Strategies in Trauma and Limb Reconstruction

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2015 | November | Volume 10 | Issue 3

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Nebu Jacob, Amit Amin, Alex J. Trompeter

Management of high-energy tibial pilon fractures

[Year:2015] [Month:November] [Volume:10] [Number:3] [Pages:11] [Pages No:137 - 147]

Keywords: Pilon fractures, Management, Strategy, Algorithm, Reconstruction, Bone defects

   DOI: 10.1007/s11751-015-0231-5  |  Open Access |  How to cite  | 


Tibial pilon fractures result from high-energy trauma unlike usual ankle fractures. Their management provides numerous challenges to the orthopaedic surgeon including obtaining anatomic reduction of articular surface and the management of associated soft tissue injuries. This article aims to review major advances and principles that guide our practice today. We also discuss a treatment algorithm based on a staged approach to the fracture: initial spanning external fixation followed by definitive fixation.


Original Article

Saif Salih, C. Blakey, D. Chan, J. C. McGregor-Riley, S. L. Royston, S. Gowlett, D. Moore, Mick Dennison

The callus fracture sign: a radiological predictor of progression to hypertrophic non-union in diaphyseal tibial fractures

[Year:2015] [Month:November] [Volume:10] [Number:3] [Pages:5] [Pages No:149 - 153]

Keywords: Ilizarov technique, Tibial fracture, Fracture healing, Radiography, X-ray, Hypertrophic non-union

   DOI: 10.1007/s11751-015-0238-y  |  Open Access |  How to cite  | 


We report a radiological sign which predicts progression to hypertrophic non-union for fractures of the tibial diaphysis. Radiographs of 46 tibial fractures were reviewed independently by four orthopaedic trauma surgeons and two musculoskeletal radiologists. Patients were identified from a database of tibial fractures managed with Ilizarov frame fixation. There were 23 fractures that progressed to non-union requiring further surgery. The controls were 23 fractures that had united without need for further surgery at 1-year follow-up. Radiographs selected were the first images taken following frame removal. All radiographs were anonymised and randomized prior to review. Presence of the callus fracture sign was identified in 16 radiographs of the fractures that progressed to non-union, and 7 of the united fracture group. Sensitivity is 69.6 %. Specificity is 91.4 %. Positive and negative predictive values are 88.9 and 75.0 %, respectively. These results compare favourably with computerised tomography for predicting non-union. Intra- and inter-observer reliability was good (κ = 0.68), and moderate (κ = 0.57), respectively. The callus fracture sign is a useful radiological predictor of progression to non-union and may represent insufficient mechanical stability at the fracture site.


Original Article

Jesse M. van Buijtenen, Mischa L. C. van Tunen, Wietse P. Zuidema, Emile A. Heilbron, Jeroen de Haan, Henrica C. W. de Vet, Robert J. Derksen

Inter- and intra-observer agreement of the AO classification for operatively treated distal radius fractures

[Year:2015] [Month:November] [Volume:10] [Number:3] [Pages:5] [Pages No:155 - 159]

Keywords: Distal radius fracture, Surgical procedures, Intra-observer agreement, Inter-observer agreement, AO classification, C-type fractures

   DOI: 10.1007/s11751-015-0237-z  |  Open Access |  How to cite  | 


The reproducibility of the AO classification for distal radius fractures remains a topic of debate. Previous studies showed variable reproducibility results. Important treatment decisions depend on correct classification, especially in comminuted, intra-articular fractures. Therefore, reliable reproducibility results need to be undisputedly determined. Hence, the study objective was to assess inter- and intra-observer agreement of the AO classification for operatively treated distal radius fractures. A database of 54 radiographs of all AO types (A, B and C) and groups (A2-3, B1-3, and C1-3) of distal radius fractures was assessed in twofold. Likewise, a subset of 152 radiographs of solely C-type groups (C1-3) was assessed. All fractures were classified by six observers with different experience levels: three consultant trauma surgeons, one sixth-year trauma surgery resident, a consultant trauma radiologist, and an intern with limited experienced. The inter-observer agreement of both main types and groups was moderate (κ = 0.49 resp. κ = 0.48) in combination with a good intra-observer agreement (κ = 0.68 resp. κ = 0.70). The inter-observer agreement of the subset C-type fractures group was fair (κ = 0.27) with moderate intra-observer agreement (κ = 0.43). According to these results, the reproducibility of the AO classification of main types and groups of distal radius fractures based on conventional radiographs is insufficient (κ < 0.50), especially at group level of C-type fractures.


Original Article

Edgardo R. Rodriguez-Collazo, Maria L. Urso

Combined use of the Ilizarov method, concentrated bone marrow aspirate (cBMA), and platelet-rich plasma (PRP) to expedite healing of bimalleolar fractures

[Year:2015] [Month:November] [Volume:10] [Number:3] [Pages:6] [Pages No:161 - 166]

Keywords: Mesenchymal stem cell, Tibia, Fracture, Fibula, Nonunion, Comorbidities

   DOI: 10.1007/s11751-015-0239-x  |  Open Access |  How to cite  | 


Distal tibial and fibular fractures, particularly in patients with comorbidities, heal slowly and have a high incidence of postoperative nonunion and infection. Autologous concentrated bone marrow aspirate (cBMA) and platelet-rich plasma (PRP) increase osteogenic potential of demineralized bone matrix (DBM). The purpose of this case series was to evaluate the efficacy of cBMA, PRP, DBM in conjunction with the Ilizarov fixator as compared to DBM and the Ilizarov fixator alone in expediting fracture healing. Ten patients (mean age 52.9 years) were in the cBMA Group, and 10 patients (mean age 54 years) were in the Control Group. Comorbidities included diabetes, obesity, smoking, and renal disease. Radiographs showed a significant difference in the rate of complete healing in the cBMA Group at 16 ± 1.6 weeks post-surgery as compared to 24 ± 1.3 weeks in the Control Group (P < 0.001). No differences were observed between groups in infection rate or nonunions. We conclude that the Ilizarov fixator combined with DBM, cBMA, and PRP expedites fracture healing of the distal tibia and fibula in patients with significant comorbidities.


Original Article

Richard C. Barksfield, Fergal P. Monsell

Predicting translational deformity following opening-wedge osteotomy for lower limb realignment

[Year:2015] [Month:November] [Volume:10] [Number:3] [Pages:7] [Pages No:167 - 173]

Keywords: Opening-wedge osteotomy, Deformity analysis, Osteotomy rules, Translational deformity, Limb realignment, Obligatory translation

   DOI: 10.1007/s11751-015-0232-4  |  Open Access |  How to cite  | 


An opening-wedge osteotomy is well recognised for the management of limb deformity and requires an understanding of the principles of geometry. Translation at the osteotomy is needed when the osteotomy is performed away from the centre of rotation of angulation (CORA), but the amount of translation varies with the distance from the CORA. This translation enables proximal and distal axes on either side of the proposed osteotomy to realign. We have developed two experimental models to establish whether the amount of translation required (based on the translation deformity created) can be predicted based upon simple trigonometry. A predictive algorithm was derived where translational deformity was predicted as 2(tan α × d), where α represents 50 % of the desired angular correction, and d is the distance of the desired osteotomy site from the CORA. A simulated model was developed using TraumaCad online digital software suite (Brainlab AG, Germany). Osteotomies were simulated in the distal femur, proximal tibia and distal tibia for nine sets of lower limb scanograms at incremental distances from the CORA and the resulting translational deformity recorded. There was strong correlation between the distance of the osteotomy from the CORA and simulated translation deformity for distal femoral deformities (correlation coefficient 0.99, p < 0.0001), proximal tibial deformities (correlation coefficient 0.93–0.99, p < 0.0001) and distal tibial deformities (correlation coefficient 0.99, p < 0.0001). There was excellent agreement between the predictive algorithm and simulated translational deformity for all nine simulations (correlation coefficient 0.93–0.99, p < 0.0001). Translational deformity following corrective osteotomy for lower limb deformity can be anticipated and predicted based upon the angular correction and the distance between the planned osteotomy site and the CORA.



César Salcedo Cánovas

Bone elongation using monolateral external fixation: a practical guide

[Year:2015] [Month:November] [Volume:10] [Number:3] [Pages:14] [Pages No:175 - 188]

Keywords: Lengthening, Fixator, Monolateral, Callotasis, Elongation, Guide

   DOI: 10.1007/s11751-015-0236-0  |  Open Access |  How to cite  | 


In the literature, we can find many articles that describe in detail specific complex procedures related to the limb reconstruction. However, the general information on the biological and mechanical bases of callotasis is out of date, and the surgeons must relate to works dating from the early 1980s. These articles also come from a period in which the callotasis technique was being developed and, therefore, incur in discrepancies depending on the year they were written or the school of the author. This paper provides a general and summarised overview of the theoretical and practical aspects interesting to a surgeon that needs clear information on the bone elongations performed with the help of a monolateral external fixator.



Claire Marie C. Durban, Seung-Yup Lee, Hong-Chul Lim

Above-the-knee replantation in a child: a case report with a 24-year follow-up

[Year:2015] [Month:November] [Volume:10] [Number:3] [Pages:5] [Pages No:189 - 193]

Keywords: Lower limb, Lower limb replantation, Above-knee amputation, Replantation in children

   DOI: 10.1007/s11751-015-0230-6  |  Open Access |  How to cite  | 


Replantation of an amputated limb is generally contraindicated in crushing and traction injuries. Injury to muscle tissue and skin also creates difficulties in coverage, and bony fractures may shorten limb length which can impede lower extremity function. Numerous cases have been reported on the successful replantation of the lower limb in children; however, review of previous English literature has documented only very few replantation at the thigh level, and those with severe crushing injury resulted in subsequent amputation. We report a case of successful thigh-level replantation in a 3-year-old child who sustained a crushing–traction type of injury with a follow-up of 24 years. After the replantation, early and late complications developed but these were successfully managed. On her last visit, the patient had pain-free ambulation without assistance, had intact protective sensation distal to the injury, and was very satisfied with the outcome. Replantation of the lower limb in children with crushing or avulsion type of injuries is still a worthwhile procedure. However, both the patient and the family should be aware that multiple surgeries may be needed to accommodate to long-term complications such as joint stiffness, scar contractures, and limb length discrepancies.



Masuo Hanada, H. Kadota, T. Matsunobu, E. Shimada, Y. Iwamoto

Non-anatomical reconstruction of lateral ulnar collateral ligament of the elbow after tumor resection

[Year:2015] [Month:November] [Volume:10] [Number:3] [Pages:5] [Pages No:195 - 199]

Keywords: Elbow, Lateral ulnar collateral ligament reconstruction, Radial forearm flap, Tumor wide resection

   DOI: 10.1007/s11751-015-0235-1  |  Open Access |  How to cite  | 


We present the case of an 80-year-old man with a tumor recurrence on his right arm 6 years after initial treatment. The lateral aspect of the elbow joint, involving overlaying skin, muscles, tendons, joint capsule, lateral collateral ligament complex, the lateral 1/3 of the capitellum, and lateral epicondyle of humerus were excised in the tumor resection. Intraoperative assessment revealed multidirectional instability of the elbow, and joint stabilization was needed. Because the lateral epicondyle was resected, graft placement in an anatomical position was impossible to carry out. Therefore, non-anatomical reconstruction of lateral ulnar collateral ligament with palmaris longus tendon graft was performed. The skin was reconstructed using an antegrade pedicled radial forearm flap. For wrist extension reconstruction, the pronator quadratus tendon was transferred to the extensor carpi radialis brevis tendon. One year after the operation, elbow range of motion was 5–130°. The patient remains symptom free. The Mayo elbow performance score is good. The Musculoskeletal Tumor Society rating score is excellent. To our knowledge, this is the first report of an elbow lateral ulnar collateral ligament reconstruction after tumor resection.


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