Percutan Percutaneous eous Navicular Navicular ORIF: ORIF: A A Novel Technique Novel Technique I h I hav ave n e no o po poten tential c tial con onfli flicts cts wi with th the the pre prese senta ntation tion. Paul Paul Kupch Kupcha MD; MD; Geary Geary Gutowski Gutowski PA PA-C. C.
Introd Introduction uction Navicular fractures are common midfoot fractures that are commonly missed and difficult to treat. Navicular fractures compromise 62% of all midfoot injuries. Forces translating from distal to proximal cause the navicular to compress upon the talar dome. These forces cause the navicular to displace radially like staves of a barrel. Cerclage cable wiring has been described to neutralize the mechanism of injury. Note: Radial Note: Post-operative displacement of image of the fracture fractures. fragments .
Meth Methods ods We employed a technique for a circumferential cabling to act like a barrel hoop to reverse and neutralize the deforming radial forces. A 2005 case report in Foot and Ankle International described a single case fixed with an open wiring technique. Initially a transverse open technique with a large wire passer was utilized. This was abandoned in favor of a percutaneous method using two - 1 cm incisions. A single surgeon performed all 20 surgical cases of cabling. Percutaneous Technique Open Technique
Surgical Surgical Technique Technique The The app appro roac ach h ev evolve olved d from an from an ope open n tr tran ansv sver erse se do dors rsal al incision incision to to a a percutaneous percutaneous te tech chniqu nique. e. Two Two sma small ll incision incisions s wer were e mad made e ov over er med medial ial an and late d latera ral l po poles of les of th the e na navicu vicular lar to to pa pass ss th the e ca cable ble. . Th The e ca cable ble was was eithe either r pa pass ssed ed with with th the e trochanteri trochanteric ca cable ble pa pass sser er or or was was pu pull lled ed into into plac place e afte after fi r firs rst t pa pass ssing ing a a mor more e malleab malleable le high high te tens nsion ion su sutu ture re. . Fluo Fluoro rosc scop opy y was was use used d intr intra-op oper erat atively. ively.
A A small i small incision made ov ncision made over er medial medial pole of the pole of the navicular navicular.
The Dahl The Dahl-Miles Miles cable passer cable passer is is passed f passed from ei rom either pol ther pole pla e plantar ntar along the along the navicul navicular ar.
Flou Flourosc roscop opy ca can n be be utili utilized for incision zed for incision po positioning. The sitioning. The Dahl Dahl-Mi Miles les ca cable ble pa passer is sser is pa passed ssed from eithe from either pole r pole plan plantar alon tar along g the the na navicular vicular. . Note Note: pa passer be sser being ing inserte inserted d from from latera lateral l to med to medial ial po pole. le.
Pass ass tip tip of cab of cable thr le through ough the the cann cannulatio ulation of the c of the cable pa able passe sser.
The ca The cable is then pas ble is then passed dorsally sed dorsally with a with a kelly kelly or curv or curved ed hemosta hemostat i t into nto the the same incision same incision
Blocking Blocking (positional) K (positional) K-wires can be wires can be placed placed to fine t to fine tune po une position sition of the c of the cable able prior to ten prior to tensioning if sioning if n needed. eeded.
Crimping block Crimping block is placed and the w is placed and the wire ire tensione tensioned. After which the cable is cut. d. After which the cable is cut.
Intra Intra-operative images operative images before before cutting the cable. cutting the cable.
Results Results We We believe tha believe that this te t this techn chnique ique results results in in sup superior erior fixation of fixation of nav navicular icular fracture fractures. s. Ci Circumferential rcumferential cabling neutraliz cabling neutralizes the deforming es the deforming forces by revers forces by reversing the ing the mech mechanism of anism of injury injury Th These ese cas cases es demo demonstra nstrate a safe, quick te a safe, quick, minimal , minimal incision surgical technique incision surgical technique which provides which provides exc excellent ellent fixation of the fixation of the nav navicular icular fracture fracture fragmen fragments. ts.
Conc Conclusion lusion Per Percut cutaneous aneous cer cerclage clage cabling cabling of of navicular navicular fractur fr actures es is is an an innovative innovative technique t technique to o fixate fixate the these se fr fract acture ures. s. This This sur surgical techniq gical technique is ue is safe a safe and expedient nd expedient. . We We believe that believe that thi this s ser series ies pat patient ients s conclusively conclusively shows shows excellent reduction and excellent reduction and ion . fixat fixation
Add Additional itional Illustrative llustrative Pre Pre- ope operat rative Case Image ive Case Images
Additional Additional Illustrative Illustrative Post Post- operative operative Case Case Images Images
Pre-Operative Images Post-Operative Images
Ref Refer eren ence ces 1. Naidu V, Singh S, et al. Cerclage Wire Fixation of Navicular Body Fractures – A Treatment Based on Mechanism of Injury. Foot & Ankle International. 26 (3): 267-269. 2005 2. Kupcha P, Freeland E et al. Fixation of Navicular Body Fractures With a Cerclage Wire Technique. Techniques in Foot & Ankle Surgery. 14(4):177-180, December 2015
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