Strategies in Trauma and Limb Reconstruction

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2022 | May-August | Volume 17 | Issue 2

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Original Article

Nihar S Shah, James C Kyriakedes

An MRI-based Study to Investigate If the Patella is Truly Centred between the Femoral Condyles in the Coronal Plane

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:5] [Pages No:63 - 67]

Keywords: Guided growth, Hemiepiphysiodesis, Ideal knee radiograph, Lateral deviation of patella, Orthogonal imaging, Patellar centring

   DOI: 10.5005/jp-journals-10080-1561  |  Open Access |  How to cite  | 


Background: An AP knee radiograph is considered adequate if the patella is centred between the femoral condyles. Our previous studies demonstrated a tendency for lateral patellar deviation on an AP view orthogonal to the posterior femoral condyles. However, findings were based on cadaveric samples limited by the lack of soft tissue effects on patellar positioning. Materials and methods: After excluding those with deformity or damage to osseous or ligamentous structures, 106 knee MRI scans were randomly selected. Patellar centring was calculated as a percentage of total distal femoral intercondylar width and represented how lateral the centre of the patella is located with respect to the midpoint of the femoral condyles. Multiple regression analysis was performed to determine the relationship between patellar centring and age, gender, anatomic lateral distal femoral angle (aLDFA), medial proximal tibial angle (MPTA) and tibial tuberosity to trochlear groove (TT-TG) distance. Results: There were 35 males and 71 females included in the study with a mean age of 29 ± 14 years. Mean patellar centring was 8 ± 4%. There was a statistically significant correlation between TT-TG distance and positive (lateral) patellar centring (standardised β = 0.36, p <0.01). There were no associations between aLDFA and MPTA with patellar centring. Conclusion: This study demonstrates that the patella is rarely perfectly centred and is usually positioned slightly laterally within the femoral condyles in an AP view orthogonal to the posterior aspect of the femoral condyles. The use of supine MRI scans makes this data relevant to a patient on the operating room table.


Original Article

Luigi Meccariello, Vincenzo Caiaffa, Ante Prkic, Denise Eygendaal, Michele Bisaccia, Giuseppe Pica, Sonia Utrilla-Hernando, Roberta Pica, Giuseppe Rollo

Treatment of Unstable Elbow Injuries with a Hinged Elbow Fixator: Subjective and Objective Results

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:6] [Pages No:68 - 73]

Keywords: Complications, Dislocation, Fracture, Hinged external fixator, Instability, Ligament, Outcomes

   DOI: 10.5005/jp-journals-10080-1553  |  Open Access |  How to cite  | 


Introduction: Injuries around the elbow pose a challenging problem for orthopaedic surgeons. The complex bony architecture of the joint should be restored and the thin soft tissue envelope needs to be handled with meticulous care. Elbow instability is a complication seen after dislocations and fractures of the elbow and remains a treatment challenge. The purpose of this study was to provide subjective and objective results following the surgical treatment of unstable elbow dislocations with an external hinged fixation technique. Methods: Forty-six consecutive patients with complex trauma of the elbow with instability after ligament reconstruction were enrolled between January 2017 and December 2019. The parameters used to quantify the subjective and objective functional results were the Mayo Elbow Score (MES, objective) and Oxford Elbow Score (OES, subjective), and clinical stability of the elbow joint. We also performed a radiological follow-up of the fractures. Results: The mean MES and OES scores were good at the 12-month follow-up. We had 38 patients with stable joints and 8 patients with minor instability. Using the stress test, we saw a significant difference in the affected joint under varus stress (6.7 ± 1.8 mm) compared to the healthy joint (5.8 ± 1.2 mm) laterally. Furthermore, medially the gap was significantly larger (5.8 ± 0.8 mm, treated elbow) than the contralateral gap under valgus stress (4.3 ± 0.8 mm) (p <0.001). Twenty-one complications occurred in 46 patients (46%): Seven patients had a clinical change of elbow axis: Three valgus (6%), four varus (9%); Superficial wound infection occurred in one case (2%) and ulnar nerve dysfunction in two (4%). The most common medium-term complication was post-traumatic osteoarthritis in eight cases (17%). Heterotopic ossification occurred in five patients (11%) and elbow stiffness in five cases (11%). Conclusion: The use of the hinged elbow external fixator in the treatment of complex elbow trauma is a valid therapeutic adjunct to ligamentous reconstruction showing encouraging results with acceptable complications.


Original Article

Sabeel Ahmad, Tushar Gupta, Sajid Ansari, Aakriti Jain, Sitanshu Barik, Vivek Singh

Intramedullary Crossed K-wire Fixation for the Hand Fractures is a Useful Treatment Modality: A Prospective Observational Study

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:7] [Pages No:74 - 80]

Keywords: Crossed intramedullary, Hand, K-wire, Metacarpal, Phalanx

   DOI: 10.5005/jp-journals-10080-1556  |  Open Access |  How to cite  | 


Background: Various modalities of treatment have been used for the management of metacarpal and phalangeal fractures which include K-wire fixation, mini plates, lag screws fixation, intramedullary screw fixation and external fixator application. The aim of this study was to analyse complications and patient-related functional outcomes after antegrade or retrograde crossed intramedullary K-wire fixation of metacarpal and proximal phalangeal fractures. Methods: Thirty-one patients (36–fractures, 16–metacarpals, 20–proximal phalanx) meeting the study criteria were included in this prospective study. Fixation of the fractures was done by use of crossed intramedullary K-wire using the principles of 3-point fixation. Results: The mean preoperative angulation of the fractures noted in this study was 35.8° which was significantly reduced at final follow-up. Union was noted at a mean period of 4.2 ± 6.8 weeks. The mean range of motion at the metacarpophalangeal and proximal interphalangeal joint was 96.4% and 86.3%, respectively as compared to the opposite hand. Stiffness (n = 3, 14.2%) and persistent pain (n = 2, 9.5%) at the joints were the most common complications noted in this study. Conclusion: Crossed percutaneous intramedullary fixation of small bone fractures of the hand is a versatile method with advantages such as cost-effectiveness and lesser operative time when compared to other modalities of fixation. Earlier range of motion (ROM) exercises can be started due to preservation of gliding planes, no surgical wound along with good fracture stability and minimal hardware impingement.


Original Article

Michelangelo Scaglione, Francesco Casella, Edoardo Ipponi, Federico Agretti, Simone Polloni, Michele Giuntoli, Stefano Marchetti

Multifocal Humeral Fractures: Clinical Results, Functional Outcomes and Flowchart of Surgical Treatment

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:7] [Pages No:81 - 87]

Keywords: Bone screws, Elbow, External fixators, Fracture fixation, Humeral fractures, Intramedullary, Segmental, Shoulder

   DOI: 10.5005/jp-journals-10080-1559  |  Open Access |  How to cite  | 


Aim and objective: Multifocal fractures of the humerus are rare. The aim of our study is to evaluate the effectiveness of surgical treatment and propose a modification to the Maresca–Pascarella classification. A flowchart for surgical treatment is provided. Materials and methods: Thirty-one patients with multifocal humeral fractures were treated and evaluated. The Maresca–Pascarella classification was used. All were treated using with either plates and screws, external fixation or intramedullary nailing. Functional outcomes were evaluated using the QuickDASH test, the University of California – Los Angeles (UCLA) shoulder score and the Mayo elbow performance score (MEPS). Results: There were 12 Type A, 17 Type B, 1 Type C and 1 of combined fractures of the proximal and distal epiphysis. Of the 31 patients, 5 were lost to the follow-up (FU), 1 died of pulmonary embolism (PE) and the remaining 25 had a mean FU of 19.8 (7–35) months. Three patients had radial nerve damage and 1 went to a non-union that required further surgical intervention. The mean QuickDASH score was 15.7, the average UCLA shoulder score was 26.3 and the mean MEPS elbow score resulted to be 83.0. Conclusion: Although multifocal fractures are severe injuries, patients are able to recover good functionality if treated judiciously. Clinical significance: We proposed a standardised surgical approach based on the fracture characteristics, site and a modified Maresca–Pascarella classification.


Original Article

Jason Ting, Elizabeth Moulder, Ross Muir, Elizabeth Barron, Yvonne Hadland, Hemant Sharma

The Incidence of Deep Infection Following Lower Leg Circular Frame Fixation with Minimum of 1-year Follow-up from Frame Removal

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:4] [Pages No:88 - 91]

Keywords: Deep infection, Frame surgery, Incidence, Periarticular fractures

   DOI: 10.5005/jp-journals-10080-1558  |  Open Access |  How to cite  | 


Aim: Superficial pin site infection is a common problem associated with external fixation, which has been extensively reported. However, the incidence and risk factors with regard to deep infection are rarely reported in the literature. In this study, we investigate and explore the incidence and risk factors of deep infection following circular frame surgery. For the purpose of this study, deep infection was defined as persistent discharge or collection for which surgical intervention was recommended. Materials and methods: This study is retrospective review of all patients who underwent frame surgery between April 1, 2015 and April 1, 2019 in our unit with a minimum of 1 year follow-up following frame removal. We recorded patient demographics, patient risk factors, trauma or elective procedure, number of days the frame was in situ, location of infection and fracture pattern. Results: Three-hundred and four patients were identified. Twenty-seven patients were excluded as they were lost to follow-up or had their primary frame surgery as a treatment for infection. This provided us with 277 patients for analysis. The mean age was 47 years (range: 9–89 years), the male to female ratio was 1.5:1, and 80% were trauma frames. Thirteen patients (4.69%) developed deep infection, and all occurred in trauma patients. Of the 13 patients who developed deep infection, 4 had infection before frame removal, and infection occurred in 9 after frame removal. Deep infections occurred in 8 patients within a year of frame removal and in one patient between 1 and 2 years of frame removal. Within the 13 frame procedures for trauma, 12 were periarticular multi-fragmentary fractures, 3 of which were open, and the remaining were an open diaphyseal fracture. The periarticular fractures were more likely to develop deep infection than diaphyseal fractures (p = 0.033). Twelve patients (out of 13) also had concurrent minimally invasive internal fixation with screws in very close proximity of the wires. Conclusion: The rate of deep infection following circular frame surgery appears to be low. Pooled, multi-centre data would be required to analyse risk factors; however, multi-fragmentary, periarticular fracture and the requirement for additional internal fixation appear to be an associated factor.



Stephen Quinnan

Invited Commentary: The Incidence of Deep Infection Following Lower Leg Circular Frame with Minimum of 1-year Follow-up from Frame Removal

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:1] [Pages No:92 - 92]

   DOI: 10.5005/jp-journals-10080-1563  |  Open Access |  How to cite  | 



David W Shields, Alexis-Dimitris Iliadis, Erin Kelly, Nima Heidari, Bilal Jamal

Pin-site Infection: A Systematic Review of Prevention Strategies

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:12] [Pages No:93 - 104]

Keywords: Classification, Diagnosis, External fixation, Management, Pin-site infection, Prevention, Systematic review

   DOI: 10.5005/jp-journals-10080-1562  |  Open Access |  How to cite  | 


Introduction: Circular frame fixation remains a key tool in the armamentarium of the limb reconstruction surgeon. One of the key drawbacks is the onset of pin-site infection (PSI). As a result of limited evidence and consensus of PSI prevention, a wide variation in practice remains. Aim: The principal aim of this review is to synthesise primary research concerning all aspects of treatment regarded as relevant to PSI in frame constructs. Materials and methods: Comparative studies until week 26, 2021, were included in the trial. Studies were included that concerned patients undergoing management of a musculoskeletal condition in which pin-site care is necessary for over 4 weeks. Results: Eighteen studies over a 13-year period were captured using the search strategy. Sulphadiazine and hydrogen peroxide cleansing was found to reduce PSI, with the use of low-energy fine wires and hydroxyapatite (HA)-coated pins also associated with lower infection rate. The remainder of studies found no significant improvement across interventions. Conclusion: There is no superiority between weekly and daily care. Low-energy pin-insertion technique had lower rates of infection. Sulphadiazine has positive results as a pin-care solution, but more research is necessary to determine the most effective care regime. Current literature is limited by absence of established definitions and by a lack of studies addressing all aspects of care relevant to PSI.



Ahmad S Naja, Nour Bouji, Mohamad Nasser Eddine, Humaid Alfarii, Rudolf Reindl, Yehia Tfayli, Mohamad Issa, Said Saghieh

A Meta-analysis Comparing External Fixation against Open Reduction and Internal Fixation for the Management of Tibial Plateau Fractures

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:12] [Pages No:105 - 116]

Keywords: External fixator, Fracture, Internal fracture fixation, Tibia

   DOI: 10.5005/jp-journals-10080-1557  |  Open Access |  How to cite  | 


Aim: This article aims to compare the outcomes between open reduction and internal fixation (ORIF) and external fixation (ExFix) in tibial plateau fractures. Background: Open reduction and internal fixation and external fixation are common methods for managing tibial plateau fractures without a consensus of choice. Materials and methods: PubMed, Cochrane Library, Ovid, CINAHL®, Scopus, and Embase were searched. Clinical studies in humans comparing ExFix and ORIF for tibial plateau fractures were included. Case reports, pathological, and biomechanical studies were excluded. Two investigators reviewed the studies independently, and any discrepancies were resolved. The quality and heterogeneity of each study were assessed in addition to calculating the odds ratio (OR) of the surgical outcomes and complications at a 95% confidence interval, with p <0.05 as statistical significance. Results: Of the 14 included studies, one was a randomised trial, one was a prospective study, and 12 were retrospective studies. The 865 fractures identified across the studies constituted 458 (52.9%) in the ExFix group and 407 (47.1%) in the ORIF group. Most studies indicated a better outcome for ORIF as compared to ExFix. Open reduction and internal fixation had a lower incidence of superficial infection and postoperative osteoarthritis, while ExFix revealed a lower proportion with heterotopic ossification (HTO). Conclusion: ExFix has a higher rate of superficial infections and osteoarthritis, whereas ORIF has a higher incidence of HTO. Larger studies are needed to compare outcomes and investigate the findings of this study further. Clinical significance: This up-to-date meta-analysis on tibial plateau management will help surgeons make evidence-based decisions regarding the use of ORIF versus ExFix.

Supplementary files



Om Lahoti, Naveen Abhishetty, Mohannad Al-Mukhtar

Transfocal Osteotomy to Treat Shear (Oblique) Non-union of Tibia

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:6] [Pages No:117 - 122]

Keywords: Aseptic non-union, Biomechanics, Cohort study, Compression force, Fracture geometry, Osteotomy, Shear force, Taylor Spatial Frame, Tibia

   DOI: 10.5005/jp-journals-10080-1555  |  Open Access |  How to cite  | 


Aseptic non-unions of tibial shaft fractures often need surgical treatment which carry significant socio-economic implications. The causes for non-union include patient co-morbidities, high energy trauma, open fractures and fracture geometry. Oblique fractures are subject to shear forces and, if not adequately neutralised, will fail to unite. Experiments have shown that callus formation is poor in oblique fractures due to local shear stresses. We report a technique of minimally invasive transfocal transverse osteotomy and compression in a hexapod circular fixator, Taylor Spatial Frame (TSF) for 12 patients treated with a shear non-union of tibia between 2010 and 2019. There are four female and eight male patients. The average age is 49 years (range from 26 to 72 years). The fracture pattern was oblique (30–45°) in all cases. Healing of the non-union occurred in 12 cases with one case needed additional treatment with bone marrow aspirate and demineralized bone matrix. The technique of creating a minimally invasive transfocal transverse osteotomy through the oblique non-union of tibia and the use of a hexapod circular fixator to compress the osteotomy is described and adds to the range of treatments available for aseptic non-union of tibia.



Ahmed H Elhessy, Jessica C Rivera, Henry T Shu, Taj-Jamal Andrews, John E Herzenberg, Janet D Conway

Intramedullary Canal Injection of Vancomycin- and Tobramycin-loaded Calcium Sulfate: A Novel Technique for the Treatment of Chronic Intramedullary Osteomyelitis

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:8] [Pages No:123 - 130]

Keywords: Antibiotic-loaded calcium sulfate, Bone infection, Chronic osteomyelitis, Local antibiotic delivery, Long bone infection, Retrospective review

   DOI: 10.5005/jp-journals-10080-1554  |  Open Access |  How to cite  | 


Aim: In this study, we present a detailed surgical technique for treating chronic osteomyelitis (COM) of the intramedullary canal with injectable tobramycin and vancomycin-loaded calcium sulfate (CS). Background: Chronic osteomyelitis of the long bones has been treated using antibiotic-impregnated polymethyl methacrylate (PMMA), which typically requires a second procedure for removal. Technique: Removal of the infected intramedullary nail (if any), copious irrigation, canal reaming, and intramedullary canal injection of vancomycin- and tobramycin-loaded calcium sulfate as a single-stage procedure for the treatment of COM of long bones. Conclusion: Intramedullary injection of vancomycin- and tobramycin-loaded CS can be used as a single-stage procedure for the treatment of long bone intramedullary COM. Further studies are necessary to compare the long-term outcomes of antibiotic-coated CS vs other antibiotic carriers for infection eradication. Clinical significance: The authors have endeavored to explain the best surgical technique to eradicate long bones COM with injectable tobramycin and vancomycin-loaded CS.

Supplementary files



Ethan Ponton, Ali Bakkai, Douglas J Courtemanche

Late Ankle Reconstruction in a Child with Remote Traumatic Medial Malleolus Loss: Clinical and Radiographic Outcomes

[Year:2022] [Month:May-August] [Volume:17] [Number:2] [Pages:5] [Pages No:131 - 135]

Keywords: Growth arrest, Iliac crest autograft, Lawn mower injury, Leg length discrepancy, Medial malleolus reconstruction, Physeal fracture, Severe open ankle injury, Traumatic bone loss, Varus deformity

   DOI: 10.5005/jp-journals-10080-1552  |  Open Access |  How to cite  | 


Aim: This article aims to describe a novel surgical technique for medial malleolar reconstruction in a young child. Background: Severe open ankle injuries that result in bone and soft tissue loss carry a high risk for complications, especially in children who are still growing. These injuries can cause abnormal growth patterns, degenerative diseases, and recurrent instability. Cases of medial malleolar reconstruction have been previously described but none in a child this young. Case description: We present a case of an 13-year-old girl who suffered an open injury to the medial distal tibia with traumatic loss of the medial malleolus at the age of 2 and later suffered a Salter-Harris II fracture to the ipsilateral distal fibula. She presented with varus alignment, a leg length discrepancy, premature asymmetrical growth arrest, chronic non-union of the distal fibula physeal fracture, and severe attenuation of the deltoid ligament. Her secondary deformities were managed with distal fibula osteotomy and fixation, distal tibial hemi-plafond corrective osteotomy, and medial malleolus reconstruction with iliac crest autograft. Her leg length discrepancy was corrected by epiphysiodesis of the contralateral distal femur and proximal tibia. At the 2-year follow-up, the alignment was well maintained, the graft was healing well, and the patient reported no pain and being able to walk and play sports without a brace. Conclusion: Surgical reconstruction of the medial malleolus with correction for abnormal angulation and leg length discrepancies is critical to promoting healthy growth patterns and quality of life for paediatric patients. This severe open ankle injury can be successfully managed by distal fibula osteotomy and fixation, distal tibial intra-articular osteotomy, and medial malleolus reconstruction with iliac crest autograft. Clinical significance: This novel technique is an effective method for the surgical management of paediatric traumatic medial malleolar bone loss in children who are skeletally immature and are at risk of complications due to further growth.


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