Introduction

There are concerns that patient-reported outcome measures (PROMs) currently used for adults requiring, undergoing or after undergoing lower limb reconstruction (LLR) are not adequately capturing the range of experiences important to these patients. The ‘Patient-Reported Outcome Measure for Lower Limb Reconstruction’ (PROLLIT) study developed a conceptual framework of outcomes identified as important and relevant by adult LLR patients. This review explored whether existing PROMs address these outcomes, and exhibit content validity in this population.

Introduction

Knee arthrodesis is a useful limb salvage technique to maintain function in patients with complex and infected total knee arthroplasties (TKA). There are a number of commonly used external fixators, but no consensus on which of these are optimal.

The aim of this study was to synthesise the current literature to guide clinical decision making and improve patient outcomes. We systematically review the literature to compare outcomes of external fixators in arthrodesis following infected TKA.

Introduction

Schatzker V & VI tibial plateau fractures are serious life-changing injuries often resulting in significant complications including post-traumatic arthritis. Reported incidence of secondary TKA following ORIF of all tibial plateau fractures is 7.3% and 13% for Schatzker V & VI tibial. This study reports a 15-year single centre experience of CEF of Schatzker V & VI fractures including PROMs and incidence of secondary TKA. This study was approved by the local Institutional board.

Introduction

Circular external frames (CEF) are commonly used for a wide variety of indications, often when other devices are not appropriate. Circular frames are particularly associated with pin-site infection (PSI). Currently there is a gap in the available literature surrounding the risk of frame use with in-situ prosthetic joints. This retrospective study investigated the incidence of prosthetic joint infection (PJI) in a series of patients with in-situ arthroplasties treated with CEF.

Introduction

Intra articular distal tibia fractures can lead to post-traumatic osteoarthritis. Joint distraction has shown promise in elective cases. However, its application in acute fractures remains unexplored. This pilot study aims to fill this knowledge gap by investigating the benefits of joint distraction in acute fractures.

Introduction

Frame configuration for the management of complex tibial fractures is highly variable and is dependent not only on fracture pattern and soft tissue condition but also surgeon preference. The optimal number of rings to use when designing a frame remains uncertain. Traditionally, larger, stiffer constructs with multiple rings per segment were thought to offer optimal conditions for bone healing, however, the concept of reverse dynamisation questions this approach.

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Introduction

Circular frames for ankle fusion are usually reserved for complex clinical scenarios. Current literature is heterogenous and difficult to interpret. We aimed to study the indications and outcomes of this procedure in detail.

Introduction

Wide, tumor-like resection for chronic osteomyelitis (COM), a standard practice previously, has been challenged recently with adequate, local debridement. This paper reviews the evolution of surgical debridement for long bone osteomyelitis, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Introduction

We undertook a qualitative study to explore what is important to people with lower limb conditions requiring reconstruction (LLR) and how it impacted their quality of life (QOL), in order to develop a conceptual framework for a new patient reported outcome measure (PROM). This builds on a previous qualitative evidence synthesis of existing research to develop a preliminary conceptual framework as part of the Patient Reported Outcomes for Lower Limb Reconstruction (PROLLIT) study.

Aims

Nearly 99,000 total knee arthroplasties (TKAs) are performed in UK annually. Despite plenty of research, the satisfaction rate of this surgery is around 80%. One of the important intraoperative factors affecting the outcome is alignment. The relationship between joint obliquity and functional outcomes is not well understood. Therefore, a study is required to investigate and compare the effects of two types of alignment (mechanical and kinematic) on functional outcomes and range of motion.

Introduction

Deformity influences the weight bearing stresses on the knee joint. Correction of mechanical alignment is performed to offload the knee and slow the rate of degenerative change. Fixator assisted deformity correction facilitates accurate correction prior to internal fixation. We present our results with standard Ilizarov and UNYCO system assisted deformity correction of the lower limb.

Introduction

There are currently no quality of life Patient Reported Outcome Measures (PROMs) that have been validated for patients with conditions requiring lower limb reconstructive surgery. The extent to which current generic and lower limb specific PROMs address relevant dimensions for these patients is unclear.

Introduction

Patient reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction on patient's quality of life (QOL). Existing measures have not been developed to specifically capture patient experiences amongst adults with lower limb conditions that require reconstruction surgery. This systematic review of qualitative studies (qualitative evidence synthesis) aimed to identify what is important to these patients.

Introduction

Superficial pin site infection is a common problem associated with external fixation, which has been extensively reported. However, the incidence and risk factors with regards to deep infection is rarely reported in the literature. In this study, we investigate and explore the incidence and risk factors of deep infection following circular frame surgery. For the purpose of this study, deep infection was defined as: persistent discharge or collection for which surgical intervention was recommended.

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.

Aims

Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame.

Aims

Bone demonstrates good healing capacity, with a variety of strategies being utilized to enhance this healing. One potential strategy that has been suggested is the use of stem cells to accelerate healing.

Aim

Despite advances in surgical and antibiotic therapies the treatment of chronic osteomyelitis remains complex and is often associated with a significant financial burden to the National Health Service. The aim of this review was to identify the different types of single-stage procedures being performed for this condition as well as to evaluate their effectiveness.

Introduction

Fracture and deformity after frame removal is a known risk in 9–14.5% of patients after circular frame treatment. The aims of this study were to assess the effectiveness of our staged protocol for frame removal and risk factors for the protocol failure.

The management of chronic osteomyelitis is fraught with difficulties; a multi-disciplinary team approach is recommended for optimum outcome. Thorough debridement, dead space management and organism targeted antibiotic therapy the gives best clinical results. Calcium sulphate beads impregnated with antibiotic is an absorbable option for prolonged local antibiotic elution and dead space management.

This study aims to analyse the early results of single stage management of osteomyelitis with antibiotic impregnated calcium sulphate beads. Following surgical debridement, calcium sulphate impregnated typically with tobramycin and/or vancomycin is inserted to obliterate the dead space. Intravenous antibiotics – typically teicoplanin and piperacillin-tazobactam – are administered until culture results permit rationalisation to narrow spectrum agents. Patients are followed up in Infectious Diseases and Orthopaedic clinics for a period of 12 months and discharged if quiescence is achieved.

We conducted a retrospective analysis of our prospective database to identify patients treated with our single stage protocol for chronic osteomyelitis. We excluded patients that had (1) less than 6 months of follow up, (2) incomplete metal-ware removal, (3) patients lost to follow up. Fourteen patients (9 men, 5 women) with mean age of 41 (16–73) years and mean follow up of 9 (6–12) months were included in study. Eleven patients had previous surgeries involving internal fixation; the rest were primary osteomyelitis. Seven patients had washouts and removal of metal-ware procedures for osteomyelitis prior to referral to the bone infection service. Clinical, radiographic, and laboratory (microbiological, biochemical and haematological) methods were used to monitor response to treatment.

Cierney-Mader classification determined that 8 patients were classed as type A (normal hosts); 4 as BS (systemically compromised); 2 as BLS (locally and systemically compromised). Anatomic analysis suggested 7 were Type 1 (medullary osteomyelitis); the remaining 7 were type 3 (localised disease). Five patients were staged IA; three each staged IIIA and IIIBS; and one each staged IBs, IBLS, IIIBLS.

Staphylococcus Aureus was the commonest causative organism.

Follow up radiograph monitoring indicated absorption of the beads by 3 months.

There has been no evidence of recurrence based on clinical, radiographic and blood based parameters in all patients.

Short-term results of single stage osteomyelitis treatment with calcium sulphate beads impregnated with antibiotics are promising.

Open fractures of the long bones of the limbs are associated with an increased risk of osteomyelitis and few studies investigate this complication in circular frames. We reviewed the incidence of and contributory factors toward infection-related outcomes in Grade 3 open fractures, managed with a circular frame, at a single centre.

We performed a retrospective study of consecutive adult patients presenting with a Grade 3 open fracture, who required a circular frame for definitive skeletal fixation from 2005 to 2014. Patient case notes, microbiology results and radiological studies were reviewed for demographic details and surgical management. Infection-related outcomes were classified as ‘possible’ and ‘definitive’, based on clinical findings, microbiology and imaging features at follow-up at 6 and 12 months.

74 patients were identified with an average age of 43 years. There were 70 unilateral and 4 bilateral limb injuries. Most treated limbs had a tibial fracture (97%). There were 24 Gustillo-Anderson grade 3A, 37 grade 3B, 4 grade 3C and 9 not sub-classified. 33% of patients were debrided on the day of injury. Average time to circular frame installation was 14 days. 27 Ilizarov, 44 Taylor spatial and 3 other circular frames were used. A variety of plastic surgery reconstruction was used to provide wound coverage: skin grafts, local and free flaps. Circular frames were in place for 259 days on average. 10 patients (1 bilateral limb fracture) still have their frames in-situ. Additional bone grafting to the fracture site was carried out in 13 patients and 15 limbs (1 patient had 2 episodes of bone grafting to the same limb). 8 limbs in 8 patients were excluded from infection-related outcome analysis: 4 patients lost to follow-up, 2 patients who went on to below knee amputation and 2 patients had <6 months’ follow-up. 13 patients (14 limbs) had only 6 months’ follow-up and 53 patients (56 limbs) had 12 months’ follow-up. There were 5 patients (5 limbs) with ‘possible’ infection (7%): 1 screw infection and 4 soft tissue infections. 1 patient (1 limb) had a tissue-confirmed ‘definitive’ infected non-union (1.4%).

Patients managed with circular frames typically have complex fracture configurations less amenable to other methods of definitive fixation. Our patient cohort has a limb salvage rate (97%) and a soft tissue infection rate (‘possible’ infection) comparable to other reported series. We report a low rate of osteomyelitis (‘definitive’ infection) in consecutive patients managed using our protocol.

Chronic osteomyelitis is a challenging problem and a growing burden for the National Health Service. Conventional method of treatment is 2 stage surgery, with debridement and prolonged courses of antibiotics. Recently single stage treatment of chronic osteomyelitis is gaining popularity due decreased patient morbidity and cost effectiveness. Dead space management in single stage treatment is accomplished by either a muscle / myocutaneous or antibiotic loaded calcium sulphate beads.

We analysed the cost effectiveness of two dead space management strategies in single stage treatment of osteomyelitis. Study is designed to analyse the health economics at 2 time points; 45 days post surgery and 2 years post surgery. We report preliminary results at 45 days post surgery.

Setting – Level 1 trauma centre and university hospital

Approval – Ethics committee approved study

10 patients in each group were retrospectively analysed through patient records. Each group was identified for standard demographics, duration of procedure, hospital stay, type and duration of postoperative antibiotics, number of out patient visits in first 45 days and recurrence of infection.

Table attached details the results of both groups

In health technology assessment four quadrant model, CSB appears in quadrant II suggesting that it is more cost effective.

Based on small data set and on assessment only evaluating cost, at 45 days assessment, antibiotic calcium sulphate beads from a Health Economic Cost Effectiveness Analysis offers a better economic outcome. This is holding constant the morbidity of the patients and effectiveness, assuming both treatments are standards of care, which is best evaluated at 24 months.

Background:

Potential injury to the common peroneal nerve at the level of the fibula head/neck junction during fine wire insertion in stabilization of proximal fibula, is a recognised complication. This study aims to relate the course of the common peroneal nerve to fibula head transfixion wire.

Methods:

Total radiation exposure accumulated during circular frame treatment of distal tibial fractures was quantified in 47 patients treated by a single surgeon from March 2011 until Nov 2014. The radiation exposures for all relevant radiology procedures for the distal tibial injury were included to estimate the radiation risk to the patient.

Background:

Septic arthritis following intra-capsular penetration of the knee by external fixation devices is a complication of traction/fixation devices. This study aimed to demonstrate the capsular attachments and reflections of the distal femur to determine safe placements of wires.

Theatre efficiency is an increasingly important factor as the health service is faced with an ever greater number of patients, but tighter fiscal restrictions. We carried out an audit was to utilise data collected routinely on the Opera Surgical Management System (CHCA, Canada) to look at the efficiency of orthopaedic theatre usage, and to look for potential areas of improvement. The data related to all elective procedures carried out by a single Orthopaedic Consultant in a city hospital, over a one year period.

We found that lists frequently started late, with the first patient of the day entering the anaesthetic room after 9 am on over 50% of occasions. The reasons for this were not regularly recorded. There was a wide variability in the length of time taken to anaesthetise and position the patients. Although there was a weak association with the underlying health of the patients (ASA score), the seniority of the anaesthetist was not available for correlation. The turnaround time between cases was variable, with a tendency for it to take longer over the lunchtime hours. Almost a third of lists finished before 4.30 pm, mainly due to patient cancellations, however nearly a third of lists finished after 5.30 pm.

We found that data routinely collected on our theatre management system provides useful information that could potentially be used to fine-tune our peri-operative processes, however greater detail about specific timings and delays affecting the patient journey would be required before any recommendations could be made to improve theatre efficiency.

Both conservative and operative forms of treatment have been recommended for patients with a ‘floating shoulder’. We compared the results of conservative and operative treatment in 25 patients with this injury and investigated the use of the glenopolar angle (GPA) as an indicator of the functional outcome. A total of 13 patients (ten male and three female; mean age 32.5 years (24.7 to 40.4)) were treated conservatively and 12 patients (ten male and two female; mean age 33.67 years (24.6 to 42.7)) were treated operatively by fixation of the clavicular fracture alone. Outcome was assessed using the Herscovici score, which was also related to changes in the GPA at one year post-operatively.

The mean Herscovici score was significantly better three months and two years after the injury in the operative group (p < 0.001 and p = 0.003, respectively). There was a negative correlation between the change in GPA and the Herscovici score at two years follow-up in both the conservative and operative groups, but neither were statistically significant (r = -0.295 and r = -0.19, respectively). There was a significant difference between the pre- and post-operative GPA in the operative group (p = 0.017).

When compared with conservative treatment, fixation of the clavicle alone gives better results in the treatment of patients with a floating shoulder. The GPA changes significantly with fixation of clavicle alone but there is no significant correlation between the pre-injury GPA and the final clinical outcome in these patients.

Cite this article: Bone Joint J 2013;95-B:815–19.

Introduction

The optimal treatment of high-energy tibia fractures remains controversial. The role of external fixators has been shown to be crucial. This study aimed to compare the effectiveness of using either Taylor Spatial Frame (TSF) or Ilizarov frames in treatment of high-energy tibia fractures in a tertiary trauma referral centre.

Abstract

We present here the results of a prospective follow-up study of radiological and functional outcome in 43 patients treated using the Taylor Spatial Frame (TSF) for definitive management of tibial fractures.

Introduction

The Ilizarov (IF) and Taylor Spatial (TSF) external fixator frames are commonly used to manage complex fractures and bone deformities and a dedicated Frame Service Team at our unit supports patients during pre- and post-operative period. Few studies have assessed the satisfaction of patients who have been treated with Circular frames.

AIM

To study the incidence of thromboembolism among patients treated with ring fixators in lower limb injuries and their risk factor association.

Introduction

Restoration of mechanical axis is one of the main aims during Total Knee Arthroplasty (TKA) surgery. Treatment of osteoarthritis (OA) of the knee with extra-articular deformity either in femur or in tibia poses a technical challenge in achieving this aim. Insufficient correction of axis is associated with poor clinical outcome of total knee arthroplasty (TKA). Extra-articular deformity can either be addressed with compensatory intra-articular bone resection at the time of TKA or correctional osteotomy prior to or at the time of TKA.

Purpose of study

The aim of this study is to evaluate the role of low intensity pulsed ultrasound, Exogen in the treatment of delayed and non unions. Methodology: We conducted a retrospective study of 292 patients who has had Exogen treatment for delayed and non union from 2005 to 2009. Patient's age, sex, associated co morbidities, smoking history, medications, type of fractures (open/closed), infection and site of fractures were sought for. 271 patients' data (228 delayed and 43 non unions) were available during the study with mean age of 53.5 yrs.

Exogen therapy was initiated at 3–4 months for delayed unions and 6–12 months for non unions in 61 tibia (15 open); 31 femur (2 open); 20 scaphoid; 38 5th metatarsal; 31 ankle (2 open); 17 ulna (1 open); 15 radius (3 open); 29 humerus (2 open); 16 clavicles; 6 olecranon; 4 pilon (2 open) and 2 metacarpal fractures.

Introduction

There are controversies in the literature about thoracoplasty and its effect on lung function changes. The aim of the study was to evaluate the effect and outcome of thoracoplasty in conjunction with pedicle screw construct in the treatment of thoracic adolescent idiopathic scoliosis on lung functions.

Introduction

Open tibial fractures are associated with increased risk of complications, particularly a higher risk of infections and decreased functional outcome.

The present study was conducted to evaluate the cost of physiotherapy both for inpatient and outpatient services. Significant physiotherapy resources are required to rehabilitate patients with an Ilizarov or Taylor Spatial Frame (TSF). Within Hull and East Yorkshire Hospitals NHS Trust Physiotherapy department the average number of outpatient treatment sessions per routine patient is 6. In comparison, the average number of treatment sessions required for a patient with an ilizarov (or TSF) is 24 for a trauma patient and 33 for a patient undergoing an elective procedure.

Seventy three (73) patients received physiotherapy treatment with an Ilizarov frame or a Taylor spatial frame between April 2008 and April 2010. Physiotherapy input was recorded (in minutes) for the patients identified. This included treatment received as an inpatient as well as an outpatient (if the patient received their treatment within Hull and East Yorkshire NHS trust).

Data collection was divided into either trauma or elective procedure for analytical purposes. The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an inpatient with an ilizarov frame is £121.82 per case (trauma) and £133.15 per case (elective).

The average cost of physiotherapy treatment to Hull and East Yorkshire Hospitals NHS Trust for an outpatient for a trauma case was calculated as £404.65 and £521.41for an average elective case. This is in comparison to a routine patient costing the service £60.29 (when treated by a Band 7 physiotherapist). The present study gives valuable data for future business planning and assistance with the setting of local or national tariffs for the treatment of this patient group.

Aim

Chronic osteomyelitis still remains challenging and expensive to treat in spite of advances in antibiotics and operative techniques. We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure.

Background

Complex tibial fractures are difficult to treat. The costs associated with hospitalization can be substantial, yet it is unknown how these vary depending upon the type of implant used. There have been multiple studies on economics of tibial fractures but none of these studies actually focussed on costing of illizarov and taylor spatial frames. We discuss the cost analysis of 200 tibial fractures treated with illizarov or taylor spatial frames. The purpose of this study was to compare the cost of treatment of complex tibial fractures with reimbursement given to the hospital in treating such injuries.

Introduction

Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections.

Spinal stenosis and disc herniation are the two most frequent causes of lumbosacral nerve root compression. This can result in muscle weakness and present with or without pain. The difficulty when managing patients with these conditions is knowing when surgery is better than non-operative treatment: the evidence is controversial. Younger patients with a lesser degree of weakness for a shorter period of time have been shown to respond better to surgical treatment than older patients with greater weakness for longer. However, they also constitute a group that fares better without surgery. The main indication for surgical treatment in the management of patients with lumbosacral nerve root compression should be pain rather than weakness.

Purpose

Shoulder dislocations account for 50 % of all dislocations, of which 98% are anterior dislocations. Different techniques have been described in literature with variable success, which depends upon type of dislocation, technique used and muscle relaxation.

AIM

Chronic osteomyelitis still remains challenging and expensive to treat inspite of advances in antibiotics and operative techniques.

We present our experience with free muscle flap after radical debridement of chronic osteomyelitis, performed as a single stage procedure.

Introduction

Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3×2ml) and single (1×6ml) dosing regimens of hylan G-F 20

Introduction

Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3×2ml) and single (1×6ml) dosing regimens of hylan G-F 20.

Introduction

The policy of treating open fractures within 6 hrs can result in complex operations being performed under sub optimal conditions. The purpose of this study was to determine the association between time to initial debridement and rate of infection in high energy (Grade III) open fractures of Tibia.

Plasma levels of cobalt and chromium ions and Metal Artefact Reduction Sequence (MARS)-MRI scans were performed on patients with 209 consecutive, unilateral, symptomatic metal-on-metal (MoM) hip arthroplasties. There was wide variation in plasma cobalt and chromium levels, and MARS-MRI scans were positive for adverse reaction to metal debris (ARMD) in 84 hips (40%). There was a significant difference in the median plasma cobalt and chromium levels between those with positive and negative MARS-MRI scans (p < 0.001). Compared with MARS-MRI as the potential reference standard for the diagnosis of ARMD, the sensitivity of metal ion analysis for cobalt or chromium with a cut-off of > 7 µg/l was 57%. The specificity was 65%, positive predictive value was 52% and the negative predictive value was 69% in symptomatic patients. A lowered threshold of > 3.5 µg/l for cobalt and chromium ion levels improved the sensitivity and negative predictive value to 86% and 74% but at the expense of specificity (27%) and positive predictive value (44%).

Metal ion analysis is not recommended as a sole indirect screening test in the surveillance of symptomatic patients with a MoM arthroplasty. The investigating clinicians should have a low threshold for obtaining cross-sectional imaging in these patients, even in the presence of low plasma metal ion levels.

Introduction

Spinal infections constitute a spectrum of disease comprising pyogenic, tuberculous, nonpyogenic-nontuberculous and postoperative spinal infections. The aim of this study was to review the epidemiology, diagnostic yield of first and second biopsy procedures and microbiology trends from Sheffield Spinal Infection Database along with analysing prognostic predictors in spinal infections.

Introduction

Spinal osteosarcomas are quite rare and the optimal treatment strategy is unknown. We report a series of 9 cases of osteosarcoma of the spine treated with intralesional resection and adjuvant combination therapy in order to evaluate their clinico-pathological correlation, recurrence rate and survival.