Low-intensity pulsed ultrasound does not influence bone healing by distraction osteogenesis: a multicentre double-blind randomised control trial.

AIMS: The aim of this double-blind prospective randomised controlled trial was to assess whether low intensity pulsed ultrasound (LIPUS) accelerated or enhanced the rate of bone healing in adult patients undergoing distraction osteogenesis. PATIENTS AND METHODS: A total of 62 adult patients undergoing limb lengthening or bone transport by distraction osteogenesis were randomised to treatment with either an active (n = 32) or a placebo (n = 30) ultrasound device. A standardised corticotomy was performed in the proximal tibial metaphysis and a circular Ilizarov frame was used in all patients. The rate of distraction was also standardised. The primary outcome measure was the time to removal of the frame after adjusting for the length of distraction in days/cm for both the per protocol (PP) and the intention-to-treat (ITT) groups. The assessor was blinded to the form of treatment. A secondary outcome was to identify covariates affecting the time to removal of the frame. RESULTS: There was no difference in the time to removal of the frame between the PP (difference in favour of the control group was 10.1 days/cm, 95% confidence interval (CI) -3.2 to 23.4, p = 0.054) or ITT (difference 5.0 days/cm, 95% CI -8.2 to 18.21, p = 0.226) groups. The smoking status was the only covariate which increased the time to removal of the frame (hazard ratio 0.47, 95% CI 0.22 to 0.97, p = 0.042). CONCLUSION: LIPUS does not influence the rate of bone healing in patients who undergo distraction osteogenesis. Smoking may influence bone healing. Cite this article: Bone Joint J 2017;99-B:494-502.

Sensorimotor dysfunction after limb fracture - An exploratory study.

BACKGROUND: Chronic pain is often associated with sensorimotor dysfunction but little is known about the early impact of limb fracture on sensory and motor performance. This exploratory study sought to assess these changes in patients with recent wrist and ankle fractures. A secondary aim was to determine the incidence of Complex Regional Pain Syndrome (CRPS) and its clinical features. METHODS: Fifty-three patients at a UK fracture centre underwent Quantitative Sensory Testing (QST), Motor Imagery (MI) and Body Perception Disturbance (BPD) assessments ≤5 weeks post-fracture (Time 1). Subjective evaluation of recovery and clinical examination for CRPS was conducted 5 weeks later (Time 2, 50 patients). Patient-reported outcomes of pain, psychological distress and limb function were collected at Times 1 and 2, and 6 months after T1 (Time 3, 36 patients, postal questionnaire). RESULTS: Quantitative sensory testing at Time 1 demonstrated cold and pressure-pain hyperalgesia in the fractured limb compared to the non-fractured side (p < 0.05). Imagined movements were reported as significantly more difficult to perform on the fractured side (p < 0.001). There was evidence of BPD in the fractured limb, similar to that found in CRPS. The incidence of CRPS was 9.4%; however, individual signs and symptoms of the condition were commonly present (70% reported ≥ one symptom). Only 33% of patients reported to being 'back to normal' 6 months after fracture with 34% reporting ongoing pain. CONCLUSIONS: Limb fracture is associated with changes in pain perceptions, motor planning, and disruption to body perception. Signs and symptoms of CRPS, ongoing pain and delayed recovery post-fracture are common. WHAT DOES THIS STUDY ADD?: In the immediate post-fracture period: Body perception disturbance is reported in the fractured limb. Imagined movements of the fractured limb are less vivid and associated with pain This study contributes to the incidence literature on CRPS.

NICE work.

This editorial examines the influence of the National Institute for Clinical Excellence (NICE) on the conduct of orthopaedic surgery. It proffers criticism and suggests ways of improvement.

Anatomy of pilon fractures of the distal tibia.

In a series of 126 consecutive pilon fractures, we have described anatomically explicable fragments. Fracture lines describing these fragments have revealed ten types of pilon fracture which belong to two families, sagittal and coronal. The type of fracture is dictated by the energy of injury, the direction of the force of injury and the age of the patient.

Track of a fiber fuse: a Rayleigh instability in optical waveguides.

The phenomenon colloquially known as a fiber fuse occurs when an optical fiber carrying high power is damaged or in some way abused. Beginning at the damage site a brilliant, highly visible plasmalike disturbance propagates back toward the optical source at speeds ranging from 0.3 to approximately 3 m/s, leaving in its wake a trail of bubbles and voids. We suggest that the bubble tracks in fused fibers are the result of a classic Rayleigh instability that is due to capillary effects in the molten silica that surrounds the vaporized fiber core. We report measurements of the bubble distribution and the collapse time that are consistent with this contention.

Intravenous regional guanethidine blockade in the treatment of post-traumatic complex regional pain syndrome type 1 (algodystrophy) of the hand.

A total of 57 patients, aged between 23 and 86 years, with complex regional pain syndrome (CRPS) type 1 nine weeks after an isolated closed fracture of the distal radius, was randomised to receive either serial intravenous regional blockade (IVRB) with 15 mg of guanethidine in 30 ml of 0.5% prilocaine or serial IVRB with 30 ml of normal saline at weekly intervals until the tenderness in their fingers had resolved or they had received a maximum of four IVRBs. The analgesic efficacy was assessed at 24 hours, 48 hours and one week after each procedure by the dolorimetry ratio and verbal pain scores, and at intervals up to six months after the fracture. There was no significant difference in the number of IVRBs administered or in finger tenderness, stiffness or grip strength between the two groups. The guanethidine group experienced more pain in the affected hand (p = 0.025) and at six months had more vasomotor instability (p < 0.0001) compared with the control group. IVRB using guanethidine offers no significant analgesic advantage over a normal saline placebo block in the treatment of early CRPS type 1 of the hand after fracture of the distal radius. It does not improve the outcome of this condition and may delay the resolution of vasomotor instability when compared with the placebo.

Ultraviolet photosensitive response in an antimony-doped optical fiber.

A silica optical fiber doped with Sb is fabricated with a refractive-index profile that is comparable with standard single-mode fiber. In D(2)-loaded samples, we observe UV photosensitivity with an initial refractive-index-modulation growth rate six times higher than that of the equivalent Ge-doped standard fibers. Enhanced temperature stability of the Bragg grating strength up to 200 degrees C is also observed. Grating growth kinetics in the Sb-doped fiber is compared with those of other Ge-doped photosensitive fibers.

Fractures of the tuberosity of the calcaneus.

We describe 24 fractures of the tuberosity of the calcaneus in 22 patients. Three were similar to the type of avulsion fracture which has been well-defined but the remainder represent a group which has been unrecognised previously. Using CT and operative findings we have defined the different patterns of fracture of the calcaneal tuberosity. Ten fractures extended into the subtalar joint, but did not fit the pattern of the common intra-articular fracture as described classically. We have defined a new pattern which consists of a fracture of the medial calcaneal process with a further fracture which separates the upper part of the tuberosity in the semicoronal plane. Non-operative treatment of displaced fractures resulted in a mis-shapen heel and a poor functional outcome. Open reduction and internal fixation with either a plate or compression screw did not give satisfactory fixation. We prefer to use an oblique lateral tension-band wire. This technique gave excellent fixation and we recommend it for the treatment of displaced fractures of the tuberosity of the calcaneus.

Ipsilateral vascularised fibular transport for massive defects of the tibia.

The ipsilateral and contralateral fibulae have been used as a vascularised bone graft for loss of tibial bone usually by methods which have involved specialised microvascular techniques to preserve or re-establish the blood supply. We have developed a method of tibialisation of the fibula using the Ilizarov fixator system, ipsilateral vascularised fibular transport (IVFT), and have used it in five patients with massive loss of tibial bone after treatment of an open fracture, infected nonunion or chronic osteomyelitis. All had successful transport, proximal and distal union, and hypertrophy of the graft without fracture. One developed a squamous-cell carcinoma which ultimately required amputation of the limb. The advantage of IVFT is that the fibular segment retains its vascularity without the need for microvascular dissection or anastomoses. Superiosteal formation of new bone occurs if the tibial periosteal bed is retained. Other procedures such as corticotomy and lengthening can be carried out concurrently.

Use of modified Ilizarov olive wires as pushing wires.

We describe a technique for the use of modified Ilizarov olive wires to stabilize bone fragments or segments or to act as a "motor" to move individual bone fragments. This technique was used in twelve patients with severe articular or comminuted open fractures referred to the unit for reconstruction with the Ilizarov frame. Six patients had comminuted plafond fractures of the tibia, and three had tibial plateau fractures. In these cases the articular fragments were reduced and stabilized until union. The modified pushing olive wire is a valuable adjunct to the Ilizarov frame.

End caps for the intramedullary nail: a help or a hindrance?

End caps on intramedullary nails are intended to facilitate removal and to allow length adjustment of the nail in situ. A case is reported in which the end cap made nail removal technically more difficult.

The yielding of tensioned fine wires in the Ilizarov frame.

The Ilizarov frame uses tensioned fine wires to support bone fragments. The objective of this study was to determine whether these wires deformed plastically under functional load bearing and to determine the significance of such deformation on the long-term performance of frames used for treating lower limb conditions. The mechanical characteristics of the wires were determined by means of destructive tensile tests and used in the construction of a series of finite element models replicating typical frame configurations. Each model was then subjected to a single load cycle representing a single step and the residual displacement (i.e. plastic deformation) was determined. In each case a residual displacement of between 0.26 and 0.42 mm was observed giving a corresponding reduction in wire tension of between 8.3 and 32.8 per cent. These reductions in wire tension reduce the frame's overall stiffness and so compromise its ability to inhibit high-amplitude axial and shear motions at the fracture site which are deleterious to the healing outcome.

The extended lateral approach to the hindfoot. Anatomical basis and surgical implications.

We have recently described an extended lateral approach to the hindfoot for the operative treatment of displaced intra-articular fractures of the calcaneum. It has the advantage of avoiding damage to the sural nerve and preserving blood supply to allow prompt healing. We dissected 15 formalin-preserved cadavers, taking photographs to show the structures of the posterolateral aspect of the hindfoot and ankle. We describe a superficial and a deep triangle: the deep triangle contains a constant posterior peroneal artery which supplies the skin of the posterolateral heel. An approach designed to expose the sural nerve will divide this important artery and cause ischaemia of the posterior skin. The extended lateral approach elevates the sural nerve in a thick flap and preserves the blood supply of the skin. We have reviewed 150 consecutive patients after the use of this approach to study the indications for operation, the quality of wound healing, any damage to the sural nerve and other complications. We recommend the careful use of this approach. Our understanding of its anatomical basis has allowed us to widen the indications for its use.

Distraction osteogenesis through high energy fractures.

We present a series of three patients with segmental, high energy open tibial fractures with bone loss (2-7 cm), where we have used distraction through a fracture site to replace lost bone. The open fracture was treated by debridement and shortening to eliminate the bone and soft tissue defect. Limb length was restored by distraction instituted through the closed segmental fracture. The length of regenerate formed at the fracture site ranged from 10 to 30 mm. In each case, bone formation at the distracted fracture site was satisfactory and times for regenerate consolidation were similar to those seen in standard corticotomies. These findings suggest that new bone will form in distraction reliably from high-energy fracture sites.

Tumors around implants.

In 1989, A. G. Apley recommended cautious surveillance of malignant tumors that developed in association with orthopaedic implants. This retrospective review of the Bristol Bone Tumour Register between 1980 and 1992 reports on 240 malignant soft tissue sarcomas. Eighteen developed in the thigh region of patients more than 50 years old, and 4 of these developed in the soft tissues around a hip arthroplasty.

Properties of tissue from around cemented joint implants with erosive and/or linear osteolysis.

Levels of bone remodeling agents were measured in conditioned media from cultures of periprosthetic pseudosynovial membranes and related to the radiographic features of the failed joint implants. Radiographs of both cemented hip (n = 28) and cemented knee (n = 11) implants were examined and the pattern of radiolucency was classified as erosive linear, or mixed. Similar levels of interleukin-1-beta (IL-1 beta), interleukin-6, tumor necrosis factor alpha (TNF-alpha), transforming growth factor beta-1, and prostaglandin E2 (PGE2) were found in pseudosynovial membrane conditioned media from all 3 groups of hips and the knee group (all linear). Significant correlations were evident only between PGE2 and TNF-alpha levels in the linear hip group and PGE2 and IL-1 beta levels in the knee group. A close correlation was found between IL-1 beta and TNF-alpha in both linear and erosive hips. It is suggested that coregulation of these bone remodeling agents differs with the radiographic appearance of the failed joint implants. As all the implants were cemented and the results contrast with those of others obtained with pseudosynovial membrane conditioned media from cementless implants, it is considered that cement critically influences the process of implant failure.

Bone-membrane interface in aseptic loosening of total joint arthroplasties.

In 19 patients who underwent revision arthroplasty for aseptic loosening of total joint arthroplasty, specimens were taken at the time of operation to include the bone-membrane interface. In 16 (84%) of the specimens, sufficient visualization of the interface was possible to allow histologic interpretation. In 13 of these cases, there was prominent evidence of classic bone remodeling with osteoclast-mediated resorption and active new bone formation. These results suggest that the osteolysis in aseptic loosening is mediated through osteoclastic bone resorption and that the bone found in such areas is extremely active. The findings help to explain the efficacy of impacted morselized bone-graft in the treatment of bone lysis in aseptic loosening.