Penthrox® (Methoxyflurane) as an Analgesic for Removal of Circular External Fixators and Minor Procedures during the COVID-19 Pandemic.

Introduction: Methoxyflurane has excellent analgesic properties and is approved for use in the United Kingdom and Ireland since 2015. It is currently used in emergency departments for analgesia during fracture reductions. During the COVID-19 pandemic, with theatre access severely restricted, Penthrox® had the potential to provide adequate pain relief to aid frame and wire removal in the clinic setting. Materials and methods: Patients presenting to the limb reconstruction service elective clinic and requiring frame removal or minor procedures were included in the study. Patients with renal, cardiac or hepatic disease, a history of sensitivity to fluorinated anaesthetic agents and those on any nephrotoxic or enzyme-inducing drugs were excluded. All procedures were performed in an appropriate isolated room in the clinic. Patient demographics, procedure details, visual analogue score, Richmond Agitation Scale and patient satisfaction were recorded. Results: A total of 39 patients were included in the study of which 17 had Ilizarov frames removed, 10 had hexapod removals, nine had heel rings removed and three had an external fixator removed. Eleven patients received additional pain relief in the form of oral analgesia. All patients were satisfied or very satisfied with the experience. One patient required a general anaesthetic for the removal of a wire that could not be removed in the clinic due to bony overgrowth. Conclusion: Patient satisfaction was very high (>95%), and it was possible to perform frame removals and minor procedures in the clinic environment during the COVID-19 pandemic. We see potential for regular use of Penthrox® in the future for the removal of external fixation outside of the operating theatre. Clinical significance: Penthrox as an analgesic for frame adjustments and removals is safe and has the potential for significant financial savings for the National Health Service (NHS). How to cite this article: Debuka E, Birkenhead P, Shah S, et al. Penthrox® (Methoxyflurane) as an Analgesic for Removal of Circular External Fixators and Minor Procedures during the COVID-19 Pandemic. Strategies Trauma Limb Reconstr 2023;18(2):82-86.

Circular External Fixator Removal in the Outpatient Clinic Using Regional Anaesthesia: A Pilot Study of a Novel Approach.

Introduction: External fixator (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under general anaesthesia in an operating theatre. This practice is resource-intensive and limits the amount of time available for other surgical cases in the operating theatre. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate the EF removal in an outpatient setting. Design and methods: This prospective case series evaluated the first 50 consecutive cases of EF removal in the outpatient clinic between 10/06/22 and 03/02/23. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirements and then were asked to evaluate their experience and perceived pain using the visual analogue scale (VAS). Results: Fifty patients were included in the study. The mean age was 46.8 years (range 21-85 years). About 54% of the patients were male patients (N = 27). Post-procedure, all patients indicated positive satisfaction ratings, each participant responded as either 'satisfied' (N = 6), 'very satisfied' (N = 24) or 'highly satisfied' (N = 20). In addition, 90% of the participants reported that they would opt for this method of EF removal again in future. The VAS for pain immediately following completion of the procedure was low, with a mean score of 0.36 (range 0-4), where a score of 0 = 'No pain', and 10 = 'worst pain possible'. The median score was 0. Conclusion: We present the first description of outpatient EF removal using regional anaesthesia, with a prospective case series of 50 fully conscious patients from whom the EF was removed. This novel technique is likely to be cost-effective, reproducible, and safe. This technique reduces the burden of EF removal from an operating list and also improves the patient's experience when compared with other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this technique also demonstrates a method of improving environmental sustainability. How to cite this article: Williams LM, Stamps G, Peak H, et al. Circular External Fixator Removal in the Outpatient Clinic Using Regional Anaesthesia: A Pilot Study of A Novel Approach. Strategies Trauma Limb Reconstr 2023;18(1):7-11.

Effectiveness of an Antibiotic-impregnated Bioabsorbable Carrier for the Treatment of Chronic Intramedullary and Diffuse Osteomyelitis.

Aim: The surgical management of chronic intramedullary osteomyelitis involves debridement of affected non-viable tissue and the use of antibiotics. Where surgery leaves a cavity, dead-space management is often through antibiotic-impregnated bone cement. These depots of local antibiotics are variable in elution properties and need removal. We review our unit's experience using a bioabsorbable synthetic calcium sulphate to deliver gentamicin as an adjunct in the treatment of osteomyelitis involving the medullary canal. Materials and methods: We retrospectively reviewed 34 patients with chronic osteomyelitis who were treated using this method in our institute. Variables recorded included aetiology, previous interventions, diagnostic criteria, radiological features, serology, and microbiology. The Cierny-Mader system was used to classify. Follow-up involved a survival analysis to time to recurrence, clinical and functional assessment (AOFAS-Ankle/IOWA knee/Oxford Hip/DASH scores) and a general health outcome questionnaire (SF36). The primary outcome measure was clinical recurrence of infection. Results: There were 24 male and 10 female patients. The mean age at presentation was 47 years (20-67). Clinical, laboratory, radiological, and patient reported outcomes were obtained at a median follow-up of 2.5 years (1.4-6.6 years). The bones involved were the femur (14, 41%), tibia (16, 47%), radius (1, 3%), and humerus (3, 9%). There were 13 cases classified as Cierny-Mader stage IV (diffuse with intramedullary osteomyelitis) and 21 cases as Cierny-Mader stage I. The median Oxford Hip score was 38 (11 patients, range 9-48). The median AOFAS score was 78 (14 patients, range 23-100). The median IOWA knee score was 71 (25 patients, range 22-95). The median DASH score was 33 (2 patients, range 1.7-64.2). There were two recurrences. The treatment success to date is 94%. Conclusion: In our series of patients, bioabsorbable carriers of antibiotics appear to be effective adjuncts to surgical treatment of osteomyelitis and were associated with high clinical success rates. How to cite this article: Selvaratnam V, Roche A, Narayan B, et al. Effectiveness of an Antibiotic-impregnated Bioabsorbable Carrier for the Treatment of Chronic Intramedullary and Diffuse Osteomyelitis. Strategies Trauma Limb Reconstr 2023;18(3):148-154.

Circular frames without x-ray - lessons learned regarding radiation exposure during tibial deformity correction from Low & Middle Income Countries?

Circular frames are a successful way of treating difficult fractures and non-unions. At our institution (CSC) in Phnom Penh, Cambodia, our method differs from developed healthcare systems in that we do not use x-ray to site the frames. A retrospective cohort study was performed between CSC and a UK LRS unit. Demographics, diagnosis, frame type, pre- and post-op deformity, proximal and distal construct alignment comparative to the tibia, and time to union or failure. 70 patients in total were identified and were randomly selected from a hospital in UK. Demographics & deformity were similar and failed to reach significant difference on testing: union rate 70% v. 82%, time to union 9.8 v. 8.5 months, and radiation exposure mean 0 v. 74 cGy/cm2 (range 6.4-326.7). These are startlingly homogenous results considering the differing resources available. We believe that ring fixators are a viable treatment method in austere environments where image intensifiers are unavailable, and demand no unnecessary radiation exposure.

Fine wire versus locking plate fixation of type C pilon fractures.

PURPOSE: The successful treatment of high energy pilon fractures (AO-OTA 43C) can be achieved with a fine wire circular external fixator (CEF) or locking plate construct (ORIF). There is no consensus on whether ORIF or CEF achieves superior outcomes, and both have unique complications. We report early to mid-term outcomes comparing type C pilon fractures treated with ORIF and CEF. METHODS: An 8-year retrospective review was performed on all patients who underwent ORIF or CEF for closed 43C fractures in a tertiary orthoplastic centre. Outcomes included unplanned return to theatre prior to union including superficial and deep surgical site infections (SSI), non-union and post-traumatic osteoarthritis (PTOA) needing fusion. RESULTS: 76 patients underwent ORIF and 59 patients had CEF, with a mean follow-up of 2 years. 7/76 (9.2%) patients who underwent ORIF had a superficial SSI; 2 patients (2.6%) required a formal debridement for deep SSI; none required a flap. 13/59 patients (22%) had a pin track infection following CEF. With the numbers available, there was no significant difference in rates of unplanned return to theatre before bone healing (ORIF 7/76, 9.2%, CEF 9/59, 15.2%, p = 0.7), rates of mal-union (1.7% CEF, 3.9% ORIF, p = 0.7), deep SSI (p = 0.9), time to union (ORIF: 8.1 months v CEF 10.8 months, p = 0.51), non-union (p = 0.24) and fusion for PTOA (ORIF: 6/76, CEF 2/59, p = 0.46). CONCLUSION: With correct patient selection, both ORIF and CEF offer equivalent and favourable early to mid-term outcomes with regard to deep SSI, non-union, mal-union and PTOA. Although statistically insignificant, ORIF with more than 2 plates carries a risk of superficial and deep SSI, whilst CEF is associated with a 22% pin track infection rate. These unique risks must be discussed with the patient as part of a shared decision-making process.

Current concepts in the prevention, diagnosis and treatment of fracture-related infection (FRI).

Fracture-related infection (FRI) is one of the most challenging complications following operative management of fractures. It can have profound implications for the patient, can be associated with considerable morbidity and often lead to impaired outcomes. There are significant healthcare-related costs. In recent years, there has been significant progress towards developing preventative strategies. Furthermore, diagnostic algorithms and management protocols have recently been reported. Lack of a strong evidence base has previously hindered efforts to implement these and develop established standards of care. There are multiple aspects of care that need to be considered and a multi-disciplinary approach is recommended. In this narrative review, we present the most up-to-date recommendations in the prevention, diagnosis and management of FRI.

Bifocal treatment for peri-articular femoral nonunions: A retrospective case series review.

AIM: This is a retrospective review of complex periarticular femoral nonunions where bone loss from comminution at original fracture, subsequent infection or lysis was identified and treated by radical excision, internal fixation, and concurrent femoral lengthening from a different level. MATERIAL AND METHOD: Sixteen patients with a mean age of 41 years were treated. There were 6 infected nonunions. Ten nonunions were located in the distal femur and the remaining proximal. Case notes and radiograph review were used to determine fracture union, lengthening achieved, and complications. Patient outcome was assessed using the SF-12, Tegner-Lysholm Knee Score, and Oxford Hip Score. RESULTS: Fracture union was achieved in all patients. The mean lengthening performed was 51 mm (range 30-80) with a fixator time averaging 39 weeks (range 17-80). The bone healing index was 1.9 months/cm. All but 2 patients were restored to within 5 mm of opposite leg length; 1 patient subsequently underwent contralateral limb shortening. The SF-12 had a mean Physical Health Composite Score of 40.0 (22.4-52.9) and a mean Mental Health Composite Score of 49 (30.7-62.0). The Oxford Hip Score was scored at a mean of 39 (21-47) and the Tegner-Lysholm score had a mean of 71 (36-94). There were 3 cases of fracture/deformity from the lengthened bone column (regenerate) and 2 patients required a quadricepsplasty for knee stiffness that was present prior to the treatment for the nonunion. CONCLUSION: Bifocal treatment of complex periarticular femoral nonunions offers a single solution for dealing with bone loss, nonunion, and instability. The method is safe and reliable but has, as with all methods involving distraction osteogenesis, a significant complication rate. Despite this caution, the patients' outcomes were satisfactory.

The history, evolution and basic science of osteotomy techniques.

Osteotomy techniques date back to Hippocrates circa 415 BC (Jones Hippocrates collected works I, Harvard University Press, Cambridge, 2006; Brorson in Clin Orthop Relat Res 467(7):1907-1914, 2009). There is debate about the best way to divide the bone surgically and which technique yields the best bone regenerate in lengthening; ensuring predictable new bone formation and healing of the osteotomy are the primary goals. We review the history and techniques of the osteotomy and consider the evidence for optimum bone formation. Methods discussed include variants of the 'drill and osteotome' technique, use of the Gigli saw and use of a power saw. Differences in bone formation through the different techniques are covered.

Is device-assisted reduction prior to semi-extended intramedullary nailing of distal tibial fractures necessary?

INTRODUCTION: Traditional methods of nailing distal tibial fractures have an unacceptable risk of mal-alignment due to difficulty in obtaining and maintaining reduction intra-operatively. Methods to obtain and maintain reduction when nailing these fractures, and therefore reducing the risk of Mal-alignment include modified external fixators, distractors and commercial reduction tools. Semi-extended intramedullary nailing of distal tibial fractures via a supra-patellar approach is now being used more commonly. The aim of this study was to assess whether a commercial reduction device (Staffordshire Orthopaedic Reduction Machine - STORM, Intelligent Orthopaedics, Stafffordshire, UK) is necessary to reduce the risk of mal-alignment in patients undergoing semi-extended nailing for distal tibial fractures. METHODOLOGY: A case-control study was conducted in 20 patients who had STORM-assisted reduction of distal tibial fractures prior to intramedullary nailing and 20 controls without STORM. The control group was matched for age, sex, fracture type (AO/OTA), ASA and gender. All patients had an intramedullary nail (IMN) using the semi-extended system. Primary outcome measures were coronal and sagittal mal-alignment. Secondary outcome measure was unplanned return to theatre for complications and problems with fracture healing. RESULTS: There was no difference in post-operative mal-alignment in both groups. There was no significant difference in time to union in both groups Both groups had equal number of patients requiring unplanned return to theatre. The STORM group was associated with a significantly increased operative time [p=0.007, 130.3min (SD 49.4) STORM vs 95.6 mins (SD 22.9) Control]. CONCLUSION: Intraoperative use of STORM significantly increases operative time with no difference in outcome. The superior orthogonal views and manual control obtained during semi-extended nailing via a supra-patellar approach obviate the need for additional methods: of intraoperative reduction for this fracture group.

Management of high-energy tibial pilon fractures.

Tibial pilon fractures result from high-energy trauma unlike usual ankle fractures. Their management provides numerous challenges to the orthopaedic surgeon including obtaining anatomic reduction of articular surface and the management of associated soft tissue injuries. This article aims to review major advances and principles that guide our practice today. We also discuss a treatment algorithm based on a staged approach to the fracture: initial spanning external fixation followed by definitive fixation.

An Unusual Ankle Injury: The Bosworth-Pilon Fracture.

The Bosworth injury occurs when the distal fibula becomes entrapped posterior to the posterior tibial tubercle, usually as a result of a supination external rotation injury. This uncommon occurrence is a recognized cause of an irreducible ankle dislocation. A pilon fracture is usually a high-energy injury caused by the talus being driven upward into the tibial plafond. The resulting bone and soft tissue injuries often require a staged approach to management. The present report is the first in the medical data to describe a Bosworth injury complicating a pilon fracture. We also discuss a management approach for this rare fracture.

Bicondylar tibial fractures: Internal or external fixation?

Bicondylar fractures of the tibia, representing the Schatzker V and VI fractures represent a challenging problem. Any treatment protocol should aim at restoring articular congruity and the metaphyseo-diaphsyeal dissociation (MDD)-both of these are equally important to long-term outcome. Both internal and external fixations have their proponents, and each method of treatment is associated with its unique features and complications. We review the initial and definitive management of these injuries, and the advantages and disadvantages of each method of definitive fixation. We suggest the use of a protocol for definitive management, using either internal or external fixation as deemed appropriate. This protocol is based on the fracture configuration, local soft tissue status and patient condition. In a nutshell, if the fracture pattern and soft tissue status are amenable plate fixation (single or double) is performed, otherwise limited open reduction and articular surface reconstruction with screws and circular frame is performed.

Treatment of nonunion and malunion of trauma of the foot and ankle using external fixation.

Salvage of nonunion and malunion of trauma of the foot and ankle is often challenging surgery. Internal fixation provides the mainstay of most orthopedic surgeons' treatment of these conditions. Patient systemic factors, local factors, and the complex nature of these often multiplanar deformities may make external fixation a more viable option. This article provides an overview of the principles and results of the use of external fixation.

Distraction osteogenesis and nonunion of the docking site: is there an ideal treatment option?

Docking sites are the result of a classic bone transport technique for dealing with bone loss. Union may prove to be the rate-limiting step in the duration of treatment. Strategies to improve union have focused on surgical manipulation such as immediate coaptation of the margins of the segmental defect in the process of acute shortening to prevent fibrocartilaginous capping of the ends of bone during transport. This procedure has the highest success rate for union but is limited by its effect on the limb's vascularity. Other techniques for improving union involve compression, alternate compression-distraction, and bone grafts, all of which induce union to a variable degree. The application of external stimulators and bone morphogenetic proteins, the use of which is supported in fracture healing and even regenerate formation, is as yet unproven at docking sites.

A comparison of the long-term morbidity following deep circumflex iliac and fibula free flaps for reconstruction following head and neck cancer.

Composite free tissue transfer has an established role in head and neck oncology for the reconstruction of the bony defect following tumor ablation, and while donor-site morbidity is variably reported, there is little consensus on the most favorable donor site. The fibula and deep circumflex iliac artery have distinct advantages in terms of the volume and length of bone in mandibular reconstruction. Few studies have compared their donor-site morbidity. The aim of this study was to compare the fibula and deep circumflex iliac artery flaps using a review of the case notes and cross-sectional review of patients attending a research clinic for validated orthopedic examination and completion of health-related quality-of-life questionnaires. Between February of 1993 and May of 2001, 44 fibula free flaps and 73 deep circumflex iliac artery free flaps were performed. Ninety-nine case notes and 36 patients were available for review of donor-site morbidity. Sixteen patients with fibula flaps and 20 patients with deep circumflex iliac artery flaps took part in the clinical examination component of the study, which was composed of a clinical examination by an orthopedic surgeon using the American Orthopedic Foot and Ankle Society ankle scoring system and the Harris hip scoring system, and two patient-completed questionnaires, the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. Subjective and objective markers of morbidity related to both flaps were similar in most parameters. However, fibula flaps were associated with more problems with donor-site healing, reduced power, and sensation. Poor orthopedic scores for both flaps were associated with notably poor scores on the University of Washington Questionnaire and the Hospital Anxiety and Depression Scale. The study would suggest that both deep circumflex iliac artery and fibula donor sites result in an acceptable and comparable morbidity for most patients, but in cases in which significant donor-site morbidity is encountered, health-related quality of life is significantly compromised.