Introduction. In Europe, injectable collagenase clostridium histolyticum (CCH) is a novel, minimally invasive, non-surgical therapy with efficacy in correcting Dupuytren's contracture (DC). We evaluated the efficacy and tolerability of 5 CCH injections using a protocol designed to follow clinical practice. Methods. This was a 20-center, 9-month, open-label study in which DC patients with primary flexion deformities 20° (100° for MP; 80° for PIP) received 3 CCH (0.58 mg) injections/joint (5 injections/patient) at 30-day intervals. The primary endpoint was clinical success, defined as a reduction in contracture to 5° 30 days after the last injection (“Day 30”). After first injection into a prioritized joint, patients opted to receive up to 2 more injections into the same cord or cords from other affected joints whether or not they achieved clinical success with the first joint. Adverse events (AEs) were monitored. Results. For the primary endpoint, 71% of MP (n=343) and 41% of PIP (n=244) joints showed a reduction in contracture to 5° with CCH injections. Of joints that did not achieve clinical success, 66% of MP (n=100) and 38% of PIP joints (n=144) showed 50% reduction in contracture after CCH. For range of motion (ROM), mean±SD increase from baseline to Day 30 was 33.0±16.2° for MP and 27.5±18.5° for PIP joints. Most commonly reported AEs were localized edema, bruising, pain, swelling, and tenderness; most resolved without intervention. Two serious AEs, deep vein thrombosis in the leg and tendonitis with partial tendon/ligament injury, were deemed possibly and probably related to treatment, respectively. Conclusions. Results from this open-label study, designed to follow clinical practice, provide support for the efficacy of CCH in correcting the flexion deformity of MP/PIP joints caused by DC. Clinical success and ROM improvements were comparable to those observed in randomized, placebo-controlled trials. This study was funded by Auxilium Pharmaceuticals, Inc

Aim. To review current military orthopaedic experience and establish if there exists a consensus of opinion in how and if to perform fasciotomy of the foot and to guide other clinicians. Method. A questionnaire was sent to 10 DMS orthopaedic consultants to identify their experience with foot compartment syndrome and performing fasciotomies. Results. 50% had performed a foot fasciotomy (average 2, range 1-6) over an average of 6.2 years as consultant and an average of 7.3 months deployed. Most commonly two dorsal and a medial incision were used to decompress the foot, while one advocated not decompressing and accepting the contractures, a view consistent with some civilian literature. Discussion. The debate surrounding decompression stems from the rarity of the condition, the lack of consensus regarding the anatomy of the foot compartments and whether to accept the inevitable contractures by not decompressing. Given that foot compartment syndrome may not be seen during civilian training, then there is a requirement for guidance for the deploying military surgeon. Conclusion. DMS clinicians need to remain vigilant to compartment syndrome of the foot and especially in cases of crush or blast injury or of multiple fractures. If diagnosed or even if an impending compartment syndrome is suspected then the foot should be decompressed and the deployed orthopaedic surgeon should be capable of performing it

Introduction. Muscle stiffness and joint contractures are common complications of limb lengthening. Authors have demonstrated less permanent soft tissue complications with intramedullary lengthening than external fixation. Our aim was to evaluate the joint response following intramedullary femoral lengthening and need for physiotherapy and alteration to rate/rhythm of lengthening. Method. A retrospective review of documentation for all femoral Precice nails in our centre inserted between 2012 and 2017. This involved 98 nails (68 antegrade, 30 retrograde) in 88 patients (59 males, 29 females) with a mean age of 32 years (range 12–69 yrs). We excluded cases where there was no documentation regarding Range of Movement (ROM). Bilateral lengthenings were recorded as separate cases. This left 50 antegrade, 16 retrograde cases with hip ROM data and 55 antegrade, 26 retrograde cases with Knee ROM data. Results. Hip. In the antegrade group 20 cases (39%) developed no stiffness throughout treatment. ROM decreased in 61% (n=30) of cases and the median length at which this occurred was 3cm. Where a retrograde nail was inserted 62.5% of cases (n=10) maintained normal range of motion. The median length at which ROM decreased was 3.25cm, this occurred in 6 cases (37.5%). . Knee. Where the antegrade nail was inserted, 22 cases (40%) did not develop stiffness. There was reduced ROM in 33 cases (60%), occurring at a median distance of 2cm. The median distance at which reduced ROM occurred with the retrograde nails was 1.5cm, this occurred in 23 cases (88.5%). 3 cases did not develop stiffness. All cases regained full ROM. Conclusion. Although there was no permanent loss, Joint Stiffness still occurs with intramedullary limb lengthening and there remains the need for regular physiotherapy. There are no data from other institutions for comparison. Rehabilitation guidelines and a proforma to accurately monitor patients ROM throughout treatment have been developed

Introduction. We present a series of patients who have had secondary reconstruction of war injuries to the upper and lower limbs, sustained during the Iraq and Afghanistan conflicts. Material and Methods. All patients were seen at the combined Peripheral Nerve Injuries Clinic at the Defence Medical Centre for Rehabilitation, Headley Court. All surgery was performed at Odstock Hospital. Procedures include scar excision and neurolysis (all patients), release of scar contractures, tenolysis, tendon transfers, revision nerve grafts, excision of neuroma, and soft tissue reconstruction using pedicled or free flaps. Results. 24 patients have been treated at the time of submission. We have using 13 free flaps (1 free groin flap, 9 anterolateral thigh, 3 parascapular, with 4 as through-flow flaps) and 1 pedicled groin flap, with no flap losses. There were 6 amputation stump revisions (1 above elbow, 5 below knee). The majority (n=23) have had nerve recovery distal to the level of injury following revision surgery. Conclusions. Nerve repairs recover following neurolysis (and revision nerve graft if necessary) with provision of good soft tissue cover. Release of scar contractures with flap cover allows healing of chronic wounds and permits mobilisation of joints. Thin fasciocutaneous flaps provide good contour and can be elevated more easily than skin grafted muscle flaps for secondary surgery. Free or regional flaps are preferable to local flaps in high energy-transfer military wounds. Immediate complex reconstruction is not always appropriate in multiply-injured patients

Aims

Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes.

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75). All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°

Limb length deficiency, secondary to trauma or infection, is a common reason for referral to our tertiary service. After experiencing troubles with the Intramedullary Skeletal Kinetic Distractor (ISKD), we changed implant to the magnet operated Precice nail. We evaluated the safety and reliability of this novel device and compared it to our early ISKD results. To minimise variables, we selected femurs only. In total, we reviewed medical and radiographic records of 20 cases (8 ISKD, 12 Precise) from 2010–2015. At each postoperative visit, the accuracy and precision of distraction and complications were recorded. Accuracy reflected how close the measured lengthening was to the prescribed distraction at each postoperative visit. Precision reflected how close the repeated measurements were to each other over the course of total lengthening period. No patients were lost to follow-up (1–3.5 years). With the Precice nail (2012–2015), 11/12 were male and 10/12 were caused by trauma. The mean age was 34. Mean total lengthening was 38mm (range, 29–53mm), with an accuracy of 98percnt; and precision of 92percnt;. All patients achieved target lengthening at a rate of 1mm lengthening per day. In one case, the Precice nail fractured and this was revised successfully. With the ISKD group (2010–2012), 8/8 had complications (magnet jamming, nail breakage, equinus contractures and claw toes), with 25percnt; achieving accurate lengthening and precision of 38percnt;. Our results so far have justified our change in implant choice and, in our experience, support the Precice nail as being safe and precise

A series of 26 children was referred to our specialist unit with a ‘pink pulseless hand’ following a supracondylar fracture of the distal humerus after a mean period of three months (4 days to 12 months) except for one referred after almost three years. They were followed up for a mean of 15.5 years (4 to 26). The neurovascular injuries and resulting impairment in function and salvage procedures were recorded. The mean age at presentation was 8.6 years (2 to 12). There were eight girls and 18 boys. Only four of the 26 patients had undergone immediate surgical exploration before referral and three of these four had a satisfactory outcome. In one child the brachial artery had been explored unsuccessfully at 48 hours. As a result 23 of the 26 children presented with established ischaemic contracture of the forearm and hand. Two responded to conservative stretching. In the remaining 21 the antecubital fossa was explored. The aim of surgery was to try to improve the function of the hand and forearm, to assess nerve, vessel and muscle damage, to relieve entrapment and to minimise future disturbance of growth. Based on our results we recommend urgent exploration of the vessels and nerves in a child with a ‘pink pulseless hand’, not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia

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To explore staff experiences of a multicentre pilot randomized controlled trial (RCT) comparing intramedullary nails and circular frame external fixation for segmental tibial fractures.

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Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy.

Purpose of this study is to create an experimental model of electrophysologic evaluation of the supraspinatus muscle on rats, after traumatic rupture of its tendon. The population of this study consisted of 10 male Sprague Dawley rats weighting 300–400g. Under general anaesthesia we proceeded with traumatic rupture of the supraspinatus tendon and exposure of the muscle. The scapula was immobilized, and the supraspinatus tendon was attached to a force transducer using a 3–0 silk thread. A dissection was performed in order to identify the suprascapular nerve, which was then stimulated with a silver electrode. Stimulations were produced by a stimulator (Digitimer Stimulator DS9A) and were controlled by a programmer (Digitimer D4030). Fiber length was adjusted until a single stimulus pulse elicited maximum force during a twitch under isometric conditions. Rectangular pulses of 0.5 ms duration were applied to elicit twitch contractions. During the recordings, muscles were rinsed with Krebs solution of approximately 37 8C (pH 7.2–7.4) and aerated with a mixture of 95% O2 and 5% CO2. The output from the transducer was amplified and recorded on a digital interface (CED). The following parameters were measured at room temperature (20–21 8C): single twitch tension; time to peak; half relaxation time; tetanic tensions at 10, 20, 40, 80 and 100 Hz; and fatigue index, which was evaluated using a protocol of low frequency (40 Hz) tetanic contraction, during 250 ms in a cycle of 1 s, for a total time of 180 s. The fatigue index value was then calculated by the formula [fatigue index=(initial tetanic tension − end tetanic tension) ∗ 100/(initial tetanic tension)]. In the end, the transducer was calibrated with standard weights and tensions were converted to grams. The mean single twitch was 8.2, the time to peak 0.034 msec and the half relaxation time 0.028 msec. The strength of titanic muscle contractures was 5.7 msec at 10Hz and 17.7 at 100Hz. Finally, the fatigue index was calculated at 48.4. We believe that electrophysiologic evaluation of the supraspinatus muscle in rats will help us understanding the pathology of muscle atrophy after rotator cuff tears and possibly the functional restoration after cuff repair

Between 1993 and 1999, we treated ten patients with comminuted fractures of the olecranon by multiple tension-band wiring and a graft from the iliac crest. Their mean age was 35 years (19 to 56). The mean follow-up was for 28.5 months (15 to 46) and the mean time to union of the fractures was four months (3 to 7). No patient reported difficulties with activities of daily living or symptoms of instability of the elbow. The mean flexion was to 135° (125 to 145) with a mean flexion contracture of 15° (10 to 30). The mean pronation was 70° (60 to 80) and mean supination 79° (70 to 90). Only three patients had mild pain and loss of strength. Five patients had excellent and five good results with a mean Broberg and Morrey index score of 94.5 points (84 to 100). Our results compare favourably with those previously reported and the technique is thought to be a practical alternative to plate fixation in fractures with extreme comminution

We reviewed 25 patients with tibial diaphyseal fractures which had been complicated by an acute compartment syndrome. Thirteen had undergone continuous monitoring of the compartment pressure and the other 12 had not. The average delay from injury to fasciotomy in the monitored group was 16 hours and in the non-monitored group 32 hours (p < 0.05). Of the 12 surviving patients in the monitored group, none had any sequelae of acute compartment syndrome at final review at an average of 10.5 months. Of the 11 surviving patients in the non-monitored group, ten had definite sequelae with muscle weakness and contractures (p < 0.01). There was also a significant delay in tibial union in the non-monitored group (p < 0.05). We recommend that, when equipment is available, all patients with tibial fractures should have continuous compartment monitoring to minimise the incidence of acute compartment syndrome

Introduction. Dupuytren's disease (DD) is a fibro-proliferative disorder of the palmar fascia whereby a collagen cord contracts affected joints, resulting in flexion deformity that can impair hand function. Currently, surgery is the only effective treatment option in Europe. This 2-part study, consisting of a surgeon survey and chart audit, was designed to assess current surgical practice patterns by DD severity. We report results from the surgeon survey. Methods. A total of 687 participants, including 579 orthopedic surgeons (of which 383 were hand specialists) and 108 plastic surgeons, who had been practicing for >3 and <30 years and operated on 5 DD patients between September and December 2008 were surveyed in 12 countries (UK, Germany, France, Italy, Spain, Hungary, Czech Republic, Poland, Netherlands, Sweden, Denmark, Finland). The survey included queries about procedures performed, factors involved in the decision to use a procedure, satisfaction with the procedure, use of physiotherapy, and recurrence. Results. Regardless of specialty, about 95% of surgeons performed fasciectomy in the previous 12 months. Rates for needle aponeurotomy (NA; 36%) and fasciotomy (70%) were comparable across specialties; a larger proportion of plastic surgeons (65%) used dermofasciectomy (DF) than did orthopaedic (39%) and hand surgeons (44%). Decisions to use NA/fasciotomy were driven mainly by patient comfort and quality-of-life issues (eg, aged >70 y, aesthetics, activity impairment); surgeon satisfaction was linked to shorter recovery times, reduced patient burden, few complications, and restored finger function. Decisions to use open surgeries were based mostly on DD characteristics (eg, contracture severity, speed of progression, recurrence), and surgeon satisfaction was linked to intervention efficacy and durability of the outcome. The percentage of surgeons prescribing physiotherapy and the duration of therapy increased with complexity of the first procedure: NA=86%, 5.3 weeks; fasciotomy=94%, 5.4; fasciectomy=97%, 6.7; and DF=99%, 8.7. On average, 90% of patients were enrolled in a physiotherapy program after undergoing a procedure for DD. Using survey responses, recurrence rates appeared to decrease and time to recurrence increased with procedure complexity: NA=44%, 17 months; fasciotomy=32%, 21; fasciectomy=20%, 29; and DF=20%, 34. Conclusions. To our knowledge, based on the number of participants and countries, this is the largest survey to date to collect, quantify, and describe information about the surgical management of DD in Europe. Although data from all countries were combined and results from the specialties were collapsed, it is a critical first step toward understanding DD treatment patterns. Opportunities to learn more about country- and specialty-specific practices will be presented elsewhere. This study was funded by Pfizer Inc

We reviewed 11 patients who had been treated between January 1986 and June 1994 for severe foot injuries by tendon transfer with microvascular free flaps. Their mean age was 5.6 years (3 to 8). Five had simultaneous tendon transfer and a microvascular free flap and six had separate operations. The mean interval between the tendon transfer and the microvascular free flap was 5.8 months (2 to 15) and the mean time between the initial injury and the tendon transfer was 9.6 months (2 to 21). The anterior tibial tendon was split in five of six cases. The posterior tibial tendon was used three times and the extensor digitorum longus tendon twice. The mean follow-up was 39.7 months (24 to 126). There were nine excellent and two good results. Postoperative complications included loosening of the transferred tendon (2), plantar flexion contracture (1) mild flat foot deformity (1) and hypertrophic scars (2). We recommend tendon transfer with a microvascular free flap in children with foot injuries combined with nerve injury and extensive loss of skin, soft tissue and tendon

Aims

In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia.

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Many authors have reported a shorter treatment time when using trifocal bone transport (TFT) rather than bifocal bone transport (BFT) in the management of long segmental tibial bone defects. However, the difference in the incidence of additional procedures, the true complications, and the final results have not been investigated.

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This study reviews the use of a titanium mesh cage (TMC) as an adjunct to intramedullary nail or plate reconstruction of an extra-articular segmental long bone defect.

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The aim of this study was to evaluate near-infrared spectroscopy (NIRS) as a continuous, non-invasive monitor for acute compartment syndrome (ACS).

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This is a prospective randomised controlled trial comparing the functional outcomes of plate fixation and elastic stable intramedullary nailing (ESIN) of completely displaced mid-shaft fractures of the clavicle in the active adult population.