Introduction

Classical fixation using a circular frame involves two rings per segment and in many units this remains the norm whether using ilizarov or hexapod type frames. We present the results of two ring circular frame at King's College Hospital.

Our aim was to ascertain if K-wire configuration had any influence on the infection and complication rate for base of 4th and 5th metacarpal fractures. We hypothesised that in individuals whose wires crossed the 4th and 5th carpometacarpal joint (CMCJ), the rate of complications and infection would be higher.

Data was retrospectively analysed from a single centre. 106 consecutive patients with a base of 5th (with or without an associated 4th metacarpal fracture) were analysed between October 2016 and May 2021. Patients were split into two groups for comparison; those who did not have K-wires crossing the CMCJ's and those in whose fixation had wires crossing the joints. Confounding factors were accounted for and Statistical analysis was performed using SPSS version 20 software.

Of 106 patients, 60 (56.6%) patients did have K-wires crossing the CMCJ. Wire size ranged from 1.2-2.0 with 65 individuals (65.7%) having size 1.6 wires inserted. The majority of patients, 66 (62.9%) underwent fixation with two wires (range 1-4). The majority of infected cases (88.9%) were in patients who had k-wires crossing the CMCJ, this trended towards clinical significance (p=0.09). Infection was associated with delay to theatre (p=0.002) and longer operative time (p=0.002).

In patients with a base of 4th and 5th metacarpal fractures, we have demonstrated an increased risk of post-operative infection with a K-wire configuration that crosses the CMCJ. Biomechanical studies would be of use in determining the exact amount of movement across the CMCJ, with the different K-wire configuration in common use, and this will be part of a follow-up study.

Our aim was to explore factors associated with early post operative infection for surgically managed base of 4th/5th metacarpal fractures. We hypothesised that K-wires crossing the 4th and 5th carpometacarpal joint (CMCJ) would be associated with an increased risk of post-operative infection.

Data from consecutive patients requiring surgical fixation for a base of 4th/5th metacarpal fracture from October 2016 to May 2021 were collected. Patient demographics, time to surgery, length of surgery, operator experience, use of tourniquet, intra-operative antibiotics, number and thickness of K-wire used, as well as whether or not the K-wires crossed CMCJ joints were recorded. Factors associated with post operative infection were assessed using Chi Squared test and univariable logistic regression using R studio.

Of 107 patients, 10 (9.3%) suffered post operative infection. Time to surgery (p 0.006) and length of operation (p=0.005) were higher in those experiencing infection. There was a trend towards higher risk of infection seen in those who had K-wires crossed (p=0.06). On univariable analysis, patients who had wires crossed were >7 times more likely to experience infection than those who didn't (OR 7.79 (95% CI, 1.39 - 146.0, p=0.056). Age, smoking, K-wire size, number of K-wires used, intraoperative antibiotics, tourniquet use and operator experience were not associated with infection.

In patients with a base of 4th/5th metacarpal fractures requiring surgical fixation, we find an increased risk of post-operative infection associated with K-wires crossing the CMCJ, which has implications for surgical technique. Larger prospective studies would be useful in further delineating these findings.

Introduction

Patients undergoing complex limb reconstruction are often under immense physical, psychological and financial stress. We already provide psychological support within our unit. We have identified that patients struggle to obtain proper advice on the financial support to which they are entitled. In September 2019, rebuildcharity.org commissioned a Citizens Advice Clinic. One advisor from the local Citizens Advice staffs the clinic. Currently we have no set criteria for referral and patients can be referred by any member of the limb reconstruction team. Although severely affected by the coronavirus pandemic and the disruption of all routine work we were able to run clinics from September 2019 to March 2020 and September 2020 to January 2021. We present our initial results.

Introduction

The Direct Anterior Approach (DAA) offers potential advantages of quicker rehabilitation compared to posterior approach THR. The aim of this study was to compare hospital based and early clinical outcomes between these two groups with utilisation of Enhanced Recovery After Surgery (ERAS) protocol.

The purpose of this study is to describe the use of the PHILOS plate (Synthes) in reverse configuration to treat complex distal humeral non-unions.

Non-union is a frequent complication of distal humeral fracture. It is a challenging problem due to the complex anatomy of the distal humerus, small distal fragment heavily loaded by the forearm acting as a long lever arm with powerful forces increasing the chances of displacement. Rigid fixation and stability with a device of high “pull-out” strength is required. The PHILOS plate has been used in reverse configuration to achieve good fixation while allowing central posterior placement of the implant.

11 patients with established non-union of distal humeral fractures were included in this study. No patient in whom this implant was used has been excluded. Initial fixation was revised using the PHILOS plate in reverse configuration and good fixation was achieved. Bone graft substitutes were used in all cases. Patients were followed to bony union, and functional recovery.

All fractures united. One required revision of plate due to fatigue failure. Average time to union was 8 months with excellent restoration of elbow function.

A reversed PHILOS plate provides an excellent method of fixation in distal humeral non-union, often complicated by distorted anatomy and previous surgical intervention. It has a high “pull-out” strength and may be placed in the centre of the posterior humerus, allowing proximal extension of the fixation as far as is required. It provides secure distal fixation without impinging on the olecranon fossa. It is more versatile and easier to use than available pre contoured plating systems.

The purpose of this study was to identify the prevalence of common mental disorders in patients undergoing complex limb reconstruction.

Patients undergoing limb reconstruction are vulnerable to mental health problem as they must adapt to significant and prolonged physical disability. Treatment emphasis has been on restoration and rehabilitation of physical health with little or no attention given to spectrum of psychological consequences. IMPARTS (Integrating Mental and Physical healthcare: Research, Training and Services) is a King's Health Partners initiative aiming to develop informatics to improve detection and management of common mental disorders in medical settings. IMPARTS screening in the King's College Hospital limb reconstruction clinic commenced in April 2012.

Outpatients attending between April 2012 and November 2013 were screened prior to their appointment. Patients were screened for symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), alcohol dependence and drug use.

In total, 298 individual patients were screened. The prevalence of depression was found to be 21.8%, with 6.4% experiencing suicidal thoughts. Probable anxiety disorder was identified in 20.7% of patients. Symptoms of PTSD were reported by 29.2%, with 9.0% reporting severe symptoms. Probable alcohol dependence was identified in 2.7% of patients, and 3.0% screened positive for drug misuse.

The consequences of undergoing limb reconstruction stretch beyond the physical problem to mental well-being, rendering patients vulnerable to mental health problems and substance misuse. Early detection and management of such problems may have a significant effect on physical treatment outcome and rehabilitation to productive social life. There is urgent need to integrate mental health care as part of early management of severely injured patients.

Gold standard for the management of non-union is open surgical debridement, stabilisation, and autologous bone grafting. LIPUS is becoming more popular, yet the evidence is still inconclusive. LIPUS involves the use of ultrasound at the fracture site with little risk to the patient.

The purpose of this study was to assess effectiveness and cost benefit of LIPUS in the management of non-unions post sustaining an open fracture.

We retrospectively reviewed 29 patients with open fractures with established non-union undergoing LIPUS since 2010 (4 females, mean age 48) range 3–27 months, mean 9 months, either post injury or last intervention. All were tertiary referrals, sustaining injuries to the following areas; Tibial 21, Femur 6, Humerus 2, Radius 1. Definitive fixation being; 9 TSF's, 11 IMN's, 9 plates. (undergoing a mean 2.4 procedures). Aside from sustaining an open fracture, 7 had risk factors for non-unions 5 smokers, 2 NSAID's. Failure of treatment was based on undertaking bone grafting.

In 28 patients (1 lost to follow up) union was achieved in 71% (mean 157 days). All were screened for infection, 4 had organisms on enrichment culture. 8 (5 Gustillo Anderson Grade 3A/B) injuries did not show evidence of callus formation, LIPUS was discontinued and grafting performed. Open fractures were graded as; 7 Grade 1, 4 Grade 2, 8 Grade 3A, 10 Grade 3B being received. Of these; 20 underwent primary closure, 6 free flaps and 3 SSG. The cost of LIPUS is approx £2500, compared bone grafting using autologous iliac crest graft with no medical comorbidities of £3715.

This case series further supports union rates after LIPUS. Cost and morbidity benefit of utilising LIPUS over opting for bone grafting initially is £1215 per patient. Whilst autologous bone grafting is currently the gold standard, it is not without morbidity. We achieved union rates of 71% despite a number of patients having recognised risk factors, showing that LIPUS is a useful resource in the management of non-union.

Objectives

Fracture non-union poses a significant challenge to treating orthopaedic surgeons. These patients often require multiple surgical procedures. The incidence of complications after Autologous Bone Graft (ABG) harvesting has been reported up to 44%. These complications include persistent severe donor site pain, infection, heterotopic ossification and antalgic gait. We retrospectively compared the use of BMP-7 alone in long bone fracture Non-union, with patients in whom BMP-7 was used in combination with the Autologous Bone Graft (ABG).

We present a series of 11 patients with infected tibial intramedullary nails which were treated at our tertiary referral centre from January 2000 to November 2009. All of them were males and the mean age was 36 years (26 to 47 years). All the patients had sustained post traumatic fractures which were treated with intramedullary nail. Four patients (36%) had sustained open fractures in whom adequate soft tissue cover was provided by plastic surgeons. Five of them (45%) were smokers.

All of them underwent surgical debridement. Nine out of 11 patients had removal of metal work followed by one or more of the following procedures such as reaming, exchange nailing, excision of sequestrum, application of antibiotic beads and stabilisation with a frame with or without several bone grafts at a later date.

Out of 11 patients six (55%) had no further episodes of infection, three (27%) still need short courses of antibiotics when the disease flares up and two (18%) underwent amputation. Causative organisms were isolated in all the patients. Commonest organism was MRSA. Overall, most of the organisms were sensitive to Vancomycin and resistant to Penicillin.

Despite exploring most of the surgical procedures described for infected tibial intramedullary nails we have potentially eradicated infection only in about half of our patients. Hence we would like to emphasise that this condition still remains a serious problem and demands further insight in its management

Introduction

PIPJ replacement has become increasingly popular however, there is very little clinical data available apart from small studies and those from the originators of the prostheses. We present a review of our initial experience with the Acension^(c) Pyro-carbon PIP joint.

Ballistic fractures are devastating injuries often necessitating reconstructive surgery or amputation. Complications following surgery are common, particularly in the austere environment of war. Workload from the recent conflict was documented in order to guide future medical need. All data on ballistic fractures was collected prospectively. Fractures were scored using the Red Cross Fracture Classification.

During the first two weeks of the conflict, 202 Field Hospital was the sole British hospital in the region. Thereafter, until the end of the conflict, it became the tertiary referral hospital for cases requiring orthopaedic and plastic surgery opinions. Thirty-nine patients, with 50 ballistic fractures were treated by British military surgeons. Patients were predominantly Iraqi (20 enemy prisoners of war and 15 civilians); 4 children sustained five fractures.

Fifty percent were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. A total of 30 per cent of wounds became infected, 12 per cent were deep infection necessitating surgical drainage. Thirteen limbs were amputated; seven were traumatic amputations.

Ballistic fractures remain a challenge for surgeons in times of war. There is a continued need to relearn the principles of war surgery in order to minimise complications and restore function. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts.

Introduction: Trochanteric osteotomy provides excellent exposure to perform hip replacement surgery. In the UK, 5.9% of primary hip replacements are performed using an osteotomy. Trochanteric non union is one of the complications of this approach. The aim of this study was to investigate the role of release of posterior trochanteric soft tissue release on the incidence of trochanteric non-union.

Method: We present the results of 100 patients who underwent primary cemented total hip replacement at our centre using the biplanar, intracapsular osteotomy. Group A (50 patients) had received a posterior trochanteric soft tissue release as part of the approach and Group B (50 patients) had not. Patients were followed up clinically and radiologically.

Results: In group A the trochanteric non union rate was 12% and in group B 2% (p< 0.05). According to the Hodgkinson’s classification of trochaneric non-union, all the non-unions in group A were grade 3 (> 1.5 cm migration) and group B was grade 2 (< 1.5cm migration).

Discussion: The two different techniques were examined on cadaveric specimens and it was noted that the obturator externus tendon was consistently cut as a part of the posterior soft tissue release. We conclude that this important structure should not be released as part of this approach to hip replacement. Obturator externus is an important adductor of the trochanter and preserving it decreases the incidence of trochanteric non-union.

Human recombinant Osteogenic Protein 1 or rhBMP-7 is licensed for use in tibial non-union where autologous bone grafting has failed. Through its osteoconductive and osteoinductive properties, its application may be more widely applied. We audited our use of rhBMP-7 and present the largest series currently reported in the literature.

We reviewed 107 consecutive patients on whom rhBMP-7 was used over a 5-year period (2002–2007). Demographic and clinical details (e.g indication, site, use of adjuncts, previous surgery, smoking status, time to union, mean follow up etc) were entered into an electronic spreadsheet.

RhBMP-7 was used in 112 sites on 107 patients (65 male, 42 female). Ages ranged from 16yrs to 89yrs (mean 47.6). Non-union was the main indication for surgery (82 cases). RhBMP-7 was used alone in 39 cases and with autologous bone graft (56 cases). In other cases demineralised bone matrix, USS and bone allograft were used as adjuncts. Tibia (42 cases), femur (29 cases), humerus (21 cases) were the most common sites of administration. Mean number of operations prior to use of rhBMP-7 was 1.6 (range 1–20). In all cases, union was achieved in 65% (73/112) with a mean union time 5.8 months. The ‘rhBMP-7 alone’ subgroup demonstrated union in 83% (30/36), mean union time 5.15 months. 68% (56/82) of cases treated for nonunion subsequently united with rhBMP-7.

Our results suggest rhBMP-7 is useful in the management of fracture non-union and limb reconstruction surgery irrespective of site. It promotes bone healing of non-unions subjected to multiple operations previously. It may be indicated in those patients in whom autologous bone graft harvest is undesirable or not possible or as an adjunct to bone grafting. Moreover we did not detect any adverse reactions specific to the administration of rhBMP-7.

The dynamic association between the immune system and the skeletal system has recently been appreciated. It has been suggested that cells involved in the inflammatory cascade might modulate the bone fracture repair process. Interestingly a number of studies have demonstrated that ability of the T lymphocyte to affect bone remodelling and health profoundly. For example the presence of T lymphocytes has been shown to increase bone resorption during experimental induced arthritis. We wanted to investigate the role of specific T lymphocytes in fracture repair and required an in vivo model to deplete CD4 and CD8 T lymphocytes selectively.

Method The cell lines of Anti-L3T4 (CD4), Anti-Lyt-2 (CD8) and Anti-phytochrome were obtained from ECACC and produced by Edinburgh University group, Immunosolv. Anti-phytochrome (AFRC MAC 51) antibody was used as the control. To each group of 5 murine models 50ìL of CD4 or CD8 or control antibody was injected ip on days 0, 1, 2, 7, 8, and 9. The body weight and behaviour were measured. On day 20 the spleens were sampled and a single cell suspension was created for each murine model. PE CD8 antibody and FITC CD4 antibody were then added to each sample. Each spleen sample was then cell sorted using the FACS machine.

Results Compared to the control group the murine model injected with CD4 antibody had only 1.14 % of CD4 T cells remaining (mean 2.462 % +/− 0.270). Similarly, the murine models injected with CD8 antibody had only 1.8% of CD8 T cells remaining (mean 1.723 % +/− 1.036).

Conclusion Our results suggest that to investigate the role of T lymphocytes in fracture repair, specific T lymphocytes can be successfully depleted with the repeated use of antibodies.

Fracture repair is a wound healing process that in young healthy patients usually proceeds to uncomplicated union. However, the healing cascade is delayed with increasing age, medication and certain diseases such as rheumatoid arthritis.

Recently the important role of the immune system in fracture repair has become apparent within the emerging subject of Osteoimmunology. Patients with rheumatoid arthritis have an altered immune system and therefore we have investigated the hypothesis that patients with rheumatoid arthritis have a higher incidence of non-union after a fracture compared to patients without rheumatoid arthritis.

Method: The Edinburgh Royal Infirmary computer database was searched over a 10 year period (May 1996- May 2006) to identify all patients with non-union out of the total number of patients presenting with fractures. These patients groups were then subdivided into patients that had and did not have rheumatoid arthritis. Patients were excluded if they were lost to follow up, or if the fracture either occurred before the May 1996 or management continued passed May 2006. In this study non-union was defined as failure to heal within expected timescale and lack of progression at serial x-rays (all non-union were diagnosed at least 3 months from fracture).

Results: From May 1996 through to May 2006, 8,456 patients with fracture were defined. 71 of these patients with fractures had rheumatoid arthritis. Of these patients 63 had union of their fractures whilst 8 patients developed non-union of their fracture (11.3%). In a total of 8385 non rheumatoid arthritis patients 164 developed non-union of their fracture compared to 8221 patients who had union of their fractures (2%). Comparison between these two patient groups suggests rheumatoid arthritis patients are more likely to develop non-union of traumatic fractures (Chi squared test, p value < 0.001).

Patients with rheumatoid arthritis who progressed to non-union were on the following medication, Gold (1), Indomethacin (1), Non steroidal anti-inflammatories (4), Combination analgesia (2), Antihypertensives (2), Omeprazole (1) and Thyroxine (1).

Discussion: The results from this study suggest that patients with rheumatoid arthritis have a greater incidence of non-union after a fracture compared to patients without rheumatoid arthritis. This maybe due to the abnormal immune system in rheumatoid arthritis patients. However rheumatoid arthritis patients are often on a number of medications and these drugs rather than the innate alteration of the immune system may be responsible for the altered healthy response. However whether as a result of the rheumatoid arthritis itself or the medication, our study demonstrates a higher non-union rate in the rheumatoid arthritis patients and this needs to be taken into account when treating rheumatoid arthritis patients with fractures.

Introduction: We performed a retrospective case control study in 80 patients who under went revision hip surgery at our unit.

Methodology: Group A (40 patients), received tranexamic acid and intra-operative cell salvage. Group B (40 patients) a matched control did not receive these treatments. Each group was divided into 4 sub groups; revision of both components, revision of components + bone grafting, revision acetabular component +/− bone grafting and revision femoral component +/− bone graft.

Results: In group A the total number of units transfused was 139 compared to 52 in group B. This represents a reduction in blood usage of 37%. The mean amount of blood transfused from cell salvage in each group was 858mls, 477mls, 228mls and 464mls. There was a significant difference in the amount of blood returned between the groups (p< 0.0001). In the control group 37 patients needed transfusion, in the study group 22 (p< 0.0001). At our unit a cost analysis calculation has shown total revenue saving of £88,000 and a potential saving throughout the trust of £316,688 per year.

Discussion: To our knowledge this is the first study to examine the use of cell salvage and tranexamic acid in revision hip surgery. Our results show that a significant reduction in blood transfusion can be made using this technique. It is vital that blood conserving strategies are developed so that future revision surgery can continue.

We retrospectively reviewed 19 femoral non-unions. Age group ranged from 17–72 yrs with mean of 40 yrs. 12 were men and 7 were women. 11 fractures involved diaphysis and 8 involved supracondylar area. 5 cases were infected non-unions. Time from fracture to defini-tive treatment varied from 5 to 88 months (mean 21 months). Open technique was used in 18 cases. In 8 cases we have used autogenous cancellous bone graft and in 3 cases BMP7 was used in addition to bone graft. 9 cases were treated with Ilizarov frame without bone graft, 6 with plate & bone graft, 3 with intramedullary nail and 1 with bone graft alone. Internal bone transport was carried out in 5 cases to achieve limb length equality. Fracture union was achieved in 16 patients with 7 excellent and 8 good results as per ASAMI criteria. 15 cases achieved excellent to good functional results. Because of persistent infection, 2 distal femoral non-unions required transfemoral amputation. Treatment was discontinued due to psychiatric illness in 1 patient with Ilizarov frame. Two of the patients in Supracondylar group developed knee stiffness. Pin tract infection is a common complication in Ilizarov group.

Adequate reduction & stabilization is key to success. Non-unions without any complications can be treated with exchange nail or open reduction and plating. Ilizarov method is effective for non-unions complicated by distal location, infection and bone loss. Psychological assessment is important before considering Ilizarov method of treatment.

Introduction: It is unknown what effect distraction osteogenesis has on bone blood flow to the affected limb. Our study analyzed in vivo measurement of tibial blood flow during distraction osteogenesis using Doppler ultrasonography.

Materials and Methods: Blood flow was measured in the femoral artery, with Doppler ultrasonography in five people treated with bi-focal tibial distraction osteogenesis. The normal leg was used as the control to correct for differences in cardiac output. Measurements for each leg were taken and means recorded preoperatively, at 1 week postoperatively, and at subsequent intervals up to 6 months.

Results: Preoperative blood flow varied from 0.5 – 2.25. All treated legs demonstrated increases in flow from 2.25 – 5.75, with peaks in the first weeks following osteotomy. Significant increases in blood flow during treatment with distraction osteogenesis, confirming previous experimental studies.

Discussion: Blood flow plays a significant role in the successful outcome of this treatment. Compression of the non-union at the time of peak blood flow gives more reliable union than bone transport methods, where docking takes place when blood flow has returned towards the control limb.

Background: Ballistic fractures produce a significant burden on medical facilities in war. Workload from the recent conflict was documented in order to guide future medical needs.

Method: All data on ballistic fractures was collected prospectively. Wounds were scored using the Red Cross Wound Classification and the Red Cross Fracture Classification.

Results: During the first two weeks of the conflict, 202 Field Hospital was the sole British hospital in the region. Thereafter, until the end of the conflict, it became the tertiary referral hospital for cases requiring orthopaedic and plastic surgery opinions. Thirty-nine patients, with 50 ballistic fractures, had their initial surgery performed by British military surgeons. Fifty-two percent (26/50) were caused by bullets. Seventeen upper limb fractures and 33 lower limb fractures were sustained. Four children sustained five fractures. Thirty per cent of wounds became infected. Thirteen limbs were amputated; seven were traumatic amputations. The relationship between those fractures with adverse outcomes and their fracture and wound scores will be discussed.

Conclusion: War is changing; modern conflicts appear likely to be fought in urban or remote environments, producing different wounding patterns and placing civilians in the line of fire. Military medical skills training and available resources must reflect these fundamental changes in order to properly prepare for future conflicts.