Do Patients Achieve "Full Weight-bearing" Immediately Following Application of Circular Frame Fixation of the Lower Limb?

Introduction: The decision to use circular frame fixation for lower limb trauma, or elective deformity correction, often accompanies the assertion that the patient will be able to fully weight-bear through the limb immediately following surgery. Materials and methods: About 53 patients underwent retrospective review. Included in the study were current attendees of adult specialist physiotherapy, following circular frame application to the lower leg at our Institution between August 2018 and January 2020. Cases with incomplete data, cases given postoperative status of non-weight-bearing, those with physiotherapy follow-up conducted elsewhere, or cases of polytrauma were excluded from the study.Weight-bearing assessment and rehabilitation supervision were at the discretion of the physiotherapy team. The clinical concept of 'full weight-bearing' is poorly defined, but was documented in the context of displaying a stable gait using elbow crutches and subsequently without walking aids. Comparative data was analysed using an unpaired, two-tailed Welch's t-test. Results: Mean postoperative time to full weight-bearing using crutches was 28.3 days (0-159) (n = 40).Mean postoperative time to independent full weight-bearing with no walking aids was 230.6 days (35-393), or 7.1 months (0-12) (n= 34).No significant differences were seen between:Frames for open injuries (n= 5) vs closed injuries (n = 17; p > 0.4).Joint-spanning constructs (n= 18) vs non-spanning constructs (n = 21; p > 0.6), orTreatment of intra-articular injuries (n = 14) vs extra-articular injuries (n = 17; p > 0.2).Interpretation of these results should be made with caution due to sample size. Conclusion: The ability to permit patients to fully weight-bear immediately after surgery is often a distinct advantage of the circular frame over other fixation modalities, for a variety of indications. However, it does not follow that patients are capable of doing so; there is a long dependency on walking aids. This would appear to be the case irrespective of open/closed injuries, intra-/extra-articular injuries, or the use of a spanning construct across the knee or ankle. How to cite this article: Craig A, Barron E, Sharma H, et al. Do Patients Achieve "Full Weight-bearing" Immediately Following Application of Circular Frame Fixation of the Lower Limb? Strategies Trauma Limb Reconstr 2024;19(1):40-44.

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.

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.

A multicentre, randomized, parallel group, superiority study to compare the clinical effectiveness and cost-effectiveness of external frame versus internal locking plate for complete articular pilon fracture fixation in adults.

AIMS: A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients' quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures. METHODS: A randomized controlled trial (RCT) of 334 adult patients diagnosed with a closed type C pilon fracture will be conducted. Internal locking plate fixation will be compared with external frame fixation. The primary outcome and endpoint will be the Disability Rating Index (a patient self-reported assessment of physical disability) at 12 months. This will also be measured at baseline, three, six, and 24 months after randomization. Secondary outcomes include the Olerud and Molander Ankle Score (OMAS), the five-level EuroQol five-dimenison score (EQ-5D-5L), complications (including bone healing), resource use, work impact, and patient treatment preference. The acceptability of the treatments and study design to patients and health care professionals will be explored through qualitative methods. DISCUSSION: The two treatments being compared are the most commonly used for this injury, however there is uncertainty over which is most clinically and cost-effective. The Articular Pilon Fracture (ACTIVE) Trial is a sufficiently powered and rigorously designed study to inform clinical decisions for the treatment of adults with this injury. Cite this article: Bone Jt Open 2021;2(3):150-163.

Use of Common Inflammatory Markers in the Long-Term Screening of Total Hip Arthroprosthesis Infections: Our Experience.

Orthopedic implants have become essential components of modern medicine. The risk of infection of total hip arthroplasty (THA) is 1.5%-2%. Are the C-reactive protein (CRP), the erythrocyte sedimentation rate (ESR), and procalcitonin (PCT) good markers for THA infection screenings? From February 2009 to December 2012 at our Department of Orthopedics and Traumatology, 1248 patients were treated with THA. No prosthesis was cemented. All patients received antibiotic prophylaxis. All patients were discharged approximately 7.4 days after surgery with this clinical and radiographic follow-up program at 15 days and 1, 3, 6, 12, 24, and 36 months after surgery. Blood samples to determine ESR, CRP, and PCT values were taken at 1 hour before surgery and 15 days and 1, 3, 6, 12, 24, and 36 months after surgery. During follow-ups there were 22 cases of THA infections; according the Widmer classification, infections are hematogenous ones in 16 cases, late chronic ones in 5 cases, and early postoperative ones in 1 case. In all cases the three markers were considered positive; in 6 cases there were no radiological signs of septic loosening. ESR, CRP, and PCT proved to have a greater diagnostic accuracy than X-rays in predicting late chronic and early postoperative infections. These markers are valuable support for the surgeon in monitoring the prosthetic implant lifespan.

Diets High in Fiber and Vegetable Protein Are Associated with Low Lumbar Bone Mineral Density in Young Athletes with Oligoamenorrhea.

BACKGROUND: Associations of bone mineral density (BMD) with specific food components, including dietary fiber and isoflavones (that have a negative association with serum estrogen), are unclear and need to be determined, particularly in populations more likely to consume large amounts of these nutrients (such as young athletes). OBJECTIVE: To determine dietary intake of specific food components in athletes with oligoamenorrhea (OA) compared to athletes with eumenorrhea (EA) and nonathletes (NA), and associations of the dietary intake of these nutrients with lumbar spine BMD. DESIGN AND SUBJECTS: This cross-sectional study evaluated 68 OA, 24 EA, and 26 NA individuals aged 14 to 23 years. Measurements included 4-day food records, a dual x-ray absorptiometry scan evaluating lumbar spine BMD and body composition, and hormone levels. Multivariate analysis was used to estimate associations of nutrients with lumbar spine BMD. RESULTS: Compared with EA and NA, OA had higher intake of fiber, phytic acid, and vegetable protein (all P values <0.0001). Intake of isoflavones, genistein, and daidzein was higher in OA than NA (P=0.003 and P=0.0002, respectively). OA had lower consumption of energy from saturated fatty acids than NA (P=0.002). After controlling for confounders such as body weight, menstrual status (indicative of estrogen status), calcium intake, and serum vitamin D (known BMD determinants), lumbar spine BMD z scores were inversely associated with dietary fiber (ß=-.30; P=0.01), vegetable protein (ß= -.28; P=0.02), phytic acid (ß=-.27; P=0.02), genistein (ß=-.25; P=0.01), and daidzein (ß=-.24; P=0.01), and positively associated with percent energy from fatty acids (ß=.32; P=0.0006). CONCLUSIONS: Compared with EA and NA, OA had a higher dietary intake of fiber, vegetable protein, and phytic acid, which were inversely associated with lumbar spine BMD z scores. Further studies are needed to assess dietary recommendations for OA to optimize bone accrual.

A fungal perspective on conservation biology.

Hitherto fungi have rarely been considered in conservation biology, but this is changing as the field moves from addressing single species issues to an integrative ecosystem-based approach. The current emphasis on biodiversity as a provider of ecosystem services throws the spotlight on the vast diversity of fungi, their crucial roles in terrestrial ecosystems, and the benefits of considering fungi in concert with animals and plants. We reviewed the role of fungi in ecosystems and composed an overview of the current state of conservation of fungi. There are 5 areas in which fungi can be readily integrated into conservation: as providers of habitats and processes important for other organisms; as indicators of desired or undesired trends in ecosystem functioning; as indicators of habitats of conservation value; as providers of powerful links between human societies and the natural world because of their value as food, medicine, and biotechnological tools; and as sources of novel tools and approaches for conservation of megadiverse organism groups. We hope conservation professionals will value the potential of fungi, engage mycologists in their work, and appreciate the crucial role of fungi in nature.

Functional outcomes after tibial shaft fractures treated using the Taylor spatial frame.

OBJECTIVES: To analyze functional and radiologic outcomes of tibial shaft fractures treated with the Taylor spatial frame (TSF). DESIGN: Prospective follow-up study of radiologic and functional outcomes. SETTING: University teaching hospital. PATIENTS: From January 2006 to December 2012, prospective data were collected for 56 consecutive patients completing treatment of a tibial shaft fracture with the TSF. INTERVENTION: Treatment of tibial shaft fractures, including those with simple extension into the knee or ankle joints, using the TSF. MAIN OUTCOME MEASUREMENTS: Residual deformity on x-ray and functional outcomes using the EQ-5D health status questionnaire, Iowa Knee and Ankle Evaluation Rating System scores, and Olerud and Molander Ankle score were recorded 1 year after frame removal. RESULTS: Average residual deformity was 1.8 degrees in the coronal and 1.6 degrees in the sagittal planes. EQ-5D outcomes showed patients returning to a health status no different from scores for the UK population as a whole. Iowa Knee scores demonstrated "good" or "excellent" outcomes in 87.3% of our cohort (mean, 90). Ankle Evaluation Rating System scores and Olerud and Molander Ankle scores showed "good" or "excellent" outcomes in 76.8% and 89.3% of our cohort, respectively (mean, 84.1 and 84). CONCLUSIONS: Use of the TSF for treatment of tibial fractures, with support from a dedicated limb reconstruction rehabilitation team, has a number of technical advantages while producing good functional and surgical outcomes, with patients recovering to a pre-injury health status. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Health literacy and the clozapine patient.

AIMS: To estimate the prevalence of limited health literacy in patients receiving clozapine for schizophrenia. To develop and produce a pharmacist-designed clozapine patient information leaflet (PIL) which has a higher readability score than the company-produced PIL. STUDY DESIGN: This was a cross sectional prevalence study. METHODS: Ethical approval for the study was granted by the local ethics committee. Patients, over 18 years, attending the Clozapine Clinic of a Cork urban teaching hospital, were asked to participate in the study. Demographics such as gender, age, employment and smoking status, were gathered from all participants. The total daily clozapine dose, duration of clozapine treatment, and information regarding the clozapine DVD was also noted. The Rapid Estimate of Adult Literacy in Medicine (REALM) health literacy (HL) screening tool was then administered to each patient. A user-friendly PIL on clozapine was designed by the pharmacist, which was assessed for readability and compared to the company-produced PIL using the FRES and FKGL. Data were analysed using SPSS Version 15. RESULTS: Forty patients (65% male, 95% unemployed and 70% smokers) of average age 38.0 years (+/- 11.2) completed the REALM. The average score was 60.6 (+/- 8.7). Twenty-nine patients (72.5%) were found to have "adequate" health literacy. The remaining eleven patients were found to have either "marginal" or "low" health literacy. The pharmacist-designed PIL would have been readable by 95% of the study population, in contrast to 72.5% with the company-designed PIL. CONCLUSIONS: More than a quarter of the population were found to have marginal or low health literacy. Patient information should be matched to the health literacy level of the target population.