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Implants and Late Reconstruction
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Implants and Late Reconstruction
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Upload Date:
2025-04-27T01:16:31.5991445Z
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Language: EN.
Segment:0 .
WILL EARDLEY: What I'm going to talk to you about is essentially the late reconstruction elements of care and about conversion from external to internal fixation, and also about contamination and infection, because that all goes hand in hand.
WILL EARDLEY: So essentially it's an orthoplastics reconstructive talk, mindful of the austere environment. So essentially we're facing old adversaries. Nothing changes in conflicts and trauma surgery and these old adversaries are holes and problems with the skin. Organisms, the infection. Gaining bony union and stability because we want to heal the bones and joint stiffness. Those are the things that even when we've saved a life, we've saved a limb,
WILL EARDLEY: often these are the challenges that come next, and that's where we are at the minute. And this is part of what I would term the reconstructive landscape. And if these things aren't addressed in every step of what we do, then a suboptimal outcome may happen. So in terms of that, first I want to touch on infection in conflict wounded because how we manage the organism burden and what it does to people is different than it is in civilian practice.
WILL EARDLEY: There's many, many similarities and parallels, but this is something that's so important because it really does determine outcome for those wounded as a result of conflict. So when you're dealing with these cases, what do you need to be thinking? You need to be thinking about infection. You need to be thinking about contamination and then preventing that from turning into infection. You need to be thinking about your host type. Now, in conflict, it's normally fit young men, but it depends on who's involved
WILL EARDLEY: and you need to be thinking about the host because everyone behaves differently. And bugs tend to grow in groups around hospitals and so it's really important that you have an overview of everything that's growing in your hospital and your organisms that you find, because that's your nosocomial burden. So really be mindful about what's growing in all of your wounds, not just the patient in front of you.
WILL EARDLEY: Have you got a treatment plan? You need a treatment plan. You can't just let these cases unravel. So the treatment plan, your antimicrobial treatment plan is must be divided in your head into prophylactic, what you're going to give to prevent and also for ongoing care should you have a problem. And obviously what is plan B if infection occurs? So if you do something to someone, what's going to happen to your bone, your skin and the organisms?
WILL EARDLEY: You need to have that in your head. So that's how I like to see it. These things are preventable, and we need to be mindful all the way through the reconstructive process of the impact of infection. From a reconstructive point of view, no skin, no hope. If you haven't got good quality skin cover, there really is slim chance of really good union without overwhelming infection.
WILL EARDLEY: So we talked about needing to think about infection, we need to think about skin. If you've got infection and good skin, there is some hope so it's about application of principles. Like I said, soft tissue cover. You have to think about the impact of the soft tissue, because that will dictate pretty much everything. You need to be able to manage and control infection, and you need to choose something that's going to give you an appropriate strain environment for the choice of fracture healing.
WILL EARDLEY: Nine times out of 10 or eight times out of 10, it's going to be secondary bone healing and that's how I work out what the right device is and it's so important that decision making is on point when you've got a problem with infection or contamination and soft tissue cover. So choose how you're going to heal this bone in the light of the skin and in the lighter organisms.
WILL EARDLEY: And that will really help you work out the sweet spot for the best type of implant. Pain management, the impact of all those things. The soft tissue cover, the donor site, the lat dorsi donor site for flap, how that's going to affect pain management in people that have sometimes been exposed to a lot of pain so the principle is really involved pain management. Rehabilitation, that stiffness is so important.
WILL EARDLEY: And you have to have a plan B and a plan C and a plan D revisiting the above these principles. So your plan A. What you'd most like to do, what you think would be best all round needs to be all of those things. Now, there's no point in having a plan B, there's no point about having a get out of jail. There's no point about having something that you're going to do if plan A goes wrong that doesn't involve the same things, because you might have a great plan B for the strain environment, right?
WILL EARDLEY: If that doesn't work, I'm going to do this implant. But if that then compromises something you've already done well, so you might want to be thinking about doing another implant, but that actually might compromise your soft tissue cover so your plan B has to include all the same stuff. And it's hard. It's really tricky.
WILL EARDLEY: And you may want to discuss these cases with other people frequently. For the really complex stuff we share cases and discuss our plans. Plan C is the same, so there's no point in having a plan B, a plan C, a plan D that don't involve the same things because you're going to get false reassurance so you need to have all of the bases covered for every plan that you have.
WILL EARDLEY: By the time you get to plan C, plan D you're in, you're in bother but it you know, it might not be that easy, but you essentially want to tick as many boxes as possible. Now we're moving on to a bit more specifics about internal fixation and transition from external fixation and this is an absolutely fantastic piece of work for the surgeon dealing with these types of injuries.
WILL EARDLEY: And some of what I'm going to talk about is lifted from this book and I'd like to give them the credit for that. So when we talk about taking someone who's been very badly injured, both musculoskeletally and sometimes systemically with lung and brain and chest problems, terrible pelvis problems that we used to see abroad, we talk about single procedure and internal fixation.
WILL EARDLEY: So we're going to talk about internal fixation, conversion to internal fixation and I'm going to touch on a couple of papers because people do talk about these papers about internal fixation done really pretty far forward just because the evidence is there. Again, this is all kind of level 4 evidence and it's stuff that we did is the best way to explain it. So this is a US military series. It's predominantly blunt trauma.
WILL EARDLEY: That's really important to note. So the bulk of these patients weren't penetrating injury or blast. When you, when you boil down to it, when they're discussing the outcomes of these injuries, they're predominantly ankle fractures and hip fractures. They describe minimal infection. The thing is it's a self-selecting but probably non generalizable series and what I mean by that
WILL EARDLEY: is this, these surgeons performed judicious internal fixation in some patients and they did OK is the best way to look at it. Quite far forward. And they're very good in the fact that they don't say that this is something that should be generalized but I think it's remiss if we don't discuss these papers and people aren't aware of them, because otherwise people will turn to them for advice.
WILL EARDLEY: So again, there are documents such as this and the next one that talk about internal fixation in theater however, this shouldn't be considered the norm. And part of the reason why is that not all far forward facilities are as advanced as this. This is another case series. This is a single surgeon case series from two deployments recently. So this was of non US military personnel.
WILL EARDLEY: The first one was about military personnel. This was about locals. Afghan National Army and locals that were operated on because they couldn't do the external fixation and sent back to the United States. These are people that were going to be staying in country. As with any of these series, as you can imagine, the follow up was very limited. It discussed the level 3 facility being modern, ventilation and clean
WILL EARDLEY: so this isn't what a lot of forward surgeons would find so it's a bit of a strange circumstance. And as I say that with judicious use and the right people, that internal fixation quite far forward does have a role but it shouldn't be routine practice. And also, the other thing is that people comment, and this is about any form of war surgery with different populations, is that there is the impact on the host nation
WILL EARDLEY: if you do get a deep infection and there's metal inside there and there isn't the facility to take the metal out with all of the kit that we would have in our hospitals, there is a duty of care there. So the authors are very clear that these are really a report on the art of the possible, as opposed to something that should be recommended and that's really important that message gets across.
WILL EARDLEY: So that's a little bit about what's been said about purely early internal fixation. It's not recommended and we move on. So, what the next big thing and this is what the bulk of this part of the talk is going to be about is what we call sequential external infection, sorry sequential external fixation and then internal fixation.
WILL EARDLEY: There's a lot of literature on this. So I've called it the main event. This is the thing that we're talking about the most. This is converting people from their damage control external fixation to a more permanent device and the main event. It's done throughout the world. There is varied but very diverse literature on this. None of the literature is high quality. It's heterogeneous patient groups, heterogeneous injuries, heterogeneous practice.
WILL EARDLEY: Basically, there's nothing that's a constant in this, so it makes it nearly impossible. There is a synthesis later, but it's nearly impossible to synthesize anything meaningful. Key factors. So the main things that we talk about that are keep coming out as comparators are is the duration of external fixation. So how long the person is in an external fixator before the next surgery.
WILL EARDLEY: So time in ex-fix before definitive surgery. That's important and keeps coming up as a variable. And then we talk about single or two stage. That's, that's the main thing that keeps coming up. And yeah just remember that the thinking behind this needs to sit inside all those principles. So this is work by John Clasper, who was a mentor of mine, who when I did my doctorate work, he was my supervisor and they'd done an awful lot of work, really very basic.
WILL EARDLEY: I mean that in the kindest sense in that it's really just gives us the really important information that we need, we need to know. So what they did was a series of experiments on animals looking at essentially the behavior of pin sites with no broken bone and no definitive surgery to follow, and then moved on to look at pin sites with definitive surgery and pin sites with broken bones and contamination. And so here we go in intramedullary nailing.
WILL EARDLEY: So what the first paper showed that the accumulation of fluid around a pin site really did make a difference and we know this. All of us who do limb reconstruction know that the pin bone interface is everything. And if you've got poor technique or big open pins, that's a problem. So that's pretty much straight forward.
WILL EARDLEY: And then they went to look at the effect of the spread of infection with intramedullary nailing and essentially, that there was found they found there was infection was spread throughout the entire bone and even just having one pin site contaminated in the bone, the distal pin sites all blew out. And that's pretty much straightforward as you can imagine.
WILL EARDLEY: But this was the first time really that it was studied in detail, which is fantastic. And when even if you have heavily contaminated pin sites, even with all of the best things that we can do before intramedullary nailing, the, there were still problems afterwards. So even with lavage, even with antibiotics, heavily contaminated pin sites will lead to problems. And you'll see in a lot of the papers that we discuss in a minute that is, that holds true.
WILL EARDLEY: So if you've got heavily contaminated pin sites or a series of them, certainly not having a pin site holding may be a problem, but these are, I really commend these papers to really get down to the real basics of this kind of care. What's really fantastic in this, and really makes a big difference, is that when they looked, so they nailed a load of intact tibias after contaminating the pin sites. So contaminated pin sites, took the pin sites pins out, nailed the tibia.
WILL EARDLEY: The one animal that did really badly was one with a fracture, which is really interesting because it does show that element of instability that adds to it. So that went on to then for them to develop a model with a fracture. And essentially if you've got a heavily contaminated pin pin sites and you do straight nailing straight away, there's going to be trouble. And that's, it's great science.
WILL EARDLEY: These are great. Some of my favorite experiments and I really commend these and it really does help us understand. It's just an animal model saying what we know is if you've got terrible pin site problems, going straight away for nailing is going to be a problem. It's pretty straightforward. So the next thing you may ask is that what's the what's the best thing to do if you do have pin sites, you know, even if you've just got straightforward pin sites that are not infected, it does
WILL EARDLEY: it, doesn't make a big difference to debride them and again, the outcomes on this are so heterogeneous. There's studies that say you should, the studies that say you shouldn't. I think it's common sense. I think if you've got really clean, straightforward pin sites, I don't tend to debride them. I think that other things that you do in terms of how you do your definitive next stages, make a bigger difference
WILL EARDLEY: personally. I think in the femur, when you've got these quite deep pin sites, I tend to debride them because it makes sense to me. There is no science to it, but I think that there's such a big cavity in that pin site that cleaning out the muscle interface and cleaning out the bone makes sense, but there's no real science to that. Essentially, you can do which whatever you wish.
WILL EARDLEY: So we get into clinical series. So Clasper's work was about animal work and it showed us what we kind of know now that if things are heavily contaminated, it's not going to go too well. This is now clinical work and I'm just going to show you it's such this is the only real randomized trial. This was randomizing fixation with nails versus moving from, so ex-fix and then nail or ex-fix and then cast.
WILL EARDLEY: It's been done quite some time ago but I'm pulling out the salient points is that 27 days an external fixation and then so this was sequential. So having a pin site holiday, 10 days in cast so ex-fix comes off, 10 days in a cast and for the intramedullary group there's one deep infection so this is having a pin site holiday. And a lot of diff, there's so many different studies I've got them pretty much all here
WILL EARDLEY: so this talk will give you pretty much every reference there is on this. Nine weeks in ex-fix, mix of single and two stage you can see here. No increased complications as long as there's no pin site infections and that's what gets us back to Claspers work is that in these patients clinically that don't have good going pin site infections, the chance of a later infection is much less, which makes an awful lot of sense
WILL EARDLEY: and it does resonate with John Claspers work in the sheep. Here we go. Again, you can see the quality of the literature for patients. You know, it's a case. It's a small group of cases that did OK. You know, you would, you'd argue with the science behind this and, and the generalizability and again from our previous number of patients that were in nine weeks in external fixation, this is 48 to 72 hours.
WILL EARDLEY: So it's really difficult to compare any of these, which we'll see. Again, time in frame really does make a difference. That's the one thing. This group termed, you know, less than 14 days, 14 to 28 and more than 28 days, and essentially infection rates go up because you have the frame on for longer. That ties in exactly as we've just seen about the contamination.
WILL EARDLEY: There's no doubt about that. So time in frame does make a difference and that's pretty obvious. Again, another one of the key most quoted papers and here we have six weeks and this is sequential where the nailing was performed about seven weeks after injury. So you know, the index procedure was performed about a week after the frame coming off
WILL EARDLEY: and pin site infection was, again, one of the key elements of this so sequential nailing doesn't do well with pin site infections. Again another quite big series, 41 open fractures of tibial shaft. They again pretty low infection rates. So this is tibial shaft of 39 patients. Adequate follow up. Only two had a deep infection.
WILL EARDLEY: And the average duration of external fixation was 17 days here and then 9 days. So people talk about a 9, 10 day pin site holiday in cast. That's what a lot of our current thinking is based on these studies but you can see how heterogeneous they are. All the outcome measures differently and it's really important that we remember that. But there's another study coming next, which I'll show you, which I think you need to,
WILL EARDLEY: we really need to think about how good the literature is, because this study here, 41 open fractures, 5% had a deep infection. But then there's another one here looking at conversion of external fixation to intramedullary nail and this was I believe this series was without a pin site holiday and about 30% had an infection so the pendulum of the evidence swings all over the place.
WILL EARDLEY: It's really difficult to pin down because none of these series are really all that good. One thing that we know is that the femur is more forgiving for definite. Now, I found this interesting, actually, because some of my pin sites in the femur, I don't know if it's the way I do them. The pin sites in the femur can be pretty terrible and one would think that would lead to more problems
WILL EARDLEY: but I think that's just more about the limb segment and the femur is a bit more forgiving. And in this series, this is a series where the operations have been done throughout the military evacuation chain and you can see they're young men effectively. 125 closed femoral fractures. External fixation done pretty much straight away and then the nailing done about a week later.
WILL EARDLEY: And this is ex-fix on week later. Conversion to nail with no pin site holiday and infection rate 2.5%. But these with closed femur fractures remember in fit young man, so these aren't with blast injuries with massive open wounds. So this is where we need to really remember. This is a femoral series of femoral fractures nailed relatively early
WILL EARDLEY: but the devil is in the detail of the type of injuries. So this is closed femur OK. So that's the femur, bit more forgiving. Again on the femur. Another series. This is a civilian from Shock Trauma. Again pretty straightforward. What we know now immediate external fixation closed by, followed by early close nailing safe treatment. Makes sense.
WILL EARDLEY: Good hosts. Closed matches. Again, another series later on from Shock Trauma. External fixation is a viable alternative to attain temporary rigid stabilization and then followed by nailing with limited complications. So the femur is more forgiving and clearly the better host you do it in, the better. So femur more forgiving than the tibia. Now, I said that evidence synthesis was pretty difficult
WILL EARDLEY: and it is but it doesn't stop Mo Bhandari from giving us another fantastic paper. So looking at, they've looked at the evidence behind these injuries and you can see I've taken this straight from the paper that there's one level one trial, which there's aren't, there aren't many other evidence syntheses that would be based on that.
WILL EARDLEY: Everything else is level three or four and you can basically distill this. It's a great resource this and it's done by some really pretty senior authors. So the bottom line is for sequential femoral nailing following external fixation. The infection rates are pretty good and the union rates are pretty high. Again, for the tibia things are slightly less good. You know infection rates are much higher, although the union rates are, you know, pretty good.
WILL EARDLEY: And when you look across all of these studies, the early groups are so heterogeneous that they're difficult to compare. But what most of the research would agree on is that there's compelling evidence that when you're getting out to 28 days and more, the risk of infection jumps up significantly. So the research is really very poor. The studies are small and it's really difficult to base things on.
WILL EARDLEY: But one thing that you can draw from this, both the preclinical work and the clinical work, is if you've got really good going pin site infection, you should not nail. That seems pretty obvious, but that's the main finding really. The tibia is less forgiving than the femur, and the femur you can nail with a bit more confidence and perhaps a few more problems on board before you have a significant infection.
WILL EARDLEY: And that sequence, doing things, having a break seems to provide improvement. So we then go on to talk about what we can do. So for example, what I would do is I have often taken external fixators off, and I have reamed the canal and placed a off label antibiotic temporizing homemade antibiotic nail down that can provide it, that sort of thing, and then have a pin site holiday.
WILL EARDLEY: I think that works well for me. That's something that we can do and you're getting the benefit of cleaning the canal out. We use the reamer irrigator aspirator and you ream the nail, put a reaming one down nicely. You ream out the canal so the canal is ready for the nail, and you get the benefit of the two weeks of elution. So that's something that we can do. We then follow it with a definitive nail
WILL EARDLEY: and we have been using the Synthes ETN PROtect nail that's sprayed with plasma, sprayed with gentamicin. This is a series from the Royal London, which is interesting because we've in my practice these are small numbers so I'm not talking about huge amount of cases. We've had favorable results that I've not had a deep infection with sequential FRI. I've not had a problem when I've taken an infective case and I've treated like this, but the guys from London have done many more than I have
WILL EARDLEY: and they found that not great results when using it in FRI, which is really interesting. Which goes back to the point that if you've already got an infection, things are challenging. So yeah, so this is the antibiotic nail. We also use a substance called DAC; defensive antibacterial coating, which is essentially a slime, which you can place on a non antibiotic coated nail.
WILL EARDLEY: And just to show the heterogeneity of the literature, there's another group, this time in Germany I believe, who actually found that their results even with FRI were pretty good. So the pendulum of the literature is there. You can use augmented devices. These are something that we do tend to use for high risk patients, and it's something to bear in mind if you're doing late reconstruction.
WILL EARDLEY: I think we can say that doing conversion from external to internal is safe. There are so many variables that need to come in mind. So that's where go to the principles first. Think about where you want to be, follow those principles and you will narrow down your complication profile for definite because the literature is so diverse, because of it's so heterogeneous.
WILL EARDLEY: Definitely as little time in external fixator as possible. That's, that's obvious to anybody and if you do have pin site problems, then I probably would go cautious with going sequential. That makes a lot of sense to me. That's what I've done in the past, and there's definitely loads of evidence that is something you can do. The problem is it's more operations for the patients and it's a longer in-hospital stay.
WILL EARDLEY: But if 10 days in hospital with a couple of operations done well, and then out and rehabbing actually might be an overall balance better for the patient. It's something to bear in mind. So to summarize, you know, we know where we've been. There's been an awful lot of incredible good conflict surgery done. So we know where we've been. We know where we are now, which is the reconstructive landscape
WILL EARDLEY: and I think, I hope I've just added a bit to that about thinking about those organisms, thinking about the resources we have to guide us. Pretty much everything about conversion to internal fixation is in this talk that is available in the literature. Think about infection please, at all times and include this in your plan B, C and D. What are you going to do if there's an infection and how do you manage infection?
WILL EARDLEY: Always have a protocol. Please don't be a surprised infection surgeon. Have it ready. They should be. They will come and get you at any opportunity and you need to be ready. Decision making. We looked at those principles. Remember that.
WILL EARDLEY: Think less about an individual implant. Think more about the skin, the soft tissue, the infection that you've got, the infection that you might get and your rehab and your pain management, all those things. And remember that every plan A, B and C you have has to have all that inside it. And we've mentioned there about conversion of external fixation to internal fixation.
WILL EARDLEY: There's no right answer. There's no paper that gives you the definitive. Femur is more tolerant than tibia. Tibia with pin site problems, converting to infix is going to be a problem. So that's when you might take a drift out into using augmented implants and doing things sequentially to have a holiday and a clean up. That's, that's the basis of it. Now, this isn't the most scientific presentation, you will hear.
WILL EARDLEY: It's distillation of stuff that I know, and that only comes from stuff that many, many people have taught me and I try and teach others. That's the beauty of doing trauma, and particularly with infection and recon, is it's difficult to put P value on anything. It's distillation of knowledge and I really commend looking backwards.
WILL EARDLEY: What I write shouldn't really influence, because what I write is just a distillation of what's been written for generations. So I hope that makes sense. I hope that that has been of use. It's quite philosophical and I'll probably watch it more than once. I wish you the best of luck. [VIDEO ENDS]
Segment:0 .
WILL EARDLEY: What I'm going to talk to you about is essentially the late reconstruction elements of care and about conversion from external to internal fixation, and also about contamination and infection, because that all goes hand in hand.
WILL EARDLEY: So essentially it's an orthoplastics reconstructive talk, mindful of the austere environment. So essentially we're facing old adversaries. Nothing changes in conflicts and trauma surgery and these old adversaries are holes and problems with the skin. Organisms, the infection. Gaining bony union and stability because we want to heal the bones and joint stiffness. Those are the things that even when we've saved a life, we've saved a limb,
WILL EARDLEY: often these are the challenges that come next, and that's where we are at the minute. And this is part of what I would term the reconstructive landscape. And if these things aren't addressed in every step of what we do, then a suboptimal outcome may happen. So in terms of that, first I want to touch on infection in conflict wounded because how we manage the organism burden and what it does to people is different than it is in civilian practice.
WILL EARDLEY: There's many, many similarities and parallels, but this is something that's so important because it really does determine outcome for those wounded as a result of conflict. So when you're dealing with these cases, what do you need to be thinking? You need to be thinking about infection. You need to be thinking about contamination and then preventing that from turning into infection. You need to be thinking about your host type. Now, in conflict, it's normally fit young men, but it depends on who's involved
WILL EARDLEY: and you need to be thinking about the host because everyone behaves differently. And bugs tend to grow in groups around hospitals and so it's really important that you have an overview of everything that's growing in your hospital and your organisms that you find, because that's your nosocomial burden. So really be mindful about what's growing in all of your wounds, not just the patient in front of you.
WILL EARDLEY: Have you got a treatment plan? You need a treatment plan. You can't just let these cases unravel. So the treatment plan, your antimicrobial treatment plan is must be divided in your head into prophylactic, what you're going to give to prevent and also for ongoing care should you have a problem. And obviously what is plan B if infection occurs? So if you do something to someone, what's going to happen to your bone, your skin and the organisms?
WILL EARDLEY: You need to have that in your head. So that's how I like to see it. These things are preventable, and we need to be mindful all the way through the reconstructive process of the impact of infection. From a reconstructive point of view, no skin, no hope. If you haven't got good quality skin cover, there really is slim chance of really good union without overwhelming infection.
WILL EARDLEY: So we talked about needing to think about infection, we need to think about skin. If you've got infection and good skin, there is some hope so it's about application of principles. Like I said, soft tissue cover. You have to think about the impact of the soft tissue, because that will dictate pretty much everything. You need to be able to manage and control infection, and you need to choose something that's going to give you an appropriate strain environment for the choice of fracture healing.
WILL EARDLEY: Nine times out of 10 or eight times out of 10, it's going to be secondary bone healing and that's how I work out what the right device is and it's so important that decision making is on point when you've got a problem with infection or contamination and soft tissue cover. So choose how you're going to heal this bone in the light of the skin and in the lighter organisms.
WILL EARDLEY: And that will really help you work out the sweet spot for the best type of implant. Pain management, the impact of all those things. The soft tissue cover, the donor site, the lat dorsi donor site for flap, how that's going to affect pain management in people that have sometimes been exposed to a lot of pain so the principle is really involved pain management. Rehabilitation, that stiffness is so important.
WILL EARDLEY: And you have to have a plan B and a plan C and a plan D revisiting the above these principles. So your plan A. What you'd most like to do, what you think would be best all round needs to be all of those things. Now, there's no point in having a plan B, there's no point about having a get out of jail. There's no point about having something that you're going to do if plan A goes wrong that doesn't involve the same things, because you might have a great plan B for the strain environment, right?
WILL EARDLEY: If that doesn't work, I'm going to do this implant. But if that then compromises something you've already done well, so you might want to be thinking about doing another implant, but that actually might compromise your soft tissue cover so your plan B has to include all the same stuff. And it's hard. It's really tricky.
WILL EARDLEY: And you may want to discuss these cases with other people frequently. For the really complex stuff we share cases and discuss our plans. Plan C is the same, so there's no point in having a plan B, a plan C, a plan D that don't involve the same things because you're going to get false reassurance so you need to have all of the bases covered for every plan that you have.
WILL EARDLEY: By the time you get to plan C, plan D you're in, you're in bother but it you know, it might not be that easy, but you essentially want to tick as many boxes as possible. Now we're moving on to a bit more specifics about internal fixation and transition from external fixation and this is an absolutely fantastic piece of work for the surgeon dealing with these types of injuries.
WILL EARDLEY: And some of what I'm going to talk about is lifted from this book and I'd like to give them the credit for that. So when we talk about taking someone who's been very badly injured, both musculoskeletally and sometimes systemically with lung and brain and chest problems, terrible pelvis problems that we used to see abroad, we talk about single procedure and internal fixation.
WILL EARDLEY: So we're going to talk about internal fixation, conversion to internal fixation and I'm going to touch on a couple of papers because people do talk about these papers about internal fixation done really pretty far forward just because the evidence is there. Again, this is all kind of level 4 evidence and it's stuff that we did is the best way to explain it. So this is a US military series. It's predominantly blunt trauma.
WILL EARDLEY: That's really important to note. So the bulk of these patients weren't penetrating injury or blast. When you, when you boil down to it, when they're discussing the outcomes of these injuries, they're predominantly ankle fractures and hip fractures. They describe minimal infection. The thing is it's a self-selecting but probably non generalizable series and what I mean by that
WILL EARDLEY: is this, these surgeons performed judicious internal fixation in some patients and they did OK is the best way to look at it. Quite far forward. And they're very good in the fact that they don't say that this is something that should be generalized but I think it's remiss if we don't discuss these papers and people aren't aware of them, because otherwise people will turn to them for advice.
WILL EARDLEY: So again, there are documents such as this and the next one that talk about internal fixation in theater however, this shouldn't be considered the norm. And part of the reason why is that not all far forward facilities are as advanced as this. This is another case series. This is a single surgeon case series from two deployments recently. So this was of non US military personnel.
WILL EARDLEY: The first one was about military personnel. This was about locals. Afghan National Army and locals that were operated on because they couldn't do the external fixation and sent back to the United States. These are people that were going to be staying in country. As with any of these series, as you can imagine, the follow up was very limited. It discussed the level 3 facility being modern, ventilation and clean
WILL EARDLEY: so this isn't what a lot of forward surgeons would find so it's a bit of a strange circumstance. And as I say that with judicious use and the right people, that internal fixation quite far forward does have a role but it shouldn't be routine practice. And also, the other thing is that people comment, and this is about any form of war surgery with different populations, is that there is the impact on the host nation
WILL EARDLEY: if you do get a deep infection and there's metal inside there and there isn't the facility to take the metal out with all of the kit that we would have in our hospitals, there is a duty of care there. So the authors are very clear that these are really a report on the art of the possible, as opposed to something that should be recommended and that's really important that message gets across.
WILL EARDLEY: So that's a little bit about what's been said about purely early internal fixation. It's not recommended and we move on. So, what the next big thing and this is what the bulk of this part of the talk is going to be about is what we call sequential external infection, sorry sequential external fixation and then internal fixation.
WILL EARDLEY: There's a lot of literature on this. So I've called it the main event. This is the thing that we're talking about the most. This is converting people from their damage control external fixation to a more permanent device and the main event. It's done throughout the world. There is varied but very diverse literature on this. None of the literature is high quality. It's heterogeneous patient groups, heterogeneous injuries, heterogeneous practice.
WILL EARDLEY: Basically, there's nothing that's a constant in this, so it makes it nearly impossible. There is a synthesis later, but it's nearly impossible to synthesize anything meaningful. Key factors. So the main things that we talk about that are keep coming out as comparators are is the duration of external fixation. So how long the person is in an external fixator before the next surgery.
WILL EARDLEY: So time in ex-fix before definitive surgery. That's important and keeps coming up as a variable. And then we talk about single or two stage. That's, that's the main thing that keeps coming up. And yeah just remember that the thinking behind this needs to sit inside all those principles. So this is work by John Clasper, who was a mentor of mine, who when I did my doctorate work, he was my supervisor and they'd done an awful lot of work, really very basic.
WILL EARDLEY: I mean that in the kindest sense in that it's really just gives us the really important information that we need, we need to know. So what they did was a series of experiments on animals looking at essentially the behavior of pin sites with no broken bone and no definitive surgery to follow, and then moved on to look at pin sites with definitive surgery and pin sites with broken bones and contamination. And so here we go in intramedullary nailing.
WILL EARDLEY: So what the first paper showed that the accumulation of fluid around a pin site really did make a difference and we know this. All of us who do limb reconstruction know that the pin bone interface is everything. And if you've got poor technique or big open pins, that's a problem. So that's pretty much straight forward.
WILL EARDLEY: And then they went to look at the effect of the spread of infection with intramedullary nailing and essentially, that there was found they found there was infection was spread throughout the entire bone and even just having one pin site contaminated in the bone, the distal pin sites all blew out. And that's pretty much straightforward as you can imagine.
WILL EARDLEY: But this was the first time really that it was studied in detail, which is fantastic. And when even if you have heavily contaminated pin sites, even with all of the best things that we can do before intramedullary nailing, the, there were still problems afterwards. So even with lavage, even with antibiotics, heavily contaminated pin sites will lead to problems. And you'll see in a lot of the papers that we discuss in a minute that is, that holds true.
WILL EARDLEY: So if you've got heavily contaminated pin sites or a series of them, certainly not having a pin site holding may be a problem, but these are, I really commend these papers to really get down to the real basics of this kind of care. What's really fantastic in this, and really makes a big difference, is that when they looked, so they nailed a load of intact tibias after contaminating the pin sites. So contaminated pin sites, took the pin sites pins out, nailed the tibia.
WILL EARDLEY: The one animal that did really badly was one with a fracture, which is really interesting because it does show that element of instability that adds to it. So that went on to then for them to develop a model with a fracture. And essentially if you've got a heavily contaminated pin pin sites and you do straight nailing straight away, there's going to be trouble. And that's, it's great science.
WILL EARDLEY: These are great. Some of my favorite experiments and I really commend these and it really does help us understand. It's just an animal model saying what we know is if you've got terrible pin site problems, going straight away for nailing is going to be a problem. It's pretty straightforward. So the next thing you may ask is that what's the what's the best thing to do if you do have pin sites, you know, even if you've just got straightforward pin sites that are not infected, it does
WILL EARDLEY: it, doesn't make a big difference to debride them and again, the outcomes on this are so heterogeneous. There's studies that say you should, the studies that say you shouldn't. I think it's common sense. I think if you've got really clean, straightforward pin sites, I don't tend to debride them. I think that other things that you do in terms of how you do your definitive next stages, make a bigger difference
WILL EARDLEY: personally. I think in the femur, when you've got these quite deep pin sites, I tend to debride them because it makes sense to me. There is no science to it, but I think that there's such a big cavity in that pin site that cleaning out the muscle interface and cleaning out the bone makes sense, but there's no real science to that. Essentially, you can do which whatever you wish.
WILL EARDLEY: So we get into clinical series. So Clasper's work was about animal work and it showed us what we kind of know now that if things are heavily contaminated, it's not going to go too well. This is now clinical work and I'm just going to show you it's such this is the only real randomized trial. This was randomizing fixation with nails versus moving from, so ex-fix and then nail or ex-fix and then cast.
WILL EARDLEY: It's been done quite some time ago but I'm pulling out the salient points is that 27 days an external fixation and then so this was sequential. So having a pin site holiday, 10 days in cast so ex-fix comes off, 10 days in a cast and for the intramedullary group there's one deep infection so this is having a pin site holiday. And a lot of diff, there's so many different studies I've got them pretty much all here
WILL EARDLEY: so this talk will give you pretty much every reference there is on this. Nine weeks in ex-fix, mix of single and two stage you can see here. No increased complications as long as there's no pin site infections and that's what gets us back to Claspers work is that in these patients clinically that don't have good going pin site infections, the chance of a later infection is much less, which makes an awful lot of sense
WILL EARDLEY: and it does resonate with John Claspers work in the sheep. Here we go. Again, you can see the quality of the literature for patients. You know, it's a case. It's a small group of cases that did OK. You know, you would, you'd argue with the science behind this and, and the generalizability and again from our previous number of patients that were in nine weeks in external fixation, this is 48 to 72 hours.
WILL EARDLEY: So it's really difficult to compare any of these, which we'll see. Again, time in frame really does make a difference. That's the one thing. This group termed, you know, less than 14 days, 14 to 28 and more than 28 days, and essentially infection rates go up because you have the frame on for longer. That ties in exactly as we've just seen about the contamination.
WILL EARDLEY: There's no doubt about that. So time in frame does make a difference and that's pretty obvious. Again, another one of the key most quoted papers and here we have six weeks and this is sequential where the nailing was performed about seven weeks after injury. So you know, the index procedure was performed about a week after the frame coming off
WILL EARDLEY: and pin site infection was, again, one of the key elements of this so sequential nailing doesn't do well with pin site infections. Again another quite big series, 41 open fractures of tibial shaft. They again pretty low infection rates. So this is tibial shaft of 39 patients. Adequate follow up. Only two had a deep infection.
WILL EARDLEY: And the average duration of external fixation was 17 days here and then 9 days. So people talk about a 9, 10 day pin site holiday in cast. That's what a lot of our current thinking is based on these studies but you can see how heterogeneous they are. All the outcome measures differently and it's really important that we remember that. But there's another study coming next, which I'll show you, which I think you need to,
WILL EARDLEY: we really need to think about how good the literature is, because this study here, 41 open fractures, 5% had a deep infection. But then there's another one here looking at conversion of external fixation to intramedullary nail and this was I believe this series was without a pin site holiday and about 30% had an infection so the pendulum of the evidence swings all over the place.
WILL EARDLEY: It's really difficult to pin down because none of these series are really all that good. One thing that we know is that the femur is more forgiving for definite. Now, I found this interesting, actually, because some of my pin sites in the femur, I don't know if it's the way I do them. The pin sites in the femur can be pretty terrible and one would think that would lead to more problems
WILL EARDLEY: but I think that's just more about the limb segment and the femur is a bit more forgiving. And in this series, this is a series where the operations have been done throughout the military evacuation chain and you can see they're young men effectively. 125 closed femoral fractures. External fixation done pretty much straight away and then the nailing done about a week later.
WILL EARDLEY: And this is ex-fix on week later. Conversion to nail with no pin site holiday and infection rate 2.5%. But these with closed femur fractures remember in fit young man, so these aren't with blast injuries with massive open wounds. So this is where we need to really remember. This is a femoral series of femoral fractures nailed relatively early
WILL EARDLEY: but the devil is in the detail of the type of injuries. So this is closed femur OK. So that's the femur, bit more forgiving. Again on the femur. Another series. This is a civilian from Shock Trauma. Again pretty straightforward. What we know now immediate external fixation closed by, followed by early close nailing safe treatment. Makes sense.
WILL EARDLEY: Good hosts. Closed matches. Again, another series later on from Shock Trauma. External fixation is a viable alternative to attain temporary rigid stabilization and then followed by nailing with limited complications. So the femur is more forgiving and clearly the better host you do it in, the better. So femur more forgiving than the tibia. Now, I said that evidence synthesis was pretty difficult
WILL EARDLEY: and it is but it doesn't stop Mo Bhandari from giving us another fantastic paper. So looking at, they've looked at the evidence behind these injuries and you can see I've taken this straight from the paper that there's one level one trial, which there's aren't, there aren't many other evidence syntheses that would be based on that.
WILL EARDLEY: Everything else is level three or four and you can basically distill this. It's a great resource this and it's done by some really pretty senior authors. So the bottom line is for sequential femoral nailing following external fixation. The infection rates are pretty good and the union rates are pretty high. Again, for the tibia things are slightly less good. You know infection rates are much higher, although the union rates are, you know, pretty good.
WILL EARDLEY: And when you look across all of these studies, the early groups are so heterogeneous that they're difficult to compare. But what most of the research would agree on is that there's compelling evidence that when you're getting out to 28 days and more, the risk of infection jumps up significantly. So the research is really very poor. The studies are small and it's really difficult to base things on.
WILL EARDLEY: But one thing that you can draw from this, both the preclinical work and the clinical work, is if you've got really good going pin site infection, you should not nail. That seems pretty obvious, but that's the main finding really. The tibia is less forgiving than the femur, and the femur you can nail with a bit more confidence and perhaps a few more problems on board before you have a significant infection.
WILL EARDLEY: And that sequence, doing things, having a break seems to provide improvement. So we then go on to talk about what we can do. So for example, what I would do is I have often taken external fixators off, and I have reamed the canal and placed a off label antibiotic temporizing homemade antibiotic nail down that can provide it, that sort of thing, and then have a pin site holiday.
WILL EARDLEY: I think that works well for me. That's something that we can do and you're getting the benefit of cleaning the canal out. We use the reamer irrigator aspirator and you ream the nail, put a reaming one down nicely. You ream out the canal so the canal is ready for the nail, and you get the benefit of the two weeks of elution. So that's something that we can do. We then follow it with a definitive nail
WILL EARDLEY: and we have been using the Synthes ETN PROtect nail that's sprayed with plasma, sprayed with gentamicin. This is a series from the Royal London, which is interesting because we've in my practice these are small numbers so I'm not talking about huge amount of cases. We've had favorable results that I've not had a deep infection with sequential FRI. I've not had a problem when I've taken an infective case and I've treated like this, but the guys from London have done many more than I have
WILL EARDLEY: and they found that not great results when using it in FRI, which is really interesting. Which goes back to the point that if you've already got an infection, things are challenging. So yeah, so this is the antibiotic nail. We also use a substance called DAC; defensive antibacterial coating, which is essentially a slime, which you can place on a non antibiotic coated nail.
WILL EARDLEY: And just to show the heterogeneity of the literature, there's another group, this time in Germany I believe, who actually found that their results even with FRI were pretty good. So the pendulum of the literature is there. You can use augmented devices. These are something that we do tend to use for high risk patients, and it's something to bear in mind if you're doing late reconstruction.
WILL EARDLEY: I think we can say that doing conversion from external to internal is safe. There are so many variables that need to come in mind. So that's where go to the principles first. Think about where you want to be, follow those principles and you will narrow down your complication profile for definite because the literature is so diverse, because of it's so heterogeneous.
WILL EARDLEY: Definitely as little time in external fixator as possible. That's, that's obvious to anybody and if you do have pin site problems, then I probably would go cautious with going sequential. That makes a lot of sense to me. That's what I've done in the past, and there's definitely loads of evidence that is something you can do. The problem is it's more operations for the patients and it's a longer in-hospital stay.
WILL EARDLEY: But if 10 days in hospital with a couple of operations done well, and then out and rehabbing actually might be an overall balance better for the patient. It's something to bear in mind. So to summarize, you know, we know where we've been. There's been an awful lot of incredible good conflict surgery done. So we know where we've been. We know where we are now, which is the reconstructive landscape
WILL EARDLEY: and I think, I hope I've just added a bit to that about thinking about those organisms, thinking about the resources we have to guide us. Pretty much everything about conversion to internal fixation is in this talk that is available in the literature. Think about infection please, at all times and include this in your plan B, C and D. What are you going to do if there's an infection and how do you manage infection?
WILL EARDLEY: Always have a protocol. Please don't be a surprised infection surgeon. Have it ready. They should be. They will come and get you at any opportunity and you need to be ready. Decision making. We looked at those principles. Remember that.
WILL EARDLEY: Think less about an individual implant. Think more about the skin, the soft tissue, the infection that you've got, the infection that you might get and your rehab and your pain management, all those things. And remember that every plan A, B and C you have has to have all that inside it. And we've mentioned there about conversion of external fixation to internal fixation.
WILL EARDLEY: There's no right answer. There's no paper that gives you the definitive. Femur is more tolerant than tibia. Tibia with pin site problems, converting to infix is going to be a problem. So that's when you might take a drift out into using augmented implants and doing things sequentially to have a holiday and a clean up. That's, that's the basis of it. Now, this isn't the most scientific presentation, you will hear.
WILL EARDLEY: It's distillation of stuff that I know, and that only comes from stuff that many, many people have taught me and I try and teach others. That's the beauty of doing trauma, and particularly with infection and recon, is it's difficult to put P value on anything. It's distillation of knowledge and I really commend looking backwards.
WILL EARDLEY: What I write shouldn't really influence, because what I write is just a distillation of what's been written for generations. So I hope that makes sense. I hope that that has been of use. It's quite philosophical and I'll probably watch it more than once. I wish you the best of luck. [VIDEO ENDS]
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