Aims. Safety concerns surrounding osseointegration are a significant barrier to replacing socket prosthesis as the standard of care following limb amputation. While implanted osseointegrated prostheses traditionally occur in two stages, a one-stage approach has emerged. Currently, there is no existing comparison of the outcomes of these different approaches. To address safety concerns, this study sought to determine whether a one-stage osseointegration procedure is associated with fewer adverse events than the two-staged approach. Methods. A comprehensive electronic search and quantitative data analysis from eligible studies were performed. Inclusion criteria were adults with a limb amputation managed with a one- or two-stage osseointegration procedure with follow-up reporting of complications. Results. A total of 19 studies were included: four one-stage, 14 two-stage, and one article with both one- and two-stage groups. Superficial infection was the most common complication (one-stage: 38% vs two-stage: 52%). There was a notable difference in the incidence of osteomyelitis (one-stage: nil vs two-stage: 10%) and implant failure (one-stage: 1% vs two-stage: 9%). Fracture incidence was equivocal (one-stage: 13% vs two-stage: 12%), and comparison of soft-tissue, stoma, and mechanical related complications was not possible. Conclusion. This review suggests that the one-stage approach is favourable compared to the two-stage, because the incidence of complications was slightly lower in the one-stage cohort, with a pertinent difference in the incidence of osteomyelitis and implant failure. Cite this article: Bone Jt Open 2023;4(7):539–550

Aims. Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set. Methods. A total of 11 databases were searched. A subset of studies published between 1 October 2020 and 1 January 2011 from a larger review mapping research on limb reconstruction and limb amputation for the management of lower limb COM were eligible. All outcomes were extracted and recorded verbatim. Outcomes were grouped and categorized as per the revised Williamson and Clarke taxonomy. Results. A total of 3,303 records were screened, of which 99 studies were included. Most studies were case series (77/99; 78%) and assessed one method of reconstruction (68/99; 69%). A total of 511 outcomes were reported, which were grouped into 58 distinct outcomes. Overall, 143/511 of all outcomes (28%) were provided with a clear, in-text definition, and 231 outcomes (45%) had details reported of how and when they were measured. The most commonly reported outcome was ‘recurrence of osteomyelitis’ (62; 12%). The single-most patient-reported outcome measure was ‘pain’. Conclusion. This study has highlighted significant inconsistencies in the defining, reporting, and measuring of outcomes across studies investigating surgical management for chronic osteomyelitis of the lower limb in adults. Future studies should clearly report complete details of how outcomes are defined and measured, including timing. The development of a standardized core outcome set would be of significant benefit in order to allow evidence synthesis and comparison across studies. Cite this article: Bone Jt Open 2023;4(3):146–157

Aim. To assess the spread of foot infection and its impact on the outcomes of major amputations of lower extremities in diabetic patients. Method. In a multicentre retrospective and prospective cohort study, we included adult diabetic patients (≥ 18 years) who underwent a major amputation of a lower limb in 5 hospitals between 2000 and 2009, 2012 and 2014. A total of 51 patients were included (of which 27 (52.94%) were men and 24 (47.06%) were women) with the mean age of 65.51 years (SD=16.99). Concomitant section's osseous slice biopsy (BA) and percutaneous bone biopsy of the distal site (BD) were performed during limb amputation. A new surgical set-up and new instruments were used to try and reduce the likelihood of cross-contamination during surgery. A positive culture was defined as the identification of at least 1 species of bacteria not belonging to the skin flora or at least 2 bacteria belonging to the skin flora (CoNS (coagulase negative staphylococci), Corynebacterium spp, Propionibacterium acnes) with the same antibiotic susceptibility profiles. A doubtful culture was defined as the identification of 1 species of bacteria belonging to the skin flora. The patients were followed-up for 1 year. Stump outcomes were assessed on the delay of complete healing, equipment, need of re-intervention and antibiotics. Results. In total, 51 BA were performed during major lower limb amputations (17 above the knee and 34 below the knee) in diabetic patients. Nine (17.65%) bacterial culture results from BA specimens were positive, 7 (13.73%) doubtful and 35 (68.63%) sterile. Before amputation, 23 patients (45.1%) had not received any antibiotics, including 16 (31.37%) with an antibiotic-free interval of 15 days or more. Microorganisms identified in BA were also cultured from the distal site in 33.33% of the cases. Positive BA was associated with prolonged complete stump healing, delay of complete healing (more than 6 months), re-amputation and the need of antibiotics. Conclusions. The microorganisms identified from BA play a role in stump healing in diabetic patients. BA is useful during major limb amputation due to infectious complications and antibiotic therapy could be corrected on the basis of the BA culture results

Aim. Data of optimal management of infections after internal fixation (IIF) is scarce and long-term follow-up results often lack. We analyzed characteristics of infections after intramedullary (IIIF) and extramedullary long bone fixation (IEIF) and evaluated their infection and functional outcome. Method. Consecutive patients with IIF diagnosed at our institution from 01/2010-10/2017 were retrospectively included. Infection was defined as visible purulence, sinus tract, microbial growth in ≥2 independent samples or positive histopathology. The outcome was compared before and after implementation of a comprehensive surgical and antimicrobial treatment algorithm in 04/2013. Results. Of 127 patients, infection involved lower extremity in 111 patients (87%). Median age was 53 years (range, 19–89 years), 70% were men. Fixation was performed with intramedullary nail in 47 (37%) and with extramedullary osteosynthesis (plates, screws, pins) in 80 patients (63%). At infection diagnosis, the implant was in situ in 96 patients (76%), whereas 31 patients (24%) had residual osteomyelitis after implant removal. The time from bone fixation to infection was longer in IIIF than IEIF (25 vs. 7 months, p=0.027). Pain was reported in 55 patients (43%) and local infection signs in 96 patients (75%), including sinus tract in 46 patients, more commonly reported after IIIF than IEIF (49% vs. 29%, p=0.035). Infections were monomicrobial in 85 (67%), polymicrobial in 18 (14%) and culture-negative in 23 patients (18%). Most common pathogens were S. aureus (43%), coagulase-negative staphylococci (28%) and gram-negative rods (22%). Débridement (with device retention, if present) was performed in 40, device removal in 43, one-stage exchange in 16 and two-stage exchange in 20 patients. One patient had no surgery and 7 patients underwent limb amputation. 43 patients (34%) were treated before implementation of the interdisciplinary treatment concept and 84 patients (66%) afterwards. Among 111 patients with available follow-up (median, 5.2 months; range, 0.2–86 months), in 78 cases (70%) infection eradication was achieved (similar in IIIF and IEIF). However, overall infection and functional outcome was only 48% (53 patients). After implementation of the treatment algorithm, the infection outcome improved from 56% to 79% (p=0.03) and the overall success from 33% to 56% (p=0.016). Conclusions. Approximately half of infections after IIF failed in terms of infection eradication or restoration of function. After implementation of standardized surgical and antibiotic treatment concept, infection and functional outcome improved significantly. No significant differences between IIIF and IEIF was observed in terms of infection and functional success

The accepted mechanism of traumatic limb amputation following blast is initial bone disruption due to the shock wave, with amputation completed by the blast wind; survival is considered unlikely. The high survival rate of traumatic amputees following explosion, from the current conflict in Afghanistan, is at odds with previous work. We reviewed extremity injuries, sustained in Afghanistan by UK military personnel, over a 2 year period. 774 British servicemen and women sustained AIS >1 injuries, 72.6% of whom survived. No significant difference was found in the survival rates following explosive blast or gunshot (p>0.05). 169 casualties (21.8%) sustained 263 lower limb and 74 upper limb traumatic amputations. Amputations were more common in the lower than the upper limbs and more common in the extremity proximal bone. Bilateral lower limb amputations were more common than a unilateral lower limb amputation. The majority (99%) of major amputations were sustained as a result of explosion. 46.3% (74) of those who sustained a major amputation following explosion survived. Rates of fatalities caused by explosion, or by small arms are not statistically different. Blast-mediated amputations are not universally fatal, and a significant number were through joint, calling into question previously proposed mechanisms

Between November 1994 and June 1999, 35 patients referred to our Problem Fracture Service with chronic diaphyseal osteomyelitis were treated using a closed double-lumen suction irrigation system after reaming and arthroscopic debridement of the intramedullary canal. This is a modified system based on that of Lautenbach. Between June and July 2007 the patients were reviewed by postal questionnaire and telephone and from the case notes. At a mean follow-up of 101 months (2 to 150), 26 had no evidence of recurrence and four had died from unrelated causes with no evidence of recurrent infection. One had been lost to follow-up at two months and was therefore excluded. Four had persisting problems with sinus discharge and one had his limb amputated for recurrent metaplastic change. Our results represent a clearance of infection of 85.3% (29 of 34), with recurrence in 11.8% (4 of 34). They are comparable to the results of the Papineau and Belfast techniques, but with considerably less surgical insult to the patient

We reviewed 100 consecutive primary sarcoma patients identified from coding records from January 2009 to April 2011. A computerised system was used to access theatre records, and operative details were checked against patient notes to ensure accuracy. Data on demographics, pathology, surgical and oncological management was collected. Of the 100 patients reviewed, 52 were male and 48 female with an average age of 64.9 years (range 23–102 years). Of the 100 operations performed, 13 had primary reconstruction with a myocutanoeus flap, of which 9 varieties were used. Twenty-five patients had reconstruction with a split or full thickness skin graft and 9 patients had a limb amputation. Length of inpatient stay ranged from 0 to 63 days and was greatest for our amputee's. Mean operative time did not increase significantly with rise in case complexity. 31 of our patients received post-operative radiotherapy, one patient had induction radiotherapy whilst another had induction chemotherapy. 5 out of the 100 patients underwent re-excision due to incomplete margins being obtained at primary wide local excisions. We had one patient with a failed free latissimus dorsi flap, in which secondary reconstruction with pedicled gastrocnemius and skin grafting was successful. One patient had a scalp flap following a re-excision of a positive margin of an angiosarcoma. Using a combined oncological orthopaedic and reconstructive plastic surgery approach, in our centre 38% of patients require some form of soft tissue reconstruction following tumour resection, with 13% of all patients requiring microvascular flap reconstruction. We have a 9% amputation rate, which is comparable with other published series. Reconstruction following soft tissue sarcoma is complex and highly demanding, the challenges being best met by a combined orthoplastic surgical team

On 7 July 2005, four bombs were detonated on the London transport system. Three of these bombs exploded almost simultaneously at 08:50h affecting the underground tube network at Aldgate, King's Cross and Edgware Road stations. The fourth bomb exploded at 09:47h on a double-decker bus in Tavistock Square. There were 54 deaths in total at the scenes and over 700 injured. 194 patients were brought to the Royal London Hospital. 167 were assessed in a designated minor injuries unit and discharged on the same day. 27 patients were admitted of whom 7 required ITU care, 1 died in theatre and 1 died post-operatively. The median Injurity Severity Score (ISS) in this group of patients was 6 (range 0-48) and the mean ISS was 12. The general pattern of injury in the critically ill patients was of mangled lower limbs and multiple, severely contaminated fragment wounds. Hepatitis B prophylaxis was administered to those patients with wounds contaminated by foreign biological material. 11 primary limb amputations were performed in 7 patients. 9 limb fasciotomies, 5 laparotomies and 1 sternotomy were carried out. 3 patients had blast lung injury. All patients who underwent primary amputations and debridement received further regular inspections in theatre. These inspections formed the majority of our theatre work. Under no circumstance was initial reconstructive surgery attempted. Delayed primary closure and split skin grafting of all wounds was completed by the end of the second week. There have been no sepsis-related deaths. Our experience at The Royal London has allowed us to revisit the principles of blast wound management in a peacetime setting. A number of lessons were learned regarding communication and resource allocation. A multi-disciplinary approach with the successful execution of a major incident plan is the key to managing an event of this magnitude

Aims

Diabetes mellitus is the most common co-morbidity associated with necrotising fasciitis. This study aims to compare the clinical presentation, investigations, Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) score, microbiology and outcome of management of this condition in diabetic and non-diabetic patients.

A two-year retrospective survey in southern Ethiopia revealed that 49 amputations had been performed, 25 of which were for gangrene following tight splintage applied by traditional bone setters. The aim of this study was to determine if it was possible to reduce this incidence of gangrene by offering one-day instructional courses to bone setters. In ten separate one-day courses 112 tradition healers attended. In addition, two-day courses were given to local health assistants, who also received written instructions for the safe care of fractures. A two-year prospective study revealed a marked reduction in amputations, from 49 to 25, with only seven rather than 25 being required for gangrene.

We found that it is possible to educate traditional healers so that fewer gangrenous limbs require to be amputated.