Complications of Low-Profile Plate Fixation of Phalanx Fractures

Phalangeal fractures: A retrospective comparison of open reduction and internal fixation vs. closed reduction and percutaneous pinning

The treatment of phalangeal fractures is guided by fracture characteristics, patient factors and surgeon judgment. This study retrospectively compares characteristics of phalangeal fractures treated with closed reduction percutaneous pinning (CRPP) with those of fractures treated with open reduction internal fixation (ORIF) to identify risk factors associated with reoperation. A total of 901 phalangeal fractures were included and treated operatively by either CRPP (748 fractures, 83 ​%) or ORIF (153 fractures, 17 ​%). Demographics, surgical management, and complication data were collected. Statistical analyses were performed to stratify risk associations and identify potential predictors of reoperation. With multivariate analysis and bootstrapped LASSO regression, fractures addressed by means of ORIF (vs. CRPP), work-related fractures, and open fractures were found to be independently associated with reoperation. These findings can be used to guide patient selection, surgical planning and timing of fracture repair.

Level of evidence

Level III, Therapeutic.

Enhanced Degradability of Thiol-Ene Composites through the Inclusion of Isosorbide-Based Polycarbonates

Open reduction internal fixation metal plates and screws remain the established standard-of-care for complex fracture fixation. They, however, have drawbacks such as limited customization, soft-tissue adhesions, and a lack of degradation. Bone cements and composites are being developed as alternative fixation techniques in order to overcome these issues. One such composite is a strong, stiff, and shapeable hydroxyapatite-containing material consisting of 1,3,5-triazine-2,4,6-trione (TATO) monomers, which cures through high energy visible light-induced thiol-ene coupling (TEC) chemistry. Previous human cadaver and in vivo studies have shown that patches of this composite provide sufficient fixation for healing bone fractures; however, the composite lacks degradability. To promote degradation through hydrolysis, new allyl-functionalized isosorbide-based polycarbonates have been added into the composite formulation, and their impact has been evaluated. Three polycarbonates with allyl functionalities, located at the termini (aPC1 and aPC2) or in the backbone (aPC3), were synthesized. Composites containing 1, 3, and 5 wt % of aPCs 1-3 were formulated and evaluated with regard to mechanical properties, water absorption, hydrolytic degradation, and cytotoxicity. Allyl-functionalized polycaprolactone (aPCL) was synthesized and used as a comparison. When integrated into the composite, aPC3 significantly impacted the material's properties, with the 5 wt % aPC3 formulation showing a significant increase in degradation of 469%, relative to the formulation not containing any aPCs after 8 weeks' immersion in PBS, along with a modest decrease in modulus of 28% to 4.01 (0.3) GPa. Osteosyntheses combining the aPC3 3 and 5 wt % formulations with screws on synthetic bones with ostectomies matched or outperformed the ones made with the previously studied neat composite with regard to bending stiffness and strength in four-point monotonic bending before and after immersion in PBS. The favorable mechanical properties, increased degradation, and nontoxic characteristics of the materials present aPC3 as a promising additive for the TATO composite formulations. This combination resulted in stiff composites with long-term degradation that are suitable for bone fracture repair.

Biomechanical performance of a novel light-curable bone fixation technique

Traumatic bone fractures are often debilitating injuries that may require surgical fixation to ensure sufficient healing. Currently, the most frequently used osteosynthesis materials are metal-based; however, in certain cases, such as complex comminuted osteoporotic fractures, they may not provide the best solution due to their rigid and non-customizable nature. In phalanx fractures in particular, metal plates have been shown to induce joint stiffness and soft tissue adhesions. A new osteosynthesis method using a light curable polymer composite has been developed. This method has demonstrated itself to be a versatile solution that can be shaped by surgeons in situ and has been shown to induce no soft tissue adhesions. In this study, the biomechanical performance of AdhFix was compared to conventional metal plates. The osteosyntheses were tested in seven different groups with varying loading modality (bending and torsion), osteotomy gap size, and fixation type and size in a sheep phalanx model. AdhFix demonstrated statistically higher stiffnesses in torsion (64.64 ± 9.27 and 114.08 ± 20.98 Nmm/° vs. 33.88 ± 3.10 Nmm/°) and in reduced fractures in bending (13.70 ± 2.75 Nm/mm vs. 8.69 ± 1.16 Nmm/°), while the metal plates were stiffer in unreduced fractures (7.44 ± 1.75 Nm/mm vs. 2.70 ± 0.72 Nmm/°). The metal plates withstood equivalent or significantly higher torques in torsion (534.28 ± 25.74 Nmm vs. 614.10 ± 118.44 and 414.82 ± 70.98 Nmm) and significantly higher bending moments (19.51 ± 2.24 and 22.72 ± 2.68 Nm vs. 5.38 ± 0.73 and 1.22 ± 0.30 Nm). This study illustrated that the AdhFix platform is a viable, customizable solution that is comparable to the mechanical properties of traditional metal plates within the range of physiological loading values reported in literature.

Cost Analysis of Intramedullary Screw versus Plate Osteosynthesis for Phalangeal and Metacarpal Fractures: An Observational Study

Background: To compare the observed healthcare and societal costs of intramedullary screw (IMS) and plate fixation of extra-articular metacarpal and phalangeal fractures in a contemporary Australian context. Methods: A retrospective analysis, based on previously published data, was performed utilising information from Australian public and private hospitals, the Medicare Benefits Schedule (MBS) and the Australian Bureau of Statistics. Results: Plate fixation demonstrated longer surgical lengths (32 minutes, compared to 25 minutes), greater hardware costs (AUD 1,088 vs. AUD 355), more extended follow-up requirements (6.3 months, compared to 5 months) and higher rates of subsequent hardware removal (24% compared to 4.6%), resulting in an increased healthcare expenditure of AUD 1,519.41 in the public system, and AUD 1,698.59 in the private sector. Wage losses were estimated at AUD 15,515.78 when the fracture cohort is fixed by a plate, and AUD 13,542.43 when using an IMS - a differential of AUD 1,973.35. Conclusions: There is a substantial saving to both the health system and the patient when using IMS fixation over dorsal plating for the fixation of extra-articular metacarpal and phalangeal fractures. Level of Evidence: Level III (Cost Utility).

Retrospective review on tenolysis after phalangeal fractures: A Hong Kong local center experience

Background/Purpose: This is a local retrospective review on the outcomes of tenolysis after phalangeal fracture. Methods: The clinical outcome of nine patients (mean age 51.9 years) with finger fractures and subsequent tenolysis performed were reviewed. Range of motion was evaluated. Results: Extensor tenolysis, capsulotomy with or without flexor tenolysis was performed at a mean of 8.2 months after hand fracture with fracture fixation done. The total active motion (TAM) improved from 121° preoperatively to 173° postoperatively ( p = 0.02). Significant improvement of motion was observed at the proximal interphalangeal joint ( p = 0.012). All patient's range of motion improved after surgery. Conclusion: The gain of motion of 52° is comparable to other series. Release of all pathological anatomy and aggressive mobilization may improve the result further. Tenolysis can provide an encouraging improvement of active motion for stiff finger after phalangeal fractures. Recent results using WALANT technique showed satisfactory outcome. Future study on WALANT technique may further consolidate its potential benefit.

The effects of adding splint use to corticosteroid injection for the treatment of trigger finger: A randomized controlled trial

BACKGROUND

Trigger finger is the most common flexor tendinopathy affecting the general population. We evaluated the effects of adding a static metacarpophalangeal joint splint to corticosteroid injection for the management of trigger finger in the short term.

METHODS

We carried out a randomized controlled trial with two parallel arms in Department of Physical Medicine and Rehabilitation at a university hospital. We randomly allocated 60 participants (34 women) with trigger fingers other than the thumb to two groups (both n = 30). The mean (SD) age was 41.5 (7.6) years. All participants received a single injection of 40 mg methylprednisolone plus 0.5 ml of lidocaine at the A1 pulley. Patients in the splint group wore a full time static splint for blocking the metacarpophalangeal joint for 3 months. The primary outcome was the Numerical Pain Rating Scale and the secondary outcomes were Boston questionnaire scores for symptom severity and functional status, grip strength, and the stages of stenosing tenosynovitis. We measured the outcomes at baseline, and in 1 and 3 months post-intervention.

RESULTS

Both interventions were effective; however, the splint group showed more reductions in pain (p = 0.013) and symptom severity (p = 0.047) and a larger decrease in the stages of tenosynovitis (p = 0.004) after 3 months. There was no significant difference in decreasing functional scores between the groups (p = 0.162). The splint group had a better (but not statistically significant) restoring grip strength (p = 0.056).

CONCLUSION

Wearing of a static metacarpophalangeal joint splint for 3 months following a single injection of corticosteroid increases and stabilises the benefits of the treatment for trigger finger.

Dynavisc as an Adhesion Barrier in Finger Phalangeal Plate Fixation—a Prospective Case Series of 8 Patients

Purpose

Adhesion problems are common after plate fixation of finger phalanges and often lead to stiffness and reoperations with plate removal and tenolysis. The aim of this prospective case series was to study the effect of the adhesion barrier gel Dynavisc on total active motion (TAM), postoperative pain, and grip strength after plate fixation of phalangeal fractures. Total active motion at 3 months after surgery was the primary outcome.

Methods

Eight patients with a fracture of the proximal phalanx underwent surgery with open reduction and plate fixation. The adhesion barrier Dynavisc was applied between plate and extensor tendon and between tendon and skin. Results in terms of pain, grip strength, and TAM at 2 weeks, 3 months, and 1 year after surgery were collected. Results on TAM were classified according to Page and Stern.

Results

After 3 months, only 2 patients had a result classified as excellent. After 1 year, 3 patients fulfilled the criteria for an excellent result. There were no adverse events. Patients with long-standing postoperative pain had a worse outcome on TAM.

Conclusions

The antiadhesive effect of Dynavisc in this prospective case series was unconvincing. Only 2 patients had an excellent result on TAM at 3 months. Because the gel is resorbed within 30 days after application, it is questionable whether the gel had a role in improvement that occurred later in the postoperative course. Larger, randomized studies would be required to show any anti-adherent effect of Dynavisc definitively in finger fracture surgery.

Type of study/level of evidence

Therapeutic IV.