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Unicortical fixation of metacarpal fractures–Is it strong enough?
1608
Methods: 17 patients (7M, 10F: age 4 months to 149 months) with syndromic craniosynostosis (3 Apert, 3 Pfeiffer, 2 chromosomal anomaly, 2 Muenke, 2 Crouzon, 2 combined sagittal/lambdoid, 3 unknown) underwent posterior craniotomy with application of KLS-Martin distractors for correction of elevated intracranial pressure (n Z 9) and/or correction of turribrachycephaly (n Z 15). Distraction (0.5 mm bid) commenced on the first post-operative day and consolidation period was 8e10 weeks (follow-up 8e68 months). CT-based intracranial volumes and sagittal ray analysis pre- and post-distraction were analyzed with GE Healthcare AW VolumeShare2 software. Results: Posterior cranial vault distraction was successful in achieving normocephaly in 8 patients. Two patients underwent mono-bloc fronto-facial advancement and 6 patients underwent subsequent planned fronto-orbital advancement. Elevated ICP was resolved in 5/6 patients. Complications included 1 technical failure requiring redo surgery, 2 skin breakdowns overlying the distractor, 1 infection and 3 CSF leaks. Mean intracranial volume increase was 34% (range 24e42%). Sagittal ray analysis demonstrated mean reduction on vertical height of the cranium of 7.7% based on a standard cranial index of vertical height over transverse width. Conclusions: Posterior cranial vault distraction provides a controlled expansion of the brachycephalic cranium with correction of turribrachycephaly and resolution of intracranial hypertension in select cases.
LYMPHATICOVENOUS ANASTOMOSES VS FREE LYMPHONODE SURGERY Sinikka H. Suominen Helsinki University Hospital, Finland Introduction and aims: Surgical treatment of lymphoedema is challenging,and although we have many operative options available, there are no comparative studies. Material and methods: The patients files of 40 patients with postoperative lymphoedema were evaluated and 20 consecutive patients with lymphaticovenous anastomoses (LVA) and 20 with free lymphonode transfer, were involved in this retrospective study. All patients had at least one year follow up. All LVA:s were performed using near infrared spectroscopy with indosyanine green preoperatively to assess lymphvessels. All lymphonodes were harvested along the SIEA vessels and anastomosed to thoracodorsal vessels after thorough scar release in the axilla. All patients were preoperatively wearing a garment and undergoing regular lymphotherapy, conservative methods were at maximal use. Results: In the lymphaticovenous group, if less than 3 anastomoses could be performed, the results was poor and all patients were rescheduled for another operation. If>4 anastomoses could be achieved, 60% of the patients had some circumference and softness benefit. In the lymphonode transfer group all patients had some benefit, reduction in circumpherence or softness. All but 2 who reached three years follow up had been able to leave out the garment and lymphotherapy, but only 4 reached the circumpherence of the healthy arm. Postoperative lymphoscintigrapy revealed no donor site problems. Conclusion(s): In this study free lymphonode transfer seems to produce superior results to LVA:s. However, it is a major procedure when LVA:s can be performed in local anaesthesia. A smaller
Abstracts
operation produces smaller results and patients should be well informed preoperatively.
UNICORTICAL FIXATION OF METACARPAL FRACTURESeIS IT STRONG ENOUGH? John K. Dickson, Sameer Gujral, Waseem Bhat, James Paget, Jenny O’Neill, Simon J. Lee Frenchay Hospital, North Bristol NHS Trust, United Kingdom Introduction and aims: Plate fixation of metacarpal fractures can be associated with a high rate of complications including stiffness, nonunion, infection, tendon ruptures and neurovascular injury. Bicortical fixation provides a strong fixation but can damage the flexor tendons and neurovascular structures due to overdrilling or proud volar screw tips. Unicortical fixation avoids these problems but may not be strong enough to enable adequate postoperative mobilisation. We hypothesized that fixation using a 4 2 hole 3D plate and 8 unicortical screws would be as strong as fixation using a 4-hole straight plate and 4 bicortical screws. In both cases, the fixation would involve four cortices either side of the fracture. Material and methods: 40 unicortical and 40 bicortical fixations were compared using a cadaveric metacarpal model. Unicortical fixation was performed using an 8-hole parallel plate. Bicortical fixation was performed using a 4-hole straight plate. A four-point bending system was used to test the constructs. Results: The mean force at failure was 414 38N for the unicortical group and 296 29N for the bicortical group (p Z 0.0005). The mean energy required to break the fixation was 0.962 0.101 J for the unicortical group and 0.565 0.061 J for the bicortical group (p Z 0.0002). Conclusion(s): Fixation of mid-shaft transverse fractures of the metacarpal using an 4 2 hole 3D plate and unicortical screws provides greater strength than a 4-hole straight plate and bicortical screws. Unicortical fixation, performed in this way, should therefore be strong enough to enable adequate post-operative mobilisation.
NON-SURGICAL MANAGEMENT OF CLOSED BONY MALLET INJURIES: A FIVE-YEAR RETROSPECTIVE ANALYSIS IN ST THOMAS HOSPITAL HAND TRAUMA CENTER Margarita Moustaki, Georgios Orfaniotis, Sarah Cowan-Rawcliffe, Serhiy Aleksyeyenko, Jamil S. Ahmed Guy’s and St Thomas’ NHS Foundation Trust, United Kingdom Introduction and aims: Mallet injuries comprise a common presentation of hand trauma cases, however, they often pose a challenging problem with regards to their management. The aim of this study is to analyze the management of closed mallet finger fractures and evaluate the clinical outcomes following conservative treatment. Material and methods: We performed a retrospective data analysis of all the patients with closed bony mallet injuries, treated in our unit within a 5-year period (2007e2012).Percentage of articular surface involved and degree of DIPJ subluxation were recorded, following radiographic evaluation by the senior author
Methods: 17 patients (7M, 10F: age 4 months to 149 months) with syndromic craniosynostosis (3 Apert, 3 Pfeiffer, 2 chromosomal anomaly, 2 Muenke, 2 Crouzon, 2 combined sagittal/lambdoid, 3 unknown) underwent posterior craniotomy with application of KLS-Martin distractors for correction of elevated intracranial pressure (n Z 9) and/or correction of turribrachycephaly (n Z 15). Distraction (0.5 mm bid) commenced on the first post-operative day and consolidation period was 8e10 weeks (follow-up 8e68 months). CT-based intracranial volumes and sagittal ray analysis pre- and post-distraction were analyzed with GE Healthcare AW VolumeShare2 software. Results: Posterior cranial vault distraction was successful in achieving normocephaly in 8 patients. Two patients underwent mono-bloc fronto-facial advancement and 6 patients underwent subsequent planned fronto-orbital advancement. Elevated ICP was resolved in 5/6 patients. Complications included 1 technical failure requiring redo surgery, 2 skin breakdowns overlying the distractor, 1 infection and 3 CSF leaks. Mean intracranial volume increase was 34% (range 24e42%). Sagittal ray analysis demonstrated mean reduction on vertical height of the cranium of 7.7% based on a standard cranial index of vertical height over transverse width. Conclusions: Posterior cranial vault distraction provides a controlled expansion of the brachycephalic cranium with correction of turribrachycephaly and resolution of intracranial hypertension in select cases.
LYMPHATICOVENOUS ANASTOMOSES VS FREE LYMPHONODE SURGERY Sinikka H. Suominen Helsinki University Hospital, Finland Introduction and aims: Surgical treatment of lymphoedema is challenging,and although we have many operative options available, there are no comparative studies. Material and methods: The patients files of 40 patients with postoperative lymphoedema were evaluated and 20 consecutive patients with lymphaticovenous anastomoses (LVA) and 20 with free lymphonode transfer, were involved in this retrospective study. All patients had at least one year follow up. All LVA:s were performed using near infrared spectroscopy with indosyanine green preoperatively to assess lymphvessels. All lymphonodes were harvested along the SIEA vessels and anastomosed to thoracodorsal vessels after thorough scar release in the axilla. All patients were preoperatively wearing a garment and undergoing regular lymphotherapy, conservative methods were at maximal use. Results: In the lymphaticovenous group, if less than 3 anastomoses could be performed, the results was poor and all patients were rescheduled for another operation. If>4 anastomoses could be achieved, 60% of the patients had some circumference and softness benefit. In the lymphonode transfer group all patients had some benefit, reduction in circumpherence or softness. All but 2 who reached three years follow up had been able to leave out the garment and lymphotherapy, but only 4 reached the circumpherence of the healthy arm. Postoperative lymphoscintigrapy revealed no donor site problems. Conclusion(s): In this study free lymphonode transfer seems to produce superior results to LVA:s. However, it is a major procedure when LVA:s can be performed in local anaesthesia. A smaller
Abstracts
operation produces smaller results and patients should be well informed preoperatively.
UNICORTICAL FIXATION OF METACARPAL FRACTURESeIS IT STRONG ENOUGH? John K. Dickson, Sameer Gujral, Waseem Bhat, James Paget, Jenny O’Neill, Simon J. Lee Frenchay Hospital, North Bristol NHS Trust, United Kingdom Introduction and aims: Plate fixation of metacarpal fractures can be associated with a high rate of complications including stiffness, nonunion, infection, tendon ruptures and neurovascular injury. Bicortical fixation provides a strong fixation but can damage the flexor tendons and neurovascular structures due to overdrilling or proud volar screw tips. Unicortical fixation avoids these problems but may not be strong enough to enable adequate postoperative mobilisation. We hypothesized that fixation using a 4 2 hole 3D plate and 8 unicortical screws would be as strong as fixation using a 4-hole straight plate and 4 bicortical screws. In both cases, the fixation would involve four cortices either side of the fracture. Material and methods: 40 unicortical and 40 bicortical fixations were compared using a cadaveric metacarpal model. Unicortical fixation was performed using an 8-hole parallel plate. Bicortical fixation was performed using a 4-hole straight plate. A four-point bending system was used to test the constructs. Results: The mean force at failure was 414 38N for the unicortical group and 296 29N for the bicortical group (p Z 0.0005). The mean energy required to break the fixation was 0.962 0.101 J for the unicortical group and 0.565 0.061 J for the bicortical group (p Z 0.0002). Conclusion(s): Fixation of mid-shaft transverse fractures of the metacarpal using an 4 2 hole 3D plate and unicortical screws provides greater strength than a 4-hole straight plate and bicortical screws. Unicortical fixation, performed in this way, should therefore be strong enough to enable adequate post-operative mobilisation.
NON-SURGICAL MANAGEMENT OF CLOSED BONY MALLET INJURIES: A FIVE-YEAR RETROSPECTIVE ANALYSIS IN ST THOMAS HOSPITAL HAND TRAUMA CENTER Margarita Moustaki, Georgios Orfaniotis, Sarah Cowan-Rawcliffe, Serhiy Aleksyeyenko, Jamil S. Ahmed Guy’s and St Thomas’ NHS Foundation Trust, United Kingdom Introduction and aims: Mallet injuries comprise a common presentation of hand trauma cases, however, they often pose a challenging problem with regards to their management. The aim of this study is to analyze the management of closed mallet finger fractures and evaluate the clinical outcomes following conservative treatment. Material and methods: We performed a retrospective data analysis of all the patients with closed bony mallet injuries, treated in our unit within a 5-year period (2007e2012).Percentage of articular surface involved and degree of DIPJ subluxation were recorded, following radiographic evaluation by the senior author