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Can K-Wires And Steinmann Pins Make A Comeback?
When it comes to fixation options, surgeons have an abundance of choices. These authors share how Kirschner wire and Steinmann pin fixation can be valuable in a variety of procedures.
Surgeons have advocated various devices for skeletal fixation including screws, plates, monofilament wire, intramedullary devices, staples and external fixators. Screw fixation is common but screws may induce cortical fracture, which can result in inadequate fixation, especially in the face of osteopenic bone. This can induce loss of stability at osteotomy or syndesis sites, leading to significant postoperative complications. Plate fixation is also common but has disadvantages in cost. In addition there can be challenges in achieving well-opposed, reciprocal joint surfaces in bones with irregular cortical topography. Plates can also obscure radiographic visualization of fracture healing and trabeculation across an arthrodesis site.
Surgeon Martin Kirschner first introduced metallic pins in 1909 as a method of stabilization across fracture and arthrodesis sites.1 Taylor later described the use of Kirschner wire (K-wire) fixation in 1940 and believed the use of K-wires would decrease motion at the site of intended fusion.2 Yu and colleagues described the use of two K-wires for first interphalangeal joint arthrodesis of the hallux to prevent migration, loosening and rotation, and enhance stabilization of arthrodesis surfaces.3 This technique effectively allowed surgeons to maintain stable fixation even in patients with compromised bone density.
The surgeon F
ritz Steinmann introduced Steinmann pins as a method of applying skeletal traction to the femur with two pins applied to the femoral condyles.4 Coughlin and Mann utilized two 3.5-mm double-ended threaded Steinmann pins to salvage failed Keller-type resection arthroplasties with success in each patient with relief of preoperative pain and cocked up hallux deformities.5 Mah and Banks demonstrated a predictable and reproducible technique for first metatarsophalangeal joint (MPJ) fusion with K-wire fixation and immediate ambulation.6
In 1989, the lock pin K-wire technique for fixation of Austin-type osteotomies became popular.7 This technique effectively eliminated the tendency of pin migration and increased stability. One can use two lock pins in patients with compromised bone stock. Surgeons have employed the lock pin fixation technique for a variety of applications such as an Austin-type osteotomy, first MPJ arthrodesis, tailor bunionectomy, Lapidus arthrodesis and triple arthrodesis.8
Applying K-Wires And Steinmann Pins In Specific Applications
The aim of this article is to shed light on applications of K-wire and Steinmann pin applications.
Digital arthrodesis. Surgeons can employ smaller K-wires (1.1 to 1.6 mm or 0.045 to 0.062 inches) in an “all inside” technique for digital arthrodesis when drilling the wires in a retrograde fashion down the medullary canal into the base of the proximal phalanx. To avoid intraarticular penetration of the K-wire, one can inspect the MPJ visually, in addition to the use of intraoperative radiographs. Bend the wire and cut, allowing approximately 0.5 cm distal to the bend apex. Then use the cut remnant to create a pilot hole in the intermediate phalanx and position the phalanx over the bent portion of the inserted wire. Then scrupulously repair the collateral ligaments for added stability.
Metatarsophalangeal arthrodesis and lesser osteotomies. In combination with a first MPJ arthrodesis, a second MPJ arthrodesis provides an alternative option to reconstruction of the digital deformity or amputation in geriatric patients with low ambulatory demands. Place K-wires across the arthrodesis site and cut them flush with the dorsal cortex of the bone or in lock-pin fashion.
For a dorsiflexory or shortening osteotomy of a metatarsal, one can drive a K-wire (1.1 to 1.6 mm or 0.045 to 0.062 inches) from dorsal to plantar and cut it flush with the dorsal cortex for transverse plane stability. The length of the wire for a traditional Weil osteotomy is 10 to 12 mm, which one can mark with a skin scribe prior to placement of the wire. In addition, using tactile sensation will allow the surgeon to feel penetration of the plantar cortex.
Double arthrodesis in the first ray. Using two full-length Kirschner wires or Steinmann pins (1.6 mm or 0.062 inches), one can perform a combined first MPJ arthrodesis and interphalangeal joint arthrodesis with axial placement of the wires and remove the wires once syndesis has occurred.
Lisfranc fracture/dislocations. One can reduce injuries to the Lisfranc complex percutaneously or in an open reduction with lock pin Kirschner wires (1.6 mm or 0.062 inches).
Subtalar joint arthrodesis. One can perform subtalar joint arthrodesis procedures utilizing Steinman pins 2.0 mm to 3.0 mm (5/64 to 1/8 inches). Place these across the joint and cut the pins flush with the bone or use them with a lock pin or sta-pin technique against the lateral talar process to serve as a benchmark for position as well as a second point of fixation.9
Ankle/rearfoot arthrodesis. The photo at right shows a case of significant architectural deformation secondary to Charcot neuro-osteoarthropathy. The patient was free of infection with a significant equinovarus deformity and obliteration of the rearfoot joints ongoing for five years. Over that time span, the patient was only able to ambulate with crutches and could not place any weight on the left lower extremity.
Surgeons used Steinmann pins of 2 to 3 mm (5/64 to 1/8 inches) to stabilize the sizable joints of the rearfoot/ankle. Exit of the tibial cortex can improve bony purchase and enhance stability following a wedge osteotomy resection.
In the photo at above right, one can see a stable fibrous union with definitive correction of the equinovarus deformity. The patient is able to ambulate in a diabetic shoe with a buildup without the use of assistive devices.
In Conclusion
K-wires and Steinmann pins are versatile in lieu of or in combination with other forms of fixation. Surgeons can use wires and pins as the primary choice of fixation and achieve satisfactory results when they couple this fixation with sound surgical technique.
Unpredictable complications can occur with any fixation technique. K-wires and Steinman pins are associated with loosening and external migration, pin tract irritation and infections.3 Pins are known for dislodgement despite precautionary measures such as the use of threaded pins and bending of the distal end in geriatric patients.10
That said, K-wires and Steinmann pins are simple and inexpensive devices. With the ever rising costs of implants and other fixation devices, perhaps it is time for the future to meet the past.
Dr. Canales is Chief of the Division of Podiatry at St. Vincent Charity Medical Center in Cleveland.
Dr. Chuang is a first-year podiatric surgical resident at St. Vincent Charity Medical Center in Cleveland.
Dr. Razzante is a third-year podiatric surgical resident at St. Vincent Charity Medical Center in Cleveland.
Dr. Clougherty is the Chief Resident at St. Vincent Charity Medical Center in Cleveland.
References
1. Huber W. Historical remarks on Martin Kirschner and the development of the Kirschner (K) wire. Indian J Plast Surg. 2008; 41(1):89-92.
2. Taylor RG. An operative procedure for the treatment of hammer-toe and claw-toe. J Bone Joint Surg Am. 1940; 22:608-609.
3. Park C, Ahn J, Yu K, Lee W. Plate fixation for proximal chevron osteotomy has greater risk for hallux valgus recurrence than Kirschner wire fixation. Int Orthop. 2013; 37(6):1085-1092
4. Peltier L. A brief history of traction. J Bone Joint Surg Am. 1968; 50(8):1603-1617.
5. Coughlin M, Mann R. Arthrodesis of the first metatarsophalangeal joint as salvage for the failed Keller procedure. J Bone Joint Surg Am. 1987; 69(1):68-75.
6. Mah C, Banks A. Immediate weight bearing following first metatarsalphalangeal joint fusion with Kirschner wire fixation. J Foot Ankle Surg. 2009; 48(1):3-8.
7. Yu GV, Thornton DL. First metatarsophalangeal joint arthrodesis. In: McGlamry ED, ed. Reconstructive Surgery of the Foot and Leg: Update '89. Podiatry Institute, Tucker, GA, 1989.
8. Banks A. The lock pin technique – its note just for bunions. Podiatry Institute Update. 2002; 28:153-156.
9. Yu G. Curettage technique for major rearfoot fusions. In Camasta C, Vickers NS, Ruch JA, eds. Reconstructive Surgery of the Foot and Leg, Update ’93. Podiatry Institute Publishing, Tucker, GA, 1993 pp. 260-257.
10. Mian M, Nahed B, Walcott B, Coumans J. Intraspinal migration of a clavicular Steinmann pin: case report and management strategy. J Clin Neuroscience. 2012; 19(2):310-313.
Additional References
11. Camasta C, Cass A. Buried Kirschner-wire fixation for hammertoe arthrodesis. Podiatry Institute Update. 2008; 2.
12. Canales M, Razzante M, Ehredt Jr D, Clougherty C. A simple method of intramedullary fixation for proximal interphalangeal arthrodesis. J Foot Ankle Surg. 2014; 53(6):817-825.
13. Dalmia L, Brosky T. Locking Pin Technique Revisited. Podiatry Institute. 2008; 15.
14. Judge MS, Masowick A. A technique of lateral process blockade for subtalar joint fusion: an easy economical, and effective method to prevent rotation. J Foot Ankle Surg. 2013; 52(2):271-275.
15. Yu GV, Malay SD. Enhance fixation of the traditional Austin bunionectomy. Foot Ankle Quart. 1999; 2(1)27-36.
16. Yu G, Shook J. Arthrodesis of the first metatarsophalangeal joint. In Banks AS, Downey MS, Martin DE, eds. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery, Volume 4, 2001; Lippincott, Williams and Wilkins, Philadelphia, pp. 581-607.
17. Yu G, Vargo F. Hallux interphalangeal arthrodesis: a simple technical pearl. Podiatry Institute Update. 2002; 22:129-134.
