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Osteochondral fracture of talus treated with bio absorbable pins
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The Foot 18 (2008) 56–58
Case report
Osteochondral fracture of talus treated with bio absorbable pins Prakash Chandran a,∗ , Ravindra P. Kamath b , Aneel Nihal b b
a Trauma and Orthopaedics, Arrowe Park Hospital, Wirral, United Kingdom Department of Trauma and Orthopaedics, Hull Royal Infirmary, Hull, West Yorkshire, United Kingdom
Received 24 September 2007; accepted 24 October 2007
Abstract We report a case of osteochondral fracture of the talus treated by open reduction and internal fixation with bioabsorbable pins. A displaced osteochondral fracture of the lateral aspect of the talar dome measuring 7.5 mm × 3.8 mm × 5 mm was treated by open reduction and fixation with bioabsorbable (poly-p-dioxanone) pins. Satisfactory healing of the osteochondral fracture was achieved without any complications and the patient had good functional outcome. We believe that poly-p-dioxanone pins are a safe and effective option to consider while treating osteochondral fractures of the talus. Published by Elsevier Ltd. Keywords: Osteochondral fracture; Talus; Bioabsorbable pins
1. Introduction Increasing awareness and improved accessibility to imaging has lead to increased reporting of osteochondral fractures of the talus. Osteochondral lesions are relatively common and usually occur as a result of trauma. They often go unrecognized and lead to an osteochondral defect that may eventually result in secondary osteoarthrosis. Detection of these lesions has been aided by CT, MR imaging and bone scan. With limited ability of the hyaline cartilage to repair itself, surgical intervention is often necessary to create an optimal healing environment [2]. The goal of all treatment methods is to provide a stable, congruent joint surface, restore function, and prevent the evolution of osteoarthrosis. Acute osteochondral fragments can be replaced and internally fixed [3,6] or the fragment arthroscopically excised with curettage and drilling of the surface [8]. Internal fixation devices include metal screws/pins or bioabsorbable pins. Metal pins/screws may occasionally need removal if there is collapse of the osteochondral fragment, while such complication could be avoided by the use of bio absorbable pins. However bioabsorbable pins for intraar∗ Corresponding author at: 15 Cresswell Close, Callands, Warrington, North Cheshire WA5 9UA, United Kingdom. Tel.: +44 7919403862. E-mail address: [email protected] (P. Chandran).
0958-2592/$ – see front matter. Published by Elsevier Ltd. doi:10.1016/j.foot.2007.10.001
ticular use are yet to be widely used. Results indicate that absorbable implants are biocompatible and effective in the fixation of osteochondral fragments [4]. Though bioabsorbable pins have been used in the treatment of various fractures, their use in the treatment of osteochondral fractures of the talus has not been widely reported. We report a case of osteochondral fracture treated successfully with a bio absorbable pin.
2. Case report A 26-year-old joiner tripped over scaffolding at work and fell from a height of 5 feet, sustaining injury to his left ankle. He presented to the accident and emergency department with a painful bruised ankle and inability to weight bear. Anterioposterior, lateral and oblique radiographs of the ankle showed an osteochondral fracture of the talar dome (Fig. 1). CT scan of his ankle showed a displaced osteochondral fracture of the lateral aspect of the talar dome measuring 7.5 mm × 3.8 mm × 5 mm (Fig. 2), no other injuries were identified. The patient underwent open reduction and internal fixation of this fracture. An anterolateral arthrotomy was performed and the talar dome identified, osteochondral fracture was exposed and defined, the fractured fragment was found to be displaced and rotated by 180 degrees with the articular
P. Chandran et al. / The Foot 18 (2008) 56–58
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Fig. 3. Intra operative picture of the osteochondral fragment following fixation with bioabsorbable screws. Fig. 1. X-ray showing osteochondral fracture on dome of the talus.
surface of the fragment facing the talar dome and the fractured surface was facing the tibial plafond. The fragment was reduced anatomically and held in the reduced position with three 40 mm × 1.3 mm absorbable pins (Orthosorb® bioabsorbable pin) (Fig. 3). Postoperatively the leg was supported in a below knee plaster cast and was kept nonweight bearing for 6 weeks. Touch weight bearing was allowed at the end of 6 weeks in a below knee removable splint. Full weight bearing was allowed at 3 months post-fixation. At the last follow up 12 months post-surgery, the patient had no pain and was mobilising full weight bearing, he had 10 degrees of dorsiflexion and 30 degrees of plantar flexion at his ankle joint which was pain free. X-ray and MR scan of his ankle
Fig. 4. CT picture of the talus following satisfactory healing of the osteochondral fracture.
showed satisfactory healing of the fracture with no evidence of avascular necrosis (Fig. 4).
3. Discussion
Fig. 2. Computed tomogram showing osteochondral fracture on the dome of the talus.
Early recognition and appropriate treatment of osteochondral fractures involving the talus is necessary in order to produce favourable results [2]. Though osteochondral fractures have been satisfactorily treated by excision of the osteochondral fragment [8], early treatment with open reduction and internal fixation using a low profile screw or pins may prevent occurrence of secondary osteoarthritis [6]. For fixation of the osteochondral fragments, bioabsorbable pins are available as an alternate choice to metal fixation. The gradual absorption of these pins allows for optimum transfer of support to the bone as the healing of fracture progresses.
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P. Chandran et al. / The Foot 18 (2008) 56–58
These pins provide the same support as metal fixation for protection against shear and rotational forces, while eliminating most of its disadvantages. However, use of bioabsorbable implants has been reported to be associated with adverse tissue reaction [1] which can be mild in the form of painful erythematous papule, or of medium severity with a sinus that may discharged remnants of the implant for a short time or severe with extensive osteolytic lesions adjacent to the implant tracks with formation of a sterile discharging sinus [5]. Bio absorbable pins commonly used in fracture fixation include polyglycolide pins (Biofix® ), polylactide acid and poly-p-dioxanone (PDS) (Orhosorb® ). Studies have demonstrated that absorbable implants are biocompatible and are effective for fixation of osteochondral fragments [4]. Numerous trials have compared the use of bioabsorbable pins with each other and with metal pins. Lavery et al. [7] compared polyglycolide pins with poly-p-dioxanone pins in the fixation of the first metatarsal osteotomies and reported more complications with polyglycolide pins. Comparing poly-pdioxanone pins to K wires for fixation following chevron osteotomy, Gill et al. [5] found no difference between them and concluded that bioabsorbable pins can be reliably used to fix osteotomies without undue risk of osteolysis and other complications. Lavery et al. [7] compared Biofix, polyglycolide pins and Orthosorb, polydioxanon pins, in fixation of first metatarsal osteotomies and complications were more common in osteotomies fixed with Biofix compared with Orthosorb.
Bioabsorbable pins have been used in the treatment of various fractures; there is limited literature on its use for intra articular fractures. We achieved satisfactory healing of the osteochondral fracture of the talus with poly-p-dioxanone (PDS) without any complications and the patient had good functional outcome. We believe that poly-p-dioxanone pins are a safe and effective option to consider while fixing osteochondral fractures of the talus.
References [1] Bostman OM, Pihlajamaki HK. Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop Relat Res 2000;371:216–27. [2] Chaney DM, Toups J, Foster J. Osteochondral fractures of the talus. Clin Podiatr Med Surg 2001;18(3):481–93. [3] Farmer JM, Martin DF, Boles CA, Curl WW. Chondral and osteochondral injuries. Diagnosis and management. Clin Sports Med 2001;20(2):299–320. [4] Fuchs M, Vosshenrich R, Dumont C, Sturmer KM. Reification of osteochondral fragments using absorbable implants. First results of a retrospective study. Chirurg 2003;74(6):554–61. [5] Gill LH, Martin DF, Coumas JM, Kiebzak GM. Fixation with bioabsorbable pins in chevron bunionectomy. J Bone Joint Surg Am 1997;79(10):1510–8. [6] Jimenez AL, Morgan Jr JH. Talar fractures: three case studies. J Am Podiatr Med Assoc 2001;91(8):415–21. [7] Lavery LA, Peterson JED, Pollack R, Higgins KR. Risk of complications of first metatarsal head osteotomies with biodegradable pin fixation: biofix versus orthosorb. J Foot Ankle Surg 1994;33(4):334–40. [8] Schuman L, Struijs PA, van Dijk CN. Traumatic osteochondral lesions of the talar dome. Orthopade 2001;30(1):66–72.
The Foot 18 (2008) 56–58
Case report
Osteochondral fracture of talus treated with bio absorbable pins Prakash Chandran a,∗ , Ravindra P. Kamath b , Aneel Nihal b b
a Trauma and Orthopaedics, Arrowe Park Hospital, Wirral, United Kingdom Department of Trauma and Orthopaedics, Hull Royal Infirmary, Hull, West Yorkshire, United Kingdom
Received 24 September 2007; accepted 24 October 2007
Abstract We report a case of osteochondral fracture of the talus treated by open reduction and internal fixation with bioabsorbable pins. A displaced osteochondral fracture of the lateral aspect of the talar dome measuring 7.5 mm × 3.8 mm × 5 mm was treated by open reduction and fixation with bioabsorbable (poly-p-dioxanone) pins. Satisfactory healing of the osteochondral fracture was achieved without any complications and the patient had good functional outcome. We believe that poly-p-dioxanone pins are a safe and effective option to consider while treating osteochondral fractures of the talus. Published by Elsevier Ltd. Keywords: Osteochondral fracture; Talus; Bioabsorbable pins
1. Introduction Increasing awareness and improved accessibility to imaging has lead to increased reporting of osteochondral fractures of the talus. Osteochondral lesions are relatively common and usually occur as a result of trauma. They often go unrecognized and lead to an osteochondral defect that may eventually result in secondary osteoarthrosis. Detection of these lesions has been aided by CT, MR imaging and bone scan. With limited ability of the hyaline cartilage to repair itself, surgical intervention is often necessary to create an optimal healing environment [2]. The goal of all treatment methods is to provide a stable, congruent joint surface, restore function, and prevent the evolution of osteoarthrosis. Acute osteochondral fragments can be replaced and internally fixed [3,6] or the fragment arthroscopically excised with curettage and drilling of the surface [8]. Internal fixation devices include metal screws/pins or bioabsorbable pins. Metal pins/screws may occasionally need removal if there is collapse of the osteochondral fragment, while such complication could be avoided by the use of bio absorbable pins. However bioabsorbable pins for intraar∗ Corresponding author at: 15 Cresswell Close, Callands, Warrington, North Cheshire WA5 9UA, United Kingdom. Tel.: +44 7919403862. E-mail address: [email protected] (P. Chandran).
0958-2592/$ – see front matter. Published by Elsevier Ltd. doi:10.1016/j.foot.2007.10.001
ticular use are yet to be widely used. Results indicate that absorbable implants are biocompatible and effective in the fixation of osteochondral fragments [4]. Though bioabsorbable pins have been used in the treatment of various fractures, their use in the treatment of osteochondral fractures of the talus has not been widely reported. We report a case of osteochondral fracture treated successfully with a bio absorbable pin.
2. Case report A 26-year-old joiner tripped over scaffolding at work and fell from a height of 5 feet, sustaining injury to his left ankle. He presented to the accident and emergency department with a painful bruised ankle and inability to weight bear. Anterioposterior, lateral and oblique radiographs of the ankle showed an osteochondral fracture of the talar dome (Fig. 1). CT scan of his ankle showed a displaced osteochondral fracture of the lateral aspect of the talar dome measuring 7.5 mm × 3.8 mm × 5 mm (Fig. 2), no other injuries were identified. The patient underwent open reduction and internal fixation of this fracture. An anterolateral arthrotomy was performed and the talar dome identified, osteochondral fracture was exposed and defined, the fractured fragment was found to be displaced and rotated by 180 degrees with the articular
P. Chandran et al. / The Foot 18 (2008) 56–58
57
Fig. 3. Intra operative picture of the osteochondral fragment following fixation with bioabsorbable screws. Fig. 1. X-ray showing osteochondral fracture on dome of the talus.
surface of the fragment facing the talar dome and the fractured surface was facing the tibial plafond. The fragment was reduced anatomically and held in the reduced position with three 40 mm × 1.3 mm absorbable pins (Orthosorb® bioabsorbable pin) (Fig. 3). Postoperatively the leg was supported in a below knee plaster cast and was kept nonweight bearing for 6 weeks. Touch weight bearing was allowed at the end of 6 weeks in a below knee removable splint. Full weight bearing was allowed at 3 months post-fixation. At the last follow up 12 months post-surgery, the patient had no pain and was mobilising full weight bearing, he had 10 degrees of dorsiflexion and 30 degrees of plantar flexion at his ankle joint which was pain free. X-ray and MR scan of his ankle
Fig. 4. CT picture of the talus following satisfactory healing of the osteochondral fracture.
showed satisfactory healing of the fracture with no evidence of avascular necrosis (Fig. 4).
3. Discussion
Fig. 2. Computed tomogram showing osteochondral fracture on the dome of the talus.
Early recognition and appropriate treatment of osteochondral fractures involving the talus is necessary in order to produce favourable results [2]. Though osteochondral fractures have been satisfactorily treated by excision of the osteochondral fragment [8], early treatment with open reduction and internal fixation using a low profile screw or pins may prevent occurrence of secondary osteoarthritis [6]. For fixation of the osteochondral fragments, bioabsorbable pins are available as an alternate choice to metal fixation. The gradual absorption of these pins allows for optimum transfer of support to the bone as the healing of fracture progresses.
58
P. Chandran et al. / The Foot 18 (2008) 56–58
These pins provide the same support as metal fixation for protection against shear and rotational forces, while eliminating most of its disadvantages. However, use of bioabsorbable implants has been reported to be associated with adverse tissue reaction [1] which can be mild in the form of painful erythematous papule, or of medium severity with a sinus that may discharged remnants of the implant for a short time or severe with extensive osteolytic lesions adjacent to the implant tracks with formation of a sterile discharging sinus [5]. Bio absorbable pins commonly used in fracture fixation include polyglycolide pins (Biofix® ), polylactide acid and poly-p-dioxanone (PDS) (Orhosorb® ). Studies have demonstrated that absorbable implants are biocompatible and are effective for fixation of osteochondral fragments [4]. Numerous trials have compared the use of bioabsorbable pins with each other and with metal pins. Lavery et al. [7] compared polyglycolide pins with poly-p-dioxanone pins in the fixation of the first metatarsal osteotomies and reported more complications with polyglycolide pins. Comparing poly-pdioxanone pins to K wires for fixation following chevron osteotomy, Gill et al. [5] found no difference between them and concluded that bioabsorbable pins can be reliably used to fix osteotomies without undue risk of osteolysis and other complications. Lavery et al. [7] compared Biofix, polyglycolide pins and Orthosorb, polydioxanon pins, in fixation of first metatarsal osteotomies and complications were more common in osteotomies fixed with Biofix compared with Orthosorb.
Bioabsorbable pins have been used in the treatment of various fractures; there is limited literature on its use for intra articular fractures. We achieved satisfactory healing of the osteochondral fracture of the talus with poly-p-dioxanone (PDS) without any complications and the patient had good functional outcome. We believe that poly-p-dioxanone pins are a safe and effective option to consider while fixing osteochondral fractures of the talus.
References [1] Bostman OM, Pihlajamaki HK. Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop Relat Res 2000;371:216–27. [2] Chaney DM, Toups J, Foster J. Osteochondral fractures of the talus. Clin Podiatr Med Surg 2001;18(3):481–93. [3] Farmer JM, Martin DF, Boles CA, Curl WW. Chondral and osteochondral injuries. Diagnosis and management. Clin Sports Med 2001;20(2):299–320. [4] Fuchs M, Vosshenrich R, Dumont C, Sturmer KM. Reification of osteochondral fragments using absorbable implants. First results of a retrospective study. Chirurg 2003;74(6):554–61. [5] Gill LH, Martin DF, Coumas JM, Kiebzak GM. Fixation with bioabsorbable pins in chevron bunionectomy. J Bone Joint Surg Am 1997;79(10):1510–8. [6] Jimenez AL, Morgan Jr JH. Talar fractures: three case studies. J Am Podiatr Med Assoc 2001;91(8):415–21. [7] Lavery LA, Peterson JED, Pollack R, Higgins KR. Risk of complications of first metatarsal head osteotomies with biodegradable pin fixation: biofix versus orthosorb. J Foot Ankle Surg 1994;33(4):334–40. [8] Schuman L, Struijs PA, van Dijk CN. Traumatic osteochondral lesions of the talar dome. Orthopade 2001;30(1):66–72.