Introduction

Open tibial fractures typically occur as a consequence of high energy trauma in patients of working age resulting in high rates of deep infection and poor functional outcome. Whilst improved rates of limb salvage, avoidance of infection and better ultimate function have been attributed to improved centralisation of care in orthoplastic units, there remains no universally accepted method of definitive management of these injuries. The aim of this study is to the report the experience of a major trauma centre utilising circular frames as definitive fixation in patients sustaining Gustilo-Anderson (GA) 3B open fractures

Introduction:

Bicondylar tibial plateau fractures are serious periarticular injuries. We investigated outcomes in injuries managed with Ilizarov external fixators.

The purpose of the study was to retrospectively assess the patients treated to date with the vac ulta system using a technique of antibiotic instillation.

The vac ulta system is licensed for use with anti-septic instillation fluid but we have now treated a number of patients with antibiotic instillation under the guidance of the microbiology department. All patients being treated with the vac ulta system were included in the study. There were no exclusions. Pathology treated, infecting organism, antibiotic used and length of treatment were all recorded. Any antibiotic related complications were noted. Treatment was judged successful with resolution of presenting symptoms, normalization of inflammatory markers and three negative foam cultures.

There were 21 patients included in the study. There were 13 male and 8 female patients. Length of treatment ranged from 1 week to 10 weeks with a mean of 4.2 weeks. Follow up ranged from 1 month to 42 months with a mean follow up of 17.9 months

The most common pathogen was Staph. Aureus(11 cases). Enterobacter, ESBL, Strep. Milleri, MRSA and Citrobacter were also treated. Antibiotics instilled included flucloxacillin, meropenem, gentamicin, vancomycin, meropenem and teicoplanin. There were no antibiotic reactions/allergies. Pathologies treated included osteomyelitis, two stage amputations for infection, infected non-union and infected metalwork. Infection recurred in 2 of 21 patients (10%), with one recurring at 18 months and one at 2 years.

The 90% treatment success rate is highly encouraging in this notoriously difficult group of patients to treat. In this series vac instill was an effective treatment of infection and allows antibiotic treatment to be targeted to the infected tissues. There were no adverse reactions seen.

Larger series with longer follow up are no needed but we believe this technique is safe, successful and easily administered can be cautiously adopted on a wider basis.

The aim of the study is to evaluate how patients over 65 years of age cope with the Ilizarov method of treatment, compared with patients a decade younger.

Two age groups were selected, 50–65 years versus 65 years and over. 20 consecutive patients were recruited for each group. SF36 scores were completed pre-operatively, at 6 weeks post op and 6 weeks post frame removal. 41 patients were recruited in total.

Seven patients were lost to follow up – 2 died, 2 became too ill to continue with treatment, 3 did not complete the SF36. This left 34 patients.

T test was used to analyse the results.

Both age groups showed an equal and statistically significant drop in SF36 scores whilst the Ilizarov frame was on (p<0.01 for each group).

After frame removal, SF36 in the >65 group was not significantly different to pre-operative values.

In the younger group, SF36 after frame removal was still significantly lower than pre-operative values (p<0.01).

Age makes no difference in how patients cope with the ilizarov frame during treatment. Older patients have low pre-injury function levels, but appear to return to this level quickly after frame removal. Younger patients do not recover pre-injury function in 6 weeks after completion of treatment.

UK Objective

To evaluate the technique of transverse debridement, acute shortening and subsequent distraction histiogenesis in the management of open tibial fractures with bone and soft tissue loss thus avoiding the need for flap coverage.

Introduction

Corrective femoral osteotomy in adults, as a closed procedure with the use of an intramedullary saw, is an elegant, minimally invasive technique for the correction of lower limb length inequalities or problems of torsion. Stabilisation following the osteotomy was achieved with a cephalo-medullary nail. We report the indications, results and complications following use of this technique.

One of the most challenging cases encountered by orthopaedic surgeons is chronic osteomyelitis. The mainstays of successful treatment include: radical debridement, stabilisation of the bone if necessary; control of infection and finally skin cover or closure.

Negative pressure dressings have been used for over 10 years in the treatment of acute and chronic wounds with recognised benefits. Topical negative pressure wound therapy with instillation of solution in the local area (VAC Instill Therapy System®) is a new device available in the armamentarium of a limb reconstruction surgeon. This device automatically delivers instillation fluid into the infected wound, where this fluid is held for a while before application of topical negative pressure. This cycle helps remove infectious material leading to clean closed moist environment for better wound healing.

Senior authors (MGD and SLR) have used this VAC Instill therapy in 10 cases of chronic osteomyelitis from April 2007 to November 2008. All patients have been included in this study. All patients had (thorough) bony and soft tissue debridement followed by application of VAC Instill therapy with local delivery of antibiotics.

All patients were male with mean age of 39 years (range 20–56 years). There were eight cases of tibial osteomyelitis, one distal radial and one calcaneal osteomyelitis. Most had mixed growth, with Staphylococcus being most common infecting organism. Average duration for VAC Instill therapy was 32 days (range 20–71 days). Average hospital stay was 33 days (range 15–85 days) and average time to wound closure was 39 days (range 19–90). There were two failures of treatment one later had Lautenbach procedure and other had below knee amputation.

We conclude that VAC Instill therapy is very successful in the management of chronic osteomyelitis. These are the only early results available in the literature. Further studies are needed to back these findings.

Background: The Ilizarov Method is well established for lower limb trauma and reconstruction. However, although the same principles apply, its use in the upper limb is less well described.

Aims of Study: To review indications and outcomes of all Ilizarov arm fixators applied by the two limb reconstruction surgeons in our unit.

Methods and Results: All patients treated using an upper limb Ilizarov frame were identified and reviewed. Demographic data, indications and durations of frames collected. Fifty-one cases identified. Average age 43 (17–81). Tertiary referrals in 63%. Previous surgery in 78%. Mechanism of injury included: 37% RTA, 40% simple falls. Reasons for frame usually multifactorial including 22 for non-unions. 43% of fixators applied acutely (< 6 weeks). Average frame time was 152 days (34–343). Over 80% achieved expected outcome –obtaining good function or fracture union. 14 needed further frame surgery including 5 for frame removal, 3 adjustments and 2 corticotomies. Most frames removed in clinic.

Complications: 30% superficial pin site infection. No deep wire infections. 1 wrist malunion requiring delayed correction. 2 patients had neurological complications from frame surgery. One radial palsy possibly from humeral plate removal. One median palsy due to pressure from wire. One patient had an above-elbow amputation for persistent infection.

Conclusions: The Ilizarov technique appears well tolerated and successful despite often infected or deformed tissues. Indication and intended purpose of arm frames very varied. This technique allows stabilization (with/without bone loss), treatment of non-unions and lengthening/bone transport. The Ilizarov Method is valuable for limb salvage/reconstruction.

Aims: To investigate adequacy of temporary ex-fix in grade III open fractures of the tibia, prior to definitive treatment by Flap & Frame at 2 UK trauma centres.

Methods: Between 2000 and 2006 all open fractures of the tibia treated by the Ilizarov Method at our two institutions were entered onto the Flap & Frame database. The database was searched for all temporary external fixators placed prior to definitive Ilizarov fixation. Data collected – ex-fix type, whether revision was necessary, reasons for revision.

Results:

97 grade III open fractures in 95 patients

Discussion: Recently Naique and Pearse showed a revision rate of skeletal fixation of 48% in grade IIIb open fractures referred to their tertiary centre. In our series 34% of temporary external fixators needed revision. Modular systems such as Hoffman II and AO required no revision, irrespective of whether they were applied at trauma centre or DGH.

All Hoffman hybrids needed revision, due to both instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular (Hoffmann II/AO), due to poor plastics access.

Conclusion: We recommend modular external fixation systems such as Hoffman II or AO if problems of temporary external fixation of open tibial fractures are to be avoided. Hybrid temporary external fixation should be abandoned as temporary fixation in such an injury

Introduction: To assess the effectiveness of a regional basic external fixation trauma course.

Methods: Effectiveness of an annual, low-cost, Royal College of Surgeons of England approved, regional basic ex-fix course, led by consultant trauma experts from Yorkshire, UK, covering anatomy, surgical techniques, biomechanics, early management of open fractures and temporary external fixation placement was assessed. Pre- and post-course questionnaires asking grade, current hospital, previous experience, and a mini-test to design a temporary ex-fix construct for four fracture patterns (IIIb open tibia, open book pelvis, Schatzker 6, and total articular pilon) were used. Designs were assessed for stability, safe corridors and plastics assess.

Results:

- 10/22 participants had not previously attended an ex-fix course.

Discussion: Recently Pearse and Naique reported a 48% fixation revision rate in open tibial fractures transferred for tertiary care, suggesting that improved core skills are required to ensure appropriate packaging of patients prior to transfer with open, complex articular and pelvic fractures.

Participation in a simple ex-fix course improves knowledge of ex-fix design. Retention of knowledge must be reassessed after several months.

This course fills a gap in education of basic external fixation for orthopaedic trainees. We recommend every region with a tertiary referral system for complex trauma utilises this course.

Introduction: The hub and spoke model of trauma describes fracture stabilisation prior to referral. Many arrive at tertiary centres with inadequate temporary external fixation. This study investigates ex-fix availability, training and awareness of referral protocols in two regions.

Methods: Hospitals feeding two regional trauma centres were targeted with two telephone questionnaires, one for on-call orthopaedic SpRs and one for theatre nursing staff ascertaining ex-fix availability, training, knowledge of regional referral protocols, and clinical scenarios to establish common practice in each unit.

Results: 16 hospitals: 15 SpRs, 16 nurses responded

Equipment: 0/31 aware guidelines for ex-fix stock

- Ex-fix trays per unit (all manufacturers) mean = 4.14 (1–9)

SpRs:

- mean year of training = 2.2

Referral Protocols:

- 7/31 aware of transfer protocol

Discussion: A deficiency of ex-fix equipment for DCO/ polytrauma exists across many units in both regions. No accepted advice on equipment level requirement exists.

All trainees had attended ex-fix teaching. Those who had only attended generic courses were less confident in DCO scenarios.

Most favoured a specific regional ex-fix course.

Tertiary care protocols have been distributed, but many units are unaware of their existence. A regular regional audit of trauma referrals would provide protocol reinforcement and opportunity for feedback.

Introduction: To investigate adequacy of temporary ex-fix in grade III open fractures of the tibia, prior to definitive treatment by Flap & Frame at 2 UK trauma centres.

Methods: From 2000 – 2006 all open fractures of the tibia treated by the Ilizarov Method at our two institutions were entered onto the Flap & Frame database. The database was searched for all temporary external fixators placed prior to definitive Ilizarov fixation. Data collected - ex-fix type, whether revision necessary, reasons for revision.

Results:

- 97 grade III open fractures in 95 patients

Discussion: Naique and Pearse described a revision rate of skeletal fixation of 48% in grade IIIb open fractures referred to their tertiary centre. In our series 34% of temporary external fixators needed revision. Modular systems (Hoffman II and AO) required no revision, irrespective of application at a trauma centre or DGH.

All Hoffman hybrids needed revision, due to instability and plastics access. Significantly more non modular (Orthofix) ex-fixes required revision compared to modular, for poor plastics access.

We recommend modular external fixator application (Hoffman II or AO) to avoid problems with temporary external fixation of open tibial fractures. Hybrid temporary external fixation should be abandoned in such injuries.

To review indications and outcomes of all Ilizarov arm fixators applied by the two limb reconstruction surgeons. All patients treated with an upper limb Ilizarov frame were identified. Casenotes were reviewed. Demographic data, indications and duration of frames collected. Forty-seven patients had application of an arm frame. Average age 43 (17–81). Tertiary referrals in 72%. Previous surgery in 79%. Mechanism of injury included: 37% RTA, 40% simple falls. Reasons for frame usually multifactorial. Half of fixators applied acutely (< 6 weeks), 17 for non-unions. Two patients had neurological complications from frame surgery. One radial palsy possibly from humeral plate removal. One median palsy due to pressure from wire. Average frame time was 152 days (34–343). Over 80% achieved expected outcome -obtaining good function or fracture union. One patient had an above elbow amputation for persistent infection. Fourteen needed further frame surgery including 5 for frame removal, 3 adjustments and 2 corticotomies for lengthening. Most frames removed in clinic. The Ilizarov technique appears well tolerated and successful despite often infected or deformed tissues. Indications and intended function of arm frames very varied. This technique allows stabilisation (with/without bone loss), treatment of non-unions and lengthening/ bone transport. The Ilizarov technique is valuable for limb salvage/ reconstruction.

We present a series of ten hypertrophic nonunions in which bony alignment and length were restored and union induced by external fixation and callus distraction. The mean length gained was 3.5 cm (1 to 6) and the mean angular correction was 13.5° (0 to 40). The mean treatment time was 10.2 months (3 to 15) and mean follow-up was 40 months (6 to 71). There have been no refractures or loss of correction or length.

The technique of callus distraction at a site of hypertrophic nonunion can correct shortening and angulation as well as induce bony union. No extra equipment is needed beyond readily-available external fixation systems.