The Limb Reconstruction Service treats a wide variety of conditions including complex trauma, post-traumatic deformities, limb and joint reconstruction, limb lengthening and bone infection.
This includes the use of fine wire frames, Precice nails and cabling systems.
It can be accessed directly through admission to the Major Trauma Centre or via a complex lower limb referral from another centre.
The service works closely with the bone infection and plastics teams and collaboratively with the wider multidisciplinary team based at Addenbrooke’s Hospital.
Non-urgent advice: Patients can access this service in two ways
- Directly or as a trauma transfer to Addenbrookes’ Hospital from another hospital as a result of an accident needing urgent specialist treatment
- A referral from another hospital or GP
How the Service works
Assessment
Newly referred patients will typically be seen by the team to perform an initial assessment.
The Consultant will explain the treatment plans and answer all questions. Patients are consented in clinic for planned procedures or on the wards if they are still in-patients from major trauma injuries. If the patient is consented in clinic we ask that they bring the consent form with them on the day of surgery to avoid delays
Patients requiring treatment with a fine wire frame receive individualised teaching on the proposed treatment plan and how to adapt to a fine wire frame from the Specialist Nurse in clinic, or on the inpatient ward if they have been involved in an accident and admitted to Addenbrooke’s hospital. At this stage the patient is given a written information book and provided with contact details for the Limb Reconstruction Team and an exercise programme from the Physiotherapy team.
Patients with skin grafts and temporary external fixators
If the patient has sustained a recent traumatic injury and had skin grafts with the Plastic Surgical team, they will either have internal fixation with metalwork or have a temporary external fixator applied for their bony injury. This is then removed after the grafts have healed, normally approximately 4 weeks later. This will be done in theatre and a fine wire frame applied if they have extensive bone loss or significant deformity which could not be treatment with internal fixation.
Admissions for scheduled surgery
Admission is normally on the day of surgery, patients are contacted a few days before by the Trauma Co-ordinators or the Bookers to ensure that they know where to go and when to be nil by mouth.
It is advisable to bring loose clothing and if they are having a fine wire frame or external cabling trousers with side openings are easiest.
Sensible walking shoes and firm, well supported slippers to make mobilisation easier.
Day of Surgery
Once admitted patients are reviewed by the anaesthetist
Pre operative check lists are completed and patients are given wrist bands which are checked frequently by the teams and asked to put theatre gowns on.
These are all day operating lists and every effort is made to stick to scheduling times but as Addenbrooke’s is a major trauma centre there is the possibility that this could change, if there is an emergency life threatening case.
Post- operative instructions
These are often patient specific, however mobilisation generally starts the next day and it is important that this starts as soon as possible to avoid joint stiffness. Often an X-ray is taken but patients can often mobilise before this is done and the team will advise whether or not weight can be put through the operated limb.
At first patients are normally on pain controlled analgesia pumps and as they progress and their pain is controlled this is reviewed regularly and stepped down when appropriate to tablets and patients are sent home with pain killers.
Patients are also given anti-coagulation injections to reduce the risk of blood clots, they or a family member are taught how to give these, or a district nurse can be arranged if they are unable to manage this.
Fine wire frames
If the patient has a fine frame a post -operative X-ray is done and the Specialist Nurse will give the patient a frame prescription and teach them how to follow this, do the frame adjustments and look after the pin sites. If bone transport is required they are shown how to turn clickers or dice, how frequently (normally one quarter turn four times a day) and provided with a clicker chart to record this. Family and friends/carers can also be taught how to look after the frame and do all adjustments as required.
Once patients are safely managing their fames and independently mobile we will discharge home. If mobility is slow or more support is needed, we will repatriate to local hospitals if required.
Cables for limb lengthening
Patients with cables for limb lengthening are taught how to manage this system by the Specialist Nurse and once the patient can safely manage all cable adjustments, pin-site care and are mobile they will be discharged home. These patients are reviewed regularly in clinic with x-rays on arrival.
Precice nails
For patients who are having limb lengthening with Precice Nails the Specialist Nurse will review, explain how this system works and how to use the magnets. A mark will be made on the patient’s leg during the operation to show where the magnet needs to be applied. This process is normally done by the patient four times and day and is regularly reviewed in clinic with x-rays on arrival. Contact numbers for the company and written instructions on application are given for additional support.
Patients with Precice nails can often go home one day post-surgery, once they are happy using their magnets for limb lengthening and safely mobilising independently.
Bone infection patients
For patients with bone infections there is also extensive input and support from the bone infection team. The treatment will be discussed with the team, who will regularly review throughout the hospital stay prescribing individual antibiotic treatment plans in response to specimen and blood results.
In some instances patients may be required to remain in hospital until certain specimen and culture results are back.
Patients may have antibiotics for longer periods of time but often this can be adapted for them to be able to go home as soon as possible, depending upon the infection. Either the patient or a designated family member will be taught to give the antibiotics intravenously (through a line in the arm) if they can manage, or we will arrange for this to be given by the specialist team. During this period they may require regular bloods and this is also sorted out by the bone infection team.
Reviews whilst in hospital
Patients are reviewed daily by the specialist nurse Monday- Friday, they are taught how to follow frames prescriptions, do bone transport or cable adjustments, pin site care and analgesia is reviewed and adjusted as needed. They have regular medical reviews with both the specialist nurse and medical team members.
The Lead Consultant does ward rounds which are attended by the Specialist Nurse, Registrars and Physiotherapists on Tuesdays and Fridays.
Bone infection and Plastics reviews are done separately.
Physiotherapy
The Physiotherapists will review regularly whilst in hospital and give an exercise plan. It is extremely important that this is followed throughout the treatment in hospital and on discharge to reduce the risk of potential complications.
Occupational therapy
If any adaptations or specialist equipment is required the patient will be reviewed by the occupational therapy team and appropriate equipment arranged.
Wheelchairs
If wheelchairs are required they can be obtained via local Red Cross services.
Outpatient follow-up
The patient will have regular out- patient appointments which will be sent to them through the post and clinics are on Tuesday mornings and Friday afternoons. Often X-rays are needed before seeing the team and if they have fine wire frames a new frame prescription will be made and given in clinic, with frame adjustments made as needed. Consequently, it is advisable to arrive before the booked appointment times by at least half an hour so that x-rays can be done and delays avoided.
If transport is needed to attend these clinics this is arranged through the patient’s GP surgery, so please contact them to arrange this.
Patient support
Krkovic limb constructions website (opens in a new tab)
Patient Support Group for Patients with fine wire frames
Monthly meetings on a Friday lunchtime.
The team
Lead consultant
Mr Matija Krkovic (Trauma and Orthopaedics)
Plastics consultants
Mr Ahmed Abood (Plastics)
Mr Keith Anderson (Plastics)
Bone Infection consultant
Dr Emma Nickerson (Infectious Diseases)
Clinical Nurse Specialist
Elizabeth Shirland (Trauma and Orthopaedics)
Physiotherapists
Georgia Darnell
Elizabeth Ingham