Ortopedická klinika UK.2.LF a FN Motol - Dětská a dospělá ortopedie a traumatologie

1. Ortopedická klinika UK.2.LF a FN Motol- Dětská a dospělá ortopedie a traumatologie

2. Ostheosynthesis

3. Fracture healing • Inflammatory response • Reparative response • Remodelling 

4. Inflammatory response • Time of injury to 24-72 hours • Injured tissues and platelets release vasoactive mediators, growth factors and other cytokines. • These cytokines influence cell migration, proliferation, differentiation and matrix synthesis.   • Growth factors recruit fibroblasts, mesenchymal cells & osteoprogenitor cells to the fracture site. • Macrophages, PMNs & mast cells (48hr) arrive at the fracture site to begin the process of removing the tissue debris.

5. Important cytokines in bone healing

6. Reparative response • – 2 days to 2 weeks • Vasoactive substances (Nitric Oxide & Endothelial Stimulating Angiogenesis Factor) cause neovascularisation & local vasodilation • Undifferentiated mesenchymal cells migrate to the fracture site and have the ability to form cells which in turn form cartilage, bone or fibrous tissue. • The fracture haematoma is organised and fibroblasts and chondroblasts appear between the bone ends and cartilage is formed (Type II collagen). • The amount of callus formed is inversely proportional to the amount of immobilisation of the fracture. • In fractures that are fixed with rigid compression plates there can be primary bone healing with little or no visible callus formation.

7. Types of callus

8. Remodelling  • Middle of repair phase up to 7 years • Remodelling of the woven bone is dependent on the mechanical forces applied to it (Wolff’s Law - 'form follows function') • Fracture healing is complete when there is repopulation of the medullary canal • Cortical bone • Remodelling occurs by invasion of an osteoclast “cutting cone” which is then followed by osteoblasts which lay down new lamellar bone (osteon) • Cancellous bone • Remodelling occurs on the surface of the trabeculae which causes the trabeculae to become thicker

9. Factors influencing bone healing

10. Fracture managemet • first aid - immobilisation • conservative • operative

11. Nonoperative • immobilization with casting or splintingmade from fiberglass or plaster of Paris (POP). • Closed reduction is needed if the fracture is significant displaced or angulated -the nonoperative technique:is achieved by applying traction to the long axis of the injured limb and then reversing the mechanism of injury/fracture • Traction

12. Traction • fractures and dislocations that are not able to be treated by casting • skin traction, traction tapes attached to the skin of the limb segment below the fractureusually 10% of the patient's body weightis rarely used as definitive therapy in adults;(the traction is maintained until the patient is taken to the operating room for ORIF or hemiarthroplasty in NOF fr.) • skeletal traction, a pin (eg, Steinmann pin, KI wires) is placed through a bone distal to the fracture Weights applied to this pin and the patient is placed in an apparatus to facilitate traction and nursing care Skeletal traction is most commonly used in femur fractures: A pin is placed in the distal femur or proximal tibia 1-2 cm posterior to the tibial tuberosity

13. Sceletal traction

14. Operative • Failed nonoperative (closed) management • Unstable fractures that cannot be adequately maintained in a reduced position • Displaced intra-articular fractures (>2 mm) • Patients with fractures that are known to heal poorly following nonoperative management (eg, femoral neck fractures) • Large avulsion fractures that disrupt the muscle-tendon or ligamentous function of an affected joint (eg, patella, olecranon fracture, ) • Impending pathologic fractures • Multiple traumatic injuries with fractures involving the pelvis, femur, or vertebrae • Unstable open fractures or complicated open fractures • Fractures in individuals who are poor candidates for nonoperative management that requires prolonged immobilization (eg, elderly patients with proximal femur fractures) • Fractures in growth areas in skeletally immature individuals that have increased risk for growth arrest (eg, Salter-Harris types III-V) • Nonunions or malunions that have failed to respond to nonoperative treatment

15. Surgical therapy • In 1958, the Association for the Study of Internal Fixation (ASIF) OA( Arbeitsgemeinschaft für Osteosynthesefragen) 4 treatment goals • Anatomic reduction of the fracture fragments:diaphysis: anatomical alignment assuring length, angulation, and rotationintra-articular fractures:anatomic reduction of all fragments. • Stable internal fixation to fulfill biomechanical demands • Preservation of blood supply to the injured area of the extremity • Active pain-free mobilization of adjacent muscles and joints

16. Surgical therapy • ORIF - Open reduction and internal fixation Kirschner wires (K- wires) Plates and screws • Intramedullary nailing • External fixation

17. Open reduction and internal fixation • exposing the fracture site and obtaining a reduction of the fracture • must be stabilized and maintained

18. AO principles • System • Fixation elements • Surgical technique • Complications resolving • Manual

19. New technique

20. Kirschner wires • commonly usedin fractures around joints. • resist only changes in alignment,they do not resist rotation and have poor resistance to torque and bending forces • used as adjunctive fixation for screws or plates and screws • casting or splinting is used in conjunction. • can be placed percutaneously • adequate for small fragments in metaphyseal and epiphyseal regions, especially in fractures of the distal foot, wrist, and hand, ( Colles fractures, and in displaced metacarpal and phalangeal fractures after closed reduction )

22. Plates and screws • designs vary depending on the anatomic region and size of the bone • used in the management of articular fractures • allows early ROM and the use of muscles and joints • strength and stability, neutralize forces • Buttress plates counteract compression and shear - metaphysis and epiphysis used around joints to support intra-articular fractures • Compression plates (DCP – Dinamic commpression plate, LC-DCP low contact dinamic commpression plate) counteract bending, shear, and torsion, eccentrically loaded holes in the plate used in long bones (fibula, radius, and ulna) • Neutralization plates combination with interfragmentary screw fixation interfragmentarycompression screws provide compression, plate neutralizes torsional, bending, and shear forces (lag screws increases the stability of the construct) (fibula, radius and ulna, and humerus) • Bridge plates - management of multifragmented diaphyseal and metaphyseal fractures.

26. Contraindications of ORIF • Active infection (local or systemic) or osteomyelitis • Osteoporotic bone that is too weak to sustain internal or external fixation • Soft tissues overlying the fracture or surgical approach that are poor in quality due to burns, surgical scars, or infection (In such scenarios, soft tissue coverage is recommended.) • Medical conditions that contraindicate surgery or anesthesia (eg, recent myocardial infarction) • Cases in which amputation would better serve the limb and the patient

27. widely accepted operate like an internal splint allows for compressive forces at the fracture site, which stimulates bone healing minimally invasive procedures femoral shaft fr. UFN,tibial shaft fr. UTN; humeral shaft fr. UHN. ESIN Elastic stabilization intramedullary nailing TEN –titanium elastic nail Intramedullary nails: flexible or rigid, locked(maintain alignment and length, and limit rotation) or unlocked, reamed or unreamed, Intramedullary nailing

30. Complications surgical management • Neurologic and vascular injury • Compartment syndrome • Infection • Thromboembolic events • Avascular necrosis • Posttraumatic arthritis

31. Neurologic and vascular injury • nerve injury - patient experiences motor or sensory deficiencies • Arterial injury - pulses are diminished or absent -immediate realignment, angiography is indicated - vascular surgeons (knee dislocations, proximal tibial fractures, and supracondylar humerus fractures)

32. Compartment syndrome • reported by von Volkmann in 1872, potentially limb-threatening condition, • tissue pressure exceeds perfusion pressure in a closed anatomic space ( hand, forearm, upper arm, most commonly occurs in the anterior compartment of the leg) • involves tissue necrosis; functional limb impairment; renal failure secondary to rhabdomyolysis, which may lead to death • occur after traumatic injury, after ischemia (eg, after hemorrhage or thromboembolic event); and in rare cases, with exercise • Clinically:pain out of proportion to the degree of injury, pain with passive stretch of the involved muscles, pallor, paresthesia, pulselessness is a late finding • can be measuredgreater 30 mm Hg indicates surgical fasciotomy of the affected compartments.

33. Infection • local infection: cellulitis, osteomyelitis, systemic infection, sepsis • Early recognition prevents the development of sepsis • The most common pathogen is Staphylococcus aureus, group A streptococci, coagulase-negative staphylococci, enterococci • ATB should be administered if an infection is suspected, • lab: C-reactive protein(CRP),erythrocyte sedimentation rate (ESR) • If infection cannot be eradicated with antibiotics, I&D of the surgical wound may be necessary, with removal of the hardware, but only if it is not performing its role.

34. Thromboembolic events • may occur after trauma with prolongedimmobilization • immobile for 10 or more days have a 67% incidence of thrombosis (Canale, 1998) • prophylaxis is effective in decreasing the incidence of deep vein thrombosis, but it has not been shown to be effective in decreasing the incidence of fatal pulmonary embolism. • Prophylactic anticoagulation LMWH, Warfarin, • early mobilization

35. Avascular necrosis • disruption of blood supply to a region of bone • can lead to nonunion, bone collapse, or degenerative changes • associated with NOF # and femoral head #, scaphoid, talar neck and body, and proximal humerus.

36. Posttraumatic arthritis • common in intra-articular fractures • fractures that are not adequately reduced • management: arthroscopic debridement, osteotomy, arthroplasty, or arthrodesis

37. In 1907 in Alvin Lambotte, 1952 Ilizarev provides stabilizationat a distance from the fracture site without interfering with the soft tissue structures maintains length, alignment, and rotation without requiring casting allows inspection types: Wagner, Orthofix, Unifix, Indications Open fractures with significant soft tissue disruption (eg, type II or III open fractures) Soft tissue injury (eg, burns) Pelvic fractures (temporarily) Severely comminuted and unstable fractures Fractures that are associated with bony deficits Limb-lengthening procedures Fractures associated with infection or nonunion arthrodesis External fixation

39. Complications of external fixation • pin tract infection, • pin loosening or breakage, • interference with joint motion, • neurovascular damage when placing pins, • malalignment caused by poor placement of the fixator, • delayed union and malunion

40. Spetial types of osteosynthesis • LISS ( less invasive stabilisation system) implants for MIPPO (minimal invasive percutane plate osteosynthesis) • -Herbert´s screw – scafoid # • DHS – NOF# basicervical • PFN – NOF # pertrochanteric • Phillos –prox. humerus • DCS (dinamic condylar screw) and DFN (distal femoral nail) - dist. femur • Pilon plate – dist. tibia