Aims

Patients undergoing femoral lengthening by external fixation tolerate treatment less well when compared to tibial lengthening. Lengthening of the femur with an intramedullary device may have advantages.

Although patients with a history of venous thromboembolism (VTE) who undergo lower limb joint replacement are thought to be at high risk of further VTE, the actual rate of recurrence has not been reported.

The purpose of this study was to identify the recurrence rate of VTE in patients who had undergone lower limb joint replacement, and to compare it with that of patients who had undergone a joint replacement without a history of VTE.

From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR, 243 revision THR, 152 revision TKR) in 5967 patients (68% female, mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively identified 118 consecutive treatment episodes in 106 patients (65% female, mean age 70; 51 to 88,) who had suffered a previous VTE. Despite mechanical prophylaxis and anticoagulation with warfarin, we had four recurrences by three months (3.4% of 118) and six by one year (5.1% of 118). In comparison, in all our other joint replacements the rate of VTE was 0.54% (35/6528).

The relative risk of a VTE by 90 days in patients who had undergone a joint replacement with a history of VTE compared with those with a joint replacement and no history of VTE was 6.3 (95% confidence interval, 2.3 to 17.5). There were five complications in the previous VTE group related to bleeding or over-anticoagulation.

Cite this article: Bone Joint J 2014;96-B:1515–19.

We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs.

Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036).

The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.

Cite this article: Bone Joint J 2013;95-B:1673–80.

We hypothesised that adjuvant intermittent pneumatic compression (IPC) beneath a plaster cast would reduce the risk of deep-vein thrombosis (DVT) during post-operative immobilisation of the lower limb. Of 87 patients with acute tendo Achillis (TA) rupture, 26 were prospectively randomised post-operatively after open TA repair. The treatment group (n = 14) received two weeks of IPC of the foot for at least six hours daily under a plaster cast. The control group (n = 12) had no additional treatment. At two weeks post-operatively all patients received an orthosis until follow-up at six weeks. At two and six weeks the incidence of DVT was assessed using colour duplex sonography by two ultrasonographers blinded to the treatment. Two patients withdrew from the study due to inability to tolerate IPC treatment.

An interim analysis demonstrated a high incidence of DVT in both the IPC group (9 of 12, 75%) and the controls (6 of 12, 50%) (p = 0.18). No significant differences in incidence were detected at two (p = 0.33) or six weeks (p = 0.08) post-operatively. Malfunction of the IPC leading to a second plaster cast was found to correlate with an increased DVT risk at two weeks (φ = 0.71; p = 0.019), leading to a premature abandonment of the study.

We cannot recommend adjuvant treatment with foot IPC under a plaster cast for outpatient DVT prevention during post-operative immobilisation, owing to a high incidence of DVT related to malfunctioning of this type of IPC application.

Cite this article: Bone Joint J 2013;95-B:1227–31.

Internal lengthening devices in the femur lengthen along the anatomical axis, potentially creating lateral shift of the mechanical axis. We aimed to determine whether femoral lengthening along the anatomical axis has an inadvertent effect on lower limb alignment. Isolated femoral lengthening using the Intramedullary Skeletal Kinetic Distractor was performed in 27 femora in 24 patients (mean age 32 years (16 to 57)). Patients who underwent simultaneous realignment procedures or concurrent tibial lengthening, or who developed mal- or nonunion, were excluded. Pre-operative and six-month post-operative radiographs were used to measure lower limb alignment. The mean lengthening achieved was 4.4 cm (1.5 to 8.0). In 26 of 27 limbs, the mechanical axis shifted laterally by a mean of 1.0 mm/cm of lengthening (0 to 3.5). In one femur that was initially in varus, a 3 mm medial shift occurred during a lengthening of 2.2 cm.

In a normally aligned limb, intramedullary lengthening along the anatomical axis of the femur results in a lateral shift of the mechanical axis by approximately 1 mm for each 1 cm of lengthening.

We investigated the fracture-free survival of long bones stabilised by a telescopic intramedullary rod (TIMR) in patients with osteogenesis imperfecta with respect to the remodelling status of fracture or osteotomy sites and TIMR regions, in order to identify risk factors for fracture. A total of 44 femora and 28 tibiae in 25 patients with a mean age of 5.0 years (1.9 to 10.5) at presentation were studied. There were six patients with Sillence type I, five with type III, 13 with type IV and one with type V osteogenesis imperfecta. All received bisphosphonate treatment at the same stage during the mean follow-up of 7.3 years (0.5 to 18.1). The fracture-free survival was estimated at 6.2 years (95% confidence interval 5.1 to 7.3) by Kaplan-Meier analysis. More than half the fracture or osteotomy sites remained in a less-remodelled state at the latest follow-up or time of fracture. Of the 33 fractures, 29 (87.9%) occurred in long bones containing a less-remodelled site, and these fractures were located at this site. The relative fracture risk at the rod tip was significantly greater than in any other TIMR region (p < 0.001), and this was higher in bone segments having a less-remodelled site.

This study shows a persistent fracture risk in TIMR-stabilised long bones, especially at less-remodelled fracture or osteotomy sites and at the rod tip.

We performed two independent, randomised, controlled trials in order to assess the potential benefits of immediate weight-bearing mobilisation after rupture of the tendo Achillis. The first trial, on operatively-treated patients showed an improved functional outcome for patients mobilised fully weight-bearing after surgical repair. Two cases of re-rupture in the treatment group suggested that careful patient selection is required as patients need to follow a structured rehabilitation regimen. The second trial, on conservatively-treated patients, provided no evidence of a functional benefit from immediate weight-bearing mobilisation. However, the practical advantages of immediate weight-bearing did not predispose the patients to a higher complication rate. In particular, there was no evidence of tendon lengthening or a higher re-rupture rate. We would advocate immediate weight-bearing mobilisation for the rehabilitation of all patients with rupture of the tendo Achillis.

Diabetes mellitus is considered an indicator of poor prognosis for acute ankle fractures, but this risk may be specific to an identifiable subpopulation. We retrospectively reviewed 42 patients with both diabetes mellitus and an acute, closed, rotational ankle fracture. Patients were individually matched to controls by age, gender, fracture type, and surgical vs non-surgical treatment. Outcomes were major complications during the first six months of treatment. We contrasted secondarily 21 diabetic patients with and 21 without diabetic comorbidities. Diabetic patients and controls did not differ significantly in total complication rates. More diabetic patients required long-term bracing. Diabetic patients without comorbidities had complication rates equal to their controls. Diabetic patients with comorbidities had complications at a higher rate (ten patients; 47%) than matched controls (three patients; 14%, p = 0.034). A history of Charcot neuroarthropathy led to the highest rates of complication. An increased risk of complications in diabetic patients with closed rotational fractures of the ankle are specific to a subpopulation with identifiable related comorbidities.

We have studied 105 patients with 107 acute, primary, dislocations of the glenohumeral joint seen between January 1, 1991 and July 1, 1994. The mean time of follow-up was 71 months (46 to 91). In 34% the injury occurred during a sports activity and in 28% at home. The bias toward sport was even greater in patients less than 40 years of age, and in men. In patients older than 40 years of age, and in women, the dislocation occurred more often at home. The overall probability of recurrence within four years was 26%. Age was the most significant prognostic factor in recurrence which took place in 64% of patients less than 20 years of age and in 6% of those older than 40 years. Statistically, there was no difference between the rates of recurrence in patients who were active in sport and those who were not. The mean Rowe score for the whole group was 87 (15 to 100). Associated fractures were found in 20 patients (19%) and nerve injuries in 22 (21%). None of those in whom a fracture of the greater tuberosity was seen subsequently suffered a recurrent dislocation. At follow-up we found that 36 patients (34%) had not returned to their former employment but in only 2% was this owing to the injured shoulder