A major trauma centre experience with gentamicin-coated tibial intramedullary nails (ETN PROtect™) in acute primary open fracture fixation and complex revision surgery.

PURPOSE: Fracture-related infections (FRI) following intramedullary nailing for tibial shaft fractures remain challenging to treat with associated high patient morbidity and health care costs. Recently, antibiotic-coated nails have been introduced as a strategy to reduce implant related infection rates in high-risk patients. We present the largest single-centre case series on ETN PROtect® outcomes reporting on fracture union, infection rates and treatment complications. METHODS: Fifty-six adult patients underwent surgery with ETN PROtect® between 01/09/17 and 31/12/20. Indications consisted of acute open fractures and complex revision cases (previous FRI, non-union surgery and re-fracture) with a mean of three prior surgical interventions. We report on patient demographics, union rates and deep infection. Minimum follow-up was one year. RESULTS: One (1.8%) patient developed a deep surgical infection and associated non-union requiring further surgery. In addition, we identified three cases (5.4%) of aseptic non-union following facture treatment with ETN PROtect®. Of the five patients who underwent staged complex revision surgery for established FRI with ETN PROtect®, all had treatment failure with ongoing symptoms of deep infection requiring implant removal and further treatment. CONCLUSION: Use of the ETN PROtect® nail in high-risk patients (open fractures and those initially treated with external fixation) and in those patients with aseptic non-unions, demonstrates promising outcomes in the prevention of implant-related infection. In our limited series we have failed to observe any benefit over uncoated nails, when used in treating cases of previously established FRI/osteomyelitis and would therefore advise caution in their use, especially in view of the high cost.

Pediatric Lower Limb Lengthening Using the PRECICE Nail: Our Experience With 50 Cases.

BACKGROUND: Limb lengthening using intramedullary externally controlled motorized devices is becoming increasingly popular. There is limited literature regarding their use in the pediatric and adolescent population. This study reviews outcomes on 50 consecutive cases of intramedullary lower limb lengthening surgery in this population. METHODS: A retrospective review of all pediatric and adolescent patients treated in our institution by intramedullary lengthening for lower limb length discrepancy using the PRECICE and STRYDE intramedullary lengthening nails between 2013 and 2019. All patients were operated by a single surgeon. Data were prospectively recorded. We report on nail accuracy and reliability, consolidation index, time to full weight-bearing from completion of lengthening, joint range of movement, ASAMI bone and functional scores, presence of problems, obstacles and complications, and patient reported outcome measures (PROMS). RESULTS: Fifty cases (43 femoral and 7 tibial nails) were performed in 42 patients (20 males, 48% and 22 females, 52%). Six patients had bilateral lengthening and 2 patients had sequential lengthening. There were 28 antegrade femoral, 13 retrograde femoral and 5 tibia PRECICE nails, 2 tibial and 2 femoral PRECICE STRYDE nails. Mean age at surgery was 15 years old (12 to 17). Mean preoperative length discrepancy was 49 mm (20 to 90). Mean achieved lengthening was 46.5 mm (20 to 80). Mean percentage lengthening was 12.6% (5% to 25%). Nail accuracy was 96% and reliability 90%. Average distraction rate was 0.92 mm/d for femur and 0.64 mm/d for tibias. Consolidation index was 28 d/cm (18 to 43) and 39 d/cm (20 to 47), respectively. Time from completion of lengthening to independent full weight-bearing as observed in clinic was 45 days (21 to 70) and 34.2 days (23 to 50), respectively. ASAMI bone and functional scores were favorable and PROMS demonstrated high patient satisfaction levels. No significant complications were observed. CONCLUSIONS: We have demonstrated excellent clinical results and high patient satisfaction with intramedullary lengthening in a pediatric/adolescent population. We highly recommend thorough preoperative preparation, patient education, and a multidisciplinary approach. LEVEL OF EVIDENCE: Level IV.

Reducing the Risk of Ring Breakage in Taylor Spatial Frames: The Effect of Frame Configuration on Strain at the Half-ring Junction.

AIM: We have encountered four cases with Taylor spatial frames (TSF) (Smith & Nephew, Memphis, TN, USA) with breakage at the half-ring junction of the distal ring. This study examines the strain produced on different locations of the distal ring during loading and the effects on the strain of altering the frame construct. MATERIALS AND METHODS: We mounted two ring TSF constructs on tibia saw bone models. The proximal ring was the same in all constructs and consisted of a 2/3 180 mm ring attached with three wires. Construct 1 is reproducing the configuration of cases where failure was seen. The distal 155 mm ring is attached with three half pins. The half-ring junction is located in the midline. Construct 2 has a different half pin placement and an additional wire on the distal ring. Constructs 3 and 4 have the same half pin configuration to construct 1 but the distal ring is rotated 60° internally and externally, respectively. Strain gauges were attached to different locations and measurements recorded during loading. Statistical analysis was performed. RESULTS: Highest strain values were recorded at the half-ring junction of constructs 1 and 2 (>600 microstrains (µÎµ) in tension). Rotating the ring 60° internally significantly reduces the strain at the half-ring junction (<300 µÎµ) whilst external rotation by 60° further reduces the strain (<180 µÎµ). Ring strain is higher in areas close to half pin attachments. CONCLUSION: The highest strain is in the half-ring junction as the half rings are subjected to different loading modes. The thickness of the half-ring is halved and the second moment of area reduced further increasing breakage risk. Placing this junction close to the half pin-frame interface, as dictated by the anatomical safe zone further increases the strain. Rotating the distal ring 60° significantly reduces the strain at the half-ring junction. CLINICAL SIGNIFICANCE: Ring breakage is a rare but significant complication. This is the first study to address this potential mode of TSF failure. Insights and technical tips from this study can help reduce this. HOW TO CITE THIS ARTICLE: Iliadis AD, Bebja R, Wang K, et al. Reducing the Risk of Ring Breakage in Taylor Spatial Frames: The Effect of Frame Configuration on Strain at the Half-ring Junction. Strategies Trauma Limb Reconstr 2020;15(3):146-150.

Thromboprophylaxis in Intramedullary Limb Lengthening Surgery.

AIM: The use of intramedullary lengthening devices is becoming increasingly popular. There are limited data regarding the incidence of venous thromboembolism following intramedullary lengthening surgery and no reports or guidance for current practice on use of thromboprophylaxis. Following a case of post-operative deep vein thrombosis in our institution, we felt that it is important to assess best practice. We conducted a national survey to collect data that would describe current practice and help develop consensus for treatment. MATERIALS AND METHODS: We identified surgeons across the UK that perform adult intramedullary limb lengthening through the British Limb Reconstruction Society membership and a Precise Users database. Surgeons were contacted and asked to respond to an online survey. Responses to thromboprophylaxis regimes employed in their practice and cases of venous thromboembolism were collated. RESULTS: 24 out of 54 surgeons identified responded with a total of 454 cases of adult intramedullary lengthening (352 femoral and 102 tibial nails) performed over a five year period (January 2015-January 2020). Only one case of deep venous thrombosis (DVT) following femoral lengthening was reported. There is wide variability in practice both in terms of thromboprophylaxis risk assessment, choice of medications and duration of treatment. The vast majority of surgeons (85%) felt that there was insufficient evidence available to guide their practice. CONCLUSIONS: Intramedullary lengthening is a surgical treatment growing in popularity. There are limited data available to guide decision-making regarding aspects of treatment such as thromboprophylaxis. This is reflected in the wide variation in practice reported in this study. There are both a need and a desire to gather data that will allow us to come to a consensus and to guide safe practice. CLINICAL SIGNIFICANCE: Venous thromboembolism is a potential complication of lower limb lengthening surgery. We report on national incidence and current practices of thromboprophylaxis to allow for informed decision-making and help develop consensus for best practice. HOW TO CITE THIS ARTICLE: Iliadis AD, Timms A, Fugazzotto S, et al. Thromboprophylaxis in Intramedullary Limb Lengthening Surgery. Strategies Trauma Limb Reconstr 2020;15(3):151-156.

Paediatric bone and joint infection.

Despite advances in understanding and management, paediatric osteoarticular infections continue to pose diagnostic difficulties for clinicians. Delays in diagnosis can lead to potentially devastating morbidity.No single investigation, including joint aspiration, is sufficiently reliable to diagnose conclusively paediatric bone and joint infection. Diagnosis should be based on a combination of clinical signs, imaging and laboratory investigations. Algorithms should supplement, and not replace, clinical decision making in all cases.The roles of aspiration, arthrotomy and arthroscopy in the treatment of septic arthritis are not clearly defined. There is a very limited role for surgery in the management of acute haematogenous osteomyelitis.The ideal duration and mode of administration of antibiotic therapy for osteoarticular paediatric infection is not yet fully defined but there is increasing evidence that shorter courses (three weeks) and early conversion (day four) to oral administration is safe and effective in appropriate cases. Clear and concise antibiotic guidelines should be available based on local population characteristics, pathogens and their sensitivities.Kingella kingae is increasingly identified through polymerase chain reaction and is now recognised as the commonest pathogen in children aged under four years. Methicillin-resistant Staphylococcus aureus and Panton-Valentine leukocidin-producing strains of Staph. aureus are being increasingly reported.A multidisciplinary integrated evidence-based approach is required to optimise outcomes.Further large-scale, multicentre studies are needed to delineate the optimal management of paediatric osteoarticular infection. Cite this article: EFORT Open Rev 2017;1:7-12. DOI: 10.1302/2058-5241.2.160027.