Closed Transverse Pinning for Reduction and Fixation of Metatarsal Neck Fractures: Surgical Technique

Most metatarsal neck fractures can be successfully treated non-operatively in a cast boot. Displaced metatarsal neck fractures tend to be less stable and have a propensity for the distal fragment to angulate, secondary to the strong flexor tendons, which often forces the distal fracture fragment in a plantar direction and leads to relative metatarsal shortening. Most literature is focussed on antegrade fixation of metatarsal neck fractures using pre-bent K wires or thin elastic nails. Apart from the technical challenges, this technique is limited when bones are osteoporotic as the pre-bent distal end of the K-wire may penetrate the plantar cortex of the proximal metatarsal and prevent the wire from entering the medullary canal of the metatarsal and advancing to the fracture site. Furthermore, when the medullary canal is narrow especially in Asian patients, it may be difficult to pass a bent K-wire through the isthmus of the metatarsal shaft. We describe an innovative technique of closed transverse wiring of the metatarsal head necks that has a distinct advantage in Asian population with osteoporotic bones. With percutaneous manipulation using digital pressure, closed reduction of fracture fragments of the most displaced fracture is done under fluoroscopic guidance to achieve a satisfactory alignment followed by closed transverse wiring of the metatarsal heads. With this procedure, adjacent fractures remain stable within an acceptable range because of intermetatarsal ligaments connected to the adjacent intact head. Our technique has a relatively short operating time and allows for early motion of the metatarso-phalangeal joint. This is especially useful for those with osteoporosis, narrow canal, soft tissue compromise, intra-operative failure of ante-grade pinning and in scenarios of limited surgical equipment/expertise.     

竹筏原理在Pilon骨折中的应用

目的 总结利用竹筏原理,采用T 形锁定板和苜蓿钢板治疗Pilon 骨折的经验.方法 36 例Pilon骨折患者按Ruedi-Allgower 分型,达Ⅱ型19 例,Ⅲ型17 例,均采用切开复位,L 形锁定板或苜蓿钢板内固定术.结果 治疗后,临床疗效优良率80.6%,其中Ⅱ型达84.2%,Ⅲ型达76.5%.结论 利用竹筏原理,采用L 形锁定板或苜蓿钢板治疗Pilon 骨折,具有固定稳定性可靠,有利于骨折愈合和早期关节负重的优点,其远期疗效有待于进一步讨论.     

木筏克氏针技术在胫骨平台塌陷性骨折中的应用

目的:总结木筏克氏针技术在塌陷性胫骨平台骨折治疗中的应用。方法:2013年1月至2015年1月采用锁定钢板结合木筏克氏针技术治疗胫骨平台骨折患者45例,男33例,女12例;年龄22～56岁,平均44.2岁。骨折类型按Schatzker分型;Ⅱ型6例,Ⅲ型8例,Ⅳ型4例,Ⅴ型22例,Ⅵ型5例。所有患者给予2～5根克氏针内固定。有骨缺损者给予同种异体骨植骨。术后3个月开始部分负重,5个月完全负重。观察术后并发症情况,并采用Rasmussen临床和放射评分进行临床评价。结果:45例患者均获得随访,时间10～23个月,平均14个月。根据Rasmussen临床和放射评分方法,临床评分23.58±6.33,放射评分14.00±6.33.4例患者有严重骨质疏松,术后出现不同程度关节面塌陷,5例患者出现创伤性骨性关节炎。结论:木筏克氏针、解剖钢板内固定技术可有效固定并支撑平台塌陷及小关节面碎骨块,增大支撑表面积,降低术后复位丢失率。     

Arthrodesis of proximal inter-phalangeal joint for hammertoe: intramedullary device options

Background

Proximal inter-phalangeal (PIP) joint arthrodesis today represents the standard treatment for structured hammertoes; however, recently, a lot of new intramedullary devices for the fixation of this arthrodesis have been introduced. The purpose of this work is to look at the currently available devices and to perform a review of the present literature.

Materials and methods

A literature search of PubMed/Medline and Google Scholar databases, considering works published up until September 2014 and using the keywords: hammertoe, arthrodesis, PIP joint, fusion, intramedullary devices, and K-wire, was performed. The published papers were included in the present study only if they met the following inclusion criteria: English articles, arthrodesis of PIP joints for hammertoes with new generation intramedullary devices, series with n > 10. Studies using absorbable pins or screws that are considered as another kind of fixation that involved more than one articulation, as well as comments, letters to the editor, or newsletters were excluded.

Results

Nine publications were included. Of the patients’ reports, 93–100 % were good or excellent concerning satisfaction. Radiological arthrodesis was achieved in 60.5–100 % of cases. Three of the publications compared the new devices with the K-wire. Of these three articles, two employed the traditional technique and one the buried technique. The AOFAS score, evaluated in three publications, showed a delta of 19, 45 and 58 points. Major complications, which required a secondary surgical revision, were between 0 and 8.6 %. The complications of the K-wire and the new devices were similar; also the reoperation rate was close to equal (maximal difference 2 %). On the other hand, these kinds of devices definitely have a higher price, compared to the K-wire.

Conclusion

The use of these new devices provides good results; however, their high price is currently a problem. For this reason, cost-benefit studies seem to be necessary to justify their use as standard treatment.

Level of evidence

Level III systematic review.     

Surgical Treatment of Fresh Complete Acromioclavicular Dislocation by Coracoid Process Transfer and K-Wire Transfixation

Acromioclavicular dislocations are very common shoulder injuries. The optimal treatment for acute high-grade acromioclavicular joint injury remains a matter of debate. The purpose of this study was to evaluate the results of surgical treatment of complete acromioclavicular dislocation using coracoid process transfer and temporary K-wire transfixation. Twenty-one patients with complete acromioclavicular dislocation underwent coracoid process transfer and temporary K-wire transfixation. Patients were assessed at the follow-up based on visual analog scores (VAS), the Constant–Murley scoring system and the UCLA shoulder rating system. Radiographs were taken to check up vertical instability. The mean follow-up was 32.1 months (25–47 months). The mean Constant and Murley score and UCLA shoulder rating score was 89.9 ± 8.4 and 30.1 ± 4.4. There were fourteen excellent functional results and six results and one poor result. The overall rate of satisfaction, which means an excellent or good result, was 95.2 %. Nineteen patients (90.4 %) maintained their previous jobs or resume their daily activities. The mean final pain score, as measured from 1 to 10 on the visual analog scale, was 1.91 ± 1.09. The radiographic analysis revealed twenty patients had maintained reduction at the final follow-up. The coracoid process transfer and temporary K-wire transfixation is a reliable treatment for a complete acromioclavicular dislocation.     

External wire-frame fixation of digital skin grafts: A non-invasive alternative to the K-wire insertion method

Background and Aim

The current skin graft fixation methods for digits, including the Kirschner wire insertion technique, can be limited by inadequate or excessive fixation and complications such as infection or secondary injuries. Therefore, the external wire-frame fixation method was invented and used for skin grafting of digits. This study aimed to investigate external wire-frame fixation of digital skin grafts as a non-invasive alternative to the K-wire insertion method.

Methods

In 2005–2012, 15 patients with burn scar contractures on the hand digits received a skin graft that was then fixed with an external wire frame. The intra-operative time needed to make the wire frame, the postoperative time to frame and suture removal, the graft survival rate, the effect of contracture release and the complications were recorded.

Results

In all cases, the contracture release was 100%. The complete graft survival rate was 98.6%. Four patients had epithelial necrosis in <5% of the total area. There were no other complications such as pressure ulcer or hypoxia of fingers.

Conclusions

External wire-frame fixation is simple, minimally invasive and a custom-made technique for skin grafting of the fingers. It was designed for its potential benefits and the decreased risk it poses to patients with scar contractures on their fingers. It can be implemented in three phases of grafting, does not affect the epiphyseal line or subsequent finger growth and is suitable for children with multi-digit involvement.     

肩外侧小切口内固定治疗肱骨近端骨折的解剖学研究

目的为临床应用小切口治疗肱骨近端骨折提供解剖学依据。方法在30具成人肩标本上,测量腋神经上缘与大结节顶点、肩峰上缘的距离;模拟手术操作,观察肱骨头颈、腋神经、旋肱前后动脉与克氏针的关系。结果经统计分析大结节顶点、肩峰上缘距腋神经距离分别为34.1±3.7 mm,53.4±5.5 mm;大结节距水平基准线的距离为31.8±2.8 mm,固定肱骨头克氏针在距肱骨头至水平基准线1.5倍距离以上时进针不会损伤腋神经;固定大结节克氏针在≥60°进针时出针点在肱骨颈下方1～2 cm,远离血管神经。结论大结节下0～3 cm是手术操作的相对安全区域,固定肱骨头的克氏针进针点应在距肱骨头至水平基准线1.5倍以上距离,固定大结节的克氏针与肱骨干保持≥60°成角,有助于避免损伤腋血管神经。     

克氏针内固定加中药熏洗治疗掌指骨骨折术后功能恢复随访分析

目的 探讨克氏针内固定加中药熏洗治疗掌指骨骨折的疗效及对术后功能恢复的影响。方法 收集我院手外科收治的掌指骨骨折患者60例,随机分为观察组和对照组各30例。两组均行切开复位克氏针内固定手术治疗,术后观察组在进行功能锻炼的同时配合中药熏洗治疗,对照组仅进行功能锻炼。术后随访6—12个月,比较两组术后关节功能恢复情况。结果 与对照组比较,观察组骨折愈合时问短（t=5．48）,术后并发症发生率低（X^2=5．48）,住院时问短（t=5．48）,差异具有统计学意义（P〈0．05）。根据Harris髋关节功能评分的标准评价两组术后手指功能恢复情况,观察组术后手指功能恢复优良率显著优于对照组（x。=5．48,P〈0．05）。结论 应用克氏针内固定治疗掌指骨骨折术后功能锻炼配合中药熏洗疗法的效果明显优于单纯术后功能锻炼,可以最大程度地恢复手指关节的功能。     

Complications when using threaded K-wire fixation for displaced intra-articular calcaneal fractures

A retrospective chart review was performed on patients treated at a level one trauma centre for displaced intra-articular calcaneal fractures by a single trauma surgeon between January 1998 and July 2007. Patients were treated with open reduction and internal fixation utilising the extended lateral incision and a new type of fixation not described before. Threaded 1.575 mm (0.062 in.) Kirschner wires (K-wires) were used for fixation post-operatively along with standard plates, screws and bone substitute.There were 278 fractures in 246 patients that were treated with ORIF for displaced intra-articular calcaneal fractures during this 9-year period. Standard calcaneal lateral approach and hardware was supplemented with percutaneous threaded K-wires. An average of 5.0 fully threaded 1.575 mm K-wires were inserted per calcaneal fracture. Five (1.8%) patients had a K-wire infection; 0.6% of all K-wires became infected and 3.1% of K-wires broke.Lateral calcaneal apical wound issues are minimised and patients experience an overall low complication rate. The fixation also ensures non-weightbearing compliance.