re: outcomes and complications of treatment of ankle diastasis with tightrope fixation
TRANSCRIPT
Letters to the Editor / Injury, Int. J. Care Injured 41 (2010) 1093–10971096
the DLBP within the femoral head is only 920 mm3, less than halfof the volume of the sliding hip screw.7 Another striking differenceis that in stead of up to four excentrically placed 6.5 mmtelescrews as is the case in the Targon FN implant, in the DLBPprocedure only one winged blade is placed centrally within thefemoral head. We think this substantially simplifies the procedureand reduces the chance of penetration of the femoral head.Another consequence is the considerable reduction in the meanduration of surgery, 45 min for the Targon FN nail versus 26 min(range: 20–30 min) for the DLBP.
With the design of the Targon FN implant, we think the authorschoose a mechanical rather than a biological solution for the so-called unsolved fracture. With the design of the DLBP we aimed fora mechanical as well as a biological solution.
The first clinical results of the DLBP (Gannet) after a two yearfollow-up are now available and will soon be presented.
Conflict of interest
Both authors declare that they have no financial interest orpersonal relationship with organisations or institutes other thantheir mentioned affiliations.
References
1. Bhandari M, Devereaux PJ, Swiontkowski MF, et al. Internal fixation comparedwith arthroplasty for displaced fractures of the femoral neck A meta-analysis. JBone Joint Surg Am 2003;85-A:1673–81.
2. Linde F, Andersen E, Hvass I, et al. Avascular femoral head necrosis followingfracture fixation. Injury 1986;17:159–63.
3. Lu-Yao GL, Keller RB, Littenberg B, Wennberg JE. Outcomes after displacedfractures of the femoral neck. A meta-analysis of one hundred and six publishedreports. J Bone Joint Surg Am 1994;76:15–25.
4. Parker MJ, Stedtfeld H-W. Internal fixation of intracapsular hip fractures with adynamic locking plate: initial experience and results for 83 patients treated witha new implant. Injury 2009. doi:10.1016/j.injury.2009.09.004.
5. Parker MJ, Stockton G. Internal fixation implants for intracapsular proximalfemoral fractures in adults. Cochrane Database Syst Rev 2001;CD001467.
6. Rockwood Jr CA, Green DP, Bucholz RW, Heckman JD. Fractures in adults, 4th ed.,Philadelphia: Lippincott; 1996.
7. Roerdink WH, Aalsma AM, Nijenbanning G, van Walsum AD. The dynamiclocking blade plate, a new implant for intracapsular hip fractures: biomecha-nical comparison with the sliding hip screw and Twin Hook. Injury2009;40:283–7.
8. Stromqvist B, Hansson LI, Palmer J, et al. Scintimetric evaluation of nailed femoralneck fractures with special reference to type of osteosynthesis. Acta OrthopScand 1983;54:340–7.
Willem H. Roerdink*, Ariaan D.P. van WalsumDepartment of Traumatology, Medisch Spectrum Twente,
PO Box 50000, 7500 KA Enschede, The Netherlands
*Corresponding author. Tel.: +31 570 535060E-mail address: [email protected]
(W.H. Roerdink)
doi:10.1016/j.injury.2009.12.008
Authors’ reply
Internal fixation of intracapsular hip fractures with a dynamiclocking plate: Initial experience and results for 83 patientstreated with a new implant [Injury, in press. doi:10.1016/j.injury.2009.12.008]
Dear Sir,
We thank Drs Roerdink and Walsum for their interest in ourarticle. Like them we feel that a stable construct is essential to
reduce the risk of fracture healing complications with anintracapsular hip fracture. A fixation with rotational stability suchas the dynamic locking plate or the Targon FN plate has thepotential to achieve a more stable fixation than either multiplecancelleous screws or the sliding hip screw.
As to what extend the size of the implant affects fracturehealing remains unknown. A larger implant does potentiallyprovide a stronger fixation but at the expense of reducing the areafor bone available for revascularisation within the femoral neck.Only future clinical studies can resolve this issue.
Some limited biomechanical comparisons between the TargonFN and the sliding hip screw were undertaken in the developmentof this implant demonstrating greater resistance to rotation withthe Targon FN. Of more relevance is an independently biomecha-nical comparison between the Targon FN and the sliding hip screwthat has been undertaken on cadaveric bone with the resultsbecoming available soon.
Conflict of interest
Both authors of this article have received expenses and financialsupport from BBraun Medical Ltd. in the development andevaluation of the Targon FN implant.
Martyn Parker*Peterborough & Stamford NHS Foundation Trust,
Department of Orthoapaedics, Thorpe Road,
Peterborough PE3 6DA, UK
Hans StedtfeldRostock, Germany
*Corresponding author. Tel.: +44 01733 874000;fax: +44 01733 875013
E-mail address: [email protected]
15 January 2010
doi:10.1016/j.injury.2010.02.025
Letter to the Editor
Re: Outcomes and complications of treatment of ankle diastasiswith tightrope fixation
Dear Sir,
We read with interest the problems encountered withgranuloma formation on the medial side of the tightropesyndesmosis fixation in the paper:
Injury. 2009 November;40(11):1204–6. Epub 2009 July 22.Outcome and complications of treatment of ankle diastasis with
tightrope fixation.Willmott HJ, Singh B, David LA.It occurs to us that there may be relatively higher risk of such
problems if the thread used to pull the tightrope through to themedial side is cut flush with the skin, rather than one limb cut andthe ‘pullthrough’ or lead thread removed in its entirety. Cutting thethread flush leaves a fraying ended foreign material in asubcutaneous position, where inflammation may well occur.
It may be worth checking with the authors whether eithertechnique was recorded in the notes, and if not by asking thesurgeons involved.
Letters to the Editor / Injury, Int. J. Care Injured 41 (2010) 1093–1097 1097
We suggest whenever possible the ‘pullthrough’ thread shouldbe removed completely.
Conflict of interest
There is no conflict of interest involved.
Lisa Andrews,Crispin Southgate*
The William Harvey Hospital, Ashford, Kent, TN24 0LZ,
United Kingdom
*Corresponding author. Tel.: +44 7867786457E-mail address: [email protected]
(C. Southgate)
9 December 2009
doi:10.1016/j.injury.2009.12.010
Letter to the Editor
Re: Outcome and complications of treatment of ankle diastasiswith tightrope fixation
Dear Sir,
I am writing to respond to the comment made by Mr. CrispinSouthgate regarding my recently published article entitled ‘‘Out-come and complications of treatment of ankle diastasis withtightrope fixation’’ [Injury 40 (November (11)) (2009) 1204–1206].He raises the point that soft-tissue granuloma overlying thetightrope button may be caused by the failure to remove the pull-through sutures. The pull-through sutures consist of two loops offibrewire threaded through the oblong medial button. These suturesare used to pull the button through the bone and correctly position it,before one limb of each loop is cut and the sutures removed in theirentirety. The diastasis is then reduced and held by tensioning
remaining fibrewire and tying with three half-hitches on the lateralside. The suture ends should then be trimmed about 1 cm long.
We encountered two cases of granuloma formation, oneoverlying the lateral button, the other overlying the medialbutton. The granulomas presented at six and ten months post-implantation, respectively.
In both cases, the manufacturer’s instructions had beenfollowed verbatim (www.ankletightrope.com). The pull-throughsuture had been completely removed at initial surgery. When thetightropes themselves were subsequently removed, followinggranuloma formation, no aberrant suture material was found.
Mr. Southgate’s comments are certainly valid, and I suspect thatwere the pull-through suture to be left in place, it would irritatesoft tissues. However, in the case we reported of granulomaformation of the lateral side, this could not have been caused by apull-through suture left on the medial side. Furthermore, the delayin granuloma formation suggests to me that, rather than an irritantforeign material being present from the time of implantation,debris formed over time. I hypothesise that the fibrewire runningthrough the metal buttons undergoes micromovement as the anklemoves. This may result in generation of small debris particles dueto attrition. These particles may excite an inflammatory response,and subsequently granuloma formation. Histological examinationof the granulomas we excised demonstrated refractile materialwithin mast cells.
Conflict of interest
Neither the corresponding author, nor any other authors have,or have had, any financial and personal relationships with otherpeople, or organisations, that could inappropriately influence orbias this work.
H.J.S. WillmottDepartment of Trauma and Orthopaedics,
Maidstone General Hospital, Hermitage Lane,
Maidstone, Kent ME16 9QQ,
United Kingdom
E-mail address: [email protected]
doi:10.1016/j.injury.2010.01.107