Osteosynthesis - type surgical intervention, aimed at bone fusion. It is used for severe fractures, the presence of fragments, the threat of damage to blood vessels and nerve endings. The type and method of osteosynthesis prescribed depends on the severity of the injury and location. The operation is classified according to the time of care (primary and delayed), access (minimally invasive, open).
There are also external, submersible and outdated methods of osteosynthesis. During the rehabilitation period after osteosynthesis, electrophoresis, exercise therapy, UHF, vitamins and healing baths are used. Possible complications: infection of the area, osteomyelitis, arthritis, false joints, necrosis and others.
Literally, the term means bone fusion. In practical terms, osteosynthesis is a surgical operation, the purpose of which is to connect and firmly fix bones, as well as their fragments, with the help of metal structures, followed by anatomically correct and rapid fusion of injured bones.
Modern methods of osteosynthesis are divided into two groups and many subgroups. The choice of one or another combination depends on the attending physician, the availability necessary materials, equipment, severity and type of fracture, its location, general condition of the patient and the timing within which it is necessary to carry out surgery.
Types and methods of osteosynthesis
Osteosynthesis is classified into types according to several factors.
- Depending on the time of assistance:
- primary (in the first 8-12 hours after injury);
- delayed (more than 12 hours after injury).
It is believed that the earlier the operation is performed, the better the outcome. This is not entirely true - the operation should be performed only if there are indications for it and according to the doctor’s decision.
2. By access:
- minimally invasive (through small incisions distant from the fracture site);
- open (via surgical wound in the area of the fracture).
The less access there is, the better for the patient - both in terms of recovery time and for aesthetic reasons.
3. Regarding the location of the metal structure:
— External
- distraction-compression (when installing devices with external fixation);
- ultrasonic osteosynthesis (using special ultrasound devices);
— Immersion method
- intramedullary (placement of a wire or pin into the medullary canal);
- bone osteosynthesis (attachment of plates to the outer surface of the bone);
- transosseous (the fixator passes through the bone itself in the fracture zone);
- bone grafting (using your own bone instead of metal);
- the method is outdated
- osteosynthesis according to Weber (using knitting needles and wires).
The doctor selects methods of osteosynthesis in accordance with the indications and performed diagnostic measures. The key diagnostic methods are radiography and computed tomography of the damaged area of the body. It is also necessary to do general clinical tests.
Technique of external transosseous osteometallosynthesis
External transosseous compression-distraction osteosynthesis gained enormous popularity after the invention of external fixation devices similar to the Ilizarov apparatus and other authors.
Metal structures have the same structural principle. They consist of various elements, such as knitting needles, pins, clamps, arcs, half-arches. The number of parts may vary and is selected in accordance with the clinical case or the wishes of the patient.
The fixing element is inserted in a direction perpendicular to the bone axis and is tightly attached to the bone. After this, it is fixed with special arches. And so on several times until a good foundation is formed, thanks to which you can avoid unnecessary pressure on the fracture site. This makes it possible to use the limb within three to four days after surgery.
The method allows for high-quality reduction and stable fixation without the presence of metal parts at the site of damage. Indicated for fractures of the limbs. The method itself is complex and requires the traumatologist to have good skills and knowledge in this area. Immersion osteosynthesis is characterized by the introduction of fixators directly into the fracture zone.
Technique of bone (submersible) osteometallosynthesis
Overbone osteosynthesis is a functionally complex method. Plates are used as clamps to connect fragments different shapes and quantities, the material for which is most often titanium.
IN last years use plates with angular and polyaxial stability. The peculiarity is that there is a thread on the screw head and in the plate itself, which greatly increases the stability of the osteosynthesis.
The plates are attached to the bone using screws or wires, special rings and half rings. In cases where special materials are not available, soft suture material can be used. The method makes it possible to provide stable functional osteosynthesis and carry out early movements in the joints.
Suitable for the treatment of flat and tubular bones. The above described technique has found application in dentistry and maxillofacial surgery.
Technique of intraosseous, submersible osteometallosynthesis
Osteosynthesis surgery can be either open (manipulation in the area of the fracture) or minimally invasive (through small incisions away from the fracture site). The essence of the method is to insert a metal rod, pin or knitting needle into the medullary canal. After insertion into the medullary canal, the rod must be secured with screws or specially adapted clamps.
The fixing element is inserted into the medullary canal using a canal guide under X-ray or ultrasound control. The choice of fixator depends on the fracture and its location.
The technique is used for fractures of the diaphysis of long tubular bones with a transverse or oblique fracture line. It happens that this method is used for comminuted fractures; in such situations, a pin of a special design is used with the possibility of fixation from the inside. The fragments are fixed with screws that are attached to the rod.
Technique of transosseous (submersible) osteometallosynthesis
The fragments are fixed using screws or screws, which are selected so that the length of the latter is greater than the diameter of the bone. Fixation is carried out by screwing a screw or screw into the bone up to the cap, which tightly fixes the fragment to the bone.
The method is relevant for a large number of bone fragments, as well as for a spiral fracture (when the fracture line is helical).
Osteosynthesis with Weber wires and wires is usually used to restore bones in fractures of the patella, medial malleolus, or olecranon. The essence of the method is to fix the bones with a knitting needle and wire. The method is very simple but effective.
Application in maxillofacial surgery
Osteosynthesis has not bypassed dentistry either. facial surgery. Specialists in these fields have mastered and continue to study osteometallosynthesis. It is used to eliminate congenital or acquired defects of the face and jaw, as well as to treat deformities and fractures of the bones of the facial skull. The technique is based on marginal fit and is performed using orthodontic structures. You can change the shape of your jaw in the same way.
Indications and contraindications
Two main groups of indications can be distinguished.
Absolute indications for the use of osteosynthesis:
- for fractures that cannot be treated with conservative methods;
- fracture surgical cervix femur with displacement of fragments;
- collarbone fracture;
- fractures with rupture of vascular ligaments;
- with damage to the joint and joint capsule;
- if it is impossible to eliminate the displacement of fragments from a fracture;
- the presence of a threat of damage to nearby tissues, blood vessels and nerves;
- Patellar fractures.
Relative:
- if desired, shorten the duration of the disease (professional athletes, military);
- the presence of a small number of fragments;
- people with constant pain caused by improper healing of a fracture;
- pinching of nerve endings;
- fractures that heal poorly and take a long time.
It is very important for the doctor to take into account contraindications. Otherwise, the patient's condition may worsen. The main contraindications include:
- states of shock;
- a large number of injuries (polytrauma);
- inflammatory diseases in the fracture area;
- osteomyelitis;
- tuberculosis of bones;
- phlegmon and abscesses of nearby tissues;
- severe pathologies of the respiratory system, cardiovascular system, nervous system, as well as chronic diseases;
- advanced age;
- arthritis of the joints near which surgery will take place;
- oncological bone diseases (including secondary metastatic bone lesions);
- oncological diseases of the blood.
A qualified doctor will definitely carry out additional research to exclude contraindications.
Patient rehabilitation
Rehabilitation after osteosynthesis plays an important role in the duration and quality of the patient’s recovery. This process is no less important than the operation itself. Required individual approach to every patient. The doctor should consider the following:
- extent of damage;
- location of the fracture;
- age;
- general state body;
- the method of operation that was performed.
The recovery period includes a number of mandatory activities, each of which has great importance in recovery. If all doctor's instructions are followed, recovery is quick and without complications. Basic rehabilitation methods:
- diet therapy (increasing the level of calcium in foods);
- electrophoresis;
- medicinal baths;
- vitamin therapy;
- for pain, non-steroidal anti-inflammatory drugs.
The patient’s recovery time directly depends on the chosen combination of restorative procedures.
Complications after surgery
Complications after osteosynthesis can vary from minor to very serious. To avoid them, you must follow all the doctor’s recommendations and carry out rehabilitation measures correctly. This will help significantly reduce the risk of complications.
Common complications include:
- introduction of infection;
- osteomyelitis (purulent-necrotic process developing in the bone, bone marrow and nearby soft tissues);
- bleeding;
- fat embolism - more often with bone fractures lower limb(femur, tibia);
- false, not true joints;
- arthritis;
- necrosis of the wound edges due to compression in parts various designs;
- breakdown of the fixator with subsequent migration of its parts to other tissues.
Osteometalosynthesis remains advanced method treatment of severe fractures.
All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.
Osteosynthesis is a surgical operation to connect and fix bone fragments formed during fractures. The purpose of osteosynthesis is to create optimal conditions for anatomically correct fusion of bone tissue. Radical surgery is indicated when conservative treatment is considered ineffective. The conclusion about the inappropriateness of a therapeutic course is made on the basis diagnostic study, or after unsuccessful use traditional methods for healing of fractures.
To connect fragments of the osteoarticular apparatus, frame structures or separate fixing elements are used. The choice of the type of fixator depends on the nature, scale and location of the injury.
Scope of osteosynthesis
Currently, well-developed and time-tested osteosynthesis techniques are successfully used in surgical orthopedics for injuries of the following departments:
- Shoulder girdle; shoulder joint shoulder; forearm;
- Elbow joint;
- Pelvic bones;
- Hip joint;
- Shin and ankle joint;
- Hip;
- Brush;
- Foot.
Osteosynthesis of bones and joints involves restoring the natural integrity of the skeletal system (comparing fragments), fixing fragments, and creating conditions for the fastest possible rehabilitation.
Indications for osteosynthesis
Absolute indications for osteosynthesis are fresh fractures, which, according to accumulated statistical data and due to the structural features of the musculoskeletal system, cannot heal without surgery. These are, first of all, fractures of the femoral neck, patella, radius, elbow joint, clavicle, complicated by significant displacement of fragments, formation of hematomas and rupture of the vascular ligament.
Relative indications for osteosynthesis there are strict requirements for rehabilitation periods. Urgent surgeries are prescribed for professional athletes, military personnel, sought-after specialists, and also for patients suffering from pain caused by improperly healed fractures ( pain syndrome causes pinching of nerve endings).
Types of osteosynthesis
All types of surgery to restore joint anatomy by mapping and fixation bone fragments carried out using two methods - submersible or external osteosynthesis
External osteosynthesis. The compression-distraction technique does not involve exposing the fracture site. As fixators, the needles of the guide apparatus are used (Dr. Ilizarov’s technique), passed through the injured bone structures (the direction of the fixation structure must be perpendicular to the bone axis).
Immersion osteosynthesis– an operation in which a fixing element is inserted directly into the fracture area. The design of the latch is selected taking into account clinical picture injuries. In surgery, three methods of performing submersible osteosynthesis are used: extraosseous, transosseous, intraosseous.
External transosseous osteosynthesis technique
Osteosynthesis using a guide apparatus allows you to fix bone fragments, while maintaining the natural mobility of the articular ligament in the injured area. This approach creates favorable conditions for the regeneration of osteochondral tissue. Transosseous osteosynthesis is indicated for fractures of the tibia, open fractures of the tibia, and humerus.
The guide apparatus (type of design by Ilizarov, Gudushauri, Akulich, Tkachenko), consisting of fixing rods, two rings and crossed spokes, is assembled in advance, having studied the nature of the location of the fragments using an x-ray.
From a technical point of view correct installation apparatus in which they are used different types knitting needles is a difficult task for a traumatologist, since the operation requires mathematical precision of movements, understanding of the engineering design of the device, and the ability to make operational decisions during the operation.
The effectiveness of competently performed transosseous osteosynthesis is extremely high (recovery period takes 2-3 weeks), no special preoperative preparation of the patient is required. There are practically no contraindications for performing surgery using an external fixation device. The transosseous osteosynthesis technique is used in each case if its use is appropriate.
Technique of bone (submersible) osteosynthesis
Bone osteosynthesis, when fixators are installed on the outside of the bone, is used for uncomplicated displaced fractures (comminuted, flap-like, transverse, periarticular forms). Metal plates connected to the bone tissue with screws are used as fixing elements. Additional fixators that the surgeon can use to strengthen the joining of fragments are the following parts:
Structural elements are made of metals and alloys (titanium, stainless steel, composites).
Technique of intraosseous (immersion osteosynthesis)
In practice, two techniques are used for intraosseous (intramedullary) osteosynthesis - these are closed and open type operations. Closed surgery is performed in two stages - first, bone fragments are compared using a guide apparatus, then a hollow metal rod is inserted into the medullary canal. The fixation element, advanced with the help of a guide device into the bone through a small incision, is installed under X-ray control. At the end of the operation, the guidewire is removed and sutures are applied.
At open method the fracture area is exposed, and the fragments are compared using a surgical instrument, without the use of special equipment. This technique is simpler and more reliable, but at the same time, like any abdominal surgery, is accompanied by blood loss, violation of the integrity of soft tissues, and the risk of developing infectious complications.
Locked intramedullary fusion (BIOS) is used for diaphyseal fractures (fractures of long bones in the middle part). The name of the technique is due to the fact that the metal fixation rod is blocked in the medullary canal by screw elements.
In cases of femoral neck fractures, the high effectiveness of osteosynthesis has been proven. at a young age, When bone well supplied with blood. The technique is not used in the treatment of elderly patients who, even with relatively good health indicators, experience degenerative changes in the joint-skeletal system. Brittle Bones cannot withstand the weight of metal structures, resulting in additional injuries.
After intraosseous surgery on the hip, a plaster cast is not applied.
For intraosseous osteosynthesis of the bones of the forearm, ankle and lower leg, an immobilization splint is used.
The femur is the most vulnerable to a fracture of the diaphysis (at a young age, the injury most often occurs in professional athletes and fans of extreme car driving). To fasten fragments of the femur, elements of various designs are used (depending on the nature of the injury and its scale) - three-bladed nails, screws with a spring mechanism, U-shaped structures.
Contraindications to the use of BIOS are:
- Arthrosis of 3-4 degrees with pronounced degenerative changes;
- Arthritis in the acute stage;
- Purulent infections;
- Diseases of the hematopoietic organs;
- Impossibility of installing a fixator (the width of the medullary canal is less than 3 mm);
- Childhood.
Osteosynthesis of the femoral neck without splinter displacements is carried out using a closed method. To increase the stabilization of the skeletal system, a fixing element is inserted into the hip joint and subsequently secured in the wall of the acetabulum.
The stability of intramedullary osteosynthesis depends on the nature of the fracture and the type of fixation chosen by the surgeon. The most effective fixation is provided for fractures with straight and oblique lines. The use of an excessively thin rod can lead to deformation and breakage of the structure, which is a direct need for secondary osteosynthesis.
Technical complications after operations (in other words, doctor errors) are not often encountered in surgical practice. This is due to the widespread introduction of high-precision monitoring equipment and innovative technologies Detailed osteosynthesis techniques and extensive experience accumulated in orthopedic surgery make it possible to foresee all possible negative aspects that may arise during the operation or during the rehabilitation period.
Technique for transosseous (submersible) osteosynthesis
Fixing elements (bolts or screw elements) are inserted into the bone in the fracture area in a transverse or oblique-transverse direction. This osteosynthesis technique used for helical fractures (that is, when the fracture line of the bones resembles a spiral). For strong fixation of fragments, screws of such a size are used that the connecting element protrudes slightly beyond the diameter of the bone. The head of the screw or screw tightly presses the bone fragments against each other, providing a moderate compression effect.
For oblique fractures with a steep fracture line, the technique of creating a bone suture is used, the essence of which is to “bind” the fragments with a fixing tape (round wire or flexible stainless steel plate tape)
In the area of the injured areas, holes are drilled through which wire rods are pulled, used to fix the bone fragments at the points of contact. The clamps are firmly pulled together and secured. After signs of healing of the fracture appear, the wire is removed to prevent atrophy of the bone tissues compressed by the metal (as a rule, a second operation is performed 3 months after the osteosynthesis operation).
The technique of using a bone suture is indicated for fractures of the humeral condyle, patella and olecranon.
It is very important to carry out primary osteosynthesis as soon as possible for fractures in the elbow and knee area. Conservative treatment It is extremely rarely effective, and, moreover, leads to limited flexion-extension mobility of the joint.
The surgeon selects a technique for fixing fragments based on data x-rays. For a simple fracture (with one fragment and without displacement), the Weber osteosynthesis technique is used - the bone is fixed with two titanium wires and wire. If several fragments have formed and they have been displaced, then metal (titanium or steel) plates with screws are used.
Application of osteosynthesis in maxillofacial surgery
Osteosynthesis is successfully used in maxillofacial surgery. The purpose of the operation is to eliminate congenital or acquired abnormalities of the skull. To eliminate deformations lower jaw formed as a result of injuries or improper development of the masticatory apparatus, the compression-distraction method is used. Compression is created using orthodontic structures fixed in oral cavity. The clamps create uniform pressure on the bone fragments, ensuring a tight marginal connection. IN surgical dentistry A combination of different structures is often used to restore the anatomical shape of the jaw.
Complications after osteosynthesis
Unpleasant consequences after minimally invasive forms of surgery are extremely rare. When performing open operations, the following complications may develop:
- Soft tissue infection;
- Osteomyelitis;
- Internal hemorrhage;
- Arthritis;
- Embolism.
After the operation, antibiotics and anticoagulants are prescribed for preventive purposes, painkillers are prescribed according to indications (on the third day, drugs are prescribed taking into account patient complaints).
Rehabilitation after osteosynthesis
The rehabilitation time after osteosynthesis depends on several factors:
- Complexity of injury;
- Locations of injury
- Type of osteosynthesis technique used;
- Age;
- Health conditions.
The recovery program is developed individually for each patient and includes several areas: physical therapy, UHF, electrophoresis, therapeutic baths, mud therapy (balneology).
After elbow surgery patients experience for two to three days severe pain, but, despite this unpleasant fact, it is necessary to develop the hand. In the first days, the exercises are carried out by a doctor, rotational movements, flexion-extension, extension of the limb. IN further patient performs all points of the physical education program independently.
To develop the knee, hip joint special simulators are used, with the help of which the load on the joint apparatus is gradually increased, muscles and ligaments are strengthened. IN mandatory therapeutic massage is prescribed.
P after immersion osteosynthesis of the femur, elbow, patella, tibia The recovery period takes from 3 to 6 months, after using the transosseous external technique - 1-2 months.
Conversation with a doctor
If osteosynthesis surgery is planned, the patient should receive as much information as possible about the upcoming treatment and rehabilitation course. This knowledge will help you properly prepare for your stay in the clinic and for the rehabilitation program.
First of all, you should find out what type of fracture you have, what type of osteosynthesis the doctor plans to use, and what the risks of complications are. The patient must be aware of the methods further treatment, terms of rehabilitation. Absolutely all people are concerned about the following questions: “When can I start working?”, “How fully can I care for myself after surgery?”, and “How severe will the pain be after surgery?”
The specialist must cover everything in detail, consistently, and in an accessible form. important points The patient has the right to find out how the fixations used in osteosynthesis differ from each other and why the surgeon chose this particular type of design. Questions should be thematic and clearly formulated.
Remember that the work of a surgeon is extremely complex, responsible, and constantly associated with stressful situations. Try to follow all the instructions of your doctor, and do not neglect any recommendations. This is the main basis quick recovery after a serious injury.
Cost of the operation
The cost of osteosynthesis surgery depends on the severity of the injury and, accordingly, on the complexity of the methods used. medical technologies. Other factors affecting the price medical care, are: the cost of the fixing structure and medicines, level of service before (and after) surgery. For example, osteosynthesis of the clavicle or elbow joint in different medical institutions can cost from 35 to 80 thousand rubles, surgery on the tibia - from 90 to 200 thousand rubles.
Remember that the metal structures must be removed after healing of the fracture - for this, repeated surgery is performed, for which you will have to pay, although an order of magnitude less (from 6 to 35 thousand rubles).
Free operations are carried out according to a quota. This is a very real possibility for patients who may wait 6 months to a year. The traumatologist writes a referral for additional examination and passing a medical commission (at your place of residence).
For external osteosynthesis they use different kinds plates The plates are fixed to the bone using cortical and cancellous screws, the rules of use of which are similar to those described when describing osteosynthesis with screws.
According to the biomechanical conditions that are created in the fracture zone, all plates can be divided into neutralizing (bypass) and dynamic compression. When using shunt plates, the main part of the load falls on the retainer. This leads to a series negative consequences: osteoporosis in the non-load-bearing area of the bone, reduced efficiency of osteoreparation in the fracture zone, as well as an increased risk of plate and screw fracture. Dynamic compression plates allow you to distribute the load between the fixator and the bone and avoid these disadvantages. Installation of plates in a neutralizing (bypass) mode is justified only for comminuted and multi-comminuted fractures, when compression will lead to displacement of fragments, as well as for some intra-articular fractures.
According to the method of connecting the screw to the plate, there are: 1) plates with round holes; 2) plates with oval holes; 3) dynamic compression plates; 4) plates with angular stability of the screw (Fig. 32).
Plates with round holes are shunting and currently their use for osteosynthesis of fractures of the diaphysis of long bones is not justified.
Plates with oval holes allow intraoperatively to achieve the effect of simultaneous interfragmental compression only through the use of additional devices (contractors), which complicates the technology of osteosynthesis and requires an increase in the size of the surgical access. Therefore, at present, dynamic compression plates are most often used: DCP (S. Perren et al. 1969) and LC-DCP (S. Perren et al. 1989). The configuration of the holes of the dynamic compression plates is such that final stage When the screw is inserted into the bone, its head “slides” towards the middle of the plate. Considering that all the holes are located symmetrically relative to the middle of the fixator, when it is correctly centered over the fracture zone, the fragments come together. To implement the technology of dynamic compression plates, neutral and eccentric (load) drill guides are used (Fig. 33). Using only neutral guides allows the dynamic compression plate to be placed where indicated in a virtually shunt-like manner. Thanks to the shape of the holes, it is possible to insert screws into the plate at an angle of up to 200 (DCP) - 400 (LC-DCP) in its longitudinal direction and up to 70 in the transverse direction.
Additional interfragmental compression can be achieved due to excessive bending of the elastic plate during modeling so that after pulling it to the bone with screws, a “spring” effect occurs, aimed at bringing together and compressing bone fragments.
When installing plates, an inevitable negative aspect is the pressure of the implant on the periosteum, which leads to impaired blood circulation in it, the development of bone atrophy, early osteoporosis and a slowdown in the consolidation process. To minimize the pressure of the fixator on the bone, plates with limited contact were proposed, having spherical notches on their surface adjacent to the bone (LC-DCP plates), significantly reducing the area of contact with the periosteum (Fig.
An important stage in the development of external osteosynthesis was the creation of plates with angular stability of screws, suggesting their rigid fixation in the holes of the plate through threads. Plates with angular stability of the screw allow the fixator to be installed above the bone surface (epiperiosteal), avoiding even minimal pressure of the plate on the periosteum and skeletonization of the bone during implantation. In addition, the greater strength of fixation of fragments with such plates allowed all screws or a significant part of them to be passed through only one layer of compact bone (monocortical), which reduced the traumatic nature of osteosynthesis. Angular screw-stabilized plates can have limited contact (LC) or point contact to the bone surface (PC-Fix). Screw angular stability plates are designed in two versions: with round threaded holes (PC-Fix, LISS) or with double holes (LCP and LC-LCP). The double hole plate (Fig. 35) combines the advantages of dynamic compression plates (smooth part of the hole for the insertion of conventional screws) and plates with angular stability of the screw (threaded hole). There are various types of plates that implement LCP technology for osteosynthesis of fractures of the diaphysis of long bones of the extremities, intra- and periarticular fractures. The thickness of LC-LCP plates for fixing periarticular fractures can be smoothly reduced in the part of the plate intended for the metaepiphyseal zone of the bone from 4.5 mm to 3.5 mm, and double holes with this technical solution in its thicker part are intended for screws with a diameter of 5.0 mm, in thinner ones - 4.5 mm and 3.5 mm. An important advantage of plates with angular stability of the screw is the anatomical nature of their shape, which makes it possible to largely avoid modeling the plate, as well as secondary displacements of fragments when tightening the screws.
To better adapt the plate to the shape of the bone, as well as increase the strength of osteosynthesis, they are manufactured in the following options: straight, half-, third- and quarter-tubular (according to the degree of bending of the plate plane along the axis of the fixator); in addition, the plates can be narrow (with a single-row arrangement of holes) and wide (with a double-row arrangement of holes).
If the fracture line or zone (for example, in comminuted fractures) is large, sometimes “tunnel” osteosynthesis is used. With this method of osteosynthesis, surgical approaches are performed above and below the site of bone damage, and the plate is placed closed in the thickness of the soft tissue. In such situations, a long plate is fixed with 3-4 screws to the proximal and distal fragments, without isolating small intermediate bone fragments (“bridge” osteosynthesis). When fixing fractures in the consolidation stage, “wave-shaped” modeling of the plate is performed (Fig. 36) to go around the developing callus, as well as to place bone grafts under the plate in case of fusion disorders (“wave-shaped” osteosynthesis). Minimally invasive LISS plates can be placed in the soft tissue tunnel through a limited incision and skin punctures. The screws in them are passed through a special guide along the trocars. “Tunnel” osteosynthesis and fixation with LISS plates involves the use of external repositioning devices (for example, a femoral distractor), as well as X-ray video and television support.
Reconstructive plates are intended for osteosynthesis of fragments in those fracture locations where complex multiplanar modeling of the fixator is necessary (pelvis, clavicle, etc.). Triangular or round notches between the holes of the reconstruction plates make it quite easy to bend them in the plane of the fixator (Fig. 37).
For osteosynthesis of fragments for peri- and intra-articular fractures, there are special plates that allow them to be effectively attached to the epiphyseal ends of bones. The end parts of these plates are made in the form of shaped support platforms with holes through which compression screws and blades are passed various shapes etc. (Fig. 38), as well as in the form of a finished blade. Thus, for fixing fractures of the trochanteric region of the femur, angular plates with a blade located at an angle of 1300, 950 to its axis are intended. After forming the canal with a special chisel using a guide and orienting pins, the plate blade is driven into the femoral neck, and the rest of the plate is attached with cancellous and cortical screws (Fig. 39).
In addition, a dynamic hip screw (DHS), fixed in a similar plate, has been proposed for osteosynthesis of fragments in fractures of the neck and trochanteric region of the femur. This special cannulated screw is inserted instead of a blade into the neck of the femur, and its threaded part is located in the central fragment (head) of the femur. The use of a DHS screw allows not only to increase the strength of fragment fixation and the mechanical reliability of the structure, but also to provide additional interfragmental compression.
Osteosynthesis is a type of surgical intervention that is used for bone fractures. Plates for osteosynthesis are needed to ensure that the elements of the damaged bone structure are fixed in a stationary state. Such devices provide strong, stable fixation of bone fragments until they completely heal. Fixation, which is carried out promptly, ensures stabilization of the fracture site and proper bone fusion.
Plates as a way to connect bone fragments
Osteosynthesis - method surgery, during which fragments of bone structures are connected and fixed with special devices in the area of the fracture.
Plates are fixing devices. They are made from different metals that are resistant to oxidation inside the body. The following materials are used:
- titanium alloy;
- stainless steel;
- molybdenum-chromium-nickel alloy;
- artificial materials that dissolve in the patient’s body.
The fixing devices are located inside the body, but on the outside of the bone. They attach bone fragments to the main surface. To fix the plate to the bone base, the following types of screws are used:
- cortical;
- spongy.
Efficiency of fixation devices
The operation is performed in order to connect all the fragments. During surgery, surgeons can change the plate by bending and modeling - the device adapts to the bone from its anatomical features. Compression of bone fragments is achieved. A strong, stable fixation is ensured, the fragments are compared and held in the required position so that the bone parts heal correctly. For osteosynthesis to be successful, you need:
- anatomically clearly and correctly compare bone fragments;
- fix them firmly;
- provide them and the tissues that surround them with minimal trauma, maintaining normal blood circulation in the fracture sites.
The disadvantage of osteosynthesis with plates is that the periosteum can be damaged during fixation, which can provoke osteoporosis and bone atrophy, since blood circulation in this area is disrupted. To avoid this, they produce clamps that have special notches and allow them to reduce pressure on the surface of the periosteum. To perform the intervention, plates that have different parameters are used.
Types of fixing plates for osteosynthesis
The variety of plates allows you to choose the optimal one for each case. Plate clamps are:
- Shunting (neutralizing). Most of the load is provided by the fixator, which can result in undesirable consequences such as osteoporosis or a decrease in the effectiveness of osteosynthesis at the fracture site.
- Compressing. The load is distributed by the bone and the fixator.
Shunts are used for fractures of the comminuted and multi-fragmented type, when the fragments are displaced, as well as for certain types of fractures inside the joint. In other cases, compressive types of clamps are used. The holes in the fixing device for screws are:
- oval;
- cut at an angle;
- round.
To avoid damage to the periosteum, LC-DCP plates are produced. They allow you to reduce the area of contact with the periosteum. Plates that provide angular screw stability are effective for osteosynthesis. The thread promotes rigid and durable fixation in the holes of the devices. The fixator in them is installed epiperiosteally - above the bone surface, which avoids its pressure on the periosteum area. For plates with angular screw stability, contact with the bone surface occurs:
- PC-Fix - point;
- LC - limited.
The following types of plates are distinguished:
- narrow - the holes are located in 1 row;
- wide - double-row holes.
Fastener parameters
The choice of fixator depends on the type of injury. With external osteosynthesis, surgical intervention is performed using implants with different parameters. There are different widths, thicknesses, shapes and lengths of the plate in which the screw holes are made. The large working length helps reduce the load on the screws. Choice plate retainer depends on the type of fracture and the strength properties of the bone for which external osteosynthesis needs to be applied. The plates provide bone fixation in such parts of the body as:
- brush;
- shin;
- forearm and shoulder joint;
- collarbone;
- hip joint area.
If the patient is diagnosed dangerous fracture bones, in which separate pieces of hard tissue have formed, he needs to undergo osteosynthesis. This procedure allows you to correctly compare the fragments using special devices and devices, which will ensure that the pieces do not move on long time. All types of surgical reduction preserve the functionality of movement of the segment axis. The manipulation stabilizes and fixes the damaged area until healing occurs.
Most often, osteosynthesis is used for fractures inside joints, if the integrity of the surface has been compromised, or for damage to long tubular bones or the lower jaw. Before proceeding with such a complex operation, the patient must be carefully examined using a tomograph. This will allow doctors to draw up an accurate treatment plan, choose the optimal method, set of instruments and fixatives.
Types of procedure
Since this is a very complex operation that requires high precision, it is best to carry out the manipulation on the first day after the injury. But this is not always possible, so osteosynthesis can be divided into 2 types, taking into account the time of execution: primary and delayed. The latter type requires more accurate diagnosis, because there are cases of formation of a false joint or improper fusion of bones. In any case, the operation will be performed only after diagnosis and examination. For this purpose, ultrasound, x-ray and computed tomography are used.
The next method of classifying the types of this operation depends on the method of introducing fixing elements. There are only 2 options: submersible and external.
The first is also called internal osteosynthesis. To carry it out, use the following clamps:
- knitting needles;
- pins;
- plates;
- screws.
Intraosseous osteosynthesis is a type of submersible method in which a fixator (nails or pins) is inserted under X-ray control into the bone. Doctors perform closed and open surgery using this technique, which depends on the area and nature of the fracture. Another technique is bone osteosynthesis. This variation makes it possible to connect the bone. Main fasteners:
- rings;
- screws;
- screws;
- wire;
- metal tape.
Transosseous osteosynthesis is prescribed if the fixator needs to be inserted through the wall of the bone tube in the transverse or oblique transverse direction. For this, an orthopedic traumatologist uses knitting needles or screws. The external transosseous method of repositioning fragments is carried out after exposing the fracture zone.
For this operation, doctors use special distraction-compression devices that stably fix the affected area. The fusion option allows the patient to recover faster after surgery and avoid plaster immobilization. It is worth mentioning separately ultrasound procedure. This new technique osteosynthesis, which is not yet used so often.
Indications and contraindications
The main indications for this treatment method are not that extensive. Osteosynthesis is prescribed to a patient if, along with a bone fracture, he is diagnosed with pinched soft tissue that is pinched by fragments, or if a major nerve is damaged.
Besides, surgically They treat complex fractures that are beyond the capabilities of a traumatologist. Typically these are injuries to the femoral neck, olecranon or displaced patella. Separate view consider closed fracture, which can turn into open due to perforation of the skin.
Osteosynthesis is also indicated for pseudarthrosis, as well as if the patient’s bone fragments have separated after a previous operation or they have not healed (slow recovery). The procedure is prescribed if the patient cannot undergo a closed operation. Surgical intervention is performed for injuries to the collarbone, joints, lower leg, hip, and spine.
- Contraindications for such manipulation consist of several points.
- For example, they do not use this procedure when an infection is introduced into the affected area.
- If a person open fracture, but the area is too large, osteosynthesis is not prescribed.
- You should not resort to such an operation if the patient’s general condition is unsatisfactory.
- venous insufficiency of the extremities;
- systemic hard tissue disease;
- dangerous pathologies of internal organs.
Briefly about innovative methods
Modern medicine is significantly different from early methods through minimally invasive osteosynthesis. This technique allows fragments to be fused using small skin incisions, and doctors are able to perform both extraosseous and intraosseous surgery. This treatment option has a beneficial effect on the fusion process, after which the patient no longer needs cosmetic surgery.
A variation of this method is BIOS - intramedullary blocking osteosynthesis. It is used in the treatment of fractures of tubular bones of the extremities. All operations are monitored using an x-ray installation. The doctor makes a small incision 5 cm long. A special rod, made of titanium alloy or medical steel, is inserted into the medullary canal. It is fixed with screws, for which the specialist makes several punctures (about 1 cm) on the surface of the skin.
The essence of this method is to transfer part of the load from the damaged bone to the rod inside it. Since during the procedure there is no need to open the fracture zone, healing occurs much faster, because doctors are able to maintain the integrity of the blood supply system. After the operation, the patient is not put in plaster, so the recovery time is minimal.
There are extramedullary and intramedullary osteosynthesis. The first option involves the use of external devices of a spoke design, as well as the combination of fragments using screws and plates. The second allows you to fix the affected area using rods that are inserted into the medullary canal.
Femur
Such fractures are considered extremely serious and are most often diagnosed in older people. There are 3 types of femur fractures:
- at the top;
- in the lower part;
- femoral diaphysis
In the first case, the operation is performed if the patient’s general condition is satisfactory and he does not have impacted injuries to the femoral neck. Typically, surgery is performed on the third day after injury. Osteosynthesis of the femur requires the use of the following instruments:
- three-bladed nail;
- cannulated screw;
- L-shaped plate.
Before the operation, the patient will undergo skeletal traction and an x-ray. During reposition, doctors will accurately compare bone fragments and then fix them necessary tool. The technique for treating a midline fracture of this bone requires the use of a three-blade nail.
In type 2 fractures, surgery is scheduled on the 6th day after the injury, but before that the patient must undergo skeletal traction. Doctors use rods and plates for fusion, devices that will fix the affected area externally. Features of the procedure: it is strictly forbidden to perform it on patients in serious condition. If fragments of hard tissue can injure the hip, they should be immediately immobilized. This usually occurs with combined or fragmented injuries.
After such a procedure, the patient is faced with the question of whether it is necessary to remove the plate, because this is another stress for the body. Such an operation is urgently necessary, if fusion does not occur, its conflict with any joint structure is diagnosed, which causes contracture of the latter.
Removal of metal structures is indicated if the patient had a fixator installed during surgery, which over time developed metallosis (corrosion).
Other factors for plate removal surgery:
- infectious process;
- migration or fracture of metal structures;
- planned step-by-step removal as part of recovery (the stage is included in the entire course of treatment);
- playing sports;
- cosmetic procedure to remove a scar;
- osteoporosis.
Options for upper limb surgery
The operation is performed for fractures of the bones of the extremities, so the procedure is often prescribed to fuse the hard tissues of the arm, leg, and hip. Osteosynthesis of the humerus can be performed using the Demyanov method, using compression plates, or Tkachenko, Kaplan-Antonov fixators, but with removable contractors. Manipulation is prescribed for fractures on the diaphysis of the humerus if conservative therapy does not bring success.
Another surgical option involves treatment with a pin, which must be inserted through the proximal fragment. To do this, the doctor will have to expose the broken bone in the damaged area, find the tubercle and cut the skin over it. After this, an awl is used to make a hole through which the rod is driven into the medullary cavity. The fragments will need to be accurately compared and the inserted element advanced to the full length. The same manipulation can be performed through the distal piece of bone.
If a patient is diagnosed with an intra-articular fracture of the olecranon, it is best to undergo surgery to install metal structures. The procedure is performed immediately after the injury. Osteosynthesis of the olecranon requires fixation of the fragments, but before this manipulation the physician will need to completely eliminate the displacement. The patient wears the cast for 4 weeks or more, as this area is difficult to treat.
One of the most popular methods of osteosynthesis is Weber fusion. To do this, the specialist uses a titanium knitting needle (2 pieces) and wire, from which a special loop is made. But in most cases, the mobility of the limb will be permanently limited.
Lower limb
Separately should be considered different fractures dyphyses of the tibia bones. Most often, patients come to a traumatologist with problems of the tibia. It is the largest and most important for the normal functioning of the lower limb. Previously, doctors carried out long-term treatment using plaster and skeletal traction, but this technology is ineffective, so more stable methods are now used.
Osteosynthesis of the tibia is a procedure that reduces rehabilitation time and is a minimally invasive option. In the event of a fracture of the diaphysis, the specialist will install a locking rod, and treat intra-articular damage by inserting a plate. External fixation devices are used to heal open fractures.
Ankle osteosynthesis is indicated in the presence of a large number of comminuted, helical, rotational, avulsion or comminuted fractures. The operation requires a mandatory preliminary X-ray, and sometimes a tomography and MRI are needed. The closed type of injury is fused using an Ilizarov apparatus and needles are inserted into the damaged area. In case of foot fractures (usually the metatarsal bones are affected), the fragments are fixed using the intramedullary method with the introduction of thin pins. In addition, the medic will apply a plaster cast, which should be worn for 2 months.
Patient rehabilitation
After the operation, you need to carefully monitor your well-being and, at the slightest negative symptoms, contact a specialist (acute pain, swelling or fever). These symptoms are normal in the first few days, but they should not appear until several weeks after the procedure.
