Introduction

Compartment syndrome can be a life changing consequence of injury to a limb. If not diagnosed and treated early it can lead to permanent disability. Neurovascular observations done on the ward by nursing staff, are often our early warning system to those developing compartment syndrome. But are these adequate for detecting the early signs of compartment syndrome? Our aim was to compare the quality and variability of charts across the UK major trauma network.

Introduction

The use of intramedullary lengthening devices is becoming increasingly popular. There are no published data regarding the incidence of venous thromboembolism following intramedullary lengthening and no reports or guidance for current practices on use of thromboprophylaxis. Following a case of post-operative deep vein thrombosis in our institution, we felt that it is important to assess best practice. We conducted this survey to collect data that would describe current practice and help guide consensus for treatment.

Aims

Anatomical atlases document classical safe corridors for the placement of transosseous fine wires through the calcaneum during circular frame external fixation. During this process, the posterior tibial neurovascular bundle (PTNVB) is placed at risk, though this has not been previously quantified. We describe a cadaveric study to investigate a safe technique for posterolateral to anteromedial fine wire insertion through the body of the calcaneum.

Introduction

The case of Montgomery in 2015 considered standards of risk disclosure, whether alternative treatments had been discussed, standards of professional performance, and the importance of patient autonomy.

Aims

The aim of this study was to report the clinical, functional and radiological outcomes of children and adolescents with tibial fractures treated using the Ilizarov method.

We analysed the functional and psychological outcomes in children and adolescents with complex tibial fractures treated with the Ilizarov method at our frame unit.

An observational study with prospective data collection and retrospective analysis of clinical data was undertaken. Patients younger than 18 years and an open physis were included. The Ilizarov method (combined with percutaneous screw fixation in physeal injuries) was applied and immediate weightbearing recommended.

Sixty four patients (50 male, 14 female) aged between 4 and 17 years were admitted to our Major Trauma Centre from 2013 until 2016 (25 tertiary referrals). Thirty one (48%) patients were involved in road traffic accidents, 12 (19%) sustained injuries in full contact sports. The average weight was 51 kg (range 16–105 kg). Twenty three open tibial fractures (14 Gustilo 3A and 9 Gustilo 3B) and 15 associated physeal injuries were treated among a cohort of closed tibial fractures with significant displacement (10 failed conservative treatment prior to frame treatment).

We report a 100% union rate with a median hospital stay of 4 days (range 2–19) and a median frame time of 105 days (range 62–205 days). Malunions (> 5 degrees in any plane) were not observed. Three patients required bone transport. At the time of submission, 70% of patients and their parents reported functional outcomes using the Paediatric Quality of Life Inventory (PedsQL) at minimum six months post frame. The PedsQLTM 4.0 Generic Core Scales are comprised of parallel child self-report and parent proxy-report formats. Children's physical average scores were 79 out of 100 and average psychosocial scores were 80 out of 100 and for parent average physical scores were 78 out of 100 and the same for parent average psychosocial scores. These results suggest high levels of quality of life on the PedsQL. The median visual analogue health score (0–100) was 81 out of 100 (71–100), median Lysholm knee scores 98 (range 49–100) and median Olerud & Molander ankle scores 75 (range 40 – 100).

Regardless of age, weight and soft tissue damage and complexity of fracture pattern, the Ilizarov method has shown to be safe and effective treating tibial fractures in the paediatric and adolescent population admitted to our Major Trauma Centre. Furthermore, patients reported high physical and psychosocial functioning following treatment.

Level of evidence: IV (case series)

Intramedullary infection in long bones represents a complex clinical challenge, with an increasing incidence due to the increasing use of intramedullary fixation. We report a prospective case series using an intramedullary reaming device, the Reamer–Irrigator–Aspirator (RIA) system, in association with antibiotic cement rods for the treatment of lower limb long bone infections. A total of 24 such patients, 16 men and eight women, with a mean age of 44.5 years (17 to 75), 14 with femoral and 10 with tibial infection, were treated in a staged manner over a period of 2.5 years in a single referral centre. Of these, 21 patients had had previous surgery, usually for fixation of a fracture (seven had sustained an open fracture originally and one had undergone fasciotomies). According to the Cierny–Mader classification system, 18 patients were classified as type 1A, four as 3A (discharging sinus tract), one as type 4A and one as type 1B. Staphylococcus species were isolated in 20 patients (83.3%). Local antibiotic delivery was used in the form of impregnated cement rods in 23 patients. These were removed at a mean of 2.6 months (1 to 5). Pathogen-specific antibiotics were administered systemically for a mean of six weeks (3 to 18). At a mean follow-up of 21 months (8 to 36), 23 patients (96%) had no evidence of recurrent infection. One underwent a planned trans-tibial amputation two weeks post-operatively due to peripheral vascular disease and chronic recalcitrant osteomyelitis of the tibia and foot. The combination of RIA reaming, the administration of systemic pathogen-specific antibiotics and local delivery using impregnated cement rods proved to be a safe and efficient form of treatment in these patients.

Cite this article: Bone Joint J 2014; 96-B:783–8.

Introduction

Segmental tibia fractures are high-energy injuries that are difficult to treat. We report on the use of the Ilizarov Method to treat 40 consecutive AO42C (35) and AO42B3 (5) fractures by a single surgeon. Fractures with bone loss requiring transport were excluded, as were fractures initially treated with nail or plate.

Introduction

Reaming of the canal is an important step in the debridement phase of treating intramedullary infections. Numerous techniques of radical canal debridement have been successfully reported. The use of the Reamer-Irrigation-Aspiration system (RIA-Synthes) is currently expanding to include this clinical scenario.

We report on the use of the Ilizarov method to treat 40 consecutive fractures of the tibial shaft (35 AO 42C fractures and five AO 42B3 fractures) in adults. There were 28 men and 12 women with a mean age of 43 years (19 to 81). The series included 19 open fractures (six Gustilo grade 3A and 13 grade 3B) and 21 closed injuries. The mean time from injury to application of definitive Ilizarov frame was eight days (0 to 35) with 36 fractures successfully uniting without the need for any bone-stimulating procedure. The four remaining patients with nonunion healed with a second frame. There were no amputations and no deep infections. None required intervention for malunion. The total time to healing was calculated from date of injury to removal of the frame, with a median of 166 days (mean 187, (87 to 370)). Minor complications included snapped wires in two patients and minor pin-site infections treated with oral antibiotics in nine patients (23%). Clinical scores were available for 32 of the 40 patients at a median of 55 months (mean 62, (26 to 99)) post-injury, with ‘good’ Olerud and Molander ankle scores (median 80, mean 75, (10 to 100)), ‘excellent’ Lysholm knee scores (median 97, mean 88, (29 to 100)), a median Tegner activity score of 4 (mean 4, (0 to 9)) (comparable to ‘moderately heavy labour / cycling and jogging’) and Short Form-12 scores that exceeded the mean of the population as a whole (median physical component score 55 (mean 51, (20 to 64)), median mental component score 57 (mean 53, (21 to 62)). In conclusion, the Ilizarov method is a safe and reliable way of treating complex tibial shaft fractures with a high rate of primary union.

The purpose of this study was to evaluate the efficacy of human recombinant osteogenic protein 1 (rhBMP-7) for the treatment of fracture non-unions and to estimate the health economics aspect of its administration.

Twenty-four patients (18 males, mean age 39.1 (range 18-79)) with 25 fracture non-unions were treated with rhBMP-7 in our institution (mean follow-up 15.4 months (range 6-29)). Successful completion of treatment was defined as the achievement of both clinical and radiological union. The cost of each treatment episode was estimated including hospital stay, theatre time, orthopaedic implants, drug administration, investigations, clinic attendances, and physiotherapy treatments. The total cost of all episodes up to the point of receiving BMP-7 and similarly following treatment with BMP-7 were estimated and analysed.

Of the 25 cases, 21 were atrophic (3 associated with bone loss) and 4 were infected non-unions. The mean number of operations performed prior to rhBMP-7 application was 3.4, including autologous bone graft in 9 cases and bone marrow injection in one case. In 21 out of the 25 cases (84%), both clinical and radiological union occurred. Mean hospital stay before and after receiving rhBMP-7 was 26.84 days per fracture and 7.8 days per fracture respectively. Total cost of treatments prior to BMP-7 was £346,117 [£13,844.68 per fracture]. Costs incurred following BMP-7 administration were estimated as £183,460 [£7,338.4 per fracture].

rhBMP-7 was used as a bone stimulating agent with or without conventional bone grafting with a success rate of 84% in this series of patients with persistent fracture non-unions. The average cost of its application was £7,338 [53.0% of the total costs of previous unsuccessful treatment of non –unions, p<0.05). Treating non-union is costly, but the financial burden could be reduced by early rhBMP-7 administration when a complicated or persistent non-union is present or anticipated. Therefore, this study supports the view that rhBMP-7 is a safe and power adjunct to be considered in the surgeon's armamentarium for the management of such difficult cases.

Guidelines on the care of the seriously injured have led to widespread changes in clinical practice. The ‘hub and spoke’ model of trauma care means increasing numbers of patients with complex problems are concentrated into regional centres. Though providing the highest standards of treatment, this has cost implications for the receiving unit, particularly given the Department of Health's move towards a ‘Payment by Results’ model of health provision. We undertook an economic evaluation of complex limb reconstruction within our tertiary referral unit.

Patients referred to the complex trauma service were identified. Patients were assigned to either a ‘complicated’ or ‘straightforward’ group by two consultant surgeons, based on the nature of their treatment. 5 cases from each group were randomly selected for further analysis. Data pertaining to the direct healthcare costs for these patients was analysed. Costs per investigation/intervention were obtained relating to hospital stay, outpatient care, operative interventions and investigations. Overall 26 patients were referred to our complex trauma service from other units over 6 months.

A mean of £8,375 (6,163) per patient was recouped using current Service Level Agreements. This amounts to a £26,587 deficit per patient, or £1,394,905 per year assuming current referral rates.

Those planning a service treating complex trauma must allow for the considerable costs involved and make provisions to recoup this from the referring Primary Care Trust.

Wire crossing angle affects the stability of circular fine wire frames. Anatomical atlases document safe ‘corridors’ to avoid neurovascular structures, although this may limit crossing angle. In the distal tibia the furthest posteriolateral safe corridor described is through the fibula. The present study describes a new and safe ‘retro-fibular’ corridor for wire placement in the distal tibia that provides a greater crossing angle. Two different methods of wire insertion are considered to determine which provides greater protection to neurovascular structures.

A dissection based study of 20 embalmed lower limbs divided into two groups. 1.8mm wires were inserted at increments along the tibia, from posterolateral to antero-medial, at 30–45 degrees to the sagittal plane. In the first group wires were placed against the posterior surface of the fibula and ‘stepped’ medially onto the tibia. In the second wires were inserted midway between the border of the fibula and tendoachilles. Standard dissection techniques were used to identify the path of wires and distance from neurovascular structures.

In group one distal tibial wires avoided the posterior tibial neurovascular bundle (mean distance 21.7mm) although passed close to the peroneal artery (mean distance 1.2mm). In group two both the posterior tibial and peroneal structures were avoided (mean distances 15.5mm and 7.1mm respectively). Comparison of the two groups shows a significant difference (p< 0.001).

Retrofibular wire placement is safe in the distal quarter of the tibia and facilitates an optimal crossing angle, although is not described in standard atlases. Insertion of wires mid-way between the posteromedial border of the fibula and the tendoachilles appears the most reliable technique.

Anatomical atlases document safe corridors for placement of wires when using fine-wire circular external fixation. The furthest posterolateral corridor described in the distal tibia is through the fibula. This limits the crossing angle and stability of the frame. In this paper we describe a new, safe Retro-Fibular Wire corridor, which provides greater crossing angles and increased stability. In a cadaver study, 20 formalin-treated legs were divided into two groups. Wires were inserted into the distal quarter of the tibia using two possible corridors and standard techniques of dissection identified the distance of the wires from neurovascular structures.

In both groups the posterior tibial neurovascular bundle was avoided. In group A the peroneal artery was at risk. In group B this injury was avoided. Comparison of the groups showed a significant difference (p < 0.001).

We recommend the Retro-Fibular wire technique whereby wires are inserted into the tibia mid-way between the posteromedial border of the fibula and the tendo Achillis, at 30° to 45° to the sagittal plane, and introduced from a posterolateral to an anteromedial position. Subsequently, when using this technique in 30 patients, we have had no neurovascular complications or problems relating to tethering of the peroneal tendons.

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: Surgeons treating tibial fractures by the Ilizarov Method are faced with the diagnostic dilemma of determining whether a fracture has united to remove the frame safely.

Methods: Considering frame removal we use three criteria:

Consideration of natural history of the injury – characteristics of the injury and existing knowledge of healing times.

Results: Premature frame removal was identified in 2/106 tibial fractures treated with Ilizarov frames. In both cases subsequent CT scanning identified a healed fibula and stiff non-union of the tibia. In both, original fracture geometry was complex, with fracture lines outwith the planes of radiographic assessment. Timely frame removal in104/106 (98%).

Discussion: In both cases of premature removal the frame was reapplied to achieve union. Premature removal must be balanced against the patient’s desire to have their cumbersome fixator removed at the earliest opportunity.

It is said “It is better to leave a frame on one month too long than to remove it a day too soon”, but this merely emphasises that timing of frame removal remains an art rather than an exact science.

Marsh and Montgomery have previously suggested use of CT scanning to assess union in peri-articular fractures. We recommend that in high energy tibial fractures whose fracture pattern geometry lies outwith the antero-posterior and lateral radiograph views, a CT scan should be considered to detect stiff non-union and avoid premature frame removal.

Introduction: An important factor affecting the stability of circular fine wire frames is the wire crossing angle, where an angle of 90 degrees confers optimal stability. Safe anatomical ‘corridors’ have been described to avoid neurovascular structures, but often limit the crossing angle. In the distal tibia the posterior tibial artery and tibial nerve wind medially facilitating safe placement of a posterior to anterior ‘retrofibular’ wire. The present study aims to identify structures at risk during ‘retrofibular’ wire placement and determine the level at which this can be used safely.

Methods: A dissection based study of 10 embalmed lower limbs. Wires of 1.8mm diameter were inserted at increments along the tibia. These were placed against the posterior surface of the fibula and ‘stepped’ medially past the posteromedial border onto the tibia. Wires were introduced from posterior to anterior, between 30 degrees and 45 degrees to the sagittal plane. This angle is estimated, reproducing clinical practice. Standard dissection techniques were used to identify the path of wires and distance from neurovascular structures.

Results: In the distal quarter of the tibia wires avoided the posterior tibial neurovascular bundle (mean distance 21.7mm) although passed close to the peroneal artery (mean distance 1.2 mm). Of the 30 wires placed in the distal tibia, 29 (97%) passed through the leg without damage to any neurovascular structures. Anterior tendons were tethered by 13% of wires placed in the distal quarter of the tibia.

Discussion: Retrofibular wire placement facilitates an optimal crossing angle, although is not described in standard atlases. Use in the lower quarter of the tibia does not threaten the posterior tibial neurovascular bundle. However, peroneal artery injury is a possibility. The clinical significance of peroneal artery injury at this level is unclear but should be considered when using this technique.

Introduction: Pilon fractures are severe injuries of the distal tibia usually characterised by severe soft tissue “hit” in addition to the underlying fracture. Historically, plating techniques have led to a significant rate of serious complications. This study describes our early experience treating such injuries by the Ilizarov Method.

Methods: 30 patients were prospectively identified and followed up beyond frame removal clinically and by case note review. Fractures classified according to AO. Bony union evaluated radiologically and clinically – remodelling of bone trabeculae on two radiographs and ability to weight bear without discomfort/walking aids on a dynamised frame.

Results:

Mean age 45.3 years, male: female = 26:4.

Seven fractures were Grade 3 open.

Patients were grouped as follows:

43-A .1/.2/.3 = 1/2/2

Two patients with 43-C.3 fracture had additional corticotomy for bone loss.

Twenty-nine pilons united.

Overall mean time to union was 20 weeks.

Times to union (weeks):

Group 43-A: - median = 20, mean = 21.

24 patients had no major complications. One Grade 3B open 43-C.3 fracture had deep sepsis prior to transfer to our unit which could not be eradicated – this led to transtibial amputation. Two patients had valgus mal-union and One had stiff nonunion requiring a second frame. Eleven patients experienced superficial pinsite infection that resolved with oral antibiotic therapy. Two deep pinsite infections were eradicated by overdrilling.

Conclusion: The Ilizarov method offers safe and reliable healing for distal tibial pilon fractures in mean 20 weeks, with low levels of serious complications despite the severity of the initial injuries.

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.