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Name:
Suzuki Frame Application (Pin and Rubber Dynamic Traction)
Description:
Suzuki Frame Application (Pin and Rubber Dynamic Traction)
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Duration:
T00H20M53S
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https://cadmoreoriginalmedia.blob.core.windows.net/6dfeb0a2-5b40-46bc-9b02-d592c0afd7c5/Suzuki Frame Application (Pin and Rubber Dynamic Traction).mp4?sv=2019-02-02&sr=c&sig=qsuO7q0j0QZnsGVjaG554ZijMJXxX7cZNJ2TJ7ymPDY%3D&st=2024-11-23T09%3A40%3A30Z&se=2024-11-23T11%3A45%3A30Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Hello, yesterday, I'm going to take you through a surgery, in which we are going to apply a dynamic traction, which we also call as a Suzuki traction. And it's usually used for fracture of approximately differential joints. Now this has been published by Suzuki, who was a surgeon in Japan in 1994 and there have been several modifications as how you can use it.
But I'm going to show you a technique which is the original technique, and I would also recommend you to read his paper, which was published in 1994 and I will take you step by step as how to do this procedure correctly. Before I demonstrate how I do this procedure, I think it's extremely important that I tell you and I give you some basic information that will make you understand this procedure in a better way.
So I have drawn proximal phalanx, middle phalanx and distal phalanx that is P1, P2, P3. Now usually we will use three pins and I usually use three pins, but you can get away by using only two pins. So I will show you the first pin that we will put. Is this on the center of the head of the proximal phalanx? And this is called an axial traction pin. And the usual size with k-wire that we will use for this is 1.2. You don't want to be using anything more than 1.2. You don't want to be using anything less than 1.2 because then it becomes very, very flimsy.
The second pin, which is called the hook pin, will go on the head of the middle phalanx, or P2. And this is usually 1.31 cable is used, but you can choose to use 1.2 if you want to use, but I will use one. Mm-hmm the third pin is called the reduction pin, and most of the times this is used when there is an associated subluxation or dislocation.
It helps in reducing the joint, making it more aligned, but it also adds stability. So there are occasions, even when there are no subluxation. I will put this pin and this is again one pin and this is to help reduction. So now these are the three pins exhilaration, pain reduction, pin and hook pin. Now, if you see the traction pin, this will point upwards. You need to bend upwards.
Hook pin is going to be bent downwards and reduction pin will bend upward. Facing this way and I will show you and it will become more clear when I will show you the surgery. Now let's talk about how reduction pin can be used for volar or dorsal subluxation of the proximal phalange joint. So this will be our first pin, the exact reaction pin.
This will be our second pin that will be hooked pin. Now this is the reduction pin. So if this is dorsally subluxation, you will put this pin more dorsal. So if this is the access, you will put dorsal and this pin will go on top of it. So what it will do, it will push it down and it will help in the reduction. So if it is a dorsal subluxation, this axial traction pin will go on top of the reduction pin.
On a similar note, if it is a wall of subluxation, you will put this on the axis. If you draw the axis here, you draw. You put it slightly volar and then this will go underneath it. And then it will lift it up. And this way it helps in the reduction. So this is the theoretical aspect of it, and as I said in my intro, I think you should read the paper now lets me demonstrate how I apply it on a patient.
So a patient today is a 31-year-old gentleman who is an avid cricket player who unfortunately sustained injury to his right little finger while trying to stop the ball while fielding and has sustained this complex fracture, which is completed articular of the base of his second phalanx. Now, if you try to open this fracture. And fix it, the look usually very good on x-rays. But in terms of functions, they almost always end up having a stiff joint, which complicates the results, and they have suboptimal functional result.
Now, specific keyframe is an excellent device because you don't open the fracture and your patient can start moving pretty much straight away. And the results are excellent, so I will take you step by step as how to do this procedure safely. So we are now ready. We have prepped and stripped the patient.
We don't use any tourniquet. The surgery is performed under ring blocks, so you don't need to give any general anesthetic and it's usually pain free. I'm going to sit on this side. The screen will be right in the front on my left hand side so that I can have access to all the images. Is going to come from the front, my trollies on the side. So let's start this surgery and I will take you step by step is how to do it properly.
So we need this IV set not to transfuse, but we will use end of it to make rubber bands. You need a 9 inch K-wire 1.2. If you don't have access to this, then you can use the guidewire, which is used for 6.5 catalytic screw. Then you need to either 1.2 or preferably one cable, which are six inches, which will be used for the hook pin and reduction pin.
You need some fine nose pliers so that you can bend and make hooks properly, and this is a towel for a locking plate. I use it to bend it. Then you need a scale. So these are the basic things that you need when you apply a Suzuki traction. So the first thing is that you need a true lateral use, I'm using a guide wire and I'm trying to locate the center of the head of the proximal phalanx, and I will check it on the system.
And next thing will be I will show you how it looks on the system. So if you see our guidewire is right on the center of the head of the proximal phalanx and this is where you should pass a wire, so I'm just going to put a mark with my pen. Onto the patient can. Well, the second step will be now to find the center of rotation of.
The second phalanx, its head, so again, same thing, I have used a wire here and I have checked it on the CR and Warren will show you how it looks on the same. So now, if you look at our K-wire, it is pretty much on the center. I'm going to readjust it once I pass my wire, so the next step will be to pass our nine axial correction pin on head of our proximal phalanx.
So the first wire is our 1.2 wire nine. so I'm just trying to pass it. So now I have passed my first wire, and I've checked it on both AP and lateral. It is in the center of the proximal phalanx head and it is parallel to the joint line, so it looks pretty good. So I'm just going to pass it through. And then we are going to bend it.
So now we have passed our wire and then I'm just going to hold the end of one side and then just going to bend it up like this and use a player because then it will leave three or 4m of wire on the outside. So this way you will have something. Outside the skin, and it doesn't irritate the skin, so this is our first word going in. So just make it like this and then flip it back.
So that it's out of your way. So I think Warren didn't show you how it looked on AP and laterals, if you see AP, it's parallel to the joint and then lateral it is in the center of the proximal phalanx. And this is your ideal position and this is what you want to be. Now, once you cut the wire, just flip it back and this is how it looks.
So now we have cut the sharp end so that it doesn't harm you now, in original description of a Suzuki who was from Japan. He said that your wire should be at least centimeters long from tip of your finger. So this is almost five, so we have got enough. So that is why you need a nine wire. So just after cutting it, flip it back now using the same principle as this for our hook wire.
We are going to use a millimeter. OK, while six inches on this occasion. Now one thing I forgot to tell you was that once you mark the center of rotation of the head of these two phalanx, you draw a line in between and that will be your axis. So if you have a case of subluxation, then you may have to readjust your wire wool or to it or dorsal to it, depending upon the type of dislocation.
And then hence it is extremely important that you mark this. So this is our line, and the next step will be to pass our one wire, which will be over for our hook, which is called the hook pin. So using the same principle, I passed my second layer and then I have checked the position on AP and lateral, and I'll show you how it looks. So if you look at our screen on the left, our wire's right in the center of the head.
And if you look at the screen over on the right, it is parallel to the joint. One thing I would like to stress if you are a beginner is when I will ask Warren to focus it on the patient and then I will show you what I wanted to reinforce. Now I have been the wife on this occasion, but if you are starting up and you have got your gaining experience, then you can don't. You don't bend the wire, just leave it straight like that.
And try to aim this wire parallel to it. They should be both parallel and I am just putting my wire on the axis of the previous line and you can see both of them are parallel, so you can put both of them straight and then bend it. But because it comes in the way I just bend it before, so it's entirely up to you. Now this is our two wires are gone. The axial traction wire is gone in and the hook hook pin wire is going in.
Let's see whether, if there is a need for the third wire as per description of Suzuki, and it's usually use when you have got associated subluxation. So if you look at the images both on the left and the right, of course it's an intractable fracture. Still, there is some displacement, but the position looks pretty acceptable. And if the patient can mobilize in this particular position, I think he will have good results.
There's no obvious subluxation, so let's see. I will just I've just manipulated this fracture slightly, and I would like to take a lateral just to check whether I have made it better or not. So on my manipulation, there was not much difference. There was evidence of maybe slight subluxation. So just to add stability to the construct, I have added the third wire. So if you look at the position of the third wire, the reduction wire, I have applied in the neutral axis on this occasion because there is no evidence of any clear bullet or subluxation.
I have added it just to improve the stability of our construct. The wire is parallel to all other wires and it is just distal to our fracture site, so it's perfectly positioned. So now we just need to bend our wires. So this will bend like this? And this will bend like this. So this is our interaction, while this is our book, we're.
And now this is our word which will be holding up the reduction. So I'm not bending the reduction right upwards. So both where will be band upwards? Just like that. So these are three wires which are used for. So the key to action now we just need to make hooks. And that will be our next step.
Now, when we need to make a hook, this is how you make the hook, our existing structure, while the hook will be pointing upwards or digitally and hook of our. The hook wire will be pointing towards the body that is approximately and this reduction wide will be pointing up first. We just need to bend it.
So I'm just going to use different tools to bend it and I'll show you how I do it. We are bending the first took you need to measure 2.5 centimeters from your hook pen. So I'm just lining with my cockpit at 2.5 centimeters is roughly here. And saying we. 2.5 centimeters is roughly here from this is the position we are going to bend our axle traction cover to make a hook.
So I'm using a combination of. pliers and this 3.5 system. To bend the sock. And make a hook for our. Collection, so this is the finicky bit of the operation. Just be patient, so I'm just going to paint it a little bit. So this is looking downwards at the same day. I'm going to bend it upwards. So this is our one side done and this is how it looks.
So I'm just going to repeat the same thing on the other side, and I'll join you. So now this is. Our hook made for the rubber bands. Now this is pointing upwards. I will do the same thing, but this will be pointing downwards or towards the patient. So same thing using a combination of pliers and your tools.
I'm going to bend it and make it pointing downwards. So now we have band it. This is facing downwards, this is facing upwards. I'm just going to cut it. Can I have the cut off, please? So let's have the cutter. I'm just going to cut this here. I'm just going to cut this here, and I'm just going to bend this a little bit more.
So if you see the orientation of the wires, this one is. The reduction, what is looking up at our. The spin, OK, what is going on top of it, so it's not going underneath it, depending upon whether it's a wall or of subluxation, you can change the position. But on this occasion, I have kept it like this.
And I'm just going to make a final cut. So I'm just going to cut this here. But this is how it's going to be made. And now it's just a matter of attaching the rubber bands on to this hook. So I'll show you how I make my rubber bands. We're just going to take one or two of this and cut it like that.
So just. Uh, just. So we are going. To make rubber bands out of this, I just take the tubing out. The smaller circles are usually better, so take the tubing out. And these two will be used as rubber bands. So you just use this as a rubber band.
So just going to pass through it. Using an art clip, and then you can easily stretch it and then pass it on top of. The other wire. Like this? And you can use both the one wire if necessary. To adjust the texture, so let's pass what of the first? I think there's a hole in my glove, so I just need to change it.
What? so now this is our frame complete Suzuki frame, so this is our acceleration wire loop upwards. This is our hook band hook wire. This is pointing downwards. This is pointing upwards. And it is going underneath it. So our disk wires are going on top of this reduction wire.
Now you can increase the distance. It's around 1.5 centimeters. You can have it up to two 2.5 centimeters, but distance between two hooks. But the whole idea is that you should have the structure of the joint and you should see one arm of joint line. The joint line was not seen before, but with just single rubber band.
I will show you how it looks on the x ray, on AP and lateral. So if you look at the image on the left, you can see the joint line around one of them. And on your right, if you see the little, the joint line is nicely created. The joint is also nicely reduced. So this is. Good enough, you don't want to have more destruction, because then it is very difficult for patients to do physiotherapy so you can use one more one rubber band or more than one rubber band if necessary on this occasion.
One rubber band is more than enough. This is our Suzuki frame complete, and the advantage is the patient can start mobilizing the hand pretty much straight away. So I'll show you. Now make a first. The patient can start mobilizing pretty much straight away, so it's already flexing more than enough. So you need to give adequate analgesia and aggressive physiotherapy to make best out of it.
But the whole advantage is you don't immobilize even for a second, so patient can get going straight away. So this is enough of a surgery. So because was this was a demonstration on how to apply a Suzuki traction, it is an extremely rewarding surgery. If you do it correctly and the patient does physiotherapy well and it leads to good to excellent outcome every single time, I think the critical step for me will be to use the right size of guidewire.
I think the thickest why you should use this 1.2 and don't go any more thicker than that. I have used the while, as it was described in Suzuki's original description, so I use 1.2 m and one wire. But you are fine to use all three 1.2 m wires, but identify the center of rotation, pass them parallel to each other. And if you do this, I can guarantee you that you will have much, much better result than a fixed k wire or any kind of fixed surgery in form of either chest or a wire, or even an open procedure.
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Segment:0 .
Hello, yesterday, I'm going to take you through a surgery, in which we are going to apply a dynamic traction, which we also call as a Suzuki traction. And it's usually used for fracture of approximately differential joints. Now this has been published by Suzuki, who was a surgeon in Japan in 1994 and there have been several modifications as how you can use it.
But I'm going to show you a technique which is the original technique, and I would also recommend you to read his paper, which was published in 1994 and I will take you step by step as how to do this procedure correctly. Before I demonstrate how I do this procedure, I think it's extremely important that I tell you and I give you some basic information that will make you understand this procedure in a better way.
So I have drawn proximal phalanx, middle phalanx and distal phalanx that is P1, P2, P3. Now usually we will use three pins and I usually use three pins, but you can get away by using only two pins. So I will show you the first pin that we will put. Is this on the center of the head of the proximal phalanx? And this is called an axial traction pin. And the usual size with k-wire that we will use for this is 1.2. You don't want to be using anything more than 1.2. You don't want to be using anything less than 1.2 because then it becomes very, very flimsy.
The second pin, which is called the hook pin, will go on the head of the middle phalanx, or P2. And this is usually 1.31 cable is used, but you can choose to use 1.2 if you want to use, but I will use one. Mm-hmm the third pin is called the reduction pin, and most of the times this is used when there is an associated subluxation or dislocation.
It helps in reducing the joint, making it more aligned, but it also adds stability. So there are occasions, even when there are no subluxation. I will put this pin and this is again one pin and this is to help reduction. So now these are the three pins exhilaration, pain reduction, pin and hook pin. Now, if you see the traction pin, this will point upwards. You need to bend upwards.
Hook pin is going to be bent downwards and reduction pin will bend upward. Facing this way and I will show you and it will become more clear when I will show you the surgery. Now let's talk about how reduction pin can be used for volar or dorsal subluxation of the proximal phalange joint. So this will be our first pin, the exact reaction pin.
This will be our second pin that will be hooked pin. Now this is the reduction pin. So if this is dorsally subluxation, you will put this pin more dorsal. So if this is the access, you will put dorsal and this pin will go on top of it. So what it will do, it will push it down and it will help in the reduction. So if it is a dorsal subluxation, this axial traction pin will go on top of the reduction pin.
On a similar note, if it is a wall of subluxation, you will put this on the axis. If you draw the axis here, you draw. You put it slightly volar and then this will go underneath it. And then it will lift it up. And this way it helps in the reduction. So this is the theoretical aspect of it, and as I said in my intro, I think you should read the paper now lets me demonstrate how I apply it on a patient.
So a patient today is a 31-year-old gentleman who is an avid cricket player who unfortunately sustained injury to his right little finger while trying to stop the ball while fielding and has sustained this complex fracture, which is completed articular of the base of his second phalanx. Now, if you try to open this fracture. And fix it, the look usually very good on x-rays. But in terms of functions, they almost always end up having a stiff joint, which complicates the results, and they have suboptimal functional result.
Now, specific keyframe is an excellent device because you don't open the fracture and your patient can start moving pretty much straight away. And the results are excellent, so I will take you step by step as how to do this procedure safely. So we are now ready. We have prepped and stripped the patient.
We don't use any tourniquet. The surgery is performed under ring blocks, so you don't need to give any general anesthetic and it's usually pain free. I'm going to sit on this side. The screen will be right in the front on my left hand side so that I can have access to all the images. Is going to come from the front, my trollies on the side. So let's start this surgery and I will take you step by step is how to do it properly.
So we need this IV set not to transfuse, but we will use end of it to make rubber bands. You need a 9 inch K-wire 1.2. If you don't have access to this, then you can use the guidewire, which is used for 6.5 catalytic screw. Then you need to either 1.2 or preferably one cable, which are six inches, which will be used for the hook pin and reduction pin.
You need some fine nose pliers so that you can bend and make hooks properly, and this is a towel for a locking plate. I use it to bend it. Then you need a scale. So these are the basic things that you need when you apply a Suzuki traction. So the first thing is that you need a true lateral use, I'm using a guide wire and I'm trying to locate the center of the head of the proximal phalanx, and I will check it on the system.
And next thing will be I will show you how it looks on the system. So if you see our guidewire is right on the center of the head of the proximal phalanx and this is where you should pass a wire, so I'm just going to put a mark with my pen. Onto the patient can. Well, the second step will be now to find the center of rotation of.
The second phalanx, its head, so again, same thing, I have used a wire here and I have checked it on the CR and Warren will show you how it looks on the same. So now, if you look at our K-wire, it is pretty much on the center. I'm going to readjust it once I pass my wire, so the next step will be to pass our nine axial correction pin on head of our proximal phalanx.
So the first wire is our 1.2 wire nine. so I'm just trying to pass it. So now I have passed my first wire, and I've checked it on both AP and lateral. It is in the center of the proximal phalanx head and it is parallel to the joint line, so it looks pretty good. So I'm just going to pass it through. And then we are going to bend it.
So now we have passed our wire and then I'm just going to hold the end of one side and then just going to bend it up like this and use a player because then it will leave three or 4m of wire on the outside. So this way you will have something. Outside the skin, and it doesn't irritate the skin, so this is our first word going in. So just make it like this and then flip it back.
So that it's out of your way. So I think Warren didn't show you how it looked on AP and laterals, if you see AP, it's parallel to the joint and then lateral it is in the center of the proximal phalanx. And this is your ideal position and this is what you want to be. Now, once you cut the wire, just flip it back and this is how it looks.
So now we have cut the sharp end so that it doesn't harm you now, in original description of a Suzuki who was from Japan. He said that your wire should be at least centimeters long from tip of your finger. So this is almost five, so we have got enough. So that is why you need a nine wire. So just after cutting it, flip it back now using the same principle as this for our hook wire.
We are going to use a millimeter. OK, while six inches on this occasion. Now one thing I forgot to tell you was that once you mark the center of rotation of the head of these two phalanx, you draw a line in between and that will be your axis. So if you have a case of subluxation, then you may have to readjust your wire wool or to it or dorsal to it, depending upon the type of dislocation.
And then hence it is extremely important that you mark this. So this is our line, and the next step will be to pass our one wire, which will be over for our hook, which is called the hook pin. So using the same principle, I passed my second layer and then I have checked the position on AP and lateral, and I'll show you how it looks. So if you look at our screen on the left, our wire's right in the center of the head.
And if you look at the screen over on the right, it is parallel to the joint. One thing I would like to stress if you are a beginner is when I will ask Warren to focus it on the patient and then I will show you what I wanted to reinforce. Now I have been the wife on this occasion, but if you are starting up and you have got your gaining experience, then you can don't. You don't bend the wire, just leave it straight like that.
And try to aim this wire parallel to it. They should be both parallel and I am just putting my wire on the axis of the previous line and you can see both of them are parallel, so you can put both of them straight and then bend it. But because it comes in the way I just bend it before, so it's entirely up to you. Now this is our two wires are gone. The axial traction wire is gone in and the hook hook pin wire is going in.
Let's see whether, if there is a need for the third wire as per description of Suzuki, and it's usually use when you have got associated subluxation. So if you look at the images both on the left and the right, of course it's an intractable fracture. Still, there is some displacement, but the position looks pretty acceptable. And if the patient can mobilize in this particular position, I think he will have good results.
There's no obvious subluxation, so let's see. I will just I've just manipulated this fracture slightly, and I would like to take a lateral just to check whether I have made it better or not. So on my manipulation, there was not much difference. There was evidence of maybe slight subluxation. So just to add stability to the construct, I have added the third wire. So if you look at the position of the third wire, the reduction wire, I have applied in the neutral axis on this occasion because there is no evidence of any clear bullet or subluxation.
I have added it just to improve the stability of our construct. The wire is parallel to all other wires and it is just distal to our fracture site, so it's perfectly positioned. So now we just need to bend our wires. So this will bend like this? And this will bend like this. So this is our interaction, while this is our book, we're.
And now this is our word which will be holding up the reduction. So I'm not bending the reduction right upwards. So both where will be band upwards? Just like that. So these are three wires which are used for. So the key to action now we just need to make hooks. And that will be our next step.
Now, when we need to make a hook, this is how you make the hook, our existing structure, while the hook will be pointing upwards or digitally and hook of our. The hook wire will be pointing towards the body that is approximately and this reduction wide will be pointing up first. We just need to bend it.
So I'm just going to use different tools to bend it and I'll show you how I do it. We are bending the first took you need to measure 2.5 centimeters from your hook pen. So I'm just lining with my cockpit at 2.5 centimeters is roughly here. And saying we. 2.5 centimeters is roughly here from this is the position we are going to bend our axle traction cover to make a hook.
So I'm using a combination of. pliers and this 3.5 system. To bend the sock. And make a hook for our. Collection, so this is the finicky bit of the operation. Just be patient, so I'm just going to paint it a little bit. So this is looking downwards at the same day. I'm going to bend it upwards. So this is our one side done and this is how it looks.
So I'm just going to repeat the same thing on the other side, and I'll join you. So now this is. Our hook made for the rubber bands. Now this is pointing upwards. I will do the same thing, but this will be pointing downwards or towards the patient. So same thing using a combination of pliers and your tools.
I'm going to bend it and make it pointing downwards. So now we have band it. This is facing downwards, this is facing upwards. I'm just going to cut it. Can I have the cut off, please? So let's have the cutter. I'm just going to cut this here. I'm just going to cut this here, and I'm just going to bend this a little bit more.
So if you see the orientation of the wires, this one is. The reduction, what is looking up at our. The spin, OK, what is going on top of it, so it's not going underneath it, depending upon whether it's a wall or of subluxation, you can change the position. But on this occasion, I have kept it like this.
And I'm just going to make a final cut. So I'm just going to cut this here. But this is how it's going to be made. And now it's just a matter of attaching the rubber bands on to this hook. So I'll show you how I make my rubber bands. We're just going to take one or two of this and cut it like that.
So just. Uh, just. So we are going. To make rubber bands out of this, I just take the tubing out. The smaller circles are usually better, so take the tubing out. And these two will be used as rubber bands. So you just use this as a rubber band.
So just going to pass through it. Using an art clip, and then you can easily stretch it and then pass it on top of. The other wire. Like this? And you can use both the one wire if necessary. To adjust the texture, so let's pass what of the first? I think there's a hole in my glove, so I just need to change it.
What? so now this is our frame complete Suzuki frame, so this is our acceleration wire loop upwards. This is our hook band hook wire. This is pointing downwards. This is pointing upwards. And it is going underneath it. So our disk wires are going on top of this reduction wire.
Now you can increase the distance. It's around 1.5 centimeters. You can have it up to two 2.5 centimeters, but distance between two hooks. But the whole idea is that you should have the structure of the joint and you should see one arm of joint line. The joint line was not seen before, but with just single rubber band.
I will show you how it looks on the x ray, on AP and lateral. So if you look at the image on the left, you can see the joint line around one of them. And on your right, if you see the little, the joint line is nicely created. The joint is also nicely reduced. So this is. Good enough, you don't want to have more destruction, because then it is very difficult for patients to do physiotherapy so you can use one more one rubber band or more than one rubber band if necessary on this occasion.
One rubber band is more than enough. This is our Suzuki frame complete, and the advantage is the patient can start mobilizing the hand pretty much straight away. So I'll show you. Now make a first. The patient can start mobilizing pretty much straight away, so it's already flexing more than enough. So you need to give adequate analgesia and aggressive physiotherapy to make best out of it.
But the whole advantage is you don't immobilize even for a second, so patient can get going straight away. So this is enough of a surgery. So because was this was a demonstration on how to apply a Suzuki traction, it is an extremely rewarding surgery. If you do it correctly and the patient does physiotherapy well and it leads to good to excellent outcome every single time, I think the critical step for me will be to use the right size of guidewire.
I think the thickest why you should use this 1.2 and don't go any more thicker than that. I have used the while, as it was described in Suzuki's original description, so I use 1.2 m and one wire. But you are fine to use all three 1.2 m wires, but identify the center of rotation, pass them parallel to each other. And if you do this, I can guarantee you that you will have much, much better result than a fixed k wire or any kind of fixed surgery in form of either chest or a wire, or even an open procedure.
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