Extracortical (extracortical) osteosynthesis is an operation to restore the integrity of the bone after a fracture by applying a specially selected plate to it. Performed in an open manner. Modern plates make it possible to securely fix parts of the bone by blocking the screw heads in the holes, which are inserted into the bone fragments.
Indications for this type of surgery for fractures may include bone fragments that cannot be reduced using a closed method, the presence of one or more bone fragments, or fractures involving joints (intra-articular fractures).
The advantages of osteosynthesis, or why you should choose this treatment method?
- The “osteosynthesis” operation helps to avoid traction and wearing external fixation structures, for example, the Ilizarov apparatus.
- Osteosynthesis ensures proper healing of the fracture zone. Even if a comminuted fracture occurs, during the operation the fragments will be accurately compared and fixed in the correct position.
- With the help of bone osteosynthesis, old, pathological, and improperly healed fractures can be corrected.
- Already 2 days after osteosynthesis, you can put a load on the damaged bone. This is actively used in rehabilitation for the most complete and rapid restoration of functions in the early postoperative period.
- The postoperative period for osteosynthesis is short, the patient can quickly return to his normal life. This has a positive effect on the psychological state of the person who has suffered trauma.
- There is no need to wear a cast.
- There are no scars left or they are practically invisible. Osteosynthesis is performed through minimal skin incisions of 2-3 cm, which usually heal without a scar.
- Without pain. The operation is performed under general or regional anesthesia. In any case, you will not feel pain. Due to minimal trauma, pain in the postoperative period is not pronounced and is easily relieved with standard analgesics.
- Minimum complications. Optical equipment allows you to perform manipulations under high magnification under visual control. This eliminates the risk of incorrect comparison of fragments. In the postoperative period, antibiotics are prescribed, which eliminates the possibility of developing infectious complications.
- Removal of metal structures is often not required. The materials used are biologically inert, i.e. do not enter into any interaction with body tissues, therefore they can be installed for life.
Department of Traumatology and Orthopedics
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V. V. LOZHKIN, V. I. ZORYA
Moscow State Medical and Dental University named after. A.I. Evdokimova, Moscow
Information about the author:
Lozhkin Vladislav Viktorovich – postgraduate student of the Department of Traumatology and Orthopedics of Moscow State Medical University, e-mail: [email protected] Zorya Vasily Iosifovich – Head of the Department of Traumatology and Orthopedics of Moscow State Medical University, Professor, Doctor of Medical Sciences, e-mail: [email protected]
Expanding indications for osteosynthesis of fractures increases the number of complications in surgical traumatology. Among the complications, the problem of destruction of implants is especially important. The article provides a review of the literature over the past 10 years, which summarizes all relevant information on the frequency of this complication.
Fractures of metal fixators with the progressive use of new osteosynthesis technologies are taking first place among its severe complications. No universal causes and mechanisms of metal fixator fractures have been identified.
Key words: implant failure, complications during osteosynthesis.
Against the backdrop of the continuing incidence of injuries in the adult population, indications for surgical treatment of fractures have expanded in recent years. Indications for open reduction and fixation of a fracture with an implant are cases of intra-articular fractures, as well as extra-articular fractures with significant displacement or fractures that are unstable, the retention of which is impossible with conservative methods. In addition to these indications, a significant trend in recent years is the need for intensive rehabilitation of the patient and his return to normal physical activity in the coming days after surgery. The Orthopedic Association AO Foundation believes that the resumption of weight bearing on the limb after surgical treatment should be carried out within two to three days.
The above factors increase the number of implants installed for emergency trauma. The world leader in the production of internal implants for traumatology, SynthesDePue (a subsidiary of Johnson & Johnson) reports sales of $2.5 billion in its published financial statements for 2021. Stryker in its 2015 report reports $9.9 billion, Smith & Nephew $475 million. According to the HW&Co report, in the United States alone in 2015, the number of patients in need of orthopedic implants reached 48 million people and increased by 18% compared to 2010. Such a number of operations with internal fixation of fractures brings to the fore new types of complications that previously traumatologists encountered much less often. One of these complications is postoperative suppuration. The second, rarer complication is a fracture of the internal implant.
Frequency
There is much conflicting data regarding the incidence of fixator fractures. The frequency of fractures correlates with the severity and location of the fracture.
S.E. Nikitin (2003) [1] in his dissertation points to 14% of cases of implant fractures, 6% of which were complicated by secondary displacement of fragments, i.e. essentially a re-fracture. Bondarenko A.V. et al. (2004) [2] studied the incidence of fractures of bone implants in trauma patients. He gives data of 11% destruction of plates. Imanaliev A.B. et al. (2014)[3] in a similar study of 116 people reported a 14.6% implant fracture rate. Popov V.P. (2014) [4] in a large study of bone osteosynthesis of only closed lower extremity fractures reported a 1.8% incidence of implant fractures.
The frequency of fixator fractures reported by the authors appears to vary greatly. An even greater difference in the results of internal osteosynthesis is observed when separating cases of implant fractures from general statistics depending on the severity of the initial injury. So, Bondarenko A.V. et al. (2004) [2] indicates 30.9% of implant fractures after osteosynthesis of open fractures, and only 8.1% after closed ones.
We reviewed reports in the literature of fractures of bone implants (plates) and intramedullary nails with reported fracture rates by segment.
Collarbone
Included in our study as a bone belonging to the girdle of the upper limb, the clavicle is one of the most frequently operated fracture sites.
Kleweno CP (2011) [5] in a comparative study between intramedullary and extramedullary osteosynthesis presents 14 patients operated on with external osteosynthesis. In one of them, delayed consolidation of the fracture was noted, which ultimately led to a plate fracture, which amounted to 7.1%. One case of plate fracture (4%) out of 25 operated patients was reported by Dhakad RK (2016) [6], Zehir S [7] of 21 operated patients 4.8%, Andrade-Silva FB (2015) [8] - out of 29 operated 3.4%, Meijden OA et al (2015) [9] – out of 58 cases – 1.7%. Calbiyik M. et al (2017) [10] in a group of 40 patients operated on with a plate, reported three cases (7.5%) of destruction of the metal fixator. Lee YS (2007) [11] included 62 patients of the older age group in his study. All of them underwent open osteosynthesis with a plate. In 2 patients (3.2%) a fracture was noted. The combined results of plate fractures after osteosynthesis of the clavicle are presented in Table. 1. From table. 1 it follows that after osteosynthesis of the clavicle there were plates in 10 cases, which is 4%.
Shoulder
Claessen et al. (2015) [12] studied the treatment outcomes of 129 people with type C distal humerus fractures. Only patients with bicondylar fractures were included in the study. Of these, 16 cases required reoperation, 8 of which had nonunion, and 8 had an implant fracture (6.2%). The author points to obesity, smoking, diabetes and arthritis as risk factors. However, he notes that the incidence of implant fractures does not depend on the surgeon, his experience or the use of special surgical techniques. Micic ID et al. (2009) [13] reported 9 cases of failure of osteosynthesis of the proximal end of the humerus with the LCP plate out of 95 operated patients. Among the fractures complicated by instability of fixation, there were five two-part, three three-part, and one four-part Neeir fractures. The average patient age was 69.8 years. All cases were observed in the first 4 weeks after osteosynthesis, and only in one case was an implant fracture observed. All patients were reoperated; they underwent six reosteosynthesis operations and three shoulder joint replacements. The authors cite bone resorption and loss of medial support for the plate as the main risk factors, which led to implant fracture in 1% of cases. Faraj D (2011) [14] provides the results of treatment of 92 patients with fractures of the proximal end of the humerus. The study included all types of proximal Neeer fractures, and the average patient age was 66.2 years. Osteosynthesis was performed with Philos and LPHP plates. Complications were noted in 36 people. 27 patients underwent repeated surgery. An implant fracture was noted in one patient in the first group, and in five in the second. Of these, one plate fracture was in the proximal section, five fractures were in the distal section. The overall implant fracture rate was 6.5%. L. Obert et al. (2013) [15] in a large randomized retrospective analysis of complications of treatment of fractures of the distal end of the humerus provides data on 410 patients, of which 289 were operated on. The authors cite the incidence of implant fractures as 7% of cases. Schmidt-Horlohé KH et al. (2013) [16] provides the results of treatment of 46 severe (type C) fractures of the distal humerus. The absolute majority of fractures (77%) were type C3 according to the AO classification. Of these, 12 patients suffered open fractures. He noted 16 different complications, including 6 cases (13%) of plate fracture. Korner J (2005) [17] provides the results of treatment of 45 patients over 60 years of age with fractures of the distal end of the humerus. The majority of patients (29 cases) were admitted with type C fractures. Various problems with the use of implants were noted in 12 patients, of which three cases (6.6%) resulted in implant fracture. Südkamp N et al. (2009) [18], in a study of the results of treatment of proximal humerus fractures, reported three cases (1.6%) of plate fracture. The study included 187 patients, the average age of the patients was 62.9 years. All patients were operated on with open bone osteosynthesis using a locked plate. The majority of fractures according to the AO classification were type B1. D. Aksu N. et al (2010) [19] performed osteosynthesis in 103 patients with fractures of the proximal humerus. The vast majority (93) of fractures were fixed with a Philos plate. Complications were noted in only 10 of them, and implant fracture in only 1 case (0.97%). The results of the analysis and the incidence of plate fractures after osteosynthesis of the humerus are presented in Table. 2.
As can be seen from table. 2, according to foreign authors, implant fractures after osteosynthesis of the humerus at various levels in 1097 patients amounted to 5.2%
Forearm
Plate JF et al. (2015) [20], in a published study of patients with distal radius fractures treated with either intramedullary or external osteosynthesis, reported 3 cases of pin fracture and one case of volar plate fracture in groups of 30 people each. The incidence of fractures was 10% in the group after intramedullary osteosynthesis, and 3.3% in the group after bone osteosynthesis. Kevin C. Chung et al. (2008) [21], in their analysis of the results of osteosynthesis of the distal radius with volar plates, reported three cases of plate fracture (12%) in a group of 25 elderly people. In a similar group of young patients, they did not notice such complications.
Unfortunately, in the period we have observed over the past 10 years, there are no more indications of plate fractures during osteosynthesis of the forearm. The final data of external osteosynthesis of the forearm bones are presented in Table. 3.
Hip
Gunadham et al. (2014) [22] provides data on the consequences of osteosynthesis of pertrochanteric femoral fractures with angular stability plates (PF-LCP) in 26 patients. The average age of the patients was 42 years, weight 64.7 kg. The majority of fractures were type B, 23.1% B1, 26.9% B2. Of the operated patients, 2 had a plate fracture, and another patient had a screw fracture. All fractures (7.6%) occurred between 2 and 7 months after surgery. Martin Homan et al. (2013) [23] analyzed 111 cases of fracture of the distal metaepiphysis of the femur. All patients (106 people) were operated on using a blocked plate. The average age of the patient was 54 years. 34.2% of comorbidities had obesity, 18.9% had diabetes mellitus, and 18.9% were smokers. 40.5% of fractures were open, of which 39.5% were Gustilio type III. Plate destruction was observed in three cases in the fracture zone, and in three more distally. All plate fractures (5.4%) were accompanied by impaired bone fusion with the formation of a pseudarthrosis. No difference was found between steel and titanium implants, and the introduction of additional screws into the plate also did not affect the outcome of the operation. Mark L. Prasarn et al (2012) [24] studied the frequency and nature of complications after intra- and extramedullary internal osteosynthesis in patients with a fracture of the proximal femoral metaepiphysis and concomitant osteoporosis. In this group there were 10 patients with external metal fixators, fracture of which was noted in three of them (30%). There were no fractures of intramedullary structures. In the control group of 20 people receiving treatment for osteoporosis, there were no implant fractures. Jain JK et al. (2013) [25] analyzed the consequences of treatment of periarticular and intra-articular fractures of the knee joint. There were 38 patients in the group, 20 cases of distal femur and 20 proximal tibia fractures. Nine cases of hip fracture were classified as type A, 11 as type C according to the AO classification. The vast majority of fractures were operated on using minimally invasive techniques (90% of tibial fractures and 70% of femoral fractures) using plates. There was one case of plate fracture during femoral osteosynthesis in the seventh week after surgery. The patient was operated on again, reosteosynthesis with an intramedullary pin. The authors believe that the cause of the fracture was early loading of the injured limb, contrary to the recommendations of surgeons. In addition, another patient had fracture of all proximal screws in the plate at 24 weeks. The authors find it difficult to indicate the reasons for this fracture. The implant fracture rate was 5.0%. Zha GC et al. (2011) [26] operated on 104 people with transsubtrochanteric femoral fractures. The average age of the patients was 75 years. Osteosynthesis of all fractures was performed with the proximal femoral angular stability plate PFLCP. The average operation time was 35.5 minutes, the average blood loss was 150 ml. The authors note an extremely low rate of complications associated with fracture healing: only one case of implant fracture (11%) and one case of pseudarthrosis. The implant fracture occurred 3 months after surgery. The patient was reoperated using the same method, and union was achieved.
The final data of external osteosynthesis of the femur are presented in Table. 4.
As follows from table. 4, according to foreign traumatologists, implant fractures after hip osteosynthesis in 271 patients amounted to 4.7%
Shin
Ahmad MA et al. (2012) [27] presents the results of osteosynthesis of the tibia bones with a plate with angular stability. The complication rate in the group was 27%, and he further reports one case of implant failure (5.5%) that did not affect fracture healing. Siddhartha et al. (2014) [28] used modern tactics of minimally invasive access for osteosynthesis of fractures of the distal tibia. In general, he notes an extremely low rate of complications with this osteosynthesis technique. There were 50 patients in the group, the average age was 36 years. All fractures were closed or open according to the Gustilio I classification. 90% of the fractures were extra-articular, 6% partially intra-articular, 4% complete intra-articular. The overall implant fracture rate was 1.25%. TWLau [29] et al. (2008) also used a minimally invasive approach and describes the results of treatment of 48 patients. One of them had a fracture of two screws in the plate under conditions of postoperative suppuration. After staged surgical treatment, the infectious process was stopped. There was no nonunion of the fracture. The internal implant fracture rate was 2%. Hazarika S, Chakravarthy J, Cooper J. (2006) [30] present the results of osteosynthesis with plates with angular stability of distal open and closed fractures of the tibia in 20 patients. Their average age was 44.7 years. There was one case of fixator fracture (5.5%) at 32 weeks after surgery. Reosteosynthesis was performed using a DCP plate.
One case of fixator fracture (2.4%) among 42 patients operated on using a minimally invasive approach was reported by Bahari S.S. al. (2007) [31], Aksekili MA et al. (2012) [32] of 35 operated patients – 2.8%, Wang Cheng, Ying Li, and Wang Manyi (2011) [33] – 6.6%, Maulli et al. (2004) [34] – 10.5% of 19 operated patients, Francois et al. (2004) [35] – 10% of 10 operated patients.
The listed cases of fixator fractures after osteosynthesis of the tibia bones and their frequency are presented in Table. 5.
From the table Table 5 shows that after external osteosynthesis of the tibia bones in 257 patients, plate fractures were diagnosed in 7% of cases.
Fractures of intramedullary fixators
Hip. Among the implants used for osteosynthesis, the most commonly used are the gamma pin and the proximal femoral pin. There are enough studies regarding fractures of these implants, but, unfortunately, they all concern implants older than 10 years in manufacture: the last large study regarding this type of implant was published in 2004.
A similar situation with reports of fractures of implants for osteosynthesis of the femoral diaphysis
Shin
Fracture of the axial implant is a rare occurrence in tibial osteosynthesis. This is caused by the peculiarities of the load distribution on the screws during intramedullary osteosynthesis. Among the published cases of implant fractures over the past 10 years, there is not a single case of axial implant fracture. The latest mention of pin failure in tibial fractures in large cohort studies is found in Blachut PA (1997) [36]. In his study, there was one pin fracture out of 63 osteosynthesis procedures. Fracture of locking screws occurs many times more often, but their number remains extremely low. Bhandari M, (2008) [37] reports 13 cases of screw fractures during osteosynthesis with reaming (a total of 416 operations in the study), and 29 cases during osteosynthesis without reaming). Liheng Xia et al. (2014) [38] indicates more frequent screw fractures during osteosynthesis without reaming, while his analysis mostly includes data for 1990-2000. However, even in such a long-term period, only two cases of fracture of the main implant were noted, including the one we mentioned above.
Shoulder
Similar to the above localizations, we were unable to find comprehensive analyzes of the incidence of intramedullary implant fractures during shoulder osteosynthesis in medical journals. Only one mention by Caforio M et al. (2016) [39] about a fracture of the distal locking screw during osteosynthesis of the shoulder in a group of 43 operated patients.
Conclusion
Fractures of metal fixators with the progressive use of new osteosynthesis technologies are taking first place among its severe complications. Universal causes and mechanisms of metal fixation fractures have not yet been identified. For different locations of osteosynthesis, the leading etiological factors for implant destruction differ. Further study of the pathogenesis of integrity damage is necessary to identify ways to prevent this complication.
Conflict of interest
The authors of this article have confirmed that there are no conflicts of interest to disclose.
List of literature / References
1. Nikitin, S.E. Orthosis therapy in the system of complex treatment of limb fractures and their consequences in adults. / Nikitin S.E. // Dissertation for the degree of Doctor of Medical Sciences - Moscow - 2012
Nikitin, SE Ortezoterapiya v sisteme kompleksnogo lecheniya perelomov kostei konechnostei i ikh posledstvii u vzroslykh. / Nikitin SE // Dissertatsiya na soiskanie stepeni doktora meditsinskikh nauk – Moscow – 2012
2. Bondarenko, A.V. Destruction of implants during external osteosynthesis of long bone fractures. / Bondarenko A.V., Raspopova E.A., Peleganchuk V.A. // Bulletin of Traumatology and Orthopedics named after N.N. Priorov - 2004 - Vol 2. - P. 41-43
Bondarenko, AV Razrushenie implantov pri nakostnom osteosinteze perelomov dlinnykh kostei. / Bondarenko AV, Raspopova EA, Peleganchuk VA // Vestnik travmatologii i ortopedii im.NNPriorova – 2004 – Vol 2. – P. 41-43
3. Imanaliev, A.B. Destruction of bone plates during osteosynthesis of long bone fractures. / Imanaliev A.B., Imanaliev A.A., Ayatov A.S. // TRAUMATOLOGY FOR WOMEN ORTHOPEDICS – 2014 – Vol 3-4 – P. 82-86
Imanaliev, AB Razrushenie nakostnykh plastin pri osteosintezeperelomov dlinnykh kostei. / Imanaliev AB, Imanaliev AA, Ayatov AS // TRAVMATOLOGIYa ZhENE ORTOPEDIYa – 2014 – Vol 3-4 – P. 82-86
4. Popov, V.P. Complications during external osteosynthesis in patients with fractures of long bones / Popov V.P., Zdrelko V.P., Trukhachev I.G. et al. // Genius of Orthopedics – 2014 – Vol 2 – P. 5-9
Popov, VP Oslozhneniya pri nakostnom osteosinteze u bol'nykh s perelomami dlinnykh trubchatykh kostei / Popov VP, Zdrel'ko VP, Trukhachev IG s soavt. // Genii Ortopedii – 2014 – Vol 2 – P. 5-9
5. Kleweno, CP Midsha clavicular fractures: comparison of intramedullary pin and plate xation. / Kleweno, CP, Jawa A, Wells JH et al. // J Shoulder Elbow Surg. – 2011 – Vol 20 (7) – P. 1114-1117
6. Dhakad, RK Plating versus conservative treatment in midsha fractures of clavicle: A comparative study. / Dhakad RK, Panwar M., Gupta S. // J Clin Orthop Trauma – 2021 – Vol 7 – P. 166-170
7. Zehir, S Comparison of novel intramedullary nailing with miniinvasive plating in surgical xation of displaced midsha clavicle fractures / Zehir S1, Zehir R, Şahin E et al. // Arch Orthop Trauma Surg – 2015 – Vol. 135 – P. 339-344
8. Andrade-Silva, FB Single, superiorly placed reconstruction plate compared with exible intramedullary nailing for midsha clavicular fractures: a prospective, randomized controlled trial. / Andrade-Silva FB, Kojima KE, Joeris A et al // J Bone Joint Surg Am – 2015 – Vol. 97 (8) – P. 620-626
9. van der Meijden, OA Operative treatment of dislocated midsha clavicular fractures: plate or intramedullary nail xation? A randomized controlled trial / van der Meijden OA, Houwert RM, Hulsmans M. et al. // J Bone Joint Surg Am – 2015 – Vol. 97 (8) – P. 613-619
10. Calbiyik, M. Prospective randomized study comparing results of xation for clavicular sha fractures with intramedullary nail or locking compression plate. / Calbiyik M., Ipek D., Taskoparan M. // Int Orthop – 2021 – Vol. 41(1) – P.173-179
11. Lee, YS Operative treatment of midclavicular fractures in 62 elderly patients: knowles pin versus plate / Lee YS, Lin CC, Huang CR // Orthopedics – 2007 – Vol. 30(11) – P. 959-964
12. Claessen, FM Plate and Screw Fixation of Bicolumnar Distal Humerus Fractures: Factors Associated With Loosening or Breakage of Implants or Nonunion. / Claessen FM, Braun Y., Peters RM et al // J Hand Surg Am – 2015 – Vol. 40(10) – P. 2045-2051
13. Micic, ID Analysis of early failure of the locking compression plate in osteoporotic proximal humerus fractures. / Micic ID, Kim KC, Shin DJ et al. // J Orthop Sci – 2009 – Vol. 14 (5) – P. 596-601
14. Faraj, D Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up./ Faraj D., Kooistra BW, Vd Stappen WA et al // Eur J Orthop Surg Traumatol – 2011 – Vol. 21 (1) – P. 7-12
15. Obert, L Distal humerus fractures in patients over 65: Complications / Obert L., Ferrier M., Jacquot A. et al //Orthop Traumatol Surg Res – 2013 – Vol 99(8) – P. 909-913
16. Schmidt-Horlohé, KH Promising results a er the treatment of simple and complex distal humerus type C fractures by angularstable double-plate osteosynthesis. / Schmidt-Horlohé KH, Bonk A., Wilde P. et al // Orthop Traumatol Surg Res – 2013 – Vol. 99(5) – P. 531-541
17. Korner, J. Distal humerus fractures in elderly patients: results a er open reduction and internal xation / Korner J., Lill H., Müller LP et al.// Osteoporos Int. – 2005 – Vol. 16 – P. 73-79
18. Südkamp, N Open reduction and internal xation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. / Südkamp N., Bayer J., Hepp P. et al // J Bone Joint Surg Am – 2009 – Vol 91 (6) – P. 1320-1328
19. Aksu, N Complications encountered in proximal humerus fractures treated with locking plate xation. / Aksu N., Göğüş A., Kara AN et al // Acta Orthop Traumatol Turc – 2010 – Vol. 44(2) – P. 89-96
20. Plate, J. F. Randomized comparison of volar locking plates and intramedullary nails for unstable distal radius fractures. / Plate JF, Ganey DL, Emory CL // J Hand Surg Am – 2015 – Vol. 40(6) – P. 1095-1101
21. Kevin C. Chung A Comparative Outcomes Study Using the Volar Locking Plating System for Distal Radius Fractures in both Young Adults and Adults Older than 60 Years / Kevin C. Chung, Lee Squitieri, BS, and H. Myra Kim // J Hand Surg Am – 2008 – Vol. 33(6) – P. 809-819
22. Gunadham, U e outcome in early cases of treatment of subtrochanteric fractures with proximal femur locking compression plate. / Gunadham U., Jampa J., Suntornsup S. et al // Malays Orthop J – 2014 – Vol 8(2) – P. 22-28
23. Ho mann, MF Clinical outcomes of locked plating of distal femoral fractures in a retrospective cohort / Ho mann MF, Jones CB, Sietsema DL et al // J Orthop Surg Res – 2013 – Vol.8 – P.43
24. Prasarn, ML Bisphosphonate-associated Femur Fractures Have High Complication Rates with Operative Fixation / Prasarn ML, Ahn J, Helfet DL et al. // Clin Orthop Relat Res – 2012 – Vol. 470 – P. 2295-2301
25. Jain, JK Locked compression plating for periand intra-articular fractures around the knee. / Jain JK, Asif N., Ahmad S. et al. // Orthop Surg – 2013 – Vol. 5(4) – P. 255-260
26. Zha, GC Treatment of pertrochanteric fractures with a proximal femur locking compression plate. / Zha GC, Chen ZL, Qi XB et al. // Injury – 2011 – Vol. 42(11) – P. 1294-1299
27. Ahmad, M.A. Percutaneous locking plates for fractures of the distal tibia: our experience and a review of the literature / Ahmad M.A., Sivaraman A., Zia A. et al. // J Trauma Acute Care -Surg – 2012 – Vol. 72 – P.81-87
28. Siddhartha, VP Management of fractures of the distal third tibia by minimally invasive plate osteosynthesis – A prospective series of 50 patients / Siddhartha VP, Hitesh L., Deepak M. et al.// J Clin Orthop Trauma – 2014 – Vol. 5 – P.129-136
29. Lau, TW Wound complication of minimally invasive plate osteosynthesis in distal tibia fractures / Lau TW, Leung F., Chan C. F et al. // Int Orthop – 2008 – Vol.32 (5) – P. 697-703
30. Hazarika, S. Minimally invasive locking plate osteosynthesis for fractures of the distal tibia—results in 20 patients. / Hazarika S, Chakravarthy J, Cooper J.// Injury – 2006 – Vol. 37(9) – P. 877-887
31. Bahari, S. Minimally invasive percutaneous plate xation of distal tibia fractures./ Bahari S., Lenehan B, Khan H et al // Acta Orthop Belg2007 – Vol. 73(5) – P.635-640
32. Aksekili, MA e results of minimally invasive percutaneous plate osteosynthesis (MIPPO) in distal and diaphyseal tibial fractures. / Aksekili MA, Celik I., Arslan AK et al. // Acta Orthop Traumatol Turc – 2012 – Vol. 46 (3) – P.161-167
33 Wang, C. Comparison study of two surgical options for distal tibia fracture—minimally invasive plate osteosynthesis vs. open reduction and internal xation / Wang Cheng, Ying Li, and Wang Manyi // Int Orthop – 2011 – Vol. 35(5) – P.737-742
34. Ma ulli, N. Percutaneous plating of distal tibial fractures / Ma ulli, N., Toms AD, McMurtie A. et al // Int Orthop – 2004 – Vol.28(3) – P.159-162
35. Francois, J. Percutaneous plate xation of fractures of the distal tibia. / Francois J., Vandeputte G., Verheyden F. et al. // Acta Orthop Belg – 2004 – Vol. 70(2) – P. 148-154
36. Blachut, PA Interlocking intramedullary nailing with and without reaming for the treatment of closed fractures of the tibial sha. A prospective, randomized study. / Blachut PA, O'Brien PJ, Meek RN et al // J Bone Joint Surg Am – 2007 – Vol. 79(5) – P.640-646
37. Bhandari, M Randomized trial of reamed and unreamed intramedullary nailing of tibial sha fractures. / Bhandari M., Guyatt G., Tornetta P 3rd et al // J Bone Joint Surg Am – 2008 – Vol 90 (12) – P. 2567-2578
38. Liheng, X. A Meta-analysis of Reamed Versus Unreamed Intramedullary Nailing for the Treatment of Closed Tibial Fractures / Liheng Xia, Jian Zhou, Yongtao Zhang et al.// Orthopedics – 2014 – Vol.37 – P.332-338
39. Caforio M. Long endomedullary nail in proximal third humeral sha fractures. / Caforio M., Maniscalco P., Colombo M. et al // Injury – 2021 – Vol.47 – P.64-70
FRACTURES OF IMPLANTS IN OSTEOSYNTHESIS OF LIMB BONES (LITERATURE REVIEW)
VI ZORYA, VV LOZHKIN
Moscow State Medical and Dental University AI Evdokimov, Moscow
Expanding indications for osteosynthesis of fractures increase the number of complications in operative trauma. Among the complications, the problem of destroying implants is especially important. e article gives a review of literature over the past 10 years, which summarizes all relevant information on the frequency of these complications.
Breakage of implants with progressive use of new technologies of an osteosynthesis comes out on top among its heavy complications. e universal reasons and mechanisms of changes of metalclamps are not revealed.
Key words: implant breakage; implant failure complications of osteosynthesis.
Indications and contraindications for osteosynthesis:
The absolute indication for surgery is complex fractures that cannot be repaired without surgery.
As a rule, these are fractures with a large number of fragments in which nerves, blood vessels, tendons, ligaments, etc. were damaged. Osteosynthesis is also performed for:
- Fractures that do not heal or heal slowly;
- Fractures in which the fragments have shifted during conservative treatment;
- Hallux valgus and flat feet.
Contraindications to osteosynthesis are severe somatic diseases, especially in the stage of decompensation, the general poor health of the patient, as well as fractures in which the damage area is very large and the tissues are infected.
Features of bone osteosynthesis
This type of operation is performed using titanium plates of different sizes. The latest achievement in this area is compression-type plates that have special holes along their entire length. They allow you to fix the heads of the screws in the plate, which in turn are inserted into the bone tissue of the fragments. After tightening the screws, maximum fixation of bone fragments is ensured and compression is created between them.
This method of installing plates allows for faster bone healing and ensures proper fixation. This eliminates the possibility of improper fusion or other complications.
From above, the fracture site is covered with the patient's viable soft tissues.
Even before performing external osteosynthesis surgery, it is important to choose the right plate. The choice depends on:
- type of injury
- number of bone fragments,
- location of the fracture,
- anatomical shape of the bone.
A correctly selected plate allows you to completely restore the anatomical shape of the damaged bone. This helps the patient return to normal activities as quickly as possible.
How is osteosynthesis performed?
The surgeon controls all manipulations using optical surgical equipment, which transmits a full-color image in high resolution under high magnification to the monitor screen. Through a skin incision of 2-3 cm, structures made of titanium or other metals that are safe for health are introduced into the fracture zone. They can be rods, screws, screws, plates, etc. During the operation, the fragments are securely fixed with these structures. After installing the fixators, the soft tissues are sutured in layers, and an aseptic dressing is applied.
Osteosynthesis can be performed on the day you visit the clinic or 1-2 days later. The period of hospitalization after surgery is usually 1-3 days.
What metal is used in orthopedic surgery?
Previously, implants were made of gold, silver, lead and aluminum. One of the latest discoveries was the use of titanium. Nowadays, after many years of testing, it has been proven that of all the metal implants in the human body, titanium implants are the most suitable type for a number of reasons. The most important reasons are that it can last a long time, reportedly 20 years. Another important feature is that it is not susceptible to corrosion in the human body and is easily accepted by the body as it is more resistant to dangerous reactions.
But that is not all. In fact, there is a long list of possibilities for titanium. The most important factors:
- It has low density and causes irritation to people.
- It's proven to be strong.
- It is very resistant to oxidation.
- Titanium is non-magnetic and non-toxic.
- It is light in weight.
- It is less susceptible to allergies compared to other metals.
- It is less rigid and easy to use.
Two negative points of a titanium implant:
- This can lead to allergic symptoms, although researchers believe that patients are not allergic to titanium, but are allergic to impurities in titanium, which include nickel, chromium, and also cadmium.
- Since titanium is good in the metal categories, it is an expensive metal and not many people can afford it.
To find out whether a person is allergic to titanium or not, a test is done before surgery. The name of the test is MELISA. This test is very accurate and takes a sample of your blood to check whether it is sensitive to titanium or not.
Removal of metal structures:
Surgical treatment at the ABIA clinic is performed using modern materials that are safe for health. However, in many cases, operating traumatologists recommend removing the fixation structure after healing of the fracture zone in order to exclude rare cases of the development of long-term complications. It is better to do this 8-12 months after osteosynthesis.
After removal of metal structures, soft tissue healing occurs quickly. The incision is made along the old scar, a cosmetic suture is applied, due to which the scar becomes almost invisible after healing.
External fixation devices (percutaneous technique)
The technique allows you to reposition and carefully fix the fragments without exposing the fracture area. Its essence is to pass rods or knitting needles through the bone tissue, which are fixed externally in a special apparatus. Now there are monolateral, circular, sector, semicircular, bilateral and combined devices. Preference is often given to rod models. The use of external fixators is an indispensable method of treating highly sensitive injuries, such as mine explosions and gunshots, which are accompanied by significant damage to both bones and soft tissues. The peripheral blood supply to the limb must be preserved.
Postoperative period and rehabilitation:
The patient remains in the clinic after the operation for 2-3 days. Already starting from 3-4 days, you can begin active recovery measures, including physical therapy, physiotherapy and massage.
On average, the recovery time after a minimally invasive operation performed at the ABIA clinic is 2-3 times shorter than after a classic open osteosynthesis operation. The absence of the need to wear a cast, as well as the possibility of a speedy return to work and active life, significantly improves the quality of life of our patients in the postoperative period.
Features of using pins
During intraosseous surgical treatment, pins are inserted into the medullary cavity of the long parts of the tubular bones. The advantages of the technique are low trauma, the ability to put a load on the injured limb after just a few days. The operation is performed for transverse bone fractures with sufficient volume of the bone marrow cavity. For more durable fixation, pins with holes for screws are used, which are passed through the bone. This is BIOS, that is, blocked intramedullary osteosynthesis. Self-locking Fixion pins are also used. They allow you to perform the operation as quickly as possible and are used even for comminuted fractures.
Recovery
It’s not enough to just put a plate and fix the fracture; it’s important that the person can then live and work fully. is carried out only under the supervision of an experienced specialist. The approximate period required for full recovery is about a month, but it can last for a longer period of time. If the fracture is matched correctly, the desire of the patient himself is required and the result will not be long in coming.
Simple movements in the joints are indicated after the wound has healed, but provided that displacement does not threaten. As the fracture consolidates, weight bearing on the limb is indicated, first using crutches, then a cane or walker. After surgery on the upper extremities, the load on the operated segment is performed using expanders, weights, and dumbbells. The use of therapeutic exercises in a lying or sitting position is indicated.
Each type of fracture requires its own set of exercises. A rehabilitation doctor or traumatologist will help you choose them. After each operation, a different complex is shown. After some operations, recovery is carried out only in the form of movements in the joints without supporting the limb. If you neglect this rule, the result will be lost and the fracture will move.
Discussion
Despite the development of medicine in general and maxillofacial surgery in particular, the problem of providing emergency medical care for fractures of the facial skull remains not fully resolved. Due to the increase in the number of road traffic accidents and domestic conflicts, and the passion of young people for traumatic sports, there has been an increase in the number of victims with injuries to the facial skull, among which fractures of the lower jaw occupy the first place [12].
The difficulty of early diagnosis of fractures of the angle of the mandible is associated with the insufficient information content of routine methods of radiation examination (radiography of the skull in frontal or lateral projection), late referral of victims to specialized maxillofacial hospitals and, as a consequence, the choice of irrational methods of treatment, which in turn leads to development of various kinds of complications, reduction in the quality of treatment and life of patients.
Rehabilitation period
After the pin is installed, a rehabilitation period begins. The patient should attend the dressing room regularly. For two months, dressing is carried out strictly in sterile hospital conditions. It is not recommended to carry it out at home during this period - there is a risk of getting an infection.
In addition, during dressing, an x-ray is taken, the doctor looks at the results of osteosynthesis. A physical therapy specialist prescribes limb development classes for the patient. Loads are necessary for the hand to function normally. Special exercises are used for development.
What it is
At the present stage, a variety of plate options are used in traumatology. They can have different shapes, depending on the area of the bone where they should be installed. There are significant differences in the holes in which the screw, due to the head, reliably fixes the fracture.
All plates have certain functions:
- restoration of normal bone anatomy;
- acceleration of fusion;
- early loading on the operated area.
But in order to install the plate on the bone, a large number of tools are required. And they have been developed, making the operation faster.
When and where is the operation performed?
Osteosynthesis surgery is performed if it is impossible to achieve optimal results using traction or casting. During surgery, screws and plates are used to fix the fragments.
Anatomically, the shoulder is the part of the arm that is located above the elbow. There are vulnerable areas here that can be broken if you fall or get your shoulder caught in a door. The most fragile area is the surgical neck. This is a department that is located on the border with the body.
Fractures can occur in three parts of the humerus:
- upper;
- lower;
- in the body of the humerus.
The doctor decides how advisable it is to perform osteosynthesis surgery. In some cases, he consults with the patient's loved ones. For example, consultation with relatives is necessary if the patient is elderly.
Types of plates
All fracture plates are designed based on the fracture and its location, as well as the functions they are intended to perform. Highlight:
- protective (neutralization);
- supporting (supporting);
- compression (tightening);
- with partial contact;
- with full contact;
- microplates.
The process of applying a plate to a bone is called metal osteosynthesis. All implantable plates are designed for lifelong use after surgery.