Of 48 consecutive children with Gartland III supracondylar fractures, 11 (23%) had evidence of vascular injury, with an absent radial pulse. The hand was pink and warm in eight and white and cold in the other three patients. They underwent colour-coded duplex scanning (CCDS) and ultrasound velocimetry (UV) to investigate the patency of the brachial artery and arterial blood flow. In seven patients with a pink pulseless hand, CCDS showed a displaced, kinked and spastic brachial artery and a thrombosis was present in the other. In all cases UV showed reduced blood flow in the hand. In three patients with a white pulseless hand, scanning demonstrated a laceration in the brachial artery and/or thrombosis. In all cases, the fracture was reduced under general anaesthesia and fixed with Kirschner wires. Of the seven patients with a pink pulseless hand without thrombosis, the radial pulse returned after reduction in four cases. The remaining three underwent exploration, along with the patients with laceration in the brachial artery and/or thrombosis.

We believe that the traditional strategy of watchful waiting in children in whom the radial pulse remains absent in spite of good peripheral perfusion should be revisited. Vascular investigation using these non-invasive techniques that are quick and reliable is recommended in the management of these patients.

Cite this article: Bone Joint J 2013;95-B:694–98.

Osteotomies are commonly carried out in orthopaedic surgery, particularly in limb reconstruction. Complications are uncommon provided that sufficient care is taken and a sound technique used. We describe three cases of formation of false aneurysm after osteotomy, with acute, delayed and asymptomatic onset. The diagnosis was supported by ultrasound investigation, and confirmed by angiography. Embolisation with coils was a successful method of treatment. We recommend a safe method of osteotomy with good bone exposure and adequate soft-tissue protection.

Introduction. The use of thoracic pedicle screws for the treatment of adolescent idiopathic scoliosis (AIS) has gained widespread popularity. Many techniques has been described to increase the accuracy of free hand placement; however the placement of pedicle screws in the deformed spine poses unique challenges because of possible neurologic and vascular complications. We are describing a universal way of insertion of pedicle thoracic screws which has been applied in many pathologies including the deformed spine. Methods. Our technique includes exposure of the superior facet of the corresponding body to identify its lateral border border which together with the superior border of the TP denotes our entry point which is just lateral to this crossing, we make a short entry with a straight Lenke probe then continue the track with a strong ball probe to go safely through the cancellous bone of the body. This is retrospective review of radiographs and clinical notes of all the patients who underwent posterior thoracic instrumentation by pedicle screws using the same single technique by one surgeon between June 2008 and December 2009; 1653 screws in 167 consecutive patients (119 females and 48 males). There were 139 deformities, 130 scoliosis (AIS 80, Congenital 31, Neuromuscular 10 and Degenerative 9), 19 kyphosis and 18 other diagnoses (fractures 14, revision 3 and tumour 1). Results. The recorded complications for all the patients were: 1 patient had pain due to nerve impingement, 1 parasthesia and 1 CSF leak intraoperatively. There were no revision of any of the screws, no vascular complications. Conclusion. Thoracic pedicle screws can be inserted with a universal point of entry using the same technique in all the levels of the dorsal spine. This technique seems to be simple and safe. Ethics approval: None. Interest Statement: None

Aim and method We report the outcomes of 100 consecutive diabetic patients who had been prescribed diabetic footwear for 10 years. A podiatrist and orthotist reviewed them at a dedicated clinic. The study aim was to assess footwear efficacy and prevention of ulcers, re-ulceration and amputations. Conclusion Protective footwear is essential in maintaining healthy diabetic feet. Amputations were only due to vascular complications. All 56 patients who attended remained intact at 2 years. Of the seven ulcerations at 5 years, three went onto below-knee amputation. At 10 years, there were a further three ulcerations, resulting in one minor black toe and one further BK amputation. Adherence with follow up including footwear review minimises risk. Re-ulceration at 5 years is associated with risk of amputation. Ten-year mortality is high due to vascular complications. Summary Continued patient adherence with Orthotic therapy confers benefit and minimised re-ulceration. Follow up by Orthotists is an under-utilised resource

Talectomy was performed on 31 rigid clubfeet in 13 boys and 10 girls. Sixteen patients had myelomeningocele and seven arthrogryposis. The procedure was undertaken as a salvage operation on 22 feet. Seven patients had an additional cuboidectomy. The mean age of the patients was 3.7 years (2 to 9). The patients were followed up for a mean of 4.5 years. Assessment included foot position, appearance and mobility, orthotic or shoe-wear fitting and walking capacity. Calcaneal position at the ankle was assessed radiologically. The results in 18 feet were good and in seven were satisfactory. There were six failures. Primary talectomy produced better results in children above the age of two years than ssecondary procedure in the older children. One of the patients developed a severe vascular complication, followed by sepsis, and required amputation of the foot. The other failures were due to recurrence of equines deformity. Talectomy performed for severe rigid clubfoot achieved satisfactory correction in most of our patients. Excision of the talus as a salvage procedure carries a risk of incomplete correction and vascular complication

Purpose: Vascular complications in lumbar disc surgery are rare, difficult to diagnose and may have serious consequences. We review our experience in eight cases treated in the past 30 years. Methods: Between 1976 and 2005 we operated on 16,391 cases of vascular pathology, eight for vascular complications after lumbar discectomy (herniated disc), six men and two women aged 36 to 70 (mean 52 years). The symptoms were abdominal pain in four, ischial irradiation in one, episodes of heart failure in one, limb oedema in two, acute haemorrhage in three, abdominal murmur in two. The diagnosis was made during surgery in two cases and immediately postoperative in the third due to severe hypovolemia. The others were diagnosed because of abdominal murmur, limb oedema and suspected abdominal aneurism. Abdominal CT scans and arteriography were performed in five cases. Treatment was surgical, with direct closure in seven cases and interposition of a Dacron aortoiliac prosthesis in the other. No sequelae were seen during follow-up, which lasted a maximum of fifteen years. All the patients returned to normal life and there was no mortality. Conclusions: Because of the severity and rareness of this complication, few cases have been described in the literature, and its real incidence is therefore unknown. We should think of it whenever there is any unexplained, sustained haemodynamic disorder during lumbar disc surgery or immediately postoperative. Treatment should be immediate

Aim: Vascular complications associated with locked intramedullary tibial nailing are rare but always serious. The purpose of this cadaveric study is to define the risk of vascular complications after proximal locking in intramedullary tibial nailing. Material and Methods: Seven fresh cadaver legs were obtained from the University Hospital of loannina. The Grosse & Kempf Tibial Locking Nail was used with anterior-posterior locking. Each procedure was performed according to a standard protocol. The insertion point of the tibial nail was just above the level of the tibial tuberosity. The direction of the proximal locking screw was oblique from caudal to cranial and from lateral to medial. For imaging, both the nail and screws were removed and titanium screws were inserted, thereby allowing good visualization. Results: MRI sections combined with CT and 3D-CT have been used to illustrate the findings, as they clearly demonstrate the relationships between the locking screws and adjacent vascular structures. Analysis of these findings highlighted the surgical risks associated with this type of proximal locking and its direction. Conclusions: Proximal anterior-posterior locking in intramedullary tibial nailing is a hazardous procedure because of the small distance between tibia and vascular structures. The use of a new direction for proximal anterior-posterior locking is recommended

Purpose: Vascular complications associated with locked intramedullary tibial nailing are rare but always serious. The purpose of this cadaveric study is to deþne the risk of vascular complications after proximal locking in intramedullary tibial nailing. Methods: Seven fresh cadaver legs were obtained from the University Hospital of Ioannina. The Grosse & Kempf Tibial Locking Nail was used with anterior-posterior locking. Each procedure was performed according to a standard protocol. The insertion point of the tibial nail was just above the level of the tibial tuberosity. The direction of the proximal locking screw was oblique from caudal to cranial and from lateral to medial. For imaging, both the nail and screws were removed and titanium screws were inserted, thereby allowing good visualization. Results: MRI sections combined with CT and 3D-CT have been used to illustrate the þndings, as they clearly demonstrate the relationships between the locking screws and adjacent vascular structures. Analysis of these þndings highlighted the surgical risks associated with this type of proximal locking and its direction. Conclusions: Proximal anteriorposterior locking in intramedullary tibial nailing is a hazardous procedure because of the small distance between tibia and vascular structures. The use of a new direction for proximal anterior-posterior locking is recommended as an alternative procedure to eliminate the potential for iatrogenic lesions

We adduce the following conclusions from our experience of using this spring-loaded compression screw on completely displaced medial fractures of the femoral neck:. 1. That this method probably eliminates non-union when the head is fully viable. 2. That primary "first-intention" osseous union occurs in approximately 33·3 per cent of cases. 3. That a vascular complication, of varying severity, undetectable by orthodox radiological tests, is revealed by extrusion of the screw in 66·6 per cent of cases. 4. That these observations disprove the idea that the main obstacle to revascularisation of an ischaemic head is the existence of forces so inclined to the axis of the femoral neck as to cause "shear.". 5. That, compared with the Smith-Petersen nail used for completely displaced fractures, continuous spring compression can materially reduce the incidence of utter mechanical failure within the first year after operation. This is the result of "mushroom" impaction which itself can resist shearing strain and so can permit function as a fibrous union. 6. That early and rapid extrusion is a sensitive indication of a vascular complication in the head. Forewarned by this, activity can be restricted, or possibly other measures adopted, to anticipate or permanently postpone serious trouble

Study design: A retrospective evaluation of screw position after double rod anterior spinal fusion in idiopathic scoliosis using computerised tomography (CT). Objective: To evaluate screw position and complications related to screw position after double rod anterior instrumentation in idiopathic scoliosis. Summary of Background Data: Anterior instrumentation and fusion in idiopathic scoliosis is gaining widespread use. However, no studies have been published regarding the accuracy of screw placement and screw related complications in double rod and double screw anterior spinal fusion and instrumentation in idiopathic thoracolumbar scoliosis surgery. Methods: CT examinations were performed after anterior spinal fusion and instrumentation in 17 patients with idiopathic scoliosis. The vertebral rotation at each level was measured. At each instrumented level the position of the screw and the plate relative to the spinal canal, relative to the neural foramen and relative to the aorta was measured. Complications related to screw position were registered. Results: 189 screws in 17 patients were evaluated. The average age of the patients was 31 years (range 15–53 years). Fourteen patients had a left convex thoracolumbar curve and three patients a right convex thoracolumbar curve. The mean lumbar apical rotation preoperatively was 27°. Malposition occurred in 23% of the total number of screws. Three screws were in the spinal canal (1%). This resulted in pain in the right leg. However, electromyography showed no abnormalities. On three levels there was contact between the instrumentation and the aorta. No vascular complications did occur. 113 screws (ten patients) were placed under fluoroscopic guidance and 76 screws (seven patients) were placed without use of fluoroscopy. No complications related to screw position were observed in the group in which the screws were placed under fluoroscopic guidance. Conclusions: Adequate placement of two screws in the vertebra in idiopathic scoliosis is a technically demanding procedure, which results in frequent malposition, fortunately with a low risk of neurological and vascular complications

Purpose of the study: To analyse 300 supracondylar fractures with major displacement presenting with acute vascular comprimise and to propose an effective therapeutic strategy in a tertiary referral centre. Material and Methods: Three hundred patients aged 18 months to 14 years were treated for Larange stage IV supracondylar fracture of the humerus in the same centre. Acute vascular compromise was noted in 46 cases (15%). The radial pulse was absent in all patients with two different contexts: ‘pink hand’ with good distal perfusion in 41 cases (13.5%) and ‘white hand’ with ischemia in five cases (1.5%). Nerve injury was associated in half of the cases, predominantly involving the medial nerve (87%). Emergency management included repeated assessment of the vascular and nervous status using a departmental protocol and Doppler control together with oxygen saturation. Emergency anatomical reduction and stable percutaneous fixation, with lateral and medial wires via a minimal medial exposure to control the ulnar nerve, was performed in all cases. Post-operative immobilisation with a posterior splint at 90° of elbow flexion. Repeated postoperative clinical surveillance: distal perfusion, O2 saturation and Doppler assessment. Results: 90% of the cases with vascular compromise had posterolateral displacement. Post reduction, the radial pulse was restored immediately in 28 cases and secondarily in 10. The three remaining cases with an absent radial pulse but with a pink hand developed ischemia necessitating surgical exploration revealing incarceration of the brachial artery and medial nerve within the fracture site. Release of the brachial artery restored the radial pulse. The five cases of primary ischemia with absent pulse and a white hand were managed by emergency reduction followed by exploratory surgery and vascular repair which restored the radial pulse, excepting one case which required anterior fasciotomy. Conclusion: Early vascular complications after stage IV supracondylar humerus fractures are common in children. This study identified the following points: priority is required for reduction of these fracture and emergency stabilisation; posterolateral displacement is associated with a higher risk of vascular complications; these injuries should be treated in a specialised centre; the absence of a radial pulse with a pink hand warrants repeated observation during the postoperative period; it is not an absolute indication for invasive investigation and surgical exploration; the absence of a pulse with a white hand requires surgical vascular exploration

Purpose of the study: The rate of intra and postoperative complications is generally high after surgery for neurogenic paraosteoarthropathy, also termed hetero-topic ossification. Material and methods: We present a series of 60 cases of osteoma involving the hip joint, analyzing complications in comparison with data in the literature. Results and discussion: Vascular complications (n=7): one required suture of the common femoral artery, three ligature of the deep femoral artery, two ligature of the deep femoral vein and one ligature of the collateral branches of the deep femoral vessels. Mean intraoperative blood loss was 1300 cc. None of the vascular complications gave rise to death or amputation. Early septic complications (n=4): three occurred after simple resection of the ossification and cured after surgical revision and antibiotics with no major impact on joint motion; one occurred after a procedure for resection of the ossification plus total hip arthroplasty and led to ankylosis of the hip joint but cured after surgical revision and prolonged antibiotic therapy. Sepsis was favored by a long hemorrhagic surgical procedure in patients at risk. Neurological complications (n=0): such complications are greatly feared but rare. Posterior ossifications expose the sciatic nerve to injury but generally displacement the nerve rather than enclosing it in the osteoma. Fracture complications (n=1): the outcome was favorable, both in terms of bone healing and joint motion. A classical complication mentioned in the literature and synonym to recurrent ossification or invalidating residual stiffness. Most are favored by ankylosis, osteoporosis, immobilization and a particularly dynamic surgeon. Recurrences (n=6): all were posttraumatic with a delay from accident to surgery ≥ 18 months. Conclusion: Complications are related to the localization of the osteoma (relations with nerves and vessels), associated osteopathy, and the complete or partial joint stiffness. Preoperative imaging (x-rays and computed tomography with contrast injection) should localize the osteoma, keeping in mind that certain localizations create preferential conditions for certain risks. An analysis of the topography of the paraosteoarthropathy should enable the surgeon to choose the most appropriate approach. Intraoperatively, risk assessment can usefully anticipate complications which always compromise functional outcome

Aims

Ilium is the most common site of pelvic Ewing’s sarcoma (ES). Resection of the ilium and iliosacral joint causes pelvic disruption. However, the outcomes of resection and reconstruction are not well described. In this study, we report patients’ outcomes after resection of the ilium and iliosacral ES and reconstruction with a tibial strut allograft.

Aims

Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries.

Aims

The aim of this study was to reassess the rate of neurological, psoas-related, and abdominal complications associated with L4-L5 lateral lumbar interbody fusion (LLIF) undertaken using a standardized preoperative assessment and surgical technique.

Purpose: The bifoliated vascularised fibula graft is an attractive alternative for reconstruction of large bone segments. The purpose of this work was to evaluate mid-term results and the usefulness of two surgical techniques: skin island flap monitoring and the arterio-venous loop. Material and methods: This retrospective analysis included fourteen patients (eleven men and three women) treated between 1992 and 2002. Mean age was 30 years (10–54). Indications were complications of open fractures in nine patients, major bone loss in two, septic nonunion in four, and aseptic nonunion in three. Reconstruction was performed after bone tumour resection in five patients involving immediate reconstruction after failure of an infected massive allograft in four of them. Localisations were: tibia (n=6), femur (n=5), humerus (n=2), and pelvis (n=1). Average bone loss was 10 cm (7–15 cm). Minimal pinning, cerclage or screwing was used to stabilise the flap completed by internal fixation in four patients and external fixation in ten. A monitoring skin island was used for twelve patients (the island was technically impossible in two patients). Vascular anastomoses were performed in seven patients using an arteriovenous loop, performed as a preliminary measure in six. Results: Mean follow-up was 35 months. One patient died early from tumour progression. Among the seven patients who had an arteriovenous loop, one required revision for a vascular complication. For the seven “classical” bypasses, there were three intraoperative or early complications requiring revision of the anastomoses. Nonunion developed despite early revision in the four patients whose monitoring skin island suffered. Consolidation was achieved without revision in all patients who skin island did not suffer; time to bone healing was eleven months for seven of them. Conclusion: Bone healing was related to the quality of graft vacularisation. Clinical observation of the monitoring island was the best way to identify vascular complications early and initiate treatment. Use of a preliminary arteriovenous loop decreased the risk of vascular insufficiency inherent with long bypasses and shortened operative time

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Aims. Periacetabular osteotomy is an effective way of treating symptomatic hip dysplasia. We describe a new minimally invasive technique using a modification of the Smith-Peterson approach. We performed a prospective, longitudinal cohort study to assess for any compromise in acetabular correction when using this approach, and to see if the procedure would have a higher complication rate than that quoted in the literature for other approaches. We also assessed for any improvement in functional outcome. Patients and Methods. From 168 consecutive patients (189 hips) who underwent acetabular correction between March 2010 and March 2013 we excluded those who had undergone previous pelvic surgery for DDH and those being treated for acetabular retroversion. The remaining 151 patients (15 men, 136 women) (166 hips) had a mean age of 32 years (15 to 56) and the mean duration of follow-up was 2.8 years (1.2 to 4.5). In all 90% of cases were Tönnis grade 0 or 1. Functional outcomes were assessed using the Non Arthritic Hip Score (NAHS), University of California, Los Angeles (UCLA) and Tegner activity scores. Results. The mean pre-operative lateral centre-edge angle was 14.2° (-5° to 30°) and the mean acetabular index was 18.4° (4° to 40°). Post-operatively these were 31° (18° to 46°) and 3° (-7° to 29°), respectively, a significant improvement in both (p < 0.001). Allogenic blood transfusion was required in two patients (1.2%). There were no major nerve or vascular complications, and no wound infections. At the time of last follow-up, we noted a significant improvement in functional outcome scores: UCLA improved by 2.31 points, Tegner improved by 1.08 points, and the NAHS improved by 25.4 points (p < 0.001 for each). Hypermobility and longer duration of surgery were significant negative predictors for a good post-operative UCLA score, while residual retroversion was a positive predictor of post-operative UCLA score. Conclusion. We have found this approach to be safe and effective, facilitating early recovery from surgery. Cite this article: Bone Joint J 2017;99-B:22–8

Aims

Developmental dysplasia of the hip (DDH) describes a pathological relationship between the femoral head and acetabulum. Periacetabular osteotomy (PAO) may be used to treat this condition. The aim of this study was to evaluate the results of PAO in adolescents and adults with persistent DDH.

Introduction. Periacetabular osteotomy has been described as an effective way of treating symptomatic hip dysplasia. We describe a new minimally invasive technique using a modification of the Smith Peterson approach. Patients/Materials & Methods. 189 consecutive patients operated on between March 2010 and March 2013 were included in the study. Patients who had undergone previous pelvic surgery for DDH were excluded. There were 174 females and 15 males. The mean age was 31 years (15–56) and the mean duration of follow-up was 29 months (14 – 53 months). 90% of cases were Tonnis grade 0 or 1. Twenty-three patients were operated on for primary acetabular retroversion. Functional outcomes were assessed using the NAHS, UCLA and Tegner activity scores. The surgical procedure is performed through an 8–10 cm skin crease incision; a soft tissue sleeve is elevated from the anterior superior iliac spine. The interval medial to the rectus femoris is developed. The hip joint is not opened and fixation of the osteotomy was with three 4.5mm cortical screws. A cell saver was routinely used. Results. For the dysplasia group the mean pre-operative lateral centre edge angle was 14.2degrees (−5degrees to 30degrees) and the mean acetabular index was 18.4degrees (4degrees to 40degrees). Post-operatively these were 31degrees (18degrees to 46degrees) and 3degrees (−7degrees to 29degrees) respectively. An allogenic blood transfusion was required in 3 patients (1.5%). The mean duration of surgery was 105 minutes. There were no major nerve or vascular complications and no wound infections. At the time of last follow-up, we noted a significant improvement in functional outcome scores: UCLA improved by 2.31 points, Tegner improved by 1.08 points, and the NAHS improved by 25.4 points. Conclusion. We have found this approach to be safe and effective, facilitating early recovery from surgery