Introduction. Circular external frames (CEF) are commonly used for a wide variety of indications, often when other devices are not appropriate. Circular frames are particularly associated with pin-site infection (PSI). Currently there is a gap in the available literature surrounding the risk of frame use with in-situ prosthetic joints. This retrospective study investigated the incidence of prosthetic joint infection (PJI) in a series of patients with in-situ arthroplasties treated with CEF. Materials & Methods. From a departmental database of 1052 frames performed from March 2007-March 2023, the outcomes of 34 patients (40 frames) with in-situ arthroplasties at the time of CEF were reviewed (mean follow-up 70 months). Patient identification was by review of all local and regional imaging. The primary outcome was development of PJI during or following CEF and subsequent need for surgical intervention. Secondary outcomes were development of superficial pin site or deep bone infection (without PJI). Results. Of 40 frames used to treat 34 patients, no PJIs were detected. Average patient age was 67 (range 55–82). 22 had cardio-respiratory disease, 11 diabetes, 15 smoked and 8 were immunosuppressed. 53 arthroplasties were in situ at the time of treatment, 12 involving the same bone as the frame. Average time in frame was 253 days. 23 patients developed PSI, 2 required a further procedure for persistent deep bone infection not involving the arthroplasties. Conclusions. Although this study involves a relatively low numbers of patients, our results are reassuring that circular frame management in patients with in-situ arthroplasty does not represent an unacceptable risk of PJI. We hope to promote these findings and encourage multi-centre collaboration to expand on the available evidence to better answer this important yet under-reported clinical question

Introduction. Superficial pin site infection is a common problem associated with external fixation, which has been extensively reported. However, the incidence and risk factors with regards to deep infection is rarely reported in the literature. In this study, we investigate and explore the incidence and risk factors of deep infection following circular frame surgery. For the purpose of this study, deep infection was defined as: persistent discharge or collection for which surgical intervention was recommended. Materials and Methods. Retrospective review of all patients whom underwent frame surgery between 1. st. of April 2015 to 1. st. April 2019 in our unit with a minimum of 1 year follow up following frame removal. We recorded patient demographics, patient risk factors, trauma or elective procedure, number of days the frame was in situ, location of infection and fracture pattern. Results. 304 patients were identified. 27 patients were excluded as they were lost to follow up or had their primary frame surgery as a treatment for infection. This provided us with 277 patients for analysis. Mean age was 47 years (range 9–89 years), the male to female ratio was 1.5:1 and 80% were trauma frames. 13 patients (4.69%) developed deep infection and all occurred in trauma patients. Of the 13 patients who developed deep infection, 4 had infection before frame removal and 9 occurred after frame removal. 8 deep infections occurred within a year of frame removal, 1 occurred between 1 and 2 years. Within the 13 frame procedures for trauma, 12 were periarticular multifragmentary fractures, 3 of which were open, and the remaining was an open diaphyseal fracture. The periarticular fractures were more likely to develop deep infection than diaphyseal fractures (p–0.033). 12 patients (out of 13) also had concurrent minimally invasive internal fixation with screws in very close proximity of the wires. Conclusions. The rate of deep infection following circular frame surgery appears to be low. Pooled, multicentre data would be required to analyse risk factors however multifragmentary, periarticular fracture and the requirement for additional internal fixation appears to be an associated factor

Introduction. Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures. Materials & Methods. A prospectively maintained database was interrogated to identify all patients. Case notes and radiographs were reviewed to collate patient demographics and injury factors . The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions. Results. 247 open tibial fractures with a soft tissue manipulation in order to achieve skin cover, of which 203 had a minimum follow up of 2 years. Mean age was 43.2 years old, with 72% males, 34% smokers and 3% diabetics. Total duration of frame management averaged 6.4 months (SD 7.7). Nine (4.4%) patients developed a deep infection and 41 (20%) exhibited signs of a pin site infection. Seventy-five (37%) of patients had a secondary intervention of which; 8 comprised debridement of deep infection, 1 amputation for deep infection and the remainder adjustments of frames. Conclusions. Orthoplastic care including circular frame fixation for GA 3B fractures of the tibia results in a low rate of deep infection, around a quarter of contemporary literature for internal fixation

Open fractures of the long bones of the limbs are associated with an increased risk of osteomyelitis and few studies investigate this complication in circular frames. We reviewed the incidence of and contributory factors toward infection-related outcomes in Grade 3 open fractures, managed with a circular frame, at a single centre. We performed a retrospective study of consecutive adult patients presenting with a Grade 3 open fracture, who required a circular frame for definitive skeletal fixation from 2005 to 2014. Patient case notes, microbiology results and radiological studies were reviewed for demographic details and surgical management. Infection-related outcomes were classified as ‘possible’ and ‘definitive’, based on clinical findings, microbiology and imaging features at follow-up at 6 and 12 months. 74 patients were identified with an average age of 43 years. There were 70 unilateral and 4 bilateral limb injuries. Most treated limbs had a tibial fracture (97%). There were 24 Gustillo-Anderson grade 3A, 37 grade 3B, 4 grade 3C and 9 not sub-classified. 33% of patients were debrided on the day of injury. Average time to circular frame installation was 14 days. 27 Ilizarov, 44 Taylor spatial and 3 other circular frames were used. A variety of plastic surgery reconstruction was used to provide wound coverage: skin grafts, local and free flaps. Circular frames were in place for 259 days on average. 10 patients (1 bilateral limb fracture) still have their frames in-situ. Additional bone grafting to the fracture site was carried out in 13 patients and 15 limbs (1 patient had 2 episodes of bone grafting to the same limb). 8 limbs in 8 patients were excluded from infection-related outcome analysis: 4 patients lost to follow-up, 2 patients who went on to below knee amputation and 2 patients had <6 months’ follow-up. 13 patients (14 limbs) had only 6 months’ follow-up and 53 patients (56 limbs) had 12 months’ follow-up. There were 5 patients (5 limbs) with ‘possible’ infection (7%): 1 screw infection and 4 soft tissue infections. 1 patient (1 limb) had a tissue-confirmed ‘definitive’ infected non-union (1.4%). Patients managed with circular frames typically have complex fracture configurations less amenable to other methods of definitive fixation. Our patient cohort has a limb salvage rate (97%) and a soft tissue infection rate (‘possible’ infection) comparable to other reported series. We report a low rate of osteomyelitis (‘definitive’ infection) in consecutive patients managed using our protocol

Statement of Purpose. To compare the functional outcome of Distal Tibial Metaphyseal fracture treated with Circular frame compared vs. Locking Plate. Methods and Results. Distal Tibial Metaphyseal fractures were retrospectively identified over an 18 month period. Each fracture was assessed individually using radiographs. All paediatric, compound, tibial plateau and intra-articular fractures were excluded from the study. Other methods of fixation including intramedullary nailing were also excluded. The remaining fractures were assigned to either the circular frame fixation or the locking plate intervention group. Outcomes were assessed using radiographs for union dates and microbiology results for evidence of infection. Patients were followed up by postal questionnaires, which included a modified American Orthopaedic Foot and Ankle Score (AOFAS), the Olerud and Molander Score (O&M) and a custom questionnaire. The custom questionnaire asked about co-morbidities, smoking status and work days lost following surgery. After exclusions, 30 patients (Frame=15, Plate=15), were sent out questionnaires via post. We received completed questionnaires from 21 patients (Frame=11, Plate=10) giving us a response rate of 70%. Results show no difference in infection rates, skin necrosis, non-union or re-operation rates. There was also no significant difference in patient AOFAS and O&M scores at follow up. Conclusion. There is no significant difference in complications and functional Outcomes between locking plate fixation and circular frames in the treatment of distal Tibial Metaphyseal fractures

Tibial non-union causes significant morbidity and functional impairment. Circular frames are valuable tools in the treatment of non-union, however prolonged treatment often causes patients increased morbidity due to pin site problems together with personal and emotional strains. The purpose of this study was to assess patient centred outcomes following treatment of tibial non-union in circular frame. We identified 21 patients who had undergone treatment of tibial non-union using a circular frame. Patients were sent questionnaires utilising the Enneking scoring system and EQ-5D general health questionnaire. Fourteen patients responded. There were 3 females, mean age was 48.2 years. The average number of previous operations was 1.2. All patients went on to achieve union with a mean 10.1 months (6–20) in frame. The mean Enneking score was 58.0% (34.3–77.1). Two patients were enthusiastic about their treatment, two liked it, three were satisfied, four accepted and would do it again while three accepted it but would not do it again. The Euroqol questionnaire results showed that 8 patients had some difficulty with mobility, 10 had some difficulty with usual activities and 12 moderate pain. There was no significant difference in the EQ VAS score of overall health state for treated patients compared with predicted scores for an age and sex matched UK population (77.7 vs 83.1, p=0.07). Our study shows that many patients undergoing limb salvage with circular frames for tibial non-union continue to have clinically significant symptoms, however the majority would undergo similar treatment again and we found no difference in overall health state compared with age and sex matched predicted scores. Circular frames are undoubtedly a valuable tool in the management of non-union however patients should be given realistic counselling regarding the treatment and expected outcome

Introduction. Introduction: Pre-operative counselling to prepare patients for frame surgery is important to ensure expectations of recovery and rehabilitation are realistic and anxiety is reduced. The aim of the study was to ascertain whether the current clinical nurse specialist frames counselling session (CNS FCS) prepared patients adequately for life with a frame as well as to explore information patients felt was missing. Materials & Methods. Materials and Method: Patient reported questions were used to assess frames patient views on the CNS FCS. Thirty frames patients were asked about the CNS FCS information, involvement in decision making, factors influencing frames surgery decision and patient experience. Results. Results: There were 27 patients who received CNS frames counselling and 82% of those (N=22) said they definitely received enough information to make a decision when faced with a choice of surgical plans. 85% (N=23) reported definitely feeling involved in the decision making process with factors contributing to choosing frame treatment being lower risk of deep infection, quicker / safer recovery and advice from the limb reconstruction team. 48% (N=13) definitely felt the CNS FCS gave them a realistic idea of what it's like to live with a frame and 52% (N=14) answered yes to some extent. Feedback on providing more information around sleeping with a frame was provided which has been added to future CNS FCS. Conclusions. Conclusion: The current CNS FCS does prepare patients for frames surgery and life with a circular frame and important points raised by patients in this study have been added to future patient information sessions. Regular patient satisfaction audits should be carried out to ensure information remains useful and current patient needs and concerns are met

Introduction. The optimal management of intra-articular tibial plateau fractures with metaphyseal-diaphyseal dissociation remains challenging and controversial. We report results using the technique of limited open reduction with external fixation using a fine wire circular frame. Method. Between 1994 –2006, 83 eligible patients were identified. Case notes were reviewed; X-Rays and CT scans were examined and used to rank-order the severity of injury. ‘Musculoskeletal Functional Assessment’ (MFA) and ‘Knee Outcome Survey’ (KOS) questionnaires were completed and axial alignment X-Rays were taken to assess functional and radiological outcome. Results. 47 patients were available for follow-up at mean 57 months post injury. All fractures had united. There were 3 cases (6.39%) of pin site infection that necessitated debridement of superficial soft tissues. There were no cases of deep infection. Functional outcome. The mean MFA score was 24.7 points (range, 2 to 68 points). Leisure & recreation (51.06), mobility (37.02) and emotional score (33.22) were most affected. The mean KOS was 73.11 (range, 18.75 to 96.25). When compared to control population, our patient cohort still have significant persistent levels of disability. No correlation was found between severity of injury, nor any patient demographic factors and functional outcome. 26 patients (85.1%) had returned to employment, though 29.8% had either been forced to change occupation or were limited in their original occupation by their injury. Radiological outcome. Knee subluxation was found to have a significant association with poorer MFA (-0.323 p = 0.028) and KOS scores (0.304 p = 0.04). No other radiological measures correlated with functional outcome. Conclusion. Treatment of these severe injuries by circular frame and limited internal fixation is a safe and effective operative option. It offers early mobilisation and movement of the knee, with a low complication rate and functional outcome equivalent to other treatment modalities

Ilizarov frame removal often occurs in the outpatient setting, and previous data has shown it can be a painful experience. Frames with a total of four or more olive wires or half-pins in combination yielded increased pain scores at frame removal.

Sublingual fentanyl provides rapid onset, short acting analgesia for painful procedures such as dressing changes in burns patients. We hypothesised that administration of sublingual fentanyl, prior to frame removal would improve patients' pain scores.

Twenty-one patients were given 100 mcg sublingual fentanyl prior to frame removal. Their pain scores were documented on an 11-point (0–10) numeric visual scale before, immediately after, 15 and 30 minutes after frame removal, and the following day. The same nurse specialist removed all the frames. Nitrous oxide was available for patients if they needed further analgesia.

The majority of frames were removed from tibia. The average patient age was 40.8 years. Each frame had a median of 9 wires (range 2–17), and 4 olives (2–8). Eight frames had half pins (range 1–4, median 2). Fourteen patients used nitrous oxide in addition to fentanyl.

Overall, the average pain score was 3.1. This peaked at 7.5 immediately after frame removal, but 15 minutes following removal the average was 2.5. Patients who had supplementary nitrous oxide had higher pain scores throughout (though not beforehand), although these differences were not statistically significant.

Four patients (19%) reported adverse effects following administration, but none required medical intervention.

Patients' pain scores averaged 2.52 within 15 minutes of removal, compared with 5.25 from our previous review. This suggests that fentanyl may be beneficial in frame removal, but our sample size was small, and more research is needed in this area.

Early methods of treating high-energy tibial plateau fractures by open reduction and internal fixation led to high infection rates and complications. Alternative treatment methods include minimally invasive techniques and implants, external fixator stabilisation (monolateral and circular) and temporary external fixation followed by delayed definitive surgery. A clear understanding of the different fracture types is critical in achieving optimum results with minimally invasive techniques. The Chertsey classification system is based on the direction of force at the time of injury and helps with surgical planning. There are three groups: valgus, varus or axial fracture patterns.

124 tibial plateau fractures have been surgically treated in our hospital since 1995; there were 62 valgus, 14 varus and 48 axial type fracture patterns. Seventy-nine underwent open reduction with internal fixation, and forty-five had an Ilizarov frame. For valgus fractures the average IOWA knee score was 88 if internally fixed or 86 with an Ilizarov frame, range of motion was 140 and 131 degrees and time to union was 81 versus 126 days respectively. Varus fractures had an IOWA score of 83 (ORIF) and 95 (Ilizarov), ROM of 138 and 130 degrees and time to union of 95 versus 82 days. For axial fractures the average IOWA knee score was 85 (ORIF) compared to 82 (Ilizarov), the ROM was 124 degrees for both groups and time to union was 102 days and 141 days respectively.

Deep vein thrombosis occurred in 9% of cases with an Ilizarov and one patient required a total knee replacement for painful post-traumatic osteoarthritis. The infection rate for those internally fixed was 2.5%, three patients required a total knee replacement and 2.5% suffered a DVT.

Our results are comparable to the literature and the Chertsey classification of tibial plateau fractures helps with surgical planning.

Currently the debate continues in definitive fixation method for complex tibial plateau fractures. The aim of surgical management remains prevention of further damage to the articular cartilage, whilst avoiding iatrogenic risks - Low Risk Surgery (LRS). The purpose of this study was to determine the functional impact, clinical radiological outcome following tibial plateau fractures treated with either external fixation or internal fixation.

124 Schatzker IV-VI tibial plateau fractures were reviewed following surgical fixation. Fractures analysed included 24 type IV, 20 type V and 80 type VI tibial plateau fractures. The majority of Schatzker IV fractures were treated with internal fixation, but 67 of 80 Schatzker VI fractures were treated with the Ilizarov method. The average IOWA knee score, was 86 (16 to 100) and the average range of motion was 133 degrees (60 to 150). There were no differences between the circular fixator group and the internal fixation group in terms of range of motion or IOWA scores. There were comparable functional outcomes and complication rates between both groups.

In summary patients with high energy tibial plateau fracture treated with internal or external fixation, have a good chance of achieving satisfactory long term knee function.

Aims. The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. Methods. We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture. Results. There were 244 frames (230 patients) included in the analyses, of which 90 were Ilizarov type frames and 154 were hexapods. There were 149 frames which underwent single-stage reloading and 95 frames which underwent a two-stage reloading protocol. Mechanical failure occurred after frame removal in 13 frames (5%), which suffered refracture. There were no cases of change in alignment. There was no difference between refracture patients who underwent single-stage or two-stage reloading protocols (p = 0.772). In all, 14 patients had failure prevented through identification with the reloading protocol. Conclusion. Our reloading protocol is a simple and effective way to confirm the timing of frame removal and minimize the rate of mechanical failure. Similar failure rates occurred between patients undergoing single-stage and two-stage reloading protocols. If the surgeon is confident with clinical and radiological assessment, it may be possible to progress directly to stage two and decrease frame time and patient morbidity. Cite this article: Bone Jt Open 2022;3(5):359–366

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

Introduction. Numerous fixation modalities can be used for various indications, including deformity correction, trauma, infection, and non-union. The Modular Rail System (MRS) is a well-tolerated apparatus that is a viable option for patients who do not want a circular frame or for whom internal fixation is not appropriate due to poor soft tissues/co-morbidities. This case series evaluates the outcomes of the use of the MRS in our centre. Materials and Methods. Cases were identified from a prospectively gathered database. Data were collected including indication for treatment, frame duration, complications and treatment outcome. Eighteen eligible cases were identified (mean age 26, range 8–71). The MRS was sited in the femur in 14 cases, the tibia in three and the fibula in one. In nine cases, a circular frame was sited on the tibia below a femoral MRS. Frames were removed at an average of 20 weeks (range 7–31). Results. Eight complications occurred in six patients including fracture following removal (2), premature union (2), deep infection (1), scar complications (1), pin exchange (1) and non-union (1). 17/18 patients achieved their treatment goal and a satisfactory clinical outcome. Conclusions. We have demonstrated the use of the MRS in both trauma and elective practice and have found it to be well tolerated in our cohort of patients, particularly the paediatric and elderly populations. This case series demonstrates that, with the correct patient selection, the MRS is a versatile adjunct for use in limb reconstruction cases

Introduction. Routine radiographs in the follow-up of circular frames is commonplace, however the effect on clinical decision making is unclear. Previous work locally has suggested that >95% of radiographs, particularly at early time points, do not affect clinical management. This study was conducted to assess the impact of a transition to early remote follow-up on circular frame patients with limited radiographic assessment. Materials and Methods. Patients were identified from a prospective limb reconstruction database. Data were collected including the number of clinic appointments, type of clinic appointment, number of radiographs performed, and impact this had on clinical management. This was compared to our previous cohort of 85 patients undergoing standard follow-up. Results. Fourteen patients were eligible for inclusion (mean age 45, range 26–75). Circular frames were indicated for trauma (12), or limb reconstruction (2). Following introduction of remote follow-up, the mean number of face-to-face appointments reduced from 6.1 to 1.7 to the point of frame removal. Conversion from telephone follow-up to face-to-face follow-up was required in just one case where hardware failure occurred. The number of radiographs during treatment was reduced from a mean of 22 to 11 (range 4–20). Conclusions. Remote follow-up of circular frame patients was associated with significantly fewer radiographs and face-to-face appointments, without significantly increasing complications. We believe this is a safe and effective method of follow-up, optimising resource use in line with the NHS long term plan. Data collection is ongoing, and a larger cohort would be available for presentation

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. Materials & Methods. Cases were identified using a prospectively collected database of adult patients presenting between July 2018 and August 2021. Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Score (AOFAS), the 5-level EQ-5D (EQ5D5L), the Lysholm Knee Scoring Scale (LKSS), the Olerud-Molendar Ankle Score (OMAS), and the Tegner Activity Scale (TAS). Postoperative radiographs were analysed for fracture union and to quantify malunion (as described in Dror Paleys Principles of Deformity Correction). Results. The mean AOFAS, EQ5D5L, LKSS and OMAS scores showed an initial drop from pre-op to early time points and then steady increase over the early, mid, late and frame-off time points, with a resultant score higher than pre-op. Malunion was found in 35 (41.7%) patients, 7 patients had a malunion within 5 degrees of normal, 15 from 5–10 degrees of normal, 12 from 10–15 degrees of normal and 2 out with 15 degrees of normal. Conclusions. Circular frame fixation is an attractive option in complex lower limb trauma where alternative fixation methods are unsuitable. Whilst post-operative success to the surgeon might be determined radiographically, patient reported outcomes give a functionally important, objective measure of the success of the surgery to the patient

Introduction. We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy. Materials & Methods. A systematic review of the literature was conducted searching EMBASE, MEDLINE and Cochrane library for all articles discussing infected bone regenerate- a paucity of information was found. Abstracts were independently reviewed by 2 authors (LH and LT). In total, there were 16 papers, and then subsequently analysed we identified two case reports regarding infected regenerate. Results. Developing an infection in a regenerate is highly rare with very few reported cases within the published literature. The literature identified risk factors for an infected regenerate, with open fracture and smoking being the two consistent factors. The open fracture deep infection rate is cited at 10% in most publications, this is at the site of the open fracture and not within the regenerate. Conclusions. Infection within the regenerate during distraction osteogenesis is highly unusual, with only two other published papers in the literature to the best of our knowledge. This should be borne in mind when managing patients with infection of unknown sources in cases of distraction osteogenesis

Blount's disease is by far common cause of significant genu varum in paediatric age group. The deformity can range from simple varus deformity to significant varus, shortening of tibia and internal torsion of tibia, depending up on type and stage of Blount's disease. Several studies have shown excellent correction with the use of circular frame. The trend has moved from Ilizarov circular frame to Taylor Spatial Frame. The most accepted method of achieving correction of all components is by performing proximal tibial osteotomy and gradual correction of mechanical axis. Traditionally two additional procedures – fibular osteotomy and fixation of distal tibio-fibular syndesmosis are also added. However, the role of these additional procedures, which are not without their complications, is not well evaluated. A recent study had shown that correction of tibia vara without lengthening can be achieved without fibular osteotomy. However, use of distal tibio-fibular syndesmosis fixation (either with a wire or a screw) remains controversial. We present our experience in treating Blount's deformity with circular frame without stabilization of distal tibio-fibular syndesmosis. 10 patients were treated at our tertiary referral centre between 2000 to 2010. There were 7 boys and 3 girls. Age at surgery ranged from 8 yrs – 15 yrs. The mean patient age was 11.5 yrs. Two patients were treated with Ilizarov frame and 8 with Taylor Spatial Frame. Indications for surgery were unacceptable deformity (varus and internal rotation), with or without shortening. Varus deformity ranged from 10 degrees to 40 degrees. All tibiae were lengthened and the range of lengthening was from 1cm to 3.5cm. Fibular osteotomy was carried out in all patients. Tibio-fibular syndesmosis was never stabilized distally. All the patients were encouraged to mobilise full weight bearing as soon as tolerated and all of them had gradual correction of deformity usually starting a week following the surgery. We achieved target correction of varus, internal rotation and leg length discrepancy in all patients. The commonest hurdle was superficial pin tract infection which resolved with short courses of oral antibiotics. Follow up ranged from 6 months to 10 yrs. Clinical and radiological evaluation of ankle did not show any abnormality in all these cases. Satisfactory correction of Blount's disease (tibia vara and leg length discrepancy) can be achieved with circular frame without the stabilization of distal tibio-fibular syndesmosis

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

Introduction. Introduction: Pin site infection is a common complication during treatment with a circular frame external fixator and increases time and support patients require from the limb reconstruction team. Wound swabs were not routinely sent by the clinical nurse specialists prior to this study, with most pin site infections treated as Staphylococcus aureus with flucloxacillin (clindamycin in penicillin allergy). The aim of this study was to ascertain whether routine sending of wound swabs in pin site infection would change antibiotic treatment. Materials & Methods. Materials and Method: Patients presenting at clinic or physiotherapy with clinical signs of pin site infection were assessed using the Maz Oxford Nuffield (MON) Pin Site Infection Grading System© (OUH, 2021). Antibiotics were commenced as per unit guidelines and swabs sent for microscopy, culture and sensitivity. Results. Results: There were forty patients treated with pin site infections. Swab results showed S. aureus in 60% (N=24), other organisms in 15% (N=6) and no growth or mixed skin organisms in 10% (N=10). Flucloxacillin was prescribed to 77.5% (n=31) of patients with the remaining 22.5% (n=9) of patients receiving clindamycin (due to allergy) or rifampicin and ciprofloxacin (due to a previous MRSA diagnosis). Antibiotic management was subsequently changed in only 5% (n=2) of patients due to one patient with a new MRSA diagnosis and one patient growing Enterobacter in three pin sites tested. Conclusions. Conclusion: This study has shown that routine swab testing of pin sites does not usually change antibiotic management but should still be used in multiple, severe or unresolving pin site infections