Aims. This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients. Methods. A total of 1,047 limb osteomyelitis patients aged 18 years or older who underwent debridement and intraoperative culture at our clinic centre from 1 January 2011 to 31 December 2020 were included. Patient characteristics, infection eradication, and complications were analyzed between culture-negative and culture-positive cohorts. Results. Of these patients, 264 (25.2%) had negative cultures. Patients with a culture-negative compared with a culture-positive status were more likely to have the following characteristics: younger age (≤ 40 years) (113/264 (42.8%) vs 257/783 (32.8%); p = 0.004), a haematogenous aetiology (75/264 (28.4%) vs 150/783 (19.2%); p = 0.002), Cierny-Mader host A (79/264 (29.9%) vs 142/783 (18.1%); p < 0.001), antibiotic use before sampling (34/264 (12.9%) vs 41/783 (5.2%); p＜0.001), fewer taken samples (n＜3) (48/264 (18.2%) vs 60/783 (7.7%); p＜0.001), and less frequent presentation with a sinus (156/264 (59.1%) vs 665/783 (84.9%); p < 0.001). After initial treatments of first-debridement and antimicrobial, infection eradication was inferior in culture-positive osteomyelitis patients, with a 2.24-fold increase (odds ratio 2.24 (95% confidence interval 1.42 to 3.52)) in the redebridement rate following multivariate analysis. No statistically significant differences were found in long-term recurrence and complications within the two-year follow-up. Conclusion. We identified several factors being associated with the culture-negative result in osteomyelitis patients. In addition, the data also indicate that culture negativity is a positive prognostic factor in early infection eradication. These results constitute the basis of optimizing clinical management and patient consultations. Cite this article: Bone Joint J 2024;106-B(7):720–727

Aims. Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Methods. Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. Results. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. Conclusion. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769–774

Introduction. This study evaluates the need for limb reconstruction surgery in Syria and gives examples of how this service has been delivered by UK surgeons. The conflict in Syria has resulted in over 500,000 deaths and 1.2 million injured. There is not yet a centre for limb reconstruction surgery in the country. Injuries from gunshots and shrapnel were not common prior to the civil war resulting in a paucity of experience. Methods. The senior author spent two weeks in Syria to perform limb reconstruction surgery, to help to train local surgeons and assess the capacity of the facilities available to cope with the limb reconstruction workload. Results. 93 outpatients were assessed over the course of ten days, and 72 of these required definitive surgical intervention. 33 of these patients were candidates for intervention with circular frames. As well as outpatient assessment, surgical procedures were carried out on 22 patients. 11 procedures involved the application of circular frames; 4 involved the application of monolateral fixators and there were 2 other frame related procedures. Discussion. The lack of definitive capacity exists because of shortfalls in equipment, training, and surgical time. The outpatient assessments of patients given temporary or no treatment, who require definitive surgical intervention allows a projection of the need for 3900 surgical procedures over the course of a year, for the patients within the catchment area of this hospital alone. This is an overwhelming number that cannot be achieved without external help. Conclusion. The limb reconstruction workload in Syria is enormous, and rising every day. There are opportunities for members of the BLRS to contribute to mitigating this human suffering by providing this service

Purpose. To review the natural history of posteromedial bowing of the tibia and the outcome of limb reconstruction in this condition. Patients and Methods. 38 patients with posteromedial bowing of the tibia presenting between 2000–2016 were identified. Mean follow up from presentation was 78 months. Seventeen patients underwent lengthening and deformity correction surgery, whilst 3 further patients are awaiting lengthening and deformity correction procedures. Results. The greatest correction of deformity occurred in the first year of life, but after the age of 4 years, remodelling was limited. The absolute leg length discrepancy (LLD) increased throughout growth with a mean 14.3% discrepancy in tibial length. In the lengthening group, mean length gained per episode was 45mm (35–60). Mean duration in frame was 192 days, with a healing index of 42.4 days/cm. Significantly higher rates of recurrence in LLD were seen in those undergoing lengthening under the age of 10 years (p=0.046). Four contralateral epiphysiodeses were also performed. Conclusions. Posteromedial bowing of the tibia improves spontaneously during the first years of life, but in 20/38 (53%) patients, limb reconstruction was indicated for significant residual deformity and/or worsening length discrepancy. For larger discrepancies and persistent deformity, limb reconstruction with a hexapod external fixator is an effective technique and should be considered as part of the treatment options. Level of evidence. Level 4 (Case series)

Limb reconstruction requires high levels of patient compliance and impacts heavily on social circumstances. The epidemiology and socioeconomic description of trauma patients has been well documented, however no study has assessed the epidemiology of limb reconstruction patients. The aim of this project is to describe patients attending Limb Reconstruction Services (LRS) in order to highlight and address the social implications of their care. All LRS cases under a single surgeon in a district general hospital were included from 2010 – 2016. Demographics, ASA grade, smoking status, mental health status and employment status were collated. Postcode was converted into an Index of Multiple Deprivation score using GeoConvert® software. Patient socioeconomic status was then ranked into national deprivation score quintiles (quintile 1 is most affluent, quintile 5 is most deprived). Deprivation scores were adjusted by census data and analysed with Student's T-test. The distance from the patient's residence to the hospital was generated through AA route planner®. Patient attendance at clinic and elective or emergency admissions was also assessed. Patient outcomes were not part of this research. There were 53 patients, of which 66% (n=35) were male, with a mean age of 45 years (range 21–89 years). Most patients were smokers (55%, n=29), 83% (n=42) were ASA 1 or 2 (there were no ASA 4 patients). The majority of indications were for acute trauma (49%), chronic complications of trauma (32%), congenital deformity (15%) and salvage fusion (4%). Mental health issues affected 23% (n=12) of cases and 57% of working-aged patients were unemployed. Mental health patients had a higher rate of trauma as an indication than the rest of the cohort (93% vs. 76%). Deprivation quintiles identified that LRS patients were more deprived (63% in quintiles 4 and 5 vs. 12% of 1 and 2), but this failed to reach statistical significance (p=0.9359). The mean distance from residence to hospital was 12 miles (range 0.35–105 miles, median 7 miles). The patients derived from a large region made up of 12 local authorities. There was a mean of 17 individual LRS clinic attendances per patient (range: 3–42). Cumulative distance travelled for each patient during LRS treatment was a mean of 495 miles (range 28 – 2008 miles). The total distance travelled for all 53 patients was over 26,000 miles. The results largely mirror the findings of trauma demographic and socioeconomic epidemiology, due to the majority of LRS indications being post-traumatic in this series. The high rates of unemployment and mental health problems may be a risk factor for requiring LRS management, or may be a product of the treatment. Clinicians may want to consider a social care strategy alongside their surgical strategy and fully utilise their broader MDT to address the social inequalities in these patients. This strategy should include a mental health assessment, smoking cessation therapy, sign-posted support for employment circumstances and a plan for travel to the hospital. The utilisation and cost of ambulance services was not possible with this methodology. Further work should prospectively assess the changes in housing circumstances, community healthcare needs and whether there was a return to employment and independent ambulation at the end of treatment

Aims. To evaluate whether an ultra-low-dose CT protocol can diagnose selected limb fractures as well as conventional CT (C-CT). Patients and Methods. We prospectively studied 40 consecutive patients with a limb fracture in whom a CT scan was indicated. These were scanned using an ultra-low-dose CT Reduced Effective Dose Using Computed Tomography In Orthopaedic Injury (REDUCTION) protocol. Studies from 16 selected cases were compared with 16 C-CT scans matched for age, gender and type of fracture. Studies were assessed for diagnosis and image quality. Descriptive and reliability statistics were calculated. The total effective radiation dose for each scanned site was compared. Results. The mean estimated effective dose (ED) for the REDUCTION protocol was 0.03 milliSieverts (mSv) and 0.43 mSv (p < 0.005) for C-CT. The sensitivity (Sn), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of the REDUCTION protocol to detect fractures were 0.98, 0.89, 0.98 and 0.89 respectively when two occult fractures were excluded. Inter- and intra-observer reliability for diagnosis using the REDUCTION protocol (κ = 0.75, κ = 0.71) were similar to those of C-CT (κ = 0.85, κ = 0.82). Using the REDUCTION protocol, 3D CT reconstructions were equivalent in quality and diagnostic information to those generated by C-CT (κ = 0.87, κ = 0.94). Conclusion. With a near 14-fold reduction in estimated ED compared with C-CT, the REDUCTION protocol reduces the amount of CT radiation substantially without significant diagnostic decay. It produces images that appear to be comparable with those of C-CT for evaluating fractures of the limbs. Cite this article: Bone Joint J 2016;98-B:1668-73

Component malalignment has long been implicated in poor implant survival in Total Knee Arthroplasty (TKA). Malalignment can occur in orientation of bony cuts, and in component cementation/implantation. Several systems exist to aid bony cut alignment (navigation, shape matching), but final implantation technique is common to all TKA. Correction of errors in bony cut alignment at cementation/implantation by surgeons has been described. Changes in alignment at this stage are likely to result in asymmetrical cement penetration, which is implicated in early failure. This study reviewed a consecutive series of 150 primary cemented TKAs using an imageless navigation system (aiming for neutral overall limb alignment). Deviation at implantation was calculated by comparing limb alignment recorded using the trial components with limb alignment recorded with the final implanted components, prior to closure. 136 patients (91%) had a final overall limb alignment within 2° of neutral. Three patients (2%) had a final overall limb alignment greater than 3° from neutral. Deviation occurring at implantation is shown in Figure 1 with deviations distributed around zero (mode 0, median 0.3, range −2 to +4,)

The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 – 2010 were contacted and interviewed. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation in the same period. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria, of which 30 patients (61%) were followed-up. Ten of the 30 patients required revision surgery, 3 of which involved conversion to a circular frame. Twenty-two of the 30 patients (73%) recovered sufficiently to complete a basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma

Introduction. Distraction histogenesis is utilised for cosmetic reasons in patients with constitutional short stature, achondroplasias, or height dysphoria. One of the considerations of patients and surgeons alike, is the preservation of aesthetically acceptable body proportions after the lengthening i.e which segment of the lower limb to lengthen and by how much, in order to preserve the patient's proportions within -or as close as possible to- the normal range of human body proportions. Sound anthropometric data on the normal range of the human body proportions is currently lacking. The aim of this study is to calculate the normal range of the ratio between the lengths of the lower limb, upper limb, femur, tibia, stature and trunk. Methods. Data form standardized measurements of the lengths of the tibia, femur, arm, stature, lower limb, upper limb was obtained from a sample population of 6068 healthy men and women servicing in the US Army. The mean, median, range and standard deviation were calculated for the following ratios of lengths: whole lower limb/leg, Stature/leg, Whole lower limb/thigh, Stature/thigh, Siting height/whole lower limb, Stature/Whole lower limb, Arm Span/Stature, Whole upper limb/Whole lower limb. Results. The ratios show normal distribution. Results are presented separately for men and women for the total sample population and for subgroups based on ethnic origin (White, Black, Hispanic and Asian). Discussion. This study is one of the first to provide specific anthropometric data from a large sample population relevant to the evidence-based preoperative planning and patient counselling before cosmetic limb lengthening procedures

Introduction. The Precice nail is the latest intramedullary lengthening nail with excellent early outcomes. Implant complications have led to modification of the nail design. The aim of this study was to perform a retrieval study of Precice nails following lower limb lengthening. To assess macroscopic and microscopic changes to the implants and assess differences following design modification, with identification of potential surgical, implant and patient risk factors. Method. 15 nails were retrieved from 13 patients following lower limb lengthening. Macroscopic and microscopic surface damage to the nails were identified. Further analysis included radiology and micro-CT prior to sectioning. The internal mechanism was then analysed with Scanning Electron Microscopy and Energy Dispersive X-ray Spectroscopy to identify corrosion. Results. 7 male and 3 females underwent 12 femoral lengthenings, 9 antegrade and 3 retrograde. 3 females underwent tibial lengthening. All patients obtained the desired length with no implant failure and full regenerate consolidation. Surface degradation was noted on the telescopic part of every nail design, less on the latest implants. Microscopic analysis confirmed fretting and pitting corrosion. Following sectioning black debris was noted in all implants. The early designs were found to have fractured actuator pins and the pin and bearings had evidence of corrosive debris. The latest designs had evidence of biological deposits suggestive of fluid ingress within the nail. Conclusion. This study suggests fluid ingress occurs with every generation of Precice nail despite modifications. The presence of biological fluid could be an early warning sign of potential corrosion. This in theory could lead to actuator pin fracture and implant failure. The clinical relevance is the potential re-use of a “dormant” nail in patients requiring secondary limb segment lengthening. Retraction of the nail in-situ and re-use for further lengthening requires careful consent for potential implant failure

Care of complex and open fractures may provide better results if undertaken in larger units, typically Major Trauma Centres (MTCs) or Orthoplastic units. Some ‘complex injuries’ may still be admitted to units lacking specialist services potentially delaying definitive treatment. The aim of this study was to analyse the referral pattern for acute inpatient transfer in an adult limb reconstruction unit for one calendar year. Prospectively collected data from an electronic database for 2016 was reviewed. All records were evaluated for, diagnosis, time from injury to referral, nature of initial treatment, time to transfer, details of definitive surgery, and time to repatriation. There were 91 formal electronic referrals, 84 of which considered appropriate for inpatient transfer. 74 were for fresh complex fractures, including 22 pilon fractures and 23 bicondylar tibial fractures. Median delay to request transfers for acute trauma was 3 days (0d-19d), delay from referral to transfer was 8.5 days (1d-31d) and delay from date of injury to definitive surgery was 13 days (1d-52d). 9 patients with Grade 3 open fractures and had primary debridement at the referring institution with a median delay to definitive orthoplastic surgery of 9 days (5d-20d). Only 17 of 61 per-articular fractures had spanning external fixation at the referring institution. Delay to repatriation was 8 days (0d–72d). This study demonstrates organisational failures in acute orthopaedic care: open fractures not being primarily treated in orthoplastic centres or MTCs, delays in transfers due to bed-blocks, and significant delays in repatriation. It also demonstrates scope for improvement in clinical practice, and in particular, the need to reinforce the advantages of spanning external fixation of periarticular fractures. Our data serves to highlight continuing problems in delivery of acute fracture care, despite widely publicised recent national guidelines

Aim. Simultaneous application of Ilizarov frames and free muscle flaps to treat osteomyelitis or infected non-unions is currently not standard practice in the UK, in part related to logistical issues, surgical duration and challenging access for microvascular anastomosis. We present the outcomes for 56 such patients. Methods. Retrospective single centre consecutive series between 2005–2017. We recorded comorbidities, Cierny-Mader and Weber-Cech classification, the Ilizarov method used, flap and anastomosis used, follow-up duration, time to union and complications. Results. 56 patients (55 tibiae and 1 forearm) were included (mean age 48 years). Thirty-four cases had osteomyelitis (20/34 Cierny-Mader Stage IV) and 22 had an infected non-union (14/22 Weber-Cech Type E or F). Forty-six patients had a segmental defect after resection. Monofocal compression was used in 14, monofocal distraction in 15, bifocal compression/distraction in 8, bone transport in 9 and a protective frame in 10. 8/56 had an ankle fusion, 7/56 had an angular deformity corrected at the same time and 32 also had local antibiotic carrier inserted. Forty-six gracilis, 9 latissimus dorsi and 1 rectus abdominus flaps were used. Six cases required urgent flap re-exploration (5 anastomotic revisions and 1 haematoma washout) with 4/6 successfully salvaged. Two cases suffered total flap failure (3.6%). Both had successful revision free muscle flaps with the frame in situ at 10 and 16 days respectively. There were no partial flap failures and no failures in bone transport frames. Mean follow-up was 22 months (4–89). Excluding three cases that still have a frame on, 42/43 (97.7%) achieved bony union. Recurrence of infection occurred in 8.9%. All were infection free at final follow-up after further surgery. Conclusions. With the right expertise, simultaneous Ilizarov frame and free muscle flap is safe and effective in treating complex limb infection, and is not associated with an increased flap failure rate. Level of evidence. III

Objectives. The biomembrane (induced membrane) formed around polymethylmethacrylate (PMMA) spacers has value in clinical applications for bone defect reconstruction. Few studies have evaluated its cellular, molecular or stem cell features. Our objective was to characterise induced membrane morphology, molecular features and osteogenic stem cell characteristics. Methods. Following Institutional Review Board approval, biomembrane specimens were obtained from 12 patient surgeries for management of segmental bony defects (mean patient age 40.7 years, standard deviation 14.4). Biomembranes from nine tibias and three femurs were processed for morphologic, molecular or stem cell analyses. Gene expression was determined using the Affymetrix GeneChip Operating Software (GCOS). Molecular analyses compared biomembrane gene expression patterns with a mineralising osteoblast culture, and gene expression in specimens with longer spacer duration (> 12 weeks) with specimens with shorter durations. Statistical analyses used the unpaired student t-test (two tailed; p < 0.05 was considered significant). Results. Average PMMA spacer in vivo time was 11.9 weeks (six to 18). Trabecular bone was present in 33.3% of the biomembrane specimens; bone presence did not correlate with spacer duration. Biomembrane morphology showed high vascularity and collagen content and positive staining for the key bone forming regulators, bone morphogenetic protein 2 (BMP2) and runt-related transcription factor 2 (RUNX2). Positive differentiation of cultured biomembrane cells for osteogenesis was found in cells from patients with PMMA present for six to 17 weeks. Stem cell differentiation showed greater variability in pluripotency for osteogenic potential (70.0%) compared with chondrogenic or adipogenic potentials (100% and 90.0%, respectively). Significant upregulation of BMP2 and 6, numerous collagens, and bone gla protein was present in biomembrane compared with the cultured cell line. Biomembranes with longer resident PMMA spacer duration (vs those with shorter residence) showed significant upregulation of bone-related, stem cell, and vascular-related genes. Conclusion. The biomembrane technique is gaining favour in the management of complicated bone defects. Novel data on biological mechanisms provide improved understanding of the biomembrane’s osteogenic potential and molecular properties. Cite this article: Dr H. E. Gruber. Osteogenic, stem cell and molecular characterisation of the human induced membrane from extremity bone defects. Bone Joint Res 2016;5:106–115. DOI: 10.1302/2046-3758.54.2000483

Aim To develop a militarily relevant complex extremity wounding model. Study Design Controlled laboratory study with New Zealand White Rabbits. Method Phase One: Injury Development. Under general anaesthesia, the flexor carpi ulnaris of the right forelimb was exposed and high energy, short duration impact delivered via drop test rig. Anaesthesia was maintained for three hours, the animal was recovered and saline soaked gauze and supportive bandaging applied. 48 hrs later, the animal was culled and muscle harvested for histological analysis. Analgesia was administered daily, animals checked by experienced staff at least twice daily and temperatures recorded by subcutaneous transponder. Phase Two: Contamination. Sequential groups of animals had inoculums of 1×102, 1×106 and 1×108/100μl of Staphylococcus aureus administered to the muscle immediately after injury. Animals were recovered as phase one. At 48 hours, animals were culled, muscle harvested and axillary lymph nodes sampled. Quantitative microbiological analysis was performed on the muscle. Results: Six animals given a loading of 0.5kg yielded consistent injury with 20% of the muscle becoming necrotic. Representative of injury from ballistic trauma, this was adopted as standard. Twenty-two subsequent animals were exposed to the injury and inoculated with the challenge doses. 1×106/100μl S.aureus provided the greatest consistency in recovered yield. There were no adverse effects on animal welfare and body temperatures were always within normal limits. Discussion. This model enables a consistent, contaminated soft tissue injury to be delivered in vivo. It will allow the investigation of complex wound management including wound coverage and fracture fixation

A 7-day randomised controlled pre-clinical trial utilising an existing extremity war wound model compared the efficacy of saline soaked gauze to commercially available dressings. The Flexor Carpi Ulnaris of anaesthetised rabbits was exposed to high-energy trauma using a computer-controlled jig and inoculated with 10. 6. Staphylococcus aureus 3 hours prior to application of dressing. Quantitative microbiological assessment demonstrated reduced bacterial counts in INADINE (Iodine) and ACTICOAT (Nanocrystalline Silver) groups and an increase in ACTIVON TULLE (Manuka Honey) group (2-way ANOVA p<0.05). Clinical observations were made throughout the study. Haematology and plasma cytokines were analysed at intervals. Post-mortem histopathology included subjective semi-quantitative assessment of pathology severity using light microscopy to grade muscle injury and lymph node activation. Tissue samples were also examined using scanning electron microscopy (SEM). There were no bacteraemias, abscesses, purulent discharge or evidence of contralateral axillary lymph node activation. There were no significant differences in animal behaviour, weight change, maximum body temperature or white blood cell count elevation nor in pathology severity in muscle or lymph nodes (Kruskal-Wallis). There was no evidence of bacterial penetration or biofilm formation on SEM. Interleukin-4 and Tumour Necrosis Factor α levels were significantly higher in the ACTIVON TULLE group (1-way ANOVA p<0.05). This time-limited study demonstrated a statistically significant reduction in Staphylococcus aureus counts in wounds dressed with INADINE and ACTICOAT and an increase in wounds dressed with ACTIVON TULLE. There was no evidence that any of these dressings cause harm but nor have we established any definite clinical advantage associated with the use of the dressings tested in this study

Introduction. Since 2001 we use the flexible intramedullary nailing (FIN) in bone lengthening in children. This study estimates results of EF+FIN association considering the duration of external fixation and complications. Materials and Methods. Since 2001 we performed 294 bone lengthenings (338 segments of UL and LL) in 250 children 3 to 16 years old (11.01±0.23 in average). The length discrepancy was congenital in 163 cases, the sequelae of trauma or osteomyelitis were observed in 87 patients. In group I (195 cases) the Ilizarov fixator alone was applied, in group II the Ilizarov fixator (91 cases) or TSF® (8cases) were combined with FIN. The healing index was compared between the groups of the same etiology with similar type of distraction osteosynthesis. The date of consolidation corresponded to the day of removal of the external fixator, while intramedullary nails remained in place thus protecting the bone. Healing index was calculated by relating the duration of wearing of the external fixator (in days) and the amount of lengthening (in cm). Results. Reduction of the healing index is noted in each compared category. Thus, in congenital shortening in monofocal distraction osteosynthesis of the femur the healing index decreased from 29.8 (group I) to 20.4 days per cm, in bifocal tibial lengthening from 22.7 (group I) to 16.3d/cm (group II), in humeral lengthening – from 30.2 to 21.3 d/cm. In fact, it appears that the association of the external fixator of the Ilizarov type or TSF® with FIN allows to reduce the healing index significantly: in 12 of 16 compared categories the reduction of the index was from 20% to 40% or from 4.0 to 19.1 days per cm. In group I four cases of deep infection of soft tissues, 2 osteomyelitis, 21 fractures or deformities after frame removal were manifested. In group II – onlyone case of deformation after frame removal, absence of severe infectious complications, 8 cases of migration of the intramedullary wires. Discussion. FIN creates an elastic and resistant system during the lengthening. We even suggest that it stimulates the formation considering an apparent decrease of the healing index. On the other hand, the elasticity of nails prevents secondary fractures or deformations after frame removal. Conclusion. Combination of the circular EF and FIN in limb lengthening in children significantly decreases the duration of external fixation and the amount of severe infections and fractures

The use of external fixation in the management of long bone fractures has long been recognised.

The aim of this study was to compare 3 differing constructs of Hoffman-2 and Hoffman-3 External Fixator systems to assess which potentially withstood the greatest load.

Three different constructs (2, 3 and 4-bar) of Hoffman 2 and 3 External Fixation systems were tested. A UHMWPE tube was utilised as a bone substitute to construct a biomechanically reproducible model which could be tested on an MTS testing jig. Each construct was loaded to 3, 5, 8, 12 and 15mm of displacement at the fracture gap. Each construct was cyclically loaded 200 times for each test and repeated 5 times.

The results demonstrate that the Hoffman-3 configurations withstood a load of at least twice that of the Hoffman 2 configurations across all displacements. Using a 2-way ANOVA test at all displacements the 2-bar configuration withstood greater load than the 3 bar (P<0.0001). With Hoffman 2 the 2-bar configuration withstood a greater load than the 4 bar diamond configuration.

These results demonstrate that Hoffman-3 External Fixation Device has a greater axial loading capacity than its Hoffman-2 predecessor.

Leg length discrepancy (LLD) can adversely affect functional outcome and patient satisfaction after total hip arthroplasty. We describe a novel intraoperative technique for femoral component insertion.

We aimed to determine if this technique resulted in the desired femoral placement, as templated, and if this was associated with a reduced LLD.

A series of fifty consecutive primary total hip replacements were studied. Preoperative digital templating was performed on standardised PA radiographs of the hips by the senior surgeon. The preoperative LLD was calculated and the distance from the superior tip of the greater trochanter to the predicted shoulder of the stem was calculated (GT-S). Intraoperatively, this length was marked on the rasp handle and the stem inserted to the predetermined level by the surgeon. This level corresponded to the tip of the greater trochanter and formed a continuous line to the mark on the rasp handle. Three independent blinded observers measured the GT-S on the postoperative radiographs. We assessed the relationship between the senior author's GT-S (preoperative) and the observers' GT-S (postoperative) using a Person correlation. The observers also measured the preoperative and postoperative LLD, and the inter-observer variability was calculated as the intra-class correlation coefficient.

There was a strong correlation of preoperative and postoperative GT-S (R=0.87), suggesting that the stem was inserted as planned. The mean preoperative and postoperative LLD were −4.3 mm (−21.4–4) and −0.9 mm (−9.8–8.6), respectively (p<0.001).

This technique consistently minimised LLD in this series. This technique is quick, non-invasive and does not require supplementary equipment.

The aim of this study was to establish medium term outcomes in military casualties following severe open tibia fractures.

Cases from a previously published series were contacted and assessed with the SF-36 outcome tool. Their results were then compared to a similar study of military trans-tibial amputees.

Of the original data set of 49 patients, 30 patients were followed up and completed an SF-36 (61%) with a median follow-up of 4 years (49 months, IQR 397–63). Ten of the 30 required revision surgery, 3 of which involved conversion from initial fixation to a circular frame. Twenty-two of the 30 patients recovered sufficiently to complete a military basic fitness test. The median physical component of SF-36 in the tibia fracture group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in the amputation or fracture group reporting pain (p= 0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney).

We present the patient reported outcomes following combat open tibia fracture and show that they are similar to those achieved after trans-tibial amputation.

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5).

All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly.