Aims. Complex fractures of the femur and tibia with associated severe soft tissue injury are often devastating for the individual. The aim of this study was to describe the two-year patient-reported outcomes of patients in a civilian population who sustained a complex fracture of the femur or tibia with a Mangled Extremity Severity Score (MESS) of ≥ 7, whereby the score ranges from 2 (lowest severity) to 11 (highest severity). Methods. Patients aged ≥ 16 years with a fractured femur or tibia and a MESS of ≥ 7 were extracted from the Victorian Orthopaedic Trauma Outcomes Registry (January 2007 to December 2018). Cases were grouped into surgical amputation or limb salvage. Descriptive analysis were used to examine return to work rates, three-level EuroQol five-dimension questionnaire (EQ-5D-3L), and Glasgow Outcome Scale-Extended (GOS-E) outcomes at 12 and 24 months post-injury. Results. In all, 111 patients were included: 90 (81%) patients who underwent salvage and 21 (19%) patients with surgical amputation. The mean age of patients was 45.8 years (SD 15.8), 93 (84%) were male, 37 (33%) were involved in motor vehicle collisions, and the mean MESS score was 8.2 (SD 1.4). Two-year outcomes in the cohort were poor: six (7%) patients achieved a GOS-E good recovery, the mean EQ-5D-3L summary score was 0.52 (SD 0.27), and 17 (20%) patients had returned to work. Conclusion. A small proportion of patients with severe lower limb injury (MESS ≥ 7) achieved a good level of function 24 months post-injury. Further follow-up is needed to better understand the long-term trajectory of these patients, including delayed amputation, hospital readmissions, and healthcare utilization. Cite this article: Bone Joint J 2021;103-B(4):769–774

The treatment of infected exposed implants which have been used for internal fixation usually involves debridement and removal of the implant. This can result in an unstable fracture or spinal column. Muscle flaps may be used to salvage these implants since they provide soft-tissue cover and fresh vascularity. However, there have been few reports concerning their use and these have concentrated on the eradication of the infection and successful soft-tissue cover as the endpoint. There is no information on the factors which may influence the successful salvage of the implant using muscle flaps. We studied the results and factors affecting outcome in nine pedicled muscle flaps used in the treatment of exposed metal internal fixation with salvage of the implant as the primary endpoint. This was achieved in four cases. Factors predicting success were age < 30 years, the absence of comorbid conditions and a favourable microbiological profile. The growth of multiple organisms, a history of smoking and the presence of methicillin-resistant Staphylococcus aureus on wound cultures indicated a poor outcome. The use of antibiotic beads, vacuum-assisted closure and dressing, the surgical site, the type of flap performed and the time from primary surgery to flap cover were not predictive of outcome

Limb-injury severity scores are designed to assess orthopaedic and vascular injuries. In Gustilo type-IIIA and type-IIIB injuries they have poor sensitivity and specificity to predict salvage or outcome. We have designed a trauma score to grade the severity of injury to the covering tissues, the bones and the functional tissues, grading the three components from one to five. Seven comorbid conditions known to influence the management and prognosis have been given a score of two each. The score was validated in 109 consecutive open injuries of the tibia, 42 type-IIIA and 67 type-IIIB. The total score was used to assess the possibilities of salvage and the outcome was measured by dividing the injuries into four groups according to their scores as follows: group I scored less than 5, group II 6 to 10, group III 11 to 15 and group IV 16 or more. A score of 14 to indicate amputation had the highest sensitivity and specificity. Our trauma score compared favourably with the Mangled Extremity Severity score in sensitivity (98% and 99%), specificity (100% and 17%), positive predictive value (100% and 97.5%) and negative predictive value (70% and 50%), respectively. A receiver-operating characteristic curve constructed for 67 type-IIIB injuries to assess the efficiency of the scores to predict salvage, showed that the area under the curve for this score was better (0.988 (± 0.013 . sem. )) than the Mangled Extremity Severity score (0.938 (± 0.039 . sem. )). All limbs in group IV and one in group III underwent amputation. Of the salvaged limbs, there was a significant difference in the three groups for the requirement of a flap for wound cover, the time to union, the number of surgical procedures required, the total days as an in-patient and the incidence of deep infection (p < 0.001 for all). The individual scores for covering and functional tissues were also found to offer specific guidelines in the management of these complex injuries. The scoring system was found to be simple in application and reliable in prognosis for both limb-salvage and outcome measures in type-IIIA and type-IIIB open injuries of the tibia

Aims. The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment. Patients and Methods. Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale. Results. In the atypical group, union was achieved in 12 patients (85.7%) at a mean of 8.4 months (4 to 12). The mean follow-up was 31.2 months (12 to 92) The plate broke in one patient requiring further stabilization with a longer plate and strut-allograft. Another patient with failure of fixation and varus angulation at the fracture site declined further surgery. In the typical group, union was achieved in 18 patients (85.7%) at a mean of 7.9 months (4 to 12). There was no difference in the mean Harris Hip Score between the two groups (83.1 points vs 86.8 points; p = 0.522) at the time of final follow-up. Sanders functional rating scores were good or excellent in 78.6% of the atypical group and in 81.0% of the typical group. Conclusion. The 95° angled blade plate was shown to be an effective fixation modality for nonunion of atypical subtrochanteric fractures with a high rate of union and functional improvement, comparable to those after fractures not associated with bisphosphonate treatment. Cite this article: Bone Joint J 2018;100-B:1511–17

We evaluated the outcome of treatment of nonunion of an intracapsular fracture of the femoral neck in young patients using two cannulated screws and a vascularised bone graft. A total of 32 patients (15 women and 17 men, with a mean age of 36.5 years; 20 to 50) with failed internal fixation of an intracapsular fracture were included in the study. Following removal of the primary fixation, two cannulated compression screws were inserted with a vascularised iliac crest bone graft based on the ascending branch of the lateral femoral circumflex artery. At a mean follow-up of 6.8 years (4 to 10), union was achieved in 27 hips (84%). A total of five patients with a mean age of 40.5 years (35 to 50) had a persistent nonunion and underwent total hip arthroplasty as also did two patients whose fracture united but who developed osteonecrosis of the femoral head two years post-operatively. Statistical analysis showed that younger patients achieved earlier and more reliable union (p < 0.001). The functional outcome, as assessed by the Harris Hip score, was better in patients aged < 45 years compared with those aged > 45 years (p < 0.001). . These findings suggest that further fixation using two cannulated compression screws and a vascularised iliac crest bone graft is an effective salvage treatment in patients aged <  45 years, in whom osteosynthesis of a displaced intracapsular fractures of the femoral neck has failed. Cite this article: Bone Joint J 2015; 97-B:988–91

Four men who presented with chronic dislocation of the radial head and nonunion or malunion of the ulna were reviewed after open reduction of the radial head and internal fixation of the ulna in attempted overcorrection. Their mean age was 37 years (28 to 46) and the mean interval between injury and reconstruction was nine months (4 to 18).

The mean follow-up was 24 months (15 to 36). One patient who had undergone secondary excision of the radial head was also followed up for comparison.

The three patients who had followed the treatment protocol had nearly normal flexion, extension and supination and only very occasional pain. All had considerable loss of pronation which did not affect patient satisfaction.

Preservation of the radial head in chronic adult Monteggia fractures appears to be a promising mode of treatment.

We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight.

The mean external fixation time was 309.8 days. According to Paley’s grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.

We describe a patient with a Mason type-III fracture of the head of the radius associated with traumatic dislocation of the elbow. The radial head was intact throughout its circumference despite being completely detached from the shaft and devoid of any soft-tissue attachments. Severe comminution of the radial neck prevented reconstruction by internal fixation and precluded prosthetic replacement of the head. The head was fixed to the shaft with a tricortical iliac-crest bone graft which replaced the neck. Two years later, the patient had a stable elbow with flexion from 10° to 130°. Radiologically, the head of the radius appeared to be viable and the bone graft had incorporated.

Aims. The aim of this study was to investigate the rate of revision for distal femoral arthroplasty (DFA) performed as a primary procedure for native knee fractures using data from the Australian Orthopaedic Association National Joint Arthroplasty Registry (AOANJRR). Methods. Data from the AOANJRR were obtained for DFA performed as primary procedures for native knee fractures from 1 September 1999 to 31 December 2020. Pathological fractures and revision for failed internal fixation were excluded. The five prostheses identified were the Global Modular Arthroplasty System, the Modular Arthroplasty System, the Modular Universal Tumour And Revision System, the Orthopaedic Salvage System, and the Segmental System. Patient demographic data (age, sex, and American Society of Anesthesiologists grade) were obtained, where available. Kaplan-Meier estimates of survival were used to determine the rate of revision, and the reasons for revision and mortality data were examined. Results. The AOANJRR identified 153 primary DFAs performed for native knee fractures in 151 patients during the study period, with 63.3% of these (n = 97) performed within the last five years. The median follow-up was 2.1 years (interquartile range 0.8 to 4.4). The patient population was 84.8% female (n = 128), with a mean age of 76.1 years (SD 11.9). The cumulative percent revision rate at three years was 10%. The most common reason for revision was loosening, followed by infection. Patient survival at one year was 87.5%, decreasing to 72.8% at three years postoperatively. Conclusion. The use of DFA to treat native knee fractures is increasing, with 63.3% of cases performed within the last five years. While long-term data are not available, the results of this study suggest that DFA may be a reasonable option for elderly patients with native knee fractures where fixation is not feasible, or for whom prolonged non-weightbearing may be detrimental. Cite this article: Bone Joint J 2022;104-B(7):894–901

Aims. Open fractures of the tibia are a heterogeneous group of injuries that can present a number of challenges to the treating surgeon. Consequently, few surgeons can reliably advise patients and relatives about the expected outcomes. The aim of this study was to determine whether these outcomes are predictable by using the Ganga Hospital Score (GHS). This has been shown to be a useful method of scoring open injuries to inform wound management and decide between limb salvage and amputation. Methods. We collected data on 182 consecutive patients with a type II, IIIA, or IIIB open fracture of the tibia who presented to our hospital between July and December 2016. For the purposes of the study, the patients were jointly treated by experienced consultant orthopaedic and plastic surgeons who determined the type of treatment. Separately, the study team (SP, HS, AD, JD) independently calculated the GHS and prospectively collected data on six outcomes for each patient. These included time to bony union, number of admissions, length of hospital stay, total length of treatment, final functional score, and number of operations. Spearman’s correlation was used to compare GHS with each outcome. Forward stepwise linear regression was used to generate predictive models based on components of the GHS. Five-fold cross-validation was used to prevent models from over-fitting. Results. The mean follow-up was 11.4 months (3 to 31). The mean time to union was 9.7 months (3 to 21), the mean number of operations was 2.8 (1 to 11), the mean time in hospital was 17.7 days (5 to 84), the mean length of treatment was 92.7 days (5 to 730), the mean number of admissions was 1.7 (1 to 6), and the mean functional score (Lower Extremity Functional Score (LEFS)) was 60.13 (33 to 80). There was a significant correlation between the GHS and each of the outcome measures. A predictive model was generated from which the GHS could be used to predict the various outcome measures. Conclusion. The GHS can be used to predict the outcome of patients who present with an open fracture of the tibia. Our model generates a numerical value for each outcome measure that can be used in clinical practice to inform the treating team and to advise patients. Cite this article: Bone Joint J 2020;102-B(1):26–32

Aims

Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

Aims. The management of open lower limb fractures in the United Kingdom has evolved over the last ten years with the introduction of major trauma networks (MTNs), the publication of standards of care and the wide acceptance of a combined orthopaedic and plastic surgical approach to management. The aims of this study were to report recent changes in outcome of open tibial fractures following the implementation of these changes. Patients and Methods. Data on all patients with an open tibial fracture presenting to a major trauma centre between 2011 and 2012 were collected prospectively. The treatment and outcomes of the 65 Gustilo Anderson Grade III B tibial fractures were compared with historical data from the same unit. . Results. The volume of cases, the proportion of patients directly admitted and undergoing first debridement in a major trauma centre all increased. The rate of limb salvage was maintained at 94% and a successful limb reconstruction rate of 98.5% was achieved. The rate of deep bone infection improved to 1.6% (one patient) in the follow-up period. . Conclusion. The reasons for these improvements are multifactorial, but the major trauma network facilitating early presentation to the major trauma centre, senior orthopaedic and plastic surgical involvement at every stage and proactive microbiological management, may be important factors. . Take home message: This study demonstrates that a systemised trauma network combined with evidence based practice can lead to improvements in patient care. Cite this article: Bone Joint J 2016;98-B:420–4

Controversy continues to surround the management of patients with an open fracture of the lower limb and an associated vascular injury (Gustilo type IIIC). This study reports our 15-year experience with these fractures and their outcome in 18 patients (15 male and three female). Their mean age was 30.7 years (8 to 54) and mean Mangled Extremity Severity Score (MESS) at presentation was 6.9 (3 to 10). A total of 15 lower limbs were salvaged and three underwent amputation (two immediate and one delayed). Four patients underwent stabilisation of the fracture by external fixation and 12 with an internal device. A total of 11 patients had damage to multiple arteries and eight had a vein graft. Wound cover was achieved with a pedicled flap in three and a free flap in six. Seven patients developed a wound infection and four developed nonunion requiring further surgery. At a mean follow-up of five years (4.1 to 6.6) the mean visual analogue scale for pain was 64 (10 to 90). Depression and anxiety were common. Activities were limited mainly because of pain, and the MESS was a valid predictor of the functional outcome. Distal tibial fractures had an increased rate of nonunion when associated with posterior tibial artery damage, and seven patients (39%) were not able to return to their previous occupation

Between 2000 and 2006 we performed salvage tibiotalar arthrodesis in 17 diabetic patients (17 ankles) with grossly unstable ankles caused by bimalleolar fractures complicated by Charcot neuro-arthropathy. There were ten women and seven men with a mean age of 61.6 years (57 to 69). A crossed-screw technique was used. Two screws were used in eight patients and three screws in nine. Additional graft from the malleoli was used in all patients. The mean follow-up was 26 months (12 to 48) and the mean time to union was 5.8 months (4 to 8). A stable ankle was achieved in 14 patients (82.4%), nine of whom had bony fusion and five had a stiff fibrous union. The results were significantly better in underweight patients, in those in whom surgery had been performed three to six months after the onset of acute Charcot arthropathy, in those who had received anti-resorptive medication during the acute stage, in those without extensive peripheral neuropathy, and in those with adequate peripheral oxygen saturation (> 95%). The arthrodesis failed because of avascular necrosis of the talus in only three patients (17.6%), who developed grossly unstable, ulcerated hindfeet, and required below-knee amputation

Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons

A series of 26 children was referred to our specialist unit with a ‘pink pulseless hand’ following a supracondylar fracture of the distal humerus after a mean period of three months (4 days to 12 months) except for one referred after almost three years. They were followed up for a mean of 15.5 years (4 to 26). The neurovascular injuries and resulting impairment in function and salvage procedures were recorded. The mean age at presentation was 8.6 years (2 to 12). There were eight girls and 18 boys. Only four of the 26 patients had undergone immediate surgical exploration before referral and three of these four had a satisfactory outcome. In one child the brachial artery had been explored unsuccessfully at 48 hours. As a result 23 of the 26 children presented with established ischaemic contracture of the forearm and hand. Two responded to conservative stretching. In the remaining 21 the antecubital fossa was explored. The aim of surgery was to try to improve the function of the hand and forearm, to assess nerve, vessel and muscle damage, to relieve entrapment and to minimise future disturbance of growth. Based on our results we recommend urgent exploration of the vessels and nerves in a child with a ‘pink pulseless hand’, not relieved by reduction of a supracondylar fracture of the distal humerus and presenting with persistent and increasing pain suggestive of a deepening nerve lesion and critical ischaemia

We define the long-term outcomes and rates of further operative intervention following displaced Bennett’s fractures treated with Kirschner (K-) wire fixation between 1996 and 2009. We retrospectively identified 143 patients (127 men and 16 women) with a mean age at the time of injury of 33.2 years (18 to 75). Electronic records were examined and patients were invited to complete the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire in addition to a satisfaction questionnaire. The time since injury was a mean of 11.5 years (3.4 to 18.5). In total 11 patients had died, one had developed dementia and 12 patients were lost to follow-up. This left 119 patients available for recruitment. Of these, 57 did not respond, leaving a study group of 62 patients. Patients reported excellent functional outcomes and high levels of satisfaction at follow-up. Median satisfaction was 94% (interquartile range 91.5 to 97.5) and the mean DASH score was 3.0 (0 to 38). None of the patients had undergone salvage procedures and none of the responders had changed occupation or sporting activities. Long-term patient reported outcomes following displaced Bennett’s fractures treated by closed reduction and K-wire fixation show excellent functional results and a high level of patient satisfaction. The rate of infection is low and similar to other surgical procedures with percutaneous K-wires. Cite this article: Bone Joint J 2015;97-B:1004–6

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (> 72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure

Fractures of the distal radius occurring in young adults are treated increasingly by open surgical techniques, partly because of concern that failure to restore the alignment of the fracture accurately may cause symptomatic post-traumatic osteoarthritis in future years. We reviewed 106 adults who had sustained a fracture of the distal radius between 1960 and 1968 and who were below the age of 40 years at the time of injury. We carried out a clinical and radiological assessment at a mean follow-up of 38 years (33 to 42). No patient had required a salvage procedure. While there was radiological evidence of post-traumatic osteoarthritis after an intra-articular fracture in 68% of patients (27 of 40), the disabilities of the arm, shoulder and hand (DASH) scores were not different from population norms, and function, as assessed by the Patient Evaluation Measure, was impaired by less than 10%. Ordinal logistic regression analysis showed a significant relationship between narrowing of the joint space and extra-articular malunion (dorsal angulation and radial shortening) as well as intra-articular injury. Multivariate analysis revealed that grip strength had fallen to 89% of that of the uninjured side in the presence of dorsal malunion, but no measure of extra-articular malunion was significantly related to either the Patient Evaluation Measure or DASH scores. While anatomical reduction is the principal aim of treatment, imperfect reduction of these fractures may not result in symptomatic arthritis in the long term, and this should be considered when counselling patients on the risks and benefits of the many treatment options available

Aims

To describe a new objective classification for open fractures of the lower limb and to correlate the classification with patient-centred outcomes.