Introduction. Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures. Materials & Methods. We undertook a restrospective cohort study comprising patients with intra-articular distal tibia and pilon fractures treated with a circular ring fixator (CRF) at a single center. Prospective data collection included radiological assessments, Patient-Reported Outcome Measures (PROM), necessity for additional procedures, and Kellgren and Lawrence grade (KL) for osteoarthritis (OA). 137 patients were included in the study, 30 in the distraction group and 107 in the non-distraction group. There was no significant difference between the groups. Results. Mean follow-up was 3.73 years. There was no significant difference between the groups in overall complications or need for further procedures. There was no significant difference in progression of KL between the groups (1.81 vs 2.0, p=0.38) mean follow up 1.90 years. PROM data was available for 44 patients (6 distraction, 38 non-distraction) with a mean follow-up of 1.71 years. There was no significant difference in EQ5D (p=0.32) and C Olerud-H Molander scores (p=0.17). Conclusions. This pilot study suggests that joint distraction is safe in the acute setting. However, the study's impact is constrained by a relatively small patient cohort and a short-term follow-up period. Future investigations should prioritise longer-term follow-ups and involve a larger patient population to more comprehensively evaluate the potential benefits of joint distraction in acute fractures

We report on the clinical, radiographic and functional outcomes after salvage arthrodesis for complex ankle and hind-foot problems - the Portsmouth experience with the Ilizarov ring fixator. 11 patients underwent ankle and hind-foot (tibio-calcaneal) arthrodeses using an Ilizarov ring fixator between 2006 and 2010. The indications included failed fusion after primary arthrodesis, sepsis complicating internal fixation of fractures, talar avascular necrosis and failed total ankle arthroplasty (TAR). All patients had undergone multiple previous surgeries, which had failed. There were 8 males and 3 females in this group. Average age of the patients was 58 (43 years – 77 years) Mean follow up was 36 months (7 – 60 months). Mean frame time was 24 weeks (15 – 36 weeks). BMP 2 (Inductos) was used in three cases. The procedure was combined with a proximal corticotomy and lengthening in 2 patients who had undergone a talectomy and tibio-calcaneal fusion. There were no major complications apart from minor pin site infections requiring oral antibiotics. There were no deep infections, thromo-embolic issues, CRPS, or functional problems on account of limb shortening. Patients were assessed clinically, radiologically and using functional outcome scores - EQ50 and AOFAS. Solid arthrodesis was achieved in all but one patient who was subsequently revised with a hind-foot nail. All patients were satisfied with their overall improvement in pain and function. We conclude that this is an effective salvage technique for complex ankle and hind-foot problems in patients with impaired healing potential, insufficient bone stock and progressive deformity

Aim. Untreated or improperly managed osteomyelitis can lead to several complications, bone loss being one of the most challenging to manage. Bone transport is just one of the surgical options available for filling the bone gaps and promote bone union. This presentation focuses on bone transport for long bones gaps in paediatric age group, highlighting its advantages and disadvantages, its indications and its complications. Method. Between 2006 and 2014. 71 patients underwent a procedure of bone transport. Out of them, 39 were males and 32 females, with an average age at presentation of 8.7 years. The bone involved were tibia (27 right, 25 left), femur (4 right, 9 left), radius (1 right, 4 left) and ulna (1 right). Clinically speaking, the children presented with one of the following picture:. ‐. Pathological fracture, with sequestration without or minimum involucrum formation. ‐. Extensive, extruded diaphyseal sequestrum, with loss of soft tissues. ‐. Post-surgical gap, with residual or quiescent infection. Bone transport was preceded by one of the following procedure: sequestrectomy, sequestrectomy and external fixation, external fixation with sequestrum in situ. Monolateral fixator was used in 46 patients, ring fixator in 25. Bone transport started 7 days after the osteotomy, at the rhythm of 1 mm per day. Plastic surgery procedures were used in 3 kids. Results. Bone reconstruction was primarily obtained in 50 patients; non-union at the docking point was observed in 18. It required additional procedures of bone graft or site refreshening, associated with external fixation. Pins replacements and/or fixator adjustment were required in 24 patients. Several procedures were required during transport to overcome technical mistakes or to handle unexpected complications. All patients were able to walk unsupported. Reduced knee flexion was observed in 11 patients, knee fusion in 4, ankle fusion in 3, limb length discrepancy in 20, axial deformity in 6. Conclusions. Bone transport has proved to be a reliable technique for managing segmental bone defects in children. It requires long time and it is prone to several complications. Strict medical supervision is necessary all along the process. Besides filling the gap, it can achieve limb equalization when needed. The presence of infection is not a contraindication to concurrent sequestrectomy and transport. The treatment is long, challenging, strenuous for the patient, the family and the medical staff but the results can be rewarding in terms of limb function

Purpose:. This study attempts to establish whether biomechanical manipulation through distraction can result in fracture union. Method:. A retrospective clinical audit of 15 patients with delayed or hypertrophic non-unions treated successfully with closed distraction in circular external fixation. Average time to union, complications and complication rates were also reviewed. Inclusion criteria: all patients with delayed or hypertrophic non-union, treated by closed distraction between 2004 and 2011. Results:. Fifteen patients included in the study. The average time to union was 188 days. The most common complication was local pin tract sepsis. The most serious complication was a broken fixation ring that needed replacement. Conclusion:. Biomechanical fracture strain is calculated by dividing the fracture gap distance by the change in the fracture distance i.e. FRACTURE STRAIN = DIFFERENCE IN L/L Hypertrophic non-union occurs when the fracture strain is more than 10 %. This formula shows that by increasing the fracture gap, the fracture strain will decrease This concept is contrary to the current practice of compressing the fracture. This study shows that distraction can be used to manipulate the biomechanical circumstances that dictate the development of fracture non-union. Furthermore ring fixators are ideal devices to use for biomechanical manipulation

Statement of purpose. To determine whether the amount of fibula resection in fibula osteotomy influences outcome in deformity correction surgery. Methods. Retrospective case note and imaging review was performed on a cohort of 45 patients from November 2005 to July 2009 treated with lengthening and/or correction for leg deformity in either an adult or paediatric limb reconstruction centre. Method, extent and level of original fibular resection was recorded, as well as type of fixator, distraction regime and total gap at osteotomy site after distraction. Outcome was measured as premature, expected or non-union and subsequent need for reintervention. Results. Fibula osteotomies were made in 45 patients with a mean age of 23 (median 16, range 6–65). 14 subsequently underwent lengthening only, 15 correction of deformity only and 16 a combination of the two. 32 cases used the Ilizarov frame, four the Taylor-Spatial frame and 9 the Sheffield ring fixator. The mean extent of fibular resection was 3.6 mm (range 0.5–17 mm), with saw osteotomy used more frequently than drill or osteotome. Mean latency from surgery to distractions starting was 6 days. Premature union preventing further distraction/correction occurred in four cases, three of which required repeat osteotomy and one which resolved after increasing the rate of distractions. 37 osteotomies went on to unite, with four non-unions. These non-unions were asymptomatic and did not require further intervention. Conclusion. The extent of fibular resection does not appear to directly influence outcome in terms of symptomatic fibular non-union requiring intervention. Care needs to be taken in the paediatric population to guard against premature union requiring repeat osteotomy

AIM. To study the incidence of thromboembolism among patients treated with ring fixators in lower limb injuries and their risk factor association. METHODS & MATERIALS. Notes of 180 (130 men & 50 women) patients treated with circular frame were retrospectively studied. Risk factors for thromboembolism as advised by NICE were recorded and scored. The duration of pre-operative limb immobilisation, hospital stay and duration of frame, were also recorded. RESULTS. Amongst 180 patients, there were 133 closed and 47 open tibial fractures. 4.4% (n=8) of patients suffered thromboembolic (4 DVT, 4 PE) event, which varied from early post op (13 days) period to delayed period (107 days post surgery). None of the patients were on prophylactic anticoagulation when they suffered thromboembolic event. Their average BMI was 31.3 ± 3.8 (S.D) while it was 27.2 ± 4.8 (S.D) for the rest. Other risk factors did not influence thromboembolic events. Patients affected by thromboembolic complications had the limb immobilised for 6.59 days (0 to 31), spent 20.5 days (7 to 44) in hospital and 29.4 weeks (11 to 54) in frame versus 6.15 days (0 to 35), 14.39 days (3 to 74) and 25.67 weeks (10 to 111) respectively in patients without thromboembolic complications. CONCLUSION. Small patient pool is the limitation of our study; however, obesity appears to be a risk factor. Incidence of thromboembolic events is significant enough to consider routine prophylaxis, although both prophylaxis and duration is open to debate

Arthrodesis. Today, knee arthrodesis is most commonly performed for cases of chronic sepsis after total knee arthroplasty in patients who are not candidates for reimplantation. This is typically a host in whom the risk of recurrent infection is high, especially when extensor mechanism problems such as patellar tendon rupture is present. Local and systemic host factors place the patient at this high risk for failure of reimplantation. Local factors include chronic lymphedema, major vessel disease, venous stasis, extensive scarring and radiation fibrosis. Systemic problems include malnutrition, malignancy, extremes of age, hepatic or renal failure, diabetes mellitus and alcohol abuse. Also, at least in one study, patients who fail one two-stage reimplantation have at least a 50% change for recurrence the second time. Methods of knee arthrodesis include external fixation, single or double plate fixation and intramedullary nailing either monolithic or modular. External fixation can be performed as a single procedure. With external ring fixators leg lengthening has been described. Plate and nailing procedures are commonly performed after the infection is eradicated. If infection recurs but fusion has occurred, removal of a modular nail may be difficult although techniques have been described. Fusion rates of 85% to 100% have been reported with the newer techniques and fusion rates are usually correlated with the amount of bone loss after removal of the prosthesis. Optimal position of fusion is slight anatomic valgus and slight flexion. Placing a bowed intramedullary nail with the bow anteromedially can facilitate this alignment. One study comparing arthrodesis after failed knee arthroplasty with primary total knee replacement found nearly identical Short-Form 36 scores. Physical mobility was better with knee arthroplasty but pain control was better with arthrodesis. Resection Arthroplasty. Indication: Low demand patient with comorbidities. Results: Falahee et al.; 28 knees;15 patients walked independently; Most severely disabled more satisfied. Less disabled least satisfied. Amputation - Above the Knee Amputations after TKA (Sierra et al). Prevalence: 0.36% (all causes – most common was peripheral vascular disease), 0.14% (for causes related to TKA: infection, periprosthetic fracture, pain, bone loss, vascular complication). Results: 25 amputations for causes related to TKA; Avg 8.6 years after TKA. Complications: deep infection 5, superficial infection 1, skin necrosis 1, perioperative death 1. 9 of 25 fitted with above knee prosthesis; Only 5 were walking even to limited degree with prosthesis

Introduction. Objective was to assess clinical results of treatment of Infected Non Union (INU) of long bones, using Antibiotic Cement Impregnated Nail (ACIN), a single or two staged approach, Stage 1 - Debridement, eradication of infection, primary stabilization with (ACIN). 2nd Stage - Definitive stabilization and early rehabilitation. Methods. 185 cases of infected non-union of long bones from Jan 2002 to Jan 2009 were treated in this hospital. 46 females and 139 males, age varied from 17–65 years (Avg. 40). Tibia was the commonest bone to be affected, followed by femur & humerus. The control of infection was by debridement, antibiotic cement impregnated K-nail (ACIN) insertion with or without Ilizarov ring fixator application, second stage treatment by definitive internal fixation and bone grafting was done if required. Average duration of follow up, was 26 months (14–58 months). Main outcome measurements were assessment of bone healing, functional outcome, healing time and complications. Results. Out of the 185 cases treated in our institute 174 (93.7%) patients achieved union at an average of 8 months. 2 limbs with non union tibia fractures were amputed on demand by patients, 2 limbs developed severe edema, 7 patients did not achieve union, inspite of repeated procedures. Infection was controlled early especially in Type 1 non unions. 5 patients had persistent infection though mild inspite of 2 or 3 surgeries of exploration and curettage. Discussion and conclusion. The two staged procedure described gives satisfactory results. Antibiotic and cement impregnated nails and beads achieve good infection control without any complications and reduce the healing time. Ilizarov fixator helps in stabilization, compression, deformity correction at the same time and plays a significant role in the path to union. Fixator should be removed as early as possible to avoid restriction of movements

Aims

The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients.

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.

External fixation is widely used in orthopaedic and trauma surgery. Infections around pin or wire sites, which are usually localised, non-invasive, and are easily managed, are common. Occasionally, more serious invasive complications such as necrotising fasciitis (NF) and toxic shock syndrome (TSS) may occur.

We retrospectively reviewed all patients who underwent external fixation between 1997 and 2012 in our limb lengthening and reconstruction programme. A total of eight patients (seven female and one male) with a mean age of 20 years (5 to 45) in which pin/wire track infections became limb- or life-threatening were identified. Of these, four were due to TSS and four to NF. Their management is described. A satisfactory outcome was obtained with early diagnosis and aggressive medical and surgical treatment.

Clinicians caring for patients who have external fixation and in whom infection has developed should be aware of the possibility of these more serious complications. Early diagnosis and aggressive treatment are required in order to obtain a satisfactory outcome.

Cite this article: Bone Joint J 2015;97-B:1296–1300.

Ten patients, who were unsuitable for limb lengthening over an intramedullary nail, underwent lengthening with a submuscular locking plate. Their mean age at operation was 18.5 years (11 to 40). After fixing a locking plate submuscularly on the proximal segment, an external fixator was applied to lengthen the bone after corticotomy. Lengthening was at 1 mm/day and on reaching the target length, three or four screws were placed in the plate in the distal segment and the external fixator was removed. All patients achieved the pre-operative target length at a mean of 4.0 cm (3.2 to 5.5). The mean duration of external fixation was 61.6 days (45 to 113) and the mean external fixation index was 15.1 days/cm (13.2 to 20.5), which was less than one-third of the mean healing index (48 days/cm (41.3 to 55). There were only minor complications.

Lengthening with a submuscular locking plate can successfully permit early removal of the fixator with fewer complications and is a useful alternative in children or when nailing is difficult.

Limb lengthening by callus distraction and external fixation has a high rate of complications. We describe our experience using an intramedullary nail (Fitbone) which contains a motorised and programmable sliding mechanism for limb lengthening and bone transport. Between 2001 and 2004 we lengthened 13 femora and 11 tibiae in ten patients (seven men and three women) with a mean age of 32 years (21 to 47) using this nail. The indications for operation were short stature in six patients and developmental or acquired disorders in the rest.

The mean lengthening achieved was 40 mm (27 to 60). The mean length of stay in hospital was seven days (5 to 9). The mean healing index was 35 days/cm (18.8 to 70.9). There were no cases of implant-related infection or malunion.