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This study addresses the evolution of the orthopaedic management of patients with hypophosphatemic rickets, with the aim of providing skeletal mature aligned lower limbs, with minimal surgical insult.
Methods
We describe a case series of 8 patients with hypophosphatemic rickets that highlight an evolution in practice over the last 8 years. Our initial treatment involved external fixation with circular frames, addressing both axial deformity and length. Two contralateral long bones were addressed simultaneously and surgery was conducted in early adolescence. Problems encountered were poor quality regenerate, requiring prolonged periods in external fixation, and often recurrence of deformity following frame removal. Minor deformity recurrence made planning for the often inevitable knee replacement difficulty. Our current management is that patients only start surgical correction once skeletal maturity has been reached, two contralateral axial long bone corrections are performed using CHAOS (computer hexapod-assisted orthopaedic surgery) procedures with IM nails and multiple osteotomies (occasionally locking plates are required). Patients are able to fully weight bear immediately post operatively, after a suitable recovery period the remaining bones can be corrected. Then lengthening can be considered once the osteotomies have fully consolidated by exchange nailing of the femur, for an IM lengthening nail. At this stage the patient is able to fully consider the risks and benefits of this final and potentially unnecessary procedure.
Conclusions
Hypophosphotaemic rickets is a rare condition, both the disease and its management can have severe effects on patients both physically and psychologically, at Bristol we have developed an treatment pathway that we feel helps to minimize the physical and psychological effects of treatment, with the end result of aligned lower limbs, that should provide a good basis for arthroplasty surgery if required in adulthood.
Purpose
To investigate the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) with external fixator use and to help establish whether current guidelines are appropriate.
Methods
Case notes of individuals undergoing external fixator application by the senior author (PC) from March 2005 to June 2011 were examined. In this period 207 individuals underwent 255 primary applications of Ilizarov, Taylor Spatial Frame (TSF) or monolateral fixator. Fixators applied were 173 tibial, 63 femoral and 19 to other bones. Records were obtained for 182 individuals (88%), representing 214 operations (84%).
AIM
To study the incidence of thromboembolism among patients treated with ring fixators in lower limb injuries and their risk factor association.
METHODS & MATERIALS
Notes of 180 (130 men & 50 women) patients treated with circular frame were retrospectively studied. Risk factors for thromboembolism as advised by NICE were recorded and scored. The duration of pre-operative limb immobilisation, hospital stay and duration of frame, were also recorded.
Aims and Objectives
To assess the efficacy of linezolid in the treatment of orthopaedic related infection and the instance of adverse reactions.
Methods
The management of 22 patients treated with oral linezolid for orthopaedic related infections were reviewed. Patients were selected from the hospital database using clinical coding related to orthopaedic infections and all patients were managed within a single tertiary referral centre. These included infected joint arthroplasty (10 patients), infection following fracture fixation (8 patients), septic arthritis and soft tissue infection (non trauma 4 patients). All patients were treated with oral linezolid therapy, and in each case treatment was initiated with the involvement of a microbiologist, as per trust anti-microbial policy. A diagnosis of infection was confirmed on basis of both subjective and objective markers.
We present our experience of treating 57 cases of bone defects associated with chronic osteomyelitis (COM) and a new algorithm for their treatment.
A retrospective analysis of our operation database revealed 377 patients treated for COM (2002–2010). 76 (20%) had bone defects, of these 57 had notes and x-rays available.
Data was collected on: age, sex, type/extent of bone involved, number/type of procedures, and length of stay. The tibia was most commonly affected (63%), followed by the femur (21%). Infection control procedures included debridement, drilling and sequestrectomy. Long-term antibiotics were seldom used. Prerequisites to reconstruction surgery were; fully healed skin, absence of sequestrae on x-ray and no antibiotics for 2-months. Decision on the method of treatment of defect was made depending on; age, defect size, viability of periosteum and physes, condition of soft tissues and coexisting deformity.
Initial treatment was; plaster stabilisation (15), frame stabilisation (6), free fibula structural bone grafts (9), ipsilateral vascularised fibula graft (7), non-structural cancellous bone graft (8), bone transport (8) and amputation (4).
Little is known about osteomyelitis-induced bone defects, which cause massive morbidity in developing countries. Our novel research shows that these can be treated successfully, often by relatively simple methods. In the absence of ongoing infection, non-vascularised bone grafting techniques are often successful. Bone transport or vascularised grafting are more reliable but more complex solutions.
Introduction
The Ilizarov (IF) and Taylor Spatial (TSF) external fixator frames are commonly used to manage complex fractures and bone deformities and a dedicated Frame Service Team at our unit supports patients during pre- and post-operative period. Few studies have assessed the satisfaction of patients who have been treated with Circular frames.
Methods
A questionnaire was designed and distributed to 56 consecutive patients treated with a circular frame. Data was collected prospectively. Questions were focused on information given pre op, during treatment, overall satisfaction with the frame, morbidity and areas in which the frame service could be improved.
Patients with skeletal dysplasia are prone to developing advanced degenerative knee disease requiring total knee replacement (TKR) at a younger age than the general population. TKR in this unique group of patients is a technically demanding procedure due to the bone deformity, flexion contracture, generalised hypotonia and ligamentous laxity. We set out to retrospectively review the outcome of 11 TKR's performed in eight patients with skeletal dysplasia at our institution using the SMILES custom-made rotating-hinge total knee system. There were 3 males and 5 females with mean age 57 years (range, 41–79 years), mean height 138 cm (range, 122–155 cm) and mean weight 56 kg (range, 40–102 kg). Preoperative diagnoses included achondroplasia, spondyloepiphyseal dysplasia, pseudoachondroplasia, multiple epiphyseal dysplasia, morquio syndrome, diastrophic dysplasia and Larson's Syndrome. Patients were followed clinically and radiographically for a mean of 7 years (range, 3–11.5 years). Knee pain and function improved in all 11 joints. Mean Knee Society clinical and function scores improved from 24 (range, 14–36) and 20 points (range, 5–40) preoperatively to 68 (range, 28–80) and 50 points (range, 22–74) respectively at final follow-up. Four complications were recorded (36%), including a patellar fracture following a fall, a tibial periprosthetic fracture, persistent anterior knee pain and a femoral component revision for aseptic loosening. Our results suggest that custom rotating-hinge TKR in patients with skeletal dysplasia is effective at relieving pain, optimising movement and improving function. It compensates for bony deformity and ligament deficiency and reduces the need for corrective osteotomy. Patellofemoral joint complications are frequent and functional outcome is worse than primary TKR in the general population.
Submission endorsed by Mr Peter Calder, Consultant Orthopaedic Surgeon and Society member
Purpose of the study
We conducted a study to assess the accuracy of Spatial CAD software in computing the mounting and deformity parameters.
Methods and end results
We mounted a two-ring construct on a sawbone tibia and accurately measured the mounting parameters of this frame. Then we obtained three sets of x-rays – orthogonal without magnification marker, orthogonal with magnification marker placed at the level of the bone and non orthogonal views – and put these images through software and obtained mounting and deformity parameters.
Results were independently assessed and we found that the Spatial CAD™ software was accurate within 1 mm and 1 degree when orthogonal images with marker sphere placed at the bone level were used. Non-orthogonal images, with marker sphere, yielded accurate axial frame offset but other mounting parameters were at least 6 mm more than the actual measurements. Understandably angular measurements were different. In the third set of films we used frame hardware – Rancho Cube width (12 mm) as a calibrator. Since the cube was not in the same plane as the bone all measurements were way off actual measurements.
UK Objective
To evaluate the technique of transverse debridement, acute shortening and subsequent distraction histiogenesis in the management of open tibial fractures with bone and soft tissue loss thus avoiding the need for flap coverage.
Methods
We present a retrospective review of 18 patients with Gustillo grade III open tibial fractures between 2006 and 2011. Initially managed with debridement to provide bony apposition through transverse wound excision. This allowed primary wound closure without tension, or mobilization of local muscle followed by split skin graft to provide cover. Temporary mono-lateral external fixation was utilized to allow soft tissue resuscitation, followed by Ilizarov frame for definitive fracture stabilization. In some cases it was possible to apply an Ilizarov frame at the time of initial debridement. Leg length discrepancy was subsequently corrected by corticotomy and distraction histiogenesis. Union was evaluated radiologically and clinically.
Introduction
The ability of activated platelets to induce cellular proliferation is well recognised. In a previous diffusion model, platelets combined with Tri-calcium phosphate (TCP) led to an osteoprogenitor mitogenic response followed by cellular differentiation. This study was designed to look at osteoprogenitor responses when cultured directly onto TCP granules combined with activated platelets.
Method
Human osteoprogenitors were loaded onto TCP with activated platelets at a low seeding density and high seeding densities. Cellular proliferation was assessed using the pico-green DNA content analysis. Differentiation towards osteoblastic phenotype was assessed using an alkaline phosphatase assay. RNA extraction, reverse transcription and quantitative real-time polymerase chain reaction was used to assess gene expression for type 1 collagen and osteocalcin. Histological assessment for live/dead staining and alkaline phosphatase was used on cultured granule samples.
Abstract
We present here the results of a prospective follow-up study of radiological and functional outcome in 43 patients treated using the Taylor Spatial Frame (TSF) for definitive management of tibial fractures.
Patients & Methods
Over a five-year period data was collected from all patients completing treatment of a tibial fracture with the TSF. Residual deformity on x-ray and functional outcomes using the EQ-5D health status questionnaire, Iowa Knee and Ankle-Evaluation Rating System scores and Olerud & Molander Ankle Score (OMAS) were recorded one year following completion of frame treatment.
Introduction
Corrective femoral osteotomy in adults, as a closed procedure with the use of an intramedullary saw, is an elegant, minimally invasive technique for the correction of lower limb length inequalities or problems of torsion. Stabilisation following the osteotomy was achieved with a cephalo-medullary nail. We report the indications, results and complications following use of this technique.
Aim
The aim of the study was to review consecutive patients who underwent closed femoral rotational or shortening osteotomy using an intramedullary saw over a ten-year period.
Purposes of the study
To assess safety, lengths gained, frame time and perform cost analysis of the technique of submuscular plating to the femur and tibia following distraction osteogenesis.
Introduction
Since 2005 we have performed submuscular plating to the femur and tibia after distraction osteogenesis in order to shorten time in external fixator.
Malformation and hypoplasia of the clavicle can result in pain, impaired function, restricted shoulder movement, subjective feeling of instability and cosmetic deformity. There are no reports of clavicle lengthening by osteotomy and distraction osteogenesis (DO). This is a retrospective review of 5 patients (7 clavicles) who underwent clavicle lengthening by DO using a monolateral external fixator for clavicular hypoplasia. There were 3 males and 2 females with mean age 15 years (9 to 23) and mean follow-up 21 months (8 to 51). Preoperative diagnoses included Klippel-Feil syndrome, cleidocranial dysplasia with torticollis, congenital myopathy and Noonans syndrome and obstetric brachial plexus injury. Mean length gained was 31 mm (15 to 41) which represens an average of 24.7% of overall bone length. Mean time in fixator was 174 days (161 to 263) and mean external fixation index was 56 days/cm. Two patients required internal fixation following fixator removal to consolidate union and one required additional internal fixation for atrophic regenerate. Mean preoperative oxford shoulder score improved from 28.5 to 41 and all patients were extremely satisfied with their result. Two patients developed pin site infections. Clavicular lengthening by distraction osteogenesis for congenital clavicular hypoplasia is a previously unreported technique that enables gradual correction of deformity without risking brachial plexus traction injury following acute correction. It has the potential to improve shoulder pain, function, range of movement and cosmesis. Distraction ≥25% of overall bone length may require additional plate fixation to consolidate union.
Aim/Purpose
Review our unique experience in the management of 29 consecutive casualties who survived open pelvic fractures following a blast mechanism.
Methods and Results
Retrospective study utilising a prospectively collected combat trauma registry. Records of UK Service Personnel sustaining open pelvic fractures from an explosion from Aug 2008 – Aug 2010 identified. Casualties who survived to be repatriated to the Royal Centre for Defence Medicine, University Hospital Birmingham were selected for further study. The median New Injury Severity Score (NISS) was 41. Mean blood requirement in the first 24 hours was 60.3 units. In addition to their orthopaedic injury, 6 (21%) had an associated vascular injury, 7(24%) had a bowel injury, 11 (38%) had a genital injury and 7(24%) had a bladder injury. 8 (28%) fractures were managed definitively with external fixation, and 7 (24%) fractures required internal fixation. Of those patients who underwent internal fixation, 5 (57%) required removal of metalwork for infection. Faecal diversion was performed on 9 (31%) casualties. Median length of stay was 70.5 days, and mean total operative time was 29.6 hours. At a mean 20.3 months follow-up, 24 (83%) were able to ambulate, and 26 (90%) had clinical and radiological evidence of pelvic ring stability.
Purpose of the study
To use a simple way of manipulating Taylor Spatial Frame to achieve soft tissue closure by acute intentional deformation and then gradually achieving anatomical alignment of the fracture without complex deformity and frame parameters.
Methods and end results
10 consecutive cases of Gustillo III B open fractures of tibia and of soft tissue defect due to infected implant were treated with a new technique of acute intentional deformation using Taylor Spatial frame to successfully close the soft tissue defect without plastic surgery. We describe a new simple technique of achieving anatomical alignment of the fracture after creating complex deformity to close the soft tissue defect. We achieved complete full thickness cover of the exposed bone in all cases without plastic surgery and restored the bone to anatomical alignment. Only one patient needed additional Taylor Spatial Frame total residual prescription to correct minor residual deformity.
Introduction
Taylor Spatial Frame (TSF) has been designed to treat complex tibial, foot and ankle deformities using computer software. We have performed various osteotomies in combination with different soft tissue procedures, with the use of TSF.
Material and Methods
A retrospective study of 20 consecutive patients operated by, senior author SSM, from 2004 onwards who underwent surgical correction of tibia, ankle, midfoot and hind foot including lateral column lengthening, calcaneal and midfoot osteotomies. Demographic details, diagnosis, procedures (including previous operations), length of follow-up, outcome and complications were recorded. Of the 20 patients, 13 were men and 7 women. The mean age was 39 years (range 18 to 70). 5 patients had TSF for malunion or non-union of ankle fractures, malunion of tibia (5), congenital talipes equino-varus(3), acute fracture of ankle (2), one patient each for spina bifida, Poliomyelitis, Charcot-Marie-Tooth disease, equino-varus due to periventricular leuco-encephalopathy and avascular necrosis of the talus. Bilateral TSF for torsional malalignment of tibia (1)
Introduction
The optimal treatment of high-energy tibia fractures remains controversial. The role of external fixators has been shown to be crucial. This study aimed to compare the effectiveness of using either Taylor Spatial Frame (TSF) or Ilizarov frames in treatment of high-energy tibia fractures in a tertiary trauma referral centre.
Methodology
Retrospective review of consecutive series identified two treatment groups; Group 1(TSF) and Group 2 (Ilizarov). Time in frame (healing time) was defined as time from insertion to removal of frame. All patients with incomplete data secondary to loss to follow-up or death were eliminated.
Purpose
To demonstrate experience of bone transport arthrodesis of the knee with simultaneous lengthening in the treatment of infected peri-articular fracture fixation associated with large condylar defects.
Methods
Four patients (3 male/1 female), mean age 46.5 years (37–57 y) with post-traumatic osteomyelitis involving the knee were treated by radical debridement, removal of all metalwork and frame application. Substantial condylar defects resulted (6–10 cm) with loss of extensor mechanism. Parenteral antibiotics were administered for several weeks. Two patients required muscle flaps. Bone transport was utilised to achieve an arthrodesis whilst simultaneously lengthening. In three cases a ‘peg in socket’ construct was fashioned to ensure stability of the arthrodesis.
Introduction
Restoration of mechanical axis is one of the main aims during Total Knee Arthroplasty (TKA) surgery. Treatment of osteoarthritis (OA) of the knee with extra-articular deformity either in femur or in tibia poses a technical challenge in achieving this aim. Insufficient correction of axis is associated with poor clinical outcome of total knee arthroplasty (TKA). Extra-articular deformity can either be addressed with compensatory intra-articular bone resection at the time of TKA or correctional osteotomy prior to or at the time of TKA.
Patients & Methods & Results
We present our experience of treating 7 patients with knee arthritis (9 knees) and significant extra-articular deformity.
Two patients had OA knee with severe valgus deformity in tibia from recurrent stress fractures. One was treated with one-stage corrective osteotomy and long stem modular TKA. The other had deformity correction with two level tibial osteotomy with intramedullary nail and modular long stem TKA later. Both required tibial tubercle osteotomy during TKA.
Two patients with bilateral OA knees and significant varus deformity had sequential deformity correction with Taylor Spatial Frame (TSF) followed by TKA on one side and a single stage intra-articular correction during TKA on the other.
Three patients with knee OA and associated deformity (femoral - two pt., tibia one pt.) had symptom resolution with just correction of malaligment with Taylor Spatial Frame (TSF) and did not require TKA.
Introduction
We describe a minimally invasive technique that permits intra-focal bone graft of non-union sites with minimal disturbance of soft tissues and vascularity, and present the results of this technique.
Materials and Methods
10 patients with established tibia fracture non-union were judged suitable for the technique, and were treated in our limb reconstruction unit between January 1995 to June 2007. Eight patients were male, 2 were females with a mean age of 37.4 years (27–64). Five fractures were in the distal tibia and five were diaphyseal fractures. Five fractures were as a result of high velocity and 6 fractures were open. Average number of previous operations were 3 (range 1–7). Time lapse between injury to trephine grafting procedure was mean of 34 (6–168 months)
5 patients had a sedentary job, 2 were labourers and 2 were not working. There were 5 smokers and 2 obese patients. Six cases were of infected non-unions.
Objective
The aim of this retrospective study is to assess the functional and radiological outcome of a multi-planar corrective osteotomy, distraction and locking fixed angle volar plate as the standard of treatment of distal radius mal-unions that require multi-planar correction.
Methods
We conducted a retrospective study on 13 consecutive patients – 4 males, 9 females (mean age 49). All patients underwent volar approach, open wedge distraction osteotomy locking fixed angle volar plate and cancellous bone grafting Radiographic measurements and functional assessments were taken preoperatively, 3, 6 months and one year.
Purpose of the study
To assess use of Taylor Spatial Frame to correct posttraumatic equinus contracture of ankle by soft tissue distraction. Description of a successful technique.
Methods and end results
We have treated five cases of severe and resistant equinus contracture (20–30 degrees) between 2005 and 2010. All cases resulted from severe soft tissue injury and compartment syndrome of affected limb. They had undergone prolonged treatment for open fracture of tibia prior to referral to our institute and failed to respond to at least six months of aggressive physiotherapy. In all cases fractures did not involve ankle articular surface and all tibial fractures had united. Three out five cases also had associated peroneal nerve palsy. Our procedure included Tendo Achilles Lengthening, ankle and subtalar capsulotomy and application of two-ring Taylor Spatial Frame. We used long bone module to correct the deformity gradually. All deformities were over corrected by 5–10% to prevent recurrence. We successfully corrected equinus deformity in all cases. Follow up ranged from three months to five years and we found no recurrence. Patients with peroneal palsy were provided with Ankle Foot Orthosis (AFO).
