Paper & Research: Minimal Invasive Procedures, a study artiped2009

8/14/2019 Paper & Research: Minimal Invasive Procedures, a study artiped2009

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Minimally Invasive Plate Osteosynthesis with

Systems with Angular Stability in

Complex Distal Femoral Fractures.Design, Biomechanics and Clinical Results

P.D. Srbu1, E Carata2, T. Petreu1,

R. Asaftei1, P. Botez1

1 Gr.T.Popa University of Medicine

and Pharmacy, Iasi, Romania2 Gh. Asachi Technical University,

Iasi, Romania


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AO CLASSIFICATIONAO CLASSIFICATION

AA

BB

CC

A1A1 A2A2 A3A3

B1B1 B2B2 B3B3

C1C1 C2C2 C3C3

EXTRAARTICULAR

PARTIAL

ARTICULAR

COMPLETE

ARTICULAR


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Deforming forcesDeforming forces

QuadricepsQuadriceps shorteningshortening

AdductorsAdductors varusvarus

GastrocnemiusGastrocnemius recurvatumrecurvatum


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DISTAL FEMORAL FRACTURES

Wiss D.A. et al Rockwood and Green`s Fractures in Adults, Fourth Edition, 1996, 1972-1994

70-90%70-90% GOOD RESULTSGOOD RESULTS BYBY CLASSIC SURGCLASSIC SURGIICAL TREATMENTCAL TREATMENT

COMMINUTION

SOFT TISSUES DAMAGE

OSTEOPOROSIS

COMPLEX

INTRAARTICULAR TRACTS


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Operative goalsOperative goals

Anatomical articular reductionAnatomical articular reduction

Axial alignmentAxial alignment

Stable fixationStable fixation -- early range of movementearly range of movement

Preservation of blood supplyPreservation of blood supply


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OPEN REDUCTIONOPEN REDUCTION ANDAND INTERNAL FIXATIONINTERNAL FIXATION (ORIF)(ORIF)

Sanders R. et al J.Bone Joint Surg. Am., 1991, 73, 341-346; 2. Schatzker J., Lambert D.C. Clin. Orthop., 1979, 138, 77-83.

LARGE DISSECTIONS

LIGATURE OF THE

PERFORATING ARTERIES

EXCESSIVE DEPERIOSTATION

FRAGMENT DEVITALISATION

HIGH incidence for

infections, nonunions,iterative fractures, bone grafting


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Absolute stability (plate and screws)

OPEN REDUCTION AND INTERNAL FIXATION


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Absolute stability (plate and screws)

OPEN REDUCTION AND INTERNAL FIXATION

ROM - 0/0/115

Excellent final result (Neer score 86)


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Damage to the periosteum:

Escape of hematoma

Diffusion of pluripotent mesenchymal cellsNecrosis at the fracture site

OPEN REDUCTIONOPEN REDUCTION ANDAND INTERNAL FIXATIONINTERNAL FIXATION (ORIF)(ORIF)

NOT like this !!


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Biological plate osteosynthesis

new types of plates

Limited Contact DynamicCompression Plate (LC-DCP)1

Point Contact Fixator (PC-Fix)1

Less Invasive Stabilization System(LISS)1

Specificaly Design for MIPO

(Angular stability)

1. Miclau T. Injury, 1997, vol. 28, suppl. 1, 3-6; 2. Frigg R. Injury, 2001, 32, suppl. 3, 24-31


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Relative stability

Small amount of motion between fragments leads to callus

formation and indirect bone healing


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Relative stability

Healing occurs if the interfragmental strain remains below the

critical strain level for the repair tissue

The more fragments present, the less strain between fragments

and the less rigid the construct requirement

preop. preop. 4 months preop.


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IMPLANT OPTIONSIMPLANT OPTIONS

- 95 Condylar Blade Plate- Dynamic Condylar Screw (DCS)

- Dynamic Martin Screw (DMS)

- Chiron-Uthza Plate

- Condylar Butress Plate

- Angular Stable Plates

INTRAMEDUINTRAMEDULLLARLARYY

implantsimplants

EXTRAMEDUEXTRAMEDULLLARLARYY

implantsimplants

- Anterograde interlocking nail-Retrograde interlocking nail

(supracondylar)


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Trapezoidal shapeTrapezoidal shape

10 25

Distal femoral geometry


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Direct screws to avoid joint

Too longout medial

AP x-rayscrews end 1 cm

short of projected medial cortex

Distal femoral geometry


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Biological plate osteosynthesis

surgical techniques - indirect reduction -

Avoids medial dissection1

Lateral exposure

may decrease the

periosteal and medullary

circulation2

1. Kinast C. et al Clin. Orthop. 1989, 238, 122 130; 2. Farouk O. OTA, Annual Meeting Boston, 1996, Abstract Book, 133 - 134


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BIOLOGICAL PLATE OSTEOSYNTHESIS

- TUNNELING TECHNIQUE -

Skin and subcutis incision

Vastus lateralis left intact

RETROGRADE INTRAMEDULLARY NAILING


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RETROGRADE INTRAMEDULLARY NAILING


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MINIMALLY INVASIVE PLATE OSTEOSYNTHESIS

(MIPO)

Limits the amount of both

medial and lateral dissection

MIPO techniques:

MIPO with proximal anddistal incisions1

MIPPO (using DCS - specialinstruments)2

TARPO (intraarticular

fractures)3

MIPO with plates withangular stability4

1. Wenda K. Et al Injury, 1997, vol. 28, suppl 1, 13 19; 2. Krettek C. et al Injury, 1997, vol. 28, suppl. 1, 20-30

3. Krettek C. et al Injury, 1997, vol. 28, suppl. 1, 31-41, 4. Kregor P.J. et al Injury, 2001, vol. 32, suppl. 3, 32-47


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MINIMALLY INVASIVEMINIMALLY INVASIVE PLATEPLATE

OSTEOSYNTHESISOSTEOSYNTHESIS

((PROXIMAL AND DISTAL INCISIONSPROXIMAL AND DISTAL INCISIONS))


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FOR EXTRAARTICULAR FRACTURESFOR EXTRAARTICULAR FRACTURES

MINIMALLY INVASIVEMINIMALLY INVASIVE PLATEPLATE

OSTEOSYNTHESISOSTEOSYNTHESIS

((PROXIMAL AND DISTAL INCISIONSPROXIMAL AND DISTAL INCISIONS))

MIPO WITHMIPO WITH DCSDCS


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preoperative

MIPO WITHMIPO WITH DCSDCS

18 months

postoperative

MIPO WITH DCS


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preop.

MIPO WITH DCS

postop.

Type II Gustilo Open fracture

caused by low velocity bullet

I J

1 yr postop.

MIPO WITH DCS


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MIPO WITH DCSType II Gustilo Open fracture

caused by low velocity bullet

MINIMALLY INVASIVE PERCUTANEOUS PLATEMINIMALLY INVASIVE PERCUTANEOUS PLATE


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OSTEOSYNTHESIS -OSTEOSYNTHESIS - MIPMIPPPOO

1. Krettek C. et al Injury, 1997, vol. 28, suppl. 1, 20-30;



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OSTEOSYNTHESIS -OSTEOSYNTHESIS - MIPMIPPPOO

1. Krettek C. et al Injury, 1997, vol. 28, suppl. 1, 20-30;

TRANSARTICULAR APPROACH AND RETROGRADE PLATETRANSARTICULAR APPROACH AND RETROGRADE PLATE


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OSTEOSYNTHESIS - TARPOOSTEOSYNTHESIS - TARPO

1. Wenda K. et al Injury, 1997, vol. 28, suppl. 1, 13-19; Krettek C. et al Injury, 1997, vol. 28, suppl. 1, 20-30; 3. Krettek C. et al Injury,

1997, vol. 28, suppl. 1, 31-41; 4. Kregor P. J. et al Injury, 2001, vol. 32, suppl. 3, 32-47

SPECIAL CASESPATIENT: A M AGE:48 traffic accident victim the 1st case


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PATIENT: A.M. AGE:48, traffic accident victim, the 1st case

treated by MIPO Technique using a condylar buttress plate

(CBP) TARPO Technique National Premiere



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OSTEOSYNTHESIS - TARPOOSTEOSYNTHESIS - TARPO

TARPOTARPO withwith DDynamicynamic CCondylarondylarSScrewcrew(DCS)DCS)

BILATERAL DISTAL FEMORAL FRACTURESBILATERAL DISTAL FEMORAL FRACTURES


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BILATERAL DISTAL FEMORAL FRACTURESBILATERAL DISTAL FEMORAL FRACTURES

CT BASED ANALYSISCT BASED ANALYSIS

f th t f th di t l ff th t f th di t l f 11


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of the geometry of the distal femurof the geometry of the distal femur11

Guy P., Krettek C., CT based analysis of the geometry of the distal femur, Injury, 1999, vol. 29, suppl 3

MEAN ST.DEV LIMITS

LFC* 63 5 50 72

ICZ* 30 4 23 40DIG* 6 2 3 10

Wdcs * 70 6 62 84

MFA 51 5 40 58

JSA 170-250+ 81 1 77 84

INTRAOPERATIVE RESTORATION OF LIMB AXES,


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INTRAOPERATIVE RESTORATION OF LIMB AXES,

ROTATION AND LENGTH

THE CABLE TECHNIQUE

(frontal plane) difficult withtraction table

LESSER TROCHANTERSHAPE SIGN if intact(rotational aligment)

LATERAL FLUOROSCOPIC

PROJECTION (sagital plane)

RECURVATUM SIGN of the

distal femur (sagital plane)

METERSTICK TECHNIQUE

(length)

COMPLICATIONS OF INTERNAL FIXATIONCOMPLICATIONS OF INTERNAL FIXATION


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WITH CLASSIC PLATESWITH CLASSIC PLATES

IMMEDIATE DISPLACEMENT

SECONDARY DISPLACEMENT

PERIOSTEAL

COMPRESSION

Distal ScrewDistal Screw SlipSlip


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Dreinhfer K. International Osteoporosis Survey aggregated findings,Dreinhfer K. International Osteoporosis Survey aggregated findings,

BoneBone && Joint Decade 2000 - 2010Joint Decade 2000 - 2010

Preop.Preop. Postop.Postop. 22 monthsmonths postop.postop.

pp

(classic plates)(classic plates)

MIPOMIPO withwith DCSDCS


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G.E, F, 55 yrs, polytrauma by traffic accident; (A,B) distal femoral fracture type C3/AO,

opened, type II Gustilo; (C,D) TARPO condylar butress plate, with limited contract


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G.E, F, 55 yrs, polytrauma by traffic accident; (A,B) distal femoral fracture type C3/AO, opened,

type II Gustilo; (C,D) TARPO condylar butress plate, with limited contract


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G.E, F, 55 yrs, polytrauma by traffic accident; (A,B) distal femoral fracture type C3/AO, opened,

type II Gustilo; (C,D) TARPO condylar butress plate, with limited contract


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G.E, F, 55 yrs, polytrauma by traffic accident; control at 2 months

(front / lateral view)

2 months

po

VARUS


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LISSLISS LLessessIInvasivenvasiveSStabilisationtabilisationSSystemystem

PLATES WITH ANGULAR STABILITYPLATES WITH ANGULAR STABILITY

-- internalinternal fixator -fixator -


internal fixatinternal fixatoror


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LISSLISS LLessess IInvasivenvasiveSStabilisationtabilisation SSystemystem

LCPLCP LLockedocked CCompressionompression PPlatelate

-- internal fixatinternal fixator -or -

LISS SYSTEM WITH 2-PARTS AIMING DEVICELISS SYSTEM WITH 2-PARTS AIMING DEVICE


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Differences between distribution of the

biomechanical load for standard plates (A)by comparison with LISS (B)

and the bone implant interface


-- internalinternal fixators -fixators -


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LISS-DFLISS-DF

-- internalinternal fixators -fixators -

LCP-DFLCP-DF

ADVANTAGES OF THE INTERNAL FIXATORADVANTAGES OF THE INTERNAL FIXATOR


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MAINTAIN PRIMARY REDICTIONMAINTAIN PRIMARY REDICTION

CLASSICCLASSICPLATEPLATE

INTERNALINTERNALFIXATORFIXATOR



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STABILITY UNDER LOADSTABILITY UNDER LOAD

LACK OF SCREW SLIPLACK OF SCREW SLIP





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REDUCES THE RISK OF THEREDUCES THE RISK OF THE

SECONDARY DISPLACEMENTSECONDARY DISPLACEMENT





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INTEGRAL PERIOSTEUMINTEGRAL PERIOSTEUM

MAINTENANCE OF THE OSTEO-MAINTENANCE OF THE OSTEO-

PERIOSTEAL BLOOD SUPPLYPERIOSTEAL BLOOD SUPPLY



CLASSIC PLATES vs LOCKED PLATESCLASSIC PLATES vs LOCKED PLATES


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LISS SYSTEM WITH 2-PARTS AIMING DEVICELISS SYSTEM WITH 2-PARTS AIMING DEVICE


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LCP - DFLCP - DF


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PROSPECTIVE STUDY


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15 PATIENTS with 15 complex fractures of the distal femur:

AO classification: 3 type A2, 5 type A3, 4 type C2, 3 type C3

3 open fractures: 1 grade I, 1 grade II, 1 grade IIIA (Gustilo)

2 periprosthetic knee fractures

MINIMALLY INVASIVE OSTEOSYNTHESISMINIMALLY INVASIVE OSTEOSYNTHESIS WITHWITH

LISS 10 cases

LCP-DF 5 cases

MIPOMIPO WITHWITH LISSLISS


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D.E., FEMALE, AGE

39, SYSTEMICSCLERODERMA

Preop. Postop. 1 month postop

G H

4 month postop

MIPO WITH LISS - operative technique


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MIPO WITH LISS operative technique

D.E., FEMALE, AGE 39, SYSTEMIC SCLERODERMA

TARPO WITH LISS


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V.V., M., 20 yrs, polytrauma

Distal femoral fracture C3/AO

TARPO WITH LISS


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V.V., M., 20 yrs, polytrauma

Distal femoral fracture C3/AO

TARPO with LCP-DF


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Distal femoral fracture C3/AO open type IIIA, with bone loss

45 days

TARPO with LCP-DF


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3 months

TARPO with LCP-DF


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TARPO with LCP-DF


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3 months Bone grafting / Bone substitute


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Skiing trauma, LISS Day 0, intraoperatively C-arm control did not show the 20

angulation (b). Ten days after operation the axis was corrected.

Follow-up 1 year (c,d). (courtesy N. Schwarz, Klagenfurt)

LISS-DFLISS-DF ININ

PERIPERIPROSTHETICPROSTHETIC


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C.A.

FEMALE

AGE 77

Total Hip

Arthroplasty5 yearsago

FRACTURESFRACTURES


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LISS-DFLISS-DF ININ

PERIPERIPROSTHETICPROSTHETIC

FRACTURESFRACTURES

Fewer screws/longer plates


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Longer plates improve the construct by

increasing the lever arm of the plate

Longer plates require fewer screws to

achieve optimal fixation (near fracture and

farthest from fracture)

The strain on longer plates is reduced as is

the strain on the screws

Fewer screws minimize damage to the bone- A tensioned plate without lag screws acts as

an elastic but rigid spring

Christopher G Finkemeier, Granite Bay, USA

Mini - max fixation


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Gotzen et al, 1983

=

1 The main aim

The flexible elasticfixation concept


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1. The main aim

- to imitate spontaneous healing

- to allow early motion

2. This technology supports MIPO

3. The KEY = ELASTICITY

4. The displacement of the fracture under

load must be reversible

5. In osteoporotic bones implant

deformability = The KEY (LCP-LISS)

45 DAYS P.O.

RESULTS


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Radiographic union 12,4 weeks (7-20)Radiographic union 12,4 weeks (7-20)

No bone grafting 14 fracturesNo bone grafting 14 fractures- 1 case open fracture IIIA and bone loss,1 case open fracture IIIA and bone loss,

secondary bone grafting with osteoconductivesecondary bone grafting with osteoconductive

bone substitutionbone substitution- no infections or implant failuresno infections or implant failures- 2 cs varus/valgus diformities >52 cs varus/valgus diformities >5- length: 0,5 cm (0-1,8)length: 0,5 cm (0-1,8)- 1 cs - discrepancies > 1,5 cm1 cs - discrepancies > 1,5 cm

Final outcome (NEER SCORE):- Excellent 10 cases- Satisfactory 5 cases

LCP

Condylar plate


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Condylar plate

Holes for compaction

Combined holes for

locked 5 mm screws or

4,5 mm cortical screws

Anatomical shape

Peripheral holes

5 mm cannulated locked

screws or 5mm cannulated

conical screws

Central holes

7,3 mm cannulated locked

screws or 7,3 mm

cannulated conical screws

Plates with polyaxial stability


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Plates with poliaxial stability


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3 mths p.o. 4 mths p.o.

Plates with poliaxial stability


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5 mths p.o. Resection, fixation by plate with polyaxialstability, bone grafting and bone substitute

TIPS AND TRICKSfor internal fixators


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- Longer plates- Judicious use of screws with balanced fixation- Good close reduction before plate fixation and screw insertion- Avoiding the eccentrical plate placement (with missing the

monocortical scrwes into the diaphysis) small incision near the

last holes in the plate

- Usage of bicortical screws for severe osteoporosis- Primary bone grafting is not recommended- Secondary bone grafting when callus is not seen in Xray at 6

months p.o. (open fractures with bone loss)- Total weight bearing when on radiologic consolidation

CCONCLUSIONSONCLUSIONSADVANTAGES:

LISS-DF and LCP-DF:


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no other implant covers such a wide range of indications improvement of the percutaneous techniques

SAFE and EXCELLENT procedure The UNIQUE answer in:

Fr. C3/AO with short distal fragmentPeriprosthetic fracturesPeriprosthetic fractures Fractures on osteoporotic bone (better than CBP and retrograde nail) Open fractures

DISADVANTAGES:

LISS-DF and LCP-DF:Demanding technique, requires

expertise with MINIMALLY INVASIVEMINIMALLY INVASIVEOSTEOSYNTHESISOSTEOSYNTHESIS Expensive implantsExpensive implants


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Paper & Research: Minimal Invasive Procedures, a study artiped2009