INTRAFOCAL PINNING FOR DORSALLY DISPLACED DISTAL RADIUS FRACTURES

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INTRODUCTION

Fractures of the distal radius represent about 15% of all fractures seen in the emergency units and departments [1]. Different therapeutic methods have been described, and they all aim at achieving a sustained anatomic reduction and restoring the congruity of both the radio-carpal and radio-ulnar joints [2]. Although all methods intend to regain good functionality of the wrist and upper limb, there is still a lack of consensus regarding the optimal treatment method [2-6]. The surgical treatment of dorsal-ly displaced distal radius fractures has recentdorsal-ly evolved after the introduction of new generations of low-profile anatomic locking plates and screws [2]. Among various surgical modalities, intrafocal pinning, first described by Kapandji in 1976 [7], has gained large popularity, espe-cially in the French literature between 1980 and 2000. The use of locking plates has been associated with tremendous

increased costs for healthcare providers [3,8], and this is where the cheaper method of intrafocal pinning has an obvious economic advantage. The authors aim at present-ing their experience with this technique in a series of patients they treated for dorsally displaced distal radius fractures between 1994 and 1999.

MATERIAL AND METHODS

Between January 1994 and January 1999, intrafocal pin-ning, known as Kapandji technique, was used by two of the authors (RJ and AHC) to treat 138 patients with dor-sally displaced distal radius fractures. Because of the ret-rospective nature of this study, only 56 patients could be reviewed and evaluated at the end of the study. The rea-sons for the dropouts among the remaining 82 patients were: refusal to present for assessment, inability to con-tact patient, or failure to meet the inclusion criteria. The inclusion criteria were: distal radius fracture with or without fracture of distal ulna or ulnar styloid, dorsal displacement, availability of initial and postoperative X-rays, minimal follow-up period of 6 months, and patient availability to undergo clinical and radiological assess-ment of both wrists at the time of evaluation in May 1999. Lack of any one of these criteria, as well as a his-tory of previous wrist fracture of any side, were grounds for exclusion.

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INTRAFOCAL PINNING FOR DORSALLY DISPLACED DISTAL RADIUS FRACTURES

http://www.lebanesemedicaljournal.org/articles/65-3/original4.pdf Amer Camille ABDALLAH1

, Ibrahim HAIDAR1-2

, Oussama EL HAJJ1-2

, Assad TAHA3

Roger JAWISH1-4

, Ali Hassan CHAMSEDDINE1-2

Abdallah AC, Haidar I, El Hajj O, Taha A, Jawish R, Chamseddine AH. Intrafocal pinning for dorsally displaced distal radius fractures. J Med Liban 2017 ; 65 (3) : 146-156.

Abdallah AC, Haidar I, El Hajj O, Taha A, Jawish R, Chamseddine AH. Embrochage intrafocal des fractures du radius distal à déplacement dorsal. J Med Liban 2017 ; 65 (3) : 146-156.

ABSTRACT

Intrafocal pinning of dorsally displaced distal radius fractures, as described by Kapandji in 1976, was very popular during the last two decades of the last century. This method has clear economic advantages over other modern methods of internal fixation such as locking plates. The authors aim at presenting the results of a series of 56 patients operated for distal radius fractures between 1994 and 1999. All patients were clinically reviewed and radiographically assessed at a mean of 16 months follow-up.

The authors believe that intrafocal pinning remains a valuable method for the treatment of dorsally displaced extra-articular distal radius fractures; however, it should be used with caution in presence of epiphyseal and dorsal metaphyseal comminution.

Keywords : distal radius fracture; intrafocal pinning; Kapandji technique

RÉSUMÉ

L’embrochage intrafocal des fractures de l’extré-mité distale du radius à déplacement dorsal, décrit par Kapandji en 1976, a connu une grande popularité pendant les deux der-nières décennies du siècle dernier. Cette technique présente des avantages économiques évidents par rapport aux mé-thodes modernes de fixation telle que la plaque verrouillée. Les auteurs présentent les résultats d’une série de 56 patients trai-tés pour de telles fractures entre 1994 et 1999. Tous les patients ont été cliniquement revus et radiographiquement évalués au recul moyen de 16 mois.

Pour les auteurs, l’embrochage intrafocal des fractures extra-articulaires à déplacement dorsal de l’extrémité distale du radius reste une méthode valable ; cependant elle doit être utilisée avec précaution en cas de comminution épiphysaire et métaphysaire dorsale.

Mots-clés : fracture du radius distal; embrochage intrafocal; technique de Kapandji

In memory of the late Professor Roger Jawish.

From Divisions of Orthopaedics and Trauma Surgery in Beirut, Lebanon: 1Bellevue University Medical Center, Faculty of Medical Sciences, Lebanese University; 2Sahel General Hospital - University Medical Center; 3American University of Beirut Medical Center; 4SacréCœur Hospital -University Medical Center.

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The study included 56 patients aged between 17 and 76 years, with a mean of 58 years. There were 23 females and 33 males; the right wrist was involved in 26 patients and the left one in 30. All patients were treated with the same surgical technique, under general or loco-regional anaesthesia, in the supine position with the upper limb on a side table, and the use of a tourniquet. After gentle closed reduction the surgeon faithfully fol-lowed the surgical technique described by Kapandji [7,

9-11], using 3 unthreaded pins 18/10 to 22/10 mm diam-eter. Fluoroscopic C-Arm control was used to assess reduction and appropriate position of pins at the end of fixation, and the pins were cut back around 1 cm from the dorsal cortex; they were finally buried between the superficial layer of the dorsal extensor retinaculum and the deep layer of the skin at the time of closure. In three patients, an articulated wrist-spanning external fixator was used in addition to pinning (from the radius to the

FIGURE1. Extra-articular type-2 fracture with dorsal comminution.

Preoperative (a, b), postoperative (c, d) and final follow-up radiographs (e, f). Satisfactory radiographic and clinical results.

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metacarpal); it was removed at 8 weeks at the same time as the intrafocal pins. No postoperative immobiliza-tion was used in 24 patients, while a volar splint was applied in 19 patients and a circular cast in 10; immobi-lization was removed at 3 weeks postoperatively in all 29 patients. Rehabilitation was prescribed only for the 3 patients in whom an external fixator was used. In all patients, the pins were removed at 6 to 8 weeks, under local anesthesia.

RESULTS

According to Kapandji classification [12], there were:

3 type-1 fractures (extra-articular, one epiphyseal fragment, dorsal displacement, no dorsal comminution)

30 type-2 fractures (Fig. 1) (extra-articular, one epiphy-seal fragment, dorsal displacement, dorsal comminution),

7 type-3 fractures (articular, 2 fragments, frontal T)

5 type-4 fractures (Fig. 2) (articular, 2 fragments,

FIGURE2. Intra-articular type-4 fracture.

Preoperative (a, b), postoperative (c, d) and final follow-up radiographs (e, f). Satisfactory radiographic and clinical results.

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sagittal T)

10 type-9 fractures (Fig. 3) (epiphyseal comminution), and finally

1 type-10 fracture (distal radius and distal ulna, ulnar styloid excluded).

In total, 71.4% of fractures were extra-articular (types 1 and 2), 14.2% simple intra-articular (types 3 and 4), and 12.5% comminuted intra-articular (type-9). The three fractures treated with additional external fixator were two type-9 fractures and one type-10.

Patients underwent clinical and radiological

assess-ment of the fractured and uninjured wrist at periods ranging between 6 and 52 months (mean 16 months). In addition to fracture healing, radiological assessment included measurements of the radial coronal inclination, the radial sagittal inclination or volar tilt, and the ulnar variance, as adopted by Kapandji [11].

The values obtained on the immediate postoperative and the final radiographs of both wrists (the fractured and unin-jured) were recorded, and the differences in the values

FIGURE3. Intra-articular type-9 fracture.

Preoperative (a, b), postoperative (c, d) and final follow-up radiographs (e, f). Satisfactory clinical and radiographic results.

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between the fractured and intact sides were also separately recorded. A score ranging from 0 to 3 was given to each one of these differences (Tables I and II). When any measure-ment indicated a borderline value bestween two scores, the worse score was adopted. A final radiographic score from 0 to 9 was given to each patient after adding together the scores of the three measurements. The final radiographic result for each patient was then classified according to the final note obtained by this addition, as shown in Table III. A comparison between immediate postoperative and final follow-up radiographic results, according to the fracture’s type, was finally made (Table IV).

Final radiographic assessment showed 30.3% excellent, 30.3% good, 25% fair, and 14.2% poor results (Table IV).

Clinical assessment at final follow-up was done according to Gartland and Werley score [13], based on residual clinical deformity (0-3 points), subjective evalu-ation (0-6 points), objective evaluevalu-ation (0-5 points), and complications including arthritic changes and pain (0-5 points), median nerve complication (1-3 points), and poor fingers function (1-2 points). It revealed excellent result (0-2 points) in 37.5% of cases, good (3-8 points) in 34%, fair (9-20 points) in 14.2% and poor (> 20 points) in 14.2% (Table V).

TABLE I

SCORE ALLOCATED FOR THE RADIOGRAPHIC MEASUREMENTS OF THE RADIAL CORONAL INCLINATION AND THE RADIAL SAGITTAL INCLINATION OR VOLAR TILT

Difference* D < 5° 5° ≤ D < 10° 10° ≤ D < 15° D ≥ 15°

Score 0 1 2 3

*D: difference in º between the normal & operated side measurements.

TABLE III

THE FINAL RADIOGRAPHIC SCORE FOR EACH PATIENT IS MADE BY ADDITION OF THE 3 SCORES PREVIOUSLY DOCUMENTED FOR THE MEASUREMENTS OF THE RADIAL CORONAL INCLINATION,THE RADIAL VOLAR TILT AND THE ULNAR VARIANCE

Final Radiographic Score 0 1-3 4-6 7-9

Radiographic Result Excellent Good Fair Poor

TABLE II

SCORE ALLOCATED FOR THE RADIOGRAPHIC MEASUREMENT OF THE ULNAR VARIANCE

Différence* D<3mm 3mm≤ D < 6mm 6mm≤ D < 12mm D ≥ 12mm

Score 0 1 2 3

*D: difference in mm between the normal & operated side measurements.

TABLE IV

RADIOGRAPHIC RESULTS ACCORDING TO THE FRACTURE TYPE: IMMEDIATELY POSTOPERATIVE (IPO) AND FINAL FOLLOW-UP (FFU)

Radiographic Excellent Good Fair Poor Total

result IPO FFU IPO FFU IPO FFU IPO FFU IPO FFU

Fracture type (66%) (30.3%) (19.6%) (30.3%) (10.7%) (25%) (3.5%) (14.2%) Type 1 3 3 0 0 0 0 0 0 3 3 Type 2 24 12 6 10 0 6 0 2 30 30 Type 3 3 0 3 4 1 2 0 1 7 7 Type 4 2 0 1 1 2 2 0 2 5 5 Type 9 4 2 1 1 3 4 2 3 10 10 Type 10 1 0 0 1 0 0 0 0 1 1 Total 37 17 11 17 6 14 2 8 56 56 TABLE V

FINAL RADIOGRAPHIC (RR) AND CLINICAL RESULTS (CR) ACCORDING TO THE FRACTURE TYPE

Radiographic Excellent Good Fair Poor Total

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Complications occurred in 14 cases (25%) and con-sisted of neuroma of the sensory branch of the radial nerve in 1 patient (1.8%), rupture of the extensor ten-don of the 3rd& 4thfingers at the dorsum of the wrist

in 1 patient (1.8%), dorsal pin migration with skin irri-tation in 3 patients (5.3%), volar pin migration (Fig. 4) in 1 patient (1.8%), and regional sympathetic

dystro-phy (RSD) in 8 patients (14.2%). All 3 patients treat-ed with additional external fixator were among the 8 patients with RSD (Fig. 5). All the RSD patients responded to medical treatment except for one of the external fixator group, who had type-9 fracture and ended up with limitation of motion of the wrist and fingers.

FIGURE4. Good reduction and fixation of extra-articular fracture (a, b) with volar migration of one pin (c, d).

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DISCUSSION

In 1976, Kapandji first reported a technique of intrafo-cal pinning for extra-articular dorsally displaced distal radius fractures, using two conventional Kirschner wires [7]. He then made several technical modifica-tions, and sequentially recommended the use of fully

threaded pins, partially threaded pins with additional end cup, and finally the special so-called “Arum” pins [11]. The aim was to improve the sustained buttress reduction effect of the pins, and to minimize pin relat-ed complications in terms of migration and soft tissue problems. Although early indications were limited to dorsal displaced extra-articular fractures, Kapandji

FIGURE5. Intra-articular comminuted type-9 fracture treated with intrafocal pinning and External Fixator.

Preoperative (a, b), postoperative (c, d) and final follow-up radiographs (e, f). Note the aspect of patchy osteoporotic changes secondary to regional sympathetic dystrophy.

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enlarged the spectrum of indications of his technique to include intra-articular fractures and volarly dis-placed fractures; more than two pins started to be employed in order to stabilize different specific epi-physeal fragments [10,11].

For more than 20 years following the initial descrip-tion, Kapandji technique gained wide popularity in the treatment of dorsally displaced distal radius fractures, especially in French literature.

Discordance between radiologic and clinical results was noted in our series. Our radiologic results were satisfactory in 60.6% (30.3% excellent and 30.3% good) and unsatisfactory in 39.2% (25% fair and 14.2% poor), while the clinical results were satisfacto-ry in 71.5% (37.5% excellent and 34% good) and un-satisfactory in 28.4% (14.2% fair and 14.2% poor). Kapandji reported 64% satisfactory, 21.15% fair, and 15% poor clinical results, with improvement of the ulnar variance in only 48% of cases [11]. He stated that functional and anatomic results were not corre-lated, and noticed that many patients with malunion ended up with good results and nearly normal wrist function [11]. Epinette et al. reported 88% satisfactory subjective and objective clinical results; nevertheless, the radiologic results of their series revealed 70% sat-isfactory (41% excellent and 29% good) and 30% un-satisfactory results (18% fair and 12% poor) with a 29% incidence of malunion [14]. Haentjens and Casteleyn could not demonstrate any relationship between the quality of reduction and the final clinical result after Kapandji procedure [15]. In contrast, others consid-ered that clinical outcome depends on the fracture type and treatment mo-dality, as well as the quality of re-duction [16].

Fornasieri et al. compared the results of intrafocal pinning of extra-articular “compression-extension” fractures with those of conservative treatment, using cast immobilization [17]. Although functional results were uniformly excellent with both techniques at 21 months follow-up, radiographic results were signifi-cantly better with the Kapandji procedure. Loss of ini-tial reduction at follow-up was noted by many authors after intrafocal pinning [9,14-16]. Excellent and good radiographic results of our series dropped from 85.6% in the initial postoperative assessment to 60.6% at final follow-up, with a concomitant increase of fair and poor results from 14.2% to 39.2%. Although excellent and good radiographic results were initially achieved in all type-2 fractures, only 73.3% remained as such at the final follow-up, and 26.6% ended up with fair and poor results; moreover 50% of type-2 fractures that were initially qualified as having excel-lent initial reduction lost the reduction. Compared to the initial radiographic results, fair and poor final results increased by 3 times for type-3, and doubled for type-4 fractures; finally fair and poor results of type-9 fractures increased from 50% in postoperative-ly to 70% at final follow-up (Table IV). According to

Kapandji, the occurrence of secondary displacement at the fracture site is usually related to borderline indi-cation of this procedure as well as to technical errors [9]. In 1987, he wrote a personal testimony after 10-year experience with his procedure, and acknowl-edged that the ideal indication for intrafocal pinning is the “simple” extra-articular Colles fracture without intra-articular extension or dorso-ulnar “third frag-ment”; only extra-articular fractures with minimal dorsal comminution and good bone quality may also benefit from intrafocal pinning [9].

Although Epinette et al. recommended using this technique in most cases of Colles’ fractures, they also recognized that “this method becomes gradually less satisfactory as the posterior comminution and the joint involvement increase” [14]. Finally, Haentjens and Casteleyn observed “significant loss of reduction between the first postoperative day and the 1-year follow-up radiographs” [15].

Many authors compared the Kapandji procedure to other methods of pinning. A prospective comparative randomized study by Fikry et al. demonstrated bet-ter overall objective and radiographic scores for the group of patients treated with Py procedure - an intramedullary flexible pinning - than those with Kapandji procedure; however, subjective results were comparable for both techniques [18]. The authors sug-gested that the Kapandji procedure is indicated for extra-articular Colles’ fractures without dorsal com-minution. For Delattre et al. [19,20], Kapandji tech-nique provided 85% of very good and good results compared to 70% for the Py technique; this difference was even more evident in the incidence of poor results, with 3.5% for Kapandji procedure and 18% for Py. Lenoble et al. were unable to demonstrate any advantages of intrafocal pinning over trans-styloid fixation at two years follow-up; however, although clinical results were comparable, radial shortening and positive ulnar variance were significantly more common with the Kapandji procedure than those treated with trans-styloid fixation [16].

Fornasieri et al. noted ulno-carpal impingement in 10.7% of patients treated with intrafocal pinning, a complication directly related to radial shortening and positive ulnar variance [17]. Jawish et al. have recent-ly suggested preventing this complication by an acute shortening osteotomy of the distal ulna when perform-ing intrafocal pinnperform-ing in osteoporotic wrist fractures [21]. In order to increase fixation stability, Delattre and Catonné recommended a modified Kapandji in-trafocal pinning, the combined or mixed-pinning; they advised multiplying the number of intrafocal pins as needed in order to stabilize each specific and individ-ual fragment, and to replace the latero-radial intrafo-cal pin with a trans-styloid latero-radial pin, especially in comminuted metaphyso-epiphyseal fractures [22].

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for extra-articular fractures without substantial meta-physeal comminution [3].

Over-reduction in the sagittal plane with iatrogenic increased volar tilt was reported in association with an exaggerated “vertical” direction of the dorsal pins [9]. Minimal increase of volar tilt without clinical impairment occurred in two patients of our series (3.5%) (Fig. 6). Peyroux et al. reported 5% of over-reduction with in-creased volar tilt; they recommended overcoming this problem by doing gentle reduction of the initial displace-ment and directing the dorsal pins not more than 45° along the axis of the radius [23].

Although a high overall complication rate was seen in our series (25%), only few of them can be qualified as being serious. Among the eight cases of RSD, five who had been treated with intrafocal pinning alone, had com-plete resolution with medical treatment, without any se-quel; among the remaining three cases that had been treated with additional external fixation, only one did not respond to treatment and ended up with hand stiffness.

There were four cases of pin migration, and these can be considered as minor complications because they did not cause any injury to any of the nearby structures. Among the 14 complications in our series, we believe that only two can be qualified as being serious and can be direct-ly related to the technique itself: the neuroma of the sen-sory branch of the radial nerve, and the rupture of the extensor of the 3rdand 4thfingers.

Various complications have been associated with the Kapandji procedure in the literature, with a cumulative rate of 26% reported by Epinette et al. [14] and 60% by Fornasieri et al. [17]. Epinette et al., however, stated that complications associated with “negative” results were only seen in 7% of cases [14]. Pin migration was en-countered in 2.5-7% of cases [14,16,17,23], and was cor-related with the presence of osteoporosis [9,22]. Dorsal migration necessitated premature removal because of skin irritation and perforation, while volar migration re-quired a volar approach for removal [9]. Kapandji advo-cated overcoming the pin migration problem by using partially threaded pins and “Arum” type pins [11]. Teno-synovitis and rupture of extensor tendons at the dorsum of the wrist were encountered in about 7% [14,18]; accu-rate technique and use of pins with end cup or “Arum” type pins were advised to avoid tendon related problems [11]. Epinette et al. reported hypoesthesia of the sensory branch of the radial nerve at the wrist without neuroma in 4% [14], while Fornasieri et al. reported symptomatic neuromas in 21.5% of cases [17]. This complication can also be avoided by a meticulous technique of pin inser-tion and pin removal. Although regional sympathetic dystrophic syndrome was reported with various inci-dences between 3 to 21% [14,17], it seems mainly relat-ed to the pain inducrelat-ed by early motion [16]; the practice of immediate wrist and finger motion postoperatively was promoted by Kapandji as a main advantage of this procedure [7, 9-11].

The relationship between functional outcome and ra-diographic findings after treatment of distal radius frac-tures has been debated [24,25]. The assumption that resti-tution of normal anatomy of the distal radius is associated with good functional results, especially in the elderly [27], has triggered many discussions [26]. Although many clas-sical reports showed direct relationship between good results and restitution of the anatomy of distal radius frac-tures in young adults [28-30], only few articles utilized evaluation tools based on patient-perceived outcome [31-35]. Recent literature reveals a rising interest for open reduction and internal fixation of distal radius fractures with volar locking plates [31,34-36]. A prospective ran-domized study by McFadyen et al. showed better clinical and radiologic results with volar locking plates, compared with percutaneous pinning, even for extra-articular frac-tures [37]. Nevertheless, both, a recent Cochrane Review [5] and a guideline report on distal radius fractures [6], were unable to suggest enough evidence-based clinical practice guidelines to recommend one method of surgical fixation over another.

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CONCLUSION

Our clinical and radiological results were overall satis-factory and comparable to the literature; however, because of the propensity for gradual and progressive loss of reduction encountered after intrafocal pinning, the decision to use it should be carefully considered, especially in articular fractures and metaphyseal com-minution.

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