Introduction. Transtibial osseointegration (TFOI) for amputees has limited but clear literature identifying superior quality of life and mobility versus a socketed prosthesis. Some amputees have knee arthritis that would be relieved by a total knee replacement (TKR). No other group has reported performing a TKR in association with TTOI (TKR+TTOI). We report the outcomes of nine patients who had TKR+TTOI, followed for an average 6.5 years. Materials & Methods. Our osseointegration registry was retrospectively reviewed to identify all patients who had TTOI and who also had TKR, performed at least two years prior. Four patients had TKR first the TTOI, four patients had simultaneous TKR+TTOI, and one patient had 1 OI first then TKR. All constructs were in continuity from hinged TKR to the prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but two patients did not have complete survey and mobility tests at both time periods. Results. Six (67%) were male, average age 51.2±14.7 years. All primary amputations were performed to manage traumatic injury or its sequelae. No patients died. Five patients (56%) developed infection leading to eventual transfemoral amputation 36.0±15.3 months later, and 1 patient had a single debridement six years after TTOI with no additional surgery in the subsequent two years. All patients who had transfemoral amputation elected for and received transfemoral osseointegration, and no infections occurred, although one patient sustained a periprosthetic fracture which was managed with internal fixation and implant retention and walks independently. The proportion of patients who wore their prosthesis at least 8 hours daily was 5/9=56%, versus 7/9=78% (p=.620). Even after proximal level amputation, the QTFA scores improved versus prior to TKR+TTOI, although not significantly: Global (45.2±20.3 vs 66.7±27.6, p=.179), Problem (39.8±19.8 vs 21.5±16.8, p=.205), Mobility (54.8±28.1 vs 67.7±25.0, p=.356). SF36 changes were also non-significant: Mental (58.6±7.0 vs 46.1±11.0, p=.068), Physical (34.3±6.1 vs 35.2±13.7, p=.904). Conclusions. TKR+TTOI presents a high risk for eventual infection prompting subsequent transfemoral amputation. Although none of these patients died, in general, TKR infection can lead to patient mortality. Given the exceptional benefit to preserving the knee joint to preserve amputee mobility and quality of life, it would be devastating to flatly force transtibial amputees with severe degenerative knee joint pain and unable to use a socket prosthesis to choose between TTOI but a painful knee, or preemptive transfemoral amputation for transfemoral osseointegration. Therefore, TTOI for patients who also request TKR must be considered cautiously. Given that this frequency of infection does not occur in patients who have total hip replacement in association with transfemoral osseointegration, the underlying issue may not be that linked joint replacement with osseointegrated limb replacement is incompatible, but may require further consideration of biological barriers to ascending infection and/or significant changes to implant design, surgical technique, or other yet-uncertain factors

Introduction. Open fractures of the tibia are disabling injuries with a significant risk of deep infection. Treatment involves early antibiotic administration, early and aggressive surgical debridement, and may require complex soft tissue coverage techniques. The extent of disruption to the skin and soft-tissue envelope often varies, with ‘simple’ open fractures (defined by the Orthopaedic Trauma Society (OTS) open fracture severity classification) able to be closed primarily, whilst others may require shortening or soft-tissue reconstruction. This study aimed to determine whether OTS simple tibial open fractures received different rates of adequate debridement and plastic surgical presence at initial debridement, compared with OTS complex injuries, and whether rates of fracture-related infection, nonunion, or reoperation differed between the groups. Materials & Methods. A consecutive series of open tibia fractures managed at a tertiary UK Major Trauma Centre between January 2021 and November 2022 were included. Patient demographics, injury characteristics, timing of antibiotic delivery, timing and method of definitive fixation, and frequency of plastic surgical presence at initial debridement were retrospectively collected. The delivery of bone ends at initial debridement was used as a proxy for adequacy of surgical debridement. The primary outcome measure was rate of fracture-related infection, secondary outcomes included rates of reoperation, nonunion, and amputation. Chi2 Tests and independent samples T-tests were used to assess nominal and continuous outcomes respectively between simple and complex injuries. Ordinal data was assessed using nonparametric equivalent tests. Results. 79 patients with open fractures of the tibia were included. 70.8% of patients were male, with mean age 50.4 years (SD 19.2) and BMI 26.4 Kg/m2 (SD 6.0). Injuries were mostly sustained by low-energy falls (n = 28, 35.4%) and from road traffic accidents (n = 26, 32.9%). 27 (34.2%) were OTS simple open fractures. Simple open fractures were most commonly Gustillo-Anderson grade 1 (38.5%), or 2 (30.8%), whilst complex open fractures were mostly grade 3B (66.7%) (p < 0.001). Fracture-related infection rates in OTS simple and complex open fractures were 25.9% and 25.5% respectively (p = 0.967), and nonunion rates were 32% and 37.8% (p = 0.637). Primary amputation was less common in simple (0%) than in complex open fractures (20%, p = 0.012), there were no differences in delayed amputation rates (7.4% and 6% respectively, p = 0.811). Simple open fractures were less likely to have plastic surgeons present at initial debridement compared to complex open fractures (18.5% and 44%, p = 0.025), and less likely to have bone ends delivered through the skin at initial debridement (25.9% and 61.2%, p = 0.003). There were no differences in patient age, delays to antibiotic administration, or reoperation rates between OTS simple and OTS complex fractures (p > 0.05). Conclusions. Despite involving less significant soft tissue injury, OTS simple open tibia fractures had comparable deep infection and nonunion rates to complex fractures and received early plastic surgical input and adequate debridement less frequently. The severity of open fractures with less significant soft tissue injury may be underrecognized and therefore undertreated, although further prospective study is needed

Aim. To evaluate clinical outcomes for patients with osteomyelitis at a major trauma centre limb reconstruction unit. Method. We prospectively evaluated 137 patients on the limb reconstruction database with long bone osteomyelitis. Data on initial diagnosis, management (bone resection, use of external fixation, dead space and soft tissue management), microbiology and 2-year outcomes were collated. 11 patients' data was incomplete and 9 underwent primary amputations; these were excluded from microbiology data analysis. The patient data was categorised into microbiological culture negative or culture positive groups. Inter-group comparisons were made to evaluate two-year outcomes and percentage failure rate. Results. Forty percent (55/137) of patients presented with infected non-union, 20% (27/137) infected fractures, 19% (26/137) chronic osteomyelitis without implants and 14% (19/137) had infected metalwork. Removal of metalwork, reaming and debridement were the most frequently performed procedures, often in combination. 3% of patients failed treatment and had persistent infected non-union. The most common microorganisms identified in the culture positive group were Staphylococcus aureus (47.6%), Coagulase Negative Staphylococcus species (11.9%) and Enterobacter cloacae (11.9%), however multiple organism growth was more common than single organism growth, 53% and 47% respectively. 8% of culture negative patients had histological evidence of infection on biopsy. Conclusions. The 2-year failure rate (persistent infective non-union) was higher in the culture negative group (8%) than the culture positive group (1%). The higher failure rate may be secondary to lack of organisms isolated and available sensitivities from deep tissue samples. In 9 cases patient preference led to primary amputation over limb salvage procedures, without further infection. Our work highlights the array of factors contributing to outcome in this patient group. The incidence of micro-organisms commonly encountered in this cohort will provide further evidence to support choice of antibiotic for empirical therapy especially in cases which are culture negative. Finally, there are many challenges in achieving adequate outcomes in patients with long bone infections thus the need for a multidisciplinary team approach in this patient cohort is invaluable. Routine histology testing may be beneficial as this may highlight infective processes in culture negative patents thereby allowing optimization of patient management

Introduction. Blunt trauma of the lower limb can lead to vascular injury causing devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). Secondary aims included establishing the patient complications and outcomes. Materials and Methods. Retrospective analysis found that from 2013–18, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Long-term functional outcomes were determined using postal and telephone questionnaires. Results. Twenty-four patients were male and 6 were female, their mean ages were 32 and 49 respectively. Of the 32 limbs, 27 (84%) were salvaged. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Eleven limbs had prophylactic fasciotomies, 3 limbs developed compartment syndrome – all successfully treated, and three contracted deep infections – one of which necessitated amputation. All but 1 patient survived their injuries and were discharged from hospital. Of the 15 questionnaire responses, self-reported limb function was understandably worse post-injury with patients experiencing mild pain on average. In addition, there was a long-standing psychological impact and the injuries altered many patients’ normal lives significantly, 10 experiencing financial difficulties and 6 having changed or lost jobs post-injury. Conclusions. Fortunately, 27 (84%) limbs were salvaged and nearly all patients survived these injuries when treated at an MTC. Whilst the number of complications was low, the future challenges these patients face are wide-ranging and significant

To assess the efficacy of a combined orthoplastic approach to the management of severe grade III fractures of the lower limb, we looked at the functional and radiological outcome of 100 consecutive fractures from a specialist centre. A prospective analysis was performed on 100 consecutive open tibial fractures (98 patients). An early decision was made by a specialist multidisciplinary team as to whether the injured limb was reconstructable. In the reconstruction group there were 84 Gustilo grade IIIB/C injuries. Definitive skeletal stabilisation was most commonly with a circular frame (60%) or intramedullary nail (20%). The mean time to union was 26 weeks for diaphyseal fractures, 20 weeks for metaphyseal fractures and 10 weeks for ankle fractures. There was one aseptic non-union which is still undergoing treatment. The anterolateral thigh free flap was the most common soft tissue reconstruction used (42%). There were minimal surgical complications and only one free flap failure. Mean time to follow-up was 24 months. The mean limb functional score (modified enneking) was 83% of that of the normal limb and was not influenced by the site of fracture or type of fixation. The mean SF-36 score was 75 and there was a high return to employment (70%). In the primary amputation group there were 16 grade IIIB/C injuries. Mean time to follow-up was 38 months. The mean SF-36 score for the below knee amputees was 58 and there was again a high return to employment (58%). In the reconstruction group there is a 99% limb salvage rate with infection-free union to date and no delayed amputations. A higher return to functional activity/employment was achieved in the reconstruction group compared to the primary amputation group. Our results demonstrate that by using a combined orthoplastic approach in a specialist centre excellent results can be achieved for all patients presenting with severe open lower limb injuries

Introduction. The available scoring methods and outcome analysis methods in lower extremity skeletal trauma with vascular injuries are not always specific. Biochemical parameters like venous blood lactate, bicarbonate and serum CPK (at the time of admission and serial monitoring) were measured to assess whether they supplement clinical parameters in predicting limb salvageability in lower extremity skeletal trauma with vascular injuries. Materials and methods: 74 adult patients with long bone fracture of lower limb associated with vascular injury (open and closed) were included in the study group. Patients with significant head injury (who cannot provide informed consent) and those with mangled extremities (MESS score>8) were excluded. Methodology. Pre-operative requirement for fasciotomy was recorded. A vascular surgery consultation was obtained. CT angiography and DSA were performed if needed only. Venous blood samples from the injured limb were withdrawn for lactate and bicarbonate analysis. Serum CPK was estimated at the time of admission and repeated at 6, 12, 24, 48 and 72 hours after admission. A record was maintained about the type and duration of surgery, blood loss, type of anaesthesia used and fasciotomy in the post-operative period. Results. Of the 74 patients included in the study, 55 patients were taken up for a revascularization procedure, 13 patients for primary amputation and in remaining six patients, no vascular surgery was required. If the level of bicarbonate in the injured limb was less than 16.5 mmol/L, pH < 6.89 the probability of survival of the limb after a revascularization procedure is low and the injured limb will need an amputation eventually. Lactate levels and creatinine kinase were not of any predictive value regarding the outcome of the injured limb. Conclusion. Along with clinical signs, low levels of bicarbonate (<16.5 mmol/L), pH (<6.89), and high levels of pCO2, base deficit in the injured limb at the time of presentation were associated with the less favorable outcome-amputation

Since 2008 the improvised explosive device has been responsible for a significant proportion of injuries sustained whilst on operational duty in Afghanistan. Vehicles have been developed and adapted to offer maximal protection to service personnel. As a result of the decrease in mortality, there has been an increase in the severity of injuries to the lower limb. Hind-foot injuries are a difficult cohort of injuries to treat successfully. Those that are amenable to reconstruction carry a significant morbidity, which may result in either early or delayed amputation. There has been a new injury pattern to the lower limb, not previously described in the medical literature. This pattern consists of a displaced intra-articular calcaneal fracture, distal third tibial fracture and midfoot injury within the same limb. We believe the combination of the three injuries form the “unhappy triad of the ankle”. Each of the injuries is individually reconstructable, but the combination of all three primary amputation should be considered as part of the surgical options

Purpose. We aim to determine the amputation rate and identify predictors of outcome in patients with tibial fractures and associated popliteal artery injuries at a level 1 trauma unit draining a large geographical region. Material and methods. All patients with popliteal artery injuries and tibial fractures treated at a level 1 trauma unit between 1999 and 2010 were assessed retrospectively regarding amputation rates and prognostic factors and tested for significance with a Z-test of proportions. Results. Thirty consecutive patients were reviewed with a mean age of 30.5 years and a male preponderance of 73.3%. Motor vehicle accidents (MVAs) and gunshot wounds (GSWs) constituted the mechanism of injury in 17 patients (56.7%) and 11 patients (36.7%) respectively. Twenty-one cases were polytrauma patients. Intra and extra-articular metaphyseal fractures (AO 41 A-C) were seen in 19 patients and diaphyseal fractures (42 A-C) in 7 patients. Primary amputation was performed in 7 patients and delayed amputation in 10 patients giving an overall amputation rate of 56.7%. Amputation rates in MVAs and GSWs were similar (57.9% and 54.5% respectively). Delays from injury to revascularization of more than 6 hours, delays from hospital admission to revascularization of more than 2 hours and initial clinical assessment of non-viability were associated with higher rates of limb loss of 60.9%, 62.5% and 60% respectively. Signs of threatened viability together with delay from admission to theatre more than 2 hours showed the highest amputation rate of 68,4%. These results are trends and not statistically significant with 95% confidence interval. Conclusion. More than half of the patients with these injuries required amputation. Predictors of amputation remain elusive; however, these results suggest that initial presentation of a threatened limb in the context of a tibial fracture may necessitate intervention within the first 2 hours of presentation in order to improve the outcome. NO DISCLOSURES

Background. Decisions about local treatment are important in osteosarcoma treatment. The purpose of this study was to review decisions about local treatment in one centre. Methods. This was a retrospective review of the records of all patients with high-grade extremity osteosarcoma presenting to our centre between 1997 and 2008. Particular attention was paid to local control decisions. Results. 54 patients were included, 37 were male. Median age was 18 (4.1 to 71.3 years). The anatomical location was distal femur in 33, tibia in 8, humerus in 7, ankle/foot in 3, fibula in 2 and clavicle in 1. 8 (14.8%) patients had metastases at presentation. 13 (24.1%) patients underwent primary amputation, predominantly in the early years of the series. The remaining 41 patients had limb-sparing surgery, 5 of whom had microscopically positive margins. 21 of 54 (38.8%) had >90% necrosis in the resected tumour. 3 patients had poor necrosis and positive margins. These were a 70 yo intolerant of chemotherapy, who refused amputation, developed LR and metastatic disease; a 15 yo with metastatic disease, who had a secondary amputation and metastatectomy and survived and a 43 yo who developed metastases and LR on chemotherapy. 4 further patients had local recurrence after LSS. All had poor necrosis after chemotherapy but adequate margins. All developed metastatic disease and 3 have died. Overall survival was 60%. 5-year survival without metastatic disease at presentation was 65%. Conclusion. Our series is similar to other centres. Challenges include older patients, poor response to chemotherapy and metastases

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