Aims. To compare results of institutional preferences with regard to treatment of soft tissues in the setting of open tibial shaft fractures. Methods. We present a retrospective review of open tibial shaft fractures at two high-volume level 1 trauma centres with differing practices with regard to the acute management of soft tissues. Site 1 attempts acute primary closure, while site 2 prefers delayed closure/coverage. Comparisons include percentage of primary closure, number of surgical procedures until definitive closure, percentage requiring soft tissue coverage, and percentage of 90-day wound complication. Results. Overall, there were 219 patients at site 1 and 282 patients at site 2. Differences in rates of acute wound closure were seen (168 (78%) at site 1 vs 101 (36%) at site 2). A mean of 1.5 procedures for definitive closure was seen at site 1 compared to 3.4 at site 2. No differences were seen in complication, nonunion, or amputation rates. Similar results were seen in a sub-analysis of type III injuries. Conclusion. Comparing outcomes of open tibial shaft fractures at two institutions with different rates initial wound management, no differences were seen in 90-day wound complications, nonunion rates, or need for amputation. Attempted acute closure resulted in a lower number of planned secondary procedures when compared with planned delayed closure. Providers should consider either acute closure or delayed coverage based on the injury characteristics, surgeon preference and institutional resources without concern that the decision at the time of index surgery will lead to an increased risk of complication. Cite this article: Bone Joint Open 2020;1-8:481–487

Introduction: A successful total knee replacement (TKR) relies upon effective soft tissue management. Historically, soft tissue balancing has been difficult to assess and quantify intraoperatively. Computer navigation permits us to accurately assess kinematics during surgery. In a previous study we performed a series of varus and valgus stress measurements in extension to devise an algorithm for soft tissue management. In this study we evaluate the effectiveness of this algorithm. Methods: This prospective study used the Orthopilot® CT-free navigation system during TKR for 57 patients with end-stage arthritis. We collected intraoperative kinematic data for 42 varus knees. Pre- and post-operatively, a varus and valgus stress was applied at maximum extension, recording the mechanical femorotibial (MFT) angle. There were no patellar resurfacings. The following medial releases were performed based upon the kinematics and the algorithm below:. No release–MFT angle not less than −12° with varus stress, greater than 2° with valgus stress, and/or if extension deficit was not greater than 5°. Moderate release–MFT angle less than −12° with varus stress, between −5° and 2° with valgus stress, and/or extension deficit not greater than 5°. Proximal release–MFT angle less than −12° with varus stress, less than −5° with valgus stress, and/or extension deficit greater than 5°. Results: Pre-operatively, the mean MFT angle was −9.6°varus (−3° to −22°) with varus stress and −0.8°varus (4° to −11°) with valgus stress. Post-operatively, the mean MFT angle was −3.5° varus (0° to −5°) with varus stress, and 2.1° valgus (4° to −1°) with valgus stress. Using regressional analysis, there was a strong linear correlation between both varus (r=0.871, p< 0.0001) and valgus (r=0.894, p< 0.0001) stresses and the MFT angle. Post-operatively, the mean MFT angle was maintained within a narrow range (0° to −5° with varus stress, 4° to −1° with valgus stress), with no outliers. There were no extension deficits. Conclusions: Using computer navigation a quantifiable soft tissue management system was introduced. We evaluated this algorithm, and obtained reproducible results within a narrow range and no outliers. This algorithm may provide an effective soft tissue management plan in TKR

Total knee replacement (TKR) has become the standard procedure in management of degenerative joint disease with its success depending mainly on two factors: three dimensional alignment and soft tissue balancing. The aim of this work was to develop and validate an algorithm to indicate appropriate medial soft tissue release during TKR for varus knees using initial kinematics quantified via navigation techniques.

Kinematic data was collected intra-operatively for 46 patients with primary end-stage osteoarthritis undergoing TKR surgery using a CT-free navigation system. All patients had preoperative varus knees and medial release was made using the surgeon’s experience. From this data an algorithm was developed to define the medial release based on the pre-operative mechanical femoral-tibial angle with valgus stress;

No release (tibial cut only) when valgus stress > −2/3°. Moderate release (medial aspect of tibia +/− semimembranosous tendon) when valgus stress > −5° and < −2°. Extensive release (proximal) when valgus stress < −5°. If there was a fixed flexion deformity > 5° then a posterior release was performed.

This algorithm was validated on a further set of 35 patients where it was used to determine the medial release based only on the kinematic data. The post-operative varus and valgus stress angles for the two groups were compared and showed good outcomes in terms of distribution and outliers.

The results showed that the algorithm was a suitable tool to indicate the type of release required based on intra-operatively measured pre-implant valgus stress and extension deficit angles. It reduced the percentage of releases made and the results were more appropriate than the decisions made by an experienced surgeon.

Traditional teaching, and indeed the impression from the BOA BAPS working party report on open tibial fractures, suggests that soft tissue cover of the distal third of the leg will often need a free flap.

However, more recently with the introduction of propeller flaps by Quaba, and the reintroduction of the concept of Ponten's nerve oriented flaps with the reverse sural artery flap, the role of free tissue transfer comes into question. The attraction of local flaps for distal third fractures is the reduced operating time, reduced morbidity of donor site, versatility and reliability. However, detractors would argue that muscle enhances bone union and reduces local infection. Previous reviews of lower limb soft tissue cover look at all areas of the leg. This series of 30 (14 free and 16 local flaps) cases looks exclusively at the distal third fractures, compares the complication rate of free versus local flaps and looks at the change in approach to distal third fractures with the more recently described fascio-cutaneous flaps. Our results challenge the conventional teaching and indicate that fasciocutaneous flaps can play a more active role in distal third fractures.

Our study shows that the local flaps are a valuable alternative to free flaps for managing soft tissue defects in distal third fractures of tibia especially in smaller wound size and low energy fractures. The advantages are lesser operating time, reliability, versatility, lesser wound complication and osteomyelitis incidence, earlier flap cover and lesser post op morbidity leading to shorter hospital stay. The free flaps on balance are probably better with larger soft tissue defects and with more severe limb injury. This supports the use of fascio-cutaneous flaps in distal third tibial fractures.

Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery

Introduction. Fracture related infection (FRI) is a challenging complication to manage in an orthoplastic setting. Consensus guidelines have been created to standardise the diagnosis of FRI and comprise confirmatory and suggestive criteria. In this study, the aim is to assess the diagnostic criteria and management of FRI with a particular focus on soft tissue reconstruction. Materials & Methods. A retrospective study to identify the outcomes of FRI in the lower limb over a five year period at a Major Trauma Centre. Fracture specific information that was analysed includes: open versus closed, fractured bone(s) and site, initial fracture management, method of diagnosis and soft tissue management. Results. A total of 40 patients were identified, 80% of whom were male (n= 32). The mean age for FRI diagnosis was 54 years (range 18–83 years). In our patient cohort, 10% were immunosuppressed and another 12.5% had a formal diagnosis of Diabetes Mellitus. A diagnosis of acute FRI (i.e. < six weeks from time of injury) was made in 9 patients (22.5%). Chronic FRI was noted in 25 patients (62.5%). There was equal incidence of FRI in patients with closed fractures and open fractures (42.5%). Tibia and fibula fractures were most common (87.5%, n=35). Regardless of fractured bone(s), the more distal the fracture the higher the incidence of FRI (60% distal versus 12.5% proximal). Gram-positive cocci were the most commonly identified pathogens, identified in 25% of patients. Five patients underwent free flap reconstruction, two patients received pedicled muscle flaps and another two patients received split thickness skin grafts. Conclusions. The diagnosis of FRI can be confirmed through the presence of a combination of confirmatory and suggestive criteria. We advocate a staged approach in the management of FRI with radical wound excision and temporary coverage followed by definitive soft tissue reconstruction

Objectives. Open fracture classification systems are limited in their use. Our objective was to classify open tibia and femur fractures using the OTS classification system in a region with high incidence of gunshot fractures. One hundred and thirty-seven patients with diaphyseal tibia and femur open fractures were identified from a prospectively collected cohort of patients. This database contained all cases (closed and open fractures) of tibial and femoral intramedullary nailed patients older than 18 years old during the period of September 2017 to May 2021. Exclusion criteria included closed fractures, non-viable limbs, open fractures > 48 hours to first surgical debridement and patients unable to follow up over a period of 12 months (a total of 24). Open fractures captured and classified in the HOST study using the Gustilo-Anderson classification, were reviewed and reclassified using the OTS open fracture classification system, analysing gunshot fractures in particular. Ninety percent were males with a mean age of 34. Most common mechanism was civilian gunshot wounds (gsw) in 54.7% of cases. In 52.6% of cases soft tissue management was healing via secondary intention, these not encompassed in the classification. Fracture classification was OTS Simple in 23.4%, Complex B in 24.1% and 52.6% of cases unclassified. The OTS classification system was not comprehensive in the classification of open tibia and femur fractures in a setting of high incidence of gunshot fractures. An amendment has been proposed to alter acute management to appropriate wound care and to subcategorise Simple into A and B subdivisions; no soft tissue intervention and primary closure respectively. This will render the OTS classification system more inclusive to all open fractures of all causes with the potential to better guide patient care and clinical research

Standard fixation for intra-articular distal humerus fracture is open reduction and internal fixation (ORIF). However, high energy fractures of the distal humerus are often accompanied with soft tissue injuries and or vascular injuries which limits the use of internal fixation. In our report, we describe a highly complex distal humerus fracture that showed promising healing via a ring external fixator. A 26-year-old man sustained a Gustillo Anderson Grade IIIB intra-articular distal humerus fracture of the non-dominant limb with bone loss at the lateral column. The injury was managed with aggressive wound debridement and cross elbow stabilization via a hinged ring external fixator. Post operative wound managed with foam dressing. Post-operatively, early controlled mobilization of elbow commenced. Fracture union achieved by 9 weeks and frame removed once fracture united. No surgical site infection or non-union observed throughout follow up. At 2 years follow up, flexion - extension of elbow is 20°- 100°, forearm supination 65°, forearm pronation 60° with no significant valgus or varus deformity. The extent of normal anatomic restoration in elbow fracture fixation determines the quality of elbow function with most common complication being elbow stiffness. Ring fixator is a non-invasive external device which provides firm stabilization of fracture while allowing for adequate soft tissue management. It provides continuous axial micro-movements in the frame which promotes callus formation while avoiding translation or angulation between the fragments. In appropriate frame design, they allow for early rehabilitation of joint where normal range of motion can be allowed in controlled manner immediately post-fixation. Functional outcome of elbow fracture from ring external fixation is comparable to ORIF due to better rehabilitation and lower complications. Ring external fixator in our patient achieved acceptable functional outcome and fracture alignment meanwhile the fracture was not complicated with common complications seen in ORIF. In conclusion, ring external fixator is as effective as ORIF in treating complex distal humeral fractures and should be considered for definitive fixation in such fractures

Introduction. Since the expanded war in Ukraine in 2022, explosives, mines, debris, blast waves, and other factors have predominantly caused injuries during artillery or rocket attacks. These injuries, such as those from shelling shrapnel, involve high-energy penetrating agents, resulting in extensive necrosis and notable characteristics like soft tissue defects and multiple fragmentary fractures with bone tissue defects and a high rate of infection complications caused by multi resistant gram-negative (MRGN) pathogens. Material and Methods. We conducted a prospective study at our center between March 2022 and December 2023. Out of the 56 patients from Ukraine, 21 met the inclusion criteria who had severe war injuries were included in the study. Each of these patients presented with multiple injuries to both bones and soft tissues, having initially undergone treatment in Ukraine involving multiple surgeries. The diagnosis of infection was established based on the EBJIS criteria. Prior to our treatment patients had undergone multiple revision surgeries, including debridement, biopsies, implant and fixator replacement. Additionally, soft tissue management required previously VAC therapy and flap reconstruction for successful treatment. Results. All 21 infections manifested as bone infections (11; 52%), followed by implant-associated infections (5; 24%), soft tissue infections (4; 19%), and septic arthritis (1; 5%). In all patients, the infection was polymicrobial, caused by 3- and 4-MRGN pathogens, as Klebsiella pneumonia 4MRGN, Proteus mirabilis 4MRGN, Enterobacter cloacae 4MRGN etc. Upon admission, all patients carried a diagnosis and exhibited signs indicative of chronic infection. 19 (90.5%) patients required complex antibiotic regimens combined with multiple wound revisions and debridements, changes of fixators and combination of systemic and local antibiotic therapy. In 6 patients (28%) high dosages of local antibiotics such as gentamycin, vancomycin and meropenem were incorporated into a carrier of bio-absorbable calcium sulfate, calcium sulfate/hydroxyapatite which were introduced into the hip joint, femoral canal or bone defect for dead space management during the surgery. When local antibiotics were administered at intervals, the microbiology results at implantation showed negative results. 2 (9%) patients had new infections (different site, different pathogens), 1 (4.8%) is still under the treatment. In 17 (81%) patients infection complications were treated successfully with no recurrence of infection. Conclusion. War injuries result in complex bone and soft-tissue infections caused by 3-, 4-MRGN pathogens. Addressing this challenge necessitates multidisciplinary approach with multiple, thorough surgical debridements, effective local, and systemic antimicrobial therapy. As for the outlook we can see potential in local antibiotic carriers

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Introduction and Objective. Despite the low incidence of pilon fractures among lower limb injuries, their high-impact nature presents difficulties in surgical management and recovery. Current literature includes a wide range of different management strategies, however there is no universal treatment algorithm. We aim to determine clinical outcomes in patients with open and closed pilon fractures, managed using a treatment algorithm that was applied consistently over the span of this study. Materials and Methods. This retrospective study was conducted at a single institution, including 141 pilon fractures in 135 patients, from August 2014 to January 2021. AO/OTA classification was used to classify fractures. Among closed fractures, 12 had type 43A, 18 had type 43B, 61 had type 43C. Among open fractures, 11 had type 43A, 12 had type 43B, 27 had type 43C. Open fractures were further classified with Gustilo-Anderson (GA); type 1: n=8, type 2: n=10, type 3A: n=12, type 3B: n=20. Our treatment algorithm consisted of fine wire fixator (FWF) for severely comminuted closed fractures (AO/OTA type 43C3), or open fractures with severe soft tissue injury (GA type 3). Otherwise, open reduction internal fixation (ORIF) was performed. When required, minimally invasive osteosynthesis (MIO) was performed in combination with FWF to improve joint congruency. All open fractures, and closed fractures with severe soft tissue injury (skin contusion, fracture blister, severe oedema) were initially treated with temporary ankle-spanning external fixation. For all open fracture patients, surgical debridement, soft tissue cover with a free or pedicled flap were performed. For GA types 1 and 2, this was done with ORIF in the same operating session. Those with severe soft tissue injury (GA type 3) were treated with FWF four to six weeks after soft tissue management was completed. Primary outcome was AOFAS Ankle-Hindfoot score at 3, 6 and 12-months post-treatment. Secondary outcomes include time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time. All complications were recorded. Results. Mean AOFAS score 3, 6, and 12 months post-treatment for open and closed fracture patients were 44.12 and 53.99 (p=0.007), 62.38 and 67.68 (p=0.203), 78.44 and 84.06 (p=0.256), respectively. 119 of the 141 fractures healed without further intervention (84.4%). Average time to bone union was 51.46 and 36.48 weeks for open and closed fractures, respectively (p=0.019). Union took longer in closed fracture patients treated with FWF than ORIF (p=0.025). On average, open and closed fracture patients took 12.29 and 10.76 weeks to PWB (p=0.361); 24.04 and 20.31 weeks to FWB (p=0.235), respectively. Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (25%), superficial infection (22%). Open fracture was a risk factor for non-union (p=0.042; OR=2.558, 95% CI 1.016–6.441), bone defect (p=0.001; OR=5.973, 95% CI 1.986–17.967), and superficial infection (p<0.001; OR=4.167, 95% CI 1.978–8.781). Conclusions. The use of a two-staged approach involving temporary external fixation followed by definitive fixation, provides a stable milieu for soft tissue recovery. FWF combined with MIO, where required for severely comminuted closed fractures, and FWF for open fractures with severe soft tissue injury, are safe methods achieving low complication rates and good functional recovery

Introduction. External fixators are common surgical orthopaedic treatments for the management of complex fractures and in particular, the use of circular frame fixation within patients requiring limb reconstruction. It is well known that common complications relating to muscle length and patient function without rehabilitation can occur. Despite this there remains a lack of high-quality clinical trials in this area investigating the role of physiotherapy or rehabilitation in the management of these patients. We aim to complete a systematic review of rehabilitation techniques for patients undergoing external fixator treatment for Limb Reconstruction of the lower limb. Materials & Methods. A comprehensive search of AMED, CINAHL, MEDLINE and COCHRANE databases was conducted to identify relevant articles for inclusion, using a search strategy developed in collaboration with a research librarian. Inclusion criteria consisted of adults aged 18 years and over who have experienced leg trauma (open fracture, soft tissue damage), elective leg deformity corrective surgery, bone infection or fracture non-union who have been treated with the use of an external fixator for fixation. Specific exclusion criteria were patients below the age of 18 years old, patients with cancer, treatment of the injury with internal nail, patients who underwent amputation, the use of external fixators for soft tissue contracture management, editorials, comment papers, review papers, conference proceedings and non-English papers. Titles, abstracts, and full texts were screened for suitability by pairs of reviewers according to the inclusion and exclusion criteria using Rayyan QCRI online software. Any conflicts were resolved through discussion with three independent specialist senior reviewers. Following full text screening, references lists of included articles were manually searched to ensure that all relevant studies were identified. Due to lack of evidence, forward searching was also completed for studies included in the review. Data quality was assessed using the mixed methods appraisal tool and the CERT assessment tool was utilised to look at completeness of reporting of exercise interventions. Results. A total number of 832 articles were initially retrieved from our search once duplicate articles removed. After title and abstract screening, 45 articles remained for full text screening. Of these, 11 articles met our inclusion criteria and included for data extraction. Conclusions. We expect high variability of results due to our inclusion criteria and therefore plan to conduct a narrative synthesis to summarise the findings whilst measing against the mixed methods appraisal tool and CERT assessment scores to assess the data quality. We anticipate lower assessment scores within the fewer articles found and therefore poorer-quality data. We currently are in the process of finalising this data extraction. This will be completed ready for submission and potential presentation at the BLRS conference in March 2023

Aim. Calcaneal osteomyelitis is an uncommon and challenging condition. In this systemic review we aim to analyse the concomitant use of bone debridement and soft tissue management for patients diagnosed with calcaneal osteomyelitis. Method. A complete computerised and comprehensive literature search of Pubmed and Cochrane database was undertaken from January 2000 to October 2018. During the review, studies were screened for information about the surgical and antimicrobial treatment, the complications, the reinfection rate and the functional outcome of patients with calcaneal osteomyelitis. Results. Of the 20 studies included, seven (35%) described bone treatment only, six (30%) soft tissue treatment only, five (25%) soft tissue and bone treatment, and two (10%) focused on prognostic factors and differences in outcomes between diabetic and non-diabetic patients. In the studies with bone treatment only, infection recurrence ranged from 0 to 35% and the amputation rate from 0 to 29%. If soft tissue coverage was also needed, both the reinfection rate and amputation rate ranged from 0 to 24%. Studies presenting the functional status showed preservation or even improvement of the preoperative ambulatory status. Conclusions. Calcaneal osteomyelitis is difficult to treat. A multidisciplinary approach involving orthopaedic surgeons, plastic surgeons and infectious disease physicians is necessary for treatment success. Based on the localisation and size of the bone and soft tissue defect, decision for surgical treatment should be made

Abstract. Objective. There is no specific framework for the clinical management of sports related brachial plexus injuries. Necessarily, rehabilitation is based on injury presentation and clinical diagnostics but it is unclear what the underlying evidence base to inform rehabilitative management. Methods. A systematic review of the literature was undertaken in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We applied the PEO criteria to inform our search strategy to find articles that reported the rehabilitative management of brachial plexus injuries sustained while playing contact sports. An electronic search of Medline, CINAHL, SPORTDiscus and Web of Science from inception to 3rd November 2022 was conducted. MESH terms and Boolean operators were employed. We applied an English language restriction but no other filters. Manual searches of Google Scholar and citation searching of included manuscripts were also completed. All study types were considered for inclusion provided they were published as peer-reviewed primary research articles and contained relevant information. Two investigators independently carried out the searches, screened by title, abstract and full text. Two researchers independently extracted the data from included articles. Data was cross-checked by a third researcher to ensure consistency. To assess internal validity and risk of bias, the Joanna Briggs Institute (JBI) critical appraisal tools were utilised. Results. The search generated 88 articles. Following removal of duplicates, 43 papers were evaluated against the eligibility criteria. Nine were eligible for full text review, with the majority of exclusions being expert opinion articles. Eight case reports were included. One article reported three individuals, resulting in data for ten athletes. The mean age was 19.8 years (±4.09). Injuries occurred in five American football players, two wrestlers, two rugby players, and a basketball player. No two studies applied the same diagnostic terminology and the severity of injury varied widely. Burning pain and altered sensation was the most commonly reported symptom, alongside motor weakness in the upper limb. Clinical presentation and management differed by injury pattern. Traction injuries caused biceps motor weakness and atrophy of the deltoid region, whereas compression injuries led to rotator cuff weakness. In all cases treatment was separated into acute and rehabilitative management phases, however the time frames related to these differed. Acute interventions varied but essentially entailed soft tissue inflammation management. Rehabilitation approaches variously included strengthening of shoulder complex and cervical musculature. Return-to-play criteria was opaque. The methodological quality of the case reports was acceptable. Four met all nine of the JBI evaluation criteria, and a further three met at least 75% of items. Conclusion(s). There is a distinct lack of evidence supporting rehabilitation management of sports related brachial plexus injury. Through systematic review we found only eight reports, representing ten individual case studies. No trials, cohort studies, or even retrospective registry-based studies are available to inform clinical management, which, necessarily, is driven by expert opinion and application of basic rehabilitation principles. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Flexion contracture is a common deformity encountered in patients requiring total knee replacements (TKR). Both the soft tissue envelope and articular bones are involved in the knee extension lag. A few studies in the past have assessed the relationship between bone cuts and extension deficit by using goniometers and rulers. Using navigation for TKR enables the accurate measurement of knee flexion contracture and bone cuts. The aim of this study was to try to establish a relationship between extension lag correction and the size of bone cuts made. 104 continuous TKR were completed by a single consultant using the OrthoPilot. ®. (BBraun, Aesculap) navigation system and Columbus implants. 74 knees had preoperative flexion contracture (including neutral knees) while 30 were in hyperextension. Data was recorded prospectively using the navigation system. These included preoperative flexion and extension angles, actual bone cuts of tibia and femur (both medial and lateral), postoperative correction of flexion and extension angle, size of the prosthesis with thickness of polyethylene and soft tissue release. Of the 74 knees with fixed flexion, 57 had no release and 13 had a posterior release (4 had an intermediate release and were excluded from the study). For knees with fixed flexion (n=70) there was a significant statistical difference between the pre and post implant extension angle (p < < 0.0001). There was no correlation between the thickness of bone cuts and postoperative extension lag either for the group with no release (p=0.495) or posterior release (p=0.516). There was also no correlation between bone cuts and preoperative angles for either type of release (p=0.348 and p=0.262). There was a significant difference between the preoperative extension deformity for the two soft tissue releases performed (p=0.00019), the mean fixed flexion angles being −4.4° and −10.4° for no release and posterior release respectively. Flexion contracture deformity in TKR can theoretically be solved in two ways: either by extensively releasing the soft tissue or by increasing the extension gap by cutting more bone (logically the distal femur). Appropriate soft tissue management and release in TKR is crucial in balancing the prosthesis in the coronal as well as the lateral plane. This study seems to confirm the supremacy of soft tissue management and release over bone cut resection. Cutting more or less bone could in fact lead to a poorer outcome as this will change the joint line level without having any additional beneficial effect in correcting the flexion contracture. Conversely adequate soft tissue release has corrected the flexion contracture when needed. In conclusion, there was no correlation between bone cut resection and extension lag correction and with large extension deficits, a posterior soft tissue release and osteophytes resection was more important than bone cuts

Flexion contracture is a common deformity encountered in patients requiring total knee arthroplasty (TKA). Both the soft tissue envelope and articular bones are involved in the knee extension lag. A few studies in the past have assessed the relationship between bone cuts and extension deficit by using goniometers and rulers. Using navigation for TKA enables the accurate measurement of knee flexion contracture and bone cuts. The aim of this study was to try to establish a relationship between extension lag correction and the size of bone cuts made. One hundred and four continuous TKA were completed by a single consultant using the OrthoPilot® (BBraun, Aesculap) navigation system and Columbus implants. Seventy-four knees had preoperative flexion contracture (including neutral knees) while 30 were in hyperextension. Data was recorded prospectively using the navigation system. These included preoperative flexion and extension angles, actual bone cuts of tibia and femur (both medial and lateral), postoperative correction of flexion and extension angle, size of the prosthesis with thickness of polyethylene and soft tissue release. Of the 74 knees with fixed flexion, 57 had no release and 13 had a posterior release (four had an intermediate release and were excluded from the study). For knees with fixed flexion (n = 70) there was a significant statistical difference between the pre and post implant extension angle (p < < 0.0001). There was no correlation between the thickness of bone cuts and postoperative extension lag either for the group with no release (p = 0.495) or posterior release (p = 0.516). There was also no correlation between bone cuts and preoperative angles for either type of release (p = 0.348 and p = 0.262). There was a significant difference between the preoperative extension deformity for the two soft tissue releases performed (p = 0.00019), the mean fixed flexion angles being −4.4° and −10.4° for no release and posterior release respectively. Flexion contracture deformity in TKA can theoretically be solved in two ways: either by extensively releasing the soft tissue or by increasing the extension gap by cutting more bone (logically the distal femur). Appropriate soft tissue management and release in TKA is crucial in balancing the prosthesis in the coronal as well as the lateral plane. This study seems to confirm the supremacy of soft tissue management and release over bone cut resection. Cutting more or less bone could in fact lead to a poorer outcome as this will change the joint line level without having any additional beneficial effect in correcting the flexion contracture. Conversely adequate soft tissue release has corrected the flexion contracture when needed. In conclusion, there was no correlation between bone cut resection and extension lag correction and with large extension deficits, a posterior soft tissue release and osteophytes resection was more important than bone cuts

Introduction: Accurate soft tissue balancing is an essential part of total knee replacement (TKR), but has been difficult to quantify using traditional instrumentation methods. Computer navigation systems allow us to accurately assess intra-operative kinematics, which are affected by soft tissue management. The aims of this study were to evaluate the role of varus and valgus stress measurements and subsequently devise an algorithm for soft tissue management during TKR. Methods: We used the Orthopilot® CT-free navigation system during TKR for patients with primary end-stage arthritis. This was a prospective study with 71 patients collecting intra-operative kinematic data. 57 knees were varus, 13 valgus, and 1 well aligned. Pre- and post-operatively, the surgeon applied a varus and valgus stress at maximum extension, recording the mechanical femorotibial (MFT) angle. There were no patellar resurfacings. We compared the kinematics of each varus knee. Based upon the kinematics and the surgeon’s experience the following medial releases were performed as usual and divided into three categories:. No release (limited medial approach). Moderate release (postero-medial release including the semimembranosis). Proximal (extensive) release. Results: Pre-operatively, the mean MFT angle was −9.6° (−3° to −22°) with varus stress and −0.8° (4° to −11°) with valgus stress. Post-operatively, the mean MFT angle was −3.7° (−1° to −7°) with varus stress, and 1.1° (4° to −3°) with valgus stress. Using regressional analysis, there was a strong linear correlation between both varus (r=0.742, p< 0.0001) and valgus (r=0.771, p< 0.0001) stresses and the MFT angle. With the following medial releases, these kinematics were found:. No release – MFT angle not less than −12° with varus stress, greater than 2° with valgus stress, and/or if extension deficit was not greater than 5°. Moderate release – MFT angle less than −12° with varus stress, between −5° and 2° with valgus stress, and/or extension deficit not greater than 5°. Proximal release – MFT angle less than −12° with varus stress, less than −5° with valgus stress, and/or extension deficit greater than 5°. The results show that post-operatively, the mean MFT angle is maintained within a narrow range (−1° to −7° with varus stress, 4° to −3° with valgus stress). 5/57(9%) patients had a mean MFT angle of 6.4°(0° to 7°) with valgus stress, and were considered to have been over-corrected. There were no extension deficits. Conclusions: Navigation allows us to quantify soft tissue balancing based upon the initial kinematics with varus and valgus stress testing. From these measurements, an algorithm was developed, which showed that an appropriate release was made in 52/57 (91%) patients, but this may require some adjustment to reduce the number of outlying results

Background. To improve patient pathways we have, in selected patients, begun to acutely apply circular (rather than temporary monolateral) fixators with simultaneous or subsequent soft tissue closure. We present early results. Methods. Adult patients treated using an Ilizarov frame prior to soft tissue management were identified from our Ilizarov database. This data was supplemented by medical record review. Results. 26 cases were identified (22 open fractures (11 IIIA, 11 IIIB), 1 compartment syndrome and 3 infected salvage). All IIIA injuries were closed acutely alongside frame application. In IIIB fractures, 3 were closed following acute shortening, 1 required a local flap and 7 free tissue transfer. Soft tissue reconstruction was simultaneous to frame application in 5 patients, the remainder within 72 hours. In salvage cases, 2 required free and one a local muscle flap, all after frame application. There were no soft tissue cover failures. One patient underwent evacuation of a flap haematoma, there were no other unexpected returns to theatre for soft tissue problems. No patients required adjustment of frame components to allow soft tissue access. Conclusion. This approach appears to simplify treatment, reducing length of stay. We are collecting a matched patient series treated by traditional pathways for comparison

Aim. The incidence of deep infections after internal fixation of ankle and lower leg fractures is estimated 1 to 2%. Hindfoot arthrodesis by retrograde intramedullary nailing (IMN) is a potential alternative to external fixation for post-infectious ankle destruction. The aim of this study was to evaluate the clinical results, complications and effects of soft tissue management with this treatment modality. Method. This is a single-center retrospective review of routine hospital data from 21 patients (15 men, 6 women, median age 65 [range, 21 to 87] years) undergoing IMN arthrodesis of the hindfoot for post-traumatic infections between January 1st, 2012 and March 15, 2018. We observed four bimalleolar, eight trimalleolar, three pilon fractures, and six distal lower leg fractures. Six and three patients had sustained second- and third degree open fractures, respectively. Early- and late-onset surgical infections were observed in 8 and 13 cases. Four participants had diabetes mellitus, two arterial occlusive disease, and four had both. Six patients were smokers. Results. Intraoperative cultures before implanting the nail revealed staphylococcus aureus in 12, staphylococcus epidermidis in five, and enterococcus faecalis in eight cases. After a median follow-up of 21 months, infection was considered cured in 19 / 21 subjects (90%, 95% confidence interval 70 – 99%). Soft tissue comminution required coverage with a suralis flap in five patients, and with a latissimus dorsi flap in another three. Mesh graft was necessary in 8 / 21 reconstructions. Conclusions. Tibiotalocalcaneal fusion by IMN is an effective salvage procedure for post-traumatic ankle infections. Arthrodesis and definitive wound closure or plastic flap coverage can be performed as single-stage surgery. By resecting the prominent distal fibula, lateral soft tissue defects can be managed more easily. The small sample size prohibited a more detailed analysis of exposure variables, but 8 / 13 patients in this cohort had at least one known risk factor for infection and prolonged healing

Improve the quality of care mine-explosive wounds and preventing infection in mine blast injury. We have treated 19 patients affected by MEI during Anti-Terrorist Operation (ATO) in Ukraine. The patients had been received by our department within 5–28 days after the injury. All patients were comprehensively examined (general surgeon, neurosurgeon, thoracic surgeon, CT, X-ray, ultrasound, lab tests). 14/19 patients had an open fractures (10 of those 14 had a soft tissue defects). All patients with open fractures underwent secondary surgical treatment (radical debridement, irrigation, ultrasonic cavitation, fracture stabilization by external fixation). The patients with soft tissue defects underwent variety of plastic surgery. After soft tissues healing a plate or IM nail was installed. Evaluation of results was based on X-ray monitoring and the lower limb function assessment. 16 patients had full fracture consolidation and good function, 3 patients had slow consolidation and limitation of movement. Analysis of treatment showed that adherence to radical debridement and thorough soft tissue management led to significant reducing of the incidence of infectious complications in combat related fractures