Introduction. The various problems that are managed with circular external fixation (e.g. deformity, complex fractures) also typically require serial plain x-ray imaging. One of the challenges here is that the relatively radio-opaque components of the circular external fixator (e.g. the rings) can obscure the view of the area of interest (e.g. osteotomy site, fracture site). In this presentation we describe how the geometry of the x-ray beam affects the produced image and how we can use knowledge of this to our advantage. Whilst this can be applied to any long bone, we have focused on the tibia, given that it's the most common long bone that is treated by circular external fixation. Materials & Methods. In the first part of the presentation we describe the known attributes (geometry) of the x-ray beam and postulate what effect it would have when we x-ray a long bone that is surrounded by a circular external fixator. In the second part we demonstrate this in practice using a tibia and a 3 ring circular external fixator. Differing x-ray beam orientations are used to demonstrate both how the geometry of the beam affects the produced image and how we can use this to our advantage to better visualise part of the bone. Results. The practical part of the study confirmed the theoretical part. Conclusions. Knowledge of the beam geometry can be used to minimise the obscuring nature of the circular fixator. This technique is simple and can be easily taught to the radiographer. It is a useful adjunct for the limb reconstruction surgeon

Purpose of study. Pin tract infection is a common complication with the use of circular external fixators. HIV infection itself is frequently quoted as a relative contra-indication for the use of circular external fixators for complex trauma and limb reconstruction in HIV seropositive individuals. Methods. Between July 2008 and December 2012, 286 patients were treated with circular external fixators at our tertiary level government hospital. A retrospective review was undertaken to compare the rate and severity of pin tract sepsis in HIV seropositive and seronegative patients. Results. Two-hundred and twenty-three patients met the inclusion and exclusion criteria. Pin tract sepsis was found in 51 patients overall (22.8%). The incidences of pin tract sepsis in the seropositive group, seronegative group, and the unknown group are 22.5%, 22.8% and 23.8% respectively, and the differences were not statistically significant. The severity of pin tract sepsis in the individual groups was also similar. Conclusion. Pin tract sepsis is a common complication with the use of circular external fixators. The incidence and severity of pin tract infection is not influenced by HIV infection, and should not in itself deter from the use of circular external fixators for complex trauma and limb reconstruction in HIV seropositive individuals. NO DISCLOSURES

Introduction

External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting.

Introduction. The vast majority of orthopaedic surgeons use C-arm fluoroscopy in the operating theatre when building a circular external fixator. In the absence of previous research in this area, we hypothesised that the surgeon who builds a circular external fixator is exposed to a greater amount of radiation purely as a result of the presence of the metallic fixator in the x-ray beam. The aim of our study therefore was to investigate how the presence of a circular external fixator affects the radiation dose to the surgeon and the surgical assistant. Materials & Methods. A simulated environment was created using a radiolucent operating table, an acrylic lower limb phantom (below knee segment), various configurations of metalic circular external fixation, and a standard size C-arm image intensifier. The variables investigated were 1. the amount of metal in the beam 2. the orientation of the beam (PA vertical vs lateral) 3. the horizonal distance of the person from the beam (surgeon vs assistant) and 4. the vertical distance of the various body parts from the beam (e.g. thyroid, groin). In terms of radiation dose, we recorded two things : 1. the dose produced by the image intensifier 2. the dose rate at standardised positions in the operating theatre. The latter was done using a solid-state survey sensor. These positions represented both where the surgeon and surgical assistant typically stand plus the heights of their various body regions relative to the operating table. Results. The effect of the presence of the circular external fixator : all frame constructs tested resulted in a statistically significant greater radiation dose both produced by the image intensifier and received by the surgical team. The effect of the beam orientation : the PA (vertical) orientation resulted in a statistically significant greater radiation dose for the surgeon than did the lateral orientation, but made no difference for the assistant. The effect of horizontal distance from the beam : unsurprisingly, the surgeon (who was closer to the beam) received a statistically significant greater radiation dose than the assistant. The effect of vertical distance from the beam : for the surgeon, the dose received was highest at the level of the phantom leg / frame, whilst for the assistant there was no statistically significant difference for any level. Conclusions. To our knowledge, this is the first study investigating the radiation dose rate to the orthopaedic surgeon when building a circular external fixator. We found that the surgeon does indeed receive a ‘double whammy’ because the image intensifier puts out a greater amount of radiation plus the metalic frame scatters more of the x-ray beam. Whilst the amounts are relatively small, we think that it's important to quantify doses that orthopaedic surgeons receive to ensure optimal radiation practices

Introduction. Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt. Materials & Methods. Data of patients with complex lower limb injuries treated before, during and after the pandemic were collected from our in-house trauma database, theatre records and follow up clinics. The rationale for choosing other techniques over a circular frame, the type of alternative technique used, the cost of such alternatives, the need for soft tissue reconstruction, time to recovery, complications and amputation rates were compared among groups. Results. These data suggest comparable outcomes between circular frames and alternative techniques can be achieved. A notable reduction in the number of circular frames applied during the review period was observed. Furthermore, frame fixation was associated with more frequent outpatient review and the associated implications for resource management. Conclusions. Conclusion: The Covid-19 pandemic has posed great challenges to the Trauma and Orthopaedic community, forcing us to be flexible by adopting alternative treatment methods to traditional circular external fixation. These alternatives have proven feasible and potentially more cost effective, prompting their adoption in the post pandemic era. However, this change of practice is not without potential consequences and continued investigation is warranted

We report the results of using a combination of fixator-assisted nailing with lengthening over an intramedullary nail in patients with tibial deformity and shortening. Between 1997 and 2007, 13 tibiae in nine patients with a mean age of 25.4 years (17 to 34) were treated with a unilateral external fixator for acute correction of deformity, followed by lengthening over an intramedullary nail with a circular external fixator applied at the same operating session. At the end of the distraction period locking screws were inserted through the intramedullary nail and the external fixator was removed. The mean amount of lengthening was 5.9 cm (2 to 8). The mean time of external fixation was 90 days (38 to 265). The mean external fixation index was 15.8 days/cm (8.9 to 33.1) and the mean bone healing index was 38 days/cm (30 to 60). One patient developed an equinus deformity which responded to stretching and bracing. Another developed a drop foot due to a compartment syndrome, which was treated by fasciotomy. It recovered in three months. Two patients required bone grafting for poor callus formation. We conclude that the combination of fixator-assisted nailing with lengthening over an intramedullary nail can reduce the overall external fixation time and prevent fractures and deformity of the regenerated bone

Introduction. The accuracy of hexapod circular external fixator deformity correction is contingent on the precision of radiographic analysis during the planning stage. The aim of this study was to compare the SMART TSF (Smith and Nephew, Memphis, Tennessee) in-suite radiographic analysis methods with the traditional manual deformity analysis methods in terms of accuracy of correction. Materials and Methods. Sawbones models were used to simulate two commonly encountered clinical scenarios. Traditional manual radiographic analysis and digital SMART TSF analysis methods were used to correct the simulated deformities. Results. The final outcomes of all six analysis methods across both simulated scenarios were satisfactory. Any differences in residual deformity between the analysis methods are unlikely to be clinically relevant. All three SMART TSF digital analyses were faster to complete than manual radiographic analyses. Conclusions. With experience and a good understanding of the software, manual radiographic analysis can be extremely accurate and remains the gold standard for deformity analysis. In-suite SMART TSF radiographic analysis is fast and accurate to within clinically relevant parameters. Surgeons can with confidence trust the SMART TSF software to provide analysis and corrections that are clinically acceptable

Introduction. In my paediatric Orthopaedic practice I use Kirchner wires for the fixation of the TSF on bone. I noted a significant percentage of wire loosening during the post-operative period. The aim of this project was to establish the effectiveness of the wire clamping mechanism and find ways to reduce the incidence of wire loosening when using the TSF. Materials and Methods. In the first instance wire slippage was measured intra-operatively after the tensioner was removed using an intra-operative professional camera. Following this study mechanical tests were performed in the lab measuring the pull out properties of Kirchner wires using different bolts and different torque levels in order to tighten the wire on the fixator. Results. Our clinical study confirmed wire slippage intra-operatively immediately after the tensioner was removed. Wire slippage after the tensioner was removed was found to vary from 0.01 mm to 0.51 mm (mean 0.19 mm). Our mechanical tests showed that the ideal torque for tightening the wire on the frame using a bolt was around 15 N.m. A comparison between cannulated and slotted bolts suggested that cannulated bolts are more effective as a clamping mechanism. A comparison between aluminium made Taylor Spatial frame rings and stainless steel made Ilizarov rings suggested that the Taylor Spatial frame rings are more effective as part of a clamping mechanism. Conclusions. It is important that clinicians routinely measure the torque they use to clamp wires on circular external fixators. Clinicians and manufacturers are informed that the type of bolt used is important in maintaining wire tension. Manufacturers should design the ideal bolt which effectively grips the wire without the risk of fracture. The Ilizarov frame clamping mechanism can be effectively used with the Taylor Spatial frame

Introduction. Introduction: Pin site infection is a common complication during treatment with a circular frame external fixator and increases time and support patients require from the limb reconstruction team. Wound swabs were not routinely sent by the clinical nurse specialists prior to this study, with most pin site infections treated as Staphylococcus aureus with flucloxacillin (clindamycin in penicillin allergy). The aim of this study was to ascertain whether routine sending of wound swabs in pin site infection would change antibiotic treatment. Materials & Methods. Materials and Method: Patients presenting at clinic or physiotherapy with clinical signs of pin site infection were assessed using the Maz Oxford Nuffield (MON) Pin Site Infection Grading System© (OUH, 2021). Antibiotics were commenced as per unit guidelines and swabs sent for microscopy, culture and sensitivity. Results. Results: There were forty patients treated with pin site infections. Swab results showed S. aureus in 60% (N=24), other organisms in 15% (N=6) and no growth or mixed skin organisms in 10% (N=10). Flucloxacillin was prescribed to 77.5% (n=31) of patients with the remaining 22.5% (n=9) of patients receiving clindamycin (due to allergy) or rifampicin and ciprofloxacin (due to a previous MRSA diagnosis). Antibiotic management was subsequently changed in only 5% (n=2) of patients due to one patient with a new MRSA diagnosis and one patient growing Enterobacter in three pin sites tested. Conclusions. Conclusion: This study has shown that routine swab testing of pin sites does not usually change antibiotic management but should still be used in multiple, severe or unresolving pin site infections

The aim of this abstract is to show that when dealing with an infected non-union, all possibilities of treatment must be considered in order to choose the best treatment plan for each patient. This case shows the evolution of an infected non-union following type III open fractures which, after the used of several methods that failed, had to be solved with amputation. We present a case report of a 41 years old man, with a type IIIA open fracture of the right tibia and fibula. Initially, he was treated with an external fixator, which was removed and plate implanted. After this, he who presented to us with an infected non-union. He was submitted to surgery, the plate was removed and a circular external fixator was used. Six months later, the external fixator was removed and a reamed intramedullary nail was implanted with bone graft from iliac crest. One year later, the facture site was still mobile, so he was submitted to fixation with internal plate. As this last method also failed, a bellow knee amputation was performed, 4 years after the initial event. After several attempts with several distinctive methods, the infected non-union had to be solved with the sacrifice of the limb. The treatment of infected non-union is one of the most difficult in Orthopedic Surgery. There are several procedure that can be used. When all these fail, amputation and consequent limb prosthetic substitution, might allow the patient to return to the society

The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of acute lower limb trauma in our institution over a twenty year period. We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute lower limb trauma. We identified 68 fractures in 63 patients. There were 11 femoral fractures and 57 tibial fractures. All fractures were classified using the AO Classification system, and most fractures were Type C fractures. We used an Ilizarov frame in 53 patients and a Taylor Spatial Frame in 15 patients. The mean time in frame was 365 days for a femoral fracture and 230 days for a tibial fracture. There were five tibial non-unions giving an overall union rate of 93%. Factors associated with non-union included high energy trauma and cigarette smoking. The vast majority of lower limb fractures can be treated using ‘conventional’ methods. Complex fractures which are not amenable to open reduction and internal fixation or cast immobilisation can be treated in a frame with excellent results. The paucity of published reports regarding the use of frames for complex trauma reflects the under-utilisation of the technique

Purpose of Study. Bicondylar tibial plateau fractures are serious injuries to a major weight bearing joint. These injuries are often associated with severe soft tissue injuries that complicate the surgical management. This retrospective study evaluates the management of these high-energy injuries with the use of limited open reduction and fine wire circular external fixation. Methods. Between July 2008 and June 2012, 54 consecutive patients (19 females and 35 males) with high-energy tibial plateau fractures were treated at our tertiary level government hospital. All patients were treated with limited open reduction, and cannulated screw fixation combined with fine wire circular external fixators as the definitive management. The records of these patients were reviewed. Results. Forty-six patients met the inclusion and exclusion criteria. Thirty-six patients had Schatzker type-VI and ten patients had Schatzker type-V fractures. All fractures united without loss of operative reduction. No wound complications, osteomyelitis or septic arthritis occurred. Average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin tract infection was the most common complication encountered. Conclusion. Fine wire circular external fixation combined with limited open reduction and cannulated screw fixation consistently produced good functional results without serious complications. NO DISCLOSURES

The purpose of this study was to review the outcomes and complications of all circular external fixators (frames) used for the management of sterile and infected fracture non-unions in the lower limb in our institution over a twenty year period. We retrospectively reviewed a prospectively compiled database of all frames applied in our institution and identified all frames which were applied for acute lower limb trauma. We identified 76 non-unions in 76 patients. There were 22 femoral non-unions and 54 tibial non-unions. Five femoral non-unions and 12 tibial non-unions were confirmed infected. The mean time in frame was 281 days for a sterile non-union and 457 days for an infected non-union. There was a union rate of 87% for sterile non-unions and 71% of infected non-unions at cessation of treatment. Factors associated with persistent non-union included cigarette smoking, soft tissue complications, and excessive pin-site toilet by the patient. Lower-limb fracture non-unions can be extremely difficult to treat. The patients included in our study had previously undergone more traditional treatments in an attempt to establish union. The results presented demonstrate that circular frames are an excellent treatment modality in non-unions resistant to other forms of treatment. We would recommend this as a first line treatment for patients at higher risk of developing fracture non-union

The purpose of this study was to review the outcomes of four children with genu valgum secondary to Hurler Syndrome treated with circular external fixators (frames) for angular correction. We retrospectively reviewed the medical and radiographic records of four children with Hurler Syndrome and genu valgum treated with frames. Three children had simultaneous bilateral tibial corrections. The fourth child had unilateral femoral correction. The mean age of the children was 14 years at application of frame. Mean duration of frame was 113 days for the tibial frames, and the femoral frame remained in-situ for 150 days. Correction was assessed clinically, and radiologically with x-rays and CT scannograms, with excellent results in all four cases. The complexities of each individual case necessitated specific and individualised treatment for each child. Complications included further deformities arising in treated and un-treated long-bones both during and after application of frame. Prior to the introduction of bone marrow transplantation, the average life expectancy of children with Hurler Syndrome was seven years. With bone marrow transplantation, affected children are now living much longer, and many develop characteristic long bone deformities in their lower limbs. These deformities are progressive and can be multifocal and polyostotic. Managament can be extremely challenging, and prior reports of management with hemiepiphysiodesis with staples and 8-plates have been mixed. We believe that this is the first series of circular frame lower limb reconstruction in children with Hurler Syndrome. The flexibility and adaptability of frames confers a unique advantage in the management of these complex deformities

Background:. Various surgical flaps have been described for the reconstruction of post traumatic soft tissue defects of the heel. These techniques are not all familiar to orthopaedic surgeons. The presented technique is based on the use of a reverse flow island sural flap combined with a circular external fixator. Material:. This presentation is a review of 8 cases performed between 2003 and 2012. Results:. All cases were males with an average age of 39 years (16–56) with a follow up period between 2 and 10 years. The soft tissue defects were located around the heel and Achilles tendon as a result of road traffic accidents involving motor cycles. Six patients had associated bony injuries of the foot and ankle related to the soft tissue defect. All flaps remained viable, and cover was easily achieved with direct closure. Three cases required debridement of subsequent superficial necrosis and additional split skin grafting. Although the flaps are insensate per design, there were no associated problems of late onset pressure ulcers. The circular fixation added the additional benefit of protection and easy access of the posterior flap during the post-operative period. Mild venous congestion was a temporary feature, of no long term consequence. Conclusion:. The sural fasciocutaneous flap is a useful adjunct for the treatment of complex soft tissue defects around the heel and ankle. The main advantages include simplicity of design and easy execution, avoids the need for complex microsurgical techniques and can be performed with simple loupe magnification, and thus realistically falls within the realm of the treating orthopaedic surgeon

Background:. Wide resection of infected bone increases the chances of eradication of infection in patients with chronic osteomyelitis. Aggressive debridement is, however, frequently complicated by the creation of large bone defects. The use of antibiotic-impregnated PMMA spacers, as a customized dead space management tool, has recently grown in popularity. In addition to certain biological advantages, the spacer also offers a therapeutic benefit by serving as a vehicle for delivery of local adjuvant antibiotics. Methods:. This retrospective case series involved 11 patients with chronic osteomyelitis, managed with tibial bone transport through an induced membrane using circular external fixation. All patients were treated according to a standardized treatment protocol and we review the anatomic nature of the disease, the physiological status of the host, the surgical procedures performed, as well as the outcome of treatment in terms of eradication of infection, time to union and the complications that occurred. Results:. Nine patients, with a mean bone defect of 6 cm (range: 2–8 cm) were included in the study. At a mean follow-up of 24 months (range: 14–45 months) eradication of osteomyelitis was achieved in all patients without the need for reoperation for infection. Failure of the skeletal reconstruction occurred in two patients. Six major and four minor complications were experienced. After a mean time of 70 weeks (range: 30 to 104 weeks) in the circular external fixator all but one docking site had united and all regenerated segments were consolidated. Conclusion:. Bone transport, using circular external fixation, through the induced membrane created by the temporary insertion of a PMMA appears to be a useful technique in the management of post-infective tibial bone defects larger than 4 cm in size. Patient selection appears to be a crucial step in ensuring a successful outcome in terms of the resolution of infection

Abstract. We present here the results of a prospective follow-up study of radiological and functional outcome in 43 patients treated using the Taylor Spatial Frame (TSF) for definitive management of tibial fractures. Patients & Methods. Over a five-year period data was collected from all patients completing treatment of a tibial fracture with the TSF. Residual deformity on x-ray and functional outcomes using the EQ-5D health status questionnaire, Iowa Knee and Ankle-Evaluation Rating System scores and Olerud & Molander Ankle Score (OMAS) were recorded one year following completion of frame treatment. Results. No residual deformity greater than 10° was seen on AP or lateral radiographs and EQ-5D outcomes showed no statistically significant difference to data representative of the UK population as a whole. “Good” or “excellent” outcome scores were recorded in 92.9% of our cohort on Iowa Knee scoring and in 79% on Ankle-Evaluation Rating System scoring (Mean scores 92 and 86.5). 93% of OMAS scores showed “good” or “excellent” outcomes (mean score 85). These results demonstrate good return of isolated knee and ankle function within one year of completion of frame treatment but also, more significantly, a complete return to normal day-to-day “health status” as compared to the population at large. Conclusion. As a result we conclude that in tibial fractures suited to treatment with a circular external fixator, use of the TSF has a number of technical advantages while producing good functional and radiological outcomes and an overall return of pre-injury “health status” levels

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Aims

Computer hexapod assisted orthopaedic surgery (CHAOS), is a method to achieve the intra-operative correction of long bone deformities using a hexapod external fixator before definitive internal fixation with minimally invasive stabilisation techniques.

The aims of this study were to determine the reliability of this method in a consecutive case series of patients undergoing femoral deformity correction, with a minimum six-month follow-up, to assess the complications and to define the ideal group of patients for whom this treatment is appropriate.