Pressure distribution in carpometacarpal joint, due to step-off in operatively treated Bennett's fractures

Outcomes of Percutaneous Pinning for Interfragmentary Fixation in Treating Bennett Fractures With Tiny Avulsion Fragments

For Bennett fractures with tiny avulsion fragments, healing may be jeopardized owing to limited fracture contact surface if displacement of reduced fracture junctions occurs. This study aimed to assess the efficacy of treating Bennett fractures with tiny avulsion fragments using percutaneous small-diameter K-wires for tiny fragment fixation and thumb carpometacarpal (CMC) joint transfixation. From 2011 to 2019, we retrospectively enrolled patients with Gedda type 3 Bennett fractures who underwent operation with K-wire percutaneous pinning for the tiny fragment and CMC joint. We enrolled a total of 13 patients (13 fractures) with a mean age of 26.9 years (range, 18-42 years) at operation and a mean follow-up time of 17.9 months (range, 12-34 months). At the final follow-up, the shortened Disabilities of the Arm, Shoulder and Hand Questionnaire mean score was 4.7, and the visual analog scale score for pain during activity was 0.7. Mean grip strength was 34.7 kg (97.7% of the value on the unaffected side). Mean pinch strength was 5.4 kg (90.5% of the value on the unaffected side). Mean first web opening angle was 66.2° (96.6% of the value on the unaffected side). There were no changes in gap and step-off during the healing process and no osteoarthritic changes in the thumb CMC joint at the final follow-up. For Bennett fractures with tiny avulsion fragment, percutaneous treatment with small-diameter K-wires for fragment fixation and thumb CMC joint transfixation provides a viable alternative with fracture healing and good functional outcomes. [Orthopedics. 2023;46(2):103-107.].

Influence of differences in bone morphology on the distribution patterns of subchondral bone density across the trapeziometacarpal joint

We aimed to clarify the effects of morphological patterns of the trapezium and first metacarpal on the distribution of subchondral bone density across the articular surface of the trapeziometacarpal (TMC) joint using computed tomography osteoabsorptiometry. Thirty-three patients with normal TMC joints were evaluated. The percentages of the high-density areas in the radial-dorsal and ulnar-volar regions of the trapezium were significantly higher than that in the ulnar-dorsal region, and that of the ulnar-dorsal region of the first metacarpal was significantly lower than in the other three regions. The percentage of the high-density area of the radial-dorsal region of the trapezium and trapezial inclination (TI) showed a significant positive correlation, and the percentages of the high-density areas in the ulnar-dorsal and ulnar-volar regions had significant negative correlations with TI at the articular surface of the first metacarpal. These results indicate that bony morphologic differences in the trapezium affect the distribution pattern of subchondral bone density through the TMC joint.

Open reduction and internal fixation versus closed reduction and percutaneous fixation in the treatment of Bennett fractures: A systematic review

PURPOSE

Open reduction and internal fixation (ORIF) of Bennett fractures is increasingly preferred over closed reduction and percutaneous fixation (CRIF) in an attempt to prevent the development of post-traumatic arthrosis. The aim of this systematic review was to determine whether the preference for ORIF is justified based on the available literature regarding functional outcome and complications after surgery.

METHODS

A systematic review was performed in Medline, Embase, Cochrane CENTRAL, Web of science, and Google scholar. Duplicates were removed and title and abstract were screened after which full text articles were analysed. The reference lists of selected articles were screened for additional relevant studies. Study characteristics were recorded and methodological qualities were assessed after which data was extracted from the included articles. The Eaton-Littler score for post-traumatic arthrosis (primary outcome) on follow-up X-rays was used as primary outcome. Secondary outcomes were Grip strength, Pinch strength, persistent pain, fixation failure, functional impairment, infection and surgery time.

RESULTS

Ten studies were included; three retrospective comparative studies and seven retrospective case series. Of the 215 patients in these studies, 138 had been treated using an open technique and 77 by a closed percutaneous technique. The pooled rate of post-traumatic arthrosis was 57.5% (26.6-85.5) in the ORIF group versus 26.1% (3.9-59.0) in the CRIF group. Mean surgical operation time was 71.9 min for ORIF and 30.2 min for percutaneous patients. Fixation failure was significantly more often seen in the ORIF patients, 8.2% (0.7-22.8) vs. 2.9% (0.8-9.1), Risk Ratio 1.132 (0.01-176.745); p = 0.048. Infection was only seen in 5 CRIF patients. Persistent pain was seen in 32.9% (0.6-83.1) in ORIF patients versus 22.3% (8.1-41.1) in the CRIF patients. The pooled means Grip strength was 48.3 kg (95% CI; 39.7-56.9) versus 43.4 kg (95% CI; 22.9-63.8) for ORIF and CRPF, respectively. Functional impairment was similar between the two groups, 1.4% (0.1-4.4) vs 1.8% (0.1-5.7) respectively.

CONCLUSION

The analysed data do not confirm ORIF to prevent post-traumatic arthrosis, secondly more fixation failure and pain was seen in the ORIF group. The pooled data show percutaneous fixation to be preferable over ORIF in the surgical treatment of Bennett fractures.

Bennett's fracture: Comparative study between open and closed surgical techniques

The aim of this study was to assess long-term outcomes of surgically treated Bennett fractures, while comparing open reduction and internal fixation (ORIF) with closed reduction and percutaneous fixation (CRPF). Patients treated between 1994 and 2010 were assessed retrospectively during an outpatient visit using a validated questionnaire (i.e. DASH, pain assessed through VAS), sensory testing, grip- and pinch-strength and radiographic analysis for post-traumatic arthritis. Fifty patients were included. Mean follow-up was 10 years. Mean age at trauma was 34 years. ORIF was used in 35 patients. CRPF was used in 15 patients. No differences in grip- and pinch-strength were found. Re-operations were needed in five ORIF-treated patients. Higher Pain Scores (VAS) were seen in the ORIF-treated patients. No correlation was found between surgical technique and functional outcomes. A persistent step-off or gap larger than 2 mm after surgical fixation was significantly correlated with post-traumatic arthritis at 10 years' follow-up. The need to perform ORIF for anatomical reduction seems to be less important in preventing post-traumatic arthritis as a persistent step-off or gap of more than 2 mm was found to be significantly correlated with the development of post-traumatic arthritis. Secondly, both techniques lead to good functional outcomes, although persistent pain was seen in the ORIF-treated patients. Bennett fractures can therefore be safely treated with CRPF when the persistent step-off and gap after fixation do not exceed 2 mm. LEVEL OF EVIDENCE: Therapeutic study, Level III.

Arthroscopic Management of Bennett Fracture

Bennett fracture is the most common fracture of the thumb. Choosing the appropriate approach to fracture fixation requires a thorough knowledge of the anatomy surrounding the first carpometacarpal joint, which is necessary to prevent injury to local sensory nerves and tendons. Although no study has shown superior outcomes compared with open reduction internal fixation and fluoroscopically guided closed reduction and percutaneous pinning, arthroscopic-assisted fixation allows for debridement of the carpometacarpal joint, direct visualization of the articular surface during reduction, and has minimal morbidity and associated complications.

Sesamoid bone transfer for metacarpophalangeal hyperextension instability of the thumb: A CT-osteoabsorptiometry study

BACKGROUND AND AIM

Hyperextension instability of the metacarpophalangeal (MCP) joint of the thumb may result in pain, malfunction, and accelerated osteoarthritis in the carpometacarpal (CMC) joint. One method of treatment is sesamoid arthrodesis. The aim of this study is to investigate if a sesamoid transfer as a treatment of hyperextension instability of the thumb MCP joint leads to an altered distribution of the subchondral mineralisation and a negative clinical outcome.

METHODS

Sesamoid transfer was performed on 12 patients with hyperextension instability of the MCP joint of the thumb. The range of motion (ROM) and radiologic outcome were assessed. Pinch and power grip strength were measured and compared to the nonoperated side. To determine the areas of maximum subchondral mineralisation in the joint, computed tomography (CT)-osteoabsorptiometry was performed to determine the long-term stress distribution within the joint.

RESULTS

The distributions of the stress zones in the operated and nonoperated thumbs were not statistically different a median of 5 years following the sesamoid transfer procedure. There was no difference in the functional and radiological results between the operated and nonoperated thumbs.

CONCLUSION

If it is assumed that the nonoperated thumb represents the normal condition for each individual, then it may be deduced that the operation achieves good clinical results, and the distribution of the subchondral mineralisation does not change.