Strategies in Trauma and Limb Reconstruction

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2024 | January-April | Volume 19 | Issue 1

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British Limb Reconstruction Society Research Collaborative, Simon Matthew Graham

Identifying Research Priorities in Limb Reconstruction Surgery in the United Kingdom

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:8] [Pages No:1 - 8]

Keywords: Deformity, Delphi, Limb reconstruction, Musculoskeletal infection, Non-union research priorities, Trauma

   DOI: 10.5005/jp-journals-10080-1598  |  Open Access |  How to cite  | 


Introduction: Limb reconstruction surgery (LRS) has a wide range of clinical applications within orthopaedic and trauma surgery. We sought a consensus view from limb reconstruction healthcare practitioners across the United Kingdom to help guide research priorities within LRS. Our aim is to guide future clinical research in LRS, and assist healthcare practitioners, clinical academics, and funding bodies in identifying key research priorities to improve patient care. Materials and methods: A modified Delphi approach was used; it involved an initial scoping survey and a 2-round Delphi process to identify the consensus research priorities in both adult and paediatric LRS. Participants were asked to rank approved submitted questions according to perceived importance on a 5-point Likert scale, where 1 represented lowest importance and 5 indicated highest importance. Mean scores were calculated to identify a consensus of the top ten research priorities for adult and paediatric LRS. Results: One hundred and fifteen participants primarily from across the United Kingdom working in LRS contributed to the modified Delphi process. Participants ranked and then re-ranked the presented research topics in terms of perceived importance. This led to the identification of a top ten research priorities in both adult and paediatric LRS, respectively, based on the collective responses of LRS practitioners. The highest-ranked questions in both adult and paediatric practice related to how to best assess and record patient-reported outcome measures (PROMs) in LRS patients. Other priorities included the effectiveness of specialist physiotherapy, the use of patient-focused psychological support, and the use of various operative management strategies for infection and limb length discrepancies. Conclusion: We present a consensus-driven research priority study that outlines the key research topics and themes determined by healthcare professionals within LRS in the United Kingdom. Clinical significance: These questions will assist funding bodies in prioritising where research funding may be best utilised and help drive future improvement in patient care.



Jonathan Ming Ren French, Joshua Filer, Kathryn Hogan, James William Alexander Fletcher, Stephen Mitchell

Computer Hexapod-assisted Orthopaedic Surgery for the Correction of Multiplanar Deformities throughout the Lower Limb

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:6] [Pages No:9 - 14]

Keywords: Chaos, Deformity correction, Hexapod frame

   DOI: 10.5005/jp-journals-10080-1608  |  Open Access |  How to cite  | 


Introduction: Computerised hexapod-assisted orthopaedic surgery (CHAOS) is a method by which complex multiplanar, multilevel deformity can be corrected with a high degree of accuracy utilising minimally invasive techniques within a single operative event. This study's aim was to report the reliability, accuracy and magnitude of correction achieved, alongside patient-reported outcomes and risk factors for complications when using the CHAOS technique throughout the lower limb. Materials and methods: Retrospective review of medical records and radiographs for consecutive patients who underwent CHAOS for lower limb deformity correction at a tertiary centre between 2012 and 2020. Results: There were 70 cases in 56 patients, with the site of surgery being the femur in 48 cases, proximal tibia in 17 and distal tibia in 5 cases. Multiplanar correction was performed in 43 cases, and multilevel osteotomy was undertaken in 23 cases. Fixation was undertaken with intramedullary nailing (IMN) in 49 cases and locked plates in 21. The maximum corrections were 40° rotation, 20° coronal angulation, 51° sagittal angulation and 62-mm mechanical axis deviation (MAD). Deformity correction was mechanically satisfactory in all patients bar one who was undercorrected requiring revision. The mean patient global impression of change (PGIC) score was 6.2 out of 7. Overall complication rate was 12/70 (17%). Complications from femoral surgery included two nonunions, one case of undercorrection, one case of stiffness, one muscle hernia and one pulmonary embolism. Complications from tibial surgery were one compartment syndrome, one pseudoaneurysm of the anterior tibial artery requiring stenting, one transient neurapraxia of the common peroneal nerve, one locking plate fatigue failure, one seroma and one superficial wound infection. Conclusion: Computerised hexapod-assisted orthopaedic surgery can be used for accurate correction of complex multilevel and multiplanar deformities of both the femur and tibia. The risk profile appears to differ between femoral and tibial surgeries, and also to that of traditional circular frame correction. Patients remain highly satisfied with both the functional and symptomatic outcomes.



Isabelle TS Koster, Matthijs M den Os, Martin VH Rutten, Thibault RI van den Dungen, Tim de Jong, Hay AH Winters, Caroline Driessen

The Effect of Regional Anaesthesia on Free Flap Survival in Lower Extremity Reconstructions

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:6] [Pages No:15 - 20]

Keywords: Flap survival, Free flaps, Lower extremity, Peripheral nerve block, Regional anaesthesia

   DOI: 10.5005/jp-journals-10080-1612  |  Open Access |  How to cite  | 


Background: The effect of different modalities of anaesthesia in microvascular free flap surgery has been a topic of ongoing debate. Comparative data to study the effect of general anaesthesia and regional anaesthesia in the form of peripheral nerve blocks (PNBs) on lower extremity free flap survival is lacking to date. This study aims to elucidate the effect of regional anaesthesia on flap survival in lower extremity free flap reconstructions. Methods: A retrospective cohort study of all patients who underwent free vascularised flap reconstruction of the lower extremities between 2012 and 2021 at the Amsterdam University Medical Centre (UMC), The Netherlands, and between 2019 and 2021 at the Radboud UMC, Nijmegen, The Netherlands. In this cohort, we analysed partial and total flap failures. Results: In this cohort, 87 patients received a total of 102 microvascular free flap reconstructions of the lower extremity. In 20.5% of these operations, patients received a supplemental PNB. Total flap failure was 23.8% in the regional anaesthesia group compared to 21% in the group with general anaesthesia only (p = 0.779). Operation time was longer for patients with regional anaesthesia (p = 0.057). Length of stay was on average 2 days shorter for patients with supplemental regional anaesthesia (p = 0.716). Discussion: This is the largest cohort comparing flap survival in patients receiving general anaesthesia to general anaesthesia with a PNB in lower extremity reconstructions to date. We cannot attribute a significant beneficial or detrimental effect of regional anaesthesia to flap survival. High failure rates stress the need for future studies.



Florian A Frank, Eoghan Pomeroy, Andrew J Hotchen, David Stubbs, Jamie Y Ferguson, Martin McNally

Clinical Outcome following Management of Severe Osteomyelitis due to Pin Site Infection

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:5] [Pages No:21 - 25]

Keywords: Local antibiotics, One-stage surgery, Osteomyelitis, Pin site infection, Retrospective cohort study

   DOI: 10.5005/jp-journals-10080-1607  |  Open Access |  How to cite  | 


Aim: This study has investigated cases of pin site infection (PSI) which required surgery for persistent osteomyelitis (OM) despite pin removal. Materials and methods: Patients requiring surgery for OM after PSI between 2011 and 2021 were included in this retrospective cohort study. Single-stage surgery was performed in accordance with a protocol at one institution. This involved deep sampling, debridement, implantation of local antibiotics, culture-specific systemic antibiotics and soft tissue closure. A successful outcome was defined as an infection-free interval of at least 24 months following surgery. Results: Twenty-seven patients were identified (the sites were 22 tibias, 2 humeri, 2 calcanei, 1 radius); about 85% of them were males with a median age of 53.9 years. The majority of infections (21/27) followed fracture treatment. Fifteen patients were classified as BACH uncomplicated and 12 were BACH complex. Staphylococci were the most common pathogens, polymicrobial infections were detected in five cases (19%). Seven patients required flap coverage which was performed in the same operation. After a median of 3.99 years (2.00–8.05) follow-up, all patients remained infection free at the site of the former OM. Wound leakage after local antibiotic treatment was seen in 3/27 (11.1%) cases but did not require further treatment. Conclusion: Osteomyelitis after PSI is uncommon but has major implications for the patient as 7 patients needed flap coverage. This reinforces the need for careful pin placement and pin site care to prevent deep infection. These infections were treated in accordance with a protocol and were not managed simply by curettage. All patients treated in this manner remained infection-free after a minimum follow-up of 2 years suggesting that this protocol is effective. Clinical significance: Pin site infection is a very common complication in external fixation. The sequela of a chronic pin site OM is rare but the implications to the patient are huge. In this series, more than a quarter of patients required flap coverage as part of the treatment of the deep infection.



Shao-Ting J Tsang, Gadi Z Epstein, Nando Ferreira

Critical Bone Defect Affecting the Outcome of Management in Anatomical Type IV Chronic Osteomyelitis

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:6] [Pages No:26 - 31]

Keywords: Cierny and Mader classification, Chronic osteomyelitis, Critical bone defect

   DOI: 10.5005/jp-journals-10080-1610  |  Open Access |  How to cite  | 


Background: The Cierny and Mader classification assists with decision-making by stratifying host status and the pathoanatomy of the disease. However, the anatomical type IV represents a heterogenous group with regard to treatment requirements and outcomes. We propose that modification of the Cierny and Mader anatomical classification with an additional type V classifier (diffuse corticomedullary involvement with an associated critical bone defect) will allow more accurate stratification of patients and tailoring of treatment strategies. Methods: A retrospective review of 83 patients undergoing treatment for Cierny and Mader anatomical type IV osteomyelitis of the appendicular skeleton at a single centre was performed. Results: Risk factors for the presence of a critical bone defect were female patients [OR 3.1 (95% CI, 1.08–8.92)] and requirement for soft tissue reconstruction [OR 3.35 (95% CI, 1.35–8.31)]; osteomyelitis of the femur was negatively associated with the presence of a critical bone defect [OR 0.13 (95% CI, 0.03–0.66)]. There was no statistically significant risk of adverse outcomes (failure to eradicate infection or achieve bone union) associated with the presence of a critical-sized bone defect. The median time to the bone union was ten months (95% CI, 7.9–12.1 months). There was a statistically significant difference in the median time to bone union between cases with a critical bone defect [12.0 months (95% CI, 10.2–13.7 months)] and those without [6.0 months (95% CI, 4.8–7.1 months)]. Conclusion: This study provided evidence to support the introduction of a new subgroup of the Cierny and Mader anatomical classification (Type V). Using a standardised approach to management, comparable early outcomes can be achieved in patients with Cierny and Mader anatomical type V osteomyelitis. However, to achieve a successful outcome, there is a requirement for additional bone and soft tissue reconstruction procedures with an associated increase in treatment time.



Rahul Geetala, James Zhang, Daniel Maghsoudi, Amindu Madigasekara, Matija Krkovic

The Use of the Taylor Spatial Frame in Treating Tibial Osteomyelitis Following Traumatic Tibial Fracture

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:4] [Pages No:32 - 35]

Keywords: Distraction osteogenesis, Ilizarov technique, Osteomyelitis, Taylor spatial frame

   DOI: 10.5005/jp-journals-10080-1613  |  Open Access |  How to cite  | 


Introduction: Tibial osteomyelitis can follow open fractures with bacteria colonising the wound and persisting through biofilm and sequestrum formation. The treatment is complex, requiring eradication through debridement before limb reconstruction, for which the Taylor spatial frame (TSF) is one option. This study evaluates patient outcomes after reconstruction and identifies factors associated with post-operative complications. Materials and methods: Fifty-one cases of tibial osteomyelitis were treated by the Ilizarov technique from 2015 to 2021 at a major trauma centre. Bacterial samples and treatment factors were assessed. Patient outcomes were complication rates and time to bony union. Complications were expressed as odds-ratios (OR) with 95% confidence intervals. Linear regression was used to assess factors associated with time to union. Results: The mean follow-up was 24.1 months with the mean time to radiological union being 11 months. Post-operative complications were noted in 76.5% of patients with pin-site infections most common (52.9%), followed by fracture malunion (29.4%). Smoking was associated with increased fracture malunion (OR = 4.148, 95% confidence Interval [1.13–15.18], p = 0.031). The time to union was positively associated with complications, age and time to full weight-bearing (FWB). All other measured factors were found not significant. Conclusion: Tibial osteomyelitis is treated reliably by debridement and reconstruction using the Ilizarov technique using a TSF application. The most common complication was pin-site infection. Optimising patients through cessation of smoking and encouraging post-operative weight-bearing can reduce the complication rate and improve time to union. Clinical significance: The Ilizarov technique using a TSF can treat significant deformities that result from the management of tibial osteomyelitis.



Bruna S Bezerra, Thaisa A Araujo, Gustavo G Cardonia, João R Lima Couto, Fábio L Rodrigues

The Applicability of Dynamic External Fixator in a Prospective Evaluation of Open Tibial Fracture Treatment

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:4] [Pages No:36 - 39]

Keywords: Bone healing, Complications, Dynamic external fixator, Open tibia fractures, Surgical debridement

   DOI: 10.5005/jp-journals-10080-1606  |  Open Access |  How to cite  | 


Aim: This prospective study assessed the clinical and radiological outcomes of open tibia fractures treated with a dynamic external fixator. Materials and methods: Twenty-five patients underwent surgical debridement and stabilisation with a dynamic external fixator between November 2016 and April 2022. Regular follow-up evaluated bone healing progression. Results: Favourable outcomes were demonstrated in 20 patients. However, there were three cases of non-union, two of which subsequently deformed, and two cases of pin site-related infection. There were no fracture site infections. Conclusion: This study demonstrates the use of dynamic external fixation in the treatment of open tibia fractures. The low incidence of complications suggests its effectiveness and potential.



Andy Craig, Elizabeth Barron, Hemant Sharma, Elizabeth Moulder

Do Patients Achieve “Full Weight-bearing” Immediately Following Application of Circular Frame Fixation of the Lower Limb?

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:5] [Pages No:40 - 44]

Keywords: Early ambulation, External fixators, Recovery of function, Rehabilitation, Tibial Frature, Weight-bearing

   DOI: 10.5005/jp-journals-10080-1605  |  Open Access |  How to cite  | 


Introduction: The decision to use circular frame fixation for lower limb trauma, or elective deformity correction, often accompanies the assertion that the patient will be able to fully weight-bear through the limb immediately following surgery. Materials and methods: About 53 patients underwent retrospective review. Included in the study were current attendees of adult specialist physiotherapy, following circular frame application to the lower leg at our Institution between August 2018 and January 2020. Cases with incomplete data, cases given postoperative status of non-weight-bearing, those with physiotherapy follow-up conducted elsewhere, or cases of polytrauma were excluded from the study. Weight-bearing assessment and rehabilitation supervision were at the discretion of the physiotherapy team. The clinical concept of ‘full weight-bearing’ is poorly defined, but was documented in the context of displaying a stable gait using elbow crutches and subsequently without walking aids. Comparative data was analysed using an unpaired, two-tailed Welch's t-test. Results: Mean postoperative time to full weight-bearing using crutches was 28.3 days (0–159) (n = 40). Mean postoperative time to independent full weight-bearing with no walking aids was 230.6 days (35–393), or 7.1 months (0–12) (n = 34). No significant differences were seen between: • Frames for open injuries (n = 5) vs closed injuries (n = 17; p > 0.4). • Joint-spanning constructs (n = 18) vs non-spanning constructs (n = 21; p > 0.6), or • Treatment of intra-articular injuries (n = 14) vs extra-articular injuries (n = 17; p > 0.2). Interpretation of these results should be made with caution due to sample size. Conclusion: The ability to permit patients to fully weight-bear immediately after surgery is often a distinct advantage of the circular frame over other fixation modalities, for a variety of indications. However, it does not follow that patients are capable of doing so; there is a long dependency on walking aids. This would appear to be the case irrespective of open/closed injuries, intra-/extra-articular injuries, or the use of a spanning construct across the knee or ankle.



Jessica R Pawson, Daniel Church, Joanna Fletcher, Rebecca AL Wood, Catherine Hilton, James Lloyd, Jade Brien, Kathryn C Collins

Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:11] [Pages No:45 - 55]

Keywords: Circular frame, Ex-fix, External fixation, External fixator, Limb reconstruction, Lower limb fracture, Physiotherapy, Rehabilitation, Systematic review

   DOI: 10.5005/jp-journals-10080-1609  |  Open Access |  How to cite  | 


Introduction: External fixation devices are commonly used in orthopaedic surgery to manage a range of pathologies. In this patient population, there is currently no consensus on optimal rehabilitation techniques. There exists a large variation in practice, with a limited understanding of how these affect treatment outcomes. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review was conducted of Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PEDro, and COCHRANE databases, grey literature sources and forward and backward searching of included articles. Studies were selected following rigorous screening with predefined inclusion criteria. Data quality was assessed using validated appraisal tools. Articles were synthesised by rehabilitation type and descriptive analysis was subsequently performed. Results: From 1,156 articles identified, 18 were eligible for inclusion. The overall quality was low, with clinical commentaries and case studies being the most common study type. Studies were synthesised by rehabilitation type, the most common themes being gait re-education, strengthening, therapy-assisted, active exercises and weight-bearing exercises. Conclusion: There is a lack of high-quality evidence to support meaningful recommendations and guide rehabilitation practices for this patient cohort. Further research for patients being treated in external fixation, especially related to the potential effects of physical rehabilitation on bone healing, return of strength, mobility and independent function is likely to have transferability within wider orthopaedic populations. Clinical significance: This systematic review is unable to provide clinical recommendations due to the poor quality of the available literature. However, it is hoped this paper will provide a foundation for further research to improve rehabilitation for patients being treated with external fixation.



Hesham Mohamed Elbaseet, AbdelKhalek Hafez Ibrahim, Nariman Abol Oyoun, Mohamed Abdelhady Abdelzaher, Mohamed Khaled

Management of Combined Fracture Neck of Femur and Femoral Deformity in Osteogenesis Imperfecta Patient: A Case Report

[Year:2024] [Month:January-April] [Volume:19] [Number:1] [Pages:4] [Pages No:56 - 59]

Keywords: Fracture neck of femur, Osteogenesis imperfecta, Proximal femoral deformity, Telescoping nail, Wagner technique

   DOI: 10.5005/jp-journals-10080-1611  |  Open Access |  How to cite  | 


Osteogenesis imperfecta (OI) patients usually sustain repeated fractures from trivial trauma and also have skeletal deformities that affect walking. The bone fragility and repeated fractures produce deformities of the long bones especially in femur and tibia. However, neck of femur (NOF) fractures in OI are rarely described. A 11-year-old male patient known to have OI (Sillence type IV) sustained a NOF fracture after a fall. He also had proximal femoral anterolateral bowing proximally and over an intramedullary (IM) rod inserted 4 years back. He was treated by corrective osteotomy and stabilisation with an IM telescoping nail for the deformed femur and the Wagner technique for the NOF fracture. One year after operation, the patient had recovered satisfactory functional outcome with union of the NOF fracture and correction of the femoral deformity. Conclusion: The method of the Wagner technique can achieve stable fixation for femoral neck fractures and introduces the least interference with concurrent telescoping nail insertion.


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