Scaphoid excision and limited wrist fusion: a comparison of K-wire and circular plate fixation.
ABSTRACT: The purpose of this study was to compare the clinical outcome, union rate, and complications of a consecutive series of Scaphoid excision and limited wrist arthrodesis performed by a single surgeon using distal radius bone graft and K-wires or circular plate fixation. A sequential series of ten patients(11 wrists) who were stabilized with temporary K-wires were compared to 11 patients (11 wrists) who were stabilized with a circular plate. Minimum follow-up was 1 year. One patient in the K-wire group was converted to a wrist fusion. Six of the remaining ten patients in the K-wire fixation group and 8 of the 11 patients in the circular plate fixation group returned for the following blinded evaluations: Quick DASH, analog pain scale, range of motion, grip and pinch strength, plain x-ray, and multi-detector computed tomography evaluation. One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in any of remaining measures or rate of complications. This study shows that equivalent results can be obtained using circular plate fixation compared to K-wires when equivalent bone graft source and fusion technique are used. If K-wire removal requires a return to the OR, circular plate fixation is more cost-effective.
Project description:<h4>Objectives</h4>To compare the clinical effectiveness of Kirschner wire fixation with locking plate fixation for patients with a dorsally displaced fracture of the distal radius.<h4>Design</h4>A multicentre two arm parallel group assessor blind randomised controlled trial with 1:1 treatment allocation.<h4>Setting</h4>18 trauma centres in the United Kingdom.<h4>Participants</h4>461 adults with a dorsally displaced fracture of the distal radius within 3 cm of the radiocarpal joint that required surgical fixation. Patients were excluded if the surgeon thought that the surface of the wrist joint was so badly displaced it required open reduction.<h4>Interventions</h4>Kirschner wire fixation: wires are passed through the skin over the dorsal aspect of the distal radius and into the bone to hold the fracture in the correct anatomical position. Locking plate fixation: a locking plate is applied through an incision over the volar (palm) aspect of the wrist and secured to the bone with fixed angle locking screws.<h4>Main outcome measures</h4><h4>Primary outcome measure</h4>validated patient rated wrist evaluation (PRWE). This rates wrist function in two (equally weighted) sections concerning the patient's experience of pain and disability to give a score out of 100.<h4>Secondary outcomes</h4>disabilities of arm, shoulder, and hand (DASH) score, the EuroQol (EQ-5D), and complications related to the surgery.<h4>Results</h4>The baseline characteristics of the two groups were well balanced, and over 90% of patients completed follow-up. The wrist function of both groups of patients improved by 12 months. There was no clinically relevant difference in the patient rated wrist score at three, six, or 12 months (difference in favour of the plate group was -1.3, 95% confidence interval -4.5 to 1.8; P=0.40). Nor was there a clinically relevant difference in health related quality of life or the number of complications in each group.<h4>Conclusions</h4>Contrary to the existing literature, and against the rapidly increasing use of locking plate fixation, this trial found no difference in functional outcome in patients with dorsally displaced fractures of the distal radius treated with Kirschner wires or volar locking plates. Kirschner wire fixation, however, is cheaper and quicker to perform.<h4>Trial registration</h4>Current Controlled Trials ISCRTN 31379280. UKCRN 8956.
Project description:PURPOSE:We hypothesised that intercarpal K-wire fixation of adjacent carpal bones would reduce torque and lever force within a fractured scaphoid bone. METHODS:In eight cadaver wrists, a scaphoid osteotomy was stabilised using a locking nail, which also functioned as a sensor to measure isometric torque and lever forces between the fragments. The wrist was moved through 80% of full range of motion (ROM) to generate torque and force within the scaphoid. Testing was performed with and without loading of the wrist and K-wire stabilisation of the adjacent carpal bones. RESULTS:Average torque and lever force values were 49.6 ± 25.1 Nmm and 3.5 ± 0.9?N during extension and 41 ± 26.7?Nmm and 8.1 ± 2.8?N during flexion. Torque and lever force did not depend on scaphoid size, individual wrist ROM, or deviations of the sensor versus the anatomic axis. K-wire fixation did not produce significant changes in average torque and lever force values except with wrist radial abduction (P = 0.0485). Other than wrist extension, torque direction was not predictable. CONCLUSION:In unstable scaphoid fractures, we suggest securing rotational stability with selected implants for functional postoperative care. Wrist ROM within 20% extension and radial abduction to 50% flexion limit torque and lever force exacerbation between scaphoid fragments.
Project description:BACKGROUND:Scaphoid excision and four-corner arthrodesis is an acceptable salvage procedure for the treatment of scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists, since first popularized in the 1980s. We investigated the potential application of novel bioabsorbable plates and screws made of un-sintered hydroxyapatite/poly-L-lactide composite for the treatment of metacarpal fractures. We used this material for the fixation of four-corner fusions for SLAC or SNAC wrists commencing from April 2009. The purpose of this study was to clarify the controversy in the literature regarding the use of these plates. METHODS:The surgical procedures and clinical outcomes of four-corner fusions using a bioabsorbable (poly-L-lactic acid and hydroxyapatite) plate were reported. Ten patients (mean age, 59.2?years) with SLAC or SNAC wrists underwent fusions between April 2009 and June 2016. The primary diseases were scapholunate ligament injury, Preiser disease, and scaphoid pseudarthrosis. The mean postoperative follow-up period was 45.9?months (range, 12-86). RESULTS:In all patients, bone union was achieved without dislocation or pain. The mean wrist flexion and extension arc improved from 78.5 degrees before surgery to 90.5 degrees after surgery. Mean grip strength improved from 51 to 69% after surgery, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score improved from 53.5 to 14.3. No complications such as infection, avascular swelling, or tendon adhesion were observed. This implant requires no removal of internal fixation devices, produces stable outcomes, and is an effective fusion technique. CONCLUSIONS:We summarized the outcomes of four-corner arthrodesis using bioabsorbable plates. Satisfactory clinical results were shown, with no obvious complications. This novel plate also serves as a good alternative for patients who are allergic to metals. Furthermore, bioabsorbable plates are advantageous as they do not require removal.
Project description:Background ?Vascularized bone grafting (VBG) has the potential to yield reliable results in scaphoid nonunion; however, results across studies have been highly variable. This study critically evaluates surgical techniques, fracture location, and patient selection in relation to radiographic, clinical, and patient-centered outcomes after VBG for scaphoid nonunion. Methods ?We conducted a systematic review of the literature for the use of VBG in scaphoid nonunion. Physical examination, radiographic, and patient-centered outcomes were assessed. Four substratifications were performed: the location of scaphoid nonunion, pedicled versus free technique, Kirschner wire (K-wire) versus screw fixation, and VBG done as a primary versus revision procedure. Results ?A total of 41 publications were included in final analysis. VBG had an 84.7% union rate at 13 weeks after surgery. On an average, 89% of patients returned to preinjury activity levels by 18 weeks after surgery and 91% of patients reported satisfaction with the procedure. Proximal pole nonunions demonstrated similar union rates but lower functionality scores compared with nonunions across all regions of the scaphoid. Pedicled techniques demonstrated slightly improved range of motion compared with free technique. K-wire versus screw fixation demonstrated significantly higher union rates and faster union times. There were no differences in outcomes for VBG done as a primary versus revision procedure. Conclusion ?VBG serves as a viable option for the treatment of scaphoid nonunion, with consistent union rates in addition to significantly improved postoperative patient functionality. The fixation of these vascularized bone grafts with K-wires versus screw fixation may result in superior radiologic outcomes. Level of Evidence ?Therapeutic, Level III, systematic review.
Project description:Fractures of the distal radius are common with a variable prognosis in case of intra articular extension. The available options include Plaster, External fixation, Prefabricated Splintage using Ligamentotaxis, K-wire fixation, and open reduction internal fixation with T-plate without an as yet clear advantage of one over the others. If these fractures are allowed to collapse, radial shortening, angulation and articular incongruity may cause permanent deformity and loss of function. This limited small scale study was intended to compare the functional results of treatment of these fractures with a T plate and K-wires.This was a prospective experimental study conducted at department of Orthopedics of PGMI/Lahore General Hospital, Lahore. Total 30 patients were included and randomized into two groups of 15 patients each. Group-A patients were treated with Krischner's wires and Group-B patients were treated with a T-Plate with open reduction. Informed consent was taken. Post operative follow up was done for 12 weeks for the outcome parameters (Green and O'Brien score).Mean age of patients in Group-A and B was 36.13±9.81 and 44.73±7.86 years respectively. In Group-A there were 10 male and 5 female patients and in Group-B there were 8 male and seven female patients respectively. In Group-A nine patients presented with Fernandez type-II and six patients presented with Fernandez type-III fracture. While in Group-B 10 patients presented with Fernandez type-II and five patients presented with Fernandez type-III fracture. Among Group-A patient's final outcome was excellent in 86.67% patients while in Group-B only 53.33% patients had excellent outcome at three months follow up.Percutaneous Kirschner's wires appeared to be more effective as compared to T-Plate fixation in terms of functional outcome for treating intra-articular distal radius fractures.
Project description:An acute perilunate wrist injury that is unreduced for more than 6 weeks results in severe disability, and even open reduction with stabilization through wide dorsal and volar approaches is technically challenging. This report describes an arthroscopic technique for reduction and percutaneous wire stabilization of a chronic perilunate wrist dislocations. The technique involves initial radiocarpal and midcarpal access through the 6R and 3-4 portals, and these portals are used for synovectomy and debridement of capsular flap tears. The midcarpal joint is accessed initially through the radiocarpal joint, and additional midcarpal portals are used for sequential perilunate adhesiolysis before carpal mobilization and reduction. A percutaneous wire drilled into the lunate is used as a joystick to manipulate the lunate into its anatomic alignment along the carpal bones, and percutaneous transcarpal wire fixation is performed to stabilize the carpus. Arthroscopic and fluoroscopic guidance is used to optimize anatomic reduction and to confirm stability. The wrist is immobilized for 6 weeks; the percutaneous wires are removed thereafter, and the wrist is mobilized. Overall, the arthroscopic technique provides a safe and reproducible method for treatment of this complex chronic injury.
Project description:The author has designed a custom-made titanium plate for total wrist fusion for small-handed persons or patients with failed partial wrist fusions. From May 2011 to April 2013, this plate was used on 13 wrists, 5 of them with a minimum follow-up of 1 year. This implant is downsized compared with the standard wrist fusion plate: lower in profile, shorter in length, and narrower than the standard one. It is fixed to the radius by means of 2.7-mm screws and to the capitate and third metacarpal with 2.4-mm screws. In the curved plate all the screws are locked to the plate with a predetermined coaxial angle. The plate has a curvature to fit the dorsum of the carpus; it is 10° dorsally extended and has undercuts on the contact areas at the radius and third metacarpal dorsal surface. The indication for this implant is a short-statured patient for whom the standard plate is too large and bulky; a failed partial wrist fusion or proximal row carpectomy, for which a shorter plate is needed because only one articulation should be fused (midcarpal or radiocapitate joint); or both. The five wrists (two primary fusions and three failed radioscapholunate [RSL] fusions) healed between 11 and 14 weeks. No plate loosening was observed, and none of the patients felt painful prominence to the distal end of the plate on the dorsum of the hand.
Project description:Background Hardware-related complications more than 6 months after total wrist arthrodesis are rarely reported, and controversy remains around the inclusion of the middle finger carpometacarpal joint (CMCJ) in the fusion mass. Purpose To determine the frequency of hardware-related complications including plate fractures, screw fractures, and symptomatic plate/screw loosening, and to investigate whether failure to fuse the middle finger CMCJ contributed to these hardware complications. Patients and Methods A retrospective chart review was designed to identify long-term hardware-related complications following 122 wrist arthrodeses using plate fixation. Patients with at least 6 months of follow-up were reviewed to determine the number of complications, the involvement of the middle finger CMCJ, and the procedures required to address these complications. Results At a median of 2.5 years following arthrodesis (range, 6 months-19 years), 20 (16%) hardware-related complications occurred and included screw fracture (n = 12), plate loosening (n = 5), and plate fracture (n = 3). Thirteen (65%) of the hardware complications occurred after the CMCJ was not fused during the procedure. The CMCJ did not fuse after attempted arthrodesis in 6 additional wrists. Conclusions Persistent middle finger CMCJ micromotion was likely present in 19/20 wrists (95%) that experienced symptomatic hardware complications. Given the occurrence of hardware failures centering on this joint, it is our recommendation that, unless one plans for routine plate removal within a given timeframe, the middle finger CMCJ must be included in the fusion mass. Level 4 Therapeutic Case Series.
Project description:Four-corner fusion (4CF) is an accepted and regularly performed procedure when managing posttraumatic degenerative disorders in the wrist. This procedure consists of excision of the entire scaphoid in association with midcarpal fusion of the remaining four ulnar carpal bones (hamate, capitate, lunate, and triquetrum). In the majority of cases, the long-term outcome is a functional painless wrist. However, the exact procedure to best achieve a rapid solid bone union of the fusion mass without hardware complications remains controversial. The authors have developed a precise system to ensure precise positioning, firm fixation, and fusion at the midcarpal joint together with an early postoperative recovery, avoiding some of the issues reported with other implants used for 4CF. The described implant is a circular plate accommodating variable angle locking screws as well as compression screws that can firmly fix the plate to the carpal bones. The locking technology produces a very solid construct. A special reaming-distraction-compression guide has also been developed to both countersink the plate on the underlying carpal bone mass and allow distraction of the midcarpal joint for debridement and cancellous bone graft interposition. The features of the implant, its surgical technique, and a relevant case are described.
Project description:Purpose The purpose of this study was to evaluate the outcomes of perilunate dislocations and fracture-dislocations treated with arthroscopically assisted mini-invasive reduction and fixation. Methods Between June 2012 and May 2014, 24 patients who had a dorsal perilunate dislocation or fracture-dislocation were treated with arthroscopically assisted reduction and percutaneous fixation. The mean follow-up was 14.8 months (range 6-32 months). Clinical outcomes were evaluated on the basis of range of motion; grip strength; Mayo Wrist Score; Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire; and Patient-Rated Wrist Evaluation (PRWE) score. Radiographic evaluations included time to scaphoid union, carpal alignments, and any development of arthritis. Results The range of flexion-extension motion of the injured wrist averaged 86% of the values for the contralateral wrist. The grip strength of the injured wrist averaged 83% of the values for the contralateral wrists. The mean QuickDASH score was 6, and the mean PRWE score was 10. According to the Mayo Wrist Scores, overall functional outcomes were rated as excellent in 13 patients (54%), good in 6 (25%), fair in 4 (17%), and poor in 1 (4%). Scaphoid nonunion developed in one patient. Reduction obtained during the operation was maintained within normal ranges in all patients. Arthritis had not developed in any patient at final follow-up. Conclusions Arthroscopically assisted mini-invasive reduction with percutaneous fixation is a reliable and favorable alternative in the treatment of perilunate injuries according to our early follow-up results.Level IV, Therapeutic.