The existing methods of assessing limb lengthening during total hip arthroplasty (THA) are prone to error because the measurements are not parallel to the limb lengthening axis. In order to address this, we designed a caliper to estimate limb lengthening during THA and evaluated its accuracy compared with our previous device, the straight caliper. Limb lengths were measured in 100 patients. The L-shaped caliper was used in 50 cases and the straight caliper in 50. The correlation between intra-operative and post-operative radiographic measurements was significantly improved using the L-shaped device (p < 0.0001, r = 0.934). This method was extremely accurate in predicting changes in limb length due to surgery

We describe the application of a non-invasive extendible endoprosthetic replacement in skeletally-mature patients undergoing revision for failed joint replacement with resultant limb-length inequality after malignant or non-malignant disease. This prosthesis was developed for tumour surgery in skeletally-immature patients but has now been adapted for use in revision procedures to reconstruct the joint or facilitate an arthrodesis, replace bony defects and allow limb length to be restored gradually in the post-operative period. We record the short-term results in nine patients who have had this procedure after multiple previous reconstructive operations. In six, the initial reconstruction had been performed with either allograft or endoprosthetic replacement for neoplastic disease and in three for non-neoplastic disease. The essential components of the prosthesis are a magnetic disc, a gearbox and a drive screw which allows painless lengthening of the prosthesis using the principle of electromagnetic induction. The mean age of the patients was 37 years (18 to 68) with a mean follow-up of 34 months (12 to 62). They had previously undergone a mean of six (2 to 14) open procedures on the affected limb before revision with the non-invasive extendible endoprosthesis. The mean length gained was 56 mm (19 to 107) requiring a mean of nine (3 to 20) lengthening episodes performed in the outpatient department. There was one case of recurrent infection after revision of a previously infected implant and one fracture of the prosthesis after a fall. No amputations were performed. Planned exchange of the prosthesis was required in three patients after attainment of the maximum lengthening capacity of the implant. There was no failure of the lengthening mechanism. The Mean Musculoskeletal Tumour Society rating score was 22 of 30 available points (18 to 28). The use of a non-invasive extendible endoprosthesis in this manner provided patients with good functional results and restoration of leg-length equality, without the need for multiple open lengthening procedures

The use of endoprostheses for limb salvage in primary bone tumours is highly specialised. Studies have shown no significant difference in survival, function or quality of life between patients with limb salvage and those with amputation. We have derived a formula for calculating the ongoing costs of limb salvage with an endoprosthesis which is based on actual costs and uses historical data to show the likelihood of further surgery or revision. Comparative data for amputation are also shown. Using current prices, the cost-effectiveness of surgery with an endoprosthesis is clearly demonstrated

Bone sarcomas are rare cancers and orthopaedic surgeons come across them infrequently, sometimes unexpectedly during surgical procedures. We investigated the outcomes of patients who underwent a surgical procedure where sarcomas were found unexpectedly and were subsequently referred to our unit for treatment. We identified 95 patients (44 intra-lesional excisions, 35 fracture fixations, 16 joint replacements) with mean age of 48 years (11 to 83); 60% were males (n = 57). Local recurrence arose in 40% who underwent limb salvage surgery versus 12% who had an amputation. Despite achieving local control, overall survival was worse for patients treated with amputation rather than limb salvage (54% vs 75% five-year survival). Factors that negatively influenced survival were invasive primary surgery (fracture fixation, joint replacement), a delay of greater than two months until referral to our oncology service, and high-grade tumours. Survival in these circumstances depends mostly on factors that are determined prior to definitive treatment by a tertiary orthopaedic oncology unit. Limb salvage in this group of patients is associated with a higher rate of inadequate marginal surgery and, consequently, higher local recurrence rates than amputation, but should still be attempted whenever possible, as local control is not the primary determinant of survival. . Cite this article: Bone Joint J 2014;96-B:665–72

One of the most important factors in the rehabilitation of the amputee is the preparation of the patient and stump for limb fitting and training. The different procedures for the upper and lower extremities are described. Emphasis is laid on the importance of early reassurance and rehabilitation whenever possible. Patients unavoidably immobilised for long periods require general physical reconditioning before limb fitting and training can be undertaken. Special care is needed to avoid the upper limb amputee's becoming dependent on the surviving hand and using the artificial limb only for its cosmetic effect

Between January 1992 and December 1998, we treated 24 patients with necrotising fasciitis of a limb. There were 15 men and nine women with a mean age of 59.8 years (5 to 86). The infection was usually confused with cellulitis. Exquisite pain and early systemic toxicity were the most consistent clinical features. Diabetes mellitus and hepatic cirrhosis were the most commonly associated medical diseases. One third of the patients died. Those with involvement of the limbs above the knee or elbow on admission had a significantly higher rate of mortality than those with distal lesions (Fisher’s exact test, p = 0.027). There was no correlation between mortality and advanced age (Student’s t-test, p = 0.22) or between amputation and survival (Fisher’s exact test, p = 0.39)

This paper aims to provide evidence-based guidance for the general orthopaedic surgeon faced with the presentation of a potential soft tissue sarcoma in an extremity

We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable. We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida

Limb lengthening in nine patients was monitored by radiographs and by ultrasound scans. The distraction gap appeared as a sonolucent area within which echogenic foci developed soon after distraction commenced. By seven weeks a new cortex was detected, and medullary canal began to develop between seven and eight weeks. Ultrasound scanning can be used to measure distraction, but it was not as useful as radiographs in detecting angulation. Its use in patients undergoing limb lengthening could reduce their exposure to radiation

In an eight-year period we treated 51 cases of vascular injury associated with fractures and/or dislocations or soft-tissue injuries of the limbs. We relied on a clinical diagnosis and immediate exploration of blood vessels rather than the time-consuming procedure of arteriography. All patients were operated on by the orthopaedic residents on duty and not by vascular surgeons. Only 17 (33%) were repaired within six hours of injury. Limb viability with good function was obtained in 38. Complications included six deaths, four amputations, two renal failures and delayed occlusion in one case

The present study was undertaken to investigate the effect of fluorocarbon on the preservation of an amputated limb. The hind limbs of dogs were completely amputated through the mid-thigh; some were perfused with fluorocarbon, others with lactated Ringer's solution and some were not perfused at all. After six hours of ischaemia, all the limbs were replanted. Perfusion with fluorocarbon had an inhibitory effect on the anaerobic metabolism of an amputated limb, thus increasing the survival rate. Leakage of creatine phosphokinase from the replanted limb also was inhibited by perfusion with fluorocarbon. These effects were more striking when the amputated limb was perfused continuously rather than intermittently and when it was preserved in iced water rather than at room temperature; these measures helped to prevent replantation toxaemia and to preserve muscle function

Ten patients, who were unsuitable for limb lengthening over an intramedullary nail, underwent lengthening with a submuscular locking plate. Their mean age at operation was 18.5 years (11 to 40). After fixing a locking plate submuscularly on the proximal segment, an external fixator was applied to lengthen the bone after corticotomy. Lengthening was at 1 mm/day and on reaching the target length, three or four screws were placed in the plate in the distal segment and the external fixator was removed. All patients achieved the pre-operative target length at a mean of 4.0 cm (3.2 to 5.5). The mean duration of external fixation was 61.6 days (45 to 113) and the mean external fixation index was 15.1 days/cm (13.2 to 20.5), which was less than one-third of the mean healing index (48 days/cm (41.3 to 55). There were only minor complications. Lengthening with a submuscular locking plate can successfully permit early removal of the fixator with fewer complications and is a useful alternative in children or when nailing is difficult

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

We have reviewed our experience of the removal of deep extremity orthopaedic implants in children to establish the nature, rate and risk of complications associated with this procedure. A retrospective review was performed of 801 children who had 1223 implants inserted and subsequently removed over a period of 17 years. Bivariate analysis of possible predictors including clinical factors, complications associated with implant insertion and indications for removal and the complications encountered at removal was performed. A logistical regression model was then constructed using those predictors which were significantly associated with surgical complications from the bivariate analyses. Odds ratios estimated in the logistical regression models were converted to risk ratios. The overall rate of complications after removal of the implant was 12.5% (100 complications in 801 patients), with 48 (6.0%) major and 52 (6.5%) minor. Children with a complication after insertion of the initial implant or with a non-elective indication for removal, a neuromuscular disease associated with a seizure disorder or a neuromuscular disease in those unable to walk, had a significantly greater chance of having a major complication after removal of the implant. Children with all four of these predictors were 14.6 times more likely to have a major complication

The skeleton is the most common site to be affected by metastatic cancer. The place of surgical treatment and of different techniques of reconstruction has not been clearly defined. We have studied the rate of survival of 94 patients and the results of the surgical treatment of 91 metastases of the limbs and pelvis, and 18 of the spine. Variables included the different primary tumours, the metastatic load at the time of operation, the surgical margin, and the different techniques of reconstruction. The survival rate was 0.54 at one year and 0.27 at three years. Absence of visceral metastases and of a pathological fracture, a time interval of more than three years between the diagnosis of cancer and that of the first skeletal metastasis, thyroid carcinoma, prostate carcinoma, renal-cell carcinoma, breast cancer, and plasmacytoma were positive variables with regard to survival. The metastatic load of the skeleton and the surgical margin were not of significant influence. In tumours of the limbs and pelvis, the local failure rate was 0% after biological reconstruction (10), 3.6% after cemented or uncemented osteosynthesis (28) and 1.8% after prosthetic replacement (53). The local failure rate after stabilisation of the spine (18) was 16.6%. There was local recurrence in seven patients (6.4%), and in four of these the primary tumour was a renal-cell carcinoma. The local recurrence rate was 0% after extralesional (24) and 8.2% after intralesional resection (85). Improvements in the oncological management of patients with primary and metastatic disease have resulted in an increased survival rate. In order to avoid additional surgery, it is essential to consider the expected time of survival of the reconstruction and, in bony metastases with a potentially poor response to radiotherapy, the surgical margin

Limb lengthening by callus distraction and external fixation has a high rate of complications. We describe our experience using an intramedullary nail (Fitbone) which contains a motorised and programmable sliding mechanism for limb lengthening and bone transport. Between 2001 and 2004 we lengthened 13 femora and 11 tibiae in ten patients (seven men and three women) with a mean age of 32 years (21 to 47) using this nail. The indications for operation were short stature in six patients and developmental or acquired disorders in the rest. The mean lengthening achieved was 40 mm (27 to 60). The mean length of stay in hospital was seven days (5 to 9). The mean healing index was 35 days/cm (18.8 to 70.9). There were no cases of implant-related infection or malunion

Ischaemia threatening an injured limb gives rise to the syndrome of pain, pallor, paralysis, and pulselessness. It is due to arterial injury by laceration, compression, intra-mural rupture or contusion, or to arterial spasm with or without demonstrable local arterial damage. The differentiation of spasm without local injury from organic obstruction is not possible by clinical methods. The suggested plan of treatment and of management is:. 1. General systemic investigation (blood-pressure, blood-count, coagulation time, etc.). 2. Removal of all external pressure. 3. Resuscitation. 4. Direct attempt to relieve the obstruction by operation. 5. Post-operative care. The operative procedure recommended is:. 1. Manipulative reduction of the fracture if possible. 2. Proximal control of the artery. 3. Arteriography. 4. Exposure of the occluded artery (unless contra-indicated by time factors and by the anatomy of the collateral circulation), liberation and mobilisation of the vessel, repair by suture where such is necessary and possible, and arterectomy only forirreparable local damage. 5. The provision of sympathetic block by injection or by sympathectomy. The important elements of post-operative care are:. 1. To maintain the blood-pressure while cooling the limb and heating the patient

This retrospective study compared post-operative epidural analgesia (E), continuous peripheral nerve blocks (CPNB) and morphine infusion (M) in 68 children undergoing limb reconstruction with circular frames. The data collected included episodes of severe pain, post-operative duration of analgesia, requirement for top-up analgesia, number of osteotomies, side effects and complications. There was a significant difference between the number of episodes of severe pain in patients receiving a morphine infusion and those receiving epidurals or CPNB (M vs E, p < 0.0001; M vs CPNB, p = 0.018). The CPNB group was associated with the lowest incidence of episodes of severe pain and top-up analgesia. Epidural analgesia was associated with significantly more nausea and vomiting than morphine infusion (p = 0.053) and CPNB (p = 0.023). It also had a significantly higher incidence of motor blockade than CPNB (p < 0.01). We found that the most effective method of post-operative analgesia for children undergoing lower limb reconstruction was sciatic nerve catheterisation and continuous infusion

Between December 1995 and March 2003, 38 adult patients with intermediate or high-grade liposarcoma in a limb were treated by limb-sparing surgery and post-operative radiotherapy. The ten-year local recurrence-free survival was 83%, the ten-year metastasis-free survival 61%, the ten-year disease-free survival 51% and the ten-year overall survival 67%. Analysis of failure and success showed no association with the age of the patients, gender, the location of the primary tumour, the type of liposarcoma and the quality of resection. Our results indicate that liposarcoma may recur even ten years after the end of definitive therapy and may spread to unexpected sites as for soft-tissue sarcoma

The response of the muscle is critical in determining the functional outcome of limb lengthening. We hypothesised that muscle response would vary with age and therefore studied the response of the muscles during tibial lengthening in ten young and ten mature rabbits. A bromodeoxyuridine technique was used to identify the dividing cells. The young rabbits demonstrated a significantly greater proliferative response to the distraction stimulus than the mature ones. This was particularly pronounced at the myotendinous junction, but was also evident within the muscle belly. Younger muscle adapted better to lengthening, suggesting that in patients in whom a large degree of muscle lengthening is required it may be beneficial to carry out this procedure when they are young, in order to achieve the optimal functional result