Distal Pin Research Articles

Can applied external fixators be sterilized for surgery? A prospective cohort study of orthopaedic trauma patients

BackgroundTemporary external fixators are often used to stabilize fractures when definitive fracture surgery must be delayed. Sometimes, external fixators are left in place during repeat operations, including definitive internal fixation of tibial pilon and tibial plateau fractures. It is unknown how well current surgical preparation sterilizes these devices, which become part of the surgical field. Our hypothesis was that our institution’s standard surgical preparation creates a low rate of culture-positive environments on external fixators at the time of surgical skin incision. MethodsWe prospectively consented and enrolled patients to obtain cultures (48 patients, 55 external fixators, 165 sets of culture data). After standard preparation and immediately before incision, cultures were obtained from three sites on each external fixator: 1) most distal pin 1cm from pin-skin interface, 2) most distal bar at midpoint between pin and clamp connectors, and 3) most distal clamp at bar-clamp interface. Our standard preparation for patients with external fixation in place is to don sterile gloves and wipe down all components of the external fixator with 70% alcohol-soaked sterile 4×4in gauze sponges before skin preparation. The skin and external fixator are then prepped in the usual fashion with ChloraPrep for closed wounds or with povidone iodine scrub and paint for open wounds. Swabs were processed and organisms from cultures identified. Clinicians were blinded to study results until study completion. ResultsTwo of 165 cultures (1.2%; 95% confidence interval [CI]: 0–2.9%) were positive for common pathogens sometimes observed in surgical site infection. Four cultures (2.4%; 95% CI: 0–4.8%) had pathogens that are rarely associated with surgical site infection, and four (2.4%; 95% CI: 0–4.8%) had nonpathogenic organisms. ConclusionUsing 70% alcohol on external fixators plus either ChloraPrep for closed wounds or povidone iodine for open wounds seems to result in a low rate of positive cultures. Most species that were isolated are infrequently identified as sources of surgical site infections. This preparation protocol might be effective at producing a relatively clean environment at the time of surgery for patients with external fixators already in place.

Biomechanical Analysis of the Risk of an Unused Guide Pin Hole on the Postoperative Subtrochanteric Fractures After Femoral Neck Fracture Pinning

Subtrochanteric fractures after pinning for femoral neck fractures, though occurred rarely but serious complication, are supposed to relate with unused guide pin holes around the distal pin. The purpose of this study is to evaluate and analyse the effect of stress distribution around the distal pin

Evidence-based review of Colles’ fracture

Background A Colles’ fracture occurs as a transverse fracture of the metaphyseal region of the distal radius, approximately 25–40 mm proximal to the radio-carpal joint, and is associated with dorsal displacement and angulation of the distal fragment. Other features include radial shortening and palmar tilt. Key radiological measurements usually noted are that of radial length (normally 11 mm), dorsal angulation of the distal radius (normally 10° volar angulation) and radial inclination (normally 22°). A Colles’ fracture is one of the most common types of osteoporotic fractures seen, especially in females above the age of 50. Incidence of men vs. women over the age of 35 was 9/10,000 vs. 37/10,000, respectively. Management Conservative management is commonly an option in stable or minimally displaced fractures which are described as ≤2 mm loss of radial height, ≤5° change in radial inclination and ≤10° of dorsal angulation. This can be managed in a plaster cast for five to six weeks. Furthermore, age of >60 years was found to be the most important factor in predicting whether a reduced unstable fracture would redisplace. Kirschner-wire fixation is a useful and simple operative method to help stabilise fragments that are not severely comminuted. This option was found to be better than plaster cast management alone, but was associated with surgical complications such as infection and nerve injuries. A more common management option utilised for unstable fractures today is open reduction and internal fixation using either dorsal or volar plates. Dorsal plates are less commonly used due to increased risk of volar collapse and tendon rupture with up to a 22% removal of implant rate due to tendon irritation. Volar plates are more popular as they allow a more stable fixation and thus early mobilisation with a better radiological outcome when compared against K-wire fixation. They are also associated with a lower incidence of tendon complications. External fixation management options may either be bridging or nonbridging in regards to the radio-carpal joint. Immobilising the wrist with a bridging external fixation device can be an option when managing a severely comminuted fracture without a large enough distal fragment to secure a distal pin. However, dorsal malunion was six times more likely when compared against a nonbridging option. Though studies showed external fixation devices provided better radiological outcomes when compared to conservative management, there is insufficient evidence to conclude that long-term functional outcomes are also improved. Prevention Often a fracture of this nature is considered as one of the first signs of osteoporosis in a middle-aged adult. Hormone replacement therapies and use of bisphosphonate therapy have been proven to reduce the risk of osteoporotic fractures with alendronate being found to significantly reduce the risk of spine, hip and wrist fractures in postmenopausal women with a mean age of 70 years. Incorporation of other health care professionals such as physiotherapists and occupational therapists is also of vital importance to ensure osteoporotic patients are at a lower risk of sustaining falls.

Reconstruction of the anterior cruciate ligament by means of an anteromedial portal and femoral fixation using Rigidfix

ObjectiveTo evaluate a series of patients who underwent surgery for reconstruction of the anterior cruciate ligament with flexor tendons, by means of the anteromedial transportal technique using Rigidfix for femoral fixation, and to analyze the positioning of the pins by means of tomography. MethodsThirty-two patients were included in the study. The clinical evaluation was done using the Lysholm, subjective IKDC and Rolimeter. All of them underwent computed tomography with 3D reconstruction in order to evaluate the entry point and positioning of the Rigidfix pins in relation to the joint cartilage of the lateral condyle of the femur. ResultsThe mean Lysholm score obtained was 87.81 and the subjective IKDC was 83.72. Among the 32 patients evaluated, 43% returned to activities that were considered to be very vigorous, 9% vigorous, 37.5% moderate and 12.5% light. In 16 patients (50%), the distal entry point of the Rigidfix pin was located outside of the cartilage (extracartilage); in seven (21.87%), the distal pin injured the joint cartilage (intracartilage); and in nine (28.12%), it was at the border of the lateral condyle of the femur. ConclusionThe patients who underwent ACL reconstruction by means of the anteromedial transportal using the Rigidfix system presented satisfactory clinical results over the length of follow-up evaluated. However, the risk of lesions of the joint cartilage from the distal Rigidfix pin needs to be taken into consideration when the technique via an anteromedial portal is used. Further studies with larger numbers of patients and longer follow-up times should be conducted for better evaluation.

Reconstrução do ligamento cruzado anterior pelo portal anteromedial e fixação femoral com Rigidfix

ObjectiveTo evaluate a series of patients who underwent surgery for reconstruction of the anterior cruciate ligament with flexor tendons, by means of the anteromedial transportal technique using Rigidfix for femoral fixation, and to analyze the positioning of the pins by means of tomography. MethodsThirty‐two patients were included in the study. The clinical evaluation was done using the Lysholm, subjective IKDC and Rolimeter. All of them underwent computed tomography with 3D reconstruction in order to evaluate the entry point and positioning of the Rigidfix pins in relation to the joint cartilage of the lateral condyle of the femur. ResultsThe mean Lysholm score obtained was 87.81 and the subjective IKDC was 83.72. Among the 32 patients evaluated, 43% returned to activities that were considered to be very vigorous, 9% vigorous, 37.5% moderate and 12.5% light. In 16 patients (50%), the distal entry point of the Rigidfix pin was located outside of the cartilage (extracartilage); in seven (21.87%), the distal pin injured the joint cartilage (intracartilage); and in nine (28.12%), it was at the border of the lateral condyle of the femur. ConclusionThe patients who underwent ACL reconstruction by means of the anteromedial transportal using the Rigidfix system presented satisfactory clinical results over the length of follow‐up evaluated. However, the risk of lesions of the joint cartilage from the distal Rigidfix pin needs to be taken into consideration when the technique via an anteromedial portal is used. Further studies with larger numbers of patients and longer follow‐up times should be conducted for better evaluation.

Comparison of 2 Equine Transfixation Pin Casts and the Effects of Pin Removal

To (1) compare strain on the dorsal aspect of the proximal phalanx (P1) between 2 types of transfixation pin casts (TPC) and (2) evaluate the change in strain as the pins are removed. Experimental. Equine cadaver forelimbs (n = 10 pair). Each limb of a pair was assigned to 1 of 2 TPC constructs. Construct 1 consisted of a TPC with 2 positive profile, centrally threaded pins placed in the distal aspect of the third metacarpus (MC3) and construct 2 had 4 smooth Steinmann pins placed similarly. A strain gauge was mounted on P1 and axial compression (444.8-5337.9 N) applied. One forelimb of each pair was tested as a control with no construct in place. The 2 TPC groups were retested after removal of 1 proximal (n = 5 limbs) or distal (n = 5) pin from construct 1, and 2 proximal (n = 5) or distal (n = 5) pins from construct 2. Limb specimens were retested after all pins had been removed. There was a significant decrease in strain between both TPC constructs and the non-casted control at all loads except 444.8 N. There was no significant difference in strain reduction between the 2 TPC constructs. After proximal pin removal there was a 7% (construct 1) and 10% (construct 2) increase in strain. When distal pins were removed there was a 0.5% (construct 1) and 1% (construct 2) increase in strain. The difference between proximal and distal pin removal was only statistically different from each other at high loads. Both constructs provided equivalent reduction in strain. Removal of the proximal pin(s) increased the strain.

Anatomic Single Bundle Anterior Cruciate Ligament Reconstruction Using Two Cross Pins: Cadaveric Study and Clinical Application

Background: Anatomic single bundle is a widely accepted technique for anterior cruciate ligament (ACL) reconstruction. The research question: are transverse pins safe to fix the ACL graft on the femoral side in anatomic single bundle ACL reconstruction? Material and Methods: Ten cadaveric femoral dry bones were tested in this study. Thirty mm long sockets were prepared in the center of the anatomic ACL footprints. Transverse pin guide for soft tissue graft was used to prepare pin sites through the femoral sockets using three different positions. The positions (A) and (B) had a lateral entry point and differ in their inclination in relation to the joint line; while (A) has a 15° open laterally plane, (B) has a 15° closed laterally. The last position (C) had a medial entry point for the transverse pins. The relations of the transverse pins to the anatomic landmarks (lateral epicondyle and articular cartilage) in addition to the path of the pins within the femoral sockets were recorded. Results: Pins inserted while the guide in position (A) crossed the center of the femoral sockets and were fully seated within the bone of the distal femur. Distal pins inserted through inclination (B) were found to penetrate the posterior cortex of the distal femur proximal to the lateral femoral condyle. Pins inserted from the medial side (C) achieved central position through the femoral tunnel. The entry point for transverse pins through lateral entry points was very close to the attachment of the lateral collateral ligament at the lateral epicondyle while medial entry point avoided important structures. Conclusion: Transverse pins inserted through the lateral entry point carry the risk of penetrating the posterior cortex of the femur and/or damage the attachment of the lateral collateral ligament. Medial entry point may give a safer approach but needs further adjustments of the guides and clinical trials of the technique.

Use of a modified transfixation pin cast for treatment of comminuted phalangeal fractures in horses

To (1) report a modified transfixation pin cast technique, using dorsal recumbency for fracture reduction, distal positioning of the pins in the epiphysis and distal metaphysis, and a hybrid cast, combining plaster of Paris (POP) and fiberglass casting, and (2) report outcome in 11 adult horses. Case series. Adult horses (n = 11) with comminuted phalangeal fractures. Horses were anesthetized and positioned in dorsal recumbency. The phalangeal fracture was reduced by limb traction using a cable attached to the hoof. Screw fixation in lag fashion of fracture fragments was performed when possible. Transfixation casting was performed using two 6.3 mm positive profile centrally threaded pins with the 1st pin placed in the epiphysis of the metacarpus/tarsus at the center of, or slightly proximal to, the condylar fossa and the 2nd one 3-4 cm proximal. A hybrid cast was applied. Forelimbs were involved in 9 horses and the hind limb in 2. Pins were maintained for a minimum of 6 weeks. No pin loosening was observed at the time of removal (6-8 weeks). A pony fractured the distal aspect of the metacarpus at the proximal pin. Nine horses survived (82%); none of the horses developed septic arthritis despite the distal location of the distal pin, close to the fetlock joint. This modified transfixation pin casting technique was associated with good pin longevity and could reduce the risk of secondary pin hole fractures and pin loosening.

Reply to the Letter to the Editor: Mid-America Orthopaedic Association Physician in Training Award: Surgical Technique: Pediatric Supracondylar Humerus Fractures: A Technique to Aid Closed Reduction

To the Editor: I appreciate the exuberant and detailed response by Ozkaya and colleagues. Additionally, I appreciate the reference to their prior published “joy-stick” technique [3]. Finding more options and techniques to improve supracondylar humeral fracture care is to be encouraged [1]. First, the authors claim that the lateral to medial K-wire insertion below the level of the deltoid insertion is safer than our posterior to anterior Schantz pin distal triceps insertion. We believe that our technique is actually safer than theirs. Since the radial nerve courses from proximal to distal and ulnar, to radial distal, to the deltoid muscle, and anterior to the triceps muscle, their technique could jeopardize injury to the radial nerve more than our technique, which does not jeopardize any potential neural structures [2]. Posteriorly, we have the least risky pin insertion site. We had no clinical injury to the triceps integrity or function. In fact, percutaneous insertion of a pin through the deltoid or triceps has the same effect. We agree that more distal pin insertion allows for greater control of the diaphyseal segment and overall reduction quality. We disagree that these fractures do not require “tremendous effort,” since some fractures require extensive control of translation, rotation, flexion/extension, and length. Secondly, we had not experienced any problems utilizing 2.5 mm terminally threaded Schantz pins. In fact, the 2.5 mm size is perfectly situated between the 2 mm and 3 mm pins utilized by Parmaksizoglu and colleagues [3]. Additionally, the terminal thread prevents translation and anterior protrusion versus a smooth pin. We have not had any problems such as iatrogenic fractures, ectopic bone, or callus formation from our 2.5 mm pin technique. The one patient that had an open technique had impalement of distal humerus within the brachialis that did not get “milked out” or disengaged. We are sorry that we did not elaborate further with this example in the original article. Again, we would like to thank the CORR® journal for publishing our technique and Ozkaya et al. for continuing an important dialogue regarding treatment of the patients whom we treat.

Minimally invasive plate osteosynthesis of distal tibial fracture using a posterolateral approach: a cadaveric study and preliminary report

We have read the article by Kritsaneephaiboon et al. [1] with great interest. We congratulate them for opening new horizons on the MIPO technique using the posterolateral approach; however, we have some reservations regarding it. First, the authors have described the posterolateral approach to the tibial shaft, for the proximal incision, which was classically described by Harmon et al. [2] in 1945. However the authors have used only a one-inch incision, and to retract the heavy bulk of muscles on the posterior aspect of tibia through such a small incision and placing screws on the posterior aspect seems to be technically quite difficult. Also, exerting overzealous traction in doing so, could endanger the posterior tibial vessels and the tibial nerve. We would like to know what, if any, special tips or tricks the authors suggest to overcome such a problem. Second, although the authors have studied and mentioned the relationship of the implant to the posterior tibial vessels and tibial nerve, they have not mentioned anything regarding the peroneal vessels. These vessels seem to be particularly at high risk of injury considering their proximity to the postero-medial aspect of fibula, especially when performing sharp dissection of the FHL and tibialis posterior from the posterior aspect of fibula as the authors have suggested. This is all the more important considering the fact that in around 5–8 % of individuals the Peroneal artery is the dominant supply to the foot (a condition known as Peroneal arteria magna) [3, 4]. Third, the authors state that they placed three screws in the proximal segment; we would like to know how the distal most screw in the proximal segment was placed, because it seems unlikely that it was placed through the one-inch proximal incision. Also, keeping in mind the principle of internal fixation while bridging a comminuted fracture, it is recommended that screws adjacent to the fracture should be placed as close to the fracture site as possible to enhance the construct stability. If we use the posterolateral approach it will not be possible to place these screws percutaneously, as such an application would be too dangerous, whereas exposure of the fracture site for the same purpose would negate the potential benefits of the MIPO technique. Since percutaneous application would seem to be too risky it also precludes the use of lag screws and placement of the pointed reduction clamps and K-wires, which are commonly used as a tool in provisional reduction during the MIPO technique. Another point which we would like clarified was why removal of the external fixator and internal fixation were performed the same sitting after six weeks. The usual recommendation is that internal fixation can be done in the same sitting if done within two weeks of application of the external fixator, whereas it is advisable to wait for pin tracts to heal if it is done after two weeks, as all pin sites are taken to be potentially infective. Furthermore, when a two-staged delayed internal fixation is planned it is advisable to place the Schanz pins well away from the anticipated location of plates and screws [5]; which is not the case in this scenario, since it is quite clearly visible that the distal pin in the proximal fragment is near the second most proximal screw in the post-operative X-ray.

Predrilling Does Not Improve the Pullout Strength of External Fixator Pins

External fixator pins are thought to have improved pullout strength if inserted into both cortices and if pilot holes are drilled. We tested these hypotheses and investigated effects of osteoporosis and pin location on pin pullout strength. Self-drilling external fixator pins were inserted using 4 techniques: 1) predrilled bicortically inserted, 2) not predrilled bicortically inserted, 3) not predrilled unicortically inserted, and 4) technique 2 with far cortex disengaged to test holding power of near cortex in isolation. Ninety-six samples were tested from four locations in 12 matched pairs of cadaveric femora [6 pairs osteoporotic (T ≤ -2.5), six pairs nonosteoporotic (T > -2.5)]. Pullout force was tested on materials testing system until failure of pin-bone interface. Bicortical pin placement and location within femur had substantial effects on the holding power of the pins. Osteoporosis had statistically significant effect but with smaller effect size (P = 0.05). No significant difference in holding power was observed between predrilling and no predrilling techniques (P = 0.27). We observed only a trend toward "stripping effect" in near cortex with technique 4. Bicortical placement rendered 69% greater holding power than unicortical. Proximal placement rendered 56% greater holding power than distal. Osteoporotic samples had 15% less holding power than nonosteoporotic samples. Single-cortex pin placement, osteoporotic bone, and more distal pin location decreased pin pullout strength. We did not observe a significant mechanical advantage of predrilling for modern external fixator pins. The near cortex of a pin inserted into 2 cortices without predrilling did not exhibit substantial stripping effect.

Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed

We present a case of painful radial nerve palsy following application of a humeral lengthening frame. At re-operation, the radial nerve was found to be compressed against a distal pin. This was re-sited providing immediate pain relief and a gradual resolution of the radial nerve palsy. Pain in association with a nerve palsy should alert the clinician to the possibility of nerve compression that may benefit from urgent decompression.

A Cadaveric Simulation of Distal Femoral Traction Shows Safety in Magnetic Resonance Imaging

The purpose of this study was to evaluate the safety of a distal femoral traction pin subjected to a 1.5-T magnetic resonance image (MRI) with regard to pin migration and implant heating in a cadaveric model. Deflection angles of various traction pins as well as a Bohler-style Steinmann Pin Tractor Bow (tractor bow) and a Kirschner wire bow subjected to a 1.5-T clinical MRI were measured. Tractions pins were placed into a cadaveric femur and the tractor bow was attached to the most distal pin to simulate distal femoral traction. Temperature and migration were measured after subjecting the cadaveric leg to a "worst-case scenario" MRI sequence for 30 minutes. All traction pins and bows showed deflection. The Kirschner wire bow showed a hazardous level of deflection and was immediately removed from further testing. The pin temperature changes were not significantly different than the changes in the MRI room temperature and a conduction loop was not seen in the combination pin and tractor bow. There was no significant migration of any pin nor was there objective loosening from pin vibration. Implant-quality stainless steel traction pins show no signs of adverse heating or pin migration when subjected to 1.5-T MRI clinical scanning. Kirschner bows are highly ferromagnetic and should not be used unless individually tested for safety. Steinmann Pin Tractor Bows that show weak ferromagnetism preliminarily appear safe to use during a 1.5-T MRI and do not produce a conduction loop with excessive heating in a cadaveric model, although further testing is indicated.

External fixation of fractures of the distal radius

Background and purpose External fixators allowing movement during fracture healing are commonly used for treatment of unstable distal radius fractures. The dynamic Dynawrist fixator with the distal pins in metacarpal bone may avoid fixation problems in comminuted fractures and may reduce the risk of nerve injury. We compared anatomical and functional outcome for the well-established Hoffmann compact II non-bridging fixator and for the Dynawrist fixator.Patients and methods 75 patients with unstable distal radius fractures were randomized to treatment with either the Hoffman compact II fixator (the H-group) or the Dynawrist fixator (the D-group). Anatomical and functional variables were recorded preoperatively, postoperatively, and at 6, 12, 24, and 52 weeks. Pain was assessed using the VAS score and function was assessed using DASH score.Results Postoperatively, radial tilt, inclination, and radial length all improved statistically significantly in both groups. At time of removal of the fixators, the H group had superior volar radial tilt. At the 52-week follow-up, there were no statistically significant differences between the groups regarding anatomical variables. At 6 weeks, flexion was greater in the D group but at 12, 24, and 52 weeks flexion was similar in the two groups, as were the other wrist and forearm movements. There were no statistically significant differences between the groups according to VAS and DASH scores. 3 nerve injuries occurred in the H group and 1 in the D group (p = 0.4), all of which were transient.Interpretation The Dynawrist bridging but dynamic fixator gives radiographic and functional outcome similar to that of the Hoffman II compact non-bridging fixator.

Modified Rush Pin Technique for Two- or Three-Part Proximal Humeral Fractures

To report the outcomes of modified Rush pin fixation for proximal humeral fractures. 42 men and 20 women aged 19 to 94 (mean, 64) years with 2- or 3-part proximal humeral fractures underwent reduction and fixation using the modified Rush pin technique. 11 patients died from reasons unrelated to the surgery. Of 40 (out of 51) patients completing a subjective functional assessment using an Oxford Shoulder Questionnaire, 28 (70%) had 2-part and 10 (25%) had 3-part displaced fractures, and the remaining 2 (5%) had fracture-dislocations (one being 2-part and one 3-part). 25 (63%) patients were very satisfied (including one with a 3-part fracture after 6 months of rehabilitation), 7 (17%) were moderately satisfied, and 8 (20%) were not satisfied. There were 8 complications, including pin cut-out from the proximal fragment (n=2), proximal pin migration (n=2), distal pin migration (n=1), cortical perforation during surgery (n=1), mild ulnar nerve symptoms (n=1). No patients had non-union, myositis ossificans, avascular necrosis of the humeral head, or axillary nerve injury. The modified Rush pin fixation minimises tissue dissection; the implants are cheap and readily available; and the technical expertise is easily learnt. This technique is a suitable alternative of fixing proximal humeral fractures, especially in the elderly.

A Tapered‐Sleeve Transcortical Pin External Skeletal Fixation Device for Use in Horses: Development, Application, and Experience

To report development, configuration, application, and results of a tapered-sleeve transcortical pin external skeletal fixation device (TSP ESFD) for use on fractures of the distal aspect of the equine limb. Optimization analysis of a TSP ESFD was carried out with mechanical testing and review of clinical case outcomes. Cadaveric adult third metacarpal bones (MC3) for mechanical testing; horses (n=7) with severely comminuted proximal (6; P1) or second (1) phalanx fractures. Mechanical testing of methods for attachment of TSP to the sidebars were tested as well as optimization of pin diameters. Outcome of clinical cases managed with the TSP ESFD were compared with outcomes of horses treated with previous ESFD. A TSP ESFD using 7.94 mm diameter pins was used. Survival rate was 71%. One horse with an infected P1 fracture and contralateral laminitis subsequently fractured MC3 through the distal pin hole while wearing the TSP ESFD. One mare with contralateral laminitis was euthanatized. Three horses had open fractures. Design improvements incorporated into the TSP ESFD should increase treatment success. External skeletal fixation continues to be a viable treatment alternative for severe injuries of the distal aspect of the equine limb. TSP ESFD should improve on the success of treatment by decreasing complications of bone fracture at the pin interface.

Pin-Site Myiasis: A Rare Complication of a Treated Open Fracture of Tibia

Pin-site myiasis is a rare complication of external fixation of open fractures of the tibia. Case report and literature review. A 32 year-old man with a history of alcohol and drug abuse presented with an open fracture of the middle third of the fibula and tibia (Gustilo type IIIA) after a motor vehicle crash. Definitive surgical correction of the fracture was made with the insertion of an external skeletal fixator, type Baummer, with 2 bars, 6 pins, and 12 rotules. After three weeks, he presented again with a primary complaint of purulent secretion and maggots at the distal pin site. On removal of the pin, significant destruction of peripheral tissue was evidenced, with a wound approximately 5 cm diameter, from which 105 maggots were extracted, being identified as Cochliomyia hominivorax. There have been no previous reports of myiasis involving an external skeletal fixation and pin, and only one similar case has been reported in a patient with a halo orthosis for the management of a gunshot wound of the neck. As in that case, presumably, in our patient, myiasis occurred via the small infected wound adjacent to the distal pin. Adequate treatment for myiasis requires complete removal of the maggots, as well as antimicrobial therapy.

Inferior fixation with a new pin design for external fixation: A randomized study in 50 patients operated on by the hemicallotasis technique

Background and purpose Tibial osteotomy by the hemicallotasis technique (HCO) requires strong pin fixation. We compared pin fixation in HCO using a new self-drilling XCaliber pin (Orthofix) with optimized thread and tip design, with the commonly used standard pin (Orthofix).Patients and methods 50 patients, mean age 51 (35–66) years, to be treated by HCO were randomized to standard pins or XCaliber pins. In the metaphyseal bone, hydroxyapatite-coated (HA-coated) pins were used in both types of pins. In the diaphyseal bone, non-coated pins were used. The torque forces for insertion and extraction (in Nm) were measured.Results The insertion torque was higher for both the proximal and distal standard pins (2.1 Nm (SD 0.9) and 7.0 Nm (1.3), respectively) than for the XCaliber pins (1.3 Nm (0.8) and 3.6 Nm (1.4)). The extraction torque force was higher for the proximal standard pins (4.3 Nm (3.1)) than for the proximal XCaliber pins (1.5 Nm (1.7)) (p < 0.001). The extraction torque for the distal standard pins was 1.9 Nm (2.0) and for the distal XCaliber pins it was 1.4 Nm (1.1).Interpretation The commonly used standard pin gives stronger fixation during the treatment of HCO.

Gradual Reduction of Distal Radial Malunion Using Distraction Osteogenesis

To evaluate gradual distraction lengthening or distraction osteogenesis as a technique for treating malunions of the distal radius. Twenty patients with clinical and radiographic evidence of distal radius malunion were treated with osteotomy of the distal radius using distraction osteogenesis. At the follow-up evaluation each patient was evaluated for healing rates, complications, resolution of pain, and radiographic alignment. Surgical treatment consisted of an application of a nonbridging external fixator that could be distracted to correct the deformity. A loosely set screw that connected the distal pins to the fixator served as a hinge and allowed the distal radius to rotate into a corrected position. Gradual distraction via distraction osteogenesis was initiated 1 week after surgery. Seventeen osteotomies healed uneventfully in an average of 9 weeks. Complications included 9 pin track infections. Two nonunions required bone grafting. One patient inadvertently compressed rather than distracted the fixator, leading to premature healing of the osteotomy. One patient ruptured the extensor pollicis longus. All complications resolved with additional intervention. Overall the patients showed radiographic and symptomatic improvement. An external fixator and distraction lengthening through distraction osteogenesis is a viable alternative to plate fixation and bone grafting. In 18 of 20 of our patients, the technique eliminated the need for bone grafting and the need for a second surgical procedure to remove a dorsal plate.

Arthrodesis With External Fixation in the Unstable or Misaligned Charcot Ankle in Patients With Diabetes Mellitus

The unstable or misaligned Charcot ankle with or without chronic foot ulceration is a major clinical challenge. When it cannot be accommodated with an ankle foot orthosis, surgical treatment is indicated in order to avoid leg amputation. This requires extensive soft tissue release and bony resection to realign the foot and arthrodesis with internal or external fixation. The guidance in the literature favors internal fixation. This article reports results with external fixation in 11 patients (12 feet) over a period of 12 years. External fixation was chosen as the surgical option because of the presence of foot ulcers with the attendent risk of infection. There were 7 tibio-talar and 5 tibio-calcaneal fusions. Compression was applied for 6 weeks with an external frame according to Charnley, followed by 6 weeks with total-contact cast. Weight bearing with a rigid leather brace was allowed after 12 weeks. In one case, transtibial amputation was required due to loosening of the distal pins from osteopenic disintegrating bone. In 11 cases (92%), the foot was successfully realigned and independent walking with a brace retained during the follow-up of median 48 months (10-102 months). Bony union took place in 5 out of 7 cases with tibio-talar fusion and in 1 out of 5 with tibio-calcaneal fusion. The functional result in cases with fibrous union was, however, satisfactory. Although meaningful comparisons of series are difficult to conduct and interpret from, the limb salvage rate was similar to results with internal fixation. The authors consider the results to be encouraging and to be used to develop a higher level of evidence.