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Background:
External fixators are not as well tolerated around the femur when compared to the tibia. Lengthening with an intramedullary device is therefore attractive.
Method:
We reviewed all cases of femoral lengthening performed at our unit from 2007 to 2014. Cases of non-unions, concurrent deformities, congenital limb deficiencies and lengthening with an unstable hip were excluded. This left 33 cases for review. Healing index, implant tolerance and complications were compared.
Background:
Closed femoral shortening (CFS) is a recognised procedure for managing leg length discrepancy (LLD).
Method:
We report twenty-nine consecutive patients with LLD who underwent CFS using an intramedullary saw and nail. Mean age was 29.2 years (16.1–65.8). The primary outcome was accuracy of correction. Secondary outcomes were complications, union, ASAMI score and re-operation, alongside Patient Reported Outcome Measures (PROMs), using EQ5D-5L and GROC.
Background:
Acute deformity correction with the help of osteotomies and stabilisation with intramedullary (IM) nail is a recognised technique. We present our case series of long bong deformity correction using an innovative technique that aids accurate correction after osteotomy and insertion of IM nail.
Technique:
On preoperative measurements the distance of the joint surface from the point of intersection of the joint orientation angle with the convex cortex and also its distance from apex of deformity were noted. These distances were reproduced intraoperatively and guide pin was inserted towards premeasured point in the convex cortex. Osteotomy was performed and appropriate sized locked IM nail inserted with the help of temporary blocking screws, resulting in the correction of deformities.
Background:
Leg length discrepancy related to absence of the femoral head with proximal migration of the femur presents a treatment dilemma. Late sequelae of neonatal hip sepsis and chronic hip dislocation due to developmental dysplasia are the most common causes. Traditional teaching dictates that the hip is stabilised prior to limb lengthening. Reconstructive options alter the shape of the proximal femur which complicates future surgery.
Methods:
We retrospectively reviewed 3 cases of femoral lengthening with an ‘unstable’ hip without prior stabilization. The aetiology was neonatal hip sepsis in 2 cases and chronic hip dislocation due to developmental dysplasia in 1 case. Lengthening was performed with the use of a retrograde Precice lengthening nail.
Several low energy osteotomy techniques are described in the literature but there is limited evidence comparing healing indices. We present a retrospective review of two techniques to evaluate an optimum method.
Method:
Two cohorts of patients underwent osteotomy of the tibia using a Gigli saw (n=15) or DeBastiani corticotomy (n=12) technique. Indications for surgery included limb lengthening and bone transport for defect reconstruction with a minimal distraction of 2 cm. The patient radiographs were anonymised and the regenerate assessed by the two senior authors who were blinded to the osteotomy type. Bone quality was recorded along the anterior, posterior, medial and lateral cortices, graded 1–5 from absent to full consolidation over time in frame. The time to 3 cortices healed/regenerate length was calculated. The time to consolidation of the anterior, posterior, medial and lateral cortices were compared.
Results:
The mean 3 cortices index in the Gigli group was 2.0 months/cm and in the DeBastiani group 1.8 months/cm, This was not a significant difference. In both groups anterior bone formation was slower, and in 50% and 33% of the Gigli and DeBastiani groups respectively the anterior cortex did not fully heal by the time of frame removal.
Background:
Charcot arthropathy is a condition related to the loss of protective sensation of a joint. It normally presents in its early inflammatory phase, followed by bone destruction. Recognised treatment for this is total contact casting (TCC). However, in a small group this may be unsuccessful in preventing deformity progression. TCC can also be difficult in the presence of recalcitrant ulceration and deformed feet.
Method:
40 patients, with a diagnosis of Charcot foot, were followed from presentation in our unit over 3 years. An Ilizarov frame was used for two groups: those in the early phase who showed progressive deformity despite TCC (5 patients) and those with chronic ulceration (4 patients). Frames were modified to allow weight-bearing on the frame (with no foot contact). All other patents were treated with TCC.
Background:
Segmental defects of long bones are notoriously demanding and difficult to treat. We evaluate nine cases where the Masquelet induced membrane technique to substitute bone loss has been used. We discuss the method compared to other types of bone reconstruction and share our tips and tricks to reduce treatment time and improve patient comfort.
Method:
Eight patients (nine injuries) operated between 2011 and 2014 were included. Four were infected. Outcome was time-to weight-bearing, consolidation, complications, bone grafting.
Introduction:
The developing world often lacks the resources to effectively treat the most serious injuries, potentially resulting in severe complications of orthopaedic trauma, including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are now a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide.
Aims:
This project studied the effectiveness of locally made antibiotic beads, analysing their effectiveness after being gas sterilised, packaged and kept in storage.
Background:
– A multidisciplinary approach is essential to treat chronic osteomyelitis. Surgical debridement of macroscopic infection precedes targeted antibiotics to eradicate microscopic infection. This study analyses early results of our single-stage protocol for chronic osteomyelitis using antibiotic-impregnated calcium sulphate beads (Stimulan).
Methods:
– We retrospectively analysed patients with primary or secondary chronic osteomyelitis treated with Stimulan. Patients with incomplete metal-work removal or follow up less than 3 months were excluded. Our study focused on 15 patients (10 male) with an average age of 40.5 years (16–73 years), average follow up of 10.6 months (3 – 21 months). There were 12 cases of secondary osteomyelitis (3 primary). Majority of cases involved the tibia, femur or humerus. Following debridement Stimulan mixed with Vancomycin and/or tobramycin was placed to obliterate dead space and deliver local antibiotics. Intravenous antibiotics, typically piperacillin/tazobactam and/or teicoplanin, were administered post-operatively until tissue culture results were known – rationalised long term antibiotic regimen followed thereafter.
Background:
In 1931, Gaenslen reported treatment of haematogenous calcaneal osteomyelitis through an incision on the sole of the heel, without the use of antibiotics. We have modified his approach to allow shorter healing times and early mobilisation in a modern series of cases.
Method:
Sixteen patients with Cierny-Mader Stage IIIB chronic osteomyelitis were treated with split-heel incision, calcaneal osteotomy, radical excision, local antibiotics, direct skin closure and parenteral antibiotics. 4 patients had diabetic foot infection with neuropathy, 5 had infection after open injuries, 4 had haematogenous osteomyelitis and 3 had Grade 4 pressure ulceration with bone involvement. 14 had sinuses/ulcers and 12 had undergone previous surgery. Primary outcomes were eradication of infection, time to sinus/ulcer healing, mobility and need for modified shoes.
Objective:
To assess efficacy of pulsed ultrasound for accelerating regenerate consolidation.
Design:
A multicentre two arm patient and assessor double blind RCT
Background:
Delay in fracture healing is a complex clinical and economic issue for patients and health services. Established non-unions are debilitating and often difficult to treat. Bone morphogenic proteins (BMPs) may play an important role in bone and cartilage formation, fracture healing and the repair of other musculoskeletal tissues. There is, however, a paucity of data on the use of BMPs in fracture healing and to date its role remains unclear.
Objectives:
To describe the 9-year experience of the Limb Reconstruction Team, Belfast in using BMP 2 for fracture non-unions.
Background:
The Exogen Ultrasound Device is licensed for fracture non-union under NICE guideline MTG-12. Reimbursement is offered if there is no fracture union after 250 days of treatment as per manufacturer guidelines. Quoted healing rates vary between 62% and 100%: we compare our results to these.
Method:
A retrospective audit of all patients who received Exogen for long bone non-union was undertaken. The indication, duration of treatment, fracture outcome and compliance with the recommended treatment pathway were recorded.
Background:
Lower limb reconstruction is performed in trauma centres where uplifted tariffs support the treatment of severely injured patients. Calculation of Healthcare Resource Groups (HRG4) codes is affected by the accuracy of clinical coding, determining the financial viability of this service in a district general hospital (DGH).
Methods:
A prospective review of coding was performed for 17 sequential patients treated using ring fixation. Relevant clinical codes and HRG4 tariffs were obtained, allowing comparison with operation notes (including pertinent diagnostic information) and implant costs. Hexapod and paediatric cases were excluded.
Background:
Little is known about the forces carried by the Taylor Spatial Frame (TSF) hexapod fixator. Our aim was to measure the TSF resultant force and how this changed during the consolidation phase.
Method:
Five patients undergoing correction of tibial deformities were recruited. Measurements were taken at 2, 4, 8 and 12 weeks post-correction during various activities. Instrumented struts incorporating strain gauges measuring axial force were temporarily used each time. Strut forces and lengths were used to determine frame kinetics. The resultant axial fixator forces and moments were calculated relative to sitting. Ground reaction forces (GRF) were measured using the treadmill force plates.
Background:
Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires.
Methods:
The attachments of the capsule to the distal femur were measured in cadaveric knees. Medially and laterally measurements were expressed as percentages related to the maximal AP diameter of the distal femur.
The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 – 2010 were contacted and interviewed. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation in the same period. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria, of which 30 patients (61%) were followed-up. Ten of the 30 patients required revision surgery, 3 of which involved conversion to a circular frame. Twenty-two of the 30 patients (73%) recovered sufficiently to complete a basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35–54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.
Background:
The outcomes of open tibial fractures in a paediatric population are reported.
Methods:
A retrospective analysis of consecutive cases, classified by the Gustilo-Anderson system, over the last 8 years was undertaken. The outcomes recorded were time to union, non-union, infection rates and re-operation rates.
The aim of this study was to characterise severe open tibial shaft fractures sustained by UK military personnel over 10-years of combat and to determine the infection rate and factors that influence it. The UK military Joint Theatre Trauma Registry was searched and X-rays, clinical notes and microbiological records were reviewed for all patients. One hundred GA III open tibia fractures in 89 patients were identified. Three fractures were not followed up for 12-months and were therefore excluded. Twenty-two (23%) of the remaining 97 tibial fractures were complicated by infection requiring surgical treatment, with
Background:
The aim of this study was to review the surgical complications and clinical outcomes of patients with Pilon fractures treated with Ilizarov frames.
Methods:
Data collected included surgical complications, grade of initial injury using the Ruedi-Allgower classification and quality of reduction according to the Teeny and Wiss criteria. Outcome scores were collected retrospectively using the Foot and Ankle Disability Index (FADI).
Introduction:
Bicondylar tibial plateau fractures are serious periarticular injuries. We investigated outcomes in injuries managed with Ilizarov external fixators.
Methods:
We retrospectively reviewed bicondylar tibial plateau fractures treated with Ilizarov fixators in a major trauma centre from 2008–2012. Radiological parameters were measured from standardised weight-bearing radiographs. A subset (n=34) had patient-related outcome measures.
Background:
Potential injury to the common peroneal nerve at the level of the fibula head/neck junction during fine wire insertion in stabilization of proximal fibula, is a recognised complication. This study aims to relate the course of the common peroneal nerve to fibula head transfixion wire.
Methods:
Standard 1.8mm Ilizarov wires were inserted percutaneously in the fibula head of cadaveric knees. The course of the common peroneal nerve was dissected calculating wire to nerve distance.
Background:
Pilon fractures are complex intra-articular fractures of the tibial plafond associated with significant short and long morbidity. Minimising surgical complications is essential.
Methods:
Clinical and radiological outcomes in 49 patients with AO type 43B and 43C fractures were evaluated retrospectively. Definitive management depended on patient factors, soft tissue injury and fracture pattern.
Background
The Schatzker classification is applied in the management of tibial plateau fractures. The unique pattern of Schatzker VI fractures requires recognition for proper fixation.
Method:
We have treated 33 patients with Schatzker IV tibial plateau fractures including non-unions and mal-unions. Patients had a temporary spanning Ilizarov frame with intraoperative distraction, articular reconstruction and olive wires for indirect reduction. No open surgery was performed. Patients mobilised fully weight-bearing and underwent post-operative CT scan and regular outpatient reviews. At six weeks the femoral ring was removed, and patients underwent a staged dynamisation protocol prior to frame removal.
Introduction:
Paley et al has developed a multiplier method for calculating both leg length and total height. In the development of this algorithm, they evaluated the effect of factors including bone age and sex. They established that sex had a significant impact, but adjusting for bone age did not improve accuracy. Bone age and menarche have been shown to improve other height prediction models.
Purpose:
We used a large prospective cohort to evaluate if the multiplier is independent of physiological age using menarche as a proxy.
Background:
Developing a successful outpatient service for Ilizarov frame removal provides both patient and cost benefits. Misinformation and patient trepidation can be detrimental to recovery and influence choices. Education may play an important role in tailoring an efficacious service.
Objective:
Review Belfast Regional Limb Reconstruction frame removal practice, introduce changes aimed at improving care and evaluate effects.
Methods:
Total radiation exposure accumulated during circular frame treatment of distal tibial fractures was quantified in 47 patients treated by a single surgeon from March 2011 until Nov 2014. The radiation exposures for all relevant radiology procedures for the distal tibial injury were included to estimate the radiation risk to the patient.
Results:
The median time of treatment in the frame was 169 days (range 105 – 368 days). Patients underwent a median of 13 sets of plain radiographs; at least one intra operative exposure and 16 patients underwent CT scanning. The median total effective dose per patient from time of injury to discharge was 0.025 mSv (interquartile range 0.013 – 0.162 and minimum to maximum 0.01–0.53). CT scanning is the only variable shown to be an independent predictor of cumulative radiation dose on multivariate analysis, with a 13 fold increase in overall exposure.
Background:
Paley et al has developed the multiplier method for predicting leg length. It is a tool that is used clinically to predict leg length discrepancy. The method is also a way of comparing different populations, to identify differences in growth trajectory. This has been done by identifying the differing multipliers for girls and boys. However it has not been used to identify trends in populations separated by time. Tanner showed that in the first half of the twentieth century girls went from an average age of menarche of 15 in 1900, to 13 in 1970, how this has affected growth trajectory over the last 50 years has not been studied.
Purpose:
The multiplier method is based on data collected in the 1950's by Anderson and Green, we aim to assess whether there has been a change in growth trajectory between this historical cohort and a contemporary European based cohort.
