The Journal of Foot & Ankle Surgery xxx (2016) 1–3
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Original Research
Complications of Kirschner Wire Use in Open Reduction and Internal Fixation of Calcaneal Fractures Maarten C. Dorr, MSc 1, Manouk Backes, MD, MSc 2, Jan S.K. Luitse, MD, MSc 2, Vincent M. de Jong, MD, MSc 2, Tim Schepers, MD, PhD 2 1 2
Faculty of Medicine, University of Maastricht, Maastricht, The Netherlands Trauma Unit, Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 3
The most important goal of surgical management of displaced intra-articular calcaneal fractures is anatomic correction. This reduction is usually stabilized using plate and screw osteosynthesis. In addition, Kirschner wires (K-wires) can be used to maintain the surgical reduction or stability of the construct. In the present study, we evaluated the frequency and type of use of additional K-wires and subsequent migration in the surgical management of displaced intra-articular calcaneal fractures. The data from 279 patients treated surgically from January 1, 2000 to December 31, 2014 in a level 1 trauma center using an extended lateral approach were analyzed after 1 year of follow-up. All postoperative radiographic images were reviewed to identify the cases in which K-wires were used. Data on the number and type of K-wires used, K-wire location, and K-wire migration found on follow-up imaging studies were collected. Of the 279 patients, 69 K-wires had been used in 49 (18%) patients. A total of 25 (36%) lost (buried), 38 (55%) bent, and 6 (9%) unmodified straight K-wires had been placed. Overall, in 4 (5.8%) of 69 K-wires, secondary dislocation was seen. One (4%) of the lost, 3 (50%) of the unmodified, and none of the bent K-wires showed secondary dislocation. K-wire migration was seen in 5.8% of the cases. None of the bent K-wires and only 1 of the lost K-wires had migrated in the present study. These 2 techniques are preferred when using K-wire fixation in the treatment of displaced intra-articular calcaneal fractures. The use of unmodified straight K-wires should be discouraged. Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus fracture complication K-wire Kirschner wire migration
The surgical management of displaced intra-articular calcaneal fractures is complex. The calcaneus consists of 3 articulating surfaces: the posterior talocalcaneal joint, anterior talocalcaneal joint, and calcaneocuboid joint. The most important goals of treatment are anatomic correction of the posterior talocalcaneal joint, restoration of the overall anatomy (height and width), and alignment (correction of varus or valgus). Open reduction and internal fixation can be achieved using plate and screw osteosynthesis. In addition, Kirschner wires (K-wires) can be used to maintain the surgical reduction or stability of the construct, regardless of disadvantages such as drilling heat, resulting in osteonecrosis (1). The advantage of the use of K-wires is that they are easy to insert, with minimal trauma to the soft tissue and tendons. They can be inserted percutaneously, which has been Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Tim Schepers, MD, PhD, Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, P.O. Box 22660, Amsterdam 1100 DD, The Netherlands. E-mail address:
[email protected] (T. Schepers).
associated with fewer wound complications, faster recovery, and a diminished risk of swelling and stiffness (1–3). The calcaneus most often fractures in 4 to 5 key main fragments, on which, for example, the classification of Zwipp et al (4) was based. These key fragments are the lateral posterior talocalcaneal joint fragment, constant medial sustentaculum tali fragment, tuberosity fragment, and anterior process fragment, which often splits into 2 pieces (anterolateral and anteromedial) (5,6). In addition, because of high impact forces, several smaller fracture fragments can be present. These fragments could require fixation during operative management, especially if they are part of 1 of the 3 joint surfaces. Fixation of these smaller fragments can be challenging and is frequently achieved with the use of smooth K-wires. The current data on the optimal use of K-wires and subsequent complications are scarce. In the present study, we evaluated the frequency and type of the use of additional K-wires and subsequent migration in the surgical management of displaced intra-articular calcaneal fractures.
1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2016.04.003
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M.C. Dorr et al. / The Journal of Foot & Ankle Surgery xxx (2016) 1–3
Fig. 1. Radiographic views of different Kirschner wire types used in the present series: (A) lost Kirschner wire; (B) bent Kirchner wire; and (C) unmodified straight Kirchner wire.
Patients and Methods The data from all the patients who had been treated surgically from January 1, 2000 to December 31, 2014 in a level 1 trauma center using an extended lateral approach were analyzed after 1 year of follow-up. The patient characteristics were collected from the hospital electronic database. All postoperative radiographic images were reviewed by 2 of us (M.C.D., T.S.) to identify those patients in whom Kwires had been used to stabilize the construct. The K-wires were classified as a lost (buried) K-wire, a bent K-wire, or an unmodified straight K-wire (Fig. 1). The K-wire was defined as lost when it had been used to fixate central joint fragments, which were then buried underneath the lateral joint fragment (7). Bent Kwires were inserted after reduction of the lateral joint fragment or anterolateral fragment, followed by bending the K-wire 90 or 180 (8) and further insertion using a punch. An unmodified straight Kwire was inserted after reduction of the calcaneal fracture and subsequently cut off flush at the level of the lateral wall. The following data were obtained from the electronic medical records and from the radiographic images postoperatively and at the 1-year follow-up point for all patients with K-wire insertion: number of K-wires used, type of K-wire used (lost, bent, unmodified), K-wire location (subtalar joint, anterior process), and K-wire migration found on follow-up imaging studies. Results Of the 279 patients treated surgically with an extended lateral approach in the 14-year study period, 49 (18%) patients were identified with K-wires used to stabilize the final construct. Of these 49 patients, 65% were male, and the entire group had a median age of 40 (interquartile range 52 to 32) years. A total of 69 K-wires had been used in the 49 patients, with 1 to 4 K-wires placed per patient (median 1, average 1.4; Table). Overall, 4 (5.8%) of the 69 K-wires showed secondary dislocation at the 1-year follow-up point. A total of 25 lost K-wires had been placed in 21 patients. These had all been placed underneath the posterior talocalcaneal joint facet. One of these K-wires showed medial migration. It was not possible to deduce from the perioperative imaging study whether the K-wire had been inserted too deeply. The K-wire had been bent at the end in 30 patients. A total of 38 bent K-wires had been placed, of which 27 (in 22 patients) had been placed
Table Kirschner wire migration during follow-up (N ¼ 69 Kirschner wires in 49 patients) Kirschner Wire
Placement (n)
Migration (n)
%
Lost Bent Straight Total
25 38 6 69
1 0 3 4
4 0 50 5.8
below the subtalar joint and 11 (in 9 patients) in the anterior process fragments. None of the bent K-wires showed loosening or migration. In 4 patients, a total of 6 unmodified straight K-wires had been inserted (1 in the anterior process and 5 below 3 subtalar joints). In 3 patients with unmodified K-wire placement below the subtalar joint, migration of 1 K-wire was seen. In 2 patients, this was accompanied by a postoperative calcaneal collapse of 7 and 16 and in 1 patient by a superficial postoperative wound infection (Fig. 2). Discussion K-wire fixation had been used in 49 (18%) of 279 patients who had undergone surgical management of displaced intra-articular calcaneal fractures. The principal finding was that 5.8% of the K-wires had migrated during the first year of follow-up. Unmodified straight Kwires showed the greatest incidence of migration, with 3 (50%) of 6 straight K-wires having migrated. In the lost K-wire group, migration was seen in 4%. None of the bent K-wires showed migration at the 1-year follow-up point. Few studies have been reported on the optimal use of K-wire fixation and subsequent complication rates (3,9,10). Many studies have focused on the use of K-wires in the upper extremity (10,11). Little is known about the complication rates in foot and ankle surgery. Demcoe et al (9) reported a 3.1% failure rate in a retrospective study of percutaneous threaded K-wire fixation in displaced intra-articular calcaneal fractures. In a retrospective study of Lisfranc injuries, Schepers et al (12) reported a high incidence of secondary fracture displacements with the use of K-wires (37.5%). In the present study, a 0% migration rate was seen with the bent Kwires. The migrating K-wires were mainly unmodified straight Kwires that had been cut flush at the lateral wall. This was most likely the result of the slight calcaneal collapse in the 3 patients in which the K-wires had migrated outward. In the single case with migration of a lost K-wire, the migration most likely resulted from perioperative penetration of the medial cortex. It is unclear whether the K-wire had already migrated during surgery. In the present study, migration was accompanied by some collapse of the fracture in all cases in the unmodified straight K-wire group, most likely because of noncompliance (n ¼ 2) and postoperative wound infection (n ¼ 1). Postoperative wound infection is a wellknown complication of calcaneal fracture surgery (2,13,14). As a result of infection, delayed union can occur, which can also lead to Kwire migration (1). Metal implants have been used in surgical fracture treatment for decades. Recently, the use of bioabsorbable poly-L-lactic acid (PLLA) pins has been gaining interest in foot and ankle surgery owing to the improvements in polymer science. The bioabsorbable pins have high strength and low reactivity rates (15). Min et al (16) did not observe any soft tissue reactions, drainage, or sterile abscesses with the use of bioabsorbable pins for fixation of the articular fragment of the posterior facet in calcaneal surgery in the follow-up of 300 Sanders type III/IV
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Fig. 2. Radiographic views of 2 cases with migrated Kirschner wires. (A and B) Migration to Kager’s triangle and (C and D) migration laterally.
fractures. Also, none of the implants had required removal (16). One of the main disadvantages is the cost of the bioabsorbable pins, which might not be justified when considering the low overall complication rates with the use of metal K-wires. In conclusion, K-wire migration was seen in 4 of 69 K-wires placed in 49 (5.8%) patients with surgical restoration of a calcaneal fracture through the extended lateral approach. None of the bent K-wires and only 1 of the lost K-wires had migrated in the present study. These 2 techniques should be preferred when using K-wire fixation in the treatment of displaced intra-articular calcaneal fractures. The use of unmodified straight K-wires cut at the lateral cortex should be discouraged. References 1. Franssen BB, Schuurman AH, Van der Molen AM, Kon M. One century of Kirschner wires and Kirschner wire insertion techniques: a historical review. Acta Orthop Belg 76:1–6, 2010. 2. Court-Brown CM, Schmied M, Schutte BG. Factors affecting infection after calcaneal fracture fixation. Injury 40:1313–1315, 2009. 3. Walde TA, Sauer B, Degreif J, Walde HJ. Closed reduction and percutaneous Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2-10 years. Arch Orthop Trauma Surg 128:585–591, 2008. 4. Zwipp H, Tscherne H, Thermann H, Weber T. Osteosynthesis of displaced intraarticular fractures of the calcaneus: results in 123 cases. Clin Orthop Rel Res 290:76–86, 1993.
5. Miric A, Patterson BM. Pathoanatomy of intra-articular fractures of the calcaneus. J Bone Joint Surg Am 80:207–212, 1998. 6. Langdon IJ, Kerr PS, Atkins RM. Fractures of the calcaneum: the anterolateral fragment. J Bone Joint Surg Br 76:303–305, 1994. 7. Cronier P, Talha A, Massin P. Central talar fracturesdtherapeutic considerations. Injury 35(suppl 2):SB10–SB22, 2004. 8. Firoozabadi R, Kramer PA, Benirschke SK. Kirschner wire bending. J Orthop Trauma 27(11):e260–e263, 2013 Nov. http://dx.doi.org/10.1097/BOT.0b013e318290f818. 9. Demcoe AR, Verhulsdonk M, Buckley RE. Complications when using threaded Kwire fixation for displaced intra-articular calcaneal fractures. Injury 40:1297–1301, 2009. 10. Subramanian P, Kantharuban S, Shilston S, Pearce OJ. Complications of Kirschnerwire fixation in distal radius fractures. Techn Hand Up Extrem Surg 16:120–123, 2012. 11. Battle J, Carmichael KD. Incidence of pin track infections in children’s fractures treated with Kirschner wire fixation. J Pediatr Orthop 27:154–157, 2007. 12. Schepers T, Oprel PP, Van Lieshout EM. Influence of approach and implant on reduction accuracy and stability in Lisfranc fracture-dislocation at the tarsometatarsal joint. Foot Ankle Int 34:705–710, 2013. 13. Zhang W, Chen E, Xue D, Yin H, Pan Z. Risk factors for wound complications of closed calcaneal fractures after surgery: a systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 23:18, 2015. 14. Backes M, Schepers T, Beerekamp MS, Luitse JS, Goslings JC, Schep NW. Wound infections following open reduction and internal fixation of calcaneal fractures with an extended lateral approach. Int Orthop 38:767–773, 2014. 15. Zelen CM. Advances in forefoot surgery. Clin Podiatr Med Surg 30:435–444, 2013. 16. Min W, Munro M, Sanders R. Stabilization of displaced articular fragments in calcaneal fractures using bioabsorbable pin fixation: a technique guide. J Orthop Trauma 24:770–774, 2010.
