Kirschner Wires Versus Titanium Plates and Screws in Management of Unstable Phalangeal Fractures: A Randomized, Controlled Clinical Trial

Reporting of patient-reported outcomes amongst randomized clinical trials in plastic surgery: a systematic review using CONSORT-PRO

BACKGROUND

Patient-reported outcomes (PROs) are key to investigating patient perspectives in randomized controlled trials (RCTs). Standardization of PRO reporting is critical for trial generalizability and the application of findings to clinical practice. This systematic review aimed to evaluate the reporting quality of RCTs published in the top plastic surgery journals according to the consolidated standards of reporting trials (CONSORT)-PRO extension.

METHODS

We completed a comprehensive search of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. All RCTs with a validated PRO endpoint published in the top 10 plastic surgery journals (based on the 2021 Web of Science Impact Factor) from 2014 to 2023 were included. Two reviewers independently extracted data and scored the included studies using the CONSORT-PRO checklist. Univariate regression was applied to assess factors associated with reporting adherence. Studies were assessed for their risk of bias using the Cochrane Risk of Bias 2.0 tool.

RESULTS

A total of 88 RCTs were included. PROs were the primary endpoint in 50 (57%) and the secondary endpoint of 38 (43%) studies. Mean overall reporting adherence was poor (39% (±12) and 36% (±13) in studies with PRO as primary and secondary endpoints, respectively). The presence of industry support was significantly associated with greater adherence.

CONCLUSIONS

There is low adherence to the CONSORT-PRO extension among plastic surgery RCTs published in the top 10 plastic surgery journals. We encourage journals and authors to endorse and apply the CONSORT-PRO extension. This may optimize the dissemination of clinical findings from RCTs and assist patient-centered care.

Complications of osteosynthesis for long-finger metacarpal and phalanx fracture

Fractures of the metacarpals and phalanges represent a significant proportion of hand fractures. Although non-operative treatment is generally effective, some fractures require surgery. Historically, osteosynthesis using K-wires was widely used, but screw plates and then cannulated intramedullary screws have emerged as therapeutic alternatives. We assessed the complications associated with the different osteosynthesis techniques: stiffness, infection, bone consolidation and hardware-related problems. Each osteosynthesis technique has advantages and disadvantages, and choice depends on several factors. An individualized approach according to patient and fracture is essential to optimize clinical results.

Evaluating Kirschner wire fixation versus titanium plating and screws for unstable phalangeal fractures: A systematic review and meta-analysis of postoperative outcomes

Background

Unstable phalangeal fractures represent a clinical challenge in hand surgery. The choice of fixation method, whether Kirschner wire (K-wire) fixation or titanium plating with screws, often depends on surgeon preference due to the lack of comprehensive comparative data. This article aimed to compare the postoperative outcomes of K-wire fixation versus titanium plating and screws in the treatment of unstable phalangeal fractures.

Methods

This review was conducted according to the PRISMA guidelines for reporting systematic reviews and meta-analyses. A systematic review and meta-analysis of the existing literature was done encompassing PUBMED, EMBASE, Google Scholar, and Cochrane library using the keywords: "K wire/ Kirschner wire", "titanium plate/ screws", "Miniplate/ screws", and "Unstable phalan∗ fracture/ hand fracture".

Results

After screening 2374 articles, 6 final studies with a total of 414 patients were included. Operative time was significantly shorter with K-wire fixation compared to plating, by a mean difference of -27.03 ​min [95% CI -43.80, -10.26] (p ​= ​0.02). Time to radiographic union averaged 7.43 weeks with K-wires versus 8.21 weeks with titanium plates. No statistically significant differences emerged between groups for overall complications (p ​= ​0.69), infection (p ​= ​0.47), malunion (p ​= ​0.36), stiffness (p ​= ​0.11), or need for reoperation (p ​= ​0.10).

Conclusion

K-wire fixation demonstrated shorter mean operating time and faster radiographic union versus plating for unstable phalangeal fractures. These findings can guide surgical decisions and emphasize the need for individualized treatment based on fracture type and patient factors.

Choosing the proper implant for extra-articular fractures of proximal phalanges: A study on 75 cases

INTRODUCTION

Phalangeal fractures are the most common fractures of the hand and in particular the proximal phalanx of the long fingers is the most involved. These fractures can ben conservatively managed but, when the fracture pattern is considered unstable, surgical treatment is recommended. However, there is no consensus in literature about the proper surgical option for extra-articular proximal phalanx fractures.

MATERIAL AND METHODS

We compared clinical and radiographical results after treatment of 75 cases of extra-articular proximal phalanx fractures using three different surgical techniques: closed reduction and internal fixation (CRIF) with Kirschner wires (G1 group), open reduction internal fixation (ORIF) with plates and screws or lag screws (G2 group), and closed reduction and intramedullary screw fixation (CRIMEF)(G3 group).

RESULTS

We found no significant differences in term of union rate and time to fracture healing between the three groups. However, we found a significant reduction in time to return at work and in TAM at the final follow-up examination in G3 group (treated with CRIMEF) when compared with both G1 and G2. No differences in complications rate were found between three groups.

DISCUSSION

The surgical variability in the management of extra-articular phalanx fractures create lacks on standard guide for treatment.

CONCLUSIONS

In conclusion, our results showed good clinical and radiographical results with all the three surgical options. However, the closed reduction and internal fixation with intramedullary screws (CRIMEF) seems to be better in terms of time to return to work and TAM at the final follow-up, probably due to good primary stability and little risk of soft tissue adherence development.

Intramedullary Compression Screw Fixation for Middle Phalangeal Fractures

PURPOSE

This study aimed to evaluate short- and medium-term clinical and patient-reported outcomes of intramedullary compression screw fixation for extra-articular middle phalangeal fractures.

METHODS

A retrospective study was performed on a series of 20 patients (with a total of 23 fractured digits) who underwent fixation of middle phalangeal fractures between January 2020 and March 2023. The results from this cohort were compared against those for plate and K-wire fixation in the literature.

RESULTS

Total active motion was 246°; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score was 4.9; verbal numerical pain score was 1.1 of 10; mean time for return to work was 62.5 days; and a single complication was noted in the entire cohort.

CONCLUSION

Intramedullary screw fixation is a viable option in the treatment of extra-articular middle phalangeal fractures. It offers a favorable postoperative range of motion, good duration for return to function, excellent rates of complication, and low pain scores.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Treatment of Closed Finger and Metacarpal Fractures

BACKGROUND

Fractures of the fingers and metacarpal bones are the most common fracture type in the upper limb, with an incidence of 114 to 1483 per 100 000 persons per year. The clinical importance of closed finger and metacarpal fractures is often underestimated; inadequate diagnostic and therapeutic measures may result in serious harm. This review concerns the basic elements of the diagnosis and treatment of finger and metacarpal fractures.

METHODS

This review of the incidence, diagnosis and treatment of finger and metacarpal fractures is based on pertinent publications retrieved by a selective search of the literature.

RESULTS

The main focus of treatment lies on restoration of hand function in consideration of the requirements of the individual patient. The currently available evidence provides little guidance to optimal treatment (level II evidence). Although most closed fractures can be managed conservatively, individualized surgical treatment is advisable in comminuted fractures and fractures with a relevant degree of torsional malposition, axis deviation, or shortening, as well as in intra-articular fractures. Minimally invasive techniques are, in principle, to be performed wherever possible, yet open surgery is sometimes needed because of fracture morphology. Postsurgical complication rates are in the range of 32-36%, with joint fusion accounting for 67-76% of the complications. 15% involve delayed fracture healing and pseudarthrosis.

CONCLUSION

Individualized treatment for finger and metacarpal fractures can improve patients' outcomes, with major socioeconomic and societal benefits. Further high-quality studies evaluating the relative merits of the available treatments are needed as a guide to optimized therapy.

Fractures of the phalanges

Fractures of the phalanges encompass a wide range of injury patterns with variable articular and soft tissue involvement. The goals of treatment whether conservative or surgical are the restoration of function while limiting the risk of complications. An armamentarium of fixation options allows the surgeon to appropriately treat these fractures with the intention of initiating early postoperative mobilization. Previous publications report variable rates of complications following internal fixation of phalangeal fractures which represents an unsolved problem. It is incumbent on the surgeon to utilize meticulous surgical technique, achieve anatomic reduction with stable fixation and initiate early postoperative mobilization where indicated. In the following text, we review the management of most types of phalangeal fractures, except fracture-dislocations of the proximal interphalangeal joint. These injuries comprise a wide spectrum of presentation; thus, an understanding of anatomical and mechanical principles is integral to achieving a successful outcome.

Closed Reduction Percutaneous Pinning Versus Open Reduction With Plate and Screw Fixation in Management of Unstable Proximal Phalangeal Fractures: A Systematic Review and Meta-analysis

BACKGROUND

Proximal phalanx fractures are common, with surgical fixation indicated for unstable fractures. Traditionally, closed reduction percutaneous pinning (CRPP) resulted in decreased stiffness and tendon irritation compared to open reduction internal fixation (ORIF). We hypothesized that more recent studies would have more similar outcomes to CRPP. The purpose of this study was to compare CRPP and ORIF in terms of range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and complications.

METHODS

Four electronic databases were queried from 2010 to present. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, two independent reviewers performed a two-step review process to identify relevant articles. Patient demographics, total active motion (TAM), DASH, and complications were extracted. The methodological quality of each study included was assessed independently. Meta-analysis was performed for comparative trials.

RESULTS

Fourteen studies met inclusion criteria including four comparative studies: Thirteen studies included TAM. The weighted average TAM was 228 ± 34° for CRPP and 223 ± 32° for ORIF (P = .07 with 95% confidence interval (CI), -0.5 to 10.5). Seven studies evaluated DASH scores; weighted average was 8.2 ± 8.9 for CRPP and 11.7 ± 6.5 for ORIF (P < .01 with 95% CI, 1.8-5.2). Two studies directly compared CRPP to ORIF, favoring ORIF for both TAM with d = 1.07 and DASH with d = 0.23. Rates of tenolysis or hardware removal were higher for ORIF (P < .01).

CONCLUSIONS

New literature suggests more equipoise with regard to treatment of proximal phalanx fracture with CRPP versus ORIF.

TYPE OF STUDY/LEVEL OF EVIDENCE

Meta-analysis, Level II.

Comparative study of K-wire combined with screw vs. K-wire in the treatment of AO type B3.1 phalangeal fractures

PURPOSE

The purpose of this study was to introduce the surgical method of K-wire combined with screw in the treatment of Arbeitsgemeinschaftfür Osteosynthesefragen (AO) type B3.1 phalangeal fractures and to compare its clinical, radiological and functional outcomes with K-wire fixation.

METHODS

This was a retrospective comparative study. From January 2015 to February 2022, we treated 86 patients with AO type B3.1 phalangeal fractures. A total of 71 patients were finally included in the statistical analysis. Thirty-nine patients received K-wires combined with screw, and 32 patients received simple K-wires. The follow-up time was at least 6 months. Outcome measures included general information, operative time, total active motion (TAM), pinch strength, radiological union time, pain assessed by visual analog scale (VAS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, cost, and complications.

RESULTS

The follow-up time was 6-12 months, with an average of 7.9 months. All patients achieved clinical and radiological union. Compared with the K-wire fixation group, the TAM, radiological union time and VAS score of the K-wire combined with screw group had obvious advantages. Compared with the opposite healthy hand, the grip strength of the two groups was similar, and there was no significant difference in the QuickDASH score. The incidence rate of complications in the K-wire combined with screw group (2/39) was lower than that in the K-wire fixation group (7/32).

CONCLUSIONS

Compared with simple K-wire fixation, K-wire combined with screw in the treatment of AO type B3.1 phalangeal fractures is a safer and reliable surgical method. K-wire controls the rotation and plays a role similar to a "lock". The screw can exert pressure and fix it more firmly. It shortens the time of fracture healing and has a higher TAM and fewer postoperative complications.

Practice Variation in Proximal Phalangeal Fracture Management

Background: Practice variation may indicate a lack of evidence to guide management. This study investigated the preferences of operative management of proximal phalangeal fractures in Australian hand surgeons, as well as factors that may account for variations. Methods: An electronic survey of all members of the Australian Hand Surgery Society was performed. Surgeon demographic factors and surgical preferences were investigated. Three common proximal phalangeal fracture configurations were presented as cases. Potential predictors of management were explored. Results: A total of 51.9% of active hand surgeons responded. Orthopaedic surgeons were more comfortable with lateral plating and intramedullary screw fixation, while plastic surgeons preferred Kirschner wire (K-wire) fixation. Junior surgeons were more likely to believe that intramedullary screw fixation produced superior results. 53.0% of surgeons in a tertiary environment believed that adequate hand therapy was key (compared to 17.0% of clinicians in a secondary hospital). Conclusions: There is significant practice variation and a lack of standards in the management of a common clinical problem, as well as a lack of consensus on the evidence underpinning common fixation methods. Further research is needed. Level of Evidence: Level IV (Therapeutic).

Outcomes After Surgically Managed Oblique Extra-Articular Proximal Phalanx Fractures: A Comparison of Closed-Reduction Percutaneous Pinning and Open-Reduction Internal Fixation With Lag Screws

BACKGROUND

Long oblique extra-articular proximal phalanx fractures are common orthopedic injuries. When unstable and without substantial comminution, treatment options include closed-reduction percutaneous pinning (CRPP) and open-reduction internal fixation using lag screws (ORIF-screws). The aims of this study are primarily to compare the functional outcomes and complication rates between these techniques and secondarily to assess potential factors affecting outcomes after surgery.

METHODS

All patients with long oblique extra-articular proximal phalanx fractures treated surgically within a single orthopedic institution from 2010 to 2017 were identified. Outcome measures and complications were assessed at the final follow-up.

RESULTS

Sixty patients were included in the study with a mean time to the final follow-up of 41 weeks (range: 12-164 weeks). Thirty-four patients (57%) were treated with CRPP and 26 patients (43%) with ORIF-screws. The mean Disabilities of the Arm, Shoulder, and Hand score across both fixation types was 8 (range: 0-43) and did not differ significantly between the 2 groups. Mean proximal interphalangeal extension at the final follow-up was 9° short of full extension after CRPP and 13° short of full extension after ORIF-screws. The rates of flexion contracture and extensor lag were 15% and 41% in the CRPP group compared with 12% and 68% in the ORIF-screws group. Reoperation rates and complication rates did not differ significantly between fixation strategies.

CONCLUSIONS

Acceptable outcomes can be achieved after surgical fixation of long oblique extra-articular proximal phalanx fractures using both CRPP and ORIF-screws. Extensor lag may be more common after ORIF-screws.

Intramedullary Compression Screw Fixation of Proximal Phalangeal Fractures: A Systematic Literature Review

Proximal phalangeal fractures have traditionally been fixed via either Kirschner wires or dorsal plating. Concerns regarding lack of compression and potential for infection with wire fixation, and adhesion formation and stiffness with plating, have lead to alternative fixation methods, such as intramedullary screw fixation. However, the literature regarding this modality is limited. Methods: A systematic review was performed to review the literature regarding intramedullary screw fixation for proximal phalangeal fractures. English language studies that reported original data and commented on at least one postoperative measure of function were eligible for inclusion. 4 studies were eligible for inclusion, with a further 3 studies assessing proximal and middle phalanges analysed separately. Total active motion was greater than 240° in all proximal phalangeal studies; mean post-operative DASH was 3.62. 6% of patients sustained a major complication. Intramedullary screw fixation of proximal phalangeal fractures is safe, providing stable fixation to allow early motion.

K-wire Made Easy by Premarking Wire Trajectory on the Skin in Management of Finger Fractures

BACKGROUND

Hand injury in general and fractures in particular are among the most common complaints of hand trauma patients presenting to our emergency department. Depending on fracture types, geometry, locations, and stability, treatment options may vary from close reduction and splinting to close reduction and K-wire fixation, and finally, to open reduction and internal fixation. The aim of the study was to prove that premarking of K-wire trajectory helps reduce procedure and fluoroscopy time, as well as the number of wire-insertion attempts, and minimize bone and soft tissue injury in the management of phalangeal finger fractures.

METHODS

This is a prospective descriptive study aimed to describe a surgical technique. Patients who underwent close reduction and K-wire fixation of phalangeal digital fractures were enrolled. A total of 20 cases were included.

RESULTS

The total number of K-wires was 37, and the total number of successful attempts was 40; average fluoroscopy time was 22.75 seconds; and average total operative time was 14.25 minutes. Surgeries of all cases were supervised by a consultant physician, but some were performed by a junior resident in the team. The inaccuracy index was measured for the group.

CONCLUSIONS

Marking of the trajectory before placing K-wires for the management of digital fractures is not described in the literature. Our study describes an innovative operative technique that, when combined with the classic K-wire fixation technique, produces beneficial outcomes in the form of reduction in operative time and number of wire introduction attempts, with overall reduction in fluoroscopy time and soft tissue and bone damage (including false passages).

Percutaneous pinning with interphalangeal joint locked in phalanx fractures: The surgical technique and the results

BACKGROUND

The purpose of the study was to compare the operation time, the fracture healed time, the postoperative function recovery between the techniques that temporary locking of the interphalangeal joint and traditional manual reduction in the treatment of percutaneous pinning of the phalanx fractures.

METHODS

Patients with phalanx fractures from January 2015 to January 2018 who were admitted to our hospital were retrospectively reviewed. Patients received surgery with traditional manual or temporary locking of the interphalangeal joint reduction. The information of patients, including age, gender, the length of the operation, the fracture healed time, the postoperative function recovery, complication, and length of postoperative hospital stay, was collected. All of the information were evaluated and compared between the 2 groups. All of the surgery were performed by 2 experienced hand surgeons of our department. The patients in the 2 groups were followed up for an average of 6 months after surgery.

RESULTS

All patients completed the operation and were followed up completely. There was no significant difference in baseline data between the 2 groups (P > .05). The observation group who received surgery with the interphalangeal joint locked technique had significantly shorter in operative time than the control group (P < .05). And postoperative complications in the observation group were significantly less than those in the control group (P < .05). However, the postoperative functional recovery in both groups was no significant difference between the 2 groups (P > .05). And there were no significant differences in the fracture healed time and length of postoperative hospital stay between the 2 groups (P > .05).

CONCLUSION

Both surgical techniques can enable patients to achieve good function, but the technique of interphalangeal joint locked is effective in the treatment of the phalanx fractures, as it is characterized by short operations and a quick recovery. However, this technique is only suitable for extra-articular phalanx fractures that the AO/ASIF classification of type A2.3 and less than 2 weeks, not for other phalanx fractures.