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Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report of four cases
Letters to the Editor
643
LETTER TO THE EDITOR
REPLY TO THE LETTER TO THE EDITOR
Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report on four cases
Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report of four cases
Sir,
Dear Editor,
We read with interest the case series titled ‘‘Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report on four cases’’ by Houshian et al. in the August edition.2 As the authors correctly state, these fragility fractures are difficult to treat due to poor bone and soft tissue quality. Our approach to the treatment of these fractures is with an expandable retrograde calcaneotalar-tibial nail as both primary treatment and revision of failed internal fixation.1 We have treated over 60 patients in both groups with no implant related complications, and very good ranges of ankle motion following removal of the nail at 3—4 months postinsertion. The main advantages of this implant are that the ankle is not fused and regains motion after nail removal, it is effectively a closed procedure, requiring only a 1—2 cm incision to introduce the nail and no locking bolts or bone grafting are required. We do not feel that ankle fusion is required after failed fixation and that this minimally invasive technique gives very good results in a short time period. Because of the goods results with this treatment we would advocate its use as both primary treatment for osteoporotic fractures and in the revision situation.
We would like to thank Mr. Marsh et al. for their comments with regards to our article on ‘Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report on four cases’.2 We would like to make the following comments with regards to the opinions raised in their correspondence:
References [1] Lemon M, Somayaji H, Khaleel A, Elliott D. Fragility fractures of the ankle. Stabilisation with an expandable calcaneotalotibial nail. J Bone Joint Surg: Br Vol B 2005;87(6):809—13. [2] Houshian S, Bajaj S, Mohammed A. Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: a report of four cases. Injury 2006;37:791—4.
Alastair Marsh* Kostos Tilkerides David Elliott Roley Bristow Orthopaedic Unit, St Peters Hospital, Guildford Road, Chertsey, UK *Corresponding author at: 53 Upland Way, Epsom, Surrey KT18 5SN, UK. Tel.: +44 1737216848; fax: +44 7949770324 E-mail address: [email protected] (A. Marsh)
1. We agree with the authors that in these difficult to manage osteoporotic fragility ankle fractures, trans-talo-calcaneal fixation is an excellent option and generally gives good results both as primary option or as a secondary option for failed internal fixation. 2. However, the authors raise their objection as far as the ankle fusion is concerned, in this regard we read the authors’ article5 with great interest. Their comment relates to 60 cases whereas their publication describes only 12 patients, 1 of whom died. In 6 out of 11 cases (55%) the nail was not removed due to patient refusal. Further, the six patients who refused implant removal as suggested by the authors stated that they felt more stable than before their fracture. In their paper, 9 of 11 patients returned to their pre-injury mobility and had no pain, 2 of 11 (18%) had reduced mobility and mild pain, however, as 6 of 11 nails were not removed how is it possible to obtain pre-injury level of movement in the presence of the nail? These results do not translate into ‘‘very good ranges of ankle motion’’ as claimed in the letter. All these facts prove that these elderly people are happy with the fusion and would rather avoid a second surgery. 3. Removing the nail after 3—4 months poses another question, how much of ankle movements do they regain? This factor has not been made clear in their article.5 Lauge-Pedersen in both animal as well as human study proved that any joint left with an implant in situ for more than 7 weeks in the majority results in fusion anyway.3,4
doi:10.1016/j.injury.2006.11.009 DOI of original article: 10.1016/j.injury.2005.08.011.
DOI of original article: 10.1016/j.injury.2005.08.011.
644
Letters to the Editor
4. The authors admit a potential long-term complication of arthritis and cite Childress’ study of 92 patients with 1/8 in. (3.1 mm) Steinman pin showing no evidence of arthritis.1 The comparison of a Steinman pin of 3.1 mm with a 13.5 mm expandable humeral nail is not realistic, particularly in a talar surface of 30 mm 40 mm. 5. We had no problems with either locking or making an additional stab incision for introducing artificial bonegraft. 6. In our opinion, we still feel fusion is a valid option in these circumstances and further this avoids a second surgery. We hope these comments are useful for further understanding the solution for these difficult fractures in the elderly people.
References 1. Childress HM. Vertical transarticular pin fixation for unstable ankle fractures: impressions after 16 years experience. Clin Orthop 1976;120:164—71. 2. Houshian S, Bajaj SK, Mohammed AM. Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: a report on four cases. Injury 2006;37(8): 791—4. 3. Lauge-Pedersen H. By percutaneous arthrodesis. Acta Orthop Scand Suppl 2003;73(307):1—30. 4. Lauge-Pedersen H, Aspenberg P. Arthrodesis by percutaneous fixation: patello femoral arthrodesis in rabbits without debridement of the joint. Acta Orthop Scand 2002;73(2): 186—9. 5. Lemon M, Somayaji HS, Khaleel A, Elliott DS. Fragility fractures of the ankle: stabilisation with an expandable calcaneotalotibial nail. J Bone Joint Surg 2005;87(6): 809—13.
Shirzad Houshian* C. Chikkamuniyappa Abi Boys University Hospital Lewisham, SE13 6LH London, UK *Corresponding author. Tel.: +44 208 333 6994 E-mail address: [email protected] (S. Houshian) doi:10.1016/j.injury.2006.11.016
LETTER TO THE EDITOR Re: Muller M, Jahnich H, Butler-Manuel A. Inadvertent guide wire advancement in hip fracture fixation with fatal outcome [Injury 36 (2005) 679—680] Dear Sir, This case reports details the tragic complications that may occur following hip fracture fixation with inadvertent guide wire penetration into the pelvis.2 The article, which is a case report of a single patient is excellent in informing the surgeon of this rare but potentially serious complication. The authors reported the case to the Medical Devices Agency. The response of this organisation was to produce a report with recommendations for the attention of all chief executives of NHS Trusts and Health Authorities in England. They were asked to bring their report to the notice of the following. Trusts to:
Liaison Officers (for onward distribution), Orthopaedic Surgeons, Orthopaedic Managers, Directors of Surgery, Directors of Radiology, Radiologists, Superintendent Radiographers (for onward distribution to Theatre Managers), Theatre Managers, Safety Officers. Health authorities to: Liaison Officers (for onward distribution), Registration Inspection Units, Hospitals in the Independent Sector. The Medical Devices Agency had two main recommendations. Firstly that only single use guide wires should be used and discarded at the end of the operation. This is despite the fact that in the case report of Muller there was nothing to suggest the guide was bent or damaged at the start of the operation. Apart from the obvious damaging environmental effects of encouraging the use of disposable instruments, the cost implications of such a policy should be considered. A guide wire costs about £15 (21s) in the United Kingdom. Given the number of hip fracture fixations and DOI of original article: 10.1016/j.injury.2004.06.024.
643
LETTER TO THE EDITOR
REPLY TO THE LETTER TO THE EDITOR
Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report on four cases
Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report of four cases
Sir,
Dear Editor,
We read with interest the case series titled ‘‘Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report on four cases’’ by Houshian et al. in the August edition.2 As the authors correctly state, these fragility fractures are difficult to treat due to poor bone and soft tissue quality. Our approach to the treatment of these fractures is with an expandable retrograde calcaneotalar-tibial nail as both primary treatment and revision of failed internal fixation.1 We have treated over 60 patients in both groups with no implant related complications, and very good ranges of ankle motion following removal of the nail at 3—4 months postinsertion. The main advantages of this implant are that the ankle is not fused and regains motion after nail removal, it is effectively a closed procedure, requiring only a 1—2 cm incision to introduce the nail and no locking bolts or bone grafting are required. We do not feel that ankle fusion is required after failed fixation and that this minimally invasive technique gives very good results in a short time period. Because of the goods results with this treatment we would advocate its use as both primary treatment for osteoporotic fractures and in the revision situation.
We would like to thank Mr. Marsh et al. for their comments with regards to our article on ‘Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: A report on four cases’.2 We would like to make the following comments with regards to the opinions raised in their correspondence:
References [1] Lemon M, Somayaji H, Khaleel A, Elliott D. Fragility fractures of the ankle. Stabilisation with an expandable calcaneotalotibial nail. J Bone Joint Surg: Br Vol B 2005;87(6):809—13. [2] Houshian S, Bajaj S, Mohammed A. Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: a report of four cases. Injury 2006;37:791—4.
Alastair Marsh* Kostos Tilkerides David Elliott Roley Bristow Orthopaedic Unit, St Peters Hospital, Guildford Road, Chertsey, UK *Corresponding author at: 53 Upland Way, Epsom, Surrey KT18 5SN, UK. Tel.: +44 1737216848; fax: +44 7949770324 E-mail address: [email protected] (A. Marsh)
1. We agree with the authors that in these difficult to manage osteoporotic fragility ankle fractures, trans-talo-calcaneal fixation is an excellent option and generally gives good results both as primary option or as a secondary option for failed internal fixation. 2. However, the authors raise their objection as far as the ankle fusion is concerned, in this regard we read the authors’ article5 with great interest. Their comment relates to 60 cases whereas their publication describes only 12 patients, 1 of whom died. In 6 out of 11 cases (55%) the nail was not removed due to patient refusal. Further, the six patients who refused implant removal as suggested by the authors stated that they felt more stable than before their fracture. In their paper, 9 of 11 patients returned to their pre-injury mobility and had no pain, 2 of 11 (18%) had reduced mobility and mild pain, however, as 6 of 11 nails were not removed how is it possible to obtain pre-injury level of movement in the presence of the nail? These results do not translate into ‘‘very good ranges of ankle motion’’ as claimed in the letter. All these facts prove that these elderly people are happy with the fusion and would rather avoid a second surgery. 3. Removing the nail after 3—4 months poses another question, how much of ankle movements do they regain? This factor has not been made clear in their article.5 Lauge-Pedersen in both animal as well as human study proved that any joint left with an implant in situ for more than 7 weeks in the majority results in fusion anyway.3,4
doi:10.1016/j.injury.2006.11.009 DOI of original article: 10.1016/j.injury.2005.08.011.
DOI of original article: 10.1016/j.injury.2005.08.011.
644
Letters to the Editor
4. The authors admit a potential long-term complication of arthritis and cite Childress’ study of 92 patients with 1/8 in. (3.1 mm) Steinman pin showing no evidence of arthritis.1 The comparison of a Steinman pin of 3.1 mm with a 13.5 mm expandable humeral nail is not realistic, particularly in a talar surface of 30 mm 40 mm. 5. We had no problems with either locking or making an additional stab incision for introducing artificial bonegraft. 6. In our opinion, we still feel fusion is a valid option in these circumstances and further this avoids a second surgery. We hope these comments are useful for further understanding the solution for these difficult fractures in the elderly people.
References 1. Childress HM. Vertical transarticular pin fixation for unstable ankle fractures: impressions after 16 years experience. Clin Orthop 1976;120:164—71. 2. Houshian S, Bajaj SK, Mohammed AM. Salvage of osteoporotic ankle fractures after failed primary fixation with an ankle arthrodesis nail: a report on four cases. Injury 2006;37(8): 791—4. 3. Lauge-Pedersen H. By percutaneous arthrodesis. Acta Orthop Scand Suppl 2003;73(307):1—30. 4. Lauge-Pedersen H, Aspenberg P. Arthrodesis by percutaneous fixation: patello femoral arthrodesis in rabbits without debridement of the joint. Acta Orthop Scand 2002;73(2): 186—9. 5. Lemon M, Somayaji HS, Khaleel A, Elliott DS. Fragility fractures of the ankle: stabilisation with an expandable calcaneotalotibial nail. J Bone Joint Surg 2005;87(6): 809—13.
Shirzad Houshian* C. Chikkamuniyappa Abi Boys University Hospital Lewisham, SE13 6LH London, UK *Corresponding author. Tel.: +44 208 333 6994 E-mail address: [email protected] (S. Houshian) doi:10.1016/j.injury.2006.11.016
LETTER TO THE EDITOR Re: Muller M, Jahnich H, Butler-Manuel A. Inadvertent guide wire advancement in hip fracture fixation with fatal outcome [Injury 36 (2005) 679—680] Dear Sir, This case reports details the tragic complications that may occur following hip fracture fixation with inadvertent guide wire penetration into the pelvis.2 The article, which is a case report of a single patient is excellent in informing the surgeon of this rare but potentially serious complication. The authors reported the case to the Medical Devices Agency. The response of this organisation was to produce a report with recommendations for the attention of all chief executives of NHS Trusts and Health Authorities in England. They were asked to bring their report to the notice of the following. Trusts to:
Liaison Officers (for onward distribution), Orthopaedic Surgeons, Orthopaedic Managers, Directors of Surgery, Directors of Radiology, Radiologists, Superintendent Radiographers (for onward distribution to Theatre Managers), Theatre Managers, Safety Officers. Health authorities to: Liaison Officers (for onward distribution), Registration Inspection Units, Hospitals in the Independent Sector. The Medical Devices Agency had two main recommendations. Firstly that only single use guide wires should be used and discarded at the end of the operation. This is despite the fact that in the case report of Muller there was nothing to suggest the guide was bent or damaged at the start of the operation. Apart from the obvious damaging environmental effects of encouraging the use of disposable instruments, the cost implications of such a policy should be considered. A guide wire costs about £15 (21s) in the United Kingdom. Given the number of hip fracture fixations and DOI of original article: 10.1016/j.injury.2004.06.024.