Choosing the proper implant for extra-articular fractures of proximal phalanges: A study on 75 cases.

INTRODUCTION: Phalangeal fractures are the most common fractures of the hand and in particular the proximal phalanx of the long fingers is the most involved. These fractures can ben conservatively managed but, when the fracture pattern is considered unstable, surgical treatment is recommended. However, there is no consensus in literature about the proper surgical option for extra-articular proximal phalanx fractures. MATERIAL AND METHODS: We compared clinical and radiographical results after treatment of 75 cases of extra-articular proximal phalanx fractures using three different surgical techniques: closed reduction and internal fixation (CRIF) with Kirschner wires (G1 group), open reduction internal fixation (ORIF) with plates and screws or lag screws (G2 group), and closed reduction and intramedullary screw fixation (CRIMEF)(G3 group). RESULTS: We found no significant differences in term of union rate and time to fracture healing between the three groups. However, we found a significant reduction in time to return at work and in TAM at the final follow-up examination in G3 group (treated with CRIMEF) when compared with both G1 and G2. No differences in complications rate were found between three groups. DISCUSSION: The surgical variability in the management of extra-articular phalanx fractures create lacks on standard guide for treatment. CONCLUSIONS: In conclusion, our results showed good clinical and radiographical results with all the three surgical options. However, the closed reduction and internal fixation with intramedullary screws (CRIMEF) seems to be better in terms of time to return to work and TAM at the final follow-up, probably due to good primary stability and little risk of soft tissue adherence development.

Percutaneous headless screws and wide-awake anesthesia to fix metacarpal and phalangeal fractures: outcomes of the first 56 cases.

Phalangeal (P) and metacarpal (MC) fractures are very common injuries, with potentially disabling, residual impairment, deformities or stiffness. Conservative treatment represents the strategy of choice in most cases, but in unstable fractures and/or high-demanding patients, surgical fixation could be required. Ideally, the best treatment choice will be the intramedullary fixation systems, if possible without the implant protruding from the skin. Intramedullary headless screw fixation could be the reliable option to achieve a primary fixation, allowing an early active movement, with regard to the fractures site. The Authors analyzed the results achieved after 56 extra-articular unstable fractures (31 phalangeal fracture and 25 metacarpal fracture) treated with intramedullary headless compression screws. After surgery, patients underwent early mobilization without splinting. The results of the study suggest that this technique could be a reliable therapeutic option in order to obtain early mobilization and quick return to work after a phalangeal or metacarpal fracture, especially for high-demanding patients.

Treatment of flexor tendon reconstruction failures: multicentric experience with Brunelli active tendon implant.

INTRODUCTION: Secondary repair of flexor tendon injuries remain a challenging procedure for hand surgeons. Usually, secondary reconstruction should be performed by staged approach. When the tendon and pulley integrity are intact, tenolysis may be the first surgical option. One-/two-stage tendon grafts are suggested when the integrity of flexor tendon is compromised. Active tendon implants (Brunelli prostheses) may represent an efficient option in patients with a poor prognosis, as well as whenever classical techniques fail. Due to lack of literature about this second-line treatment, the authors present the experience of two different orthopedic departments with the permanent active tendon implant. MATERIALS AND METHOD: Nineteen consecutive patients with failed previous flexor tendons repairs were treated with active tendon implants between 2000 and 2011. The functional outcome of the patients was examined with a mean follow-up of 5.6 years, using Strickland assessment and QuickDASH. RESULTS: In 16 cases, the tendon implants were well tolerated and patients resulted satisfied with a QuickDASH score less than 33. Strickland score was fair to excellent in 10 patients. We registered adhesion complications in 3 cases. CONCLUSION: We can conclude that these prostheses represent an alternative to biological reconstructions and a potentially permanent procedure in complicated flexor tendon injuries. LEVEL OF EVIDENCE: Multicentric case series, Level IV.

A local anesthesia without tourniquet for distal fibula hardware removal after open reduction and internal fixation: the safe use of epinephrine in the foot. A randomized clinical study.

Hardware removal after surgical treatment fracture is one of the most common procedures in orthopaedic daily activity. A percentage from 14.5 to 21 of total removal involves the ankle joint. Trying to reduce the important socio-economic impact of this surgical procedure, we thought to perform it using the Wide Awake Local Anaesthesia Without Tourniquet (WALANT), a particular technique presented by D. Lalonde that associated a local anaesthetic drug with epinephrine in order to obtain an effective haemostatic effect despite the lack of a tourniquet. Nowadays, the WALANT efficiency and safety in hand surgery is widely demonstrated in literature but there are no data about its use in lower limb extremity surgeries. Authors performed a randomized study with 60 patients whom underwent distal fibula hardware removal between 2014 and 2016; they were divided into two groups: Group A under loco-regional anaesthesia with tourniquet and Group B under WALANT. We did not find significant differences in term of maximum pain level felt during the anaesthesiologic and surgical procedure. However, the use of WALANT significantly reduced post-operative pain levels. The WALANT procedures also reduced the number of hospitalization days. No differences in term of post-operative complication rates were found. In conclusion, the WALANT can be considered as a suitable option for distal fibula hardware removal in selected patients; it shows important clinical and economic advantages compared to the traditional loco-regional anaesthesia with tourniquet. This study also lays the foundation for the use of the WALANT beyond the field of hand surgery only.

Intramedullary headless screw fixation for fractures of the proximal and middle phalanges in the digits of the hand: a review of 31 consecutive fractures.

UNLABELLED: We present the results of 26 patients with 31 consecutive displaced or unstable extra-articular fractures of the base and shaft of the proximal and middle phalanges of the digits of the hand, treated over a period of 12 months with an intramedullary headless compression screw and early mobilization with no splinting. All fractures healed with no major complications. Only one patient, who had a pathological fracture through an enchondroma, required a tenolysis to improve the mobility of the finger. This technique seems to be technically simple, effective and with few drawbacks. LEVEL OF EVIDENCE: IV.

Treatment of proximal phalangeal fractures with an antegrade intramedullary screw: a cadaver study.

The aim of this study was to quantify the articular cartilage defect created with two different antegrade techniques of intramedullary osteosynthesis with a headless compression screw inserted through the metacarpophalangeal joint. In 12 out of 24 fingers from six cadaveric hands, a trans-articular technique with cannulated headless compression screws (2.2 and 3.0 mm diameter) was used; whereas in the other 12 fingers, an intra-articular fixation technique was used. The areas of the articular surface and the defects created were measured with a digital image software program. All measurements were made twice by two observers. In the intra-articular technique, the average defect in the base of the articular surface of the proximal phalanx was 4.6% with the 2.2 mm headless compression screw and 8.5% with the 3.0 mm screw. In the trans-articular technique, the defect size was slightly smaller; 4.2% with the 2.2 mm screw and 8% with the 3.0 mm screw, but the differences were not statistically significant. The main advantage of the intra-articular technique was that it avoided damage to the articular surface of the metacarpal head.