Strategies in Trauma and Limb Reconstruction

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Volume 18, Number 3, September-December 2023
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Konstantins Plotnikovs, Jekaterina Kamenska, Jevgenijs Movcans, Vitalijs Pasters, Leonid Solomin, Haralds Plaudis

Artificial Deformity Creation as a Method for Limb Salvage for Patients with Massive Tibial and Soft Tissue Defects: A Report of 26 Cases

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:7] [Pages No:133 - 139]

Keywords: Artificial deformity creation, Ilizarov, Interim deformity, Limb lengthening, Limb salvage, Ortho-SUV frame

   DOI: 10.5005/jp-journals-10080-1599  |  Open Access |  How to cite  | 


Soft tissue and bone defects that occur consequence of high-energy trauma are serious and challenging problems. The aim of this retrospective cohort study is to show that the artificial deformity creation (ADCr) method allows the closure of soft-tissue defects, avoids amputation, and can facilitate the reconstruction of bone defects and restore limb length. Patients and methods: Twenty-six adult patients (age range 20–81 years) with soft tissue defects of the lower limb were treated at the Riga East University Hospital from 2018 to 2021. All patients were treated using the ADCr method which is the technique of establishing an interim deformity for resolving tissue loss. The lower extremity functional scale (LEFS) and application of methods of ilizarov (ASAMI) criteria were used for the evaluation of bone healing and lower extremity function. Results: Complete union was achieved in all cases. The functional evaluation showed that most patients could achieve excellent and good results and return to activities of daily living. The functional result was poor in one case of a multi-fragmentary distal tibial articular fracture for which an ankle fusion was performed. Final union in this case was achieved with some residual deformity. Conclusion: The method of ADCr is an effective surgical technique in cases of severe tibial injuries with concomitant loss of bone and soft tissues. This method could be used in cases when either a plastic or microsurgeon is not available or for instances when closing the defect with a flap is either impossible or contraindicated. Excellent and good functional results are possible without severe complications.



Alice Wei Ting Wang, Harpreet Chhina, Anthony Cooper

Multimodal Analgesia for Paediatric Patients Undergoing Lower Limb Reconstruction with External Fixators: A Prospective Case Series of Post-operative Pain and Functional Goals

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:8] [Pages No:140 - 147]

Keywords: Analgesia, External fixation, Lower limb, Pain, Paediatric, Post-operative

   DOI: 10.5005/jp-journals-10080-1601  |  Open Access |  How to cite  | 


Aim: Limb reconstruction with external fixators requires appropriate pain management to promote effective analgesia and healing while minimising adverse events of the analgesic technique used. The objective of this prospective case series was to evaluate a multimodal analgesia regimen designed to reduce opioid requirements and hence reduce the opioid-related side effect profile. Materials and methods: A prospective cohort of patients undergoing lower limb reconstruction surgery (LRS) were managed through an evidence-informed multimodal analgesia guideline (MMAG), including acetaminophen, pregabalin, dexmedetomidine, IV lidocaine, and opioids. Outcome measures included intraoperative and post-operative opioid administration, post-operative pain scores, time to achieve mobilisation milestones, and post-operative complications. Surveys were conducted to obtain patient reported experiences. Results: 26 patients were included in this prospective case series. 110.59 (84.29, 162.13) (median, interquartile range) µg/kg/hr intraoperative IV morphine equivalent opioids were administered. In the first 48 hours post-operatively, patients received 11.49 (6.41, 19.35) µg/kg/hr of IV morphine equivalent dose. Median level of pain (0–10) in the first 48 post-operative hours was 2 (1, 2). Patients achieved mobilisation. And 19/20 patients surveyed reported ‘yes’ to having effective pain management; 17/20 patients had no unwanted side effects associated with analgesia medications. There were no cases of compartment syndrome. Conclusion: This multimodal analgesia regime applied to patients undergoing lower LRS with external fixators demonstrates the feasibility of this analgesic regimen which revealed effective pain control, early mobilisation, with minimal side effects, but warrants further study. Clinical significance: This study provides valuable evidence that this standardised multimodal anaesthesia and analgesia regimen is feasible, offers adequate post-operative comfort and encourages early mobilization while minimising opioid use and adverse events in a paediatric LRS population at our institution.



Veenesh Selvaratnam, Andrew Roche, Badri Narayan, Nikolaos Giotakis, Shoumit Mukhopadhaya, Hifz Aniq, Selvadurai Nayagam

Effectiveness of an Antibiotic-impregnated Bioabsorbable Carrier for the Treatment of Chronic Intramedullary and Diffuse Osteomyelitis

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:7] [Pages No:148 - 154]

Keywords: Antibiotics-loaded calcium sulphate, Bioabsorbable, Calcium sulphate, Chronic osteomyelitis, Cierny and Mader classification, Cohort Study, Osteomyelitis

   DOI: 10.5005/jp-journals-10080-1602  |  Open Access |  How to cite  | 


Aim: The surgical management of chronic intramedullary osteomyelitis involves debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead-space management is often through antibiotic-impregnated bone cement. These depots of local antibiotics are variable in elution properties and need removal. We review our unit's experience using a bioabsorbable synthetic calcium sulphate to deliver gentamicin as an adjunct in the treatment of osteomyelitis involving the medullary canal. Materials and methods: We retrospectively reviewed 34 patients with chronic osteomyelitis who were treated using this method in our institute. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology, and microbiology. The Cierny–Mader system was used to classify. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip/DASH scores) and a general health outcome questionnaire (SF36). The primary outcome measure was clinical recurrence of infection. Results: There were 24 male and 10 female patients. The mean age at presentation was 47 years (20–67). Clinical, laboratory, radiological, and patient reported outcomes were obtained at a median follow-up of 2.5 years (1.4–6.6 years). The bones involved were the femur (14, 41%), tibia (16, 47%), radius (1, 3%), and humerus (3, 9%). There were 13 cases classified as Cierny–Mader stage IV (diffuse with intramedullary osteomyelitis) and 21 cases as Cierny-Mader stage I. The median Oxford Hip score was 38 (11 patients, range 9–48). The median AOFAS score was 78 (14 patients, range 23–100). The median IOWA knee score was 71 (25 patients, range 22–95). The median DASH score was 33 (2 patients, range 1.7–64.2). There were two recurrences. The treatment success to date is 94%. Conclusion: In our series of patients, bioabsorbable carriers of antibiotics appear to be effective adjuncts to surgical treatment of osteomyelitis and were associated with high clinical success rates.



Oriol Pujol, Matías Vicente, Sara Castellanos, Nayana Joshi-Jubert, Pablo Corona

Preliminary Outcomes of a Staged Percutaneous Retrograde Prefabricated Gentamicin-coated Intramedullary Nail to Manage Complications after Ankle Fusion through Tibial Bone Transport

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:8] [Pages No:155 - 162]

Keywords: Ankle fusion, Antibiotic coating, Bone defect, Bone infection, Bone transport, Cohort study, ETN PROtect, Infection prophylaxis, Tibial nail

   DOI: 10.5005/jp-journals-10080-1595  |  Open Access |  How to cite  | 


Aim: Distal tibial injuries combining bone loss, articular destruction and infection can be treated through distraction osteogenesis combined with ankle fusion. Bone transport is not without complications. This study investigates our preliminary results using a retrograde prefabricated gentamicin-coated nail (ETN PROtect®) to treat complications after infected bone defects of the distal tibial were managed by ankle arthrodesis and distraction osteogenesis. Materials and methods: This is a retrospective case series study. All consecutive patients with bone transport complications after ankle arthrodesis and distraction osteogenesis who were subsequently operated on using a retrograde ETN PROtect® nail were analysed. The cases occurred between 2017 and 2020. The primary objective was to report on the resolution of the clinical problem and the risk of deep infection after nail implantation. Results: Five patients have included: two docking site non-unions, two regenerated bone fractures and one hypotrophic regenerated bone. These complications were resolved in all patients (5/5, 100%). A painless, stable and plantigrade ankle arthrodesis was achieved in all cases. No patient developed a local infection or required nail removal (mean follow-up: 35.2 months). The mean LEFS score was 46.8 ± 13.8 and the mean knee ROM was 112 ± 12.7°. All patients tolerated full weight-bearing. All patients were very satisfied with the procedure (mean SAPS score was 93.8 points). Conclusion: The staged retrograde nailing technique using the ETN PROtect® nail may represent an effective and safe treatment for bone transport complications in high-infection-risk patients. Furthermore, the technique allows simultaneous achievement of ankle arthrodesis. The patients had good functional outcomes and were satisfied with the procedure. Clinical significance: This strategy of using retrograde gentamicin-coated tibial nails offers a solution to resolve bone transport complications while simultaneously achieving functional ankle arthrodesis.



Evelyn P Murphy, Gerard A Sheridan, Brian J Page, Michael D Greenstein, Jason S Hoellwarth, Austin T Fragomen, S Robert Rozbruch

Modern Internet Search Analytics and Osseointegration: What are Patients Asking and Reading Online?

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:6] [Pages No:163 - 168]

Keywords: Cost, Google, Online health information, Osseointegration, Prosthesis, Search analytics

   DOI: 10.5005/jp-journals-10080-1603  |  Open Access |  How to cite  | 


Background: Osseointegration (OI) limb has been performed for over 30 years and is an example of an advance in technology and surgical technique which has led to improvements in patient mobility and quality of life. An increasing number of patients seek information about osseointegration. The aim of this study was to categorise the most frequently asked questions by patients using the Google search engine and the most frequently accessed websites with the highest return on answers. The secondary aims of this study were to assess the quality of the information provided on those websites and to stratify, by category, which websites provide the best quality information. Materials and methods: Ten permutations and conjugations of the word ‘osseointegration’ were entered into Google. The first fifty ‘People also ask’ and associated websites by Google's machine learning and natural language processing engine were collected for each search term. The Rothwell classification system of questions by topic (Fact, Value, Policy) and websites by category was used (Commercial, Academic, Medical Practice, Single Surgeon Personal, Government, Social Media). Website quality was assessed using the Journal of the American Medical Association (JAMA) benchmark criteria (Likert-style rating 0-4). Pearson's Chi-squared and Student's t-tests were performed for statistical analysis as appropriate (significance, p < 0.05). Results: The 10 search terms generated 454 questions and referenced 408 websites. Of the 454 questions generated, the most common question categories were fact (70.8%), value (19.2%), and policy (10%). The most common website type was social media (37.4%). The most common question types were technical details (30.4%), specific activity (20.6%), and cost (14.1%). Only 1.6% of questions related to risks and complications. Generally, website quality was poor with 64.1% having a JAMA score of 0 or 1. Websites that were categorised as ‘Government’ had the highest overall JAMA scores: 71.4% had a score of 4. Conclusion: Based on Google search engine's results, the most commonly asked questions about osteointegration related to technical details, specific activities and cost; only 1.6% related to risks and complications. Interestingly, social media websites represented the highest volume of search result referrals. Overall, the quality of websites was poor with the most factual information coming from governmental websites.



Leonid N Solomin, Anton A Semenistyy, Artem V Komarov, Vladimir V Khominets, Gerard A Sheridan, S Robert Rozbruch

Universal Long Bone Nonunion Classification

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:5] [Pages No:169 - 173]

Keywords: Aseptic nonunion, Atrophic nonunion, Bone defect, Bone loss, Classification, Hypertrophic nonunion, Nonunion, Normotrophic nonunion, Oligotrophic nonunion, Pseudarthrosis

   DOI: 10.5005/jp-journals-10080-1597  |  Open Access |  How to cite  | 


Aim and background: The management of bone union disorders is a complex problem in orthopaedics, requiring a reliable and comprehensive classification system for accurate diagnosis and treatment. Despite advances in understanding pathophysiology, diagnosis, and treatment in this area, there is no generally accepted classification system. The aim of our work was to create a comprehensive classification, which will systemize the vast majority of bone union disorders, underline their differences and form the basis for their treatment. Methods: The key criteria for nonunion evaluation and treatment were identified based on the conducted literature review: Time from the initial event (delayed union or nonunion), location, type of pathology (A, Hypertrophic; B, Normotrophic; C, Oligotrophic) and the presence of hardware. Based on these criteria the ULBNC has been developed. Atrophic nonunions were excluded from this classification as they are considered segmental bone defects with special classification. Results: The ULBNC is based on the same principles of coding as the “gold standard” AO/OTA Fractures Classification system with alpha-numeric coding “from simple to complex.” The choice of treatment method depends on the type, group, and subgroup of the nonunion as described. Conclusion: Universal Long Bone Nonunion Classification (ULBNC) is an alphanumeric system that describes the localization, type of pathology and morphologic characteristics of a nonunion. The use of ULBNC in practice and research will optimize and standardize the treatment of various types of bone healing disorders and eventually improve clinical outcomes.



Alan Katz, Évelyne Dumas, Reggie Hamdy

Anterior Hemiepiphysiodesis of the Distal Tibia: A Step-by-step Surgical Technique Guide

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:7] [Pages No:174 - 180]

Keywords: Ankle, Clubfoot, Equines, Guided growth, Surgical anatomy, Tibia

   DOI: 10.5005/jp-journals-10080-1596  |  Open Access |  How to cite  | 


Aim: This paper aims to serve as a guide for surgeons to prepare, execute, and perfect anterior hemiepiphysiodesis of the distal tibia (AHDT). Background: Treatment of persistent or recurrent equinus deformity following multiple conservative and surgical interventions in patients with idiopathic clubfoot or neuromuscular conditions can be challenging, and multiple surgical options are presented in the existing literature. Anterior hemiepiphysiodesis of the distal tibia is an option that seems to be safe and efficient in treating this entity. To the best of our knowledge, there is not yet any detailed description of this surgical technique in the English literature. Technique: The AHDT detailed surgical technique includes patient positioning, careful distal anterior tibial approach, placement of guided growth plates, fixation with epiphyseal and metaphyseal screws under fluoroscopic guidance, meticulous closure, and postoperative measures. Conclusion: This guide can be used pre-operatively to plan the surgery, intra-operatively to aid in smooth and safe step progression, and post-operatively to assist in critical critiquing. Clinical significance: By understanding the various stages of the surgery as well as the anatomy, pitfalls can be avoided and AHDT can be performed efficiently.



Ahmed Nageeb Mahmoud, John Tracy Watson, Daniel S Horwitz

Modified Masquelet Technique and Primary Tibial Metaphyseal Shortening for the Management of Proximal Tibial-infected Non-union in a Patient with Alcohol-induced Neuropathy: A Case Study

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:5] [Pages No:181 - 185]

Keywords: Alcohol, Infected non-union, Masquelet, Neuropathy, Tibia

   DOI: 10.5005/jp-journals-10080-1604  |  Open Access |  How to cite  | 


Aim: To highlight the role of the Masquelet technique as a limb salvage procedure for a neuropathic patient presenting with infected non-union of proximal tibia. Background: The management of an infected non-union in neuropathic patients is most challenging; with various treatment options available, the prognosis is often guarded. Case description: A 37-year-old male with chronic polyneuropathy, also possessing a contralateral midfoot Charcot arthropathy secondary to a history of alcohol abuse, developed infection after a proximal tibial osteotomy for a preceding mal-non-union of a proximal tibia fracture. The management included hardware removal, excision of necrotic bone, interim insertion of antibiotic-loaded bone cement followed by an acute shortening and revision of the internal fixation utilising a second surgical incision. Successful bone union and eradication of infection was achieved and maintained after 13 months follow-up. Conclusion: A successful outcome was achieved for an infected non-union of a long bone in a neuropathic patient using the Masquelet technique which was then followed with a second-stage removal of the spacer and shortening. By performing the revision ORIF surgery utilising a different skin incision in the setting of complicated previous surgical scars proved to be a viable technique towards reducing risk of recurrence of infection and a good outcome. Clinical significance: Utilisation of the Masquelet technique and limb shortening in a staged manner for the management of long bone infections in neuropathic patients has not been reported before and may be valuable in such demanding clinical situations.



Marieke P Noorlander-Borgdorff, Georgios F Giannakópoulos, Henri AH Winters, Matthijs Botman

The Pedicled Fibula Flap for Lower Limb Reconstruction

[Year:2023] [Month:September-December] [Volume:18] [Number:3] [Pages:8] [Pages No:186 - 193]

Keywords: Critical bone defect, Fibula flap, Limb reconstruction, Orthoplastic, Pedicled flap, Skin island, Surgical technique, Tibia, Vascularised bone flap

   DOI: 10.5005/jp-journals-10080-1600  |  Open Access |  How to cite  | 


The pedicled fibula flap is a reliable technique to treat large defects in the tibia. Despite increasing evidence of its efficacy and good long-term outcomes, a knowledge gap exists in its indications and technique. This instructional article presents a comprehensive overview of the indications, pre-operative planning, step-by-step surgery, and subsequent post-operative management.


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