Extracapsular placement of distal tibial transfixation wires

BACKGROUND: Treatment of tibial plafond fractures with external fixation may involve use of transfixation wires within the periarticular region. Pin track infections that develop along wires placed intracapsularly may lead to joint infection. To our knowledge, there have been no previous investigations assessing the circumferential reflection of the ankle capsule or the potential for communication between the distal tibiofibular joint and the tibiotalar joint. The purpose of this study was to define these anatomic entities to provide guidelines for safe extracapsular placement of distal tibial wires. METHODS: Twelve fresh-frozen cadaveric ankles and three ankles of living human volunteers were utilized for this study. High-resolution magnetic resonance imaging was performed on each ankle after pressurized distention of the joint capsule with gadolinium solution. The perpendicular distance from the subchondral bone at the joint line to the capsular synovial reflection was measured with use of a verified technique. The cadaveric ankles were sectioned, the capsular synovial reflections were measured by investigators who were blinded to the imaging results, and the corresponding measurements were compared. RESULTS: The anterolateral capsular synovial region displayed the most proximal reflection in all specimens (mean, 9.3 mm; maximum, 12.2 mm). The anteromedial region displayed less reflection (mean, 3.3 mm; maximum, 5.5 mm). All posteromedial and posterolateral synovial reflections were 12.2 mm from the subchondral surface of the plafond avoids penetration of the capsule. The distal tibiofibular joint communicates with the tibiotalar joint and thus should not be penetrated, to ensure extracapsular placement of the wires.     

Safe extracapsular placement of proximal tibia transfixation pins.

OBJECTIVE: To identify the anatomic detail of the knee joint capsular insertion site on the proximal tibia, specifically as it relates to transfixation pins. DESIGN: Identification of capsular anatomy by anatomical dissection of cadaveric specimens, with radiography and arthroscopy of patients. SETTING: Cadaveric dissection. OUTCOME MEASURES: Anatomic observation of the capsular attachment site in relation to the tibial articular surface. RESULTS: The capsule inserts four to fourteen millimeters below the articular surface in a regular pattern. The anterior half of the circumference is close to the joint line (less than six millimeters). Posteromedially and posterolaterally, there are extensions distally to fourteen millimeters, occasionally communicating with the tibiofibular joint. CONCLUSION: Transfixing wires and half-pins can be placed in the proximal tibia without capsular penetration if kept more than fourteen millimeters from the subchondral line. If wire placement closer to the joint is required, wires should be placed in Zone 1 (the anterior half) and at least six millimeters from subchondral bone to avoid capsular penetration.     

Outcome after anatomic reduction and transfixation with Kirschner wires of Lisfranc joint injuries

Injuries to the tarsometatarsal (Lisfranc) joint are uncommon, and the results of treatment are often unsatisfactory. Open reduction and internal fixation has been recommended as the treatment of choice for most unstable injuries. In the present study, we reviewed 16 patients who underwent closed or open reduction and Kirschner-wire transfixation of a Lisfranc injury in an 11-year period. Mean follow-up was 44 (range, 12–108) months. Average American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score was 78 (range, 45–100) points. Eight patients (50%) developed posttraumatic arthritis of the tarsometatarsal joints. The major cause was nonanatomical reduction, whereas patients with purely ligamentous injury showed a trend toward poorer postoperative outcome. On the basis of our study, open anatomical reduction of fracture-dislocations of the Lisfranc joint and Kirschner-wire transfixation leads to the best long-term outcome.     

胫骨近端外侧锁定钢板治疗胫骨近端C型骨折

目的探讨胫骨近端外侧锁定钢板治疗胫骨近端C型骨折的效果。方法对23例胫骨近端C型骨折采用胫骨近端外侧锁定钢板固定。采用HSS膝关节功能评分系统进行评定。结果 23例获得随访,时间13~27个月。骨折均愈合,无骨折畸形愈合、内固定失败等并发症发生。HSS膝关节功能系统结果:优14例,良6例,中3例。结论对于内髁骨折块较完整的胫骨近端C型骨折,应用胫骨近端外侧锁定钢板并发症少、内固定可靠,能取得较好的临床疗效。     

Anatomical study of the placement of proximal oblique locking screws in intramedullary tibial nailing

Intramedullary tibial nailing was performed in ten paired cadavers and the insertion of a medial-to-lateral proximal oblique locking screw was simulated in each specimen. Anatomical dissection was undertaken to determine the relationship of the common peroneal nerve to the cross-screw. The common peroneal nerve was contacted directly in four tibiae and the cross-screw was a mean of 2.6 mm (1.0 to 10.7) away from the nerve in the remaining 16. Iatrogenic injury to the common peroneal nerve by medial-to-lateral proximal oblique locking screws is therefore a significant risk during tibial nailing.     

Clinical outcome after transfixation of the epiphysis with Kirschner wires in unstable slipped capital femoral epiphysis

Treatment of slipped capital femoral epiphysis (SCFE) is still controversial. Agreement has not yet been reached on the appropriate time to perform surgery, the necessity of repositioning manoeuvres, the type of implants for stabilisation, or the need for prophylactic treatment of the contralateral side. In this retrospective study, we present 29 patients with unstable (acute and acute-on-chronic) SCFE treated by internal fixation of the epiphysis with three or four Kirschner wires both therapeutically on the affected side and prophylactically on the not (yet) affected side. After hardware removal and mean follow-up of 3.5 years, radiological and clinical examination of hip function was carried out. X-ray in two planes showed no incidence of any slip progression. Applying the score used by Heyman and Herndon, 18 results (62.1%) were classified as excellent, nine (31.1%) as good, one (3.4%) as fair, and one (3.4%) as poor. The rate of severe complications such as chondrolysis and avascular necrosis of the femoral head was low in our series (0% and 6.8%, respectively). This form of therapeutic management shows good clinical results with low complication rates. The slip can be efficiently stabilised, progression is reliably prevented, and remodelling of the joint gives the patient good overall hip function. We see no indication for emergency surgery.     

Dynamic transfixation in unstable dislocation fracture of the proximal interphalangeal joint

Unstable fracture dislocations of the PIP-joint are difficult to manage, because the primary joint destruction and the necessity of immobilisation often result in joint stiffness and the loss of immobilisation may promote chronic subluxation. In the case described in the article we treated the unstable fracture dislocation with a dynamic transfixation with a "force couple splint" following the open reconstruction and internal fixation of the destroyed joint. The application of this dynamic transfixation allowed early active mobility exercising of the PIP-joint during bone healing and produced an excellent result.     

Nonoperative treatment of intracapsular fractures of the proximal femur

Of 2776 intracapsular fractures of the proximal femur, 18% of the patients were treated nonoperatively. Included in the group of patients who were treated conservatively were children, patients with cardiac problems or mental problems, stroke, renal failure, multiple disseminated malignancies, and patients who chose nonoperative treatment. The medical treatment protocol can be divided into two stages: Initially, (1) nursing of a bedridden patient with emphasis on the prevention of complications; and (2) once partial bone union has occurred, the attempted rehabilitation to independent ambulation. Paramedical services provide a major contribution during inpatient therapy and during the preparation for returning the patient to the community. A multidisciplinary medical team evaluates and assesses the patient's needs and rehabilitation potential and in cooperation with the patient and the family, an operative plan then is established.     

The management of intracapsular fractures of the proximal femur

The optimum choice of treatment for an intracapsular fracture cannot be based purely on the radiological appearance of the fracture and on the age of the patient. Although these are the main considerations many other factors need to be evaluated for each individual patient. Figure 1 gives a flow diagram which helps to aid decision in treatment. The intracapsular fracture should not be thought of as the unsolved fracture. Internal fixation is indicated for selected fractures. Some require arthroplasty and for others either treatment can be used. The clinician must assess each of the individual risk factors for healing in each patient, and then decide if the risk of failure of internal fixation is high enough to justify replacing the femoral head with an arthroplasty.     

MIPPO技术治疗胫骨近端骨折

2008年5月－2010年1月,我院应用MIPPO技术使用锁定加压钢板治疗21例胫骨近端骨折患者,疗效满意。     

Biological approach to treatment of intra-articular proximal tibial fractures with double osteosynthesis

The treatment of intra-articular proximal tibial fractures is associated with complications, and much conflicting literature exists concerning the treatment of choice. In our study, an attempt has been made to develop an ideal and adequate treatment protocol for these intra-articular fractures. The principle of double osteosynthesis, i.e., lateral minimally invasive plate osteosynthesis (MIPO), was combined with a medial external fixator to treat 22 intra-articular proximal tibial fractures with soft tissue injury with a mean follow-up of 25 months. Superficial pin track infection was observed in one case, and no soft tissue breakdown was noted. Loss of articular reconstruction was reported in one case. Bridging callus was seen at 12 weeks (8 weeks-7 months). The principle of substitution or double osteosynthesis, i.e., lateral MIPO, was combined with a medial external fixator and proved to be a fairly good method of fixation in terms of results and complications.     

Safe corridor for fibular transfixation wire in relation to common peroneal nerve: A cadaveric analysis

BackgroundPeroneal nerve impalement is a recognized complication of percutaneous placement of fibular transfixation wires by palpatory method after increase use of ilizarov technique in treatment of Tibial fractures, deformity correction and limb lengthening. The purpose of this study was to identify the relationship between the Common Peroneal Nerve (CPN) and the palpable landmark, fibular head for insertion of proximal fibular transfixation wire, safe zones in proximal tibia and percentage of fibula where nerve crosses the neck.MethodsStandard 1.8-mm Ilizarov k- wires were inserted in the fibula head of fresh 10 un-embalmed cadaveric knees. Wires were inserted percutaneously to the fibula head by palpatory technique. The course of common peroneal nerve was dissected. Distances from wire entry point to the course of the common peroneal nerve were measured post-wire insertion.ResultsThe mean distance of the common peroneal nerve from the anterior aspect of the broadest point of the fibular head was 25.10 ± 4.39 mm (range 16–35 mm). Common peroneal nerve was seen to cross the neck of fibula at a mean distance of 32.3 ± 8.53 mm (range 20–50 mm). Wire placement was found to be on average, 46% of the maximal AP diameter of the fibula head and 44% of the distance from tip of fibula to the point of nerve crossing fibula neck.ConclusionWe recommend Proximal fibula transfixation wires are safer to pass with in 2 cm from the tip of the styloid process of the fibula, Anterior half of the head of fibula, <8% of total fibular length, Ventral half of the anterior compartment to avoid injury to peroneal fan. The palpable landmark of fibula is a misinterpretation; it is just the prominent subcutaneous portion of fibula and not the styloid process of fibula which on dissection was located much posterior. Better to take fluoroscopic guidance in difficult cases where palpation of head of fibula is difficult.     

Classification and diagnosis of intracapsular fractures of the proximal femur

Intracapsular fractures of the hip have been classified by different authors with a basis on various concepts. Pauwels classified these fractures according to the angle of inclination; Linton used trabecular disposition among the fractural fragments, and Garden described four types according to the order of displacement. The AO group used the comprehensive classification of fractures of the long bones and divided them among types, groups, and subgroups. However, the presence of posterior comminution of the femoral neck in intracapsular fractures as a factor foretelling instability was overlooked by each of the aforementioned classifications. With a basis on the factors previously described, the current authors developed a classification in which the criteria of instability in intracapsular fractures are given priority. Consequently, the characteristics of full or partial lines, angulation, displacement, and the presence of posterior comminution have been considered. Radiology is the first complementary study for diagnosis; it enables observation of the fracture line or trabecular changes in most cases and fragmental displacement and posterior comminution of the neck. In patients with stress fractures, radiographs often fail to show alterations, so a different diagnostic methodology is required. A diagnosis algorithm is presented. Differential diagnoses are focused toward diseases that may reveal images of pseudofractures.     

Injury to the anterior tibial system during percutaneous plating of a proximal tibial fracture

Minimally invasive osteosynthesis of proximal tibial fractures has grown in popularity in recent years. This article describes a patient with a Schatzker type VI proximal tibial fracture (AO/OTA type 41.C3) and previous compartment syndrome treated with definitive fixation 8 weeks after initial injury with a precontoured proximal tibial plate and a distal targeting device. Brisk bleeding occurred during percutaneous insertion of a cortical screw at the midshaft of the tibia. Surgical exploration revealed sidewall tearing of the anterior tibial artery and vein, which were clipped at the screw insertion site. After the bleeding was controlled, the patient had a strong palpable posterior tibial pulse with no palpable dorsalis pedis pulse, and the foot remained well perfused. Function of the deep peroneal nerve was normal postoperatively. Previous concerns regarding the percutaneous treatment of proximal tibial fractures have focused on the risks of damage to the superficial peroneal nerve from distal screws. Based on cadaveric studies, percutaneously and laterally based screw placement in the distal tibial metaphysis threatens injury to the anterior tibial system. However, with alterations to the normal anatomy caused by severe trauma, previously described safe zones may be changed and neurovascular structures may be exposed to risk in locations that were previously thought safe.     

Austin-Moore hemiarthroplasty for failed osteosynthesis of intracapsular proximal femoral fractures

We studied the outcome of 100 uncemented Austin-Moore hemiarthroplasties used as a revision procedure for failed osteosynthesis of intracapsular femoral fractures. This group was compared with 730 patients in whom an uncemented Austin-Moore prosthesis had been used as the primary treatment for an intracapsular femoral fracture. The results indicate that the study group had more pain at 1-year post-fracture. There were also significantly more revision procedures in those who had the arthroplasty performed as a salvage procedure. In general, the results of uncemented Austin-Moore hemiarthroplasty used as a revision procedure for failed osteosynthesis are inferior to that for primary hemiarthroplasty. We would advocate that for any case in which there are signs of acetabular damage a total hip replacement might be a better procedure. For the remainder, an alternative arthroplasty should be considered with an uncemented Austin-Moore prosthesis reserved for only the very frail.