Orthopaedic Surgery - Information for Patients Considering/ Following Limb Reconstruction

Limb Reconstruction System (LRS)

TL Hex Frame 

Overview

Fine wire circular frames are devices that are used for treating musculoskeletal conditions that would not be amenable to treatment by conventional surgery.

Such conditions include bone infections that involve large amounts of bone or un-united fractures that have been resistant to more standard treatments.

Additionally, they may be used for limb lengthening and correction of complex deformities, such as club foot.

The fine wire circular frames surround the affected part of the limb and are attached to the bone by means of thin wires or pins. The rings may be gradually moved relative to each other and this allows segments of bone to be moved within the limb. The circular frames are on the limb for variable periods of time but for the more difficult problems, they may be needed for a year or more.

They generally allow weight to be borne by the limb and so if you have a problem in the lower limb you are generally able to walk with the frame, even before the limb has healed.

The frames are generally very effective but they may be difficult to live with on a daily basis and you will have to work with the physiotherapist to keep your joints supple. In addition, you will occasionally get pin site infections (an infection at the site where the wire or the pin pierces the skin) and these will need to be treated with antibiotics.

Alternative to the use of fine wire circular frames

Occasionally there is no alternative treatment other than amputation, especially if there is a large amount of bone that has been lost from the limb or is badly infected.

Your surgeon may choose to use a fine wire circular frame even if there are alternative surgical strategies. If this is the case, it is likely that the alternative surgical strategies carry a high risk of complications such as wound breakdown and further bone infection.

Introduction

The purpose of this leaflet is to provide you with information that will help you through your treatment/consideration of treatment.

Common difficulties for you

• The length of the treatment varies depending on the procedure it can be several months to a couple of years (please discuss this with your surgeon)
• The routine of pin site care
• Hygiene
• Clothing
• Physiotherapy
• Sleeping
• Boredom/depression
• Worrying about taking time off work/financial
• Lack of exercise
• Worrying about possible complications i.e. pin site infections
• Stress on the family
• Loss of independence/driving

Families cope better if:

• They keep to as normal a family life as possible, bearing in mind that it will be difficult to do small tasks at first but this will improve with time
• They are well informed about what is involved

Limb reconstruction specialist nurse

For those patients who have planned surgery i.e. not immediately following an accident which resulted in you having a frame applied. You will meet the Specialist Nurses in the outpatient’s department following referral from your consultant. They will discuss the treatment with you and may introduce you to a patient who has/is undergoing a similar treatment. This will enable you to make an informed decision about whether this treatment is for you.

They will visit you on the ward following your surgery and you will see the specialist nurses every week at the Friday clinic. They will support you and your family throughout your treatment.  You will also see them around in clinic.

Stop smoking

This will shorten treatment time and increase your chances of the treatment working as smoking delays bone healing. If you need help then you can speak to someone from the “Stop Smoking Service” or your GP.

Telephone: 0161 212 4050

After your operation

The first sight of the frame can be a shock to you and your family (particularly trauma patients). You may feel angry and/or upset. You may not be able to look at the fixator initially - this is perfectly normal and does not usually last for long.

Pain relief

You may have a morphine infusion pump (PCA) when you return from theatre, which allows you to control how much you need. The anaesthetist (who puts you to sleep) will discuss your options with you prior to your operation which may also include having a “nerve block” which will numb your leg (usually lasts 12 hours or so.) The PCA is usually taken down after a day or two and you will be given pain killers in the form of tablets.

You must communicate with your nurse to ensure you get the correct pain relief. If you are having problems controlling your pain then the pain team may need to come and assess you.

• Pain - this can occur where the wires enter the leg, at the area where the bone was broken or from the nerves/ligaments/ muscles. You will usually be given codeine and paracetamol or morphine and paracetamol. The pain should start to settle after a few days, unless you are undergoing limb lengthening - please see note on this
• Muscle spasms - this is common in patients who have sustained severe fractures/or in patients undergoing corrective surgery to lengthen/straighten etc. Baclofen is the treatment of choice, pain killers (as mentioned above) will not relieve this
• Nerve pain - this can be due to a wire pressing on a superficial nerve or due to the nature of your injury. Patients describe this as a burning/toothache type pain. Amitriptyline or Gabapentin are the treatment of choice, pain killers will not relieve this. Sometimes we may need to remove the offending wire.

It is important to recognise where the pain is so that the problem can be sorted out.

If you have been taking anti-inflammatory tablets such as Ibuprofen or Diclofenac (Voltarol) then these should be stopped one week before your surgery. These tablets should not be taken at any time during your frame treatment as they can delay bone healing.

Limb lengthening/corrective surgery

You will be shown how to adjust your frame by the specialist nurse/doctor on the ward/in clinic between seven to ten days.

Distraction pain (when you are pulling your bone ends apart to lengthen/correct a deformity etc.) can be very painful and you may need to increase the amount of pain killers that you take.

Any medication must be prescribed by a doctor so please ensure that you discuss this with the team or your GP.

Post operatively

On the first day after your surgery, the physios will get you up and walking with the most appropriate walking aid. Most patients are able to fully weight bear (unplanned trauma patients usually aren’t because this is a new injury). If the frame involves your ankle joint then it may be difficult for you to wear your normal shoe, if so the orthotist will make you a shoe.  Occupational therapists will also make you a foot drop splint to prevent your foot from dropping i.e. pointing downwards, which can result in a shortening of your tendon in your heel (Achilles tendon).

Physiotherapy

Physiotherapy is a vital part of your treatment. You need to try and co-ordinate your exercises with your painkillers.

Aims

• To prevent complications e.g. contractures and deformities
• To increase range of movement and muscle strength
• To decrease pain and swelling
• To achieve and maintain maximum mobility

Muscle tightness and contractures

This will occur if you are lengthening your limb but not doing the exercises to stretch your muscles to keep up. This can lead to contractures or deformity and pain. Sometimes we may need to slow down the rate at which you are lengthening.

Joint stiffness

This mainly occurs in the knee, ankle or foot. Swelling and pain can prevent you from exercising your joints and they can become very stiff. It is very important to move them in order to relieve this, even if this hurts (which it will).

Weak muscles

If you do not use your leg (or arm) your muscles will waste away and become weak. Exercise and weight bearing can prevent this.

It is very important to weight bear (once your doctor has told you to) as this stimulates your bone to heal and may well reduce the time that you need to be in your frame.

All exercises should be completed 5 -10 times as able, 3 times per day
 

Range of movement exercises

1.    Hip and knee flexion

Lying on your back. Bend and straighten your leg. If able, use a towel around the bottom of your foot or around your knee/thigh to help. Take care not to push too hard into the towel with your leg if your weight bearing has been restricted by your Consultant.

2.    Hip abduction

Lying on your back with your leg straight, bring your leg out to the side and then back to mid position.

3.    Knee extension

Lying on your back. Raise your ankle on a folded pillow or rolled blanket. Push the back of your knee down and hold for 20 seconds.

4.    Ankle dorsiflexion

Sit with your leg straight out in front of you. Put a towel around your foot. Gently pull the towel and feel the stretch in your calf. Hold for 20 seconds.

5.    Ankle inversion & eversion

Sit with your leg straight out in front of you. Put a towel around your foot.

Gently pull the towel with your right hand so the outer border (little toe) of your foot rises. Hold for 20 seconds.

Gently pull the towel with your left hand so the inner border (big toe) of your foot rises. Hold for 20 seconds.

 

Strengthening exercises

All exercises should be completed 5 -10 times as able, 3 times per day

1.    Static Glutes

Lying on your back or in sitting. Squeeze or tense your buttocks and hold the squeeze for 10 seconds.

 2.    Static quads

Lying on your back with legs straight. Push the back of your knee down firmly against the bed. Hold for 10 seconds.

 3.    Inner range quads

Lying on your back. Place rolled blanket or folded pillow under your knee. Straighten your leg and hold for 10 seconds. Slowly lower your leg.

4.    Straight leg raise

Lying on your back with legs straight. Bend your unaffected leg. Exercise the affected leg by pulling your toes up, straightening the knee and lifting the straight leg off the bed. Hold for 10 seconds. Slowly lower your leg.

5.    Static hamstrings

Lying on your back. Bend your knee and push your heel into the bed. Hold for 10 seconds.

6.    Resisted plantarflexion

Sit with leg straight out in front of you. Put band or towel around the bottom of your foot. Hold both ends of the band/ towel and push your foot down against the band/towel. Hold for 10 seconds.

If you do not have a band/towel, push your foot down against the bottom of the bed.

7.    Resisted dorsiflexion

Sit with leg straight out in front of you. Put band or towel around the top of your foot. Pull your foot up against the band/ towel. Hold for 10 seconds.

 

Seated exercises

All exercises should be completed 5 -10 times as able, 3 times per day.

1.    Inner range quads

Straighten your affected leg and hold it up for 10 seconds. Lower gently

2.    Hip flexion

Lift your knee up and hold for 10 seconds. Slowly lower back down

3.    Resisted knee flexion

Your therapist will tie a band to the bottom of your bed. Sit facing the bed. Place the band around the back of your ankle. Pull your foot back stretching the band. Hold for 10 seconds

4.    Resisted dorsiflexion

Place your other foot over the top of your affected foot. Push up with your affected foot. Hold for 10 seconds. Your therapist will tie a band to the bottom of your bed. Sit facing the bed. Place the band around the top of your foot. Pull your foot up stretching the band. Hold for 10 seconds.

5.    Knee extension

Sit with your ankle raised on a footstool. Push the back of your knee down and hold for 20 seconds.

6.    Knee flexion

Practise bending your knee by sliding your foot back. Once your knee is as bent as possible hold in that position for 20 seconds.

Pin site care

We use the kurgan method of pin site care.

You will be taught how to clean your pin sites by the ward staff (there is an information booklet on this which explains step by step how to clean them; it will also guide you on how to recognise a pin site infection etc.) you should be given this before you go home.

If you develop a pin site infection - the antibiotic of choice is Flucloxacillin 500mg-1g four times per day for two weeks. if you are allergic to this, then you will need Erythromycin/Cindamycin - same dose etc.

You are only able to shower your frame once your surgical wound has healed. Until this time you will have to cover your leg with a large plastic bag whilst showering.

You are encouraged to shower your frame and leg once a week on the day your pin site care is due.

The frame can get very dusty etc. so this is important.

If you do not have a shower then you can buy a shower attachment or alternatively, rest your leg over a baby bath and pour clean running water over it.

PLEASE DO NOT soak/submerge your leg in a bath - this will lead to infection.

Sometimes your skin may “tent” up around the pin i.e. gathers/ puckers. This can cause pain/reduce mobility and may lead to a pin site infection. This would need to be released under local anaesthetic i.e. we would numb the skin and then release the skin by cutting it.

Discharge

If you have stairs at home you will only be discharged home once you can complete stairs safely.

Once you are home the daily exercises must be continued. You are advised to attend the frame class, which runs every Friday in the physiotherapy department. The purpose of the group is to encourage active exercise in an emotionally supportive environment-both from fellow patients and staff. Fellow patients are a great resource and will offer some sound advice.

Coping at home

It is very common for patients to feel a little nervous at first about leaving the security of the hospital ward and having to cope at home.

You will be given the contact numbers for the specialist nurse and the ward (out of hours).

You will be reviewed in the clinic 7-14 days after discharge and usually monthly thereafter, with an X-Ray on arrival.

Clothing

Clothes/underwear may be adapted using Velcro, press studs and zips.

You may insert triangular panels to the inside hem on your pants with velcro.

Popper pants/detachable lower leg sportswear are available from some sports shops.

Flared/bell bottom pants are ideal.

They may be purchased from markets, Primark, Peacocks etc. Remember to buy a few sizes larger.

Work

You will need several weeks off. For patients having planned surgery, you may be able to make arrangements with your employer to reduce your hours/work from home.

Some patients are able to continue work if they have a fairly sedentary job and work in a clean environment.

If you are adjusting your frame you may need to stay off until you have completed your adjustments, this can be very painful and you may need to take strong pain killers during this period. Therefore, you may find it difficult to concentrate.

Driving

Some patients are able to drive an automatic which have right foot controls. Alternatively, the foot controls can be converted to a left foot control if it is your right leg that is being treated.

If you are going to be in the frame for a year or more then it might be worth considering having your car converted to an automatic/standard automatic converted to a left foot control.

If you are interested then you need to contact Motability - this usually costs £200 approx. Make sure that you have permission from your doctor and your insurance company if you are planning on driving.

You should not drive if you are taking pain killers stronger than paracetamol.
 
You may have to accept that for the duration of your treatment you will have to rely on family and friends.

Hospital transport is available for both your clinic appointments and the nurse- group. You will be given the number for hospital transport on discharge from your ward, alternatively you can ask the clinic receptionists’ for the number. Staff are no longer able to book transport for patients.

Sleeping

You can use several pillows or a bean bag to rest your leg in l Use old bedding - sharp wires can tear your sheets despite having plastic tubing on them - so make sure you use your old bedding. For the bigger half pins, elastoplast tape is very useful and may save your partner from injury too! l Some patients prefer to have a bed cradle to prevent their bedding or duvet from weighing down on their limb - you will have to buy this.

Boredom

It is very important to try and maintain a structure to your day.

If you keep busy then you are likely to focus less on your frame and sleep better. Napping during the day will inevitably result in a poor nights sleep.

You could take up a new hobby; painting, learn a new language etc.

Do not isolate yourself at home it is important to go out and maintain friendships etc.

Sitting at home will only make your time in a frame seem longer.

Emotional problems

You will have good and bad days; feelings of hopelessness can be overcome by maximising your independence.

Talk to family and friends.

Sometimes it can be difficult to off load to your loved ones for fear of over burdening them, so remember to talk to the hospital staff and your GP - counselling can always be arranged.

Holidays

It is not advisable to fly long distances and in some Eastern European countries they may not have the facilities to treat you in the event of any problems.

Please discuss this with your consultant.

REMEMBER to keep your leg out of the sun as your skin may blister and keep it warm in the winter. You can easily make a cover for your frame with a pillowcase or we can give you some stockinette (footless loose stocking) to cover it - please ask the clinic staff/specialist nurse.

Benefits/Citizens Advice

Offer advice on a whole range of things i.e. housing, industrial tribunal etc.

You may also be entitled to benefits during your treatment – get some advice from a benefits advisor.

If you pay for your prescriptions then this can prove to be very costly during your treatment – it may be cheaper to buy a prepayment certificate at your local pharmacy.
 
You can pick up a HC12 leaflet from your GP which will give you some guidance.

What happens when my fixator comes off?

Most patients have their frames removed in clinic using penthrox unless they are on the femur (thigh) or have several wires going through the foot.

If you come to the support group you will get the chance to speak to patients who will have had them removed in clinic.

If you feel that you could not tolerate this then ask your doctor to remove it under a general anaesthetic (where you will be put to sleep). Your name will be added to the waiting list and this may take several weeks.

Once your frame is removed, you will have a plaster applied for approximately six weeks, at which point you will be x-rayed and reviewed by your consultant.

Useful contact numbers

Specialist Nurse
Clinic - 0161 206 4894
Pager - 07623 621 293

Associate Specialist Nurse
Clinic - 0161 206 4894
Bleep – 5152 Monday to Friday 9am to 4pm

Orthopaedic Treatment Rooms - 0161 206 4894

Plaster Room - 0161 206 4900

Orthopaedic Outpatient Clinic - 0161 206 4902

Ward B5 - 0161 206 4600

Ward B6 - 0161 206 4574

Ward H4 - 0161 206 4578
 
Physiotherapy Gym - 0161 206 1090

Orthopaedic secretaries
Lisa Hubert - 0161 206 8314
Diane Whelan - 0161 206 5830
Chelsea Peace - 0161 206 1234