Aims. This study describes the Osseointegration Group of Australia’s Accelerated Protocol two-stage strategy (OGAAP-1) for the osseointegrated reconstruction of amputated limbs. Patients and Methods. We report clinical outcomes in 50 unilateral trans-femoral amputees with a mean age of 49.4 years (24 to 73), with a minimum one-year follow-up. Outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation, the health assessment questionnaire Short-Form-36 Health Survey, the Amputation Mobility Predictor scores presented as K-levels, 6 Minute Walk Test and timed up and go tests. Adverse events included soft-tissue problems, infection, fractures and failure of the implant. Results. Our results demonstrated statistically significant improvements in all five outcome measures. A total of 27 patients experienced adverse events but at the conclusion of the study, all 50 were walking on osseointegrated prostheses. Conclusion. These results demonstrate that osseointegrated prostheses are a suitable alternative to socket-fit devices for amputees experiencing socket-related discomfort and that our strategy offers more rapid progress to walking than other similar protocols. Cite this article: Bone Joint J 2016;98-B:952–60

Deep vein thrombosis is a common complication of immobilising the lower limb after surgery. We hypothesised that intermittent pneumatic compression (IPC) therapy in outpatients who had undergone surgical repair of acute ruptures of the Achilles tendon could reduce the incidence of this problem.

A total of 150 patients who had undergone surgical repair of the Achilles tendon were randomised to either treatment with IPC for six hours per day (n = 74) under an orthosis or treatment as usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively, the incidence of deep vein thrombosis was assessed using blinded, double-reported compression duplex ultrasound. At this point, IPC was discontinued and all patients were immobilised in an orthosis for a further four weeks. At six weeks post-operatively, a second compression duplex ultrasound scan was performed.

At two weeks, the incidence of deep vein thrombosis was 21% in the treated group and 37% in the control group (p = 0.042). Age over 39 years was found to be a strong risk factor for deep vein thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI) 2.14 to 10.96). Treatment with IPC, corrected for age differences between groups, reduced the risk of deep vein thrombosis at the two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks, the incidence of deep vein thrombosis was 52% in the treated group and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC appears to be an effective method of reducing the risk of deep vein thrombosis in the early stages of post-operative immobilisation of outpatients. Further research is necessary to elucidate whether it can confer similar benefits over longer periods of immobilisation and in a more heterogeneous group of patients.

Cite this article: Bone Joint J 2015;97-B:675–80.

Although gradual bone transport may permit the restoration of large-diameter bones, complications are common owing to the long duration of external fixation. In order to reduce such complications, a new technique of bone transport involving the use of an external fixator and a locking plate was devised for segmental tibial bone defects.

A total of ten patients (nine men, one woman) with a mean age at operation of 40.4 years (16 to 64) underwent distraction osteogenesis with a locking plate to treat previously infected post-traumatic segmental tibial defects. The locking plate was fixed percutaneously to bridge proximal and distal segments, and was followed by external fixation. After docking, percutaneous screws were fixed at the transported segment through plate holes. At the same time, bone grafting was performed at the docking site with the external fixator removed.

The mean defect size was 5.9 cm (3.8 to 9.3) and mean external fixation index was 13.4 days/cm (11.8 to 19.5). In all cases, primary union of the docking site and distraction callus was achieved, with an excellent bony result. There was no recurrence of deep infection or osteomyelitis, and with the exception of one patient with a pre-existing peroneal nerve injury, all achieved an excellent or good functional result.

With short external fixation times and low complication rates, bone transport with a locking plate could be recommended for patients with segmental tibial defects.

Cite this article: Bone Joint J 2013;95-B:1667–72.

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.

We compared lower limb coronal alignment measurements obtained pre- and post-operatively with long-leg radiographs and computer navigation in patients undergoing primary total knee replacement (TKR). A series of 185 patients had their pre- and post-implant radiological and computer-navigation system measurements of coronal alignment compared using the Bland-Altman method. The study included 81 men and 104 women with a mean age of 68.5 years (32 to 87) and a mean body mass index of 31.7 kg/m² (19 to 49). Pre-implant Bland–Altman limits of agreement were -9.4° to 8.6° with a repeatability coefficient of 9.0°. The Bland–Altman plot showed a tendency for the radiological measurement to indicate a higher level of pre-operative deformity than the corresponding navigation measurement. Post-implant limits of agreement were -5.0° to 5.4° with a repeatability coefficient of 5.2°. The tendency for valgus knees to have greater deformity on the radiograph was still seen, but was weaker for varus knees.

The alignment seen or measured intra-operatively during TKR is not necessarily the same as the deformity seen on a standing long-leg radiograph either pre- or post-operatively. Further investigation into the effect of weight-bearing and surgical exposure of the joint on the mechanical femorotibial angle is required to enable the most appropriate intra-operative alignment to be selected.

We report the results of intramedullary leg lengthening conducted between 2002 and 2009 using the Intramedullary Skeletal Kinetic Distractor in 69 unilateral lengthenings involving 58 femora and 11 tibiae. We identified difficulties that occurred during the treatment and assessed whether they were specifically due to the implant or independent of it. Paley’s classification for evaluating problems, obstacles and complications with external fixators was adopted, and implant-specific difficulties were continuously noted. There were seven failures requiring premature removal of the device, in four due to nail breakage and three for other reasons, and five unsuccessful outcomes after completion of the lengthening. In all, 116 difficulties were noted in 45 patients, with only 24 having problem-free courses. In addition to the difficulties arising from the use of external fixators, there were almost the same number again of implant-specific difficulties. Nevertheless, successful femoral lengthening was achieved in 52 of the 58 patients (90%). However, successful tibial lengthening was only achieved in five of 11 patients (45%)

Between October 2001 and September 2009 we lengthened 242 lower-limb segments in 180 patients using the Intramedullary Skeletal Kinetic Distractor (ISKD). Mechanical failure was defined either as breakage of the ISKD or failure of the internal mechanism to activate. Retrieved nails which failed mechanically were examined by the manufacturer for defects. In all, 15 ISKDs in 12 patients (13 limbs) failed mechanically representing an overall failure rate of 6.2%, with fracture of the device occurring in ten of the 15 failures. Two nails in one patient failed to lengthen and had to be replaced. The manufacturer detected an error in the assembly of the nail, which prompted a wide recall. One nail jammed after being forcefully inserted, and two nails failed to lengthen fully. Lengthening was achieved in all 12 patients, although three required a second operation to exchange a defective nail for a new, functioning device.

The ISKD is a complex mechanical device which lengthens by the oscillation of two telescopic sections connected by a threaded rod. The junction between these sections is surrounded by a keyring collar. This keyring collar is the weakest part of the device.

Patients with diabetes mellitus may develop plantar flexion contractures (equinus) which may increase forefoot pressure during walking. In order to determine the relationship between equinus and forefoot pressure, we measured forefoot pressure during walking in 27 adult diabetics with a mean age of 66.3 years (sd 7.4) and a mean duration of the condition of 13.4 years (sd 12.6) using an Emed mat. Maximum dorsiflexion of the ankle was determined using a custom device which an examiner used to apply a dorsiflexing torque of 10 Nm (sd 1) for five seconds.

Simple linear regression showed that the relationship between equinus and peak forefoot pressure was significant (p < 0.0471), but that only a small portion of the variance was accounted for (R² = 0.149). This indicates that equinus has only a limited role in causing high forefoot pressure. Our findings suggest caution in undertaking of tendon-lengthening procedures to reduce peak forefoot plantar pressures in diabetic subjects until clearer indications are established.

We have assessed the proximal capsular extension of the ankle joint in 18 patients who had a contrast-enhanced MRI ankle arthrogram in order to delineate the capsular attachments.

We noted consistent proximal capsular extensions anterior to the distal tibia and in the tibiofibular recess. The mean capsular extension anterior to the distal tibia was 9.6 mm (4.9 to 27.0) proximal to the anteroinferior tibial margin and 3.8 mm (−2.1 to 9.3) proximal to the dome of the tibial plafond. In the tibiofibular recess, the mean capsular extension was 19.2 mm (12.7 to 38.0) proximal to the anteroinferior tibial margin and 13.4 mm (5.8 to 20.5) proximal to the dome of the tibial plafond.

These areas of proximal capsular extensions run the risk of being traversed during the insertion of finewires for the treatment of fractures of the distal tibia. Surgeons using these techniques should be aware of this anatomy in order to minimise the risk of septic arthritis.

Our aim in this prospective study was to determine the best diagnostic method for discriminating between patients with and without osteochondral lesions of the talus, with special relevance to the value of MRI compared with the new technique of multidetector helical CT. We compared the diagnostic value of history, physical examination and standard radiography, a 4 cm heel-rise view, helical CT, MRI, and diagnostic arthroscopy for simultaneous detection or exclusion of osteochondral lesions of the talus. A consecutive series of 103 patients (104 ankles) with chronic ankle pain was included in this study. Of these, 29 with 35 osteochondral lesions were identified. Twenty-seven lesions were located in the talus.

Our findings showed that helical CT, MRI and diagnostic arthroscopy were significantly better than history, physical examination and standard radiography for detecting or excluding an osteochondral lesion. Also, MRI and diagnostic arthroscopy performed better than a mortise view with a 4 cm heel-rise. We did not find a statistically significant difference between helical CT and MRI. Diagnostic arthroscopy did not perform better than helical CT and MRI for detecting or excluding an osteochondral lesion.

Reimplantation is a well-established procedure in reconstructive surgery. This is especially so after amputation of the upper limb since prostheses provide limited function. In unilateral amputation of the lower leg orthotopic reimplantation is the treatment of choice. With bilateral amputation, in which orthotopic reimplantation is not possible because of the complexity of the trauma, heterotopic reimplantation is an option. We report five patients who received orthotopic and two who received heterotopic reimplantations of the lower leg. We assessed the functional outcome with reference to cutaneous sensation, mobility, pain, and the cosmetic result. The functional outcome was good, as was the patients’ satisfaction. Their mobility, stability, and psychological state were satisfactory. Patients with heterotopic reimplantations preferred the reimplanted leg to a prosthesis. Although reimplantation of the lower leg requires prolonged hospitalisation, delayed mobilisation and secondary operations, we conclude that there is an indication for this operation in order to improve the patient’s quality of life