Antegrade Intramedullary Fixation Research Articles

Intra-Articular Antegrade Intramedullary Screw Fixation for Proximal Phalanx Fractures: Impact of Articular Surface Defects on Joint Contact Pressures.

Intramedullary headless screw fixation is increasingly used for fixation of proximal phalanx fractures. However, the impact of screw entry defects on joint contact pressures is not well defined and may have implications for arthrosis. The objective of this cadaveric biomechanical study was to assess joint contact pressures at the metacarpophalangeal (MCP) joint before and after passage of 2 sizes of antegrade intramedullary fixation. Seven fresh frozen cadaver specimens without arthritis or deformity were included in this study. Antegrade intramedullary screw fixation of proximal phalanx fracture was simulated using an intra-articular technique. Flexible pressure sensors were inserted into the MCP joints and cyclic loading was performed. Peak contact pressures were determined and averaged across loading cycles for each finger in the native state, with 2.4- and 3.5-mm drill defects in line with the medullary canal. Peak pressure increased with the size of the drill hole defect. Contact pressure increases were greater in extension, with peak contact pressures increased by 24% for the 2.4-mm defect and 52% for the 3.5-mm defect. Increase in peak contact pressure was statistically significant with a 3.5-mm articular defect. Contact pressures were not consistently increased for the 2.4-mm defect. Testing in flexion of 45° resulted in reduced contact pressure for these defects. Our study demonstrates that antegrade intramedullary fixation of proximal phalanx fractures can increase MCP joint peak contact pressures, particularly in an extended joint position. Effect increases with defect size. This has implications for the management of proximal phalanx fractures using this technique.

Antegrade Intramedullary Fixation for Clavicular Shaft Fracture: A Technical Trick.

The standard open reduction and internal fixation technique with a plate and screws for a simple mid shaft clavicular fracture necessitates a relatively large incision and can also lead to variable amount of keloid scar formation. Historically, other techniques of more minimally invasive retrograde intramedullary fixation with the entry point posterolaterally on the shoulder have shown their own disadvantages and complications. We present a surgical technique of antegrade intramedullary fixation for mid shaft clavicular fractures and an illustrative case series.

Comparison of Antegrade Percutaneous Intramedullary K-wire Fixation and Transverse Pinning for Treatment of Unstable Displaced Metacarpal Neck and Shaft Fractures: A Prospective Interventional Study

Introduction: Metacarpal fractures account for upto 10% of all body fractures and 36% of all hand fractures in adolescents, young adults, and active adults. Fractures of the metacarpal shaft and neck are common in all metacarpal fractures after direct trauma, roadside accidents, or sports injuries. The ratio of the shaft to the neck is 1:2. Closed reduction and plaster of paris cast can be used to treat the majority of these fractures conservatively. Unstable and comminuted fractures necessitate surgery. Aim: To compare the clinical, functional and radiological outcomes in antegrade intramedullary fixation and transverse pinning of metacarpal fractures in patients of unstable and displaced metacarpal shaft and neck fractures. Materials and Methods: A single-institutional prospective interventional study identified 60 cases of metacarpal fractures between November 2019 to August 2021. Each of the cases met the inclusion criteria for closed extra-articular fractures, displaced and unstable fractures of the metacarpal bone. The patients were divided into two groups having 30 subjects each, randomly allotted to two groups (Antegrade intramedullary K-wiring and Transverse Pinning). Outcomes were compared for range of movement by the American Society of Hand Surgeons Total Active Motion score (ASSH TAM), Visual Analog Scale (VAS), and radiological parameters (Angulation). Patients were followed-up for 12 weeks. Complications were listed in terms of pin site infection. Results: Most of the patients were found to be in the third decade of life. The fracture union was achieved at 8±2 weeks. Clinical evaluation done by VAS score which was found to be statistically insignificant between two groups (p-value=0.243). Radiological assessment evaluated by measuring postoperative angulation between two groups was found to be statistically insignificant (p-value=0.248). Difference in functional evaluation between the two groups done by ASSH TAM was found to statistically significant between the groups (p-value=0.036). Conclusion: Both antegrade intramedullary K-wiring and transverse pinning demonstrate good and comparable results for extra-articular neck and shaft metacarpal fractures. However, the former is superior in terms of final range of motion as per ASSH TAM score.

Comparison of Results Based on the Number of Kirschner Wires of Different Diameters in Antegrade Intramedullary Fixation of Fifth Metacarpal Neck Fractures

Purpose: The purpose of this study was to compare the clinical and radiological results of patients with fifth metacarpal neck fractures using different sizes and numbers of Kirschner wires (K-wire).Methods: A single institutional retrospective review identified 67 patients with a fifth metacarpal neck fracture between January 2015 and July 2020. The minimum follow-up time was 6 months and they were all treated within 6.4 days of the initial injury. Either one K-wire (1.6 mm), two K-wires (1.1 mm), or three K-wires (0.9 mm) was used. We analyzed the bone union period, and K-wire removal period, duration of surgery, total active motion, intramedullary diameter, pre/postoperative shortening, and pre/postoperative angulation clinically. We used a Method of Shortening Stipulated to measure shortening and the Medullary Canal-lateral view method for angulation. The intramedullary diameter was measured in the mid-shaft of the fifth metacarpal bone in the coronal view. Total active motion was measured at the time of follow-up in our outpatient department.Results: Clinical and radiological parameters showed no statistically significant differences. Even though it did not present a statistical significance, the absolute mean duration of surgery was the shortest in a single K-wire group. Conclusion: The clinical and radiological outcomes of surgery were comparable regardless of the number of K-wires inserted. However, we could look forward to gaining potential benefit from shortened operation time in a single K-wire group. Since stable fixation can be obtained even if one K-wire is used, inserting one thick K-wire into the intramedullary canal can be an alternative according to the surgeon’s preference.

Antegrade intramedullary fixation for adolescent fifth metacarpal neck fracture and its impact on epiphyseal growth

BackgroundAntegrade intramedullary nailing (AIMN) with Kirschner wire (K-wire) is a minimally invasive osteosynthesis technique. This procedure has been widely performed to treat the fifth metacarpal neck fracture (FMNF) in adults. This study was performed to determine whether using AIMN with a single K-wire to treat FMNF in adolescents would have good clinical and radiographic outcomes.MethodsIn this retrospective study, 21 children (aged 11–16 years) with FMNF were treated using AIMN with a single K-wire from May 2017 to January 2020 in our hospital. Indications for intervention were severe displacement with malrotation deformity, apex dorsal angulation of greater than 40°, or both. Collected data included apex dorsal angulation, range of motion (ROM) in the fifth metacarpophalangeal (MCP) joint, Visual Analog Scale (VAS) for pain, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) score.ResultsAll patients were followed up for 12–24 months (average, 16.57 months), and all patients obtained anatomical reduction postoperatively. The healing time was 2.69 ± 0.83 months (range, 2–4 months). Average apex dorsal angulation was reduced significantly from 44.49°±2.64° to 15.74°±2.47° (P < 0.001). The average ROM in the MCP joint and apex dorsal angulation of the injured side were not significantly different from those of the uninjured side. The average DASH score was 1.76 ± 1.48 (range, 0–4), the mean VAS was 0.19 ± 0.60 (range, 0–2), and the mean grip strength was 91.55 %±4.52 % (range, 85–101 %). No secondary displacement, dysfunction, nonunion, infection, or osteonecrosis was observed during the follow-up. Although premature epiphyseal closure was found in one patient, no long-term clinical finding of angulation or shortening was identified.ConclusionsAntegrade intramedullary fixation with single K-wire was an effective and reliable technique that successfully resulted in good functional and cosmetic outcomes for treating adolescents with FMNF. The impact on the growth plate was low in this population given that most patients were at or approaching skeletal maturity.Level of evidenceLevel IV.

Minimally invasive antegrade intramedullary fixation for unstable subcapital fracture of the fifth metacarpal by single elastic nail

Background Fractures of the neck of the fifth metacarpal are common and mainly occur in young men. The injury often occurs through aggression, such as a fist fight or punching a hard object. The aim of this study was to assess clinical and radiological outcomes of fifth metacarpal neck fractures using minimally invasive antegrade single intramedullary fixation prepending elastic nails in the selected patients and to explore the ideal puncture point to avoid iatrogenic ulnar nerve injury. Patients and methods A single elastic nail with suitable diameter was used in 24 cases of fifth metacarpal neck fractures with dorsal angulation over 45°. An initial entry point was perforated at the ulnar-dorsal base of the metacarpal. The nail was inserted in an antegrade approach. The nail was usually removed at about 8 weeks postoperatively. Results This study reported the results of 24 patients who were affected by closed fractures of the neck of the fifth metacarpal bone (boxer’s fracture) and were treated with percutaneous single elastic intramedullary nailing to verify the effectiveness of this surgical treatment. The average follow-up period was 20.75 months. The parameters evaluated included angulation, rotational alignment, postoperative metacarpophalangeal range of motion, and time to union. At the final follow-up, no patient reported residual pain, and all fractures proceeded to bony union. Conclusion The authors recommend that this percutaneous single elastic intramedullary nailing was a minimally invasive and reliable fixation technique for fifth metacarpal neck fractures with good functional results and low morbidity.

Antegrade Percutaneous Intramedullary Fixation Technique for Metacarpal Fractures: Prospective Study on 150 Cases.

The aim of our study was to assess the results of antegrade percutaneous intramedullary Kirschner wire (K-wire) fixation, for the treatment of unstable displaced metacarpal fractures in a large number of cases, in order to support the usage of this mini-invasive technique in the largest variety of fractures as possible. Every patient meeting the inclusion criteria was treated with closed reduction and antegrade intramedullary fixation with 1 or 2 K-wire from January 2013. A total of 150 patients with 165 metacarpal fractures were evaluated until February 2016. Average follow-up duration was 10 weeks. The clinical outcome was assessed by the total active motion of the digit, presence of rotational deformity, Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) score, and Patient-Rated Wrist/Hand Evaluation (PRWHE) score. The radiographic outcome was assessed by evaluating the dorsal angulation and shortening of the metacarpal, comparing the postoperative radiography and the first radiography showing fracture healing. Comparing the injured and contralateral digit average total active motion after 10 weeks from surgery, no statistical significance emerged. No patient developed extensor tendon irritation, so that there was no need to perform tenolysis, ever. The average Quick Disabilities of the Arm, Shoulder, and Hand score was 12.3 (range, 0 to 37). The average Patient-Rated Wrist/Hand Evaluation score was 19 (range, 0 to 41). Fracture union was steadily achieved. Radiographic assessment showed a nonsignificant postoperative loss of reduction. Antegrade intramedullary K-wire fixation technique is valid, reproducible, cheap, and perfectly suited to the treatment of metacarpal fractures requiring surgery, providing immediate mobilization and excellent outcomes for a very wide variety of fractures.

Outcome of antegrade intramedullary fixation for juvenile fifth metacarpal neck fracture with titanium elastic nail.

The purpose of the current study was to assess the outcome of antegrade intramedullary fixation with titanium elastic nail (TEN) in displaced fifth metacarpal neck fractures. The present study included 69 consecutive juvenile patients with displaced fifth metacarpal fractures. The head-shaft angle of the fifth metacarpal and range of motion (ROM) of the metacarpophalangeal (MCP) joint were evaluated. A disabilities of the arm, shoulder and hand (DASH) questionnaire was used to assess upper arm function. The head-shaft angle of the affected side was significantly improved postoperatively (P<0.05). No marked difference was observed between the affected and unaffected side in head-shaft angle and ROM. The average DASH score was 1.7 (range, 0-6.0). All patients obtained anatomical reduction postoperatively and the average healing time was 5.7±1.09 weeks (range, 5-10 weeks) with no non-union cases. Therefore antegrade intramedullary fixation with TEN is recommended as an easy, reliable and minimally invasive surgical technique for treating displaced fifth metacarpal neck fractures.

Radiologic Changes by Early Motion in Neck Fractures of the Fifth Metacarpal Treated with Antegrade Intramedullary Fixation.

As intramedullary (IM) fixation is one of the fixation methods used in neck fractures of the fifth metacarpal, an early motion of injured finger can be allowed. The purpose of this study is to evaluate whether immediate active motion affects the stability of antegrade IM fixation in surgical treatment of neck fractures of the fifth metacarpal bone and to assess related factors. Thirty one patients treated by closed reduction and antegrade IM fixation were consecutively enrolled. All patients started active motion of the little finger since 7 postoperative days and only daily activities including writing, typing or washing were allowed until the union of fracture. All fractures were healed within four to eight weeks. The changes of angulation, fifth metacarpal length and tip to head distance of K-wire were compared between immediate postoperative radiographs and radiographs at eight weeks. In addition, the effects by age, gender, initial angulation and comminution of the metacarpal neck were assessed. The average change of angulation was 0.12°, 5th metacarpal length was 1.49mm and tip to head distance of K-wire was 1.31mm. There was no significant difference in the change of angulation (p = 0.137). But, there were significant differences in the change of 5th metacarpal length and tip to head distance of K-wire ([Formula: see text]). The change of angulation was related to a comminution of the metacarpal neck and that of 5th metacarpal length was related to age and sex. The change of 5th metacarpal length and tip to head distance of K-wire can occur by an early mobilization in the antegrade IM fixation for neck fractures of the fifth metacarpal. However, we thought that an early active motion after surgery is important to increase the patients' satisfaction, even though careful selection of candidates is necessary.

Antegrade intramedullary fixation of humeral shaft fractures by Rush pins

Most humeral shaft fractures (>90%) heal with nonsurgical management, which is practiced by the use of hanging cast, but it is most effective only in spiral or oblique fracture pattern. During this immobilization period, the patients must remain upright or semi-upright at all times, even while sleeping, with the cast in a dependent position for effectiveness. It causes suffering to most patients. Intramedullary flexible nailing used for displaced transverse humeral shaft fracture was advocated decades ago. Now, we try to use Rush pins to fulfill the theory of “filling-up” and “3-point” fixation. Nine patients (five men and four women) underwent this closed reduction and internal fixation with Rush pin procedure between July 2007 and June 2009. Their average age was 43.2 years (range, 19–68 years). The union status was checked by radiologic and physical examinations. The shoulder function was evaluated by Oxford Shoulder Questionnaire. The surgery was performed with an incision on lateral cortex of humeral surgical neck. The size and number of Rush pins were decided according to the inner diameter and length of the humeral shaft. The Rush pins were prebent before insertion. The whole procedure of pin insertion was carried out under C-arm guidance. None of these patients had radial nerve injury or pin migration. Two complications were noted, one with proximal hook prominence and the other one with nonunion of fracture because of overdistraction. Otherwise, all the other patients regained pretraumatic shoulder range of motion, union of fracture, and were satisfied with the shoulder function and clinical result. Although it is technique demanding, it has the benefits of avoiding damaging rotator cuff and exposing radial nerve, saving operating time, minimizing soft tissue dissection, and being cost-effective. Furthermore, patients had a better life quality during the period of immobilization because of fracture.

Biomechanical research of antegrade intramedullary fixation for the metacarpal fractures

To study the biomechanical characteristics of antegrade intramedullary fixation for metacarpal fractures. From March to May 2008, both the 4th and 5th metacarpals from 25 formalin embalmed cadaver hands had three-point bending test after transverse osteotomy followed by randomly fixation with one of the following three methods: plate and screw, antegrade intramedullary K-wire, crossed K-wire. While, both the 2nd and 3rd metacarpals had torsional loading test after the same management as the 4th and 5th metacarpal had undergone. In the three-point bending test, both the maximum bending moment (M(max)) and bending rigidity (EI) of the antegrade intramedullary K-wire were comparable with those of the plate and screw, and were significantly larger than those of the crossed K-wire. In the torsional loading test, the antegrade intramedullary K-wire had a statistically smaller maximum torque (T(max)) than the plate and screw, and had a comparable T(max) with the crossed K-wire; while, the torsional rigidity (GJ) of the intramedullary K-wire was statistically weaker than that of both the plate and screw and the crossed wire. One single antegrade intramedullary K-wire can provide a satisfactory M(max) and EI for metacarpal fixation and shows relatively weak in the torsional loading test. The injured finger should be well protected to avoid torsional deformity in clinical practice.

Anatomical study of the surgical approach for antegrade intramedullary fixation of the fourth and fifth metacarpal fractures

Objective To summarize the postoperative complications of antegrade intramedullary fixation of the fourth and the fifth metacarpal fractures,and study the anatomic features of the surgical approach.Methods One hundred and twenty two patients with metacarpal fractures who had undergone antegrade intramedullary fixation were followed up and postoperative complications involving nerves and tendons were observed.Anatomical dissection was carried our in 16 formalin embalmed adult cadaver forearms.The course of the dorsal cutaneous branch of the ulnar nerve and the extensor tendons were traced and observed.The distances from the optimal pinning sites for antegrade intramedullary fixation of the fourth and fifth metacarpal fractures to the surrounding nerve branches and extensor tendons were measured.Results Postoperative sensory disturbance on the ulnar side of the dorsal hand occurred in 8.0%(9/112)of the patients.Seven of these patients had complete recovery,whereas the other two still had sensory symptoms.There was no tendon adhesion,tendon irritation or rupture.The distances from the optimal pinning site of the fourth metacaroal to the middle branch and transverse branch of ulnar nerve dorsal cutaneous branch were(4.9±1.4)mm and(12.9±2.8)mm,respectively.The distances to extensor digitorum of the little finger and extensor digiti minimi were(2.8±1.5)mm and(4.9±1.5)mm,respectively.The distances from the optimal pinning site of fifth metacarpal to the ulnar branch,the middle branch and the extensor digiti minimi were(4.7±2.1)mm,(5.7±1.5)mm and(3.0±1.5)mm,respectively.Conclusion Both the ulnodorsal aspects of the fourth and fifth metacarpal bases were the relatively safe pinning zones for antegrade intramedullary fixation of metacarpal fractures.Careful manipulation should he done to avoid injury of the nerve and tendon. Key words: Metacarpal bones; Fracture fixation,internal; Follow-up studies; Anatomy

Antegrade intramedullary fixation of the neck and subcapital fractures of the fifth metacarpal

To investigate the treatment of the displaced neck and subcapital fractures of the fifth metacarpal. Thirty-one patients with the neck and subcapital fractures of the fifth metacarpal had been operated on with antegrade intramedullary fixation between January and August 2005. There was 11 subcapital fractures (group A), and 20 neck fractures (group B). Following closed reduction of the fracture, a blunt 2.0 mm diameter K-wire, which was pre-bent into 20 degrees at the distal end, was inserted into the medullary canal of the fifth metacarpal and fixed the fractures. Postoperatively, patients in group A were immobilized in a short arm plaster splint for 4 weeks, and the ones in group B were treated with unrestricted mobilization. Operative time was 18 min averagely (range 5 to 30 min). Twenty-nine of 31 patients obtained anatomic reduction, and 2 patients had 2/3 apposition of bone end and no rotational deformity. Follow-up was available for all patients. The average follow-up interval was 4 months, with a range of 3 - 6 months. The head/shaft angle of the fifth metacarpal in group A was 63.4 degrees +/- 14.5 degrees preoperatively, and 15.0 degrees +/- 2.5 degrees postoperatively, and 15.4 degrees +/- 2.6 degrees in 3 months postoperatively. The difference between preoperative and postoperative angles was highly significant. The range of motion of the metacarpal joint was 89.5 degrees +/- 4.3 degrees postoperatively, which was not significantly different compared with that of uninjured side. The head/shaft angle in group B was 59.1 degrees +/- 10.0 degrees preoperatively, and 15.9 degrees +/- 2.5 degrees postoperatively, and 15.5 degrees +/- 2.8 degrees in 3 months postoperatively. The difference between preoperative and postoperative angles was highly significant. The range of motion of the metacarpal joint was 88.6 degrees +/- 3.6 degrees postoperatively, which was not significantly different compared with that of uninjured side. The technique is technically easy to perform, minimally invasive, low-cost, allowing early hand mobilization, with good functional results and low morbidity, and it has been proved to be an ideal method.

Fixation of humeral head fractures with antegrade intramedullary nailing

The new method of antegrade intramedullary fixation of humeral head fractures is based on a straight proximal humeral nail with special head fixation screws and conventional interlocking screws at the proximal end of the shaft fragment leaving an axillary nerve shelter space in between. The nail acts as a central load carrier. The head fixation screws run through threaded holes in the proximal end of the nail thus being held in a stiff angle and without gliding. The entry points of these screws correspond to the anatomical main portions of the lesser and greater tubercle. They allow a three-dimensional screw grip to the subchondral bony layer of the head fragment. The purpose of this intramedullary construct is to keep the fracture stable at a grade which allows instant postoperative active exercise and which corresponds to the needs of mechanical tranquility in a predominantly endosteal healing area. In a prospective clinical study 45 patients could be followed up after 3, 6 and 12 months. We found an ongoing improvement of the postoperative results up to an average Constant Score of 85.7 pts after one year. The complication rate was 16 %. The main complication was the screw protrusion into the joint.

A Comparison of Treatment between Plate Fixation and Antegrade Intramedullary Fixation of the Humeral Shaft Fractures

A Comparison of Treatment between Plate Fixation and Antegrade Intramedullary Fixation of the Humeral Shaft Fractures