Pressure ulcers are a common and recurrent clinical condition in paraplegic patients, requiring specialized equipment and care, as well as surgical interventions in order to treat them. This is especially true whenever and infection is declared, which will delay or impair ulcer epitelization. These surgical interventions require a good use of various myocutaneos flaps to cover all defects. Problem arises whenever there is not enough flap tissue to cover the entire ulcer, or when multiple surgeries to correct previous ulcers have already been performed.

Our goal is to describe the use of a last resort surgical technique for covering infected pressure ulcers.

This is a retrospective and descriptive case report based on data from clinical records, patient observation and analysis of complementary exams.

We present the case of a 30-years-old man, paraplegic for 10 years due to motor vehicle accident with spinal cord injury. Since the accident, and although he used adapted equipment and pressure relief mattresses and wheelchair cushions, he developed recurrent, infected ulcers in the perineal and sacral area, being operated on for multiple times by the Plastic and Reconstructive Surgery (PRS) department, for surgical debridement and ulcer coverage with tensor faciae latae and hamstrings myocutaneous flaps.

Despite all treatment, patient developed a stage IV perineal ulcer, which ranged from his left great trochanter to the right buttock, and a simultaneous stage IV sacral ulcer. Both ulcers were infected with meticilin-resistent Staphylococcus aureus (MRSA), sensitive to vancomycin. The patient's left hip joint was also infected (due to a direct trajectory to the perineal ulcer) and subluxated (due to absence of soft tissue support).

A multidisciplinary team assembled and decision was made to disarticulate the patient's left hip, debride and irrigate extensively the surgical site, and use a double gastrocnemius myocutaneous fillet flap in-continuity, in a surgical collaboration between the Orthopaedics and PRS department. This should provide satisfactory soft tissue ulcer coverage as well as facilitate antibiotics penetrance and infection eradication.

Surgery went without complications and the patient healed uneventfully. He resumed unrestricted positioning for sitting and wheelchair mobilization. Now, at two years follow-up, the patient still has no recurrence of either the ulcer or the infection.

This surgical technique provided robust soft tissue coverage for the ulcers, as well as an important aid for infection control. It proved to be a viable option in a paraplegic patient, when more traditional flap techniques can no longer be used and with a recurrent infection.

Aim. Repeat revision surgery of total hip or knee replacement may lead to massive bone loss of the femur. If these defects exceed a critical amount a stable fixation of a proximal or distal femur replacement may not be possible. In these extraordinary cases a total femur replacement (TFR) may be used as an option for limb salvage. In this retrospective study we examined complications, revision free survival (RFS), amputation free survival (AFS) and risk factors for decreased RFS and AFS following a TRF in cases of revision arthroplasty with a special focus on periprosthetic joint infection (PJI). Method. We included all implantations of a TFR in revision surgery from 2006–2018. Patients with a primary implantation of a TFR for oncological indications were not included. Complications were classified using the Henderson Classification. Primary endpoints were revision of the TFR or disarticulation of the hip. The minimum follow up was 24 month. RFS and AFS were analyzed using Kaplan-Meier method, patients´ medical history was analyzed for possible risk factors for decreased RFS and AFS. Results. After applying the inclusion criteria 58 cases of a TFR in revision surgery were included with a median follow-up of 48.5 month. The median age at surgery was 68 years and the median amount of prior surgeries was 3. A soft tissue failure (Henderson Type I) appeared in 16 cases (28%) of which 13 (22%) needed revision surgery. A PJI of the TFR (Henderson Type IV) appeared in 32 cases (55%) resulting in 18 (31%) removals of the TFR and implantation of a total femur spacer. Disarticulation of the hip following a therapy resistant PJI was performed in 17 cases (29%). The overall 2-year RFS was 36% (95% confidence interval(CI) 24–48%). Patients with a Body mass Index (BMI) >30kg/m² had a decreased RFS after 24 month (>30kg/m² 11% (95%CI 0–25%) vs. <30kg/m² 50% (95%CI 34–66%)p<0.01). The overall AFS after 5 years was 68% (95%CI 54–83%). A PJI of the TFR and a BMI >30kg/m² was significantly correlated with a lower 5-year AFS (PJI 46% (95%CI 27–66%) vs no PJI 100%p<0.001) (BMI >30kg/m² 30% (95% KI 3–57%) vs. <30km/m² 85% (95% KI 73–98%)p<0.01). Conclusions. A TFR in revision arthroplasty is a valuable option for limb salvage but complications in need of further revision surgery are common. Patients with a BMI >30kg/m² should be informed regarding the increased risk for revision surgery and loss of extremity before operation

Introduction. Amputation or disarticulation is a reliable option for management of severe foot deformities and limb-length discrepancies, the surgical restoration of which are unpredictable or unfavourable. Of the various surgeries involving foot ablation, Syme's amputation is preferred for congenital deformities as it provides a growing, weight bearing stump with proprioception and cushioning. Materials and Methods. We reviewed data of all children who underwent Syme's amputation over the past 13 years at our institution. Surgical technique followed the same principles for Syme's but varied with surgeons. Results. Ten boys and ten girls, with an average age of 18 months and average follow up of 70 months were included in the study. The most common indication was fibular hemimelia. Wound complications were reported in three children, phantom pain in one, heel pad migration in two. None had wound dehiscence, flap necrosis, stump overgrowth, or calcaneal regrowth. None of this required surgical intervention. One child required an amputation at a higher-level secondary to a congenital malformation of nervous tissue in the affected leg. Prosthetic compatibility was 94.7 % and none used mobility aids. Six children participated in sports. Conclusions. Syme amputation is a safe and potentially advantageous procedure in children, with a low incidence of complications to offer patients with non-salvageable foot conditions. It offers good prosthetic use with minimal risk of complications and can offer patients a functional solution with only one surgical intervention throughout their childhood

This work examines the Upper limb (UL) blast-mediated traumatic amputation (TA) significance from recent operations in Afghanistan. It is hypothesized that the presence of an UL amputation at any level is an independent predictor of torso injury. A joint theatre trauma registry search was performed to determine the number of British casualties with TA and their associated injuries. UL TA accounted for 15.7% of all amputations; distributed: shoulder disarticulation 2.5%, trans-humeral 30%, elbow disarticulation 10%, trans-radial 20% and hand 37.5%. The presence of an UL amputation was more likely in dismounted casualties (P=0.015) and is a predictor of an increased number of total body regions injured and thoracic injuries (P 0.001 and P 0.026 respectively). An increased Injury Severity Score (ISS) was seen in patients with multiple amputations involving the UL (UL TA present ISS=30, no UL TA ISS=21; P=0.000) and the ISS was not significantly different whether mounted or dismounted (P=0.806). The presence of an upper limb amputation at any level should insight in the receiving clinician a high index of suspicion of concomitant internal injury; especially thoracic injury. Therefore with regards to blast mediated TA the injury patterns observed reflect a primary and tertiary blast mechanism of injury

Many pre-clinical models of atrophic non-union do not reflect the clinical scenario, some create a critical size defect, or involve cauterization of the tissue which is uncommonly seen in patients. Atrophic non-union is usually developed following high energy trauma leading to periosteal stripping. The most recent reliable model with these aspects involves creating a non-critical gap of 1mm with periosteal and endosteal stripping. However, this method uses an external fixator for fracture fixation, whereas intramedullary nailing is the standard fixation device for long bone fractures. OBJECTIVES. To establish a clinically relevant model of atrophic non-union using intramedullary nail and (1) ex vivo and in vivo validation and characterization of this model, (2) establishing a standardized method for leg positioning for a reliable x-ray imaging. Ex vivo evaluation: 40 rat's cadavers (adult male 5–6 months old), were divided into five groups (n=8 in each): the first group was fixed with 20G intramedullary nail, the second group with 18G nail, the third group with 4-hole plate, the fourth group with 6-hole plate, and the fifth group with an external fixator. Tibiae were harvested by leg disarticulation from the knee and ankle joints. Each group was then subdivided into two subgroups for mechanical testing: one for axial loading (n=4) and one for 4-point bending (n=4) using Zwick/Roell® machine. Statistical analysis was carried out by ANOVA with a fisher post-hoc comparison between groups. A p-value less than 0.05 was considered statistically significant. To maintain the non-critical gap, a spacer was inserted in the gap, the design was refined to minimize the effect on the healing surface area. In vivo evaluation was done to validate and characterize the model. Here, a 1 mm gap was created with periosteal and endosteal stripping to induce non-union. The fracture was then fixed by a hypodermic needle. A proper x-ray technique must show fibula in both views. Therefore, a leg holder was used to hold the knee and ankle joints in 90º flexion and the foot was placed in a perpendicular direction with the x-ray film. Lateral view was taken with the foot parallel to the x-ray film. Ex vivo: axial load stiffness data revealed that intramedullary nails are significantly stronger and stiffer than other devices. Bending load to failure showed that 18G nails are significantly stronger than 20G, thus it is used for the in vivo experiments. In vivo: final iteration revealed 3/3 non-union, and in controls with the periosteum and endosteum intact but with the 1mm non-critical gap, it progressed to 3/3 union. X-ray positioning: A-P view in supine position, there was an unavoidable degree of external rotation in the lower limb, thus the lower part of the fibula appeared behind the tibia. To overcome this, a P-A view of the leg was performed with the body in prone rather, this arrangement allowed both upper and lower parts of the fibula to appear clearly in both views. We report a novel model of atrophic non-union, the surgical procedure is relatively simple and the model is reproducible

Altered distal radioulnar joint contact (DRUJ) mechanics are thought to cause degenerative changes in the joint following injury. Much of the current research examining DRUJ arthrokinematics focuses on the effect of joint malalignment and resultant degenerative changes. Little is known regarding native cartilage contact mechanics in the distal radioulnar joint. Moreover, current techniques used to measure joint contact rely on invasive procedures and are limited to statically loaded positions. The purpose of this study was to examine native distal radioulnar joint contact mechanics during simulated active and passive forearm rotation using a non-invasive imaging approach. Testing was performed using 8 fresh frozen cadaveric specimens (6 men: 2 women, mean age 62 years) with no CT evidence of osteoarthritis. The specimens were thawed and surgically prepared for biomechanical testing by isolating the tendons of relevant muscles involved in forearm rotation. The humerus was then rigidly secured to a wrist simulator allowing for simulated active and passive forearm rotation. Three-dimensional (3D) cartilage surface reconstructions of the distal radius and ulna were created using volumetric data acquired from computed tomography after joint disarticulation. Using optically tracked motion data and 3D surface reconstructions, the relative position of the cartilage models was rendered and used to measure DRUJ cartilage contact mechanics. The results of this study indicate that contact area was maximal in the DRUJ at 10 degrees of supination (p=0.002). There was more contact area in supination than pronation for both active (p=0.005) and passive (p=0.027) forearm rotation. There was no statistically significant difference in the size of the DRUJ contact patch when comparing analogous rotation angles for simulated active and passive forearm motion (p=0.55). The contact centroid moved 10.5±2.6 mm volar along the volar-dorsal axis during simulated active supination. Along the proximal-distal axis, the contact centroid moved 5.7±2.4 mm proximal during simulated active supination. Using the technique employed in this study, it was possible to non-invasively examine joint cartilage contact mechanics of the distal radioulnar joint while undergoing simulated, continuous active and passive forearm rotation. Overall, there were higher contact area values in supination compared with pronation, with a peak at 10 degrees of supination. The contact centroid moved volarly and proximally with supination. There was no difference in the measured cartilage contact area when comparing active and passive forearm rotation. This study gives new insight into the changes in contact patterns at the native distal radioulnar joint during simulated forearm rotation, and has implications for increasing our understanding of altered joint contact mechanics in the setting of deformity

Total knee arthroplasty can largely impact the functioning of a knee. To minimize the impact of surgery and increase patient satisfaction, it is believed that restoring knee stability and control of the laxity has the potential to improve surgical outcome. In that respect, it is hypothesized that a well-balanced knee restores the native knee's laxity and stability, whereas unbalanced conditions result in an increased laxity and instability. This study intends to precisely evaluate knee laxity and stability in a cadaveric model in order to improve the clinical evaluation of the knee laxity under surgical conditions. This paper provides insight in the design considerations and methodology of a novel knee simulator and the preliminary results. In a first phase, a new knee simulator has therefore been developed. This simulator allows quantifying the knee kinematics and surgical feel at the time of surgery in a laboratory environment. More specifically, full lower limb specimens can be mounted in the simulator. This overcomes the need for disarticulation at the hip and ankle, often reported in cadaveric testing. The latter is believed to potentially release the tension in the knee and should therefore be avoided. Note that in respect to surgical conditions no muscle activation is considered for this simulator. To facilitate a repeatable and unbiased evaluation of the knee kinematics, it is important that the knee simulator provides full kinematic freedom to the tested knee specimen. To obtain six degrees of freedom, a dedicated hip and ankle setup has been created (figure 1). The hip setup constrains the hip joint to a single axis hinge joint around the femoral head center. The remaining five degrees of freedom are built into the ankle setup. More specifically, the ankle setup has two translational degrees of freedom and full rotational freedom. The translational freedom is provided along the specimen's proximal-distal axis and medio-lateral axis. The rotational freedom is provided at a single point, using a ball in socket joint located along the mechanical axis of the tibia. The translation along the proximal-distal axis is thereby actively controlled by the operator, simulating heel push conditions. In addition to studying the neutral path kinematics, the presented simulator allows evaluating the laxity boundaries throughout the range of motion. Therefore, a constant internal/external torque can be applied to the tibia. Alternatively, a constant varus/valgus moment can be simulated. Second, following the design and construction of this simulator, a set of ten cadaveric knees has been tested on this simulator, both before and after TKA surgery. For the native knees, the results of these tests confirm the kinematic freedom provided to the tested knee. In addition, the laxity envelope around the neutral path can be realistically evaluated and quantified. Conclusion. Design and evaluation of new knee simulator that allows synchronous studying of the knee kinematics, contact loads and tensile forces, under neutral conditions and extreme varus/valgus moment or internal/external tibial torque

Squamous Cell Carcinoma (SCC) is a rare complication of chronic osteomyelitis (OM), arising in a sinus tract (Marjolin's Ulcer). We routinely send samples for histological analysis for all longstanding sinus tracts in patients with chronic osteomyelitis. We reviewed the clinical features and outcomes of patients with SCC arising from chronic osteomyellitis. A retrospective study was performed of patients with osteomyelitis between January 2004 and December 2014 in a single tertiary referral centre. Clinical notes, microbiology and histo-pathological records were reviewed for patients who had squamous cell carcinoma associated with OM. We treated 9 patients with chronic osteomyelitis related squamous cell carcinoma. The mean age at time of diagnosis was 51 years (range 41–81 years) with 4 females and 5 males. The mean duration of osteomyelitis was 16.5 years (3–30 years) before diagnosis of SCC. SCC arose in osteomyelitis of the ischium in 5 patients, sacrum in 1 patient, femur in 1 patient and tibia in 2 patients. Osteomyelitis was due to pressure ulceration in 7 patients and post-traumatic infection in 2 patients. The histology showed well differentiated SCC in 4 cases and moderately differentiated SCC in 2 cases with invasion. Two patients had SCC with involvement of bone. One patient had metastatic SCC to bowel. All patients had polymicrobial or Gram-negative cultures from microbiology samples. Four patients (57%) in our series died as result of their cancer despite wide resection. The mean survival after diagnosis of SCC was 1.3 years and mean age at time of death was 44.7 years. Two of these patients had ischial disease and were treated with hip disarticulation, hemi-pelvectomy and iliac node clearance. Five patients remain disease free at a mean of 3.4 years (range 0.1 – 7yrs) after excision surgery. One patient in this group underwent a through-hip amputation, one underwent an above knee amputation and one underwent excision of ischium and surrounding sinuses. Of note, all these patients had clear staging scans at time of diagnosis. This case series demonstrates the consequences of an uncommon complication of osteomyelitis. In our series only 3 patients underwent biopsy for suspected SCC due to clinical appearances. The other cases were all identified incidentally after routine histological sampling, demonstrating the importance of this practice

Isolated talonavicular arthrodesis is a common procedure particularly for posttraumatic arthritis and rheumatoid arthritis. Two surgical approaches are commonly used: the medial and the dorsal approach. It is recognized that access to the lateral aspect of the talonavicular joint can be limited when using the medial approach and it is our experience that using the dorsal approach addresses this issue. We performed an anatomical study using cadaver specimens, to compare the amount of articular surface that can be accessed, and therefore prepared for arthodesis, by each surgical approach. Medial and dorsal approaches to the talonavicular joint were performed on each of 11 cadaveric specimens (10 fresh frozen, 1 embalmed). Distraction of the joint was performed as used intraoperatively for preparation of articular surfaces during talonavicular arthrodesis. The accessible area of articular surface was marked for each of the two approaches using a previous reported technique. Disarticulation was performed and the marked surface area was quantified using an immersion digital microscribe, allowing a three dimensional virtual model of the articular surfaces to be assessed. The median percentage of accessible total talonavicular articular surface for the medial and dorsal approaches was 71% and 92% respectively. This difference was significant (Wilcoxon Signed Ranks Test, p< 0.001). This study provides quantifiable measurements of the articular surface accessible by the medial and dorsal approaches to the talonavicular joint. These data support for the use of the dorsal approach for talonavicular arthrodesis

The purpose of this study is to provide a systematic review of the literature and assess outcome of our experience of Ilizarov Bone Transport in reconstruction for primary malignant tumours of bone (PMTB). A systematic review of the literature for reported cases of primary reconstruction of PMTB using distraction osteogenesis was performed. All cases of distraction osteogenesis for primary reconstruction of PMTB in our institution were reviewed. Outcome was determined from retrospective review of case notes and radiology. Patients were contacted to define final status. There are few cases of primary reconstruction of PMTB using Ilizarov method in the literature. Most reports relate to benign tumours or reconstruction of secondary deformities or non-union after tumour resection. At our institution we have treated 7 patients with bone defects resulting from excision of a PMTB. Mean age was 42.1 years (23–48). Tumours occurred in the tibia in 4 cases and the femur in 3 cases. Histologic diagnosis was chondrosarcoma in 3, malignant fibrous histiocytoma in 2, adamantinoma in 1 and malignant intraosseous nerve sheath tumour in 1. All patients were assessed through the hospital sarcoma board and shown to have isolated bone lesions without metastases. Mean bone defect after resection was 13.1 cm (10–17). Mean frame time was 13.6 months (5–23). Mean follow-up was 46 months (15–137). Complications included pin infection, docking site non-union, premature fusion of corticotomy, soft tissue infection and minor varus deformity. There was one local recurrence of tumour at five months after resection, resulting in a through hip disarticulation. The other cases remain tumour-free with united, well-aligned bones and acceptable long-term function. PMTB is rare and poses a major reconstructive dilemma. Distraction osteogenesis provides an effective method of biologic reconstruction in selected cases, and good outcomes can be achieved