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FIXATION OF METACARPAL FRACTURES USING ABSORBABLE HEMI-CERCLAGE SUTURES
FIXATION OF METACARPAL FRACTURES USING ABSORBABLE HEMI-CERCLAGE SUTURES P. BRUÈSER, R. KREIN and G. LARKIN From the Department of Hand, Plastic and Reconstructive Surgery, Malteser Krankenhaus, Bonn, Germany
We retrospectively reviewed the use of biodegradable hemi-cerclage sutures in the treatment of 79 metacarpal fractures in 66 patients. The polyglycolic acid hemi-cerclages achieved sucient fracture ®xation to permit early motion exercises, but fractures were also immobilized for a mean of 3.7 (range, 1.5±6) weeks postoperatively, during which time physiotherapy was given. Adequate bony stability was achieved after a mean of 4.5 (range, 3.5±7) weeks and fracture redisplacement occurred in only one case. Journal of Hand Surgery (British and European Volume, 1999) 24B: 6: 683±687 unstable fractures or those that remained in unacceptable alignment after closed manipulation. They included metacarpal shaft, head, and basal fractures; 71 had an oblique or spiral con®guration and eight were comminuted. Three fractures had articular involvement. Two aected the thumb, seven the index, 21 the middle, 33 the ring and 16 the small ®nger metacarpal. The mean age of the patients was 34.3 years (range, 11±82). The results were assessed retrospectively from the notes. Outcome measures included time to bony union, duration of immobilization, total active motion (TAM) at the end of treatment, and complications. The mean (SD) length of follow-up was 6.1 (1.2) weeks. During the ®rst part of our study, all fractures were X-rayed every 2 weeks up to bony union to check alignment of the fracture (Fig 1), but later, X-rays were only taken immediately postoperatively and at 4 weeks. If bony union was incomplete at that time, a further X-ray was taken at 6 weeks.
Metacarpal fractures are relatively common injuries and can be treated by a variety of operative and nonoperative techniques. The main objective is to provide sucient stability to the anatomically reduced fracture to allow early mobilization of the hand. The importance of fracture stability following fracture ®xation has led to the development of many techniques, but none are free from complications (Stern, 1993). Plate ®xation is commonly used, but requires extensive exposure and can cause much scarring, joint stiness and tendon adhesion. Furthermore, the plates sometimes have to be removed which subjects the patient to the risks of a further operation and incurs further ®nancial and other economic costs. Biodegradable implants were described by Kulkarni et al. (1966), and Cutright et al. (1971) ®rst reported the successful use of polylactic acid sutures for the ®xation of mandibular fractures in rhesus monkeys. Ewers and HaÈrle (1985) have since reported on the use of biodegradable bone sutures for fractures or osteotomies in oral and maxillofacial surgery, and osteochondral fragments have been successfully ®xed using absorbable screws made of polydioxanone (PDS) in animal experiments (Gay and Bucher, 1985). The use of absorbable cerclages and pins in the management of fractures of the hand has previously been reported (Haas, 1986; Kumta et al., 1992; Merle and Voche, 1994; Meyer-Clement et al., 1984; Rustemeier and Ganûmann, 1986; Sko et al., 1995; WuÈstner et al., 1986) and Rehm et al. (1997) have described their advantages and disadvantages as well as the latest developments in biodegradable implants. However, the limited stability of biodegradable implants has restricted their clinical use and technical development. We retrospectively reviewed the use and results of absorbable hemi-cerclages using polyglycolic acid (PGA) sutures in the treatment of metacarpal fractures.
Operation Open reduction of the metacarpal fractures was carried out via a standard dorsal approach. After reduction, two or more drill holes (1 mm diameter) were placed across, and preferably at right angles to, the fracture. Polyglycolic sutures (2/0) were then passed through the holes and knotted on either the radial or ulnar side of the metacarpal so as to prevent irritation of the extensor tendon (Fig 2). The distance between the hemi-cerclages was usually 1 to 1.5 cm. After surgery, the operated hand was immobilized on a metacarpal plaster splint in the intrinsic-plus position, but controlled unresisted motion exercises were begun from the second postoperative day. During the followup period the patients were reviewed once weekly in the out-patient clinic.
PATIENTS AND METHODS
RESULTS
Between 1986 and 1996, 66 patients with a total of 79 metacarpal fractures requiring operation were treated with absorbable hemi-cerclages. These were either
Bony union occurred without complications in 78 of the 79 metacarpal fractures. A 57-year-old woman with a 683
684
torsion fracture of the small ®nger metacarpal shaft developed a delayed union as a result of repeated premature use of the hand and then underwent revision fracture ®xation with a mini-plate and bone graft. After surgery, the fractures were immobilized for a mean of 3.7 weeks (range, 1.5±6), but the plaster splint was removed at each follow-up review to allow controlled unresisted motion exercises. In no case did the fracture redisplace and there were no problems of wound healing. After a mean of 4.5 weeks (range, 3.5±
THE JOURNAL OF HAND SURGERY VOL. 24B No. 6 DECEMBER 1999
7), the X-rays showed trabeculae crossing the fracture site or sucient callus. It was sometimes dicult to make a de®nite assessment of bony union, but in 45% of the cases unequivocal absorption zones were seen around the fracture site. Some radiological evidence of osteolysis was observed around the drill holes in 5% of the cases (Fig 3). The total active digital motion at the end of treatment had a mean of 98% (range, 85±100) and the patients were discharged after a mean of 6.1 weeks (range, 4±7.5), when many returned to work.
Fig 1 (a) Fractures of the middle and ring metacarpals with articular involvement in the right hand of a 42-year-old man. (b) Fourth postoperative day after hemi-cerclage.
ABSORBABLE HEMI-CERCLAGE SUTURES FOR METACARPAL FRACTURES
685
Fig 1 (c) Six weeks after operation, there was normal clinical function of the injured hand.
Fig 2 Technique of hemi-cerclage of metacarpal bone.
DISCUSSION The aim of primary internal ®xation of metacarpal fractures is to achieve functionally stable ®xation which permits early active mobilization of the hand. The perceived importance of rigid stability has led to increasingly re®ned, complex and more expensive ®xation techniques, but each method has speci®c disadvantages (Black et al., 1985; Stern et al., 1987; Stern, 1993). We used 2/0 polyglycolide sutures with a mean (SD) tensile strength of 838 (19) N/mm2. This reduces by 50% after approximately 17 days and there is a total absorption time of 70 days (Thiede et al., 1980; 1981). In the hemi-cerclage technique, the PGA suture is passed
through the bone at right angles to the fracture and knotted either on the radial or ulnar side. This ®xes the bone fragments directly to one another and produces angular and rotational stability without constricting the complete circumference of the periosteum, in contrast to full cerclages. Although PGA hemi-cerclages produce much less stability than other bone ®xation techniques, our study shows that they provide sucient stability for metacarpal fractures. Gentle ®nger exercises were tolerated and did not cause fracture displacement, but we felt that a splint was required for a mean of 3.7 weeks. Meyer-Clement et al. (1984) treated fractures of the phalanges with absorbable transosseous cerclages and immobilized them for 14 days. Haas (1986) immobilized metacarpal head fractures treated with polydioxanone rods for a similar period. Good patient compliance is vital because this type of ®xation does not provide sucient stability for unrestricted hand use. The use of biodegradable implants for hand fractures, fusions and tendon avulsions from bone has been described by others (Kumta et al., 1992; Merle and Voche, 1994; Rustemeier and Ganûmann, 1986; Sko et al., 1995; WuÈstner et al., 1986) and biodegradable implants have been successfully used in trauma (BoÈstman et al., 1990; Gay and Bucher, 1985; Homann et al., 1989; Miketa and Prigo, 1994; Svenson et al., 1994; Weiler et al., 1996) and maxillofacial surgery (Ewers and HaÈrle, 1985). However, the limited stability produced by biodegradable materials restricts their use primarily to osteochondral fragments, fractures of paraarticular cancellous bone, and fractures with low mechanical load and fast healing times.
686
THE JOURNAL OF HAND SURGERY VOL. 24B No. 6 DECEMBER 1999
Fig 3 Fractures of the middle and ring metacarpal in the left hand; slight osteolysis around drill holes and visible resorption zone at fracture site with callus formation.
Zones of bone resorption and callus formation were observed in about 45% of fractures, which could be interpreted as demonstrating the limited stability of hemi-cerclage ®xation and as a sign of secondary fracture healing. Osteolysis at the sites of bone ®xation was identi®ed radiologically in only 5% of the cases in the present study and should not be regarded as a complication. It is probably a normal reaction to the absorbable bone ®xation material, as macrophages are activated by their degradation products and osteoclasts are stimulated via mediators such as interleukine and prostaglandins (Tegnander et al., 1994; Weiler et al., 1996). Claes et al. (1996) have stated that the slow breakdown of the implant reduces the risk of a foreign body reaction, but only Svenson et al. (1994) have observed any disturbances of bone healing with polyglycolic acid rods. However, biodegradable materials have caused a variety of complications, including local soft-tissue reactions, abacterial wound infections, subcutaneous and intra-articular eusions, and sinus formation (BoÈstman et al., 1990; Miketa and Prigo, 1994; Tegnander et al., 1994; Weiler et al., 1996). The amount of material implanted with hemicerclages is small and the technique of fracture ®xation is simple, causing only minimal damage to surrounding tissues. Our results suggest that biodegradable hemicerclage ®xation of metacarpal fractures produces as good results as other standard ®xation techniques, but direct comparisons are impossible. Open procedures, such as screw or plate ®xation, achieve a good postoperative total range of motion in 82 to 100% of cases, but have a complication rate of at least 3 to 10% (SchoÈttle et al., 1985). Stern et al. (1987) found restricted
motion in up to 29% of cases. Good results can also be achieved with closed reduction and percutaneous pinning (Jones, 1987) and external ®xation (Shehadi, 1991). The hemi-cerclage technique is one of the most economical forms of fracture ®xation and requires no special instruments. In addition, there is no need for implant removal. Its ideal indications are oblique and spiral fractures of the metacarpal shaft, but comminuted fractures can also be managed satisfactorily. References Black D, Mann DJ, Constine R, Daniels AU (1985). Comparison of internal ®xation techniques in metacarpal fractures. Journal of Hand Surgery, 10A: 466±472. BoÈstman OM, Hirvensalo E, MaÈkinen J, Rokkanen P (1990). Foreign body reactions to fracture ®xation implants of biodegradable synthetic polymers. Journal of Bone and Joint Surgery, 72B: 592±596. Claes LE, Ignatius AA, Rehm KE, Scholz C (1996). New bioresorbable pin for the reduction of small bony fragments: design, mechanical properties and in vitro degradation. Biomaterials, 17: 1621±1626. Cutright DE, Hunsuck EE, Beasley JD (1971). Fracture reduction using biodegradable material, polylactic acid. Journal of Oral Surgery, 29: 393±397. Ewers R, HaÈrle F (1985). Experimental and clinical results of new advances in the treatment of facial trauma. Plastic and Reconstructive Surgery, 75: 25±31. Gay B, Bucher H (1985). Tierexperimentelle Untersuchung zur Anwendung von absorbierbaren Osteosyntheseschrauben aus Polydioxanon (PDS). Unfallchirurg, 88: 126±133. Haas HG (1986). PDS Splinte zur Frakturbehandlung. Handchirurgie, 18: 295± 297. Homann R, Krettek C, Haas N, Tscherne H (1989). Die distale Radiusfraktur. Frakturstabilisierung mit biodegradablen Osteosynthese-Stiften (Bio®xR). Unfallchirurg, 92: 430±434. Jones WW (1987). Biomechanics of small bone ®xation. Clinical Orthopaedics and Related Research, 214: 11±18. Kulkarni RK, Pani KC, Neumann C, Leonhard F (1966). Polylactic acid for surgical implants. Archives of Surgery; 93: 839±843. Kumta SM, Spinner R, Leung PC (1992). Absorbable intramedullary implants for hand fractures. Journal of Bone and Joint Surgery, 74B: 563±566.
ABSORBABLE HEMI-CERCLAGE SUTURES FOR METACARPAL FRACTURES Merle M, Voche PH (1994). Absorbable osteosynthesis: experimental and clinical approach in surgery of the hand. Bulletin et Memoires de 1'Academie Royale de Medicine de Belgique, 149: 329±339. Meyer-Clement M, BruÈser P, BoÈnningho N, Stober R (1984). Dexon-Cerclagen am Handskelett. Handchirurgie, 16: 189±191. Miketa JP, Prigo MM (1994). Foreign body reaction to absorbable implant ®xation of osteotomies. Journal of Foot and Ankle Surgery, 33: 623± 627. Rehm KE, Helling HJ, Gatzka C (1997). Neue Entwicklung beim Einsatz resorbierbarer Implantate. OrthopaÈde, 26: 489±497. Rustemeier M, Ganûmann M (1986). Versorgung von knoÈchernen Strecksehnenabrissen mit resorbierbaren Materialien. Handchirurgie, 18: 302±303. SchoÈttle H, Stier GB, Langendor HU (1985). Ergebnisse der operativen Behandlung von Frakturen der Mittelhand und Finger. Unfallchirurgie, 11: 76±83. Shehadi ST (1991). External ®xation of metacarpal and phalangeal fractures. Journal of Hand Surgery, 16A: 544±550. Sko HD, Hecker AT, Hayes WC, Sebell-Sklar R, Straughn N (1995). Bone suture anchors in hand surgery. Journal of Hand Surgery, 20B: 245±248. Stern PJ. Fractures of the metacarpals and phalanges. In Green DP (Ed.) Operative hand surgery, 3rd edn. New York, Churchill Livingstone, 1993, Vol. 1: 695±758. Stern PJ, Wieser MJ, Reilly DG (1987). Complications of plate ®xation in hand skeleton. Clinical Orthopaedics and Related Research, 214: 59±65. Svenson PJ, Janarv PM, Hirsch G (1994). Internal ®xation with biodegradable rods in pediatric fractures: one year follow-up of ®fty patients. Journal of Pediatric Orthopaedics, 14: 220±224.
687
Tegnander A, Engbretsen L, Bergh K, Eide E, Holen KJ, Iversen OJ (1994). Activation of complement system and adverse eects of biodegradable pins of polylactic acid (Bio®xR) in osteochondrosis dissecans. Acta Orthopaedica Scandinavica, 65: 472±475. Thiede A, LuÈnstedt B, Sonntag HG (1980). Untersuchung in vivo zum linearen Reiûfestigkeitsverlust von absorbierbaren vollsynthetischen FaÈden. Der Chirurg, 52: 768±773. Thiede A, LuÈnstedt B, Beck C (1981). Absorbierbare Nahtmaterialien der 2. Generation. Gewebeverhalten und erweiterte Indikationen. Langenbecks Archiv fuÈr Chirurgie, 355: 479±484. Weiler A, Helling HJ, Kirch U, Zirbes T, Rehm KE (1996). Foreign-body reaction and the course of osteolysis after polyglycolide implants for fracture ®xation. Journal of Bone and Joint Surgery, 78B: 369±376. WuÈstner MC, Partecke BD, Buck-Gramcko D (1986). Resorbierbare PDS Splinte zur Frakturstabilisierung und fuÈr Arthrodesen an der Hand. Handchirurgie, 18: 298±301.
Received: 17 November 1998 Accepted after revision: 2 August 1999 R. Krein MD, Department of Hand, Plastic and Reconstructive Surgery, Malteser Krankenhaus, von-Hompesch-Strasse 1, D-53123 Bonn, Germany. # 1999 The British Society for Surgery of the Hand Article no. jhsb.1999.0296
We retrospectively reviewed the use of biodegradable hemi-cerclage sutures in the treatment of 79 metacarpal fractures in 66 patients. The polyglycolic acid hemi-cerclages achieved sucient fracture ®xation to permit early motion exercises, but fractures were also immobilized for a mean of 3.7 (range, 1.5±6) weeks postoperatively, during which time physiotherapy was given. Adequate bony stability was achieved after a mean of 4.5 (range, 3.5±7) weeks and fracture redisplacement occurred in only one case. Journal of Hand Surgery (British and European Volume, 1999) 24B: 6: 683±687 unstable fractures or those that remained in unacceptable alignment after closed manipulation. They included metacarpal shaft, head, and basal fractures; 71 had an oblique or spiral con®guration and eight were comminuted. Three fractures had articular involvement. Two aected the thumb, seven the index, 21 the middle, 33 the ring and 16 the small ®nger metacarpal. The mean age of the patients was 34.3 years (range, 11±82). The results were assessed retrospectively from the notes. Outcome measures included time to bony union, duration of immobilization, total active motion (TAM) at the end of treatment, and complications. The mean (SD) length of follow-up was 6.1 (1.2) weeks. During the ®rst part of our study, all fractures were X-rayed every 2 weeks up to bony union to check alignment of the fracture (Fig 1), but later, X-rays were only taken immediately postoperatively and at 4 weeks. If bony union was incomplete at that time, a further X-ray was taken at 6 weeks.
Metacarpal fractures are relatively common injuries and can be treated by a variety of operative and nonoperative techniques. The main objective is to provide sucient stability to the anatomically reduced fracture to allow early mobilization of the hand. The importance of fracture stability following fracture ®xation has led to the development of many techniques, but none are free from complications (Stern, 1993). Plate ®xation is commonly used, but requires extensive exposure and can cause much scarring, joint stiness and tendon adhesion. Furthermore, the plates sometimes have to be removed which subjects the patient to the risks of a further operation and incurs further ®nancial and other economic costs. Biodegradable implants were described by Kulkarni et al. (1966), and Cutright et al. (1971) ®rst reported the successful use of polylactic acid sutures for the ®xation of mandibular fractures in rhesus monkeys. Ewers and HaÈrle (1985) have since reported on the use of biodegradable bone sutures for fractures or osteotomies in oral and maxillofacial surgery, and osteochondral fragments have been successfully ®xed using absorbable screws made of polydioxanone (PDS) in animal experiments (Gay and Bucher, 1985). The use of absorbable cerclages and pins in the management of fractures of the hand has previously been reported (Haas, 1986; Kumta et al., 1992; Merle and Voche, 1994; Meyer-Clement et al., 1984; Rustemeier and Ganûmann, 1986; Sko et al., 1995; WuÈstner et al., 1986) and Rehm et al. (1997) have described their advantages and disadvantages as well as the latest developments in biodegradable implants. However, the limited stability of biodegradable implants has restricted their clinical use and technical development. We retrospectively reviewed the use and results of absorbable hemi-cerclages using polyglycolic acid (PGA) sutures in the treatment of metacarpal fractures.
Operation Open reduction of the metacarpal fractures was carried out via a standard dorsal approach. After reduction, two or more drill holes (1 mm diameter) were placed across, and preferably at right angles to, the fracture. Polyglycolic sutures (2/0) were then passed through the holes and knotted on either the radial or ulnar side of the metacarpal so as to prevent irritation of the extensor tendon (Fig 2). The distance between the hemi-cerclages was usually 1 to 1.5 cm. After surgery, the operated hand was immobilized on a metacarpal plaster splint in the intrinsic-plus position, but controlled unresisted motion exercises were begun from the second postoperative day. During the followup period the patients were reviewed once weekly in the out-patient clinic.
PATIENTS AND METHODS
RESULTS
Between 1986 and 1996, 66 patients with a total of 79 metacarpal fractures requiring operation were treated with absorbable hemi-cerclages. These were either
Bony union occurred without complications in 78 of the 79 metacarpal fractures. A 57-year-old woman with a 683
684
torsion fracture of the small ®nger metacarpal shaft developed a delayed union as a result of repeated premature use of the hand and then underwent revision fracture ®xation with a mini-plate and bone graft. After surgery, the fractures were immobilized for a mean of 3.7 weeks (range, 1.5±6), but the plaster splint was removed at each follow-up review to allow controlled unresisted motion exercises. In no case did the fracture redisplace and there were no problems of wound healing. After a mean of 4.5 weeks (range, 3.5±
THE JOURNAL OF HAND SURGERY VOL. 24B No. 6 DECEMBER 1999
7), the X-rays showed trabeculae crossing the fracture site or sucient callus. It was sometimes dicult to make a de®nite assessment of bony union, but in 45% of the cases unequivocal absorption zones were seen around the fracture site. Some radiological evidence of osteolysis was observed around the drill holes in 5% of the cases (Fig 3). The total active digital motion at the end of treatment had a mean of 98% (range, 85±100) and the patients were discharged after a mean of 6.1 weeks (range, 4±7.5), when many returned to work.
Fig 1 (a) Fractures of the middle and ring metacarpals with articular involvement in the right hand of a 42-year-old man. (b) Fourth postoperative day after hemi-cerclage.
ABSORBABLE HEMI-CERCLAGE SUTURES FOR METACARPAL FRACTURES
685
Fig 1 (c) Six weeks after operation, there was normal clinical function of the injured hand.
Fig 2 Technique of hemi-cerclage of metacarpal bone.
DISCUSSION The aim of primary internal ®xation of metacarpal fractures is to achieve functionally stable ®xation which permits early active mobilization of the hand. The perceived importance of rigid stability has led to increasingly re®ned, complex and more expensive ®xation techniques, but each method has speci®c disadvantages (Black et al., 1985; Stern et al., 1987; Stern, 1993). We used 2/0 polyglycolide sutures with a mean (SD) tensile strength of 838 (19) N/mm2. This reduces by 50% after approximately 17 days and there is a total absorption time of 70 days (Thiede et al., 1980; 1981). In the hemi-cerclage technique, the PGA suture is passed
through the bone at right angles to the fracture and knotted either on the radial or ulnar side. This ®xes the bone fragments directly to one another and produces angular and rotational stability without constricting the complete circumference of the periosteum, in contrast to full cerclages. Although PGA hemi-cerclages produce much less stability than other bone ®xation techniques, our study shows that they provide sucient stability for metacarpal fractures. Gentle ®nger exercises were tolerated and did not cause fracture displacement, but we felt that a splint was required for a mean of 3.7 weeks. Meyer-Clement et al. (1984) treated fractures of the phalanges with absorbable transosseous cerclages and immobilized them for 14 days. Haas (1986) immobilized metacarpal head fractures treated with polydioxanone rods for a similar period. Good patient compliance is vital because this type of ®xation does not provide sucient stability for unrestricted hand use. The use of biodegradable implants for hand fractures, fusions and tendon avulsions from bone has been described by others (Kumta et al., 1992; Merle and Voche, 1994; Rustemeier and Ganûmann, 1986; Sko et al., 1995; WuÈstner et al., 1986) and biodegradable implants have been successfully used in trauma (BoÈstman et al., 1990; Gay and Bucher, 1985; Homann et al., 1989; Miketa and Prigo, 1994; Svenson et al., 1994; Weiler et al., 1996) and maxillofacial surgery (Ewers and HaÈrle, 1985). However, the limited stability produced by biodegradable materials restricts their use primarily to osteochondral fragments, fractures of paraarticular cancellous bone, and fractures with low mechanical load and fast healing times.
686
THE JOURNAL OF HAND SURGERY VOL. 24B No. 6 DECEMBER 1999
Fig 3 Fractures of the middle and ring metacarpal in the left hand; slight osteolysis around drill holes and visible resorption zone at fracture site with callus formation.
Zones of bone resorption and callus formation were observed in about 45% of fractures, which could be interpreted as demonstrating the limited stability of hemi-cerclage ®xation and as a sign of secondary fracture healing. Osteolysis at the sites of bone ®xation was identi®ed radiologically in only 5% of the cases in the present study and should not be regarded as a complication. It is probably a normal reaction to the absorbable bone ®xation material, as macrophages are activated by their degradation products and osteoclasts are stimulated via mediators such as interleukine and prostaglandins (Tegnander et al., 1994; Weiler et al., 1996). Claes et al. (1996) have stated that the slow breakdown of the implant reduces the risk of a foreign body reaction, but only Svenson et al. (1994) have observed any disturbances of bone healing with polyglycolic acid rods. However, biodegradable materials have caused a variety of complications, including local soft-tissue reactions, abacterial wound infections, subcutaneous and intra-articular eusions, and sinus formation (BoÈstman et al., 1990; Miketa and Prigo, 1994; Tegnander et al., 1994; Weiler et al., 1996). The amount of material implanted with hemicerclages is small and the technique of fracture ®xation is simple, causing only minimal damage to surrounding tissues. Our results suggest that biodegradable hemicerclage ®xation of metacarpal fractures produces as good results as other standard ®xation techniques, but direct comparisons are impossible. Open procedures, such as screw or plate ®xation, achieve a good postoperative total range of motion in 82 to 100% of cases, but have a complication rate of at least 3 to 10% (SchoÈttle et al., 1985). Stern et al. (1987) found restricted
motion in up to 29% of cases. Good results can also be achieved with closed reduction and percutaneous pinning (Jones, 1987) and external ®xation (Shehadi, 1991). The hemi-cerclage technique is one of the most economical forms of fracture ®xation and requires no special instruments. In addition, there is no need for implant removal. Its ideal indications are oblique and spiral fractures of the metacarpal shaft, but comminuted fractures can also be managed satisfactorily. References Black D, Mann DJ, Constine R, Daniels AU (1985). Comparison of internal ®xation techniques in metacarpal fractures. Journal of Hand Surgery, 10A: 466±472. BoÈstman OM, Hirvensalo E, MaÈkinen J, Rokkanen P (1990). Foreign body reactions to fracture ®xation implants of biodegradable synthetic polymers. Journal of Bone and Joint Surgery, 72B: 592±596. Claes LE, Ignatius AA, Rehm KE, Scholz C (1996). New bioresorbable pin for the reduction of small bony fragments: design, mechanical properties and in vitro degradation. Biomaterials, 17: 1621±1626. Cutright DE, Hunsuck EE, Beasley JD (1971). Fracture reduction using biodegradable material, polylactic acid. Journal of Oral Surgery, 29: 393±397. Ewers R, HaÈrle F (1985). Experimental and clinical results of new advances in the treatment of facial trauma. Plastic and Reconstructive Surgery, 75: 25±31. Gay B, Bucher H (1985). Tierexperimentelle Untersuchung zur Anwendung von absorbierbaren Osteosyntheseschrauben aus Polydioxanon (PDS). Unfallchirurg, 88: 126±133. Haas HG (1986). PDS Splinte zur Frakturbehandlung. Handchirurgie, 18: 295± 297. Homann R, Krettek C, Haas N, Tscherne H (1989). Die distale Radiusfraktur. Frakturstabilisierung mit biodegradablen Osteosynthese-Stiften (Bio®xR). Unfallchirurg, 92: 430±434. Jones WW (1987). Biomechanics of small bone ®xation. Clinical Orthopaedics and Related Research, 214: 11±18. Kulkarni RK, Pani KC, Neumann C, Leonhard F (1966). Polylactic acid for surgical implants. Archives of Surgery; 93: 839±843. Kumta SM, Spinner R, Leung PC (1992). Absorbable intramedullary implants for hand fractures. Journal of Bone and Joint Surgery, 74B: 563±566.
ABSORBABLE HEMI-CERCLAGE SUTURES FOR METACARPAL FRACTURES Merle M, Voche PH (1994). Absorbable osteosynthesis: experimental and clinical approach in surgery of the hand. Bulletin et Memoires de 1'Academie Royale de Medicine de Belgique, 149: 329±339. Meyer-Clement M, BruÈser P, BoÈnningho N, Stober R (1984). Dexon-Cerclagen am Handskelett. Handchirurgie, 16: 189±191. Miketa JP, Prigo MM (1994). Foreign body reaction to absorbable implant ®xation of osteotomies. Journal of Foot and Ankle Surgery, 33: 623± 627. Rehm KE, Helling HJ, Gatzka C (1997). Neue Entwicklung beim Einsatz resorbierbarer Implantate. OrthopaÈde, 26: 489±497. Rustemeier M, Ganûmann M (1986). Versorgung von knoÈchernen Strecksehnenabrissen mit resorbierbaren Materialien. Handchirurgie, 18: 302±303. SchoÈttle H, Stier GB, Langendor HU (1985). Ergebnisse der operativen Behandlung von Frakturen der Mittelhand und Finger. Unfallchirurgie, 11: 76±83. Shehadi ST (1991). External ®xation of metacarpal and phalangeal fractures. Journal of Hand Surgery, 16A: 544±550. Sko HD, Hecker AT, Hayes WC, Sebell-Sklar R, Straughn N (1995). Bone suture anchors in hand surgery. Journal of Hand Surgery, 20B: 245±248. Stern PJ. Fractures of the metacarpals and phalanges. In Green DP (Ed.) Operative hand surgery, 3rd edn. New York, Churchill Livingstone, 1993, Vol. 1: 695±758. Stern PJ, Wieser MJ, Reilly DG (1987). Complications of plate ®xation in hand skeleton. Clinical Orthopaedics and Related Research, 214: 59±65. Svenson PJ, Janarv PM, Hirsch G (1994). Internal ®xation with biodegradable rods in pediatric fractures: one year follow-up of ®fty patients. Journal of Pediatric Orthopaedics, 14: 220±224.
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Received: 17 November 1998 Accepted after revision: 2 August 1999 R. Krein MD, Department of Hand, Plastic and Reconstructive Surgery, Malteser Krankenhaus, von-Hompesch-Strasse 1, D-53123 Bonn, Germany. # 1999 The British Society for Surgery of the Hand Article no. jhsb.1999.0296