Strategies in Trauma and Limb Reconstruction

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2023 | January-April | Volume 18 | Issue 1

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Selvadurai Nayagam


[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:1] [Pages No:1 - 1]

Keywords: Ilizarov, Instructional, Limb reconstruction

   DOI: 10.5005/jp-journals-10080-1584  |  Open Access |  How to cite  | 


Original Article

Rosalind Groenewoud, Harpreet Chhina, Jeffrey Bone, Sanjeev Sabharwal, Chris Iobst, Anirejuoritse Bafor, Anthony Cooper

Inter- and Intra-rater Reliability of the Checketts’ Grading System for Pin-site Infections across All Skin Colours

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:5] [Pages No:2 - 6]

Keywords: Checketts grading system, Inter-rater reliability, Paediatric, Pin site infections, Skin

   DOI: 10.5005/jp-journals-10080-1581  |  Open Access |  How to cite  | 


The Checketts’ grading system (CGS) is the only classification that provides both a description of how to visually grade the infection and the appropriate course of treatment. There are no studies on the reliability of this system nor on whether skin colour can influence applicability. This study aims to determine the inter-rater and intra-rater reliability of the CGS to assess whether this scale could be used as a universal grading system across all skin colours. A survey consisting of 134 anonymised photographs of pin-site infections was sent out to orthopaedic surgeons specialising in limb lengthening and reconstruction and to patients or carers of individuals who had external fixators. For each photograph, the participants were asked to grade the infection using the CGS, rate their confidence in their chosen grade on a Likert scale and assign a treatment option. The participants were supplied with the CGS at the beginning of the survey, after the 45th and 90th photographs. The inter-rater reliability of the CGS between the surgeons, expressed as an intraclass correlation coefficient (ICC), was poor-to-moderate at both time points (ICC = 0.56 for baseline survey and ICC = 0.48 for follow-up). This was similar for the patient or caretaker group. There was a lower inter-rater reliability for grading of dark skin as opposed to light skin by surgeons but not for patients or caretakers. The inter-rater reliability of treatment decisions between the surgeons was poor at both time points (kappa = 0.30 and 0.22) with similar inter-rater reliability for dark (kappa = 0.26 and 0.23) compared with light skin (kappa = 0.29 and 2.6). This was similar for the patient or caretaker group. The surgeons’ confidence (Table 4) in grading was low (median = 1). The patient or caretaker group's confidence in their grading was modest (median = 2). The reliability of the CGS as assessed here demonstrates poor-to-moderate inter-rater reliability which makes interpretation of published pin site infection rates using this scale difficult. The design of new grading systems will need to consider skin colour to reduce inequities in medical decision-making.


Original Article

Luke Michael Williams, Giles Stamps, Helen Peak, Shiv Kumar Singh, Nicholas Peterson

Circular External Fixator Removal in the Outpatient Clinic Using Regional Anaesthesia: A Pilot Study of a Novel Approach

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:5] [Pages No:7 - 11]

Keywords: External fixator, Frame removal, Limb reconstruction, Relative stability, Regional anaesthesia, Ultrasound-guided nerve blocks

   DOI: 10.5005/jp-journals-10080-1582  |  Open Access |  How to cite  | 


Introduction: External fixator (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under general anaesthesia in an operating theatre. This practice is resource-intensive and limits the amount of time available for other surgical cases in the operating theatre. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate the EF removal in an outpatient setting. Design and methods: This prospective case series evaluated the first 50 consecutive cases of EF removal in the outpatient clinic between 10/06/22 and 03/02/23. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirements and then were asked to evaluate their experience and perceived pain using the visual analogue scale (VAS). Results: Fifty patients were included in the study. The mean age was 46.8 years (range 21–85 years). About 54% of the patients were male patients (N = 27). Post-procedure, all patients indicated positive satisfaction ratings, each participant responded as either ‘satisfied’ (N = 6), ‘very satisfied’ (N = 24) or ‘highly satisfied’ (N = 20). In addition, 90% of the participants reported that they would opt for this method of EF removal again in future. The VAS for pain immediately following completion of the procedure was low, with a mean score of 0.36 (range 0–4), where a score of 0 = ‘No pain’, and 10 = ‘worst pain possible’. The median score was 0. Conclusion: We present the first description of outpatient EF removal using regional anaesthesia, with a prospective case series of 50 fully conscious patients from whom the EF was removed. This novel technique is likely to be cost-effective, reproducible, and safe. This technique reduces the burden of EF removal from an operating list and also improves the patient's experience when compared with other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this technique also demonstrates a method of improving environmental sustainability.


Original Article

Dedi Ho, Raymond W Liu, Philip K McClure

Correlation between Femoral Neck Version, Sagittal Femoral Bowing Angle and Sagittal Offset of the Femoral Head from the Distal Femur Axis in an Osteological Collection

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:4] [Pages No:12 - 15]

Keywords: Femoral anteversion, Osteological study, Sagittal femoral bowing angle

   DOI: 10.5005/jp-journals-10080-1577  |  Open Access |  How to cite  | 


Aim: Radiographic analysis of lower limb alignment is crucial for the planning and evaluation of deformity correction. Assessment in the sagittal plane is often overlooked compared with the coronal plane for a variety of reasons. We aimed to investigate the relationship between the femoral head in the sagittal plane and femoral neck version in the axial plane, and how sagittal femoral bowing angle (sFBA) may contribute. Materials and methods: Twenty-five each of high (1–2 standard deviations above mean), normal (2.5° below to 2.5° above the mean), and low (1–2 standard deviations below the mean) version femurs were randomly selected from an osteological collection database, photographed and measured for sFBA and sagittal offset of femoral head from the distal femur axis. Lines were drawn within the proximal and distal quartiles of the shaft to create sFBA. The offset of the distal quartile line and the femoral head was also measured. High intra- and inter-observer correlations were established. The relationship between parameters was assessed using the Pearson coefficient (r). Results: Sagittal offset of the femoral head from the distal femur axis was found to be highly correlated with sFBA (r = 0.78), and only mildly with femoral neck version (r = 0.52). Sagittal femoral bowing angle and femoral neck version share no relationship (r = 0.05). Conclusions: Neither the sFBA nor sagittal femoral head offset is strongly associated with femoral neck version. Clinical significance: Our data reinforce the need for long leg lateral films to include the femoral head in sagittal deformity analysis, as imaging limited to the knee will not account for the effect of bowing on femoral head position.


Original Article

Mohamed Hafez, Nicolas Nicolaou, Amaka Offiah, Phillips Obasohan, Simon Dixon, Stephen Giles, Sanjeev Madan, James Alfred Fernandes

How Much Does Paediatric Femoral Lengthening Cost? A Cost Comparison between Magnetic Lengthening Nails and External Fixators

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:5] [Pages No:16 - 20]

Keywords: Cost analysis, Distraction osteogenesis, External fixator lengthening, Femoral lengthening, Hybrid lengthening, Intramedullary lengthening, Lengthening nail, Limb lengthening, Motorised implantable nail, Short stature

   DOI: 10.5005/jp-journals-10080-1573  |  Open Access |  How to cite  | 


Aim: Motorised intramedullary lengthening nails are considered more expensive than external fixators for limb lengthening. This research aims to compare the cost of femoral lengthening in children using the PRECICE magnetic lengthening nail with external fixation. Methods: Retrospective analysis of 50 children who underwent femoral lengthening. One group included patients who were treated with PRECICE lengthening nails, the other group included patients who had lengthening with external fixation. Each group included 25 patients aged between 11 and 17 years. The patients in both groups were matched for age. Cost analysis was performed following micro-costing and analysis of the used resources during the different phases of the treatments. Results: Each group's mean patient age was 14.7 years. Lengthening nails were associated with longer operative times compared with external fixators, both for implantation and removal surgery (p-values of 0.007 and < 0.0001, respectively). Length of stay following the implantation surgery, frequency of radiographs and frequency of outpatient department appointments were all lower with lengthening nails. The overall cost of lengthening nails was £1393 more than external fixators, however, this difference was not statistically significant (p-value = 0.088). Conclusion: The difference in the mean costs between femoral lengthening with lengthening nails versus external fixators was not statistically significant. Further research to review the effectiveness of the devices and the quality of life during the lengthening process is crucial for robust health economic evaluation.


Original Article

Ashish Mittal, Sachin Allahabadi, Rishab Jayaram, Abhinav Nalluri, Matt Callahan, Sanjeev Sabharwal

Trends and Practices in Limb Lengthening: An 11-year US Database Study

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:11] [Pages No:21 - 31]

Keywords: Distraction osteogenesis, External fixator lengthening, Hybrid lengthening, Intramedullary lengthening, Lengthening nail, Limb lengthening, Motorised implantable nail, Short stature

   DOI: 10.5005/jp-journals-10080-1574  |  Open Access |  How to cite  | 


Aim: Over the past couple of decades, limb lengthening has evolved to encompass various implants and techniques. The purpose of this study was to (1) determine trends in the utilisation of various limb lengthening techniques for the femur and tibia in the United States, (2) determine trends in 1-year readmission rate following limb lengthening procedures and (3) to study the relationship of limb lengthening implant used and payment method used with the underlying diagnosis associated with limb shortening. Materials and methods: Inpatient data were acquired using the Healthcare Cost and Utilisation Project (HCUP) database from 2005 to 2015 from seven states in the United States. Patients with an International Classification of Diseases (ICD)-9 code for limb lengthening of the femur or tibia were included. A total of 2,563 patients were included. Data were analysed using descriptive statistics, and chi-square test was used for comparison of subcategories. Linear regression analysis was used to examine trends over time. Results: There was a strong linear trend towards increasing proportional use of internal lengthening of the femur from 2011 to 2015 (R2 = 0.99) with an increase of 10.2% per year. A similar trend towards increasing proportional use of internal lengthening of the tibia was seen from 2011 to 2015 (R2 = 0.87) with an increase of 4.9% per year. There was a moderate correlation showing a decrease in readmission rate of 1.07% per year from 2005 to 2015 (R2 = 0.55). Patients with short stature had increased use of internal lengthening and self-payment compared to patients with congenital, post-traumatic or other diagnoses. Conclusion: There was increasing use of internal lengthening techniques from 2011 to 2015. Patients with short stature had higher use of internal lengthening technique and self-pay for payment method. Clinical significance: Intramedullary devices have seen increasing use for limb lengthening procedures. Lengthening technique and payment method may differ by underlying diagnosis.


Original Article

Chun Hong Tang, Abdullah Addar, James A Fernandes

Amputation vs Reconstruction in Type IV Tibial Hemimelia: Functional Outcomes and Description of a Novel Surgical Technique

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:5] [Pages No:32 - 36]

Keywords: Amputation, Deformity correction, Limb reconstruction, Skeletal dysplasia, Tibial hemimelia

   DOI: 10.5005/jp-journals-10080-1576  |  Open Access |  How to cite  | 


Introduction: The management of tibial hemimelia can be complex and involve either amputation or reconstruction. The decision made carries significant implications on patients and their families. This is a case series in the management of Type IV tibial hemimelia with a description of a novel surgical technique in the reconstructive arm of the pathway. Materials and methods: The study included four patients with bilateral tibial hemimelia have an amputation in one limb and reconstructive surgery on the other. The reconstruction involved a supratalar double osteotomy of the tibia and fibula, followed by a staged hindfoot osteotomy using a circular ring fixator. Functional outcomes are reported using the Special Interest Group in Amputee Medicine (SIGAM) and the short form 12 (SF-12) methods. Results: The mean age of patients in our cohort is 14 years (3–27 years) with mean age of surgery at 3 years. One case had an amputation following initial reconstructive surgery due to psychological distress and regressive behaviour. SIGAM functional outcome scores of F were recorded in three of four cases, with one patient performing at level B. On the reconstructive side, two of three patients reported a mean physical short form 12 (SF-12) score of 56.7 and a mental SF-12 score of 55.7. One patient reported a physical SF-12 score of 28.5 and a mental SF-12 score of 30.3. Discussion and conclusion: A reconstructive option provides a satisfactory functional outcome, comparable to the population mean, in the majority of patients in our cohort. Clinical significance: A staged supratalar double osteotomy followed later by a hindfoot osteotomy is effective in centralising the ankle and creates a plantigrade weight-bearing platform for ambulation in patients with Type IV tibial hemimelia.



Beth Lineham, Bernard van Duren, Hemant Pandit

The Feasibility of Hinged Knee Arthrodiastasis for Cartilage Regeneration: A Systematic Review of the Literature

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:7] [Pages No:37 - 43]

Keywords: Arthrodiastasis, Arthrodistraction, Cartilage, Knee joint distraction, Range of motion

   DOI: 10.5005/jp-journals-10080-1578  |  Open Access |  How to cite  | 


Introduction: Knee joint distraction (KJD) is a potential technique for cartilage regeneration in young patients with osteoarthritis of the knee. Static distraction has been utilised typically; however, a significant proportion of patients complain of knee stiffness post-distractor removal. The use of a hinged distractor may reduce the duration and severity of post-treatment knee stiffness by maintaining the range of motion during distraction. Furthermore, improved cartilage regeneration has been demonstrated in hinged ankle joint distraction as compared to static, and this may also be demonstrated at the knee. An evidence review was undertaken to inform further research and a potential change in practice. Aim: A systematic review of all primary research on hinged knee joint distraction for cartilage regeneration. Methods: An online systematic search of citation databases was conducted. Quality assessment and data extraction were undertaken by two separate researchers. Results: The literature search returned a small number of relevant studies, of which 7 were included. Three of these were animal studies, two cadaveric and two case series. The study quality was low or very low. There was significant methodological heterogeneity with difficulties encountered in the transfer of constructs from animal and cadaveric studies to humans. Issues faced included difficulties with hinge placement and pin site pain in motion. Conclusion: The feasibility of hinged knee joint distraction has yet to be proven. Any further research attempting to establish the benefits of hinged-over static knee distraction will have to take construct design considerations into account.



Sebastien Viaud-Ambrosino, Jean-Baptiste de Villeneuve Bargemon, Najib Kachouh, Andre Gay, Alice Mayoly, Regis Legre, Charlotte Jaloux, Caroline Curvale

Free Fibula Flap in Traumatic Femoral Bone Reconstruction: A 10-year Review

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:7] [Pages No:44 - 50]

Keywords: Bone reconstruction, Femoral reconstruction, Free fibula flap, Loss of bone substance

   DOI: 10.5005/jp-journals-10080-1575  |  Open Access |  How to cite  | 


Introduction: The loss of femoral bone substance represents a major therapeutic issue. When the loss of bone substance is extensive, or the local condition is unfavourable, there are few satisfactory solutions. In this study, we share our experience of large femoral bone reconstruction by free fibula flap. Materials and methods: A retrospective monocentric chart review (2007–2017) was performed for 26 patients after receiving a pure bone-free fibula flap operation. The times of consolidation and hypertrophy of the graft were analysed according to the fixation with a 2-year follow-up. Results: The time to consolidation was 8.7 months (range, 6–15) for double plates, 7.2 months (range, 5–11) for locked plates, 6 months (range, 5–7) for external fixators and plate blades and 8 months (range, 7–9) for intramedullary nails. Full weight-bearing was resumed at an average of 6.5 months (range, 5–10) postoperatively. It was authorised at 7 months (range, 5–10) for patients fixed by double plate, at 6.3 months (range, 5–9) for those fixed by a locked plate, at 5.5 months (range, 5–6) for those fixed by an external fixator or plate blade and at 7 months for those fixed by an intramedullary nail. Conclusion: Free fibula flap remains reliable in the face of a great loss of bone material after trauma, with high consolidation rates. The choice of fixation must be reasoned and should offer a compromise between stability, allowing consolidation and hypertrophy of the graft, and rigidity, exposing the risk of massive osteosynthesis dismantling. Other multicentric studies, including more patients, should be carried out to compare the techniques of fixation.



Muadh AlZeedi, J Patrick Park, Yousef Marwan, Khaled Mousa Abu-Dalu, Reggie Hamdy, Chantal Janelle

Growth Modulation for the Treatment of Juvenile Hallux Valgus: A Systematic Review of Literature

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:5] [Pages No:51 - 55]

Keywords: Epiphysiodesis, Growth modulation, Hemiepiphysiodesis, Juvenile hallux valgus, Paediatric hallux valgus

   DOI: 10.5005/jp-journals-10080-1579  |  Open Access |  How to cite  | 


Background: Juvenile hallux valgus (JHV) is a forefoot deformity that causes pain and functional limitation. Treatment poses a challenge in terms of the optimal technique and timing of intervention. A systematic review of the literature on the use of growth modulation in treating JHV was conducted. Materials and methods: The literature review was performed using PubMed and EMBASE searches for articles investigating growth modulation in the treatment of JHV published before December 1st, 2021. Seven articles were included in the final review that matched the inclusion and exclusion criteria. The primary outcomes included the degree of correction of hallux valgus angle and intermetatarsal angle. A qualitative assessment of the articles was done due to the heterogeneity of the growth modulation methods used in these articles. Results: A total of 135 feet from 78 patients were included from the reviewed articles. Growth modulation methods included temporary screw lateral hemiepiphysiodesis of the first metatarsal, lateral drilling hemiepiphysiodesis of the first metatarsal, and a trephine plug removal of the lateral epiphysis followed by cancellous bone graft insertion. The degree of correction of the hallux valgus and intermetatarsal angles were found to be statistically significant in all studies, regardless of the technique. Conclusion: Growth modulation for JHV by lateral hemiepiphysiodesis using minimally invasive techniques produced favourable radiologic outcomes with some evidence of clinical improvement. Larger, prospective and comparative studies with objective clinical outcome measures may further consolidate this surgical approach as a mean to treating this deformity.



Neil Eisenstein, Ben Fisher, Selvadurai Nayagam

Tibialis Posterior Tendon Transfer for the Management of Foot Drop

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:7] [Pages No:56 - 62]

Keywords: Ankle, Compartment syndromes, Peroneal neuropathies, Tendon transfer

   DOI: 10.5005/jp-journals-10080-1583  |  Open Access |  How to cite  | 


The transfer of a normal tibialis posterior through the interosseous membrane to the dorsum of the foot can restore active ankle dorsiflexion where this has been lost from common peroneal injury, anterior compartment muscle loss, or in some neurological conditions. An appraisal of the indications, planning, and a step-by-step description is provided.



Elizabeth K Tissingh, Jonathan Wright, Peter Calder

Early Weight Bearing in Lengthening Nails

[Year:2023] [Month:January-April] [Volume:18] [Number:1] [Pages:1] [Pages No:63 - 63]

Keywords: Distraction osteogenesis, External fixator lengthening, Hybrid lengthening, Internal lengthening nail, Intramedullary lengthening, Lengthening nail, Limb lengthening, Motorised implantable nail, Short stature

   DOI: 10.5005/jp-journals-10080-1580  |  Open Access |  How to cite  | 


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