Strategies in Trauma and Limb Reconstruction最新文献

Aim and objective: Genu recurvatum is a rare deformity for which minimal literature exists. Non-operative management typically gives unsatisfactory results. This study aims to evaluate the treatment of genu recurvatum with a hexapod frame.

Materials and methods: A single-center retrospective chart review of genu recurvatum cases treated with a hexapod fixator application was performed. Radiographic parameters included the following: leg length discrepancy (LLD), angle of recurvatum, angle of tilt of the tibial plateau, patellar height and anatomic proximal posterior tibial angle (aPPTA). Radiographic and functional results were evaluated.

Results: A total of five patients with six limbs corrected with a hexapod frame were found. Aetiology included post-traumatic (2), post-infectious (1) and idiopathic (3). The mean age at application was 13.36 (5.5-18.0) years. The total mean time in the fixator was 225 (160-412) days. The LLD decreased from a mean of 35.6 mm (0.7-50) preoperatively to a mean of 14.8 (1.0-39.3) postoperatively. The average patellar height remained similar 0.97 (0.69-1.2)-0.97 (0.51-1.6). The angle of the tilt of the tibial plateau improved from a preoperative mean of 66° (58.5-73.5°)-92.5° (80-98.5°). The angle of recurvatum improved from a preoperative mean of 26.4° (18.5-31°)-5.0° (0-9°). The aPTTA improved from (102-118°)-85.5° (77-96°).

Conclusion: Osteotomy distal to the tibial tuberosity and deformity correction using a hexapod frame allows for multiplanar correction. Throughout treatment, soft tissue management with physical therapy remained key to prevent knee contracture.

Clinical significance: A hexapod frame is a safe and accurate technique that allows correction of genu recurvatum along with concomitant deformities with low risk of complications.

How to cite this article: Johnson L, McCammon J, Cooper A. Correction of Genu Recurvatum Deformity Using a Hexapod Frame: A Case Series and Review of the Literature. Strategies Trauma Limb Reconstr 2021;16(2):116-119.

Purpose: The purpose of this study is to evaluate the short-term results of lateral closing wedge osteotomy with medial hemiplateau elevation for the management of severe infantile Blount's disease.

Materials and methods: In this prospective study, 11 cases of severe Blount's disease (Langenskiold stages five and six) were managed in the period between January 2017 and January 2020. Double osteotomy technique was applied, namely a metaphyseal closing wedge and a medial hemiplateau elevation, through a single midline incision. Fixation was achieved by a medial anatomical locked plate. Patients were evaluated clinically according to a modified version of paediatric outcomes data collection Instrument (PODCI) and radiologically by measuring the angle between the tibial and the femoral shaft, the mechanical axis deviation (MAD) and the angle of the medial tibial plateau (MTP) depression.

Results: The average follow-up period was 2 years. Healing of the osteotomies was achieved in all cases after the index operation within an average of 3 months. Based on our modification of the PODCI score, five cases had an excellent outcome, five were good, and one case ended with a fair outcome. No major complications were encountered in this study.

Conclusion: The management of severe Blount's disease by acute correction using the aforementioned technique has been proven to achieve acceptable clinical and radiological outcomes without significant complications.

Level of evidence: Level IV case series study.

How to cite this article: Nada AA, Hammad ME, Eltanahy AF, et al. Acute Correction and Plate Fixation for the Management of Severe Infantile Blount's Disease: Short-term Results. Strategies Trauma Limb Reconstr 2021;16(2):78-85.

This case report outlines the use of the distal pedicle of the sartorius muscle in the coverage of a large bony and soft tissue defects of the distal femur in a trauma setting. How to cite this article: McArdle C, Louette S, Wilks D, et al. Distally Based Sartorius Flap for Soft Tissue Coverage of the Distal Femur. Strategies Trauma Limb Reconstr 2021;16(2):120-122.

Aim and objective: This study was designed to test and compare the mechanical performance of the biplanar ArthroSave KneeReviver and a circular frame construct with the intended use of providing a mechanically favourable environment for cartilage regeneration across a knee joint.

Materials and methods: Three similar constructs of the two devices were applied to biomechanical testing sawbones, with the knee distracted by 8 mm. The constructs were vertically loaded to 800 N in an Instron testing machine at 20 mm/minute. Tests were conducted in neutral hip flexion and at 12° of hip flexion and extension, to mimic leg position in gait. Displacement measurements were taken from the Instron machine, and three-dimensional joint motion was recorded using an Optotrak Certus motion capture system.

Results: Overall axial rigidity was similar between the two devices (circular frame, 81.6 N/mm ± 5.9; and KneeReviver, 79.5 N/mm ± 25.1 with hip neutral) and similar in different hip positions. At the point of joint contact, the overall rigidity of the circular frame increased significantly more than the KneeReviver (491 N/mm ± 27 and 93 N/mm ± 32, respectively, p <0.001). There was more variability between models in the KneeReviver. There was more off-axis motion in the KneeReviver, mainly due to increasing knee flexion on loading. This was exacerbated with the hip in flexion and extension but remained small, with the maximal off-axis displacement being 7 mm/3°.

Conclusion: The circular frame provides a similar mechanical environment to the novel KneeReviver device, for which most clinical data are available. These findings suggest that both devices appear a viable option for knee joint distraction (KJD). Further clinical data will help inform mode of application.

Clinical significance: KJD is a relatively novel technique for use in osteoarthritis (OA), and it remains unclear which distraction devices provide appropriate mechanics. Our testing gives evidence to support either option for further use.

How to cite this article: Chowdhury JMY, Lineham B, Pallett M, et al. Comparison of Mechanical Performance between Circular Frames and Biplanar Distraction Devices for Knee Joint Distraction. Strategies Trauma Limb Reconstr 2021;16(2):71-77.

Background: Intramedullary lengthening nails have shown excellent short-term results. The FITBONE and the PRECICE nail are the two most commonly used intramedullary lengthening nails. The manufacturer of each nail recommends the removal of the implant after the completion of the treatment. Despite the need for removal of each nail, the authors are not aware of any prior publications documenting the results of standard intramedullary lengthening nail removal. Therefore, the aim of this study was to examine the intraoperative and postoperative complications of elective intramedullary lengthening nail removals.

Materials and methods: We performed a retrospective chart review of patients operated with intramedullary lengthening nails at two limb reconstruction centres (one in the United States, and the second in Denmark). Data retrieved from the patient charts included patient demographics, nail information and any complications occurring at or after nail removal. Only lower limb lengthening with FITBONE and PRECICE or STRYDE nails that had an elective nail removal was included.

Result: A total of 271 elective nail removals were included in the study. Complications occurred during 3% of the nail removals and in 13% after nail removal. There were 18 reported cases with postoperative knee pain. All these patients had nail removal through the knee joint, representing 8% of the retrograde femur nail removals and 7% of the tibia nail removals. Four postoperative fractures occurred, of which two needed surgery. Eleven percent of femur removals and 26% of tibial removals sustained a complication.

Conclusion and clinical significance: This study emphasises the importance of adequate follow-up of the bone lengthening patient even after the nail has been removed. It also shows that the recommended removal of the intramedullary nail (IMN) lengthening nails must be included in studies reporting on the overall risks of complications using bone lengthening nails.

How to cite this article: Frost MW, Kold S, Rahbek O, et al. Complications in Elective Removal of 271 Bone Lengthening Nails (FITBONE, PRECICE and STRYDE). Strategies Trauma Limb Reconstr 2021;16(2):110-115.

Introduction: Fibrous dysplasia (FD) of bone can be present with pain, deformity and pathological fractures. Management is both medical and surgical. Little literature exists on the surgical management of both monostotic and polyostotic FD. We present our experience of limb reconstruction surgery in this pathological group of bone disease.

Materials and methods: A retrospective cohort of children who underwent limb reconstruction surgery at a single high-volume paediatric centre was identified from a prospective database. Case notes and radiographs were reviewed. Surgical techniques, outcomes and difficulties were explored.

Results: Twenty-one patients were identified aged between 7 and 13 at presentation to the limb reconstruction unit. Eleven were female, nine had McCune-Albright syndrome, seven had polyostotic FD and five had monostotic. Proximal femoral varus procurvatum deformity was the most common site requiring surgical intervention. The distal femur, tibia, humerus and forearm were also treated.Methods include deformity correction with intramedullary fixation including endo-exo-endo techniques, elastic nailing, guided growth, circular fixator technique and fixator-assisted plating. Correction of deformity and leg length discrepancies was common.The osteotomies went on to heal with no nonunions or delayed healing. We encountered secondary deformity at distal end of nails as the children grew as expected. These were managed with revision nailing techniques and in some cases external fixation. There was one implant failure, which did not require revision surgery.

Conclusion: The surgical management of pathological bone disease is challenging. Corrective osteotomies with intramedullary fixation can be very successful if appropriate limb reconstruction principles are adhered to. Deformity correction, guided growth and lengthening can all be successfully achieved in bone affected by FD. Polyostotic FD can be present with secondary deformities, and these can be difficult to manage.

How to cite this article: Hampton MJ, Weston-Simmons S, Giles SN, et al. Deformity Correction, Surgical Stabilisation and Limb Length Equalisation in Patients with Fibrous Dysplasia: A 20-year Experience. Strategies Trauma Limb Reconstr 2021;16(1):41-45.

Aim and background: A systemic method for the application of Ilizarov fixators and on-table fracture reduction is described in this instructional article. This technique has been developed from the unit's practice in adult patients. The indications, underlying principles and rationale for the method are also discussed.

Technique: The basic concept involves the construction of a series of concentric, colinear rings aligned with the mechanical axis of the limb. An orthogonal ring block is initially placed on the proximal segment and extended distally. Wire to ring reduction techniques are used resulting in the contact, alignment and stability required for early full weight-bearing, free movement of knee and ankle, and subsequent healing.

Conclusion and clinical significance: Our step-by-step guide takes the reader through a systematic approach to surgery along with tips and tricks on how to achieve reduction and avoid the common pitfalls. With this method, it is possible to achieve an on-table reduction and correction of a multiplanar deformity without the use of expensive hexapod technology. This may allow less experienced users reproduce the technique with a shorter learning curve.

How to cite this article: Messner J, Prior CP, Pincher B et al. Ilizarov Method for Acute Paediatric Tibial Fractures. Strategies Trauma Limb Reconstr 2021;16(1):46-52.

Aim: Our aim is to report the successful treatment of an intraosseous haemangioma of tibia with an atypical presentation through a multidisciplinary approach of preoperative embolisation, a subtotal resection of the tibia and subsequent reconstruction with the Ilizarov medial fibular translation technique.

Background: En bloc excision is the treatment of choice for large tumours of the tibia. However, there is no single recommended method for the reconstruction of the resulting bony defect.

Case: A 22-year-old female presented with a massive intraosseous haemangioma of the entire tibia. Sequential, multimodal treatment consisted of (1) preembolisation, (2) en bloc resection and (3) reconstruction of the extensive skeletal defect via the Ilizarov method of fibular medialisation. Radiologic union occurred at 6 months and graft hypertrophy at 22 months. At 45 months, the patient was fully weight-bearing without need for an assistive device.

Conclusion: Resection and reconstruction of a large intraosseous haemangioma of the tibia can be treated successfully using a well-planned sequential management of embolisation, resection and Ilizarov fibular grafting.

Significance: This report highlights the successful management of an unusually extensive and difficult tumour through appropriate and meticulous perioperative multidisciplinary planning, execution and follow-up.

How to cite this article: Barsales KAD, Javier J, Catibog JJ, et al. Huge Intraosseous Tibial Haemangioma Managed with Embolisation, Excision and Fibular Ilizarov Reconstruction: A Case Report. Strategies Trauma Limb Reconstr 2021;16(1):60-63.

Aim and objective: To assess the use of arm length (AL) for the estimation of tibial nail length preoperatively and compare its accuracy to various established upper and lower limb anthropometric parameters.

Material and methods: This prospective study of 54 patients assessed upper limb parameters as a possible alternative for intraoperatively measured tibial nail length. The anthropometric parameters measured independently by two observers were AL, olecranon to fifth metacarpal head (OMD), tibial tuberosity to medial malleolus (TT-MM), tibial tuberosity to medial malleolus minus 20 mm (TT-MM-20 mm) and knee joint line to medial malleolus minus 40 mm (KJL-MM-40) and compared to final nail size used intraoperatively. Two observers were used. Bland-Altman plots were constructed to assess the limits of agreement to intraoperative estimates of optimum nail length. A repeatability assessment was also assessed by both observers.

Results: None of the anthropometric parameters showed limits of agreement within ±10 mm of nail length. AL showed the least average difference and best limits of agreement among all the anthropometric parameters. Among the lower limb parameters, the KJL-MM showed the least average difference but poorer limits of agreement to nail length. The OMD measurement showed a greater average difference than the AL indicating it is a poorer upper limb parameter for predicting nail length.

Conclusion: AL as measured between the angle of the acromion to the lateral epicondyle can be used as a preoperative upper limb anthropometric estimate of nail length to one nail size of the optimum length. Further studies with a larger sample size may reduce the confidence intervals and help justify its wider use.

How to cite this article: Sharma A, Sinha S, Gupta S, et al. Evaluation of Arm Length as a New Upper Limb Anthropometric Method for Preoperative Estimation of Tibial Intramedullary Nail Length. Strategies Trauma Limb Reconstr 2021;16(1):20-26.