Strategies in Trauma and Limb Reconstruction

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2018 | November | Volume 13 | Issue 3

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Gareth Medlock, Iain M. Stevenson, Alan J. Johnstone

Uniting the un-united: should established non-unions of femoral shaft fractures initially treated with IM nails be treated by plate augmentation instead of exchange IM nailing? A systematic review

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:10] [Pages No:119 - 128]

Keywords: Femoral non-union, Femoral fracture, Intramedullary nailing, Adjunctive plating

   DOI: 10.1007/s11751-018-0323-0  |  Open Access |  How to cite  | 


The majority of femoral fractures are surgically treated with intramedullary nails. Non-union rate is low but challenging and costly if it occurs. There have been encouraging results from the use of augmentative plating as a treatment for non-union of femoral fractures. We performed a systematic review of the literature to compare union rates, time to union and complications between exchange nailing and augmentative plating as a primary procedure following a diagnosis of femoral non-union following initial nailing. We found a total of 21 papers, which found the mean union rate of augmentative plating to be 99.8% compared to 74% (P = 2.05−12) found for exchange nailing. Times to union were comparable at 5.9 months for augmentative plating and 6.3 months for exchange nailing (P = 0.68916), and complication rate was 4% for augmentative plating compared to 20% for exchange nailing. From the evidence available, plate augmentation provides a more reliable union rate if used as the first operative intervention on a non-union of a femoral fracture compared to exchange nailing. Level of Evidence IV Systematic review of therapeutic studies.


Original Article

Saif Salih, Edward Mills, Jonathan McGregor-Riley, Mick Dennison, Simon Royston

Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft tissue loss

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:7] [Pages No:129 - 135]

Keywords: Open fractures, Tibia, Circular frame, Ilizarov frame, Soft tissue flap, Limb reconstruction, Distraction histogenesis, Deformity correction

   DOI: 10.1007/s11751-018-0316-z  |  Open Access |  How to cite  | 


This retrospective case series evaluates the technique of transverse debridement, acute shortening and subsequent distraction histogenesis in the management of open tibial fractures with bone and soft tissue loss, thereby avoiding the need for a soft tissue flap to cover the wound. Thirty-one patients with Gustilo grade III open tibial fractures between 2001 and 2011 were initially managed with transverse wound extensions, debridement and shortening to provide bony apposition and allowing primary wound closure without tension, or coverage with mobilization of soft tissue and split skin graft. Temporary monolateral external fixation was used to allow soft tissues resuscitation, followed by Ilizarov frame for definitive fracture stabilization. Leg length discrepancy was corrected by corticotomy and distraction histogenesis. Union was evaluated radiologically and clinically. Patients’ mean age was 37.3 years (18.3–59.3). Mean bone defect was 3.2 cm (1–8 cm). Mean time to union was 40.1 weeks (12.6–80.7 weeks), and median frame index was 75 days/cm. Median lengthening index (time in frame after corticotomy for lengthening) was 63 days/cm. Mean clinic follow-up was 79 weeks (23–174). Six patients had a total of seven complications. Four patients re-fractured after frame removal, one of whom required a second frame. Two patients required a second frame for correction of residual deformity, and one patient developed a stiff non-union which united following a second frame. There were no cases of deep infection. Acute shortening followed by distraction histogenesis is a safe method for the acute treatment of open tibial fractures with bone and soft tissue loss. This method also avoids the cost, logistical issues and morbidity associated with the use of local or free-tissue transfer flaps and has a low rate of serious complications despite the injury severity.


Original Article

Carlos A. Peña-Solórzano, Matthew R. Dimmock, David W. Albrecht, David M. Paganin, Richard B. Bassed, Mitzi Klein, Peter C. Harris

Effect of external fixation rod coupling in computed tomography

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:13] [Pages No:137 - 149]

Keywords: Computed tomography, Rod coupling, Dual-energy CT, Metal artefact reduction, Metal artefacts

   DOI: 10.1007/s11751-018-0318-x  |  Open Access |  How to cite  | 


External fixation is a common tool in the treatment of complex fractures, correction of limb deformity, and salvage arthrodesis. These devices typically incorporate radio-opaque metal rods/struts connected at varying distances and orientations between rings. Whilst the predominant imaging modality is plain film radiology, computed tomography (CT) may be performed in order for the surgeon to make a more confident clinical decision (e.g. timing of frame removal, assessment of degree of arthrodesis). We used a fractured sheep leg to systematically assess CT imaging performance with a Discovery CT750 HD CT scanner (GE Healthcare) to show how rod coupling in both traditional Ilizarov and hexapod frames distorts images. We also investigated the role of dual-energy CT (DECT) and metal artefact reduction software (MARS) on the visualisation of the fractured leg. Whilst mechanical reasons predominantly dictate the rod/strut configurations when building a circular frame, rod coupling in CT can be minimised. Firstly, ideally, all or all but one rod can be removed during imaging resulting in no rod coupling. If this is not possible, strategies for configuring the rods to minimise the effect of the rod coupling on the region of interest are demonstrated, e.g., in the case of a four-rod construct, switching the two anterior rods to a more central single one will achieve this goal without particularly jeopardising mechanical strength for a short period. It is also shown that the addition of DECT and MARS results in a reduction of artefacts, but also affects tissue and bone differentiation.


Original Article

Mikhail Bekarev, Abraham M. Goch, David S. Geller, Evan S. Garfein

Distally based anterolateral thigh flap: an underutilized option for peri-patellar wound coverage

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:12] [Pages No:151 - 162]

Keywords: Anterolateral thigh flap, Knee coverage, Peri-patellar wound, Knee defect

   DOI: 10.1007/s11751-018-0319-9  |  Open Access |  How to cite  | 


Wound coverage in the supra-patellar area presents a significant challenge for orthopaedic and reconstructive surgeons due to the need for preservation of knee joint function but the paucity of regional soft tissue flaps available. While many orthopaedic and reconstructive surgeons make use of the rotational gastrocnemius flap for coverage of peri-patellar defects, this flap has certain limitations. The goal of this study was to report a single-centre experience with the use of the distally based anterolateral thigh flap (ALT) and review the current literature on the use of the ALT for peri-patellar defects. In this report, both a single-centre experience using distally based anterolateral thigh (ALT) island flaps for supra-patellar wound coverage and the existing literature on this topic were reviewed. A systematic literature review was performed to assess the use of the ALT for peri-patellar wounds. Five patients with a mean age of 69 underwent a distally based ALT flap for coverage of peri-patellar defects. Four out of 5 flaps survived at the end of their respective follow-up. Based on this combined experience, the distally based reverse-flow anterolateral thigh island flap represents a useful but relatively underutilized option for appropriately selected supra-patellar wounds due to minimal donor site morbidity, multiple flap components, and predictable pedicle anatomy. The flap's major weakness is its potentially unreliable venous drainage, requiring delay or secondary venous outflow anastomosis. Given the ALT flap's favourable profile, the authors recommend consideration for its use when managing a peri-patellar coverage wound issue.


Original Article

Georg W. Omlor, Vera Lohnherr, Pit Hetto, Simone Gantz, Jörg Fellenberg, Christian Merle, Thorsten Guehring, Burkhard Lehner

Surgical therapy of benign and low-grade malignant intramedullary chondroid lesions of the distal femur: intralesional resection and bone cement filling with or without osteosynthesis

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:8] [Pages No:163 - 170]

Keywords: Chondroid lesion, Enchondroma, Atypical cartilaginous tumor, Chondrosarcoma, Femur, Compound osteosynthesis

   DOI: 10.1007/s11751-018-0321-2  |  Open Access |  How to cite  | 


Surgical treatment of benign and low-grade malignant intramedullary chondroid lesions at the distal femur is not well analyzed compared to higher-grade chondrosarcomas. Localization at the distal femur offers high biomechanical risks requiring sophisticated treatment strategy, but scientific guidelines are missing. We therefore wanted to analyze a series of equally treated patients with intralesional resection and bone cement filling with and without additional osteosynthesis. Twenty-two consecutive patients could be included with intralesional excision and filling with polymethylmethacrylate bone cement alone (n = 10) or with compound bone cement osteosynthesis using a locking compression plate (n = 12). Clinical and radiological outcome was retrospectively evaluated including tumor recurrences, complications, satisfaction, pain, and function. Mean follow-up was 55 months (range 7–159 months). Complication rate was generally high with lesion-associated fractures both in the osteosynthesis group (n = 2) and in the non-osteosynthesis group (n = 2). All fractures occurred in lesions that reached the diaphysis. No fractures were found in meta-epiphyseal lesions. No tumor recurrence was found until final follow-up. Clinical outcome was good to excellent for both groups, but patients with additional osteosynthesis had significantly longer surgery time, more blood loss, longer postoperative stay in the hospital, more complications, more pain, less satisfaction, and worse functional outcome. Intralesional resection strategy was oncologically safe without local recurrences but revealed high risk of biomechanical complications if the lesion reached the diaphysis with an equal fracture rate no matter whether osteosynthesis was used or not. Additional osteosynthesis significantly worsened final clinical outcome and had more overall complications. This study may help guide surgeons to avoid overtreatment with additional osteosynthesis after curettage and bone cement filling of intramedullary lesions of the distal femur. Meta-epiphyseal lesions will need additional osteosynthesis rarely, contrary to diaphyseal lesions with considerable cortical thinning.


Original Article

Timothy R Nunn, M. Etsub, T. Tilahun, R. O. E. Gardner, V. Allgar, A. M. Wainwright, C. B. D. Lavy

Development and validation of a delayed presenting clubfoot score to predict the response to Ponseti casting for children aged 2–10

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:7] [Pages No:171 - 177]

Keywords: Clubfoot, Childhood, Delayed presenting, Score

   DOI: 10.1007/s11751-018-0324-z  |  Open Access |  How to cite  | 


The aim of the study was to develop a simple and reliable clinical scoring system for delayed presenting clubfeet and assess how this score predicts the response to Ponseti casting. We measured all elements of the Diméglio and the Pirani scoring systems. To determine which aspects were useful in assessing children with delayed presenting clubfeet, 4 assessors examined 42 feet (28 patients) between the ages of 2–10 years. Selected variables demonstrating good agreement were combined to make a novel score and were assessed prospectively on a separate consecutive cohort of children with clubfeet aged 2–10, comprising 100 clubfeet (64 patients). Inter-observer and intra-observer agreement was found to be greatest using the following clinically measured angles of the deformities. These were plantaris, adductus, varus, equinus of the ankle and rotation around the talar head in the frontal plane (PAVER). Measured angles of 1–20, 21–45 and > 45 degrees scored 1, 2 and 3 points, respectively. The PAVER score was derived from both the sum of points derived from measured angles and a multiplier according to age. The sum of the points was multiplied with 1, 1.5 or 2 for ages 2–4, 5–7 and 8–10, respectively. This demonstrated a good association with the total number of casts to achieve a full correction (tau = 0.71). A score greater than 18 out of 30 indicated a cast-resistant clubfoot. The score could be used clinically for prognosis and treatment, and for research purposes to compare the severity of clubfoot deformities.



Gautam J. K. Tawari, Rajan Maheshwari, Sanjeev S. Madan

Extra-articular deformity correction using Taylor spatial frame prior to total knee arthroplasty

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:6] [Pages No:179 - 184]

Keywords: Tibial deformity, Tibial non-union, Total knee arthroplasty, Staged surgery, Osteoarthritis

   DOI: 10.1007/s11751-018-0310-5  |  Open Access |  How to cite  | 


A good long-term outcome following a total knee arthroplasty relies on restoration of the mechanical axis and effective soft tissue balancing of the prosthetic knee. Arthroplasty surgery in patients with secondary osteoarthritis of the knee with an extra-articular tibial deformity is a complex and challenging procedure. The correction of mal-alignment of the mechanical axis is associated with unpredictable result and with higher revision rates. Single-staged deformity correction and replacement surgery often result in the use of constraint implants. We describe our experience with staged correction of deformity using a Taylor Spatial Frame (TSF) followed by total knee arthroplasty in these patients and highlight the advantage of staged approach. The use of TSF fixator for deformity correction prior to a primary total knee arthroplasty has not been described in the literature. We describe three cases of secondary osteoarthritis of the knee associated with multiplanar tibial deformity treated effectively with a total knee arthroplasty following deformity correction and union using a TSF. All patients had an improved Knee Society score and Oxford Knee score postoperatively and were satisfied with their replacement outcome. Staged deformity correction followed by arthroplasty allows the use of standard primary arthroplasty implants with predicable results and flexible aftercare. This approach may also provide significant improvement of patient symptoms following correction of deformity resulting in deferment of the arthroplasty surgery.



Philip K. Lim, Bharat Sampathi, Nathan M. Moroski, John A. Scolaro

Acute femoral shortening for reconstruction of a complex lower extremity crush injury

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:5] [Pages No:185 - 189]

Keywords: Femoral shortening, Knee disarticulation, Traumatic amputation, Open femur, Fracture

   DOI: 10.1007/s11751-018-0311-4  |  Open Access |  How to cite  | 


Traumatic through-knee or transfemoral amputations with concomitant ipsilateral femoral fractures are extremely rare injuries. The initial goal of management is patient resuscitation and stabilization. Subsequent interventions focus on limb salvage and the creation of a residual limb that can be fitted successfully for a functional lower extremity prosthesis. We present the case of a patient who sustained a traumatic through-knee amputation ipsilateral to an open comminuted femoral fracture. Soft tissue injury prohibited initial primary closure over the distal femoral condyles. A functional residual limb was achieved with acute femoral shortening, maintenance of the femoral condyles and fracture stabilization with a short retrograde intramedullary nail. This approach allowed maintenance of muscular attachments to the femur, soft tissue closure and resulted in a residual limb of acceptable length with a broad weight-bearing surface that was fitted with a prosthesis successfully.



Dmitry Popkov

Use of flexible intramedullary nailing in combination with an external fixator for a postoperative defect and pseudarthrosis of femur in a girl with osteogenesis imperfecta type VIII: a case report

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:7] [Pages No:191 - 197]

Keywords: Osteogenesis imperfecta type VIII, Flexible intramedullary nailing, External fixation

   DOI: 10.1007/s11751-018-0320-3  |  Open Access |  How to cite  | 


Telescopic rodding has been developed in order to obtain long-lasting osteosynthesis in the growing long bones of children with osteogenesis imperfecta (OI). The major and still unsolved drawback of any telescopic rod or nail design is a lack of rotational stability and, currently, no telescopic system allows immediate weight-bearing. When these problems are associated with insufficient longitudinal bone stability and diminished healing capacity, the result can be unfavourable causing secondary bone fragment displacement, delayed or non-union. This article presents a case report of operative treatment in a 9-year-old girl affected with OI type VIII complicated with postoperative defect and pseudarthrosis of the femur causing functional impairment with loss of walking ability. A combination of intramedullary flexible nailing and minimal external fixation was applied for treatment of femoral defect-pseudarthrosis in a girl of 9 years with OI type VIII. Intramedullary and extramedullary nails with wrapping of titanium nickel mesh subperiosteally provided osteosynthesis and deformity correction of the tibia of a small intramedullary canal diameter. Upright standing and walking with progressive weight-bearing was started 4 days after surgery. There were no septic or vascular complications nor complications related to Ilizarov fixator. Radiographs demonstrated bone union in the femur 46 days after surgery. At the follow-up visit 9 months after fixator removal, clinical alignment remained excellent without any relapse of deformity. Bone remodelling with restitution of medullary canal was noted on lower limb radiographs. The patient was able to stand and walk without pain with an aide or walker. At the follow-up visit 17 months after fixator removal, there was no decrease in achieved functional abilities and the treatment outcome remained satisfactory. Use of an external fixator with intramedullary nailing for treatment of postoperative pseudarthrosis in patient with severe OI (recessive form of OI, type VIII) provides longitudinal, rotational and angular stability. Furthermore, this approach ensured early functional activity and walking with full weight-bearing, both favourable conditions for bone tissue regeneration. The external fixator was applied for a short period and only for additional stability and not for progressive deformity correction or other manipulation. In addition, the combination of intramedullary and extramedullary nailing and subperiosteal titanium nickel mesh seems to be promising for osteosynthesis in the deformity correction of bones with small diameter in children with OI.



Nuno Alegrete

Two consecutive limb lengthenings with the same PRECICE nail: a technical note

[Year:2018] [Month:November] [Volume:13] [Number:3] [Pages:6] [Pages No:199 - 204]

Keywords: Limb, Lengthening, Magnetic, Nail, Deformity

   DOI: 10.1007/s11751-018-0317-y  |  Open Access |  How to cite  | 


Purpose The most significant advance in our time about limb lengthening is the magnetic lengthening nail, as the first reports appeared to show good results with accurate lengthening rates and good regenerate bone formation. The described complication rate is generally low. They avoid external fixation elements, and are activated transcutaneously, so the patient's pain and discomfort are reduced and the rehabilitation is faster and more effective. The aim of authors is to describe a special technical issue of the PRECICE system: the nail can be extended inside the patient limb (after the osteotomy), but it also can be retracted inside the limb after achieving the bone union. Methods The authors present a case in which the limb lengthening has been performed in consecutive lengthening periods using the same nail. The nail was extended and retracted by altering the settings on the external remote control as well as accurately setting the rate of distraction. Results After two consecutive femoral lengthening with the same PRECICE nail, the patient no longer has a significant lower limb length discrepancy and patient satisfaction was high. During this clinical case, we were not confronted with any type of complications. Conclusion This technique utilizes the principles and advantages of lengthening over an magnetic lengthening nail, avoids the necessity of nail removal and minimizes the complication rates and the overall time for complete recovery. Level of evidence Level IV.


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