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Percutaneous Versus Open Approach for Retrograde Intramedullary Metacarpal Fixation - Cadaveric and Clinical Outcomes
Stephen M Himmelberg, MD
1, Alexander D Jeffs, M.D.
2, Nicholas C Bank, M.D.
2; G. Aman Luther, MD
3(1)University of North Carolina, Chapel Hill, NC, (2)The University of North Carolina School of Medicine, Chapel Hill, NC, (3)WakeMed Hospital, Raleigh, NC
Introduction:
For the surgical fixation of metacarpal fractures, recent data shows a trend towards retrograde intramedullary fixation. However, no evidence exists on the optimal surgical approach for this technique. We hypothesized that a percutaneous approach may result in higher extensor tendon injury than an open approach but would show improved functional outcomes.
Methods:
A percutaneous and open approach were assessed in 4 cadaveric specimens (10 metacarpals per group). For the percutaneous group, a 0.5 cm incision was made over the metacarpal head, through only skin. For the open approach, a 1.5 cm incision was made over the metacarpal head, the ulnar sagittal band was incised, and capsule opened. For each approach, a guidewire, drill and then a 4.0 mm fully threaded headless compression screw were inserted under fluoroscopy. Following screw insertion, the specimens were assessed for extensor tendon injury. After cadaveric assessment, a retrospective cohort of patients was collected with operatively treated closed metacarpal shaft fractures utilizing an IMTN with minimum three month follow-up. We compared patients with open versus percutaneous approaches. Outcome measures included Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, visual analog scale (VAS) pain scores, total active motion (TAM), grip strength, extensor tendon lag, surgical time, and radiographic shortening/angulation.
Results:
Cadaveric dissection demonstrated no occurrences of extensor tendon injury in either group. In the percutaneous group, 9/10 specimens demonstrated screw hole passage ulnar to the extensor tendon. The retrospective cohort comprised 54 patients with 56 metacarpal shaft fractures. Patients treated with a percutaneous approach demonstrated significantly shorter surgical times than those with an open approach (9 minutes vs 16 minutes, p<0.05). In the percutaneous group, there were superior short-term TAM, QuickDASH scores, VAS pain scores and grip strength. Final follow-up demonstrated no difference in TAM, QuickDASH scores, VAS pain scores, grip strength or radiographic shortening/angulation. There were no cases of extensor lag in either group.
Discussion:
In our cadaveric arm, following percutaneous insertion there were no occurrences of extensor tendon injury. Furthermore, in our clinical arm patients treated with a percutaneous approach demonstrated no instances of extensor lag providing evidence for the safety of a percutaneous approach. In terms of functional outcomes as measured by QuickDASH scores, TAM, and VAS pain scores the percutaneous approach favored superior outcomes during short term follow up. While no differences were seen at long term follow up, these findings highlight accelerated return to normalcy for those treated percutaneously.
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