Aim: The consent process involves supported decision-making between the surgeon and the patient. Both potential benefits and material risks of the procedure require explanation, with adequate time for reflection. The complexity of limb reconstruction surgery includes the potential for multiple types of complications. In an attempt to delineate the material risks in lower limb lengthening, a literature review was undertaken to ascertain the published rates of complications. Materials and methods: A review of articles from 2003 to 2023 via PubMed and Google Scholar, including keywords ‘lengthening’, ‘tibia’, ‘lengthening nail’ and ‘external fixator’ was undertaken. Studies with a minimum of 20 patients, undergoing lengthening of the femur, tibia, or both by an external fixator and/or an intramedullary lengthening nail were included for analysis. Complications were reported according to Paley's problems, obstacles, and complications. Results: Twenty-two papers met the inclusion criteria. The commonest complications listed following lengthening using an external fixator were pin site infections (52% in the femur and 18.8% in the tibia), delayed consolidation (8.3%), bone re-fracture (13%), and joint stiffness (18.8%). Following femoral lengthening using the intramedullary lengthening nails reported complication rates were lower, including implant issues (8%) and delayed consolidation (6%). Conclusion: Patients require a full understanding of both benefits and potential harms when undergoing any surgical intervention. Our study has identified the published rates of complications following lower limb lengthening. These figures can be used to guide the consultation and enable surgeons to audit their own surgical results against the published literature.

Aim: To evaluate the level of burnout among international limb reconstruction surgeons. Background: Burnout describes chronic workplace stress that has not been successfully managed. Limb reconstruction surgeons may be particularly at risk for burnout. The development of necessary skills and expertise has a steep learning curve and the patients are among the most complex in orthopaedics, with multiple failed surgeries and high complication rates. Methods: An internet-based REDCap survey consisted of demographic questions, four open-ended questions, and two valid, reliable measures: (1) Patient Health Questionnaire 4 (PHQ-4)—a screening tool for anxiety and depression, and (2) The Maslach Burnout Inventory–Human Services Survey for Medical Personnel (MBI-HSS-MP) which measures levels of depersonalization, emotional exhaustion, and low personal achievement. The surveys were distributed to international limb reconstruction surgeons. Statistical analysis consisted of descriptive and non-parametric analysis: Chi-square and Kruskal–Wallis tests. Results: There were 103 surgeon responses from at least one country of each of the six populated continents. Eighty-three percent of the respondents were male. The career level distribution was early (1–10 years’ experience) = 51%, mid (11–20 years’ experience) = 30%, and late (>20 years’ experience) = 20%. Twenty-four percent stated they were currently being treated or had been treated in the past for mood or anxiety or both with medication or counselling. Based on the MBI-HSS-MP scores, 38% of limb reconstruction surgeons displayed burnout symptoms, and 16% exhibited severe burnout. The mid-career had the highest levels of overall burnout; there was no statistical significance between the groups. The PHQ-4 scores were within normal limits. Discussion: In this study sample, 38% displayed burnout symptoms and 16% exhibited severe burnout. The mid-career group had the highest level of burnout. Clinical significance: Unmanaged burnout can lead to major depression or suicidal ideation, or both. Support systems for limb reconstruction surgeons need to be developed and maintained.

Aim: Reconstruction of segmental bone defects with bone transport is a well-established treatment. Mechanical complications at the docking site after frame removal are common. These complications include malunion, non-union, axial deviation and refracture. A simple tool to assess the healing of the docking site is currently lacking. The aim of this study is to evaluate the use of the modified RUST (mRUST) score in the setting of bone transport and to identify factors associated with an increased risk of docking site complications. Methods: This retrospective study was conducted at a single tertiary centre in South Africa, included 24 patients with a tibial bone defect treated with bone transport and a circular frame between 2014 and 2023. Demographic data, clinical and bone transport characteristics were recorded. Mechanical complications, such as fracture, non-union, any angulation >5°, shortening >5 mm, or any other complication requiring reoperation, were recorded. The mRUST was adapted as a ratio for the purpose of this study to overcome the common occurrence of cortices being obscured by the frame. The mRUST ratio was applied before and after frame removal for each patient by three appraisers. Comparison between the groups with and without complications was performed regarding bone transport characteristics, docking site configuration and mRUST ratio. The correlation of the score between radiographs before and after frame removal was assessed. The inter-rater reliability of the mRUST was analysed using Fleiss Kappa statistics for each cortex individually and the intraclass correlation coefficient (ICC) for the mRUST ratio. Results: In this study, 20 men and 4 women with a median age of 26 years were included. The overall rate of mechanical complications after frame removal was 21.7%. Complications were all related to the docking site, with two angulations, two fractures and one non-union. Demographics, bone transport characteristics and mRUST ratio before and after frame removal were similar between the two groups. Regarding the configuration of the docking site, an angle of 45° or more between the bone surfaces was associated with the occurrence of mechanical complications (p < 0.001). The correlation of the mean mRUST ratio before and after frame removal showed a moderate relationship, with a Spearman correlation coefficient of 0.50 (p-value 0.13). The inter-rater reliability of the mRUST was “fair” (kappa 0.21–0.40) for the scoring of individual cortices, except for one score which was “slight” (kappa 0.00–0.20). The ICC of the mRUST ratio was 0.662 on radiographs with the frame, and 0.759 after frame removal. Conclusion: This study did not find the mRUST or mRUST ratio useful in assessing the healing of the docking site to decide on the best time to remove the frame. However, a notable finding was that the shape and orientation of the bone ends meeting at the docking site might well be relevant to decrease complication rates. If the angle between the bony surfaces is 45° or more, it may be associated with an increased risk of complications. It may be worthwhile considering reshaping these bone ends at the time of debridement or formal docking procedure to be more collinear, in order to reduce the potential for mechanical complications such as non-union, axial deviation or refracture at the docking site.

Introduction: Angular deformities of the tibia and femur lead to mechanical axis deviation (MAD) of the lower limb and malorientation of the joints adjacent to the deformity. The current study analyses the outcomes of using a medial closing wedge high tibial osteotomy (MCWHTO) for the management of genu valgum with high medial proximal tibial angle (MPTA), and combined MCWHTO with lateral opening-wedge distal femoral osteotomy (LOWDFO) in the setting of concomitant genu varum with low lateral distal femoral angle (LDFA). Methods: There were 18 high tibial osteotomy (HTO)-only and 13 combined HTO + distal femoral osteotomy (DFO) procedures performed. The primary radiographic outcome variables included postoperative MPTA and MAD (in mm). The accuracy of MAD correction was expressed as a percentage. The postoperative posterior proximal tibial angle (PPTA) and limb length discrepancy (LLD) were also measured as secondary radiographic outcome variables. The clinical outcome variables included intraoperative surgical complications (e.g., hinge fracture), all-causes for revision, union rate, time to union, and postoperative knee range of motion. Functional outcomes used included the LDSRS, PROMIS, and EuroQOL scores. Results: The mean preoperative MPTA was 92.9° (SD = 1.81, range: 88–96). After surgical correction, the mean MPTA was 86.0° (SD = 1.80, range: 83–90) (p < 0.0001). The mean preoperative MAD was 32.5 mm (SD = 20.16, range: 10–77) lateral to the centre of the knee joint. The mean postoperative MAD was 2.44 mm medial to the centre of the joint (SD = 7.13, range: 13 medial – 15 lateral) (p < 0.0001). The mean change in MAD achieved through surgical correction was 38.16 mm (SD = 17.94, range: 13–77). The accuracy of MAD correction was 96.1% (SD = 0.06%, range: 81.25–100%). The time to unassisted WB was a mean of 75 days (SD = 44.5, range: 44–242). There was a single stable hinge fracture and one case of chronic regional pain syndrome diagnosed. There were no cases of non-union and no indications for revision surgery in any case. Conclusion: Medial closing wedge high tibial osteotomy is an effective surgical procedure for the management of genu valgum deformity. The MPTA, LDFA, and MAD can be accurately corrected without significantly altering PPTA or limb length. It may be combined with open lateral distal femoral osteotomy for cases with femoral and tibial contributions to deformity without significantly impacting clinical outcomes. Functional outcomes, specifically relating to self-image are significantly improved after the MCWHTO has been performed.

Aim: Knee stiffness limits activities of daily living with treatment having no gold standard technique currently. We present follow-up data 1-year after quadricepsplasty using the Adolphson–Cerqueira technique for the treatment of knee stiffness in a Brazilian population sample. Materials and methods: This retrospective study included patients who underwent a quadricepsplasty using the Adolphson–Cerqueira technique between January 2006 and March 2023 at our institution. The inclusion criteria were: (1) Knee stiffness with a range of motion <70°; (2) Patellar excursion ≥2 mm on physical examination; (3) Available knee radiography in the anteroposterior and lateral views; and (4) A follow-up at 1 year postoperatively. The Judet Classification was used to assess the outcome of the quadricepsplasty. Results: Sixty-seven patients were included. The results were 6% poor, 31.3% fair, 44.8% good, and 17.9% excellent according to the Judet Classification. A correlation was observed between age and the gain in range of motion at the 1-year postoperative follow-up, and between the gain in range of motion intraoperatively and that at the 1-year follow-up. There were five cases of complications (7.46%): one of patellar fracture, three of quadriceps tendon rupture, and one of avulsion fracture in the superior pole of the patella. Conclusion: Quadricepsplasty using the Adolphson–Cerqueira technique produced satisfactory results overall for improving knee joint stiffness and had a complication rate comparable with other currently used techniques. Clinical significance: Loss of knee range of motion remains a difficult problem without there being a clear gold standard in treatment. Many different options are described in the literature. We provide a further option with follow-up results.

Supplementary Video

Objective: To evaluate the role of post-debridement cultures in the prevention of future infection following open fractures. Design: Retrospective Cohort Study and Literature Review. Setting: Division of Orthopaedic Surgery, Sultan Qaboos University Hospital, Academic and tertiary health care, Muscat, Oman. Participants: A total of 166 patients from a cohort study and 539 patients from the literature review with open fractures. There were 640 cumulative patients fit the inclusion and exclusion criteria. Intervention: Using predetermined inclusion and exclusion criteria, data on all open fractures were gathered from the electronic health system of a single institution between 2010 and 2019. PubMed and Embase electronic databases were also searched for relevant articles relating to post-surgical debridement culture and its correlation with future infection. Main outcome measures: Assessing the benefit, role of post-debridement cultures in the prevention of future infection following open fractures. Results: Combining the results of this retrospective cohort study and previously published data, there were 640 Gustilo-Anderson grades II and III open fractures which had post-debridement screening. Eighty-eight patients (13.8%) developed an infection, out of which 16 had positive post- debridement cultures (18.2%). Only four grew similar organisms at screening and infection stages, two of which had different antibiotic resistance patterns at the infection stage. Seventy-two fractures had negative post-debridement screening swabs (81.8%). Of the 59 (9.2%) fractures with positive screening only four (6.8% of the infected fractures) developed later deep infection. All these 59 cases had culture-guided antibiotic treatment, with or without surgical debridement. Conclusion: Although the bacterial growth of post-debridement cultures is low, post-debridement screening as part of a comprehensive management protocol may have a role in reducing deep infection in open fractures. This is particularly the case in Gustilo and Anderson type 3 open fractures, the risk of infection is high. The poor association between organisms isolated from screening and those from subsequent deep infection may mean that the later infective organisms have been acquired from a secondary colonisation source after the debridement. Level of evidence: III

This paper describes a modification of the traditional fascial tongue surgical approach to the distal humerus. In particular, we describe the reflection and utilisation of radial and ulnar triceps bundles to allow complete visualisation of the distal humerus. This extensile technique allows access to the entirety of the distal humerus and provides excellent visualisation to the operating surgeon. Indications for the surgical approach include open reduction with internal fixation of fractures (both intra- and extra-articular) and total elbow replacement. Whilst standard approaches to the distal humerus are well described, this modification describes a new surgical approach that improves access and visualisation of the traditional fascial tongue technique. Alternative approaches to improve visualisation include an olecranon osteotomy; the triceps bundle modification allows excellent exposure to the distal humerus whilst avoiding complications associated with an olecranon osteotomy. The surgical technique is illustrated with intra-operative photographs, which aim to aid in guiding the surgeon in undertaking critical steps of this approach.

Aim: There are significant challenges in the treatment of a severe rigid ankle equinus caused by a flat-topped talus, arthrogryposis, burn sequelae, or extensive scarring. Conventional approaches, such as soft tissue releases, often fail due to joint incongruence or compromised soft tissues, thereby necessitating supramalleolar osteotomies. The classic transverse supramalleolar osteotomy (TSO) of the distal tibia can lead to secondary anterior translation of the centre of rotation of the ankle and alters mechanical and anatomical axes. An alternative technique involves an oblique closing wedge osteotomy of the distal tibia, with a fulcrum near the ankle joint. This technical note delineates the planning parameters and procedural steps for the oblique dorsiflexion osteotomy of the distal tibia (ODODT). Method: Using an anterior approach to the distal tibia, the “alpha angle,” which determines the size of the closing wedge required for the foot to be plantigrade, is resected with a fulcrum at the most posterior part of the ankle joint, ensuring that the posterior cortex remains intact. The inclination of this resected wedge is planned preoperatively and is referred to as the “beta angle.” This aims to equalise the lengths on both sides of the osteotomy. For osteotomy fixation, 2 or 3 cannulated screws in lag mode are employed. Postoperatively, a short cast boot is used for 6 weeks. Results: The ODODT is a salvage solution for severe rigid ankle equinus when first-line foot and ankle procedures are impractical due to tibiotalar incongruence or poor soft tissues. Advantages include minimal translation of the centre of rotation of the ankle, excellent stability when the posterior cortex remains intact, avoidance of large internal fixation devices, and cost-effectiveness, making it suitable for low-resource settings.

Background: Tibia vara is a three-dimensional deformity of the proximal tibia, varus, internal tibial torsion and procurvatum. It is an uncommon deformity with the surgical management varied. This study describes the outcomes of tibia vara management using a corrective transverse osteotomy in one centre. Materials and methods: A retrospective cohort study was conducted involving eight patients with tibia vara (ten tibias). Consent was obtained for treatment using an acute corrective osteotomy. Measurements of Drennan's angle, the tibiofemoral angle (TFA) and the procurvatum angle were measured preoperatively and postoperatively both just after surgery and at 1 year. A validated questionnaire—the Knee Outcome Survey of Activity Daily Living (KOS-ADL)—was utilised to assess clinical function and outcome. Also recorded were the intraoperative and postoperative complications, the radiological lower limb alignments, the union rate and the recurrence of deformity. Results: There were eight patients involved in this study with a total of ten tibias (six with unilateral tibias and two with bilateral tibias). The mean age of the patients was 11.3 years old (ranging from 8 to 15 years old) with most males (five males and three females). The affected tibias were 6 right sided and 4 left sided. Measurements of Drennan's angle, the TFA and the procurvatum angle were used to determine lower limb alignment preoperatively, postoperatively (immediate post-surgery) and at 1-year follow-up. Functional parameters were measured using the KOS-ADL. A descriptive analysis between the preoperative and postoperative variables was done. The mean for Drennan's angle was 21.6 (±5.2) preoperatively, 3.6 (± 2.3) postoperatively and 4.9 (±2.8) at 1-year follow-up. The TFA was improved from 22.6 (±6.1) preoperatively to 3.5 (±2.8) postoperatively and 4.4 (±2.0) at 1-year follow-up. The procurvatum angle was improved preoperatively from 8.20 (±7.5) to 2.40 (±2.5) postoperatively and 2.20 (±2.5) at 1-year follow-up. At the latest follow-up, the ADLS mean score was 98.5 (±2.6) while the SAS mean score was 97.5 (±3.3). The mean length follow-up period was 2 years (ranging from 1 year to 3 years). None of the patients developed postoperative complications with all achieving union without deformity recurrence in the period of observation. Conclusion: This study revealed that acute correction via a corrective transverse osteotomy of the tibia is a safe and effective method in treating tibia vara.

Aim: The treatment of massive diaphyseal tibial bone defects remains challenging with poor results seen from treatment modalities other than bone transport (BT). Current methods of BT require lengthy periods in a circular external fixator. Despite recent modifications in BT techniques via circular external fixator such as multifocal transport and immediate intramedullary nailing after docking, circular external fixation remains poorly tolerated with a high complication profile. Newer technologies such as magnetic lengthening nails have shown promise to provide alternatives to BT without resorting to long-term circular external fixation. Plate-assisted bone segment transport (PABST) has demonstrated success as an all-internal BT technique. Prior case reports have shown a modest ability to treat massive defects with varying success. Technique: A novel all-internal cable and pulley augmentation to a PABST technique for a massive (185 mm) tibial defect was utilised during a retrograde transport. The authors describe a patient scenario in which this augment allowed continued transport that could not be treated with an additional Precice nail recharge. Conclusion: Augmentation of PABST with a cable and pulley construct can successfully treat massive diaphyseal defects. Clinical significance: This cable and pulley modification to PABST allows for the treatment of massive tibial defects without the need for magnetic lengthening nail exchange or conversion to external fixation.