Distal Pin Research Articles

Effects of the Direction of Two Kirschner Wires on Combined Tibial Plateau Leveling Osteotomy and Tibial Tuberosity Transposition in Miniature Breed Dogs: An Ex Vivo Study.

This study evaluates the impact of Kirschner wire (K-wire) insertion direction on the biomechanical properties of combined tibial plateau leveling osteotomy (TPLO) and tibial tuberosity transposition (TTT) procedures in small-breed dogs with cranial cruciate ligament rupture and medial patella luxation. Twenty-one cadaveric tibiae were divided into two groups; the specimens were divided into two groups; one underwent TPLO-TTT with a proximal pin placement (Group TTP), and the other received TPLO-TTT with a distal pin placement (Group TTD). For both pin placements, two additional subgroups were formed: one with a 0.56 mm tension band (Groups TTP0.56 and TTD0.56) and the other with a 0.76 mm tension band (Groups TTP0.76 and TTD0.76). The tensile force was applied, and failure load and mode were recorded. The distal pin direction in Group TTD0.56 exhibited a significantly higher mean failure load (380.1 N) compared to the proximal pin direction in Group TTP0.56 (302.2 N, p = 0.028). No significant differences were observed among the other groups. This study concludes that distal pin placement can provide similar or improved mechanical stability in cases with limited space for proximal pin placement during combined TPLO and TTT procedures.

Treatment of Infected Nonunion of Fracture of the Proximal Third of Tibia Using Ilizarov Ring Fixator: A Case Series

Abstract Introduction: Nonunions (NUs) of the fractured proximal third of the tibia are challenging to manage owing to a capacious canal and scarce anterior soft-tissue cover. Infection further complicates the use of internal fixators in such patients. We present a study of 25 cases of infected NU of the proximal third of the tibia that we treated using the Ilizarov ring fixator over 10 years. Materials and Methods: Twenty-three men and two women with infected NU of the proximal tibial meta-diaphyseal junction were studied. The mean age of the patients was 39.2 years. Treatment involved thorough debridement of the NU site with freshening of the bone ends followed by the application of a 3-ring hybrid Ilizarov construct. The patients were followed at regular intervals to assess the infection control, union, limb function, and complications. Results: Successful union and eradication of infection were achieved in 21 patients. Union was not satisfactory in four cases. The average fixator time was 7.12 months. Average knee flexion of 99.2° was observed. The Association for the Study and Application of the Methods of Ilizarov score was excellent in 56% of cases and good in 28%. Six patients required soft-tissue reconstruction. One patient suffered a fracture at the distal pin site while one had a refracture 4 months after treatment completion. Three patients developed a discharging sinus which required debridement and oral antibiotics. Conclusion: The Ilizarov construct provides multilevel, multidirectional, and multiplanar stability, aiding early mobility. Appropriate case selection, sound soft-tissue reconstruction, robust infection control, and good patient compliance are important for the success of the treatment.

Anatomic consideration of the radial nerve in relation to humeral length for unilateral external fixation: a retrospective study using magnetic resonance imaging findings in korean

BackgroundThis study aimed to present a safe zone for distal pin insertion for external fixation using magnetic resonance imaging (MRI) images.MethodsAll patients who took at least one upper arm MRI from June 2003 to July 2021 were searched via a clinical data warehouse. For measuring the humerus length, proximal and distal landmarks were set as the highest protruding point of the humeral head and lowermost margin of ossified bone of the lateral condyle, respectively. For children or adolescents with incomplete ossification, the uppermost and lowermost ossified margin of the ossification centers were set as proximal and distal landmarks respectively. The anterior exit point (AEP) was defined as the location of the radial nerve exiting the lateral intermuscular septum to the anterior humerus and distance between the distal margin of the humerus and AEP was measured. The proportions between the AEP and full humeral length were calculated.ResultsA total of 132 patients were enrolled for final analysis. The mean humerus length was 29.4 cm (range 12.9–34.6 cm). The mean distance between the ossified lateral condyle and AEP was 6.6 cm (range 3.0–10.6 cm). The mean ratio of the anterior exit point and humeral length was 22.5% (range 15.1–30.8%). The minimum ratio was 15.1%.ConclusionA percutaneous distal pin insertion for humeral lengthening with an external fixator may be safely done within 15% length of the distal humerus. If pin insertion is required more proximal than distal 15% of the humeral shaft, an open procedure or preoperative radiographic assessment is advised to prevent iatrogenic radial nerve injury.

PO-04-045 HOW TO VISUALIZE BIPOLAR ABLATION CATHETERS ON 3D MAPPING FOR BIPOLAR RADIOFREQUENCY CATHETER ABLATION AND MINIMIZE FLUOROSCOPY

Bipolar radiofrequency catheter ablation (RFCA) strategy using two ablation catheters may require prolonged fluoroscopy time because of challenges with catheter positioning. Intracardiac echocardiographic images may only offer limited views to help maneuver both ablation catheters. To simultaneously visualize both ablation catheters on the 3D mapping system for localizing the ablation target and minimizing fluoroscopy. A bipolar RFCA system was set up with connections to the grounding pad and two distal pins connected to the distal electrodes of the THERMOCOOL SMARTTOUCH® SF ablation catheter (Biosense Webster) with 1-6-2mm spacing (Figure A). Case 1: A 51-year-old male with familial HCM presented with VT storm for which he was externally cardioverted. The patient underwent VT ablation during which the VT was localized to LV summit. Due to difficulty achieving transmural lesions with unipolar ablation, bipolar RFCA with two ablation catheters on posteroseptal RVOT and below the RCC was performed with successful elimination of the clinical VT. The distal 3rd and 4th electrodes on the second ablation catheter was connected to our bipolar circuit, which was visualized on CARTO® 3D mapping (Biosense Webster) (Figure B). Case 2: A 62-year-old male with a CRT-D for cardiac sarcoidosis and non-ischemic cardiomyopathy, and a recent endocardial VT ablation in the setting of VT storm presented with multiple ICD shocks. Patient underwent repeat ablation with further endocardial substrate modification and epicardial ablation. With the second ablation catheter on the epicardium, the distal 3rd and 4th electrodes were visualized, and the dome of the catheter tip was created on CARTO® (Figure C). The patient underwent an extensive endocardial and epicardial ablation but remained inducible with slower VT for which he underwent further heart transplant evaluation. Utilizing a novel bipolar RFCA set-up that allows visualization of both ablation catheters on the 3D mapping system may offer better target localization and less fluoroscopy exposure.

Nonpathological phalangeal fractures in cattle: 17 cases (2004-2020).

To characterize clinical findings and outcomes for cattle with nonpathological phalangeal fractures. 17 cattle with nonpathological phalangeal fractures. Medical records of a teaching hospital were reviewed to identify cattle treated for nonpathological phalangeal fracture between May 2004 and May 2020. Information extracted from the records of study-eligible animals included signalment, history, clinical and diagnostic imaging findings, treatment, and survival to hospital discharge. Long-term outcome was assessed by telephone communication with owners. 9 bulls and 8 heifers or cows (age range, 1 to 7 years) of various breeds and uses were evaluated. Five of the 9 bulls were bucking stock, which were overrepresented in the study population. Seven animals had 8 distal phalanx fractures; 10 animals had 11 proximal phalanx fractures. Eight animals were treated by application of a hoof block on the unaffected adjacent digit, 7 animals were treated with a distal limb (n = 6) or transfixation pin (1) cast in addition to a hoof block, 1 animal was treated with a hoof trim to elevate and alleviate weight bearing on the affected digit, and 1 animal was euthanized immediately after diagnosis. Sixteen animals survived to hospital discharge. Follow-up was obtained for 12 animals, of which 9 returned to functionable use and 3 were culled. Results suggested cattle with a nonpathological phalangeal fracture have a favorable prognosis for return to function following application of a hoof block to the unaffected adjacent digit with or without a distal limb cast.

Abstract 14382: Association of Atherosclerotic Plaque Burden and FFR CT- Serial Cardiac CTA Study

Introduction: Cross-sectional studies have shown the association of atherosclerotic plaque burden and FFR CT . However, the relationship between changes in anatomic CCTA parameters and FFR CT has not been evaluated. In the present study, we sought to study the natural history of FFR CT and to observe the impact of coronary plaque characteristics on intracoronary hemodynamics over time as assessed by noninvasive CCTA. Methods: Patients who had undergone baseline and follow-up CCTA were included. Coronary plaque scores and vessel stenosis severity were quantified on CCTA. Multivariate linear regression was used to examine the association of change in the per vessel FFR CT , average distal FFR CT, and the most diseased vessel FFR CT with total plaque score(TPS), coronary artery calcium(CAC), total segment stenosis (TSS), segment involvement score (SIS). Results: Final analysis included 101 subjects (83% male; age 65.5 ± 10.1 years). After adjusting for several cardiovascular risk factors, on a per-vessel basis involving the most significant lesion, a 1 unit increase in TPS resulted on average in a 0.008 decrease in FFR in the most diseased vessel, p=0.004, after adjusting for several risk factors. Using the average FFR CT of the distal LAD, RCA, and LCX, a 1 unit increase in TPS results on average in a 0.004 decrease in the distal average FFR, p=0.026. A 1 unit increase in TPS results on average in 0.005 decrease in the RCA distal pins of FFR, p=0.033 (Table 1). There are no significant associations of the LCX and LAD FFR with TPS. There are no significant associations of the change in FFR CT with TSS, SIS or CAC progression. Conclusion: Worsening atherosclerotic plaque burden is associated with worsening physiology as assessed on CCTA as assessed by FFR CT . Therapies that stabilize or regress plaque may improve overall physiology. Further prospective trials are required to validate these findings.

External Delta Fixator in the Postoperative Management of Microsurgical Flaps in the Lower Limb: Experience of a Tertiary Hospital.

Objective To evaluate the use of external fixators in the delta-type kickstand configuration as an adjuvant method in the postoperative period of patients submitted to free flaps in the lower limbs. Methods A total of 17 external delta fixators were used in patients submitted to free flaps in the lower limbs. The surgical technique was performed in a standardized manner, with the distal pin located 6 cm proximally to the anastomosis, and the proximal pin, 6 cm distally to the anterior tuberosity of the tibia. Results The mean age of the sample was of 34.76 years (range: 15 to 66 years). In total, 11 men and 6 women were selected. The posterior tibial artery was used in 14 cases, and the anterior tibial artery, in 3 cases. The mean time of use of the external fixators was of 3.88 weeks. The rate of reoperation was of 17.64%; that of retail loss was of 11.76%; that of success rate was of 88.23%; and the rate of infection was of 5.9%. Conclusion The use of delta-type fixators as an adjunct method in the postoperative period is reliable; however, more studies are needed to evaluate its true role in the postoperative period.

The aiming device for cervical distractor pin insertion: a proof-of-concept, feasibility study

BackgroundRestoration of cervical lordosis after anterior discectomy and fusion is a desirable goal. Proper insertion of the vertebral distraction or Caspar pin can assist lordotic restoration by either putting the tips divergently or parallel to the index vertebral endplates. With inexperienced surgeons, the traditional free-hand technique for Caspar pin insertion may require multiple insertion attempts that may compromise the vertebral body and increase radiation exposure during pin localization. Our purpose is to perform a proof-of-concept, feasibility study to evaluate the effectiveness of a pin insertion aiming device for vertebral distraction pin insertion.MethodsA Smith-Robinson approach and anterior cervical discectomy were performed from C3 to C7 in 10 human cadaveric specimens. Caspar pins were inserted using a novel pin insertion aiming device at C3-4, C4-5, C5-6, and C6-7. The angles between the cervical endplate slope and Caspar pin alignment were measured with lateral cervical imaging.ResultsThe average Superior Endplate-to-Caspar Pin angle (SE-CP) and the average Inferior Endplate-to-Caspar Pin angle (IE-CP) were 6.2 ± 2.0° and 6.3 ± 2.2° respectively. For the proximal pins, the SE-CP and the IE-CP were 4.0 ± 1.1°and 5.2 ± 2.4° respectively. For the distal pins, the SE-CP and the IE-CP were 7.7 ± 1.4° and 6.2 ± 2.0° respectively. No cervical endplate violations occurred.ConclusionThe novel Caspar pin insertion aiming device can control the pin entry points and pin direction with the average SE-CP and average IE-CP of 6.2 ± 2.0° and 6.3 ± 2.2°, respectively. The study shows that the average different angles between the Caspar pin and cervical endplate are less than 7°.

Biomechanics of external fixator of distal radius fracture, a new approach: Mutifix Wrist

The purpose of this study was to assess factors affecting fixator stiffness with a finite element model and an experimental validation with particular attention to a new fixator device named Mutifix Wrist® (NCS Lab srl, Carpi, MO, Italy). Mechanical tests were carried out to determine the stiffness of the construct with different configurations. The obtained results were compared to those obtained with the Hoffmann II Compact (Howmedica-Osteonics Inc. Rutherford, NJ, USA). Data were sampled at 20Hz and test speed was 0.05mm/s. For each loading condition, tests were performed four times. A FEM campaign was also conducted to analyze how geometrical variables (type of configuration and K-wire diameter) affect both stiffness and stress distribution of the fixator. Stiffness, axial displacement, magnitude of the displacement, magnitude and localization of the peak stress of the construct were all analyzed. Axial compression tests showed that the axial displacement reached by the machine actuator when the measured force reached 45N was 0.56mm ± 0.13 on average. Magnitude of the displacement along with peak stress magnitude and localization varied through the several configuration tested, but it resulted that the distal pin near the fracture gap was the more stressed one in all cases except those in which the fracture line is crossed. From the tests performed, it emerged that the addiction of a K-wire provides a construct stiffening and a consequent local stress reduction; while span increase reduces stiffness and increase the local stress. If a K-wire is implanted through the fracture site, the axial stiffness is significantly increased.

Une simple fixation externe à bas prix pour les fractures luxations de la main

Fracture dislocation is one of the most common and challenging problems in hand surgery. Pin fixation is the most common fixation device in the hand but sometimes we need to use external fixators in hand fractures and diseases. Commercial hand external fixators are expensive and sometimes they are not available. Since it has been presented some alternative solutions for this technique to overcome these problems, like Suzuki technique, Pin stabilizing with syringe or orthopedic cement and so on. We introduce a new alternative for this treatment, which is simple, available and with low price. Pi frame can be used as static or dynamic external fixator. From June 2016 to February 2018, 24 patients with hand and finger problems and trauma underwent external fixation stabilizing with Pi frame, including 8 phalangeal fracture, 6 PIP fracture dislocations, 7 metacarpal fracture and 3 congenital diseases. Eighteen cases as static and 6 cases as dynamic fixator. Technique For static external fixator we inserted the 1–1.5 mm pins at proper sites for example perpendicular to fracture lines and bent them to be caught with electric strip terminal block (Venus industrial group, Iran). For dynamic type, the proximal pin inserted parallel to articular surface and in the center of rotation of the adjacent joint. The pin bent 90 degrees and attached to the distal pins with a strip terminal block. We had one patient with delayed union, 6 patients with different degrees of limitation of joint motion. We had not seen any cases with pin tract infection, hyper-sensibility to the frame pin loosening or complaint of the appearances of the device. Fracture dislocation in hand is difficult to manage. Ilizarov and other external fixators has been evolved to overcome this problem but they are expensive and they are not available in some centers. Strip terminal block is a low price device available in all electrical stores. As a temporary external fixator it needs no bio-compatible studies. It is suitable everywhere but specially in area with lower outcomes and economic sanction. Pi mini external fixator is an available, simple with low price device with almost satisfactory results in difficult hand problems.

Is actual surgical experience reflected in virtual reality simulation surgery for a femoral neck fracture?

A virtual reality simulator developed for orthopaedic and trauma surgical training has been introduced. However, it is unclear whether the experiences of actual surgery are reflected in virtual reality simulation surgery (VRSS) using a simulator. The aim of this study is to investigate whether the results in VRSS differ between a trauma expert and a trauma novice. In Group A (expert), there are ten orthopaedic trauma surgeons and in Group B (novice) ten residents within 2years after medical school graduation. VRSS for a femoral neck fracture using Hansson hook-pins (Test 1) and Hansson twin hook plate (Test 2) was performed. The parameters evaluated were total procedure time (s), fluoroscopy time (s), number of times X-ray was used (defined by the number of times the foot pedal was used), number of retries in guide placement, and final implant position. In Test 1, the averages of four parameters (distance to posterior cortex (p = 0.009), distal pin distance above lesser trochanter (p = 0.015), distal pin hook angular error (p = 0.004), and distal pin tip distance to centre (lateral) (p = 0.015)) were significantly different between Groups A and B. In Test 2, no parameters in a mean were significantly different between groups, but seven parameters in a variance (guide wire distance to joint surface (p = 0.0191), twin hook length outside barrel (p = 0.011), twin hook tip distance to centre (lateral) (p = 0.042), twin hook distance to centre of lateral cortex (lateral) (p = 0.016), plate end alignment error (lateral) (p = 0.027), guide wire angle with lateral cortex (front) (p = 0.024), and 3.2-mm drill outside cortex (p = 0.000)) were significantly different between groups. In Test 1, Group B showed significantly longer fluoroscopy time than Group A (p = 0.044). In Test 2, Group B showed significantly fewer instances of X-ray use than Group A (p = 0.046). Our study showed that the experiences of actual surgery are reflected in the result of VRSS using the simulator.

Effect of Metacarpal Fixation Configuration on Strength and Fracture Gap Displacements in a Cadaveric Model of Externally Fixed Distal Radius Fractures.

Background: The purpose of the study was to determine the biomechanical effect of distal pin configuration in unilateral external fixation of distal radius fracture in a cadaveric model. Methods: A standardized 2-part extra-articular distal radius fracture model with dorsal comminution was created in 6 matched pairs of cadaveric upper extremities. Specimens within each matched pair were randomly assigned to either 4 or 6 cortices of distal pin metacarpal fixation. Cyclic, compressive loads were applied to the palmar hand. Results: No significant differences were detected in maximum forces. Six-cortex metacarpal fixation showed significantly lower magnitude of actuator displacement at 100 N cyclic loading. The difference in construct stiffness did not translate to disparities in angular and translational interfragmentary displacement at the fracture gap. Conclusions: Utilizing only 4 cortices and sparing the middle finger metacarpal avoids the need for a more transverse orientation required with 6-cortex fixation, which may otherwise impede thumb motion.

Neurovascular structures at risk with percutaneous fixation in tarsometatarsal fusion: A cadaveric study

IntroductionFirst tarsometatarsal (TMT) joint fusion is routinely used for arthritis and deformities. Common fixation methods include a locking plate construct, cross-screws, or combinations of the two. Cross screws have proven effective for union and stability; however, there is a potential for harm to nearby neurovascular structures due to the nature of percutaneous insertion technique. This study assessed risk of damage to the superficial peroneal nerve with percutaneous TMT fusion. MethodsNine fresh-frozen cadaver specimens were included. A medial incision in the internervous plane was made for TMT joint preparation. Two crossed percutaneous wires followed by 4.0 cc screws were placed in the dorsal aspect of the proximal aspect of first metatarsal and in the medial cuneiform. Both were 10–15 mm from the TMT joint line. The dorsal aspect of the foot was dissected and examined for neurovascular interruptions, particularly branches of the superficial peroneal nerve. ResultsResults showed a mean distance of 4.33 mm from the proximal pin to the medial branch of the superficial peroneal nerve. The distal pin had a mean distance of 6.44 mm from the medial branch, with one pin 9 mm from the lateral branch. One incident of direct injury to the neurovascular bundle was observed. ConclusionPreparing the joint from the medial side using a percutaneous approach is less invasive, but presents a relative risk for neuritis. Care should be taken during insertion of the percutaneous screw after TMT joint preparation for fusion.Level of Evidence: Level V, cadaver study.

Induced membrane technique for clavicle reconstruction in paediatric patients: Report of four cases

BackgroundClavicular reconstruction in paediatric patients is a rarely performed procedure that often raises complex technical challenges and produces unreliable outcomes. The induced membrane technique is an innovative two-stage procedure involving cement spacer placement into the defect to induce the development of a membrane, followed by the implantation of a cortical-cancellous bone graft. The primary objective of this study was to assess the medium- and long-term clinical and radiographic outcomes of clavicular reconstruction using the induced membrane technique in children and to highlight the advantages and drawbacks of this technique. The secondary objectives were to evaluate the fixation and the outcomes according to age and to the underlying diagnosis. HypothesisClavicular reconstruction using the induced membrane technique produces good outcomes in paediatric patients. Patients and methodsThe induced membrane technique was used for clavicular reconstruction in 4 children with a mean age of 9.7 years (range, 7.4–12.3 years). The diagnosis was congenital pseudarthrosis of the clavicle in 3 patients and aneurysmal bone cyst in 1 patient. Shoulder pain and mobility were assessed at last follow-up. Radiological bone healing was evaluated using the total radiographic union score (RUS, range, 0–10). Complications and number of procedures per patient were recorded. ResultsMean follow-up was 3.9 years (range, 1–8.4 years). None of the patients had pain or motion range limitation. After 6 months, the clavicle was healed with a RUS of 10 in all patients. The mean number of surgical procedures per patient was 3.75 (range, 3–5). Two patients required revision surgery for distal pin migration and another for a subcutaneous abscess under the pin. DiscussionWhen used for clavicular reconstruction, the induced membrane technique is effective and associated with a low complication rate. The induced membrane technique therefore deserves to be viewed as an alternative to other methods. Level of evidenceIV, retrospective observational study.

Locating the ulnar nerve during elbow arthroscopy using palpation is only accurate proximal to the medial epicondyle

PurposeKnowledge of ulnar nerve position is of utmost importance to avoid iatrogenic injury in elbow arthroscopy. The aim of this study was to determine how accurate surgeons are in locating the ulnar nerve after fluid extravasation has already occurred, and basing their localization solely on palpation of anatomical landmarks.MethodsSeven cadaveric elbows were used and seven experienced surgeons in elbow arthroscopy participated. An arthroscopic setting was simulated and fluids were pumped into the joint from the posterior compartment for 15 min. For each cadaveric elbow, one surgeon was asked to locate the ulnar nerve solely by palpation of the anatomical landmarks, and subsequently pin the ulnar nerve at two positions: within 5 cm proximal and another within 5 cm distal of a line connecting the medial epicondyle and the tip of the olecranon. Subsequently, the elbows were dissected using a standard medial elbow approach and the distances between the pins and ulnar nerve were measured.ResultsThe median distance between the ulnar nerve and the proximal pins was 0 mm (range 0–0 mm), and between the ulnar nerve and the distal pins was 2 mm (range 0–10 mm), showing a statistically significant difference (p = 0.009). All seven proximally placed pins (100%) transfixed the ulnar nerve versus two out of seven distally placed pins (29%) (p = 0.021).ConclusionsIn a setting simulating an already initiated arthroscopic procedure, the sole palpation of the anatomical landmarks allows experienced elbow surgeons to accurately locate the ulnar nerve only in its course proximal to the medial epicondyle (7/7, 100%), whereas a significantly reduced accuracy is documented when the same surgeons attempt to locate the nerve distal to the medial epicondyle (2/7, 29%; p = 0.021). Current findings support the establishment of a proximal anteromedial portal over a distal anteromedial portal to access the anterior compartment after tissue extravasation has occurred with regard to ulnar nerve safety.

Surgical treatment of the lower leg open fracture with lesions of the main blood vessels. A case report

Introduction. Open fractures of the lower leg degree IIIC by Gustilo belong to the most serious open fractures of the lower leg segment.These fractures are, along with the main blood vessels damage, often followed by a severe soft-tissue damage of the lower leg. Case report. Patient 20 years old, sustained a severe open fracture of the left lower leg in a car accident, with the disruption of the continuity of the main left lower leg arteries. After clinical examination and radiography (X-ray) diagnosis, the primary treatment of the open fracture fragment wound, reposition of the left lower leg and stabilization of the open fractures by the external skeletal fixator were performed. In the postoperative period, there was a manifestation of acute ischemia of the left foot. Arteriography verified discontinuity of all three crural arteries at the level of the fracture line. The patient was immediately surgically treated. Revascularization of the extremities was performed by reconstruction of the anterior tibial artery by 15 centimeters long saphenous graft interposition with creation of distal anastomosis at the level of the dorsal artery of the foot. Large soft tissue defect and reconstructed vessels were covered with transpositional fasciocutaneous flap. The postoperative course was accompanied by proper graft flow. Control X-ray examination verified fracture of the distal pin of external skeletal fixator with the healing of fractures of the tibia with angular deformity. The external fixator was removed, except for the residual part of the pin in the distal part of the lower leg. During the control examination after completion of the treatment, the patient walked without mobility aid. Conclusion. External skeletal fracture fixation, damaged blood vessels reconstruction and early covering of the soft-tissue shin defect are basic elements in saving the injured limb. The long term goal of treatment of open lower leg fractures with an injury of the main blood vessels is to allow patients return to usual daily activities and professional work.

A 3-Dimensional Analysis of the Fracture Planes in Pediatric Lateral Humeral Condyle Fractures for Image-Based Pin Positioning During Fixation.

To determine the 3-dimensional morphology of pediatric lateral condylar physeal fractures using 3-dimensional computed tomography (3D-CT) and to identify optimal pin positions for percutaneous pinning. Prospective case series of consecutively treated patients. Tertiary university hospital setting. Preoperative 3D-CTs in pediatric surgical candidates diagnosed with lateral condylar physeal fractures. Closed reduction and percutaneous pinning was performed. Reconstructed images of the distal humerus were aligned accordingly to determine the coronal (α), sagittal (β), and axial tilt (γ) angles of the fracture plane. Both α and β were also measured on plain radiography. Image-based position of the 2 pins was calculated preoperatively using 3D-CT, based on anteroposterior and lateral views. Final angle of pins was measured on postoperative radiographs. A total of 29 fractures were assessed. 3D-CT reconstruction images of fractures showed a posterolateral fracture fragment with reference to the long axis of the humerus. The mean α, β, and γ were 62 degrees [95% confidence interval (CI), 59-64], 69 degrees (95% CI, 65-72), and 36 degrees (95% CI, 34-38). Both α and β measured on plain radiography were not significantly different from 3D-CT measurements (P = 0.6712, 0.6218). Average postoperative pin angles were 144 degrees (95% CI, 140-147) and 161 degrees (95% CI, 158-165) for the proximal pin, and 118 degrees (95% CI, 114-122) and 115 degrees (95% CI, 110-120) for the distal pin, on anteroposterior and lateral views, respectively, resulting in similar trajectories to the preoperatively calculated pin positions. Our study adds to the current knowledge by providing an image-based angular reference of the fracture configuration in pediatric lateral humeral condyle fractures, which may be used during percutaneous pinning. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Complications of Aptis DRUJ Arthroplasty

Consulting Fee: Arthrex, Acumed (Huang) Speakers Bureau: Arthrex, Acumed (Huang) Ownership Interest: Stock in Imagen Technologies (Hanel) The Aptis total DRUJ prosthesis is a semiconstrained implant designed for treatment of DRUJ arthritis and instability. There are limited published studies assessing outcomes of patients undergoing the Aptis total DRUJ arthroplasty, with reports of favorable outcomes with 95% or greater 5-year survival rates.1-5 The purpose of this study is to analyze short-term complications of the Aptis total DRUJ prosthesis. A retrospective chart review of patients undergoing Aptis DRUJ arthroplasty from 2007-2015 at a single institution was performed. Patient demographics including gender, age, etiology of injury, occupation, and prior surgical procedures were collected. Records were analyzed for complications and need for subsequent surgical procedures. Radiographs were evaluated for radiographic evidence of implant loosening, periprosthetic fracture, and heterotopic ossification. Fifty-one Aptis DRUJ arthroplasties were performed over eight years by two hand surgeons at one institution. Twenty-two complications necessitating operative management occurred in 18 of 51 patients (35%). A total of 32 procedures were undertaken to address these complications (Table 22-1). Complications requiring revision surgery included 5 periprosthetic fractures (Fig. 22-1), 3 infections, 2 implant component failures, 2 instances of aseptic loosening, and 2 cases of heterotopic ossification at the DRUJ. Five of the 51 implants (10%) were explanted with three (6%) removed due to infection. •Complications of Aptis DRUJ arthroplasty are common, with 35% (18/51) of cases requiring additional surgical procedures.•The most common complications were periprosthetic fractures, infections necessitating explant, neuromas, and elbow pain from increased forearm motion.•Demographics including age, smoking, etiology of injury, worker’s compensation, and number of prior procedures did not have a significant impact on rate of complications.•There is a need for prospective studies on functional outcomes in this patient population.Table 22-1Procedures Performed after Replacement of DRUJ – Related to ComplicationsRevision of Aptis Components Explant4 Simultaneous explant and revision arthroplasty1 Delayed revision arthroplasty2 Poly exchange1 Revision for screw failure1 Revision for aseptic loosening of screws and radial peg1ORIF for periprosthetic fracture5Repair of distal radius nonunion1I&D4Neuroma excision Dorsal cutaneous branch ulnar nerve2 PIN neurectomy1Tenolysis EDC tenolysis1 Extensor tenolysis with ECU transposition1Excision of ectopic bone DRUJ2Elbow procedures HO excision of joint capsule1 Radial head arthroplasty1 Revision radial head arthroplasty1 Manipulation under anesthesia1Creation of a one bone forearm Proximal RUJ arthrodesis (from instability after DRUJ arthroplasty explant)1 Open table in a new tab

Prospective study of unstable distal radius fractures treated with external fixation in Indian rural set-up

Aim: Distal radius fracture is common fracture in daily orthopaedic practice accounting for 1/6th of all the fractures. Conventionally the fractures were treated with closed reduction and immobilization with casts. Even though union of these fractures occurs, they have a very high incidence of going in for malunion and wrist joint instability especially with comminution & intra articular extension cases. Moreover a change in trend to younger age groups as a result of RTA’s (road traffic accidents) & trauma is leading to more complicated fractures with intraarticular extension and comminution. Also the importance of anatomical alignment and reconstruction of radiocarpal and radioulnar ulnar joints has been emphasized in recent trends. Hence the management of distal radius fractures changed from universal use of cast immobilisation to operative interventions. Aim of this study is to observe the effect of external fixation for unstable distal radius fractures in rural set up. Materials and methods: Prospective analysis of 30 patients with unstable distal radius fractures, who were operated at MIMS hospital, nellimarla village, vizianagaram district between may 2016 to feb 2017 treated with external fixator. Patient position- supine with arm table support. For external fixation of the wrist we used the 4 mm (small) external fixator system. For pin insertion into the second metacarpal, the distal pin is inserted proximal to the transition of the metacarpal head into the shaft and the more proximal pin is inserted distal to transition of the shaft into the metacarpal base.The proximal two pins are inserted proximal to the muscle bellies of abductor pollicis longus (APL) and extensor pollicis brevis (EPB). Proximal to these muscles, the radial shaft is palpated through the skin between the bellies of the extensor digitorum communis (EDC) and extensor carpi radialis longus/brevis (ECRL/ ECRB) over a distance of 3-4 cm at which the proximal pins inserted into the radial shaft with 4-5cms apart. Longitudinal traction is applied on the thumb and index finger or the distal partial frame to reduce the fracture. T clamps are fixed to bridging rods, first proximally followed by tightening of distal fragment T clamps to maintain the traction and reduction, there by healing of fracture by the principle of ligamentotaxis. Results: Average Mean hospital stay is 4days, there are 13males and 17 females between age group 28-60yrs, 27 cases out of 30 had functional and radiological union by 12weeks (range 6-18 weeks), 2 had pin track infection which were treated successfully with iv antibiotics. 1 patient had deep bone infection and pin loosening which was managed with external fixator removal, long course antibiotics and casing. We followed standard Sarmiento radiological scoring system, Gartland and Werley Score (demerit system) demerit point scoring system, DASH scores, Green & O Brien grade scoring systems to evaluate the end results. Conclusion: External fixation of unstable distal radius fractures can be considered as effective treatment in elderly populations of Indian rural set up as it is simple, cost effective, short duration procedure with good results.

The radial nerve danger zone: A cadaver study

Certain distal humerus fractures and elbow fracture dislocations warrant early fixation with an external fixator. The distal humerus is close to the radial nerve and a hazardous area for the placement of an external fixator. No known safe zone for the placement of an external fixator has been identified on the lateral border of the humerus. We record the incidence of radial nerve damage following external pin fixation and note the relation of the radial nerve to each pin. A total of 39 cadavers were dissected for this study. Two 4 mm pins were placed with a multi-pin clamp into the lateral border of the right and left humerus at 100 mm and 70 mm proximal to the lateral epicondyle. We dissected the upper limbs and recorded the incidence of radial nerve damage and the position of the nerve in relation to the two pins. Data for right and left sides were combined. The radial nerve was damaged by the proximal and distal pin in 56.4% and 20.5% respectively. The radial nerve was located anterior to the proximal pin (41%) and distal pin (79.5%). The radial nerve was located posterior to the proximal pin (2.6%) and distal pin (0.0%). We were unable to identify a safe zone from this study. We propose that pins should be placed less than 100 mm proximally from the lateral epicondyle and as posterior as possible to minimise the risk of radial nerve damage.