Aims

Retrospective review of a consecutive series of 1,168 total ankle replacements (TAR) performed at Wrightington, to analyse modes of failure and clinical outcomes following TAR failure.

Introduction

Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. We present our experience of using fine wire frames to correct severe midfoot deformity, followed by internal beaming to maintain the correction.

Introduction

Open fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC).

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.

The undergraduate curricula in the UK have no designated modules on sarcomas. Lumps and bumps are commonly presented to surgeons, hence awareness of sarcoma is important.

The aim of this study was to identify the awareness and knowledge of orthopaedic and surgical trainees relating to the presentation, referral and management of sarcomas.

Participants were invited to take part and complete an online questionnaire. Sarcoma knowledge was assessed using a variety of questions. Key resources were provided to improve knowledge at the end of the questionnaire.

There were 250 respondents, which included medical students (n=49), foundation doctors (n=37), core surgical trainees (n=58), registrars (n=73), post-CCT surgeons (n=9) and academic fellows (n=4). Both UK and international trainees were included. 45% did not recall receiving sarcoma teaching at undergraduate level, with 61% stating they did not have adequate training to identify sarcoma “red flags”. 58% did not have sufficient background knowledge of sarcomas whilst 38% were unable to identify sarcoma red flags. 64% and 25% of trainees had insufficient knowledge of the correct referral process and management for sarcomas respectively.

There appears to be a deficiency in training regarding sarcoma identification and management within trainees. “Red flags” for lumps are not widely known who may be asked to review these patients. Many trainees are not aware of the national guidelines for referral and management. The large sample of respondents is likely to be representative of the larger trend and may lead to inappropriate management, poor outcomes and litigation.

Calcium sulphate (CaSO₄) is a recognised form of delivery of antibiotic for the treatment of bone infection. Complications inherent in the rapid reabsorption are well recognised (predominantly that of wound breakdown and leakage). There is little data on the frequency of these complications. The purpose of this study was to quantify the incidence of wound leakage from CaSO₄ and the service impact in orthopaedic surgery.

Infective limb reconstruction cases managed with gentamicin impregnated CaSO₄ between 2004–2012 were identified. Co-morbidities and factors influencing wound leakage were recorded. Medical and wound care notes were analysed. Episodes of delayed discharge and unscheduled clinic attendance due to wound leakage were recorded.

80 patients (18 female, 62 male), with a mean age of 45 years (18–80 years, median 46 years) underwent 84 procedures utilising CaSO₄. 47 were in the tibia, 14 in the femur, 10 in the humerus. A mean of 36 mL (4–150 mL, median 22 ml, unknown in 18 cases) was used.

31 cases (37%) had post-operative wound leakage, the majority from the tibia(55%) and femur(25%). 21 cases (25%) leaked within the first week. Each 10 ml rise in CaSO₄ volume lead to a 50% rise in leakage incidence. Leak duration ranged from 4 days–10 months. The majority leaked between 1–4 months before ceasing spontaneously and without specific treatment.

14 cases (17%) required a cumulative 32 unscheduled clinic appointments for leakage. Further surgery was required for infection in 7 cases (8.3%). Delayed discharge was not clearly attributable to CaSO₄. The mode of skin closure and cultured organism did not affect leakage.

CaSO₄ has unpredictable leakage, but is present in 1/3 of patients. Volume of CaSO₄ impacts on leakage. Leakage usually self-resolves and does not clearly impact on final outcomes. The cost impact of ongoing wound care and additional clinic appointments may be substantial.

Definitions and perceptions of good and poor outcome vary between patients and surgeons, and perceived inadequate outcome can lead to litigation. We investigated outcomes of litigation claims relating to non-union and deformity following lower limb long bone fractures from 1995 to 2010.

The database of all 10456 claims related to Trauma and Orthopaedic Surgery was obtained from the NHS Litigation Authority. Data was searched for “deformity, non-union and mal-union”, excluding spine, arthroplasty, foot and upper limb surgery. The type of complaint, whether defended or not, and costs was analysed.

241 claims met our criteria, 204 of which were closed, and 37 unsettled. Deformity/mal-union constituted 97, and non-union 143. Coronal/sagittal deformity cost £4.2 million, mean £45,487 (60% received compensation). Rotational mal-unions cost £1.6 million, mean £114,263 (87% received compensation). Non-union cost £5.3 million, mean £75,866 (60% received compensation).

Mean legal fees for coronal/sagittal deformity was £18,772, rotational deformity £37,384, and non-union £24,680. The total cost of litigation was £12.2 million, with a mean of £59,597 per settled claim. The mean pay-out for all confirmed negligence/liability was £56,046 (£1,300–£500,000, median £21,500) per case.

Non-union is an accepted complication following fracture surgery. However, this does not mitigate against non-union being seen as representing a poor standard of care. While it is unclear whether the payouts reflect a defensive culture or were due to avoidable errors, and notwithstanding the limitations of the database, we argue that failure of the index surgery should prompt a referral to a specialist centre.

The cosmetic appearances of rotational malalignment results in higher compensation, reinforcing outward perception of outcome as being more important than harmful effects.

We also note that the database sometimes contained conflicting and incomplete data, and make a case for standardisation of this component of the outcome process to allow for learning and reflection.

The purpose of this study is to report a unique overgrowth syndrome and discuss the insights into the complex orthopaedic management.

Written consent to report this case was granted. The patient's condition, wrongly diagnosed as Proteus syndrome, is characterised by a genetic mutation in PIK3CA, a critical regulator of cell growth. This lead to unregulated cellular division of fibroblasts isolated to the lower limbs. The legs weighed 117 kg, with a circumference of >110 cm. In addition to lower limb overgrowth, numerous musculoskeletal and organ pathologies have been encountered since birth requiring treatment from a wide variety of healthcare specialists and basic scientists. At 32 years, the patient developed septicaemia secondary to an infected foot ulcer. Amputation had been discussed in the elective setting, however the presence of sepsis expedited surgery. The above knee amputation took 9 hours and four assistants including a plastic surgeon. A difficult dissection revealed a deep subcutaneous fatty layer that integrated with deep muscle, massive hypertrophy of cutaneous nerves and the sciatic nerve and ossification within the distal quarter of the quadriceps muscles requiring osteotomy. The lower limb osteology was grossly aberrant. The size of the amputated limb did not permit use of a tourniquet and cell salvage reintroduced 10.5 litres of blood with a further 6 units of red cells intra-operatively. The leg stump successfully took to a split-skin graft. A unique phenomenon was witnessed post-operatively whereby the stump continued to grow due to upregulation of fibroblasts secondary to trauma. Targeted genetic therapies have been successfully developed to suppress this stump growth.

This unique and unclassified overgrowth syndrome was caused by a mutation in the PIK3CA gene. Orthopaedic management of the oversized limb was complex requiring multiple surgeons and prolonged general anesthetic. A multi-disciplinary approach to this condition is required for optimizing outcomes in these patients.

Claims for clinical negligence are increasing annually. Limb reconstructive surgery recognises ‘problems, obstacles, and complications’ as part of the treatment process, but this does not prevent a claim for an alleged poor result or a complication.

We analysed claims for clinical negligence in the National Health Service in England and Wales for issues following limb reconstructive surgery.

A database of all 10,456 claims related to Trauma and Orthopaedic Surgery from 1995–2010 was obtained from the NHS Litigation Authority. A Search Function for keywords “Ilizarov, limb reconstruction, external fixation, and pin-site” was used for subset analysis. Data was analysed for type of complaint, whether defended or not, and for costs.

52 claims fitted our filters - 48 were closed, and 4 ongoing. The claims included damage to local structures (n=3), missed compartment syndrome (n=2), premature frame removal (n=5), infection (n=13), wrong-site-surgery (n=1), poor outcome (n=16) and technical error (n=10). Seven patients underwent amputation. The total cost of litigation was £4,444,344, with a mean of £90,700 per settled claim. 40% were successfully defended, with defence cost of £15,322. The mean pay-out for confirmed negligence/liability was £90,056 (£1,500-£419,999, median £45,000) per case.

We believe this is the first study looking at complications following limb reconstruction from this perspective.

Analysis reveals a spectrum of claims for negligence. Perceived technical errors and poor outcome predominate. Whilst the limitations of the database preclude against identification of whether the procedures were carried out in specialist units, claims for technical errors are a cause for concern. These will be discussed in detail. Outcomes following limb reconstruction are difficult to quantify, and the settling of claims for a perceived poor outcome makes the case for pre-operative counselling and the need for robust outcome measures in our specialty.

Hemiarthroplasty and proximal femoral fixation are common procedures performed in trauma units, but there is very little information regarding post-operative pain experience. Pain control is a keystone in the successful management of hip fractures. A sound strategy of pain management is easier to implement in patients where pain levels can be predicted, allowing for an effective balanced analgesic regime.

Analysis was performed on patients presenting with a hip fracture in two hospitals. Patients with a diagnosis of dementia were excluded. Post-operative pain scores were taken from patient observation charts using a verbal analogue scale. Post-operative opiate consumption was calculated from inpatient drug charts.

357 patients were included, 205 patients underwent a cemented hemiarthroplasty (HG) and 152 had fixation with a dynamic hip screw (DG). No significant difference was found in the length of hospital stay. HG patients recorded a mean morphine requirement of 20.2mg compared with 40.3mg for the DG group. Although the early pain score difference was significant (p=0.009), after 4 days, the scores were equivalent. This may support the notion of non-surgical factors determining the total length of hospital stay.

The reason for the elevated pain scores and higher morphine requirement in the DHS group remains unclear. One theory is the fracture site still exists, and it is possible that pre-existing hip arthritis may continue to be symptomatic. It is important to recognise the difference in pain experienced between the groups and analgesia should be tailored towards the individual, allowing for improved peri-operative surgical care and patient experience.

Total disc replacement (TDR) is the gold standard for lumbar degenerative disc disease in selected patient groups. Traditional TDR designs benefit from a wealth of literature and use a polyethylene inlay pseudo-disc between two metal endplates. There is scarce literature for novel monomodular implants that form an artificial construct of woven annulus and central nucleus, providing physiological motion preservation.

The aim was to compare the evolving changes to radiological position between monomodular and traditional implants and assess the relationship of migration with bone densitometry.

This retrospective series of consecutive patients undergoing TDR under a single surgeon recorded demographics, co-morbidities, previous surgery and clinical outcomes. Measurements of endplate subsidence, lordosis and spondylolisthesis taken from weight-bearing erect x-rays at 0, 3, 6 and 12 months. Radiological outcomes were compared against CT bone densitometry.

33 monomodular and 13 traditional implants. Mean age 40 years. All patients had degenerative disc disease. Monomodular and traditional implants were as likely to develop lordosis (p=0.32), endplate subsidence (p=0.78) or spondylolisthesis (p=0.98). Comparison between endplate subsidence and low bone densitometry were insignificant (p=0.47). Developing lordosis in the monomodular implant was related to low bone density; mean 134vs.184mg/cm³ (p=0.018). Three monomodular implants developed a posterior hinge after migrating into lordosis. One traditional implant dislocated, requiring emergency fusion.

Radiological outcomes are comparable between traditional and monomodular implants. The larger endplate-footprint of the monomodular implant did reduce subsidence. Monomodular implants pivoting on a posterior hinge may fail early. Bone densitometry may identify patients who will drift into lordosis.

Subacromial corticosteroid injections are a well-recognised management for chronic shoulder pain and are routinely used in general practice and musculoskeletal clinics. Mycobacterium tuberculosis (TB) of a joint is a rare presentation in the United Kingdom. International literature exists for cases of reactivated latent tuberculosis following intra-articular corticosteroid injections in a knee; however there are no reports of a primary presentation of undiagnosed TB in a joint following therapeutic corticosteroid injections.

A seventy-four year old lady presented with a one-year history of a painful shoulder, which clinically manifested as a rotator cuff tear with impingement syndrome. Following three subacromial depo-medrone injections, the patient developed a painless “cold” lump which was investigated as a suspicious, possibly metastatic lesion. This lump slowly developed a sinus and a subsequent MRI scan identified a large intra-articular abscess formation. The sinus then progressed to a large intra-articular 5×8 cm cavity with exposed bone (picture available). The patient had no diagnosis of TB but had pathogen exposure as a child via her parents.

The patient underwent three weeks of multiple débridement and intravenous amoxicillin/flucloxacillin to treat Staphylococcus aureus grown on an initial culture. Despite best efforts the wound further dehisced with a very painful and immobile shoulder. Given the poor response to penicillin and ongoing wound breakdown there was a suspicion of TB. After a further fortnight, Mycobacterium tuberculosis was eventually cultured and quadruple antimicrobial therapy commenced. Ongoing débridement of the rotator cuff and bone was required alongside two months of unremitting closed vacuum dressing. The wound remained persistently open and excision of the humeral head was necessary, followed by secondary wound closure. There were no extra-articular manifestations of TB in this patient. At present the shoulder is de-functioned, the wound healed and shoulder pain free.

This unique case study highlights that intra-articular corticosteroid can precipitate the first presentation of Mycobacterium tuberculosis septic arthritis. The evolution of symptoms mimic many other shoulder complaints making confident diagnosis a challenge. The infective bone and joint destruction did not respond to the management described in the current literature. There remains a further management issues as to whether arthroplasty surgery can be offered to post-TB infected shoulder joints.

Taking a TB exposure history is indicated prior to local immunosuppressant injection, particularly in the older age group of western populations and ethnicities with known risk factors.

We present our experience of treating 57 cases of bone defects associated with chronic osteomyelitis (COM) and an algorithm for their treatment.

A retrospective analysis of our operation database revealed 377 patients treated for COM (2002–2010). 76 (20%) had bone defects, of these 57 had notes and x-rays available. The tibia was most commonly affected (63%), followed by the femur (21%). Infection control procedures included debridement, drilling and sequestrectomy. Long-term antibiotics were seldom used. Prerequisites to reconstruction surgery were; fully healed skin, absence of sequestrae on x-ray and no antibiotics for 2-months. Decision on the method of treatment of defect was made depending on; age, defect size, viability of periosteum and physes, condition of soft tissues and coexisting deformity.

Initial treatment was; plaster stabilisation (15), frame stabilisation (6), free fibula structural bone grafts (9), ipsilateral vascularised fibula graft (7), non-structural cancellous bone graft (8), bone transport (8) and amputation (4). Forty three (75%) patients were successfully treated with initial strategy. Initial treatment therefore failed in 14 (25%) patients. Successful treatment subsequently used was; structural bone grafting (6), non-structural bone grafting (4), bone transport (3) and Rush Rod stabilisation (1).

Little is known about osteomyelitis-induced bone defects, which cause massive morbidity in developing countries. Our novel research shows that these can be treated successfully, often by relatively simple methods. In the absence of ongoing infection, non-vascularised bone grafting techniques are often successful. Bone transport or vascularised grafting are more reliable but more complex solutions.

Distal femoral growth plate (DFGP) fractures were originally described as the ‘wagon wheel’ fractures, because they were noted to occur in the young boys who ran alongside wagons passing at speed and got their leg caught between the spokes. The resultant high energy injury was a forceful hyperextension and twisting of the knee. There was a significant incidence of severe complications with these injuries. In our setting, in a developing country, we noted that DFGP injuries appeared more common and tended to occur with a lower energy mechanism of injury.

To investigate if this were a real phenomena, we designed a prospective study looking at DFGP injuries with the primary outcome measure being the mechanism of injury and the secondary outcome measures including method of fixation and functional outcome.

The inclusion criteria for the study were all patients that presented with a DFGP fracture over a period of one year. There were no exclusion criteria. All data was collected prospectively on a standard proforma. Patients were treated according to a standard treatment regimen: where the fracture could be reduced closed and was stable, plaster cast only. Where a fracture could be reduced closed and was unstable, percutaneous pin fixation, where a fracture could not be reduced closed, open reduction and internal fixation.

Forty-three patients were included in the study. 39/43 (91%) of the patients were boys, and the average age was 15.5 years (standard deviation, SD, 3.2 years). Thirty-three (77%) of the injuries resulted from low energy trauma, with the majority (28/33) resulting from sporting injuries, predominately football, with others having simple falls (3/33) or falling off bicycles (2/33). The 10 high energy injuries resulted from pedestrians (3/10) or cyclists (1/10) hit by cars and falling from a height (6/10). Some significant differences were seen in the mean ages of the high and low energy groups. The low energy group were significantly older, with a mean age of 16.3 years (SD 2.8 years) compared to 13.1 years (SD 3.1 years) for the higher energy group (Student’s t-test, p=0.004). When comparing the type of fracture, according to the Salter Harris classification, significantly more Salter Harris IV and V fractures were seen in the high energy group (Chi Squared test, p=0.039) compared to the low. Open fractures were 1/10 (10%) of the high energy group, but there were no open fractures in the low energy group. Complications including infection and amputation, only occurred in the high energy group.

This is the first study to show, that in some countries, the DFGP injury may be more commonly due to a low energy mechanism of injury. The reasons for this may include delayed physeal closure, that has been previously shown in this group.

A number of series report limb length discrepancy in long bone chronic osteomyelitis, however in most cases, it is shortening of the affected bone. This is thought to be due to damage in the affected growth plate leading to early growth arrest. However, it is known that the inflammatory state of chronic osteomyelitis results in an increased blood supply and, as in other conditions such as rheumatoid arthritis, the increased blood supply results in overgrowth of the affected bone.

In order to study the effect of long bone chronic osteomyelitis on limb length, we designed a prospective trial of 42 consecutive patients presenting to our unit with chronic osteomyelitis of a long bone. The inclusion criteria were all patients presenting with a long bone osteomyelitis. There were no exclusion criteria. The mean age at presentation was 10.3 years. The mean duration of symptoms of 18.2 months prior to presentation. For 37 (88%) of patients the cause of osteomyelitis was haematogenous. On examination, 3 (7%) patients had shortening of the long bone compared to the unaffected side (of an average of 2.5cm), whilst 13 (31%) patients had overgrowth of the affected bone (average overgrowth 2.2cm). The most common bone affected was the tibia (20/42, 48%), followed by the femur (8/42, 19%) and the humerus (6/42, 14%).

All patients underwent radiographic analysis, and the average percentage of long bone affected was 59%. 8/42 (12%) of patients had at least one physis affected (2 of these patients had undergrowth and 1 had overgrowth).

This large prospective series of patients is the first in the world literature to show the effect of osteomyelitis on the growth of long bones, in particular an overgrowth rate of 31%. We suggest that the mechanism for this is related to the duration of symptoms. In areas of the world where there is poor access to health care, there is consequently a prolonged period of increased blood supply as a result of inflammation. This increased blood supply may make limb length discrepancy is more likely to be due to overgrowth rather than undergrowth.

The study sought to compare infection and union rates in HIV positive patients sustaining severe open tibial fractures, with those in healthy controls.

In a prospective study, consecutive adult patients with Gustilo grade 2 or 3 open tibial fractures who consented to enter the study were enrolled and treated according to a standard regime. The regime consisted of intravenous antibiotics, emergency wound excision and irrigation, wound left open, fracture stabilisation by external fixation, wound inspection at 48 hours and closure if clinically indicated. 27 patients with 28 fractures entered of whom 7 patients were HIV positive.

At 3 months, 2 of the HIV positive cases had satisfactory wound healing, while 5 were infected. In the HIV negative controls, 17 had satisfactory wound healing while 4 were infected (p=0.020, Fishers exact test).

At 6 months 4 HIV positive patients were united, 3 were ununited. At the same time, 16 HIV negative patients were united, 1 ununited, and 4 lost to follow-up (p=0.059, Fishers exact test).

Open tibial fractures in HIV positive patients are prone to wound sepsis and may show a tendency to delayed or non-union.