Strategies in Trauma and Limb Reconstruction

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2016 | April | Volume 11 | Issue 1

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Original Article

Francesca Giovannini, Luigi de Palma, Andrea Panfighi, Mario Marinelli

Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fractures: a meta-analysis of randomised controlled trials

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:4] [Pages No:1 - 4]

Keywords: External fixation, Intramedullary nailing, Open tibia fractures

   DOI: 10.1007/s11751-016-0245-7  |  Open Access |  How to cite  | 


Open tibial shaft fractures are the most common of long-bone open fractures. Management of the fracture is either by intramedullary nailing (IMN) or by external fixation (EF). Since the literature does not indicate clearly which is more effective, a meta-analysis was conducted to establish which approach is more suitable to treat Gustilo type III fractures. MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE and CINAHL databases were searched for randomised controlled trials (RCT) describing IMN and EF treatment of Gustilo type III fractures. As of 15 November 2012, five RCT involving 239 patients had been published; the outcomes examined in this study are their surgical complications. Data analysis led complications to be grouped into infection, fracture healing problems (non-union, malunion) and “other complications” (vascular injury, revision surgery, soft tissue damage, mechanical failure and tibial malalignment). IMN was associated with lower rates of infection and fracture healing problems; the differences between the two approaches for “other complications” were not significant. The data indicate that IMN is the treatment of choice for Gustilo type III fractures.


Original Article

Benjamin F. Plucknette, Chad A. Krueger, Jessica C. Rivera, Joseph C. Wenke

Combat-related bridge synostosis versus traditional transtibial amputation: comparison of military-specific outcomes

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:7] [Pages No:5 - 11]

Keywords: Transtibial, Combat related, Amputation, Ertl, Burgess, Outcomes, Military specific

   DOI: 10.1007/s11751-015-0240-4  |  Open Access |  How to cite  | 


The aim of our study was to determine military-specific outcomes for transtibial amputations of US Service members using either the traditional technique (Burgess) or the Ertl technique. All US Service members sustaining transtibial, combat-related amputation from September 2001 through July 2011 were reviewed. Amputation type, mechanism of injury, time interval to amputation, age, sex, branch of service, rank, force, nature, and injury severity score were recorded. Outcomes were determined by analyzing military-specific medical review results, to include the following: Physical Evaluation Board Liaison Office (PEBLO) rating (0–100), PEBLO outcome (permanent retirement, temporary disability retirement, separation without benefits, continuation of active duty, or fit for redeployment), and the rate of redeployment. Amputation type (Ertl vs. Burgess) was determined by reviewing postoperative radiographs and radiology reports. Data from all of the above categories were compared for both Ertl and Burgess amputees. Of 512 subjects identified, 478 had radiographs or radiology reports distinguishing between Ertl or Burgess transtibial amputation. A total of 406 subjects underwent the Burgess procedure, and 72 subjects underwent the Ertl procedure. There was not a significant difference between the two groups in review board rating (p = 0.858), review board outcome (p = 0.102), or ability to deploy (p = 0.106); however, subjects that underwent the Ertl procedure remained on active duty at a significantly higher rate (p = 0.021). There is a higher rate of remaining on active duty using the Ertl technique. This study suggests that there is an improvement in functional outcome with the Ertl technique.


Original Article

J. G. Penn-Barwell, P. M. Bennett, D. E. Mortiboy, C. A. Fries, A. F. G. Groom, I. D. Sargeant

Factors influencing infection in 10 years of battlefield open tibia fractures

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:6] [Pages No:13 - 18]

Keywords: Combat, War, Injuries and wounds, Open fracture, Tibia, Infection, Limb salvage, Military

   DOI: 10.1007/s11751-016-0250-x  |  Open Access |  How to cite  | 


The aim of this study was to characterise severe open tibial shaft fractures sustained by the UK military personnel over 10 years of combat in Iraq and Afghanistan. The UK military Joint Theatre Trauma Registry was searched for all such injuries, and clinical records were reviewed for all patients. One hundred Gustilo–Anderson III tibia fractures in 89 patients were identified in the 10 year study period; the majority sustained injuries through explosive weapons (63, 68 %) with the remainder being injured from gunshot wounds. 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, with S. aureus being the causative agent in 13/22 infected fractures (59 %). Neither injury severity, mechanism, the use of an external fixator, the need for vascularised tissue transfer nor smoking status was associated with subsequent infection. Bone loss was significantly associated with subsequent infection (p < 0.0001, Fisher's exact test). This study presents 10 years of open tibial fractures sustained in Iraq and Afghanistan. Most infection in combat open tibia fractures is caused by familiar organisms, i.e. S. aureus. While the overall severity of a casualty's injuries was not associated with infection, the degree of bone loss from the fracture was.


Original Article

Mootaz F. Thakeb, Mahmoud A. Mahran, El-Hussein M. El-Motassem

Bone transport for the management of severely comminuted fractures without bone loss

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:6] [Pages No:19 - 24]

Keywords: Bone transport, Comminuted fractures, Ilizarov technique, Contained bone defect, Internal bone loss

   DOI: 10.1007/s11751-016-0241-y  |  Open Access |  How to cite  | 


This study aims to provide a new method for treatment of severely comminuted fractures without bone loss using the well-known technique of bone transport. Sixteen patients suffering from severely comminuted fractures with closed soft tissue injury were prospectively treated using bone transport by Ilizarov circular fixator. There were 14 male and 2 female patients. The mean age was 36.5 years (27–45). There were 13 proximal tibial metaphyseal fractures, one tibial diaphyseal fracture and two femoral distal metaphyseal fractures. All patients had closed soft tissue. The mean length of the comminution gap was 50.3 mm (40–64). Fracture healing occurred in 15 patients. The mean healing time was 23.4 weeks (14–30). No bone stimulating procedures were needed for either the fracture or distraction site. Using the IOWA knee and ankle score for assessment of the 15 patients who completed treatment: the functional outcome for the knee was excellent in 11 patients, good in three and fair in one. The ankle score was excellent in 12 patients, good in two and fair in one. According to Paley and Maar's, bone results were excellent in 14 patients, good in one patient and poor in the patient who had failure of the procedure. The results achieved in this work are encouraging to keep on applying this technique to treat fractures that meet the following criteria: metaphyseal, with total circumferential comminution involving more than 4 cm of the bone length.


Original Article

Ahmet Adnan Karaarslan, Nihat Acar, Hakan Aycan, Erhan Sesli

The functional results of tibial shaft fractures treated with intramedullary nail compressed by proximal tube

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:5] [Pages No:25 - 29]

Keywords: Tibial fractures, Fracture fixation, Compression nail, Fracture nonunion

   DOI: 10.1007/s11751-016-0242-x  |  Open Access |  How to cite  | 


Nailing of tibial shaft fractures is considered the gold standard surgical method by many surgeons. The aim of this retrospective study was to investigate and compare the clinical outcome of tibial shaft fractures treated with intramedullary nails compressed by proximal tube and conventional intramedullary interlocking nails. Fifty-seven patients with tibial shaft fractures, treated with intramedullary nails compressed by proximal tube (n = 32) and the conventional interlocking nails (n = 25), were reviewed. All fractures except for one were united without any additional surgical intervention in the proximal compression tube nail group, whereas in the conventional interlocking nail group, six patients needed dynamization surgery (p = 0.005) and three cases of nonunion were recorded. In the proximal compression tube nail group, faster union occurred in 20 ± 2 (16–24) weeks (mean ± SD; range) without failure of locking screws and proximal nail migration, whereas in the conventional interlocking nail group, union occurred in 22 ± 2.5 (17–27) weeks (p = 0.001) with two failures of locking screws and two proximal nail migration. The proximal compression tube nail system is safer than the conventional nailing methods for the treatment for transverse and oblique tibial shaft fractures with a less rate of nonunion, proximal locking screw failure and proximal nail migration.


Original Article

Alfred Cyril Roy, Sandeep Albert, Mohamad Gouse, Dan Barnabas Inja

Functional outcome of knee arthrodesis with a monorail external fixator

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:5] [Pages No:31 - 35]

Keywords: Knee arthrodesis, External fixator, Tuberculous arthritis, Post-septic sequelae, Post-traumatic sequelae

   DOI: 10.1007/s11751-016-0247-5  |  Open Access |  How to cite  | 


Several methods for obtaining knee arthrodesis have been described in the literature and world; over, the commonest cause for arthrodesis is a failed arthroplasty. Less commonly, as in this series, post-infective or traumatic causes may also require a knee fusion wherein arthroplasty may not be indicated. We present salient advantages along with the radiological and functional outcome of twenty four patients treated with a single monorail external fixator. All patients went on develop fusion at an average of 5.4 months with an average limb length discrepancy of 3 cm (1.5–6 cm). Improvements in functional outcome as assessed by the lower extremity functional score (LEFS), and the SF-36 was significant (p = 0.000). Knee arthrodesis with a single monorail external fixator is a reasonable single-staged salvage option in patients wherein arthroplasty may not be the ideal choice. The outcome, though far from ideal, is definitely positive and predictable.


Original Article

Levent Eralp, F. Erkal Bilen, S. Robert Rozbruch, Mehmet Kocaoglu, Ahmed I. Hammoudi

External fixation reconstruction of the residual problems of benign bone tumours

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:13] [Pages No:37 - 49]

Keywords: Benign bone tumours, External fixation, Limb reconstruction, Distraction osteogenesis, Shortening, Bone deformity

   DOI: 10.1007/s11751-016-0244-8  |  Open Access |  How to cite  | 


The mechanical features of and biologic response to using distraction osteogenesis with the circular external fixator are the unique aspects of Ilizarov's contribution that allows deformity correction and reconstruction of bone defects. We present a retrospective study of 20 patients who suffered from a variety of benign tumours for which external fixators (EF) were used to treat deformity, bone loss, and limb-length discrepancy. A total of 26 bony segments in twenty patients (10 males, 10 females; mean age 17 years; range 7–58 years) were treated with EF for residual problems from the tumour itself (primary treatment) in 8 patients and for complications related to the primary surgery (secondary treatment) in 12 patients. Histological diagnoses were Ollier's disease (n = 4), Fibrous Dysplasia (n = 5), Congenital multiple exostosis (n = 5), giant cell tumour (n = 2) and one case for chondromyxoid fibroma, desmoid fibroma, chondroma and unicameral bone cyst. Various types of external fixators used to treat these problems. These were Ilizarov, unilateral fixator, multiaxial correction frame (Biomet, Parsippany, NJ), Taylor spatial frame (Memphis, TN) and smart correction multiaxial frame. The mean follow-up time was 69.5 months (range 35–108 months). The mean external fixation time was 159.5 days (range 27–300 days). The mean external fixation index was 67.4 days/cm (12–610) in 26 limbs who underwent distraction osteogenesis. The mean length of distraction was 4.9 cm (range 0.2–14 cm). At final follow-up, all patients had returned to normal activities. Complications were in the form of knee arthrodesis in one patient, pin tract infection in six and residual shortening in eight patients. The use of EF and the principles of distraction osteogenesis, in the management of problems associated with benign bone tumours and related surgery yields successful results especially in young patients. With this approach, the risk for recurrence of shortening and deformity may be minimized with overcorrection or over-lengthening as dictated by preoperative planning.



Levent Eralp, F. Erkal Bilen, S. Robert Rozbruch, Mehmet Kocaoglu, Ahmed I. Hammouda

Erratum to: External fixation reconstruction of the residual problems of benign bone tumours

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:1] [Pages No:51 - 51]

   DOI: 10.1007/s11751-016-0248-4  |  Open Access |  How to cite  | 


Original Article

Madhavan C. Papanna, K. A. Saldanha, Binu Kurian, J. A. Fernandes, Stan Jones

The use of recombinant morphogenic protein-2(rhBMP-2) in children undergoing revision surgery for persistent non-union

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:6] [Pages No:53 - 58]

Keywords: Bone, Congenital abnormalities non-union, rhBMP-2

   DOI: 10.1007/s11751-016-0251-9  |  Open Access |  How to cite  | 


The purpose of the study was to evaluate the safety and efficacy with the use of BMP-2 for treating persistent non-unions in children with underlying complex conditions. Between October 2006 and November 2010 in our unit, 15 patients were treated with rhBMP-2 to enhance bone union. There were nine females and six males with a mean age of 9.5 years (range 4–15) at time of surgery. Seventy-five per cent of the patients required revision of internal fixation with insertion of rhBMP-2 to the non-union site, and the reminder had freshening of the non-union site with rhBMP-2 application. Patients had undergone a mean of 2 (1–5) operations prior to implantation of rhBMP-2. All the patients in the study group were available for review with mean follow-up of 44 months (range 21–70). The mean time to union was 16 weeks (range 10–28 weeks). No adverse events related to BMP-2 application were noted in our study group. Healing occurred clinically and radiographically in 16 of the 17 sites. Our study demonstrates that BMP-2 enhances healing of the persistent non-unions without any adverse events


Original Article

Anna C. Peek, Anna Timms, Kuen F. Chin, David Goodier

Patterns of healing: a comparison of two proximal tibial osteotomy techniques

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:4] [Pages No:59 - 62]

Keywords: Regenerate, Osteotomy, Healing

   DOI: 10.1007/s11751-016-0243-9  |  Open Access |  How to cite  | 


Several low-energy osteotomy techniques are described in the literature, but there is limited evidence comparing them. Our study evaluates the patterns of regenerate formation using two different osteotomy techniques. Two cohorts of patients underwent osteotomy of the tibia using a Gigli saw (n = 15) or De Bastiani corticotomy (n = 12) technique. The patient radiographs were assessed by the two senior authors who were blinded to the osteotomy type. Regenerate quality was assessed along the anterior, posterior, medial and lateral cortices, graded 1–5 from absent to full consolidation over time. The time to 3 cortices healed/regenerate length was calculated. The time to consolidation of the anterior, posterior, medial and lateral cortices was compared. The mean 3 cortices index in the Gigli group was 2.0 months/cm and in the De Bastiani group 1.8 months/cm. This was not a significant difference. In both groups, anterior bone formation was slower, and anterior cortical deficiency with a scalloped appearance was seen in 25 % of cases overall with no statistically significant difference between the two groups. Both Gigli saw and De Bastiani corticotomy techniques result in good bone formation following distraction osteogenesis. The anterior tibial cortex consolidates more slowly than the other cortices in both groups. This is likely due to deficient soft tissue cover and direct periosteal damage at time of osteotomy.


Original Article

Konstantinos Tsitskaris, Heledd Havard, Paulien Bijlsma, Robert A. Hill

Internal bone transport using a cannulated screw as a mounting device in the treatment of a post-infective ulnar defect

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:5] [Pages No:63 - 67]

Keywords: Internal bone transport, Ulnar segmental bone defect, Cannulated screw, PVL S. aureus

   DOI: 10.1007/s11751-016-0246-6  |  Open Access |  How to cite  | 


Bone transport techniques can be used to address the segmental bone loss occurring after debridement for infection. Secure fixation of the bone transport construct to the bone transport segment can be challenging, particularly if the bone is small and osteopenic. We report a case of a segmental ulnar bone defect in a young child treated with internal bone transport using a cannulated screw as the mounting device. We found this technique particularly useful in the treatment of bone loss secondary to infection, where previous treatment and prolonged immobilisation had led to osteopenia. This technique has not been previously reported.



Karthig Rajakulendran, Natasha E. Picardo, Ibraheim El-Daly, Rami Hussein

Brodie's abscess following percutaneous fixation of distal radius fracture in a child

[Year:2016] [Month:April] [Volume:11] [Number:1] [Pages:5] [Pages No:69 - 73]

Keywords: Brodie's abscess, Kirschner wires, K-wire, Infection, Subacute osteomyelitis

   DOI: 10.1007/s11751-016-0249-3  |  Open Access |  How to cite  | 


We report the case of a Brodie's abscess presenting five and a half years following closed reduction and percutaneous pinning of a distal radius fracture. The index surgery was complicated by a pin site infection that was treated successfully with antibiotics. The patient represented with forearm pain years later, and radiological investigations revealed a Brodie's abscess in the distal radius at the site of the previous Kirschner wires. The Brodie's abscess was managed through surgical curettage and antibiotics. Staphylococcus aureus and diphtheroid organisms were cultured from the intraoperative specimens. A Brodie's abscess is a form of localised subacute osteomyelitis, which usually occurs in the metaphysis of long bones and can mimic malignancy. Previous trauma or surgery has been implicated as predisposing factors. We have only identified one previously reported case of Brodie's abscess following percutaneous pinning. Ours is the first reported case in an adolescent. The aim of this paper is to raise awareness of this rare complication and review the current literature.


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