MICRONAIL Offers Minimally Invasive Alternative to Surgery
MICRONAIL Offers Minimally Invasive Alternative to Surgery

Dr. Accousti performs an orthopedic procedure on a pediatric patient
In the past, patients with wrist fractures typically had to undergo painful surgery or wear cumbersome casts until their bones healed. Today, they have an alternative which offers less scarring and quicker recovery than traditional treatments. This new technique is the MICRONAIL® Distal Radius Fixation System (MICRONAIL), manufactured by Wright Medical.

Available for only a couple of years, MICRONAIL is garnering good results for Louisiana's orthopedic patients. One Acadiana physician who highly touts the technique is New Iberia orthopedic surgeon Dr. Edward Lisecki. "If you have a certain kind of fracture of your wrist, it works very, very well for treating that fracture and getting people back within weeks to doing some of their activities of daily living," he explained.

Surgeons perform the procedure by reducing the fracture, drilling a small hole in the radius, and inserting a nail down into the bone. From the MICRONAIL device, the surgeon places titanium alloy screws to lock the fracture in place, resulting in a very rigid, stable fixation. "So, rather than putting someone in a cast, or putting someone in an external fixator, where you really can't move your wrist at all, we start moving the patient's wrist a day or two after the surgery," Lisecki said.

The MICRONAIL involves a minimally invasive surgery with a very small incision that's less than an inch long. With traditional surgery, the doctor has to cut to the length of the plate, making an incision about four to six inches in length. The MICRONAIL procedure is also fairly quick, taking only about 15 to 20 minutes to perform, as opposed to conventional surgery, which takes one to two hours.

Because patients are able to use the wrist quicker after the MICRONAIL procedure, post-surgery physical therapy time is cut in half. "So, whereas in a traditional case, I'd say it takes six weeks for the bone to heal, and then another six weeks of therapy, you are probably breaking that in half," Lisecki said. "I would say that at six weeks, most people can get back to doing almost all of their activities, like working on a keyboard, but not strenuous activities."

The big advantage for patients is that they can start using the wrist a day or two after the procedure. Conventional surgery involves placing a plate outside of the bone and using screws to affix the wrist in place, or using an external fixator to hold the metacarpals and radius with pins to the proper length. With these tedious procedures, patients are immobilized for six to eight weeks, sometimes causing them to develop bursitis or other conditions. "But with the MICRONAIL, since it is inside of the bone, there's no real irritation that it can cause," he explained.

While Lisecki believes that casting is still the best treatment for fractures, he notes that surgery is sometimes the better option for unstable breaks or patients who need to be able to use the hand and wrist. He also has used the MICRONAIL for treating fracture lines that extend into the wrist with good results.

So far, patients have been pleased with the MICRONAIL. "Every patient has really enjoyed it," Lisecki reported. "They have enjoyed being able to take showers without having to worry about getting their casts wet, and about being able to use their hands immediately. They wouldn't have it done any other way."

Cutting-Edge Procedures Make Healing Less Painful for Pediatric Patients

Treating kids orthopedically can present challenges. Unlike adults, whose growth plates have closed, children's are still open. But, the advantage of performing procedures on youngsters is that they have the unique ability to remodel their bones and correct residual deformities.

Pediatric orthopedic surgeons in Louisiana are trying to develop a better system of straightening bones while still allowing them to grow. A new frontier in treating pediatric orthopedic spine deformities involves using growing rods. One of the earlier techniques employed a "Luque trolley," which consisted of wires inserted into the spine that looped around two parallel rods. This aligned the spine while still allowing it to grow. "It worked sort of like a curtain rod, where the rod hooks would slide along rods of the spine," explained Dr. William Accousti, one of about a dozen pediatric orthopedic specialists in the state at Children's Hospital in New Orleans. "The rods kept the spine aligned while the wires were able to slide, or trolley, along them, and the spine could continue to grow."

A newer procedure uses the Vertical Expandable Prosthetic Titanium Rib (VEPTR) to correct spine deformities in young, growing children. This device is vertically attached adjacent to the spine using claw-like cradles, usually from an upper set of ribs to a lower set. From the middle, the device is expandable, providing room for growth. "It's sort of like an 'internal jack,'" Accousti described. "And, we keep cranking up this jack as the child grows to keep up with the growth of the spine and thorax."

One disadvantage with the VEPTR device is that the child has to return to the operating room for a brief expansion every six months. When the child stops growing, the VEPTR can be removed. "We are currently developing new techniques that would avoid the need for these repeat expansion procedures," Accousti said.

Most spinal surgeries are extremely painful for patients, which is why physicians at Children's Hospital have been using a new device called the "pain ball." The New Orleans group hopes to be the first to publish a report on the use of this product in scoliosis patients. "The best way to describe it is that it's like a soaker hose for Lidocaine or Marcaine," Accousti said.

These pain balls are external balloon-like chambers filled with medications. Surgeons tunnel very thin catheters about one and a half millimeters in diameter into the paraspinal muscles through tiny puncture holes near the edges of the surgical wound. Over the first two to three days post-surgery, the pain ball pushes the medication into these catheters, which helps to numb the surgical area. "Our preliminary results appear to indicate that patients are getting demonstrable pain relief from implanting these pumps and using less post-operative narcotics," Accousti reported.

Accousti has been using these pumps for just over a year. Doctors are collecting data now to publish a report on the device. "The recovery and spinal unit nurses have noticed a difference in the patients who have had the pain ball immediately after surgery," he said. "The patients seem to be more comfortable, they move more in the bed, and they don't seem to be in as much pain. We think that decreasing the negative effects of narcotic pain medications, like post-operative slowing of the digestive tract and nausea, is another benefit."

Another new procedure is called PETS (percutaneous transphyseal screw). Previously, surgeons had to place metal staples or drill out a portion of the growth plate to correct angular deformities in growing children. This involved making a three to four centimeter cut in the skin down to the growth plate, inserting a large staple into the bone across or drilling out the growth plate, then immobilizing the patient afterwards for about a week. With the PETS procedure, a surgeon makes only about a three or four millimeter incision, and places a hollow screw over a guide wire assisted by an x-ray machine. The screw crosses the growth plate and stops any further unwanted growth. "We can cause a partial growth arrest in the growth plate this way, allowing the other half to continue to grow and correct the deformity," Accousti explained.

The PETS procedure is very short, taking only about five minutes per screw, and about 15 to 20 minutes total. Patients have almost no downtime after the surgery. "I've had patients go and play sports two days after they've had this procedure," Accousti reported. "With the other procedure, you had to place them in a knee immobilizer for a period of time and keep them on crutches. And the results, I think, are better than the staples. The bones seem to correct quicker, and the procedure is reversible in cases where over-correction is realized."

Currently, Accousti is testing the PETS procedure on patients with adolescent or juvenile bunion deformities. In growing patients, these deformities typically worsen. The standard adult-type bunion procedures, which involve cutting of the bone, usually lead to recurrence of the deformity. Instead of cutting the bone, he is using a two millimeter incision to place a very small screw across the growth plate in the first toe. The goal is to prevent worsening of the condition so that the patient won't have to have more extensive surgery at adulthood.

So far, Accousti has performed the procedure on three or four patients with promising results. "As far as I know, I'm the only one doing the growth arrest procedure on children's toes using the PETS technique," he said. "I had a child playing soccer two days later. It's halted the progression in all of the kids that I've done so far."

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