September 30, 2014
10:35:41am
WSPC/135-HS
FA1
1497008
Hand Surgery, Vol. 19, No. 3 (2014) 463–467 © World Scientific Publishing Company DOI: 10.1142/S0218810414970089
SURGICAL TECHNIQUES MINIMALLY INVASIVE SURGERY FOR RADIAL NECK FRACTURES USING BONE PASTE Kazuyoshi Yamanaka and Takashi Sasaki
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
Department of Orthopaedic Surgery Saiseikai Kanagawa-ken Hospital, Japan Received 9 April 2014; Revised 31 May 2014; Accepted 2 June 2014; Published 1 October 2014 ABSTRACT We treat radial neck fractures by a minimally invasive technique using bone paste. The indication of this technique is radial neck fractures in which the continuity with the radius shaft is retained. We have treated 13 patients using this technique. As a result, the average range of motion of the elbow was 90 for supination and 92 for pronation, þ5 for extension, and 141 for flexion. The reduced position at surgery was kept unchanged until bone union. None of the patients complained of pain. The surgical scar was unnoticeable. This technique is recommended surgery for the radial neck fractures when the indication is appropriate. Keywords: Radial Neck Fracture; Minimally Invasive Surgery; Bone Paste.
INTRODUCTION
The operation was performed under general anaesthesia under fluoroscopic guidance. The bone paste that we used was BIOPECS-R r (PENTAX Corporation, Tokyo). The patient’s forearm was kept in such a position that the tilt of the radial head was clearly observed during the operation; this was the supinated position. A skin incision about 5 mm long was made on the lateral aspect of the radial neck. Blunt dissection was performed until the neck of the radius was reached. A small elevator was inserted into the fracture and the angulation was corrected using the leverage of the elevator. Bone paste was filled into the bone defect using an injection nozzle (Fig. 1). It took a few minutes for the paste to become hard. When the fracture was not stable, we inserted a Kirschner wire into the head of the radius and bent it towards the upper arm, ligated it on the upper arm, and then injected the bone paste (Fig. 2). After the paste became hard, the wire was removed. This technique was used in three patients. The wound was closed with skin tape.
Radial neck fractures usually occur as a result of excessive axial load on the forearm, for example by a fall. Surgical treatment is necessary when the displacement is thought to cause dysfunction of the elbow joint. While several types of operative techniques have been reported, the surgical invasion often results in limitation of the range of motion of the forearm. We have begun to treat radial neck fractures by a minimally invasive technique using bone paste. Herein, we introduce our new technique for the treatment of radial neck fractures and report the results obtained using this technique.
SURGICAL TECHNIQUE The indication for this technique was angulated radial neck fractures in which the continuity with the shaft of the radius was retained. Mason type III radial head fractures were excluded.
Correspondence to: Dr. Kazuyoshi Yamanaka, Department of Orthopaedic Surgery, Saiseikai Kanagawa-ken Hospital, 6-6 Tomiya-cho, Kanagawa-ku, Yokohamashi, Kanagawa-ken 221-0821, Japan. Tel: (þ81) 45-432-1111, Fax: (þ81) 45-432-1119, E-mail: [email protected] 463
September 30, 2014
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
464
10:35:41am
WSPC/135-HS
FA1
1497008
K. Yamanaka & T. Sasaki
(A)
(B)
(C)
(D)
(E)
(F)
Fig. 1 Surgical procedure. (A) Blunt dissection to the fracture site. (B) Insertion of a small elevator into the fracture. (C) Reduction using the leverage of the elevator. (D) Insertion of nozzle. (E) Injection of bone paste. (F) Fixation of fracture after bone paste injection.
An above-elbow posterior splint was applied for one week. Supination/pronation exercises in a cylinder cast were started at one week, and flexion/extension exercises of the elbow at 2.5 weeks after the procedure.
MATERIALS AND METHODS
Fig. 2
Stabilisation of the fracture using a Kirschner wire.
We have treated 13 patients, including three males and 10 females, using this technique (Table 1). The patients ranged in age from 14 to 59 years old at the time of the injury. The injury was caused by a fall, bicycle accident, or snowboard accident in the patients. The patients were followed-up for 55 to 225 days. We evaluated the range of motion of the elbow, the x-ray findings as to bone union, leakage of bone paste, and loss of reduction, the clinical results using the Mayo Elbow Performance Index,1 and the appearance of the surgical scar.
Side
31 47 39 20 58 14 17 53 49 49 40 40 59
F M F F F F F F M F F M F
R L L R R L R R L R R L L
Snow board Fall Fall Fall Fall Fall Fall Bicycle Fall fall Bicycle Fall Bicycle
196 189 83 97 167 60 55 58 119 65 199 225 78
Days
Follow-up Period 15 10 20 18 15 18 13 12 16 11 18 17 23
0 0 0 1 0 0 0 0 0 0 0 1 3
0 0 0 1 0 0 0 0 0 2 1 1 4
No No No No No No No No No No Yes Yes Yes
þ þ þ þ þ þ þ þ þ þ þ þ Disappeared — Reduced Reduced Reduced Disappeared Reduced Reduced Reduced Reduced Disappeared Disappeared Reduced
Tilt of Radial Head Leakage of Paste Joystick Pre-op. Post-op. Final Technique Post-op. Final
Mayo Elbow Performance Index. Classification: Excellent > 90; Good 75–89; Fair 60–74; Poor < 60.
1 2 3 4 5 6 7 8 9 10 11 12 13
Cause of Injury 90 100 90 90 100 100 90 90 80 90 85 90 80
100 90 90 90 90 90 90 80 90 90 80 90 90
7 3 14 14 7 4 9 6 0 2 10 9 9
143 140 145 145 140 140 147 137 140 133 110 144 139
100 100 100 100 100 100 100 100 100 100 95 100 100
Range of Motion of the Elbow Mayo Elbow Supination Pronation Extension Flexion Performance Index
WSPC/135-HS
Pt. Age Sex R/L
Data of Patients.
10:35:45am
Table 1
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
September 30, 2014 1497008
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Minimally Invasive Surgery for Radial Neck Fractures Using Bone Paste 465
September 30, 2014
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K. Yamanaka & T. Sasaki
(A)
(B)
(C)
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
Fig. 3 Changes of the leaked bone paste after the operation. (A) X-ray photo at injury. (B) Just after the operation. Some amount of paste was seen around the radial neck. (C) About 119 days after the operation. The leaked paste has almost disappeared.
RESULTS The average range of motion was 90 for supination and 92 for pronation, þ5 for extension, and 141 for flexion. The reduced position at surgery was kept unchanged until bone union. None of the patients complained of pain. All the patients were rated as showing excellent performance according to the Mayo Elbow Performance Index. Leakage of the paste around the fracture was observed in 12 cases at surgery, but this reduced in size or disappeared in all the cases (Fig. 3). No symptoms attributable to paste leakage were observed in those cases. The surgical scar was not noticeable in any of the patients.
ILLUSTRATIVE CASE A 31-year-old female injured her right elbow in a snowboarding accident. The x-ray showed radius neck fracture in which the
(A)
(A) Fig. 5
(B)
(A) Just after the operation. (B) Six months after the operation.
continuity with the radius shaft was maintained (Fig. 4). The fracture was reduced and fixed using our technique (Fig. 5A). The x-ray at six months after the operation showed that the fracture had healed without loss of reduction (Fig. 5B). She
(B)
Fig. 4 X-ray at injury in a 31 year-old female. Tilting deformity of the radial neck fracture is observed.
Fig. 6
Appearance of the surgical scar (arrow).
September 30, 2014
10:35:47am
WSPC/135-HS
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1497008
Minimally Invasive Surgery for Radial Neck Fractures Using Bone Paste
had a good range of motion of the elbow and forearm, and the scar was not noticeable (Fig. 6).
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
DISCUSSION Several kinds of surgical techniques have been reported for radial neck fractures, including those involving the use of plates2,3 or low profile screws.4 These techniques inevitably need incision of the annular ligament and exposure of the fracture site, which may lead to the formation of adhesions around the fracture, resulting in limitation of the range of motion of the forearm. Retrograde intramedullary pinnings5,6 have also been reported, which may be less invasive to the fracture site, but are technically more demanding. In radial neck fractures caused by longitudinal compression forces, e.g. falls, the radial head is impacted on the shaft, but the periosteum and some part of the cortex of the neck is spared. Therefore, when the head is reduced to the normal position and supported by the bone paste filled into the fracture void, the periosteum becomes tight and the fracture stable. The technique using bone paste needs no incision of the annular ligament, which results in a reduced risk of adhesions causing limitation of the range of motion. BIOPEX-R r is a biodegradable bone paste consisting of mainly -tri calcium phosphate. It is prepared by kneading the powder and the liquid material supplied with it, and becomes hard in five to 15 minutes at 37 C. It is used to fill bone defects in the field of orthopaedics, such as in surgery for distal radius fractures7 and vertebroplasty for osteoporotic vertebral fractures.8 As the results in our present patient series indicate, it has sufficient strength to maintain radial neck fractures in the reduced position until completion of bone union. Leakage of the paste near the injection site was observed in 12 cases, but none in the joint space. The leaked paste reduced in size or
467
disappeared in all cases. No undesirable effects were observed in those cases, therefore, the material is considered to be suitable for the treatment of radial neck fractures. Too much pressure to inject paste should be avoided in order to reduce the risk of leakage into the joints. In conclusion, minimally invasive surgery for radial neck fractures using bone paste is recommended as a suitable surgical technique for achieving recovery of normal function of the elbow without a conspicuous surgical scar.
References 1. Morrey BF, The Elbow and Its Disorders, 2 nd ed., W. B. Saunders Company, Philadelphia, pp. 95–96, 1993. 2. Ramon Soler R, Paz Tarela J, Soler Minores JM, Internal fixation of fractures of the proximal end of the radius in adults, Injury 10:268–272, 1979. 3. Leung KS, Tse PY, A new method of fixing radial neck fractures: brief report, J Bone Joint Surg Br 71:326–327, 1989. 4. Smith AM, Morrey BF, Steinmann SP, Low profile fixation of radial head and neck fractures: surgical technique and clinical experience, J Orthop Trauma 21:718–724, 2007. 5. Metaizeau JP, Lascombes P, Lemelle JL, Finlayson D, Prevot J, Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning, J Pediatr Orthop 13:355–360, 1993. 6. Keller HW, Rehm KE, Helling J, Intramedullary reduction and stabilisation of adult radial neck fractures, J Bone Joint Surg Br 76:406–408, 1994. 7. Iida K, Sudo A, Ishiguro S, Clinical and radiological results of calcium phosphate cement-associated balloon osteoplasty for Colles’ fractures in osteoporotic senile female patients, J Orthop Sci 15:204–209, 2010. 8. Nakano M, Hirano N, Matsuura K, Watanabe H, Kitagawa H, Ishihara H, et al. Percutaneous transpedicular vertebroplasty with calcium phosphate cement in the treatment of osteoporotic vertebral compression and burst fractures, J Neurosurg (Spine) 97:287–293, 2002.
10:35:41am
WSPC/135-HS
FA1
1497008
Hand Surgery, Vol. 19, No. 3 (2014) 463–467 © World Scientific Publishing Company DOI: 10.1142/S0218810414970089
SURGICAL TECHNIQUES MINIMALLY INVASIVE SURGERY FOR RADIAL NECK FRACTURES USING BONE PASTE Kazuyoshi Yamanaka and Takashi Sasaki
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
Department of Orthopaedic Surgery Saiseikai Kanagawa-ken Hospital, Japan Received 9 April 2014; Revised 31 May 2014; Accepted 2 June 2014; Published 1 October 2014 ABSTRACT We treat radial neck fractures by a minimally invasive technique using bone paste. The indication of this technique is radial neck fractures in which the continuity with the radius shaft is retained. We have treated 13 patients using this technique. As a result, the average range of motion of the elbow was 90 for supination and 92 for pronation, þ5 for extension, and 141 for flexion. The reduced position at surgery was kept unchanged until bone union. None of the patients complained of pain. The surgical scar was unnoticeable. This technique is recommended surgery for the radial neck fractures when the indication is appropriate. Keywords: Radial Neck Fracture; Minimally Invasive Surgery; Bone Paste.
INTRODUCTION
The operation was performed under general anaesthesia under fluoroscopic guidance. The bone paste that we used was BIOPECS-R r (PENTAX Corporation, Tokyo). The patient’s forearm was kept in such a position that the tilt of the radial head was clearly observed during the operation; this was the supinated position. A skin incision about 5 mm long was made on the lateral aspect of the radial neck. Blunt dissection was performed until the neck of the radius was reached. A small elevator was inserted into the fracture and the angulation was corrected using the leverage of the elevator. Bone paste was filled into the bone defect using an injection nozzle (Fig. 1). It took a few minutes for the paste to become hard. When the fracture was not stable, we inserted a Kirschner wire into the head of the radius and bent it towards the upper arm, ligated it on the upper arm, and then injected the bone paste (Fig. 2). After the paste became hard, the wire was removed. This technique was used in three patients. The wound was closed with skin tape.
Radial neck fractures usually occur as a result of excessive axial load on the forearm, for example by a fall. Surgical treatment is necessary when the displacement is thought to cause dysfunction of the elbow joint. While several types of operative techniques have been reported, the surgical invasion often results in limitation of the range of motion of the forearm. We have begun to treat radial neck fractures by a minimally invasive technique using bone paste. Herein, we introduce our new technique for the treatment of radial neck fractures and report the results obtained using this technique.
SURGICAL TECHNIQUE The indication for this technique was angulated radial neck fractures in which the continuity with the shaft of the radius was retained. Mason type III radial head fractures were excluded.
Correspondence to: Dr. Kazuyoshi Yamanaka, Department of Orthopaedic Surgery, Saiseikai Kanagawa-ken Hospital, 6-6 Tomiya-cho, Kanagawa-ku, Yokohamashi, Kanagawa-ken 221-0821, Japan. Tel: (þ81) 45-432-1111, Fax: (þ81) 45-432-1119, E-mail: [email protected] 463
September 30, 2014
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
464
10:35:41am
WSPC/135-HS
FA1
1497008
K. Yamanaka & T. Sasaki
(A)
(B)
(C)
(D)
(E)
(F)
Fig. 1 Surgical procedure. (A) Blunt dissection to the fracture site. (B) Insertion of a small elevator into the fracture. (C) Reduction using the leverage of the elevator. (D) Insertion of nozzle. (E) Injection of bone paste. (F) Fixation of fracture after bone paste injection.
An above-elbow posterior splint was applied for one week. Supination/pronation exercises in a cylinder cast were started at one week, and flexion/extension exercises of the elbow at 2.5 weeks after the procedure.
MATERIALS AND METHODS
Fig. 2
Stabilisation of the fracture using a Kirschner wire.
We have treated 13 patients, including three males and 10 females, using this technique (Table 1). The patients ranged in age from 14 to 59 years old at the time of the injury. The injury was caused by a fall, bicycle accident, or snowboard accident in the patients. The patients were followed-up for 55 to 225 days. We evaluated the range of motion of the elbow, the x-ray findings as to bone union, leakage of bone paste, and loss of reduction, the clinical results using the Mayo Elbow Performance Index,1 and the appearance of the surgical scar.
Side
31 47 39 20 58 14 17 53 49 49 40 40 59
F M F F F F F F M F F M F
R L L R R L R R L R R L L
Snow board Fall Fall Fall Fall Fall Fall Bicycle Fall fall Bicycle Fall Bicycle
196 189 83 97 167 60 55 58 119 65 199 225 78
Days
Follow-up Period 15 10 20 18 15 18 13 12 16 11 18 17 23
0 0 0 1 0 0 0 0 0 0 0 1 3
0 0 0 1 0 0 0 0 0 2 1 1 4
No No No No No No No No No No Yes Yes Yes
þ þ þ þ þ þ þ þ þ þ þ þ Disappeared — Reduced Reduced Reduced Disappeared Reduced Reduced Reduced Reduced Disappeared Disappeared Reduced
Tilt of Radial Head Leakage of Paste Joystick Pre-op. Post-op. Final Technique Post-op. Final
Mayo Elbow Performance Index. Classification: Excellent > 90; Good 75–89; Fair 60–74; Poor < 60.
1 2 3 4 5 6 7 8 9 10 11 12 13
Cause of Injury 90 100 90 90 100 100 90 90 80 90 85 90 80
100 90 90 90 90 90 90 80 90 90 80 90 90
7 3 14 14 7 4 9 6 0 2 10 9 9
143 140 145 145 140 140 147 137 140 133 110 144 139
100 100 100 100 100 100 100 100 100 100 95 100 100
Range of Motion of the Elbow Mayo Elbow Supination Pronation Extension Flexion Performance Index
WSPC/135-HS
Pt. Age Sex R/L
Data of Patients.
10:35:45am
Table 1
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
September 30, 2014 1497008
FA1
Minimally Invasive Surgery for Radial Neck Fractures Using Bone Paste 465
September 30, 2014
466
10:35:45am
WSPC/135-HS
FA1
1497008
K. Yamanaka & T. Sasaki
(A)
(B)
(C)
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
Fig. 3 Changes of the leaked bone paste after the operation. (A) X-ray photo at injury. (B) Just after the operation. Some amount of paste was seen around the radial neck. (C) About 119 days after the operation. The leaked paste has almost disappeared.
RESULTS The average range of motion was 90 for supination and 92 for pronation, þ5 for extension, and 141 for flexion. The reduced position at surgery was kept unchanged until bone union. None of the patients complained of pain. All the patients were rated as showing excellent performance according to the Mayo Elbow Performance Index. Leakage of the paste around the fracture was observed in 12 cases at surgery, but this reduced in size or disappeared in all the cases (Fig. 3). No symptoms attributable to paste leakage were observed in those cases. The surgical scar was not noticeable in any of the patients.
ILLUSTRATIVE CASE A 31-year-old female injured her right elbow in a snowboarding accident. The x-ray showed radius neck fracture in which the
(A)
(A) Fig. 5
(B)
(A) Just after the operation. (B) Six months after the operation.
continuity with the radius shaft was maintained (Fig. 4). The fracture was reduced and fixed using our technique (Fig. 5A). The x-ray at six months after the operation showed that the fracture had healed without loss of reduction (Fig. 5B). She
(B)
Fig. 4 X-ray at injury in a 31 year-old female. Tilting deformity of the radial neck fracture is observed.
Fig. 6
Appearance of the surgical scar (arrow).
September 30, 2014
10:35:47am
WSPC/135-HS
FA1
1497008
Minimally Invasive Surgery for Radial Neck Fractures Using Bone Paste
had a good range of motion of the elbow and forearm, and the scar was not noticeable (Fig. 6).
Hand Surg. 2014.19:463-467. Downloaded from www.worldscientific.com by FLINDERS UNIVERSITY LIBRARY on 01/12/15. For personal use only.
DISCUSSION Several kinds of surgical techniques have been reported for radial neck fractures, including those involving the use of plates2,3 or low profile screws.4 These techniques inevitably need incision of the annular ligament and exposure of the fracture site, which may lead to the formation of adhesions around the fracture, resulting in limitation of the range of motion of the forearm. Retrograde intramedullary pinnings5,6 have also been reported, which may be less invasive to the fracture site, but are technically more demanding. In radial neck fractures caused by longitudinal compression forces, e.g. falls, the radial head is impacted on the shaft, but the periosteum and some part of the cortex of the neck is spared. Therefore, when the head is reduced to the normal position and supported by the bone paste filled into the fracture void, the periosteum becomes tight and the fracture stable. The technique using bone paste needs no incision of the annular ligament, which results in a reduced risk of adhesions causing limitation of the range of motion. BIOPEX-R r is a biodegradable bone paste consisting of mainly -tri calcium phosphate. It is prepared by kneading the powder and the liquid material supplied with it, and becomes hard in five to 15 minutes at 37 C. It is used to fill bone defects in the field of orthopaedics, such as in surgery for distal radius fractures7 and vertebroplasty for osteoporotic vertebral fractures.8 As the results in our present patient series indicate, it has sufficient strength to maintain radial neck fractures in the reduced position until completion of bone union. Leakage of the paste near the injection site was observed in 12 cases, but none in the joint space. The leaked paste reduced in size or
467
disappeared in all cases. No undesirable effects were observed in those cases, therefore, the material is considered to be suitable for the treatment of radial neck fractures. Too much pressure to inject paste should be avoided in order to reduce the risk of leakage into the joints. In conclusion, minimally invasive surgery for radial neck fractures using bone paste is recommended as a suitable surgical technique for achieving recovery of normal function of the elbow without a conspicuous surgical scar.
References 1. Morrey BF, The Elbow and Its Disorders, 2 nd ed., W. B. Saunders Company, Philadelphia, pp. 95–96, 1993. 2. Ramon Soler R, Paz Tarela J, Soler Minores JM, Internal fixation of fractures of the proximal end of the radius in adults, Injury 10:268–272, 1979. 3. Leung KS, Tse PY, A new method of fixing radial neck fractures: brief report, J Bone Joint Surg Br 71:326–327, 1989. 4. Smith AM, Morrey BF, Steinmann SP, Low profile fixation of radial head and neck fractures: surgical technique and clinical experience, J Orthop Trauma 21:718–724, 2007. 5. Metaizeau JP, Lascombes P, Lemelle JL, Finlayson D, Prevot J, Reduction and fixation of displaced radial neck fractures by closed intramedullary pinning, J Pediatr Orthop 13:355–360, 1993. 6. Keller HW, Rehm KE, Helling J, Intramedullary reduction and stabilisation of adult radial neck fractures, J Bone Joint Surg Br 76:406–408, 1994. 7. Iida K, Sudo A, Ishiguro S, Clinical and radiological results of calcium phosphate cement-associated balloon osteoplasty for Colles’ fractures in osteoporotic senile female patients, J Orthop Sci 15:204–209, 2010. 8. Nakano M, Hirano N, Matsuura K, Watanabe H, Kitagawa H, Ishihara H, et al. Percutaneous transpedicular vertebroplasty with calcium phosphate cement in the treatment of osteoporotic vertebral compression and burst fractures, J Neurosurg (Spine) 97:287–293, 2002.
