James Livingstone

Computer hexapod assisted orthopaedic surgery (CHAOS) in the correction of long bone fracture and deformity

Summary: We describe a surgical technique using the Taylor Spatial Frame intraoperatively to correct complex multiplanar deformities of the distal femur prior to definitive internal fixation using minimally invasive stabilization techniques. Eight procedures were done in 7 patients. All deformities were complex oblique plane deformities, often with a rotational component, and ranged from 10 degrees valgus to 35 degrees varus; up to 45 degrees of external rotation; 10 mm of translation and in 1 case, 100 mm of shortening. All patients underwent acute intraoperative deformity correction mediated by the Taylor Spatial Frame prior to definitive internal fixation using either a percutaneous locking plate or locked intramedullary nail. Deformity correction and restoration of the mechanical axis were achieved in all cases. There were no cases of wound breakdown, infection, nerve palsy or compartment syndrome. We believe the Taylor Spatial Frame can be effectively and safely used to assist the acute correction and subsequent internal fixation of limb deformity.

Informed consent in trauma: Does written information improve patient recall of risks? A prospective randomised study

Informed consent is vital to good surgical practice. Pain, sedative medication and psychological distress resulting from trauma are likely to adversely affect a patients ability to understand and retain information thus impairing the quality of the consent process. This study aims to assess whether provision of written information improves trauma patients recall of the risks associated with their surgery. 121 consecutive trauma patients were randomised to receive structured verbal information or structured verbal information with the addition of supplementary written information at the time of obtaining consent for their surgery. Patients were followed up post-operatively (mean 3.2 days) with a questionnaire to assess recall of risks discussed during the consent interview and satisfaction with the consent process. Recall of risks discussed in the consent interview was found to be significantly improved in the group receiving written and verbal information compared to verbal information alone (mean questionnaire score 41% vs. 64%), p=0.0014 using the Mann-Whitney U test. Patient satisfaction with the consent process was improved in the group receiving written and verbal information and 90% of patients in both groups expressed a preference for both written and verbal information compared to verbal information alone. Patients awaiting surgery following trauma can pose a challenge to adequately inform about benefits conferred, the likely post operative course and potential risks. Written information is a simple and cost-effective means to improve the consent process and was popular with patients.

Complex regional pain syndrome (type 1): a comparison of 2 diagnostic criteria methods

BackgroundComplex regional pain syndrome (CRPS) is a common problem presenting to orthopedic surgeons or pain therapists, most frequently encountered after trauma or surgery to a limb. Because of a lack of a simple objective diagnostic test, diagnosis is reliant on clinical assessment. Prospective studies have repeatedly demonstrated a higher incidence than retrospective studies, an observation that has been challenged owing to the lack of uniformity of diagnostic criteria across specialties and workers researching the condition. MethodsA series of 262 adult patients presenting to the Bristol Royal Infirmary with a closed unilateral distal radial fracture were assessed at a mean of 9.47 weeks after their injury bya single clinician (J.A.L.). Each assessment made allowed comparison of the modified International Association for the Study of Pain (Bruehl) criteria for the presence of CRPS with the criteria described by Atkins. FindingsThe incidence of CRPS was similar using either criteria (Bruehl 20.61% vs. Atkins 22.52%). Using the Bruehl criteria as a gold standard, there was strong diagnostic agreement (κ=0.79, sensitivity=0.87, specificity=0.94). Disagreements between the 2 criteria methods were found in 19 patients. The majority of these discordances were due to differences in pain and sensory abnormality assessment. InterpretationThese findings show that the Bruehl and Atkins criteria are basically concordant. The differences reflect only minor variations in the assessment of pain. Agreement between researchers in the orthopedic and pain therapy communities will allow improved understanding of CRPS.

Taylor Spatial Frame Application With the Aid of a Fine Wire Half Frame

The Taylor Spatial Frame has become an important part of the trauma and reconstruction surgeons armamentarium. We describe a technique to assist in the application of this device that does not hinder the use of the image intensifier or rely on an assistant to hold a constant position and aids provisional fracture reduction.

Computer hexapod-assisted orthopaedic surgery provides a predictable and safe method of femoral deformity correction

Aims Computer hexapod assisted orthopaedic surgery (CHAOS), is a method to achieve the intraoperative correction of long bone deformities using a hexapod external fixator before definitive internal fixation with minimally invasive stabilisation techniques. The aims of this study were to determine the reliability of this method in a consecutive case series of patients undergoing femoral deformity correction, with a minimum six‐month follow‐up, to assess the complications and to define the ideal group of patients for whom this treatment is appropriate. Patients and Methods The medical records and radiographs of all patients who underwent CHAOS for femoral deformity at our institution between 2005 and 2011 were retrospectively reviewed. Records were available for all 55 consecutive procedures undertaken in 49 patients with a mean age of 35.6 years (10.9 to 75.3) at the time of surgery. Results Patients were assessed at a mean interval of 44 months (6 to 90) following surgery. The indications were broad; the most common were vitamin D resistant rickets (n = 10), growth plate arrest (n = 6) and post‐traumatic deformity (n = 20). Multi‐planar correction was required in 33 cases. A single level osteotomy was performed in 43 cases. Locking plates were used to stabilise the osteotomy in 33 cases and intramedullary nails in the remainder. Complications included two nonunions, one death, one below‐knee deep vein thrombosis, one deep infection and one revision procedure due to initial under‐correction. There were no neurovascular injuries or incidence of compartment syndrome. Conclusion This is the largest reported series of femoral deformity corrections using the CHAOS technique. This series demonstrates that precise intra‐operative realignment is possible with a hexapod external fixator prior to definitive stabilisation with contemporary internal fixation. This combination allows reproducible correction of complex femoral deformity from a wide variety of diagnoses and age range with a low complication rate.

Posttraumatic proximal tibial growth arrest: a rare injury managed successfully with ring fixators.

A ring fixator was used in the treatment of five patients (ages 11 to 16 years) with proximal tibial growth arrest after trauma. The mean corrections were 14.2° (maximum 28°, minimum 0°) in the saggital plane and 14° (maximum 38°, minimum 2°) in the coronal plane. Leg length discrepancy was also corrected (max 1 cm). The average time in frame was 17.8 weeks, with an average correction time of 29.8 days. Knee Society Clinical Rating System scores post operatively ranged from 95–100. All patients returned to full activity, and would accept the same treatment if offered again. The circular fixator is an effective, minimally invasive method for treating the complex deformities arising from this rare injury. Patients remain active during treatment, encouraging a rapid return to school/work activities.

The bicipital aponeurosis may be involved in the anatomical etiology of arterial compromise after swelling in supracondylar fracture.

A 7-year-old girl presented with a Gartland grade III supracondylar fracture and no radial pulse. After open reduction, it was established that the brachial artery was free of the fracture site; the limb however remained nonviable. The brachial artery was then approached anteriorly and the bicipital aponeurosis was seen to kink the artery. Once the bicipital aponeurosis was released and the remaining spasm treated with arteriotomy and papaverine, a good pulse returned. Despite the fracture being reduced and the artery remaining free of it, there remained a structural impediment to flow in the brachial artery. If the pulse does not return after fixation of a supracondylar fracture, then exploration of the brachial artery is indicated. When a patient is taken to the operating room for fixation of a supracondylar fracture, the facilities and expertise to explore the brachial artery must be made available. In centers where an on-call vascular service is not available, we recommend that the orthopaedic training programs give consideration to including “exploration of the brachial artery” as a facet of orthopaedic surgical training.