Strategies in Trauma and Limb Reconstruction最新文献

Introduction: Managing post-traumatic critical bone defects in the tibia remains challenging. Vascularised free fibula grafts (VFFG) are an attractive option due to their versatility and ability to integrate with host bone. However, they are challenging, and their role compared to alternative techniques, such as bone transport and Masquelet, remains unclear. This study aims to assess the safety and effectiveness of free fibula flaps in reconstructing critical tibia defects following trauma.

Materials and methods: Five databases were searched for English-language studies from inception until August 2024. Inclusion criteria involved adult patients undergoing VFFG to the tibia for trauma-induced bone defects. Case reports and studies involving non-traumatic and/or critical bone injury and/or those not undergoing fibula transfer were excluded. Bias was assessed using the ROBINS-I tool.

Results: Fifteen studies involving 83 patients with a mean age of 35.07 ± 12.16 (range: 18-65) were included. Ipsilateral fibula transfer was preferred (n = 13, 80%), of and 89.7% fibulas (n = 35) were transferred using a single-barrel approach. The average union rate was 93.08% (95% CI: 86.56, 99.61) across the 74 patients where union outcomes were reported. Flap survival was 100% in seven studies, whilst two studies reported lower survival rates, the lowest being 50%. The overall complication rate was 39.98% (95% CI: 28.25, 51.71), with stress fractures occurring in 35.5% (n = 16) of cases. Revision rates varied from 10 to 40%. The risk of bias was high in 12 studies, and only three studies had a moderate risk. Four studies compared VFFG to alternative management strategies.

Conclusion: Vascularised free fibula grafts are effective for reconstructing large segmental tibia defects post-trauma, achieving high union and flap survival rates. However, complication rates are high, and study heterogeneity limits definitive conclusions on the technique's superiority. Further prospective comparative studies are required to characterise the role of VFFG.

How to cite this article: How to cite this article: Glynou SP, Georgiannakis A, Ardolino D, et al. Vascularised Fibula Transfer for Post-traumatic Critical Tibial Bone Defects: A Systematic Review. Strategies Trauma Limb Reconstr 2025;20(1):37-46.

This article presents a practical technique for distal intramedullary nail locking based on fluoroscopic triangulation. Unlike traditional methods, which require precise orientation of the C-arm to obtain perfect circles on radiographs, this approach allows locking to be performed with less radiation exposure and surgical time. The technique does not require additional equipment. It is thus proposed as a safe and efficient technique for distal locking.

How to cite this article: Barroso MM, Blanco JC, de Armas JN, et al. A Trigonometric Technique for Distal Locking of Intramedullary Nails without the Need for Specific Instrumentation. Strategies Trauma Limb Reconstr 2025;20(1):47-49.

Aims and background: In the field of deformity analysis, the values for reference lines (both anatomical and mechanical) and reference angles of the femur and tibia are established. However, current data regarding the reference lines and angles of the humerus are limited, which limits comprehensive planning for deformity correction.The aim of this research was to establish standard values for the anatomical axis and angles of the humerus as measured in both the frontal and sagittal planes.

Materials and methods: Radiographic images of the upper arms of 36 healthy participants (comprising 15 women and 21 men) were examined by utilizing two common imaging techniques: Anteroposterior and lateral views. Inclusion criteria for participants were over 18 years of age, have no prior upper limb injuries; no reports of pain in the upper limb joints; the lack of any musculoskeletal diseases and the absence of deformities. On the anteroposterior radiograph, assessments were made of joint intersections with the anatomical axis, along with the anatomical medial proximal humeral angle (aMPHA) and the anatomical lateral distal humeral angle (aLDHA). The lateral radiograph analysis focussed on joint intersections with the anatomical axis, the anatomical posterior proximal humerus angle (aPPHA) and the anatomical posterior distal humerus angle (aPDHA).

Results: In the frontal plane, the anatomical axis intersected the proximal joint line of the humerus at the border of 36.6 ± 5.7 mm (76.57%) medially and 11.1 ± 4.5 mm (23.43%) laterally. At the distal joint line, the intersection occurred at the border of 22.5 ± 3.9 mm (37.88%) medially and 36.9 ± 5.6 mm (62.12%) laterally. In the sagittal plane, the anatomical axis intersected the proximal joint line at the border of 41.1 ± 11 mm (39.83%) in front and 62.1 ± 12.4 mm (60.17%) behind, and the distal joint line at the border of 16.1 ± 3.4 mm (76.3%) in front and 5.0 ± 2.1 mm (23.7%) behind. The following reference angle values were obtained: aMPHA = 45.2° ± 5.0°, aLDHA = 78° ± 4.1°, aPPHA = 56.8° ± 8.8° and aPDHA = 16.4° ± 3.1°.

Conclusion: The obtained data will allow us to perform analysis, preoperative planning and evaluate the results of correction of humeral bone deformities with the accuracy required for clinical needs.

Clinical significance: This study provides orthopaedic surgeons with new reference lines and angles of the humerus that are essential tools for deformity correction planning and estimating the results of deformity correction.

How to cite this article: Vilenskii VA, Baushev MA, Solomin LN. Reference Lines and Angles of the Upper Arm. Strategies Trauma Limb Reconstr 2025;20(1):1-5.

Background: Elective stature lengthening (ESL) has gained popularity among individuals seeking to increase their height. Despite its growing appeal, online information about ESL often lacks consistency and transparency. This study evaluates the quality and comprehensiveness of online resources available to prospective patients, focusing on clarity in communication, cost, recovery expectations, and complications.

Methods: Using a secret shopper methodology, we contacted 27 eligible orthopaedic practices globally that offered ESL, posing as a healthy 35-year-old male seeking ESL. Practices were contacted via email and follow-up phone calls using a standardised script. Responses were analysed to evaluate the availability, depth, and variability of information on key topics, including surgery duration, recovery time, cost, insurance coverage, and complications.

Results: Contact was successfully established with 17 (63%) of practices. However, only 3/27 (11%) of the contacted practices answered all scripted questions. Cost estimates varied substantially, ranging from $15,000 to $150,118 (mean = $77,133, SD = $35,603.58). Recovery time was similarly variable, ranging from 2 to 365 days (mean = 202 days, SD = 137.27). Crucial details, such as patient eligibility and potential complications, were frequently omitted.

Conclusion: The study highlights a critical need for improved transparency and standardisation in online resources for ESL. Addressing these gaps could enhance patient trust, satisfaction, and informed decision-making, underscoring the importance of establishing guidelines for consistent communication in this emerging field.

How to cite this article: Shenoy DA, Santamaria G, Gomez-Alvarado F, et al. Information Transparency for Elective Stature Lengthening Surgery: A Secret Shopper Study. Strategies Trauma Limb Reconstr 2025;20(1):31-36.

Aims and background: Intra-articular distal tibia fractures can lead to post-traumatic osteoarthritis (PTOA). Joint distraction has shown promise in elective cases of osteoarthritis (OA) by temporarily offloading joint forces and potentially facilitating cartilage regeneration. However, its application in acute fractures remains unexplored. This pilot study aims to investigate the benefits of joint distraction in acute fractures.

Material and methods: A retrospective cohort study comprising consecutive patients with intra-articular distal tibia and pilon fractures, treated with a circular ring fixator (CRF) and ankle distraction as part of their fracture management, was undertaken at a single centre.Prospective data collection included radiological assessments, patient-reported outcome measures (PROM), complications, necessity for additional procedures, and the Kellgren and Lawrence grade (KL) for OA.

Results: There were 137 patients included in the study, among them 30 in the distraction group and 107 in the non-distraction group. There were no significant differences in age, gender, distribution of open or closed fractures, diabetic status, and smoking status between the groups. Mean follow-up was 3.73 years.There was no significant difference between the distraction and non-distraction groups in overall complications or need for further procedures. The mean radiological follow-up was 1.90 years, there was no significant difference in progression of KL between the groups (1.81 vs 2.0, p = 0.38). There were 32 patients who had radiological follow-up exceeding 2 years (average 3.52 years); here there was no significant difference between these groups (mean change 2.18 vs 2.4, p = 0.87).Patient-reported outcome measures data was available for 44 patients (6 in the distraction group, 38 in the non-distraction group) with a mean follow-up of 1.71 years. There were no significant differences in EQ5D and C Olerud-H Molander scores between the two groups.

Conclusion: Ankle joint distraction in the management of acute ankle fractures did not influence outcomes for patients in short and medium term follow-up. Future work should investigate for long-term effects of this auxiliary technique when using circular external fixators, in particular on the development of PTOA.

How to cite this article: Faraj A, Hammett F, Lineham B, et al. Outcomes of Acute Ankle Distraction for Intra-articular Distal Tibial and Pilon Fractures. Strategies Trauma Limb Reconstr 2025;20(1):6-10.

Lower limb free flaps require regular monitoring in the immediate days postoperatively and often involve prolonged outpatient wound care. Post-operative dressings are complicated when a circular external fixator is used. Circumferential post-operative dressings are the standard option, such as Jelonet/gauze/wool/crepe. An alternative option is the use of Jelonet and gauze, with Gamgee (JGG) wrapped loosely over the frame instead. This allows easier monitoring with complete flap visualisation, avoids constriction and allows much quicker dressing application. This dressing option has been previously described, but no comparative study between standard dressings and JGG dressings has been made. A retrospective study was conducted for consecutive patients treated with a circular frame and free flap for reconstruction of either an acute open tibial fracture or fracture-related infection between January 2022 and October 2023. Demographics, comorbidities, perioperative details, flap and wound healing outcomes were recorded and analysed using Jamovi 2.3.21. Thirty-one patients (average age 43 years) were identified, 81% open fracture, 42% gracilis, 36% ALT. A total of 48% had standard dressings, and 52% JGG. No statistically significant difference was found between the dressing groups for flap failure, inpatient stay, or time to complete healing. This study demonstrates clinical equivalence in outcomes between standard and JGG dressings for this patient group. The JGG dressing also has the advantages of quick and easy application, with improved flap visualisation. We recommend its use in this patient group.

How to cite this article: Jageer P, Kiely J, Day S, et al. A Comparative Analysis of Standard vs Jelonet/Gauze/Gamgee Dressing for Lower Limb Free Flap Reconstruction. Strategies Trauma Limb Reconstr 2025;20(1):56-58.

Background: Transcutaneous osseointegration following amputation (TOFA) is an alternative to standard prosthesis by directly anchoring a metal implant to the skeletal residuum. However, there is a paucity of data concerning whether TOFA is safe and reasonable for patients with lower limb amputation to manage complications of sepsis. The primary aim of this study was to record adverse post-TOFA events for nine patients (15 limbs) whose index amputations were performed to manage sepsis-related complications. The secondary aim was to compare the pre- and post-TOFA mobility and quality of life (QoL).

Methods: A retrospective review of our practice's prospectively maintained osseointegration database was performed. Patients with transfemoral and/or transtibial osseointegration for a limb in which the original amputation was performed to manage sepsis, at least two years prior to the study date, were included. This yielded nine patients with 15 osseointegrated limbs. Adverse events were antibiotics for infection or unplanned surgery. Outcomes were recorded using the SF-36 Health Survey and the Questionnaire for persons with a transfemoral amputation. Formal mobility evaluations included a 6-minute walk test and physician-determined K-levels.

Results: The cohort had a mean age of 42.8 ± 6.5 (range: 35.0-52.4) years. The mean body mass index (BMI) was 27.2 ± 11.0 (18.4-54.5). Six patients (67%) underwent bilateral osseointegration, and three (33%) patients underwent unilateral osseointegration. Six patients (67%) representing 12 limbs (80%) had an uneventful course post-osseointegration. One (11%) patient had intravenous antibiotics to manage a superficial infection. One (11%) other patient had a periprosthetic femur fracture managed by open reduction internal fixation. No systemic complications, additional surgeries, or implant removals occurred. 75% (6/8) achieved K-level ≥ 2 post-osseointegration. There was no significant change in the 6-minute walk test.

Conclusion: Lower limb osseointegration is a safe and effective rehabilitation option for patients whose amputations were a result of sepsis.

Clinical significance: Further judicious use of TOFA for these patients seems highly merited.

How to cite this article: Panzures AC, Akhtar MA, Hoellwarth, JS, et al. Transcutaneous Osseointegration for Amputees as a Result of Sepsis Management: A Case Series of Nine Patients with a Mean Follow-up of 4 Years. Strategies Trauma Limb Reconstr 2025;20(1):17-24.

Background: Controversy remains on the most effective method of treating open tibia shaft fractures. The timing of the different treatment variables remains at the heart of this dispute. This study aimed to investigate outcomes of open tibial shaft fractures. Specific objectives were to determine the association of time delay to antibiotic administration, surgical debridement, definitive skeletal stabilisation and soft tissue reconstruction, and the development of fracture-related infection (FRI).

Materials and methods: A total of 227 patients with 237 open tibia shaft fractures were included. The time from arrival to (1) antibiotic administration (<3 hours vs >3 hours); (2) primary debridement in theatre (<24 hours vs >24 hours); (3) definitive skeletal stabilization (<5 days vs >5 days); (4) definitive soft tissue reconstruction (<5 vs >5 days); and (5) time to union was recorded. The number of debridements and the length of hospital stay were also recorded.

Results: Patients who waited more than 5 days for definitive skeletal fixation or soft tissue reconstruction had a significant increase in FRI [odds ratio (OR) 4.7, 95% confidence intervals (CI): 2.0-10.9 and OR 4.7, 95% CI: 2.0-11.0, respectively]. Patients who underwent more than two formal debridements also had a higher risk of developing FRI than those who only had ≤2 debridements (OR 15.6, 95% CI: 5.8-41.6).

Conclusion: Time delays in managing open tibia shaft fractures are associated with an increased risk of FRI. Definitive soft tissue reconstruction and skeletal stabilisation should not be delayed for more than 5 days.

Clinical significance: Fracture-related infection following open tibia shaft fractures can be mitigated by reducing treatment delays, specific to definitive soft tissue reconstruction and skeletal stabilisation.

How to cite this article: Kock FM, Basson TR, Burger MC, et al. The Effect of Treatment Delays on Fracture-related Infection in Open Tibia Shaft Fractures: A Retrospective Cohort Study. Strategies Trauma Limb Reconstr 2025;20(1):25-30.

Charcot neuroarthropathy involving foot is a frequent and potentially a devastating complication of diabetes. In addition to good control of diabetes, surgical shoes and regular podiatric treatment, correction of foot deformity to prevent ulceration, deep infection and limb loss are now well established. Vascular insufficiency is common in this group of patients and traditional revascularisation procedures do not always succeed in healing ulcers and treating critical ischaemia. It compromises wound and bone healing. We report successful use of a modified technique of tibial cortex transverse transport (TTT) in a case where traditional revascularisation methods failed to correct critical ischaemia. We have achieved successful soft tissue and bone healing using this technique.

How to cite this article: Al Omar H, Lahoti O, Edmonds M, et al. Ischaemic Charcot Midfoot Reconstruction Combined with Lateral Tibial Cortex Transverse Transport: Case Report. Strategies Trauma Limb Reconstr 2025;20(1):50-55.