M Manca

Improvement of the bone-pin interface strength in osteoporotic bone with use of hydroxyapatite-coated tapered external-fixation pins. A prospective, randomized clinical study of wrist fractures

Background: Achieving adequate fixation strength in osteoporotic bone is a challenge. In this study, we examined the use of hydroxyapatite-coated tapered external-fixation pins for the fixation of wrist fractures in patients with osteoporosis. Methods: Twenty female patients with osteoporosis and a fracture of the wrist were divided into two paired groups and randomized to receive either standard tapered pins or hydroxyapatite-coated tapered pins. Two pins were inserted in the distal part of the radius, two pins were inserted in the second metacarpal, and an external fixation device was mounted. All fixation devices were removed six weeks after surgery. Results: The mean pin-insertion torque (and standard deviation) was 461 ± 254 Nmm in the group managed with standard pins and 332 ± 176 Nmm in the group managed with hydroxyapatite-coated pins (p = 0.01). The mean pin-extraction torque was 191 ± 155 Nmm in the group managed with standard pins and 600 ± 214 Nmm in the group managed with hydroxyapatite-coated pins (p < 0.0001, power 95%). The mean extraction torque was lower than the corresponding insertion torque at each pin position in the group managed with standard pins (p < 0.05), whereas the mean extraction torque was higher than the corresponding insertion torque at each pin position in the group managed with hydroxyapatite-coated pins (p = 0.001). Two patients managed with standard pins and no patient managed with hydroxyapatite-coated pins had a pin-track infection. Pain during pin removal did not differ between the two groups. Conclusions: The present study showed that hydroxyapatite-coated tapered external-fixation pins provided improved fixation in the treatment of wrist fractures in patients with osteoporosis.

Combined percutaneous internal and external fixation of type-C tibial plafond fractures: A review of twenty-two cases

Type-C tibial plafond fractures are a challenge in trauma surgery 1-4. They are usually caused by high-energy trauma and are frequently associated with marked soft-tissue damage 5. Treatment is sometimes complicated by the presence of other injuries 6. Conservative treatment of these fractures with traction, bracing, and immobilization in a cast rarely permits accurate reconstruction of fibular length and reduction of the articular surface of the tibial plafond. In type-C tibial plafond fractures, it is necessary to restore fibular length, anatomically reduce the articular part of the fracture to minimize the risk of secondary arthritis, and provide stable articular and metaphyseal fixation to promote fracture-healing 3,7. These goals should be achieved with a technique that is as minimally invasive as possible. Open reduction and internal fixation with plates and screws, as introduced by Ruedi and Allgower 3, and reported by several other authors to have provided good results 1,8,9, permits accurate reduction of the articular surface but with a high rate of deep infection, wound dehiscence, and soft-tissue problems 10. The use of closed reduction and percutaneous fixation techniques has reduced the incidence of wound complications 6,11. This technique is usually sufficient to reduce and stabilize the articular fragments with use of fluoroscopic or arthroscopic guidance, but it is not adequate to control the metaphyseal fragments. For these reasons, some authors have recommended surgical techniques based on closed internal fixation of the articular fracture and circular external fixation of the metaphyseal fracture 5,12-16. The aim of this study was to review the results of fluoroscopically monitored closed reduction combined with percutaneous internal and hybrid external fixation of type-C tibial plafond fractures. Twenty-two type-C tibial plafond fractures in …

Surgical treatment of complex tibial plateau fractures by closed reduction and external fixation. A review of 32 consecutive cases operated

Complex tibial plateau fractures are a challenge in trauma surgery. In these fractures it is necessary to anatomically reduce the articular part of the fracture and to obtain stable fixation. The aim of this study is to review the results of a surgical technique consisting of fluoroscopic closed reduction and combined percutaneous internal and external fixation. Thirty-two complex tibial plateau fractures in 32 patients were included. Twenty-one fractures were closed, 4 were open Gustilo grade I, 3 were Gustilo grade II and 4 were Gustilo grade III. The mean age was 37.8 years (range 21–64 years). Surgery was performed with patients in transcalcaneal traction and the knee flexed at 30° was used. Through a 1-cm incision centred over the tibial metaphysis of the tibia, a 3.2-mm hole was drilled in the antero-medial tibial aspect. The tibial plateau fracture fragments were elevated using either 1 or 2 curved Kirschner wires under fluoroscopy to control the reduction. Then the fragments were fixed with 2 cannulated AO screws inserted through small incisions into the medial aspect of the tibial plateau. Knee rehabilitation started postoperatively. Weight bearing started after 8–12 weeks depending upon the radiographic appearance. All external fixators were removed in outpatient facilities. All patients were clinically and radiographically evaluated at a mean follow-up of 48 months (range 38–57 months). Clinical results were evaluated according to the Knee Society clinical score. Average healing time was 24 weeks (range 18–29 weeks). In 1 patient a non-union occurred. This patient was treated with open reduction and plate fixation. In 2 patients a varus knee deformity occurred and a surgical correction was performed. There were no surgical complications. Mean knee range of motion was 105° (range 75–125°) and mean Knee Society clinical score was 89. Twenty-five results were scored as excellent, 4 good, 2 fair and 1 poor. Using this technique there is limited soft tissue damage and virtually no periosteum damage to the fracture fragments. However anatomical reconstruction of the joint can be obtained. Furthermore knee rehabilitation can be started immediately after surgery. We think that these factors were responsible for the optimal clinical long-term results.