不同内固定在舟大小多角骨融合术中稳定性的比较研究

目的 比较舟骨和大、小多角骨(scaphoid-trapezium-trapezoid,STT)融合器与克氏针在STT融合术中内固定强度的差异.方法 12侧新鲜冷冻尸体前臂标本,随机分为融合器组(使用STT融合器)和克氏针组(使用克氏针)2组,模拟进行STT融合术,术后以夹具固定于腕动力测试仪上模拟腕关节主要活动.活动前后均拍摄腕关节标准正侧位X线片,测量桡舟角、桡舟间距、舟骨长度及STT融合体稳定角.结果 融合器组:当腕关节运动范围增加到屈曲45°、背伸40°、尺偏30°、桡偏15°时,客观指标与初始状态相比较变化差异均无统计学意义(P＞0.05).克氏针组:当腕关节运动范围增加到屈曲35°、背伸30°、桡偏10°时,客观指标与初始状态相比较变化差异均有统计学意义(P＜0.05).尺偏30°运动后融合体稳定角与初始状态相比较差异有统计学意义(P＜0.05).结论 STT融合器在舟骨和大、小多角骨融合术中内固定强度大于传统内固定物中的克氏针.     

Perilunate fracture-dislocations of the wrist: comparison of temporary screw versus K-wire fixation

PURPOSE: Temporary intercarpal screw fixation has been suggested as an alternative to temporary K-wire fixation in the treatment of perilunate wrist dislocations. We compared the 2 treatment methods in 2 retrospective cohorts with a null hypothesis that there would be no difference in final wrist motion. METHODS: Eighteen patients with surgically treated perilunate wrist dislocations (9 treated with intercarpal screws, 9 with intercarpal K-wires) were evaluated an average of 44 months after injury. The intercarpal screws were removed an average of 5 months and the K-wires an average of 3 months after the initial procedure. Complications included 3 pin track infections (1 with wrist sepsis), 2 scaphoid nonunions (screw fixation), and 2 patients with loss of reduction (K-wire fixation) treated with repeat surgery. RESULTS: Four patients (2 in each cohort) had wrist arthrodesis with poor results. Among the 14 remaining patients the final flexion arc was 97 degrees for patients treated with screw fixation compared with 73 degrees for patients treated with K-wires. The mean grip strength was 74% (screw fixation) and 67% (K-wire) that of the uninjured arm. According to the Mayo Modified Wrist Score, the functional result was excellent in 1 patient (screw), good in 2 patients (1 each group), fair in 6 patients (3 in each group), and poor in 9 patients (4 screws, 5 K-wire). Seven patients (2 screws, 5 K-wires) had grade 2 or 3 midcarpal arthritis according to the criteria of Knirk and Jupiter, but none had more than mild radiocarpal arthritis. CONCLUSIONS: The results of treatment with temporary screws are comparable to the results of treatment with temporary K-wires. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.     

Changes in hand function following wrist arthrodesis in cerebal palsy

Eleven wrists in ten patients with cerebral palsy underwent wrist arthrodesis. All patients were reviewed between 6 and 121 months after surgery. Operative technique involved AO plate fixation in nine wrists. When the distal radial physis was still open (two wrists), stabilization was achieved using K-wires. A proximal row carpectomy was performed in eight patients. Soft tissue releases were necessary in three wrists. The procedure achieved its aim of improving hygiene and cosmesis. Functional improvement in the hand was noted in eight wrists. Function was consistently improved in athetoid patients.     

Four-corner fusion and scaphoid excision using headless compression screws for SLAC and SNAC wrist deformities

Scapholunate advanced collapse and scaphoid nonunion advanced collapse wrist deformities are the most common causes of traumatic arthritis of the wrist. Four-corner fusion and scaphoid excision has proven to be an effective procedure for relieving pain and preserving range of motion in the wrist joint. Several methods for providing fixation of the midcarpal joint during fusion have been used, including K-wires, staples, and the Spider plate. K-wire fixation has proven effective, but requires a period of cast immobilization to protect the fusion mass. The Spider plate was promising, but has not been without complications. The development and improvements in cannulated headless compression screws has resulted in increased indications for their use, including fixation for 4-corner fusion. We review the technique and tips developed by the senior author over the last several years using headless compression screws for fixation of the midcarpal joint. Acutrak 2 Standard implants were used. This technique has allowed for early range of motion with reliable fusion rates.     

Lunotriquetral arthrodesis using cancellous bone graft.

Previous reports of lunotriquetral arthrodesis suggest relatively low rates of primary fusion without the use of permanent fixation and/or prolonged immobilization. We performed 26 lunotriquetral arthrodeses in 24 patients with a technique using cancellous bone graft to fill a biconcave space created in the adjoining bones with parallel K-wire fixation. The indications included symptomatic lunotriquetral instability and degenerative arthritis. All patients received conservative treatment before surgery. Primary fusion was achieved in all wrists in an average of 50 days. Postoperative wrist flexion/extension averaged 77%/80% of unaffected sides. Radial/ulnar deviation averaged 95%/91% of unaffected sides. Pain relief was good or very good in 83%. Eight-eight percent returned to the workforce. This study shows reliable, effective results with a technique that adheres to the principles of intercarpal arthrodesis and avoids permanent internal fixation.     

Biomechanical comparison of three fixation techniques used for four-corner arthrodesis

Clinical results following four-corner arthrodesis vary and suggest that nonunion may be related to certain fixation techniques. The purpose of our study was to examine the displacement between the lunate and capitate following a simulated four-corner arthrodesis with the hypothesis that three types of fixation (Kirschner wires, dorsal circular plate, and a locked dorsal circular plate) would allow different amounts of displacement during simulated wrist flexion and extension. Cadaver wrists with simulated four-corner arthrodeses were loaded cyclically either to implant failure or until the lunocapitate displacement exceeded 1 mm. The locked dorsal circular plate group was significantly more stable than the dorsal circular plate and K-wire groups (p = 0.018 and p = 0.006). While these locked dorsal circular plates appear to be very stable our results are limited only to the biomechanical behavior of these fixation techniques within a cadaver model.     

A comparison of plate and pin fixation for arthrodesis of the rheumatoid wrist

This retrospective study compared plate fixation versus pin fixation in 57 patients with rheumatoid arthritis who underwent wrist arthrodesis. Fixation was achieved by using plates in 32 patients and longitudinal pins in 25 patients. Clinical follow-up averaged 29 months (range: 12-57 months) and radiographic follow-up averaged 16 months (range 12-39 months). Union occurred in 97% of the wrists fixed with plates and in 96% of the wrists fixed with pins. There were 6 (19%) complications in the plate group and 7 (28%) complications in the pin group. Three (12%) wrists fixed with pins moved from the immediate postoperative position to a position of relative volar flexion, while radiographs showed no changes in wrist position in the plate group. With both methods, successful arthrodesis stabilized the wrist in a high percentage of patients. Plate fixation offers an excellent alternative method for arthrodesis of the rheumatoid wrist.     

Percutaneous K-wire fixation versus palmar plating with locking screws for Colles' fractures

Different methods exist to treat distal radius fractures. A prospective randomized study was conducted to establish whether palmar plate fixation with locking screws gave better results than percutaneous K-wire fixation in patients over 50 years of age. Only fractures with dorsal displacement after a simple fall were included in the study. Twenty wrists were treated with K-wires and 20 with a plate. Radiological parameters were measured on preoperative radiographs and at five weeks postoperatively. Clinical results and DASH scores were determined at three months postoperatively and at more than one year. No significant difference in radial inclination, palmar tilt, clinical outcome and DASH score was found between plating and K-wires, but the mean difference in ulnar variance between pre- and postoperative radiographs was significantly better with plates. It can be concluded that plates were superior to K-wires in restoring ulnar variance, but functional outcome was similar with both techniques.     

Les fractures du radius distal après 70 ans : ostéosynthèse par plaque palmaire ou broches ?

In a growing elderly osteoporotic population, the management of distal radius fractures remains without consensus as to volar distal plate versus K-wires. The goal of this retrospective study was to evaluate these treatments in elderly people. In a series of 38 patients over 70 years, 21 were treated by a volar plate and 17 by percutaneous K-wire fixation. Follow-up was at least 6 months. Results were analyzed using the disabilities of the arm, shoulder and hand (DASH), patient-rated wrist evaluation (PRWE) and Herzberg score by an independent operator. Radiological parameters were radio-ulnar variance, radial inclination and palmar or dorsal tilt. Radio-ulnar variance was better for the plate group (?0.7 mm versus ?0.1 mm in K-wires). Mean functional outcomes were good but there were more satisfied patients in the plate group (67% versus 39% for the K-wire group). Secondary displacements were frequent in both groups but more with K-wires (50% versus 37% in case of plates). Six articles about surgical treatment of elderly radius distal fractures were published up to 2009 showing similar results. However, they analyze only global mean scores. Volar plates give more stability and a higher rate of satisfaction, with similar results of wrist mobility and grasp strength. The main advantage of the plates is earlier return to daily activities.     

Wrist arthrodesis by intramedullary rod fixation: a valuable technique

Arthrodesis of the wrist with intramedullary rod fixation is a simple technique that provides the opportunity for performing concomitant procedures. Iliac bone graft usually is not required with this technique, as the intramedullary rod is a load-sharing construct that allows compression at the fusion site and facilitates union. Rod removal usually is optional, and the long intramedullary beam effect of the rod can function as an internal splint if fibrous or hypoplastic union occurs. Early mobilization is possible, sometimes with only minimal splinting. The results with use of this technique over a ten year period of time in ten wrists (nine patients) with endstage radiocarpal joint instability are reported.     

Screw fixation of scaphoid fractures: a biomechanical assessment of screw length and screw augmentation

PURPOSE: To assess the biomechanical stability relative to screw length and K-wire augmentation in scaphoid fracture fixation using a flexibility testing protocol and cadaver scaphoids whose soft tissue attachments remained undisturbed. Our hypothesis was 2-fold: increasing screw length and augmenting fixation with a K-wire would improve fracture fragment stability, individually and in combination. METHODS: Flexion and extension loading applied through wrist tendons was performed on 10 cadaveric wrists after volar wedge scaphoid osteotomy and internal fixation. Each wrist participated in 3 experimental groups: short screw, long screw, and long screw augmented with a K-wire transfixing the distal pole to the capitate. Interfragmentary displacements were measured. RESULTS: Analysis of variance showed significantly less fracture fragment motion with longer screws than with short screws in 4 of the 6 displacement axes. The flexion/extension axis rotations for the short, long, and augmented long-screw groups were 8.2 degrees +/- 4.8 degrees, 3.9 degrees +/- 1.6 degrees, and 1.8 degrees +/- 1.3 degrees, respectively. Although K-wire augmentation reduced displacement of the fracture fragments it did not decrease interfragmentary motion significantly when compared with the long-screw group. CONCLUSIONS: Under physiologically applied loading of cadaveric wrists with unstable scaphoid waist fractures the long screw provided significantly greater stability than the short screw. Although K-wire augmentation in the long-screw group did improve stability the improvements were not significant. Based in part on the biomechanical data from this study it is our recommendation that the optimally placed screw for scaphoid fracture fixation stability is a long screw positioned down the central axis of the scaphoid deep into subchondral bone.     

Wrist arthrodesis: modified Gill's technique

Twenty-five wrist arthrodesis procedures were performed on 24 patients, applying a modification of Gill's technique, which used a corticocancellous strut graft from the distal radius. Patients were followed up until solid bony fusion was established. Union was achieved in 21 of 25 wrists and was subsequently achieved with a further procedure in the remaining four wrists. We have found that the modified Gill's technique is a reliable, simple procedure with a low complication rate which does not require the harvest of a distant bone graft.     

Use of external fixation for perilunate dislocations and fracture dislocations

The purpose of this study was to review clinical and radiographic outcomes of perilunate dislocations and fracture dislocations treated with external fixation and K-wire fixation. Twenty patients (18 males and two females) with a mean age of 38 years (range 18–59) who had an acute dorsal perilunate dislocation or fracture dislocation were treated with the use of wrist external fixator and K-wires. The injuries included 12 perilunate dislocations, seven trans-scaphoid perilunate fracture dislocations, and one trans-styloid perilunate fracture dislocation. The median time from trauma to operation was 8 h (2–12 h). Indirect reduction via ligamentotaxis was achieved in all perilunate dislocation, and provisional K-wire fixation was added. In five of seven trans-scaphoid perilunate fracture dislocations, indirect reduction was achieved; whereas in the other two as well as in the case of trans-styloid perilunate fracture dislocation, open reduction was required. External fixator was supplemented with K-wires for stabilization of the fractures and the intercarpal intervals. The interosseous and capsular ligaments were not repaired, even after open reduction of fracture dislocations. The mean follow-up was 39 months (range 18–68 months). Range of motion and grip strength were measured. Cooney’s scoring system was used for the assessment of clinical function. Radiographic evaluation included time to scaphoid union, measurement of radiographic parameters (scapholunate gap, scapholunate angle, lunotriquetral gap, and carpal height ratio) and any development of arthritis. The flexion-extension motion arc and grip strength of the injured wrist averaged 80 and 88%, respectively, of the corresponding values for the contralateral wrists. According to Cooney’s clinical scoring system, overall functional outcomes were rated as excellent in four patients, good in eight, fair in six, and poor in two. Eighteen patients returned to their former occupations. Two patients with a trans-scaphoid perilunate injury developed nonunion of the scaphoid; one of them required scaphoid excision and midcarpal fusion. Two patients had radiographic evidence of arthritis. The use of external fixation and provisional K-wire fixation for the treatment of acute perilunate dislocations is associated with satisfactory midterm functional and radiographic outcomes. This minimally invasive treatment option is simple, reliable, and minimally invasive method that provides proper restoration and stable fixation of carpal alignment.     

Management of Non-United Four-Corner Fusions

Purpose Wrist degeneration, resulting from scaphoid nonunion or scapholunate ligamentous disruption, is widely managed with scaphoid excision with four-corner fusion. There are no specific details in the literature regarding “salvage” of nonunion after attempted “four-corner fusions” or the patient outcomes. The purpose of this paper is to present the results of patients who underwent treatment for nonunion after four-corner fusion, the subsequent surgeries done for wrist salvage and the functional results. Methods We reviewed, retrospectively, 37 patients who underwent limited wrist fusion using circular plate fixation, of which eight cases (22%) went on to nonunion and necessitated revision surgeries with plate exchange and bone graft. (Table 1) Five of eight patients were available to return to the clinic, and the wrist range of motion and the disabilities of the arm, shoulder, and hand (DASH) score were recorded. Results The average DASH score was 46 (range, 15 to 60.8). Grip on the affected limb was, on the average, 62% of the contralateral limb. Average arc of wrist motion was 70° (35.7° of flexion and 34.3° of extension). Three of the five patients were laborers, and two returned to the previous employment. The remaining two patients returned to their previous sedentary jobs. All patients reported difficulty with recreational activities involving heavy activity. Conclusions Complications of four-corner arthrodesis using circular plate fixation were recorded, revealing a high number of nonunions and hardware failures. All nonunions were salvaged with allograft or autogenous grafting with plate revision; however, the patients did have considerable limitations.     

Volar locking plates versus Kirschner wires for distal radial fractures—A cost analysis study

Background

There is an increasing trend for managing dorsally angulated distal radial fractures with locked volar plate fixation in fractures that may have previously been managed with percutaneous Kirschner wire (K-wire) fixation. There has been no prospective randomised trial comparing locked volar plate fixation with percutaneous K-wire fixation. In the absence of data guiding management with regard to clinical effectiveness, we have examined the cost of each technique.

Methods

Patients’ details were collected retrospectively between June 2007 and June 2008. Ten consecutive patients who underwent percutaneous K-wire fixation for a distal radius fracture and the 10 who were treated by locked volar plate fixation were identified and their hospital notes retrieved. All patients had a closed extra-articular distal radial fracture with dorsal angulation. The duration and type of operation, including number of wires or screws used, were recorded.

Results

The mean age of the patients was 54 years for the locking plate group and 34 years for the percutaneous K-wire group. The mean time taken to perform percutaneous K-wire fixation with an average of two K-wires was 56 min. The mean time for applying a volar locked plate was 121 min. The cost of a pack of 10 K-wires was £3. The total cost of a standard volar locking plate and screws used was £787.

Discussion

In the absence of research comparing clinical end points, cost must play a major factor in determining the type of operation offered. A 56-min operation to percutaneously fix a distal radial fracture with K-wires costs £662. This compares to a cost of £2212 for a 121-min locked volar plate fixation. There is a calculated difference of £1549 and 65 min.

Conclusion

With use of a locked volar plate for patients under the age of 70 years there is a loss of £652 for the Trust with the present NHS tariffs.     

Technical note: "look-ahead" navigation method for K-wire fixation in rhinoplasty.

OBJECTIVE: The Kirschner wire (K-wire) technique for fixation of rib cartilage grafts to the maxilla is a powerful tool in rhinoplasty. It gives the nose unparalleled anterior projection. However, the technique is challenging because of poor maxillary visualization through the open rhinoplasty approach. Inaccurate K-wire placement can cause dental injury or violation of the nasal/palatal mucosa. This study evaluates the efficacy of a surgical navigation system to guide K-wire placement. STUDY DESIGN: K-wires were placed, through an open rhinoplasty approach, into the maxilla of 12 fresh cadaver heads by a single surgeon. Six control specimens had K-wires placed without navigation. Six treatment specimens had K-wires placed with the "look-ahead navigation method," in which a surgical navigation device was attached to the K-wire gun. All maxillae were then sectioned to determine the final location of the K-wires. RESULTS: Four out of five (80%) of the K-wires were successfully placed in the treatment group, although only 3 out of 6 (50%) of the K-wires were successfully placed in the control group. One treatment K-wire was dislodged during the sectioning process and had to be excluded. The average K-wire deviation in the axial plane was less for the treatment group (0.2 +/- 0.4 mm) than for the control group (1.8 +/- 1.5 mm; P < .05). CONCLUSION: When surgical navigation is used in K-wired cartilage strut graft placement to maxilla, it can improve the accuracy of K-wire placement. This may result in reduced complications due to errant K-wire placement.     

Outcomes of an aseptic technique for Kirschner wire percutaneous pinning in the hand and wrist

IntroductionKirschner wires (K-wires) have been shown to effectively stabilize fractures of the hand and wrist, but are associated with high infection rates, which may limit its use. Previous literature has attributed the risk of infection to many different aspects of a fixation technique. However, we introduce an approach to percutaneous K-wire pinning to mitigate the risk of infection.MethodsPatients undergoing K-wire fixation procedures of the hand and wrist were retrospectively queried. All cases were performed under the same principles of our technique. None of the K-wires were buried, nor bent and were covered with betadine-soaked alcohol pads as pin site dressings. Pins were removed in an outpatient procedure room up to 12 weeks postoperatively and were then assessed for signs of superficial or deep infection.Results90 patients were included in this study across a variety of K-wire fixation operations in the hand and wrist. No patients presented with any signs of infection or other complications necessitating postoperative antibiotics, early pin removal, or reoperation.Discussion/ConclusionThe specific guidelines of our technique resulted in no cases of pin site infection, despite a largely underserved patient population. Our low incidence of infection was maintained without the use of prophylactic antibiotics and in patients with long periods of fixation. While the high infection rates in previous literature have often been associated with wires left exposed, the principles of our technique allow for K-wire fixations to be performed percutaneously without burying the wires. This may allow for improved cost and time efficiency, without compromising patient safety.     

Surgical treatment of unstable fractures of the distal clavicle: a comparative study of Kirschner wire and clavicular hook plate fixation

During 1988-1999 39 unstable fractures of the distal clavicle (Neer 2) were operated on in Oulu University Hospital. Kirschner wire (K-wire) fixation was used in 22 cases and a clavicular hook plate in 17. Shoulder symptoms and function were assessed using self-administered questionnaires devised by L'Insalata et al. (1997), and Constant scoring. Mean follow-up was 6.2 years in the K-wire fixation group and 2.0 years in the clavicular hook plate one. The mean L'Insalata scores were 91 in both groups (92% and 93% of the contralateral side) and the mean Constant scores 84 (95% and 90 (96%) for K-wire fixation and the clavicular hook plate, respectively. Complications commonly occurred with K-wires, which migrated in 12 cases, resulting in loss of reduction in 7 and infection in 3, and 2 cases of non-union. In the clavicular hook plate group, there was 1 complication, a fracture of the clavicle, and 2 cases of non-union. We conclude that shoulder symptoms were reduced and function restored to an adequate level by both methods, but complications were unacceptably frequent when K-wires were used. The clavicular hook plate was better in this respect and it is therefore recommended.     

Surgical treatment of unstable fractures of the distal clavicle: A comparative study of Kirschner wire and clavicular hook plate fixation

During 1988-1999 39 unstable fractures of the distal clavicle (Neer 2) were operated on in Oulu University Hospital. Kirschner wire (K-wire) fixation was used in 22 cases and a clavicular hook plate in 17. Shoulder symptoms and function were assessed using self-administered questionnaires devised by L'Insalata et al. (1997), and Constant scoring. Mean follow-up was 6.2 years in the K-wire fixation group and 2.0 years in the clavicular hook plate one. The mean L'Insalata scores were 91 in both groups (92% and 93% of the contralateral side) and the mean Constant scores 84 (95%) and 90 (96%) for K-wire fixation and the clavicular hook plate, respectively. Complications commonly occurred with K-wires, which migrated in 12 cases, resulting in loss of reduction in 7 and infection in 3, and 2 cases of non-union. In the clavicular hook plate group, there was 1 complication, a fracture of the clavicle, and 2 cases of non-union. We conclude that shoulder symptoms were reduced and function restored to an adequate level by both methods, but complications were unacceptably frequent when K-wires were used. The clavicular hook plate was better in this respect and it is therefore recommended.     

Four-corner fusion of the wrist: clinical and radiographic outcome of 31 patients

Background

Four-corner fusion is a rational surgical option for the management of degenerative conditions of the wrist. Most related studies have compared four-corner fusion with scaphoid excision or proximal row carpectomy, with a variety of reported results. To enhance the literature, we performed this study to evaluate a series of patients with degenerative conditions of the wrist treated with four-corner fusion using 3 surgical techniques and to discuss the clinical and radiographic outcome of the patients.

Materials and methods

We retrospectively studied 31 patients (24 men, 7 women; mean age, 43 years; 9 heavy manual laborers) who underwent four-corner fusion of their wrists for degenerative conditions from 2005 to 2015. Internal fixation was done using multiple Kirschner wires (14 patients), headless compressive screws (8 patients), or a circular plate (9 patients). Mean follow-up was 4 years (1–11 years). We evaluated the clinical outcome with the Patient-Rated Wrist Evaluation (PRWE) score and fusion with radiographs.

Results

All patients experienced improvement of their pain, function, range of motion and grip strength (p < 0.05). Twenty-three patients (74 %) reported no pain, and eight patients reported mild, occasional pain. Twenty-one patients (68 %) were able to do usual and specific activities. Mean wrist motion improved to 70 % and mean grip strength improved to 85 % of opposite wrist. Two heavy manual labor patients requested a job modification because of wrist impairment. Radiographs of the wrist showed fusion of all fused joints in 28 (90.3 %) patients and partial fusion in three patients (9.7 %). No patient with partial fusion required a reoperation for symptomatic nonunion until the period of this study. Three patients experienced complications (10 %). Two patients treated with a circular plate experienced complex regional pain syndrome and painful implant impingement; another patient treated with Kirschner wires and headless compression screws experienced radiolunate arthritis from impingement of the lunate screw to the radius.

Conclusions

Four-corner fusion is a reliable limited wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation.