Cerclage Fixation of Navicular Fractures

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Navicular fractures are commonly seen midfoot fractures that can be easily missed and difficult to treat. More severe fractures result from forces that compress the talar head into the navicular causing the navicular to displace radially like staves of a barrel. In a case report from Foot and Ankle International, Naidu and Singh (2005) showed a displaced comminuted intra-articular navicular fracture that was treated innovatively with a cerclage wiring technique. To our knowledge, this is the only published report of a navicular fracture treated with this approach. Since that time the senior author has treated over 25 of these severe fractures with a similar cerclage wiring technique. Over time this technique has evolved and now preferentially involves use of an Arthrex FiberTape cerclage system. Methods: The surgical technique is described as follows. First a small incision is made over the medial pole of the navicular. A lead suture is then passed after subperiosteal dissection along the plantar surface of the navicular and received at a similar incision at the lateral pole. The original technique we employed involved the use of a Dall-Miles cable and cable passer but has been supplanted by the lead suture technique or by using the needle of an Arthrex FiberTape. Once control of the plantar surface is accomplished, subperiosteal dissection is made along the dorsal surface with a Kelly clamp or small periosteal elevator. The lead suture is then delivered to the medial pole which then allows for circumferential control of the fracture fragments. The FiberTape is then passed by pulling the lead suture which delivers the FiberTape circumferentially. This provides indirect reduction by radial compression as it is sequentially tightened. Results: We have performed over 25 cases in a similar manner and in our experience have found this to be the best fixation and reduction technique available (Image 1 & 2). Conclusion: This approach demonstrates a safe, expedient, minimal incision surgical approach that provides optimal fixation of these difficult navicular fractures.

The Impact of Different Augmentative Methods on the Expression of Inflammatory Factors

Many animal studies show that an intact periosteum plays an important role in osseous regeneration. The potential effect of an in vivo periosteal barrier membrane on the expression of specific proteins has not been examined sufficiently. The aim of the present study is to investigate the influence of the flap preparation method and collagen membrane on the emission of inflammatory factors. This study examines 20 patients with dental implants who had previously undergone an augmentation. A soft tissue sample was taken during augmentation and 3 months later from the same location. Samples were always taken from the margins of a previously prepared mucoperiosteal flap. The flap was raised with a conventional periosteal elevator in the control group and with a piezoelectric device in the test group. In both groups, we covered half of the augmented bone with a native collagen membrane (NCM; Geistlich Bio-Gide). This allowed us to examine the same incision area with and without a membrane. An immunohistochemical analysis was performed for collagen IV, fibronectin, and inflammatory factors such as cluster of differentiation 31 (CD31), cyclooxygenase-2 (COX-2), and interleukin 6 (IL-6). There was a clear difference in the expression of specific proteins after the piezoelectric device and the periosteal elevator were used. The expression of fibronectin, IL-6, and COX-2 was higher after preparation with the periosteal elevator than after piezoelectric periosteum dissection. The expression of collagen IV was higher after the piezoelectric procedure. No difference was observed for CD31. The membrane had no effect on the expression of collagen IV, fibronectin, IL-6, and COX-2. The type of periosteal preparation influences the expression of specific proteins. With regard to the factors examined here, NCM did not appear to influence the wound healing cascade.

Percutaneous K-Wires Fixation of Displaced Intra-articular Calcaneal Fractures (A Novel Technique)

Category: Hindfoot Introduction/Purpose: The operative treatment of calcaneal fractures has been a controversial topic. Open reduction and internal fixation is associated with a high incidence of postoperative soft tissue complications. Closed reduction and percutaneous K-wires fixation was used to preserve soft tissue. The aim of our study is to evaluate the outcome of closed reduction and percutaneous K-wires fixation of displaced intra-articular calcaneal fractures. Methods: Twenty two displaced intra-articular calcaneal fractures were treated by closed reduction and percutaneous K-wires fixation. The clinical evaluation was based on Maryland Foot Score. According to Sander’s Classification, Eleven fractures were type II, nine were type III and two were type IV. Bimanual compression across the calcaneus was applied to reduce the calcaneal width. A Schanz screw was inserted into the calcaneal tuberosity and was forcibly pushed downwards to elevate the depressed fragment. Two parallel 2 mm K-wires were placed from the posterior inferior corner of the calcaneus across the posterior facet and into the talar body. The reduction of the articular surface was maintained by two crossing subchondral 2 mm K-wires. If the reduction was not satisfactory, a 1-2 cm long transverse incision was used just below the tip of the lateral malleolus. A small tipped periosteal elevator was introduced to elevate the depressed fragment before K-wire fixation. Results: The mean follow up period was 7.68 months. The clinical outcome revealed 18 fractures (81.8%) of satisfactory (14 excellent and 4 good), and 4 patients (18.2%) of unsatisfactory results (4 fair and 0 poor). The mean time of radiological union was 11.86 (range 10 – 14) weeks. One patient had pin tract infection. One patient developed heel widening. Conclusion: Closed reduction and percutaneous K-wires fixation of calcaneal fractures minimizes the soft tissue complications and postoperative scar formation. The mini approach for elevation of the depressed posterior facet restores the articular surface and decreases late subtalar arthritis.