Strategies in Trauma and Limb Reconstruction

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2021 | May-August | Volume 16 | Issue 2

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Original Article

Pritish Singh, Dhananjay Sabat, Saurabh Dutt, Rakesh Sehrawat, Balu Prashanth, Anubhav Vichitra, Vinod Kumar

Accuracy and Efficacy of Software-guided Bony Realignment in Periarticular Deformities of the Lower Limb

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:6] [Pages No:65 - 70]

Keywords: Deformity severity score, Ilizarov fixator, Ortho-SUV frame, Periarticular deformities, Software-guided bony realignments

   DOI: 10.5005/jp-journals-10080-1524  |  Open Access |  How to cite  | 


Aim and objective: Software-guided realignment is proposed as an easy and accurate method of achieving simultaneous multiaxial correction. The accuracy and efficacy in periarticular problems have not been investigated fully. This study investigates the results and possible clinical benefits. Materials and methods: A retrospective review was performed in 24 patients with 27 periarticular deformities of the lower limb treated by the Ilizarov technique. Bony realignment was achieved by a software-guided hexapod realignment device. The deformity category, deformity severity score (DSS) and individual deformity component scores were measured for objective quantification of each deformity. The periarticular level, number of manoeuvres, correction period and any difficulties in the execution of the correction manoeuvre were noted. Pre-procedure and post-procedure values of deformity parameters were analysed to estimate the accuracy and efficacy of the realignment device. Results: The correction manoeuvre was accomplished successfully in all patients except two. The mean correction period was 14.9 days (range, 5–38 days). The mean pre-procedure DSS was 18.7 (range 6.3–27.3), which reduced to a mean post-procedure value of 1.5 (range, 0–7.9) with a 92.0% deformity correction (p-value < 0.001)). There was a significant reversal of individual deformity components. DSS values were achieved to an excellent level (< 3.5) in 25 deformities and to good and poor levels in one deformity, respectively. Conclusion: Software-guided realignments are effective for accurate realignment of periarticular deformities using Ilizarov fixators. These devices offer simultaneous multidimensional corrections even in complex multiplanar deformities and simplify the task of deformity correction. Clinical significance: The present study assesses the accuracy and efficacy of software-guided realignments using novel concepts of deformity category, DSS and individual deformity component scores, which may overcome some of the shortcomings of conventional assessment methods.


Original Article

James MY Chowdhury, Beth Lineham, Matthew Pallett, Hemant G Pandit, Todd D Stewart, Paul J Harwood

Comparison of Mechanical Performance between Circular Frames and Biplanar Distraction Devices for Knee Joint Distraction

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:7] [Pages No:71 - 77]

Keywords: Arthrodiastasis, Arthrodistraction, Biomechanical study, Circular frame, External fixator, Knee, Knee joint distraction, Knee osteoarthritis, Pain

   DOI: 10.5005/jp-journals-10080-1530  |  Open Access |  How to cite  | 


Aim and objective: This study was designed to test and compare the mechanical performance of the biplanar ArthroSave KneeReviver and a circular frame construct with the intended use of providing a mechanically favourable environment for cartilage regeneration across a knee joint. Materials and methods: Three similar constructs of the two devices were applied to biomechanical testing sawbones, with the knee distracted by 8 mm. The constructs were vertically loaded to 800 N in an Instron testing machine at 20 mm/minute. Tests were conducted in neutral hip flexion and at 12° of hip flexion and extension, to mimic leg position in gait. Displacement measurements were taken from the Instron machine, and three-dimensional joint motion was recorded using an Optotrak Certus motion capture system. Results: Overall axial rigidity was similar between the two devices (circular frame, 81.6 N/mm ± 5.9; and KneeReviver, 79.5 N/mm ± 25.1 with hip neutral) and similar in different hip positions. At the point of joint contact, the overall rigidity of the circular frame increased significantly more than the KneeReviver (491 N/mm ± 27 and 93 N/mm ± 32, respectively, p <0.001). There was more variability between models in the KneeReviver. There was more off-axis motion in the KneeReviver, mainly due to increasing knee flexion on loading. This was exacerbated with the hip in flexion and extension but remained small, with the maximal off-axis displacement being 7 mm/3°. Conclusion: The circular frame provides a similar mechanical environment to the novel KneeReviver device, for which most clinical data are available. These findings suggest that both devices appear a viable option for knee joint distraction (KJD). Further clinical data will help inform mode of application. Clinical significance: KJD is a relatively novel technique for use in osteoarthritis (OA), and it remains unclear which distraction devices provide appropriate mechanics. Our testing gives evidence to support either option for further use.


Original Article

Abdullah A Nada, Mostafa E Hammad, Ahmed F Eltanahy, Ahmed A Gazar, Ahmed M Khalifa, Mohamed H El-Sayed

Acute Correction and Plate Fixation for the Management of Severe Infantile Blount's Disease: Short-term Results

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:8] [Pages No:78 - 85]

Keywords: Blount's disease, Closing wedge osteotomy, Double osteotomy, Hemiplateau elevation, Tibia vara

   DOI: 10.5005/jp-journals-10080-1527  |  Open Access |  How to cite  | 


Purpose: The purpose of this study is to evaluate the short-term results of lateral closing wedge osteotomy with medial hemiplateau elevation for the management of severe infantile Blount's disease. Materials and methods: In this prospective study, 11 cases of severe Blount's disease (Langenskiold stages five and six) were managed in the period between January 2017 and January 2020. Double osteotomy technique was applied, namely a metaphyseal closing wedge and a medial hemiplateau elevation, through a single midline incision. Fixation was achieved by a medial anatomical locked plate. Patients were evaluated clinically according to a modified version of paediatric outcomes data collection Instrument (PODCI) and radiologically by measuring the angle between the tibial and the femoral shaft, the mechanical axis deviation (MAD) and the angle of the medial tibial plateau (MTP) depression. Results: The average follow-up period was 2 years. Healing of the osteotomies was achieved in all cases after the index operation within an average of 3 months. Based on our modification of the PODCI score, five cases had an excellent outcome, five were good, and one case ended with a fair outcome. No major complications were encountered in this study. Conclusion: The management of severe Blount's disease by acute correction using the aforementioned technique has been proven to achieve acceptable clinical and radiological outcomes without significant complications. Level of evidence: Level IV case series study.


Original Article

Vasileios P Giannoudis, Emma Ewins, D Martin Taylor

Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:10] [Pages No:86 - 95]

Keywords: Acute treatment, Ankle arthrodesis, Distal tibia fracture, Functional outcome, Ilizarov, Infection, Pin-site infection

   DOI: 10.5005/jp-journals-10080-1516  |  Open Access |  How to cite  | 


Aims and objectives: To examine clinical and functional outcomes in patients with intra- and extra-articular distal tibial fractures treated definitively by Ilizarov fixation. Materials and methods: Patients with tibial fractures extending within 1 Müller square of the ankle joint were identified from our Ilizarov database over a 5-year period. Data on treatment and outcome were assembled from this database and supplemented by a review of patient records. General measures of health-related quality of life and limb-specific functional outcome scores were recorded. Adverse events were documented according to Paley's classification. Results: One hundred and sixty-eight patients with 169 fractures were identified, 28% were open and 63% intra-articular. One hundred and sixty-five (98%) of the fractures united, two following bone grafting in their original frames, at a median of 166.5 days (range 104–537). Three patients with nonunions united with further treatment. One patient (an end-stage diabetic) elected to undergo amputation following multiple early complications during treatment. Closed fractures united more rapidly than open (median 157 vs 183 days; p = 0.005) and true Pilon (43C3) fractures took longer to unite than other fractures (median 157 vs 177 days; p = 0.01). Sixty-seven percent of patients completed functional outcome scores. Sixty-two percent reported good or excellent ankle scores at more than 6 months post frame removal, 38% fair and 10% poor. Patients with intra-articular fractures reported significantly worse ankle scores than those with extra-articular injuries. General measures of health-related quality of life (EuroQol-5D) revealed significant ongoing effects despite good clinical outcomes. Conclusion: This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries.


Original Article

Om Lahoti, Naveen Abhishetty, Sandesh Shetty

Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7–14-year Follow-up

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:6] [Pages No:96 - 101]

Keywords: Charcot neuroarthropathy, Circular frame, Cohort study, Diabetic foot ulcers, Forefoot butt 6 × 6, Long bone TSF module, Rocker-bottom foot deformity, Taylor spatial frame

   DOI: 10.5005/jp-journals-10080-1525  |  Open Access |  How to cite  | 


Charcot arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. Conventional surgical treatment includes extensive surgical exposure, excision of bone, acute correction and internal fixation, which is not always appropriate in presence of active ulceration, infection and poor bone quality. A minimally invasive approach to osteotomies and gradual correction of deformities using a circular frame are proving helpful in minimizing the complications. Taylor Spatial Frame (TSF) hexapod with its various modules is well suited for a range of foot and ankle deformities. We have advocated minimally invasive targeted hind and mid foot osteotomies and gradual correction with Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. There are 2 female and 8 male patients in this cohort. Appropriate TSF module was chosen for each patient– a long bone module for ankle and hindfoot deformities (4 patients) and a forefoot 6x6 butt frame (6 patients) for foot deformities. An osteotomy through the midfoot was performed in all chronic stable foot deformity cases. In the ankle and hindfoot deformities, a combination of soft tissue distraction correction of equinus and acute correction of hindfoot deformity through a calcaneal osteotomy, were used. Our outcome measures are complete healing of the ulcers and resolution of infection, clinically plantigrade foot and ability to wear regular or diabetic footwear. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. We achieved ulcer and infection free plantigrade feet that fit in to regular or diabetic footwear in 9 out of 10 patients. 9 patients remain ulcer and infection free at a minimum of 7 years and maximum of 14 years follow up. Taylor Spatial Frame treatment provides an alternative to conventional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities.


Original Article

Yvette Godwin, Ahmed Almaqadma, Hafez Abukhoussa, Mohammed Obaid

Stump-plasty: An Operation Born of Necessity in Gaza

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:8] [Pages No:102 - 109]

Keywords: Ballistic injury, Cohort study, Lower limb amputee, Stump-plasty, Stump revision

   DOI: 10.5005/jp-journals-10080-1526  |  Open Access |  How to cite  | 


Aim and objective: The most recent wave of lower limb amputees in Gaza arises from ballistic injuries sustained during protests. This study evaluates the requirement for surgical revision of these mature stumps to allow prosthetic fit and mobility. Materials and methods: A multidisciplinary team (MDT) comprising a prosthetist, orthopaedic and plastic surgeons and a physiotherapist screened 104 amputee stumps (103 cases). The 27 cases selected for surgical revision (stump-plasty) are the subject of this study. The MDT prescriptions of care issued at screening were compared to surgical procedures performed at stump-plasty and the findings. Compliance with the MDT prescription was recorded. Stump issues are identified to propose modifications of primary amputation technique to mitigate future revisions. Patients’ healthcare status was assessed by questionnaire (EQ-5D-L5) at screening, then subsequently post-stump-plasty. Results: More below-knee amputees (BKAs) than above-knee amputees (AKAs) required stump-plasty. Revisions varied according to the quality of tissue present at the amputation level. AKA revisions addressed bulk and contour issues whereas BKA revisions related to bone prominence, neuroma formation and lack of soft tissue cover. Despite many variations in tissue-targeted procedures being possible, the MDT prescription was followed accurately at surgery. Suggested modifications at primary amputation to decrease revisions include improved bone tip bevelling at BKA and greater soft tissue reduction at AKA. Severed nerve management needs to be rationalised to reduce primary neuroma formation and neuroma revision at stump-plasty requires consideration to attempt to reduce the recurrent risk. Removal of the fibular remnant in short BKA stumps at primary amputation could mitigate common peroneal nerve hypersensitivity later. Following stump-plasty, amputees recorded a significantly improved score in three of five dimensions of the EQ-5D-L5 questionnaire: activities, anxiety levels and pain. Conclusion and clinical significance: Primary ballistic injury dictates the level of amputation and the resultant stump quality. Issues arising in these complex amputee stumps benefited from measured decisions and specialist care delivered by the MDT. Stump-plasty aims to improve the amputees’ prosthetic fit, mobility and health.

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Original Article

Markus W Frost, Søren Kold, Ole Rahbek, Molly Duncan

Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE)

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:6] [Pages No:110 - 115]

Keywords: Bone lengthening, Bone lengthening nails, Bone nails, FITBONE, Intraoperative complications, Postoperative complications, PRECICE, STRYDE

   DOI: 10.5005/jp-journals-10080-1529  |  Open Access |  How to cite  | 


Background: Intramedullary lengthening nails have shown excellent short-term results. The FITBONE and the PRECICE nail are the two most commonly used intramedullary lengthening nails. The manufacturer of each nail recommends the removal of the implant after the completion of the treatment. Despite the need for removal of each nail, the authors are not aware of any prior publications documenting the results of standard intramedullary lengthening nail removal. Therefore, the aim of this study was to examine the intraoperative and postoperative complications of elective intramedullary lengthening nail removals. Materials and methods: We performed a retrospective chart review of patients operated with intramedullary lengthening nails at two limb reconstruction centres (one in the United States, and the second in Denmark). Data retrieved from the patient charts included patient demographics, nail information and any complications occurring at or after nail removal. Only lower limb lengthening with FITBONE and PRECICE or STRYDE nails that had an elective nail removal was included. Result: A total of 271 elective nail removals were included in the study. Complications occurred during 3% of the nail removals and in 13% after nail removal. There were 18 reported cases with postoperative knee pain. All these patients had nail removal through the knee joint, representing 8% of the retrograde femur nail removals and 7% of the tibia nail removals. Four postoperative fractures occurred, of which two needed surgery. Eleven percent of femur removals and 26% of tibial removals sustained a complication. Conclusion and clinical significance: This study emphasises the importance of adequate follow-up of the bone lengthening patient even after the nail has been removed. It also shows that the recommended removal of the intramedullary nail (IMN) lengthening nails must be included in studies reporting on the overall risks of complications using bone lengthening nails.


Original Article

Liam Johnson, James McCammon

Correction of Genu Recurvatum Deformity Using a Hexapod Frame: A Case Series and Review of the Literature

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:4] [Pages No:116 - 119]

Keywords: Genu recurvatum, Ilizarov, Osteotomy, Taylor spatial frame

   DOI: 10.5005/jp-journals-10080-1528  |  Open Access |  How to cite  | 


Aim and objective: Genu recurvatum is a rare deformity for which minimal literature exists. Non-operative management typically gives unsatisfactory results. This study aims to evaluate the treatment of genu recurvatum with a hexapod frame. Materials and methods: A single-center retrospective chart review of genu recurvatum cases treated with a hexapod fixator application was performed. Radiographic parameters included the following: leg length discrepancy (LLD), angle of recurvatum, angle of tilt of the tibial plateau, patellar height and anatomic proximal posterior tibial angle (aPPTA). Radiographic and functional results were evaluated. Results: A total of five patients with six limbs corrected with a hexapod frame were found. Aetiology included post-traumatic (2), post-infectious (1) and idiopathic (3). The mean age at application was 13.36 (5.5–18.0) years. The total mean time in the fixator was 225 (160–412) days. The LLD decreased from a mean of 35.6 mm (0.7–50) preoperatively to a mean of 14.8 (1.0–39.3) postoperatively. The average patellar height remained similar 0.97 (0.69–1.2)–0.97 (0.51–1.6). The angle of the tilt of the tibial plateau improved from a preoperative mean of 66° (58.5–73.5°)–92.5° (80–98.5°). The angle of recurvatum improved from a preoperative mean of 26.4° (18.5–31°)–5.0° (0–9°). The aPTTA improved from (102–118°)–85.5° (77–96°). Conclusion: Osteotomy distal to the tibial tuberosity and deformity correction using a hexapod frame allows for multiplanar correction. Throughout treatment, soft tissue management with physical therapy remained key to prevent knee contracture. Clinical significance: A hexapod frame is a safe and accurate technique that allows correction of genu recurvatum along with concomitant deformities with low risk of complications.



Ciarstan McArdle, Stefan Louette, Daniel Wilks, Peter Giannoudis, Waseem Bhat

Distally Based Sartorius Flap for Soft Tissue Coverage of the Distal Femur

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:3] [Pages No:120 - 122]

Keywords: Open distal femur, Sartorius flap, Soft tissue defect

   DOI: 10.5005/jp-journals-10080-1521  |  Open Access |  How to cite  | 


This case report outlines the use of the distal pedicle of the sartorius muscle in the coverage of a large bony and soft tissue defects of the distal femur in a trauma setting.



Poornanand Goru, Syed Haque, Tim Hirst, Gopalkrishna G Verma, Abubakar Mustafa, Amer Shoaib

Regeneration of Fibula Following Distal Fibulectomy for Ankle Arthrodesis Following the Use of Calcium Sulphate Granules: A Case Series and Review of the Literature

[Year:2021] [Month:May-August] [Volume:16] [Number:2] [Pages:4] [Pages No:123 - 126]

Keywords: Calcium sulphate, Fibulectomy, Regeneration

   DOI: 10.5005/jp-journals-10080-1531  |  Open Access |  How to cite  | 


Regeneration of the fibula following partial fibulectomy is a common and well-reported phenomenon in children. However, there is limited literature on the regeneration of fibula in skeletally mature individuals. We report a case series of regeneration of the distal fibula following partial distal fibulectomy. In both these cases, calcium sulphate (Stimulan—Biocomposites, Keele, UK) antibiotic-loaded beads were used for local delivery of a high concentration of antibiotics. However, calcium sulphate worked as an osteoconductive agent and led to regeneration of the fibula. Regeneration of the fibula has its benefits and downside. Regeneration can be beneficial in patients in whom future arthroplasty is considered as total ankle replacement would not be possible in the absence of distal fibula. On the contrary, a regenerated fibula can be a source of ankle pain related to the syndesmotic joint. There is also a report of infection recurring in the regenerated fibula. Hence, while using calcium sulphate beads either as a spacer or as a vehicle for local delivery of antibiotics, the operating surgeon needs to be aware of the risk of regeneration of the fibula if the periosteum is preserved.


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