The period of post-operative treatment before surgical wounds
are completely closed remains a key window, during which one can
apply new technologies that can minimise complications. One such
technology is the use of negative pressure wound therapy to manage
and accelerate healing of the closed incisional wound (incisional
NPWT). We undertook a literature review of this emerging indication
to identify evidence within orthopaedic surgery and other surgical
disciplines. Literature that supports our current understanding
of the mechanisms of action was also reviewed in detail. Objectives
Methods
Achieving arthrodesis of the ankle can be difficult
in the presence of infection, deformity, poor soft tissues and bone loss.
We present a series of 48 patients with complex ankle pathology,
treated with the Ilizarov technique. Infection was present in 30
patients and 30Â had significant deformity before surgery. Outcome
was assessed clinically and with patient-reported outcome measures
(Modified American Orthopaedic Foot and Ankle Society (MAOFAS) scale and
the Short-Form (SF-36)). Arthrodesis was achieved in 40 patients with the Ilizarov technique
alone and in six further patients with additional surgery. Infection
was eradicated in all patients at a mean follow-up of 46.6 months
(13 to 162). Successful arthrodesis was less likely in those with
comorbidities and in tibiocalcaneal fusion compared with tibiotalar
fusion. These patients had poor general health scores compared with the
normal population before surgery. The mean MAOFAS score improved
significantly from 24.3 (0 to 90) pre-operatively to 56.2 (30 to
90) post-operatively, but there was only a modest improvement in
general health; the mean SF-36 improved from 44.8 (19 to 66) to
50.1 (21 to 76). There was a major benefit in terms of pain relief. Arthrodesis using the Ilizarov technique is an effective treatment
for complex ankle pathology, with good clinical outcomes and eradication
of infection. However, even after successful arthrodesis general
health scores remain limited. Cite this article:
The aim of this retrospective multicentre study was to report the continued occurrence of compartment syndrome secondary to paediatric supracondylar humeral fractures in the period 1995 to 2005. The inclusion criteria were children with a closed, low-energy supracondylar fracture with no associated fractures or vascular compromise, who subsequently developed compartment syndrome. There were 11 patients (seven girls and four boys) identified from eight hospitals in three countries. Ten patients with severe elbow swelling documented at presentation had a mean delay before surgery of 22 hours (6 to 64). One patient without severe swelling documented at presentation suffered arterial entrapment following reduction, with a subsequent compartment syndrome requiring fasciotomy 25 hours after the index procedure. This series is noteworthy, as all patients had low-energy injuries and presented with an intact radial pulse. Significant swelling at presentation and delay in fracture reduction may be important warning signs for the development of a compartment syndrome in children with supracondylar fractures of the humerus.
We report the case of an 82-year-old man who
underwent fasciectomy for a severe Dupuytren’s contracture, during which
an ossified lesion was encountered within the contracture and surrounding
the neurovascular bundle. The abnormal tissue was removed with difficulty
and heterotopic ossification was confirmed histologically. We believe this
is the first report of heterotopic ossification in Dupuytren’s disease.
The open blast fracture of the pelvis is considered
to be the most severe injury within the spectrum of battlefield trauma.
We report our experience of 29 consecutive patients who had sustained
this injury in Afghanistan between 2008 and 2010. Their median new
injury severity score (NISS) was 41 (8 to 75), and mean blood requirement
in the first 24 hours was 60.3 units (0 to 224). In addition to
their orthopaedic injury, six had an associated vascular injury, seven
had a bowel injury, 11 had a genital injury and seven had a bladder
injury. In all, eight fractures were managed definitively with external
fixation and seven required internal fixation. Of those patients
who underwent internal fixation, four required removal of metalwork
for infection. Faecal diversion was performed in nine cases. The
median length of hospital stay following emergency repatriation
to the United Kingdom was 70.5 days (5 to 357) and the mean total
operating time was 29.6 hours (5 to 187). At a mean follow-up of
20.3 months (13.2 to 29.9), 24 patients (82.8%) were able to walk
and 26 (89.7%) had clinical and radiological evidence of stability
of the pelvic ring. As a result of the increase in terrorism, injuries that were
previously confined exclusively to warfare can now occur anywhere,
with civilian surgeons who are involved in trauma care potentially
required to manage similar injuries. Our study demonstrates that
the management of this injury pattern demands huge resources and significant
multidisciplinary input. Given the nature of the soft-tissue injury,
we would advocate external fixation as the preferred management
of these fractures. With the advent of emerging wound and faecal
management techniques, we do not believe that faecal diversion is
necessary in all cases.
We describe 261 peripheral nerve injuries sustained
in war by 100 consecutive service men and women injured in Iraq
and Afghanistan. Their mean age was 26.5 years (18.1 to 42.6), the
median interval between injury and first review was 4.2 months (mean
8.4 months (0.36 to 48.49)) and median follow-up was 28.4 months
(mean 20.5 months (1.3 to 64.2)). The nerve lesions were predominantly
focal prolonged conduction block/neurapraxia in 116Â (45%), axonotmesis
in 92 (35%) and neurotmesis in 53 (20%) and were evenly distributed
between the upper and the lower limbs. Explosions accounted for
164 (63%): 213Â (82%) nerve injuries were associated with open wounds.
Two or more main nerves were injured in 70 patients. The ulnar,
common peroneal and tibial nerves were most commonly injured. In
69 patients there was a vascular injury, fracture, or both at the
level of the nerve lesion. Major tissue loss was present in 50 patients:
amputation of at least one limb was needed in 18. A total of 36 patients
continued in severe neuropathic pain. This paper outlines the methods used in the assessment of these
injuries and provides information about the depth and distribution
of the nerve lesions, their associated injuries and neuropathic
pain syndromes.
In skeletally immature patients, resection of
bone tumours and reconstruction of the lower limb often results
in leg-length discrepancy. The Stanmore non-invasive extendible
endoprosthesis, which uses electromagnetic induction, allows post-operative
lengthening without anaesthesia. Between 2002 and 2009, 55 children
with a mean age of 11.4 years (5Â to 16) underwent reconstruction
with this prosthesis; ten patients (18.2%) died of disseminated
disease and one child underwent amputation due to infection. We
reviewed 44 patients after a mean follow-up of 41.2 months (22 to
104). The mean Musculoskeletal Tumor Society score was 24.7 (8 to
30) and the Toronto Extremity Salvage score was 92.3% (55.2% to
99.0%). There was no local recurrence of tumour. Complications developed
in 16 patients (29.1%) and ten (18.2%) underwent revision. The mean length gained per patient was 38.6Â mm (3.5 to 161.5),
requiring a mean of 11.3Â extensions (1 to 40), and ten component
exchanges were performed in nine patients (16.4%) after attaining
the maximum lengthening capacity of the implant. There were 11Â patients
(20%) who were skeletally mature at follow-up, ten of whom had equal
leg lengths and nine had a full range of movement of the hip and
knee. This is the largest reported series using non-invasive extendible
endoprostheses after excision of primary bone tumours in skeletally
immature patients. The technique produces a good functional outcome,
with prevention of limb-length discrepancy at skeletal maturity.
We identified 16 patients with a mean age of
56.5 years (31 to 86) from a large consecutive series of patients
with proximal humeral fractures over a 15-year period, who had sustained
a fracture with skin compromise after a blunt injury. The study
group represented 0.2% of 7825 proximal humeral fractures treated
during this period and all had a displaced Neer two-part fracture
pattern. Two patterns of skin injury were identified: in ten patients
there was skin penetration at the time of the original injury, and
the other six patients initially had closed injuries. These six patients
had fracture fragments penetrating the muscular envelope to lie
subcutaneously producing either early skin tethering (two patients)
or delayed skin penetration and sinus formation (four patients).
The pattern of injury to the soft-tissue envelope and the fracture
pattern were similar for all injuries. Treatment of these injuries
was determined by the initial severity of the soft-tissue injury
and the medical status of the patient. We currently favour open
reduction and internal fixation of these fractures wherever possible,
owing to the high rate of nonunion with non-operative management.
Deep prosthetic joint infection remains an uncommon but serious complication of total hip replacement. We reviewed 24 patients with recalcitrant hip wounds following infected total hip replacement treated with either pedicled rectus femoris or vastus lateralis muscle flaps between 1998 and 2009. The mean age of the patients was 67.4 years (42 to 86) with ten men and 14 women. There had been a mean of four (1 to 8) previous attempts to close the wound. A total of 20 rectus femoris and five vastus lateralis flaps were used, with one of each type of flap failing and requiring further reconstruction. All patients had positive microbiology. At a mean follow-up of 47 months (9 to 128), 22 patients had a healed wound and two had a persistent sinus. The prosthesis had been retained in five patients. In the remainder it had been removed, and subsequently re-implanted in nine patients. Six patients continued to take antibiotics at final follow-up. This series demonstrates the effectiveness of pedicled muscle flaps in healing these infected wounds. The high number of previous debridements suggests that these flaps could have been used earlier.
Systemic capillary leak syndrome, or the Clarkson syndrome, is an extremely rare condition in which increased capillary permeability results in a massive shift of fluid into the extravascular space. This is followed rapidly by hypotensive shock, haemoconcentration, and, potentially, substantial oedema of the limbs resulting in an acute compartment syndrome. It is important for orthopaedic surgeons to be aware of this syndrome as our medical colleagues, who initially care for these patients, are less familiar with the diagnosis and the need for emergency management of the associated compartment syndrome should it develop. There have been fewer than 100 cases of this entity reported. This case report is the first to describe the subsequent development of a compartment syndrome in all four limbs. Clinical vigilance and continuous monitoring of intracompartmental pressure is necessary in these patients in order to help reduce limb-threatening complications.
Anthrax is extremely rare in the western world but is endemic to areas of south and central Asia. In early 2010 an outbreak was identified in heroin-injecting intravenous drug users in the United Kingdom and Europe. Afghanistan is currently the principal source of heroin which reaches the United Kingdom. When anthrax occurs, cutaneous disease accounts for over 95% of cases. At least 47 cases with 13 deaths have been confirmed so far. We present three cases presenting during this time with marked swelling, one resulting in compartment syndrome but all with an absence of the expected cutaneous appearances. We suggest that rather than cutaneous anthrax, these patients represent a new subcutaneous presentation of anthrax.
We present a retrospective review of 167 patients aged 18 years and under who were treated for chronic haematogenous osteomyelitis at our elective orthopaedic hospital in Malawi over a period of four years. The median age at presentation was eight years (1 to 18). There were 239 hospital admissions for treatment during the period of the study. In 117 patients one admission was necessary, in 35 two, and in 15 more than two. A surgical strategy of infection control followed by reconstruction and stabilisation was employed, based on the Beit CURE radiological classification of chronic haematogenous osteomyelitis as a guide to treatment. At a minimum follow-up of one year after the end of the study none of the patients had returned to our hospital with recurrent infection. A total of 350 operations were performed on the 167 patients. This represented 6.7% of all children’s operations performed in our hospital during this period. One operation only was required in 110 patients and none required more than three. Below-knee amputation was performed in two patients with chronic calcaneal osteomyelitis as the best surgical option for function. The most common organism cultured from operative specimens was
Breast cancer is generally managed surgically with adjuvant agents which include hormone therapy, chemotherapy, radiotherapy and bisphosphonate therapy. However, some of these adjuvant therapies may cause adverse events, including wound infection, neutropenia, bone marrow suppression and fever. The simultaneous presentation of osteonecrosis and osteomyelitis has not previously been described in patients with breast cancer undergoing hormone therapy and chemotherapy. We report a patient with breast cancer who developed bone infarcts in both legs as well as osteomyelitis in the right distal tibia after treatment which included a modified radical mastectomy, hormone therapy and chemotherapy. Simultaneous osteonecrosis and osteomyelitis should be considered in patients with breast cancer who are receiving chemotherapy and hormone therapy who present with severe bone pain, especially if there have been infective episodes during treatment.
We present the outcomes in 38 consecutive patients who had total ankle replacement using the Ankle Evolution System with a minimum follow-up of four years. Pain and function were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) score and regular standardised anteroposterior and lateral weight-bearing radiographs were obtained. Patient satisfaction and complications were recorded and the survival of the implants was demonstrated by the Kaplan-Meier method. The mean follow-up was for 57.8 months (48 to 80). The cumulative survival rate at six years was 94.7% (95% confidence interval 80.3 to 98.7). The mean total AOFAS score was 88.1 (53 to 100). The mean score for pain was 35.8 (20 to 40). Ten patients presented with edge-loading of whom nine had corrective surgery. Two ankles were revised, one to an arthrodesis and the other to replace the tibial component. Nine patients showed radiological evidence of osteolysis. They had minimal non-progressive symptoms and further surgery was not undertaken. Nevertheless, the concerns about osteolysis led to the implant being withdrawn by the manufacturer. The medium-term results of the ankle evolution system ankle replacement are satisfactory with high patient satisfaction, but the rate of osteolysis is of some concern. The long-term benefit of this procedure has yet to be determined.
Fibrin glue, also known as fibrin sealant, is now established as a haemostatic agent in surgery, but its role in orthopaedic surgery is neither well known nor clearly defined. Although it was originally used over 100 years ago, concerns about transmission of disease meant that it fell from favour. It is also available as a slow-release drug delivery system and as a substrate for cellular growth and tissue engineering. Consequently, it has the potential to be used in a number of ways in orthopaedic surgery. The purpose of this review is to address its use in surgery of the knee in which it appears to offer great promise.
Invasive group A streptococcus (iGAS) is the most common cause of monomicrobial necrotising fasciitis. Necrotising infections of the extremities may present directly to orthopaedic surgeons or by reference from another admitting specialty. Recent epidemiological data from the Health Protection Agency suggest an increasing incidence of iGAS infection in England. Almost 40% of those affected had no predisposing illnesses or risk factors, and the proportion of children presenting with infections has risen. These observations have prompted the Chief Medical Officer for the Central Alerting System in England to write to general practitioners and hospitals, highlighting the need for clinical vigilance, early diagnosis and rapid initiation of treatment in suspected cases. The purpose of this annotation is to summarise the recent epidemiological trends, describe the presenting features and outline the current investigations and treatment of this rare but life-threatening condition.
We evaluated the oncological and functional outcome of 27 patients who had limb salvage for a soft-tissue sarcoma of the foot or ankle between 1992 and 2007, with a mean follow-up of 7.5 years (1.05 to 16.2). There were 12 men and 15 women, with a mean age at presentation of 47 years (12 to 84). Referrals came from other hospitals for 16 patients who had previous biopsy or unplanned excision, and 11 presented de novo. There were 18 tumours located in the foot and nine around the ankle. Synovial sarcoma was the most frequent histological diagnosis. Excision was performed in all cases, with 16 patients requiring plastic surgical reconstruction with 13 free and three local flaps. Adjuvant treatment was undertaken in 20 patients, 18 with radiotherapy and two by chemotherapy. Limb salvage was successful in 26 of the 27 patients. There have been two local recurrences and two mesenchymal metastases. Four patients have died of their sarcoma and two of other causes. Function was evaluated with the Toronto Extremity Salvage Score and a mean overall score of 89.40 (52.1 to 100) was obtained. A questionnaire revealed that all surviving patients are able to wear normal shoes and none require a walking aid. Limb salvage can achieve good oncological and functional results with additional treatment.
Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded. At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion. Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.
Despite advances in reconstructive surgery, salvage of mangled extremities still requires long periods of treatment with many operations that can be taxing both to the surgeon and the patient. Attempts at reconstruction of severely shattered limbs necessitate counselling with regard to the protracted course of treatment and associated morbidity as well as problems which may require abandoning of the procedure and secondary amputation. We report the successful salvage of a severely comminuted and open fracture of the tibia in a 32-year-old man.
Nonunion of the tibia associated with bone loss, previous infection, obliteration of the intramedullary canal or located in the distal metaphysis poses a challenge to the surgeon and significant morbidity to patients. We retrospectively reviewed the records of 24 patients who were treated by central bone grafting and compared them to those of 20 who were treated with a traditional posterolateral graft. Central bone grafting entails a lateral approach, anterior to the fibula and interosseous membrane which is used to create a central space filled with cancellous iliac crest autograft. Upon consolidation, a tibiofibular synostosis is formed that is strong enough for weight-bearing. This procedure has advantages over other methods of treatment for selected nonunions. Of the 24 patients with central bone grafting, 23 went on to radiographic and clinical union without further intervention. All healed within a mean of 20 weeks (10 to 48). No further bone grafts were required, and few complications were encountered. These results were comparable to those of the 20 patients who underwent posterolateral bone grafting who united at a mean of 31.3 weeks (16 to 60) but one of whom required below-knee amputation for intractable sepsis. Central bone grafting is a safe and effective treatment for difficult nonunions of the tibia.