers to determine the 3D positions of the x-ray source and the image plane in the coordinate system embedded in the reference frame. Sawbone femur and tibia and femoral components of the Advance total knee system (Wright Medical Technology, Arlington, TN, USA) were used. Computed tomography of the sawbone femur and tibia was performed to allow the reconstruction of the 3D surface models. For the component, the computer aided design (CAD) model provided by the manufacturer was used. Local coordinate system of each surface model was defined based on central coordinates of 3 reference markers attached to each model. The sawbone femur and tibia were immobilized at extension, axial rotation, and varus deformity and were imaged using the biplanar SSR system. The 3D positions of the femur and tibia were recovered using an interactive 2D to 3D image registration method [Fig.2]. Then, the femoral component was installed to the sawbone femur. The 3D positions of the femur and femoral component were recovered using the above-mentioned image registration method. Overall, the largest estimation errors were 1.1 mm in translation and 0.9 deg in rotation for assessing the alignment, and within 1 mm in translation and 1 deg in rotation for assessing the implant position, demonstrating that this method has an adequate accuracy for the clinical usage

The purpose of the following study was to present the general strategy for preserving the lower extremity by knee arthrodesis and to analyze the outcome of knee arthrodeses performed by a special modular system. Between 2009 and 2014 35 knee arthrodeses were performed. 23 patients were male, 12 female. The average age was 66 years (42 to 83 years). The patients underwent an average of 6 operations because of infected knee arthroplasties previous to the knee arthrodesis. The main pathogen was S. epidermidis followed by MRSA. The arthrodeses system included a non cemented femoral and tibial stem (press fit application plus two static locking screws). These were connected by a special stem to stem clamp. Immediate postoperative full weight-bearing was possible in 32 of 35 patients. We saw 4 recurrent infections (all connected to the patients, who did not show a full weight bearing after knee arthrodesis). In two cases re-revision surgery was successful and lead to a sufficient re-arthrodesis. In two cases above-knee-amputation was necessary. Peri-implant fractures were detected in 3 cases. All of them could be cured by changing the arthrodesis stem and to a longer one bridging the fracture. In one case a stem loosening was seen. This was as well addressed by the use of a longer stem. Knee arthrodesis by a modular non cemented system is a god alternative in order to preserve the weight-bearing lower extremity. The complication rate is rather high due to the fact, that this procedure presents the final alternative to do so in patients, who are in extremis in terms of a long lasting aggressive peri-arthroplasty infection the lead to massive destruction of the soft tissue around the knee and a significant loss of function

Purpose of the study: Leg length discrepancy after THA is a common complication and source of recurrent complaints from patients. To date, no reliable and reproducible technique has come forward to enable accurate quantification of all radiological parameters of the lower limb. Nevertheless, preoperative planning for hip arthroplasty requires knowledge of many limb parameters, in particularly leg length discrepancy, femoral offset, or the head-neck angle. The most widely used method is to use the 2D radiographs. The EOS system uses two digitalised 2D images taken orthogonally in a weight-bearing position to enable 3D reconstruction of the lower limb. The inter- and intraoperator reproducibility has been studied and validated. The purpose of our study was to compare the inter- and intra-operator reproducibilities of the measures taken on the standard full-length x-ray and those determined on the 3D EOS reconstructions. Material and method: Twenty-five patients scheduled for THA were included in this study (50 lower limbs). Two independent operators determine the measures on the AP EOS view and on the 3D reconstructions obtained from two orthogonal EOS images. The following parameters were measured: femur length, tibia length, limb length, HKA, HKS, femoral offset, neck-shaft angle, head diameter, and length of the femoral neck. Each observer performed two series of measurements. Interobserver reproducibility was assessed with the intraclass correlation coefficient (CI: 95%). Student’s t test was used to compare the clinical parameters measured on the 2D and 3D images. Results: Inter- and intraobserver reproducibility were 0.867 and 0.903 on the 2D x-rays and 0.911 and 0.940 on the 3D reconstructions. The better reproducibility of the EOS reconstruction was confirmed for all parameters tested in this study. Comparison of the 3D and 2D measurements revealed significant differences. Discussion: Our study demonstrated that measurements made on EOS 3D reconstructions offer better inter- and intraobserver reproducibility than those made on the standard AP view. In addition, the 3D reconstruction takes into consideration of the projection of the anatomic structures in the plane of the AP radiograph. The EOS appears to be a pertinent tool giving reliable results for the pre- and postoperative work-up for arthroplasty of the lower limb

We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). . The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection. Cite this article: Bone Joint J 2013;95-B:1673–80

Background: Feet and lower limb deformities compromise function of children to meet there growing abilities and peer demands. Ilizarov is a known tool in the correction of lower limb deformities. Purpose: to evaluate the functional outcome of Ilizarov correction of lower limb deformities, and to compare the functional outcome of correction of feet deformity versus other lower limb segments deformity. Subjects and Methods: 94 Ilizarov corrections of lower limb deformed segments (in 63 children) were performed, of them 43 were feet, 33 were tibial and 18 were femoral deformities. Etiology of deformity was congenital in 72, acquired in 18, and developmental in 4. Functional ability of walking distance, cope with peers, single leg stance, hopping on affected leg, and climbing stairs before and after deformity correction were assessed. Results: Mean follow was 55.1 ± 30.9 months, mean age at time of operation was 11.1 ± 5.3. At last follow up the corrected deformities of lower limb had a significant increase to full walking distance from 37, to 76 lower extremities (p=0.000). Coping with peers increased from 40, to 68 (p=0.000) extremities. The single stance on the affected extremity increased from 30, to 78(p=0.000). The hopping on affected limb increased from 18, to 41(p= 0.000), climbing stairs increased from 79 and 94(p=0.000) extremities. Although disability before correction was significantly more pronounced among feet deformities as regards single stance (p=0.001), and hopping on one leg (p=0.023). The improvement to full walking distance, coping with peers, single stance, hoping and climbing stairs was significantly higher among corrected feet (p=0.000), (p=0.000), (p=0.000), (p=0.000), (p=0.000) compared to other corrected lower limb deformities. Conclusion: Deformity of feet is significantly more disabling functionally than other lower limb deformities. Ilizarov foot correction is significantly more functionally rewarding than Ilizarov correction of other lower limb deformities

Introduction

Angular deformity in the lower extremities can result in pain, gait disturbance, deformity and joint degeneration. Guided growth modulation uses the tension band principle with the goal of treatment being to normalise the mechanical axis. To assess the success of this procedure we reviewed our results in an attempt to identify patients who may not benefit from this simple and elegant procedure.

Aim : In our clinic are carried out annually, 20 high tibial osteotomy with Maquet’s technique, from 1980 up to 2002. This surgical procedure is indicated in degenerative, medial unicompartamed knee osteoarthritis with range of motion complete from at least 10° to 90° or more, in patients with age till 60 years old, active and ingreased body weight. The philosophy of this surgical procedure is the correction of mecanical axis of the lower limb. The lower limb’s axonometry preoperatively gives us precious information with regal of the mecanical axis from the normal and postoperatively clues on the success of the procedure. Material – method : From January 1998 up to December 2002 we have done 55 high tibial osteotomies – Maquet’s technique. In this work we studied 40 cases, aged from 42 to 61 years (m.a. 54), 32 women and 8 men. The patients were submitted in axonometry lower limb pro and post operatively. In two cases post operatively we were forced to correct the mecanical axis again. The final results ware very good and stable. Results : In our cases we did axonometries of the operated lower limb;s preoperatively and two weeks and six months after the operation. we noticed that the correction of the axis two weeks after operation. Conclusion : The lower limb’s axonometry is very useful and we consider it necessary for the high tibial osteotomy according Maquet. It is easy to be done, cheep and painless for the patients The information we get is critical preoperatively for the procedure and postoperatively fop the prognosis of the results

The lower limbs of vehicle occupants are vulnerable to severe injuries during under vehicle explosions. Understanding the injury mechanism and causality of injury severity could aid in developing better protection. Therefore, we tested three different knee positions in standing occupants (standing, knee in hyper-extension, knee flexed at 20˚) of a simulated under‐vehicle explosion using cadaveric limbs in a traumatic blast injury simulator; the hypothesis was that occupant posture would affect injury severity. Skeletal injuries were minimal in the cadaveric limbs with the knees flexed at 20˚. Severe, impairing injuries were observed in the foot of standing and hyper‐extended specimens. Strain gauge measurements taken from the lateral calcaneus in the standing and hyper-extended positions were more than double the strain found in specimens with the knee flexed position. The results in this study demonstrate that a vehicle occupant whose posture incorporates knee flexion at the time of an under‐vehicle explosion is likely to reduce the severity of lower limb injuries, when compared to a knee extended position

Surgical site infections following orthopaedic surgery are a serious complication associated with increased morbidity and mortality. Intra-wound antibiotic powder may be able to provide infection prophylaxis locally with less systemic adverse effects, and promising results have been reported in systematic reviews of its use in spine surgery. This study aims to analyse the efficacy and adverse effect profile of intra-wound antibiotics in reducing surgical site infections in orthopaedic surgery for traumatic pelvic and lower limb fractures.

A systematic review was conducted for studies reporting on the incidence of surgical site infections following administration of intra-wound antibiotic powder in pelvic and lower limb trauma surgery. Randomised controlled trials, cohort and case-control studies were included. A meta-analysis was conducted for deep surgical site infections.

Seven studies were included in the systematic review including six retrospective case-control studies and one randomised controlled trial. Results of the meta-analysis suggest a potential 23% reduction in the odds of developing a deep surgical site infection in patients treated with intra-operative antibiotic powder compared with those managed with intravenous antibiotics alone (OR 0.77, 95% CI 0.52 – 1.13), although the results did not reach statistical significance.

Notable selective bias against intra-wound antibiotics and suboptimal study design were found in the retrospective studies, however the randomised controlled trial reported a significant reduction in deep surgical site infections with intra-wound vancomycin powder. There were no reports of systemic adverse outcomes and minimal risk of wound complications with the use of intra-wound antibiotics.

This review suggests the use of intra-wound antibiotic powder in pelvic and lower limb trauma surgery may reduce the incidence of deep surgical site infections. Further powered studies including randomised controlled trials are required to confirm the results highlighted in this study.

Introduction

By utilising the inherent variability achievable with circular frames, surgeons can manage a wide spectrum of complex injuries, and can deal with deformity at multiple levels, in multiple planes. The aim of this study was to assess functional outcomes utilising patients reported outcome measures (PROMs) of patients being treated with circular (Ilizarov) frame fixation for complex lower limb injuries and assess these results in conjunction with the observed postoperative alignment of the patients’ limbs.

Recently we developed a personalised X-ray reconstruction-based planning and post-operative treatment evaluation system called iLeg for total knee arthroplasty or lower extremity osteotomy. Based on a patented X-ray image calibration cage and a unique 2D-3D reconstruction technique, iLeg can generate accurate patient-specific 3D models of a complete lower extremity from two standing X-rays for true 3D planning and evaluation of surgical interventions at the knee joint. The goal of this study is to validate the accuracy of this newly developed system using digitally reconstructed radiographs (DRRs) generated from CT data of 12 cadavers (24 legs). Our experimental results demonstrated an overall reconstruction accuracy of 1.3±0.2mm

Purpose: Surgical epiphysiodesis is one technique used to correct lower limb length discrepancy. Methods described include: in situ graft (Phemister, 1993), stapling (Blount, 1949), percutaneous curettage (Bowen, 1984). The purpose of this work was to evaluate a new technique described in 1998 (Metaizeau) which uses two percutaneous transphyseal screws. Material and methods: Forty-two patients (29 boys, 13 girls), mean age 13.1 years underwent the procedure. The cause of leg length discrepancy was unknown (n=12), fracture (n=16), congenital (n=7), other (n=7). Epiphysiodesis using two percutaneous screws was performed on the distal femur (n=24), the proximal tibia (n=7), both (n=11). Stance radiograms were obtained of the lower limbs before the intervention and at last follow-up to measure length of the lower limb, the tibia, and the femur. Difference with the healthy limb was determined as well as the percentage of growth comparing the healthy and epiphysiodesis sides. The operative time, duration of hospital stay and complications were studied. Results: Preoperatively, mean limb length discrepancy was 22.3 mm (10 to 70); at skeletal maturity, the difference measured 11 mm (28 to −20). Mean percent growth from epiphysiodesis to last follow-up was 3.15% for the epiphysidesis side and 6.26% for the contralateral side. Mean operative time was 20 min per bone (15–40). Complication rate was 16% including 7% stiff knee postoperatively with total recovery in two weeks, and 9% discomfort due to the presence of the screws. The growth curves showed that the epiphysiodesis was effective before three months. Mean hospital stay was 1.3 days (1–4). Discussion: The final outcome in terms of leg length discrepancy were comparable with other techniques. The rate of complications appears to be more favourable since there were no infections, no frontal or sagittal deviations, no vascular or nerve injuries, and since all complications resolved without sequelae. This intervention can be proposed as an outpatient procedure. Epithysiodesis is always obtained within three months. Conclusion: Epiphysiodesis using a percutaneous transphyseal screw is a simple method with minimal complications which provides reliable results and many advantages compared with other methods

We describe two patients with a diffuse haemangioma of the lower limb complicated by pathological fracture of the femoral shaft, one of whom was treated by a bone graft and immobilisation in a cast, and the other by external fixation and injection of bone marrow. A review of the literature identified difficulty in control of bleeding and obtaining bony union

Despite improved body armour haemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, goin and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a pre-hospital device capable of preventing pelvic and proximal lower limb haemorrhage by means of external aortic compression. The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure and abdominal girth were recorded. Doppler Ultrasound was used to identify blood flow in the Common Femoral Artery (CFA). The AAT was applied whilst the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached. 16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, BMI & abdominal girth. This study shows the Abdominal Aortic Tourniquet to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving