Douglas P. Hanel

Indirect reduction and percutaneous fixation versus open reduction and internal fixation for displaced intra-articular fractures of the distal radius: A RANDOMISED, CONTROLLED TRIAL

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups. During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised.

X-ray film measurements for healed distal radius fractures

In order to understand the effect of malunion on functional outcome, it is essential that deformity be measured in a consistent manner. A standardized method of measuring eight anatomic parameters at the distal radius was developed. By this method, six x-ray films of healed distal radius fractures were subsequently measured by 16 raters. Rater agreement was quantified by using the intraclass correlation coefficient. Tolerance limits were developed in order to estimate the expected margin of error for each parameter. Parameters measured with high rater agreement include ulnar variance, palmar tilt, and radial shift; however, even experienced clinicians did not readily agree on the size of step and gap deformity. Using the method of tolerance limits, one would expect that two randomly chosen clinicians measuring step and gap deformity on a random x-ray film will differ by more than 3 mm at least 10% of the time. Similarly, repeat step or gap measurements by the same observer are expected to differ by more than 2 mm at least 10% of the time. In view of our inability to measure deformity more accurately, the concept of a specific relationship between a given degree of deformity and outcome must be questioned. Prospective research is needed in order to improve our understanding of the precise relationship between malunion and functional outcome.

Two-, four-, and six-strand zone II flexor tendon repairs: An in situ biomechanical comparison using a cadaver model

A dynamic in vitro model of zone II flexor tendon repair was used to compare gliding resistance, gap formation, and ultimate strength of the 2-, 4-, and 6-strand repair techniques. Each of 12 hands was mounted to a loading frame with 3 flexor tendons attached to individual pneumatic cylinders. A spring attached to a pin through the distal end of each digit provided a 1.25-kg resistance force. The force required to flex each proximal interphalangeal joint to 90 degrees was determined. Following this, the tendons were sectioned and each was repaired using a different technique so that each specimen acted as its own control. The 2- and 4-strand core sutures were placed using a suture interlock technique with radial and ulnar grasping purchase of the tendon on each side of the transverse part of the repair. Each repair was accomplished using a single core stitch with the knot buried between the tendon ends. The 4-strand repair involved an additional horizontal mattress suture with the knot buried. Repair of the dorsal side of the tendon was performed followed by core suture placement. The palmar portion of the peripheral locking suture was completed after core suture placement. Following repair, each hand was remounted on the frame and cycled 1,000 times. After cyclic loading, the resulting gap between the repaired ends of each tendon was measured, the tendons were removed from the hand, and each was loaded to failure in tension. All tendon repairs showed a small, but not statistically significant, increase in gliding resistance after reconstruction. The 2-strand repair had significantly greater gap formation after cyclic loading (mean gap, 2.75 mm) than either the 4-strand (0.30 mm) or 6-strand (0.31 mm) repair. The tensile strength of the 6-strand repair (mean, 78.7 N) was significantly greater than either the 4-strand (means, 43.0 N) or 2-strand (mean, 33.9 N) repair.

A comparison of short- and long-term intravenous antibiotic therapy in the postoperative management of adult osteomyelitis

The current standard recommendation for antibiotic therapy in the management of chronic osteomyelitis is intravenous treatment for six weeks. We have compared this regime with short-term intravenous therapy followed by oral dosage. A total of 93 patients, with chronic osteomyelitis, underwent single-stage, aggressive surgical debridement and appropriate soft-tissue coverage. Culture-specific intravenous antibiotics were given for five to seven days, followed by oral therapy for six weeks. During surgery, the scar, including the sinus track, was excised en bloc. We used a high-speed, saline-cooled burr to remove necrotic bone, and osseous laser Doppler flowmetry to ensure that the remaining bone was viable. Infected nonunions (Cierny stage-IV osteomyelitis) were stabilised by internal fixation. In 38 patients management of dead space required antibiotic-impregnated polymethylmethacrylate beads, which were exchanged for an autogenous bone graft at six weeks. Free-tissue transfer often facilitated soft-tissue coverage. These 93 patients were compared with 22 consecutive patients treated previously who had the same surgical management, but received culture-specific intravenous antibiotics for six weeks. Of the 93 patients, 80 healed without further intervention. Of the 31 Cierny-IV lesions, 27 healed without another operation, and four fractures required additional bone grafts. No more wound drainage was needed. Treatment was successful in 91% of patients, regardless of the organism involved. There was no difference in outcome in terms of these variables when the series were compared. We conclude that the long-term administration of intravenous antibiotics is not necessary to achieve a high rate of clinical resolution of wound drainage for adult patients with chronic osteomyelitis.

The olecranon osteotomy: a six-year experience in the treatment of intraarticular fractures of the distal humerus.

Objectives The transolecranon exposure for distal humerus fractures is a suggested technique for improving articular visualization, allowing accurate reduction. Significant osteotomy complications such as nonunion and implant prominence have prompted recommendations for alternate exposures. The purposes of this study are to present the techniques and complications of the olecranon osteotomy for the management of distal humerus fractures, and to evaluate the adequacy of distal humeral and olecranon articular reductions. Design Retrospective review. Setting Urban level-1 University trauma center. Patients One hundred fourteen skeletally mature AO/OTA type 13-C distal humerus fractures were identified from the orthopedic trauma database and formed the study group. Intervention Seventy fractures (61%), including 42 open injuries, were managed using an intraarticular, chevron-shaped olecranon osteotomy. Osteotomy fixations were performed with an intramedullary screw and supplemental dorsal ulnar wiring, or plate stabilization. In the remaining 44 fractures (39%), soft-tissue mobilizing exposures were performed. Main Outcome Measure Patient records and radiographs were reviewed to determine injury and operative characteristics, complications, and adequacy of articular reductions. Patient interviews were conducted by telephone to identify any subsequent surgical procedures. Results The proportion of osteotomies performed increased as fracture complexity increased (P<0.001). Sixty-seven of 70 patients had adequate follow-up to determine osteotomy union. All osteotomies united. There was 1 delayed union. Sixty-one of 70 patients had adequate follow-up to determine complications associated with ulnar fixations. Five of these patients (8%) underwent elective removal of symptomatic osteotomy fixations. An additional 13 patients had olecranon implants removed in conjunction with other surgical procedures (11 elbow contracture releases, 1 humeral nonunion repair, and 1 chronic draining sinus excision). Symptomatic ulnar fixations in this group could not be reliably ascertained, but may have been present. A total of 18 of 61 patients (29.5%), therefore, had proximal ulna fixations removed. All patients treated using an olecranon osteotomy exposure demonstrated satisfactory radiographic distal humeral articular reductions. Two osteotomies required early revision osteosynthesis secondary to loss of osteotomy reduction. Conclusions In this study, no osteotomy nonunions were encountered in 67 patients, more than half of which were open injuries. Regardless of which type of fixation is used to secure the osteotomy, secure stabilization must be obtained. Isolated symptomatic olecranon fixation requiring removal occurred in approximately 8% of patients. Although not necessary for all fractures of the distal humerus, the olecranon osteotomy can be useful in the visualization of the complex articular injuries, allowing accurate articular reduction.

Zone-II Flexor Tendon Repair: A Randomized Prospective Trial of Active Place-and-Hold Therapy Compared with Passive Motion Therapy

BACKGROUND In order to improve digit motion after zone-II flexor tendon repair, rehabilitation programs have promoted either passive motion or active motion therapy. To our knowledge, no prospective randomized trial has compared the two techniques. Our objective was to compare the results of patients treated with an active therapy program and those treated with a passive motion protocol following zone-II flexor tendon repair. METHODS Between January 1996 and December 2002, 103 patients (119 digits) with zone-II flexor tendon repairs were randomized to either early active motion with place and hold or a passive motion protocol. Range of motion was measured at six, twelve, twenty-six, and fifty-two weeks following repair. Dexterity tests were performed, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire and a satisfaction score were completed at fifty-two weeks by ninety-three patients (106 injured digits). RESULTS At all time points, patients treated with the active motion program had greater interphalangeal joint motion. At the time of the final follow-up, the interphalangeal joint motion in the active place-and-hold group was a mean (and standard deviation) of 156 degrees +/- 25 degrees compared with 128 degrees +/- 22 degrees (p < 0.05) in the passive motion group. The active motion group had both significantly smaller flexion contractures and greater satisfaction scores (p < 0.05). We could identify no difference between the groups in terms of the DASH scores or dexterity tests. When the groups were stratified, those who were smokers or had a concomitant nerve injury or multiple digit injuries had less range of motion, larger flexion contractures, and decreased satisfaction scores compared with patients without these comorbidities. Treatment by a certified hand therapist resulted in better range of motion with smaller flexion contractures. Two digits in each group had tendon ruptures following repair. CONCLUSIONS Active motion therapy provides greater active finger motion than passive motion therapy after zone-II flexor tendon repair without increasing the risk of tendon rupture. Concomitant nerve injuries, multiple digit injuries, and a history of smoking negatively impact the final outcome of tendon repairs.

Use of a Distraction Plate for Distal Radial Fractures with Metaphyseal and Diaphyseal Comminution

BACKGROUND Distal radial fractures with extensive comminution involving the metaphyseal-diaphyseal junction present a major treatment dilemma. Of particular difficulty are those fractures involving the articular surface. One approach is to apply a dorsal 3.5-mm plate extra-articularly from the radius to the third metacarpal, stabilizing the diaphysis and maintaining distraction across the radiocarpal joint. METHODS Twenty-two patients treated with a distraction plate for a comminuted distal radial fracture were included in the study. With use of three limited incisions, a 3.5-mm ASIF plate was applied in distraction dorsally from the radial diaphysis, bypassing the comminuted segment, to the long-finger metacarpal, where it was fixed distally. The articular surface was anatomically reduced and was secured with Kirschner wires or screws. Eleven of the twenty-two fractures were treated with bone-grafting. The plate was removed after fracture consolidation (at an average of 124 days), and wrist motion was initiated. All patients were followed prospectively with use of radiographs, physical examination, and DASH (Disabilities of the Arm, Shoulder and Hand) scores. RESULTS All fractures united by an average of 110 days. Radiographs showed an average palmar tilt of 4.6 degrees and an average ulnar variance of neutral (0 degrees), whereas loss of radial length averaged 2 mm. Flexion and extension averaged 57 degrees and 65 degrees, respectively, and pronation and supination averaged 77 degrees and 76 degrees , respectively. The average DASH scores were 34 points at six months, 15 points at one year, and 11.5 points at the time of final follow-up (at an average of 24.8 months). According to the Gartland-Werley rating system, fourteen patients had an excellent result, six had a good result, and two had a fair result. Grip strength and the range of motion of the wrist at one year correlated inversely with the proximal extent of fracture comminution into the diaphysis. The duration of plate immobilization did not correlate with the range of motion of the wrist or with the DASH score at one year. CONCLUSIONS The use of a distraction plate combined with reduction of the articular surface and bone-grafting when needed can be an effective technique for treatment of fractures of the distal end of the radius with extensive metaphyseal and diaphyseal comminution. A functional range of motion with minimal disability can be achieved despite a prolonged period of fixation with a distraction plate across the wrist joint.

Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation.

Seventy-three patients were treated with either intrafocal pinning (Kapandji technique) alone or in combination with external fixation between 1988 and 1993 for extra-articular fractures of the distal radius (with or without a nondisplaced extension into the radiocarpal articular surface) with inadequate alignment after initial closed reduction. Sixty-one patients were available for follow-up examination at an average of 34 months (range, 24-71 months). The average age was 52 years (range, 16-84 years). Thirty-three of the patients were female. The patients all had dorsally displaced extra-articular fractures, although 56% had a nondisplaced extension of the fracture into the radiocarpal joint and 46% had a nondisplaced fracture extending into the distal radioulnar joint. The patients were separated into groups based on age, degree of comminution, and whether external fixation was also used. In the older patients, range of motion, grip strength, and pain relief were significantly better when external fixation was used, even when only 1 cortex of the radius demonstrated comminution. In the younger patients, good results in terms of range of motion, grip strength, and pain relief were obtained when percutaneous intrafocal pins were used alone in patients with comminution of only 1 surface of the radius (<50% of the metaphyseal diameter). When > or = 2 sides of the radial metaphysis were comminuted, the patients with external fixation had better results than those without external fixation. Although the correction of palmar tilt and radial tilt did result in better functional results, the restoration of radial length had the most significant effect on range of motion and grip strength.

A randomized, controlled trial of distal radius fractures with metaphyseal displacement but without joint incongruity: closed reduction and casting versus closed reduction, spanning external fixation, and optional percutaneous K-wires.

Objectives: To compare closed reduction and casting with closed reduction and external fixation with optional K-wire fixation for distal radius fractures with metaphyseal displacement but without joint incongruity. Design: Prospective study. Setting: Multicenter study at 3 University teaching hospitals. Patients/Participants: A total of 113 skeletally mature patients with distal radius fractures with metaphyseal displacement, but without joint incongruity, were randomized to receive 1 of 2 standardized treatment protocols. Patients were evaluated at 6 weeks, 6 months, 1 year, and 2 years. Intervention: Closed reduction and casting (n = 59) or closed reduction and external fixation (n = 54). Main Outcome Measurements: Upper extremity function was measured using upper extremity MFA domain scores, overall Jebsen Taylor scores, and pinch and grip strength tests. Global function and pain were measured using the SF-36. Radiographic evaluation and range of motion were documented. Results: Upper extremity MFA scores, Jebsen Taylor scores, SF-36 bodily pain scores, and grip strength improved significantly during the first year for all patients. By 2 years, mean Jebsen Taylor scores and SF 36 bodily pain scores for patients in both groups were similar to scores for normal age- and gender-matched population controls. At all points, there was a trend for better function in the external fixation; however, this did not reach statistical significance. There was a trend for better length and palmar tilt restoration with external fixation. Conclusions: For distal radius fractures with metaphyseal displacement but with a congruous joint, there exists a trend for better functional, clinical, and radiographic outcomes when treated by immediate external fixation and optional K-wire fixation.

Comparative Biomechanic Study of Flexor Tendon Repair Using FiberWire

PURPOSE FiberWire, an increasingly popular suture material, allows for strong flexor tendon repair that may allow early mobilization. This study was designed to evaluate the mechanical characteristics of FiberWire for flexor tendon repair and to identify the most effective repair technique using this material. METHODS Forty-nine human cadaver flexor tendons were randomized and tested biomechanically using one of the following techniques of flexor tendon repair performed with 3-0 FiberWire: (1) modified Kessler, (2) modified Pennington, (3) 2-strand multiple grasping, (4) 2-strand multiple locking, (5) 2-strand double cross-locks, (6) Massachusetts General Hospital, and (7) 4-strand locked cruciate. The ultimate tensile strength, 2-mm gap resistance, and failure mode of the repairs were evaluated. RESULTS Knot unraveling was the most common failure mode of FiberWire repair in 4 of the 7 techniques. Four-strand repairs and locking repairs provided significantly more strength than 2-strand repairs and grasping repairs. Multiple grasping and multiple locking repairs with 2 knots were significantly weaker than single grasping and locking repairs with a single knot. Four-strand locked cruciate repairs were significantly stronger than the other techniques (mean ultimate tensile strength 107 N, 2-mm gap force 96 N). Two-strand double cross-locks repairs were stronger than the other 2-strand repairs (mean ultimate tensile strength 69 N, 2-mm gap force 53 N). CONCLUSIONS The strength of the FiberWire repairs increased with locking repair and with increased number of strands but was not influenced by increased number of locking and grasping stitches. Four-strand locked cruciate and 2-strand double cross-locks provided the greatest strength and likely are appropriate for future clinical use in, respectively, 4-strand and 2-strand repairs. However, the poor knot-holding characteristics of FiberWire with the need of a greater number of knot throws may be of concern for surgeons using this product for flexor tendon repairs.