Limited Dissection Research Articles

Comparison of Limited and Full Dissection Abdominoplasty Using Laser Fluorescence Imaging to Evaluate Perfusion of the Abdominal Skin

In an effort to reduce risk, some surgeons promote a limited dissection abdominoplasty technique. They believe that preserving musculocutaneous perforators improves blood supply to the overlying abdominal tissue and that improved vascularity avoids seromas and reduces wound healing problems. Laser fluorescence imaging is a new method that allows quantitative measurements of perfusion. Twenty-two consecutive women undergoing abdominoplasty agreed to participate in this prospective study. The inclusion rate was 100 percent. The SPY Elite Intraoperative Perfusion Assessment System was used to quantitate flap perfusion. Patients served as their own controls to avoid confounders. All patients received superwet infusions followed by liposuction of the abdomen and flanks. First, a limited dissection was performed, preserving medial musculocutaneous perforating blood vessels and the Scarpa fascia on the lower abdomen. The rectus fascia was repaired in all cases. A temporary superficial fascial wound closure was performed. The patient was imaged after injection of the contrast agent. The dissection was then extended to a full abdominoplasty and the Scarpa fascia was removed from the lower abdomen. The patient was reimaged. Wound tension was also measured. Complications included one distal deep venous thrombosis, one infection, and one seroma. There were no cases of marginal necrosis or dehiscence. There was no significant difference (p < 0.05) in perfusion measurements comparing the limited and full dissections. Wound tensions were significantly less (p < 0.001) in the full-dissection group. The limited dissection abdominoplasty does not provide a significant improvement in perfusion compared with a full dissection. Therapeutic, II.

Feasibility, complications and oncologic results of a limited inguinal lymph node dissection in the management of penile cancer.

ABSTRACTPurpose:In patients with penile cancer (PeCa) and increased risk of inguinal lymphatic dissemination, inguinal lymphadenectomy offers a direct histological staging as the most reliable tool for assessment of the nodal metastasic status and a definitive oncologic treatment simultaneously. However, peri- and/or postoperative mutilating sequalae often occurn. We report on clinical outcome and complications of a limited inguinal lymph node (LN) dissection.Materials and Methods:Clinical and histopathological data of all patients with PeCa who underwent limited inguinal lymphadenectomy (LIL) at our institution between 1986 and 2012 were comprehensively analyzed. Perioperative results were presented in relation to one-sided procedures, if appropriate, which were assessed without cross comparison with contralateral LILs.Results:29 consecutive patients with PeCa aged 60±10.3 years were included in the current study with 57 one-sided LIL performed. Mean operative time for one-sided LIL was 89.0±37.3 minutes with 8.1±3.7 LNs removed. A complication rate of 54.4% (n=31), including 16 minor and 15 major complications was found in a total of 57 procedures with leg oedema being the most prevalent morbidity (15.8%). 4 patients with clinically positive LNs developed inguinal lymphatic recurrence within 9 months after surgery.Conclusions:Our technique of limited inguinal LN dissection provided an acceptable complication rate without aggravating morbidity. We experienced no recurrences in clinically LN negative patients, so that the approach might be a reasonable option in this scenario. In patients with enlarged LNs, radical inguinal lymphadenectomy still appears to represent the gold standard.

Prostate cancer: Can imaging accurately diagnose lymph node involvement?

Most metastatic lymph nodes in patients with prostate cancer go undetected by current imaging techniques and limited pelvic lymph node dissection (PLND), as they are small and located in difficult-to-reach areas. As the only current alternative is an extended PLND, the search for more accurate imaging techniques continues.

Sa1588 Colorectal Hybrid-ESD and ESD Outcomes in an American Referral Center

Endoscopic submucosal dissection (ESD) is increasingly used for resection of challenging colorectal adenomas in Asia. Hybrid-ESD, which incorporates a circumferential incision and limited submucosal dissection to facilitate snare resection, is also used as an alternative technique of ESD. There is little data on the safety and efficacy of these techniques in Western centers.

Fixation for metacarpal neck fracture: a biomechanical study.

There is no robust evidence of the best operative treatment for displaced unstable metacarpal neck fractures. Numerous constructs are used in the fixation of metacarpal neck fractures. Currently, two common methods are dorsal locking plate and K-wire fixation. A new metacarpal sled fixation system for metacarpal neck fracture was designed to provide fracture stability but limit dissection and avoid exposed hardware. The purpose of this study was to compare the biomechanical integrity of the metacarpal sled versus standard locking plate fixation and retrograde K-wire fixation in a simulated porcine metacarpal fracture model. Transverse metacarpal neck fractures were created in 30 porcine second metacarpals. The specimens were randomly fixed with locking plates, metacarpal sleds, or retrograde K-wires. Constructs were then loaded to failure in three-point bending. Stiffness and peak load were measured from the load-to-failure deflection curve. Data were analyzed via ANOVA, followed by Tukey-Kramer's post hoc pairwise comparison. The K-wire group had the highest initial stiffness followed by the sled group and then the plate group. Statistical difference was only found between K-wires and plate. Peak load for the K-wire group was lowest, followed by sled, and then by plate. A statistically significant difference was observed between the peak loads of the K-wires and plate, as well as the sled and plate. However, a difference in peak load was not detected between the K-wires and sled. For transverse metacarpal neck fractures, a metacarpal sled construct provides similar fixation to K-wires with limited dissection and without exposed hardware or the potential for soft tissue tethering. The new low profile construct using a minimally invasive technique would be suitable for unstable metacarpal neck fractures.

The prevalence of lymph node metastases in clinical T1N0 thoracic esophageal cancer from the results of JCOG0502.

10 Background: Recently, a limited operation to avoid needless lymph node (LN) dissection in clinical T1bN0 esophageal cancer (EC) is considered. However, how LN dissection or radiation field should be decided for such cases has not yet been clarified. The information about prevalence of LN metastases (LNMs) would be valuable when the radiation field and extent of LN dissection are considered in the treatment of T1bN0 EC. Methods: JCOG0502 is a randomized controlled trial including a patient preference arm comparing surgery alone to definitive chemoradiotherapy in clinical T1bN0 EC. By using baseline clinical and pathological data of JCOG0502, diagnosis accuracy of LNM was evaluated by comparing clinical and pathologic findings. Then, the sites of pathologic LNMs were determined and the initial sites and the prevalence of LNM were estimated. Results: Between Dec 2006 and Feb 2013, 213 patients (pts) enrolled to the surgery arm in JCOG0502. Pts with multiple lesions or without esophagectomy were excluded and remaining 186 pts were analyzed. Of the 186 pts of clinical T1bN0, 137 pts were diagnosed as LNM negative (73.7%: accuracy of diagnosis), however, 49 pts (26.3%) had pathologic LNMs. Pathologic LNMs were seen at 106recR, 106recL (all in mediastinal region) in upper thoracic (Ut) EC, 101R, 101L, 104R, 104L (in the neck region), 106recR, 106recL, 106tbL, 105, 107, 108, 109L, 110 (in the mediastinal region), 1,2,3,7, 11 (in the abdominal region) in middle thoracic (Mt) EC, and 105, 106recL, 110 (in the mediastinal region), 1, 2, 3, 7 (in the abdominal region) in lower thoracic (Lt) EC, respectively. Of the 49 pts who had pathologic LNMs, 32 pts (65%) were of pathologically N2 or more. Furthermore, 18 pts (37%) had skip LNM (LNM of N2, N3 or N4 without N1). The solitary pathologic LNM was observed in 25 pts: N1 (106recR, 106recL) in Ut, N1 (106recR, 106recL, 108), N2 (101R, 105, 110, 1, 3, 7), in Mt, N1(110, 1), N2 (106recL, 3, 7) in Lt, respectively. Conclusions: In the current status of clinical diagnosis, limited LN dissection or limited field of radiation are not recommended. In surgery, D2 LN dissection is necessary and three-field LN dissection is recommended especially in middle thoracic EC even for clinical T1bN0. Clinical trial information: UMIN000000551.

Surgical Outcome of Video-Assisted Thoracoscopic Surgery vs. Thoracotomy for Primary Lung Cancer >5 cm in Diameter.

The indications for video-assisted thoracoscopic surgery (VATS) for advanced-stage lung cancer are expanding, but the criteria vary among institutions. This study compared the minimal invasiveness and oncologic validity of VATS lobectomy and thoracotomy lobectomy for the treatment of large-diameter primary lung cancer. We retrospectively reviewed clinical features and surgical outcomes of 68 patients who underwent anatomical pulmonary resection for primary lung cancer of >5-cm diameter from July 2006 to March 2013. The patients were divided into a VATS group (Group V, n = 35) and a thoracotomy group (Group T, n = 33). Group V exhibited less intraoperative bleeding (p = 0.012) and had a shorter length of postoperative hospital stay (p = 0.024). The 1- and 5-year overall survival rates were 91.3% and 39.3% in Group V and 84.8% and 56.9% in Group T, respectively (p = 0.48). Multivariate analysis showed that limited lymph node dissection contributed to local recurrence. The extraction bag lavage cytology in Group V revealed that the positivity rate was 35.7%. VATS for primary lung cancer of >5-cm diameter is similar to thoracotomy in terms of surgical outcomes. Large tumors must be carefully maneuvered during VATS to prevent cancer cell spillage.

Neoadjuvant or adjuvant therapy for gastric cancer.

Currently, there is no international consensus on the best treatment regimen for patients with advanced resectable gastric carcinoma. In the United States, where a limited lymph-node dissection is frequently performed, adjuvant chemoradiotherapy after surgery is the standard treatment. In Europe, intensified perioperative chemotherapy is commonly administered. In Japan and South Korea, postoperative S-1-based adjuvant chemotherapy after surgery with D2 lymph-node dissection is the standard treatment. Several ongoing trials are currently evaluating the optimal sequence of chemotherapy, radiotherapy, and surgery, as well as the place of targeted therapeutic agents in the treatment of advanced gastric carcinoma.

Current trends of abdominoplasty

Objectives The aim of this study was to compare between traditional abdominoplasty and current techniques of abdominoplasty, follow complications associated with the new techniques of abdominoplasty, etiology and management, and minimize the amount of invasive surgery while maximizing the esthetic surgical results and patient benefits. Patients and methods A total of 49 patients (26 women and 23 men) between 20 and 60 years of age were studied in the period from October 2010 to October 2014 at the Plastic Surgery Department, Menofia University Hospitals. The patients were divided into three groups to compare between traditional abdominoplasty, lipoabdominoplasty with limited dissection superior to the umbilicus and lipoabdominoplasty with limited dissection superior to the umbilicus, preservation of scarpas fascia, and lowering incision line. Results A total of 49 patients (26 women and 23 men) between 20 and 60 years of age were included in this study. The study was carried out on the basis of inclusion and exclusion criteria, and the choice of participants for each group was carried out randomly. There was a statistically significant difference between different groups in age, blood transfusion, and occurrence of complications ( P < 0.05). Conclusion We recommend following the new technique of abdominoplasty, which includes lipoabdominoplasty, limited dissection superior to the umbilicus with preservation of scarp's fascia; it was found that fewer complications developed with the use of our new technique for lipoabdominoplasty compared with the use of the traditional technique, and there were greater patient benefits than observed previously.

SPONTANEOUS CORONARY ARTERY DISSECTION.

Spontaneous coronary artery dissection is a rare, but very important clinical phenomenon usually described as an uncommon cause of an acute coronary artery syndrome. It typically affects young healthy people, predominantly female, and is usually diagnosed postmortem. The overall incidence of spontaneous coronary artery dissection in coronary angiograms ranges from 0.1 to 1.1%. However, routine coronary angiography in acute coronary syndromes has demonstrated that the true incidence of this phenomenon is underestimated. The pathophysiology is unclear, and clinical presentation usually demonstrates great variability. However, three types of spontaneous coronary artery dissection have been recognized: atherosclerotic, puerperal, and idiopathic. The appropriate treatment of spontaneous coronary artery dissection is difficult, and there is no clinical consensus on the appropriate management of these patients. Reports from the literature suggest that stable patients with limited dissections demonstrate spontaneous healing with medical management alone. Recent evidence has shown an improved prognosis after urgent restoration of the coronary flow by percutaneous intervention or coronary artery bypass surgery. Reports of uncontrolled escalating coronary dissections, extension of intramural hematoma, and acute coronary thrombosis after stenting mark this method as controversial. Thus, the decision making process for the appropriate management should respect evidence based medicine and have an individual approach to each patient alone. Clinical perspectives of the spontaneous coronary artery dissection are analyzed in this review article, based on personal experience and recently published literature.

Limited dissection and early primary closure of the tracheostomy stoma in head and neck oncology operations: a retrospective study of 158 cases

Tracheostomy is an efficient and widely used method to secure a patent airway in patients undergoing major oral and maxillofacial oncology operations. The inferiorly based Björk flap technique, through a limited incision, followed by early primary skin closure, has been the preferred method in our unit. Patients who underwent tracheostomy for major oral and maxillofacial oncology operations during the period June 2005 to December 2012 were reviewed. Age, gender, preoperative diagnosis, duration the tracheostomy tube was in situ, tracheostomy-associated complications, and long-term sequelae were evaluated. A total 158 tracheostomies were performed using the same surgical approach in patients aged 18–84 years (median 59, mean 58.2, standard deviation 14.24 years). The time the tracheostomy tube was in situ ranged from 3 to 40 days (median 7, mean 9.0, standard deviation 6.52 days). The complication rate was 5.06% (8/158 patients). A major concern highlighted in previous publications is the risk of surgical emphysema with early closure. In this study, no patients developed surgical emphysema, tracheal fistula, clinical tracheal stenosis, or cosmetically unacceptable scarring of the neck. No patient died of a tracheostomy-related cause. In summary, the Björk flap with early primary closure of the skin by simple sutures provides a safe and easily managed approach, causing minimal postoperative morbidity.

Vaginal cesarean section: heir to, but not legacy of Dührssen's incision.

Vaginal cesarean section is a uterine incision technique derived from Dührssen's incision, with which it is sometimes confused. We report here our experience over 10 years with this technique, with the aim of defining the situations in which it is potentially useful. We retrospectively analyzed 24 cases of vaginal cesarean section (i.e. cervico-segmental incision) carried out from 2002 to 2011 in our tertiary maternity unit. This corresponds to an incidence of 1.1 per thousand deliveries. The main outcome measures were the indications and complications of vaginal cesarean section. The study population included 42% nulliparous women. The fetuses concerned had a median gestational age of 24 weeks + 5 days (18 to 34 weeks + 1 day) and a median weight of 595 g (340-1,250 g). The indications for vaginal cesarean section were severe maternal morbidity in 54.2% of cases, failed labor induction in 29.2% and another indication in 16.7%. All but one of the fetuses were dead or nonviable. Surgical complications were observed in three cases: two difficulties achieving hemostatic control and one bladder injury. Vaginal cesarean section is sometimes considered obsolete, but it has several advantages: technical simplicity, limited tissue dissection, low risk of hemorrhage and no abdominal scar. These features make it particularly suitable for the extraction of medium-sized dead or nonviable fetuses when pharmacological options are ineffective or not rapid enough in cases of poor maternal condition.

One-piece bone flap osteotomy using thread wire saw for fronto-orbital advancement with distraction osteogenesis in craniosynostosis.

The objectives of this study are to describe our new technique of one-piece bone flap osteotomy for fronto-orbital advancement with distraction osteogenesis in craniosynostosis using a thin, flexible, and safe thread wire saw (the T-saw) and to compare the results with those of classic osteotomy using an osteotome. Initial osteotomy is performed between two pterion burr holes using a craniotome with a guarded footplate. The outer sphenoid wing and lateral orbital rim are separated using a reciprocating saw. Limited dura dissection from inner cortex between burr holes in the pterion and nasion is performed. The T-saw is inserted through the epidural space behind the superior orbital wall between the lateral orbital rim and nasion burr hole; the osteotomy is performed with gentle reciprocating strokes. Dura protection with a malleable retractor is not absolutely necessary. Five patients underwent one-piece fronto-orbital bone flap osteotomies using a T-saw in 2009-2014. The median age was 26 months (7-132 months), median operation time was 275 min (183-303 min), and median estimated blood loss was 65 mL (20-250 mL). These values did not differ from those of control cases. No complications, including incomplete osteotomy, occurred. The T-saw creates an osteotomy as a "one-stroke sketch," so incomplete osteotomy never occurs. The osteotomy can be performed safely without protecting the dura. Osteotomy with T-saw does not negate the advantages of fronto-orbital advancement with distraction osteogenesis, including shorter operative time, less intraoperative bleeding, and fewer complications.

Oncologic Validity of Recipient Vessel Preservation in Microvascular Free-Flap Reconstruction

Objectives: The use of free-flap reconstruction requires a more limited neck dissection to allow for microvascular anastomosis. This study seeks to determine the oncologic validity of cervical vessel preservation. Materials and Methods: The current study is a prospective review of cervical vessel biopsies from patients undergoing resection of squamous cell carcinoma (SCCA) tumors of the head and neck with free tissue reconstruction. Results: From June 2010 to March 2012, 227 recipient vessel biopsies were performed on 100 patients. Three of these patients had grossly abnormal vessels, with malignancy confirmed by frozen section analysis. One patient had a vessel positive for malignancy that was grossly normal but found to have SCCA on the final pathology. Conclusions: When the recipient vessel appears grossly suspicious, a frozen section biopsy and re-resection should be considered. Recipient vessel trimmings should routinely be sent for permanent pathology since in rare cases, they can be involved by tumor, affecting the margin status, prognosis, and indications for adjuvant therapy.

Redo mitral valve replacement through a right mini-thoracotomy with an unclamped aorta.

Redo cardiac surgery represents a clinical challenge due to a higher rate of perioperative morbidity and mortality. Mitral valve (MV) re operations can particularly be demanding in patients with patent coronary grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, leaks or thrombosis). In this article we describe our technique to manage complex mitral reoperations using a minimally invasive approach, moderate hypothermia and avoiding aortic cross-clamping. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of less invasive access and continuous myocardial perfusion. The advantage of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, reducing the risk of cardiac structures or patent graft injury. Moderate hypothermia and continuous blood perfusion can guarantee adequate myocardial protection particularly in the case of patent grafts, decreasing the dangers of an incomplete or imperfect aortic clamping at mild hypothermia and potential lesions due to demanding clamp placing. Complex MV reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space with an unclamped aorta.

Subtotal Gastrectomy with Limited Lymph Node Dissection is a Feasible Treatment Option for Patients with Early Gastric Stump Cancer

The de facto standard treatment for early gastric stump cancer (GSC) has been total gastrectomy combined with radical lymph node dissection. However, some patients could benefit if partial resection of the gastric stump is feasible. We investigated the feasibility of subtotal gastrectomy for early GSC as less invasive surgery. Subtotal gastrectomy was defined as a segmental resection of the gastric remnant including the anastomosis with limited lymph node dissection. A total of 66 patients with early GSC were enrolled and 24 patients (36.4 %) underwent subtotal gastrectomy (SG group). Clinicopathological characteristics were analyzed along with those of the other 42 patients (63.6 %) who underwent total gastrectomy (TG group). There were no significant differences between the two groups in the number of lymph nodes harvested (p = 0.880). Lymph node involvement was detected in 2 patients (8.3 %) in SG group and 5 patients (11.9 %) in TG group (p = 1.000). The previous disease (benign or malignant) and surgery (Billroth I or II) did not affect the rate of nodal involvement. The 5-year overall survival rate of SG group (94.7 %) was acceptable. Subtotal gastrectomy of the gastric remnant could be a feasible treatment option for patients with early gastric stump cancer when indicated.

Re-classification of mixed-type IPMNs allows for better definition of epidemiology, biology and outcomes after surgical resection

s / Pancreatolog S4 Aims: To evaluate the long-term outcome after surgical resection of sporadic, asymptomatic NF-pNET < 2 cm, stratifying the results by resection type and histopathologic features. Patients & methods: Patients resected between June 1997 and November 2008 at our institution (minimum follow-up of 60months) were retrieved from a prospectively maintained electronic database and analyzed retrospectively. Results: Study population consisted of 49 patients (27 females and 22 males), with amedian age of 59 years (range 38-61). 31 patients underwent parenchyma-sparing resections (15 enucleations, 15 middle pancreatectomies, 1 spleen-preserving distal pancreatectomies), while 18 patients underwent formal resections (8 pancreaticoduodenectomies, 10 distal pancreactomies with splenectomy). Mean lymph node yielding was 1.35 (0-9) in atypical resections and 19 (7-32) in formal resections (p1⁄40.0001). Lymph node metastases were found in only one patient undergoing pancreaticoduodenectomy. The median tumor size was 16 mm. 48 tumors were G1, one was G2, none was G3 (2010 WHO classification). The final pathologic report showed microscopic local invasion (perineural invasion, lymph vascular invasion or fat invasion) in 8 patients. At a median followup of 80 months (60-193), 4 patients died of other causes, 4 were lost to follow-up the remaining 37 patients did not develop recurrence and are alive and disease-free. Conclusion: Long-term outcome of surgically resected asymptomatic sporadic NF-pNET < 2 cm is excellent. Atypical resections with limited lymph node dissection may be oncologically adequate. Microscopic local invasion did not impact on the natural history of the disease.

Pancreatic serous cystadenoma related mortality is almost nil

s / Pancreatolog S4 Aims: To evaluate the long-term outcome after surgical resection of sporadic, asymptomatic NF-pNET < 2 cm, stratifying the results by resection type and histopathologic features. Patients & methods: Patients resected between June 1997 and November 2008 at our institution (minimum follow-up of 60months) were retrieved from a prospectively maintained electronic database and analyzed retrospectively. Results: Study population consisted of 49 patients (27 females and 22 males), with amedian age of 59 years (range 38-61). 31 patients underwent parenchyma-sparing resections (15 enucleations, 15 middle pancreatectomies, 1 spleen-preserving distal pancreatectomies), while 18 patients underwent formal resections (8 pancreaticoduodenectomies, 10 distal pancreactomies with splenectomy). Mean lymph node yielding was 1.35 (0-9) in atypical resections and 19 (7-32) in formal resections (p1⁄40.0001). Lymph node metastases were found in only one patient undergoing pancreaticoduodenectomy. The median tumor size was 16 mm. 48 tumors were G1, one was G2, none was G3 (2010 WHO classification). The final pathologic report showed microscopic local invasion (perineural invasion, lymph vascular invasion or fat invasion) in 8 patients. At a median followup of 80 months (60-193), 4 patients died of other causes, 4 were lost to follow-up the remaining 37 patients did not develop recurrence and are alive and disease-free. Conclusion: Long-term outcome of surgically resected asymptomatic sporadic NF-pNET < 2 cm is excellent. Atypical resections with limited lymph node dissection may be oncologically adequate. Microscopic local invasion did not impact on the natural history of the disease.

The Fascial Elevation and Tendon Origin Resection Technique for the Treatment of Chronic Recalcitrant Medial Epicondylitis

Background: Medial epicondylitis is a tendinopathy of the common flexor-pronator origin, and surgical treatment is required when this condition fails to respond to nonoperative methods. This study details the development of a new technique, termed fascial elevation and tendon origin resection (FETOR), which facilitates the complete visualization and resection of the CFPO with limited soft tissue dissection. Purpose: To evaluate the outcomes of FETOR for the treatment of chronic recalcitrant medial epicondylitis. Study Design: Case series; Level of evidence, 4. Methods: The electronic medical records of patients who underwent FETOR from January 2008 to July 2011 were retrospectively reviewed. Outcome assessments included the visual analog scale (VAS) for average pain, pain at rest, and pain experienced during hard work or heavy lifting; the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; and pain-free grip strength. Preoperative and postoperative data were compared. Results: A total of 22 elbows in 20 patients with a mean age of 48.8 years (range, 29-58 years) were included. At a mean follow-up of 35.6 months (range, 16-77 months), the VAS score decreased by 93% for average pain, 94% for pain at rest, and 83% for pain during hard work or heavy lifting (P < .001). The patients’ perception of arm function as assessed using the DASH recovered to the level of the healthy population (from a mean of 51.6 ± 18.0 to 8.0 ± 11.1; P < .001). The mean pain-free grip strength improved significantly from 53.7% ± 30.3% to 97.3% ± 19.8% of the uninvolved arm (P < .001). Eighteen (90%) patients were satisfied with the surgical outcomes, while 2 patients changed their jobs because of decreased elbow function. No major complications occurred. Conclusion: The FETOR technique is an effective and safe method for the treatment of chronic recalcitrant medial epicondylitis.

Tibial Stress Fracture Secondary to Half-Pins in Circular Ring External Fixation for Charcot Foot

There is an increasing trend for surgical correction of the deformity associated with Charcot neuroarthropathy of the foot and ankle (Charcot foot) in order to allow ambulation with commercially available therapeutic footwear. The significant rate of surgical and medical morbidity associated with extensive conventional operative correction has led many surgeons to use limited surgical dissection and stabilization with circular ring external fixation. A retrospective chart review was performed on 254 patients at 2 academic medical centers who underwent surgical correction for diabetes-associated Charcot foot deformity with limited soft tissue dissection and stabilization accomplished with a statically applied circular external fixator. Tibial stress fractures developed in 10 of the patients. Seven of the fractures developed in the 42 patients in whom tibial block fixation was accomplished with half-pins (16.7%), and 3 fractures developed in the 202 patients in whom tibial block fixation was accomplished with tensioned fine wires (1.5%). Three of the tibial stress fractures were successfully treated with extension of the circular frame above the level of the stress fracture. Four fractures were successfully treated with closed intramedullary nailing and 3 with weight-bearing total contact casts. Two tibial fractures occurred through pin sites (all half-pins) in 120 nonneuropathic patients who underwent application of circular ring external fixators during the same 6-year period. Tibial stress fracture is an unusual complication associated with the use of circular ring external fixation. This investigation highlights the significantly greater risk for the development of this complication in diabetic patients undergoing surgical correction for Charcot foot deformity when half-pins are used for tibial block stabilization, compared with tensioned fine wires. We now recommend the universal use of tensioned fine wires for tibial block fixation when circular ring fixation is performed in patients with Charcot foot arthropathy. Level IV, retrospective case series.