Introduction

Charcot neuroarthropathy is a limb threatening condition and the optimal surgical strategy for limb salvage in gross foot deformity remains unclear. We present our experience of using fine wire frames to correct severe midfoot deformity, followed by internal beaming to maintain the correction.

Introduction

Methoxyflurane can cause hepatotoxicity and nephrotoxicity at anaesthetic doses but has excellent analgesic properties and no nephrotoxic effects in patients without preexisting disease. Approved for use in the UK and Ireland in 2015, it is currently being used in emergency departments for analgesia during fracture reduction. During the Covid emergency, with theatre access severely restricted and many patients unwilling to use inhaled Nitrous oxide, Penthrox had the potential to provide adequate pain relief to aid frame removals and minor procedures in the clinic.

Aims

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Background

The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications.

Calcium sulphate (CaSO₄) is a recognised form of delivery of antibiotic for the treatment of bone infection. Complications inherent in the rapid reabsorption are well recognised (predominantly that of wound breakdown and leakage). There is little data on the frequency of these complications. The purpose of this study was to quantify the incidence of wound leakage from CaSO₄ and the service impact in orthopaedic surgery.

Infective limb reconstruction cases managed with gentamicin impregnated CaSO₄ between 2004–2012 were identified. Co-morbidities and factors influencing wound leakage were recorded. Medical and wound care notes were analysed. Episodes of delayed discharge and unscheduled clinic attendance due to wound leakage were recorded.

80 patients (18 female, 62 male), with a mean age of 45 years (18–80 years, median 46 years) underwent 84 procedures utilising CaSO₄. 47 were in the tibia, 14 in the femur, 10 in the humerus. A mean of 36 mL (4–150 mL, median 22 ml, unknown in 18 cases) was used.

31 cases (37%) had post-operative wound leakage, the majority from the tibia(55%) and femur(25%). 21 cases (25%) leaked within the first week. Each 10 ml rise in CaSO₄ volume lead to a 50% rise in leakage incidence. Leak duration ranged from 4 days–10 months. The majority leaked between 1–4 months before ceasing spontaneously and without specific treatment.

14 cases (17%) required a cumulative 32 unscheduled clinic appointments for leakage. Further surgery was required for infection in 7 cases (8.3%). Delayed discharge was not clearly attributable to CaSO₄. The mode of skin closure and cultured organism did not affect leakage.

CaSO₄ has unpredictable leakage, but is present in 1/3 of patients. Volume of CaSO₄ impacts on leakage. Leakage usually self-resolves and does not clearly impact on final outcomes. The cost impact of ongoing wound care and additional clinic appointments may be substantial.

The purpose of this study was to investigate the usefulness of PET-CT in the diagnosis and treatment of long bone infections following trauma.

All patients referred to the limb reconstruction service for management of non-unions were treated by the same protocol. PET-CT with FDG was performed in all patients to assess if the non-union site was infected and if so, the extent of the infection. Those requiring operative management were treated in a 2-stage manner. Initially with debridement based on PET-CT; sampling for microbiology and histology; and then Teicoplanin and Ciprofloxacin. If samples were positive then the patients were treated for a total of 6 weeks with antibiotics based on microbiology advice before undergoing definitive fixation. The sensitivity, specificity, PPV, and NPV were then calculated for PET-CTs ability to predict presence of infection using extended cultures and histology as the gold standard.

38 consecutive patients underwent surgery, 24 male and 14 female. 24 were deemed infected on extended culture or histology. PET-CT was anecdotally found to be extremely useful at determining the extent of infection to plan debridement.

PPV 0.83

NPV 0.89

Sensitivity 0.96

Specificity 0.61

As well as providing unique ability to demarcate areas of bony infection in the presence of metalwork, the ability to detect or exclude infection was exceptional.

This is a test, however, which is operator dependent and requires a skilled Nuclear Radiology Consultant to accurately interpret images. In our relatively small pilot study the accuracy improved noticeably over one year.

PET-CT has potential to be a powerful tool in the diagnosis and treatment of long bone infection following trauma and certainly warrants further investigation.

Introduction

The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis.

The treatment of chronic osteomyelitis involves a debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead space management is practised with antibiotic impregnated cement. These depots of local antibiotics are variable in elution properties and need removal. We review the use of bioabsorbable synthetic calcium sulphate as a carrier of gentamicin and as an adjunct in treating intramedullary osteomyelitis.

A retrospective review of cases treated consecutively from 2006 to 2010 in the Royal Liverpool University Hospital was undertaken. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology and microbiology. The Cierney-Mader system was used to classify. Treatment involved removal of implants (if any), intramedullary debridement and local resection (if needed), lavage and instillation of the gentamicin carrier, supplemented with systemic antibiotics. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip) and general health outcome (SF36).

There were 31 patients (22 male, 9 female). The mean age was 47 years (20-67). Twenty-five cases were post-surgery (6 open fractures) and 6 were haematogenous in origin. The median duration of osteomyelitis was 1.6yrs. The bones affected were 42% femur, 45% tibia, 3% radius and 10% humerus. 11 cases had diffuse as well as intramedullary involvement. 9 cases underwent segment resection and bone transport. We identified Staphylococcus Aureus in 16 and Coagulase Negative Staphylococcus in 6 cases. The median follow-up was 1.7 years (0.5-5.6). The median scores attained were: AOFAS-78, DASH-32, IOWA-71, Oxford-32. There were two recurrences.

Dead space management of intramedullary infections is difficult. We describe a method for delivery of local antibiotics and provide early evidence to its efficacy. The treatment success to date is 93%.

Bioabsorbable carriers of antibiotics are efficacious adjuncts to surgical treatment of intramedullary osteomyelitis.

Introduction: The treatment of femoral nonunions remains challenging despite modern surgical techniques and adjuncts to fracture healing. We present a series of 14 patients in whom a bifocal treatment technique has been used in order to achieve bony union and correct limb length.

Methods: Patients were identified from theatre records and their hospital notes and x-rays were retrospectively reviewed. All patients underwent bifocal treatment for femoral nonunions – debridement and internal fixation (single or double plating) of the nonunion and lengthening at the opposite end of the bone to correct limb length discrepancy. Initially the procedures were staged, with treatment of the non-union then subsequent lengthening. However, our technique has evolved to perform all procedures in a single stage. All lengthening procedures were done with a monolateral (Orthofix LRS) fixator.

Results: 11 patients had distal and 3 proximal femoral nonunions. 13 patients were male and 1 female. The non-union united with the index procedure in 13 patients, 1 is still undergoing treatment. Limb length discrepancy range 2–5 cm was fully corrected in all patients with no axial deviation of the regenerate. There were no pin site problems.

Discussion: Femoral nonunions are challenging due to multiple previous procedures, insecure grip on the smaller fragment and bone loss. Successful union can be achieved by ORIF with bone grafting, but this does not restore length. Treatment by the Ilizarov method alone is associated with significant morbidity, particularly knee stiffness. A bifocal strategy provides stable internal fixation of the non-union to allow bone healing, and any consequent loss of length is safely restored. We believe this to be a safe and effective technique to treat femoral nonunions.

Introduction: The subtrochanteric area of the femur is subject to large tensile and compressive forces. The rate of nonunion following operative fixation of such fractures is about 7–20%. Revision surgery to obtain union is difficult because of the small size of the proximal fragment, muscle forces acting in 2 planes, and bone loss.

We present the results of a series of 9 consecutive patients with subtrochanteric non-unions treated by double plates.

Methods: Retrospective analysis of 9 consecutive subtrochanteric nonunions treated with double plates and additional osteoinduction (bone graft, or BG+BMP-7).

Results: There were 5 male and 4 female patients, with ages from 50–82 years (mean 65). All were treated in a single-stage procedure by implant removal, a lateral plate and a separate anterior plate. One patient had had a previous unsuccessful revision procedure with an intra-medullary device.

One patient with liver cirrhosis died 5 days postoperatively. Two patients are currently 8 weeks post surgery. All the others healed in a mean of 5.1 months (range 4–6 months).

Two patients underwent distal femoral lengthening to compensate for bone loss.

Discussion: The high muscle forces around the proximal femur require a sound mechanical environment for bone healing to occur. This is particularly marked in nonunions. The small size of the proximal fragment can result in suboptimal fixation. The addition of the anterior plate provides better fixation and also neutralizes the sagittal forces.

We believe that double plating neutralizes all the forces around the proximal femur, providing the best mechanical environment. Given the limits of the small numbers and the retrospective nature of the study, we believe that this method of treatment offers a sound surgical strategy, reflected by our success rate.

We have carried out a retrospective review of 20 patients with segmental fractures of the tibia who had been treated by circular external fixation. We describe the heterogeneity of these fractures, their association with multiple injuries and the need for multilevel stability with the least compromise of the biology of the fracture segments. The assessment of outcome included union, complications, the measurement of the functional IOWA knee and ankle scores and the general health status (Short-form 36).

The mean time to union was 21.7 weeks (12.8 to 31), with no difference being observed between proximal and distal levels of fracture. Complications were encountered in four patients. Two had nonunion at the distal level, one a wire-related infection which required further surgery and another shortening of 15 mm with 8° of valgus which was clinically insignificant. The functional scores for the knee and ankle were good to excellent, but the physical component score of the short-form 36 was lower than the population norm. This may be explained by the presence of multiple injuries affecting the overall score.

Introduction: Mal-united ankle fractures are uncommon. When they occur they produce symptoms of pain, joint effusion, limitation of dorsiflexion and are likely to lead to ankle arthritis. In such cases it has been shown that, even many months after the original fixation, correction of the ankle alignment can improve the final outcome.

Method: From May 2004 to April 2006, seven patients with a mal-united fibular fracture aged 25–62 years (average 44yrs, male: female ratio 5:2) were treated in the Foot and Ankle unit at the Royal Liverpool University Hospital. All the patients were referred with persistent pain. The range of time delay between injury and secondary surgical intervention was 3 to 16 months (average 6 months). All the patients were assessed using clinical examination, functional scoring using the AOFAS Ankle-Hindfoot score and plain radiographs. They were followed for an average of 11 months (range 6–24 months) after the surgery.

Surgical procedure: The surgical procedure involves a transverse fibular osteotomy made just above the ankle joint and below the tibio-fibular syndesmosis. The osteotomy is then distracted and internally rotated to gain the fibular length and to correct talar tilt using an image intensifier. A tri-cortical iliac bone graft and a lateral fibular plate are applied to maintain the reduction. We do not use a syndesmotic screw.

Results: We managed to regain the fibular length and reconstruct ankle mortise in all the cases. All patients showed radiological evidence of bony union on follow-up. The average time to bony union was 8 weeks. Talar shift was corrected in all patients and all had good hind foot alignment. Average AOFAS score was 82 (pain: 31.43 function: 40.57 and alignment: 10).

Conclusion: We present our early experience with fibular osteotomy aiming to correct ankle joint mal-alignment following fibular fractures. We believe this is a technique with reproducible results in our short term follow-up. It shows satisfactory functional outcome improving pain and function especially in younger patients.