Compensatory mechanisms for proximal & distal joint alignment & gait in varus knee osteoarthritis treated with high tibial osteotomy: A systematic review.

Background: Varus deformity is common in medial compartment knee osteoarthritis (OA). This coronal plane malalignment is compensated for by static and dynamic adjustments in the position of the adjacent joints, principally in the hindfoot & ankle. Varus knee OA can be treated in selected patients with high tibial osteotomy (HTO) and stabilised with a fixed angle plate or circular frame, which may reverse these compensatory adjustments. The aim of this systematic review is to determine the evidence available for static and dynamic compensations with the main objectives being to improve deformity planning and optimise patient outcomes. Method: A systematic review with meta-analysis was designed using the PRISMA template to meet the research aims & objectives. Results: A total of 1006 patients (1020 knees) with acombined mean age of 54.5 years, female:male ratio of 0.9:1 were extracted from 19 included studies. The methodologies of the majority of studies were at high risk of bias according to the Newcastle-Ottawa Scale demonstrating significant heterogeneity. The combined mean change in the HKA axis was 7.7°; MPTA 7.4°; TT, 0.21°; TI 4.56° & AJLO 4° valgus. Preoperative hindfoot valgus compensation reverts towards neutral post-HTO. There is limited evidence available for a direct relationship between static alignment and dynamic gait parameters. Conclusions: An inverse relationship between ankle and hindfoot alignment in varus deformity of the knee forms the basis of this compensation theory. In cases with a stiff hindfoot which may not revert postoperatively, the reconstructive orthopaedic surgeon may consider angulation with translation HTO, in order to optimise joint alignment and minimise transference of symptoms to the foot and ankle.

Circular external fixation for revision of failed tibia internal fixation.

BACKGROUND: The management of failed tibial fracture fixation remains a challenge for orthopaedic surgeons. This study investigate the utility and outcomes of circular external fixation in the management of failed internal fixation of tibial fractures. METHODS: Retrospective review of a prospectively collected database of a complex limb reconstruction unit at a major trauma centre was done during December 2022. Patients with failed internal fixation of tibial fracture who underwent revision surgery with circular external fixation frame were included. RESULTS: 20 patients with a mean age of 47.8 ± 16.5 years (range: 15-69) were included. Fourteen (70.0%) patients had failed plate and screws fixations, and the remaining six (30.0%) failed intramedullary nail fixation. The most common indication for revision surgery was development of early postoperative surgical site infection (5 patients; 25.0%). The mean duration of frame treatment was 199.5 ± 80.1 days (range = 49-364), while the mean follow-up duration following frame removal was 3.2 ± 1.8 years (range = 2-8). The overall union rate in this series was 100%; and all infected cases had complete resolution from infection. The total number of complications was 11, however, only two complications required surgical intervention. The most common complications reported were pin site infection (6; 30.0%) and limb length discrepancy of 2 cm (2; 10.0%). CONCLUSIONS: Circular external fixation is a reliable surgical option in the treatment of failed internal fixation of tibia fractures. This technique can provide limb salvage in complex infected and noninfected cases with a high union rate and minimal major complications.

Surgical debridement in long bone chronic osteomyelitis: is wide tumour-like resection necessary?

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. Methods: We analyzed the retrospective record review from 2014 to 2020 of patients with long bone COM. All were managed by multidisciplinary infection team (MDT) protocol. Adequate debridement was employed for all cases, and no case of wide resection was included. Results: A total of 53 patients (54 bones) with median age of 45.5 years (interquartile range 31 to 55) and mean follow-up of 29 months (12 to 59) were included. In all, ten bones were Cierny-Mader type I, 39 were type III, and five were type IV. All patients were treated with single-staged management, except for one (planned two-stage stabilization). Positive microbial cultures grew in 75%. Overall, 46 cases (85%) had resolution of COM after index procedure, and 49 (90.7%) had resolution on last follow-up. Four patients (7%) underwent second surgical procedure and six patients (11%) had complications. Conclusion: We challenge the need for wide tumour-like resection in all cases of COM. Through detailed preoperative evaluation and planning with MDT approach, adequate debridement and local delivery of high concentration of antibiotic appears to provide comparable outcomes versus radical debridement.

Complex Ankle Fusion With Circular Frames: Factors Influencing Outcomes, Complications, and Patient Satisfaction.

BACKGROUND: Circular frames for ankle fusion are reserved for complex clinical scenarios. The literature is heterogenous and conflicting. We aim to present the indications and outcomes of this procedure. METHODS: A retrospective cohort study based on a prospective database of frame surgeries performed in a tertiary institution. Inclusion criteria were patients undergoing complex ankle fusion with circular frames between 2005 and 2020, with a minimum 12-month follow-up. Data were collected on patient demographics, surgical indications, comorbidities, surgical procedures, external fixator time (EFT), length of stay (LOS), radiologic and clinical outcomes, and adverse events. Factors influencing radiologic and clinical outcomes were analyzed. RESULTS: 47 patients were included, with a median follow-up of 30 months (interquartile range [IQR] 20-40). The median age at time of surgery was 63.5 years (IQR 58-71). Patients had a median of 2 previous surgeries (IQR 1-3). The median LOS was 8.5 days, and median EFT was 237 days (IQR 166-280). Simultaneous limb lengthening (median 3.3 cm, IQR 1.9-3.5) was performed in 11 patients, increasing the EFT by a mean of 4 months. Primary and final union rates were 91.5% and 95.7%, respectively. At last follow-up, ASAMI bone scores were excellent or good in 87.2%. ASAMI functional scores were good in 79.1%. Patient satisfaction was 83.7%. In addition, 97.7% of patients experienced adverse events, most commonly pin-site related, with major complications in 30.2% and reoperations in 60.5%. There were 3 amputations. Adverse events were associated with increased age, poor soft tissue condition, severe deformities, subtalar fusions, peripheral neuropathy, peripheral vascular disease, and prolonged EFT. CONCLUSION: Complex ankle fusion using circular frames can achieve good outcomes, however time in frame may be prolonged with a high rate of adverse events. Identified risk factors for poorer outcomes should be considered in patient counselling and prognostication. LEVEL OF EVIDENCE: Level III, prognostic.

Circular external fixation for knee fusion in complex indications.

PURPOSE: Reconstructive surgery for complex knee problems is limited and challenging. The aim of this study is to report the technique, outcomes and complications of circular external fixation for knee fusion in complex indications. METHODS: Retrospective review of a prospectively collected database of a complex limb reconstruction unit was done during December 2022. Patients with complex knee problems who underwent knee fusion with circular external fixator were included. RESULTS: Fourteen patients met the inclusion criteria. The mean age of the patients was 63 ± 16.8 years. Deep infection was the indication for surgery in 11 patients (78.5%), of which 10 cases were related to previously failed revision arthroplasty. The mean duration of treatment in frame was 13 ± 4.1 months, while the mean follow-up duration following frame removal was 7.1 ± 4.2 years. Fusion was achieved in 13 patients (92.9%). The most common complication was pin site infection (6; 42.9%), of which three (21.4%) required pin/wire revision. One (7.1%) patient had fracture at the fusion site following frame removal that was treated with reapplication of the frame. CONCLUSION: Knee fusion using circular external fixation is a reliable surgical option for complex knee problems especially in infected failed revision total knee replacements.

A comparative evaluation of the time to frame removal for tibia fractures treated with hexapod and Ilizarov circular frames.

INTRODUCTION: Traditional Ilizarov and hexapod frames have different biomechanical properties and there is limited literature regarding their effect on time to fracture union or time to frame removal. METHODS: Tibial fractures managed with a circular frame at a tertiary limb reconstruction referral centre between 2011 and 2018 were retrospectively identified from a prospectively maintained database. They were classified into three treatment groups; Ilizarov style, Taylor Spatial Frame (TSF) and TrueLok Hex (TL-Hex). Data were extracted from electronic patient records and digital radiographs. The primary outcome was time to frame removal, which was seen as an indicator of clinical and radiological fracture union. Odds ratios were calculated with the clinical significance set at 30 days. RESULTS: 274 patients (median age 49 years, 36% female) were included in the analysis. 8.4% Ilizarov, 10.5% TSF and 13.5% TL-Hex frames required further surgery to aid fracture healing (p = 0.38). 30% of patients had open fractures. Median time to removal for Ilizarov, TSF & TL Hex frames was 167, 198 and 185 days respectively. There was a significant difference between Ilizarov and hexapod frames. Both TSF (OR 2.2, p<0.003) and TL-Hex (OR 1.8, p<0.04) had a significantly increased time to removal of 30 days or more compared with Ilizarov frames.The time to frame removal in metaphyseal fractures was significantly shorter for Ilizarov frame fixation than hexapod frames (p = 0.04). Open fractures were significantly more likely to require at least 30 days extra time to removal than closed fractures (OR 3.3, p<0.001). There was no significant difference in the time to frame removal between fracture location, age or sex. CONCLUSION: Ilizarov frames have demonstrated a reduced time to frame removal in the management of tibial fractures than hexapod frames. Differences in the time to frame removal, an indicator of time to fracture union, may be due to the different mechanical properties of the frame, or early disruption of the fracture haematoma through secondary frame manipulation and fracture reduction, increased proportion of metaphyseal fractures treated with Ilizarov, or patient selection. The healing time was comparable across the tibia. Pooled meta-analyses may be able to further quantify these associations.

The Incidence of Deep Infection Following Lower Leg Circular Frame Fixation with Minimum of 1-year Follow-up from Frame Removal.

Aim: Superficial pin site infection is a common problem associated with external fixation, which has been extensively reported. However, the incidence and risk factors with regard to deep infection are 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. Materials and methods: This study is retrospective review of all patients who underwent frame surgery between April 1, 2015 and April 1, 2019 in our unit with a minimum of 1 year follow-up following frame removal. We recorded patient demographics, patient risk factors, trauma or elective procedure, number of days the frame was in situ, location of infection and fracture pattern. Results: Three-hundred and four patients were identified. Twenty-seven patients were excluded as they were lost to follow-up or had their primary frame surgery as a treatment for infection. This provided us with 277 patients for analysis. The mean age was 47 years (range: 9-89 years), the male to female ratio was 1.5:1, and 80% were trauma frames. Thirteen patients (4.69%) developed deep infection, and all occurred in trauma patients. Of the 13 patients who developed deep infection, 4 had infection before frame removal, and infection occurred in 9 after frame removal. Deep infections occurred in 8 patients within a year of frame removal and in one patient between 1 and 2 years of frame removal.Within the 13 frame procedures for trauma, 12 were periarticular multi-fragmentary fractures, 3 of which were open, and the remaining were an open diaphyseal fracture. The periarticular fractures were more likely to develop deep infection than diaphyseal fractures (p = 0.033). Twelve patients (out of 13) also had concurrent minimally invasive internal fixation with screws in very close proximity of the wires. Conclusion: The rate of deep infection following circular frame surgery appears to be low. Pooled, multi-centre data would be required to analyse risk factors; however, multi-fragmentary, periarticular fracture and the requirement for additional internal fixation appear to be an associated factor. How to cite this article: Ting J, Moulder E, Muir R, et al. The Incidence of Deep Infection Following Lower Leg Circular Frame Fixation with Minimum of 1-year Follow-up from Frame Removal. Strategies Trauma Limb Reconstr 2022;17(2):88-91.

Is a staged reloading protocol effective to time the removal of circular frames? : a retrospective analysis.

AIMS: The timing of when to remove a circular frame is crucial; early removal results in refracture or deformity, while late removal increases the patient morbidity and delay in return to work. This study was designed to assess the effectiveness of a staged reloading protocol. We report the incidence of mechanical failure following both single-stage and two stage reloading protocols and analyze the associated risk factors. METHODS: We identified consecutive patients from our departmental database. Both trauma and elective cases were included, of all ages, frame types, and pathologies who underwent circular frame treatment. Our protocol is either a single-stage or two-stage process implemented by defunctioning the frame, in order to progressively increase the weightbearing load through the bone, and promote full loading prior to frame removal. Before progression, through the process we monitor patients for any increase in pain and assess radiographs for deformity or refracture. RESULTS: There were 244 frames (230 patients) included in the analyses, of which 90 were Ilizarov type frames and 154 were hexapods. There were 149 frames which underwent single-stage reloading and 95 frames which underwent a two-stage reloading protocol. Mechanical failure occurred after frame removal in 13 frames (5%), which suffered refracture. There were no cases of change in alignment. There was no difference between refracture patients who underwent single-stage or two-stage reloading protocols (p = 0.772). In all, 14 patients had failure prevented through identification with the reloading protocol. CONCLUSION: Our reloading protocol is a simple and effective way to confirm the timing of frame removal and minimize the rate of mechanical failure. Similar failure rates occurred between patients undergoing single-stage and two-stage reloading protocols. If the surgeon is confident with clinical and radiological assessment, it may be possible to progress directly to stage two and decrease frame time and patient morbidity. Cite this article: Bone Jt Open 2022;3(5):359-366.

Fine Wire Circular Fixation for Displaced Intra-Articular Calcaneal Fractures: A Systematic Review.

Intra-articular calcaneal fractures represent an ongoing challenge for the orthopedic community, with the benefits of the previous "gold standard" treatment of open reduction and internal fixation having been called into question in several large randomized controlled trials. Fine wire circular fixation may represent a useful alternative treatment for these injuries, combining minimally invasive application with rigid fixation, which allows the possibility of early weight bearing We performed a systematic review of published studies that used circular fixation for calcaneal fractures and recorded functional outcomes at follow-up. In a total of 11 studies with 255 calcaneal fractures for which there was follow-up, our inclusion criteria were met: 8.2% of fractures were bilateral, 11.9% of fractures were open fractures, and 12.6% of patients had multiple orthopedic injuries. Functional outcomes were assessed with the use of a variety of tools across the different studies, but outcomes compared favorably with those seen with open reduction and internal fixation. Although pin site infections were common (22.6%), serious complications, including deep infection (0.8%), wound infection (1.6%), and complex regional pain syndrome (0.8%), were exceedingly rare. The results suggest that this is a viable alternative treatment for calcaneal fractures, but higher-quality randomized controlled trials are required before the technique can enter mainstream use.