Strategies in Trauma and Limb Reconstruction最新文献

Background: Plate fixation is the treatment of choice for a midshaft clavicle non-union. Those non-unions that require >1 surgical procedure to heal are termed recalcitrant non-union. Regardless of the number of previously failed procedures, our surgical strategy is aimed at achieving an optimal mechanical and biological environment to facilitate healing.

Materials and methods: We performed a retrospective analysis of 14 patients with a recalcitrant clavicle non-union treated with open reduction and plate fixation combined with graft augmentation when indicated. Healing rates after index surgery were analysed. All patients were observed for at least 12 months.

Results: All patients healed at a mean time of 193.2 days (range 90-390). Five of the 14 patients had at least one positive surprise culture, for which they received antibiotic treatment. At the latest follow-up, no patient reported pain or discomfort. Mean disability of the arm, shoulder and hand (DASH) score was 16.3 points (range 0-40), indicating only mild residual impairment. A possible link was found between the time between injury and definitive surgery and the time to healing [Pearson correlation 0.527, sig. (two-tailed) 0.000].

Conclusion: This study shows 100% bone healing and good functional outcomes after surgical revision for a recalcitrant clavicle non-union.

How to cite this article: Grewal S, Baltes TPA, Wiegerinck E, et al. Treatment of a Recalcitrant Non-union of the Clavicle. Strategies Trauma Limb Reconstr 2022;17(1):1-6.

Aims: The pixel value ratio (PVR) can be used to assess regenerate consolidation after lengthening and guide advice for full weight-bearing (FWB). This study aimed to analyse the PVR in adults having femoral lengthening, the time to FWB and compare findings with the reported values in the literature.

Materials and methods: A retrospective database review identified 100 eligible patients who underwent lengthening using the PRECICE nail (68 antegrade and 32 retrograde). The PVR was calculated in each cortex on plain radiographs at every visit. The ratio between the regenerate and an average from the adjacent normal bone was calculated and plotted against the clinical decision to allow FWB.

Results: Eighty-seven patients (58 men and 29 women) were assessed; eleven had bilateral lengthening and two patients underwent lengthening twice. The median age was 30.5 years. The underlying cause of shortening was post-traumatic in 46%, with the remaining due to a wide variety of causes, including congenital 16%, syndromic 12% and other causes. The median lengthening achieved was 45 mm, at a median of 57.5 days. The PVR increased with each visit (p <0.0001). FWB was allowed at a median of 42 days after the last day of lengthening, with PVR values of 0.83, 0.84, 0.93 and 0.84 for the anterior, posterior, medial and lateral cortex noted, respectively (average 0.85). There were no implant failures, shortening or regenerate fractures. No differences were detected between antegrade and retrograde nails or with lengthening greater or less than 45 mm. One surgeon allowed earlier FWB at median 31 days with no nail failures.

Conclusion: PVR is a valuable tool that quantifies regenerate maturity and provides objectivity in deciding when to allow FWB after intramedullary lengthening with the PRECICE nail. FWB was permitted at an earlier time point, corresponding with lower PVR values than have been reported in the literature and with no mechanical failure or regenerate deformation.

How to cite this article: Elsheikh AA, Wright J, Stoddart MT, et al. Use of the Pixel Value Ratio Following Intramedullary Limb Lengthening: Uncomplicated Full Weight-bearing at Lower Threshold Values. Strategies Trauma Limb Reconstr 2022;17(1):14-18.

Aim: Dual tension-band plates are used for temporary epiphysiodesis and longitudinal guided growth. The study aim was to assess rate of correction, to identify development of femoral and tibial intra-articular deformity during correction and to document resumption of growth after plate removal.

Materials and methods: A retrospective study of 34 consecutive patients treated with dual tension-band plates between 2012 and 2020 was performed. Twenty-four patients had surgery at the distal femur, six at the proximal tibia and four at both. Twenty-five female patients were treated at a mean age of 11.6 (±1.4) years and nine male patients at 13.5 (±1.5) years. Measurements were performed on standardised long-leg radiographs and included leg-length discrepancy (LLD), joint line congruency angle (JLCA), tibial roof angle, femoral floor angle and notch-intercondylar distance. Measurements were taken pre-operatively, at the end of discrepancy correction and at skeletal maturity.

Results: The LLD reduced by a mean of 12.9 mm (95% CI 10.2-15.5) with the mean residual difference 8.4 mm (95% CI 5.4-11.4). The mean correction rate for the proximal tibia was 0.40 (SD 0.33) mm/month and 0.68 (SD 0.36) mm/month for the distal femur. A significant mean change in residual LLD [-2.5 mm (95% CI -4.2 to -0.7)] was observed between plate removal and skeletal maturity at the femoral level only. After length discrepancy correction, the tibial roof angle showed a significant difference of 8.4° (95% CI 13.4-3.4) between legs. In femoral epiphysiodesis patients, no important differences were observed.

Conclusion: A significant reduction in LLD can be achieved using dual tension-band plating. A change in intra-articular morphology was observed only in the proximal tibia and not in the distal femur. In the authors' opinion, tension-band plating is a useful tool for leg-length equalisation but should be reserved for younger patients or when residual growth is difficult to predict. It is one of the management strategies for limb-length difference prior to skeletal maturity.

How to cite this article: Tolk JJ, Merchant R, Calder PR, et al. Tension-band Plating for Leg-length Discrepancy Correction. Strategies Trauma Limb Reconstr 2022;17(1):19-25.

Aim: To evaluate the results in terms of correction and complications from gradual correction with a computer-assisted hexapod circular external fixator in a mixed cohort of children with Blount's disease.

Materials and methods: A retrospective review was performed of the correction and complications of 19 children (25 limbs) with recurrent infantile (IBD) and late-onset Blount's disease (LOBD) treated by gradual correction with a hexapod external fixator. The correction was measured by the medial proximal tibial angle (MPTA), anatomic posterior proximal tibial angle (aPPTA) and anatomic tibio-femoral angle (TFA). Obesity was present in 76% (19/25) of cases. Fifteen limbs were classified as infantile Blount's disease and 10 limbs as late-onset Blount's disease. The mean age was 12.5 years (range 7-17 years).

Results: The mean pre-operative MPTA of 59° (SD 13°, range 33-79°) was corrected to a mean of 86° (SD 5°, range 77-93°). The mean pre-operative aPPTA of 64° (SD 14°, range 33-84°) was corrected to 79° (SD 6°, range 70-90°). The median pre-operative rotation of 15° internal rotation was corrected to normal (0-15° of external rotation). Eight out of 25 limbs had severe deformities with varus or procurvatum greater than 40° or both. The mean pre-operative TFA of 28° varus (SD 13°, range 4-53°) was corrected to 1.8° valgus (SD 6°, range 14° varus to 13° valgus). The median follow-up was 19 months (range 6-67 months). The alignment after correction was "good" in 55% (11/20), "acceptable" in 35% (7/20) and "poor" in 10% (2/20).The median duration for correction was 16 days (IQR 11-31 days, range 7-71 days). The median number of prescribed correction programmes was 1 (IQR 1-2, range 1-5). The mean total time in the frame was 136 days (SD 34 days, range 85-201 days).All patients developed minor pin track infections that resolved with oral antibiotics (Category 1 complications). Four patients developed complications that necessitated modification of the treatment plan (Category 2 complications). In two cases, treatment objectives could not be achieved (Category 3 complications). Two patients treated before skeletal maturity developed recurrent genu varum.

Conclusion: Gradual correction with a computer-assisted hexapod external fixator may be a useful technique for correcting recurrent IBD or LOBD even in children with severe deformities. The results of gradual correction were similar in the two groups. While complications occur, most can be mitigated by timely intervention during the correction phase of treatment. Recurrence remains a concern if correction is performed before skeletal maturity.

Level of evidence: 4.

How to cite this article: Mare PH, Marais LC. Gradual Deformity Correction with a Computer-assisted Hexapod External Fixator in Blount's Disease. Strategies Trauma Limb Reconstr 2022;17(1):32-37.

Introduction: High-energy grade III open fractures of tibia are associated with significant complications and generate debate over the ideal fixation method. This study compares the clinical outcomes for circular frame fixation (CFF) vs intramedullary nail fixation (IMF) in grade III open tibial fractures.

Materials and methods: Single-centre retrospective study of patients admitted from January 2008 to December 2016. All patients with grade III open diaphyseal tibial fractures (AO 42 A, B, C), treated with either CFF or IMF, were included. The primary outcome was deep bone infection (DBI). Secondary outcomes were delayed or non-union, secondary intervention, and amputation.

Results: A total of 48 limbs in 47 patients had CFF, and 25 limbs in 23 patients had IMF. Median time to definitive fixation was significantly longer for CFF at 9 days (IQR 3-13) compared to IMF at 1 day (IQR 0-3.5) (p <0.001). The DBI rate was significantly lower (2 vs 16%) in the CFF group (p = 0.04). There were 14 limbs (29%) with delayed or non-union in the CFF group vs 5 limbs (20%) in the IMF group. In the CFF group, significantly more limbs required bone grafting for delayed or non-union (p = 0.03). However, there was a greater proportion of limbs in the CFF group with segmental fractures or bone loss (46 vs 4%) and these high-energy fracture patterns were associated with secondary bone grafting (p = 0.005), and with delayed or non-union (p = 0.03). A subgroup analysis of patients without segmental fractures or bone loss treated with either CFF or IMF showed no significant difference in secondary bone grafting (p >0.99) and delayed or non-union rates (p = 0.72). Overall, one patient in each group went on to have an amputation.

Conclusion: Our study found that CFF had a lower rate of DBI compared to IMF. Injuries with high-energy fracture patterns (segmental fractures or bone loss) were more likely to have delayed or non-union and require secondary bone grafting. These factors should be considered when selecting the appropriate method of definitive fixation.

How to cite this article: Natalwala I, Chuo CB, Shariatmadari I, et al. Outcomes and Incidence of Deep Bone Infection in Grade III Diaphyseal Open Tibial Fractures: Circular Fixator vs Intramedullary Nail. Strategies Trauma Limb Reconstr 2021;16(3):161-167.

Ankle fractures are a common presentation to orthopaedic surgeons, with the lateral malleolus involved in 86% of cases. A soft tissue injury can be a concomitant feature of these injuries as a result of the primary injury or following secondary wound breakdown. The peroneus brevis muscle flap provides a reliable and robust option to cover the distal third of the lower limb. With an understanding of the anatomy and cautious dissection during periosteal elevation, the perforating vessels supplying the peroneus brevis can be preserved ensuring that a valuable reconstructive option is available.

How to cite this article: Irvine E, Cochrane E, Harwood P, et al. Surgical Exposure of the Distal Fibula to Protect the Peroneus Brevis Muscle Vascular Pedicle. Strategies Trauma Limb Reconstr 2021;16(3):176-178.

Background: Amputation in the upper extremities influenced the quality of life a lot adversely. So, replantation was tried in many cases of amputation. Especially, due to good plasticity and healing capacity, replantation in children should be actively attempted. On the contrary, owing to growth potential in children, there are several late complications to happen like shortening and synostosis. There are only a few longterm follow-up reports of paediatric patients after replantation of upper extremities. We report a case of successful distal forearm replantation in a 2-year-old child who sustained a wringer injury by a sawing machine with a follow-up of 30 years.

Case description: A 2-year-old female patient was brought to our institution after a wringer injury to the distal forearm by a sawing machine. She sustained a near-total amputation at the distal forearm level with only a skin tag. Replantation was performed 4 hours after the injury. Radius and ulnar fractures were fixed with Kirschner and roll wires. The radial and ulnar arteries were anastomosed and three veins were anastomosed too. The median, ulnar, and radial nerves were managed by epi-perineurorrhaphy. The muscles were readapted, flexor tendons were performed tenorrhaphy each by each, and extensor tendons were performed grouping tenorrhaphy. Ten years after the replantation, a supination motion block was developed but successfully managed.

Conclusion: Replantation of upper limbs in children is an eceedingly worthwhile procedure. Though due to growth potential several complications were developed unlikely in adults. But those can be improved with additional procedures. Good plasticity and healing capacity of children make good functional outcomes in long-term follow-up. So, replantation of upper limbs in children should essentially be considered and aggressively performed.

How to cite this article: Hee LS, Hyung-Sik K, Hong-Chul L. Distal Forearm Replantation in a Child: A Case Report with a 30-year Followup. Strategies Trauma Limb Reconstr 2021;16(3):179-183.

Background: Isolation of the causal microorganisms in osteomyelitis presents a major challenge for treating clinicians. Several methods have been proposed to rapidly and accurately identify microorganisms. There has been an increasing interest in using Raman spectroscopy in the field of microbial detection and characterisation. This paper explores the use of Raman spectroscopy identification as one of the most difficult-to-isolate microorganisms causing osteomyelitis.

Methods and results: Fresh healthy human bone samples were collected from patients undergoing a total knee replacement. These samples were then inoculated with fresh overnight Pseudomonas aeruginosa (PAO) cultures. Bacteria growth and bone ultrastructural changes were monitored over a period of 6 weeks. The experiment demonstrated ultrastructural bony destruction caused by osteolytic PAO secretions. Raman-specific spectral signatures related to the cellular membranes of PAO structures were spotted indicating survival of bacteria on the bone surface.

Conclusion: This study showed the promising ability of Raman spectroscopy to identify the presence of bacteria on the surface of inoculated bone samples over time. It was able to detect the osteolytic activity of the bacteria as well as ultrastructure specific to PAO virulence. This method may have a role as an aid to existing diagnostic methods for fast and accurate bacterial identification in bone infection.

How to cite this article: Al Ghaithi A, Al Bimani A, Al Maskari S. Investigating the Growth of Pseudomonas aeruginosa and Its Influence on Osteolysis in Human Bone: An In Vitro Study. Strategies Trauma Limb Reconstr 2021;16(3):127-131.

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.