Introduction

Reconstruction of large defect of tibia following infection is considered as one of the most difficult problem facing the orthopaedic surgeon. Amputation with modern prosthetic fitting is a salvage procedure to treat big defects, which gives a functional result with unpredictable psychological impact.

Materials & Methods

Between January 2000 and January 2021, 56 patients (30 males and 26 females) with big defects following infection and post traumatic injury of the tibia were treated. The mean age of the patients at the time of surgery was 20.5 years (4–24 years). The fibula was mobilized medially to fill the defect and was fixed with Ilizarov fixator. The average size of the defects reconstructed was 18.5 cm (17–20 cm).

Introduction

Circular frames for ankle fusion are usually reserved for complex clinical scenarios. Current literature is heterogenous and difficult to interpret. We aimed to study the indications and outcomes of this procedure in detail.

Materials & Methods

A retrospective cohort study was performed based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiological and clinical outcomes, and adverse events. Factors influencing radiological and clinical outcomes were analysed.

Introduction

External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting.

Materials & Methods

This prospective case series evaluated the first 20 consecutive cases of EF removal in the outpatient clinic between 10/06/22 to 16/09/22. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirement, asked to evaluate their experience and perceived pain using the Visual Analogue Scale (VAS).

Introduction

Wide, tumor-like resection for chronic osteomyelitis (COM), a standard practice previously, has been challenged recently with adequate, local debridement. This paper reviews the evolution of surgical debridement for long bone osteomyelitis, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Materials & Methods

Retrospective review of records from 2014 to 2020 of patients with long bone osteomyelitis. All records were searched electronically and imaging reviewed. All patients were managed by Multidisciplinary Infection Team protocol.

Introduction

External fixators are common surgical orthopaedic treatments for the management of complex fractures and in particular, the use of circular frame fixation within patients requiring limb reconstruction. It is well known that common complications relating to muscle length and patient function without rehabilitation can occur. Despite this there remains a lack of high-quality clinical trials in this area investigating the role of physiotherapy or rehabilitation in the management of these patients. We aim to complete a systematic review of rehabilitation techniques for patients undergoing external fixator treatment for Limb Reconstruction of the lower limb.

Materials & Methods

A comprehensive search of AMED, CINAHL, MEDLINE and COCHRANE databases was conducted to identify relevant articles for inclusion, using a search strategy developed in collaboration with a research librarian. Inclusion criteria consisted of adults aged 18 years and over who have experienced leg trauma (open fracture, soft tissue damage), elective leg deformity corrective surgery, bone infection or fracture non-union who have been treated with the use of an external fixator for fixation. Specific exclusion criteria were patients below the age of 18 years old, patients with cancer, treatment of the injury with internal nail, patients who underwent amputation, the use of external fixators for soft tissue contracture management, editorials, comment papers, review papers, conference proceedings and non-English papers.

Titles, abstracts, and full texts were screened for suitability by pairs of reviewers according to the inclusion and exclusion criteria using Rayyan QCRI online software. Any conflicts were resolved through discussion with three independent specialist senior reviewers. Following full text screening, references lists of included articles were manually searched to ensure that all relevant studies were identified. Due to lack of evidence, forward searching was also completed for studies included in the review. Data quality was assessed using the mixed methods appraisal tool and the CERT assessment tool was utilised to look at completeness of reporting of exercise interventions.

Introduction

Derotation osteotomies are commonly performed in paediatric orthopaedic and limb reconstruction practice. The purpose of this study was to determine whether the use of a digital inclinometer significantly improves the accuracy in attaining the desired correction.

Materials & Methods

We designed an electronic survey regarding derotation femoral osteotomy (DFO) including methods of intra-operative angular correction assessment and acceptable margins of error for correction. This was distributed to 28 paediatric orthopaedic surgeons in our region. A DFO model was created, using an anatomic sawbone with foam covering. 8 orthopaedic surgeons each performed two 30-degree DFOs, one using K-wires and visual estimation (VE), and the other using a Digital Inclinometer (DI). Two radiologists reported pre and post procedure rotational profile CT scans to assess the achieved rotational correction.

Introduction

The various problems that are managed with circular external fixation (e.g. deformity, complex fractures) also typically require serial plain x-ray imaging.

One of the challenges here is that the relatively radio-opaque components of the circular external fixator (e.g. the rings) can obscure the view of the area of interest (e.g. osteotomy site, fracture site).

In this presentation we describe how the geometry of the x-ray beam affects the produced image and how we can use knowledge of this to our advantage.

Whilst this can be applied to any long bone, we have focused on the tibia, given that it's the most common long bone that is treated by circular external fixation.

Materials & Methods

In the first part of the presentation we describe the known attributes (geometry) of the x-ray beam and postulate what effect it would have when we x-ray a long bone that is surrounded by a circular external fixator.

In the second part we demonstrate this in practice using a tibia and a 3 ring circular external fixator. Differing x-ray beam orientations are used to demonstrate both how the geometry of the beam affects the produced image and how we can use this to our advantage to better visualise part of the bone.

Introduction

The vast majority of orthopaedic surgeons use C-arm fluoroscopy in the operating theatre when building a circular external fixator. In the absence of previous research in this area, we hypothesised that the surgeon who builds a circular external fixator is exposed to a greater amount of radiation purely as a result of the presence of the metallic fixator in the x-ray beam. The aim of our study therefore was to investigate how the presence of a circular external fixator affects the radiation dose to the surgeon and the surgical assistant.

Materials & Methods

A simulated environment was created using a radiolucent operating table, an acrylic lower limb phantom (below knee segment), various configurations of metalic circular external fixation, and a standard size C-arm image intensifier.

The variables investigated were 1. the amount of metal in the beam 2. the orientation of the beam (PA vertical vs lateral) 3. the horizonal distance of the person from the beam (surgeon vs assistant) and 4. the vertical distance of the various body parts from the beam (e.g. thyroid, groin).

In terms of radiation dose, we recorded two things : 1. the dose produced by the image intensifier 2. the dose rate at standardised positions in the operating theatre. The latter was done using a solid-state survey sensor. These positions represented both where the surgeon and surgical assistant typically stand plus the heights of their various body regions relative to the operating table..

Introduction

The management of open long bone fractures is well described and has been standardised through a number of well-established guidelines. However, there is no consensus regarding the application of local antibiotics into the open fracture site as a means of reducing infection rates.

Materials & Methods

A systematic review and meta-analysis were undertaken as per PRISMA guidelines. PROSPERO Registration CRD42022323545. PubMed, EMBASE, Scopus and CENTRAL were the databases assessed. The Newcastle Ottawa Scale and the Rob 2 Tool were used to assess bias. A qualitative synthesis of all included studies and meta-analysis of suitable subgroups was undertaken.

Introduction

Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture.

Materials & Methods

Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded.

Introduction

Non-union is an unfortunate outcome of the fracture healing process for some patients; with an estimated annual incidence of 17.4- 18.9 per 100,00. The management of these patients depicts a significant clinical challenge for surgeons and financial burden to health services. External ultrasound stimulation devices (Exogen^TM) have been highlighted as a novel non invasive therapy to achieve union in cases of delayed and non-union. The aim of the current study was to assess the rate of union in patients using Exogen^TM therapy for delayed fracture union in a district general hospital.

Materials & Methods

This is a single centre retrospective continuous cohort study. Patients were identified from a prospective database of all patients prescribed Exogen^TM therapy between June 2013- September 2021 in a district general hospital. Patient data was collected retrospectively using electronic patient records. Fracture union was assessed both clinically and radiographically and recorded in patient records. Failure of treatment was defined as progression to operative treatment due to lack of progression with ultrasound therapy or established asymptomatic non-union. Patient were excluded from the study if Exogen^TM therapy was prescribed within 6 weeks of injury.

Introduction

Percutaneous EndoProsthetic Osseointegration for Limbs (PEPOL) facilitates improved quality of life (QOL) and objective mobility for most amputees discontent with their traditional socket prosthesis (TSP) experience. Some amputees desiring PEPOL have residual bone much shorter than the currently marketed press-fit implant lengths of 14–16 cm, potentially a risk for failure to integrate. We report on the techniques used, complications experienced, the management of those complications, and the overall mobility outcomes of seven patients who had femur distraction osteogenesis (DO) with a Freedom nail followed by PEPOL.

Materials & Methods

Retrospective evaluation of a prospectively maintained database identified nine patients (5 females) who had transfemoral DO in preparation for PEPOL with two years of follow-up after PEPOL. Six patients had traumatic causes of amputation, one had perinatal complications, one was performed to manage necrotizing fasciitis and one was performed as a result of osteosarcoma.

Introduction

This study reports on minimum 2 year follow up outcomes on functional and quality of life of patients after undergoing bilateral osseointegration in comparison to traditional socket prosthesis.

Materials & Methods

This is a prospective pilot study of 35 patients, consisting of 30 males and 5 females, aged 22–66 (mean 36) years at surgery, with minimum two-year follow-up. Selection criteria were age over 18 years, bilateral amputees who had socket-related problems or were wheelchair-bound with short stumps and non-reconstructable limb pathology. Principle outcome measures included the Questionnaire for persons with a Trans-Femoral Amputation (Q-TFA), Short Form Health Survey 36 (SF-36), Six Minute Walk Test (6MWT), Timed Up and Go (TUG), and K-levels. Adverse events were recorded including infection, revision surgery, fractures, and implant failures.

Introduction

Approximately 2,000 Skeletal transcutaneous osseointegration (STOI) procedures have been performed worldwide as of 2020, more than half of which have been performed by the Osseointegration Group of Australia using a press-fit technique with either ILP or OPL implant designs. Despite the consistently demonstrated clinical benefits, concerns regarding potential complications following STOI have slowed its widespread adoption. As more patients are followed for a longer period of time, longitudinal studies have confirmed complication rates are very acceptable, similar to those of total ankle and total elbow replacements. One of the major risk category is implant removal. The primary goal of this study was to investigate the complications and technical issues associated with transtibial osseointegration implant removal due to any cause. The focus here will be on the press-fit ILP and OPL implants, including the indications for removal and patient outcomes following removal.

Materials & Methods

A review of our osseointegration registry between November 2010 and March 2022 was performed. Inclusion criteria were patients who have undergone removal of a transtibial osseointegration implant due to any cause. Selected patients either had a follow-up of at least two years or had their index osseointegration surgery at least two years prior to when the study was performed. Patients who have had osseointegration at other anatomic levels, and patients who underwent simultaneous total knee replacement with transtibial osseointegration were excluded from the registry search.

Introduction

Osseointegration has emerged as a promising alternative to rehabilitating with a traditional socket mounted prosthesis. Advantages have been reported to include improved functional mobility, better osseoperception, improved comfort, reduced pain, better biomechanical alignment and better gait, which all lead to a less restricted lifestyle and significantly improved quality of life. A major concern of the Osseointegrated approach lies in the risk of infections occurring from the permanent transcutaneous opening often referred to as the stoma. Several systematic reviews have indicated that the occurrence of minor infections can be quite common, serious complications are reported to be rare. In addition to commonly anticipated complications including fractures, surgical debridements or revisions, we have identified several significant events in which a patient may require to be readmitted and go through additional surgery. The objective of this study is to examine the rate of occurrence and reports on the best management practices of serious complications across a multi-centre review of more than 1000 osseointegration surgeries.

Materials & Methods

A detailed analysis has been performed on all osseointegration surgeries performed by the Osseointegration Group of Australia and it's affiliates between since 2010. The majority of surgeries took place in Australia, the United States, the Middle East as well as in Europe. All events leading to a re-admission and subsequent re-operation have been identified through hospital operation records and pooled together for meta-analysis. Events identified include: revision of implants, periprosthetic fracture fixation, surgical debridement due to infections, neurectomies and soft- tissue refashioning.

Introduction

LIMB-Q Kids is a new patient-reported outcome measure (PROM) for children with Lower limb differences (LLDs). The objective is to conduct an international field test study.

Materials & Methods

A mixed method multiphase approach was used to develop LIMB-Q Kids. In phase one, a systematic review was conducted to identify concepts from existing PROMs used in research with children with LLDs. A preliminary conceptual framework derived from the systematic review informed an international qualitative study. The data from qualitative interviews were used to form the LIMB-Q Kids, which was further refined through multiple rounds of cognitive debriefing interviews with children. Input was obtained from parents and healthcare professionals from Australia, Canada, Ethiopia, India, UK, and the USA. LIMB-Q Kids was translated and culturally adapted into multiple languages.

Introduction

Transfemoral osseointegration (TFOI) for amputees has substantial literature proving superior quality of life and mobility versus a socketed prosthesis. Some amputees have hip arthritis that would be relieved by a total hip replacement (THR). No other group has reported performing a THR in association with TFOI (THR+TFOI). We report the outcomes of eight patients who had THR+TFOI, followed for an average 5.2 years.

Materials & Methods

Our osseointegration registry was retrospectively reviewed to identify all patients who had TFOI and also had THR, performed at least two years prior. Six patients had TFOI then THR, one simultaneous, one THR then TFOI. All constructs were in continuity from hip to prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in subjective hip pain, K-level, daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but one patient did not have complete mobility and quality of life survey data at both time periods.

Introduction

Transtibial osseointegration (TFOI) for amputees has limited but clear literature identifying superior quality of life and mobility versus a socketed prosthesis. Some amputees have knee arthritis that would be relieved by a total knee replacement (TKR). No other group has reported performing a TKR in association with TTOI (TKR+TTOI). We report the outcomes of nine patients who had TKR+TTOI, followed for an average 6.5 years.

Materials & Methods

Our osseointegration registry was retrospectively reviewed to identify all patients who had TTOI and who also had TKR, performed at least two years prior. Four patients had TKR first the TTOI, four patients had simultaneous TKR+TTOI, and one patient had 1 OI first then TKR. All constructs were in continuity from hinged TKR to the prosthetic limb. Outcomes were: complications prompting surgical intervention, and changes in daily prosthesis wear hours, Questionnaire for Persons with a Transfemoral Amputation (QTFA), and Short Form 36 (SF36). All patients had clinical follow-up, but two patients did not have complete survey and mobility tests at both time periods.

Introduction

The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumours. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and thel ocal bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique—an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening.

Materials & Methods

We retrospectively included 10 patients (mean age 10 y)with an osteosarcoma of the distal femur, who were treated ac-cording to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome.

Introduction

Patient-reported outcome measures (PROMs) has gained momentum in the orthopaedic literature. The GOAL-LD (Gait Outcomes Assessment List for Limb Deformity) incorporates the framework of The WHO International Classification of Functioning, Disability and Health and correlates highly with the Paediatric Outcomes Data Collection Instrument (PODCI) when applied in a limb reconstruction setting. The Royal Children's Hospital Melbourne, Australia, supported by The University of Melbourne is designing and implementing a Limb Reconstruction Registry, prospectively enrolling patients with a number of key conditions and provide a mechanism for capturing surgical data and PROMs at regular follow-up intervals. LimbDREAM (The Limb Reconstruction Registry of Experience, Aspiration and Measures) has begun recruiting participants, and this paper serves as a narrative review of our design and implementation process.

Materials & Methods

After provision of a research grant, audit was conducted to examine local case mix and estimate recruitment based on conditions selected. Literature review was focussed on (i) registries in the paediatric limb reconstruction domain and (ii) use of PROMs across conditions selected. A high-level process-flow chart was constructed in order to inform governance and staffing requirements in addition to REDCap Database structure. Local as well as scalable deployment was considered. Alpha and beta testing was performed by principal and associate investigators prior to participant recruitment.

Introduction

There is no doubt that the future of limb lengthening lies with internal lengthening. Complication rates are reduced and patient satisfaction is increased. The evolution of internal lengthening peaked with the dual direction, easily inserted and externally controlled PRECICE Nail. It has excelled in performance in accuracy and satisfaction. Its versatility increased with smaller sizes and increased excursion. A field safety notice was issued was issued in October 2021 by the parent company NuVasive. The advice was monitoring of current cases and a hold on implantation until after a review of process. At the National Orthopaedic Hospital Cappagh we elected to remove all implanted nails and assess the nail integrity and physiological changes associated with implantation.

Materials & Methods

All patients in who a retained Precice nail at the time of the field safety notice were identified. Patients and families were contacted to explain the issued safety notice from the company and explain that we would be scheduling them for nail removal. This was part of our standard care but we prioritised this group on our waiting list. Consent was obtained for nail removal but also for histological assessment of canal scrapings, blood ion level analysis and independent assessment of the retrieved nail by our academic collaborators at University College Dublin. Ion levels were then repeated at an interval post removal with consent.

Introduction

External fixators are attached to bones with percutaneous pins and wires inserted through soft tissues and bone increasing the risk of infections. Such infections compromise patient outcomes e.g., through pin loosening or loss, failure of fixator to stabilise the fracture, additional surgery, increased pain, and delayed mobilisation. These infections also impact the healthcare system for example, increased OPD visits, hospitalisations, treatments, surgeries and costs. Nurses have a responsibility in the care and management of patients with external fixators and ultimately in the prevention of pin-site infection. Yet, evidence on best practices in the prevention of pin-site infection is limited and variation in pin-site management practices is evident. Various strategies are used for the prevention of pin-site infection including the use of different types of non-medicated and medicated wound dressings. The aim of this retrospective study was to investigate the use of dry gauze or iodine tulle dressings for the prevention of pin-site infections in patients with lower limb external fixators.

Methodology

A retrospective study of patients with lower limb external fixators who attended the research site between 2015–2022. Setting & Sample: The setting was the outpatient's (OPD) orthopaedic clinic in a University Teaching Hospital in Dublin, Ireland. Eligibility Criteria:

Over the age of 16, treated with an Ilizarov, Taylor Spatial frame (TSF) or Limb Reconstruction System (LRS) external fixators on lower limbs,

Follow Up Period: From time of external fixator application to first pin-site infection or removal of external fixator. Outcome Assessment: The primary outcome was pin-site infection, secondary outcomes included but were not limited to frequency of pin-site infection according to types of bone fixation, frequency of pin/wire removal and hospitalisation due to infection. Data analysis: IBM SPSS Version 25 was used for statistical analysis. Descriptive and inferential statistics were conducted as appropriate. Categorical data were analysed by counting the frequencies (number and percentages) of participants with an event as opposed to counting the number of episodes for each event. Differences between groups were analysed using Chi-square test or Fisher's exact test, where appropriate. Continuous variables were reported using mean and standard deviations and difference analysed using a two-sample independent t-test or non-parametric test (Mann-Whitney), where appropriate. Using Kaplan-Meier, survival analysis explored time to development of infection. Ethical approval: granted by local institute Research Ethics Committee on 12th March 2018.

Introduction

Adjusting an external fixator can be a daunting process for patients. Despite comprehensive training, patients often request supervision for the initial adjustments which may result in a prolonged hospital stay. Following the introduction of telemedicine during the pandemic we believed that this could be utilised to support patients with their fixator adjustments. A quality improvement project was implemented to assess and evaluate a change in practice from existing Face to Face support to a telemedicine format. The aim of the project was to reduce median length of stay (LOS).

Materials & Methods

The telemedicine platform was introduced in our unit from April 2021 with the change in practice. Using the life QI platform, run charts were used to record the numbers of patients whose LOS was 4 days or less. Median LOS was assessed prior to and following introduction of the telemedicine platform. Service user experience with telemedicine as well as overall training and education by the CNS team was sought through on-line questionnaires.

Introduction

Bone transport and distraction osteogenesis have been shown to be an effective treatment for significant bone loss in the tibia. However, traditional methods of transport are often associated with high patient morbidity due to the pain and scarring caused by the external frame components transporting the bone segment. Prolonged time in frame is also common as large sections of regenerate need significant time to consolidate before the external fixator can be removed. Cable transport has had a resurgence with the description of the balanced cable transport system. However, this introduced increasingly complex surgery along with the risk of cable weave fracture. This method also requires frame removal and intramedullary nailing, with a modified nail, to be performed in a single sitting, which raised concern regarding potential deep infection. An alternative to this method is our modified cable transport system with early intramedullary nail fixation. Internal cables reduce pain and scarring of the skin during transport and allow for well controlled transport segment alignment. The cable system is facilitated through an endosteal plate that reduces complications and removes the need for a single-stage frame removal and nailing procedure. Instead, the patients can undergo a pin-site holiday before nailing is performed using a standard tibial nail. Early intramedullary nailing once transport is complete reduces overall time in frame and allows full weight bearing as the regenerate consolidates. We present our case series of patients treated with this modified cable transport technique.

Methodolgy

Patients were identified through our limb reconstruction database and clinic notes, operative records and radiographs were reviewed. Since 2019, 8 patients (5 male : 3 female) have undergone bone transport via our modified balanced cable transport technique. Average age at time of transport was 39.6 years (range 21–58 years) with all surgeries performed by the senior author. Patients were followed up until radiological union. We recorded the length of bone transport achieved as well as any problems, obstacles or complications encountered during treatment. We evaluated outcomes of full weight bearing and return to function as well as radiological union.

Introduction

Despite the established guidelines on lower extremity free flap reconstruction by the British Orthopaedic Association Standard for Trauma (BOAST-4) the post-operative care has yet to be standardised. There is currently no coherent evidence in the literature regarding clinical monitoring, warming, dangling and compression; the optimal regimes and their respective physiological benefits. The aim of this study is to survey all UK Major Trauma Centres (MTCs) with regards to the post-operative care of lower extremity free flaps and elucidate the current protocols for clinical monitoring, warming, dangling and compression.

Materials & Methods

All UK-based adult MTCs were surveyed. We formulated a detailed questionnaire to enquire about the post-operative care of lower extremity free flap reconstructions; the number of free flap reconstructions per month and take backs per month and for which post-operative methods a protocol is used in each MTC. We asked specific questions concerning: clinical monitoring, warming, dangling and compression. This questionnaire was distributed to consultant leads in the form of multiple choice questions, with an option of free-text box for further comments, using JISC online surveys. Results were analysed in Excel and presented in percentages.

Introduction

At Sheffield Children's Hospital, treatment of leg length discrepancy is a common procedure. Historically, this has been done with external fixators. With the development in intramedullary technology, internal nails have become the preferred modality for long bone lengthening in the adolescent population. However, it is important to review whether this technology practically reduces the known challenges seen and if it brings any new issues. Therefore, the aim of this review is to retrospectively evaluate the therapeutic challenges of 16 fit-bone intramedullary femoral lengthening's at Sheffield Children's Hospital between 2021–2022.

Materials & Methods

The international classification of function (ICF) framework was used to differentiate outcomes. The patient's therapy notes were retrospectively reviewed for themes around structural, activity and participation limitation. The findings were grouped for analysis and the main themes presented.

Introduction

Intramedullary lengthening devices have been in use in older children with closed /open growth plates with good success. This study aims to present the early experience of the FITBONE nail since withdrawal of the PRECICE nail.

Materials & Methods

Retrospective analysis of both antegrade and retrograde techniques were utilized. Only patients where union was achieved and full weight bearing commenced were included. The complication rate, length gained, distraction index, weight bearing index (WBI) as well as mechanical axes were analysed.

Introduction

Aneurysmal bone cysts commonly found in lower limbs are locally aggressive masses that can lead to bony erosion, instability and fractures. This has major implications in the lower limbs especially in paediatric patients, with potential growth disturbance and deformity. In this case series we describe radical aneurysmal bone cyst resection and lower limb reconstruction using cable transport and syndesmosis preservation.

Materials & Methods

Case 1 - A 12-year-old boy presented with a two-week history of atraumatic right ankle pain. An X-ray demonstrated a distal tibia metaphyseal cyst confirmed on biopsy as an aneurysmal bone cyst. The cyst expanded on interval X-rays from 5.5cm to 8.5cm in 9 weeks. A wide-margin en-bloc resection was performed leaving a 13.8cm tibial defect. A cable transport hexapod frame and a proximal tibial osteotomy was performed, with syndesmosis screw fixation. The transport phase lasted 11 months. While in frame, the boy sustained a distal femur fracture from a fall. The femur and the docking site were plated at the same sitting and frame removed. At one-year post-frame removal he is pain-free, with full ankle dorsiflexion but plantarflexion limited to 25 degrees. He has begun graduated return to sport.

Introduction

The FitBone lengthening nail (Orthofix UK) is an intramedullary device licensed for the lengthening of long bones in adults in the UK. It contains a motor powered by electricity transmitted via an induction coil placed underneath the skin. It was developed in Germany two decades ago but uptake in the UK has only started more recently. The aim of this study was to review the first cohort of FitBone lengthening nails in a unit with significant experience of other lengthening nails (including PRECICE and Stryde).

Materials & Methods

Demographic, clinical and radiological data was prospectively collected on all FitBone cases starting in February 2022. Accuracy of lengthening rate, patient satisfaction and implant issues were all considered. Complications and learning points were recorded and discussed by the multidisciplinary team involved in the patients care.

Introduction

A greater emphasis has been placed on fracture related infection (FRI) orthopaedic practice as a separate entity in recent years. Since the publication of the FRI consensus definition and guidelines, there has been an increase in the published literature on the topic and a move towards considering FRI as separate from general orthopaedic practice and as work that requires a more specialist approach. The aim of this study was to audit current FRI practice in the UK.

Materials & Methods

Orthopaedic practice related to FRI in the UK was audited using a semi-structured questionnaire. Respondents were from a range of institutions, specialties and clinical roles to reflect the multi-disciplinary nature of treating FRI. The online tool SurveyMonkey was used to share the survey at the 2022 annual meeting of the British Limb Reconstruction Society. Twenty-one questions were asked in the following domains: scope of practice, theatre and clinic capacity, availability of the multidisciplinary team, renumeration for work and scope of FRI networks.

Introduction

Legg-Calve-Perthes (Perthes Disease) was first recognised by three physicians, Arthur Legg (1874–1939), Jacqui Calve (1875–1954) and George Perthes (1869 – 1927) in 1910. Perthes disease is a rare childhood condition that affects the hip. It occurs when the blood supply to the femoral head is disrupted. Without this blood supply, the bone cells die and avascular necrosis can occur. The Herring classification is used to diagnose the stages of Perthes Disease. It is an important prognostic factor. There are three classifications, Herring A, B and C. Herring A has no involvement of the lateral pillar with no density changes noted on x-ray. Herring B has at least 50% of the lateral pillar height maintained on x-ray. Herring C has less than 50% of the lateral pillar height on x-ray (Herring et al, 1992). Children with Perthes disease require specialist Limb Reconstruction team throughout their treatment journey, this includes Orthopaedic surgery and therapy (Physiotherapy and Occupational Therapy). The National Limb Reconstruction Therapy Team is based at the National Orthopaedic Hospital, Cappagh. The therapy team consists of 1 Clinical Specialist Physiotherapist, 1 Senior Physiotherapist and 1 Senior Occupational Therapist who provide input to this cohort. This study aims to analyse the importance of a comprehensive pre-operative assessment by the therapy team (Physiotherapist and Occupational Therapist) to maximise patient outcomes post operatively.

Methodology

This is a quantitative research study conducted by the National Limb Reconstructive Therapy Service of the National Orthopaedic Hospital in Cappagh, Dublin. The inclusion criteria for this study consisted of:

Age – Patient must be part of the Paediatric Service, i.e., under the age of 16.

Exclusion Criteria: Those not meeting the above inclusion criteria. Following the inclusion criteria, a number of cases were identified of which 10 cases were selected at random. A retrospective analysis of these samples was completed. The medical charts were reviewed as well as patient electronic healthcare records. Microsoft Excel was utilised to analyse the data and capture results.

Materials & Methods

Between 2014 and 2022, 7 children underwent bone defect/infection reconstruction using Masquelet technique, four for complications of Congenital Pseudoarthrosis of Tibia (CPT) treatment, two with chronic osteomyelitis and one for Osteogenesis imperfecta with infected nonunion. The length of the defect relative to the length of the bone (index of reconstruction expressed as a percentage), time to union and complications were evaluated with standard radiographs and from electronic medical records.

Results

The mean age was 11 years and the procedure was done in five tibiae, one femur and a metatarsal. The mean time interval was 7.1 weeks between the first and second stage surgery. The mean index of reconstruction was 25.8% and the mean follow up period was 17 months. Though six patients achieved union with a mean time to union of 6.5 months (range 4.5 to 10), two patients with multiple previous surgeries for CPT decided to have ablation despite union. The interosseous Masquelet technique of cross synostosis between the tibia and fibula is being highlighted.

Introduction

Open fragility ankle fractures involve complex decision making. There is no consensus on the method of surgical management. Our aim in this study was to analyse current management of these patients in a major trauma centre (MTC).

Materials & Methods

This cohort study evaluates the management of geriatric (≥65years) open ankle fractures in a MTC (November 2020–November 2022). The method, timing(s) and personnel involved in surgical care were assessed. Weightbearing status over the treatment course was monitored. Patient frailty was measured using the clinical frailty score (CFS).

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

Materials & Methods

A prospectively maintained database was interrogated to identify all patients. Case notes and radiographs were reviewed to collate patient demographics and injury factors . The primary outcome of interest was deep infection rate with secondary outcomes including time to union and secondary interventions

Introduction

Osteotomy is a key step in distraction osteogenesis. Various techniques of osteotomy have been described with its own benefits and pitfalls. Percutaneous osteotomy using multiple drill holes is one of the most widely used osteotomy techniques. It still remains a challenge however to keep the drill holes aligned prior to the osteotomy. Moreover, the efficacy of percutaneous irrigation practice to keep the temperature low during drilling with this technique is also debatable. With an aim to overcome these challenges, we are introducing a device called the Double Barrel Drill Sleeve (DBDS) to perform percutaneous osteotomies. We attempted to compare this method to the conventional multiple drill holes technique using laboratory experiments and clinical data.

Materials & Methods

DBDS has two adjacent parallel barrels that can fit 3.2 to 3.5 mm diameter drill bits. It has a guide member at the drilling end that can be inserted through a pre drilled hole at the near and far cortices of a bone. This provides a constant rotating point for drilling of holes through the barrels. An osteotomy simulation was performed to compare percutaneous drilling with DBDS vis-a-vis a conventional single drill sleeve (SDS) by qualified orthopaedic surgeons, mainly to assess the drilling patterns of both techniques. Percutaneous drilling was done on PVC pipes wrapped in thick sponge to simulate tubular bone with surrounding soft tissue. We also assessed the effect of indirect irrigation on temperature during drilling using the DBDS against a control group on a cadaveric bone model. Ultimately we reviewed our patients who had undergone osteotomy for distraction osteogenesis with DBDS and the conventional technique, and compared their outcomes.

Introduction

Osteomyelitis is a challenge in diagnosis and treatment. 18F-FDG PET-CT provides a non-invasive tool for diagnosing and localizing osteomyelitis with a sensitivity reaching 94% and specificity reaching 100%. We aimed to assess the agreement in identifying the geographic area of infected bone and planned resection on plain X-ray versus 18F-FDG PET-CT.

Materials & Methods

Clinical photos and X-rays of ten osteomyelitis patients were shown to ten consultant surgeons; they were asked to draw the area of infection and extent of planned surgical debridement; data will be compared to 18F-FDG PET-CT results.

Introduction

A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction.

Methodology

Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle.

Materials & Methods

A retrospective review of all consecutively treated AFFNU cases between March 2015 to December 2019 was carried out. 9 patients with a mean age of 63.87 years and M:F ratio of 7:2 met the inclusion criteria. Primary outcome variable was radiographic union at 12 months after revision surgery. All surgeries were carried out by a single surgeon. Fixation construct, neck-shaft angle, use of bone graft and immediate postoperative weight bearing protocols were recorded.

Results

Radiographic union was achieved in 7 of 9 patients (78%) after first revision surgery. 1 patient achieved union after 2nd revision surgery and 1 patient died in the early post-operative period due to pulmonary embolism. No bone grafting was used in any of the patients and weight-bearing as tolerated was allowed from the first post-operative day. The mean neck-shaft angle after non-union surgery was 136 degrees.

Introduction

Angular deformities of the distal femur can be corrected by opening, closing and neutral wedge techniques. Opening wedge (OW) and closing wedge (CW) are popular and well described in the literature. CW and OW techniques lead to leg length difference whereas the advantage of neutral wedge (NW) technique has several unique advantages. NW technique maintains limb length, wedge taken from the closing side is utilised on the opening side and since the angular correction is only half of the measured wedge on either side, translation of distal fragment is minimum. Leg lengths are not altered with this technique hence a useful technique in large deformities. We found no reports of clinical outcomes using NW technique. We present a technique of performing external fixator assisted NW correction of large valgus and varus deformities of distal femur and dual plating and discuss the results.

Materials & Methods

We have treated 20 (22 limbs – 2 patients requiring staged bilateral corrections) patients for distal femoral varus and valgus deformities with CWDFO between 2019 and 2022. Out of these 4 patients (5 limbs) requiring large corrections of distal femoral angular deformities were treated with Neutral Wedge (NW) technique. 3 patients (four limbs) had distal femoral valgus deformity and one distal femoral varus deformity. Indication for NW technique is an angular deformity (varus or valgus of distal femur) requiring > 12 mm opening/closing wedge correction. We approached the closing side first and marked out the half of the calculated wedge with K – wires in a uniplanar fashion. Then an external fixator with two Schanz screws is applied on the opposite side, inserting the distal screw parallel to the articular surface and the proximal screw 6–7 cm proximal to the first pin and at right angles to the femoral shaft mechanical axis. Then the measured wedge is removed and carefully saved. External fixator is now used to close the wedge and over correct, creating an appropriate opening wedge on the opposite side. A Tomofix (Depuoy Synthes) plate is applied on the closing side with two screws proximal to osteotomy and two distally (to be completed later). Next the osteotomy on the opposite side is exposed, the graft is inserted. mLDFA is measured under image intensifier to confirm satisfactory correction. Closing wedge side fixation is then completed followed by fixation of opposite side with a Tomofix or a locking plate.

Introduction

Introduction: Pre-operative counselling to prepare patients for frame surgery is important to ensure expectations of recovery and rehabilitation are realistic and anxiety is reduced. The aim of the study was to ascertain whether the current clinical nurse specialist frames counselling session (CNS FCS) prepared patients adequately for life with a frame as well as to explore information patients felt was missing.

Materials & Methods

Materials and Method: Patient reported questions were used to assess frames patient views on the CNS FCS. Thirty frames patients were asked about the CNS FCS information, involvement in decision making, factors influencing frames surgery decision and patient experience.

Introduction

Introduction: Pin site infection is a common complication during treatment with a circular frame external fixator and increases time and support patients require from the limb reconstruction team. Wound swabs were not routinely sent by the clinical nurse specialists prior to this study, with most pin site infections treated as Staphylococcus aureus with flucloxacillin (clindamycin in penicillin allergy). The aim of this study was to ascertain whether routine sending of wound swabs in pin site infection would change antibiotic treatment.

Materials & Methods

Materials and Method: Patients presenting at clinic or physiotherapy with clinical signs of pin site infection were assessed using the Maz Oxford Nuffield (MON) Pin Site Infection Grading System© (OUH, 2021). Antibiotics were commenced as per unit guidelines and swabs sent for microscopy, culture and sensitivity.

Introduction

The purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration.

Materials & Methods

Sixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents.

Introduction

Snapping hip syndrome is a common condition affecting 10% of the population. It is due to the advance of the iliotibial band (ITB) over the greater trochanter during lower limb movements and often associated with hip overuse, such as in athletic activities. Management is commonly conservative with physiotherapy or can be surgical to release the ITB. Here we carry out a systematic review into published surgical management and present a case report on an overlooked cause of paediatric snapping hip syndrome.

Materials & Methods

A systematic review looking at published surgical management of snapping hip was performed according to PRISMA guidelines. PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Library databases were searched for “((Snapping hip OR Iliotibial band syndrome OR ITB syndrome) AND (Management OR treatment))”. Adult and paediatric published studies were included as few results were found on paediatric snapping hip alone.

Introduction

Osteogenesis imperfect (OI) is a geno- and phenotypically heterogeneous group of congenital collagen disorders characterized by fragility and microfractures resulting in long bone deformities. OI can lead to progressive femoral coxa vara from bone and muscular imbalance and continuous microfracture about the proximal femur. If left untreated, patients develop Trendelenburg gait, leg length discrepancy, further stress fracture and acute fracture at the apex of the deformity, impingement and hip joint degeneration. In the OI patient, femoral coxa vara cannot be treated in isolation and consideration must be given to protecting the whole bone with the primary goal of verticalization and improved biomechanical stability to allow early loading, safe standing, re-orientation of the physis and avoidance of untreated sequelae. Implant constructs should therefore be designed to accommodate and protect the whole bone. The normal paediatric femoral neck shaft angle (FNSA) ranges from 135 to 145 degrees. In OI the progressive pathomechanical changes result in FNSA of significantly less than 120 degrees and decreased Hilgenreiner epiphyseal angles (HEA). Proximal femoral valgus osteotomy is considered the standard surgical treatment for coxa vara and multiple surgical techniques have been described, each with their associated complications. In this paper we present the novel technique of controlling femoral version and coronal alignment using a tubular plate and long bone protection with the use of teleoscoping rods.

Methodology

After the decision to operate had been made, a CT scan of the femur was performed. A 1:1 scale 3D printed model (AXIAL3D, Belfast, UK) was made from the CT scan to allow for accurate implant templating and osteotomy planning. In all cases a subtrochanteric osteotomy was performed and fixed using a pre-bent 3.5 mm 1/3 tubular plate. The plate was bent to allow one end to be inserted into the proximal femur to act as a blade. A channel into the femoral neck was opened using a flat osteotome. The plate was then tapped into the femoral neck to the predetermined position. The final position needed to allow one of the plate holes to accommodate the growing rod. This had to be determined pre operatively using the 3D printed model and the implants. The femoral canal was reamed, and the growing rod was placed in the femur, passing through the hole in the plate to create a construct that could effectively protect both the femoral neck and the full length of the shaft. The distal part of the plate was then fixed to the shaft using eccentric screws around the nail to complete the construct.

Introduction

Fracture related infection (FRI) is a challenging complication to manage in an orthoplastic setting. Consensus guidelines have been created to standardise the diagnosis of FRI and comprise confirmatory and suggestive criteria. In this study, the aim is to assess the diagnostic criteria and management of FRI with a particular focus on soft tissue reconstruction.

Materials & Methods

A retrospective study to identify the outcomes of FRI in the lower limb over a five year period at a Major Trauma Centre. Fracture specific information that was analysed includes: open versus closed, fractured bone(s) and site, initial fracture management, method of diagnosis and soft tissue management.

Introduction

The purpose of this study was to analyse the efficacy and complications associated with the use of Calcium Sulphate synthetic bone graft in a paediatric population. There are no published articles on the use in children.

Materials & Methods

A retrospective review was undertaken of the notes, microbiology, and X-Rays of 17 cases (in 15 patients) of calcium sulphate use in paediatric patients. As well as patient demographic data, data collected included indication, use of additional agents (antibiotics), return to theatre, and wound complications. Major complications were also assessed for.

Materials & Methods

Chronic osteomyelitis is a complex and challenging condition the successful treatment of which requires a specialist multidisciplinary approach. Prior to tertiary referral to a specialist Orthoplastic Unit, patients often receive multiple courses of antibiotics, in usually unsuccessful attempts, to eradicate infection. This often results in the development of chronic polymicrobial infection. We reviewed the intra-operative cultures of patients treated in our Orthoplastic unit over a 9-year period from 2012–2021 to determine the spectrum of polymicrobial cultures and the relationship to pre-operative cultures.

Results

We reviewed the electronic care records and laboratory results of all patients referred to or directly admitted to our unit with a diagnosis of chronic osteomyelitis between 2012–2021. We checked all culture results, antibiotic sensitivities and prescription for treatment. We also checked for any recurrence of infection within 1 year.

60 patients were treated over the 9-year period. 9 upper and 51 lower limbs. The most common referral sources were from the surgical specialties of Trauma & Orthopaedics and Plastic Surgery (62%) while an equal amount came from the Emergency Department and other inpatient medical teams, each making up 15%. A small cohort (8%) developed the infection while still being followed up post fixation.

Aetiology of Infection were post fracture fixation 41 (68%), spontaneous osteomyelitis 10 (17%), soft tissue infection 4 (7%). The remaining 5 patients (8%) had a combination failed arthroplasty, arthrodesis and chronic infection from ring sequestrum. 58 patients (97%) had positive cultures with 26 being polymicrobial. 12 cultures were gram negative (G-ve), 11 G+ve 12, 4 anaerobic and 1 Fungal. In 24 patients (40%) the pre-operative cultures and antibiotic sensitivities did not correspond to the intra-operative cultures and sensitivities. 55 patients (92%) required dual or triple therapy with 8% requiring further debridement and extended therapy. 2 (3%) patients had failed treatment requiring amputation.

Introduction

Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt.

Materials & Methods

Data of patients with complex lower limb injuries treated before, during and after the pandemic were collected from our in-house trauma database, theatre records and follow up clinics. The rationale for choosing other techniques over a circular frame, the type of alternative technique used, the cost of such alternatives, the need for soft tissue reconstruction, time to recovery, complications and amputation rates were compared among groups.

Introduction

We present a case of a 49-year-old patient who initially presented in May 2020 with an open pilon fracture. Managed with initial debridement, fixation and flap - who subsequently underwent circular frame application for failure of fixation, requiring a transport to fusion frame who developed beta-haemolytic streptococcus A within the site of the proximal corticotomy.

Materials & Methods

A systematic review of the literature was conducted searching EMBASE, MEDLINE and Cochrane library for all articles discussing infected bone regenerate- a paucity of information was found. Abstracts were independently reviewed by 2 authors (LH and LT). In total, there were 16 papers, and then subsequently analysed we identified two case reports regarding infected regenerate.