Introduction: Transosseous Ilizarov wire constructs are extensively used in the treatment of fractures, deformity correction, and limb lengthening. Obtaining satisfactory construct stability through correct wire tensioning remains essential for bone healing. The inaccuracies and inefficiencies of calibrated tensioning devices are well documented; whilst non-calibrated tensioning methods must rely on operator ‘feel’. Mastering and maintaining the skills for non-calibrated wire tensioning is challenging given the inability to easily measure wire tension. This study aimed to (1) describe a novel method for Ilizarov wire tension measurement; and (2) evaluate this novel method by examining the wire tensioning practises of subspecialty experts. Materials and methods: Firstly, a smartphone and app were validated to accurately measure defined soundwave frequencies. An online calculator was then created using a modified Euler–Bernoulli equation for a thin beam under axial tension to calculate wire tensions from excited wire frequencies. Secondly, an evaluation of the novel method was performed where the wire tensioning skills of experienced surgeons were examined. Results: The novel smartphone wire frequency measuring technique and accompanying online wire tension calculator were accurate, simple, and efficient to employ. The technique evaluation successfully assessed the wire tensioning techniques of senior Ilizarov apparatus surgeons. Discussion: Aspiring surgeons seeking to master non-calibrated Ilizarov wire tensioning techniques may now benefit from the described method, obtaining immediate feedback and allowing for accelerated skills training. In addition, experienced surgeons may audit and refine their wire tensioning practises. The application may be expanded in further studies to assess novel techniques and devices.

Introduction: Osseointegrated limb surgery for amputees is becoming increasingly common due to its advantages over traditional socket prostheses. Institutions worldwide are developing services to offer this option to suitable patients and are promoting these services online. This study aims to assess the quality and readability of the online information provided. Methods: The three most popular search engines using the English language were searched, and the first 40 websites from each search were included. All included websites were assessed for reading using the Flesch-Kincaid Grade Level (FKGL) (equivalent to the United States reading grade level), the Gunning Fog Index (G-Fog) and the Flesch Reading Ease (FRE). A quality assessment was conducted using the Journal of the American Medical Association (JAMA) benchmark criteria and the Health on the Net Certificate (HONC). Results: The initial search yielded 9,985,000 websites, of which the top 120 were assessed. Of the 23 websites in the final analysis, none had a reading grade level of sixth grade or lower. The lowest FKGL reading grade was 9.7/18, with a mean of 11.3/18 (95% CI 10.72–11.93), which corresponds with the reading level of a high school junior. The mean FRE was 38.83/100 (95% CI 36.16–41.49). The mean G-Fog score was 12.57/20 (95% CI 11.71–13.42) (representing reading levels of a college freshman). None of the 23 websites had HON certification. The mean JAMA score was 1.76 out of 4 (95% CI 1.34–2.18), meaning the information was of low to moderate quality. The mean Hospital for Special Surgery Osseointegration Information Score was 5.70 out of 16 (95% CI 4.33–7.06), indicating low quality. Discussion: A significant amount of online information is available about osseointegrated limb replacement surgery (OLRS). However, much of this content is written at a level that many patients may find difficult to understand, limiting usefulness. Additionally, the overall quality of the available information is generally low. Improving both the readability and quality of this information is essential to ensure patients have access to accurate and accessible details.

Aim and background: The aim of this study is to evaluate the outcomes of acute correction of large varus and valgus deformities with simultaneous distal femoral and tibial osteotomies. Acute correction of large coronal plane deformities is complex and if done incorrectly, can lead to problems like non-union, soft tissue problems, and joint line obliquity. Materials and methods: Radiographic, clinical, and patient-reported outcomes are analysed through a retrospective series of 21 extremities in 18 consecutive patients with coexisting femoral and tibial deformities who underwent concurrent distal femoral and proximal tibial osteotomies with acute coronal plane correction and internal fixation. Results: The mean mechanical axis deviation (MAD) correction was 56 mm for varus deformities (n = 13) and 45 mm for valgus deformities (n = 8) with an overall mean correction of the femoral tibial angle of 15° per extremity. The accuracy of correction was 92.9% compared to the goal MAD. Two patients had peri-incisional cellulitis that resolved with antibiotics. There was no incidence of non-union, deep vein thrombosis, compartment syndrome, deep infection, or peripheral nerve palsy. Patient-reported outcome scores had clinically meaningful improvements in pain, function, and mental health. Conclusion: Acute correction of large coronal plane deformities can be accurately and safely performed with simultaneous distal femoral and proximal tibial osteotomies with internal fixation. Clinical significance: This study highlights a safe method to accurately correct large coronal plane deformities in the lower extremity.

Aim and background: Technological advances have made infrared thermography (IRT) sensitive, noncontact, and low cost for medical application used in a range of fields. A widening body of research has investigated IRT in the orthopaedic setting, including the investigation of orthopaedic infection. Infrared thermography could provide a rapid, low-cost, objective, noncontact technique to aid in the diagnosis of orthopaedic infections. Methods: Electronic searches of MEDLINE, CINAHL, and EMBASE from 2000 to 2024 were made. The search strategy aimed to include all studies in adults investigating the use of IRT in orthopaedic and bone or joint trauma patients and those studies which provide baseline values, including in patients with infection. Articles were screened by title and abstract by two authors. Bias was assessed using the Newcastle−Ottawa Scale tool. Studies were heterogeneous; therefore, results were summarised in tables and presented as a narrative synthesis. Results: The search identified 36 studies. Studies have shown that IRT is useful in fracture or soft tissue diagnosis, detecting periprosthetic infection, and it may have a role in screening healthy subjects. There is still considerable variance in the application of IRT in the trauma and orthopaedic setting. Conclusion: Infrared thermography is sensitive to skin temperature changes in infected limbs following orthopaedic surgery and may be used as a low-cost, noncontact, irradiation-free screening tool to identify orthopaedic infection in the future. Future studies should identify the cost effectiveness of IRT in clinical practice. Barriers include the low incidence of orthopaedic infection and large number of confounders that can affect IRT readings. Clinical significance: Infrared thermography can provide rapid information that may be a useful adjunct in the emergency department or outpatient clinics to diagnose a range of orthopaedic conditions, including infection. Current research has yet to demonstrate clinical significance.

There is a relatively high incidence of patients recalling an injury before the appearance of a musculoskeletal (MSK) mass, especially in the hand and upper limb. Despite numerous reports of such cases, no clear pathogenetic mechanism has been elucidated to explain this. A tumour may be pre-existing, with the injury bringing the patient's attention to it, or develop coincidently following trauma. Alternatively, injury or the resultant reparative mechanisms may initiate or accelerate tumour formation. Following such a case presenting to our unit, a narrative review of the literature was conducted to determine what evidence existed to support or refute these hypotheses. This is presented along with the case. Though trauma as a cause of MSK tumours cannot be excluded, there is a lack of scientific evidence to support this theory, and further research in the field of pathophysiology and molecular biology is necessary. It is important that clinicians caring for trauma patients maintain a high index of suspicion for alternate diagnoses. A local injury may mask tumour development and lead to the incorrect conclusion that persistent symptoms are the result of failure to recover from the injury, rather than having a more sinister explanation.

The use of intramedullary lengthening nails (ILN) is now an accepted limb reconstruction technique. The most popular motorised systems enable optimal conditions for lengthening, namely stability, sub-millimetre accurate lengthening or retraction and an avoidance of common complications associated with external fixators, such as pin site infections, muscle tethering and regenerate deformity or fracture. The fitbone stainless steel implant utilises an electrical current transmitted by a subcutaneous antenna to drive the motor. The precise intramedullary system, made of titanium, is lengthened by a rotating magnet driven by an electronic remote controller. To prevent nail breakage or deformity, protected partial weight-bearing is initially advised and weight-bearing permitted when sufficient regenerate has formed in the distraction gap. Purpose: The aim of our study was to evaluate and compare the regenerate formation following lengthening using two different motorised ILN. Methods: A retrospective review identified 13 patients (13 nails) who underwent femoral lengthening using the fitbone and 14 patients (16 nails) lengthened with the precise. Patients were matched for age, sex, aetiology and length achieved. Regenerate analysis was undertaken using the pixel ratio value (PVR), calculated on the radiographs when at the desired length, followed at 4, 8, and 12 weeks. The mean of the two highest ratio values were also assessed, as an indicator that full weight-bearing would be permitted. Complications were recorded in relation to bone, soft tissues and implant. Results: Seven males and 6 females underwent 10 antegrade and 3 retrograde fitbone lengthening. Nine male and 5 female underwent 14 antegrade and one retrograde precise lengthening. The mean age at surgery was 36 years in both groups. Mean length in the fitbone group was 41.7, and 46.8 mm in the precise group. All except one fitbone patient reached the desired length (6 mm short). The regenerate fully consolidated in all patients. There was no statistical difference between the PVR measurements of the cortices at any time interval. There was no difference seen in the time for full weight-bearing or a difference seen in the mean PVR measured at this particular time. There were complications seen in the fitbone group including bolt migration, premature consolidation, and soft tissue irritation from the antenna requiring early surgical removal. There were no complications recorded in the precise group. Discussion: This study has demonstrated no difference between the regenerate formation following femoral lengthening, with either the fitbone or precise ILN. All patients had full bone consolidation and there was no difference seen in time to full weight-bearing following completion of lengthening. The rate of complications seen in the fitbone group may be explained by the learning curve of a new implant. There are several limitations including a retrospective review of a small cohort of patients. However, we conclude that both implants successfully lengthen and form excellent regenerate bone. We would recommend that the choice of implant should not be determined by the potential regenerate formation.

Aim and objective: Proximal tibial fixation of hexapod frame rings can be challenging due to a balance between concerns about the available space to provide adequate ring stability against the desire for proximal placement of corticotomies to aid regenerate formation. The aim of this study was to describe and analyse our technique for short-segment, three half-pin placement. Materials and methods: We describe a novel method of orientation and placement of half-pins to enable repeatable placement of three 6 mm pins within only 18 mm of tibia. Patients who received this configuration of half-pins over a 12-month period were identified from our institution database and analysed for complications defined as peri-implant fractures, clinically detected pin site loosening, septic arthritis, or revision surgery due to proximal pin sites. Results: We identified 26 patients who received this configuration of proximal half-pins, average age of 45 (range 24–80) with no complications reported as per our definition. Conclusion: This configuration of proximal half-pins provides excellent fixation in the minimum amount of bone possible, providing sufficient proximal tibial space for high corticotomies. Level of evidence: III – Retrospective case series.

Introduction: Acquired chronic radial head (RH) dislocations present a significant surgical challenge. Coexisting deformity, length discrepancy, and RH dysplasia, in multiply-operated patients often preclude acute correction. This study reports the clinical and radiological outcomes in children, treated with hexapod frames for gradual RH reduction. Materials and methods: Patient cohort from a prospective database was reviewed to identity all hexapod frames for RH dislocations between 2000 and 2021. Patient demographics, clinical range, and radiographic parameters were recorded. Results: From a cohort of 127 upper limb frames, 34 chronic RH dislocations (15 anterior and 17 posterior) were identified. Mean age at surgery was 10 years (5–17 years). Six pathologies were reported (17 post-traumatic, 11 multiple hereditary exostosis (MHE), two nail-patella syndrome, two Ollier's disease, one osteogenesis imperfecta, and one rickets). About 76% had a congruent RH reduction at final follow-up. Two MHE cases gradually re-dislocated. Five children had some mild persistent incongruency. Mean follow-up duration was 4.2 years (9 months to 11.5 years). Mean radiographic correction achieved in coronal plane 9°, sagittal plane 7°, and carrying angle 12°. Mean ulnar length gained was 7 mm, and final ulnar variance was 7 mm negative (congenital). All cases achieved bony union, with two requiring secondary bone grafting. Mean frame duration was 166 days. Mean final range of motion was 64° supination, 54° pronation, and 2°−138° flexion. Conclusion: The majority of children having frame correction achieve complete correction or minor subluxation, which is well tolerated clinically. Frame-assisted reduction is an effective tool for selective complex cases, irrespective of the pathology driving the RH dislocation.

Aim: We present a case where the proximal end of a cannulated tibial nail was inaccessible for removal. Background: Some common techniques for the removal of broken hardware are discussed in the literature, but there is no one technique that will work in every situation. Routine removal techniques may not suffice when removing a buried or broken tibial nail. Case description: Therefore, the fracture site was exposed, and the nail was cut. The proximal portion was removed in a retrograde fashion. Removing the distal end of the nail posed a dilemma after standard techniques failed, but it was successfully extracted by threading a Schanz pin into the exposed cannulated portion of the nail and then backslapping a T-handle. Conclusion: This is a novel technique for the removal of an incarcerated segment of a cannulated tibial nail from the distal tibia when other techniques were unsuccessful. Clinical significance: The novel method presented in this case report allows for extraction of a sunken tibial intramedullary nail when extractor seating is difficult to obtain and the incarcerated distal segment of a cannulated tibial nail cannot be removed by standard techniques.

Aim: To describe a surgical technique for the safe removal of a broken non-cannulated PRECICE bone transport nail (NuVasive Specialized Orthopedics) without compromising limb reconstruction. Background: The removal of broken non-cannulated intramedullary lengthening nails (IMLNs) is challenging. Few techniques have been described for the safe removal of these devices without compromising bone salvage. Case description: A 42-year-old male presented for complex right tibia reconstruction following a type IIIB open tibia fracture with a 92-mm bone defect. The bone defect was initially managed with an all-internal bone transport nail system (PRECICE bone transport). At the 13-month follow-up, the patient presented with a broken lengthening nail, varus limb deformity, and nonunion at the docking site. The nail components were extracted sequentially, and a burr hole was created in the distal segment of the nail through the nonunion site to facilitate removal. The residual varus deformity and tibial shaft nonunion were managed with a hexapod frame. Conclusion: The IMLN was successfully removed without compromising limb reconstruction. By sequentially removing the components of the nail and altering the distal portion of the implant through the nonunion site, safe removal of the implant without further bone loss was achieved. Clinical significance: This report describes an efficient technique for the removal of broken non-cannulated IMLNs when extractors are not available.