Pin Site Infection Research Articles

Clinical outcomes in pediatric tibial lengthening and deformity correction: a comparison of the Taylor Spatial Frame with the Orthex Hexapod System.

PurposeComparison of two hexapod frame systems in paediatric tibial deformity correction; the Taylor Spatial Frame (TSF) and Orthex Hexapod System.MethodsPaediatric patients with congenital and acquired tibial deformities treated with either TSF (between 2014 and 2016) or Orthex (between 2017 and 2019) frames were included in a retrospective comparative study. Outcome measures were healing index, pin infection rate, regenerate quality and density, software residual rate, deformity correction accuracy, strut exchanges and quality of life (QoL).ResultsThe TSF group had 17 patients (18 frames) and the Orthex group had 21 patients (25 frames). The most common indications for tibial deformity correction were fibular hemimelia (14) and septic or traumatic growth arrest (8). The median time in frame was 230 days (TSF) versus 203 days (Orthex) (p= 0.06). The mean lengthening achieved was 54 mm (TSF) and 51 mm (Orthex) (p = 0.41). The healing index was 41 days/cm (TSF) versus 43 days/cm (Orthex) (p = 0.70). Pin site infections occurred more in the TSF cohort (40%) than in the Orthex cohort (18%) (p < 0.001). The regenerate in the Orthex group showed higher density at three months (p = 0.029) and was more homogenous (p = 0.023) at six months after frame application. Strut exchanges were less frequent with the Orthex system (p < 0.0001). QoL measures were similar in both cohorts (p = 0.92).ConclusionsThis is the first study to compare two hexapod designs in paediatric orthopaedics. The Orthex system showed superiority in regenerate quality and a significant reduction in pin site infection rates. Both systems delivered predictable and accurate limb deformity correction.Level of evidenceIII

Complications with Ilizarov ring fixator in open tibial fracture

Introduction: The management of infected nonunion of the tibia is challenging, particularly with segmental bone loss, multiple draining sinuses, poor soft tissue cover, osteopenia, adjacent joint stiffness, limb deformity, or multidrug-resistant polymicrobial infection. The Ilizarov method permits early rehabilitation and addresses all the problems such as non-union, infection, shortening, soft tissue loss and deformity simultaneously at single stage. Ilizarov ring fixation technique has its own advantages as well as associated complications. Methods: The present study was a prospective randomized open study in which aim was to evaluate Complications with Ilizarov ring fixator in open tibial fracture. The study was conducted in 30 skeletally mature patients in Department of Orthopaedics, SGRD University of health sciences, Amritsar from July 2017 to May 2019. The patients were assessed clinically based on history and physical examination. Radiological evaluation using plain antero-posterior and true lateral radiographs of the involved leg was done and evaluated by complications.Results: Mean age was 37.7 years. Out of 30 cases 24(80%) were male and 6(20%) were female. Right tibia was involved in 24 cases out of 30 cases. 29 cases had history of road side accident and 1 had history of fall from height. In present study following complications were noted, limp in 12 cases(40%), ankle stiffness in 7 cases(23.33%), pin site infection in 9 cases(30%), limb oedema in 7 cases(23.33%), knee stiffness in 3 cases(10%), loosening of pins in 2 cases(6.67%), deformity in 2 cases(6.67%) and refracture in 1 case(3.33%). There was no complication of neurovascular injury, malunion, breakage of wires, axial deviation or limb length discrepancyConclusion: Limp and Pin tract infection were the most common complications. Most complications can be prevented by diligent post-operative care. Complications if diagnosed early can be managed effectively. As such advantages of Ilizarov ring fixator outweigh the associated complications.

Intrarater Reliability of Digital Thermography in Detecting Pin Site Infection: A Proof of Concept Study

Aim and objectiveThe purpose of this study was to explore the capability and Intrarater reliability of thermography in detecting pin site infection.Materials and methodsThis is an explorative proof of concept study. Clinical assessment of pin sites was performed by one examiner with the Modified Gordon Pin Infection Classification from grade 0 to 6. Thermography of the pin sites was performed with a FLIR C3 camera. The analysis of the thermographic images was done in the software FLIR Tools. The maximum skin temperature around the pin site and the maximum temperature for the whole thermographic picture were measured. An Intrarater agreement was established and test-retests were performed with different camera angles.ResultsThirteen (four females, nine males) patients (age 9–72 years) were included. Indications for frames: Fracture (n=4), two deformity correction, one lengthening and six bone transport. Days from surgery to thermography ranged from 27 to 385 days. Overall, 231 pin sites were included. Eleven pin sites were diagnosed with early signs of infection: five grade 1, five grade 2 and one grade 3. Mean pin site temperature for each patient was calculated, varied between patients from 29.0°C to 35.4°C (mean 33.9°C). With 34°C as cut-off value for infection, sensitivity was 73%; specificity, 67%; positive predictive value, 10%; and negative predictive value, 98%. Intrarater agreement for thermography was ICC 0.85 (0.77–0.92). The temperature measured was influenced by the camera positioning in relation to the pin site with a variance of 0.2.ConclusionsMeasurements of pin site temperature using the hand-held FLIR C3 infrared camera was a reliable method and the temperature was related to infection grading.Clinical significanceThis study demonstrated that digital thermography with a hand-held camera might be used for monitoring the pin sites after operations to detect early infection.How to cite this articleRahbek O, Husum HC, Fridberg M, et al. Intrarater Reliability of Digital Thermography in Detecting Pin Site Infection: A Proof of Concept Study. Strategies Trauma Limb Reconstr 2021;16(1):1–7.

Streamlining Postoperative Care After Pediatric Supracondylar Humerus Fractures: Is Follow-up After Pin Removal Routinely Needed?

Closed reduction and percutaneous pinning is the standard of care for displaced supracondylar humerus fractures (SCHFs). Although the operative management of SCHFs has achieved good consensus with low complication rates, there remains a paucity of literature on postoperative management. We hypothesized that routine office visits after pin removal can safely be avoided in uncomplicated SCHFs without compromising patient care. A retrospective review was conducted to query the electronic medical record for SCHFs, treated with closed reduction and percutaneous pinning. Patients with complicated SCHFs were excluded. Patients were divided into 2 cohorts: follow-up (FU) and nonfollow-up (NFU), depending on the presence or absence of after-pin removal (APR) FU visits. Demographics, surgical variables, number of x-rays, referrals for physical therapy, total FU visits, complications, and clinical events after pin removal up to 3 months were compared. Subgroup analysis was performed according to Gartland fracture types. A total of 179 patients were included in the study, 111 in the FU group and 68 in the NFU group. There were no significant differences found in demographics between the 2 groups. There were no significant differences in complications and APR clinical events between 2 groups (P>0.05). An average of 1.98 additional x-rays were taken APR in FU group. None of the NFU group patients required physical therapy. Excluding patients with pin site infections, 15/108 (13.9%) of FU group patients had >1 APR visits. For operatively managed uncomplicated SCHFs, patients who do not have routinely scheduled FU APR have no greater incidence of clinical events APR than patients with a scheduled FU. With a detailed discussion including expectations, timeframe for resuming activities, home exercises, and reassurance of the ease of FU if desired, routine FU APR can be safely eliminated after uncomplicated SCHFs in order to streamline postoperative care. Level III.

Treatment of completely displaced distal radial fractures with a straight plaster or manipulation under anaesthesia.

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of 'off-ended' fractures in children with at least two years of potential growth remaining. A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires. Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections. Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J2021;103-B(5):902-907.

Outcomes of an aseptic technique for Kirschner wire percutaneous pinning in the hand and wrist.

Kirschner wires (K-wires) have been shown to effectively stabilize fractures of the hand and wrist, but are associated with high infection rates, which may limit its use. Previous literature has attributed the risk of infection to many different aspects of a fixation technique. However, we introduce an approach to percutaneous K-wire pinning to mitigate the risk of infection. Patients undergoing K-wire fixation procedures of the hand and wrist were retrospectively queried. All cases were performed under the same principles of our technique. None of the K-wires were buried, nor bent and were covered with betadine-soaked alcohol pads as pin site dressings. Pins were removed in an outpatient procedure room up to 12 weeks postoperatively and were then assessed for signs of superficial or deep infection. 90 patients were included in this study across a variety of K-wire fixation operations in the hand and wrist. No patients presented with any signs of infection or other complications necessitating postoperative antibiotics, early pin removal, or reoperation. The specific guidelines of our technique resulted in no cases of pin site infection, despite a largely underserved patient population. Our low incidence of infection was maintained without the use of prophylactic antibiotics and in patients with long periods of fixation. While the high infection rates in previous literature have often been associated with wires left exposed, the principles of our technique allow for K-wire fixations to be performed percutaneously without burying the wires. This may allow for improved cost and time efficiency, without compromising patient safety.

Reducing the incidence of pin site infection in hand surgery with the use of a protocol from Ilizarov.

Reported pin site infection rates in Kirschner wire fixation in the hand and wrist vary from 2% to 35%. In our unit we follow a strict pin site management protocol adapted from the Russian Ilizarov Scientific Centre. This study aims to identify if our current protocol reduces the incidence of pin site infection in hand and wrist surgery, and improves wire survival rates, to a level where exposed wires can be used safely. A retrospective review of 200 patients, treated with 369 percutaneous wires, in our hand surgery department over a 6-year period was carried out. Nine patients (4.5%) were diagnosed with a pin site infection with a wire survival rate of 99.5%.In our unit using our current protocol, results support the safe use of exposed wires with appropriate pin site care initiated in theatre. Adherence to this protocol allows wires to remain in-situ throughout treatment with minimal complications.Level of evidence: IV.

Treatment Options for Pin Site Infection during Kirschner Wires in Elective Forefoot Surgery

The Kirschner wires (K-wires) are stiff and straight wires made of smooth stainless steel. These are used in surgery to aid in repairing the process of a fractured bone. In forefoot elective surgeries, these pins are mostly used for fixation of the phalangeal or metatarsal area. These wires are usually either buried or exposed, The exposed wires do not require another operation to remove them and are generally preferred. In using the forefoot surgery history of a single surgeon which was taken for 3 years. The purpose of this study is to evaluate the occurrence of infections following elective surgeries of the forefoot that were fixed using k-pins and to indicate an effective treatment option for resolving the infection. The inclusion criteria set for this study was to remove any patient having any disease except for diabetes. Moreover, the age limit was set to be 18 - 44, making a final sample of 50 people, prescribed prophylactic antibiotics or early removal of k-pins, where necessary. The researcher recorded demographic and biological data from the patients such as age, BMI, and smoking status were recorded. The researcher conducted a Univariate analysis via a Chi-square test. 50 Patients (82 K-wires) were analyzed. Results showed that surgery type, BMI, and smoking were three variables that affect the infection growth significantly while diabetes and type of cleaning disinfectant had marginal effects. Further study is required to clarify the best treatments in this area, as the treatment option antibiotics have nearly similar results.

A Staged Approach to Combined Extra-articular Limb Deformity Correction and Total Ankle Arthroplasty for End-Stage Ankle Arthritis.

Patients presenting with end-stage ankle osteoarthritis (OA) in the setting of a concomitant extra-articular limb deformity pose a challenging problem that has not yet been described in the literature. We describe a case series of patients treated with external and internal fixation techniques followed by total ankle arthroplasty (TAA) in a staged approach to treat this complex presentation. Eight patients with limb deformity and end-stage ankle OA who underwent staged deformity correction and TAA from 2016 to 2019 at our institution were retrospectively identified. Average age was 58.5 (range, 49-68) years, with an average follow-up of 2.6 (range, 0.8-4.2) years. All patients underwent limb reconstruction with either tibial osteotomy with a circular frame (n=6) or intramedullary nail (n=2). Limb deformities consisted of the following: posttraumatic tibial malunion (2), limb length discrepancy (1), acquired tibial deformity (1), genu varum (2), or genu valgum (2). Radiographic parameters were assessed pre- and postoperatively on 51-inch standing and ankle radiographs: limb length discrepancy (LLD), genu varum/valgum deformity, recurvatum deformity, mechanical axis deviation, medial proximal tibial angle, lateral distal tibial angle, anterior distal tibial angle, and tibiotalar alignment. Pre- and postoperative patient-reported outcomes were assessed using 2 metrics, the Limb Deformity-Scoliosis Research Society (LD-SRS) and Patient-Reported Outcomes Measurement Information System (PROMIS) scores (Physical Function, Pain Intensity, Pain Interference, Global Physical Function, and Global Mental Function). Following staged limb deformity correction and TAA, all patients achieved correction of LLD and angular deformities of the lower limb, along with restoration of normal alignment of the ankle joint. There was significant mean improvement in all patient-reported LD-SRS and PROMIS domains, except for LD-SRS mental health. LD-SRS function improved from 2.6 (±0.7) to 4.6 (±0.2), P = .008; pain improved from 2.9 (±0.9) to 4.8 (±0.2), P = .012; self-image improved from 2.9 (±0.4) to 4.7 (±0.3), P < .001; and total LD-SRS improved from 3.3 (±0.4) to 4.8 (±0.2), P = .002. Average satisfaction was 4.9 (±0.3). PROMIS physical function improved from 32.3 (±6.8) to 51.3 (±5.3), P = .008; pain interference improved from 66.0 (±9.1) to 41.3 (±6.2), P = .004; pain intensity improved from 60.0 (±13.3) to 33.1 (±5.3), P = .007; global physical health improved from 39.3 (±6.8) to 60.7 (±5.1), P = .002; global mental health improved from 54.8 (±5.9) to 65.6 (±2.8), P = .007. There was one incidence of pin site infection and one reoperation. Deformity correction with either external frame or intramedullary nail fixation followed by TAA in a staged approach was a viable surgical option in the treatment of end-stage ankle OA with concurrent extra-articular limb deformity. This unique approach was capable of achieving deformity correction with improved patient-reported outcomes, minimal complications, and good patient satisfaction. Level IV, retrospective case series.

Comparison of K-wire versus screw fixation after open reduction of transitional (Tillaux and triplane) distal tibia fractures.

Our study aimed to compare the clinical and radiographic outcomes of transitional distal tibia fractures treated with K-wire fixation versus screw fixation after open reduction. A retrospective study was performed on all displaced transitional distal tibia fractures that underwent operative fixation. Following open reduction, surgical fixation was performed using either percutaneously inserted 2.0 mm K-wires, or 4.0 mm partially-threaded cannulated cancellous screws. Clinical and radiographic outcomes between the two groups were assessed using the modified Weber score. Other outcome measures assessed were surgical time, casting duration, follow-up duration and duration before return-to-sports. We recruited 49 patients with transitional distal tibia fractures requiring open reduction and surgical fixation. There were 18 patients in the K-wiring group (KWG), and 31 patients in the screw fixation group (SFG). All patients in both groups had excellent clinical and radiographic outcome based on the modified Weber's scoring, full radiological healing, and no residual displacement upon final follow up. The KWG had significantly shorter surgical time (41.0 min versus 75.1 min, P < 0.0001) and shorter follow-up duration needed before discharge (5.4 months versus 8.7 months, P = 0.024). However, they required a longer post-operative casting duration (7.3 weeks versus 5.3 weeks, P = 0.006). No significant difference was found for the duration before return to sports between both groups. Complications were few in this study group. Superficial pin site infection was noted in one patient in the KWG, and valgus deformity of the ankle was noted in one patient in the SFG. In our study, surgical treatment of transitional distal tibia fractures demonstrated equally excellent outcomes when treated by open reduction with either K-wire or cannulated screw fixation. Level of evidence: III.

Exact change point detection with improved power in small-sample binomial sequences.

To detect a change in the probability of a sequence of independent binomial random variables, a variety of asymptotic and exact testing procedures have been proposed. Whenever the sample size or the event rate is small, asymptotic approximations of maximally selected test statistics have been shown to be inaccurate. Although exact methods control the type I error rate, they can be overly conservative due to the discreteness of the test statistics in these situations. We extend approaches by Worsley and Halpern to develop a test that is less discrete to increase the power. Building on ideas from binary segmentation, the proposed test utilizes unused information in the binomial sequences to add a new ordering to test statistics that are of equal value. The exact distributions are derived under side conditions that arise in hypothetical segmentation steps and do not depend on the type of test statistic used (e.g., log likelihood ratio, cumulative sum, or Fisher's exact test). Using the proposed exact segmentation procedure, we construct a change point test and prove that it controls the type-I-error rate at any given nominal level. Furthermore, we prove that the new test is uniformly at least as powerful as Worsley's exact test. In a Monte Carlo simulation study, the gain in power can be remarkable, especially in scenarios with small sample size. Giving a clinical database example about pin site infections and an example assessing publication bias in neuropsychiatric drug research, we demonstrate the wide-ranging applicability of thetest.

The correction of Ollier’s disease induced extremities deformity using distraction osteogenesis by intralesional osteotomy in children patients: a cases series study

Abstract Objective the present study was aimed at evaluating the effect of distraction osteogenesis using monolateral external fixators by intralesional osteotomy in children patients of Ollier’s disease. Methods 2 male and 4 female children patients of Ollier’s disease with an average age of 7.8 years received treatment between 2008 and 2016 were included in the study, and 1 ulna, 3 femurs, 4 tibias, 1 radius, and 1 humerus were involved. The Ollier’s disease induced extremities’ deformities were corrected by distraction osteogenesis using monolateral external fixator (LRS), and the intralesional osteotomy was conducted. The original length and the distracted length, the severity of angular deformity, and the mechanical axis deviation of the affected bones were measured. The initial and ending dates of bone lengthening, as well as the installation date and removal date of frames were recorded. The distraction index (DI) and the external fixator index (EFI) were calculated. Postoperative follow-up efficacy was assessed by regular radiographic examinations. Results after treatment in all cases the length discrepancy of the affected limbs with contralateral side were less than 3 ​cm, and the angular deformities were corrected. The mean lengthened bones were 52.8 ​mm ​± ​14.9 ​mm, the average DI was 12.9 days/cm ± 1.6 days/cm, and the mean EFI was 50.5 days/cm ± 12.5 days/cm. Pain as the complication were found in all cases and was managed by analgesics. Pin site infection were reported in one case and was cured by wound care and normal use of antibiotics. One case was found to have delayed bone healing but the volume and size of the affected bone was recovered to normal about 3 months after removal of the frames. Conclusion this study revealed that distraction is beneficial for the conversion of enchondromal bone into normal bone, and intralesional osteotomy is safe and supposed to protect the remaining healthy bone segment. Taken together, distraction osteogenesis using monolateral external fixators is effective in managing the length and angular deformity of extremities caused by Ollier’s disease in children patients. The translational potential of this article: To date, no consensus for the correction of extremities deformity induced by the Ollier’s disease has been established. This study found that distraction as a treatment could promote conversion of enchondromal bone into normal bone, and intralesional osteotomy is safe and beneficial for saving the limited healthy bone on the whole bone segment from being iatrogenically damaged. Such findings will provide some references for the treatments of extremities.

Percutaneous Pinning of Fractures of the Surgical Neck of the Humerus in Children and Adolescents

Background: Proximal humerus fractures occur in children of all ages, from newborn babies to teenagers, accounting for about 2% of all childhood fractures, with the highest occurrence among the ages of 11 and 15. Aim of the work: To review and evaluate the outcomes of operative procedure of surgical neck-humerus fractures in children and adolescents using closed reductions and percutaneous pinning. Patients and methods: 20 sufferers enrolled with Proximal Humeral Fracture Displaced in the Orthopedic Surgery Department of the AL Hussein Hospital of the Al-Azhar University Medical Faculty from January 2018 to September 2019 were involved in the current research. Closed reductions and percutaneous Kirscher wires (K-wires) have been used to treat the patients surgically. Ten patients treated with threaded K-wires and other patients with unthreaded K-wires. All patients were examined in the outpatient department using postoperative x-rays to assess healing time and the postoperative range of motion. Results: Regarding complications, group A, 10 (100.0%) of the patients had no complications. Group B 8 (80.0%) of the patients had no complications, 2 (20.0%) of the patients showed a pin-site infection and no malunion was found. Regarding the healing time, 4 (40.0%) of the patients healed in the 1st month and 6 (60.0) of the patients in the 2nd month in both groups. Conclusion: Proximal humeral fractures may be managed using percutaneous pinning, which provides effective reduction and adequate temporary stabilization. This treatment modality was not correlated with any significant complications, like deep infection, avascular necrosis, or neurovascular deficiency.

Augmentation of Internal Fixation With Multiplanar External Fixator in High Risk Hind Foot Fusion Patients

Category:Hindfoot; Ankle; DiabetesIntroduction/Purpose:Achieving adequate fixation is a critical component for successful fusion. Internal fixation can be compromised in the setting of poor bone quality due to open trauma, infection, osteoporosis, neuropathic arthropathy resulting in published ankle non-union rates of 38% in high risk patients. These failures may be magnified by weightbearing non-compliance.While the use of multiplanar external fixation (MEF) alone can be utilized - it can often require an extended period of time within the frame (mean 18 weeks, range 9-28 weeks) and complications such as pin site infections. We hypothesized that hybrid fixation, MEF in conjunction with internal fixation, will provide adequate stability elevating the fusion rates in complex fusion cases while allowing early weight bearing and reduces the MEF time and infection rate.Methods:Eleven patients were identified that demonstrate significant risk factors for a successful fusion (infection, charcot, neuropathy, smoking, history of non-union) that were treated with internal fixation augmented with MEF. Patients with an active infection underwent surgical irrigation and debridement, placement of an antibiotic spacer and a course of intravenous antibiotics six weeks prior to placement of internal fixation. In these cases, MEF was placed at the time of surgical irrigation and debridement to allow for stability. In those patient’s without an active fixation, both the internal fixation and MEF were placed at the same time. Internal fixation construct was based on surgeon preference. Patients were allowed to transfer weight bear at the time of surgery and could advance as tolerated after 2 weeks. CT was utilized to assess fusion. Outcomes measured were fusion rate and occurrence of internal fixation infection.Results:The mean age of patients was 55 (range 26-75), eight patients had diabetes, three were current smokers, two were former smokers, two patients had open trauma, one patient had peripheral neuropathy and one patient had a history of a non- union with known non-compliance. Six patients had an active infection and underwent irrigation and debridement, placement of antibiotic spacer and MEF during antibiotic treatment. Seven patients underwent intramedullary nail fixation, three patients underwent plate and screw constructs and one patient underwent screw only fixation. CT demonstrated fusion in all patients (100%). The mean time for external fixation was 72 days (range 41-111). There were no cases of infected internal fixation.Conclusion:The findings of the current study suggest high rates of hind foot fusion with the use of internal fixation augmented with MEF in a complex patient group with identified high non-union risk factors. Using internal fixation, patients time in the frame is much reduced than published studies evaluating MEF alone for fusion fixation. MEF did not result in any cases of infected internal fixation. Patients with hybrid fixation also benefit from early weight bearing. We emphasize the importance of good surgical technique and infection management using this technique.

Study on functional outcome of non-union of tibial fractures managed by Ilizarov technique

Background: Non-united and infected fractures of tibia are challenging to orthopedicians. These cases are best managed by Ilizarov technique. The present study was done to assess outcome in these cases. Methods: The present observational study included 19 cases of non-united fracture of tibia. Clinical details and findings of outcomes were noted.Results: 57.9% of the cases had excellent outcome, 26.3% showed good result while poor result was seen in 5.3%. Functional outcome assessment showed that 68.4% had minimal disability, 15.8% had moderate disability while 5.3% had severe disability. Conclusion: Ilizarov technique has good outcome in non-united fractures of tibia. Pin site infection of common but can be managed adequately.

Minimally Invasive Correction for Symptomatic, Fixed Curly Toe Deformity

Category:Lesser ToesIntroduction/Purpose:Curly toe deformity is a relatively common deformity that generally occurs at the 4th and 5th proximal and/or middle phalanges but rarely presents with symptoms. Although numerous open operative techniques have been introduced, there is no established treatment yet. We report the results of minimally invasive correction for symptomatic, fixed curly toe deformity.Methods:Between 2016 and 2018, 25 consecutive percutaneous dorsolateral closing wedge-shaped osteotomies with Shannon burrs at the proximal and/or middle phalanx were performed. We assessed the postoperative clinical and radiological changes at a mean of 22.51 months of follow-up.Results:The locations of osteotomy were at the middle phalanx in 10 cases, proximal phalanx in 13 cases, and both in one case. The mean amount of corrections of varus inclination and shortening were 16.54° and 2.24 mm, respectively. The Foot and Ankle Ability Measure Activities of Daily Living scores significantly improved from 59.09 preoperatively to 74.55 at the last follow-up. There was one case of pin site infection and one case of incision site numbness due to digital nerve injury.Conclusion:Minimally invasive dorsolateral closing wedge-shape osteotomy is a simple, safe, and effective correction for symptomatic, fixed curly toe deformity.

Tibial cortex transverse distraction in treating diabetic foot ulcers: what are we concerned about?

ObjectiveTo assess the effect and complications of tibial cortex transverse distraction (TCTD) in treating diabetic foot ulcers and draw attention to the concerning issues of this procedure.MethodsThis case series included 30 patients with diabetic foot ulcers from four centers. The ulcers had not healed after >6 months. The patients then underwent TCTD combined with other procedures (debridement, vacuum sealing drainage, and others). All patients were followed up for >12 months postoperatively.ResultsThree patients underwent amputation because of aggravated infections. Tibial fractures occurred in two patients after surgery, and the fractures healed after 3 months of plaster fixation. Pin-site infections occurred in five patients, and the infected pin site healed after the patients underwent pin removal and dressing changes for 3.3 ± 2.1 weeks. The ulcers of the other 27 patients healed by 13.5 ± 8.2 weeks postoperatively, and the postoperative visual analog scale score was significantly lower than the preoperative score.ConclusionsAlthough TCTD can be performed as an adjuvant treatment for diabetic foot ulcers, the effect should not be exaggerated and the complications should not be ignored. Further research is needed to propose a standard operative procedure and avoid postoperative complications such as tibial fractures.

Correction of Bowleg Deformity in Achondroplasia through Combined Bony Realignment and Lateral Collateral Ligament Tightening.

ABSTRACTIntroductionAchondroplasia is one of the most common osteochondrodysplasias with an incidence of 1 in 26,000 live births. Bowing of lower limbs can cause significant morbidity in this population. The use of the Ilizarov external fixator to tighten collateral ligaments of the knee in children has not been reported in the literature. We report the technique and early results of lateral collateral ligament (LCL) tightening with correction of genu varum in children with achondroplasia.Materials and methodsA retrospective review of children with achondroplasia presenting with bowleg deformity who were treated by corrective osteotomy and LCL tightening was conducted. Between 1998 and 2003, 12 patients (24 limb segments) underwent this procedure and were included in the study. All patients had grade III LCL laxity preoperatively. Pre- and postoperative anteroposterior standing mechanical axis radiographs were evaluated. The final outcome was graded using the grading system of Paley et al.ResultsAll patients had bilateral corrections. The Ilizarov external fixator was used in 10 patients and the Orthofix limb reconstruction system in 2 patients. The bony realignment was achieved through monofocal or bifocal tibial osteotomies. The LCL was tightened in all limb segments using the Paley’s type II strategy. The final result was graded as excellent in 20 limb segments and good in 4 limb segments. One patient developed transient common peroneal nerve palsy, four developed grade II pin site infections, and there was premature consolidation of the tibial regenerate in one patient.How to cite this articleKurian BT, Belthur MV, Jones S, et al. Correction of Bowleg Deformity in Achondroplasia through Combined Bony Realignment and Lateral Collateral Ligament Tightening. Strategies Trauma Limb Reconstr 2019;14(3):132–138.

Displaced Physeal and Metaphyseal Fractures of Distal Radius in Children. Can Wire Fixation Achieve Better Outcome at Skeletal Maturity than Cast Alone?

Introduction:Redisplacement following fracture reduction is a known sequela during the casting period in children treated for distal radius fracture. Kirschner wire pinning can be alternatively used to maintain the reduction during fracture healing. This study was conducted to compare the outcomes at skeletal maturity of distal radius fractures in children treated with a cast alone or together with a Kirschner wire transfixation.Material and Methods:This was a retrospective study involving 57 children with metaphyseal and physeal fractures of the distal radius. There were 30 patients with metaphyseal fractures, 19 were casted, and 11 were wire transfixed. There were 27 patients with physeal fractures, 19 were treated with a cast alone, and the remaining eight underwent pinning with Kirschner wires. All were evaluated clinically, and radiologically, and their overall outcome assessed according to the scoring system, at or after skeletal maturity, at the mean follow-up of 6.5 years (3.0 to 9.0 years).Results:In the metaphysis group, patients treated with wire fixation had a restriction in wrist palmar flexion (p=0.04) compared with patients treated with a cast. There was no radiological difference between cast and wire fixation in the metaphysis group. In the physis group, restriction of motion was found in both dorsiflexion (p=0.04) and palmar flexion (p=0.01) in patients treated with wire fixation. There was a statistically significant difference in radial inclination (p=0.01) and dorsal tilt (p=0.03) between cast and wire fixation in physis group with a more increased radial inclination in wire fixation and a more dorsal tilt in patients treated with a cast. All patients were pain-free except one (5.3%) in the physis group who had only mild pain. Overall outcomes at skeletal maturity were excellent and good in all patients. Grip strength showed no statistical difference in all groups. Complications of wire fixation included radial physeal arrests, pin site infection and numbness.Conclusion:Cast and wire fixation showed excellent and good outcomes at skeletal maturity in children with previous distal radius fracture involving both metaphysis and physis. We would recommend that children who are still having at least two years of growth remaining be treated with a cast alone following a reduction unless there is a persistent unacceptable reduction warranting a wire fixation. The site of the fracture and the type of treatment have no influence on the grip strength at skeletal maturity.

Comparison of Three Different Approaches in Pediatric Gartland Type 3 Supracondylar Humerus Fractures Treated With Cross-Pinning.

IntroductionAlthough closed reduction and percutaneous pinning are the accepted treatment approaches in pediatric humerus supracondylar fractures, the treatment approach in fractures without closed reduction remains unclear. This study compared the results of three different cross-pinning treatment methods.Materials and methodsA total of 62 patients (1-13 years old) who were operated for Gartland type 3 humerus supracondylar fractures between 2007 and 2016 were evaluated retrospectively. Of the patients evaluated, 24 patients had closed reduction, 25 patients had direct reduction from the medial, and 13 patients had direct reduction from the lateral and cross-pinning. The functional and cosmetic results of the patients were evaluated according to Flynn's criteria. In addition, the Baumann angle, lateral capitellohumeral angle (LCHA), and postoperative complications were compared among groups.ResultsBoth functional and cosmetic results and the Bauman and LCHA angles were similar in all three groups. In patients with open reduction, the control duration was significantly longer than that in patients with closed reduction, and this difference was due to a recent increase in the surgeons' preference for closed surgery. Two patients underwent pin site infection and two patients developed nerve palsy. Only the first patient who developed ulnar nerve palsy recovered during follow-up. Secondary surgery was applied to the other patient who developed brachial artery occlusion with ulnar and median nerve paralysis, and they recovered during follow-up. Three patients who underwent open surgery from the medial, along with the two patients who had undergone open surgery, developed pinhole infection. These patients were subsequently recovered with antibiotherapy without further complications. A patient who underwent open lateral surgery developed compartment syndrome and fasciotomy was performed.ConclusionClosed reduction and percutaneous pinning are generally accepted approaches in the treatment of pediatric humerus supracondylar type 3 fractures. However, in cases where closed reduction cannot be achieved, pinning with the medial approach and taking the ulnar nerve and medial colon is a reliable method to avoid both ulnar nerve injury and cubitus varus.