Closed Reduction And Percutaneous Fixation Research Articles

Percutaneous fixation versus open reduction and internal fixation in treatment of medial malleolus fracture

Background: Medial malleolus fractures are common orthopedic injuries that require prompt and effective treatment. This study aimed to compare two treatment approaches, open reduction and internal fixation (ORIF) and closed reduction and percutaneous fixation (CRPF), for isolated medial malleolus fractures in adults. Methods: This randomized controlled trial included 30 patients with isolated medial malleolus fracture who were assigned to either the ORIF or CRPF group using a simple randomization method. Surgical procedures were performed as described in the study, and post-operative management included splinting and regular clinical assessments. Results: Intraoperatively, CRPF demonstrated significantly lower operative time (33±5 min vs. 50±11 min, P < 0.001) but higher X-ray exposure (33±9 vs. 25±7, P=0.014) compared to ORIF. Post-operatively, there were no significant differences between the two groups in terms of delayed union, pain with movement, soft tissue infection, or time to full union. Conclusions: Both ORIF and CRPF are viable treatment options for isolated medial malleolus fractures in adults. CRPF offers advantages in terms of shorter operative time but requires increased fluoroscopy usage. Level of Evidence: Level IV.

Closed Reduction and Percutaneous Fixation of Lisfranc Injury Using Suspensory Fixation.

This closed reduction and percutaneous fixation (CRPF) technique utilizing suspensory fixation is indicated for the treatment of Lisfranc injuries with displacement or instability of the tarsometatarsal joint complex-and typically only for low-energy, purely ligamentous Lisfranc injuries. The goal of this procedure is to restore joint stability and prevent common complications of Lisfranc injuries (e.g., midfoot arch collapse and posttraumatic arthritis) while avoiding the complications and risks associated with open reduction and internal fixation (ORIF) and primary arthrodesis. We recommend performing the procedure within 10 to 14 days of the injury; otherwise, an open debridement may be necessary to address scar tissue formation. We start with the patient in the supine position and perform a fluoroscopic stress examination of the joint. Next, the Lisfranc joint undergoes closed reduction, which is held in place with a clamp. Following reduction, a guidewire is drilled from the lateral border of the base of the 2nd metatarsal medially through the medial cuneiform, followed by a medial-to-lateral cannulated drill. The suspensory fixation is then passed lateral-to-medial, placing the suture button on the lateral cortex of the 2nd metatarsal base. The tape is then tensioned while a bioabsorbable interference screw is inserted to maintain tension. Prior studies have assessed both operative and nonoperative alternatives to CRPF with suspensory fixation for the treatment of Lisfranc injuries. Nonoperative treatment with closed reduction and cast immobilization of Lisfranc injuries is typically reserved for nondisplaced injuries; however, a number of studies have shown poor outcomes with use of this technique1-3. The 2 most common operative alternatives are ORIF and primary arthrodesis4. CRPF with suspensory fixation offers several benefits over both traditional surgical techniques such as ORIF and primary arthrodesis, as well as over percutaneous reduction and internal fixation (PRIF) with a screw. Compared with ORIF and primary arthrodesis, a number of studies have shown that percutaneous treatment of Lisfranc injuries minimizes soft-tissue trauma and reduces the risk of postoperative complications such as wound breakdown, infection, and complex regional pain syndrome, while allowing for earlier participation in rehabilitation5-10. A systematic review of outcomes following PRIF with screw fixation also showed that percutaneous treatment of Lisfranc injuries is a safe and effective technique with good functional outcomes11. When comparing PRIF with a screw to our technique of CRPF with suspensory fixation, CRPF has the added benefit of creating a nonrigid fixation in the Lisfranc joint, which allows for increased range of motion of the medial column and improved return to activity12,13. The rigid fixation in PRIF with a screw can also lead to metal irritation, intra-articular screw fracture, and impaired mobility, which often necessitate the need for screw removal13-15. This fixation-related drawback is not present with our technique, and also avoids the need for use of a biologic substitute such as tendon grafts13. Following CRPF with suspensory fixation, patients can expect to return to full activity at 12 to 16 weeks postoperatively. Postoperatively, patients are typically kept non-weight-bearing for 6 weeks. The operative foot is kept immobilized in a splint for the first 2 weeks, then transitioned to a boot. Between postoperative weeks 6 and 12, partial progressive weight-bearing is introduced with use of an arch support, progressing toward full weight-bearing13,16,17.For comparison, patients who underwent PRIF with screw fixation had a similar postoperative course, but almost all required screw removal at 4 to 6 months postoperatively13,16. Cho et al. retrospectively reviewed the results of 63 patients who underwent either PRIF with screw fixation (n = 32) or CRPF with a suture button (n = 31) and found that CRPF patients had significantly better American Orthopaedic Foot & Ankle Society midfoot scale scores (81 versus 74 points) and visual analog scale scores (3.1 versus 4.6 points) at 6 months postoperatively and prior to screw removal in the PRIF group (p < 0.001). There were no significant differences in these scores, radiographic outcomes, weight-bearing analysis, or complications at 1 year postoperatively. The authors concluded that both techniques provided comparable fixation stability and clinical outcomes. Of note, however, the PRIF group had 4 patients whose postoperative course was complicated by screw breakage13. Start with a fluoroscopic stress examination to identify all components of instability.Ensure that the reduction clamp does not interfere with or affect your guidewire path.If the joint cannot be reduced, convert to an open procedure and debride the obstruction. ORIF = open reduction and internal fixationPRIF = percutaneous reduction and internal fixationCRPF = closed reduction and percutaneous fixationNSAID = nonsteroidal anti-inflammatory drugOR = operating roomAP = anteroposteriorCT = computed tomographyMRI = magnetic resonance imagingAOFAS = American Orthopaedic Foot & Ankle SocietyVAS = visual analog scaleROM = range of motionPT = physical therapyASA = acetyl-salicylic acid (aspirin)BID = twice dailyPRN = as needed.

Effect of Percutaneous Posterior Pelvic Ring Reduction and Fixation on Patient-Reported Outcomes.

The purpose of this study was to assess patient outcomes using Patient-Reported Outcomes Measurements Information System (PROMIS) scores after closed reduction and percutaneous fixation (CRPF) of the posterior pelvic ring and determine whether quality of reduction affects the outcomes. This is a retrospective cohort study. The study involved a Level I trauma center. The study included 46 adult patients with operatively treated pelvic ring injuries (63% OTA/AO 61-B) who underwent CRPF between 2014 and 2018 at a single institution. The intervention involved closed reduction and percutaneous posterior pelvic ring fixation. The main outcome measurements were postoperative patient PROMIS scores, including physical function, pain interference, anxiety, and depression, and radiographic measurements of postoperative displacement and pelvic deformity. After CRPF, PROMIS scores of physical function, pain interference, and anxiety were significantly improved at the time of final follow-up when compared with the first postoperative visit. The amount of malreduction or pelvic deformity did not significantly affect outcome scores; however, results were limited by small sample size. CRPF of posterior pelvic ring injuries results in good functional and radiographic outcomes. Degree of malreduction may not affect outcomes as much as previously believed. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of patient outcomes after operative treatment of intra-articular calcaneus fractures.

Background: Percutaneous reduction with fixation and open reduction internal fixation are often used to treat intra-articular calcaneus fractures with no consensus on the preferred method. Open techniques have been associated with an increased risk of wound complications, while percutaneous techniques may result in inferior reduction capabilities. These injuries pose a challenge to patients as they often result in poor patient outcomes. We retrospectively analyzed patient outcomes of a single surgeon’s experience in treating these injuries at a busy urban Level 1 trauma center. Methods: Patients with intra-articular calcaneus fractures managed operatively over 10 years with a minimum six-month follow-up were included. Patients were divided into two cohorts based on operative technique: closed reduction and percutaneous fixation (CRPF) or open reduction internal fixation (ORIF). Descriptive analysis of each cohort included postoperative infection, the need for repeat operations, development of post-traumatic subtalar arthritis, and reduction capabilities as assessed by Bohler’s angle. Results: Sixty-two patients were included in this study, with 33 patients in the CRPF group and 29 patients in the ORIF group. Infection requiring a return to the operating room occurred in 1 (3%) CRPF and 7 (24%) ORIF patients. Instrumentation was removed in 23 (70%) CRPF and 9 (31%) ORIF patients. Clinical subtalar arthritis developed in 10 (30%) CRPF and 7 (24%) ORIF patients, requiring arthrodesis in 2 (6%) and 5 (17%) patients, respectively. Both techniques had acceptable restoration of Bohler’s angle immediately postoperatively and at final follow-up. Conclusions: Percutaneous reduction with fixation and open reduction internal fixation may both be considered for the surgical treatment of intra-articular calcaneal fractures. Indications for each technique may vary between surgeons, and each has its own set of risk factors and complications, however, both have been shown to result in an acceptable reduction. Level of Evidence: Level IV.

Temporary Use of Skeletal Traction in Management of Pediatric Supracondylar Humeral Fractures

The paper presents a treatment algorithm for supracondylar humeral fractures in children, involving temporary use of skeletal traction following failure of primary closed reduction and percutaneous fixation (CRPF) and introducing closed reduction after management by skeletal traction. The aim of this study was to assess the outcomes of supracondylar humerus fracture treatment performed according to the algorithm. The treatment was performed in 149 children (70 girls, 79 boys) with extension-type supracondylar humeral fractures. The study group was assessed with regard to a modified Gartland classification, neurological complications (12 children, 8%) and vascular complications (8 children, 5.4%). A total of 124 (83.2%) patients underwent emergency CRPF and 24 children (16.1%) received skeletal traction after a failed CRPF. After 2-6 days, an elective repeat CRPF procedure was attempted, which was successful in 17 children. The attempt failed in the other 7 children, who received traction and underwent open reduction under a single anesthesia. One child (0.7%) with a white and pulseless hand was treated by emergency open reduction and percutaneous fixation. The study used the Flynn criteria modified by the author. After 6 months, the results in the group treated with CRPF (both primary and following skeletal traction) were good in 90.8% of patients, satisfactory in 8.5%, and poor in 0.7%, whereas in the open reduction and percutaneous fixation group, the results were good in 87.5% of cases and satisfactory in 12.5%. 1. X-ray-guided closed reduction and percutaneous K wire fixation is a method of choice in the treatment of displaced supracondylar humeral fractures in children. If closed reduction fails, the surgeon is faced with a choice between primary open reduction and the use of direct traction through the olecranon. 2. The use of skeletal traction following failure of primary emergency CRPF results in local improvement in the fracture region and allows for scheduling an elective repeat delayed closed reduction and percutaneous K wire fixation procedure. 3. The algorithm used in clinical practice, based on literature reports and the author's experience, helps achieve good treatment outcomes.

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 evidenceTherapeutic study, Level III.

Comparison of Open Reduction and Internal Fixation Versus Closed Reduction and Percutaneous Fixation for Medial Malleolus Fractures.

Introduction:Surgical treatment of medial malleolus (MM) fractures can be performed through open or percutaneous approaches, although comparisons between these two approaches have not been undertaken. In this study, we compared patients with MM fractures treated with closed reduction and percutaneous fixation (CRPF) with patients treated with traditional open reduction and internal fixation (ORIF).Methods:A group of 165 consecutive patients underwent surgical fixation of a closed MM fracture from 2011 to 2015 at a single institution. Thirty-one underwent CRPF and 134 underwent ORIF. Patient demographics, injury characteristics, treatment methods, and outcome variables were recorded through review of patient charts, radiographs, and surgical reports.Results:The rate of MM fracture comminution was higher in the ORIF group compared with the CRPF group (9.7% vs 27.6%; P = 0.04). All other patient and injury variables were similar between the two groups. There was no statistically significant difference observed between the CRPF and ORIF groups regarding outcomes, including nonunion, malunion, time to union, rate of hardware removal, and wound complications.Discussion:Both CRPF and ORIF resulted in acceptable radiographic outcomes and low complication rates for the treatment of MM fractures.

Comparison of open reduction and internal fixation versus closed reduction and percutaneous fixation for medial malleolus fractures

Category: Ankle, Trauma Introduction/Purpose: Open approaches are often used for the operative treatment of medial malleolar (MM) fractures. Compared to percutaneous approaches, open approaches may entail an increased risk of operative morbidity, postoperative pain, wound complications, and reoperation for hardware removal. However, inherent to minimally invasive or percutaneous techniques is incomplete fracture visualizationwhich may hinder acceptable reduction. In this study, we aimed to compare patients treated with closed reduction and percutaneous fixation (CRPF) to those patients treated with traditional open reduction and internal fixation (ORIF). We hypothesized that the two groups would be similar with regard to patient factors, injury variables, and outcomes. Methods: The study group consisted of 184 consecutive patients who met inclusion criteria and were treated with operative fixation of a MM fracture from 2011-2015 at a single institution. Forty underwent CRPF and 144 underwent ORIF. Patient demographics, injury characteristics, treatment methods, and outcome variables were recorded through review of patient charts, radiographs, and operative reports. Results: Patient variables were similar between groups except for years of age, which was greater on average in the CRPF group (55 vs. 48, p = 0.03). The CRPF treatment group had a higher rate of initial open injury (22% vs. 7%, p&lt;0.01), a lower rate of MM fracture comminution (12% vs. 29%, p = 0.03), and a higher rate of provisional external fixation (35% vs. 14%, p&lt;0.01). There was no statistically significant difference observed between the CRPF and ORIF groups with regard to outcomes including: nonunion (2% vs. 3%), malunion (10% vs. 5%), time to union (10 weeks, each), removal of hardware (8% vs. 14%), or wound complications (0% vs. 4%). Conclusion: Both CRPF and ORIF resulted in acceptable radiographic outcomes and low complication rates for the treatment of MM fractures. Compared to the ORIF group, patients in the CRPF group on average were older and more often had comminution, open fractures, and provisional external fixation.

Percutaneous fixation of pediatric humeral lateral condyle fractures

Background Traditionally, the initially nondisplaced pediatric humeral lateral condyle fractures were treated conservatively, whereas displaced or rotated fractures were treated by open reduction and internal fixation (ORIF). Late displacement and nonunion were reported in some conservatively treated cases, whereas epiphyseal necrosis with or without nonunion and elbow deformity were reported in some cases treated by ORIF. Few studies have highlighted closed reduction and percutaneous fixation (CRPF) of displaced and/or rotated fractures. The aim of this study is to assess the outcome of CRPF for the treatment of pediatric humeral lateral condyle fractures. Patients and methods A prospective study included 45 cases of PHLCFs that were preoperatively classified according to classification by Song and colleagues; all cases were planned to have percutaneous fixation through either in-situ pinning if initially nondisplaced or closed reduction if displaced or rotated. If closed reduction failed, ORIF was done. The functional results were evaluated according to the modified criteria of Aggarwal and colleagues. Results CRPF was successful in 80.48% of cases with displaced and/or rotated fractures, with satisfactory clinical and radiological results and no reported surgery-related complications in any case till the last follow-up, with a mean follow-up duration of 18.6±3.04 months. ORIF was done in only eight cases (representing 19.52% of the studied cases) after failed closed reduction. There was a statistically significant difference (P Conclusion CRPF could be the treatment of choice for potentially unstable lateral humeral condyle fractures avoiding the complications of late displacement and elbow stiffness reported in some conservatively treated case. CRPF is an efficient and minimally invasive treatment option for some displaced and/or rotated fractures with very satisfactory clinical and radiological results. ORIF could be restricted only for certain complex cases or after the failure of CRPF. Level of evidence: Level IV.

Comparison of open versus percutaneous treatment for humeral head fracture

The hypothesis of this study was that percutaneous techniques lower the risk of post-traumatic avascular necrosis. In this retrospective study 83 patients were followed up clinically and radiologically for signs of avascular necrosis and nonunion after open or percutaneous treatment of proximal humerus fractures. Mean age was 50 years. Fractures were classified in 22 patients (26.5%) as two part, in 21 patients (25.3%) as three part, in 39 patients (47%) as four part, and in 1 patient (1.2%) as fracture dislocation (Neer classification). Fractures were treated in 12 patients (14.5%) by ORIF (open reduction and internal fixation) and in 71 patients (85.5%) by CRPF (closed reduction and percutaneous fixation). Both groups were statistically equally distributed according to fracture type (Mann-Whitney U, p=0.267) and age (One-way-Annova, p=0.740). The postoperative regime did not differ between the two groups. Patients suffered significantly more avascular necrosis after open treatment [five patients (50%) versus eight patients (12.7%) in the percutaneous group, Mann-Whitney, p=0.004]. The risk for avascular necrosis and nonunion increased with age. Mean age of patients with avascular necrosis was 57 years, and the age of patients with nonunion was 67 years. Percutaneous treatment of humeral head fractures seems to be a reliable method for lowering the risk of avascular necrosis in young patients.

Coronal Acetabular Fractures: The Anterior Approach in Computed Tomography-Navigated Minimally Invasive Percutaneous Fixation

To demonstrate the technical feasibility of the anterior approach to the coronal roof component of carefully selected acetabular fractures in computed tomography (CT)-navigated closed reduction and percutaneous fixation (CRPF). Four patients with nondisplaced or slightly displaced coronal fractures of the acetabular roof were treated with percutaneous screw fixation. Screws were implanted over guidepins placed under CT navigation. Mean clinical and radiological follow-up was 16 months. All screws could be placed as intended. There were no peri- or postoperative complications. Radiological follow-up showed primary osseous union. Clinical results were excellent according to a median Merle-d'Aubigné score of 18. Nondisplaced or slightly displaced coronally oriented fractures of the acetabular roof can be treated by minimally invasive percutaneous CT-navigated fixation through an anterior approach that does not endanger the sciatic nerve. Early clinical results are encouraging. Close cooperation between trauma surgeons and radiologists and careful selection of cases is mandatory.

Posterior pelvic ring fractures: closed reduction and percutaneous CT-guided sacroiliac screw fixation.

To assess the midterm results of closed reduction and percutaneous fixation (CRPF) with computed tomography (CT)-guided sacroiliac screw fixation in longitudinal posterior pelvic ring fractures. To document radiographic and CT follow-up patterns. Thirteen patients with 15 fractures were treated. Eleven patients received a unilateral, two a bilateral, screw fixation. Twenty-seven screws were implanted. Continuous on-table traction was used in six cases. Mean radiological follow-up was 13 months. Twenty-five (93%) screws were placed correctly. There was no impingement of screws on neurovascular structures. Union occurred in 12 (80%), delayed union in 2 (13%), and nonunion in 1 of 15 (7%) fractures. There was one screw breakage and two axial dislocations. Sacroiliac CRPF of longitudinal fractures of the posterior pelvic ring is technically simple, minimally invasive, well localized, and stable. It should be done by an interventional/surgical team. CT is an excellent guiding modality. Closed reduction may be a problem and succeeds best when performed as early as possible.