Consensus on managing open ankle fractures in the frail patient.

Aims: Ankle fractures are common injuries and the third most common fragility fracture. In all, 40% of ankle fractures in the frail are open and represent a complex clinical scenario, with morbidity and mortality rates similar to hip fracture patients. They have a higher risk of complications, such as wound infections, malunion, hospital-acquired infections, pressure sores, veno-thromboembolic events, and significant sarcopaenia from prolonged bed rest. Methods: A modified Delphi method was used and a group of experts with a vested interest in best practice were invited from the British Foot and Ankle Society (BOFAS), British Orthopaedic Association (BOA), Orthopaedic Trauma Society (OTS), British Association of Plastic & Reconstructive Surgeons (BAPRAS), British Geriatric Society (BGS), and the British Limb Reconstruction Society (BLRS). Results: In the first stage, there were 36 respondents to the survey, with over 70% stating their unit treats more than 20 such cases per year. There was a 50:50 split regarding if the timing of surgery should be within 36 hours, as per the hip fracture guidelines, or 72 hours, as per the open fracture guidelines. Overall, 75% would attempt primary wound closure and 25% would utilize a local flap. There was no orthopaedic agreement on fixation, and 75% would permit weightbearing immediately. In the second stage, performed at the BLRS meeting, experts discussed the survey results and agreed upon a consensus for the management of open elderly ankle fractures. Conclusion: A mutually agreed consensus from the expert panel was reached to enable the best practice for the management of patients with frailty with an open ankle fracture: 1) all units managing lower limb fragility fractures should do so through a cohorted multidisciplinary pathway. This pathway should follow the standards laid down in the "care of the older or frail orthopaedic trauma patient" British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guideline. These patients have low bone density, and we should recommend full falls and bone health assessment; 2) all open lower limb fragility fractures should be treated in a single stage within 24 hours of injury if possible; 3) all patients with fragility fractures of the lower limb should be considered for mobilisation on the day following surgery; 4) all patients with lower limb open fragility fractures should be considered for tissue sparing, with judicious debridement as a default; 5) all patients with open lower limb fragility fractures should be managed by a consultant plastic surgeon with primary closure wherever possible; and 6) the method of fixation must allow for immediate unrestricted weightbearing.

Transfocal Osteotomy to Treat Shear (Oblique) Non-union of Tibia.

Aseptic non-unions of tibial shaft fractures often need surgical treatment which carry significant socio-economic implications. The causes for non-union include patient co-morbidities, high energy trauma, open fractures and fracture geometry. Oblique fractures are subject to shear forces and, if not adequately neutralised, will fail to unite. Experiments have shown that callus formation is poor in oblique fractures due to local shear stresses. We report a technique of minimally invasive transfocal transverse osteotomy and compression in a hexapod circular fixator, Taylor Spatial Frame (TSF) for 12 patients treated with a shear non-union of tibia between 2010 and 2019. There are four female and eight male patients. The average age is 49 years (range from 26 to 72 years). The fracture pattern was oblique (30-45°) in all cases. Healing of the non-union occurred in 12 cases with one case needed additional treatment with bone marrow aspirate and demineralized bone matrix. The technique of creating a minimally invasive transfocal transverse osteotomy through the oblique non-union of tibia and the use of a hexapod circular fixator to compress the osteotomy is described and adds to the range of treatments available for aseptic non-union of tibia. How to cite this article: Lahoti O, Abhishetty N, Al-Mukhtar M. Transfocal Osteotomy to Treat Shear (Oblique) Non-union of Tibia. Strategies Trauma Limb Reconstr 2022;17(2):117-122.

A Novel Surgical Technique for Extraction of a Firmly Integrated Broken Intramedullary Nail.

Aim: To present a novel technique developed in our institution to remove incarcerated and broken intramedullary (IM) tibial and femoral nails. Background: IM nails are commonly used to treat diaphyseal fractures in both the tibia and femur. These nails can become problematic for the orthopaedic surgeon when they need to be removed, especially in the rare event that the nail has failed and broken. This can leave part of the nail deep in the bone and incarcerated. Multiple techniques have been described to remove a broken nail but we present a novel technique developed based on our experience. Technique: After all other methods to remove the broken nail have failed, a window technique can be employed. This requires a small window of bone to be removed from the cortex overlying the remaining IM nail. A carbide drill is then used to drill a hole into the nail to gain purchase. The edge of an osteotome is placed in the hole in the nail through the window and gently hammered upwards to push the nail towards the over-reamed nail entry point. The nail is repeatedly drilled and pushed until the nail can be removed. The bone window is then replaced. Conclusion: This is a novel technique that works when all other options including hooks, wire stacks and specialist nail removal techniques have failed. It is simple, efficient and effective for both the tibial and femoral nails. How to cite this article: Somerville CMB, Hanschell H, Tofighi M, et al. A Novel Surgical Technique for Extraction of a Firmly Integrated Broken Intramedullary Nail. Strategies Trauma Limb Reconstr 2022;17(1):55-58.

Management of femoral neck fracture non union with modified Pauwels' osteotomy.

Modified Pauwels' intertrochanteric osteotomy is a promising procedure to heal a non union of the femoral neck fracture, with a success rate of 80-90%. Caxa vara correction and limb length equalization can be achieved simultaneously with this procedure. Two stage surgical procedure has the advantage of keeping blood loss and bone exposure to minimise the risk of infection. We herewith present some tips and tricks and the details of doing this osteotomy.

Osteotomies for lateral compartment knee osteoarthritis.

Lateral compartment osteoarthritis (LCOA) is often associated with valgus deformity of the knee. The concept of correcting the alignment by performing distal femoral varus osteotomy (DFVO) to unload the lateral compartment is well accepted and it is viewed as the preferred option for young active patients due to dissatisfaction from arthroplasty under 55 years of age or if they wish to remain active. Beyond this there is no consensus on patient selection, preoperative assessment, techniques to achieve correction, end point of correction, return to work or sports post-surgery, and survivorship of osteotomy with conversion to a total knee replacement as the end point due to heterogenous, retrospective studies. Here, we review relevant literature to help patient selection, preoperative work up, techniques, and outcomes.

Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7-14-year Follow-up.

Charcot arthropathy related foot and ankle deformities are a serious challenge. Surgical treatment of these deformities is now well established. Conventional surgical treatment includes extensive surgical exposure, excision of bone, acute correction and internal fixation, which is not always appropriate in presence of active ulceration, infection and poor bone quality. A minimally invasive approach to osteotomies and gradual correction of deformities using a circular frame are proving helpful in minimizing the complications. Taylor Spatial Frame (TSF) hexapod with its various modules is well suited for a range of foot and ankle deformities. We have advocated minimally invasive targeted hind and mid foot osteotomies and gradual correction with Taylor Spatial Frame (TSF) in 10 patients with recurrent ulceration and deformity. There are 2 female and 8 male patients in this cohort. Appropriate TSF module was chosen for each patient- a long bone module for ankle and hindfoot deformities (4 patients) and a forefoot 6x6 butt frame (6 patients) for foot deformities. An osteotomy through the midfoot was performed in all chronic stable foot deformity cases. In the ankle and hindfoot deformities, a combination of soft tissue distraction correction of equinus and acute correction of hindfoot deformity through a calcaneal osteotomy, were used. Our outcome measures are complete healing of the ulcers and resolution of infection, clinically plantigrade foot and ability to wear regular or diabetic footwear. Complications included eight episodes of pin infection that responded to oral antibiotics only and two pin breakages. We achieved ulcer and infection free plantigrade feet that fit in to regular or diabetic footwear in 9 out of 10 patients. 9 patients remain ulcer and infection free at a minimum of 7 years and maximum of 14 years follow up. Taylor Spatial Frame treatment provides an alternative to conventional surgery in high-risk complex Charcot neuroarthropathy foot and ankle deformities. How to cite this article: Lahoti O, Abhishetty N, Shetty S. Correction of Foot Deformities from Charcot Arthropathy with the Taylor Spatial Frame: A 7-14-year Follow-up. Strategies Trauma Limb Reconstr 2021;16(2):96-101.

Not Kidding! Sequalae of elbow trauma in children.

Elbow injuries are common in children and while majority heal very well, some result in deformities of the elbow. Although deformities such as cubitus varus and non-progressive cubitus valgus are considered cosmetic by the paediatric orthopaedic surgeons and intentionally ignored, they are not always benign and can result in functional deficit due to instability, pain, tardy nerve palsies and osteoarthritis later in life. Similarly congenital and developmental conditions that do not cause major functional loss in childhood, become very disabling in adults due to increasing functional demands. Congenital radial head dislocation and radioulnar synostosis fall into this category. In this paper we discuss clinical presentation, treatment options and outcomes of common elbow conditions presenting later in the life.

Capsulorrhaphy using suture anchors in open reduction of developmental dislocation of hip: technical note.

We describe a new technique of using titanium alloy anchors to perform internally rotating capsulorrhaphy during open reduction and stabilization procedure and obliteration of pseudoacetabulum when one exists. We routinely use anterior approach via bikini incision (modified Smith-Peterson approach) to perform open reduction and internally rotating capsulorrhaphy. We describe the technique of using barbed titanium alloy anchors preloaded with nonabsorbable sutures and two needles, to accomplish a secure and easy capsulorrhaphy, in selected cases. We have used this technique in 21 hips, since 2008. None of the hips redislocated and hip movements were symmetrical in most cases at 6 months after surgery. One anchor appeared 5 mm away from the pubic ramus on first radiograph at 6 months without any adverse effect on the outcome. It did not migrate any further on follow up radiographs. MRI scan of hip obtained for another purpose confirmed that it was not intra-articular. Capsulorrhaphy using barbed titanium anchors with nonabsorbable ethibond sutures is an effective, safe and technically easy alternative to standard capsulorrhaphy using needles and sutures in selected cases.

Management of Orthopaedic Injuries in Multiply Injured Child.

Multiply injured child is a unique challenge to the medical communities worldwide. It is a leading cause of preventable mortality and morbidity in children. Common skeletal injuries include closed or open fractures of tibia and femur and pelvic injuries. Initial management focuses on saving life and then saving limb as per pediatric advanced life support and advanced trauma life support. Orthopedic management of open fracture includes splinting the limb, administration of prophylactic antibiotic, and surgical debridement of the wound when safe. However, gross contamination, compartment syndrome, and vascular injuries demand urgent attention.

Intentional deformation and closure of soft tissue defect in open tibial fractures with a taylor spatial frame--a simple technique.

OBJECTIVES: We describe a way of using Taylor spatial frames (TSFs) for acute deformation of Gustilo IIIB tibial fractures and infected tibial nonunions to close the soft tissue defects and to gradually restore anatomical alignment. We use the Direct Scheduler Utility module of the web-based software for TSFs to successfully restore the anatomical alignment. DESIGN: We report a case series of the above technique. SETTING: Care was carried out at a tertiary referral center for limb reconstruction. PATIENTS: Seven consecutive patients with significant soft tissue loss after tibial fractures were treated. INTERVENTION: Defects were closed with acute deformation of the fracture followed by gradual correction to anatomical alignment with a 2-ring TSF. MAIN OUTCOME MEASUREMENT: Successful closure of the soft tissue defect was our primary outcome measure. RESULTS: Soft tissue defects ranged from 3 to 10 cm. All healed without additional plastic surgery to cover the exposed tibia. Only 1 patient required an additional TSF prescription to achieve anatomical alignment. CONCLUSIONS: The use of the Direct Scheduler module of the web-based TSF software allows the complete correction of complex deformities without the need for obtaining complex mounting and frame parameters. We achieved successful closure of soft tissue defects and restored the anatomical tibial alignment in all our cases.

Arthroscopically assisted percutaneous fixation of triplane fracture of the distal tibia.

Triplane ankle fractures typically occur in the adolescent age group. Although many are minimally displaced and can be managed nonoperatively, some are displaced and difficult to reduce by closed methods and need open reduction and internal fixation. Traditionally satisfactory articular reduction is achieved through an open approach, which can be extensive. We describe our experience of treating displaced triplane fractures in four patients, assisted by ankle arthroscopy to ensure anatomical reduction and minimal soft tissue disruption. We achieved excellent reduction and stable fixation in all four cases. All patients regained full range of movement within 6 weeks.

Localized pigmented villonodular synovitis: arthroscopic treatment of a lesion arising from the quadriceps tendon sheath.

Pigmented villonodular synovitis (PVNS) is a rare benign proliferative growth of synovium of obscure etiology with a wide spectrum of clinical presentation. Localized PVNS, also known as giant cell tumor of the tendon sheath, is even more uncommon. Localized PVNS of the knee is a rare, idiopathic condition presenting with symptoms that can mimic other intra-articular pathologies. The condition is usually monoarticular, the knee being the most commonly affected joint. We report a rare case of PVNS arising from the quadriceps tendon sheath. It was successfully treated with arthroscopic intralesional excision. At 18 months' follow-up, there has been no recurrence.

Distraction osteogenesis to improve limb function in congenital bilateral humeroradioulnar synostosis.

Congenital bilateral humeroradioulnar fusion of the elbow is rare. Many patients tolerate unilateral elbow stiffness very well, but bilateral fixed elbows are very disabling. We report the management of a 13-year-old patient using the Ilizarov technique. The left elbow was ankylosed in 70 degrees flexion. It was gradually lengthened through an osteotomy across the fused elbow and flexed through the regenerate to 110 degrees. This has improved the function of the left arm.

Ilizarov ring fixator for a difficult case of ankle syndesmosis disruption.

Syndesmotic stabilization is recommended for tibiofibular diastasis, a Maisonneuve fracture, or syndesmotic instability after fixation of distal tibia-fibula fractures. In the case presented, a syndesmotic stabilization was performed with a screw inserted 2 cm above the tibiotalar joint Subsequent failure occurred due to the weight of the patient and a lack of compliance with the necessary nonweight bearing protocol. The Ilizarov frame was used to reduce and maintain a stable syndesmosis with a simple two-ring construct which allowed the patient to bear weight on the injured limb while his syndesmosis healed. This is not recommend as a routine method of treatment, but is presented as an extended indication of the Ilizarov frame for difficult cases.