Franz Birkholtz

Functional and psychological outcomes of delayed lower limb amputation following failed lower limb reconstruction

PURPOSE The purpose of this study was to evaluate the functional and psychological outcomes of patients who underwent delayed lower limb amputation following failed limb salvage surgery. METHODS This retrospective, descriptive study evaluated functional outcomes using the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) in 12 patients. Inclusion criteria included patients who underwent limb reconstruction and delayed amputation between July 2006 and December 2014, with an age range between 18 and 80 years of age, the ability to ambulate independently, a time interval between the last salvage procedure and amputation greater than six months, and a minimum follow-up of 24 months. Patients were contacted via telephone by the principal investigator and both the Sickness Impact Profile (SIP) and Short Form-36 (SF-36) were completed. Descriptive analysis (means and standard deviation) was used to determine outcomes for both SIP and SF-36 health profiles. RESULTS Ten patients who had amputations following failed reconstruction (2006-2014) with a mean age of 53±10years were interviewed. Six patients had a SIP <5, three patients scored between five and 10 points and one scored >10 points. The main deficit on the SF-36 was in the physical component. The SF-36 scores demonstrated a mean score of 40.8±11.5 for the physical component, and 57.4±7.9 for the mental component. Three patients returned to work after amputation and continued performing their pre-injury duties as farmers. Three other patients returned to work, but were allocated to administrative duties. Two patients were pensioners at the time of their injuries, and the only female patient was a housewife. One patient went into early retirement. CONCLUSION The results of this study strongly suggest that delayed amputation following failed limb salvage surgery can still result in good and satisfactory outcomes in the majority of patients and achieves results similar to early amputation and limb reconstruction techniques.

Radiographic analysis of hexapod external fixators: fundamental differences between the Taylor Spatial Frame and TrueLok-Hex.

Abstract Hexapod circular external fixators are extremely accurate at correcting deformities in three dimensions. In order to exploit this accuracy, however, the surgeon must be able to accurately analyse the deformity and mounting parameters on post-operative radiographs. A Sawbone® model was created to simulate a mid-shaft tibial fracture with deformity. A 180 mm ring was applied oblique to the proximal segment of the Sawbone® model, in both the sagittal and coronal planes. Standard radiographs were taken of the model and analysed using the described Taylor Spatial Frame and TrueLok-Hex methods. The TrueLok-Hex software allows the surgeon the ability to program reference rings that are not orthogonally mounted. Apart from this software difference, the described analysis methods resulted in variation in all translational measurements for both deformity and mounting parameters. In conclusion, the radiographic analysis of the Taylor Spatial Frame and TrueLok-Hex are fundamentally different. These differences must be appreciated in order to use these systems effectively.

The tibial bayonet method of wound closure

Management of open lower limb fractures with soft tissue defects can be a technically challenging orthopaedic problem. Limited availability of orthoplastic services means that alternatives to the fix and flap concept are required in order to prevent infected non-unions from developing. The proposed ‘bayonet apposition’ allows the surgeon to temporarily shorten the limb without angulating the limb or creating a bone defect and removing viable bone. The viable bone edges are overlapped in a bayonet-like manner in order to appose the wound and skin edges. The limb length is restored by gradually distracting the bone segments once the soft tissues have healed. This is facilitated with a hexapod fixator for stabilization of the fracture and distraction. Prerequisites for utilizing this method are circumferential soft tissue damage to the lower limb with viable distal tissue. The bayonet method allows primary closure of a wound and rapid restoration of the native length of the limb.

Circular external fixation and cemented PMMA spacers for the treatment of complex tibial fractures and infected nonunions with segmental bone loss

Purpose: The purpose of this study was to compare the outcome of combined circular external fixation and cemented polymethylmethacrylate (PMMA) spacer application between a cohort of patients with grade 3 open fractures and infected tibial nonunions and concomitant segmental bone loss. Methods: The study was designed as a retrospective cohort study. All patients who were treated for complex tibial fractures or infected nonunions with segmental bone loss between 2009 and 2013 were included if they were aged between 16 years and 60 years, sustained acute traumatic grade 3 open tibial fractures, presented with infected nonunion, and were followed up for a minimum of 12 months. Patients with a history of ipsilateral tibial fractures, contralateral lower extremity fractures, polytrauma, chest, or abdominal trauma and patients with head injuries were excluded. Both groups were treated with aggressive debridement, circular external fixation, and antibiotic-impregnated PMMA spacer. Outcome measures were the time in the external fixator (EFT) and the external fixation index (EFI). Results: Twenty-four patients with a mean age of 32 ± 14.7 years were included. Twelve patients with a mean age of 32 + 14 years and a mean bone defect of 82 + 36 mm were treated for acute complex grade 3 open tibial fractures, and 12 patients with a mean age of 35.1 + 15.7 years and a mean bone defect of 50 + 26 mm were treated for infected nonunions. There was no significant difference (p = 0.44) between the groups for EFT (249 ± 99 days—tibial fractures; 255 ± 142 days—infected nonunion). There were significant between group differences (p = 0.027) for EFI (37.3 ± 9.1 cm/days—tibial fractures; 56 ± 14.5 cm/days—infected nonunion). Conclusion: The findings of this study suggest that patients were treated for infected nonunion with segmental bone loss using circular external fixation, distraction osteogenesis, and antibiotic-impregnated PMMA spacers, and the spacers may not offer any advantage over a conventional approach using the principles of osteogenesis only. In contrast, antibiotic-impregnated spacers for open tibial trauma were advantageous and reduced the EFI considerably.