IntroductionThe purpose of this study is to evaluate the radiological and clinical outcomes in Northern Ireland of free vascularised fibular bone grafting for the treatment of humeral bone loss secondary to osteomyelitis. Upper limb skeletal bone loss due to osteomyelitis is a devastating and challenging complication to manage for both surgeon and patient. Patients can be left with life altering disability and functional impairment. This limb threatening complication raises the question of salvage versus amputation and the associated risk and benefits of each. Free vascularised fibula grafting is a recognised treatment option for large skeletal defects in long bones but is not without significant risk. The benefit of vascularised over non-vascularised fibula grafts include preservation of blood supply lending itself to improved remodeling and osteointegration.Materials & MethodsSixteen patients in Northern Ireland had free vascularised fibula grafting. Inclusion criteria included grafting to humeral defects secondary to osteomyelitis. Six patients were included in this study. Patients were contacted to complete DASH (Disabilities of the Arm, Shoulder and Hand) questionnaires as our primary outcome measure. Secondary outcome measures included radiological evaluation of osteointegration and associated operative complications. Complications were assessed via review of Electronic Care Record outpatient and in-patient documents.ResultsSix patients in Northern Ireland have been treated with free fibula grafting for humeral defects secondary to osteomyelitis. Regarding aetiology of osteomyelitis, five patients had sustained humeral fractures which were initially managed with open reduction internal fixation and complicated by infected non-union. These cases required removal of metalwork, segmental resection and placement of cement spacer with prolonged antibiotic therapy before return to theatre for vascularised fibula grafting. One patient developed native humeral osteomyelitis, the exact cause of which was unclear. Four patients were contactable for outcome score completion. The average DASH score was 45.5. (range 11.1 – 70.4). The median score was 50.2. With regard to post-operative complications, four of the six patients required return to theatre. Reasons were flap congestion, failure of metalwork at three months, donor site skin grafting for delayed healing and external fixation of graft fracture following trauma. Three patients experienced donor site morbidity in the form of delayed healing or infection requiring admission for intravenous antibiotics. One patient died due to cerebrovascular accident (CVA) within one month of return to theatre for a graft related complication - radiographic osteointegration was not assessed for this patient. At the time of this study, three of the remaining five patients have achieved graft osteointegration. Two patients are within 6 months of grafting procedure therefore too early to comment on radiographic osteoingreration. Radiographs to date are encouraging.ConclusionsFree vascularised fibula grafting for humeral shaft bone defects is a viable option for limb salvage but carries significant risk of complications. Our study highlights the need for proper informed consent regarding risk for this uncommon complex procedure which should only be undertaken by a multidisciplinary team in a specialist orthoplastic unit. This procedure is performed infrequently and our study has given us more information on risk and clinical outcomes to provide full and informed consent for patients in the future.
Background In the UK around 15% of the population will have gallstones and as such biliary pathology makes up a significant proportion of emergency and elective general surgical practice. Within this 10% will have choledocholithiasis; the management of which remains widely varied. A single-stage laparoscopic cholecystectomy with transcystic common bile duct exploration has been shown to be a safe and efficient option avoiding a choledochotomy and risks associated with ERCP. The aim of this study was a 12-month review of data following the adoption of this approach; assuming that laparoscopic transcystic CBD exploration was the ideal treatment for CBD stones. Methods This was a retrospective, single-centre, observational study. All patients who underwent a laparoscopic transcystic CBD exploration from June 2020 to June 2021 were included both in the elective and emergency setting. Patient demographics were varied with ages ranging from 15 to 76 and ASA classification of 1 -3, showing a significant proportion with comorbidities. Data collection was done through a review of a contemporaneous operative database and a follow-up morbidity period of 30 days was cross-referenced with electronic healthcare records. The primary outcome studied was CBD stone clearance. With secondary outcomes measures including complications, length of stay and the role of preoperative imaging versus intraoperative cholangiogram. Results A total of 49 patients were included within the study, of which 61% were emergency. The primary outcome of CBD stone clearance was achieved in all elective patients with one emergency patient requiring ERCP for a retained fragment at day 8. There were no other complications in the remaining 48 patients, making the 30-day morbidity 2% upon review of electronic care records. One patient was converted to open due to concern with regards to potential CBD injury but this was demonstrated not to be the case. The median duration of hospital admission was 3 days with a range from 0- 15, with the median stay for elective cases being 1 day. Finally, 39 patients underwent intraoperative cholangiograms prior to duct exploration as a means of identifying CBD calculi and delineating anatomy. Those 10 that did not; all had an MRCP within 30 days of surgery demonstrating CBD calculi and as such proceeded straight to CBD exploration. Conclusions Laparoscopic cholecystectomy and transcystic CBD exploration, with adequate training and exposure, is a viable and safe first-line approach for all cases of choledocholithiasis both in the elective and emergency setting; demonstrating advantages by avoiding additional procedures thereby reducing costs, inpatient bed days and a risk of further complications and being truly minimally invasive. The principal findings of this study were that the transcystic CBD exploration route can achieve successful CBD stone clearance rates in close to 98 per cent of patients with a low morbidity rate, and a short median length of hospital stay. This study of course has several potential limitations; given it was a retrospective single-centre observational study there is likely a degree of selection bias and although follow up was complete in all patients to 30 days via electronic care record it was not routine practice to offer face to face follow up given the low incidence of delayed complications. On the basis of this review, the transcystic approach has become the primary strategy for patients with common bile duct stones within this unit.
IntroductionOsteogenesis imperfect (OI) is a geno- and phenotypically heterogeneous group of congenital collagen disorders characterized by fragility and microfractures resulting in long bone deformities. OI can lead to progressive femoral coxa vara from bone and muscular imbalance and continuous microfracture about the proximal femur. If left untreated, patients develop Trendelenburg gait, leg length discrepancy, further stress fracture and acute fracture at the apex of the deformity, impingement and hip joint degeneration. In the OI patient, femoral coxa vara cannot be treated in isolation and consideration must be given to protecting the whole bone with the primary goal of verticalization and improved biomechanical stability to allow early loading, safe standing, re-orientation of the physis and avoidance of untreated sequelae. Implant constructs should therefore be designed to accommodate and protect the whole bone. The normal paediatric femoral neck shaft angle (FNSA) ranges from 135 to 145 degrees. In OI the progressive pathomechanical changes result in FNSA of significantly less than 120 degrees and decreased Hilgenreiner epiphyseal angles (HEA). Proximal femoral valgus osteotomy is considered the standard surgical treatment for coxa vara and multiple surgical techniques have been described, each with their associated complications. In this paper we present the novel technique of controlling femoral version and coronal alignment using a tubular plate and long bone protection with the use of teleoscoping rods.MethodologyAfter the decision to operate had been made, a CT scan of the femur was performed. A 1:1 scale 3D printed model (AXIAL3D, Belfast, UK) was made from the CT scan to allow for accurate implant templating and osteotomy planning. In all cases a subtrochanteric osteotomy was performed and fixed using a pre-bent 3.5 mm 1/3 tubular plate. The plate was bent to allow one end to be inserted into the proximal femur to act as a blade. A channel into the femoral neck was opened using a flat osteotome. The plate was then tapped into the femoral neck to the predetermined position. The final position needed to allow one of the plate holes to accommodate the growing rod. This had to be determined pre operatively using the 3D printed model and the implants. The femoral canal was reamed, and the growing rod was placed in the femur, passing through the hole in the plate to create a construct that could effectively protect both the femoral neck and the full length of the shaft. The distal part of the plate was then fixed to the shaft using eccentric screws around the nail to complete the construct.ResultsThree children ages 5,8 and 13 underwent the procedure. Five coxa vara femurs have undergone this technique with follow-up out to 62 months (41–85 months) from surgery. Improvements in the femoral neck shaft angle (FNSA) were av. 18o (10–38o) with pre-op coxa vara FNSA av. 99o(range 87–114o) and final FNSA 117o (105–125o). Hilgenreiner's epiphyseal angle was improved by av. 29o (2–58o). However only one hip was restored to <25o. In the initial technique employed for 3 hips, the plates were left short in the neck to avoid damaging the physis. This resulted in 2 of 3 hips fracturing through the femoral neck above the plate at approximately 1 year. There were revisions of the 3 hips to longer plates to prevent intra-capsular stress riser. All osteotomies united and both intracapsular fractures healed. No further fractures have occurred within the protected femurs and no other repeat operations have been required.ConclusionsSurgical correction of the OI coxa vara hip is complex. Bone mineral density, multiplanar deformity, a desire to maintain physeal growth and protection of the whole bone all play a role in the surgeon's decision making process. Following modifications, this technique demonstrates a novel method in planning and control of multiplanar proximal femoral deformity, resulting in restoration of the FNSA to a more appropriate anatomical alignment, preventing long bone fracture and improved femoral verticalization in the medium term follow-up.
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