Strategies in Trauma and Limb Reconstruction最新文献

Introduction: No entirely reliable method to assess union during Ilizarov treatment exists. Premature frame removal results in treatment failure, and alternative methods of assessment warrant investigation. Wire deflection might provide an indication of fracture site deformation on weight-bearing, indicating progress towards union. A previous in vitro study from our group demonstrated this approach may be clinically applicable. We investigated translation of this method into clinical practice in an observational pilot study.

Materials and methods: Patients with tibial shaft fractures treated with Ilizarov frames were recruited. A prototype depth gauge was used to measure wire deflection on weight-bearing. Investigators undertaking the measurement were blinded to the clinical stage of treatment, and clinicians caring for the patient were blinded to deflection results. Patient records were reviewed at the end of treatment to determine likely fracture stability at each time point. Deflection per kg of weight applied, per mm from the ring was compared between stable and unstable situations.

Results: Thirty-one measurements were obtained in 14 patients. The situation was deemed stable at 13 and unstable at 18 measurements. The median deflection in the stable group was 0.030 microns/kg/mm (IQR 0.005-0.104) and 0.165 microns/kg/mm (IQR 0.072-0.328) in the unstable group. This difference was statistically significant (Wilcoxon Mann-Whitney test p = 0.0014). ROC curve analysis revealed that wire deflection was able to predict clinical stability (AUC 0.84, p <0.0001). Various technical problems were encountered when using the device which would potentially limit its clinical utility in its current form.

Conclusion: In this set of observations, wire deflection was significantly associated with clinically and radiologically determined stability. Though various practical limitations were encountered in using the prototype measurement device, this proof-of-concept study supports further development of this approach. The research group plan to develop a smaller, more reliable device for further clinical testing in a larger group of patients.

How to cite this article: Lineham B, Stewart T, Ward J, et al. Measurement of Wire Deflection on Loading may Indicate Union in Ilizarov Constructs: A Pilot Study. Strategies Trauma Limb Reconstr 2021;16(3):132-137.

Aim: Intra-articular non-union of fractures is an uncommon but complex problem because in general, it is characterised by marked instability, pain, strength loss and significant functional limitation. The aim of this study is to report our prospective medium-term outcomes of the treatment of intra-articular, distal humeral aseptic non-unions using open reduction and internal fixation, augmented with artificial bone.

Materials and methods: A retrospective case series of 16 patients with intra-articular, aseptic non-unions of the distal humerus was analysed for range of motion, pain, Mayo Elbow Performance Scores (MEPS) and Oxford Elbow Scores (OES) after 12 months. Mean age was 44 years (range, 18-84 years) and mean total follow-up was 43 months (range, 24-62 months).

Results: All subjective and objective scores were significantly higher 12 months after treatment with internal fixation and artificial bone augmentation; the mean improvement on the MEPS was 18 points and 17 points on the OES. All patients returned to work, most without limitations. Autografts had worse outcomes compared to allografts regarding post-operative pain and time to return to work. No adverse events related to the artificial bone augmentation were seen and all fractures consolidated.

Conclusion: The use of two locking plates and bone graft augmentation with autografts or allografts with artificial bone grafts is a successful treatment of intra-articular distal humeral non-unions after hardware failure or biological limitations.

Clinical significance: The use of artificial bone in the treatment of septic non-unions of the upper limb is safe. When no autograft is possible because of concurrent morbidity, it can be used alone or combined with an allograft to reconstruct the affected bone without leading to extra morbidity or complications.

How to cite this article: Rollo G, Vicenti G, Rotini R, et al. Open Reduction and Internal Fixation Using Double Plating with Biological and Artificial Bone Grafting of Aseptic Non-unions of the Distal Humerus: Clinical Results. Strategies Trauma Limb Reconstr 2021;16(3):144-151.

Aim and objective: Sagittal guided growth of the distal anterior femur has been shown to be effective for the correction of fixed knee flexion deformity that is encountered in clinical practice. The opposite deformity, namely genu recurvatum, is comparatively uncommon in children. The most common aetiology is post-traumatic. Acute correction by means of osteotomy has significant associated risks. Our objective was to determine whether a posterior 8-plate would suffice in correcting tibial recurvatum and obviate the need for an osteotomy.

Materials and methods: We included a total of five deformities, three boys (one bilateral) and one girl, managed by means of tethering of the posterior proximal tibial physis with a tension band plate. Standard radiographs obtained preoperatively and at follow-up included a standing anteroposterior (AP) of the legs noting limb lengths and the mechanical axis. We also obtained standing lateral views of each knee in maximal extension to measure and compare the posterior proximal tibial angle (PPTA).

Results: The same-day surgery was well tolerated and there were no surgical or post-operative complications. The preoperative PPTA ranged from 106° to 117° and averaged 84° at follow-up. Correction occurred in an average of 20 months (range of 18-24 months). The patient with bilateral recurvatum due to Hurler's syndrome developed unilateral recurrent recurvatum culminating in percutaneous reinsertion of the metaphyseal screw. For each patient, knee hyperextension and associated pseudo-laxity resolved and limb lengths remained equal at follow-up.

Conclusion: Children with progressive genu recurvatum typically present with an insidious onset of symptoms. Guided growth of the posterior proximal tibia is a safe and effective means of correcting the deformity; osteotomy was avoided in this series.

Level of evidence: III - retrospective case series - no controls.

How to cite this article: Stevens P, Stephens A, Rothberg D. Guided Growth for Tibial Recurvatum. Strategies Trauma Limb Reconstr 2021;16(3):172-175.

Aim and objective: To study the radiological and functional outcomes as well as complications in the management of fractures involving both columns of the acetabulum using a single surgical approach.

Design: Type IV, prospective clinical study.

Setting: Level I trauma centre.

Materials and methods: Inclusion criteria were as follows: (a) patients over 20 year of age and (b) patients suffering from acetabular fractures involving both columns as per Letournel and Judet classification, namely transverse, transverse + posterior wall, T type, anterior column posterior hemi-transverse (ACPHT) and associated both columns. Exclusion criteria were as follows: (a) patient suffering from isolated anterior column, posterior column, anterior wall, posterior wall and posterior wall + column fractures; (b) patient who have undergone surgical procedures of the hip prior to trauma; and (c) compound acetabular fractures. A total of 23 patients having both column acetabulum fractures were included prospectively from June 2016 to December 2018 and followed up till 1 year postoperatively. Open reduction and internal fixation were performed through one of three described approaches, i.e., iliofemoral, Kocher-Langenbeck, and anterior intrapelvic or ilioinguinal.

Results: Our study population consisted of 30.4% transverse, 39.1% associated both columns, 21.7% T type and 8.7% anterior column + posterior hemi-transverse. Of these, 65.2% were operated using the Kocher-Langenbeck approach, while 30.4% of patients required the anterior intrapelvic approach. The remaining 4.3% of patients were operated by the iliofemoral approach. Anatomic reduction was achieved in 100% of our study population with remaining displacement less than or equal to 1°mm. At 1-year follow-up, all fractures showed a satisfactory union with an excellent Matta index in 100% study subjects. Complications at 1 year included one case of foot drop, which was present preoperatively but failed to improve and one case of post-traumatic arthritis. Average Harris Hip score (HHS) and mean Merle D'Aubigne (MDA) scores suggested good clinical outcomes in the study population.

Conclusions: A single approach can be used to achieve good functional and radiological outcomes in carefully selected bicolumnar fractures of the acetabulum, with less approach-related morbidity.

Clinical significance: Traditionally, multiple approaches are used for acetabulum fractures involving both columns, but with proper patient selection, single approach can be used with good functional and surgical outcomes.

How to cite this article: Patil A, Attarde DS, Haphiz A, et al. A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients. Strategies Trauma Limb Reconstr 2021;16(3):152-160.

Aim and objective: Software-guided realignment is proposed as an easy and accurate method of achieving simultaneous multiaxial correction. The accuracy and efficacy in periarticular problems have not been investigated fully. This study investigates the results and possible clinical benefits.

Materials and methods: A retrospective review was performed in 24 patients with 27 periarticular deformities of the lower limb treated by the Ilizarov technique. Bony realignment was achieved by a software-guided hexapod realignment device. The deformity category, deformity severity score (DSS) and individual deformity component scores were measured for objective quantification of each deformity. The periarticular level, number of manoeuvres, correction period and any difficulties in the execution of the correction manoeuvre were noted. Pre-procedure and post-procedure values of deformity parameters were analysed to estimate the accuracy and efficacy of the realignment device.

Results: The correction manoeuvre was accomplished successfully in all patients except two. The mean correction period was 14.9 days (range, 5-38 days). The mean pre-procedure DSS was 18.7 (range 6.3-27.3), which reduced to a mean post-procedure value of 1.5 (range, 0-7.9) with a 92.0% deformity correction (p-value < 0.001)). There was a significant reversal of individual deformity components. DSS values were achieved to an excellent level (< 3.5) in 25 deformities and to good and poor levels in one deformity, respectively.

Conclusion: Software-guided realignments are effective for accurate realignment of periarticular deformities using Ilizarov fixators. These devices offer simultaneous multidimensional corrections even in complex multiplanar deformities and simplify the task of deformity correction.

Clinical significance: The present study assesses the accuracy and efficacy of software-guided realignments using novel concepts of deformity category, DSS and individual deformity component scores, which may overcome some of the shortcomings of conventional assessment methods.

How to cite this article: Singh P, Sabat D, Dutt S, et al. Accuracy and Efficacy of Software-guided Bony Realignment in Periarticular Deformities of the Lower Limb. Strategies Trauma Limb Reconstr 2021;16(2):65-70.

Aims and objectives: To examine clinical and functional outcomes in patients with intra- and extra-articular distal tibial fractures treated definitively by Ilizarov fixation.

Materials and methods: Patients with tibial fractures extending within 1 Müller square of the ankle joint were identified from our Ilizarov database over a 5-year period. Data on treatment and outcome were assembled from this database and supplemented by a review of patient records. General measures of health-related quality of life and limb-specific functional outcome scores were recorded. Adverse events were documented according to Paley's classification.

Results: One hundred and sixty-eight patients with 169 fractures were identified, 28% were open and 63% intra-articular. One hundred and sixty-five (98%) of the fractures united, two following bone grafting in their original frames, at a median of 166.5 days (range 104-537). Three patients with nonunions united with further treatment. One patient (an end-stage diabetic) elected to undergo amputation following multiple early complications during treatment. Closed fractures united more rapidly than open (median 157 vs 183 days; p = 0.005) and true Pilon (43C3) fractures took longer to unite than other fractures (median 157 vs 177 days; p = 0.01).Sixty-seven percent of patients completed functional outcome scores. Sixty-two percent reported good or excellent ankle scores at more than 6 months post frame removal, 38% fair and 10% poor. Patients with intra-articular fractures reported significantly worse ankle scores than those with extra-articular injuries. General measures of health-related quality of life (EuroQol-5D) revealed significant ongoing effects despite good clinical outcomes.

Conclusion: This study demonstrates a high union and low serious complication rate, suggesting that external ring fixation is a safe and effective treatment for these injuries.

How to cite this article: Giannoudis VP, Ewins E, Taylor DM, et al. Clinical and Functional Outcomes in Patients with Distal Tibial Fracture Treated by Circular External Fixation: A Retrospective Cohort Study. Strategies Trauma Limb Reconstr 2021;16(2):86-95.

Charcot arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. Conventional surgical treatment includes extensive surgical exposure, excision of bone, acute correction and internal fixation, which is not always appropriate in presence of active ulceration, infection and poor bone quality. A minimally invasive approach to osteotomies and gradual correction of deformities using a circular frame are proving helpful in minimizing the complications. Taylor Spatial Frame (TSF) hexapod with its various modules is well suited for a range of foot and ankle deformities. We have advocated minimally invasive targeted hind and mid foot osteotomies and gradual correction with Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. There are 2 female and 8 male patients in this cohort. Appropriate TSF module was chosen for each patient- a long bone module for ankle and hindfoot deformities (4 patients) and a forefoot 6x6 butt frame (6 patients) for foot deformities. An osteotomy through the midfoot was performed in all chronic stable foot deformity cases. In the ankle and hindfoot deformities, a combination of soft tissue distraction correction of equinus and acute correction of hindfoot deformity through a calcaneal osteotomy, were used. Our outcome measures are complete healing of the ulcers and resolution of infection, clinically plantigrade foot and ability to wear regular or diabetic footwear. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. We achieved ulcer and infection free plantigrade feet that fit in to regular or diabetic footwear in 9 out of 10 patients. 9 patients remain ulcer and infection free at a minimum of 7 years and maximum of 14 years follow up. Taylor Spatial Frame treatment provides an alternative to conventional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities. How to cite this article: Lahoti O, Abhishetty N, Shetty S. Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7-14-year Follow-up. Strategies Trauma Limb Reconstr 2021;16(2):96-101.

Aim and objective: The most recent wave of lower limb amputees in Gaza arises from ballistic injuries sustained during protests. This study evaluates the requirement for surgical revision of these mature stumps to allow prosthetic fit and mobility.

Materials and methods: A multidisciplinary team (MDT) comprising a prosthetist, orthopaedic and plastic surgeons and a physiotherapist screened 104 amputee stumps (103 cases). The 27 cases selected for surgical revision (stump-plasty) are the subject of this study.The MDT prescriptions of care issued at screening were compared to surgical procedures performed at stump-plasty and the findings. Compliance with the MDT prescription was recorded. Stump issues are identified to propose modifications of primary amputation technique to mitigate future revisions.Patients' healthcare status was assessed by questionnaire (EQ-5D-L5) at screening, then subsequently post-stump-plasty.

Results: More below-knee amputees (BKAs) than above-knee amputees (AKAs) required stump-plasty. Revisions varied according to the quality of tissue present at the amputation level. AKA revisions addressed bulk and contour issues whereas BKA revisions related to bone prominence, neuroma formation and lack of soft tissue cover. Despite many variations in tissue-targeted procedures being possible, the MDT prescription was followed accurately at surgery.Suggested modifications at primary amputation to decrease revisions include improved bone tip bevelling at BKA and greater soft tissue reduction at AKA. Severed nerve management needs to be rationalised to reduce primary neuroma formation and neuroma revision at stump-plasty requires consideration to attempt to reduce the recurrent risk. Removal of the fibular remnant in short BKA stumps at primary amputation could mitigate common peroneal nerve hypersensitivity later.Following stump-plasty, amputees recorded a significantly improved score in three of five dimensions of the EQ-5D-L5 questionnaire: activities, anxiety levels and pain.

Conclusion and clinical significance: Primary ballistic injury dictates the level of amputation and the resultant stump quality. Issues arising in these complex amputee stumps benefited from measured decisions and specialist care delivered by the MDT. Stump-plasty aims to improve the amputees' prosthetic fit, mobility and health.

How to cite this article: Godwin Y, Almaqadma A, Abukhoussa H, et al. Stump-plasty: An Operation Born of Necessity in Gaza. Strategies Trauma Limb Reconstr 2021;16(2):102-109.

Regeneration of the fibula following partial fibulectomy is a common and well-reported phenomenon in children. However, there is limited literature on the regeneration of fibula in skeletally mature individuals. We report a case series of regeneration of the distal fibula following partial distal fibulectomy. In both these cases, calcium sulphate (Stimulan-Biocomposites, Keele, UK) antibiotic-loaded beads were used for local delivery of a high concentration of antibiotics. However, calcium sulphate worked as an osteoconductive agent and led to regeneration of the fibula. Regeneration of the fibula has its benefits and downside. Regeneration can be beneficial in patients in whom future arthroplasty is considered as total ankle replacement would not be possible in the absence of distal fibula. On the contrary, a regenerated fibula can be a source of ankle pain related to the syndesmotic joint. There is also a report of infection recurring in the regenerated fibula. Hence, while using calcium sulphate beads either as a spacer or as a vehicle for local delivery of antibiotics, the operating surgeon needs to be aware of the risk of regeneration of the fibula if the periosteum is preserved. How to cite this article: Goru P, Haque S, Hirst T, et al. Regeneration of Fibula Following Distal Fibulectomy for Ankle Arthrodesis Following the Use of Calcium Sulphate Granules: A Case Series and Review of the Literature. Strategies Trauma Limb Reconstr 2021;16(2):123-126.