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Papers by Paul Harwood

Research paper thumbnail of Complex Tibial Shaft Fractures in Children Involving the Distal Physis Managed with the Ilizarov Method

Strategies in Trauma and Limb Reconstruction

Introduction: Segmental fractures in the juvenile distal tibia with physeal involvement present s... more Introduction: Segmental fractures in the juvenile distal tibia with physeal involvement present specific challenges. Injury to the growth plate may be overlooked, potentially resulting in late sequelae. Fracture stabilization can be complex. Previous reports of management of such an injury are by open reduction and internal fixation. This study reviews the management and outcome of a group of such patients treated with Ilizarov external fixators. Materials and methods: Patients aged 16 or younger treated in our unit between March 2013 and November 2014 by Ilizarov circular fine wire fixation for tibial fractures with ipsilateral physeal injuries were identified. Retrospective collection of patient demographics, fracture classification, treatment pathways, fixation methods, postoperative follow-up, outcomes, and complications was undertaken. Results: Eight patients were identified; two had Gustilo and Anderson grade IIIA open injuries. All were managed definitively using an Ilizarov external fixator in combination with percutaneous screw fixation of the physeal component as required. All patients were ambulant during treatment and were allowed unrestricted weight-bearing immediately postoperative. All but one attended school. All fractures united. In follow-up, one patient had a distal tibial physeal growth arrest, but there were no other complications. Conclusion: Pediatric patients with complex distal tibial fractures should be scrutinized for concomitant physeal injury. Where identified treatment, using a combination of internal fixation and an Ilizarov fixator can be considered.

Research paper thumbnail of Amputation in Trauma—How to Achieve a Good Result from Lower Extremity Amputation Irrespective of the Level

Current Trauma Reports

Purpose of Review To provide an overview of patient management and surgical technique regarded as... more Purpose of Review To provide an overview of patient management and surgical technique regarded as best practice in optimising outcome following primary and secondary amputation in trauma patients. This is supported by evidence where available. Recent Findings There is increasing evidence that primary amputation may offer superior outcome to reconstruction in severe open lower limb injuries, particularly segmental trauma involving the foot and tibia. Similarly, patients considering complex reconstructive procedures for failed trauma management should be counselled that reported outcomes are equivalent or better following amputation and are achieved faster and with less complications. Patients should be fully informed of this when making decisions about management, though this needs to be individualised. Various surgical techniques have been associated with improved outcome and these are described herein. Careful peri-operative pain management has been associated with faster rehabilitation, better psychological response and a reduced risk of chronic pain. On discharge, patients should be linked to rehabilitation, prosthetic and clinical psychology services and these should be integrated where possible. Summary A holistic, multidisciplinary approach is recommended in all aspects of care and should be available from the outset. Patients should be optimised medically and functionally, where possible pre-operatively. Psychological assessment and early information sharing are recommended. Where this is not possible due to acuity, these issues should be addressed as soon as possible post-amputation. Particularly where the limb is severely injured, careful planning and joint operating by senior Orthopaedic, Plastic and Vascular surgeons can achieve the best results.

Research paper thumbnail of What effect has the major trauma network had on perceptions of trauma care delivery amongst trauma teams in major trauma centres and neighbouring trauma units?

European Journal of Trauma and Emergency Surgery

Research paper thumbnail of Measurement of wire deflection on loading may indicate union in Ilizarov constructs, an in vitro model

Strategies in Trauma and Limb Reconstruction

No entirely reliable method exists for assessing union during Ilizarov treatment. Premature remov... more No entirely reliable method exists for assessing union during Ilizarov treatment. Premature removal results in potential treatment failure; hence, alternative methods warrant investigation. Wire deflection might provide an indication of fracture site deformation on weight bearing, indicating progress towards union. This study aimed to test a method for assessing wire deflection within an Ilizarov frame. (1) To assess the repeatability of our novel measurement method in measuring wire deflection within an Ilizarov frame in vitro. (2) To compare the amount of wire deflection in an unstable model with that in an intact bone model. (3) To assess accuracy of this method by comparing wire deflection measured with overall machine extension. Tests were performed on clinical grade-tensioned fine wire 4-ring Ilizarov constructs stabilising a simulated fracture, with and without an unstable defect. Models were sequentially loaded to 700 N using an Instron testing machine. A digital depth gauge attached to the superior ring measured relative wire displacement at the ring closest to the fracture. Tests were repeated 3 times. (1) Both unstable and stable bone models produced highly repeatable load deformation curves (R 2 = 0.98 and 0.99). (2) In the unstable model, wires tensioned at 882 and 1274 N produced mean maximum deflections of 2.41 and 2.69 mm compared with 0.05 and 0.04 mm in the intact bone model (significant p < 0.0001). (3) Wire deflection and machine extension results were strongly correlated (r = 0.99). A measurable difference in wire deflection between stable and unstable situations exists using this method which appears accurate and repeatable, with clear correlation between displacement and load and displacement and machine extension. This approach might be clinically applicable, and further clinical testing is required.

Research paper thumbnail of Managing soft tissues in severe lower limb trauma in an ageing population

Injury, Jan 13, 2018

With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Str... more With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. Patients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. Between January 2013 and June 2016, 74 patients aged over 65 years were admitted with open lower limb fractures. 54 of these were open tibial fractures and thes...

Research paper thumbnail of Successful management of femoral trauma in a through-knee amputee with a previous malunited fracture: Implications and functional outcome

Prosthetics and Orthotics International, 2017

Background: After amputation patients are more likely to injure their residual limb. An injury of... more Background: After amputation patients are more likely to injure their residual limb. An injury of a previously amputated limb, especially if the residuum is not anatomically normal, poses a dilemma for management. Case Description and Methods: This case report discusses a femoral fracture sustained proximal to a through-knee amputation. Findings and outcomes: The fracture was at the site of a malunited fracture. A shortening osteotomy with bone graft was undertaken to improve alignment and prosthetic fit and remove poor-quality bone. This was stabilised using an intramedullary nail, supplemented with an anti-rotation plate. This fracture went on to uneventful union, and the patient was able to comfortably use a prosthesis with increased functionality compared with prior to the recent injury. Discussion: This management enabled quick healing of the fracture without the need to resort to a more proximal amputation. Conclusion: In these unusual cases, careful planning is necessary to e...

Research paper thumbnail of What Are the Biomechanical Properties of the Taylor Spatial Frame™?

Clinical orthopaedics and related research, Jan 28, 2016

The Taylor Spatial Frame™ (TSF) is a versatile variant of the traditional Ilizarov circular fixat... more The Taylor Spatial Frame™ (TSF) is a versatile variant of the traditional Ilizarov circular fixator. Although in widespread use, little comparative data exist to quantify the biomechanical effect of substituting the tried-and-tested Ilizarov construct for the TSF hexapod system. This study was designed to investigate the mechanical properties of the TSF system under physiologic loads, with and without the addition of a simulated bone model, with comparison to the standard Ilizarov frame. The mechanical behaviors of three identical four-ring TSF and Ilizarov constructs were tested under levels of axial compression, bending, and rotational torque to simulate loading during normal gait. An acrylic-pipe fracture model subsequently was mounted, using fine wires and 5 mm half pins, and the testing was repeated. Load-deformation curves, and so rigidity, for each construct were calculated, with statistical comparisons performed using paired t-tests. Under axial loading, the TSF was found to...

Research paper thumbnail of Restoration of long bone defects treated with the induced membrane technique: protocol and outcomes

Injury, 2016

This prospective study was undertaken at a regional tertiary referral centre to evaluate the resu... more This prospective study was undertaken at a regional tertiary referral centre to evaluate the results of treatment of bone defects managed with the induced membrane (IM) technique. Inclusion criteria were patients with bone defects secondary to septic non-union, chronic osteomyelitis and acute fracture with bone loss. Pathological fractures with bone loss were excluded. Data collection included patient demographics, pathology, previous surgical intervention, size of bone defect, type of graft implanted, time-to-union and complications/reinterventions. The minimum time of follow up was 12 months. Forty-three patients (32 males) met the inclusion criteria with a mean age of 47.9 years (range 18-80 years). 22 patients had an acute traumatic bone loss associated with open fracture and 21 presented with an infected non-union or underlying osteomyelitis requiring bone excision. The most common microorganisms grown were staphylcoccous aureus and coagulase negative staphylococcous. The mean ...

Research paper thumbnail of Novel Anticoagulants: New Evidence for Emerging Drugs and Their Potential Application in Major Lower Limb Surgery

Current Vascular Pharmacology, Nov 1, 2010

For decades, parenteral drugs, such as the low molecular weight heparins and unfractionated hepar... more For decades, parenteral drugs, such as the low molecular weight heparins and unfractionated heparins or vitamin K antagonists, have been used as anticoagulants for prevention of venous thromboembolism following major lower limb surgery. However, these regiments have limitations that rendered the quest for new anticoagulants mandatory. Recently, research has been focused on the development of orally active small molecules that directly target thrombin or activated factor X (FXa). These regiments exhibit a number of characteristics that an &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;ideal&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; anticoagulant should possess. Currently, two agents, dabigatran etexilate and rivaroxaban, which inhibit thrombin and FXa, respectively have been approved in the European Union and Canada for venous thromboprophylaxis in patients undergoing elective hip- or knee-replacement surgery. Other agents are at an early or late stage of clinical evaluation. In this study, we summarize the current evidence for these new developed or under development drugs regarding their applications in the filed of lower limb orthopaedic surgery.

Research paper thumbnail of Severe and multiple trauma in older patients; incidence and mortality

Injury Int J Care Injured, Mar 1, 2009

Research paper thumbnail of Inconsistencies in risk assessment

Psychiatric Bulletin, 1998

An audit of case notes and a survey of in-patients was carried out to evaluate risk assessment on... more An audit of case notes and a survey of in-patients was carried out to evaluate risk assessment on an in-patient ward. We found considerable inconsistencies between the risk assessment records in medical and nursing notes. A systematic survey found higher levels of risk than either set of notes, but combining the notes improved the quality of risk assessment compared to the survey. We suggest three key areas for action to improve risk assessment.

Research paper thumbnail of Exchange nailing for infective non-union: A single centre experience

Injury, 2009

Study rationale: The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investig... more Study rationale: The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing. Materials/patients and methods: Twenty-two (13 males, mean age 37.5 years) consecutive patients entered in this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on days 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISA. Six healthy volunteers formed the control group. Results: The median ISS was 14.5 (9-29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml, respectively. A direct correlation was observed between ISS and IL-6 and HMGB1 concentrations. HMGB1 concentrations reached to peak levels on day 6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21 ng/ml in the reamed and 2.98 ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Day 6 concentration of HMGB1 in patients with an ICU stay >5 days (n = 4), compared to the rest of the patients was 11.04 ng/ml (6.13-35.84) vs. 7.14 ng/ml (4.06-12.8), (p = 0.03). Conclusions: Femoral nailing and reaming induces a second hit as supported by the post-operative increased levels of both IL-6 and HMGB1. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immunoinflammatory process.

Research paper thumbnail of The economic impact of regional complex trauma and limb reconstruction service provision

Injury Extra, 2007

and bisphosphonate (4). DEXA scan referral was not indicated in 14 patients as 4 of them were alr... more and bisphosphonate (4). DEXA scan referral was not indicated in 14 patients as 4 of them were already on bisphosphonates and 10 patients had there abbreviated mental score was less than 7. Among the remaining 23 patients, 9 patients (40%) were referred for DEXA scan. This improvement is statistically significant (p = 0.03, chi square test). Discussion and conclusion: The re-audit shows that, although there is an improvement in the situation, we are still below the standards of secondary prevention of fragility fractures with 60% of femoral fragility fracture patients not being referred for DEXA scan. A pathway lead by a fracture liaison nurse dedicated to osteoporotic fracture patients should improve the situation.

Research paper thumbnail of The 'Retro-Fibular Wire': AN ANATOMICAL STUDY DESCRIBING A SAFE CORRIDOR FOR PLACEMENT OF FINE WIRES IN THE DISTAL TIBIA

Journal of Bone and Joint Surgery - British Volume, 2010

Anatomical atlases document safe corridors for placement of wires when using fine-wire circular e... more Anatomical atlases document safe corridors for placement of wires when using fine-wire circular external fixation. The furthest posterolateral corridor described in the distal tibia is through the fibula. This limits the crossing angle and stability of the frame. In this paper we describe a new, safe Retro-Fibular Wire corridor, which provides greater crossing angles and increased stability. In a cadaver study, 20 formalin-treated legs were divided into two groups. Wires were inserted into the distal quarter of the tibia using two possible corridors and standard techniques of dissection identified the distance of the wires from neurovascular structures. In both groups the posterior tibial neurovascular bundle was avoided. In group A the peroneal artery was at risk. In group B this injury was avoided. Comparison of the groups showed a significant difference (p < 0.001). We recommend the Retro-Fibular wire technique whereby wires are inserted into the tibia mid-way between the post...

Research paper thumbnail of Original Sin: A Cross- National Study of the Legality of Homosexual Acts

This article examines the legality of homosexual acts quantitatively in a cross-national perspect... more This article examines the legality of homosexual acts quantitatively in a cross-national perspective with a large sample of countries from 1972 to 2002. Employing path dependence as its theoretical framework, this work explains how political, economic, and legal institutions at the domestic and international levels affect the lives of individual citizens.The rights and privi- leges of individuals, the findings of this study indicate, are determined by a wide array of variables, including legal origin, economic development, religion, democratization, and the position of the nation in the international community. The authors use recently released cross-national data concerning decrimi- nalization of homosexual intercourse, economic conditions, and political institutions.A generalized estimating equation analyzes decriminalization of homosexual acts.A Cox proportional hazards model examines how long it takes to introduce this legal reform. Last, this study also offers some impor- tant lessons about civil rights and liberties more generally.

Research paper thumbnail of Long bone non-unions treated with the diamond concept: a case series of 64 patients

Injury, 2015

The aim of this retrospective study with prospectively documented data was to report the clinical... more The aim of this retrospective study with prospectively documented data was to report the clinical results of treatment of long bone non-unions using the "diamond concept". Over a 4-year period, patients that presented with a long bone non-union and were managed with the diamond conceptual framework of bone repair were evaluated. Exclusion criteria were hypertrophic, pathological, and infected non-unions. Fixation was revised as it was indicated whilst biological enhancement included the implantation of RIA graft, BMP-7 and concentrated bone marrow aspirate. Data recorded included patient demographics, initial fracture pattern and type of stabilisation, number of previous interventions, time to reoperation, time to union and functional outcome. Painless full weight bearing defined clinical union. Radiological union was defined as the presence of mature callous bridging to at least 3 bone cortices. The minimum follow up was 12 months (range 12-32). In total 64 patients (34 m...

Research paper thumbnail of What Are the Biomechanical Effects of Half-pin and Fine-wire Configurations on Fracture Site Movement in Circular Frames?

Clinical orthopaedics and related research, Jan 7, 2015

Fine-wire circular frame (Ilizarov) fixators are hypothesized to generate favorable biomechanical... more Fine-wire circular frame (Ilizarov) fixators are hypothesized to generate favorable biomechanical conditions for fracture healing, allowing axial micromotion while limiting interfragmentary shear. Use of half-pins increases fixation options and may improve patient comfort by reducing muscle irritation, but they are thought to induce interfragmentary shear, converting beam-to-cantilever loading. Little evidence exists regarding the magnitude and type of strain in such constructs during weightbearing. This biomechanical study was designed to investigate the levels of interfragmentary strain occurring during physiologic loading of an Ilizarov frame and the effect on this of substituting half-pins for fine-wires. The "control" construct was comprised of a four-ring all fine-wire construct with plain wires at 90°-crossing angles in an entirely unstable acrylic pipe synthetic fracture model. Various configurations, substituting half-pins for wires, were tested under levels of ax...

Research paper thumbnail of (ii) An update on fracture healing and non-union

Orthopaedics and Trauma, 2010

The basic science underlying the process of bone healing has been a topic of intense research act... more The basic science underlying the process of bone healing has been a topic of intense research activity over the past 50 years. Increasing understanding of events on a molecular level has allowed a greater understanding of factors that might contribute to failure of these mechanisms. From this it has been possible to introduce new treatment methods as adjuncts to traditional

Research paper thumbnail of Basal Thumb Joint (Carpometacarpal Joint)

Practical Procedures in Orthopedic Surgery, 2011

Research paper thumbnail of Common Extensor Origin (Tennis Elbow)

Practical Procedures in Orthopedic Surgery, 2011

Research paper thumbnail of Complex Tibial Shaft Fractures in Children Involving the Distal Physis Managed with the Ilizarov Method

Strategies in Trauma and Limb Reconstruction

Introduction: Segmental fractures in the juvenile distal tibia with physeal involvement present s... more Introduction: Segmental fractures in the juvenile distal tibia with physeal involvement present specific challenges. Injury to the growth plate may be overlooked, potentially resulting in late sequelae. Fracture stabilization can be complex. Previous reports of management of such an injury are by open reduction and internal fixation. This study reviews the management and outcome of a group of such patients treated with Ilizarov external fixators. Materials and methods: Patients aged 16 or younger treated in our unit between March 2013 and November 2014 by Ilizarov circular fine wire fixation for tibial fractures with ipsilateral physeal injuries were identified. Retrospective collection of patient demographics, fracture classification, treatment pathways, fixation methods, postoperative follow-up, outcomes, and complications was undertaken. Results: Eight patients were identified; two had Gustilo and Anderson grade IIIA open injuries. All were managed definitively using an Ilizarov external fixator in combination with percutaneous screw fixation of the physeal component as required. All patients were ambulant during treatment and were allowed unrestricted weight-bearing immediately postoperative. All but one attended school. All fractures united. In follow-up, one patient had a distal tibial physeal growth arrest, but there were no other complications. Conclusion: Pediatric patients with complex distal tibial fractures should be scrutinized for concomitant physeal injury. Where identified treatment, using a combination of internal fixation and an Ilizarov fixator can be considered.

Research paper thumbnail of Amputation in Trauma—How to Achieve a Good Result from Lower Extremity Amputation Irrespective of the Level

Current Trauma Reports

Purpose of Review To provide an overview of patient management and surgical technique regarded as... more Purpose of Review To provide an overview of patient management and surgical technique regarded as best practice in optimising outcome following primary and secondary amputation in trauma patients. This is supported by evidence where available. Recent Findings There is increasing evidence that primary amputation may offer superior outcome to reconstruction in severe open lower limb injuries, particularly segmental trauma involving the foot and tibia. Similarly, patients considering complex reconstructive procedures for failed trauma management should be counselled that reported outcomes are equivalent or better following amputation and are achieved faster and with less complications. Patients should be fully informed of this when making decisions about management, though this needs to be individualised. Various surgical techniques have been associated with improved outcome and these are described herein. Careful peri-operative pain management has been associated with faster rehabilitation, better psychological response and a reduced risk of chronic pain. On discharge, patients should be linked to rehabilitation, prosthetic and clinical psychology services and these should be integrated where possible. Summary A holistic, multidisciplinary approach is recommended in all aspects of care and should be available from the outset. Patients should be optimised medically and functionally, where possible pre-operatively. Psychological assessment and early information sharing are recommended. Where this is not possible due to acuity, these issues should be addressed as soon as possible post-amputation. Particularly where the limb is severely injured, careful planning and joint operating by senior Orthopaedic, Plastic and Vascular surgeons can achieve the best results.

Research paper thumbnail of What effect has the major trauma network had on perceptions of trauma care delivery amongst trauma teams in major trauma centres and neighbouring trauma units?

European Journal of Trauma and Emergency Surgery

Research paper thumbnail of Measurement of wire deflection on loading may indicate union in Ilizarov constructs, an in vitro model

Strategies in Trauma and Limb Reconstruction

No entirely reliable method exists for assessing union during Ilizarov treatment. Premature remov... more No entirely reliable method exists for assessing union during Ilizarov treatment. Premature removal results in potential treatment failure; hence, alternative methods warrant investigation. Wire deflection might provide an indication of fracture site deformation on weight bearing, indicating progress towards union. This study aimed to test a method for assessing wire deflection within an Ilizarov frame. (1) To assess the repeatability of our novel measurement method in measuring wire deflection within an Ilizarov frame in vitro. (2) To compare the amount of wire deflection in an unstable model with that in an intact bone model. (3) To assess accuracy of this method by comparing wire deflection measured with overall machine extension. Tests were performed on clinical grade-tensioned fine wire 4-ring Ilizarov constructs stabilising a simulated fracture, with and without an unstable defect. Models were sequentially loaded to 700 N using an Instron testing machine. A digital depth gauge attached to the superior ring measured relative wire displacement at the ring closest to the fracture. Tests were repeated 3 times. (1) Both unstable and stable bone models produced highly repeatable load deformation curves (R 2 = 0.98 and 0.99). (2) In the unstable model, wires tensioned at 882 and 1274 N produced mean maximum deflections of 2.41 and 2.69 mm compared with 0.05 and 0.04 mm in the intact bone model (significant p < 0.0001). (3) Wire deflection and machine extension results were strongly correlated (r = 0.99). A measurable difference in wire deflection between stable and unstable situations exists using this method which appears accurate and repeatable, with clear correlation between displacement and load and displacement and machine extension. This approach might be clinically applicable, and further clinical testing is required.

Research paper thumbnail of Managing soft tissues in severe lower limb trauma in an ageing population

Injury, Jan 13, 2018

With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Str... more With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. Patients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. Between January 2013 and June 2016, 74 patients aged over 65 years were admitted with open lower limb fractures. 54 of these were open tibial fractures and thes...

Research paper thumbnail of Successful management of femoral trauma in a through-knee amputee with a previous malunited fracture: Implications and functional outcome

Prosthetics and Orthotics International, 2017

Background: After amputation patients are more likely to injure their residual limb. An injury of... more Background: After amputation patients are more likely to injure their residual limb. An injury of a previously amputated limb, especially if the residuum is not anatomically normal, poses a dilemma for management. Case Description and Methods: This case report discusses a femoral fracture sustained proximal to a through-knee amputation. Findings and outcomes: The fracture was at the site of a malunited fracture. A shortening osteotomy with bone graft was undertaken to improve alignment and prosthetic fit and remove poor-quality bone. This was stabilised using an intramedullary nail, supplemented with an anti-rotation plate. This fracture went on to uneventful union, and the patient was able to comfortably use a prosthesis with increased functionality compared with prior to the recent injury. Discussion: This management enabled quick healing of the fracture without the need to resort to a more proximal amputation. Conclusion: In these unusual cases, careful planning is necessary to e...

Research paper thumbnail of What Are the Biomechanical Properties of the Taylor Spatial Frame™?

Clinical orthopaedics and related research, Jan 28, 2016

The Taylor Spatial Frame™ (TSF) is a versatile variant of the traditional Ilizarov circular fixat... more The Taylor Spatial Frame™ (TSF) is a versatile variant of the traditional Ilizarov circular fixator. Although in widespread use, little comparative data exist to quantify the biomechanical effect of substituting the tried-and-tested Ilizarov construct for the TSF hexapod system. This study was designed to investigate the mechanical properties of the TSF system under physiologic loads, with and without the addition of a simulated bone model, with comparison to the standard Ilizarov frame. The mechanical behaviors of three identical four-ring TSF and Ilizarov constructs were tested under levels of axial compression, bending, and rotational torque to simulate loading during normal gait. An acrylic-pipe fracture model subsequently was mounted, using fine wires and 5 mm half pins, and the testing was repeated. Load-deformation curves, and so rigidity, for each construct were calculated, with statistical comparisons performed using paired t-tests. Under axial loading, the TSF was found to...

Research paper thumbnail of Restoration of long bone defects treated with the induced membrane technique: protocol and outcomes

Injury, 2016

This prospective study was undertaken at a regional tertiary referral centre to evaluate the resu... more This prospective study was undertaken at a regional tertiary referral centre to evaluate the results of treatment of bone defects managed with the induced membrane (IM) technique. Inclusion criteria were patients with bone defects secondary to septic non-union, chronic osteomyelitis and acute fracture with bone loss. Pathological fractures with bone loss were excluded. Data collection included patient demographics, pathology, previous surgical intervention, size of bone defect, type of graft implanted, time-to-union and complications/reinterventions. The minimum time of follow up was 12 months. Forty-three patients (32 males) met the inclusion criteria with a mean age of 47.9 years (range 18-80 years). 22 patients had an acute traumatic bone loss associated with open fracture and 21 presented with an infected non-union or underlying osteomyelitis requiring bone excision. The most common microorganisms grown were staphylcoccous aureus and coagulase negative staphylococcous. The mean ...

Research paper thumbnail of Novel Anticoagulants: New Evidence for Emerging Drugs and Their Potential Application in Major Lower Limb Surgery

Current Vascular Pharmacology, Nov 1, 2010

For decades, parenteral drugs, such as the low molecular weight heparins and unfractionated hepar... more For decades, parenteral drugs, such as the low molecular weight heparins and unfractionated heparins or vitamin K antagonists, have been used as anticoagulants for prevention of venous thromboembolism following major lower limb surgery. However, these regiments have limitations that rendered the quest for new anticoagulants mandatory. Recently, research has been focused on the development of orally active small molecules that directly target thrombin or activated factor X (FXa). These regiments exhibit a number of characteristics that an &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;ideal&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; anticoagulant should possess. Currently, two agents, dabigatran etexilate and rivaroxaban, which inhibit thrombin and FXa, respectively have been approved in the European Union and Canada for venous thromboprophylaxis in patients undergoing elective hip- or knee-replacement surgery. Other agents are at an early or late stage of clinical evaluation. In this study, we summarize the current evidence for these new developed or under development drugs regarding their applications in the filed of lower limb orthopaedic surgery.

Research paper thumbnail of Severe and multiple trauma in older patients; incidence and mortality

Injury Int J Care Injured, Mar 1, 2009

Research paper thumbnail of Inconsistencies in risk assessment

Psychiatric Bulletin, 1998

An audit of case notes and a survey of in-patients was carried out to evaluate risk assessment on... more An audit of case notes and a survey of in-patients was carried out to evaluate risk assessment on an in-patient ward. We found considerable inconsistencies between the risk assessment records in medical and nursing notes. A systematic survey found higher levels of risk than either set of notes, but combining the notes improved the quality of risk assessment compared to the survey. We suggest three key areas for action to improve risk assessment.

Research paper thumbnail of Exchange nailing for infective non-union: A single centre experience

Injury, 2009

Study rationale: The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investig... more Study rationale: The role of the pro-inflammatory cytokine HMGB1 (alarmins) has not been investigated in the clinical setting. This study aims to assess its relationship to IL-6 release, ISS, and to quantify the second hit phenomenon after femoral nailing. Materials/patients and methods: Twenty-two (13 males, mean age 37.5 years) consecutive patients entered in this prospective randomised trial. All patients underwent stabilisation of the femoral shaft fracture with reamed (10 patients) or unreamed nailing. Patient demographics, ISS, and complications were recorded prospectively. Peripheral blood samples were collected on admission, induction of anaesthesia, entry into femoral canal, wound closure and on days 1, 3, and 6. Serum HMGB1 and IL-6 concentrations were measured using ELISA. Six healthy volunteers formed the control group. Results: The median ISS was 14.5 (9-29). Admission median HMGB1 and IL-6 concentrations were 7.2 ng/ml and 169 pg/ml, respectively. A direct correlation was observed between ISS and IL-6 and HMGB1 concentrations. HMGB1 concentrations reached to peak levels on day 6. On the contrary, the median concentration of IL-6 peaked around day 1 postoperatively (reamed: 780 vs. unreamed: 376 pg/ml) and then showed a downward trend. The median increase of HMGB1 by day 6 was 4.21 ng/ml in the reamed and 2.98 ng/ml in the unreamed population; the median increase of IL-6 by day 1 measured 462 pg/ml and 232 pg/ml in the respective groups. Day 6 concentration of HMGB1 in patients with an ICU stay >5 days (n = 4), compared to the rest of the patients was 11.04 ng/ml (6.13-35.84) vs. 7.14 ng/ml (4.06-12.8), (p = 0.03). Conclusions: Femoral nailing and reaming induces a second hit as supported by the post-operative increased levels of both IL-6 and HMGB1. While IL-6 has been suggested as a marker of assessment of the early inflammatory response, alarmins can provide useful information at the later stage of an evolving immunoinflammatory process.

Research paper thumbnail of The economic impact of regional complex trauma and limb reconstruction service provision

Injury Extra, 2007

and bisphosphonate (4). DEXA scan referral was not indicated in 14 patients as 4 of them were alr... more and bisphosphonate (4). DEXA scan referral was not indicated in 14 patients as 4 of them were already on bisphosphonates and 10 patients had there abbreviated mental score was less than 7. Among the remaining 23 patients, 9 patients (40%) were referred for DEXA scan. This improvement is statistically significant (p = 0.03, chi square test). Discussion and conclusion: The re-audit shows that, although there is an improvement in the situation, we are still below the standards of secondary prevention of fragility fractures with 60% of femoral fragility fracture patients not being referred for DEXA scan. A pathway lead by a fracture liaison nurse dedicated to osteoporotic fracture patients should improve the situation.

Research paper thumbnail of The 'Retro-Fibular Wire': AN ANATOMICAL STUDY DESCRIBING A SAFE CORRIDOR FOR PLACEMENT OF FINE WIRES IN THE DISTAL TIBIA

Journal of Bone and Joint Surgery - British Volume, 2010

Anatomical atlases document safe corridors for placement of wires when using fine-wire circular e... more Anatomical atlases document safe corridors for placement of wires when using fine-wire circular external fixation. The furthest posterolateral corridor described in the distal tibia is through the fibula. This limits the crossing angle and stability of the frame. In this paper we describe a new, safe Retro-Fibular Wire corridor, which provides greater crossing angles and increased stability. In a cadaver study, 20 formalin-treated legs were divided into two groups. Wires were inserted into the distal quarter of the tibia using two possible corridors and standard techniques of dissection identified the distance of the wires from neurovascular structures. In both groups the posterior tibial neurovascular bundle was avoided. In group A the peroneal artery was at risk. In group B this injury was avoided. Comparison of the groups showed a significant difference (p < 0.001). We recommend the Retro-Fibular wire technique whereby wires are inserted into the tibia mid-way between the post...

Research paper thumbnail of Original Sin: A Cross- National Study of the Legality of Homosexual Acts

This article examines the legality of homosexual acts quantitatively in a cross-national perspect... more This article examines the legality of homosexual acts quantitatively in a cross-national perspective with a large sample of countries from 1972 to 2002. Employing path dependence as its theoretical framework, this work explains how political, economic, and legal institutions at the domestic and international levels affect the lives of individual citizens.The rights and privi- leges of individuals, the findings of this study indicate, are determined by a wide array of variables, including legal origin, economic development, religion, democratization, and the position of the nation in the international community. The authors use recently released cross-national data concerning decrimi- nalization of homosexual intercourse, economic conditions, and political institutions.A generalized estimating equation analyzes decriminalization of homosexual acts.A Cox proportional hazards model examines how long it takes to introduce this legal reform. Last, this study also offers some impor- tant lessons about civil rights and liberties more generally.

Research paper thumbnail of Long bone non-unions treated with the diamond concept: a case series of 64 patients

Injury, 2015

The aim of this retrospective study with prospectively documented data was to report the clinical... more The aim of this retrospective study with prospectively documented data was to report the clinical results of treatment of long bone non-unions using the "diamond concept". Over a 4-year period, patients that presented with a long bone non-union and were managed with the diamond conceptual framework of bone repair were evaluated. Exclusion criteria were hypertrophic, pathological, and infected non-unions. Fixation was revised as it was indicated whilst biological enhancement included the implantation of RIA graft, BMP-7 and concentrated bone marrow aspirate. Data recorded included patient demographics, initial fracture pattern and type of stabilisation, number of previous interventions, time to reoperation, time to union and functional outcome. Painless full weight bearing defined clinical union. Radiological union was defined as the presence of mature callous bridging to at least 3 bone cortices. The minimum follow up was 12 months (range 12-32). In total 64 patients (34 m...

Research paper thumbnail of What Are the Biomechanical Effects of Half-pin and Fine-wire Configurations on Fracture Site Movement in Circular Frames?

Clinical orthopaedics and related research, Jan 7, 2015

Fine-wire circular frame (Ilizarov) fixators are hypothesized to generate favorable biomechanical... more Fine-wire circular frame (Ilizarov) fixators are hypothesized to generate favorable biomechanical conditions for fracture healing, allowing axial micromotion while limiting interfragmentary shear. Use of half-pins increases fixation options and may improve patient comfort by reducing muscle irritation, but they are thought to induce interfragmentary shear, converting beam-to-cantilever loading. Little evidence exists regarding the magnitude and type of strain in such constructs during weightbearing. This biomechanical study was designed to investigate the levels of interfragmentary strain occurring during physiologic loading of an Ilizarov frame and the effect on this of substituting half-pins for fine-wires. The "control" construct was comprised of a four-ring all fine-wire construct with plain wires at 90°-crossing angles in an entirely unstable acrylic pipe synthetic fracture model. Various configurations, substituting half-pins for wires, were tested under levels of ax...

Research paper thumbnail of (ii) An update on fracture healing and non-union

Orthopaedics and Trauma, 2010

The basic science underlying the process of bone healing has been a topic of intense research act... more The basic science underlying the process of bone healing has been a topic of intense research activity over the past 50 years. Increasing understanding of events on a molecular level has allowed a greater understanding of factors that might contribute to failure of these mechanisms. From this it has been possible to introduce new treatment methods as adjuncts to traditional

Research paper thumbnail of Basal Thumb Joint (Carpometacarpal Joint)

Practical Procedures in Orthopedic Surgery, 2011

Research paper thumbnail of Common Extensor Origin (Tennis Elbow)

Practical Procedures in Orthopedic Surgery, 2011