Intraosseous (intramedullary) osteosynthesis is performed using a pin that is inserted into the injured bone. This method is used to restore long tubular bones: the femur and tibia, collarbone, shoulder and forearm.
Modern pins are made from materials that are inert to bone tissue. These are special alloys that contain titanium, nickel, chromium, and cobalt. They do not affect bone tissue in any way; their microparticles are not absorbed by the body. Therefore, in many cases, it is possible not to remove the implanted pin after the fracture has completely healed.
Indications for osteosynthesis of hand bones
- A fracture that heals very slowly during standard therapeutic treatment.
- A fracture resulting in damage to the joint tissue.
- Fractures with displacement and divergence of bone fragments.
- A fracture in which there is a possibility of displacement, divergence of bone fragments or perforation of the skin.
- A fracture that has not healed properly.
- Presence of false joints.
In practice, osteosynthesis can be used for fractures of any bones:
- In maxillofacial surgery to correct facial deformities
- For fractures of the lower bones of the lower extremities and the hip joint (thigh, tibia, ankle)
- For fractures of the upper extremities (radius, humerus, forearm)
- In microsurgery, for example, osteosynthesis of hand bones (wrist, finger phalanges)
Osteosynthesis using high-tech modern treatment methods
Osteosynthesis
- connection of bone fragments. The purpose of osteosynthesis is to ensure strong fixation of the juxtaposed fragments until their complete fusion.
Modern high-tech methods of osteosynthesis require a thorough preoperative examination of the patient, a 3D tomographic examination for intra-articular fractures, clear planning of the course of surgical intervention, image intensifier technology during the operation, the availability of sets of tools for installing fixators, the ability to select a fixator in a size range, appropriate training of the operating surgeon and the entire operating team.
There are two main types of osteosynthesis:
1)
Internal (immersion) osteosynthesis
is a method of treating fractures using various implants that fix bone fragments inside the patient’s body.
Implants are pins, plates, screws, knitting needles, and wire. 2) External (transosseous) osteosynthesis
, when bone fragments are connected using distraction-compression external fixation devices (the most common of which is the Ilizarov apparatus).
Indications
Absolute indications for osteosynthesis are fractures that do not heal without surgical fastening of the fragments, for example, fractures of the olecranon and patella with divergence of fragments, some types of fractures of the femoral neck; intra-articular fractures (condyles of the femur and tibia, distal metaepiphysis of the humerus, radius) fractures in which there is a danger of perforation by a bone fragment of the skin, i.e. transformation of a closed fracture into an open one; fractures accompanied by interposition of soft tissue between fragments or complicated by damage to a great vessel or nerve.
Relative indications include the impossibility of closed reposition of fragments, secondary displacement of fragments during conservative treatment, slowly healing and non-union of fractures, and false joints.
Contraindications to immersion osteosynthesis are open fractures of limb bones with a large area of damage or contamination of soft tissues, local or general infectious process, general serious condition, severe concomitant diseases of internal organs, severe osteoporosis, decompensated vascular insufficiency of the limbs.
Osteosynthesis using pins (rods)
This type of surgical treatment is also called intraosseous or intramedullary. In this case, the pins are inserted into the internal cavity of the bone (marrow cavity) of long tubular bones, namely their long part - the diaphysis. It provides strong fixation of fragments.
The advantage of intramedullary osteosynthesis with pins is its minimal trauma and the ability to load a broken limb within a few days after surgical treatment. Non-locking pins, which are rounded rods, are used. They are inserted into the medullary cavity and jammed there. This technique is possible for transverse fractures of the femur, tibia and humerus, which have a bone marrow cavity of a sufficiently large diameter. If more durable fixation of fragments is necessary, drilling of the spinal cavity using special drills is used. The drilled spinal canal should be 1 mm narrower than the diameter of the pin in order for it to be firmly jammed.
To increase the fixation strength, special locking pins are used, which are equipped with holes at the upper and lower ends. Screws are inserted through these holes and pass through the bone. This type of osteosynthesis is called blocked intramedullary osteosynthesis (BIOS). Today, there are many different pin options for each long bone (proximal humeral pin, universal humeral pin for retrograde and antegrade placement, femoral pin for pertrochanteric placement, long trochanteric pin, short trochanteric pin, tibial pin).
Self-locking intramedullary pins of the Fixion system are also used, the use of which makes it possible to minimize the time of surgical intervention.
Using locking screws, a strong fixation of the pin is achieved in the areas of the bone above and below the fracture. Fixed fragments will not be able to shift along their length or rotate around their axis. Such pins can also be used for fractures near the end portion of long bones and even for comminuted fractures. For these cases, pins of a special design are made. In addition, the locking pins can be narrower than the medullary canal, which does not require drilling out the medullary canal and helps preserve intraosseous blood circulation.
In most cases, blocked intramedullary osteosynthesis (BIOS) is so stable that patients are allowed dosed loads on the damaged limb the very next day after surgery. Moreover, such a load stimulates the formation of callus and fracture healing. BIOS is the method of choice for fractures of the diaphysis of long tubular bones, especially the femur and tibia, since on the one hand it least disrupts the blood supply to the bone, and on the other hand it optimally accepts the axial load and allows you to reduce the time of using a cane and crutches.
Overbone osteosynthesis with plates
Bone osteosynthesis is performed using plates of various lengths, widths, shapes and thicknesses, in which holes are made. Through the holes, the plate is connected to the bone using screws.
The latest advances in bone osteosynthesis are angular stable plates and now polyaxial stable plates (LCP). In addition to the threads on the screw, with which it is screwed into the bone and fixed in it, there are threads in the holes of the plate and in the screw head, due to which the head of each screw is firmly fixed in the plate. This method of fixing screws in the plate significantly increases the stability of osteosynthesis.
Plates with angular stability were created for each of the segments of all long tubular bones, having a shape corresponding to the shape and surface of the segment. The presence of pre-bending of the plates provides significant assistance in repositioning the fracture.
Transosseous osteosynthesis with external fixation devices
A special place is occupied by external transosseous osteosynthesis, which is performed using distraction-compression devices. This method of osteosynthesis is most often used without exposing the fracture zone and makes it possible to perform reposition and stable fixation of fragments. The essence of the method is to pass wires or rods through the bone, which are fixed above the surface of the skin in an external fixation device. There are different types of devices (monolateral, bilateral, sector, semicircular, circular and combined).
Currently, preference is increasingly being given to rod-based external fixation devices, as they are the least massive and provide the greatest rigidity of fixation of bone fragments.
External fixation devices are indispensable in the treatment of complex high-energy trauma (for example, gunshot or mine explosion), accompanied by massive defects of bone and soft tissue, with preserved peripheral blood supply to the limb.
Our clinic provides:
- stable osteosynthesis (intramedullary, extraosseous, transosseous) of long tubular bones - shoulder, forearm, femur, tibia;
- stable osteosynthesis of intra-articular fractures (shoulder, elbow, wrist, hip, knee, ankle joints);
- osteosynthesis of hand and foot bones.
Contraindications
It is impossible to perform osteosynthesis of the hand and other joints:
- If the area of damage with an open fracture is too large;
- If the open fracture wound is dirty or infected.
- If the patient has a history of epileptic seizures.
- If there are vascular pathologies of the extremities.
To make sure there are no hidden contraindications, as well as to choose the most effective method for reconstructing the bones of the hand, the doctor may prescribe additional examinations: ultrasound, x-ray, three-dimensional tomography.
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.
Types of intraosseous osteosynthesis
This type of treatment for bone fractures can be performed in different ways:
- Open. Full access to the injured bone is provided, after which direct reduction and insertion of a pin into the medullary cavity are performed.
- Closed. Bone repositioning is performed without direct access to the injury site, after which the pin is installed under X-ray television control. The pin is inserted through a hole in the proximal or distal fragment.
- Half open. It is used in cases where there are fragments at the fracture site and interposition of soft tissues has occurred. A micro-incision is made just above the fracture site to perform reduction, and a pin is inserted into the bone outside this area.
The method of performing osteosynthesis surgery is selected strictly individually, depending on the nature of the injury.
Kinds
Osteosynthesis of hand bones can be performed in two ways:
- Submersible - in this case, metal elements come into contact with bone fragments and fix them directly in the fracture zone.
- External – variations on the Ilizarov, Obukhov, etc. apparatus can be used to fix bone fragments. There is no direct effect on the bone.
In turn, for immersion osteosynthesis, the generally accepted classification is based on the method of localization of the metal structure: intraosseous and onlay.
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.
Prognosis and rehabilitation after surgical treatment
To monitor healing, patients undergo radiography, CT, etc. Typically, the healing time is 4-6 months, regardless of the area of the fracture and the type of fixation. After 1-1.5 years, patients return to the doctor to remove the metal structure. However, this is not necessary, you can live with it - titanium does not enter into any reactions with tissues and does not oxidize. The plate may cause subtle discomfort, which people gradually get used to if they do not want to have to have their shoulder re-operated.
In the first week after surgery, there is pain, which can be relieved with painkillers, swelling of the arm, and body temperature may rise. After about 12-14 days, the stitches are removed. In the postoperative period, it is recommended to develop the shoulder, even through pain.
Patients are prescribed physical therapy aimed at accelerating regeneration, resolving compactions, and preventing the formation of keloid scars. For this purpose, laser physiotherapy is performed.
Another recovery technique is exercise therapy. Exercises are prescribed individually to restore mobility to the elbow joint. This is necessary because the joint loses flexibility very quickly when immobilized for a long time. And after surgery, sometimes the limb is immobilized for 2 months. It is not necessary to visit the exercise therapy room all the time. After 2-3 lessons with a trainer, you can master the technique of doing the exercises and do them at home.
The discomfort will persist for about six months. The joint will not fully extend, the scar will be compacted and red. Patients also note morning stiffness in the joint, pain when leaning on the elbow, and arm weakness. Gradually all this will pass, and the scar will turn white and become soft.