Aims. Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation. Methods. A total of 100 patients were included in this prospective, randomized, controlled monocentre study allocated to the three subgroups of dislocated ankle fracture (n = 40), pilon fracture (n = 20), and intra-articular calcaneal fracture (n = 40). Patients were randomized to the two study groups in a 1:1 ratio. The effectiveness of VIT (intervention) compared with elevation (control) was analyzed separately for the whole study population and for the three subgroups. The primary endpoint was the time from admission until operability (in days). Results. The mean length of time until operability was 8.2 days (SD 3.0) in the intervention group and 10.2 days (SD 3.7) in the control group across all three fractures groups combined (p = 0.004). An analysis of the subgroups revealed that a significant reduction in the time to operability was achieved in two of the three: with 8.6 days (SD 2.2) versus 10.6 days (SD 3.6) in ankle fractures (p = 0.043), 9.8 days (SD 4.1) versus 12.5 days (SD 5.1) in pilon fractures (p = 0.205), and 7.0 days (SD 2.6) versus 8.4 days (SD 1.5) in calcaneal fractures (p = 0.043). A lower length of stay (p = 0.007), a reduction in pain (p. preop. = 0.05; p. discharge. < 0.001) and need for narcotics (p. preop. = 0.064; p. postop. = 0.072), an increased reduction in swelling (p < 0.001), and a lower revision rate (p = 0.044) could also be seen, and a trend towards fewer complications (p = 0.216) became apparent. Conclusion. Compared with elevation, VIT results in a significant reduction in the time to achieve operability in complex joint fractures of the lower limb. Cite this article: Bone Joint J 2021;103-B(4):746–754

We prospectively assessed the diagnostic accuracy of the gravity stress test and clinical findings to evaluate the stability of the ankle mortise in patients with supination–external rotation-type fractures of the lateral malleolus without widening of the medial clear space. The cohort included 79 patients with a mean age of 44 years (16 to 82). Two surgeons assessed medial tenderness, swelling and ecchymosis and performed the external rotation (ER) stress test (a reference standard). A diagnostic radiographer performed the gravity stress test. For the gravity stress test, the positive likelihood ratio (LR) was 5.80 with a 95% confidence interval (CI) of 2.75 to 12.27, and the negative LR was 0.15 (95% CI 0.07 to 0.35), suggesting a moderate change from the pre-test probability. Medial tenderness, both alone and in combination with swelling and/or ecchymosis, indicated a small change (positive LR, 2.74 to 3.25; negative LR, 0.38 to 0.47), whereas swelling and ecchymosis indicated only minimal changes (positive LR, 1.41 to 1.65; negative LR, 0.38 to 0.47). . In conclusion, when gravity stress test results are in agreement with clinical findings, the result is likely to predict stability of the ankle mortise with an accuracy equivalent to ER stress test results. When clinical examination suggests a medial-side injury, however, the gravity stress test may give a false negative result. Cite this article: Bone Joint J 2015; 97-B:1126–31

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The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients.

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Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery.

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Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

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The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture.

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Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery.

Objective. To investigate the outcomes of patients following the chipping procedures as an alternative to bone grafting in treatment of femoral non-unions. Design. Retrospective evaluation of prospectively collected data. Setting. University hospital. Level IV, therapeutic case series. Patients. Eleven patients with femoral non-union were included. The median age of patients was 37 years (range, 19–73 years). The median follow-up was 24 months (range, 12–60 months). Intervention. Non-unions were treated by the chipping procedure and re-install of an intramedullary nail or locked plate(s). Main Outcome Measurements. Radiographic bone union, walking ability, and complication were evaluated. Results. All non-unions clinically and radiographically healed with a median time of 7.5 months (range, 6–12 months). All patients were able to walk without walking aids within 9 months after surgery. Pre-existing deformities (e.g., varus and mal-external rotation) were anatomically corrected after the revision surgery for non-union. There were no superficial or deep infections, but post-operative temporal anemia and swelling of the thigh were common complications after surgery. Conclusions. Chipping the non-union site was likely to enhance fracture healing, and this technique was useful as an alternative to bone grafting in treatment of femoral non-union, especially for both atrophic and hypertrophic non-unions with deformities

Objective. To investigate the outcomes of patients following the chipping procedures as an alternative to bone grafting in treatment of non-unions after long bone fracture. Patients. Sixteen patients with femoral or tibial non-union were included. The median follow-up was 24 months. Intervention. Non-unions were treated by the chipping procedure and re-install of an intramedullary nail or locked plate(s) without bone grafting. Main Outcome Measurements. Radiographic bone union, walking ability, and complication were evaluated. Results. Fourteen non-unions clinically and radiographically healed with a median time of 7.5 months. For these cases, patients were able to walk without walking aids within 9 months after surgery. Pre-existing deformities (e.g., varus and mal-external rotation) were anatomically corrected after the revision surgery for non-union. Radiographic consolidation could not been obtained for two cases within 12 months after chipping procedures; one nonunion after old osteomyelitis and another after supracondylar fracture. Lack of stability at chipping site may be one of the reasons for failure of the procedures. Post-operative temporal anemia and swelling of the thigh were common complications after surgery. Conclusions. Chipping the non-union site was likely to enhance fracture healing, and this technique was useful as an alternative to bone grafting in treatment of femoral non-union, especially for both atrophic and hypertrophic non-unions with deformities

The previous bioabsorbable plates have had several issues with regard to clinical usage for fractures. The aims of this study were to demonstrate the clinical results of novel bioabsorbable plates made of hydroxyapatite/poly-L-lactide and titanium plates for metacarpal fractures and to compare mechanical properties of them in a fracture model. The subjects were 33 metacarpal diaphyseal fractures of 27 consecutive patients treated with bioabsorbable plates. The mean age was 35.8 (17–78), 22 male and 5 female was included. The mean follow up period was 7.4months (2–14). All cases achieved bone union, and there were no complication especially for aseptic swelling etc. Furthermore, we compared the mechanical properties of bioabsorbable and titanium plates. There were no significant differences in 6 month postoperative clinical results including total range of active motion and % of the contralateral grip strength between patients receiving bioabsorbable and titanium plates. The bending strength and stiffness of one-third tubular bioabsorbable plate constructs were comparable with those of titanium plates for 1.5mm screws, and those of semi-tubular bioabsorbable plates were comparable with those of titanium plates for 2.0mm screws. The torsional strength of semi-tubular bioabsorbable plates was significantly greater than that of titanium plates for 2.0mm screws

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We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial.

Bone and soft tissue sarcoma is an uncommon. Benign swellings are, however, common. An approach to tertiary referral is required to accommodate the need for specialist interpretation of all concerning referrals, while maintaining an acceptable time to diagnosis and management. We aim to describe a new tertiary sarcoma service, utilising modern communication technology and the “virtual clinic” model through a multidisciplinary approach. All suspected musculoskeletal sarcoma cases are discussed, with available history and imaging, in a virtual clinic by a multidisciplinary team within a week of referral. Clinic decisions allow either immediate discharge, progress to further investigation, or clinic appointment. Data from the first thousand patients was prospectively collected for initial management decision, and final intervention, and in 625 for waiting time. Almost one third of patients were discharged from the virtual clinic without physical appointment. 45% were sent for further investigation prior to first clinic appointment. Of 625 patients with referral data, mean waiting time was 5.1 days to virtual clinic. For malignant bone and soft tissue tumours, not requiring neoadjuvant treatment, median time to surgery from virtual clinic review was 37 and 47 days respectively. Through a virtual clinic approach to tertiary sarcoma care, almost a third of referrals have been managed quickly without need for an unnecessary appointment. For 45% of patients the first appointment will be after all necessary investigations have been performed to facilitate rapid decision making. This enables shorter clinic waiting times and rapid transition from first referral to definitive management

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No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA.

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To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury.

Introduction. Over the past decade, the use of negative pressure wound therapy (NPWT) devices has increased and expanded to include a wide variety of patients. However, the safety and efficacy of NPWT over skin in open fractures is still unknown. The purpose of this study was to evaluate the complication rate and outcome of open fractures treated by NPWT over closed wounds or flaps. Materials and methods. We performed a retrospective review of prospectively collected data of 10 patients, with an average age of 37.9 years old, who underwent NPWT over surgically closed wounds or random pattern cutaneous flaps in open fractures. All wounds were debrided and closed, and NPWT was applied over the skin sequentially in emergency operations. Results. The open fracture sites were lower leg (6), foot and ankle (3), and knee (1). The reasons for applying NPWT were the expectation of improved viability of local flaps in 4, impossibility of airtight skin approximation in 3, high risk for wound healing problems due to swelling in 2, and securing of degloved skin in 1. The mean duration of NPWT was 11.3 days. There were 3 skin macerations under foam, however, no flap or degloved skin necrosis occurred. All the fractures eventually united, and there were no deep infections. Discussion and Conclusion. While skin macerations were sometimes seen, they did not affect the overall outcome. NPWT over the skin in open fractures is effective in preventing infection even in high-risk wounds

AIM. Chronic osteomyelitis still remains challenging and expensive to treat inspite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure. METHODS. We retrospectively identified eight patients (5 Females) with mean age of 63 yrs (Range40–71 yrs) Case notes were reviewed for co morbidities, Pre and post treatment inflammatory markers (plasma viscosity and CRP) and clinical staging. Mean follow up was 3 yrs (Range 1–6 yrs) All the patients were jointly operated by orthopaedic and plastic surgeons and underwent thorough debridement and muscle flap (Seven free flaps and one rotational flap) in the same sitting. All the patients were reviewed regularly by plastic and orthopaedic surgeons. Seven patients had free Gracilis flap and one had Triceps flap. Clinical assessment of reinfection was made on presence of erythema, wound discharge, pain and swelling. Primary outcome measure was resolution of infection. RESULTS. Seven patients had full resolution of osteomyelitis as evident by clinical examination and inflammatory markers. Three patients had graft problems to start with, but theses settled within six months One patient had minor wound discharge at three years which settled with conservative management. One further patient developed eczematous dermatitis around the flap which was managed successfully by the dermatologist. CONCLUSIONS. We believe this to be the only study in which both the procedures (debridement and muscle flap) are performed in one sitting. This technique is a successful and useful addition to the armamentarium of surgeons in the management of chronic osteomyelitis. Though our study is small but our results are encouraging

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To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

Introduction. Monomicrobian necrotizing cellulitis affects the skin and subcutaneous tissue as starting point the deepest level of the superficial fascia. The pathogen inoculation is by skin disruption, abrasions, burns, injections or bites. The free base cocaine is used with homemade pipes that generate pulps fingers skin microabrasions. We present 3 patients (one bilateral) with cellulitis necrotizing of the thumb caused by pricking and dermoabrasive trauma secondary to different manipulation methods for drogue use. Material and Method. Experience in 3 patients free base cocaine addicts treated in our Hospital. Medical examination shows febrile syndrome (corporal temperature over 38C), and elevation of heart rate. They present cellulitis in thumb's first and second phalanx, with thenar swelling and digital necrosis with abundant purulent discharged. All of them had a pricking trauma 36 to 48 hours before. They were under surgical intervention, by surgical cleaning with necrotic and devitalized tissue's debridement. In 3 of the 4 patients amputation of the distal phalanx was mandatory. Tissue and bone culture was made in all patients. Intravenous antibiotic was performed. Two patients miss total antibiotic treatment by early no medical discharged. Results. Due necrotizing cellulitis is an acute and aggressive pathology, that compromised general condition and the 3 patients had important and advanced lesions was mandatory to made 3 thumb amputations with 1 aggressive debridement. The specific antibiotic postoperative treatment was ciprofloxacin + clindamicin because the isolated pathogen in all the samples was Stafilococo Aureus Meticilin Resistent from the community. Conclusion. The high consume of drugs in young people and the unprotective features (social, cultural and economics) of this group, is increasing the incidence of this pathology. Due to his fast and hiperacute evolution plus the delay in consultation, a radical treatment (amputation) is require. That's why we think the prevention of this illness could avoid ending in an important disability

Introduction. Long-term ankle pain, stiffness or swelling are frequent following ankle fracture. We investigated whether engineered compression stocking (ECS) influenced functional outcome and quality of life (QoL). Methods. Ninety patients < 72 hours following ankle fracture, (59 conservative and 31 operative fixation) were randomised to i) ECS + air-cast boot or ii) air-cast boot alone. Patients were followed at 2, 4, 8, 12 weeks and 6 months for Olerud Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Score (AOFAS) and SF12v2 score with duplex imaging for deep vein thrombosis (DVT) at 4 weeks. 22 controls managed by plaster of paris (POP) were also assessed at 6 months only. Results. Of 90 patients recruited, 29 (14 ECS + boot and 15 boot alone) have completed 6 month follow up. The mean (95%CI) foot, ankle and calf circumferences of the injured leg as a percentage of the normal leg were 100%, 100% and 99% at 6 months for ECS + boot compared with 106%, 109% and 102% for boot alone (p<0.001) and 103%, 106% and 102% for POP. By 6 months, the mean OMAS score for ECS + boot was 94, significantly better than 65 for boot alone and 59 for POP (p<0.001). AOFAS scores were also significantly improved at 105 with ECS compared to 87 for boot alone and 78 for POP (p<0.001). Mean SF12v2 scores were 115 for ECS + boot and 99 for boot alone and 91 for POP (p = 0.001). Of the 78 patients completing duplex imaging at 4 week, 5 (13%) of 38 ECS + boot patients had a DVT compared with 10 (25%) of the 40 boot alone patients (p = 0.30). Conclusion. ECS improve functional outcome and quality of life following ankle fractures

Introduction. Trends in hallux valgus surgery continue to evolve. Basal metatarsal osteotomy theoretically provides the greatest correction, but is under-represented in the literature. This paper reports our early experience with a plate-fixed, opening- wedge basal osteotomy, combined with a new form of distal soft tissue correction (in preference to Akin phalangeal osteotomy). Materials and Methods. Thirty-three patients are reported here. The basal metatarsal osteotomy is fixed with the ‘Low Profile’ Arthrex titanium plate. No bone graft or filler is required, providing the osteotomy is within about 12mm of the base. Distal soft tissue correction comprised a full lateral release, and then proximal advancement of a complete capsular ‘sleeve’ on the medial side. The plate serves as a rigid anchoring point for the tensioning stitches. Using this technique, almost any degree of hallux valgus can be corrected, and there is even potential for over-correction. Functional outcome was assessed using the Manchester-Oxford foot and ankle score (MOXF). Radiographically the intermetatarsal angle was evaluated pre-operatively and at least 6 months postoperatively. Patients’ satisfaction and complication rates were recorded. Results. Clinical 87% (29 of 33) reported high satisfaction with the functional and cosmetic outcome. The opening basal wedge osteotomy slightly lengthens the first ray and as result none of our patients developed transfer metatarsalgia. Results. Radiology Hallux valgus angle (HVA) and inter-metatarsal angle (IMA) were measured on pre- and post-operative weight bearing radiographs. The radiological correction seen was very striking The mean correction of the IMA was 14 degrees; mean HVA correction was … degrees. Complications. One osteotomy was too distal, leading to a non-union, which required revision and bone grafting. Swelling and stiffness were seen in some patients, but these problems resolved steadily, with physiotherapy if needed. Discussion. This operation is a combined proximal/distal, bone/soft tissue procedure. It can obtain correction of almost any degree of hallux valgus. The slight first- ray lengthening is an advantage, as it neutralizes potential second ray problems. However, this is a very early result and long-term outcomes are as yet unknown