IntroductionAdjusting an external fixator can be a daunting process for patients. Despite comprehensive training, patients often request supervision for the initial adjustments which may result in a prolonged hospital stay. Following the introduction of telemedicine during the pandemic we believed that this could be utilised to support patients with their fixator adjustments. A quality improvement project was implemented to assess and evaluate a change in practice from existing Face to Face support to a telemedicine format. The aim of the project was to reduce median length of stay (LOS).Materials & MethodsThe telemedicine platform was introduced in our unit from April 2021 with the change in practice. Using the life QI platform, run charts were used to record the numbers of patients whose LOS was 4 days or less. Median LOS was assessed prior to and following introduction of the telemedicine platform. Service user experience with telemedicine as well as overall training and education by the CNS team was sought through on-line questionnaires.ResultsBaseline data collected from April 2019 to April 2021 showed that our median LOS for patients undergoing external fixation was 6 days with 36% of patients being discharged at day 4 or earlier. After implementation of telemedicine, median LOS reduced to 4 days with 50% of patients leaving hospital in 4 days or less. Service user responses demonstrated that 100% felt that sufficient information was provided by the CNS team, a mean score of 8.4/10 was reported when asked how confident they were when adjusting the fixator. When asked how the service could be improved access to a recorded video was suggested.ConclusionsInitial fixator adjustment support via telemedicine is not appropriate for all of our patient group due to a lack of access or co-morbidities/ social issues that necessitate a prolonged hospital stay. However, this project has demonstrated that it has had positive long-term benefits within our service through reducing our median length of stay by 2 days without compromising patient satisfaction with their care.

Introduction The use of intramedullary lengthening devices is becoming increasingly popular. There are no published data regarding the incidence of venous thromboembolism following intramedullary l...

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 loan 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.

Aims The Precice intramedullary limb-lengthening system has demonstrated significant benefits over external fixation lengthening methods, leading to a paradigm shift in limb lengthening. This study compares outcomes following antegrade and retrograde femoral lengthening in both adolescent and adult patients. Patients and Methods A retrospective review of prospectively collected data was undertaken of a consecutive series of 107 femoral lengthening operations in 92 patients. In total, 73 antegrade nails and 34 retrograde nails were inserted. Outcome was assessed by the regenerate healing index (HI), hip and knee range of movement (ROM), and the presence of any complications. Results The mean lengthening was 4.65 cm (1.5 to 8) in the antegrade group and 4.64 cm (1.6 to 8) in the retrograde group. Of the 107 lengthenings, 100 had sufficient datapoints to calculate the mean HI. This was 31.6 days/cm (15 to 108). There was a trend toward a lower (better) HI with an antegrade nail and better outcomes in adolescent patients, but these were not statistically significant. Hip and knee ROM was maintained and/or improved following commencement of femoral lengthening in 44 patients (60%) of antegrade nails and 13 patients (38%) of retrograde nails. In female patients, loss of movement occurred both earlier and following less total length achieved. Minor implant complications included locking bolt migration and in one patient deformity of the nail, but no implant failed to lengthen and there were no deep infections. Three patients had delayed union, five patients required surgical intervention for joint contracture. Conclusion This study confirms excellent results in femoral lengthening with antegrade and retrograde Precice nails. There is a trend for better healing and less restriction in hip and knee movement following antegrade nails. There are clinical scenarios, that mandate the use of a retrograde nail. However, when these are not present, we recommend the use of antegrade nailing.

We present the results of a new non-invasive lengthening nail enabling accurate control of the lengthening process and joint rehabilitation.IntroductionThe use of intramedullary lengthening nails have gained popularity as they reduce common complications associated with external fixators, including infection, joint stiffness, bone regenerate deformity, late fracture and patient implant acceptance. Current nails however are associated with complications including implant breakage, mechanical failure, runaway nail and requiring MUA to restart or obtain segment lengthening. The Precice nail incorporates magnet technology with a hand held device allowing non-invasive lengthening. The nail is also reversible allowing shortening if required. Physiotherapy can continue throughout treatment to maintain joint range of motion without concern of uncontrolled nail runaway. The lengthening is axial reducing shear/torsional forces on the regenerate.MethodThe lengthening of 4 femora was undertaken in 3 patients, mean ag...

Introduction Muscle stiffness and joint contractures are common complications of limb lengthening. Authors have demonstrated less permanent soft tissue complications with intramedullary lengthening than external fixation. Our aim was to evaluate the joint response following intramedullary femoral lengthening and need for physiotherapy and alteration to rate/rhythm of lengthening. Method A retrospective review of documentation for all femoral Precice nails in our centre inserted between 2012 and 2017. This involved 98 nails (68 antegrade, 30 retrograde) in 88 patients (59 males, 29 females) with a mean age of 32 years (range 12–69 yrs). We excluded cases where there was no documentation regarding Range of Movement (ROM). Bilateral lengthenings were recorded as separate cases. This left 50 antegrade, 16 retrograde cases with hip ROM data and 55 antegrade, 26 retrograde cases with Knee ROM data. Results Hip In the antegrade group 20 cases (39%) developed no stiffness throughout treatment. ROM decreased in 61...

Pin site care in external fixation remains a major challenge. The ideal dressing regime still remains controversial as does the type of dressing. We present an audit following the use of a sponge compression dressing in comparison to previously used sterile gauze.All pins and wires were inserted using a standardised technique. Dressings were applied during surgery to prevent haematoma formation.The new sponge dressing was applied to the wire or half-pin sites and compressed to the skin by either pierced tubing over the wire or clips at the end of the procedure. Dressings were changed weekly unless the pin sites were discharging serous fluid or frankly infected, when they were changed as required.The pin sites were evaluated for evidence of infection or irritation using the good, bad or ugly grading system. Each evaluation was performed by two of the authors on two separate occasions to assess the inter- and intra-observer error. The results were compared to those previously reported using sterile gauze as...

Several low-energy osteotomy techniques are described in the literature, but there is limited evidence comparing them. Our study evaluates the patterns of regenerate formation using two different osteotomy techniques. Two cohorts of patients underwent osteotomy of the tibia using a Gigli saw (n = 15) or De Bastiani corticotomy (n = 12) technique. The patient radiographs were assessed by the two senior authors who were blinded to the osteotomy type. Regenerate quality was assessed along the anterior, posterior, medial and lateral cortices, graded 1-5 from absent to full consolidation over time. The time to 3 cortices healed/regenerate length was calculated. The time to consolidation of the anterior, posterior, medial and lateral cortices was compared. The mean 3 cortices index in the Gigli group was 2.0 months/cm and in the De Bastiani group 1.8 months/cm. This was not a significant difference. In both groups, anterior bone formation was slower, and anterior cortical deficiency with a scalloped appearance was seen in 25 % of cases overall with no statistically significant difference between the two groups. Both Gigli saw and De Bastiani corticotomy techniques result in good bone formation following distraction osteogenesis. The anterior tibial cortex consolidates more slowly than the other cortices in both groups. This is likely due to deficient soft tissue cover and direct periosteal damage at time of osteotomy.

Several low energy osteotomy techniques are described in the literature but there is limited evidence comparing healing indices. We present a retrospective review of two techniques to evaluate an optimum method. Method: Two cohorts of patients underwent osteotomy of the tibia using a Gigli saw (n=15) or DeBastiani corticotomy (n=12) technique. Indications for surgery included limb lengthening and bone transport for defect reconstruction with a minimal distraction of 2 cm. The patient radiographs were anonymised and the regenerate assessed by the two senior authors who were blinded to the osteotomy type. Bone quality was recorded along the anterior, posterior, medial and lateral cortices, graded 1–5 from absent to full consolidation over time in frame. The time to 3 cortices healed/regenerate length was calculated. The time to consolidation of the anterior, posterior, medial and lateral cortices were compared. Results: The mean 3 cortices index in the Gigli group was 2.0 months/cm and in the DeBastiani group 1.8 months/cm, This was not a significant difference. In both groups anterior bone formation was slower, and in 50% and 33% of the Gigli and DeBastiani groups respectively the anterior cortex did not fully heal by the time of frame removal. Discussion: Both Gigli saw and DeBastiani corticotomy techniques result in good bone formation following distraction osteogenesis. The anterior tibial cortex consolidates more slowly than the other cortices in both groups. This is likely due to deficient soft tissue cover and direct periosteal damage at time of osteotomy.

Background:The Exogen Ultrasound Device is licensed for fracture non-union under NICE guideline MTG-12. Reimbursement is offered if there is no fracture union after 250 days of treatment as per man...

Attempts have been made to refine techniques involved in distraction osteogenesis to improve patient compliance and reduce complications. The prolonged use of external fixators for limb lengthening is associated with a number of problems, and in addition patient satisfaction with a cumbersome external fixator may be low. To reduce the complication rate and facilitate early removal of the external fixator by protecting the regenerate bone, lengthening over an intramedullary nail is being increasingly described. These techniques have limitations when used in skeletally immature patients and carry a risk of deep intramedullary infection. Posttraumatic limb length discrepancy is not uncommon after high-energy injuries are fixed in a shortened position secondary to bone loss. The plate applied at the time of injury may be incorporated into any subsequent lengthening process. A detailed description of the technique of lengthening over a pre-implanted distal femoral plate is followed by presentation of 2 case examples.

This consensus project was conceived in the absence of strong evidence for the effective care of pin sites and prevention of infection. The consensus involved a one-day meeting which was used to develop a series of consensus statements. These statements were then used to develop an online questionnaire which enabled participants to express their level of agreement with each statement. The following are a summary of the results of the meeting and subsequent survey:It was agreed that, in the absence of skin sensitivity, pin sites should be cleaned weekly using alcoholic chlorhexidine solution (solution strength is not specified) and non-shedding gauze.They should then be covered with a wound dressing that keeps excess moisture and exudate away from the wound.The dressings should be held in situ with a clip or 'bung' in order to apply light compression.The frequency of dressing changes should be increased in the presence of an infection or the dressing becoming saturated.On the day of dressing change the patient may swim, attend hydrotherapy and shower (not bath) the limb. The surrounding skin should be moisturised with an emollient as necessary.Patient reported symptoms and perceptions of the presence of infection should be taken seriously. Increasing pain at the pin/wire site and decreased movement, mobility or weight bearing along with spreading redness and increased swelling and discharge are indicators of the presence of infection. Frank drainage of pus is conclusive of the presence of infection, but is not present in all cases of infection.There is a need for multi-centre prospective randomised controlled trials using a standardised validated pin site assessment tool and regular review of these recommendations along with new developments in wound care. (C) 2012 Published by Elsevier Ltd.

Pin site infection is the most common complication of external fixation, a complex orthopaedic procedure used to stabilise fractures and correct limb deformity. The care of pin sites has long been debated among healthcare professionals. It is widely acknowledged that there is a lack of high quality research in this area. In 2010 a meeting with the aim of achieving consensus about pin site care took place, funded by the Royal College of Nursing Society of Orthopaedic and Trauma Nursing. The aim was for practitioners who care for pin sites on a regular basis in adult, paediatric, hospital and community environments around the UK to explore and debate current practice. This article reports the findings of this meeting and discusses the difficulties in creating guidance on this area of practice.

The surgical management of osteofibrous dysplasia (OFD), a rare developmental tumour-like condition of childhood that has a predilection for the tibia, ranges from curettage or subperiosteal resection to extraperiosteal wide resection followed by reconstruction. En-bloc excision followed by distraction osteogenesis has been described earlier for OFD. We describe a novel technique in which marginal excision was performed but instead of excising an entire segment of tibia, only the anterior portion containing the lesion was excised, sparing the uninvolved posterior cortex. Distraction osteogenesis was carried out on the anterior portion of the tibia (hemicallotasis) after acute correction of the deformity. Although the potential advantage is a decrease in time required for consolidation of the bone regenerate, this technique is dependent on the anatomical characteristics of the lesion. We describe a case in which this technique was adopted on a child with tibial OFD with resultant disease-free excision margins and deformity correction.

The care of pin sites for patients undergoing external fixation remains contentious. Our centre followed the British Consensus method (Lee-Smith et al., 2001) until a review of our antibiotic usage led us to believe we could improve our practice. Liaison with other limb reconstruction centres led us towards the Russian Protocol (Davies et al., 2005) despite the latest Cochrane report (Lethaby et al., 2008) concluding that there was insufficient evidence for any particular strategy of pin site care. This article aims to explain why we made the decision to move from ‘Britain’ to ‘Russia’.

Background:Leg length discrepancy related to absence of the femoral head with proximal migration of the femur presents a treatment dilemma. Late sequelae of neonatal hip sepsis and chronic hip disl...