Abstract

Aims

Computer hexapod assisted orthopaedic surgery (CHAOS), is a method to achieve the intra-operative correction of long bone deformities using a hexapod external fixator before definitive internal fixation with minimally invasive stabilisation techniques.

The aims of this study were to determine the reliability of this method in a consecutive case series of patients undergoing femoral deformity correction, with a minimum six-month follow-up, to assess the complications and to define the ideal group of patients for whom this treatment is appropriate.

The implementation of knee arthrodesis has become synonymous with limb salvage in the presence of chronic sepsis and bone loss around the knee. This can be seen in failed trauma surgery or knee arthroplasty as an alternative to trans-femoral amputation. There is no prior literature assessing which factors affect knee arthrodesis using external fixation devices.

Sixteen consecutive patients (four women and twelve men) made up of eleven infected knee implants, three internal fixations of the tibial following fractured tibial plateau as well as 2 infected native joints were identified. The mean age at initial surgery was 56 years (range 25 to 82 years). All procedures were performed under the direct supervision of the limb reconstruction teams using a standard protocol with either a Taylor spatial frame or Ilizarov frame. The patient records, microbiology results and radiographs of all patients who underwent knee arthrodesis at this institution between 1999 and 2010 were reviewed.

Of the 16 patients in this study knee fusion occurred in eleven patients (69%). The five patients where arthrodesis failed all had significant bone loss on the pre-operative radiographs and confirmed at surgery. We found a relationship between a significant infection of the knee with MRSA and failure to fuse. Three of the five patients had MRSA isolated from inside the knee at some stage during their treatment.

The five patients where fusion failed were on average older (mean age 63 years against 51 years) and had more extensive bone loss. Those who failed to fuse had more co-morbidities. We would conclude that where there is little or no bone loss, arthrodesis of the knee can be reliably achieved with the use of circular frame fixation. A greater number of negative factors also prolongs the amount of time spent in the external fixator. The presence of significant bone loss, infection, increased age and multiple co-morbidities requires careful evaluation and consideration of trans-femoral amputation as an alternative.

Percutaneous grafting of non-union using bone marrow concentrates has shown promising results, we present our experience and outcomes following the use of microdrilling and marrowstim in long bone non-unions.

We retrospectively reviewed all patients undergoing a marrowstim procedure for non-union in 2011–12. Casenotes and radiographs were reviewed for all. Details of injury, previous surgery and non-union interventions together with additional procedures performed after marrowstim were recorded for all patients. The time to clinical and radiological union were noted.

We identified 32 patients, in sixteen the tibia was involved in 15 the femur and in one the humerus. Ten of the 32 had undergone intervention for non-union prior to marrowstim including 4 exchange nailings, 2 nail dynamisations, 3 caption graftings, 2 compression in circular frame and 1 revision of internal fixation. Three underwent adjunctive procedures at the time of marroswstim. In 18 further procedures were required following marrowstim. In 4 this involved frame adjustment, 5 underwent exchange nailing, 4 revision internal fixation, 2 additional marrowstim, 2 autologous bone grafting and 3 a course of exogen treatment.

In total 27 achieved radiological and clinical union at a mean of 9.6 months, of these ten achieved union without requiring additional intervention following marrowstim, at a mean of 5.4 months. There were no complications relating to marrowstim harvest or application.

Marrowstim appears to be a safe and relatively cheap addition to the armamentarium for treatment of non-union. However many patients require further procedures in addition to marrowstim to achieve union. Furthermore given the range of procedures this cohort of patients have undergone before and after marrowstim intervention it is difficult to draw conclusions regarding it efficacy.

Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the majority of deformities, however distal femoral deformity is difficult to assess because of the difference between anatomic and mechanical axes. We found the described technique involving constructing a line perpendicular to a line from the tip of the greater trochanter to the centre of the femoral head inaccurate, particularly if the trochanter is abnormal. We devised a novel technique which accurately determines the CORA and extent of distal femoral deformity, allowing accurate correction.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylized as a block. A line bisecting the axis of the proximal femur is then extended distally to intersect the joint. The angle (θ) between the joint and the proximal femoral axis and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of the deformity, permitting accurate correction.

We examined the utility and reproducibility of the new method using 100 normal femora. θ = 81 ± sd 2.5°. As expected, θ correlated with femoral length (r=0.74). P (expressed as the percentage of the distance from the lateral edge of the joint block to the intersection) = 61% ± sd 8%. P was not correlated with θ.

Intra-and inter-observer errors for these measurements are within acceptable limits and observations of 30-paired normal femora demonstrate similar values for θ and p on the two sides.

We have found this technique to be universally applicable and reliable in a variety of distal femoral deformities.

Introduction

Over 300,000 patients present with fragility fractures each year. Following a hip fracture, the 30 days mortality is around 8.3 to 9.3%. Mortality increases to 20–24% after the first year and this risk may persist for at least 5 years. The most significant variables that influence mortality are age, gender, fracture type, prefracture residence, prefracture mobility and ASA scores. Common reported postoperative complications responsible for mortality in hip fracture patients include; heart failure, bronchopneumonia and infections. Most of the studies in the literature focus on management variables influencing mortality rather than the encountered postoperative medical problems leading to death.

The aim of this study is to retrospectively analyze the postoperative medical complications which led to death in a cohort of patients, following a hip fracture.

Informed consent is vital to good surgical practice. Pain, sedative medication and psychological distress resulting from trauma are likely to adversely affect a patient's ability to understand and retain information thus impairing the quality of the consent process. This study aims to assess whether provision of written information improves trauma patient's recall of the risks associated with their surgery.

121 consecutive trauma patients were randomised to receive structured verbal information or structured verbal information with the addition of supplementary written information at the time of obtaining consent for their surgery. Patients were followed up post-operatively (mean 3.2 days) with a questionnaire to assess recall of risks discussed during the consent interview and satisfaction with the consent process.

Recall of risks discussed in the consent interview was found to be significantly improved in the group receiving written and verbal information compared to verbal information alone (mean questionnaire score 41% vs. 64%), p=0.0014 using the Mann-Whitney U test. Patient satisfaction with the consent process was significantly improved in the group receiving written and verbal information, 97.9% of patients reported that they understood the risks of surgery when they signed the consent form compared to 83.2% who received verbal information alone (p=0.01). The majority of patients who received written information reported finding it helpful (93.8%) and most of the patients who did not receive written information reported they would have found it useful had it been offered (66%).

Patients awaiting surgery following trauma can pose a challenge to adequately inform about benefits conferred, the likely post operative course and potential risks. Written information is a simple and cost-effective means to improve the consent process and was popular with patients.

Lower limb mal-alignment due to deformity is a significant cause of early degenerative change and dysfunction. Standard techniques are available to determine the centre of rotation of angulation (CORA) and extent of the deformities. However, distal femoral deformity is difficult to assess because of the difference between anatomic and mechanical axes. We describe a novel technique which accurately determines the CORA and extent of distal femoral deformity.

Using standard leg alignment views of the normal femur, the distal femoral metaphysis and joint line are stylised as a block. A line bisecting the anatomical axis of the proximal femur is then extended distally to intersect the joint. The angle (?) between the joint and the proximal femoral axis, and the position (p) where the extended proximal femoral axis intersects the joint line are calculated. These measurements can then be reproduced on the abnormal distal femur in order to calculate the CORA and extent of deformity, permitting accurate correction.

We examined the utility and reproducibility of the new method using 100 normal femora. We found this technique to be universally robust in a variety of distal femoral deformities.

Introduction

The optimal management of intra-articular tibial plateau fractures with metaphyseal-diaphyseal dissociation remains challenging and controversial. We report results using the technique of limited open reduction with external fixation using a fine wire circular frame.

Simultaneous arthrodesis of the ankle and subtalar joints is an established treatment option for combined ankle and subtalar arthritis or complex hindfoot deformities. The use of a curved intra medullary nail has potential advantages in terms of stability, hindfoot alignment and avoidance of the lateral neurovascular bundle.

We devised a comparative description of the results of hindfoot fusion using a curved locking nail before and after the introduction of anatomically specific modifications to the device through a retrospective review of notes and radiographs of patients undergoing simultaneous ankle and subtalar fusion by retrograde intramedullary nailing using an ACE¯ (Humeral Nail. Patients undergoing the same procedure using the Tibiotalocalcaneal [TTC] Nail System [DePuy] were recruited and studied prospectively. The outcome was assessed by a combination of notes review, clinical examination and telephone questionnaire.

Between 1996 and 2004, 71 arthrodeses in 67 patients have been performed. The average follow up is 27 months [3-73] and mean age 58 years. Fifty-two arthrodeses utilised the ACE humeral nail and nineteen used the newer TTC nail. Both nailing systems are locked proximally and distally and provide a short radius laterally directed distal curve. Mean time to union is 4.3 months [3-10]. Average AOFAS hindfoot score post-operatively is 65, with a mean improvement of 40 points from the pre-operative score in the TTC nail group. Post-operative complications included deep infection, amputation and a non-union rate of 10% overall. In the humeral nail group, four symptomatic stress reactions [8%] and three fractures of the tibia [6%] occurred at the tip of the nail. No stress-riser effect has to date been seen in the TTC nail group. Prominent metalwork removal has also been significantly reduced in the TTC nail group.

Our results show hindfoot fusion using a curved intramedullary nail to be an effective technique in complex cases of hindfoot arthritis and deformity. Anatomically specific alterations to the nail have resulted in a significant reduction in certain complications. Alternate proximal locking options in the TTC nail have reduced prominent metalwork and, more significantly, the incidence of stress reactions and fractures appears to have been eliminated.

Methods: A Ring Fixator (Taylor Spatial Frame (TSF); Smith & Nephew, Memphis, TN), was used in the treatment of 5 patients (ages 11 to 16 years) with proximal tibial growth arrest following trauma.

Results: The mean corrections were 14.2° (max 28°, min 0°) in the saggital plane and 14° (max 38°, min 2°) in the coronal plane. Leg length discrepancy was also corrected (max 1cm). The average time in frame was 17.8 weeks, with an average correction time of 29.8 days. Knee Society Clinical Rating System (KSCRS) scores post operatively ranged from 95 to 100. All patients returned to full activity, and would accept the same treatment if offered again. The circular fixator is an effective, minimally invasive method for treating the complex deformities arising from this rare injury. Patients remain active during treatment, encouraging a rapid return to school/work activities.

A Ring Fixator (Taylor Spatial Frame (TSF); Smith & Nephew, Memphis, TN), was used in the treatment of 5 patients (ages 11 to 16 years) with proximal tibial growth arrest following trauma. The mean corrections were 14.20 (max 280, min 00) in the saggital plane and 140 (max 380, min 20) in the coronal plane. Leg length discrepancy was also corrected (max 1 cm). The average time in frame was 17.8 weeks, with an average correction time of 29.8 days. Knee Society Clinical Rating System (KSCRS) scores post operatively ranged from 95 to 100. All patients returned to full activity, and would accept the same treatment if offered again.

The circular fixator is an effective, minimally invasive method of treatment for post-traumatic proximal tibial deformity. Patients remain active during treatment encouraging a rapid return to school/work activities.

Introduction: Utilisation of day case surgery units for orthopaedic trauma is an uncommon concept. Limited reports of its use in specific orthopaedic trauma cases have been encouraging. There is currently no formal provision for day case surgery for trauma patients at our institution. The aim of this study was to identify the proportion of trauma patients that would be suitable for daycase surgery and the proportion of these that currently undergo procedures as a day case, with a view to establishing a more formalised daycase trauma service.

Methods: We undertook prospective data collection on all trauma referrals in our institution over a 1 month period in January 2008. Information was recorded for date and time of referral, admission, operation and discharge. Nature of injury, type of procedure performed, grades of surgeon involved and length, nature and reason for any pre or post-operative delay was also recorded. All patients requiring surgery were assessed on their suitability for day case as defined by pre-determined patient-related and surgery-related criteria.

Results: Of all the patients referred during the study period 129 patients required surgery. Of the operated patients 80 (62%) had a procedure suitable to be performed as a day case as defined by surgical factors. Of these, 57 (44%) patients met criteria for day surgery as defined by patient factors. Of those eligible for day case surgery (n=57), only 27% had their procedures performed as a day case. The total number of additional days spent in hospital by day case eligible patients was 69. 34 days were due to pre-operative delay and 35 were due to post operative delay. The mean number of pre operative days in hospital was 1.33(range 0–3) and post operative days 1.85 (range 0–8). There was a wide case mix of procedures performed that were deemed appropriate for day case surgery. 76% were upper limb or soft tissue procedures.The causes for pre-operative delay established two main issues. Limited dedicated operating theatre capacity for day case eligible procedures resulting in their de-prioritisation and limitations on dedicated bed availability. The cause for postoperative delay was more variable but on the whole was for reasons which with appropriate protocols could have been avoided.

Conclusions: This study has identified that a significant proportion of orthopaedic trauma workload would be appropriate to be carried out as a day case. Without an appropriate day case surgery setup, current delays are causing 69 unnecessary bed days per month in our institution. Causes for current delays are related to lack of synchrony between timing of admission and surgery and lack of appropriate discharge protocols. We are in the process of developing a plan for implementation of a dedicated day case trauma service at our institution and suggest that this may be an appropriate use of day case facilities in other trusts.

17 patients have undergone 20 microdrilling procedures to stimulate bone union in cases of established non-union. This occurred at the docking site following completion of bone transport using a stacked Taylor Spatial Frame, non-union following arthrodesis or non-union in long bone fracture.

Additional bone grafting was performed in only one patient. Further stimulation of union via injection of Bone Morphogenetic Protein was undertaken with 3 microdrilling procedures.

Of the 20 microdrilling procedures, 8 were considered fully successful in terms of stimulation of union, 7 were partially successful and 5 were not felt to have been successful.

The mean time to fully successful union following microdrilling was 11.4 weeks, ranging from 6 to 19 weeks.

There were 2 complications, both acute infections at the microdrilling site. Both of these were in patients with previous significant pin site infections.

We present the use of a microdrilling technique as a safe and effective minimally invasive technique that promotes union in cases of refractory non-union, whilst avoiding the donor site morbidity associated with open bone grafting.

We present, as a pilot study, our experience in the use of this technique in patients treated with circular frames for acute fractures, at the docking site in cases of bone transport and in cases of non-union following arthrodesis.

We have treated 17 patients with bone defects of the tibia by internal bone transport using a stacked Taylor Spatial Frame.

There were 12 cases of infected non unions, 2 cases of osteomyelitis, 1 case of acute traumatic bone loss, 1 case of non union in a patient with neurofibromatosis, and 1 case of pseudoarthrosis of the tibia.

The mean bone defect was 51.8mm (range 10–100mm).

Leg length has been restored to within 10mm in 16 cases and to within 15mm in one case. All patients have united.

Residual deformity at the docking site or regenerate was negligible in 4 patients and less than 5 degrees in any plane in the remaining 13 patients. There have been two cases of re-fracture which have united with conservative treatment and 1 case of partial peroneal nerve palsy which is recovering.

The use of a stacked Taylor Spatial Frame system is effective in mediating bone transport resulting in predictable regenerate, accurate docking and minimal induced bone deformity.

Complex regional pain syndrome (type 1) (CRPS) is a chronically painful and disabling condition commonly encountered following trauma and surgery to an extremity. The condition comprises of a combination of pain, swelling, sensory impairment, joint stiffness, trophic changes, motor abnormalities and vasomotor instability.

Post-traumatic CRPS is a significant clinical problem presenting to the orthopaedic surgeon and pain specialist. A clear understanding of the condition has been hampered by a lack of uniformity of diagnostic criteria (Van de Beek W-JT, et al Neurology2002;58:522–526). Pain therapists use the International Association of Pain (IASP) criteria (Bruehl S et al Pain1999;81:147–154) and orthopaedic surgeons the Atkins criteria (J Bone Joint Surg1990;72B:105–110).

Breuhl’s criteria use a combination of symptoms and signs from 4 distinct groups (hypersensitivity; vasomotor; swelling and sudomotor; motor and trophic).

Atkins’ criteria require the finding of vasomotor instability symptoms, abnormal finger dolorimetry and abnormal finger range of movements.

We have compared these different criteria on a series of 262 patients with distal radial fracture.

The incidence of CRPS was similar using either criteria (Bruehl 20.61% vs. Atkins 22.52%). Using the Bruehl criteria as a gold standard, there was strong diagnostic agreement (Kappa = 0.79, sensitivity = 0.87, specificity = 0.94). The main difference between the two methods was in pain assessment. 16 patients had vasomotor instability, swelling and motor changes but 12 did not complain of hypersensitivity although the dolorimetry ratio was lowered. These cases have CRPS by the Atkins criteria but not the Bruehl. In contrast 4 of these cases had normal finger dolorimetry but abnormal forearm hypersensitivity and therefore had CRPS by the Bruehl criteria and not the Atkins.

These finding show that the Bruehl and Atkins criteria are basically concordant. The differences reflect only minor variations in the assessment of pain. Agreement between researchers in the orthopaedic and pain therapy communities will allow improved understanding of the pathophysiology, possible prevention and future methods of managing CRPS.

We describe 24 fractures of the tuberosity of the calcaneus in 22 patients. Three were similar to the type of avulsion fracture which has been well-defined but the remainder represent a group which has been unrecognised previously. Using CT and operative findings we have defined the different patterns of fracture of the calcaneal tuberosity. Ten fractures extended into the subtalar joint, but did not fit the pattern of the common intra-articular fracture as described classically. We have defined a new pattern which consists of a fracture of the medial calcaneal process with a further fracture which separates the upper part of the tuberosity in the semicoronal plane.

Non-operative treatment of displaced fractures resulted in a mis-shapen heel and a poor functional outcome. Open reduction and internal fixation with either a plate or compression screw did not give satisfactory fixation.

We prefer to use an oblique lateral tension-band wire. This technique gave excellent fixation and we recommend it for the treatment of displaced fractures of the tuberosity of the calcaneus.