Stephen Matthew Quinnan

Despite advances in musculoskeletal trauma care, segmental bone loss remains a major clinical challenge. A substantial proportion of these cases are associated with fracture-related infection (FRI), which fundamentally alters the biological environment and reconstructive strategy. In this context, FRI should be considered in any patient with a segmental bone defect, and thorough surgical debridement with acquisition of multiple deep-tissue cultures represents an essential first step in management. The presence of infection reduces the likelihood of bone consolidation and eradication of disease, emphasizing the need for strict adherence to established FRI treatment principles. Depending on the extent of bone loss, host factors, and available expertise, patients may be eligible for a range of reconstructive options. Bone transport is one of these surgical methods and involves the gradual translocation of bone segments to reconstruct defects in long bones. Based on the principles of distraction osteogenesis (DO), controlled mechanical distraction promotes predictable bone regeneration according to Ilizarov's principles. Traditionally, DO has relied on circular external fixators. Recent developments involving integrated fixation, such as bone transport over a nail, have reduced morbidity and enabled faster reconstruction. Although these techniques carry a risk of contaminating the intramedullary canal, exclusive long-term use of external fixators is not harmless. Further innovations, such as motorized telescopic intramedullary nails, have led to the gradual replacement of external fixation, making the procedure less burdensome for patients. Advances in surgical skills and technology have enabled the treatment of more complex cases, making a specialized, multidisciplinary approach essential in modern clinical care.

Background: It is unclear whether postoperative pain differs by treatment type for patients with severe open tibial fractures. Methods: We performed a secondary analysis of data from the FIXIT study. Adults with severe open tibial fractures were randomized to undergo definitive modern external ring fixation (n = 122) or internal fixation (n = 132). Primary outcomes were pain intensity and interference at 6 and 12 months, measured by the Brief Pain Inventory. Secondary outcomes were Numeric Pain Rating Scale (NPRS) scores and the incidence of moderate to severe pain. Post hoc subanalysis compared pain in patients with and without pin-site infections and with and without external fixation removal. Results: At 6 months, median pain intensity did not differ significantly between the external fixation group (4.1 [interquartile range (IQR), 2.2 to 5.5]) and the internal fixation group (3.0 [IQR, 1.8 to 5.8]) (p = 0.11); however, patients who underwent external fixation had greater median pain interference (6.0 [IQR, 3.3 to 8.0]) than patients who underwent internal fixation (4.0 [IQR, 1.9 to 7.4]) (p = 0.01). At 12 months, pain intensity, pain interference, and NPRS scores did not differ by treatment type. The overall incidence of moderate to severe pain was 33% at 6 months and 35% at 12 months. At 6 months, pin-site infections were associated with greater pain intensity (p = 0.01) but not greater interference (p = 0.10). At 12 months, the presence of external fixation was associated with greater pain intensity (p = 0.01) and interference (p < 0.01). Conclusions: At 6 months after a severe open tibial fracture, patients treated with modern external ring fixation had greater pain interference than patients treated with internal fixation, partly because of pin-site infections. No differences in pain interference or intensity were seen at 12 months. At 12 months, patients with external fixation in place had greater pain intensity and interference than those whose external fixation had been removed, but this was not the case at 6 months. Approximately one-third of all patients had moderate to severe pain at both time points, highlighting that persistent pain is common, regardless of treatment type. These findings can guide surgeons in choosing ring external fixation or internal fixation for these fractures. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Background: This study compared the functional outcomes of patients with open tibial shaft fractures who were randomized to either modern external ring fixation (EF) or internal fixation (IF). We hypothesized that there would be differences in patient-reported function between the treatment groups. Methods: This preplanned analysis of secondary outcomes from the FIXIT study, a multicenter randomized clinical trial, included patients 18 to 64 years of age with a Gustilo-Anderson Type-IIIB or severe-Type IIIA diaphyseal or metaphyseal tibial fracture who were randomly assigned to either IF (n = 132) or EF (n = 122). Follow-up visits occurred at 6 weeks and 3, 6, and 12 months after randomization. Outcomes included Short Musculoskeletal Function Assessment (SMFA) scores, the Veterans RAND 12-Item Health Survey (VR-12) physical component score (PCS), use of ambulatory assistive devices, and ability to ambulate. Results: The mean VR-12 PCS was slightly higher (better) for IF (24.8) than for EF (22.6) at 3 months (mean difference, 2.2 [95% confidence interval (CI): 0.2, 4.3]; p = 0.03) and trended higher for IF (27.0) compared with EF (25.3) at 6 months (mean difference, 1.8 [95% CI: −0.9, 4.4]; p = 0.19). However, there was no difference between the groups at 12 months. There were no clinically important or significant differences in SMFA Dysfunction and Bother scores between the treatment groups at any time point. EF was associated with a higher risk of using any ambulatory assistive device at 6 months (relative risk, 1.5 [95% CI: 1.21, 1.82]; p < 0.0001). The absolute percentage of patients using any ambulatory device was 37.6% for IF and 45.4% for EF at 1 year. There was no difference in ambulatory status between the treatment groups at any time point. Conclusions: We found no difference in physical function between patients with severe tibial fractures treated with IF versus EF. There was a high rate of impairment overall. Assistive devices for walking were more often utilized in the EF group at 6 months, and both treatment groups demonstrated similar overall impairment. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Insertion of a skeletal traction pin in the distal femur or proximal tibia can be a painful and unpleasant experience for patients with a lower-extremity fracture. The purpose of this study was to determine whether providing patients with audio distraction (AD) during traction pin insertion can help to improve the patient-reported and the physician-reported experience and decrease pain and/or anxiety during the procedure. Methods: A prospective randomized controlled trial was conducted at 2 level-I trauma centers. Patients ≥18 years of age who were conscious and oriented and had a medical need for skeletal traction were included. Patients were randomized to receive AD or not receive AD during the procedure. All other procedure protocols were standardized and were the same for both groups. Surveys were completed by the patient and the physician immediately following the procedure. Patients rated their overall experience, pain, and anxiety during the procedure, and physicians rated the difficulty of the procedure, both on a 1-to-10 Likert scale. Results: A total of 54 patients met the inclusion criteria. Twenty-eight received AD and 26 did not. Femoral fractures were the most common injury (33 of 55, 60.0%). Baseline demographic characteristics did not differ between the 2 groups. The overall patient-reported procedure experience was similar between the AD and no-AD groups (3.9 ± 2.9 [95% confidence interval (CI), 3.1 to 4.7] versus 3.5 ± 2.2 [95% CI, 2.9 to 4.1], respectively; p = 0.55), as was pain (5.3 ± 3.2 [95% CI, 4.4 to 6.2] versus 6.1 ± 2.4 [95% CI, 5.4 to 6.8]; p = 0.28). However, anxiety levels were lower in the AD group (4.8 ± 3.3 [95% CI, 3.9 to 5.7] versus 7.1 ± 2.8 [95% CI, 6.3 to 7.9]; p = 0.007). Physician-reported procedure difficulty was similar between the groups (2.6 ± 2.0 [95% CI, 2.1 to 3.1] versus 2.8 ± 1.7 [95% CI, 2.3 to 3.3]; p = 0.69). Conclusions: AD is a practical, low-cost intervention that may reduce patient anxiety during lower-extremity skeletal traction pin insertion. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Summary: 3D printing and modeling has continued to grow in popularity over the past decade because the technology has matured and become more affordable and widely available. The main indications for nonbiological reconstruction of large bone defects are principally those patients where the candidate is unlikely to be successful if reconstructed by other means. Bespoke, custom, patient-specific implants can be designed to very effectively address bone loss, incorporating design elements that are particular to the needs of any given unique clinical condition. These implants are generally designed as titanium scaffolds that encourage bony incorporation at the host implant junction both proximal and distal. These scaffolds are typically considered a cellular solid, with high porosity that also promotes bone ingrowth directly into the substance of the body of the implant. Titanium scaffolds of this type have become a useful treatment alternative for large segmental bone defects around the knee, especially distal femoral defects. These are often adult patients with local or systemic compromise, or instead they may be too young to be considered candidates for reconstruction using a megaprosthesis. The process requires careful evaluation of individual patients, then matching that patient with the best treatment option, while recognizing the expectations and demands specific to that particular patient. Several cases are presented here to illustrate the variety of indications that can be successfully addressed with this technology, highlighting the quality of the clinical outcome that can be achieved despite the complexity of the pathology encountered.

How to cite this article:Quinnan S. Invited Commentary: The Incidence of Deep Infection Following Lower Leg Circular Frame with Minimum of 1-year Follow-up from Frame Removal. Strategies Trauma Limb Reconstr 2022;17(2):92.

Background: Severe lower extremity trauma among working-age adults is highly consequential for returning to work; however, the economic impact attributed to injury has not been fully quantified. The purpose of this study was to examine work and productivity loss during the year following lower extremity trauma and to calculate the economic losses associated with lost employment, lost work time (absenteeism), and productivity loss while at work (presenteeism). Methods: This is an analysis of data collected prospectively across 3 multicenter studies of lower extremity trauma outcomes in the United States. Data were used to construct a Markov model that accumulated hours lost over time due to lost employment, absenteeism, and presenteeism among patients from 18 to 64 years old who were working prior to their injury. Average U.S. wages were used to calculate economic loss overall and by sociodemographic and injury subgroups. Results: Of 857 patients working prior to injury, 47.2% had returned to work at 1 year. The average number of productive hours of work lost was 1,758.8/person, representing 84.6% of expected annual productive hours. Of the hours lost, 1,542.3 (87.7%) were due to working no hours or lost employment, 71.1 (4.0%) were due to missed hours after having returned, and 145.4 (8.3%) were due to decreased productivity while working. The 1-year economic loss due to injury totaled $64,427/patient (95% confidence interval [CI], $63,183 to $65,680). Of the 1,758.8 lost hours, approximately 88% were due to not being employed (working zero hours), 4% were due to absenteeism, and 8% were due to presenteeism. Total productivity loss was higher among older adults (≥40 years), men, those with a physically demanding job, and the most severe injuries (i.e., those leading to amputation as well as Gustilo type-IIIB tibial fractures and type-III pilon/ankle fractures). Conclusions: Patients with severe lower extremity trauma carry a substantial economic burden. The costs of lost productivity should be considered when evaluating outcomes.