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.

Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: outcomes and complications

We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15 days (range 4-37) after injury in 2020. The delay was longer than usual due to the COVID-19 pandemic. The tendons were repaired with a 6-strand core suture (M-Tang method) or a double Tsuge suture and a peripheral suture. This was followed by an early, partial-range, active flexion exercise programme. Adhesions in four digits required tenolysis. These patients were not with longest delay. Outcomes of two improved after tenolysis. The other two patients declined further surgery. One finger flexor tendon ruptured in early active motion. This was re-repaired, and final outcome was good. Overall excellent and good results using the Tang criteria were in 27 out of 31 fingers and thumbs (87%). The time elapsed between the injury and surgery is not an important risk factor for a good outcome, rather it depends on proper surgical methods, the surgeon's experience and early mobilization, properly applied. Adhesions may occur, but they can be managed with tenolysis.Level of evidence: IV.

Outcomes of 173 metacarpal and phalangeal fractures treated by intramedullary headless screw fixation with a 4-year follow-up

Surgical treatment of extra-articular metacarpal and phalangeal fractures should be considered when there is instability or in patients with high demand. To overcome the issues related to the use of Kirschner wires, external fixators, and open reduction and internal fixation procedures, intramedullary headless screw fixation (IHSF) is an alternative technique to achieve primary fracture stability and early return to daily activities. We report the data of the Italian Multicentric Intra-Medullary Experience, which includes 173 cases of extra-articular unstable fractures (38 phalanges and 135 metacarpals) treated with the IHSF. After surgery, patients underwent early mobilization without splinting. The results confirm the reliability of IHSF in cases with non-articular involvement, showing a good recovery rate in terms of bone healing and range of motion.Level of evidence: IV.

Fragment specific fixation with APTUS wrist system for volar rim fractures of the distal radius: a multicentric study

PURPOSE

Volar rim fractures of the distal radius are a spectrum of pathology that must be well identified and treated to achieve good outcomes and avoid surgical failures. New devices of fragment specific fixation have been developed during the last decades to fix this fragment. The purpose of this retrospective study was to evaluate the ability of APTUS^® wrist distal radius system to securely fix different types of volar rim fractures.

METHODS

Patients with at least 1 year of follow-up and a preoperative CT-scan evaluation of the fracture pattern were included in the study. Clinical, radiological and functional outcomes were assessed.

RESULTS

Sixty-eight patients with an average follow-up of 34, 1 months (12-61) were included in the study. There were no clinical and radiological complications, including loss of reduction, device failure and tendon ruptures. No patients required hardware removal. Wrist range of motion in flexion-extension averaged 96°, while in pronation-supination 144°. At final follow-up mean visual analogue scale pain was 1,8. Questionnaires, as dissabilities of the arm, shouldder and hand (DASH) score and patient-related wrist evolution (PRWE) score were 6,6 and 3 respectively. Grip strenght measured 86% compared to the normal side.

CONCLUSION

APTUS^® wrist presents a versatile set of fragment specific fixation plates able to easily and securely fix all types of volar rim fracture. The system can be used with other devices without any kind of interference between them. When correctly placed and used with the right indications, no late complications can be recorded.

How to ease the fixation of carpal bones? Twenty-four lesions treated by 1,5 mm headless compression screws

BACKGROUND

Carpal bone lesions are common, even in acute injuries or as sequalae of missed fractures. If not correctly diagnosed and treated, can lead to loss of function, especially in active patients. The surgical management remain difficult particularly in case of small, atypical or non-unions fragments. The treatment of heterogenic shape fractures should require a fragment specific fixation using, traditionally, Kirschner-wire (K-wire). This method of treatment remains the most popular but could be prone to some complication as: not stable fixation, need to long time immobilization and wire mobilization. Methods Nineteen patients presented with carpal bone lesions were treated by the use of HCS 1,5 mm headless compression screws. Patients were evaluated post-operative by Patient-Rated Wrist Evaluation (PRWE), the Visual Analogic Scale (VAS), Quick-DASH Score and the grip strength was measured by Jamar dynamometer.

RESULTS

Authors observed improvement of pain control and common activity; fine movements were restored; we observed no post-operative functional instability.

CONCLUSIONS

HCS 1,5 mm headless compression screws are suitable and smart technique to treat these uncommon fractures to achieve a stable primary fixation and allow an early mobilization and conciliate the versatility of K-wire and the compression action due to screws also in small bone fragment.

How hand and wrist trauma has changed during covid-19 emergency in Italy: Incidence and distribution of acute injuries. What to learn?

BACKGROUND

the purpose is to gather and analyze the statistical datas of wrist and hand injuries admitted to the Hand and Reconstructive Microsurgery and Replantation Hub center of Careggi Hospital, Florence during the first two months of COVID-19 epidemic in Italy. The Authors investigated how the drastic changes in daily activities modified the epidemiology of hand trauma lesions.

METHODS

The Authors analyzed the characteristics of hand and wrist traumatic disorders during the months of February and March comparing 2019 to 2020. Collected data included age distribution, traumatic etiology, diagnosis and type of surgical procedures.

RESULTS

The total number of orthopedic and trauma patients significantly decrease in 2020 compared to 2019 (3360 vs 1470). The number of hand and wrist injuries didn't show a significant difference between 2019 and 2020 instead (192 vs 131). The overall number of patients hospitalized and surgically treated at our Operative Unit (OU) was 168 in 2019 and 120 in 2020. Male patients resulted prevalent (60,7 M vs 39,3F/2019; 63,2 M vs 36,8F/2020). In terms of patient age, in 2020 we registered a significant reduction of cases in the 20-35-year-old age group and a significant increase in the 51-65 and 66-80-year-old age groups. Traffic-related, sport-related and fortuitous injuries significantly decreased in 2020, while the number of domestic accidents significantly increased. Analyzing the Hospital Discharge Records (HDR), we found a significant increase in the number of proximal and middle phalanx fractures; no significant differences were found for other kinds of discharge diagnosis. As for the choice of surgical treatment options, no differences were found between 2019 and 2020.

CONCLUSION

Even during drastic movement restrictions and the prolonged suspension of work and leisure activities secondary to COVID-19 epidemic in 2020, hand and wrist traumas rate remained almost the same compared to the same period of the previous year. Nevertheless, a significant change in the etiology and patient age was registered. In fact, sport and traffic-related traumas decreased respect to domestic traumas, while the previous prevalent involvement of young adults was surpassed by accidental hand traumas in the elderly and active adults.

TFCC Lesions in Children and Adolescents: Open Treatment

BACKGROUND

There has been little discussion regarding the lesion of the TFCC in pediatric and adolescent patients. This study examines 11 cases treated with open technique.

METHODS

Range of motion (ROM), strength and functional scores (QUICK DASH, PWRE, VAS pain, and NAKAMURA score) were evaluated.

RESULTS

The mean postoperative flexion-extension arc was 95% of the contralateral side, the radio-ulnar deviation 91% of the contralateral side and the pronation-supination arc 94% of the unaffected side. Grip strength was 85.6% of the uninjured wrist, pinch was 88%. The mean PRWE decreased from 84.4 to 9.85 postoperatively. The mean Q-DASH scored 10.4. The VAS pain under stress decreased from a mean of 6.8 to a mean of 2.27, while at rest it decreased from a mean of 5 to a mean of 0.5. The final clinical results obtained by Nakamura score were 2 excellent, 6 good and 3 fair.

CONCLUSIONS

This study emphasizes that open surgical TFCC repair is a safe and reliable therapeutic procedure in children and adolescent populations.

Universal 2 Wrist Arthroplasty in Rheumatoid Arthritis

Purpose  The aim of this study was to evaluate the mid- to long-term outcomes and complications in patients affected by rheumatic diseases treated with the Universal 2 (U2) total wrist arthroplasty (TWA). Methods  We reviewed, in a retrospective, noncontrolled cohort study, 22 patients affected by rheumatoid arthritis (RA), who underwent U2 total wrist replacement between March 2003 and January 2014 for the treatment of 23 rheumatoid wrists with the aim of obtaining the remission of pain and a range of motion (ROM) useful for daily activities, according to the patients' demands, as an alternative to total wrist arthrodesis. The cohort of patients included 20 females and 2 males, with a mean age of 54.9 years. Residual pain, preoperative ROM, postoperative ROM increases, grip strength, radiographic changes, long-term complications, and reasons for revision or failures were evaluated. Results  In this study, 22 patients were evaluated at a mean follow-up of 82.3 months (range: 2-12 years). All patients had good or complete pain relief, the mean visual analogue scale pain score was 0.82. The mean grip strength improved and postoperatively was 11 kg (Jamar). The mean total ROM of flexion-extension was 72.3 degrees; radial-ulnar deviation 24.9 degrees. The mean QuickDASH score of 49 and patient rate wrist/hand evaluation of 41.7 a revision surgical procedure in six cases (26%): in two cases, a carpal component revision procedure and in four cases, total implant failures requiring either conversion to a Swanson spacer or wrist joint fusion. Conclusion  TWA provides pain relief, preserves motion, and improves function in severe degenerative RA. Our results at a mid- to long-term follow-up with the U2 prosthesis were encouraging and represent, when indicated, a valid alternative to fusion which is less appealing for RA patients. Level of Evidence  Level of evidence is therapeutic IV.

Proximal interphalangeal (PIP) joint replacements with pyrolytic carbon implants in the hand

Until the late 1980s, proximal interphalangeal (PIP) joint reconstruction had been almost exclusively performed by the use of monobloc silicone spacers and associated with acceptable to good clinical outcomes.

More recently, new materials such as metal-on-polyethylene and pyrocarbon implants were proposed, associated with good short-term and mid-term results.

Pyrocarbon is a biologically inert and biocompatible material with a low tendency to wear. PIP pyrolytic implants are characterised by a graphite core, visible on radiographs and covered by a radiolucent outer layer of pyrocarbon.

New surgical techniques and better patient selection with tailored rehabilitative protocols, associated with the knowledge arising from the long-term experience with pyrocarbon implants, has demonstrated noteworthy clinical outcomes over the years, as demonstrated by recent studies.

Cite this article: EFORT Open Rev 2017;2:21–27. DOI: 10.1302/2058-5241.2.160041

A new autocentering hinged external fixator of the elbow: a device that stabilizes the elbow axis without use of the articular pin

BACKGROUND

Hinged external fixation of the elbow is an important tool for the orthopedic surgeon. It enables early postoperative mobilization that may result in better outcomes. All models require correct alignment with the elbow axis of rotation. There is a long learning curve to this procedure, it may be time-consuming, and it can be associated with a high dose of x-ray exposure. An axial pin can interfere with bone-ligament suture anchors and bone reconstruction plates.

MATERIALS AND METHODS

A new external fixator has been designed and mechanically tested. The hinge has a special gear able to freely align itself with the center of elbow rotation during passive flexion-extension movements. It has been clinically tested on 7 patients affected by traumatic and post-traumatic elbow disorders. The maintenance of the correct position has been tested clinically with computed tomography scans and radiographs.

RESULTS

All patients had correct alignment of the axis of rotation of the external fixator with the axis of elbow rotation. No cases of misalignment, loss of fixation, pin loosening, or instability were found.

CONCLUSION

A new self-centering hinged external fixator correctly aligns itself with the axis of elbow rotation. It does not interfere with ligamentous reconstruction anchors, distal plates, or screw fixation. The surgical technique is easy to learn and relatively quick. It can also be positioned without performing an arthrotomy to maintain reduction of simple dislocations of the elbow.