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Dynamic compression for small bone arthrodesis
The Journal of HAND SURGERY
Noellert and Louis
4.
5.
6.
7.
8.
and replacement with the fibula. Clin Orthop 42: 151-6, 1965 Lee MLH, Sandeman JC: Fibula autograft survival following resection of osteoclastoma of radius. Postgrad Med J 45:266-71, 1969 Parker SM, Hastings DE, Fomasier VL: Giant cell tumor of distal radius replaced by massive fibular autograft: a case report. Can J Surg 17:266-8, 1974 Mack GR, Lichtman DL, MacDonald RI: Fibular autografts for distal defects of the radius. J HAND SuRG 4:57683, 1979 Parrish FF: Treatment of bone tumors by total excision and replacement with massive autologous and homologous grafts. J Bone Joint Surg [Am] 48:968-90, 1966 Campbell CJ, Akbarria BA: Giant cell tumor of the radius treated by massive resection and tibial bone graft. J Bone Joint Surg [Am] 57:982-6, 1975
9. Smith RJ, Mankin HJ: Allograft replacement of distal radius for giant cell tumor. J HAND SURG 2:299-308, 1977 10. Gold AM: Use of a prosthesis for the distal portion of the radius following resection of a recurrent giant cell tumor. J Bone Joint Surg [Am] 39:1374-80, 1957 11. Seradge H: Distal ulnar translocation in the treatment of giant cell tumors of the distal end of the radius. J Bone Joint Surg [Am] 64:67-73, 1982 12. Weiland AJ, Kleinert HE, Kutz JE, Daniel RK: Free vascularized bone grafts in surgery of the upper extremity. J HAND SURG 4:129-44, 1979 13. Weiland AJ: Vascularized free bone transplants. J Bone Joint Surg [Am] 63:165-9, 1981 14. Campbell CJ: Invited editorial comment. J HAND SuRG 2:308-9, 1977
Dynamic compression for small bone arthrodesis A technique providing dynamic compression for arthrodesis of the small joints in the hand uses a longitudinal wire for alignment and two 0.045 Kirschner wires and methyl methacrylate cement for continuous dynamic compression. Thirty-one joints, 12 metacarpophalangeal and 19 interphalangeal, were arthrodesed by this method. There were no angular malunions or nonunions. The technique is recommended as an alternative to current fixation methods in the hand for small joint arthrodesis. (J HAND SuRG IOA:340-3, 1985.)
Richard M. Braun, M.D., and Charles E. Rhoades, M.D., San Diego, Calif.
A
simple technique for providing dynamic compression fixation appropriate for arthrodesis of small joints is reported. The method requires no special equipment or costly, complex fixation devices. Compression arthrodesis has been a proved orthopedic surgical technique since the classic study of Chamley.' Large joints offer adequate bone stock for massive appliances but small joints cannot provide this base for the application of compression devices. A study was performed to determine the compressive force developed by two 0.045 Kirschner wires positioned in the shape of a bow, separated in the center by 2.5 to 3 cm, and clamped together at the ends. These distances are encountered in clinical practice. The wires were not From the University of California Medical Center, San Diego. Calif. Received for publication May 23, 1984; accepted in revised form Sept. IO, 1984. Reprint requests: Richard M. Braun, M.D., 770 Washington St .. No. 300, San Diego, CA 92103.
340 THE JOURNAL OF HAND SURGERY
permanently bent or deformed by clamping the ends together, as dynamic compression was desired. Compression varied directly with the distance separating the wires (see Fig. 2). Strain-gauge measurement showed a range of compressive force from 650 to 800 gm with separation distances of 2.5 to 3.0 cm. This indicates that the system produces dynamic compression in addition to fixed immobilization of involved bones. The fact that the pins return to a straight shape after they are released from the clamps shows that the compression forces have acted in a dynamic fashion during the entire time of application.
Technique Fusion of the interphalangeal joint of the thumb is used as an illustrative case (Fig. l). The operative technique requires three 0.045 Kirschner wires and one package of methyl methacrylate bone cement. After preparation of the joint surfaces for arthrodesis by any standard technique, a 0.045 Kirschner
Vol. IOA, No. 3 May 1985
Dynamic compression for bone arthrodesis
341
Fig. 1. A painful arthritic deformity in the distal joint of the thumb resulted in functional impairment and inability to pinch or grasp objects without significant discomfort.
Fig. 2. The articular surfaces of the adjacent phalanges were prepared for arthrodesis. A longitudinal wire inserted across the joint assured continued longitudinal alignment. Two Kirschner wires were drilled transversely across the bones on either side of the joint. The ends of the wires were held together with Kocher clamps while a bolus of polymethyl methacrylate cement was applied to the wires on each side of the finger. Three millimeters of clearance between the skin and cement was provided. The cement bolus extended well beyond the transverse wires to hold them securely after the cement set. The wires were cut as they emerged from the hardened cement. The bow seen in the transverse wires provided constant dynamic compression to the arthrodesis.
wire is passed in a longitudinal retrograde (proximal to distal) direction through the distal bone . The joint surfaces are then approximated and set in position for arthrodesis. The Kirschner wire previously placed in the distal bone is then driven proximally across the joint. One 0.045 Kirschner wire is then passed trans-
versely through each bone, parallel to the joint line, and 1.0 to 1.5 cm proximal and distal to the joint, respectively. The distance between the transverse wires is approximately 2.5 to 3.0 cm. A Kocher clamp is used to clamp the ends of the Kirschner wires together on each side of the joint to produce a bow in the wires
342
The Journal of HAND SURGERY
Braun and Rhoades
Fig. 3. Solid arthrodesis of the distal joint of the thumb is seen 8 weeks after surgery. The thumb was asymptomatic.
that compresses the joint but does not cause plastic deformation of the wires. This produces dynamic compression across the joint. A single package of methyl methacrylate cement is mixed . Since the cement will not be implanted, older stock may be used rather than discarded. When the cement achieves a doughy consistency, it is divided in half and formed around each pair of Kirschner wires on each side of the digit. A small space is maintained between the cement and the skin as well as between the cement and the Kocher clamps . The clamps are removed after the cement hardens and the system is examined for stability. The ends of the wires are clipped as they emerge from the cement blocks. No other external fixation is required . Splinting is used at the discretion of the surgeon. We prefer to use splints during those times when the operated area is at risk for injury, such as during sleep or in crowds or if direct stress must be applied to the area such as during transfers in tetraplegic patients. Full, active motion of adjacent joints is allowed immediately. The fixation device is removed in 6 to 8 weeks (Fig. 3). In one difficult case with associated bone loss, a single curved wire was applied obliquely over the dorsum of the joint and embedded in the cement blocks before cement setting. This improved rigidity at the price of a loss of dynamic compression in the system. In recent cases in which outdated PMMA has not been available, 3M casting tape has been placed about the transverse wires in a fashion similar to that of the cement bolus. Setting occurs in a few minutes and the fixation is secure, strong, and light weight. Cast roll
cost is about $3 .00 compared with a hospital charge of $50.00 for a container of fresh cement.
Results This method has been used by the senior author in 31 cases , 12 metacarpophalangeal thumb joints and 19 interphalangeal joints, in the thumb and fingers during the last decade. All have healed without failure of fixation or angular deformity (Fig. 3) . The apparatus is well tolerated and the patients appeared to prefer this fixation to prolonged conventional casting. One cement block cracked in a very active patient. The amount of cement extending distally to the transverse pin was considered inadequate to accept the strain of the compression wire . Sufficient cement should extend proximally and distally to the transverse pins to prevent this problem. The block in question was repaired easily with the addition of freshly mixed cement (salvaged before cement setting during a hip replacement operation) applied to the existing block. Cement must extend well beyond the transverse pins so that it may contain the longitudinal forces generated by the system.
Discussion Numerous methods are currently available for arthrodesis of small joints of the hanct .2• 7 The system presented provides adequate rotational stability while applying constant dynamic compression in appropriate longitudinal alignment. The compressive effect of the bowed Kirschner wires persists until the wires are removed. When cut free from the blocks of methyl methacrylate , the wires spring back to a straight position.
Vol. IOA, No. 3 May 1985
This indicates that elastic deformation has maintained dynamic compression effectively. The combination of compression and congruous contour of the bone surfaces provided satisfactory rotational stability in all patients. This method has several advantages. The materials are already available in a standard operating room. The operation is easier to perform than the application of plates and screws. The wire removal is performed routinely in the office or clinic, and a second operative procedure is not required. The cost is much less than that of commercially available external fixators. The technique overcomes the problem of fixed distraction, sometimes present with crossed wires, and compensates for bone resorption at the fusion site during healing. This method of compression fixation may be used with virtually any standard arthrodesis technique already favored by the operating surgeon.
Dynamic compression for bone arthrodesis
REFERENCES I. Chamley J: Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg 33-B: 180, 1951 2. Carroll RE, Hill NA: Small joint arthrodesis in hand reconstruction. J Bone Joint Surg 51-A:l219, 1969 3. Ikuta Y, Tsuge K: Micro-bolts and micro-screws for fixation of small bones in the hand. Hand 6:261, 1974 4. Moberg E: Arthrodesis of finger joints. Surg Clin North Am 40:465, 1960 5. Potenza AD: A technique for arthrodesis of the finger joints. J Bone Joint Surg 55-A: 1534, 1973 6. Tupper JW: A compression arthrodesis device for small joints of the hand. Hand 4:62, 1972 7. Wexter MR, Rousso N, Weinberg H: Arthrodesis of finger joints by dynamic external compression using dorsoventral Kirschner wires and rubber bands. Plast Reconstr Surg 66:882, 1977
Studies of pathologic vasoconstriction (vasospasm) in microvascular surgery Characterization and resolution of microvascular spasm were investigated in 170 studies with the use of tail or femoral arteries of the rat. Topical epinephrine reliably produced vasospasm and topical vasodilators which included 2% and 20% lidocaine (Xylocaine) and 0.75% bupivacaine (Marcaine) were applied to resolve the vasoconstriction. Extensive vessel dissection was necessary to obtain significant resolution of vasospasm, and adventitial stripping was associated with even more impressive results. Local anesthetics appear to have a concentration dependent ability to resolve vasospasm, and 20% Xylocaine is the most effective agent yet studied. (J HAND SURG 10A:343-9, 1985.)
Charles L. Puckett, M.D., F.A.C.S., Richard R. W. Winters, M.D., Rodney K. Geter, M.D., and Diane Goebel, M.D., Columbia, Mo.
Technology and experience have allowed the microvascular surgeon to achieve very good anastomotic patency rates. However, failures continue to occur, and many anastomotic failures are largely beFrom the Division of Plastic Surgery, University of Missouri Health Sciences Center, Columbia, Mo. Received for publication March 9, 1984; accepted in revised form Aug. 7, 1984. Reprint requests: Charles L. Puckett, M.D., F.A.C.S., Division of Plastic Surgery, University of Missouri Health Sciences Center, One Hospital Dr.. Columbia, MO 65212.
yond technical control and include factors related to coagulation, platelet function, and vasoconstriction. In reviewing our microvascular failures both in replantations and free tissue transfers, pathologic vasoconstriction (vasospasm) has frequently been a contributing factor. This term refers to the tight vasoconstriction that we occasionally encountered before or after vascular anastomosis that is recalcitrant to mechanical dilation and significantly retards blood flow. It can be found in veins, but most often involves arteries. This vasospasm often defies interpretation. While proximal vasospasm THE JOURNAL OF HAND SURGERY
343
Noellert and Louis
4.
5.
6.
7.
8.
and replacement with the fibula. Clin Orthop 42: 151-6, 1965 Lee MLH, Sandeman JC: Fibula autograft survival following resection of osteoclastoma of radius. Postgrad Med J 45:266-71, 1969 Parker SM, Hastings DE, Fomasier VL: Giant cell tumor of distal radius replaced by massive fibular autograft: a case report. Can J Surg 17:266-8, 1974 Mack GR, Lichtman DL, MacDonald RI: Fibular autografts for distal defects of the radius. J HAND SuRG 4:57683, 1979 Parrish FF: Treatment of bone tumors by total excision and replacement with massive autologous and homologous grafts. J Bone Joint Surg [Am] 48:968-90, 1966 Campbell CJ, Akbarria BA: Giant cell tumor of the radius treated by massive resection and tibial bone graft. J Bone Joint Surg [Am] 57:982-6, 1975
9. Smith RJ, Mankin HJ: Allograft replacement of distal radius for giant cell tumor. J HAND SURG 2:299-308, 1977 10. Gold AM: Use of a prosthesis for the distal portion of the radius following resection of a recurrent giant cell tumor. J Bone Joint Surg [Am] 39:1374-80, 1957 11. Seradge H: Distal ulnar translocation in the treatment of giant cell tumors of the distal end of the radius. J Bone Joint Surg [Am] 64:67-73, 1982 12. Weiland AJ, Kleinert HE, Kutz JE, Daniel RK: Free vascularized bone grafts in surgery of the upper extremity. J HAND SURG 4:129-44, 1979 13. Weiland AJ: Vascularized free bone transplants. J Bone Joint Surg [Am] 63:165-9, 1981 14. Campbell CJ: Invited editorial comment. J HAND SuRG 2:308-9, 1977
Dynamic compression for small bone arthrodesis A technique providing dynamic compression for arthrodesis of the small joints in the hand uses a longitudinal wire for alignment and two 0.045 Kirschner wires and methyl methacrylate cement for continuous dynamic compression. Thirty-one joints, 12 metacarpophalangeal and 19 interphalangeal, were arthrodesed by this method. There were no angular malunions or nonunions. The technique is recommended as an alternative to current fixation methods in the hand for small joint arthrodesis. (J HAND SuRG IOA:340-3, 1985.)
Richard M. Braun, M.D., and Charles E. Rhoades, M.D., San Diego, Calif.
A
simple technique for providing dynamic compression fixation appropriate for arthrodesis of small joints is reported. The method requires no special equipment or costly, complex fixation devices. Compression arthrodesis has been a proved orthopedic surgical technique since the classic study of Chamley.' Large joints offer adequate bone stock for massive appliances but small joints cannot provide this base for the application of compression devices. A study was performed to determine the compressive force developed by two 0.045 Kirschner wires positioned in the shape of a bow, separated in the center by 2.5 to 3 cm, and clamped together at the ends. These distances are encountered in clinical practice. The wires were not From the University of California Medical Center, San Diego. Calif. Received for publication May 23, 1984; accepted in revised form Sept. IO, 1984. Reprint requests: Richard M. Braun, M.D., 770 Washington St .. No. 300, San Diego, CA 92103.
340 THE JOURNAL OF HAND SURGERY
permanently bent or deformed by clamping the ends together, as dynamic compression was desired. Compression varied directly with the distance separating the wires (see Fig. 2). Strain-gauge measurement showed a range of compressive force from 650 to 800 gm with separation distances of 2.5 to 3.0 cm. This indicates that the system produces dynamic compression in addition to fixed immobilization of involved bones. The fact that the pins return to a straight shape after they are released from the clamps shows that the compression forces have acted in a dynamic fashion during the entire time of application.
Technique Fusion of the interphalangeal joint of the thumb is used as an illustrative case (Fig. l). The operative technique requires three 0.045 Kirschner wires and one package of methyl methacrylate bone cement. After preparation of the joint surfaces for arthrodesis by any standard technique, a 0.045 Kirschner
Vol. IOA, No. 3 May 1985
Dynamic compression for bone arthrodesis
341
Fig. 1. A painful arthritic deformity in the distal joint of the thumb resulted in functional impairment and inability to pinch or grasp objects without significant discomfort.
Fig. 2. The articular surfaces of the adjacent phalanges were prepared for arthrodesis. A longitudinal wire inserted across the joint assured continued longitudinal alignment. Two Kirschner wires were drilled transversely across the bones on either side of the joint. The ends of the wires were held together with Kocher clamps while a bolus of polymethyl methacrylate cement was applied to the wires on each side of the finger. Three millimeters of clearance between the skin and cement was provided. The cement bolus extended well beyond the transverse wires to hold them securely after the cement set. The wires were cut as they emerged from the hardened cement. The bow seen in the transverse wires provided constant dynamic compression to the arthrodesis.
wire is passed in a longitudinal retrograde (proximal to distal) direction through the distal bone . The joint surfaces are then approximated and set in position for arthrodesis. The Kirschner wire previously placed in the distal bone is then driven proximally across the joint. One 0.045 Kirschner wire is then passed trans-
versely through each bone, parallel to the joint line, and 1.0 to 1.5 cm proximal and distal to the joint, respectively. The distance between the transverse wires is approximately 2.5 to 3.0 cm. A Kocher clamp is used to clamp the ends of the Kirschner wires together on each side of the joint to produce a bow in the wires
342
The Journal of HAND SURGERY
Braun and Rhoades
Fig. 3. Solid arthrodesis of the distal joint of the thumb is seen 8 weeks after surgery. The thumb was asymptomatic.
that compresses the joint but does not cause plastic deformation of the wires. This produces dynamic compression across the joint. A single package of methyl methacrylate cement is mixed . Since the cement will not be implanted, older stock may be used rather than discarded. When the cement achieves a doughy consistency, it is divided in half and formed around each pair of Kirschner wires on each side of the digit. A small space is maintained between the cement and the skin as well as between the cement and the Kocher clamps . The clamps are removed after the cement hardens and the system is examined for stability. The ends of the wires are clipped as they emerge from the cement blocks. No other external fixation is required . Splinting is used at the discretion of the surgeon. We prefer to use splints during those times when the operated area is at risk for injury, such as during sleep or in crowds or if direct stress must be applied to the area such as during transfers in tetraplegic patients. Full, active motion of adjacent joints is allowed immediately. The fixation device is removed in 6 to 8 weeks (Fig. 3). In one difficult case with associated bone loss, a single curved wire was applied obliquely over the dorsum of the joint and embedded in the cement blocks before cement setting. This improved rigidity at the price of a loss of dynamic compression in the system. In recent cases in which outdated PMMA has not been available, 3M casting tape has been placed about the transverse wires in a fashion similar to that of the cement bolus. Setting occurs in a few minutes and the fixation is secure, strong, and light weight. Cast roll
cost is about $3 .00 compared with a hospital charge of $50.00 for a container of fresh cement.
Results This method has been used by the senior author in 31 cases , 12 metacarpophalangeal thumb joints and 19 interphalangeal joints, in the thumb and fingers during the last decade. All have healed without failure of fixation or angular deformity (Fig. 3) . The apparatus is well tolerated and the patients appeared to prefer this fixation to prolonged conventional casting. One cement block cracked in a very active patient. The amount of cement extending distally to the transverse pin was considered inadequate to accept the strain of the compression wire . Sufficient cement should extend proximally and distally to the transverse pins to prevent this problem. The block in question was repaired easily with the addition of freshly mixed cement (salvaged before cement setting during a hip replacement operation) applied to the existing block. Cement must extend well beyond the transverse pins so that it may contain the longitudinal forces generated by the system.
Discussion Numerous methods are currently available for arthrodesis of small joints of the hanct .2• 7 The system presented provides adequate rotational stability while applying constant dynamic compression in appropriate longitudinal alignment. The compressive effect of the bowed Kirschner wires persists until the wires are removed. When cut free from the blocks of methyl methacrylate , the wires spring back to a straight position.
Vol. IOA, No. 3 May 1985
This indicates that elastic deformation has maintained dynamic compression effectively. The combination of compression and congruous contour of the bone surfaces provided satisfactory rotational stability in all patients. This method has several advantages. The materials are already available in a standard operating room. The operation is easier to perform than the application of plates and screws. The wire removal is performed routinely in the office or clinic, and a second operative procedure is not required. The cost is much less than that of commercially available external fixators. The technique overcomes the problem of fixed distraction, sometimes present with crossed wires, and compensates for bone resorption at the fusion site during healing. This method of compression fixation may be used with virtually any standard arthrodesis technique already favored by the operating surgeon.
Dynamic compression for bone arthrodesis
REFERENCES I. Chamley J: Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg 33-B: 180, 1951 2. Carroll RE, Hill NA: Small joint arthrodesis in hand reconstruction. J Bone Joint Surg 51-A:l219, 1969 3. Ikuta Y, Tsuge K: Micro-bolts and micro-screws for fixation of small bones in the hand. Hand 6:261, 1974 4. Moberg E: Arthrodesis of finger joints. Surg Clin North Am 40:465, 1960 5. Potenza AD: A technique for arthrodesis of the finger joints. J Bone Joint Surg 55-A: 1534, 1973 6. Tupper JW: A compression arthrodesis device for small joints of the hand. Hand 4:62, 1972 7. Wexter MR, Rousso N, Weinberg H: Arthrodesis of finger joints by dynamic external compression using dorsoventral Kirschner wires and rubber bands. Plast Reconstr Surg 66:882, 1977
Studies of pathologic vasoconstriction (vasospasm) in microvascular surgery Characterization and resolution of microvascular spasm were investigated in 170 studies with the use of tail or femoral arteries of the rat. Topical epinephrine reliably produced vasospasm and topical vasodilators which included 2% and 20% lidocaine (Xylocaine) and 0.75% bupivacaine (Marcaine) were applied to resolve the vasoconstriction. Extensive vessel dissection was necessary to obtain significant resolution of vasospasm, and adventitial stripping was associated with even more impressive results. Local anesthetics appear to have a concentration dependent ability to resolve vasospasm, and 20% Xylocaine is the most effective agent yet studied. (J HAND SURG 10A:343-9, 1985.)
Charles L. Puckett, M.D., F.A.C.S., Richard R. W. Winters, M.D., Rodney K. Geter, M.D., and Diane Goebel, M.D., Columbia, Mo.
Technology and experience have allowed the microvascular surgeon to achieve very good anastomotic patency rates. However, failures continue to occur, and many anastomotic failures are largely beFrom the Division of Plastic Surgery, University of Missouri Health Sciences Center, Columbia, Mo. Received for publication March 9, 1984; accepted in revised form Aug. 7, 1984. Reprint requests: Charles L. Puckett, M.D., F.A.C.S., Division of Plastic Surgery, University of Missouri Health Sciences Center, One Hospital Dr.. Columbia, MO 65212.
yond technical control and include factors related to coagulation, platelet function, and vasoconstriction. In reviewing our microvascular failures both in replantations and free tissue transfers, pathologic vasoconstriction (vasospasm) has frequently been a contributing factor. This term refers to the tight vasoconstriction that we occasionally encountered before or after vascular anastomosis that is recalcitrant to mechanical dilation and significantly retards blood flow. It can be found in veins, but most often involves arteries. This vasospasm often defies interpretation. While proximal vasospasm THE JOURNAL OF HAND SURGERY
343