Strategies in Trauma and Limb Reconstruction

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Volume 16, Number 1, January-April 2021

Original Article

Ole Rahbek, Hans-Christen Husum, Marie Fridberg, Arash Ghaffari, Søren Kold

Intrarater Reliability of Digital Thermography in Detecting Pin Site Infection: A Proof of Concept Study

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:7] [Pages No:1 - 7]

Keywords: FLIR C3 camera, Inter-rater/Intrarater reliability, Modified Gordon Pin Infection Classification, Pin site infection, Proof-of-concept study, Thermography

PDF  |  DOI: 10.5005/jp-journals-10080-1522  |  Open Access |  How to cite  | 


Aim and objective: The purpose of this study was to explore the capability and Intrarater reliability of thermography in detecting pin site infection. Materials and methods: This is an explorative proof of concept study. Clinical assessment of pin sites was performed by one examiner with the Modified Gordon Pin Infection Classification from grade 0 to 6. Thermography of the pin sites was performed with a FLIR C3 camera. The analysis of the thermographic images was done in the software FLIR Tools. The maximum skin temperature around the pin site and the maximum temperature for the whole thermographic picture were measured. An Intrarater agreement was established and test-retests were performed with different camera angles. Results: Thirteen (four females, nine males) patients (age 9–72 years) were included. Indications for frames: Fracture (n=4), two deformity correction, one lengthening and six bone transport. Days from surgery to thermography ranged from 27 to 385 days. Overall, 231 pin sites were included. Eleven pin sites were diagnosed with early signs of infection: five grade 1, five grade 2 and one grade 3. Mean pin site temperature for each patient was calculated, varied between patients from 29.0°C to 35.4°C (mean 33.9°C). With 34°C as cut-off value for infection, sensitivity was 73%; specificity, 67%; positive predictive value, 10%; and negative predictive value, 98%. Intrarater agreement for thermography was ICC 0.85 (0.77–0.92). The temperature measured was influenced by the camera positioning in relation to the pin site with a variance of 0.2. Conclusions: Measurements of pin site temperature using the hand-held FLIR C3 infrared camera was a reliable method and the temperature was related to infection grading. Clinical significance: This study demonstrated that digital thermography with a hand-held camera might be used for monitoring the pin sites after operations to detect early infection.

Original Article

Ahmed A Abood, Ole Rahbek, Morten L Olesen, Bjørn B Christensen, Bjarne Møller-Madsen, Søren Kold

Does Retrograde Femoral Nailing through a Normal Physis Impair Growth? An Experimental Porcine Model

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:6] [Pages No:8 - 13]

Keywords: Children, Intramedullary nail, Leg length discrepancy

PDF  |  DOI: 10.5005/jp-journals-10080-1515  |  Open Access |  How to cite  | 


Aim and objective: The insertion of an intramedullary nail may be beneficial in certain cases of leg length discrepancy (LLD) in children. However, it is unknown if the physeal injury due to the surgery may cause bone bridge formation and thereby growth arrest after removal. This study aimed to assess longitudinal interphyseal growth 16 weeks after insertion and later removal of a retrograde femoral nail passing through the physis. Moreover, to analyse the tissue forming in the empty physeal canal after removal of the nail. Materials and methods: The study was carried out using an experimental porcine model. Eleven juvenile female porcines were randomized for insertion of a retrograde femoral nail in one limb. The other limb acted as a control. The animals were housed for 8 weeks before the nail was removed and housed for 8 additional weeks, that is, 16 weeks in total. Growth was assessed by interphyseal distance on 3D magnetic resonance imaging (MRI) after 16 weeks and the operated limb was compared to the non-operated limb. Histomorphometric analysis of the physeal canal was performed. Results: No difference in longitudinal growth was observed when comparing the operated femur to the non-operated femur using MRI after 16 weeks. No osseous tissue crossing the physis was observed on MRI or histology. The empty canal in the physis after nail removal was filled with fibrous tissue 16 weeks after primary surgery. Conclusion: Growth was not impaired and no bone bridges were seen on MRI or histology 16 weeks after insertion and later removal of the retrograde femoral nail. Clinical significance: The insertion of a retrograde intramedullary femoral nail centrally through the physis and later removal might be safe, however, long-term follow-up is needed.

Original Article

Aleksey Dvorzhinskiy, David T Zhang, Austin T Fragomen, S Robert Rozbruch

Cost Comparison of Tibial Distraction Osteogenesis Using External Lengthening and Then Nailing vs Internal Magnetic Lengthening Nails

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:6] [Pages No:14 - 19]

Keywords: Bone lengthening, Circular external fixation, Distraction osteogenesis, Internal fixation combined with external ring fixation, Internal lengthening nail, Intramedullary lengthening, Leg length discrepancy, Lengthening nail, Motorized implantable nail, Tibia

PDF  |  DOI: 10.5005/jp-journals-10080-1513  |  Open Access |  How to cite  | 


Aim and objective: Tibial lengthening can be performed by distraction osteogenesis via lengthening and then nailing (LATN) or by using a magnetic lengthening nail (MLN). MLN avoids the complications of external fixation while providing accurate and easily controlled lengthening. Concerns exist still regarding the high upfront cost of the magnetic nail, which serves to limit its use in resource-poor areas and decrease adoption among cost-conscious surgeons. The purpose of this study was to compare the hospital, surgeon, and total cost between LATN and MLN when used for tibial lengthening. Materials and methods: A retrospective review was performed comparing consecutive tibial lengthening using either LATN (n = 17) or MLN (n = 15). The number of surgical procedures and time to union were compared. Surgeon and hospital payments were used to perform cost analysis after adjusting for inflation using the consumer price index (CPI). Results: Patients treated with MLN underwent fewer surgeries (3.6 vs 2.8; p < 0.001) but had a longer time to union as compared with patients treated with LATN (19.79 vs 27.84 weeks; p = 0.006). Total costs were similar ($50,345 vs $46,162; p = 0.249) although surgeon fees were lower for MLN as compared with LATN ($6,426 vs $4,428; p < 0.001). Conclusion: LATN and MLN had similar overall costs in patients undergoing tibial lengthening. MLN was associated with fewer procedures but a longer time to union as compared with LATN. Clinical significance: Despite an increased upfront cost in MLN, there was no difference in total cost between LATN and MLN when used for tibial lengthening. Thus, in cases where either method is feasible, cost may not be a deciding factor when selecting the appropriate treatment.

Original Article

Amit Sharma, Siddhartha Sinha, Sumit Gupta, Anand Gupta, Amit Narang, Parul Sharma, Rajesh K Kanojia

Evaluation of Arm Length as a New Upper Limb Anthropometric Method for Preoperative Estimation of Tibial Intramedullary Nail Length

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:7] [Pages No:20 - 26]

Keywords: Anthropometry, Arm, Intramedullary nailing, Prospective study, Tibia

PDF  |  DOI: 10.5005/jp-journals-10080-1520  |  Open Access |  How to cite  | 


Aim and objective: To assess the use of arm length (AL) for the estimation of tibial nail length preoperatively and compare its accuracy to various established upper and lower limb anthropometric parameters. Material and methods: This prospective study of 54 patients assessed upper limb parameters as a possible alternative for intraoperatively measured tibial nail length. The anthropometric parameters measured independently by two observers were AL, olecranon to fifth metacarpal head (OMD), tibial tuberosity to medial malleolus (TT-MM), tibial tuberosity to medial malleolus minus 20 mm (TT-MM-20 mm) and knee joint line to medial malleolus minus 40 mm (KJL-MM-40) and compared to final nail size used intraoperatively. Two observers were used. Bland-Altman plots were constructed to assess the limits of agreement to intraoperative estimates of optimum nail length. A repeatability assessment was also assessed by both observers. Results: None of the anthropometric parameters showed limits of agreement within ±10 mm of nail length. AL showed the least average difference and best limits of agreement among all the anthropometric parameters. Among the lower limb parameters, the KJL-MM showed the least average difference but poorer limits of agreement to nail length. The OMD measurement showed a greater average difference than the AL indicating it is a poorer upper limb parameter for predicting nail length. Conclusion: AL as measured between the angle of the acromion to the lateral epicondyle can be used as a preoperative upper limb anthropometric estimate of nail length to one nail size of the optimum length. Further studies with a larger sample size may reduce the confidence intervals and help justify its wider use.

Original Article

Shuhei Ugaji, Hidenori Matsubara, Satoshi Kato, Yasuhisa Yoshida, Tomo Hamada, Hiroyuki Tsuchiya

Patient-reported Outcome and Quality of Life after Treatment with External Fixation: A Questionnaire-based Survey

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:5] [Pages No:27 - 31]

Keywords: External fixators, Pain, Patient satisfaction, Surveys and questionnaires, Taylor Spatial Frame, Walking

PDF  |  DOI: 10.5005/jp-journals-10080-1519  |  Open Access |  How to cite  | 


Background: This survey aims to assess the satisfaction of patients who have had treatment using external fixation (EF). Materials and methods: An original questionnaire and a Short Form 36 (SF-36) were distributed to 121 patients who underwent treatment using EF for deformity correction and lengthening between 2006 and 2016. A multivariate analysis was performed on the factors associated with satisfaction. Results: Sixty patients returned a response. The average satisfaction score was 83.6 points. In the 5-point satisfaction survey, 43 of 60 patients (71.7%) responded “very satisfied” or “satisfied” and 27 patients (45.0%) responded “yes” to the question as to whether they would request EF treatment again if presenting with the original preoperative condition. In addition, the subjectively expressed tolerance for having an external fixator device on the limb was 92.1 days on average. A correlation was established with the ISOLS score. Conclusion: The top three factors that determined subjective inconvenience with EF are pain, walking, and heaviness. Although EF treatment was stressful, the satisfaction scores were high. Furthermore, the satisfaction with EF treatment was improved by (1) pain control, (2) shortening the EF period, and (3) psychological support.

Original Article

Jaco J Naude, Muhammad A Manjra, Franz Birkholtz, Annette-Christi Barnard, Kevin Tetsworth, Vaida Glatt, Erik Hohmann

Functional Outcomes and Quality of Life Following Complex Tibial Fractures Treated with Circular External Fixation: A Comparison between Proximal, Midshaft, and Distal Tibial Fractures

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:9] [Pages No:32 - 40]

Keywords: Circular external fixation, Clinical outcomes, Complex tibial fractures

PDF  |  DOI: 10.5005/jp-journals-10080-1506  |  Open Access |  How to cite  | 


Aim and objective: The purpose of this study was to compare clinical results following complex proximal, midshaft, and distal tibial fractures and investigate whether there are differences in outcomes between these locations. Materials and methods: Patients between 18 years and 65 years of age and minimum follow-up of 12 months with complex tibial fractures treated with a circular ring fixator were included. Functional outcomes were assessed using the Association for the Study and Application of Methods of Ilizarov (ASAMI) functional and bone scores, Foot Function Index (FFI), Four Step Square Test (FSST), and Timed Up and Go Test (TUG). Quality of life was assessed by the EQ-5D score. Results: A total of 45 patients were included: proximal fractures, n = 11; midshaft fractures, n = 17; and distal fractures, n = 17. ASAMI functional (p = 0.8) and bone scores (p = 0.3) were not different. Excellent and good bone scores were achieved in >90% in all groups. FFI was 30.9 + 24.7 in the proximal group, 33.9 + 27.7 in the midshaft group, and 28.8 + 26.9 in the distal group (p = 0.8). TUG was 9.0 + 2.7 sec in the proximal group, 9.0+3.5 in the midshaft group, and 8.5+2.0 in the distal group (p = 0.67). FSST was 10.7 + 2.5 sec in the proximal, 10.3 + 3.8 in the midshaft, and 8.9 + 1.8 in the distal fracture groups (p = 0.5). EQ-5D index value was highest in the distal (0.72), lowest in the proximal (0.55), and 0.70 in the midshaft fracture groups (p = 0.001). EQ-5D VAS was significantly different between the proximal (65) and midshaft (82.3) (p = 0.001) and between the distal (75) and proximal (65) fracture groups (p = 0.001). Conclusions: The results of this study suggest that the functional outcomes between proximal, midshaft, and distal complex tibial fractures are comparable. Their ability to ambulate afterward is comparable to age-related normative data, but complex tasks are more difficult and better compared to the ambulating ability of a healthy population aged 65 to 80 years. Patients with proximal tibial fractures had significantly more disability by at least one functional level and/or one health dimension.

Original Article

Matthew J Hampton, Samuel Weston-Simmons, Stephen N Giles, James A Fernandes

Deformity Correction, Surgical Stabilisation and Limb Length Equalisation in Patients with Fibrous Dysplasia: A 20-year Experience

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:5] [Pages No:41 - 45]

Keywords: Fibrous dysplasia, Limb lengthening, McCune-Albright syndrome, Osteotomy

PDF  |  DOI: 10.5005/jp-journals-10080-1523  |  Open Access |  How to cite  | 


Introduction: Fibrous dysplasia (FD) of bone can be present with pain, deformity and pathological fractures. Management is both medical and surgical. Little literature exists on the surgical management of both monostotic and polyostotic FD. We present our experience of limb reconstruction surgery in this pathological group of bone disease. Materials and methods: A retrospective cohort of children who underwent limb reconstruction surgery at a single high-volume paediatric centre was identified from a prospective database. Case notes and radiographs were reviewed. Surgical techniques, outcomes and difficulties were explored. Results: Twenty-one patients were identified aged between 7 and 13 at presentation to the limb reconstruction unit. Eleven were female, nine had McCune-Albright syndrome, seven had polyostotic FD and five had monostotic. Proximal femoral varus procurvatum deformity was the most common site requiring surgical intervention. The distal femur, tibia, humerus and forearm were also treated. Methods include deformity correction with intramedullary fixation including endo-exo-endo techniques, elastic nailing, guided growth, circular fixator technique and fixator-assisted plating. Correction of deformity and leg length discrepancies was common. The osteotomies went on to heal with no nonunions or delayed healing. We encountered secondary deformity at distal end of nails as the children grew as expected. These were managed with revision nailing techniques and in some cases external fixation. There was one implant failure, which did not require revision surgery. Conclusion: The surgical management of pathological bone disease is challenging. Corrective osteotomies with intramedullary fixation can be very successful if appropriate limb reconstruction principles are adhered to. Deformity correction, guided growth and lengthening can all be successfully achieved in bone affected by FD. Polyostotic FD can be present with secondary deformities, and these can be difficult to manage.


Juergen Messner, Christopher P Prior, Bethan Pincher, Simon Britten, Paul J Harwood, Patrick AL Foster

Ilizarov Method for Acute Paediatric Tibial Fractures

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:7] [Pages No:46 - 52]

Keywords: Ilizarov technique, paediatric tibial fracture, wire to ring reduction technique, external fixation

PDF  |  DOI: 10.5005/jp-journals-10080-1517  |  Open Access |  How to cite  | 


Aim and background: A systemic method for the application of Ilizarov fixators and on-table fracture reduction is described in this instructional article. This technique has been developed from the unit\'s practice in adult patients. The indications, underlying principles and rationale for the method are also discussed. Technique: The basic concept involves the construction of a series of concentric, colinear rings aligned with the mechanical axis of the limb. An orthogonal ring block is initially placed on the proximal segment and extended distally. Wire to ring reduction techniques are used resulting in the contact, alignment and stability required for early full weight-bearing, free movement of knee and ankle, and subsequent healing. Conclusion and clinical significance: Our step-by-step guide takes the reader through a systematic approach to surgery along with tips and tricks on how to achieve reduction and avoid the common pitfalls. With this method, it is possible to achieve an on-table reduction and correction of a multiplanar deformity without the use of expensive hexapod technology. This may allow less experienced users reproduce the technique with a shorter learning curve.


Giulia Facco, Rocco Politano, Andrea Marchesini, Letizia Senesi, Pasquale Gravina, Pier Paolo Pangrazi, Antonio P Gigante, Michele Riccio

A Peculiar Case of Open Complex Elbow Injury with Critical Bone Loss, Triceps Reinsertion, and Scar Tissue might Provide for Elbow Stability?

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:7] [Pages No:53 - 59]

Keywords: Complex elbow injury, Elbow instability, 3D printing, Olecranon bone loss

PDF  |  DOI: 10.5005/jp-journals-10080-1504  |  Open Access |  How to cite  | 


Background: Complex elbow injuries (CEIs) are severe and rare lesions, difficult to treat correctly due to the different patterns of clinical presentations. Standard methods cannot often be applied. The main goals of the treatment are performing a stable osteosynthesis of all fractures, obtaining a concentric and stable reduction of the elbow by repairing the soft tissue constraint lesions, and allowing early motion.Since the introduction of virtual reality (VR) approaches in clinical practice, three-dimensional (3D) computed tomography (CT) and 3D printing have revolutionised orthopaedic surgeries, thus helping to understand the anatomy and the pathology of complex cases. Case description: We discussed a case of CEI, characterised by an extended soft tissue (IIIB Gustilo classification) and neurovascular lesions associated with bone loss in a young female patient. Olecranon fracture was type IIIB according to Mayo classification. We outlined the steps of a pluri-tissue reconstructive approach and stressed the importance of 3D printing in the preoperative planning for such cases. Finally, peculiar final functional patient outcomes were reported. Conclusion: In this case, we found out that triceps reinsertion and scar process may provide for the joint stability in a low-demanding patient. 3D printing and VR approaches in clinical practice can be useful in the management of CEIs associated with an important bone and soft tissue loss.


Ken AD Barsales, Juanito Javier, Jolly J Catibog, Ariel Vergel de Dios, Edward HM Wang

Huge Intraosseous Tibial Haemangioma Managed with Embolisation, Excision and Fibular Ilizarov Reconstruction: A Case Report

[Year:2021] [Month:January-April] [Volume:16] [Number:1] [Pages:4] [Pages No:60 - 63]

Keywords: Case report, Embolisation, Haemangioma, Ilizarov, Limb salvage, Tibia

PDF  |  DOI: 10.5005/jp-journals-10080-1518  |  Open Access |  How to cite  | 


Aim: Our aim is to report the successful treatment of an intraosseous haemangioma of tibia with an atypical presentation through a multidisciplinary approach of preoperative embolisation, a subtotal resection of the tibia and subsequent reconstruction with the Ilizarov medial fibular translation technique. Background: En bloc excision is the treatment of choice for large tumours of the tibia. However, there is no single recommended method for the reconstruction of the resulting bony defect. Case: A 22-year-old female presented with a massive intraosseous haemangioma of the entire tibia. Sequential, multimodal treatment consisted of (1) preembolisation, (2) en bloc resection and (3) reconstruction of the extensive skeletal defect via the Ilizarov method of fibular medialisation. Radiologic union occurred at 6 months and graft hypertrophy at 22 months. At 45 months, the patient was fully weight-bearing without need for an assistive device. Conclusion: Resection and reconstruction of a large intraosseous haemangioma of the tibia can be treated successfully using a well-planned sequential management of embolisation, resection and Ilizarov fibular grafting. Significance: This report highlights the successful management of an unusually extensive and difficult tumour through appropriate and meticulous perioperative multidisciplinary planning, execution and follow-up.

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