Introduction

Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures

Introduction:

Bicondylar tibial plateau fractures are serious periarticular injuries. We investigated outcomes in injuries managed with Ilizarov external fixators.

The purpose of the study was to retrospectively assess the patients treated to date with the vac ulta system using a technique of antibiotic instillation.

The vac ulta system is licensed for use with anti-septic instillation fluid but we have now treated a number of patients with antibiotic instillation under the guidance of the microbiology department. All patients being treated with the vac ulta system were included in the study. There were no exclusions. Pathology treated, infecting organism, antibiotic used and length of treatment were all recorded. Any antibiotic related complications were noted. Treatment was judged successful with resolution of presenting symptoms, normalization of inflammatory markers and three negative foam cultures.

There were 21 patients included in the study. There were 13 male and 8 female patients. Length of treatment ranged from 1 week to 10 weeks with a mean of 4.2 weeks. Follow up ranged from 1 month to 42 months with a mean follow up of 17.9 months

The most common pathogen was Staph. Aureus(11 cases). Enterobacter, ESBL, Strep. Milleri, MRSA and Citrobacter were also treated. Antibiotics instilled included flucloxacillin, meropenem, gentamicin, vancomycin, meropenem and teicoplanin. There were no antibiotic reactions/allergies. Pathologies treated included osteomyelitis, two stage amputations for infection, infected non-union and infected metalwork. Infection recurred in 2 of 21 patients (10%), with one recurring at 18 months and one at 2 years.

The 90% treatment success rate is highly encouraging in this notoriously difficult group of patients to treat. In this series vac instill was an effective treatment of infection and allows antibiotic treatment to be targeted to the infected tissues. There were no adverse reactions seen.

Larger series with longer follow up are no needed but we believe this technique is safe, successful and easily administered can be cautiously adopted on a wider basis.

The aim of the study is to evaluate how patients over 65 years of age cope with the Ilizarov method of treatment, compared with patients a decade younger.

Two age groups were selected, 50–65 years versus 65 years and over. 20 consecutive patients were recruited for each group. SF36 scores were completed pre-operatively, at 6 weeks post op and 6 weeks post frame removal. 41 patients were recruited in total.

Seven patients were lost to follow up – 2 died, 2 became too ill to continue with treatment, 3 did not complete the SF36. This left 34 patients.

T test was used to analyse the results.

Both age groups showed an equal and statistically significant drop in SF36 scores whilst the Ilizarov frame was on (p<0.01 for each group).

After frame removal, SF36 in the >65 group was not significantly different to pre-operative values.

In the younger group, SF36 after frame removal was still significantly lower than pre-operative values (p<0.01).

Age makes no difference in how patients cope with the ilizarov frame during treatment. Older patients have low pre-injury function levels, but appear to return to this level quickly after frame removal. Younger patients do not recover pre-injury function in 6 weeks after completion of treatment.

Ilizarov frame removal often occurs in the outpatient setting, and previous data has shown it can be a painful experience. Frames with a total of four or more olive wires or half-pins in combination yielded increased pain scores at frame removal.

Sublingual fentanyl provides rapid onset, short acting analgesia for painful procedures such as dressing changes in burns patients. We hypothesised that administration of sublingual fentanyl, prior to frame removal would improve patients' pain scores.

Twenty-one patients were given 100 mcg sublingual fentanyl prior to frame removal. Their pain scores were documented on an 11-point (0–10) numeric visual scale before, immediately after, 15 and 30 minutes after frame removal, and the following day. The same nurse specialist removed all the frames. Nitrous oxide was available for patients if they needed further analgesia.

The majority of frames were removed from tibia. The average patient age was 40.8 years. Each frame had a median of 9 wires (range 2–17), and 4 olives (2–8). Eight frames had half pins (range 1–4, median 2). Fourteen patients used nitrous oxide in addition to fentanyl.

Overall, the average pain score was 3.1. This peaked at 7.5 immediately after frame removal, but 15 minutes following removal the average was 2.5. Patients who had supplementary nitrous oxide had higher pain scores throughout (though not beforehand), although these differences were not statistically significant.

Four patients (19%) reported adverse effects following administration, but none required medical intervention.

Patients' pain scores averaged 2.52 within 15 minutes of removal, compared with 5.25 from our previous review. This suggests that fentanyl may be beneficial in frame removal, but our sample size was small, and more research is needed in this area.

UK Objective

To evaluate the technique of transverse debridement, acute shortening and subsequent distraction histiogenesis in the management of open tibial fractures with bone and soft tissue loss thus avoiding the need for flap coverage.

Background

Venous thromboembolism (VTE) is a common complication of pelvic and acetabular fracture fixation. There is, however, currently limited data to guide clinical decisions on thromboprophylaxis choice in these patients.

Introduction: Circular fixators are widely utilised in orthopaedic surgery. Their biomechanical characteristics have been studied in some detail and it is known that the widest wire crossing angles yield maximum stability. Unfortunately, due to anatomical constraints, mechanically optimum wire crossing angles are seldom achievable, especially in the tibial diaphysis. Narrowed crossing angles are usually accepted thereby compromising sagittal plane bending stability. With a hybrid circular fixator, narrowed crossing angles exacerbate the problem of fracture site shear. It is hypothesised that by minimising slippage at the wire-bone interface by using threaded wires, stability can be maintained even with narrowed crossing angles. The aim of this study is to examine the effect of threaded wires on fracture site shear with a hybrid fixator.

Method: Bone-fixator models were created from nylon rods and the Orthofix Ring Fixator. Constructs with wire crossing angles of 70, 60, 45 and 30 degrees were loaded axially and in four point bending. Each construct was tested four times; the first test was not analysed. The whole fixator was then rebuilt and all tests repeated. Fracture motion (compression, angulation & shear) was measured using a strain gauge intersegmentary motion device and stiffness calculated by linear regression. Smooth & threaded wires were compared by univariate analysis of variance, which makes allowance for variation between individual frames.

Results: Axial stiffness was comparable to previous studies (85–96N/mm) with no difference between wire types. Threaded wires produced a 29% reduction in shear during axial compression (p=0.02). In four-point-bending, angulation stiffness (in the half-pin plane) was directly related to crossing angle and at all angles threaded wires were associated with a significant improvement. The table shows the effect of wire type on shear (in mm) measured in the plane of the half-pins for a 10Nm bending moment. Shear becomes appreciably higher with narrow crossing angles (almost 2mm) but this is effectively controlled by threaded wires.

Discussion: Of all the factors influencing fracture healing, the mechanical environment is one over which the surgeon has most control. It is generally accepted that excessive shear inhibits fracture healing. This study has shown that by using threaded wires in a circular frame, crossing angles can be narrowed without compromising stability. in particular they control undesirable shear motion seen with hybrid frames and narrow crossing angles. The principle is equally applicable to all-wire frames as they invariably are constructed with compromised crossing angles leading to reduced sagittal plane stability.

Patellofemoral problems represent a significant source of morbidity following total knee arthroplasty (TKA). Patellofemoral biomechanics and contact stress following TKA depends (among other factors) upon the position of the patella relative to the tibiofemoral joint. Patellar height may be altered either by changes in the tibio-femoral joint level (pseudo patella baja/alta) or by a change in patella tendon length (true patella baja/alta). The purpose of this study is to examine the latter. Two previous studies have described patella tendon shortening following TKA but both have significant limitations and produced differing results.

The aim of this study was to identify the incidence of true patella tendon shortening following TKA for the treatment of osteoarthritis (OA).

All patients undergoing primary TKA for OA in 2001 and 2002 were identified. Cases were excluded if they had rheumatoid arthritis, had undergone previous open knee surgery, suffered a significant post-op complication, or had less than 1 year radiological follow up. Case notes and radiographs of 50 knees in 34 patients were reviewed. The Insall-Salvati ratio was measured on immediate pre-op, initial post-op, and final follow-up lateral knee radiographs. Differences between mean pre and post-op ratios were compared using a paired t-test. There were 19 women and 15 men aged 47 to 84 (mean 70.4) years. The mean pre-op Insall-Salvati ratio was 0.99. The initial post-op ratio was unchanged (p=0.06). After a minimum of 1 year the mean ratio remained 1.0 (p=0.09). In no knee was there a significant change in patella tendon length.

In this study we found no evidence of patella tendon shortening. Two other studies have identified shortening in one third to two thirds of knees. The methodology of these studies is however open to criticism. The patients in neither study are representative of general orthopaedic practice; the surgical technique in one was unorthodox and the radiological measurement method in the other not validated. This work therefore represents the first study of patella tendon length following TKA using a validated radiological index in a representative osteoarthritic population.

In conclusion, TKA in this group of patients with osteoarthritis, employing a standard surgical technique was not associated with postoperative patella tendon shortening or true patella baja.

This study examines the value of a proforma in improving the standards of orthopaedic operation notes.

The standard of operation notes in orthopaedic surgery is notoriously poor. This has clinical, medicolegal and research implications. There is no published study on the influence of a proforma on the quality of orthopaedic operation notes.

An audit of the quality of operation notes in the orthopaedic department of Chesterfield and North Derbyshire Royal Hospital was undertaken. 1, 928 cases were identified from theatre log books and 88 randomly selected casenotes were scrutinised by a single observer for the legible inclusion of parameters based on Royal College of Surgeons guidelines. An operation note proforma was devised and used routinely over a period of six weeks. The effectiveness of the proforma was assessed by examining operation notes randomly selected from the procedures performed during that period. Identical parameters were assessed. Results from the two groups were compared and statistically analysed using the Wilcoxon signed ranks test. To investigate the longer term impact of proformas an identical audit was undertaken in a neighbouring unit in which a proforma had been in use for five years.

Following introduction of the proforma in Chesterfield there was a statistically significant increase in the inclusion of the assessed parameters (p=0. 001). Criteria such as the patient ID number, pre-op diagnosis, tourniquet use and time, prophylactic antibiotic administration, prosthesis details and post-op instructions showed a marked improvement. No parameter showed a significant reduction in its documentation rate. The results from Rotherham were comparable to those achieved following the introduction of the proforma in Chesterfield.

This study clearly demonstrates the effectiveness of a proforma in improving the standard of operation notes. The results from Rotherham suggest that high standards can be maintained long after the introduction of the proforma. We recommend the routine use of operation note proformas in orthopaedic surgery.