Intramedullary Pinning for Displaced Fifth Metacarpal Neck Fractures: Closed Reduction and Fixation Using Either an Open Antegrade or Percutaneous Retrograde Technique.

INTRODUCTION: Although the majority of fifth metacarpal neck fractures can be treated nonoperatively, surgery may be indicated when there is severe shortening or angulation of the metacarpal bone1. STEP 1 ANTEGRADE INTRAMEDULLARY PINNING OPERATING-ROOM SETUP AND MAKING THE INCISION: Proper positioning of the image intensifier and the treating surgeons is important. STEP 2 ANTEGRADE INTRAMEDULLARY PINNING BEND THE KIRSCHNER WIRES: Prepare and bend the Kirschner wires before insertion. STEP 3 ANTEGRADE INTRAMEDULLARY PINNING MAKE A HOLE IN THE FIFTH METACARPAL BASE: Create a hole for Kirschner wire insertion in the center of the fifth metacarpal base. STEP 4 ANTEGRADE INTRAMEDULLARY PINNING INSERT KIRSCHNER WIRES AND CLOSE THE WOUND: Insert the Kirschner wires through the hole of the fifth metacarpal base. STEP 5 ANTEGRADE INTRAMEDULLARY PINNING POSTOPERATIVE CARE: An additional skin incision is necessary to remove the Kirschner wires after bone union. STEP 1 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING OPERATING-ROOM SETUP: Proper positioning of the image intensifier and treating surgeon is important. STEP 2 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING FRACTURE REDUCTION: Reduce the fifth metacarpal neck fracture using the Jahss maneuver. STEP 3 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING INSERT KIRSCHNER WIRES: Fix the reduced metacarpal neck fracture using 2 Kirschner wires placed percutaneously in a retrograde direction, with the second wire inserted after the first wire passes the fracture site but before it passes the metacarpal base. STEP 4 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING KIRSCHNER WIRE MANAGEMENT: The proximal end of the Kirschner wire penetrating outside the dorsal skin of the wrist enables the surgeon to percutaneously retrieve the Kirschner wire after fracture union. STEP 5 PERCUTANEOUS RETROGRADE INTRAMEDULLARY PINNING POSTOPERATIVE CARE: The percutaneous Kirschner wire is retrieved. RESULTS: In a previous prospective randomized analysis of patients treated with antegrade intramedullary pinning and percutaneous retrograde intramedullary pinning for displaced fifth metacarpal neck fracture1, we found that the flexion arc of the MCP joint, visual analog pain scale score, grip strength, and DASH (Disabilities of the Arm, Shoulder and Hand) score4 were significantly better in the antegrade intramedullary pinning group at 3 months postoperatively.

Prospective randomized comparison of scar appearances between cograft of acellular dermal matrix with autologous split-thickness skin and autologous split-thickness skin graft alone for full-thickness skin defects of the extremities.

BACKGROUND: The purpose of this study was to evaluate the clinical outcomes of cografting of acellular dermal matrix with autologous split-thickness skin and autologous split-thickness skin graft alone for full-thickness skin defects on the extremities. METHODS: In this prospective randomized study, 19 consecutive patients with full-thickness skin defects on the extremities following trauma underwent grafting using either cograft of acellular dermal matrix with autologous split-thickness skin graft (nine patients, group A) or autologous split-thickness skin graft alone (10 patients, group B) from June of 2011 to December of 2012. The postoperative evaluations included observation of complications (including graft necrosis, graft detachment, or seroma formation) and Vancouver Scar Scale score. RESULTS: No statistically significant difference was found regarding complications, including graft necrosis, graft detachment, or seroma formation. At week 8, significantly lower Vancouver Scar Scale scores for vascularity, pliability, height, and total score were found in group A compared with group B. At week 12, lower scores for pliability and height and total scores were identified in group A compared with group B. CONCLUSIONS: For cases with traumatic full-thickness skin defects on the extremities, a statistically significant better result was achieved with cograft of acellular dermal matrix with autologous split-thickness skin graft than with autologous split-thickness skin graft alone in terms of Vancouver Scar Scale score. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Subtrochanteric femoral fracture during trochanteric nailing for the treatment of femoral shaft fracture.

We report on three cases of subtrochanteric femoral fractures during trochanteric intramedullary nailing for the treatment of femoral shaft fractures. Trochanteric intramedullary nails, which have a proximal lateral bend, are specifically designed for trochanteric insertion. When combined with the modified insertion technique, trochanteric intramedullary nails reduce iatrogenic fracture comminution and varus malalignment. We herein describe technical aspects of trochanteric intramedullary nailing for femoral shaft fractures to improve its application and prevent implant-derived complications.

Healing process after rigid plate fixation of humeral shaft fractures revisited.

OBJECTIVE: The purpose of this study was to describe the radiological healing process after open reduction and internal fixation (ORIF) of humeral shaft fractures with plate. MATERIALS AND METHODS: We reviewed the data of 53 consecutive patients who had undergone rigid plate fixation of OTA 12 A or B humeral shaft fracture. The mean age of the patients at the time of surgery was 39.4 (range 16-82). Quality of reduction and healing process was analysed on radiographs. Clinical symptom and disabilities of the arm, shoulder and hand (DASH) scores were recorded at follow-up visits. RESULTS: There were 28 compression and 25 neutralization platings. The mean gap size on the postoperative radiograph was 1.4 (range 0.1-6.1). 50 cases (94.3 %) healed, while three cases ended up with non-union. 28 (52.8 %) cases showed primary healing and 22 cases (41.5 %) showed secondary healing with callus bridging. Among the cases with secondary healing, callus formation with resorption was identified in 13 cases. The type of fracture, mode of compression and size of gap on radiographs after rigid plate fixation were found to be statistically significant factors for healing type (p = 0.026, 0.002, and <0.001, respectively). Three cases with non-union showed no improvement in DASH scores. CONCLUSION: Both primary and secondary healing processes were observed after rigid plate fixation of OTA 12 A or B humeral shaft fractures. Our study revealed that size of gap, mode of compression, type of fracture could affect the type of healing, and that periosteal callus formation can occur after rigid plate fixation.

Use of standard and anatomic-tilt lateral X-rays to determine distal radius volar angulation.

PURPOSE: To determine the reliability of measurements of distal radius volar tilt using either standard lateral or anatomic tilt lateral (ATL) radiographs, and to compare the mean values obtained using each radiographic method. METHODS: We obtained standard and 23° ATL plain radiographs of the distal radii of 20 patients with a distal radius fracture treated with a volar locking plate, and of 20 healthy individuals without a history of fracture of the wrist. Three orthopedic surgeons measured volar tilt twice with an interval of 4 weeks. We analyzed intraobserver and interobserver reliability and compared intraobserver means of volar tilts obtained using standard and ATL radiographs. RESULTS: The volar tilts measured using ATL radiographs in patients and healthy controls showed moderate to excellent intraobserver and interobserver reliability, whereas those determined using standard lateral radiographs showed poor to moderate intraobserver and interobserver reliability in patients and controls. However, the mean values of volar tilts measured in standard lateral radiographs and in ATL radiographs were similar in patients and not significantly different in healthy controls. CONCLUSIONS: Volar tilt measurements obtained using anatomic tilt lateral radiographs provided moderate to excellent reliability. However, we found no statistically significant difference between volar tilts determined using ATL and standard lateral radiographs. Accordingly, standard lateral and ATL radiographs are interchangeable with respect to volar tilt measurements. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Bilateral stress fracture of the femoral shaft after total knee arthroplasty: a case report.

The authors present a case of bilateral stress fracture of the femoral shaft 15 years after total knee arthroplasty. Considerable femoral bowing deformity and varus malposition of the femoral and tibial components after total knee arthroplasty may produce abnormal stresses and lead to stress fracture of the distal femur in the region of greatest curvature.

Pedicle screw-only constructs with lumbar or pelvic fixation for spinal stabilization in patients with Duchenne muscular dystrophy.

STUDY DESIGN: Retrospective case study. OBJECTIVE: We present a retrospective clinical study of 36 patients of Duchenne muscular dystrophy (DMD) treated for correction of scoliosis with pedicle screw-only constructs with the objective to analyze our technique, correction and maintenance of spinal and pelvic deformity, spinal fusion, the complications we encountered, and the adequacy of lumbar fixation. SUMMARY OF BACKGROUND DATA: Pedicle screw constructs have shown better deformity correction and maintenance as compared with other methods of instrumentation in adolescent idiopathic scoliosis. There are very few reports of pedicle screw-only constructs for DMD patients. METHODS: Thirty-six patients were followed up for an average period of 37.75 months (min 24 mo). All patients were instrumented from T2, T3, or T4 to L5 and all levels were instrumented. Pelvic fixation was performed only if the pelvic tilt was more than 15 degrees (10 patients). RESULTS: Cobb angle improved 65% (P<0.001) after surgery from a mean preoperative value of 71 degrees to an average postoperative value of 25.5 degrees. Balanced sitting posture was obtained in all patients. The lumbar lordosis improved significantly (P<0.0001) from an average preoperative value of -21.4 degrees to a mean immediate postoperative value of 23.7 degrees and to 19.5 degrees at final follow-up. In patients where pelvic fixation was performed, pelvic tilt improved 62% (P<0.0001) from an average of 25.8 degrees preoperatively to 9 degrees postoperatively to 11 degrees at final follow-up. In patients where pelvic fixation was not performed, the pelvic obliquity also improved from 10.5 degrees preoperatively to 5.8 degrees postoperatively (41.5% correction) and 8.5 degrees at final follow-up (4.2% correction). CONCLUSIONS: Pedicle screw-only constructs provide good stability allowing better correction and maintenance of coronal and lumbar deformities, obtaining good sitting balance, and mobilizing patients early after surgery. Longer follow-up is required to adequately comment on the need for pelvic stabilization.

Surgical correction and fusion using posterior-only pedicle screw construct for neuropathic scoliosis in patients with cerebral palsy: a three-year follow-up study.

STUDY DESIGN: It is a retrospective study of 52 neuromuscular scoliosis patients with cerebral palsy (CP). OBJECTIVE: To determine the effectiveness and amount of correction using posterior-only pedicle screw construct. SUMMARY OF BACKGROUND DATA: Although there have been many reports in literature supporting the use of pedicle screw-only constructs for the correction of adolescent idiopathic scoliosis, similar studies have not been reported in patients with CP. METHODS: We retrospectively evaluated outcomes of 52 neuropathic scoliosis patients (28 males and 24 females) with CP over minimum 2 years of follow-up. All patients underwent pedicle screw fixation without any anterior procedure for the correction. Pelvic fixation was done in 10 patients who had pelvis obliquity more than 15 degrees . All coronal and sagittal parameters were noted after surgery and at final follow-up. Patient's functional outcome was measured using modified Rancho Los Amigos Hospital system criteria. Complications were recorded from record sheets and any change in the ambulatory status was also recorded. RESULTS: Mean age was 22 years at the time of operation and average follow-up was 36.1 month. Cobb's angle was improved to 62.9% (P < 0.0001) from 76.8 degrees to 30.1 degrees after surgery and 31.5 degrees at final follow-up. This correction of scoliosis (41% approximately 92%) was found to be statistically significant (P < 0.0001). Overall correction in pelvic obliquity was 56.2% from 9.2 degrees before surgery to 4.0 degrees after surgery which was 43.1% at final follow-up to 5.2 degrees. Twenty-one patients (42%) improved their functional ability by grade 1 with 2 patients by grade 2. After the operation parent or caretakers of patients exhibited better sitting balance and nursing care. There were 32% complications in the series major being pulmonary. There were 2 perioperative deaths and 1 patient developed neurologic deficit due to screw impingement in canal, which was resolved after removal. CONCLUSION: We reported satisfactory coronal and sagittal correction with posterior-only pedicle screw fixation without higher complication rate in CP patients. Further long-term study is recommended to evaluate the success of pedicle screw in this population.