Strategies in Trauma and Limb Reconstruction

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2018 | August | Volume 13 | Issue 2

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Jessica C. Rivera, Jason A. Beachler

Distraction arthroplasty compared to other cartilage preservation procedures in patients with post-traumatic arthritis: a systematic review

[Year:2018] [Month:August] [Volume:13] [Number:2] [Pages:7] [Pages No:61 - 67]

Keywords: Post-traumatic arthritis, Cartilage, Joint-sparing, Distraction arthroplasty

   DOI: 10.1007/s11751-018-0305-2  |  Open Access |  How to cite  | 


Post-traumatic arthritis (PTA) is characterized by the deterioration of articular cartilage temporally associated with an articular injury. With a paucity of literature comparing joint preservation techniques, we performed a systematic review of the literature intending to describe and summarize the results of ankle distraction arthroplasty as it compares with studies on tibio-talar microfracture, allograft, and autograft for ankle joint preservation in the post-traumatic population under 50 years of age. Research databases were searched and abstracts screened for relevance on our topic of interest. Abstracts meeting screening criteria with high interobserver reliability underwent full-manuscript review and coding for pertinent citation, study level, treatment, and outcome variables. Outcome variables for patient-reported pain scales, validated outcome measurement tools, radiographic progression, reoperation/re-treatment rates, and complication rates were recorded. Out of 105 unique citations, 10 publications were included. The distraction arthroplasty studies had 36 out of 181 patients requiring reoperation for complications (19.9%), while other joint-preserving procedures studies had 40 out of 177 patients requiring reoperations for complications (22.6%). Clinical outcome scores at mean follow-up time ranging from 2 to 10 years between studies were similar. Reported results for a variety of cartilage preservation procedures, including distraction arthroplasty, are satisfactory and reoperation rates for complication are similar. Limitations in available data and underlying study quality affect synthesis of the results therein. While distraction arthroplasty is an option for cartilage preservation in patients with PTA of the ankle, the technique is highly specialized which may affect the external validity. Level of evidence: III.



Alexander S. North, Tracey Wilkinson

Surgical reconstruction of the acromioclavicular joint: Can we identify the optimal approach?

[Year:2018] [Month:August] [Volume:13] [Number:2] [Pages:6] [Pages No:69 - 74]

Keywords: Acromioclavicular, Rockwood, Reconstruction, Anatomical, Hook plate, Biomechanics

   DOI: 10.1007/s11751-018-0314-1  |  Open Access |  How to cite  | 


Injuries to the acromioclavicular (AC) joint are common, tending to occur secondary to traumatic injuries. Rockwood grade IV, V and VI injuries involve complete dislocation of the joint and require surgical reconstruction, with inconclusive literature on whether grade III injuries should be surgically or conservatively managed. There are over one hundred reported surgical techniques which reconstruct the AC joint, with little indication of which methods achieve the best results. Techniques can generally be considered as: anatomical reduction; CC ligament reconstruction; and anatomical reconstruction. Techniques which implant hardware to reduce the AC joint, such as the hook plate, are commonly implemented, but have been shown to alter the mechanics of the joint significantly, resulting in poor short-term and long-term outcomes. Methods which reconstruct both the acromioclavicular and coracoclavicular ligaments are comparatively new, and early reports suggest that they achieve biomechanical properties similar to the native joint. More focus should be placed on such techniques in the future to determine whether they offer a more suitable approach to improve patient outcomes following AC joint reconstruction.


Original Article

Beth Lineham, Todd Stewart

Measurement of wire deflection on loading may indicate union in Ilizarov constructs, an in vitro model

[Year:2018] [Month:August] [Volume:13] [Number:2] [Pages:6] [Pages No:75 - 80]

Keywords: Ilizarov, Frame, Wire deflection, Biomechanics

   DOI: 10.1007/s11751-018-0306-1  |  Open Access |  How to cite  | 


No entirely reliable method exists for assessing union during Ilizarov treatment. Premature removal results in potential treatment failure; hence, alternative methods warrant investigation. Wire deflection might provide an indication of fracture site deformation on weight bearing, indicating progress towards union. This study aimed to test a method for assessing wire deflection within an Ilizarov frame. (1) To assess the repeatability of our novel measurement method in measuring wire deflection within an Ilizarov frame in vitro. (2) To compare the amount of wire deflection in an unstable model with that in an intact bone model. (3) To assess accuracy of this method by comparing wire deflection measured with overall machine extension. Tests were performed on clinical grade-tensioned fine wire 4-ring Ilizarov constructs stabilising a simulated fracture, with and without an unstable defect. Models were sequentially loaded to 700 N using an Instron testing machine. A digital depth gauge attached to the superior ring measured relative wire displacement at the ring closest to the fracture. Tests were repeated 3 times. (1) Both unstable and stable bone models produced highly repeatable load deformation curves (R2 = 0.98 and 0.99). (2) In the unstable model, wires tensioned at 882 and 1274 N produced mean maximum deflections of 2.41 and 2.69 mm compared with 0.05 and 0.04 mm in the intact bone model (significant p < 0.0001). (3) Wire deflection and machine extension results were strongly correlated (r = 0.99). A measurable difference in wire deflection between stable and unstable situations exists using this method which appears accurate and repeatable, with clear correlation between displacement and load and displacement and machine extension. This approach might be clinically applicable, and further clinical testing is required.


Original Article

Mehraj D. Tantray, Asim Rather, Qazi Manaan, Irfan Andleeb, Mir. Mohammad, Yasmeena Gull

Role of ultrasound in detection of radiolucent foreign bodies in extremities

[Year:2018] [Month:August] [Volume:13] [Number:2] [Pages:5] [Pages No:81 - 85]

Keywords: Extremities, Foreign body, Radiolucent, Ultrasonography

   DOI: 10.1007/s11751-018-0308-z  |  Open Access |  How to cite  | 


Removal of foreign bodies from soft tissues in emergency is very challenging and becomes more problematic when it is radiolucent. Blind exploration is sometimes hazardous for patients especially when it is in proximity to a vessel or a nerve or an overlying tendon. The purpose of this study was to determine the accuracy of ultrasonography (USG) in detecting radiolucent soft tissue foreign bodies in the extremities. From January 2014 to January 2016, 120 patients with either a positive history or clinically suspected soft tissue foreign body and negative radiography were evaluated by USG with a high-frequency (13–6 MHz) linear-array transducer. The sonographic findings were used to guide surgical exploration. Out of 120 patients who underwent surgical exploration, USG was positive in 114 cases, and foreign body was retrieved in 108 cases, and among the six cases where USG was negative, foreign body was retrieved from one case. In one case with strong clinical suspicion of foreign body USG was falsely negative. Majority of foreign bodies were removed from foot (69 cases) and hands (26 cases), and rest of foreign bodies were removed from ankle (4 cases), wrist (3 cases), thigh (2 cases), leg (1 case), knee (2 cases), forearm (2 cases). Accuracy, sensitivity, and positive predictive value were determined as 94.16, 99.08, and 94.13%, respectively. The real-time high-frequency USG is a highly sensitive and accurate tool for detecting and removing radiolucent foreign bodies which cannot be visualized by routine radiography.


Original Article

Matthew Morin, Joshua Klatt, P. M. Stevens

Cozen's deformity: resolved by guided growth

[Year:2018] [Month:August] [Volume:13] [Number:2] [Pages:7] [Pages No:87 - 93]

Keywords: Cozen's phenomenon, Tibial valgus, Guided growth

   DOI: 10.1007/s11751-018-0309-y  |  Open Access |  How to cite  | 


Proximal tibial metaphyseal fractures in children can lead to progressive and symptomatic tibial valgus. Corrective osteotomy has been abandoned, due to frequent complications, including recurrent valgus deformity. While spontaneous remodelling has been reported, this is not predictable. For children with persistent deformities, we have resorted to guided growth of the tibia. We present 19 patients who were successfully treated with guided growth, tethering the proximal medial physis. There were ten boys and nine girls, ranging in age from two to 13.6 years at the time of intervention. The mean follow-up from injury was 7.3 years. We documented the intermalleolar distance, mechanical axis deviation (by zone), medial proximal tibial angle (MPTA), and leg length discrepancy. Removal of the plate, or more recently, the metaphyseal screw, was undertaken upon normalization of the mechanical axis. Including the four patients who have undergone repeat tethering for recurrent valgus (one patient—twice), we are effectively reviewing 24 Cozen's phenomena, making this the largest series reported in the literature. Correction of the mechanical axis and the proximal medial tibial angle was achieved in all but one patient. Limb length inequality at follow-up ranged from 0.1 to 1.5 cm, with a mean of 0.5 cm. There have been five recurrences in four patients to date; four corrected with repeat tethering and one is pending. Two patients developed significant over correction because of parental failure to pursue timely follow-up. Both have corrected to neutral with lateral tibial physeal tethering. Ten patients have attained skeletal maturity and required no further treatment. The remaining nine patients will be followed until maturity. Guided growth is an excellent choice for the management of post-traumatic tibial valgus. Our rationale for restricting medial overgrowth is twofold: (1) to restore the MPTA and (2) to reduce the length discrepancy due to tibial overgrowth caused by the fracture. Recognizing the potential for recurrent deformity following implant removal, our standard practice now includes removal of just the metaphyseal screw and subsequent reinsertion, in the event of rebound valgus deformity. Level of evidence Therapeutic IV, retrospective series/no control cohort.


Original Article

Natalia A. Shchudlo, Tatyana N. Varsegova, Mikhail M. Shchudlo, Mikhail A. Stepanov, Andrey A. Yemanov

Causes of peroneal neuropathy associated with orthopaedic leg lengthening in different canine models

[Year:2018] [Month:August] [Volume:13] [Number:2] [Pages:8] [Pages No:95 - 102]

Keywords: Peroneal nerve, Neuropathy, Leg lengthening, Dog

   DOI: 10.1007/s11751-018-0313-2  |  Open Access |  How to cite  | 


Peroneal neuropathy is one of the complications of orthopaedic leg lengthening. Methods of treatment include slowing of distraction and decompression both of which may lead to additional complications. The purpose of this study was to analyse the changes in histologic peroneal nerve structure during experimental orthopaedic lengthening using various modes of manual or automatic distraction. The obtained data provide the basis for better understanding of peroneal neuropathy pathogenesis and refinement of prophylaxis and preventive treatment protocols. Four experimental models of canine leg lengthening using the Ilizarov fixator were studied: 1 (n = 10)—manual distraction—1 mm/day divided into four increments; 2 (n = 12)—automatic distraction—1 mm/day in 60 increments, 3 (n = 9) and 4 (n = 9)—increased rate of high frequency automatic distraction: 3 mm/day in 120 and 180 increments, respectively. In peroneal nerves semi-thin sections cross-sectional fascicular areas, content of adipocytes in epineurium, endoneurial vascularisation, morphometric parameters of nerve fibres were assessed by computerised analysis at the end of distraction and of consolidation periods and 30 days after fixator removal. In Groups 1–2 massive nerve fibre degeneration along with epineural vessels obliteration was revealed in two cases from 22, whereas in Groups 3–4 there were 10 from 18 (p < 0.01). Injuries of perineurium and endoneurial vessels were noted in Group 3, and long-lasting thinning of nerve fascicles in Group 4. The decrease in epineurial fat tissue was revealed in all groups, more drastic in 3. Modifications and injuries of nerve sheaths and blood vessels depending on distraction rate and frequency contribute to peroneal neuropathy. Its mechanical, circulatory and metabolic causes are discussed.



Peter O Farrell, Annette-Christi Barnard, Franz Birkholtz

The tibial bayonet method of wound closure

[Year:2018] [Month:August] [Volume:13] [Number:2] [Pages:6] [Pages No:103 - 108]

Keywords: Limb salvage, Compound tibial fractures, Hexapod-assisted closure, Bayonet method, Duplication

   DOI: 10.1007/s11751-018-0304-3  |  Open Access |  How to cite  | 


Management of open lower limb fractures with soft tissue defects can be a technically challenging orthopaedic problem. Limited availability of orthoplastic services means that alternatives to the fix and flap concept are required in order to prevent infected non-unions from developing. The proposed ‘bayonet apposition’ allows the surgeon to temporarily shorten the limb without angulating the limb or creating a bone defect and removing viable bone. The viable bone edges are overlapped in a bayonet-like manner in order to appose the wound and skin edges. The limb length is restored by gradually distracting the bone segments once the soft tissues have healed. This is facilitated with a hexapod fixator for stabilization of the fracture and distraction. Prerequisites for utilizing this method are circumferential soft tissue damage to the lower limb with viable distal tissue. The bayonet method allows primary closure of a wound and rapid restoration of the native length of the limb.



Sherif Galal

The Resolution Axis Method (RAM) for lengthening of the femur with or without associated frontal plane deformity (a new method)

[Year:2018] [Month:August] [Volume:13] [Number:2] [Pages:10] [Pages No:109 - 118]

Keywords: Deformity, Femur, Lengthening, Planning

   DOI: 10.1007/s11751-018-0312-3  |  Open Access |  How to cite  | 


Introduction Femoral lengthening with or along intramedullary (IM) nails will occur along the axis of the nail coincident with the anatomical axis of the bone. In the femur particularly, such lengthening often creates lateral mechanical axis deviation as the knee is driven medially. In cases where shortening is associated with frontal plane deformity the surgeon needs to correct the deformity intra-operatively, however, subsequent lengthening along the anatomical axis will create deformity. Thus, planning for lengthening of the femur with or along IM nails, whether shortening is associated with frontal plane deformity or not, requires a completely different planning strategy. The author questioned if a resolution anatomical axis can be identified and used for planning when lengthening the femur along or with IM nails while still applying the same classic CORA deformity analysis method. Methods In a prospective study, the author included eight patients who needed femoral lengthening, five with associated frontal plane deformity and three without. The author identified a method to determine the trajectory of the nail in the lower femoral segment. It was done by calculating the angle enclosed between this resolution anatomical axis and the mechanical axis, also known as the anatomical-mechanical angle. Results This new method has proven to be effective in achieving normal alignment after lengthening is completed. Conclusion The Resolution Axis Method is a new and alternative method providing a solution for planning when lengthening the femur along the anatomical axis using an IM nail, whether a deformity is present or not.


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