There are contraindications. Specialist consultation is required.
Advantages Indications Contraindications Preparation Progress of the operation Rehabilitation
Osteosynthesis of the bones of the lower leg is a surgical operation that is performed for the purpose of repositioning (restoring in its place) and reliable fixation of bone fragments that were obtained as a result of injury to the tibia or fibula. The main goal of the procedure is to create the most physiological conditions possible for the bones to heal in their correct anatomical position. Such a radical intervention as osteosynthesis of the tibia is not recommended for all patients with fractures, but only for those in whom conservative measures have not yielded results or are inappropriate based on diagnostic results (union is impossible with casting).
For the most correct connection of bone fragments, surgeons can use frame structures or use only certain fixation options. The selection of specific devices will depend on the size of the injury, the nature of the injuries sustained and the location of the fracture, age, and additional conditions.
Advantages of tibial osteosynthesis surgery
The main advantage of such an intervention is the ability to create conditions for the fastest, full healing of a fractured leg bone. This is realized due to two conditions. The first is the reliable and most accurate fixation of all bone fragments in their places. The second is the process of early restoration of tissue functions with improved blood flow and acceleration of the regeneration process. Through the use of various structures, the bones are reliably connected, while the limb remains mobile.
Such operations are performed for complex fractures - if both bones are damaged at the same time. In addition, osteosynthesis of the left or right tibia may be recommended if the ankle area is involved in the process, if fragments are displaced and surrounding tissues are injured.
2.The essence of the method
Osteosynthesis refers to operative, surgical methods of treatment.
The primary tasks are antiseptic treatment, restoration of tissue integrity (including soft periosteal tissue, which is very important), but the main thing is reposition of bone segments and fragments, i.e. ensuring the relative spatial arrangement of bones and joints, which is provided for by the normal anatomy of the human body. In many cases, it is completely impossible to do this from the outside (for example, by repositioning and applying a plaster cast), just as it is impossible to ensure a stable, reliable, mechanically stable junction of separated segments - without which, in turn, the bones will either heal incorrectly or not heal at all. For the purpose of fixation, all kinds of artificial devices are used, the temporary implantation of which forms the fundamental basis of the osteosynthetic method. To date, a variety of designs have been developed - knitting needles, intraosseous pins, nails, screws, plates, screws, etc.
Such fixatives remain in the patient’s body for several months, sometimes up to a year or more, therefore, taking into account the risk of rejection, suppuration, and tissue degeneration, they must be made from structural materials with the properties of maximum biological inertness. Today these are mainly metal alloys (stainless steel, chromium, nickel, cobalt, titanium, molybdenum), but over time, in all likelihood, synthetic materials will be introduced, with properties approaching the characteristics of living tissues and therefore “invisible” to the immune system. systems, however, are much more durable.
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Indications for tibial osteosynthesis
Before the operation, the doctor determines the indications for osteosynthesis of the shin bones or ankle joint. Key indications include:
- the presence of compartment syndrome, severe tissue compression due to damage;
- damage to nerve trunks or vascular bundles;
- open fracture of 2-3 degrees with complications;
- diaphyseal fracture in patients with polytrauma, which requires active treatment;
- the presence of an unstable fracture, where there is displacement of bone fragments, and they are displaced by more than ½ the width of the diaphyseal part;
- unstable fracture, in which there is damage to the muscles or tendons by bone fragments or an affected bone fragment;
- there is a shortening of more than 1 cm in the area of the fracture line;
- segmental fracture;
- a fracture initially treated conservatively with secondary displacement;
- fracture of the tibia only, but with a varus deformity that exceeds 10 degrees;
- ipsilateral fracture with damage to the ligamentous apparatus in the knee joint;
- a short oblique fracture, which has a fragmentary-rotational nature, and the sharp part of the bone is displaced dorsally.
Additionally, there are a number of indications for the use of percutaneous osteosynthesis using hardware structures. They are determined by a doctor based on an analysis of numerous factors and conditions. First of all, this is the nature of the fracture. If this is an uncomplicated fracture (non-fragmented), closed reduction (with plaster casting) or screw osteosynthesis or submersible (simple type) is used. If it is a comminuted fracture that cannot be resolved by repositioning with plaster, percutaneous fixation using devices is possible.
Depending on the location of the fracture, various designs are used - osteosynthesis of the tibia with a plate, rod or pin.
During osteosynthesis, the condition of the skin over the fracture site is important. If there is dermatitis or suppuration, osteosynthesis may be prohibited.
Types of fasteners
The types of fixators are selected individually, the choice depends on the type of operation - plates, beams, screws, nails, knitting needles, screws. In most cases, bone plates and internal rods or implants are used to provide dynamic and static osteosynthesis.
Submersible intraosseous osteosynthesis is performed using implants made of chemically inert materials, including nickel, chromium, cobalt, and titanium. Alloys made from them do not cause metallosis, a phenomenon in which cells in contact with a foreign body absorb its particles and die. Osteosynthesis with a rod does not always require removal of the implant after bone fusion, since it is compatible with organic tissues and can coexist with them for decades.
One type of operation is called locking osteosynthesis and is performed with special locking pins. They have holes at both ends that are used to insert screws through the bone. Each tubular bone has its own pin:
- tibial;
- long and short trochanteric;
- proximal and universal brachial;
- femoral for pertrochanteric installation, etc.
The advantage of locking pins is their thickness; in most cases, it is narrower than the bone marrow canal, which eliminates the need to enlarge the canal by drilling and allows maintaining bone circulation.
Extramedullary reduction is performed using plates of different shapes and thicknesses, secured to the bone with screws. Most often they are equipped with removable and non-removable bringing together mechanisms. For helical and oblique fractures, wire, rings and half-rings made of stainless steel, and tape are used. For internal osteosynthesis, if special heavy-duty fixators are not used, plaster immobilization is recommended.
The cortical type of operation is performed using screws or beams - Klimov T-beam, Vorontsov angular beam, Tkachenko self-fixing beam, screws for compact and cancellous bone tissue.
For external osteosynthesis, distraction-compression devices are used that are fixed from the outside. Knitting needles or rods are inserted through the skin into the bone, and the other end is fixed to the external frame. There are several types of devices (circular, semi-circular, sector, combined, etc.). Frequently used designs were proposed by Sinilo, Sivash, Demyanov, Ilizarov (applicable on tubular bones); for intra-articular fractures there is a special design by Volkov and Oganesyan. Rod devices are very popular due to their compactness and more effective fixation.
Contraindications
There are a number of contraindications for performing external osteosynthesis of the tibia or its other variants. These include:
- severe lesions, disorders of the nervous system;
- severe damage to the surrounding tissues of the leg;
- osteoporosis;
- infectious diseases, fever, intoxication;
- immunodeficiency states;
- allergy to anesthetics;
- exacerbation of any chronic pathologies.
The doctor may determine other temporary or permanent contraindications that will limit the intervention.
Rehabilitation after osteosynthesis
The recovery course for the patient is selected by a traumatologist taking into account the individual characteristics of the body and, as a rule, includes:
- drug treatment to accelerate bone regeneration and eliminate swelling;
- massage to improve local blood circulation and prevent bedsores;
- Exercise therapy to restore normal mobility;
- physiotherapeutic procedures;
- in some cases, anticoagulants (drugs that reduce blood clotting) are prescribed.
The duration of wearing fixing devices is determined individually and, as a rule, ranges from 3 to 12 months. A planned operation is performed to remove metal structures.
How is the operation performed?
When it comes to a tibia fracture, specialists most often use the technique of intramedullary osteosynthesis, which involves drilling the bone marrow canal or without drilling. The latter method helps to minimize tissue trauma during surgery, which is important against the background of severe injuries or the threat of shock. But osteosynthesis with reaming helps to ensure a tight fit of all fixed fragments, which is especially important in the presence of a pseudarthrosis.
For open fractures, the technique of compression-distraction transosseous intervention is used. But subsequently it is necessary to walk with the device for a certain time. After healing, the device is removed and intramedullary osteosynthesis is performed. For complicated fractures, a periosteal osteosynthesis procedure is performed.
Osteosynthesis for different types of fractures
The choice of technique and fixation depends on the location and type of injured bone, as well as the complexity of the injury. Let's look at the common options:
- femur - intramedullary osteosynthesis is used most often, it is relevant for older people, since a fracture of the femur is one of the most difficult and accompanied by complications, surgery is prescribed in a higher percentage of cases;
- lower leg - intraosseous type of operation (the exception is an open fracture - a transosseous method is used);
- humerus - the method is used in the absence of other fixation options; intraosseous implantation or fastening with metal fixators of various types is possible; complex open fractures must be fixed using a device;
- ankles - used in difficult cases (some fractures can be treated in other ways), for example, with bimalleolar and trimalleolar fractures;
- clavicle - fixation with plates, knitting needles, heteropins; for false joints, intraosseous fixation is indicated.
Rehabilitation period
After surgery, it is important to strictly follow all doctor’s recommendations for rehabilitation. This is important for normalizing blood circulation, which speeds up healing and reduces the risk of secondary complications. Physiotherapy, exercise therapy, and sets of special gymnastics exercises are indicated to prevent joint contractures and weakening of muscle tone. In addition, early activity prevents congestive pneumonia and thrombosis.
Massage courses that are carried out at certain stages of rehabilitation are useful. During treatment, it is necessary to take control images that allow you to evaluate the dynamics of bone restoration.
Our clinic performs osteosynthesis of the lower leg and you can find out the price of the operation from the doctor at a preliminary consultation. Doctors at the clinic carry out various types of interventions, even in complex cases. It is important not to delay your visit if you need surgery. In addition, in our clinic you can undergo preliminary examination, preparation for surgery and post-operative rehabilitation.
1.General information
The term “osteosynthesis” literally translated from ancient Greek means the joining of bones; In English-speaking medicine, the synonym “internal fixation” is also common, which also quite accurately reflects the essence of this methodological direction in traumatological and orthopedic surgery.
Archaeological finds indicate that the first attempts to fix bones “from the inside” were made many centuries ago, in particular by healers of Central American cultures, and there is reason to believe that at least some such interventions were performed long before the patient’s death, i.e. . were carried out quite competently, ensuring intravital fusion and healing of fractures. The modern scientific paradigm of osteosynthesis dates its history only from about the middle of the 19th century. At the same time, by the turn of the 20th-21st centuries, this medical methodology was already so developed in all respects (theoretical, technical, technological, rehabilitation, etc.) that it confidently became the dominant or, as they say in medicine, the gold standard for the treatment of complex fractures. In this regard, it is necessary to note the generally recognized contribution of the Soviet and then Russian school to the development of the theory and practice of osteosynthesis (G.A. Ilizarov, M.V. Volkov, O.N. Gudushauri and many others).
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When a bone breaks, osteosynthesis is one of the methods, and most often the only one, for installing and long-term holding of fragments and splinters in the correct position. Osteosynthesis is a surgical procedure during which bone fragments are fixed with special devices.
At the beginning of the last century, doctors relied primarily on fixative bandages, most often plaster, to hold bones in place until fractures healed. Such methods very often led to unsatisfactory results, were extremely inconvenient for the patient, and took him out of active life for a long time. With this non-surgical method of treatment, fracture fusion disorders, or fusion with displacement of fragments with the development of various deformities and contractures of long-term immobilized joints, were often observed.
However, the progress of medicine, the invention of new materials, and the improvement of methods of fighting infections have allowed doctors to perform operations directly on bones, restore their anatomy and ultimately achieve better functional results.
The materials currently used for the production of metal structures are special alloys of stainless steel and titanium, which have sufficient strength and flexibility necessary to fix bone fragments until they are completely fused.
These devices are inert in relation to the internal environment of the body, and in extremely rare cases they cause an allergic reaction or rejection. The global trend is the most widespread introduction and use of internal (submersible) osteosynthesis. Such osteosynthesis is characterized by the introduction of an implant directly into the fracture area and is located either inside the bone or on its surface.
In recent years, minimally invasive surgical techniques have become widespread, when during the procedure a closed installation (reposition) of bones and fragments is performed in the correct position, and their connection is carried out by introducing a metal structure through small punctures of the skin. Thus, the integrity and relationship of soft tissues is not compromised, earlier recovery from injury is achieved, the length of stay in the hospital is reduced, and the risk of complications is reduced.
Currently, the industry produces specially designed metal structures for fractures of various types and locations, which somewhat simplifies the process of their implantation. The most commonly used types of metalwork today are screws, spokes, plates and rods. Only a specialist doctor can select the optimal type.
In recent years, the “gold standard” in the treatment of fractures of long tubular bones has been the use of intraosseous (intramedullary) osteosynthesis with rods. Fractures located near the joint are most often fixed using plates, screws and wires. After consolidation of the fracture, the implanted metal structures can be removed.