ARTHRODESIS OF THE DISTAL INTERPHALANGEAL JOINT USING A BIOABSORBABLE ROD AS AN INTRAMEDULLARY NAIL

There are several fixation techniques for arthrodesis of the distal interphalangeal joint. Since February 1999 we have used a bioabsorbable (poly-L-lactide, PLLA) rod as an intramedullary nail for arthrodesis of 15 distal interphalangeal joints and one interphalangeal joint of the thumb. The advantages include the absence of protruding hardware that would require removal, and technical simplicity. Preoperative diagnoses included degenerative arthritis in five patients, post-traumatic arthritis in 10 patients, and non-union after arthrodesis with crossed Kirschner wires in one patient. All patients were observed until there was clinical and radiographic evidence of fusion with the mean interval to fusion of 8 weeks (range 6-12). There were two cases of minor intermittent local swelling, which resolved. Fixation with a PLLA rod for arthrodesis of the distal interphalangeal joint is a simple and effective technique.     

Arthrodesis of the distal interphalangeal joint using a bioabsorbable rod as an intramedullary nail.

There are several fixation techniques for arthrodesis of the distal interphalangeal joint. Since February 1999 we have used a bioabsorbable (poly-L-lactide, PLLA) rod as an intramedullary nail for arthrodesis of 15 distal interphalangeal joints and one interphalangeal joint of the thumb. The advantages include the absence of protruding hardware that would require removal, and technical simplicity. Preoperative diagnoses included degenerative arthritis in five patients, post-traumatic arthritis in 10 patients, and non-union after arthrodesis with crossed Kirschner wires in one patient. All patients were observed until there was clinical and radiographic evidence of fusion with the mean interval to fusion of 8 weeks (range 6-12). There were two cases of minor intermittent local swelling, which resolved. Fixation with a PLLA rod for arthrodesis of the distal interphalangeal joint is a simple and effective technique.     

Minimally invasive surgery for young female patients with mild-to-moderate juvenile hallux valgus deformity

BackgroundWe aimed to compare the clinical and radiographic outcomes of minimally invasive surgery (MIS) and distal chevron metatarsal osteotomy (DCMO) for young female patients with mild-to-moderate juvenile hallux valgus deformity.MethodsWe retrospectively reviewed the radiographs and clinical findings of young female patients with mild-to-moderate juvenile hallux valgus who underwent MIS (25 feet) or DCMO (30 feet). In 12 of 25 MIS feet, 2.0-mm bio-absorbable pins were used as an additional fixation device crossing the osteotomy site, and 1.4-mm Kirschner wires were used in the remaining 13 feet.ResultsRadiographic and clinical parameters preoperatively and at the final follow-up were not significantly different between the 2 groups. There were no significant differences in the increments of hallux valgus angle (HVA), distal metatarsal articular angle, medial sesamoid position, first metatarsal length, metatarsal length index, or relative second metatarsal length. Two MIS subgroups according to the additional fixation device showed no significant differences in HVA, the first to second intermetatarsal angle lateral translation ratio, or plantar offset at the final follow-up.ConclusionsMIS for young female patients with mild-to-moderate juvenile hallux valgus deformity had similar radiographic and clinical outcomes compared to DCMO. Regarding additional fixation crossing the osteotomy site, both temporary Kirschner wires and absorbable pins showed no radiographic differences in terms of correction maintenance.Level of evidence: 3.     

Metatarsal neck osteotomy with proximal interphalangeal joint resection fixed with a single temporary pin

BACKGROUND: Screws have been recommended for fixation of the site of the metatarsal osteotomy. METHODS: A report is presented on one surgeon's experience with a temporary, single Kirschner wire instead of screws for fixation of metatarsal neck osteotomies combined with proximal interphalangeal (PIP) joint resection arthroplasty in patients with dislocated metatarsophalangeal (MTP) joints and severe hammertoe deformities. Eleven consecutive patients (13 toes) were treated between January 1999 and January 2002 (mean age, 69 years; range, 44-81 years; seven women, four men) at a tertiary care foot and ankle center. Records and radiographs were reviewed retrospectively, and all patients were examined at follow-up by one of the authors (mean follow-up, 13 months; range, 6-32 months). RESULTS: All 13 metatarsal neck osteotomies had clinical and radiographic union by 6 weeks, with no evidence of nonunion, malunion, avascular necrosis of the metatarsal head, deep wound infection, pin-tract infection, broken pins, or other serious complications. Two metatarsals (18%) had minor residual plantar calluses beneath the metatarsal head. The mean postoperative American Orthopaedic Foot and Ankle Society score was 76 of 95 points possible. All patients were satisfied with the procedure and would do it again. CONCLUSION: The use of a single, temporary K-wire provides adequate fixation for combined PIP joint resection arthroplasty and metatarsal neck osteotomy in patients with central metatarsalgia and severe hammertoe deformity.     

Tissue response to polyglycolide, polydioxanone, polylevolactide, and metallic pins in cancellous bone: An experimental study on rabbits.

The purpose of this study was to investigate, qualitatively and histoquantitatively, the tissue response of rabbit femur cancellous bone to polyglycolide (PGA), polydioxanone (PDS), polylevolactide (PLLA), and stainless steel pins under identical conditions. Eighty knees in 50 rabbits were operated on by inserting bioabsorbable pins (PGA, PDS, or PLLA) together with metallic Kirschner wire in 60, and two metallic Kirschner wires alone in 20 knees, while 20 knees served as intact controls. Follow-up times were 3, 6, 12, 24, and 52 weeks. Cancellous bone tissue response to implants was studied using histological, histomorphometrical, microradiographical, and oxytetracycline fluorescence methods. Residual fragments of PGA and PDS were seen at 24 weeks. Complete degradation of these polymers had taken place before 52 weeks. No signs of degradation of the PLLA pins were observed within the entire follow-up period. The osteoid formation surfaces at tissue implant-interface were statistically larger in all test groups as compared to intact controls. The number of macrophages at tissue implant-interfaces increased in all bioabsorbable implant specimens until 6 weeks, and with PGA until 12 weeks. No differences in the osseous response emerged when comparing groups of bioabsorbable implants with each other or with stainless steel group. Bioabsorbable pins and metallic Kirschner wires evoked an osteoconductive response in the cancellous bone surrounding implant, but the response intensity between implants displayed no differences. This suggests a simple, nonspecific walling-off new-bone front type of response. Consequently, the polymers possessed no specific osteostimulatory or osteoinhibitory properties. Within the follow-up, no significant differences in biocompatibility between the implants appeared, and no frank inflammatory foreign-body reactions occurred. The small-volume pins obviously did not exceed the local tissue tolerance and clearing capacity of the bone.     

Rheumatoid forefoot reconstruction. A long-term follow-up study

BACKGROUNDS: The purpose of the present study was to assess the results of reconstruction of the rheumatoid forefoot with arthrodesis of the metatarsophalangeal joint of the great toe, resection arthroplasty of the metatarsal heads of the lesser toes, and open repair of hammer-toe deformity (arthrodesis of the proximal interphalangeal joint) of the lesser toes when this deformity was present. METHODS: A retrospective study of forty-three consecutive patients (fifty-eight feet) with severe rheumatoid forefoot deformities was performed. Six patients (six feet) died before the most recent follow-up, and five patients (five feet) were excluded because a subtotal procedure had been performed. No patient was lost to follow-up. Thus, the study included thirty-two patients (forty-seven feet) in whom reconstruction of a rheumatoid forefoot had been performed by the author. RESULTS: All first metatarsophalangeal joints had successfully fused at an average of seventy-four months (range, thirty-seven to 108 months) postoperatively. The average postoperative hallux valgus angle was 20 degrees and the average postoperative angle subtended by the axes of the proximal phalanx and the metatarsal of the second ray (the MTP-2 angle) was 14 degrees, demonstrating that a stable first ray protected the lateral rays from later subluxation. One hundred and thirty-two (70 percent) of the 188 lesser metatarsophalangeal joints were dislocated preoperatively, compared with thirteen (7 percent) postoperatively. The result of the procedure (as rated subjectively by the patient) was excellent for twenty-three feet, good for twenty-two, and fair for two. There were no poor results. The average postoperative score according to the system of the American Orthopaedic Foot and Ankle Society was 69 points. Postoperative pain was rated as absent in eighteen feet, mild in twenty-five, moderate in four, and severe in none. Fifteen feet were not associated with any functional limitations, twenty-eight were associated with limitation of recreational activities, and four were associated with limitation of daily activities. At the time of the most recent follow-up, no special shoe requirements were reported. Fourteen feet (30 percent) had a reoperation for the removal of hardware from the first metatarsophalangeal joint, a procedure on the interphalangeal joint of the great toe, or additional procedures on the lesser toes or lesser metatarsophalangeal joints. CONCLUSIONS: In the present study, arthrodesis of the first metatarsophalangeal joint, resection arthroplasty of the lesser metatarsal heads, and repair of fixed hammer-toe deformities with intramedullary Kirschnerwire fixation resulted in a stable repair with a high percentage of successful results at an average of six years after the procedures.     

Pullout strengths of self-reinforced poly-L-lactide (SR-PLLA) rods versus Kirschner wires in bovine femur

OBJECTIVE: To determine the relative amount of fixation of self-reinforced poly-L-lactide (SR-PLLA) rods and Kirschner wires in bovine cancellous bone by comparing their pullout strength DESIGN: An in vitro laboratory study was performed using bovine femurs. Ten two-millimeter-diameter pins of each type were inserted into cancellous bone and then pulled out, using a material testing machine. The maximum force (pullout strength) was selected over other measurements to compare the amount of fixation of the two types of pins. All of the pins were retrieved for microscopic analysis. A paired t test was performed to analyze the differences between the pullout strength of the two types of pins. SETTING: Orthopaedic Bioengineering Laboratory, University of Louisville School of Medicine, Louisville, Kentucky, U.S.A. SPECIMENS: Two young fresh bovine distal femurs, ten two-millimeter-diameter Kirschner wires, ten two-millimeter-diameter bioabsorbable SR-PLLA rods MAIN OUTCOME MEASUREMENTS: Pullout strength in Newtons, and microscopic pin surface aspect after insertion. RESULTS: Significant differences were noted between the maximum force required to remove the two types of pins (p < 0.01) The K-wire mean pullout force was 37.7 N (SD 13.6), and the SR-PLLA rod mean pullout force was 53.6 N (SD 19.3). Microscopic analysis indicated surface modification only on the SR PLLA rods. DISCUSSION: SR-PLLA composites have shown comparable clinical results to their metallic counterparts. In this study, the pullout strength of SR-PLLA rods was compared with that of conventional K-wires. A significant difference (p < 0.01) favoring bioabsorbable pullout strength was noted. The bioabsorbable pin surface modification during insertion is an interesting finding that warrants further investigation as a potential source of improved fixation. CONCLUSION: SR-PLLA rods retain their hold in bovine cancellous bone better than K-wires. This finding offers to the orthopaedic surgeon more information about new pin fixation methods.     

The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: good outcome in 21 patients with 42 osteotomies

Hardly any surgical methods are available for metatarsalgia caused by a dislocated lesser metatarsophalangeal joint (MTP) that do not sacrifice the joint. We reviewed retrospectively the outcome of 60 metatarsal Weil osteotomies for correction of dislocated lesser MTP joints in 31 patients. Between 1995 and 1996, 31 consecutive patients were treated with a Weil osteotomy at 2 institutions. The Weil osteotomy is an oblique osteotomy of the metatarsal neck and shaft, parallel to the ground surface, that controls shortening of the metatarsal by internal fixation with screws or pins. At an average final follow-up of 30 (24-44) months, all patients were interviewed, using a standardized questionnaire based on the AOFAS Lesser Metatarsophalangeal-Interphalangeal Scale. Recurrent or transfer metatarsalgia, formation of callus, mobility and dislocation of the MTP were noted on physical examination. Dorsoplantar and lateral weightbearing radiographs taken preoperatively and at the time of final follow-up were examined for alignment of the metatarsal heads, subluxation or dislocation and for evidence of nonunion, or malunion of the metatarsal osteotomy. We had excellent results in 21 patients (42 osteotomies). A major complication was plantar penetrating hardware in 10 cases (3 screws and 7 pins). We conclude that the Weil osteotomy is a good method for correcting metatarsalgia caused by dislocation of the MTP joint.     

The Weil osteotomy for treatment of dislocated lesser metatarsophalangeal joints: Good outcome in 21 patients with 42 osteotomies

Hardly any surgical methods are available for metatarsalgia caused by a dislocated lesser metatarsophalangeal joint (MTP) that do not sacrifice the joint. We reviewed retrospectively the outcome of 60 metatarsal Weil osteotomies for correction of dislocated lesser MTP joints in 31 patients. Between 1995 and 1996, 31 consecutive patients were treated with a Weil osteotomy at 2 institutions. The Weil osteotomy is an oblique osteotomy of the metatarsal neck and shaft, parallel to the ground surface, that controls shortening of the metatarsal by internal fixation with screws or pins. At an average final follow-up of 30 (24-44) months, all patients were interviewed, using a standardized questionnaire based on the AOFAS Lesser Metatarsophalangeal-Interphalangeal Scale. Recurrent or transfer metatarsalgia, formation of callus, mobility and dislocation of the MTP were noted on physical examination. Dorsoplantar and lateral weightbearing radiographs taken preoperatively and at the time of final follow-up were examined for alignment of the metatarsal heads, subluxation or dislocation and for evidence of nonunion, or malunion of the metatarsal osteotomy. We had excellent results in 21 patients (42 osteotomies). A major complication was plantar penetrating hardware in 10 cases (3 screws and 7 pins). We conclude that the Weil osteotomy is a good method for correcting metatarsalgia caused by dislocation of the MTP joint.     

A bioabsorbable fixation implant for use in proximal interphalangeal joint (hammer toe) arthrodesis: Biomechanical testing in a synthetic bone substrate.

The surgical correction of hammer toe deformity of the lesser toes is one of the most commonly performed forefoot procedures. In general, percutaneous Kirschner wires are used to provide fixation to the resected proximal interphalangeal joint. Although these wires are effective, issues such as pin tract infections as well as difficult postoperative management by patients make alternative fixation methods desirable. This study biomechanically compared a threaded/barbed bioabsorbable fixation implant made of a copolymer of 82% poly-L-lactic acid and 18% polyglycolic acid with a 1.57-mm Kirschner wire using the devices to fix 2 synthetic bone blocks together. Constructs were evaluated by applying a cantilever load, which simulated a plantar force on the middle phalanx. In all cases, the failure mode was bending of the implant, with no devices fracturing. The stiffness (approximately 6-9 N/mm) and peak load (approximately 8-9 N) of the constructs using the 2 systems were equivalent. Accelerated aging at elevated temperature (47 degrees C) in a buffer solution showed that there was no reduction in mechanical properties of the bioabsorbable system after the equivalent of nearly 6 weeks in a simulated in vivo (37 degrees C) environment. These results suggest that the bioabsorbable implant would be a suitable fixation device for the hammer toe procedure.     

Kirschner wire migration from subcapital humeral fracture site, causing hydropneumothorax

Migration of wires or pins around the shoulder is a known complication, though their migration within the chest is uncommon. We report an unusual case of hydropneumothorax due to migration of a bent Kirschner wire from the right proximal humerus in a 63 year-old man. We reviewed his clinical history, physical examination, imaging findings, surgical method and outcome. We also reviewed the literature on orthopaedic wire migration and latest technique in removal of the wires. Chest radiographs and chest computerized tomography are useful in detection and diagnosis of this disorder. Regular radiographic follow-up is needed for patients with internal fixation devices; any fractured or migrated pins or wires must be removed immediately to prevent dangerous complications. It is always important to remove the wires at the end of the treatment. Early removal of fixation wires and regular follow-up if wires are retained are essential to prevent serious complications.     

Sagittal Alignment of the First Metatarsophalangeal Joint after Arthrodesis for Rheumatoid Forefoot Deformity

The present study assessed the midterm results of reconstruction for rheumatoid forefoot deformity with arthrodesis of the first metatarsophalangeal (MTP) joint, scarf osteotomy, resection arthroplasty of the metatarsal head of the lesser toes, and surgical repair of hammertoe deformity (arthrodesis of the proximal interphalangeal joint). Special focus was placed on the sagittal alignment of the first metatarsophalangeal joint after arthrodesis. We retrospectively evaluated the postoperative clinical outcomes and radiographic findings for 16 consecutive female patients (20 feet) with symptomatic rheumatoid forefoot deformities. The mean duration of follow-up was 7.9 (range 4 to 13) years. All first MTP joints and first metatarsal bones were fused successfully. The mean value of the American Orthopaedic Foot and Ankle Society and Japanese Society for Foot Surgery clinical scores significantly improved overall, except for 2 patients (10%), who complained of first toe pain at the final follow-up visit owing to sagittal misalignment of the fused first MTP joint. Sagittal alignment of the first metatarsal varies greatly because of the rheumatoid midfoot and hindfoot deformities. Therefore, inclination of the first metatarsal should be considered when determining the first MTP joint sagittal fusion angle.     

Smart Toe® Implant Versus Buried Kirschner Wire for Proximal Interphalangeal Joint Arthrodesis: A Comparative Study

The surgical correction of hammer digits offers a variety of surgical treatments ranging from arthroplasty to arthrodesis, with many options for fixation. In the present study, we compared 2 buried implants for arthrodesis of lesser digit deformities: a Smart Toe^® implant and a buried Kirschner wire. Both implants were placed in a prepared interphalangeal joint, did not violate other digital or metatarsal joints, and were not exposed percutaneously. A retrospective comparative study was performed of 117 digits with either a Smart Toe^® implant or a buried Kirschner wire, performed from January 1, 2007 to December 31, 2010. Of the 117 digits, 31 were excluded because of a lack of 90-day radiographic follow-up. The average follow-up was 94 to 1130 days. The average patient age was 61.47 (range 43 to 84) years. Of the 86 included digits, 48 were left digits and 38 were right. Of the digits corrected, 54 were second digits, 24 were third digits and 8 were fourth digits. Fifty-eight Smart Toe^® implants were found (15 with 19-mm straight; 2 with 19-mm angulated; 34 with 16-mm straight; and 7 with 16-mm angulated). Twenty-eight buried Kirschner wires were evaluated. No statistically significant difference was found between the Smart Toe^® implants and the buried Kirschner wires, including the rate of malunion, nonunion, fracture of internal fixation, and the need for revision surgery. Of the 86 implants, 87.9% of the Smart Toe^® implants and 85.7% of the buried Kirschner wires were in good position (0° to 10° of transverse angulation on radiographs). Osseous union was achieved in 68.9% of Smart Toe^® implants and 82.1% of buried Kirschner wires. Fracture of internal fixation occurred in 12 of the Smart Toe^® implants (20.7%) and 2 of the buried Kirschner wires (7.1%). Most of the fractured internal fixation and malunions or nonunions were asymptomatic, leading to revision surgery in only 8.6% of the Smart Toe^® implants and 10.7% of the buried Kirschner wires. Both the Smart Toe^® implant and the buried Kirschner wire offer a viable choice for internal fixation of an arthrodesis of the digit compared with other studies using other techniques.     

第1跖列稳定术联合第2-5跖骨头切除术治疗晚期类风湿关节炎前足畸形

目的:介绍第1跖列稳定联合第2-5跖骨头切除术治疗晚期类风湿关节炎(rheumatoid arthritis,RA)前足畸形的手术方式并对中短期临床疗效进行评价。方法:2006年10月至2010年8月收治的晚期RA前足畸形97例患者进行回顾性分析。其中,男9例,女88例;单足65例,双足32例;年龄36～67岁,平均54岁;病程6～32年,平均17年。所有病例存在严重的拇外翻同时合并第1跖跗关节不稳,第2-5跖趾关节脱位及僵硬。采用第1跖列稳定联合第2-5跖趾关节成形术对其进行治疗。通过影像学资料测量拇外翻角(Hallux valgus angle,HVA),跖骨间角(intermetatarsal angle,IMA),并采用JSSF(Japanese Society for Surgery of the Foot)评分对临床疗效进行评估。结果:97例患者中失访5例(7足),平均随访37个月(6～52个月),其中1例术后1年因急性心肌梗死死亡。术前JSSF评分(33.2±8.2)分,末次随访时改善至(67.3±3.1)分(P<0.01);HVA由术前(50.0±11.8)°纠正至术后(21.2±3.2)°(P<0.01);IMA由术前(15.5±3.6)°纠正至术后(9.7±6.6)°(P<0.01)。发生跖趾关节骨不连4足;术后8～11月摄片发现第1楔骨内高密度改变3足;出现拇内侧切口延迟愈合9足;跖趾关节内固定感染2足;跖跗关节内固定感染1足;第2-5跖趾关节术后16足畸形复发。结论:晚期RA患者的前足病变涉及范围广,畸形严重。采用第1跖趾关节融合联合Lapidus术式重建第1跖列的外形及稳定性,跖骨头切除术纠正第2-5跖趾关节畸形的方式重建前足疗效可靠。该术式适用于重度拇外翻合并IMA增大及第1跖跗关节不稳,同时存在第2-5跖趾关节僵硬性半脱位的患者。     

Modified extension-block K-wire fixation technique for the treatment of bony mallet finger

This article describes the treatment of a bony mallet finger deformity using 2 extension-block Kirschner wires (K-wires) with a transarticular K-wire fixation technique for precise alignment of the terminal extensor tendon-bone relationship and effective immobilization of the distal interphalangeal joint. Twenty-nine patients (33 fingers) with a bony mallet finger deformity and fracture fragment involving more than one-third of the articular surface were treated surgically. The fracture fragment was fixed and the mallet finger deformity was corrected in all patients using modified extension-block K-wires (2 dorsal extension-block pins) with a transarticular K-wire (volar side pin) fixation technique. Active motion of the proximal interphalangeal and metacarpophalangeal joints was not restricted. The wires are removed in the clinic 6 weeks postoperatively when the bridging trabeculae were observed in the radiographs, and immobilization in a stock splint was continued for an additional 2 weeks. According to Crawford's evaluation criteria, there were 24 (73%) excellent, 7 (21%) good, and 2 (6%) fair results. Three patients showed radiological signs of mild degenerative changes, which did not limit their daily activities. Nail ridging occurred in 3 cases (9%), which disappeared after an average of 6 months with normal growth, and mild scarring at the dorsal pin site occurred in 2 cases (6%). Modified extension-block K-wires with a transarticular K-wire fixation technique is an acceptable alternative treatment modality for the management of bony mallet finger deformities with or without subluxation of the distal phalanx.     

Osteosynthesis in digital replantation using bioabsorbable rods

There are several fixation techniques for osteosynthesis in digital replantation. Kirschner wire fixation is used commonly but the wires protrude and disturb mobilization. Moreover, it requires removal. Since February 1995, the authors have been using a bioabsorbable rod made of poly-L-lactide as an intramedullary nail for osteosynthesis in digital replantation. The advantages of this technique include the absence of protruding hardware that would require removal and technical simplicity. This method has been applied for 15 arthrodeses (12 distal interphalangeal joints, 1 proximal interphalangeal joint, and 2 interphalangeal joints of the thumb) and for 11 diaphysis fractures (5 proximal, 5 middle, and 1 distal phalanx). All patients were observed until there was clinical and radiographic evidence of fusion (average interval to fusion, 8.4 wk). Bone resorption occurred in one patient. There were no cases of nonunion or infection. Poly-L-lactide rod fixation is a simple and effective technique.     

生物可吸收内固定系统在颌面骨折的应用与影像学观察

目的 通过术前和术后影像学比较研究观察生物可吸收内固定系统(夹板与螺钉)植入人体后的长期结果。方法 对17位颌面部骨折的患者在植入町吸收夹板与螺钉内固定后的6、9、12、18、24个月时行三维CT和／或全景片检查。同时复查患者的伤口愈合、骨端固定、咬合关系恢复等情况。结果 17位患者在术后1年内检查时螺钉的透射影像均没有明显的改变；18个月时螺钉的空洞基本被骨小梁充填；2年时螺钉的空洞完全被正常的骨小梁代替。临床检查局部伤口、骨段愈合均恢复良好，咬合关系正常。结论 影像学表明可降解内固定系统在植入人体后18～24个月得到了完全的降解，完全达到临床治疗上的生理骨愈合。     

跖跗关节骨折脱位内固定方法的生物力学实验研究

通过用9只新鲜人体脚制作成分歧型脱位标本模型。解剖复位后分别采用钢丝环扎、二根克氏针、四根交叉克氏针和松质骨螺钉共四种方法做内固定并进行生物力学测验,发现各种内固定方法必须使第一、二、三跖跗关节组成一个整体,使中足成为坚固的弓形结构,可防止足弓塌陷和畸形。应用克氏针或松质骨螺钉内固定时,必须在第一跖跗关节稳定的基础上,经第一、二跖骨基底和第三楔骨交叉穿一克氏针或螺钉,使第二跖骨基底得两点固定。第一、二、三、四跖骨基底的横向骨间韧带牵拉,可阻止其向外侧移位。跖跗关节的外侧柱用一根或二枚克氏针或螺钉即可起到固定作用。骨折脱位的内侧柱必须用二枚克氏针或螺钉固定。     

Hammertoe correction with wire fixation of varying length

BackgroundProximal interphalangeal (PIP) joint fusion with Kirschner (K) -wire fixation remains a popular strategy for hammertoe correction. This study was performed to evaluate the effect of length of wire fixation on clinical outcomes.MethodsA retrospective review of all hammertoe reconstructions by a single surgeon was performed. Wire length was chosen at the surgeon’s discretion. Outcomes were assessed with metatarsophalangeal (MTP) congruency, pin complications, and PIP union.Results157 toes underwent reconstruction. Seventy had wires that spanned the MTP and 87 that did not. Wire breaks were significantly more common with longer wire fixation (P = .024). MTP incongruency was significantly more common in the MTP group (P = .014).ConclusionPin breakage was rare and only occurred in the MTP group. MTP incongruence was significantly more common in the MTP group but may not reflect surgical technique. PIP union was more common with longer wire fixation but is not clinically significant.Level of EvidenceIII     

Percutaneous fixation of proximal humeral fractures

The purpose of the current study is to evaluate the technique of closed reduction and percutaneous pinning of proximal humeral fractures and to determine whether this technique provides enough stability to permit early active range of motion and subsequent fracture healing. Fractures were classified according to Neer et al and were included if the surgical or anatomic neck were angulated greater than 45 degrees, separation between fragments was greater than 1 cm, or the greater tuberosity was displaced more than 0.5 cm. There were 21 Type II, 16 Type III, and four Type IV fractures. Fractures were pinned using distally threaded Dynamic Hip Screw guide pins, 2-mm Kirschner wires, or 2.5-mm distally threaded Schantz pins. Patients were evaluated for union rates and motion. Assessment was made using the Modified American Shoulder and Elbow Surgeons Form. Thirty-six patients with 37 fractures were available for review with followup averaging 40 months (range, 12-68 months). All patients with Neer Type IV fractures did not respond to fixation and three had avascular necrosis develop, irrespective of the type of pin used. In the remaining 33 patients with Neer Type II and Type III fractures, a union rate of 94% was observed at an average of 2.6 months. All patients had good functional results. In the current series, there were no failures using Schantz pins. There was a 20% failure rate with Dynamic Hip Screw pins (2% if the patients with Type IV fractures were excluded) and a 100% failure rate with Kirschner wires. Stable fixation with early motion and subsequently good results can be obtained using percutaneous fixation in patients with Type II and Type III fractures; however, terminally threaded pins must be used and smooth Kirschner wires must be avoided. Percutaneous fixation cannot be recommended in patients with Type IV fractures.