Strategies in Trauma and Limb Reconstruction

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2014 | August | Volume 9 | Issue 2

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Ewout S. Veltman, Anneluuk L. C. Lindenhovius

Improvements in elbow motion after resection of heterotopic bone: a systematic review

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:7] [Pages No:65 - 71]

Keywords: Heterotopic ossification, Elbow ankylosis, Systematic review, Burn, Brain injury, Elbow trauma

   DOI: 10.1007/s11751-014-0192-0  |  Open Access |  How to cite  | 


Complex elbow trauma, severe burn, or a closed head injury render patients at risk for developing heterotopic ossification around the elbow. When heterotopic ossification restricts elbow motion, some patients request surgical resection. We performed a systematic review of the literature to analyze improvement in elbow motion after resection of heterotopic ossification around the elbow. We found that, on average, etiology had little impact on outcome after resection of heterotopic ossification. Resection of heterotopic bone generally leads to improvement of elbow function.


Original Article

Andreas Leonidou, Krissen Chettiar, Simon Graham, Pouya Akhbari, Konstantinos Antonis, Eleftherios Tsiridis, Omiros Leonidou

Open reduction internal fixation of lateral humeral condyle fractures in children. A series of 105 fractures from a single institution

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:6] [Pages No:73 - 78]

Keywords: Lateral condyle fractures, ORIF, Radiological union, Lateral spurring

   DOI: 10.1007/s11751-014-0193-z  |  Open Access |  How to cite  | 


Lateral humeral condyle fractures account for 17 % of the distal humeral condyle fractures. Displaced and/or rotated fractures require appropriate reduction and stabilisation. There are, however, a number of controversies in the surgical management of these patients. The aim of the present study was to review the results of patients with a displaced lateral humeral condyle fracture treated with open reduction and internal fixation (ORIF). We retrospectively reviewed children treated with ORIF of lateral humeral condyle fractures at a single institution over a period of 13 years. All cases were identified through the trauma register. Case notes and radiographs were retrieved. Fracture classification, mode of fixation, time to union, and final outcomes at the latest follow-up were reviewed. One hundred and five lateral condyle fractures were identified in 76 male and 29 female patients. Average age was 6.2 years. Ninety-two were Milch type II and 13 Milch type I. According to the Jacob's classification, 38 were type II and 67 type III. All fractures were treated with open reduction and fixation with K-wires. Average time to radiological union was 33 days. Follow-up ranged between 2 and 8 years (average 3.2 years). Radiological hypertrophy of the lateral condyle was present in 45 cases (42 %). Three patients developed a pseudo-cubitus varus deformity. Further four patients developed a true cubitus varus. There was one case of superficial infection of the K-wires and one case of delayed union. At the latest follow-up, 96 % of the patients achieved an excellent final result and 4 % a good final result. Our results demonstrate that fracture union and excellent final outcomes can be expected in all patients using our protocol, whereby all patients with a displaced fracture are managed by ORIF with K-wire fixation, with the wires only being removed after there is evidence of radiological union. Compared to recent reports of closed reduction internal fixation, this series demonstrates good results with no complications directly relating to the open reduction technique. Level of evidence Case series, Level IV.


Original Article

Mehmet Nuri Konya, Aykut Özdemir, Hüseyin Yorgancigil, Gökhan Maralcan, Emin Uysal

Open reduction and pinning for the treatment of Gartland extension type III supracondylar humeral fractures in children

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:10] [Pages No:79 - 88]

Keywords: Children, Humerus, Supracondylar fractures, Surgical approaches, Treatment results

   DOI: 10.1007/s11751-014-0198-7  |  Open Access |  How to cite  | 


In this study, we aim to evaluate the clinical and radiological results of children who were treated with four different surgical approaches. In our clinics between February 2004 and November 2012, the children who underwent surgical treatment for supracondylar humeral fractures and whose data were available with regular follow-up of at least 1 year were included in the study. Clinical outcomes were evaluated for 54 patients with Gartland type 3 extension supracondylar fractures. Functional and cosmetic results of the patients were determined according to the Flynn criteria. Mean age of the patients was 4.9 (between 2 and 14) among which 26 of them were girls and 28 were boys. Mean operation time was 45 (35–85) min. Average length of hospital stay (LHS) was 2.9 (1–7) days. Average duration of splints was 3.5 (2–6) weeks, while the average removal period of the wires was 4.6 (3–8) weeks. Mean consolidation time was 4.6 weeks (3–8). Mean follow-up was 14.36 months. In our study, we performed 54 patients functional and cosmetic results. While 48 of the patients had satisfying results (excellent, good, or fair), six of them had unsatisfactory (poor) results. The results of this study suggest that clinical results with surgical treatment of Gartland type 3 extension fractures were satisfactory. However, the delay in the surgical treatment may cause a number of complications.


Original Article

C. Biz, C. Iacobellis

Nailing treatment in bone transport complications

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:8] [Pages No:89 - 96]

Keywords: Bone transport, Distraction osteogenesis, External fixator, Intramedullary nailing

   DOI: 10.1007/s11751-014-0196-9  |  Open Access |  How to cite  | 


A series of cases of reamed intramedullary nailings carried out after complications in regenerated bone and docking site had occurred in bone transport is presented here. Nine patients (femur = 5; tibia = 4) had treatment with resection after open fractures or infection and underwent bone transport. The mean length of regenerated bone was 9.5 cm (range 6–18 cm). After bone transport, the fixator remained in place for a mean period of 12.8 months (range 8–24 months). In six cases (femur 4; tibia 2), the thickness of the cortical wall of the regenerate column was insufficient, and in two of these, there was, in addition, nonunion of the docking site. In the two tibial cases, nailing was carried out shortly after the fixator had been removed and after refracture of the regenerated bone had occurred due to insufficient cortical thickness. In one femur, nailing was carried out for nonunion of the docking site. Follow-up involved clinical and X-ray checks. The mean follow-up was 3.9 years (range 2–6 years). In all cases, union and with complete corticalization of the regenerate column was observed at an average 6 months after nailing (range 4–11 months). Infection occurred in one tibia 4 months after nailing. The infection was treated with antibiotics, and the nail was subsequently removed. We conclude that nailing is a potential solution for regenerated bone and docking site problems but, if used after prolonged periods of external fixation, may necessitate antibiotic therapy for at least 10 days after the fixator has been removed.



Adam S. Bright, John E. Herzenberg, Dror Paley, Ian Weiner, Rolf D. Burghardt

Preliminary experience with motorized distraction for tibial lengthening

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:4] [Pages No:97 - 100]

Keywords: Bone lengthening, Limb length discrepancy, Ilizarov, External fixator, Motorized distraction, Distraction osteogenesis, Tibia

   DOI: 10.1007/s11751-014-0191-1  |  Open Access |  How to cite  | 


Limb lengthening by callus distraction is commonly performed with the use of external fixation. Lengthening is routinely performed by the patient through small increments throughout the course of a day. Ilizarov has shown that both the rate and frequency of distraction are important factors in the quality of osteogenesis. We report the effect of motorized high frequency distraction for tibial lengthening in comparison with manual low-frequency distraction at the same rate. Manual distraction (0.25 mm four times a day) in a group containing 43 tibiae was compared with motorized distraction (1/1,440 mm 1,400 times a day) in a group containing 27 tibiae. There was no significant difference in time to union or in the incidence of complications.


Original Article

Ashraf A. Khanfour, Mohamed M. El-Sayed

Efficacy of a compliant semicircular Ilizarov pin fixator module for treating infected nonunion of the femoral diaphysis

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:9] [Pages No:101 - 109]

Keywords: Femur, Ilizarov, External fixation, Infective nonunion, Compliant

   DOI: 10.1007/s11751-014-0199-6  |  Open Access |  How to cite  | 


Percutaneous transosseous Ilizarov wiring, whilst preferred in the tibia because of its unique properties, carries a high risk of complications in the femur. The aim of this work was to evaluate the efficacy of a more patient-friendly semicircular pin external fixator module built up from parts of the Ilizarov fixator components and its use in managing diaphyseal femoral nonunions. A group of 20 patients with infected diaphyseal nonunions of the femur after internal osteosynthesis were included in this study. The mean age of the patients at the time of surgery was 46 years (range 16–60, SD 15.6). The mean morbidity time since the original trauma was 10.2 months (range 6–15, SD 2.5). All the cases were fixed by the described external fixator module. Bony union with resolution of infection occurred in 18 (94.7 %) out of 19 cases after a mean period in the fixator of 11.2 months (range 8–18 SD 2.9). After a mean follow-up period of 3.5 years (range 2–9, SD 2.6), there were 14 excellent, 3 good, 1 fair and 1 poor results from radiological evaluation and 10 excellent, 7 good, 1 fair and 1 poor results from functional assessment. In conclusion, the described semi-circular pin fixator module is patient-friendly and effective in managing infected nonunions of the femoral diaphysis.


Original Article

Nando Ferreira, Leonard Charles Marais

The effect of HIV infection on the incidence and severity of circular external fixator pin track sepsis: a retrospective comparative study of 229 patients

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:5] [Pages No:111 - 115]

Keywords: HIV, Pin track sepsis, Complication, Ilizarov, Circular external fixator

   DOI: 10.1007/s11751-014-0194-y  |  Open Access |  How to cite  | 


Pin track sepsis is a common complication of circular external fixation. HIV status has been implicated as an independent risk factor for the development of pin track infection and has been cited as a reason not to attempt complex limb reconstruction in HIV-positive patients. This retrospective review of patients treated with circular external fixators looked at the incidence of pin track sepsis in HIV-positive, HIV-negative and patients whose HIV status was unknown. The records of 229 patients, 40 of whom were HIV-positive, were reviewed. The overall incidence of pin track sepsis was 22.7 %. HIV infection did not affect the incidence of pin track sepsis (p = 0.9). The severity of pin track sepsis was not influenced by HIV status (p = 0.9) or CD4 count (p = 0.2). With the employment of meticulous pin insertion techniques and an effective postoperative pin track care protocol, circular external fixation can be used safely in HIV-positive individuals.



Md Sohaib Akhtar, Rabeya Basari, A. H. Khan, Mohd Fahud Khurram

Complex reconstruction after wide excision of juvenile aponeurotic fibromatoses of upper one-third of leg

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:4] [Pages No:117 - 120]

Keywords: Juvenile musculoaponeurotic fibromatosis, Locally aggressive tumor, Complex reconstruction

   DOI: 10.1007/s11751-014-0195-x  |  Open Access |  How to cite  | 


Juvenile musculoaponeurotic fibromatoses are benign tumors which arise from musculoaponeurotic stromal cells. They rarely occur in lower extremity and more rarely in children. They are locally invasive tumors with a high incidence of recurrence after surgery. Hence, wide local excision is the treatment of choice for such tumors. However, complex reconstruction is often required to cover the resulting soft tissue defect. This report presents a 12-year-old boy with a juvenile musculoaponeurotic fibromatosis in the anteromedial aspect of the upper third of a left leg. Following wide local excision, two local flaps, medial gastrocnemius and a distally based peroneal artery perforator flap, were used to reconstruct the soft tissue defect. Reconstruction has provided an acceptable functional and cosmetic result.



Karuppaiah Karthik, Ramon Tahmassebi, Adel Tavakkolizadeh, Jonathan Compson

Management of heterotopic ossification and restricted forearm rotation after tension band wiring for olecranon fracture

[Year:2014] [Month:August] [Volume:9] [Number:2] [Pages:5] [Pages No:121 - 125]

Keywords: Olecranon fracture, Tension band wiring, Heterotopic ossification, Restricted forearm rotation, Proximal radio-ulnar synostosis

   DOI: 10.1007/s11751-014-0197-8  |  Open Access |  How to cite  | 


A 32-year-old lady presented to our clinic with persistent painful restriction of her dominant forearm movements for three months after tension band wiring of olecranon. She had full elbow flexion and extension; however, her forearm rotations were restricted and painful. Investigations revealed prominent tips of the wire, eroding the radial tuberosity with heterotopic ossification between the radius and ulna. As there was no synostosis, the patient had implant exit. During surgery, before implant removal, examination under anaesthesia revealed a mechanical block of the rotation beyond 30° on pronation and supination from neutral. However, after the removal of implant, the mechanical block eased off and with gentle manipulation, full pronation and supination were achieved. At the final follow-up at 6 months, the patient had full pain-free forearm rotation with regression of heterotopic ossification. Our case report highlights the importance of intra-operative assessment of wire tips at full supination and pronation, and in patients with restricted forearm rotation, CT scan may be needed to assess the position of the hardware is essential as it can progress to synostosis. In cases with prominent hardware, removal of the implant may suffice if performed before the development of synostosis


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