Strategies in Trauma and Limb Reconstruction

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2019 | May-August | Volume 14 | Issue 2

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Original Article

James P McEvoy, Philip Martin, Arshad Khaleel, Shobana Dissanayeke

Titanium Kirschner Wires Resist Biofilms Better Than Stainless Steel and Hydroxyapatite-coated Wires: An In Vitro Study

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:8] [Pages No:57 - 64]

Keywords: Bacterial adhesion, Biofilms, External fixation, Infection, Orthopedics

   DOI: 10.5005/jp-journals-10080-1426  |  Open Access |  How to cite  | 


Aim: External fixation surgery is frequently complicated by percutaneous pin site infection focused on the surface of the fixator pin. The primary aim of this study was to compare biofilm growth of clinically isolated pin site bacteria on Kirschner wires of different materials. Materials and methods: Two commonly infecting species, Staphylococcus epidermidis and Proteus mirabilis, were isolated from patients’ pin sites. A stirred batch bioreactor was used to grow these bacteria as single culture and co-cultured biofilms on Kirschner wires made of three different materials: stainless steel, hydroxyapatite-coated steel and titanium alloy. Results: We found that the surface density of viable cells within these biofilms was 3x higher on stainless steel and 4.5x higher on hydroxyapatitecoated wires than on the titanium wires. Conclusion: Our results suggest that the lower rates of clinical pin site infection seen with titanium Kirschner wires are due to, at least in part, titanium’s better bacterial biofilm resistance. Clinical significance: Our results are consistent with clinical studies which have found that pin site infection rates are reduced by the use of titanium relative to stainless steel or hydroxyapatite-coated pins.


Original Article

Stephen Greenfield, Kelsey M Matta, Thomas H McCoy, Austin T. Fragomen

Ankle Distraction Arthroplasty for Ankle Osteoarthritis: A Survival Analysis

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:7] [Pages No:65 - 71]

Keywords: Ankle arthritis, Ankle distraction arthroplasty, Arthrodiastasis, Avascular necrosis, External fixation

   DOI: 10.5005/jp-journals-10080-1429  |  Open Access |  How to cite  | 


Aim: The treatment algorithm for end-stage ankle arthritis is imperfect. Young or active patients are challenging to treat as fusion and replacement carry predictable consequences. Ankle distraction arthroplasty is a less commonly utilized surgical procedure for the treatment of osteoarthritis of the ankle. The purpose of this study was to report intermediate-term survival of ankle distraction and to identify factors associated with earlier time to failure. Materials and methods: A single-centre, multi-surgeon cohort of 258 cases of ankle arthritis, treated with ankle distraction or ankle distraction with supramalleolar osteotomy (SMO), was identified. Patients were contacted by phone to determine the status of the ankle (natural vs fused/replaced). Data were collected through chart review. This included patient demographics, medical comorbidities, surgical procedure, and X-ray characteristics including pattern and severity. A Cox regression model was used to determine factors associated with failure during 10 years of follow-up. Risk factors were analysed as hazard ratios (HRs) and 95% confidence intervals (CIs). Time to failure was illustrated with Kaplan–Meier (KM) curves. Results: In total, 144 cases were successfully contacted with median follow-up of 4.57 years. In total, 16.7% of ankles failed (24/144). The 5-year survival was 84% (95% CI: 78–91%). In adjusted Cox regression, female sex (HR = 2.68, p = 0.049) and avascular necrosis (AVN) of the talus (HR =3.77, p = 0.041) were significantly associated with failure risk. Conclusion: Avascular necrosis of the talus and male/female gender differences in survival were found to be significant. Our experience shows that ankle distraction is a valid and effective operation for the treatment of end-stage ankle arthritis. Clinical significance: This work is clinically significant in that it demonstrates excellent intermediate-term survival data for hinged ankle distraction for treatment of osteoarthritis of the ankle. Additionally, it evaluated patient and disease characteristics allowing improved patient counselling with regard to survival longevity. Level of evidence: IV cohort study.


Original Article

Alec Lik-Hang Hung, Jeanne M Franzone, Ahmed I Hammouda, Shawn C Standard, Wai-Wang Chau, John E Herzenberg

Bone Ninja Mobile App for Reverse Planning Method in Internal Limb Deformity and Lengthening Surgery

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:5] [Pages No:72 - 76]

Keywords: Bone lengthening, Intramedullary lengthening, Limb deformity, Motorised implantable nail, Reverse planning

   DOI: 10.5005/jp-journals-10080-1425  |  Open Access |  How to cite  | 


Aim: To report whether Bone Ninja (BN) is a reliable tool to teach the reverse planning method (RPM) for implantable intramedullary (IM) limblengthening devices and for deformity correction surgery. Background: Motorised fully implantable implantable intramedullary (IM) lengthening devices have been gaining popularity all over the world for limb-lengthening procedures. Multiple advantages have been demonstrated over external fixator-controlled lengthening. Mechanical axis deviation may result if careful preoperative planning and surgical intervention are not completed for femur cases. The RPM proposed by Baumgart has been shown to be an accurate means of arriving at the desired end point. The RPM addresses the ideal correction position accounting for length, angulation, and translation created during lengthening along the nail axis. The original description calls for the use of life-size paper tracings of the bone and large light boxes to allow planning. We propose an alternative method using a digital tool that is readily available. The BN mobile app was developed for patient/physician education and is available for the Apple iPad platform. Bone Ninja has been shown to have similar accuracy for measurements of the limb length and deformity angles when compared to the gold standard picture archiving and communication systems (PACSs). Technique: We used BN (version 4.2) on an iPad mini to perform the same RPM steps, using the same terminology originally described by Baumgart. Conclusion: Bone Ninja is a simple validated deformity correction tool with accuracy comparable to PACS. It is a reasonable alternative to paper/pencil cutouts for applying RPM for IM limb lengthening and deformity correction surgery. Clinical significance: We proposed a digitised RPM for internal limb-lengthening surgeries, which is highly feasible and practical to use conveniently without the need for the traditional tedious paper-cutting procedure and related equipment.


Original Article

Sherif Dabash, David T Zhang, Austin T. Fragomen

Blocking Screw-assisted Intramedullary Nailing Using the Reverse-rule-of-thumbs for Limb Lengthening and Deformity Correction

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:8] [Pages No:77 - 84]

Keywords: Blocking screw, Deformity correction, Internal lengthening nail, Intramedullary nail, Limb lengthening, Poller screw, Precice

   DOI: 10.5005/jp-journals-10080-1430  |  Open Access |  How to cite  | 


Introduction: Historically, blocking screws have been used to assist in acute reduction of fractures during intramedullary (IM) nailing. The reverse-rule-of-thumbs (RROT) for blocking screws was introduced to facilitate internal lengthening nail use in deformity correction and limb lengthening. Our study investigated the ability of blocking screws, using same principle, to accurately correct long-bone deformity with and without lengthening and to prevent lengthening-induced deformity. Materials and methods: This is an institutional review board (IRB)-approved retrospective study on 86 patients who had IM nail-assisted limb reconstruction of femur or tibia with blocking screws. Surgeries were performed for deformity correction, limb lengthening, or deformity correction and limb lengthening. Data on the following variables were collected: number of blocking screws, distance of each blocking screw to osteotomy, distance of osteotomy from joint line, and amount of lengthening. Mechanical axis deviation (MAD) and joint alignment parameters were measured preoperatively and at the final postoperative follow-up. The primary outcome was the ability to obtain desired MAD and joint orientation angles. Accuracies were reported as postoperative measurements relative to goal. Association for the Study and Applications of the Methods of Ilizarov (ASAMI) scores were collected. Results: The accuracy of deformity correction was within 6 mm from goal, while joint orientation was corrected to within 1.5° of goal. Number of blocking screws did not significantly impact accuracy. Distance of blocking screw to osteotomy and amount of lengthening did not affect accuracy. In femurs, osteotomies greater than 10 cm from the joint line were more accurate in MAD goal (p = 0.017). This result was not replicated in tibias. ASAMI scores were excellent or good. Conclusion: Using RROT configuration, blocking screws were effective in correcting deformities of lower extremity long bones and in preventing deformity during limb lengthening. If positioned correctly, number of screws and their distance to osteotomy did not affect accuracy. Amount of lengthening did not impact accuracy. Distal femoral osteotomy less than 10 cm from knee joint may be challenging even with using blocking screws.


Original Article

Peter Larsen, Jens Traerup, Mindaugas Mikuzis, Rasmus Elsoe

Patient-reported and Functional Outcomes of Bi-condylar Tibial Plateau Fractures Managed by Internal Screw Fixation in Combination with An Ilizarov Fixator: A Case Series of 22 Patients with Long-term Follow-up

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:7] [Pages No:85 - 91]

Keywords: Complex bicondylar tibial plateau fractures: long-term follow-up, Functional outcomes, Internal fixation combined with external ring fixation, Patient-reported outcomes

   DOI: 10.5005/jp-journals-10080-1432  |  Open Access |  How to cite  | 


Introduction: The objective of this case series was to report the long-term patient-reported and functional outcomes of complex bicondylar tibial plateau fractures in patients treated with internal fixation in combination with an Ilizarov fixator. Materials and methods: A retrospective series of cases. Patient-reported, radiological and functional outcomes were obtained with a mean of 9.4 years’ follow-up. Results: Twenty-two patients completed the follow-up. At follow-up, the mean age was 52.2 years, ranging from 26 to 69 years. The gender distribution was 14 males and 8 females. The mean knee injury and osteoarthritis outcome score (KOOS) was pain 72.5, symptoms 62.7, ADL 75.9, sport 35.4, and knee related quality of life (QOL) 56.4. Compared to a reference population, the present study reported worse outcome for the subscales: symptoms, sport, and QOL. The maximal isometric muscle strength for knee extension was 354N for the noninjured leg and 325N for the injured leg (p = 0.27). Assessment of gait functions showed a gait speed of 122.7 cm/second and a cadence of 112.7 steps/minute. Gait speed and cadence showed no significant difference when compared to a reference population. Radiological examination of knee osteoarthritis (OA) showed 6 patients presented with none OA, 13 patients with mild OA, and 3 patients with severe OA. Conclusion: Complex bicondylar tibial plateau fractures are associated with long-term decreased knee structure-specific patient-reported outcome (KOOS). In contrast, most patients presented with satisfactory long-term radiological and functional outcomes. More research is needed to understand the complex association between patient-reported outcomes and radiological and functional outcomes. Level of evidence: IV. Series of cases.



Alexandros Vris, Ossama Al-Obaedi, Kalpesh R Vaghela, Nima Heidari

Treating the Many Using a Few: A Novel Approach for the Application of External Fixators in Mass Casualties

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:2] [Pages No:92 - 93]

Keywords: Dressings, External fixators, Major incidents, Mass casualties, Trauma centers.

   DOI: 10.5005/jp-journals-10080-1428  |  Open Access |  How to cite  | 


Aim: The aim of this is to allow the use of unsterile kit (clamps and rods) in situations where the demand for external limb fixators exceeds the available sterile equipment. Background: In view of the recent rise in violence and terrorist activity, we have to be prepared for situations causing major incidences. These can place a large strain on our operating theaters and the available surgical kit due to the potential number of casualties. Materials and methods: We propose a sterile dressing technique during the application of an external limb fixator that provides an adequate seal around the pin sites and allows the use of simply decontaminated external fixator parts. Conclusion: This technique prevents the intraoperative contamination of the clamps and connecting rods, which allow for a sterile barrier to minimize pin site infections.



Peter Bates, Nima Heidari, Alexandros Vris

All Internal Bone Transport: Use of a Lengthening Nail and Double Plating for Management of Femoral Bone Loss

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:8] [Pages No:94 - 101]

Keywords: Bone loss, Bone transport, Femur, Lengthening nail

   DOI: 10.5005/jp-journals-10080-1431  |  Open Access |  How to cite  | 


Background: A variety of techniques for management of segmental femoral bone loss have been described, each with different advantages and challenges during treatment. The development of motorized lengthening nails has provided a potential for all internal bone transport, avoiding some of the difficulties with external fixation in the femur. At present, there is a limited published literature on experiences in this technique. Aim: The development of this technique aimed to overcome the difficulties previously reported for internal bone transport in the femur, particularly varus deformity and joint stiffness. Technique: We describe the technique of double plating with bone transport utilizing a magnetic lengthening nail to manage segmental femoral bone loss. The benefits of the technique are discussed, along with specific challenges and lessons that have been learned through experience of internal bone transport. Conclusion: Use of a magnetic lengthening nail and double plating as a method of all internal bone transport provides an option for the management of massive femoral bone loss, while avoiding some of the challenges that have been reported with the existing techniques. Clinical significance: This technique provides an additional method in the armamentarium of the trauma or limb reconstruction surgeon treating massive femoral bone loss.



Mauricio LD Mongon, Aurelio L Sposito, George MN Nunes, Bruno Livani, William Belangero

Boyd Amputation Using the Tension Band Technique

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:4] [Pages No:102 - 105]

Keywords: Amputation, Cerclage wiring, Operative surgical procedure, Reconstruction

   DOI: 10.5005/jp-journals-10080-1433  |  Open Access |  How to cite  | 


Background: Amputation at the level of the hindfoot results in an equinus deformity from an imbalance of muscle-tendons acting across the ankle. Boyd’s reconstruction for hindfoot amputations is a well-known technique that retains the calcaneus and fuses it with the distal tibia at the ankle mortise. It provides an excellent weight-bearing stump and in most cases does not require an artificial limb but its use has been restricted because of the difficulty in obtaining high union rates in the tibiocalcaneal fusion. Materials and methods: Five patients (four unilateral and one bilateral) underwent leg amputations from January 2012 to November 2013 using the Boyd technique for reconstructing the stump and were stabilized with a tension band. The study sample consisted of adult patients who had traumatic reasons for the amputation. Patients under 18 years old with a hindfoot that was inadequate for Boyd reconstruction (i.e., insufficient soft tissue coverage or no posterior tibial artery pulse) were excluded. One (case #2) had systemic comorbidities (e.g., hypertension, diabetes, chronic vascular insufficiency) as well as being a smoker. Three men and two women (mean age 39 years; range 21–61 years) were included. Three patients underwent amputation on the right side, one on the left side, and one bilaterally (case #5). All patients presented with Gustillo and Anderson IIIC open fractures. The mean time from lesion to amputation was 2.25 weeks (range 1–4 weeks). The mean follow-up duration was 16 (range 12–24) months. The post-surgery examination included a clinical examination and radiography. A 6 minute walk test (6 MWT) was performed on week 32 after the amputation. This study was carried out with the approval of our institution’s ethics committee. All patients provided a written informed consent form in accordance with the World Medical Association and the Declaration of Helsinki. Results: All six stumps fused successfully. The 6 MWT results were comparable to those found in the literature for other lower limb amputees. Conclusion: The tension band technique used as part of the Boyd amputation to achieve tibiocalcaneal fusion was effective in all five trauma patients. Sound fusion was achieved in all cases with the 6 MWT scores comparable to that in the literature. This technique should be considered an osteosynthesis option for the Boyd procedure. Level of evidence: Level IV, retrospective study.



Ashraf A. Khanfour, Ayman A Khanfour

Vascular Complications during Ilizarov Fixator Surgery to the Femur. Two Case Reports with the Introduction of a Method for Determining the Safe Vascular Corridor Around the Femur

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:5] [Pages No:106 - 110]

Keywords: Femur, Femoral artery, Ilizarov, Pseudoaneurysm, Safe corridor

   DOI: 10.5005/jp-journals-10080-1434  |  Open Access |  How to cite  | 


Aim: To perform an in-depth review of the safe vascular corridor around the femur in order to decrease possible vascular injury. Background: Despite regular use of half pins in the femur, there is no region entirely safe for percutaneous pin placement. Damage to a major nerve or vessel must be avoided at all costs. Vascular complications during Ilizarov fixator surgery to the femur are rare but serious. Case description: Of 306 cases of Ilizarov fixation to the femur in the period from 2002 to 2016, two cases had vascular complications. The first case developed a delayed superficial femoral artery (SFA) pseudoaneurysm and the second case sustained an early deep femoral artery (SFA) injury. Conclusion: The in-depth review of the vascular anatomy around the femur with relevance to the placement of half pins indicates that the femoral shaft segment greatest at risk to lead to a vascular injury lies between the two points: 8 and 24 cm proximal to the adductor tubercle.



Apostolos Dimitroulias, Ryhor Harbacheuski

Ipsilateral Pilon and Calcaneus Fractures: Treatment with Circular Frame without Spanning Ankle Joint

[Year:2019] [Month:May-August] [Volume:14] [Number:2] [Pages:4] [Pages No:111 - 114]

Keywords: Calcaneus fracture, Circular external fixator, External fixator, Ilizarov, Pilon fracture, Taylor spatial frame

   DOI: 10.5005/jp-journals-10080-1427  |  Open Access |  How to cite  | 


This case report describes the treatment of a 48-year-old female patient, smoker, with a closed comminuted pilon fracture (AO/OTA 43-C2.1) and ipsilateral displaced intra-articular calcaneus fracture (AO/OTA 82-C3). Two independent circular frames were applied in a way to preserve tibiotalar range of motion (ROM). The posterior facet of the calcaneus fracture was reduced through a small incision anterior to the tip of the distal fibula. A frame consisting of a two-third ring was applied to the talus and a footplate to the calcaneus was used to hold the reduction of the posterior facet and to correct varus and length. Pilon fracture was similarly reduced with a percutaneous reduction technique and stabilized with the standard two Taylor spatial frame (TSF) rings. During the course of treatment, the tibiotalar joint ROM was maintained. The frame for the calcaneus fracture was removed 10 weeks after the surgery and the frame for the pilon fracture was removed 16 weeks after the surgery. The patient’s last follow-up was 34 months after the injury. She was ambulating independently without limp and she had resumed the preinjury activity level. She had symmetric tibiotalar ROM and 50% reduction in subtalar ROM. The American Orthopaedic Foot and Ankle Society (AOFAS) Ankle–Hindfoot score was 76. Radiographs revealed healed pilon and calcaneus fractures, normal alignment of tibiotalar and subtalar joints, with some arthritic changes present to tibiotalar and subtalar joints. In conclusion, utilization of a “below the ankle” frame for the calcaneus fracture and a standard two-ring frame for the pilon fracture helps to avoid soft tissue complications and preserves tibiotalar ROM.


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