One-stage combined "fix and flap" approach for complex open Gustilo-Anderson IIIB lower limbs fractures: a prospective review of 102 cases.

BACKGROUND: Management of open fractures is challenging and requires a multidisciplinary team approach. This study aims to evaluate outcomes of open Gustilo-Anderson IIIB fractures managed at a single Ortho-Plastic centre following One-stage "Fix and Flap" approach. METHODS: Prospective data review for patients presenting with Gustilo-Anderson IIIB Fractures to our centre and managed with one-stage "Fix and Flap" approach. Postoperative outcomes are presented only for the patients who had a minimum of 12 months postoperative follow-up. RESULTS: 120 patients were included (83 males and 37 females). Mean age was 43 years (10-96). Tibia diaphysis was the most common site of injury (60%). 55.9% of injuries were road traffic accidents (RTA). 102 out of 120 patients had a minimum of 12 months follow-up (mean follow-up duration 25 months). Meantime from injury until definitive surgery was 7.71 days. Primary union achieved in 86.73%. Delayed union was encountered in 10.20%. 3.06% of patients had non-union. Limb salvage rate was 97.05% and Deep infection rate was only 0.98%. CONCLUSION: Our results showed that low infection rate, high limb salvage rate, and high union rate can be achieved in these complex injuries with meticulous technique, combined Ortho-Plastic (Fix and Flap) approach, and MDT input.

Gastrocnemius Recession in Recalcitrant Plantar Fasciitis: A Systematic Review.

Plantar fasciitis is a common cause of heel pain. Recalcitrant plantar fasciitis can be difficult to manage. Medial gastrocnemius recession is increasingly being used to treat recalcitrant plantar fasciitis, with advocates describing fewer complications and quicker recovery time than other surgical options. This systematic review aimed to determine the effectiveness of gastrocnemius recession for the treatment of patients with recalcitrant plantar fasciitis. Multiple databases were searched using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The level of evidence of each study was assessed according to the American Academy of Orthopaedic Surgeons Levels of Evidence. The level of bias for each study was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools. Seven studies were retrieved: 3 retrospective case series, 1 retrospective study that compared gastrocnemius recession to open plantar fasciotomy, 1 prospective cohort study (pre-post study with no control group), and 2 randomized controlled trials. All 6 studies that assessed pre- and postoperative pain using the Visual Analogue Scale showed a large reduction in pain postoperatively. Four studies that assessed pain at 12 months postoperatively showed a weighted mean of 76.06 ± 10.65% reduction in pain. No major complications were reported. Minor complications included sural neuritis. This review found a consistent reduction in pain following gastrocnemius release in patients with recalcitrant plantar fasciitis, suggesting it is a very promising treatment. However, the included studies are limited by low quality study designs and inherent biases, limiting the strength of recommendation. Further definitive, well-designed trials are required.

Clinical and Radiological Outcomes of Gustilo-Anderson Type IIIB Open Fractures in 125 Patients.

INTRODUCTION: This study describes single-centre outcomes of Gustilo-Anderson type IIIB open fractures in relation to the current standards in the United Kingdom, which aim at performing skeletal fixation and soft tissue coverage at an early stage to salvage the limb and achieve bone union with a minimum infection rate. METHODS: A total of 125 patients with 134 Gustilo-Anderson type IIIB open fractures, who had definitive skeletal fixation with soft tissue coverage between June 2013 and October 2021, were prospectively followed up and included in this study. RESULTS: Initial debridement was performed within 12 hours from the time of injury for 62 (49.6%) patients and within 24 hours for 119 (95.2%) patients (mean= 12.4 hours). Definitive skeletal fixation and soft tissue coverage were achieved within 72 hours for 25 (20%) patients and within seven days for 71 (57%) patients (mean= 8.5 days). The mean follow-up duration was 43.3 (6-100) months, and the limb salvage rate was 97.1%. The occurrence of deep infections was associated with time from injury to initial debridement (p=0.049). Three patients (2.4%) developed deep (metalwork) infections, all three had their initial debridement performed within 12 hours from the time of injury. There was no association between time to definitive surgery and the development of deep infection (p=0.340). Bone union was achieved in 84.3% of patients following their primary surgery. Time to union was associated with fixation modality (p=0.002) and type of soft tissue coverage (p=0.028), and was negatively correlated with time to initial debridement (p=0.002, correlation coefficient -0.321). There was a 0.27-month decrease in time to union for every hour delay in time to debridement (p=0.021). CONCLUSION: Delaying initial debridement or definitive fixation and soft tissue coverage didn't increase the rate of deep (metalwork) infections. The time to achieve bone union was negatively correlated with the time from injury to initial debridement. We advise prioritising surgical technique and availability of expertise over strict adherence to time thresholds of surgeries.

Radiological Analysis of Gentamicin Eluting Synthetic Bone Graft Substitute Used in the Management of Patients With Traumatic Bone Voids.

Background Management of traumatic bone voids has always been challenging. Gentamicin eluting synthetic bone graft substitute (Cerament-G) showed encouraging results in achieving good bone healing with a satisfactory degree of resorption when utilised as a void filler. This study aims to assess the radiological signs of Cerament-G remodelling when used for patients with traumatic bone voids. Methods Retrospective data analysis of all patients admitted to our unit between 2015 and 2021 with traumatic bone voids who had Cerament-G applied intraoperatively as a void filler. Postoperative radiographic images of the fracture site at six weeks, three months, six months, and at the final follow-up were reviewed. The radiological signs of Cerament-G integration, percent of void healing at the final follow-up were assessed. Results A total of 51 patients (52 fractures) were included in the study. Among them 10 were female and 41 were male with a mean age of 42.7 (11 - 90) years. The mean void size was 6.58 cm3. Mean follow-up duration was 9.73 months. Primary fracture union was achieved in 44 (86.3%) patients. Delayed union was reported in six (11.7%) patients, while one (1.9%) patient had non-union. Twenty-seven (52%) patients had >90% of void healing with normal trabecular bone. Twenty (38.5%) patients had 50-90% void healing with normal bone. Whereas only five (9.5%) patients had less than 50% of void healing. Conclusion Cerament-G used as a void filler for patients with traumatic bone void has resulted 98% fracture union rate with good signs of radiological remodelling into a trabecular bone. More than 50% void filling with new trabecular bone was reported in more than 90% of patients. Non-union was reported in only one patient.

A systematic review of mechanical stabilization by screw fixation without bone grafting in the management of stable scaphoid non-union.

INTRODUCTION: Sixty percent of all carpal fractures affect the scaphoid bone, with an annual incidence of 4.3/10,000. Displacement and instability are the main risk factors for non-union, but missed diagnosis, location of fracture and poor blood supply are also risk factors. Non-union is defined as non-healed fracture on radiographs 6 months after the injury and this can lead to degenerative wrist arthritis. Treatment options vary from internal fixation with bone grafting to salvage procedures including arthrodesis of carpals. We aimed to determine the effectiveness of screw fixation without bone grafting for the treatment of stable well-aligned scaphoid non-union. METHODS: In this systematic review, MEDLINE, Science Direct, Web of Science and CINHAL were searched from inception to May 2019. All clinical studies that examined the functional and radiological outcomes of screw fixation without bone grafting to treat stable scaphoid non-union were included. RESULTS: 838 articles were retained of which 6 case series, describing 95 patients who had undergone scaphoid non-union fixation without bone grafting, were included. Favourable functional outcomes were reported by the 6 included studies using validated functional outcome measures ROM improved to weighted mean of 67.5° (±13°) and 62.12° (±13°) for flexion and extension respectively. The fracture had united in 91 out of 95 participants with a union rate of 95.7% (95%, CI 89.5 to 98.8) and the weighted mean time to union was 3.8 (±1.5) months. CONCLUSION: Rigid screw fixation without bone grafting can be suggested for the treatment of selected well aligned scaphoid nonunions to achieve healing and good functional outcomes. However, adequately powered clinical studies with good methodology are essential to draw an accurate conclusion.

Posterior stabilisation without formal debridement for the treatment of non-tuberculous pyogenic spinal infection in frail and debilitated population - A systematic review and meta-analysis.

Non-tuberculous pyogenic spinal infection (PSI) incorporates a variety of different clinical conditions. Surgical interventions may be necessary for severe cases where there is evidence of spinal instability or neurological compromise. The primary surgical procedure, for late-stage PSI, focuses on the anterior approach with aggressive debridement of the infected tissue regions. An alternative treatment method that employs a posterior approach without any formal debridement, is seen as controversial. To the best of our knowledge, few case series and no systematic reviews are assessing the value of this posterior technique. We aim to evaluate the effectiveness of the posterior approach without formal debridement and the associated clinical outcomes, for PSI cases requiring surgical intervention. Several databases including MEDLINE, NHS Evidence, and the Cochrane database were searched from the date of creation of each database to December 16, 2019. A selection of the keywords used includes: "posterior approach", "debridement" and "discitis". Studies were excluded if they involved the anterior approach, carried out formal debridement, or were tuberculous spinal infection cases. We accepted any study type which included adult patients, with spinal infection at any level of the vertebral column. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used to follow standard systematic review structure. The main clinical outcomes evaluated include pain, neurological recovery (Frankel Grading System, FGS) post-operative complications, and functional outcomes (Kirkaldy-Willis Criteria and Spine Tango Combined Outcome Measure Index, COMI). Post-surgical neurological improvement was demonstrated with a mean FGS improvement of 1.12 in 102 patients over the included four articles. Post-operative neurological function was found to be improved at a statistically significant level when a random-effects model was applied, with the effect size found to be at 0.68 (p < 0.001). Pain level was improved significantly postoperatively. There were also enhanced functional outcomes post-intervention when the Kirkaldy-Willis criteria and COMI scores were assessed in certain studies. Within the limit of the available literature, our results showed that the posterior approach with posterior stabilisation without formal debridement can result in successful infection resolution, improved pain scores and neurological outcomes. However, Larger series with longer follow-up duration is strongly recommended.

Determination of the postoperative limb alignment following a high tibial osteotomy in patients with uni-compartmental knee osteoarthritis, review article.

OBJECTIVES: High tibial osteotomy is an established surgical procedure for treatment of mal-aligned Varus knees due to medial compartment knee osteoarthritis. Aims are to evaluate whether post-operative axial alignment achieves good long-term results. METHODS AND RESULTS: Literature search done and studies with a follow up period of 2 or more years were included. The mean postoperative mechanical axis varied widely from 3 to 16° with significant differences between the studies. CONCLUSION: The results suggested that medial knee osteoarthritis can be treated successfully with HTO. The post-operative valgus angle should be between 3 and 13° of valgus to achieve good long-term results.

Shaped titanium wedges for subtalar distraction arthrodesis: Early clinical and radiological results.

BACKGROUND: Displaced intraarticular calcaneum fractures are associated with late symptomatic hind foot malalignment and painful arthrosis for which distraction subtalar fusion might be considered. During subtalar distraction arthrodesis, a structural graft is often used to fill gaps. Autograft, the current gold standard, is limited in availabilityand is associated with donor-site morbidity and collapse. Allografts have the risk of infectious disease transmission, rejection and failure to integrate. The clinical outcomes and midterm results of subtalar distraction arthrodesis with biofoamtitanium wedges are presented. METHODS: A review of 4 patients (3 male and 1 female) undergoing subtalar bone block distraction arthrodesis using biofoam titanium wedges is reported. Results were evaluated clinically and radiologically Mean time from trauma to surgery was 27.5 months and mean follow up was 12 months. RESULTS: The mean FAAM ADL score improved from 31.4% preoperatively to 74.2% postoperatively and mean AOFAS score improved from 23.4 preoperatively to 69.6 postoperatively.There was improvement in all radiographic parameters, with 44% improvement in calcaneal pitch, 23% improvement in talocalcaneal angle, 21% increase in talus-first metatarsal angle, and 13.5% correction of talocalcaneal height. VAS Pain scores wasimproved from a pre-operative mean of 8 to a post-operative mean of 2. Mean time to fusion was 13 weeks. Union was achieved in all cases. CONCLUSION: Our data suggest titanium wedges may be used as a structural graft option for subtalar bone block distraction arthrodesis. Fusion rates and time to incorporation are comparable to autogenous bone graft without the associated morbidity. Level IV Case Series.

Management of Displaced Intra-Articular Calcaneal Fractures: A Comparative Study of Open and Minimally Invasive Surgery.

Objectives The ideal treatment of displaced intra-articular calcaneal fractures continues to be a subject of debate. The aim of the study was to compare the radiological outcome, cumulative radiation exposure, surgical time, time to surgery, wound healing times and cost involved in minimally invasive surgery (MIS) and open reduction internal fixation (ORIF) for calcaneal fractures. Methods This was a retrospective study of 39 calcaneum operated in our unit during 2012 to 2019, of which 20 had undergone ORIF and 19 had been operated upon following MIS. Results A total of 39 calcanea (37 patients) were operated, of which 20 had open procedure and 19 had MIS procedure, including one bilateral surgery in each group. Mean age of the patients in the MIS group was 42.18 years (range: 15-68 years) and that of the patients in the open group was 43 years (range: 21-75 years). Of the fractures, 53.84% (n = 21) was Sanders type III, 28.20% (n = 11) was type II and 17.94% (n = 7) was type IV. There was no statistically significant difference in the mean correction of Bohler's angle and Gissane's angle between the groups. The mean cost for implant used for each open procedure was £882.79, and the implant cost for each MIS procedure was £142.89. Mean utilisation of cumulative X-ray dose was significantly higher in MIS (0.764 mGy) in comparison to open surgery (0.392 mGy). The average surgical time for MIS was 64.9 minutes and that of open surgery was 106.3 minutes. Average waiting time for MIS was 6.6 days and that for ORIF was 9.8 days. Wound healing was quicker (average 13.4 days) in MIS than ORIF (average 17.2 days). All these differences were statistically significant. Conclusions Minimally invasive calcaneal fracture surgery is quicker and cheaper and can be performed earlier. It is associated with early wound healing, although it requires higher cumulative radiation dose.

Joint sparing management of hallux rigidus: Cartiva SCI vs cheilectomy a comparative review.

BACKGROUND: Hallux rigidus, or first metatarsophalangeal joing arthritis, is a very common condition which causes pain and loss of motion in the joing which can be debilitating. METHODS: Patient reported outcome measures were utilised to study the difference in day to day functionality between two common surgical management options for hallux rigidus. RESULTS: 55 Cartiva and 23 Cheilectomy patients were included in this study. The Manchester Oxford Foot and Ankle Questionnaire revealed statistically significant improvements in the cheilectomy patients when compared to Cartiva SCI.Foot and Ankle Ability Measure found no statistical difference was found between the two surgical treatments. CONCLUSION: Cheilectomy offers good post-operative functional and sporting outcomes after surgery for the management of hallux rigidus at 5 years.

Sciatica Presentations and Predictors of Poor Outcomes Following Surgical Decompression of Herniated Lumbar Discs: A Review Article.

Pain associated with sciatica is one of the most common indications for surgery. The annual rate of discectomy has increased over recent years, with a significant number of patients reporting a poor outcome or symptom recurrence after surgery. This study aims to evaluate the predictors of poor outcome for patients undergoing lumbar discectomy for sciatica. A comprehensive search was conducted to find relevant literature published between 1985 and 2019. All literature with a clear methodology were included. Many factors that affect postoperative recovery after lumbar discectomy have been reported. Some evidence suggests that sociodemographic factors, including female gender, smoking, increased age, low socioeconomic status, and low education level may be associated with less favorable outcomes after surgery. Symptom duration does not appear to be associated with a significant difference in long-term outcomes; however, early surgery (within one year) may result in a faster postoperative recovery with better early results. Furthermore, patients who had discectomy for predominant leg pain had better outcomes compared to those who had the surgery for back pain as the main presentation. There was no evidence to suggest a correlation between the size of the herniated disc and long-term outcomes of sciatica; however, a higher anatomical level of herniation (L1-2, L2-3) was associated with poorer outcomes compared to the lower level of herniation (L3-4, L4-5). A few studies suggested slow postoperative recovery correlates with unemployment and depression. We recommend that the predictors of postoperative outcomes should be taken into consideration when selecting or counseling patients for lumbar disc decompression.

Cartiva case series: The efficacy of the cartiva synthetic cartilage implant interpositional arthroplasty at one year.

BACKGROUND: The Cartiva synthetic cartilage implant (SCI) is licenced for use in management of symptomatic hallux rigidus in several countries including the UK. As of now, there are no independent series for treatment of hallux rigidus utilising polyvinyl alcohol implants. METHODS: Patients at a single centre with symptomatic hallux rigidus who underwent Cartiva implant interpositional arthroplasty were identified. First metatarsophalangeal joint arthritis was radiographically graded according to the Hattrup and Johnson (HJ) classification. Pre-operative and post-operative patient-reported outcomes (PROMs) were evaluated using the Foot and Ankle Ability Measure (FAAM) activities of daily living subscale and the Manchester-Oxford Foot Questionnaire (MOXFQ). RESULTS: 55 patients (14M, 41F) (37R and 18L) were followed up for an average of 21 months (min = 12, max = 38). 14 patients suffered from HJ2/moderate arthritis and 41 patients with grade HJ3/severe arthritis.Post-operative mean FAAM scores showed statistically significant improvement (p < 0.0001). Patients reported a 40% increase in functionality during activities of daily living.All 3 MOXFQ Domain scores improved significantly (p < 0.02). The Index score improved by 34 points (p < 0.0001).There was no correlation between length of follow up or age and PROMs (r = 0.129). No statistical difference was demonstrated between sexes. Clinically, however, males and older patients exhibited better outcomes. CONCLUSIONS: Our study shows excellent results with statistically significant improvements in functional outcomes, and promising short-term follow-up with low early revision rates. Durability and survivability of the implant will continue to be studied in this cohort.

Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite in the management of open Gustilo Anderson IIIB fractures. Prospective Review of 80 Patients from the Manchester Ortho-Plastic Unit.

BACKGROUND: This study aims to evaluate outcomes of using Adjuvant Local Antibiotic Hydroxyapatite Bio-Composite in management of Open Gustilo-Anderson IIIB Fractures. METHODS AND RESULTS: 80 patients were managed with single-stage "Fix and Flap" along with intra-operative Adjuvant Local Antibiotic Bio-Composite. Successful fracture union was achieved in 96.1% of patients, with a limb salvage rate of 96.25%. Infection rate was only 1.25%. CONCLUSION: High union rate and very low deep infection rate can be predictably achieved in complex Open Gustilo-Anderson IIIB fractures by meticulous technique, use of local adjunctive antibiotics bio-composite and a combined ortho-plastic approach.

Local flaps vs. free flaps for complex lower limb fractures: Effect of flap choice on patient-reported outcomes.

The optimal flap cover for managing open lower limb fractures is debated. Most studies have reported on surgical outcome but clinical outcome is not well recognised. We aimed to determine whether there are differences in patient-reported quality of life (QoL) outcome between local flap versus free flap. All patients admitted with lower limb open fractures were retrospectively reviewed. Patient notes were assessed for demographics, time to fracture union, wound healing and patient-reported QoL with EQ-5D-5L alongside a novel flap assessment tool. A total of 40 patients had flap reconstruction of their lower limb injury; 23 local flap (Group I) and 17 free flap (Group II). Average length of follow-up was 33.8 months. Group I - 10 revisions of flaps (43.5%) and 14 surgical complications (60.9%). Fracture union was 171 days and wound healing 130 days. EQ-5D index and EQ-VAS scores were 0.709 and 79.3, respectively. Group II - 8 revision of flaps (47.1%) and 12 surgical complications (70.6%). Fracture union was 273 days and wound healing 213 days. EQ-5D index and EQ-VAS scores were 0.525 and 57.2, respectively. Aesthetic appeal - 48% Group I vs. 66% Group II. Significant differences were found between the two flap groups with higher scores for daily living in Group I (p = 0.007) compared to higher overall flap ratings in Group II (p = 0.049). Both groups were comparable in terms of complications; while flap congestion and dehiscence were more common with free flaps statistical interrogation did not elicit significance (p > 0.05). Local flap and free flap techniques offer distinct advantages. Local flaps have better surgical outcome and patient-reported QoL in the first few years post soft tissue reconstruction. Differences between local and free reconstructive techniques in terms of patient health and function are ameliorated in the longer term.

Treatment of fragility ankle fractures using hindfoot nail, systemic review.

With an aging population, the prevalence of fragility ankle fractures is rising. The surgical management of these injuries is challenging and associated with high rates of complications. An extensive literature review (inception of data until September 2019) was undertaken to locate previous studies that have addressed the same topic. Seven studies met the inclusion criteria. The post-operative Olerud and Molander scores were comparable/slightly lower than pre-injury scores. Bony union was achieved in 90.3%-100% of cases. Hindfoot nails, when used to treat fragility ankle fractures, can facilitate early rehabilitation and restoration of function among elderly osteoporotic patients.

An overview of carbapenemase producing enterobacteriaceae (CPE) in trauma and orthopaedics.

Carbapenemase resistant enterobacteriae (CPE) may be found in asymptomatic carriers. Its incidence is increasing worldwide. Surgical patients are at increased risk of immunocompromise and of carriage progressing to active infection. Active infection with CPE caries a high mortality rate, with the bacteria being resistant to many antibiotics. This article provides details on the epidemiology, screening and management of the orthopaedic patient with CPE. The guidelines advise orthopaedic staff on ways to avoid the spread of CPE amongst inpatients.

Management of Pyogenic Spinal Infection, review of literature.

OBJECTIVE: To evaluate the available evidence for the management of Pyogenic Spinal Infection (PSI). METHODS AND RESULTS: A comprehensive search for the relevant literature published between 1990 and 2018 to evaluate the management of PSI was conducted.Nonoperative management of carefully selected patients for an adequate duration of antibiotics can result in satisfactory outcomes with low recurrence rate. When there is an indication for surgery, posterior approach, with or without debridement of infected tissue reported to be associated with good outcomes. CONCLUSION: Studies with larger sample sizes and longer duration of follow up are recommended to formulate more comprehensive evidence.

Medium-term outcome of posterior surgery in the treatment of non-tuberculous bacterial spinal infection.

OBJECTIVE: to evaluate the outcome of posterior spinal stabilization surgery for the management of bacterial spinal infection. METHODS: 21 patients with bacterial infection were managed surgically with posterior stabilization. Outcome measures included neurological status. Follow-up data collected using Spine Tango COMI questionnaires and Euro Qol EQ-5D. RESULTS: The mean improvement in neurological deficits was 0.91 Frankel grade. Residual symptoms of pain had no or minor effect on the work or usual activities in 52% of subjects, with 88% reported having either no or mid problems with mobility. CONCLUSION: Posterior surgery can improve neurological outcome in approximately half of the patients.