Introduction

Knee dislocations, vascular injuries and floating knee injuries can be initially managed by a external fixator. Fixator design constructs include the AO pattern and the Diamond pattern. However, these traditional constructs do not adhere to basic principles of external fixation. The Manchester pattern knee-spanning external fixator is a new construct pattern, which uses beam loading and multiplanar fixation. There is no data on any construct pattern. This study compares the stability of these designs.

Background

The viability of any surgical practice relies on the income that practice generates for the parent NHS Trust. The OPCS codes are a key determinant of an NHS trust's tariff for an admission. These contribute to the HRG codes - the means the NHS uses to determine the value of a patient's treatment, including operations. The clinical knowledge of coders may not differentiate specialist practice, including circular frames.

Background

Medical grade Calcium Sulphate can be used as a delivery vehicle for antibiotics. We use these for treating patients with established osteomyelitis, but also use it prophylactic for contaminated war injuries, to fill voids in bone with osteo conductve filler that delivers local antibiotics, and can integrate with bone. Although antibiotic loaded calcium sulphate is increasingly used, there is little data to demonstrate that systemic levels generated by local release of antibiotics are safe. For this reason, we routinely assay systemic levels of antibiotics.

Introduction

This study evaluates the need for limb reconstruction surgery in Syria and gives examples of how this service has been delivered by UK surgeons. The conflict in Syria has resulted in over 500,000 deaths and 1.2 million injured. There is not yet a centre for limb reconstruction surgery in the country. Injuries from gunshots and shrapnel were not common prior to the civil war resulting in a paucity of experience.

Aim

To determine if systemic toxicity occurs after the use of antibiotic loaded calcium sulphate in the treatment (1) of bone and soft tissue infection.

Although antibiotic loaded calcium sulphate is increasingly used for the local treatment of bone and soft tissue infection, there is little data to demonstrate that systemic levels generated by local release of antibiotics are safe. For this reason, we routinely assay systemic levels of antibiotics.

The ageing population and an increase in both the incidence and prevalence of cancer pose a healthcare challenge, some of which is borne by the orthopaedic community in the form of osteoporotic fractures and metastatic bone disease. In recent years there has been an increasing understanding of the pathways involved in bone metabolism relevant to osteoporosis and metastases in bone. Newer therapies may aid the management of these problems. One group of drugs, the antibody mediated anti-resorptive therapies (AMARTs) use antibodies to block bone resorption pathways. This review seeks to present a synopsis of the guidelines, pharmacology and potential pathophysiology of AMARTs and other new anti-resorptive drugs.

We evaluate the literature relating to AMARTs and new anti-resorptives with special attention on those approved for use in clinical practice.

Denosumab, a monoclonal antibody against Receptor Activator for Nuclear Factor Kappa-B Ligand. It is the first AMART approved by the National Institute for Health and Clinical Excellence and the US Food and Drug Administration. Other novel anti-resorptives awaiting approval for clinical use include Odanacatib.

Denosumab is indicated for the treatment of osteoporosis and prevention of the complications of bone metastases. Recent evidence suggests, however, that denosumab may have an adverse event profile similar to bisphosphonates, including atypical femoral fractures. It is, therefore, essential that orthopaedic surgeons are conversant with these medications and their safe usage.

Take home message: Denosumab has important orthopaedic indications and has been shown to significantly reduce patient morbidity in osteoporosis and metastatic bone disease.

Cite this article: Bone Joint J 2016;98-B:160–5.

Statement of Purpose

To compare the functional outcome of Distal Tibial Metaphyseal fracture treated with Circular frame compared vs. Locking Plate

Introduction

Morton's Neuroma is routinely treated by excision of the interdigital nerve. Traditional surgery works by denervation, but the results are variable, and recurrence is common. Multiple Morton's Neuromas present a difficult clinical challenge. MR and ultrasound often demonstrate a normal nerve or an interdigital bursa. Some experts advise division of the intermetatarsal ligament rather than excision. This case series evaluates an alternative method of treatment.

Taylor Spatial Frame (TSF) is a six axis deformity correction frame and accuracy of correction depend on the accuracy of parameters input in to the web based software. There are various methods of obtaining frame and deformity parameters (13 in total) including the use of dedicated software known as SpatialCAD™. We tested the accuracy of SpatialCAD™ using a saw bone two ring frame construct of known parameters. We mounted a two-ring (155mm) frame on a saw bone tibia and fibula unit and worked out the accurate mounting and deformity parameters. Then we obtained orthogonal and nonorthogonal antero-posterior and lateral images of frame using a metallic sphere of known dimensions placed at the level of the bone, to aid calibration of x-ray images. We also obtained orthogonal and non-orthogonal images without a calibrating sphere. We then uploaded the images in to SpatialCAD™ software and obtained the mounting and deformity parameters and compared with the real parameters. SpatialCAD™ is capable of yielding measurements within 1–2mm of actual measurements when Calibrated orthogonal images were used. The software was inaccurate when frame hardware of known dimensions was used for calibration because the hardware was not in the same plane as the bone

Limb lengthening with external fixators has many complications, like pin track infection, joint stiffness, severe pain and stress fracture after removal of external fixator. Prolonged period in external fixator interferes with rehabilitation and activities of daily living.

We describe our results with ISKD (intramedullary skeletal kinetic distractor) system, an internal limb lengthening device, activated with rotations of 3 degrees. In this retrospective cohort we performed lengthening with the use of ISKD in 12 patients from March 2006 to date. Ten patients were included in this study as two patients had not completed the stage of consolidation. There were 7 male and 3 female patients. Their average age was 44 years (range 23–63). The mean follow up period was 16 months (range 12–24 months). Two patients had tibial lengthening and eight patients had femoral lengthening. The average lengthening desired was 42.5 mm (range 2.5 mm–75 mm). The average lengthening achieved was 38 mm. Mean hospital stay was 7 days (range 5–11 days). The distraction index was 1.2 mm/day. The average time to full weight bearing was 6 months (range 4 to 10 months). Mean healing time was 10.25 months. The mean healing index was 90.7 days/cm. If we remove two patients who took long time to heal, the mean healing index drops to 61 days/cm. Two patients needed bone grafting at the distraction site. None of the patients had infection, non-union of the distraction site or breakage of the nail. None of the patients had joint stiffness. All patients were completely satisfied with the treatment and had excellent functional results. We conclude that the low rate of complications, higher patient acceptability and avoidance of external fixation make ISKD a very attractive option for limb lengthening.

Introduction

Various rehabilitation shoes are prescribed to protect the forefoot following surgery. Patients often complain of discomfort in other areas as a result of the postoperative shoe, including the knee, hip and lower back. This has never been quantified. This study aims to establish the effect on other joints using gait analysis. Methods: 11 healthy volunteers were investigated using various common types of postoperative shoe. They were studied with gait analysis equipment and the joint motion assessed with commercial software. The effect of commercial devices designed to minimise gait changes by lifting the contralateral foot were also evaluated.

Nice guidelines recommend VTE prophylaxis to patients in below knee casts following foot and ankle surgery following risk assessment. The guidelines are controversial and BOFAS recommendations reiterate the risk factors but highlight poor evidence to support these guidelines. Implementation has been variable dependent on interpretation.

58 patients who underwent hindfoot procedures and were immobilised in a cast were identified. These patients were under the care of two consultants, one of whom anticoagulates with daily enoxaparin and one who does not, providing a de facto case-control design. The patients were followed up to identify those who subsequently suffered a DVT or PE, and the clinical circumstances.

2 cases of VTE events were noted in 58 patients undergoing foot and ankle surgery. Both were elective cases managed postoperatively in cast and treated with prophylaxic enoxaparin. Both of these presented to hospital with signs of VTE greater than 6 weeks following surgery after cast removal and discontinuation of enoxaparin. No patients were considered high risk according to NICE guidelines. None of the patients who received no thromboprophylaxis had a clinical DVT.

Within our study group we found that VTE thromboprophylaxis does not influence clinically evident VTE rates. Patients who developed VTE were not considered high risk by definition of NICE guidelines but only at increased risk due to their immobility. The VTE events were initiated while the patients were receiving thromboprophylaxis. The effectiveness of the guidelines in predicting patients who would benefit from chemoprophylaxis is questionable from this study.

NICE guidelines on VTE thromboprophylaxis have been received with some concerns. Although this investigation studied only a relatively small number of patients, it raises issues about the clinical effectiveness of the guidelines in foot and ankle patients.

The treatment of very distal tibial fractures and pilon fractures is difficult. There is a wide variation in the severity of injury and the options for surgical management. Plates and external fixation each have their advantages. This retrospective study looks at complications and technical tips for anterolateral plating.

35 consecutive distal tibial platings were evaluated. The AO classification for each fracture was determined and any patient factors affecting outcome. Outcome variables included time to radiological union, infection rate, wound breakdown rate, and joint movement after treatment.

There were 32 anterolateral platings and 3 medial platings. The union rate was 95%. There were two deep infections which required surgical treatment. There were two wound breakdowns, one of which required plastic surgical intervention. Two patients had prominent metalwork, requiring removal. Other complications included deep peroneal nerve palsy, stiffness, and vascular compromise. The complication rates were lower for surgeons operating more frequently on these fractures. Two patients subsequently required bone transport and one required an amputation.

The complication rate found was similar to that reported in the literature. The few complications were however very significant for the patient and also for the surgeon as they required bone transport. Complications other than infection occurred in the few cases performed by surgeons low on their learning curve. We present technical tips for surgery. The presence of callus only after mobilisation indicates that union is slow.

Anterolateral plating is a viable option for distal tibial fractures, especially 43B fractures. There is a learning curve associated with their use. Complication rates are low overall, but significant consequences can accompany complications. As an alternative to external fixation, distal locking plates are not a pain free option for the surgeon, as well as for the patient.

Objectives

Fracture non-union poses a significant challenge to treating orthopaedic surgeons. These patients often require multiple surgical procedures. The incidence of complications after Autologous Bone Graft (ABG) harvesting has been reported up to 44%. These complications include persistent severe donor site pain, infection, heterotopic ossification and antalgic gait. We retrospectively compared the use of BMP-7 alone in long bone fracture Non-union, with patients in whom BMP-7 was used in combination with the Autologous Bone Graft (ABG).

The Mini C-arm has been heralded as a safer means of fluoroscopy. No clinical data on the use of the mini C-arm is available in the literature. The purpose of this study is to compare the exposure in clinical practice between the conventional C-arm and the mini C-arm, and to scrutinize the patterns of radiation exposure.

All operations using the mini C-arm were reviewed. A control group of patients undergoing the identical surgical procedure using the conventional C-arm was used. The Sign test was used to detect the number of exposures taken and the radiation exposure documented.

There were 16 surgical procedures where a valid control was available. The number of exposures performed with the mini C-arm was significantly greater than the conventional C-arm (p=0.05), but the emitted dose of radiation was significantly smaller for the mini C-arm (p 0.001).

The authors conclude that the mini C-arm is a safer device for use in extremity surgery, but that the Surgeon should still be careful to avoid repeated excessive exposures.

Introduction: The mini C arm is a surgeon operated fluoroscopic device for use in the operating theatre for extremity orthopaedic surgery. There have been no studies comparing the radiation dose of the mini C arm and the conventional C arm.

The aim of this study was to determine if the exposure to patient and surgeon was decreased with use of the mini C arm.

Methods: This was a case-control study. Operations performed with the mini C arm were matched for type, complexity and operator with cases performed with the conventional C arm. The number of exposures and the total time of exposure were measured, and the skin dose and scatter calculated.

Results: There were 16 case-control pairs. There was a significantly greater number of exposures taken by the surgeon operated mini C arm (p=0.02), but there was still a significantly lower exposure to the surgeon with the mini C arm (p=0.004). There was no significant difference in the patient skin dose (p=0.21).

Conclusions: The surgeon operated mini C arm results in a greater exposure time and number of exposures. Despite this, the mini C arm exposes the surgeon to less radiation compared to the conventional C arm in extremity orthopaedics. The radiation exposure with the mini C arm is approximately half that of the conventional C arm. The increased number of exposures may occur because surgeons are more trigger happy with the mini C arm, or because there are technical problems with achieving a useful image. The mini C arm should be used for extremity orthopaedics whenever possible to decrease the radiation exposure.

Background: The Mini C-arm has been heralded as a safer means of fluoroscopy. No clinical data on the use of mini C-arm is available in the literature.

Aim: The purpose of this study was to compare the exposure in clinical practice from the conventional C-arm and the Mini C-arm and scrutinize patterns of exposure.

Materials/methods: Case-Control design. All operations using the mini C-arm were reviewed. Control cases were identical operations using the conventional C-arm. The Sign test was used to detect the number of exposures taken and the dose of radiation.

Results: There were 16 operations with valid case-control pairs. The number of exposures performed was significantly greater for the mini C-arm (p=0.05), but the emitted dose of radiation was significantly smaller (p< 0.001) for the mini C-arm.

Conclusions: The mini C-arm is a safer device for extremity surgery, but the surgeon should be careful to avoid excessive exposures.

Introduction: Tension band wiring is a common technique for olecranon fracture fixation. The most commonly used material for the tension band is stainless steel wire. There are however problems associated with stainless steel wire. Ethibond (Ethicon Ltd, Edinburgh) has previously been cited as a suitable alternative material but not FiberWire. The biomechanical properties of FiberWire (Arthrex Ltd, Sheffield) as a tension band material have not been evaluated. This study aimed to investigate the properties of FiberWire and compare them with stainless steel wire and Ethibond.

Methods: Saw-bone olecranons were osteotomised identically to create an olecranon fracture. Identical tension band constructs were produced using stainless steel wire, Ethibond and FiberWire. The construct was tested by cyclical loading with an ESH dynamic testing machine (Brierley Hill, West Mids). A preload of 5N was applied before cyclical loading at levels up to 200N. The fracture gap was measured with a displacement transducer (Tokyo Sokki Kenkyujo Co, Japan).

Results: At loading up to 100N, the stainless steel wire allowed an average fracture gap of 200 micrometers. 5 gauge Ethibond allowed a larger fracture gap of 350 micrometers (p< 0.05). 2 gauge Fiberwire did not allow a significantly different fracture gap to Ethibond.

Discussion: The fracture gap with suture material was greater than with stainless steel wire, but still less then 0.5mm with loading of 100N. Free body diagram calculations determine that in a 70 kg man, this would correspond to the forces expected in extending the elbow against gravity. This means that these alternative materials are mechanically suitable for use in clinical practice for tension bands. This can avoid some of the complications of stainless steel wire.

Conclusion: 5 gauge Ethibond and 2 gauge FiberWire are biomechanically suitable as alternatives to stainless steel wire in tension band wire fixation of olecranon fractures.

Introduction: Radial Tunnel Syndrome is characterised by pain over the anterolateral proximal forearm. It is thought to result from compression of the posterior interosseous nerve, and is estimated to be present in 5% of tennis elbow syndrome. This condition has been treated with surgical decompression with varying success. Other nerve compression syndromes are treated with steroid injections and these are reliable in giving relief, even if only temporary. Blind injections have been used as a diagnostic tool in Radial Tunnel Syndrome, but guided steroid injections have not yet been evaluated.

Methods: Patients attending one hospital over three years with unresolved lateral epicondylitis were clinically diagnosed with radial tunnel syndrome. They underwent injection of the radial tunnel guided by a nerve stimulator. The patients were evaluated prior to the injection with a brief pain inventory score produced by the British Pain Society. They were evaluated three months after the injection with a further brief pain inventory score. The scores were compared with Student’s t test.

Results: Ten patients were recruited over three years. The average pain score before and after injection was not significantly different ( P = 0.4386). An interference score reflecting impeding of function as a result of pain was also not significantly different ( P = 0.095).

Discussion: The results of guided injection are worse than a series of blind injections in the literature. We question why this has occurred when the opposite would have been expected. There are several possible explanations. There may have been a double hit phenomenon with the injection only affecting one of two pathological areas. The area of compression may be more proximal to the site of injection. The pathology of radial tunnel syndrome has not been definitively described and the pathology may not be one suitable for treatment with a steroid injection. Post mortem examination of the posterior interosseous nerve in patients with this syndrome may reveal the pathology of the syndrome.

Conclusion: Guided injections for radial tunnel syndrome are not effective. The pathology of this syndrome may be different to conventional nerve compression syndromes. We question indications for surgical decompression and suggest further work to investigate this syndrome.