Strategies in Trauma and Limb Reconstruction

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2023 | May-August | Volume 18 | Issue 2

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Paul Harwood, Konrad Mader, Selvadurai Nayagam


[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:1] [Pages No:65 - 65]

   DOI: 10.5005/jp-journals-10080-1593  |  Open Access |  How to cite  | 



William Eardley

Obituary - Richard Montgomery

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:1] [Pages No:66 - 66]

   DOI: 10.5005/jp-journals-10080-1593A  |  Open Access |  How to cite  | 



Benjamin Dougal Chatterton, Jan Herman Kuiper, Derfel Pari Williams

Circumferential Periosteal Release to Treat Paediatric Leg Length Discrepancy: Medium Term Outcomes

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:6] [Pages No:67 - 72]

Keywords: Case series, Leg-length discrepancy, Lengthening, Paediatric, Periosteum

   DOI: 10.5005/jp-journals-10080-1591  |  Open Access |  How to cite  | 


Aims: This study aims to report the medium term outcomes of circumferential periosteal release of the distal femur and distal tibia in treating paediatric leg length discrepancy (LLD). Materials and methods: A retrospective case series was performed on all patients undergoing circumferential periosteal release of the distal femur and/or tibia between 2006 and 2019. Data collected included demographics, surgical indications, post-operative leg lengths, and complications. Leg length discrepancy was calculated as actual values and percentages of the longest limb length. Final actual and percentage discrepancies were compared to initial discrepancies using a paired t-test. Patterns of discrepancy over time were analysed using linear mixed models. Results: Eighteen patients (11 males) were identified, who underwent 25 procedures. The mean age at first surgery was 5.8 (range, 2–13). The commonest indication was congenital limb deficiency (7 patients). Five patients underwent repeat periosteal release, and one patient had three releases. The mean follow-up was 63 months [standard deviation (SD), 33.9]. Fifteen patients had sufficient data for statistical analysis. The mean actual discrepancy decreased from 2.07 cm (SD, 1.07) to 1.12 cm (SD, 1.62), and the mean relative discrepancy from 4.3% (SD, 2.8) to 1.5% (SD, 2.4). Significant mean reductions were seen in both actual discrepancies [0.61 cm (95% CI: 0.05–1.16; p = 0.034)], and percentage discrepancy [2.10% (95% CI: 1.0–3.1, p = <0.001]). In five patients, the operated limb overgrew the contralateral limb. Patients whose operated limb overgrew still had a reduction in LLD, with a mean residual discrepancy less than 1 cm (mean 0.7 cm, 95% CI: From −0.9 to 2.4). Conclusion: Circumferential periosteal release produces a significant decrease in both actual and percentage LLD. We believe this procedure is best indicated in younger patients with congenital LLD in whom the discrepancy is predicted to increase as they age. Clinical significance: Circumferential periosteal release produces a significant decrease in LLD. This procedure can be used to manage symptoms during growth, particularly at the point where orthotic usage may become problematic, and to potentially reduce the magnitude of surgery needed at an older age.



Robert Kaspar Wagner, Clara Guarch-Pérez, Alje P van Dam, Sebastian AJ Zaat, Peter Kloen

Antimicrobial Mechanisms and Preparation of Antibiotic-impregnated Cement-coated Locking Plates in the Treatment of Infected Non-unions

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:9] [Pages No:73 - 81]

Keywords: Antibiotic, Cement, Infection, In vitro, Non-union, Osteosynthesis, Plate

   DOI: 10.5005/jp-journals-10080-1586  |  Open Access |  How to cite  | 


Background: Antibiotic-impregnated cement-coated plates (ACPs) have been used successfully for temporary internal fixation between stages in the two-stage treatment of infected non-unions. We describe our approach of using an ACP in the staged treatment of a methicillin-resistant Staphylococcus aureus (MRSA)-infected distal femoral non-union below a total hip prosthesis. In addition, we present the results of an in vitro experiment to provide an in-depth insight into the capacity of ACPs in (i) treating residual biofilm and (ii) preventing bacterial recolonisation. Materials and methods: In the first stage, we used a titanium LISS plate coated with hand-mixed PALACOS with vancomycin (PAL-V) for temporary internal fixation combined with commercially prepared COPAL with gentamicin and vancomycin (COP-GV) to fill the segmental defect. In the second stage, the non-union was treated with double-plate fixation and bone grafting. A Kirby–Bauer agar disc diffusion assay was performed to determine the antimicrobial activity of both ACPs and a drug-release assay to measure antibiotic release over time. A biofilm killing assay was also carried out to determine if the antibiotic released was able to reduce or eradicate biofilm of the patient's MRSA strain. Results: At one-year follow-up, there was complete bone-bridging across the previous non-union. The patient was pain-free and ambulatory without need for further surgery. Both ACPs with COP-GV and PAL-V exerted an antimicrobial effect against the MRSA strain with peak concentrations of antibiotic released within the first 24 hours. Concentrations released from COP-GV in the first 24 hours in vitro caused a 7.7-fold log reduction of colony-forming units (CFU) in the biofilm. At day 50, both COP-GV and PAL-V still released concentrations of antibiotic above the respective minimal inhibitory concentrations (MIC), likely contributing to the positive clinical outcome. Conclusion: The use of an ACP provides stability and infection control in the clinical scenario of an infected non-union. This is confirmed in vitro where the release of antibiotics from ACPs is characterised by an early burst followed by a prolonged sustained release above the MIC until 50 days. The burst release from COP-GV reduces CFU in the biofilm and prevents early recolonisation through synergistic activity of the released vancomycin and gentamicin. Clinical significance: An antibiotic-impregnated cement-coated plate is a useful addition to the surgeon's armamentarium to provide temporary internal fixation without the disadvantages of external fixation and contribute to infection control in an infected non-union.



Ekansh Debuka, Patrick Birkenhead, Sohan Shah, Badri Narayan, Nikolaos Giotakis, Phillipa Thorpe, Simon Matthew Graham, Benjamin E Fischer, Nick Peterson

Penthrox® (Methoxyflurane) as an Analgesic for Removal of Circular External Fixators and Minor Procedures during the COVID-19 Pandemic

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:5] [Pages No:82 - 86]

Keywords: Circular frame, COVID-19, External fixator, Methoxyflurane, Removal, Penthrox®

   DOI: 10.5005/jp-journals-10080-1587  |  Open Access |  How to cite  | 


Introduction: Methoxyflurane has excellent analgesic properties and is approved for use in the United Kingdom and Ireland since 2015. It is currently used in emergency departments for analgesia during fracture reductions. During the COVID-19 pandemic, with theatre access severely restricted, Penthrox® had the potential to provide adequate pain relief to aid frame and wire removal in the clinic setting. Materials and methods: Patients presenting to the limb reconstruction service elective clinic and requiring frame removal or minor procedures were included in the study. Patients with renal, cardiac or hepatic disease, a history of sensitivity to fluorinated anaesthetic agents and those on any nephrotoxic or enzyme-inducing drugs were excluded. All procedures were performed in an appropriate isolated room in the clinic. Patient demographics, procedure details, visual analogue score, Richmond Agitation Scale and patient satisfaction were recorded. Results: A total of 39 patients were included in the study of which 17 had Ilizarov frames removed, 10 had hexapod removals, nine had heel rings removed and three had an external fixator removed. Eleven patients received additional pain relief in the form of oral analgesia. All patients were satisfied or very satisfied with the experience. One patient required a general anaesthetic for the removal of a wire that could not be removed in the clinic due to bony overgrowth. Conclusion: Patient satisfaction was very high (>95%), and it was possible to perform frame removals and minor procedures in the clinic environment during the COVID-19 pandemic. We see potential for regular use of Penthrox® in the future for the removal of external fixation outside of the operating theatre. Clinical significance: Penthrox as an analgesic for frame adjustments and removals is safe and has the potential for significant financial savings for the National Health Service (NHS).



Liam Barnard, Sina Karimian, Patrick Foster, Venugopal K Shankar

Blunt Vascular Trauma in the Lower Extremity at a Major Trauma Centre: Salvage Rate and Complications

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:7] [Pages No:87 - 93]

Keywords: Amputation, Blunt trauma, Lower limb, Limb salvage, Vascular injury

   DOI: 10.5005/jp-journals-10080-1588  |  Open Access |  How to cite  | 


Introduction: Blunt trauma of the lower limb with vascular injury can cause devastating outcomes, including loss of limb and even loss of life. The primary aim of this study was to determine the limb salvage rate of patients sustaining such injuries when treated at Leeds General Infirmary (LGI) since becoming a Major Trauma Centre (MTC). The secondary aim was to establish patient complications. Methods: A retrospective analysis found that from 2013 to 2018, 30 patients, comprising of 32 injured limbs, were treated for blunt trauma to the lower limb associated with vascular injury. Results: Twenty-four patients were male and six were female. Their mean ages were 32 and 49, respectively. Three limbs were deemed unsalvageable and underwent primary amputation; of the remaining 29 potentially salvageable limbs, 27 (93%) were saved. Median ischaemic times for both amputees and salvaged limbs were under 6 hours. Of the 32 limbs, 27 (84%) were salvaged. All amputees had a MESS score ≥ 7, although not all patients with MESS ≥ 7 required amputation. Eleven limbs had prophylactic fasciotomies, three limbs developed compartment syndrome – all successfully treated and three contracted deep infections – one of which necessitated amputation. All but one patient survived their injuries and were discharged from the hospital. Conclusion: Attempted salvage of 27/29 (93%) limbs was successful and all but one patient survived these injuries when treated at an MTC. MESS scoring and ischaemic time are useful but not sole predictors of limb salvage. Complication rates are low but may be significant for their future implications.



Taylor J Reif, Adam Geffner, Jason S Hoellwarth, Austin T Fragomen, S Robert Rozbruch

Precice Stryde® Magnetic Internal Lengthening Nail does not Impair Bone Healing Despite Radiographic and Clinical Symptoms

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:6] [Pages No:94 - 99]

Keywords: Distraction osteogenesis, Limb lengthening, Limb reconstruction, Precice nail

   DOI: 10.5005/jp-journals-10080-1514  |  Open Access |  How to cite  | 


Aims: The Precice Stryde® internal magnetic lengthening nail allowed many patients a full weight-bearing experience during femur and tibia lengthening, but concerns over corrosion, pain and radiographic changes led to the implant's recall. Despite the recall, it is important to understand the rate of these occurrences and their influence on the overall success of the lengthening procedure. We aimed to investigate radiographic changes, patient-reported symptoms and bone healing indices for our cohort of Stryde lengthening. Materials and methods: Our surgical database and electronic medical record system were used to review and document patient demographics, indications for lengthening, length achieved, bone healing index (BHI), location and type of radiographic changes, time until radiographic changes were first visible, presence of pain symptoms (not attributable to surgery or distraction), time to implant removal and if the pain symptoms resolved following implant extraction. Results: From January 2019 to February 2021, 90 Stryde nails (78 femur and 12 tibia) were implanted in 63 patients. The cohort included 48 males and 15 females. The average length [± standard deviation (SD)] achieved was 58.4 ± 22.7 mm. The 66 bones (73%) developed radiographic changes and were found to be 58/78 (74%) femurs and 8/12 (67%) tibias. The average time to initial radiographic changes was 168 ± 108.1 days (femur) and 276 ± 126.8 days (tibia). Late-onset pain developed in 10 femur lengthening (11.1% of all nails) surgeries across eight patients (12.7% of all patients). All patients’ pain resolved; three instances prior to nail removal and the remaining seven after nail removal. No patients were re-presented with worsening pain or radiographic changes following implant removal. Radiographic or symptomatic abnormalities did not impair bone formation. The BHI for femurs with (29.6 ± 16.6 days/cm, n = 58) vs without (29.4 ± 17.9 days/cm, n = 20) radiographic or symptomatic irregularity were nearly identical (p = 0.961). The difference between BHI for tibias with (39.3 ± 7.8 days/cm, n = 8) vs without (86.1 ± 38.2 days/cm, n = 4) radiographic changes was influenced by outliers and underpowered to draw a conclusion. Conclusion: Bone lengthening with the Stryde nail was associated with high rates of radiographic abnormalities, but symptoms were uncommon and resolved with explantation. The radiographic changes did not affect bone healing in the femur. Clinical significance: Radiographic changes including bone hypertrophy and osteolysis were common after bone lengthening with the Stryde nail, but the development of pain following consolidation was rare and resolved with implant removal. The BHI in femurs was not affected by radiographic changes.



Freideriki Poutoglidou, Matija Krkovic

The Cambridge Experience with Lower Limb Long Bone Non-union Following Fixation and the Treatment Algorithm

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:6] [Pages No:100 - 105]

Keywords: Circular external fixator, Femoral non-union, Non-union, Revision surgery, Tibial non-union, Watchful waiting

   DOI: 10.5005/jp-journals-10080-1589  |  Open Access |  How to cite  | 


Aim: Non-unions have been traditionally classified as atrophic, oligotrophic and hypertrophic and their management was primarily dictated by that. In our Unit, we have based our treatment rationale mainly on the stability of the metalwork and the presence of symptoms rather than the radiologic appearance of the non-union or the presence of infection. The aim was to present the treatment algorithm for lower limb long bone non-union following operative fixation. Materials and methods: All patients treated for a femoral or tibial non-union following fixation between 2014 and 2020 in our unit and with a minimum follow-up of 2 years were included. Non-union was defined as having no evidence of fracture healing in any cortices six months after the index procedure. Union was defined as bridging callus in at least three cortices visualized on at least two orthogonal radiographs. Information retrieved included demographic and fracture characteristics, presence of infection, evidence of metalwork stability and treatment. Outcome measures included union rate, time to union and complications. Data were analysed with the Statistical Program for Social Sciences (SPSS) using contingency tables and linear regression. A p-value of less than 0.05 was considered statistically significant. Results: Seventy-seven consecutive patients were included in the study. Union was achieved in 91% of the cases, while union was noted in all the patients treated non-operatively. The mean time to union was 14.49 months (9.98). Complications were encountered in 20 of the patients and the most common were docking site non-union and metalwork breakage. Infection was the only factor that affected time to union in a statistically significant manner (p = 0.006). Conclusion: The results of our study suggest that in cases of long bone non-union following operative fixation using signs of metalwork instability and the presence of clinical symptoms as the main indication for surgical intervention provides a satisfactory outcome. This approach prevented operative management in a large proportion of patients. Clinical significance: This article presents an algorithmic approach that could aid clinicians in their decision-making in long-bone non-union management. Level of evidence: Therapeutic level III.



Andrew G Georgiadis, Nickolas J Nahm, Mark T Dahl

Re-use of Motorised Intramedullary Limb Lengthening Nails

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:5] [Pages No:106 - 110]

Keywords: Limb length discrepancy, Motorised intramedullary lengthening, Sleeping nail, Sleeper nail

   DOI: 10.5005/jp-journals-10080-1592  |  Open Access |  How to cite  | 


Aim: This study reviews the re-use of implanted motorised intramedullary lengthening nails previously used for limb lengthening. Materials and methods: A retrospective review was performed on the re-use of motorised intramedullary lengthening nails. All patients had a magnetically controlled intramedullary lengthening nail in the femur, tibia, or humerus previously utilised for either lengthening or compression. Patients were included if the magnetically controlled intramedullary lengthening nail underwent attempted re-use either in the same lengthening episode or in a temporally separate lengthening treatment requiring another corticotomy. Results: Ten patients with 12 lengthening episodes were analysed including five tibial, five femoral and two humeral segments. Overall, seven of 12 nails (58%) were successfully re-deployed without the need for nail exchange. Two of three nails were successfully retracted and re-used for continued distraction in the same lengthening treatment. Five of nine nails (56%) were successfully reactivated in a subsequent, later lengthening episode. Conclusion: Re-use of a magnetically controlled limb lengthening nail is an off-label technique that may be considered for patients requiring ongoing or later lengthening of the femur, tibia or humerus. Regardless of whether the nail is used in the same lengthening episode or separate lengthening episode, surgeons should be prepared for exchange to a new implant. Clinical significance: Re-use of a magnetically controlled intramedullary lengthening nail will reduce surgical trauma and save implant cost in limb lengthening treatment but may only be possible in half of attempted cases.



Christopher A Iobst, Danielle N Hatfield, Stephen D Forro, Stephen M Quinnan

Magnetically Driven Intramedullary Limb Lengthening in Patients with Pre-existing Implanted Programmable Devices: A Case Series

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:6] [Pages No:111 - 116]

Keywords: Intramedullary limb lengthening, Limb length discrepancy, Pacemaker.

   DOI: 10.5005/jp-journals-10080-1590  |  Open Access |  How to cite  | 


Aim: The aim of the study is to demonstrate the safety and efficacy of the use of magnetically controlled intramedullary nails in patient with programmable implantable devices. Background: Magnetically driven intramedullary limb lengthening devices have revolutionised the field of limb reconstruction. Because the system is powered by strong magnets, there are warnings to avoid the use of the device in patients with implanted programmable devices, such as cardiac pacemakers. Materials and methods: Four patients with three different types of programmable implanted devices presented to two centres for limb lengthening and limb reconstruction. Each patient had a limb length discrepancy and desired correction using an intramedullary lengthening device. After thorough counselling about the potential risks and benefits of the procedure as well as discussions with each patient's medical team, the decision to proceed with surgery was made. Results: All four patients underwent osteoplasty with insertion of a magnetically driven intramedullary lengthening nail. Goal length was achieved with successful consolidation and subsequent nail removal in all patients. There were no malfunctions of the implantable devices during the distraction phase in any of the patients. Conclusion: With proper precautions, intramedullary lengthening can be performed safely and successfully using a magnetically driven nail in patients with previously implanted programmable devices. Clinical significance: This initial experience suggests use of magnetically controlled intramedullary nails in patient with programmable implantable devices can be undertaken safely within constraints of precautions.



Kanu Shimokawa, Hidenori Matsubara, Toshifumi Hikichi, Hiroyuki Tsuchiya

Bone Transport with the Taylor Spatial Frame Technique: A Case Series

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:6] [Pages No:117 - 122]

Keywords: Bone transport, Bone tumour, Non-union, Plate conversion, Taylor Spatial Frame

   DOI: 10.5005/jp-journals-10080-1594  |  Open Access |  How to cite  | 


Aim: Bone transport is a beneficial reconstructive method for bone defects caused by infected non-unions or bone tumours. The Taylor Spatial Frame (TSF) is a three-dimensional corrective external fixator that can be used to achieve bone transport and correct any residual deformities easily at any time. This study reports the results of bone transport using TSF. Materials and methods: This is a retrospective study of ten patients who underwent bone transport using the TSF. The mean age was 32.3 years; the femur was affected in one case and the lower leg in nine. Bone defects were due to infected non-unions in seven cases and bone tumours in three. The duration of external fixation, bone transport distance, distraction index (DI), alignment at the end of correction, leg length discrepancy, and complications were investigated. Results: The average bone transport distance was 76.0 mm. The external fixation period averaged 367 days with the DI at 20.8 days/cm. Deformity at the docking site was assessed to have an average 2.6° deformity and 2.0 mm translation in the frontal view, as well as 3.3° deformity and 3.7 mm translation in the lateral view. The mean leg length discrepancy was 10.9 mm and the percentage of the mechanical axis (%MA) was 40.6%. Four patients underwent plate conversion after correction and two required additional surgery for non-union at the docking site. Bone union was achieved in all patients and there was no reaggravation of infection or tumour recurrence. Conclusion: The TSF allowed for the correction of deformities and translations that occurred during bone transport giving excellent results. However, as with bone transport using this or other devices, additional procedures are often needed to obtain consolidation or docking site union.



DP Motta, JLR Faria, A Couto, DP Aguiar, MVG Amaral, LL Kropf, GAVA Motta, FS Cerqueira, BD Leonetti

Gradual Correction of Valgus Deformities of the Tibia Using a Monolateral External Fixator

[Year:2023] [Month:May-August] [Volume:18] [Number:2] [Pages:10] [Pages No:123 - 132]

Keywords: External fixation, Monolateral, Osteotomy, Tibia deformity, Valgus

   DOI: 10.5005/jp-journals-10080-1585  |  Open Access |  How to cite  | 


Objective: To present a review of patients subjected to gradual correction of a valgus deformity of the tibia using a monolateral external fixator. Method: This retrospective review included patients from January 2012 to May 2022 who met the following inclusion criteria: deviation of mechanical axis of the limb due to valgus deformity of the tibia; tibial deformity in the coronal plane on radiographic examination; a documented outpatient pre-operative evaluation by an orthopaedic surgeon and age between 10 and 70 years. The following exclusion criteria were applied: the presence of another tibia deformity preventing gradual correction using the proposed assembly; skin conditions incompatible with the surgical procedure; inadequate pre- or post-operative radiological evaluation; and insufficient information in the medical records. Results: The mean age of patients with a valgus deformity of the tibia was 30.8 ± 15.9 years. These patients had a body mass index (BMI) of 26.1 ± 5.5 kg/m2. A congenital or developmental aetiology was attributed to 58.3% of the cases. Most commonly, the deformity was found in the middle third of the tibia with a mean deformity of 14.7 ± 6.6 degrees. The total external fixator time ranged from 73 to 229 days (average 149.7 ± 36.1 days). The mean medial proximal and lateral distal tibial angles differed significantly for pre- and post-operative measurements (p ≤ 0.05). There were complications in eight cases; five cases of pin site infections, two cases of medial cortical fracture and one case of peroneal nerve neuropraxia. Conclusion: The proposed correction technique produces a satisfactory angular correction and with similar outcomes as described in the literature.


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