What is osteosynthesis for a hip fracture: advantages and disadvantages

Osteosynthesis means a surgical intervention during which absolutely precise reposition of femoral bone fragments with rigid fixation is performed. The associated fracture zone is secured with special structures. Metal rod and threaded systems, including devices with diaphyseal plates, act as fasteners. Their purpose is to tightly hold the recreated position of the bone in the correct position, to maintain the immobility of the fastened bone fragments until the final fusion of the damaged femoral neck.

A visual representation of the procedure.

Today, osteosynthesis is rarely used for femoral neck fractures, especially if there is an injury in an elderly person. The technique is more suitable for young and active people whose bone tissue is well supplied with blood and has a high ability to restore natural integrity. For the elderly category, this tactic can be considered as an alternative to the most suitable intervention – joint replacement. Osteosynthesis is associated with significant risks of complications (10%-60%).

In the case of patients over 60 years of age, such an operation does not guarantee that the stability of the fixation will not be disrupted and the fracture will heal even if it is intact.

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What are the advantages of osteosynthesis?

Surgery has few advantages, as evidenced by clinical observations of operated patients. One of the few advantages is the ability to preserve the hip joint without losing its anatomical components. With successful treatment, the natural joint can continue to function. However, as experience shows, the functions of the limb joint are not always fully restored. The motor support potential is usually reduced to some extent.

Osteosynthesis of the hip joint on x-ray

Some sources say that this method involves early loading of the limb with the whole body in the first days after surgery, which favors fusion. Of course, uninformed people will take this fact as an advantage. But the authors miss a very important point: this approach carries the highest risk of disruption of the fixator-bone contact due to dynamic load during movement or accidental overload of the problematic leg. For successful fusion of bone structures, the leg requires a protective regime; walking only on crutches is allowed without a full load on the hip joint for the entire period of consolidation of the fracture. This requires a minimum of 6 months.

The undeniable advantages include the widespread use of the method in Russia and the relatively low price of the medical care provided. In Moscow, depending on the severity of the injury and the types of fixators used, treatment of PSB with osteosynthesis will cost 25-85 thousand rubles, together with rehabilitation - up to $2,500. As part of the VMP, compulsory medical insurance within the Russian Federation, Russians have the opportunity to undergo the procedure for free or pay only the cost of consumables. Abroad (in Israel, Germany) osteosynthesis is performed for 5-15 thousand euros.

It is advisable to operate within the first 24-48 hours after the injury occurs. Later, the effectiveness of the method decreases, and the likelihood of consequences increases significantly.

POLYTRAUMA / POLYTRAUMA

Zagorodniy N.V., Solod E.I., Alsmadi Ya.M., Lazarev A.F., Abdulkhabirov M.A., Ananyin D.A., Petrovsky R.A., Dmitrov I.A.

Department of Traumatology and Orthopedics RUDN, State Budgetary Institution "City Clinical Hospital named after A.K. Eramishantseva DZM", Moscow, Russia

CONVERSION OSTEOSYNTHESIS IN THE TREATMENT OF PATIENTS WITH FRACTURES OF LONG BONES OF THE LIMB

Treatment of fractures of long bones of the extremities is of particular relevance in modern traumatology due to the high frequency of victims with polytrauma, as well as disability and death [1-5]. According to the literature, hip fractures account for about 2-2.7% of all fractures and are often accompanied by the development of traumatic shock [2, 4]. The mortality rate in such patients reaches 17.3%. [1]. Fractures of the lower leg bones account for 11-13% in the group of long bone fractures; Fractures of the humeral diaphysis account for 4%, and fractures of the forearm account for 11.3% of the total number of fractures [1, 6]. When using plaster casts or a skeletal traction system to treat patients with long bone fractures, not only does the treatment time lengthen, but it often results in the formation of contractures and false joints [6, 7]. Currently, many traumatologists for the treatment of patients with fractures of long bones due to polytrauma have begun to use the method of conversion osteosynthesis according to the Damage control principle, where at the first stage they use extrafocal osteosynthesis using pins, rods and pin-rod external fixation devices [2, 4, 8- 12]. After improvement of the general condition, the second stage uses intramedullary osteosynthesis using locked and non-locking pins, as well as external osteosynthesis using plates of different designs and different functions [8, 9, 13-18]. M. Bhandari and other authors indicate that upon admission of patients with comminuted fractures of long bones, especially with multiple fractures, fixation of the damaged segment with an external fixation device is necessary as anti-shock therapy [4, 17, 19-21]. However, to this day there are still different opinions about the timing and methods of conversion osteosynthesis [2, 4]. Pape H, Nicholas B. and other authors write that patients admitted to the hospital in stable or borderline condition can undergo primary internal fixation of fractures [22, 23]. Seleznev S. and other researchers believe that early osteosynthesis of long bones in case of polytrauma is that carried out no later than the first three days from the moment of injury, however, performing osteosynthesis within 4 to 10 days is characterized by an extremely high risk of infectious complications [2, 24]. Paderni and other authors believe that immersion osteosynthesis can be performed 2-3 months after the application of the external fixation device, which reduces the risk of developing severe complications: adult respiratory distress syndrome, multiple organ failure, pneumonia, sepsis [4]. Gianluca Testa and other researchers believe that the definitive treatment of patients with polytrauma long bone fractures with an external fixator is the ideal method, which gives satisfactory results with an acceptable complication rate and a reduced need for other open and invasive surgical interventions [25]. Samusenko D. and other authors prove that the Ilizarov apparatus can be used as the final method of treating victims with fractures of long bones due to polytrauma, since the apparatus transports patients over long distances and during the initial application, patients are activated with the simultaneous development of movements in adjacent joints; however, they did not observe infectious complications associated with the insertion of wires or rods [26]. Khominetz V., Pairon P. believe that an adequate choice of tactics, methods and timing of treatment for patients with fractures of long bones is important for the healing of fractures and a positive functional outcome of the treatment of patients [2, 4]. In connection with the above purpose

This study was to study the results of conversion osteosynthesis in various clinical situations and improve treatment results.

MATERIALS AND METHODS

This study is based on a prospective and retrospective analysis of clinical material from conversion osteosynthesis in 105 patients with fractures of long bones of the extremities admitted within an hour from the moment of injury for the period from January 2021 to January 2021. Of these, 56 (53%) were women and 49 (46%) were men in the age group from 18 to 67 years. Patients who died before and within 4 weeks after conversion osteosynthesis from complications not related to osteosynthesis were excluded from the study due to the need to evaluate long-term results of fracture and soft tissue healing. All patients were divided into two groups. The first group included 41 patients with fractures of long bones (femur, tibia, shoulder, forearm) due to polytrauma. The second group included 64 patients with closed isolated unstable comminuted and comminuted fractures of long bones (femur, tibia, shoulder, forearm) with severe post-traumatic swelling and closed soft tissue injury with a high risk of developing soft tissue complications. To assess long bone fractures and the condition of soft tissues, we used the international classification of fractures and soft tissue injuries of the Association of Osteosynthesis (AO). Upon admission, all patients were examined for the integrity of the skin, the severity of edema and hematoma, as well as the presence or absence of damage to the great vessels and nerves, and X-ray examinations were performed in direct and lateral projections involving adjacent joints. In order to diagnose associated trauma, computed tomography was performed from the head to the pelvis, and in case of intra-articular fractures, a CT scan of the fracture was performed for preoperative planning. Patients of the first group upon admission, as anti-shock therapy, underwent emergency fixation of the damaged segment with a rod-based external fixation device according to the principles of Damage control. This approach provided the possibility of effective care and monitoring of victims in order to prevent the development of traumatic shock, fat embolism and thrombosis of the veins of the damaged segment, as well as secondary damage to the great vessels and nerves. At the first stage, anatomical reposition in the device was not performed in order to reduce trauma to soft tissues and shorten the operation time. Special attention of the traumatology team was paid to careful handling of soft tissues, placement of transosseous elements, taking into account subsequent internal osteosynthesis and the need for stable fixation of the fracture at the first stage. For intra-articular and periarticular fractures, adjacent segments were fixed (joint-spanning external fixation technique) without fixation in the metaphyseal zone in order to enhance the degree of fixation and prevent infectious complications. After improvement of the general condition in the second stage, these patients were converted to immersion osteosynthesis with locked rods or plates, depending on the nature and location of the fractures. The minimum requirements for transition (conversion) from extrafocal fixation to immersion osteosynthesis were: hemoglobin more than 90 g/l; hematocrit more than 35; the patient is without mechanical ventilation for more than a day without dopamine (vasopressors); stabilization of blood pressure more than 90 mm Hg. Art. at least 24 hours of observation; adequate diuresis for at least 24 hours; stable blood saturation indicators for at least 24 hours of observation; absence of acidosis; absence of signs of inflammation in the area of ​​limb wounds, if any. Patients of the second group underwent primary osteosynthesis with rod devices in the presence of severe swelling and soft tissue damage, which did not allow primary immersion osteosynthesis. Fixation of fragments in external fixation devices allows to stabilize the fragments, reducing swelling and accelerating the healing of soft tissues, as well as allowing patients to move and care for themselves until the second stage of the operation. The criteria for transition to immersion osteosynthesis were: regression of soft tissue swelling, healing of skin abrasions; absence of infectious complications, satisfactory general condition of the patient according to blood tests and additional examination methods. If these conditions were met, conversion to immersion osteosynthesis with locked rods or plates was performed, depending on the nature and location of the fractures. In the postoperative period, patients in both groups were observed on an outpatient basis until the fractures healed for 1 year, with assessment visits at 6 weeks, 12 weeks, 6 months and a year. The results of treatment of patients with fractures of the long bones of the extremities were assessed using the Outcome Assessment System (OIS) proposed by Luboschitz-Matthys-Schwartzberg, which includes 9 points in scores from 6 months to 1 year after surgery. With an index of 3.5-4.0 points, the treatment result was assessed as good, with an index of 2.5-3.5 points - satisfactory, and with 2.5 points or less - unsatisfactory. When analyzing the results of treatment using the method of conversion osteosynthesis, there was no suppuration of soft tissues in the surgical area in our patients. Statistical processing of the obtained results was carried out using Excel programs. Descriptive statistics methods were used to perform the description. The study complies with the Declaration of Helsinki of the World Medical Association “Ethical principles for conducting scientific medical research involving humans” and the “Rules of clinical practice in the Russian Federation”, approved by Order of the Ministry of Health of the Russian Federation dated June 19, 2003 No. 266. All persons participating in the study gave informed consent to participate in the study.

RESULTS

Summarized data from our own observations are presented in Tables 1 and 2. The majority of patients – 62% – suffered from high-energy trauma: road accident, catatrauma, fall from a height above their own height, which caused multiple injuries and significant soft tissue trauma.

Table 1.
Distribution of patients by location of fractures and time of conversion

Table 2.
Distribution of patients into groups according to fracture location, time of conversion, and mechanism of injury

It is worth noting that, despite the condition of the soft tissues, conversion for femoral fractures, in accordance with the Damage control protocol and the pathogenesis of polytrauma, was carried out within 48-72 hours after the injury, even in the subcompensated condition of the patient. In the long-term postoperative period, 74 patients (70%) were monitored, who were able to conduct the SOI using the scale in face-to-face and correspondence formats. Of these, 56% (41) note a good result (3.5-4 points), 43% (32) – a satisfactory result, 1% – an unsatisfactory result, due to the multiple nature of the fractures and their slow consolidation.

DISCUSSION

An adequate choice of tactics, methods and timing of treatment for patients with long bone fractures, especially with polytrauma, is still a pressing issue for a positive outcome in the treatment of patients [2, 4]. According to Khomints V., Pairon P., final osteosynthesis in the early period of polytrauma led to death, especially with significant thoracic, abdominal and craniocerebral injuries [2, 4]. The death of the victims occurred in the first hours after the injury during these operations or on the 5-7th day from severe complications that developed: adult respiratory distress syndrome, multiple organ failure, pneumonia, sepsis [2]. However, according to N.V. Tishkova, long-term treatment of victims in an external fixation device until the second stage of surgery or as a final method of treatment for victims with fractures of long bones increases the risk of infectious and hypostatic complications, and also leads to great inconvenience during long periods of treatment [27]. Indeed, late conversion over 2 weeks in patients with polytrauma falls into the phase of immunosuppression (days 10-20) and is contraindicated until the immunological status is restored, and in patients with isolated trauma in the absence of systemic effects characteristic of polytrauma, the risk still increases infections, especially when simultaneously replacing a transosseous element with an intramedullary pin. In these cases, a number of researchers and practitioners recommend dismantling the external fixation device, dynamic observation in a plaster cast for a week, and after healing of the wounds from the external fixation device, performing osteosynthesis. However, performing reposition within these periods, as a rule, requires open surgery with wide access and exposure of the fracture zone, which increases the frequency of nonunions, the healing time of fractures, and provokes other complications. The use of the Ilizarov apparatus at the first stage as a final method of osteosynthesis for victims with fractures of long bones due to polytrauma is associated with a complex preparatory stage, lengthening the time of the operation and collection of the structure, which negatively affects the general condition of the patient. The use of the Ilizarov apparatus in patients with isolated fractures is a well-known technique with proven results, however, at the current stage of development of traumatology and orthopedics, the possibility of early rehabilitation, convenience and the absence of an external structure on the limb are much more attractive for the patient, who, in conditions of peacetime trauma, has the right to choose the method of osteosynthesis on the recommendation of a doctor. This study certainly has limitations. This is a prospective analysis of only cases of conversion from external fixation to internal osteosynthesis, excluding open fractures as a class. One of the aspects of the study was the assessment and search for patterns and common features in conversion osteosynthesis as a technique in general, without going into specifics. The absence of a comparison group with conservative treatment and primary osteosynthesis does not allow us to assert the unconditional advantages of conversion osteosynthesis, however, our work confirms the possibility of safe use of conversion in clinical practice. To clarify the timing and details of conversion surgical interventions, in future work it is planned to compare primary methods and add a group of late conversion osteosynthesis. The most controversial issue is the significance of the difference in the incidence of complications between early and late conversion osteosynthesis, as well as the search for optimal time intervals.

Below are 2 clinical observations.

Clinical example No. 1

Patient B., 61 years old (case history No. 10620/18 02/27/2018), was admitted to the A.K. City Clinical Hospital after a street injury. Eramishantsev with a diagnosis of “Closed multi-fragmented fracture of the left tibia and fibula in the lower third with displacement of fragments” (Fig. 1).

Figure 1. Closed comminuted fracture of the left tibia and fibula in the lower third with displacement of fragments. Direct and lateral projections

Upon admission, due to severe swelling of the lower leg and the risk of developing epidermal blisters, an operation was performed for osteosynthesis of fragments using a rod-based external fixation device (lower leg-foot arrangement). Intraoperatively, a satisfactory position of the fragments was achieved simultaneously (Fig. 2, 3). The duration of application of the external fixation device was 27 minutes.

Figure 2. Fixation of a fractured leg bone in an external fixation device

Figure 3. Appearance in external fixation device

The duration of the first stage is 5 days. On the fifth day after regression of the edema, the second stage of sequential osteosynthesis was performed: dismantling the external fixation device and intramedullary osteosynthesis with a plate and screws (Fig. 4).

Figure 4.
External osteosynthesis with plates and screws. Direct and lateral projections

The postoperative period proceeded favorably. Two days after the operation, the patient was actively moving with the help of crutches. The wounds healed by primary intention.

Clinical example No. 2

Patient V., 63 years old (case history No. 1382/19 01/10/2019) was admitted to the A.K. City Clinical Hospital. Eramishantseva 1.5 hours after falling from the sixth floor with the diagnosis: “Polytrauma, closed comminuted fracture of the left femur in the middle-lower third with displacement of fragments. Closed unstable pelvic fracture type B: rupture of the symphysis pubis, bilateral fracture of the sacrum Denis 2. Closed fracture of both calcaneus with displacement of fragments. Closed fracture of the transverse processes of L1, L2 on both sides, L5 on the left. Lung contusion. Traumatic shock grade 2-3, severity of condition on the ISS scale – 41” (Fig. 5).

Figure
5. Closed comminuted fracture of the left femur in the middle-lower third with displacement of fragments (a). Closed fracture of both calcaneal bones with displacement of fragments (b). Closed unstable pelvic fracture type B: rupture of the symphysis pubis, bilateral fracture of the sacrum, closed fracture of the transverse processes of L1, L2 on both sides, L5 on the left (c)

The patient was admitted in an unstable condition; against the background of anti-shock therapy, the hip and pelvis were fixed in an external fixation device (pelvis-femur-tibia arrangement) with a C-frame applied to the posterior parts of the pelvic ring. Intraoperatively, a satisfactory position of the fragments was achieved simultaneously (Fig. 6). The duration of application of the external fixation device was 30 minutes, and the C-frame - 15 minutes. The patient spent 5 days in the intensive care unit, where intensive therapy was performed, and on the 6th day she was transferred to the trauma department.

Figure 6.
Osteosynthesis of the anterior sections of the pelvic ring (a) and femur (b) using a rod-based external fixation device (pelvis-femur-tibia arrangement), application of a C-frame on the posterior sections of the pelvic ring (c)
On the sixth day, the second stage of sequential osteosynthesis was performed: dismantling the external fixation device of the femur-tibia, C-frame and osteosynthesis of the lateral masses of the sacrum on both sides with cannulated screws; closed retrograde blocking intramedullary osteosynthesis of the femur with a nail (Fig. 7).

Figure 7.
Removal of the C-frame and osteosynthesis of the lateral masses of the sacrum on both sides with cannulated screws (a). Dismantling of the femur-tibia external fixation device, closed retrograde locking intramedullary osteosynthesis of the femur with a nail (b)

On the tenth day, the third stage of sequential osteosynthesis was performed, dismantling the external fixation device. Fixation of the symphysis pubis with a plate with screws, osteosynthesis of the calcaneus with cannulated screws (Fig. 8).

Figure 8.
Dismantling the external fixator. Fixation of the symphysis pubis with a plate and screws (a). Osteosynthesis of the calcaneus with cannulated screws (b)

The postoperative period proceeded favorably. The patient was activated within the bed. On the 14th day she was actively moving with the help of crutches, the wounds healed by primary intention.

CONCLUSIONS:

As a result of the analysis, we came to the following conclusions: 1. The method of fixing fractures of long bones with rod-based external fixation devices at the first stage ensures stabilization of fragments and prevention of the development of shock and other post-traumatic complications, as well as secondary damage to blood vessels and nerves. 2. Conversion (transition) of extrafocal external fixation to internal osteosynthesis for patients with polytrauma is preferable within the 3-11th day, strictly limited by the general condition of the patient, as well as the degree of immunosuppression. 3. Conversion (transition) of extrafocal external fixation to internal osteosynthesis for patients with closed fractures and significant soft tissue injury is possible from 5 to 8 days after injury with a minimal threat of inflammatory complications in the postoperative period. 4. Urgent fixation of unstable fractures with rod devices leads to faster relief of soft tissue swelling, which prevents the development of hypostatic complications and creates favorable conditions for care and dynamic monitoring of the condition of soft tissues.

Funding and conflict of interest information

The study had no sponsorship. The authors declare that there are no obvious or potential conflicts of interest related to the publication of this article.

LITERATURE:

1. Yamkovoy AD. Osteosynthesis of fractures of long bones with nails. Abstracts of candidate of medical science. 01/14/15. M., 2017; 3-4. Russian (Yamkova A.D. Osteosynthesis of fractures of long bones of the extremities with nails with plastic: abstract of thesis ... candidate of medical sciences: 01.14.15. M., 2021. P. 3-4) 2. Khominets VV, Belenkiy IG , Kutyanov DI, Pechkurov AL. Management of treatment of fractures of long bones of extremities in patients with polytrauma. MEDLINE.RU. Russian Biomedical Journal

.
(Electronic journal). 2011; 12(2): 631-645. Access mode: https://medline.ru/public/art/tom12/art53.html. Russian (Khominets V.V., Belenkiy I.G., Kutyanov D.I., Pechkurov A.L. Tactics of treatment of fractures of long bones of the extremities in patients with polytraumas //MEDLINE.RU. Russian biomedical journal. (Electronic journal). 2011. T. 12, No. 2. P. 631-645. Access mode: https://medline.ru/public/art/tom12/art53.html) 3. Yamkovoy AD, Zorya VI. The use of intramedullary system fixation for the treatment of shaft fractures of long bones 2014. Priorov Herald of Traumatology and Orthopedics
.
2014; (3): 34-39. Russian (Yamkovoy A.D., Zorya V.I., The use of intramedullary osteosynthesis by a fixation system in the treatment of diaphyseal fractures of long bones 2014 // Bulletin of Traumatology and Orthopedics named after N.N. Priorov. 2014. No. 3. P 34-39) 4. Pairon P, Ossendorf C, Kuhn S, Hofmann A, Rommens PM. Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits. European Journal of Trauma and Emergency Surgery
.
2015; 41(1): 25-38 5. Kavalerskiy GM, Garkavi AV. Classifications of multiple injuries. Features of clinical course and diagnosis. Medicine of Critical Situations.
Disaster Surgery .
M.: Medical Information Agency, 2015; 165-367. Russian (Kavalersky G.M., Garkavi A.V. Classification of polytraumas. Features of clinical course and diagnosis // Medicine of emergency situations. Surgery of disasters. M.: Medical Information Agency, 2015. P. 165-376) 6. Korzh NA, Dedukh N.V. Reparative regeneration of bone: the modern view of the problem. Stages of regeneration. Orthopedics, Traumatology and Prosthetics
.
2006; (1): 77-84. Russian (Korzh N.A., Dedukh N.V. Reparative bone regeneration: a modern view of the problem. Stages of regeneration // Orthopedics, traumatology and prosthetics. 2006. No. 1. P. 77-84) 7. Backus JD, Furman BD , Swimmer T, Kent CL, McNulty AL, Defrate L, et al. Cartilage viability and catabolism in the intact porcine knee following transarticular impact loading with and without articular fracture. J. Orthop.
Res. 2011;
29(4): 501–510 8. Kobbe P, Micansky F, Lichte P, Sellei RM, Pfeifer R, Dombroski D, et al. Increased morbidity and mortality after bilateral femoral shaft fractures: myth or reality in the era of damage control. Injury.
2013;
44(2): 221-225 9. Patka P. Damage control and intramedullary nailing for long bone fractures in polytrauma patients. Injury
.
2017; 48(Suppl 1): S7-S9 10. Monni T, Birkholtz FF, de Lange P, Snyckers CH. Conversion of external fixation to internal fixation in a non-acute, reconstructive setting: a case series. Strategies Trauma Limb Reconstr
.
2013; 8(1): 25-30 11. Harbacheuski R, Fragomen A, Rozbruch S. Does lengthening and then plating (LAP) shorten the duration of external fixation? Clin Orthop Relat Res
.
2012; 470(6): 1771-1781 12. Matsubara H, Shirai T, Watanabe K, Nomura I, Tsuchiya H. Clinical outcomes of conversion surgery from an external fixator to an iodine-supported titanium alloy plate. Journal of Microbial & Biochemical Technology
.
2013; 6(1): 49-53 13. van Dongen TT, Idenburg FJ, Tan EC, Rasmussen TE, Hamming JF, Leenen LP, et al. Combat related vascular injuries: Dutch experiences from a role 2 MTF in Afghanistan .
Injury .
2016; 47(1): 94-98 14. Kataoka Y, Minehara H, Kashimi F, Hanajima T, Yamaya T, Nishimaki H, et al. Treatment combining emergency surgery and intraoperative interventional radiology for severe trauma. Injury
.
2016; 47(1): 59-63 15. Boutefnouchet T, Gregg R, Tidman J, Isaac J, Doughty H. Emergency red cells first: rapid response or speed bump? The evolution of a massive transfusion protocol for trauma in a single UK centre. Injury
.
2015; 46(9): 1772–1778 16. Recknagel S, Bindl R, Wehner T, Göckelmann M, Wehrle E, Gebhard F, et al. Conversion from external fixator to intramedullary nail causes a second hit and impairs fracture healing in a severe trauma model. Journal of Orthopedic Research
.
2013; 31(3): 465–471 17. Pairon P, Ossendorf C, Kuhn S, Hofmann A, Rommens PM. Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits. European Journal of Trauma and Emergency Surgery
.
2015; 41(1): 25-38 18. Matsumura T, Takahashi T, Miyamoto O, Saito T, Kimura A, Takeshita K. Clinical outcome of conversion from external fixation to definitive internal fixation for open fracture of the lower limb. Journal of Orthopedic Science.
2019;
Feb 13. URL: https://www.sciencedirect.com/science/article/pii/S0949265819300429?via%3Dihub 19. Xue XH, Yan SG, Cai XZ, Shi MM, Lin T. Intramedullary nailing versus plating for extra- articular distal tibial metaphyseal fracture: a systematic review and meta-analysis. Injury
.
2013; 45(4): 667-676 20. Bertrand ML, Andrés-Cano P, Pascual-López FJ. Periarticular fractures of the knee in polytrauma patients. O pen orthopedics journal
.
2015; 9: 332–346 21. Bhandari M, Zlowodzki M, Tornetta P3rd, Schmidt A, Templeman DC. Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma
.
2005; 19(2): 140–144 22. Nicholas B, Toth L, van Wessem K, Evans J, Enninghorst N, Balogh ZJ. Borderline femur fracture patients: early total care or damage control orthopedics? ANZ J Surg
.
2011; 81(3): 148–153 23. Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Annals of Surgery
.
2007; 246(3): 491-499 24. Traumatic disease and its complications. Edited by Seleznev SA. St. Petersburg: Polytekhnika, 2004. 414 p. Russian (Traumatic disease and its complications /under the general editorship of S.A. Seleznev. St. Petersburg: Politekhnika, 2004. 414 p.) 25. Testa G, Aloj D, Ghirri A, Petruccelli E, Pavone V, Massé A, et al. Treatment of femoral shaft fractures with monoaxial external fixation in polytrauma patients. F1000Research
.
2017; 6: 1333 26. Samusenko DV, Karasev AG, Martel II, Shvedov VV, Boychuk SP. Ilizarov's method in staged management of associated injury and multiple fractures. Polytrauma.
2014;
(1): 44-49. Russian (Samusenko D.V., Karasev A.G., Martel I.I., Shvedov V.V., Boychuk S.P. Ilizarov method in a staged collision with combined trauma and multiple fractures //Polytrauma. 2014. No. 1 pp. 44-49) 27. Tishkov NV, Danilov DG, Ochirov IA. Purulent complications in treatment of fractures of lower extremities with use of transosseous fixation techniques. Acta Biomedica Scientifica
. 2007; 4(56); 175-176. Russian (Tishkov N.V., Danilov D.G., Ochirov I.A. Purulent complications in the treatment of fractures of the lower extremities using transosseous osteosynthesis //Acta Biomedica Scientifica. 2007. No. S4(56). P. 175-176)

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Indications and contraindications

In the structure of injuries of the proximal zone of the femur by type of fracture, as much as 55% are lesions of the neck, and they occur mainly against the background of age-related osteoporosis. For comparison, in approximately 40% of cases the integrity of the trochanteric region is affected and in only 5% the subtrochanteric region is affected. PSB is intra-articular and therefore requires urgent early treatment. In 99.99% of cases, it cannot heal on its own, without high-precision reposition, which almost always serves as a reason for surgical intervention. The absolute indications for surgical reposition are:

• identified displacements of bone fragments of the femur, even minor ones;
• the presence of a comminuted type of fracture (more than 2 fragments are determined);
• vertical line fault;
• combined form of injury, for example, in combination with dislocation;
• improper bone fusion, developing pseudarthrosis after unsuccessful conservative or surgical therapy.

Bilateral osteosynthesis.

Like any orthopedic operation, osteosynthesis has contraindications. This is a complex and traumatic intervention, often involving opening of the joint and extensive blood loss. It is contraindicated in conditions such as:

• poor general health of the patient;
• coma, shock;
• severe diabetes mellitus;
• active form of tuberculosis;
• acute infectious pathologies;
• infections, suppuration, inflammation of the skin, soft and bone tissues in the affected area;
• severe diseases of the respiratory system, heart;
• severe thrombophlebitis of the lower extremities;
• intolerance to general anesthesia;
• serious mental disorders;
• the function of the hematopoietic system is severely impaired, coagulopathy;
• patient age >70 years (requires endoprosthetics);
• subcapital fracture, that is, the lesion is localized near the head (similarly, installation of an endoprosthesis is required).

Where is bone osteosynthesis performed?

If you have indications for osteosynthesis, it is important to understand that such a complex operation should be entrusted to experienced and qualified professionals. When you make an appointment at the Central Clinical Hospital of the Russian Academy of Sciences in Moscow, take the available examination results with you, or our doctors will refer you for an X-ray or tomographic examination directly in our clinic.

In situations of any complexity and urgency, we will come to the rescue, perform osteosynthesis and reposition bone fragments in case of fractures in order to restore the integrity and functionality of the limb.

Osteosynthesis for neck fracture

In case of PSB, internal (submersible) osteosynthesis is mainly performed. That is, a special fixing structure is connected directly to the bone structures after surgical exposure of the fracture site. In orthopedics, two types of internal connection of reduced fragments are used:

• intramedullary (intraosseous);
• extramedullary (on-bone).

Types of fractures.

The choice of fastening method depends on the nature and complexity of the damage. Sometimes combined osteosynthesis is performed during one surgical session. Regardless of the tactics used, the primary task of each of them is to ensure strong, close and immobilized contact of wound surfaces docked in an anatomically correct position.

Internal structures are made of special corrosion-resistant, biocompatible metal alloys based on steel or titanium. When producing the appropriate devices, their compatibility with the architectonics of the bones of the hip joint is taken into account.

How is osteosynthesis performed?

At the clinic of the Central Clinical Hospital of the Russian Academy of Sciences, surgeons use devices (screws, nails, plates, knitting needles, pins) made of chemically inert and biologically compatible materials to reposition bones. Thus, products made from alloys of titanium, chromium, nickel and cobalt have proven themselves well in fixing bones during fractures.

Such an approach to the selection of material for the reposition of bone fragments in case of a bone fracture not only ensures the effectiveness of the result, but in some cases does not even require removal of the metal structure if osteosynthesis was performed in a typical place using the submersible method.

Intramedullary method

With the intramedullary technique, the distal and proximal fragments are connected with special rods or pins passed through the medullary canal of each of them. Today, the advantage is on the side of blocking type endosystems. At their opposite ends there are ready-made holes for screws or peculiar bends that increase the degree of stabilization of the system. Intramedullary devices, which can be rigid or semi-elastic, can even fix multiple fragments.

Intramedullary.

The introduction of a rod/pin into the diaphysis can be done either after preliminary preparation of the canal by drilling it out, or without perforation. All intraosseous structures must be removed, which means another intervention after complete bone fusion. The repeated procedure for removing the fixators in most cases does not involve intra- and postoperative difficulties.

Complications after osteosynthesis

After performing open osteosynthesis, the following pathologies may appear:

• Embolism.
• Osteomyelitis.
• Infectious infection.
• Arthritis.
• Internal bleeding.

To avoid complications, the specialist prescribes antibiotics and medications that prevent the formation of blood clots. If there is pain, swelling, bleeding or elevated body temperature, you should immediately consult your doctor.

Extramedullary method

Extramedullary technology is the application of plates with screws, cerclage sutures made of wire material or rings on the bone. The fixing element will be located outside the medullary canal. Models of modern designs are represented by a varied assortment (L-shaped plates, plates with a three-blade nail, etc.). Bony-type implants, if we are not talking about wire sutures and the installation of rings, for the most part do not require the use of additional external fixation (plastering) of the limb.

Extramedullary.

To create a “ligament” with the extramedullary plate, the affected segment is first exposed. The neck fragments are then placed in the correct position, ensuring that the adjacent ends match exactly. Afterwards, the plate is tried on, and then it is placed on top of the bone and pressed with a bone holder. Through its holes, screws are screwed into the cortical layer of each fragment one by one. The threaded part is screwed into the end point only after bone compression has been performed using a special device.

Preoperative preparation and anesthesia

The preparatory stage before the procedure includes a number of laboratory and hardware tests and medical consultations that will allow the specialist to:

• choose the optimal surgical tactics, determine the type and dose of anesthesia;
• diagnose concomitant pathologies and at the same time take all necessary preventive measures (if there are absolute contraindications for the patient, another treatment benefit is selected);
• think in advance about a rehabilitation treatment strategy, taking into account the nature of the injury and the chosen operation, the person’s health status and age characteristics;
• find out whether the patient is psychologically ready to undergo a complex procedure and an equally simple postoperative recovery.

The period of preparation for this pathology should take place according to an accelerated program. It is necessary to operate on the patient as quickly as possible, while the injury is still “fresh”. Preoperative examination:

• X-ray of the affected area in several projections (CT, MRI is required in exceptional cases);
• biochemical blood test (including group and Rh factor, sugar level);
• hemostasiogram (blood clotting is checked);
• general clinical analysis of urine, feces;
• tests for anesthetic drugs;
• electrocardiography;
• fluorography (if not done during the current year);
• digital densitometry (a procedure to determine the degree of osteoporosis)
• examination by some highly specialized doctors (generalist, cardiologist, anesthesiologist, etc.).

Before the surgical session, the intestines are thoroughly cleansed, an antibiotic is injected and taken to the operating room. The patient is put under anesthesia on the operating table. The procedure mainly takes place under general endotracheal anesthesia with the use of muscle relaxants and artificial ventilation. The use of epidural anesthesia is quite acceptable, but it is rarely used. Conducting catheterization of the epidural space in elderly people, whose spine is significantly degenerated due to age, is very problematic and unsafe.

External transosseous osteosynthesis technique

An operation using a guide apparatus prevents the penetration of bone fragments into the tissue and does not impair the functioning of the joint. This allows you to speed up the restoration of cartilage and bones in the affected area. This operation is recommended for open fractures of the humerus and tibia, as well as for closed fractures of the tibia.

Note! The operation must be performed by an experienced expert, since different types of needles are used and it is necessary to correctly calculate the trajectory of movements and determine the design features of the device. Moreover, all calculations are made during surgery, so you need to act within a narrow time frame. A successful operation allows the patient to rehabilitate in just 20-25 days.

Intraoperative process

Let us briefly consider the features of open surgery. The entire surgical session takes place under operational X-ray control in the axial and anteroposterior projection.

1. A tourniquet is applied to the limb to avoid excessive blood loss. The skin is extensively treated with an antiseptic solution.
2. In the projection of the injured area, a linear incision of the soft tissue structures is made with a scalpel. The skin and tendon-muscle tissues entering the field of surgical access are dissected layer by layer. The length of the cut is approximately 10-15 cm.
3. The dissected soft tissues are separated and pulled apart, and the fracture site is exposed. The fragments are released and tightly aligned with each other in a perfectly aligned position.
4. The next stage is the correct installation of the selected retainer according to the planned implementation technique.
5. At the last stage of the session, the operated field is thoroughly disinfected, the wound is drained and sutured layer by layer.
6. If the implemented tactics of metal osteosynthesis include plaster immobilization, a plaster cast is applied to the leg.

An intensive course of antibiotic therapy must be prescribed immediately after surgery, since biological structures have been subjected to large-scale and deep invasion. The doctor also prescribes medications for pain and to improve the venous-vascular system. It is necessary to activate the patient at the earliest postoperative stages in order to avoid the development of serious congestion and atrophic phenomena in the body. Surgical sutures are removed after approximately 12 days.

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Poltavsky Dmitry Ilyich

Traumatologist-orthopedist

Experience 28 years

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Zubikov Vladimir Sergeevich

Traumatologist-orthopedist, Doctor of Medical Sciences, doctor of the highest category, professor

44 years of experience

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Marina Vitaly Semenovich

Traumatologist-orthopedist, head of the minimally invasive traumatology and orthopedics service

Experience 36 years

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Samilenko Igor Grigorievich

Traumatologist - orthopedist, doctor of the highest category

24 years of experience

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Complications and rehabilitation

It is known that the first osteosynthesis in Russia was performed back in 1805 by orthopedic surgeon E.O. Mukhin. This year marked the beginning of a more in-depth study of the method, improving surgical techniques, discovering new inventions for fixation, and modernizing old orthopedic structures. Many years of work by more than one generation of specialists, including the present, are devoted to the issue of increasing the efficiency of the operation and reducing the high number of unfavorable outcomes.

However, unfortunately, too high a percentage of unsatisfactory results still remains a relevant and serious problem, just as it was more than 200 years ago. The most common complications of osteosynthesis performed on the cervical part of the femur are:

• non-union of bone fragments;
• aseptic necrosis of the hip head;
• infection, abscess of the wound area;
• instability of fixation, separation of fragments;
• formation of a false joint;
• internal hemorrhage;
• osteomyelitis of the femur;
• congestive pneumonia, embolism;
• deep vein thrombosis of the limb;
• arthritis, arthrosis of the hip joint.

It is extremely important to minimize the risks of life-threatening and disability-threatening consequences and strictly adhere to the rehabilitation plan. The recovery program is prescribed by the surgeon and physical rehabilitation doctor. Specialists prescribe to their clients:

• physical therapy, consisting of passive and active exercises, training on simulators to increase the tone of the muscles of the limb and all parts of the musculoskeletal system;
• orthopedic regimen (gentle load on the sore leg, limitation of certain types of movements, movement on crutches, etc.);
• breathing exercises to normalize and support the lungs;
• physiotherapy (electrophoresis, ultrasound, magnetic therapy, etc.);
• medicinal baths based on brine, hydrogen sulfide, pine needles, etc.;
• paraffin wraps;
• massage to improve local blood flow and lymph outflow, against edema, bedsores and pulmonary congestion;
• swimming in the pool, aqua gymnastics, etc.

Full recovery takes approximately 12 months. It is by this time that the processes of regeneration and repair of bone tissue can be considered completely completed.

Technique of transosseous osteosynthesis

The method is suitable for helical fractures.
Screws and bolts are inserted into the body of the tubular bone in a transverse direction. Particular attention is paid to the size of the screws so that they protrude slightly beyond the bone tissue. In this case, the screw head strongly presses the injured bones, which has a positive effect on regeneration. If a sharp fracture line is clearly visible on the x-ray, it is recommended to use a round wire to tightly fasten the fragments. The surgeon carefully drills holes with a minimum diameter according to the markings, through which he pulls the wire. Removal of the wire is carried out immediately after the start of fusion (otherwise atrophic processes may start).