This study compares the cost-effectiveness of treating dorsally displaced distal radial fractures with a volar locking plate and percutaneous fixation. It was performed from the perspective of the National Health Service (NHS) using data from a single-centre randomised controlled trial. In total 130 patients (18 to 73 years of age) with a dorsally displaced distal radial fracture were randomised to treatment with either a volar locking plate (n = 66) or percutaneous fixation (n = 64). The methodology was according to National Institute for Health and Care Excellence guidance for technology appraisals. . There were no significant differences in quality of life scores between groups at any time point in the study. Both groups returned to baseline one year post-operatively. . NHS costs for the plate group were significantly higher (p < 0.001, 95% confidence interval 497 to 930). For an additional £713, fixation with a volar locking plate offered 0.0178 additional quality-adjusted life years in the year after surgery. The incremental cost-effectiveness ratio (ICER) for plate fixation relative to percutaneous fixation at list price was £40 068. When adjusting the prices of the implants for a 20% hospital discount, the ICER was £31 898. Patients who underwent plate fixation did not return to work earlier. We found no evidence to support the cost-effectiveness, from the perspective of the NHS, of fixation using a volar locking plate over percutaneous fixation for the operative treatment of a dorsally displaced radial fracture. Cite this article: Bone Joint J 2015;97-B:1264–70

Two-part surgical neck fractures, two-part greater tuberosity fractures and three- and four-part fractures of the proximal humerus represent a frequently encountered clinical problem. Many types of conservative treatments have been proposed, with a poor functional outcome, however; when the fracture fragments are displaced, surgery is required. Because the open reduction and the internal fixation disrupts soft tissue and increases the risk of avascular necrosis of the humeral head, closed or minimally open reduction and percutaneous pin fixation should represent an advantage. We report on 31 patients affected by fractures of the proximal humerus (n=6, two-part surgical neck fractures; n=5, with two-part greater tuberosity fractures; n=10, three-part fractures; and n=11, four- part fractures) treated with minimally open reduction and percutaneous fixation. The average age was 57 years. Most of the four-part fractures were of the valgus type with no significant lateral displacement of the articular segment. A small skin incision was performed laterally at the shoulder and a rounded-tipped instrument was introduced to obtain the fracture reduction; this latter was stabilised by percutaneous pins and cannulate screws. A satisfactory reduction was achieved in most cases. The average follow-up was 24 months (range 18–47). Only one patient, with four-part fractures associated with lateral displacement of the humeral head, showed avascular necrosis and received a prosthetic implant. Minimally open reduction and percutaneous fixation is a non-invasive technique with a low risk of avascular necrosis and infection. This surgical technique allows a stable reduction with minimal soft tissue disruption and facilitates postoperative mobilisation

Introduction and Aims:. The surgical treatment of fractures of the scaphoid with delayed presentation or with established non-union pose a formidable challenge with reported failure rates between 15% and 45%. The aim of this study is to report the results of percutaneous versus open fixation with bone grafting of these fractures. Method:. 34 Consecutive patients who underwent surgery between 2009 and 2013 for delayed presentation and established non-union of scaphoid fractures have been reviewed retrospectively. There were 27 males and 7 females with a mean age of 31 years (15 to 66). The mean delay from time of injury to operation was 12 weeks (4 weeks to 11 months) in the percutaneous fixation group and 19 months (5 months to 6 years) in the open fixation group. 19 Patients were treated with percutaneous screw fixation alone and 15 patients underwent open reduction and internal fixation supplemented with autogenous corticocancellous iliac bone graft. The classification of Slade and Dodds (2009) was used as a guide for surgical treatment and the Mini-Acutrak headless compression screw was used as the fixation device in all cases. Results:. Patients underwent final clinical and radiological assessment with plain radiographs 6 months following their surgery. There was one failed union in the percutaneous fixation group and there was one failed union in the open fixation group. One patient in the open fixation group was lost to follow up. No serious complications were recorded in either group. Conclusion:. The success of percutaneous internal fixation for acute fractures of the carpal scaphoid may be extended to include scaphoid fractures with delayed presentation and fractures of the scaphoid with established nonunion. However, appropriate patient selection is necessary to ensure optimal outcomes

Introduction: Scaphoid fractures are the most common carpal fractures, mainly affects young man. The fixation of the displaced fractures is well accepted, but more controversy is seen with the fixation of nondisplaced fractures. Surgery offers less cast time, and faster return to daily and sports activities. MATERIAL AND Methods: We present 20 patiens (17 man- 3 woman), mean age 31 years old, that sustained a nondisplaced scaphoid fracture. Surgical treatment was performed with a volar percutaneous fixation with a Herbert canulated screw. Patients were casted for 1–2 weeks and then rehabilitation was started. Results: 60% of the fractures were produced after low energy trauma. Functional evaluation 2 months postoperative were flexion 60°, extension 55°, radial deviation 21, ulnar deviation 18°. Patients returned to sports activities at 11 weeks and at 13 weeks to their previous work. Time to bone union was 9 weeks. In 5 cases pain in the place of the surgical scar were present, we had one case of sensitive branch lesion. Conclusions: The percutaneous fixation of the nondisplaced scaphoid fractures with a Herbert screw allowed a fast functional recovery, good union rate and few complications

Introduction: Carpal scaphoid fractures can be treated non-operatively in a cast, but the duration of treatment can take up to 12 weeks, with non-union rates of 15%. The hypothesis of this study was: percutaneous fixation of acute scaphoid fractures results in better union rates, faster time to union, and better function. Method: In a prospective study, 48 consecutive acute and subacute scaphoid fractures were treated with percutaneous Acutrak screws. These patients were compared to a case-matched control group treated non-operatively in a cast. Herbert-Fisher type A (‘crack’) and B4 (fracture-dislocations) fractures were excluded from the study. The implant is a cannulated headless titanium screw with conical design and continuous differential pitch for inter-fragmentary compression. The screw was introduced retrograde according to a technique devised by the senior author (MP). In addition to the standard postero-anterior and lateral views, prone and supine oblique views were used to achieve accurate screw placement. Results: There were 16 B1 (oblique), 15 B2 (waist), four B3 (proximal pole) and nine B5 (comminuted) fractures in each group. The average operation time was 19 minutes. The union rate was 97.7% in the operated group, and 81.8% (36/44) in the non-operated group (p< 0.05). The average time to union was significantly quicker in the operated group (seven weeks compared to 12 weeks, p< 0.05). At 12 weeks post-treatment the range of motion as well as the pinch and grip strengths were better in the operated group. After 24 weeks the two groups had comparable functional results. The mean time taken return to work was 2.5 weeks with percutaneous fixation compared to 13 weeks with cast treatment (p< 0.05). The average delay with cast group in return to work was 10.8 weeks with an average loss of income of $8815. The overall cost to the community with the screw treatment was $7640 more with cast treatment. There were no complications in the operated group and seven non-unions in the cast group. Conclusion: Primary percutaneous screw fixation of scaphoid fractures is reliable, fast, cost-efficient and reproducible. The learning curve is moderately steep. It results in improved union rates, decreased time to union, improved early function and early return to work. Prone and supine oblique views are invaluable in assessing accurate screw placement

We treated 22 children with a supracondylar fracture of the humerus and an ipsilateral fracture of the forearm by closed reduction and percutaneous fixation. There were four Gartland type-II and 18 Gartland type-III supracondylar fractures of the humerus. There were fractures of both bones of the forearm in 16 and of the radius in six. Both the supracondylar and the distal forearm fractures were treated by closed reduction and percutaneous fixation. The mean follow-up time was 38.6 months. At the latest follow-up there were 21 excellent or good results and one fair result. There were no cases of delayed union, nonunion or malunion. Five nerve injuries were diagnosed on admission and all recovered spontaneously within eight weeks. No patient developed a compartment syndrome

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups. During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised

Introduction: Intraarticular fractures of distal radius are associated with high energy mechanisms, are severe and difficult to obtain a surgical reduction. The aim of our paper is to compare the clinical, radiographically and activity results in workers treated with surgical and conservative procedures. MATERIAL AND METHODS: A prospective study was organized in 43 heavy-labour workers (34 male and 9 female) with unstable fractures of distal radius, treated between 2003 and 2005. The minimal follow-up was of one year. The mean age were 40 years (22–65 years) and dominant limb was involved in 40% of the cases. To treatment groups were established. Group 1, conservative treated with indirect reduction and cast immobilization (n=20) and Group 2 surgically treated with indirect reduction and percutaneous fixation with K-wires and cast immobilization (n=24). Pain, mobility and radiograhs were evaluated and also strength (isokinetics), functionality (DASH score) and, finally, the return to work at 3, 6 and 12 months. RESULTS: Fracture healing was obtained at 7 weeks but the time to return to work were 14 weeks after surgery. Pain score, at 12 months, were 2,3 points for conservative treatment and 2,9 points for the surgically group. The flexion – extension mobility loss, in relation to the contralateral wrist, was lesser in the conservative group at 3 and 6 month but similar (11°) at 12 months in both groups. Radiographs corrections were anatomically in 38% of the cases of group 1 and in 80% of group 2. Functional and strength results were similar in both groups. All the patients return to the same work activity. CONCLUSIONS: Percutaneous fixation of unstable intraarticular distal radius fracture is comparable to the conservative treatment but the percentage of anatomical reductions was higher. It would be of importance in the evolution of the patients

Between June 1996 and April 2002, 56 patients underwent closed reduction and percutaneous fixation of calcaneal fractures. Of the 39 men and 17 woman, five were lost to follow-up. The patients’ mean age was 38 years (17 to 64). Four had bilateral procedures. Using the AOFAS Ankle and Hindfoot Scale (AHS) and Visual Analogue Pain Scale (VAPS), we assessed patients preoperatively and at 6 and 12-monthly intervals. Clinical examination was undertaken preoperatively and postoperatively at 2-week, 6-week, 3-month, 6-month and 12-monthly intervals. Except at two weeks, radiographs included weight-bearing axial and lateral views at all intervals. Follow-up was for a mean period of 42 months (12 to 72). The mean time to union was 10.2 weeks (8 to 14). The AHS improved from 34 preoperatively to 85 at the most recent follow-up. The VAPS improved from 9.1 preoperatively to 2.2 at three years. The satisfaction rate was 86%. Functional results depended on the quality of the reduction of the posterior facet and the severity of the initial injury. Complications included a 5% sural nerve injury and a 3% peroneal tendinopathy. No wound complications were encountered. In selected cases, closed reduction and internal fixation of calcaneal fractures may produce results similar to those of conventional open reduction and internal fixation, with fewer complications. This technique is best performed within 24 to 72 hours of injury

With the development of systems of trauma care the management of pelvic disruption has evolved and has become increasingly refined. The goal is to achieve an anatomical reduction and stable fixation of the fracture. This requires adequate visualisation for reduction of the fracture and the placement of fixation. Despite the advances in surgical approach and technique, the functional outcomes do not always produce the desired result. New methods of percutaneous treatment in conjunction with innovative computer-based imaging have evolved in an attempt to overcome the existing difficulties. This paper presents an overview of the technical aspects of percutaneous surgery of the pelvis and acetabulum.

We present the results of a multicentre retrospective study of closed fracture dislocations of the Lisfranc joint treated by closed reduction and percutaneous screw fixation (follow-up: almost 5 years). Forty-two patients that presented between 1994 and 1999 to the authors™ institutions were selected for this study (follow-up AOFAS score 81.0 ± 13.5). A review of the literature shows that opinions differ as to the most appropriate method of treatment, be it closed or open reduction, screws or K-wires fixation, but most of the authors agree that it is imperative to achieve anatomical reduction. In our study, no statistically significant differences could be detected when outcome scores of patients with anatomical reduction were compared with outcome scores of patients with nearly anatomical reduction, in both the combined fracture dislocation and pure dislocation subgroups. The conclusion is that even a nearly anatomical reduction is considered acceptable and predictive of a satisfactory outcome. Furthermore, we found a statistically significant difference in the AOFAS score between patients with combined fracture dislocations and pure dislocations, with the latter having a worse AOFAS score. This suggests that the ligament bone interface cannot heal with sufficient strength to regain stable long-term function

Introduction: Mac Farland fracture is a joint fracture of the ankle in children, which involves the medial malleolus (Salter-Harris type III or IV) and is frequently associated with a fracture of the distal fibula. These injuries have a major risk of resulting in a medial epiphysiodesis bridge which, in turn, can lead to a varus deformity. As of today, recommended treatment for displacements wider than 2mm is open reduction with screw fixation. The aim of this study is to evaluate functional and radiological results of a new less invasive surgical procedure. Materials and Methods: We retrospectively analyzed a case series of patients who suffered from a Mac Farland fracture and underwent percutaneous screw fixation with arthrographic control. Data collected for each child included age at diagnosis, gender, mechanism and side of injury, radiological Salter-Harris classification of medial and lateral malleolus fracture, size of the fracture line gap before and after treatment, and duration of cast immobilization. Results are given according to the classification by Gleizes (2000), based on clinical and radiological criteria: good, fair, and poor. Results: There were twelve patients, five girls and seven boys, with a mean age of twelve years and six months (range: 10–15). Average follow-up was eighteen months (range: 9–57). Medial malleolus fracture was Salter-Harris type III in seven patients and type IV in five. The mean preoperative fracture line gap was 2.7mm (range: 2–4). All the patients underwent closed reduction and ankle arthrography to check for anatomical reposition. The fracture was then percutaneously fixed with two screws in nine patients and one screw in three. Duration of cast immobilization after surgery was forty-five days in average. At the time of last follow-up the functional and radiological results were good for all the patients according to Gleizes’ classification. Conclusion: Closed reduction combined to ankle arthrography followed by percutaneous osteosynthesis is, in our opinion, an interesting less invasive surgical alternative to classic open reduction and internal fixation for displaced Mac Farland fractures

Acute scaphoid fractures are commonly treated with cast for 8–12 weeks. With this prolonged period of immobilisation patients can encounter joint stiffness and muscle wasting requiring extensive physiotherapy. Despite best practice, these fractures also pose a risk of non-union and suboptimal function. Fracture location, duration of time lost from work and impairment in activities of daily living are key factors in scaphoid fracture management. The aim of our study was to compare percutaneous screw fixation of the scaphoid with other operative fixation techniques. Parameters documented were length of conservative treatment, mechanism of injury, post-op complications and patient satisfaction levels with each technique using a standardised questionnaire. Economic benefit was also measured by examining time to return to work, number of x-rays and outpatient visits required per treatment group. In this study, 76 patients requiring operative scaphoid fixation were evaluated. 27 patients underwent percutaneous fixation. Waist fractures accounted for 66% (n= 18), proximal pole fractures 33% (n=8) and distal pole fractures 4% (n=1). There were 16 non-displaced fractures (59%) and 11 displaced fractures (41%). The average length of conservative treatment was 77 days (range: 2–256 days). Within the percutaneous group 2 patients developed non-union. We did not encounter any wound infection or superficial radial nerve damage. Patients treated with early percutaneous fixation had highest satisfaction levels, returned to work earlier and required less follow-up (P< 0.001). In conclusion percutaneous screw fixation provides earlier bone union and avoids the need for prolonged immobilisation when compared to other treatment modalities. The economic benefit of early percutaneous fixation must also be considered when managing patients with scaphoid fractures

Ununited fractures of the scaphoid with extensive bone resorption are usually treated by bone grafting and internal fixation, using either an open or a minimally invasive technique. We studied the feasibility of percutaneous fixation without bone grafting in a consecutive series of 27 patients with established nonunion of an undisplaced fracture of the scaphoid and extensive local resorption of bone. They were treated by a single surgeon with rigid fixation alone, using a headless cannulated screw inserted through a volar percutaneous technique. Clinical examination, standard radiographs and CT confirmed that the fracture had united in all patients at a mean of 11.6 weeks (8 to 16), and that their functional scores had improved. We concluded that extensive resorption at the fracture site is not an absolute indication for bone grafting, and that percutaneous fixation alone will eventually produce healing of ununited undisplaced fractures of the scaphoid regardless of the size of the gap

Background. Percutaneous K-wire fixation is a well-recognised and often performed method of stabilisation for distal radius fractures. However, there is paucity in the literature regarding the infection rate after percutaneous K-wire fixation for distal radius fractures. Aims. To analyse the rate and severity of infection after percutaneous K-wire fixation for distal radius fractures. Material and methods. Between October 2004 and June 2005, 43 patients with closed distal radius fractures had percutaneous K-wire fixation. The wires were left outside the skin in all the cases for easy removal at the end of six weeks at the clinic. They were followed up in the clinic at 1, 2, 4, and 6 weeks. The pin tracts were examined at 2 weeks and six weeks, or if needed earlier. The severity of pin tract infection was graded using modified Oppenheim classification. Results. Out of 43 patients, the male to female ratio was 13:30. The mean age was 49.1 years (range 5-86 years). There were nine cases of pin tract infection, out of which three were grade I, three were grade II, two were grade III, and one was grade IV. In three cases the K-wires had to be removed earlier. Discussion. The infection rate after percutaneous K-wire fixation for distal radius fractures is high (20.9%), which is equivalent to the infection rate quoted in the literature for hybrid external fixators. As the K-wires are used to fix the fractures, the expected implant infection rate in Trauma and Orthopaedics which is less than 1% should be aimed for. However this is not the case. Hence, burying the K-wires under the skin may be an alternative to reduce the infection rate after percutaneous K-wire fixation of distal radius

We randomly allocated 60 consecutive patients with fractures of the waist of the scaphoid to percutaneous fixation with a cannulated Acutrak screw or immobilisation in a cast. The range of movement, the grip and pinch strength, the modified Green/O’Brien functional score, return to work and sports, and radiological evidence of union were evaluated at each follow-up visit. Patients were followed sequentially for one year. Those undergoing percutaneous screw fixation showed a quicker time to union (9.2 weeks vs 13.9 weeks, p < 0.001) than those treated with a cast. There was a trend towards a higher rate of nonunion in the non-operative group, although this was not statistically significant. Patients treated by operation had a more rapid return of function and to sport and full work compared with those managed conservatively. There was a very low complication rate. We recommend that all active patients should be offered percutaneous stabilisation for fractures of the waist of the scaphoid

Untreated 3- and 4-part fractures of the proximal humerus have a poor functional outcome. Open operation increases the risk of avascular necrosis and percutaneous reduction and fixation may be preferable.

We report 27 patients, 9 with 3-part and 18 with 4-part fractures, treated by percutaneous reduction and screw fixation. Thirteen of the 4-part fractures were of the valgus type with no significant lateral displacement of the articular segment, and five showed significant shift. Instruments were introduced into the fracture through small incisions so that the fragments could be manoeuvred under the control of an image intensifier, taking advantage of ligamentotaxis as far as possible. A good reduction was achieved in most cases.

The average follow-up was 24 months (18 to 47). All the 3-part fractures showed good to very good functional results, with an average Constant score of 91% (84% to 100%), and no signs of avascular necrosis. Good radiological results were achieved in 4-part fractures when impacted in valgus except for one patient with partial avascular necrosis of the head. In those with lateral displacement of the head, revision to a prosthesis was required in one patient because of avascular necrosis and in another because of secondary redisplacement of the fracture. Avascular necrosis was seen in 11% of 4-part fractures. The average Constant score in patients with 4-part fractures who did not need further operation was 87% (75% to 100%).

Fractures of the scaphoid are most common in young men; immobilisation in a cast usually means a long period away from work and athletic activities. Early rigid fixation has been shown to promote a rapid functional recovery, but open reduction and internal fixation is technically demanding with the dangers of damage to the radiocarpal ligaments, the scaphotrapezial joint, and the blood supply of the scaphoid. For minimally displaced or undisplaced B1 or B2 fractures, these problems can be overcome by percutaneous fixation. We report our technique and the results of a pilot study in 15 patients. There was no immobilisation; patients were allowed movement soon after operation, but union was obtained in all at a mean of 57 days (38 to 71). The range of movement after union was equal to that of the contralateral limb and grip strength was 98% of the contralateral side at three months. Patients were able to return to sedentary work within four days and to manual work within five weeks. Our initial results show that percutaneous scaphoid fixation for acute fractures is satisfactory and gives rapid functional recovery

The aim of this study was to prospectively assess the outcome of patients with metastatic spinal disease who underwent minimally invasive fixation of the spine for intractable pain or spinal instability.

This is a prospective audit of patients with metastatic spinal cord disease who have undergone minimally invasive fixation of the spine from August 2009 until the present date. This was assessed by pre and post-operative Oswestry Disability Index (ODI), EQ5D and Tokuhashi scores. Intra- and post-operative complications, time to theatre, length of inpatient stay, analgesia requirements, mobility, chest drain requirement and post-operative HDU and ITU stays were also recorded.

So far, 10 patients have met the criteria. There were no intra-operative complications. Post-operatively, there were no complications, chest drains, increase in analgesia or stay on the HDU or ITU. All patients showed an improvement in mobility. The mean post-operative day of mobilisation was 2 days, post-operative days until discharge 5.3 days and length of inpatient stay was shorter than traditional surgery. Blood loss was minimum except one patient with metastatic renal cell carcinoma who needed transfusion intraoperatively.

ODI, VAS and EQ-5D scores were calculated and were significantly improved compared to preoperatively.

This novel approach to management of metastatic spinal disease has resulted in improved mobility, short inpatient stays without the need for chest drains, HDU or ITU and an improved the quality of life in pallliative patients. This is a completely new strategy to treat the pain in these patients without the usual associated risks of surgery and has major advantages over traditional surgical techniques which may preclude this group of patients having any surgical stabilisation procedure at all

Aims: The study was undertaken in order to assess the clinical and radiological results of treatment of comminuted diaphyseal fractures of long bones using the principle of biological fixation, standard implants and minimum access surgery.

Methods: 20 patients operated with this method are subject of this review. All operations were performend on the orthopedic or ordinary translucent table using image intensifier. Fractures were reduced indirectly and fixed with the plate or DCS passed subcutaneously with-our accessing the fracture site.

Results: All fractures united in the average period of 5.9 months.There were no snignificant complications and no infections. Function of adjacent joints was good.

Conclusion: In case of comminuted diaphyseal fractures of long bones biological fixation with minimal access surgery principle using standard implants gives excellent clinical and radiological results and is a valuable alternative to other fixation methods