Transfixion Pins Research Articles

Clinical application of a self-designed controllable and portable double-pin traction device on calf

Objective To explore the clinical application of our self-designed controllable and portable double-pin traction device on calf in the treatment of tibiofibular fractures. Methods Our controllable and portable double-pin traction device on calf was designed to fulfill the purpose of traction and address current problems in traction for tibiofibular fractures. This device is composed of double-hole connectors, nuts of various specifications, traction pin sleeves, 2 transfixion pins and 2 threaded rods for traction. The transfixion pins are fixed at conventional traction positions. The threaded rods for traction are paralleled to the long axis of lower limb and located on both sides of the calf. Bone ends can be distracted by adjusting the nut of M8 width and the speed of pulling can be controlled. This device can be used not only for rapid traction during surgery but also for slow traction preoperatively. It was applied in the 30 patients with tibiofibular fracture who had been treated at De-partment of Orthopaedic Surgery, 920th Hospital of Joint Logistic Support Force from January to December 2017. Their radiographs were taken before traction and at 3 and 6 days after traction to observe the changes in over-lapped fracture ends and fracture gap. The lengths of distraction were measured. After limited open reduction, fracture gaps and tensions of surrounding soft-tissues were observed. Results Their radiographs before and after traction demonstrated that their overlapped and displaced fracture ends were distracted more or less. The length of distraction ranged from 7.2 mm to 45.8 mm (mean, 23.1 mm); it was 45 mm in one. Their radiographs showed that regular traction for 6 days was more obvious than that for 3 days. The limited open reduction revealed that the gap between fracture ends was expanded, the soft-tissue tension effectively relaxed, the overlapping of fracture ends diminished, and the dissection of surrounding soft-tissue and periosteum decreased, leading to less difficulty in reduction. In fractures near the joint or involving the articular surface, the joint space was expanded. The 30 patients were followed up for one to 16 months (mean, 5.8 months). No such complications as pin site infection, traction fracture or osteomyelitis was observed. Conclusion Our self-designed controllable and portable double-pin traction device on calf is effective and advantageous, because it is simple, easy, light in weight, and controllable for traction speed. Key words: Tibial fractures; Fibular fractures; External fixators; Bone nail; Traction

Fixation of Soft Tissue to Bone: Techniques and Fundamentals.

A myriad of orthopaedic injuries require surgical fixation of torn connective tissue to an osseous insertion site with either direct repair or reconstruction with a soft-tissue graft. Numerous factors influence the strength of a soft-tissue-to-bone fixation construct, including tissue quality, implant strength, contact area and pressure, and tensioning. Each fixation technique differs with respect to biologic integration, biomechanical stability, and failure mechanism. Fixation methods may or may not require an implant, such as interference screws, staples, internal buttons, transfixion pins, or suture anchors. Understanding the optimal method of soft-tissue fixation for a given scenario is crucial for successful repair or reconstruction.

Avoidance of external fixation pin induced rotational stiffness in the forearm; a cadaver study of soft tissue displacement relative to the varying position of radius and ulna fixation.

Introduction: Stiffness of forearm rotation secondary to transfixion pin sites is a frequent complication of external fixation. Conventional surgical atlases do not consider the effect of rotation on skin displacement and thus do not provide a comprehensive answer. We asked: (1) in what locations in the forearm is soft tissue displacement relative to the ulna and radius least during rotation; (2) in what positions are major neurovascular structures absent; and (3) what maximal range of rotation can be expected in forearm external fixation. Methods: Thirty-four matched cadaver arms were used to assess displacement of soft tissues at 10°, 30° and 70° of pronation and supination in relation to a testing frame. The results of these were correlated with positions in which neurovascular structures were absent and deemed insertional “Reference Positions (RP)”. Results: Expected range of rotation in diaphyseal fractures of different levels of both forearm bones was found with RP for the ulna occurring along the length of the forearm. Reference positions for the radius which provide full forearm rotation are situated only in the distal third; positions which provide partial rotation are located in the proximal and middle third. Discussion: Full range of rotation may be maintained in the case of isolated external fixation of ulnar diaphyseal fractures. In isolated external fixation of the radius a reduced range of forearm rotation may be expected.

Treatment of renal calculi in pediatric patients with minimally invasive percutaneous nephrolithotomy

Objective To evaluate the technique and efficacy of minimally invasive percutaneous nephrolithotomy (MPCNL) for renal calculi in pediatric patients. Methods From April 2009 to December 2009, 12 pediatric patients (8 males and 4 females) with renal calculi were treated by MPCNL. The age ranged from 18 to 53 months (mean 32 months). All the 12 cases were diagnosed by KUB+IVU, ultrasonography and CT. The stone had average diameter of 1. 3 cm (ranged from 1. 0 to 1. 8 cm). Seven cases had simple renal pelvis stone and 5 cases had multiple renal calyx stone. UPJ stricture was not found in this series. General anaesthesia was applied. Renal transfixion pin was punctured to select renal calices by monitoring with ultrasonography. 12 - 16 F percutaneous renal access was successfully established in all cases and calculi were fragmented by pneumatic lithotripter. Results The average operative time of MPCNL was 74 min. Phase Ⅰ lithotripsy was underwent in all patients. The phase Ⅰ stone-free rate was 67%(8/12). One cases accepted second MPCNL. The calculus clearance rate reached 75%(9/12). Three cases had residual calculi ranged from 2 to 4 mm. One of whom had ESWL 2 weeks postoperatively. All cases were followed up for 1 - 7 months, all cases were in stone free status. Conclusion Regarding the advantages of less bleeding, high clearance rate, and shorter hospital stay, MPCNL is an effective and safe treatment option for renal calculi in pediatric patients. Key words: Kidney calculi; Nephrostomy, percutaneous

Closed reduction and levering manipulation in vertebroplasty

Objective To discuss the effects of closed reduction and levering manipulation on ver-tebral height restoration and kyphosis correction in vertebroplasty for osteoporotic compression fractures. Methods From January 2005 to June 2007, a total of 38 patients with osteoporotic vertebral compression fractures were treated with vertebroplasty. In closed reduction, a transfixion pin was used to lever the collapsed vertebral endplate through the pedicle. Before and after surgery, pain relief and functional improvement were evaluated using a visual analogue scale (VAS) and the Oswestry' s disability index (ODI). Changes in ver-tebral height and kyphotic angle and distribution of bone cement in the vertebral body were observed by Lee's method. Results All patients were followed up for 6 to 24 (average, 13.4) months. The average VSA scores were reduced from preoperative 8.6±2.3 to postoperative 3.8±2.6. The average ODI scores reduced from preoperative 64.8% to postoperative 48.7%. The differences were of statistical significance. The average increase in vertebral body height was 5.8 mm anteriorly, 6.6 mm centrally, and 1.0 mm posteriorly. The mean reduction in the kyphosis angle was 9.7 degrees. The percentages of restoration of vertebral height were 54.6% at the anterior border, 58.1% at the center, and 46.5% at the posterior border. The differences were of sta-tistical significance between preoperation and postoperation. Conclusion Closed reduction and levering manipulation is effective in vertebroplasty for osteoporotie vertebral compression fractures. Key words: Osteoporosis; Spinal fractures; Vertebroplasty; Closed reduction

The “Terrible Triad” of the Elbow

The “Terrible Triad” of the Elbow

Soft tissue injuries with the use of safe corridors for transfixion wire placement during external fixation of distal tibia fractures: an anatomic study.

To determine which soft tissue structures are at risk and when joint violation can occur during small wire placement for hybrid external fixation of distal tibial fractures while adhering to published guidelines. Cadaver anatomic experiment. University orthopaedic program. SUJBECTS: Five embalmed cadavers. Placement of small wire transfixion pins in the distal tibia. Dissection and measurements. Four orthopaedic surgeons were shown diagrams that have been widely accepted as allowing for placement of transfixion pins in the distal tibia through safe corridors. Each of the orthopaedic surgeons was then asked to place two transfixion pins into each of five cadaver legs in a position that would provide stable external fixation of the metaphysis to the diaphysis with a circular fixator (forty pins total) for a distal tibial fracture within five centimeters of the plafond. The specimens were dissected, and pins impaling neurovascular structures, tendons, or the ankle capsule were recorded. The superior capsular synovial reflections were measured from the anterior joint line and the tip of the medial malleolus. These measurements were also performed on arthrograms of two extremities before their dissection. Fifty-five percent of the pins placed impaled at least one tendon that crosses the ankle joint. Neurovascular structures that were impaled included the saphenous vein (+/-10.5 percent) and the superficial peroneal nerve (+/-7.5 percent). One pin violated the superior capsular synovial reflection, which was an average of thirty-two millimeters (+/-1.58 millimeters) from the tip of the medial malleolus and twenty-one millimeters (+/-1.63 millimeters) from the anteromedial joint line. This study shows that tendons and neurovascular structures above the ankle are at risk during small transfixion pin placement, even when using safe corridors. Pins placed within two centimeters of the anterior joint line or three centimeters from the medial malleolus may be intracapsular.

Ilizarov hybrid external fixation for fractures of the distal radius: Part I. Feasibility of transfixion wire placement.

The advantages of Ilizarov external fixation, allowing early motion of adjacent joints during fixation of periarticular fractures, have not yet been applied to distal radius fractures. A magnetic resonance imaging study of 10 normal volunteers evaluated the safety of passing percutaneous transfixion pins across the distal radius in 3 forearm positions. Even in the optimal forearm position, the safe zones between the transfixion pin, vessel, nerve, or tendon was small, suggesting that open placement would be required. A cadaver study in 8 specimens demonstrated that the pins could be placed with an open technique using an aiming device and that the pins could be placed without limiting forearm rotation. The proximity of vital structures to transfixion pins dictates open placement to safely apply Ilizarov fixation to distal radius fractures.

Les fixateurs externes

The authors will highlight the advantages of external fixation in the treatment of open fractures of the leg.The first is stabilisation of the fracture site. It is obtained by using transfixion pins in multiple planes (the ideal being 2 planes between 60 and 90°). With flexible pins, stability is obtained by using multiple pins and fixing them to rings under tension.The second advantage is to allow secondary reduction and encourage consolidation by compression, distraction or dynamisation (according to Ilizarov).The third advantage is to leave the adjacent joint free which is sometimes difficult with epiphyseal and metaphyseal fractures even with the newer fixators. Preserving muscle function is sometimes difficult and depends on pin position.The fourth advantage is to be able to obtain skin cover although the use of flaps may be compromised by the pin tracks.The ideal therefore in open fractures of the leg is to fix the fracture site by pins at a distance from the fracture, to obtain skin cover after the fracture has been stabilised and then complete the assembly of the fixator.

Closed reduction and percutaneous stabilization of tibial plateau fractures.

Twenty-eight patients with tibial plateau fractures treated by closed reduction using forceful traction and percutaneous stabilization with pins or screws were reviewed. For six bicondylar fractures, transfixion pins with an external fixation device were used. In six cases, an arthroscopic exam was also done. For 21 patients, external support was used postoperatively. Twenty-one patients were followed an average of 26 months. All fractures healed. Functional ratings were: 14 excellent, 6 good, and 1 poor. Radiographic ratings were: 11 excellent, 9 good, and 1 fair. For fractures with large fragments without excessive comminution or severe central depression, this technique yields good results with minimal surgical morbidity.

Intramedullary nailing of the tibia without a fracture table: the transfixion pin distractor technique.

A series of 44 fractures of the tibia requiring operative stabilization were treated using an intraoperative external transfixion pin frame to correct angular deformity and maintain length in preparation for intramedullary (IM) nailing, eliminating the need for a fracture table. The technique requires a radiolucent operating room table; the injured extremity is draped free. A transfixion pin is inserted in the os calcis. Rotational deformity is manually corrected. Using fluoroscopic control, a second transfixion pin is inserted at a location just distal and parallel to the proximal tibial articular surface, paralleling the horizontal plane of the first pin. The transfixion pins are connected with carbon fiber rods, creating a rectangular frame. Manual fracture reduction is followed by "fine tuning" with compressor/distractor clamps as needed. Alternatively, for added reduction force, the carbon fiber rod on the concave side of the angular deformity may be replaced with the AO/ASIF universal distractor. IM nailing is then performed in the usual fashion. In this series, an acceptable reduction was obtained in all cases. This technique shortens setup time, provides complete access to the distal part of the tibia, and allows free manipulation of the limb, thereby facilitating nail insertion and placement of distal locking screws. Use of medial and lateral bars prevents the angular deformity often created or exacerbated with the use of the universal distractor alone. This technique is recommended for IM nailing of all fractures of the tibia that would otherwise require use of the fracture table or universal distractor.

Closed intramedullary nailing complicated by breakage of plastic medullary tube

Vascular complications associated with the use of any transfixing external fixator are usually attributed to improper pin insertion technique and imprecise familiarity with cross-sectional anatomy. In the case of the Ilizarov fixator these include perforation of artery, vein, or both (Behrens, 1989; Paley, 1990, 1991a). Transfixion pin configurations utilized by ring fixators predispose to vascular injury as the pins cannot pass through completely ‘safe corridors’ while maintaining optimal stability (Behrens, 1989). In the thigh, efforts to avoid damage to major neurovascular structures by using half-pins instead of transfixing pins, have led to the development of a ‘hybrid’ configuration. This combines the axially stiffer fixation of the Hoffman-type system proximally with the elasticity of the Ilizarov radial fixator distally. The unique biomechanical property of the Ilizarov fixator permits intermittent closure of the fracture gap. This takes place through a predominantly axial telescopic motion on loading, and is due to the large deflection of the thin wires (Chao and Aro, 1989). In the hybrid configuration, cyclic loading at the fracture gap is attributable mainly to motion of the distal construct because the proximal element is relatively rigid (Paley, 199Ib). Although a late presentation of asymptomatic arterial damage at the time of wire insertion cannot be excluded, in our patient late vascular erosion should be considered. This has previously been ascribed to pulsation of an artery against an adjacent wire (Paley, 1990, 1991b). We further propose that the axial micromovement of a transfixion wire against an arterial wall may be an aggravating factor in progressive arterial erosion leading to late pseudoaneurysm formation.

Anatomic basis for implantation of the Ilizarov system in the leg

Ilizarov's method of implanting an external circular fixator requires the placement of at least 8 transfixion pins. The neurovascular hazards and the need to leave the posterior and lateral compartments free motivated this study, based on serial radiographic sections after injection of the entire arterial system. Two reference pin-planes were determined, 1 posterolateral and 1 lateromedial. The sites of insertion of the pins rely on classical radiographs of the bones of the leg. The addition of beaded pins must be made on a realigned and stabilized limb. The imprecision of aim due to the bone structure and the shape of the pin leads to the definition of forbidden zones where any transfixion is dangerous. The concept of a neurovascular pyramid with its base at the distal metaphysis and of a periosseous tendinous circlet at that level implies a search for a compromise between the stability of the assembly and the dangers of the method.

Complications of external fixation of open fractures of the tibia

Forty-two cases of open fractures of the tibia treated by external fixation are presented. Forty-three per cent of patients developed sepsis around one or more pins. Pin track sepsis occurred in 78 per cent of cases involving transfixion pins through muscle and bone but in only 17 per cent of cases using transcutaneous half-pins. Malalignment of more than 5 ° in any plane was seen in 38 per cent of cases, almost half of which increased in plaster after removal of the fixator.

Unstable fractures of the distal end of the radius (Transfixion pins and a cast)

Forty-five unstable fractures of the distal end of the radius were treated with transfixion pins and plaster cast. Thirty-seven patients were personally reviewed and an analysis of the results are presented in this paper. Scheck's point system was used to grade functional results; 81.1 per cent were classified as satisfactory (excellent and good) and 18.9 per cent unsatisfactory (poor) group.

Considerations in Reducing the Infection Rate in Open Tibial Fractures

During the period from 1979 to 1980, 109 patients with open tibial fractures were treated by a cephalosporin and an aminoglycoside, and by saline and topical antibiotic wound irrigation; partial closure was used for Types I and II open tibial wounds, and all Type III wounds were left open. Stabilization was accomplished by plaster alone, external pins in plaster, or an external fixator with full transfixion pins. The overall infection rate was 4.5% (5 of 109 wounds) in this study. This represents a significant reduction from the previous infection rate of 14% in 254 open tibial fractures treated by the authors in previous years by all methods.