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Long-term follow-up of nonvascularized fibular autografts for distal radial reconstruction
Long-term follow-up of nonvascularized fibular autografts for distal radial reconstruction Three patients with giant cell tumors of the distal radius had en bloc excision of the distal radius and replacement with the ipsilateral fibula. Two of the patients were followed for 16 years and one for 14Y2 years. Forearm rotation, as well as wrist motion, was limited in all three patients, yet they remained functional and pain free except during periods of prolonged or excessive use. All three patients were pleased with the results. Bone union occurred primarily in all three patients without a supplemental bone graft or microvascular anastomosis. This method has a definite place in the hand surgeon's armamentarium when compared with radial allografts and microvascular free fibular translocation. (J HAND SuRG 10A:335-40, 1985.)
Raymond C. Noellert, M.D., and Dean S. Louis, M.D., Ann Arbor, Mich. The use of a fibular autograft for reconstruction of the distal radius has been described in several articles over the past 75 years. 1-6 Most of the cases have been brief case reports with follow-up of less than 5 years. The indication for this procedure has most frequently been the presence of a locally aggressive tumor or one that has recurred after less radical, earlier treatment. Giant cell tumors, aneurysmal bone cysts, and chondrosarcoma have been treated in this way. Alternative methods of treatment for stabilization or reconstruction after excision of the distal radius include inlay grafting and arthrodesis with cortical-cancellous grafts from the ilium, tibia, or fibula 7 • 8 ; allograft replacement9 ; custom prosthesis 10 ; pedicle bone grafts 11 ; and more recently use of autogenous fibula with microvascular reconstruction of its intrinsic blood supply. 12. 13
the biopsy tract. Extraperiosteal, en bloc resection of each lesion was performed with the required length of distal radius resection determined by preoperative xray films. The ipsilateral fibula was used in all cases. In two cases, it was step cut at its proximal juncture to allow fixation to the remaining radius with two cortical screws. Fixation was obtained with an intramedullary rod in the third case. Primary supplemental cancellous bone graft was not used. The palmar and dorsal ligamentous structures that join the radius to the carpus were detached proximally and reattached to the fibula by sutures through small drill holes. Other forms of soft tissue stabilization such as that advocated by Mack et al. 6 were not utilized. The extremity was then immobilized in a long-arm cast.
The use of fibular autografts was recently reviewed by Mack et al., 6 who considered it an excellent method of reconstruction when compared with other techniques. This article describes three additional cases of the use of free autogenous fibular grafts with a much longer period of follow-up than has been previously reported.
Case 1. N. W., a 32-year-old right-handed housewife and secretary, presented with symptoms of progressively increasing left wrist pain. Radiographs revealed a lytic lesion of the distal left radius (Fig. 1, A). An incisional biopsy was reported as consistent with a giant cell tumor of bone. The lesion recurred after curettage and bone grafting. An en bloc resection of the distal 9 cm of the radius with fibular reconstruction was performed on Dec. 17, 1968. The left upper extremity was immobilized in a long-arm cast for 6 months. Since then, the patient has continued to work as a secretary and also plays the organ. Her only complaint is mild aching pain after prolonged heavy yard work. She considers her results excellent. Her radiographs 16 years after surgery (Fig. 1, B) show a loss of cartilage space and good centralization of the carpus. Case 2. K. F., a 42-year-old right-handed truck driver, presented with symptoms of a pathologic fracture of the left distal radius. The findings of the initial biopsy suggested a giant cell tumor of bone. After the fracture had healed, the distal radius was excised and the ipsilateral fibula was trans-
Operative technique Pathologic diagnosis was made by prior biopsy in all cases. The incision was planned in order to incorporate
From the Orthopaedic Hand Service, Department of Surgery, University of Michigan Hospitals, Ann Arbor, Mich. Received for publication July 11, 1984; accepted in revised form Sept. 14, 1984. Reprint requests: Dean S. Louis, M.D., C4500 Outpatient, University of Michigan Hospitals, Ann Arbor, MI 48109.
Case histories
THE JOURNAL OF HAND SURGERY
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336
The Journal of HAND SURGERY
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Fig. lA. This large expansile lesion seen in the distal left radius was a giant cell tumor. The tumor recurred after curettage and bone grafting. posed in the distal radius in November 1967. A Rush rod was used for fixation of the 8 cm segment of fibula with continued immobilization for the next 8 months. He still continues to work full-time as a truck driver. He has no pain and considers his results excellent. Radiographs 14Y2 years after surgery (Fig. 2) show a well-maintained cartilage space. The preoperative radiographs had been destroyed at the time of this review, but they were similar to those of case 1. Case 3. L. W., a 56-year-old left-handed mechanic, presented with symptom of pain in the left wrist. Results of a biopsy of the distal radial lesion revealed a giant cell tumor of bone. In January 1968, the ipsilateral fibula was transposed for an 8 cm segment of the radius, which also was done in case 1. Postoperative immobilization in a plaster cast totaled 6 months. Because of moderate limitation of motion, he used his right hand as his dominant extremity and continued to work as a mechanic until his retirement a few years ago. He remains pain free with excellent subjective results. His radiographs 16 years after surgery (Fig. 3) show an excellent position at the junction of the fibula with the carpus and some preservation of cartilage space. His preoperative radiographs had also been destroyed, but were similar to those of the previous two cases.
Results Subjectively, all patients considered their results excellent. The affected extremity was used in all activities. None of the patients were forced to make a change in life-style or employment. Objective measurements
regarding range of motion, grip strength, and key pinch strength are listed in Table I. The radiographic findings are summarized in Table II. Of note are the lack of severe degenerative changes, the complete incorporation at the graft site, and the lack of evidence of recurring tumors. Two additional patients have had this procedure during the past 5 years; both of them have achieved primary union without supplemental bone graft. They are not included in this study because the follow-up period is too short.
Discussion Several alternative procedures are available when the distal radius must be replaced, whether as a result of trauma or because of a tumor. The procedure that is used in a given case will depend on factors such as the amount of bone Joss in the case of trauma or the extent of involvement of the radius when a tumor is the cause. Ideally, the surgeon should use a bone that is similar in size and shape and that is nonantigenic. 9 The preservation of wrist motion and forearm rotation is also desirable. Fibular transposition and allografts have the potential to preserve motion. However, allografts have the potential for antigenicity and are composed of entirely dead bone that has been altered by either radiation, freezing, or both. 9
Vol. IOA, No. 3 May 1985
Follow-up of autografts for radial reconstruction
Fig. lB. Radiographs reveal reconstruction 16 years after the ipsilateral fibula was substituted for the distal radius. Cartilage space is diminished, and there is good centralization of the carpus in relation to the distal radius.
Table I Case I ROM Extension Flex ion Radial deviation Ulnar deviation Pro nation Supination Grip strength* Right Left Key pinch strengtht Right Left *Tested with Jaymar Dynamometer. tTested with Preston Pinch Gauge.
Case 2
0-25 0-5
Case 3
0 0-30 0 0-15 0-25 0
0-80 0
0-40 0-50 0 0-10 0-80 0-30
50 pounds 35 pounds
100 pounds 80 pounds
28 pounds 20 pounds
17 pounds 18 pounds
30 pounds 30 pounds
20 pounds 20 pounds
337
The Journal of HAND SURGERY
338 Noellert and Louis
Fig. 2. Cartilage space is diminished, but still present 14V2 years after resection of the distal radius and replacement with the ipsilateral fibula.
Table II
Radiographic findings Union at graft site Degenerative changes Tumor recurrence Evidence of fracture Instability pattern Wrist subluxation
Case I
Case 2
Case 3
Complete Moderate No No
Complete Mild No No No
Complete Mild No No No No
No
Cortical cancellous inlay grafts 7 • 8 and local pedicle bone grafting leave the wrist stiff and alter the shape and function of the forearm.'' The fibular autograft with microvascular anastomosis has received considerable attention lately. The potential for nonunion and the need for later wrist fusion are still present with this method. 12 Long-term follow-up will
')
be needed before the relative merits of both procedures can be known. In this time of increasing health care costs, procedures that require more operative time even though they have great technical appeal may be doomed if there is no proven advantage. In an editorial discussing one method of reconstruction, Crawford Campbell' 5 stated that "the success of
Vol. JOA, No. 3
May 1985
Follow-up of autografts for radial reconstruction
339
Fig. 3. Good maintenance of position of the carpus and solid bony union at the bone junction are seen, 16 years after the distal radius was replaced with a fibular autograft. each method must be considered preliminary until the patients are reviewed at least five years after the operation." This article is the first to provide significant long-term follow-up for any method of distal radius reconstruction. The results presented here indicate that a free autogenous fibular graft is an efficacious method for reconstruction of the distal radius. The motion that was preserved was functional in all of our patients, although it was definitely limited (Table I). The current wave of enthusiasm for microvascular free fibular translocation and allograft replacement of the radius certainly has a place in the spectrum of possibilities for the management of similar problems. The former method has the potential advantage of earlier bone union and therefore an earlier program for postoperative mobilization. It has the disadvantage of increased operative time at a time in the evolution of health care when cost-effectiveness may become an issue. The latter method has the advantage of replicating the architecture of the distal radius. Antigenicity and
the potential for infection and rejection loom as possible serious problems with the use of allografts to replace the distal radius. The prolonged immobilization that was maintained in our cases may not have been necessary. It was a reflection of the orthopedic thinking during the period when the procedures were performed. All of our cases demonstrated some shortening of the radius, which combined with prolonged immobilization may have contributed to the overall reduction in range of motion. Long-term follow-up of other available methods is needed before meaningful comparisons can be made.
REFERENCES 1. Walther M: Resection de l'extremite inferieure du radius pour osteosarcoma. Greffe de l'extremite superieure du perone. Bull Et Mem Soc De Chir De Par 37:954, 1911 2. Lawson TL: Fibular transplant for osteoclastoma of the radius. J Bone Joint Surg [Br] 34:74-5, 1952 3. Sakellarides HT: Extensive giant cell tumor of the lower end of the radius. A report of one case treated by resection
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
Raymond C. Noellert, M.D., and Dean S. Louis, M.D., Ann Arbor, Mich. The use of a fibular autograft for reconstruction of the distal radius has been described in several articles over the past 75 years. 1-6 Most of the cases have been brief case reports with follow-up of less than 5 years. The indication for this procedure has most frequently been the presence of a locally aggressive tumor or one that has recurred after less radical, earlier treatment. Giant cell tumors, aneurysmal bone cysts, and chondrosarcoma have been treated in this way. Alternative methods of treatment for stabilization or reconstruction after excision of the distal radius include inlay grafting and arthrodesis with cortical-cancellous grafts from the ilium, tibia, or fibula 7 • 8 ; allograft replacement9 ; custom prosthesis 10 ; pedicle bone grafts 11 ; and more recently use of autogenous fibula with microvascular reconstruction of its intrinsic blood supply. 12. 13
the biopsy tract. Extraperiosteal, en bloc resection of each lesion was performed with the required length of distal radius resection determined by preoperative xray films. The ipsilateral fibula was used in all cases. In two cases, it was step cut at its proximal juncture to allow fixation to the remaining radius with two cortical screws. Fixation was obtained with an intramedullary rod in the third case. Primary supplemental cancellous bone graft was not used. The palmar and dorsal ligamentous structures that join the radius to the carpus were detached proximally and reattached to the fibula by sutures through small drill holes. Other forms of soft tissue stabilization such as that advocated by Mack et al. 6 were not utilized. The extremity was then immobilized in a long-arm cast.
The use of fibular autografts was recently reviewed by Mack et al., 6 who considered it an excellent method of reconstruction when compared with other techniques. This article describes three additional cases of the use of free autogenous fibular grafts with a much longer period of follow-up than has been previously reported.
Case 1. N. W., a 32-year-old right-handed housewife and secretary, presented with symptoms of progressively increasing left wrist pain. Radiographs revealed a lytic lesion of the distal left radius (Fig. 1, A). An incisional biopsy was reported as consistent with a giant cell tumor of bone. The lesion recurred after curettage and bone grafting. An en bloc resection of the distal 9 cm of the radius with fibular reconstruction was performed on Dec. 17, 1968. The left upper extremity was immobilized in a long-arm cast for 6 months. Since then, the patient has continued to work as a secretary and also plays the organ. Her only complaint is mild aching pain after prolonged heavy yard work. She considers her results excellent. Her radiographs 16 years after surgery (Fig. 1, B) show a loss of cartilage space and good centralization of the carpus. Case 2. K. F., a 42-year-old right-handed truck driver, presented with symptoms of a pathologic fracture of the left distal radius. The findings of the initial biopsy suggested a giant cell tumor of bone. After the fracture had healed, the distal radius was excised and the ipsilateral fibula was trans-
Operative technique Pathologic diagnosis was made by prior biopsy in all cases. The incision was planned in order to incorporate
From the Orthopaedic Hand Service, Department of Surgery, University of Michigan Hospitals, Ann Arbor, Mich. Received for publication July 11, 1984; accepted in revised form Sept. 14, 1984. Reprint requests: Dean S. Louis, M.D., C4500 Outpatient, University of Michigan Hospitals, Ann Arbor, MI 48109.
Case histories
THE JOURNAL OF HAND SURGERY
335
336
The Journal of HAND SURGERY
Noellert and Louis
Fig. lA. This large expansile lesion seen in the distal left radius was a giant cell tumor. The tumor recurred after curettage and bone grafting. posed in the distal radius in November 1967. A Rush rod was used for fixation of the 8 cm segment of fibula with continued immobilization for the next 8 months. He still continues to work full-time as a truck driver. He has no pain and considers his results excellent. Radiographs 14Y2 years after surgery (Fig. 2) show a well-maintained cartilage space. The preoperative radiographs had been destroyed at the time of this review, but they were similar to those of case 1. Case 3. L. W., a 56-year-old left-handed mechanic, presented with symptom of pain in the left wrist. Results of a biopsy of the distal radial lesion revealed a giant cell tumor of bone. In January 1968, the ipsilateral fibula was transposed for an 8 cm segment of the radius, which also was done in case 1. Postoperative immobilization in a plaster cast totaled 6 months. Because of moderate limitation of motion, he used his right hand as his dominant extremity and continued to work as a mechanic until his retirement a few years ago. He remains pain free with excellent subjective results. His radiographs 16 years after surgery (Fig. 3) show an excellent position at the junction of the fibula with the carpus and some preservation of cartilage space. His preoperative radiographs had also been destroyed, but were similar to those of the previous two cases.
Results Subjectively, all patients considered their results excellent. The affected extremity was used in all activities. None of the patients were forced to make a change in life-style or employment. Objective measurements
regarding range of motion, grip strength, and key pinch strength are listed in Table I. The radiographic findings are summarized in Table II. Of note are the lack of severe degenerative changes, the complete incorporation at the graft site, and the lack of evidence of recurring tumors. Two additional patients have had this procedure during the past 5 years; both of them have achieved primary union without supplemental bone graft. They are not included in this study because the follow-up period is too short.
Discussion Several alternative procedures are available when the distal radius must be replaced, whether as a result of trauma or because of a tumor. The procedure that is used in a given case will depend on factors such as the amount of bone Joss in the case of trauma or the extent of involvement of the radius when a tumor is the cause. Ideally, the surgeon should use a bone that is similar in size and shape and that is nonantigenic. 9 The preservation of wrist motion and forearm rotation is also desirable. Fibular transposition and allografts have the potential to preserve motion. However, allografts have the potential for antigenicity and are composed of entirely dead bone that has been altered by either radiation, freezing, or both. 9
Vol. IOA, No. 3 May 1985
Follow-up of autografts for radial reconstruction
Fig. lB. Radiographs reveal reconstruction 16 years after the ipsilateral fibula was substituted for the distal radius. Cartilage space is diminished, and there is good centralization of the carpus in relation to the distal radius.
Table I Case I ROM Extension Flex ion Radial deviation Ulnar deviation Pro nation Supination Grip strength* Right Left Key pinch strengtht Right Left *Tested with Jaymar Dynamometer. tTested with Preston Pinch Gauge.
Case 2
0-25 0-5
Case 3
0 0-30 0 0-15 0-25 0
0-80 0
0-40 0-50 0 0-10 0-80 0-30
50 pounds 35 pounds
100 pounds 80 pounds
28 pounds 20 pounds
17 pounds 18 pounds
30 pounds 30 pounds
20 pounds 20 pounds
337
The Journal of HAND SURGERY
338 Noellert and Louis
Fig. 2. Cartilage space is diminished, but still present 14V2 years after resection of the distal radius and replacement with the ipsilateral fibula.
Table II
Radiographic findings Union at graft site Degenerative changes Tumor recurrence Evidence of fracture Instability pattern Wrist subluxation
Case I
Case 2
Case 3
Complete Moderate No No
Complete Mild No No No
Complete Mild No No No No
No
Cortical cancellous inlay grafts 7 • 8 and local pedicle bone grafting leave the wrist stiff and alter the shape and function of the forearm.'' The fibular autograft with microvascular anastomosis has received considerable attention lately. The potential for nonunion and the need for later wrist fusion are still present with this method. 12 Long-term follow-up will
')
be needed before the relative merits of both procedures can be known. In this time of increasing health care costs, procedures that require more operative time even though they have great technical appeal may be doomed if there is no proven advantage. In an editorial discussing one method of reconstruction, Crawford Campbell' 5 stated that "the success of
Vol. JOA, No. 3
May 1985
Follow-up of autografts for radial reconstruction
339
Fig. 3. Good maintenance of position of the carpus and solid bony union at the bone junction are seen, 16 years after the distal radius was replaced with a fibular autograft. each method must be considered preliminary until the patients are reviewed at least five years after the operation." This article is the first to provide significant long-term follow-up for any method of distal radius reconstruction. The results presented here indicate that a free autogenous fibular graft is an efficacious method for reconstruction of the distal radius. The motion that was preserved was functional in all of our patients, although it was definitely limited (Table I). The current wave of enthusiasm for microvascular free fibular translocation and allograft replacement of the radius certainly has a place in the spectrum of possibilities for the management of similar problems. The former method has the potential advantage of earlier bone union and therefore an earlier program for postoperative mobilization. It has the disadvantage of increased operative time at a time in the evolution of health care when cost-effectiveness may become an issue. The latter method has the advantage of replicating the architecture of the distal radius. Antigenicity and
the potential for infection and rejection loom as possible serious problems with the use of allografts to replace the distal radius. The prolonged immobilization that was maintained in our cases may not have been necessary. It was a reflection of the orthopedic thinking during the period when the procedures were performed. All of our cases demonstrated some shortening of the radius, which combined with prolonged immobilization may have contributed to the overall reduction in range of motion. Long-term follow-up of other available methods is needed before meaningful comparisons can be made.
REFERENCES 1. Walther M: Resection de l'extremite inferieure du radius pour osteosarcoma. Greffe de l'extremite superieure du perone. Bull Et Mem Soc De Chir De Par 37:954, 1911 2. Lawson TL: Fibular transplant for osteoclastoma of the radius. J Bone Joint Surg [Br] 34:74-5, 1952 3. Sakellarides HT: Extensive giant cell tumor of the lower end of the radius. A report of one case treated by resection
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