home Drugs Osteosynthesis of the tibia with a plate and pin: removal surgery, rehabilitation when you can walk. Closed locked intramedullary osteosynthesis of the femur Osteosynthesis of the tibia with a plate

Osteosynthesis of the tibia with a plate and pin: removal surgery, rehabilitation when you can walk. Closed locked intramedullary osteosynthesis of the femur Osteosynthesis of the tibia with a plate

- This is in modern conditions the most common and effective method of treating injuries to bones and joints. Nowadays different types are used. Most often, such treatment is required to restore the tubular bones of the extremities. Previously, the most popular method of treating such injuries, along with casting, was the use of transosseous fixation devices. But they are bulky and inconvenient, and they often cause wound infections. Therefore, intramedullary osteosynthesis is now considered more effective to restore the integrity of tubular bones.

What is osteosynthesis

To treat bone injuries, surgery is now increasingly used rather than casting. Osteosynthesis surgery ensures more efficient and rapid bone fusion. It consists in the fact that bone fragments are combined and fixed with metal structures, pins, knitting needles or screws. Osteosynthesis, depending on the method of applying these devices, can be external or submersible.

The second method is divided into intramedullary osteosynthesis - fixation of the bone using rods inserted into the medullary canal, extramedullary, when fragments are combined using plates and screws, and transosseous - performed by special external devices of a pin design.

Characteristics of the method

The idea of intraosseous fixation of fragments was first proposed by the German scientist Kushner in the 40s of the 20th century. He was the first to perform intramedullary osteosynthesis of the femur. The rod he used was shaped like a trefoil.

But only towards the end of the century the technique of intramedullary osteosynthesis was developed and began to be widely used. Rods and other implants for locked osteosynthesis have been developed, which make it possible to firmly fix bone fragments. Depending on the purpose of use, they vary in shape, size and material. Some pins and rods allow them to be inserted into the bone without drilling out the canal, which reduces the traumatic nature of the operation. Modern rods for intramedullary osteosynthesis have a shape that follows the bends of the bone canal. They have a complex design that allows them to firmly fix the bone and prevent the fragments from moving. Rods are made from medical steel or titanium alloys.

This method is devoid of many disadvantages and complications of external structures. Now it is the most effective way to treat periarticular fractures, damage to the tubular bones of the leg, femur, shoulder, and in some cases even joints.

The technique of intramedullary osteosynthesis is effective for periarticular fractures of the limbs

Indications and contraindications for use

This operation is performed for closed fractures of the femur, humerus, and tibia. These injuries may be transverse or oblique. It is possible to use such an operation if a false joint develops due to improper bone fusion. If the injury is accompanied by damage to soft tissues, it is advisable to postpone osteosynthesis, since there is a high risk of infection of the fracture site. In this case, the operation is more difficult to perform, but it will also be effective.

Intramedullary osteosynthesis is contraindicated only in complex open fractures with extensive soft tissue damage, as well as in the presence of an infectious skin disease in the place where the pin needs to be inserted. This operation is not used in elderly patients, since due to degenerative changes in bone tissue, additional introduction of metal pins can cause complications.

Some diseases can also become an obstacle to intramedullary osteosynthesis. These are arthrosis in a late stage of development, arthritis, blood diseases, purulent infections. The operation is not performed on children due to the small width of the bone canal.

Kinds

Intramedullary osteosynthesis refers to intraosseous surgery. In this case, the fragments are repositioned and fixed with a pin, rod or screws. Depending on the method of introducing these structures into the bone canal, intramedullary osteosynthesis can be closed or open.

Previously, the open method was most often used. It is characterized by exposing the damaged area of the bone. The fragments are compared manually, and then a special rod is inserted into the medullary canal to fix them. But it is more effective closed method of osteosynthesis. It only requires a small incision. Through it, a rod is inserted into the bone canal using a special guide. All this happens under the control of an X-ray machine.

With intramedullary osteosynthesis, a rod is inserted into the medullary canal

The pins in the canal can be installed freely or with locking. In the latter case, they are additionally reinforced on both sides with screws. If osteosynthesis is performed without blocking, this increases the load on the bone marrow and increases the risk of complications. In addition, such fixation is not stable in case of oblique and helical fractures or under rotational loads. Therefore, it is more effective to use locking rods. Now they are produced with holes for screws. This operation not only firmly fixes even multiple fragments, but does not lead to compression of the bone marrow, which preserves its blood supply.

In addition, the operation differs in the method of inserting the rod. It can be introduced with preliminary drilling of the bone marrow canal, which leads to its injury. But recently, special thin rods are most often used, which do not require additional expansion of the channel.

There are even less common types of intramedullary osteosynthesis. Fragments can be fixed with several elastic rods. One straight and two rods curved opposite to each other are inserted into the bone. Their ends are bent. With this method, a plaster cast is not required. Another method was proposed in the 60s of the 20th century. The medullary canal is filled with pieces of wire so that it fills it tightly. It is believed that this method can provide more durable fixation of fragments.

When choosing the type of osteosynthesis, the doctor is guided by the patient’s condition, the type of fracture, its location and the severity of associated tissue damage.

For intramedullary osteosynthesis, rods of different designs are used

Open osteosynthesis

This operation is more common because it is simpler and more reliable. But, like any other operation, it is accompanied by blood loss and disruption of the integrity of soft tissues. Therefore, complications occur more often after open intramedullary osteosynthesis. But the advantage of using this method is the possibility of using it in complex treatment together with various devices for transosseous fixation. Separately open intramedullary osteosynthesis is now used very rarely.

During the operation, the fracture area is exposed and bone fragments are compared manually without the use of devices. This is precisely the advantage of the method, especially when there are many fragments. After comparing the fragments, they are fixed with a rod. The rod can be inserted in one of three ways.

With direct insertion, it is necessary to expose another piece of bone above the fracture. In this place, a hole is punched along the medullary canal and a nail is inserted into it, using it to compare the fragments. With retrograde insertion, they begin with the central fragment, comparing it with the rest, gradually driving the nail into the medullary canal. It is possible to insert the rod along the conductor. In this case, it also starts from the central fragment.

With intramedullary osteosynthesis of the femur, the alignment of the fragments is usually so strong that the application of plaster is not required. If surgery is performed on the lower leg, forearm or humerus, it usually ends with the application of a plaster cast.

Closed osteosynthesis

This method is now considered the most effective and safe. After it is carried out, there are no traces left. Compared to other osteosynthesis operations, it has several advantages:

minor soft tissue damage;
little blood loss;
stable fixation of bones without intervention in the fracture zone;
short operation time;
rapid restoration of limb functions;
no need to cast the limb;
Possibility of use for osteoporosis.

The essence of the method of closed intramedullary osteosynthesis is that a pin is inserted into the bone through a small incision. The incision is made away from the fracture site, so complications are rare. First, using a special apparatus, the bone fragments are repositioned. The entire operation process is monitored using radiography.

The operation of closed intramedullary osteosynthesis is low-traumatic and safe

Recently, this method has been improved. The fixing pins have holes on each edge. Screws are inserted into them through the bone, which lock the pin and prevent it and bone fragments from moving. This locked osteosynthesis ensures more efficient bone fusion and prevents complications. After all, the load during movement is distributed between the bone and the rod.

Fixation of the fracture site using this method is so strong that the very next day you can apply a dosed load to the injured limb. Performing special exercises stimulates the formation of callus. Consequently, the bone heals quickly and without complications.

A feature of locked intramedullary osteosynthesis is its higher efficiency compared to other treatment methods. It is indicated for complex fractures, combined injuries, and in the presence of many fragments. This operation can be used even in obese patients and patients with osteoporosis, since the pins that fix the bone are firmly attached in several places.

Complications

Negative consequences of intramedullary osteosynthesis are rare. They are mainly associated with the poor quality of the fixation rods, which can corrode or even break. In addition, the introduction of a foreign body into the bone marrow canal causes compression and disruption of blood supply. Bone marrow destruction may occur, causing a fat embolism or even shock. In addition, straight rods do not always correctly compare fragments of tubular bones, especially those that have a curved shape - tibia, femur and radius.

Usually, after such an operation, recovery occurs quickly; measured load on the limb can be given almost immediately

Recovery after surgery

The patient is allowed to move after closed intramedullary osteosynthesis within 1-2 days. Even with lower leg surgery, you can walk with crutches. In the first few days, severe pain in the injured limb is possible, which can be relieved with painkillers. The use of physiotherapeutic procedures is indicated to speed up healing. Be sure to perform special exercises, first under the guidance of a doctor, then on your own. Recovery usually takes from 3 to 6 months. The operation to remove the rod is even less traumatic than osteosynthesis itself.

The effectiveness of bone fixation depends on the type of injury and the correctness of the method chosen by the doctor. Fractures with smooth edges and a small number of fragments heal best. The effectiveness of the operation also depends on the type of rod. If it is too thick, there may be complications due to compression of the spinal cord. A very thin rod does not provide a strong hold and may even break. But now such medical errors are rare, since all stages of the operation are controlled by special equipment, which provides for all possible negative aspects.

In most cases, patient reviews of intramedullary osteosynthesis surgery are positive. After all, it allows you to quickly return to normal life after injury, rarely causes complications and is well tolerated. And the bone heals much better than with conventional treatment methods.

Osteosynthesis is the most common and effective method of treating bone and joint damage in modern conditions. Nowadays different types are used. Most often, such treatment is required to restore the tubular bones of the extremities. Previously, the most popular method of treating such injuries, along with casting, was the use of transosseous fixation devices. But they are bulky and inconvenient, and they often cause wound infections. Therefore, intramedullary osteosynthesis is now considered more effective to restore the integrity of tubular bones.

What is osteosynthesis

Characteristics of the method

Indications and contraindications for use

Intramedullary osteosynthesis is contraindicated only in complex open fractures with extensive soft tissue damage, as well as in the presence of an infectious skin disease in the place where the pin needs to be inserted. This operation is not used in elderly patients, since due to degenerative changes in bone tissue, additional introduction of metal pins can cause complications.

Kinds

Previously, the open method was most often used. It is characterized by exposing the damaged area of the bone. The fragments are compared manually, and then a special rod is inserted into the medullary canal to fix them. But the closed method of osteosynthesis is more effective. It only requires a small incision. Through it, a rod is inserted into the bone canal using a special guide. All this happens under the control of an X-ray machine.

When choosing the type of osteosynthesis, the doctor is guided by the patient’s condition, the type of fracture, its location and the severity of associated tissue damage.

Open osteosynthesis

Closed osteosynthesis

This method is now considered the most effective and safe. After it is carried out, there are no traces left. Compared to other osteosynthesis operations, it has several advantages:

minor soft tissue damage;
little blood loss;
stable fixation of bones without intervention in the fracture zone;
short operation time;
rapid restoration of limb functions;
no need to cast the limb;
Possibility of use for osteoporosis.

Complications

Recovery after surgery

Osteosynthesis is an operation of joining bone fragments using special fixation means, used for the treatment of fractures and various types of orthopedic surgical interventions.

Osteosynthesis is the most widely used method of treating bone fractures and false joints. With osteosynthesis, displacement of bone fragments is eliminated and their strong fixation in the correct position is ensured, the most favorable conditions for the formation of callus are created, the anatomical and functional results of treatment are improved, and the duration of treatment and the duration of disability are reduced.

Indications for osteosynthesis for fractures can be absolute and relative.

Osteosynthesis is absolutely indicated for fractures of the patella, olecranon, some fractures of the femoral neck with displacement of fragments, for fractures with significant and irreparable displacement of fragments, interposition of soft tissues, and the threat of damage to large vessels and nerves. A relative indication for osteosynthesis is the need to shorten the treatment period and eliminate minor displacements of fragments. Osteosynthesis is also indicated for open fractures after appropriate surgical treatment of soft tissues. Contraindications to osteosynthesis: severe general condition of the patient, shock, active, acute infectious diseases, severe chronic diseases and respiratory diseases. The osteosynthesis operation can be performed under general anesthesia or local anesthesia.

Rice. 1. Cerclage of tibia fragments for an oblique spiral fracture. Rice. 2. Osteosynthesis with a Lena plate for fractures of the tibia. Rice. 3. Intraosseous fixation of the femur with a metal rod. Rice. 4. Osteosynthesis of the femoral neck with a three-bladed nail.

For osteosynthesis, metal (nails, plates, screws - see Orthopedic instruments) and plastic fixatives, silk, catgut and other materials, as well as (see). Metal structures for osteosynthesis are made of a special grade of steel; they can remain in tissues for a long time without negatively affecting them or corroding. Based on the method of fastening fragments, the following types of osteosynthesis are distinguished. 1. Cerclage (wrap suture, Fig. 1) - carried out using wire or metal tape (cerclage tape). 2. Bone suture - made by passing threads or wires through bone canals drilled in the fragments to bring them together until they touch. 3. Osteosynthesis with screws, bolts and metal plates Lena. Screws and bolts are passed across the bone perpendicular to its axis, through both fragments. Metal plates are placed on the surface of the bone; they serve as an additional external “splint” (Fig. 2). 4. Osteosynthesis with metal beams. One side of the beam is carried into the medullary canal, the other is placed on the surface of the bone. 5. Intraosseous fixation of fractures using metal rods or bone pins. They are inserted into the medullary canal of both fragments, i.e. they serve as an internal “splint”.

Osteosynthesis can be performed by the open method with surgical exposure of the ends of the fragments or by the closed method (insertion of a rod into the medullary canal without opening the fracture site).

The choice of osteosynthesis method depends on the location and nature of the fracture. For diaphyseal fractures of long tubular bones (hips, bones, clavicle, etc.), intraosseous fixation with a metal rod (Kuncher, Dubrov, CITO, Bogdanov nails) has become most widespread. With intraosseous fixation of the femur (Fig. 3), a plaster cast is not applied; weight-bearing of the limb is allowed after 1 month. after surgery, recovers after 3 months. When intraosseous fixation of the bones of the forearm and lower leg requires additional immobilization with a plaster cast. Its duration depends on the type of fracture and the time of the operation, but on average it is 2-3 months. for tibia fractures and 2 months. for forearm fractures.

In case of fractures of the femoral neck, osteosynthesis of fragments is performed with a three-bladed nail (Fig. 4) using various devices (Petrov-Nenov, Kaplan devices, guide pins, etc.).

No additional plaster immobilization is required. The operation is performed mainly on elderly patients and practically only makes it possible to achieve healing of the fracture. Osteosynthesis facilitates the care of such patients, prevents the occurrence, etc. Healing of an impacted fracture of the femoral neck occurs after 6-8 months, at the same time full load on the limb is allowed.

For osteosynthesis for fractures of the shin bones, various plates and bolts are more often used. Using a metal bolt, the articular surfaces of the tibia are restored in case of intra-articular condyle fractures and “fork” divergence. For ankle fractures, fixation with a metal screw is used.

Fixators used for osteosynthesis must be removed after complete healing of the fracture, confirmed by x-ray. The exception is three-blade nails inserted for fractures of the femoral neck. They are removed only for special indications (infection, nail penetration, etc.). Excessively long stay of the fixator is undesirable, and in some cases dangerous (infection, bone damage, difficulty in late removal). Indications for immediate removal of fastening structures in case of a non-united fracture are the development of purulent processes in the area of the fracture (with fixation with plates and tapes), breakage and displacement of the fixator and other complications.

Possible complications of osteosynthesis may be wound suppuration, osteomyelitis, fatty tissue, nonunion of fragments, etc.

Caring for a patient after osteosynthesis surgery differs little from the usual care for operated patients. Particular attention should be paid to the condition of the dressing on the wound and the correct position of the operated limb.

Osteosynthesis (from the Greek osteon - bone and synthesis - connection) is the operative connection of juxtaposed bone fragments and their strong fixation using various materials. Osteosynthesis is used for both fresh and old (incorrectly fused, non-united) fractures, pseudarthrosis, after osteotomies and reconstructive operations on bones.

At the end of the 19th and beginning of the 20th century, methods of osteosynthesis using pins, screws, plates, and some types of transosseous and extraosseous fixation of fractures were proposed. G. Kuntscher developed in detail the method and technique of intraosseous fixation of fractures using a long steel nail, inserted into the medullary canal and firmly holding bone fragments. Later, various pins, rods, nails, probes were proposed for intraosseous fixation of fractures, and various plates, beams, screws, and bolts were proposed for holding bone fragments by extramedullary or transosseous osteosynthesis.

Various alloys that are resistant to corrosion were used as a material for osteosynthesis, for example vitalium - an alloy consisting of 65% cobalt, 30% chromium, 5% molybdenum; Nowadays, stainless steel and some biologically inert synthetic materials are most often used. In surgical practice, in some cases, bone materials are also used - pins, plates made of auto-, homo- or heterogeneous bone. The method of processing homo- and heterogeneous bone materials by freezing makes it possible to resort to them, for example, when replacing large bone defects.

Indications for osteosynthesis can be absolute and relative. Osteosynthesis is absolutely indicated for fractures with interposition of soft tissue between fragments, fractures with damage to blood vessels, nerves that have not fused correctly with shortening and severe impairment of limb function, and false joints; Absolute osteosynthesis is indicated for fractures of the patella, femoral neck, olecranon with pronounced displacement of bone fragments, as well as for many fractures that disrupt the shape of the limb and the function of the joints (elbow, knee, ankle). Relative indications for osteosynthesis are fractures of the clavicle with displacement of fragments, femoral neck in children, improperly healed fractures of the tibia with angular displacement and axis violation. Osteosynthesis can also be used for fresh open fractures, subject to careful surgical debridement of the soft tissue wound and the bone fragments themselves. The successful outcome of osteosynthesis is facilitated by: provision of special equipment, high surgeon technique, strict asepsis of the operation, and the use of antibiotics.

Contraindications to osteosynthesis: general serious condition of the patient, shock, diabetes, active tuberculosis, severe chronic diseases of the respiratory and cardiovascular systems, inflammatory condition of the skin, soft tissues and bones in the fracture area, acute infectious diseases.

Fresh gunshot fractures in the field can be subjected to osteosynthesis according to absolute indications after radical primary surgical treatment of the musculoskeletal wound, systematic administration of antibiotics and, if possible, direct observation of the wounded in the first 5-6 days after surgery. To successfully perform the operation, you should choose the appropriate method of anesthesia, have clear radiographs in two projections, use the most convenient and least traumatic access, select the necessary material, as well as instruments - both general surgical and special for operations on bones.

The simplest type of osteosynthesis is a bone suture, tying the fragments together with stainless steel wire, two or four sutures of which are tightened with special forceps and twisted to ensure tight contact of the fragments (Fig. 1, 1 and 2). This type of osteosynthesis is usually used for oblique fractures with a large fracture surface. However, such a method, especially when using a thin round wire, can cause unwanted atrophic changes in the fragments compressed by the wire. The latter must be removed with more or less pronounced consolidation of the fracture 2-3 months after surgery. It is more advisable to use lamellar wire rather than round wire.

A wire suture is sometimes used for intra-articular or periarticular fractures of the olecranon (Fig. 2), for fractures of the condyles or epicondyles of the shoulder, for dislocations in the acromioclavicular joint, for fractures of the patella (Fig. 3).

Rice. 1. Tying fragments with wire 1 - bone ligature with wire; 2 - bone ligature with Putti - Parama tape.

Rice. 2. Bone suture for a fracture of the olecranon.

Rice. 3. Wrapping suture for a fracture of the patella.

Rice. 4. Metal brackets for osteosynthesis during reconstructive operations: 1 - Moore - Blunt; 2 - Revenko.

Fig.5. Extractor with three-pronged nail.

Depending on the location of the fracture, it is necessary to resort to more complex methods of osteosynthesis. For fractures and pseudarthrosis of the femoral neck, fragments are nailed together with a three-bladed Smith-Petersen nail with a channel inside for a guide pin (extractor with a nail - see Fig. 5).

The Petrov-Yasnov channelless nail, which is inserted using a guide, can be successfully used. During reconstructive operations for defects of the head and neck of the femur, coxa vara, congenital and pathological dislocations, it is necessary to hold the fragment introduced into the articular cavity until fusion. The metal brackets of Moore-Blunt and T.A. Revenko are most suitable for this purpose (Fig. 4, 1 and 2). The latter consists of two connecting parts, which makes it easier to remove.

Depending on the shape of the femur fracture, various types of osteosynthesis are used. For transverse comminuted fractures, intraosseous metal osteosynthesis is used (Fig. 7); for oblique fractures with displacement, external fixation of fragments is added with cerclage sutures - tapes made of plate steel wire (Fig. 6).

Rice. 6. Combined osteosynthesis for a hip fracture: intramedullary metal rod and cerclage sutures.
Rice. 7. Intraosseous metal osteosynthesis using a Dubrov metal nail.
Rice. 8. Combined osteosynthesis: metal rod and bone graft.

Fig.9. Screwing the broken femoral condyles to the bone bed.
Rice. 10. Osteosynthesis with a metal screw for a fracture of the tibia and a rod in the fibula: 1 - direct projection; 2 - lateral projection.

To stimulate regenerative processes, especially in pseudarthrosis, after osteosynthesis, a bone graft is strengthened at the fracture site with a rod (Fig. 8).

Fractures of the femoral condyles, T- and V-shaped, with significant displacement that cannot be compared without blood, are subject to surgical treatment by screwing the fragments to the bone bed (Fig. 9). Osteosynthesis with screws is also used for fractures of the tibial condyles, as well as for ankle fractures of the tibia (Fig. 10, 1 and 2).

For transverse fractures of the tibia diaphysis, it is advisable to use intramedullary osteosynthesis with Küncher rods, and for oblique fractures, with Lenn plates, K. M. Klimov beams, and plate wire rings. In all cases on the lower leg, the operation is completed by applying a blind plaster cast for a period of 1.5-2 months to avoid loosening of the fragments, bending or even fracture of the rod.

The technique for inserting a Küncher metal rod for hip fractures is as follows. An incision is made along the anterior outer side of the thigh, along the projection line connecting the spina iliaca ant. sup. with the outer side of the patella. Having exposed the fracture site, the end of the proximal femoral fragment is lifted, a metal rod is inserted into its canal in a retrograde direction, with the eye forward, and the nail is driven in with rare but vigorous blows of the hammer. Its end extends near the greater trochanter beyond the bone. The soft tissue is dissected above the point where the nail exits and, having placed an impactor on the end of the rod, the rod is hammered in the opposite direction with blows of a hammer. When the end of the rod appears on the surface of the fracture, the distal fragment is mobilized, it is accurately compared with the proximal one, and the rod is inserted into the medullary canal to a depth sufficient for strong fixation of the fracture (so that the distal end of the rod lies in the spongy tissue of the lower metaepiphysis of the femur).

In case of a fracture of the tibia, a metal Küncher rod is inserted through the proximal fragment, through the upper metaphysis of the tibia by drilling an oblique canal into it, penetrating into the medullary cavity.

In case of fractures of the clavicle, metacarpal or metatarsal bones, as well as the phalanges of the fingers with significant displacement, the fragments can be fastened with a Kirschner wire, the free end of which is brought out for subsequent extraction when the fractures heal.

In case of fractures of the neck of the scapula with a large displacement, it is advisable to perform osteosynthesis with a metal plate with screws (Fig. 11).

Fig. 11. Osteosynthesis for a scapula fracture using a metal plate with screws.

Fig. 12. Osteoplastic arthrodesis of the knee joint according to Novachenko (stages 1-3 of the operation).

Treatment of diaphyseal fractures of the shoulder through osteosynthesis is carried out, as in the hip. The same rods are used, but of shorter length and thickness (F.R. Bogdanova, Kuncher), twisted wire. The rods are usually inserted from the distal end of the humerus, on the posterior side, above the ulnar fossa (fossa olecrani) of the humerus through an oblique canal drilled in it and communicating with the medullary cavity. The fragments can also be connected by K. M. Klimov’s beam. The proximity of the radial nerve requires special care when operating on the humerus.

In case of fractures of the humeral head with displacement or dislocation, its fragments are put together with short nails, screws, bone pins, etc. The separated fragments of the humeral condyles are connected using a bone suture or screws.

Diaphyseal fractures of the forearm with displacement of fragments are treated using intraosseous osteosynthesis with special thin metal rods, which are inserted into the bone canal of the radius from the distal fragment of the radius, and into the ulna, on the contrary, from top to bottom, from the side of the olecranon.

Recently, the method of compression osteosynthesis has become widespread, which consists of bringing bone fragments together under pressure caused by special metal structures (G. A. Egiazarov, O. N. Gudushauri, etc.).

Some types of special osteosynthesis are used at the completion of osteoplastic operations: arthrodesis of the knee joint according to N. P. Novachenko (Fig. 12); osteosynthesis during homoplastic transplantation of a semi-joint to fasten the graft to the femoral diaphysis after resection according to A. A. Korzh (Fig. 13); osteosynthesis with a “Russian castle” (Fig. 14); osteoplastic intra-extramedullary osteosynthesis according to V. D. Chaklin (Fig. 15).

Fig. 13. Osteosynthesis of a homogeneous half-joint with the femur: 1 and 2 - preparation of the graft; 3 - connection with the femoral diaphysis.

Fig. 14. Scheme of osteosynthesis according to the “Russian castle” type.

Fig. 15. Osteosynthesis with bone graft according to Chaklin.

In some cases, during osteosynthesis, bone pins of various shapes, lengths and thicknesses are used to fix fragments: for marginal fractures of the pelvic bones, for fractures of the condyles of the femur, tibia, shoulder, scaphoid of the hand, head of the radius, intercondylar eminence of the tibia, etc.

Repairing fractures in such cases, as a rule, is completed by applying plaster casts for the required period. It should be borne in mind that when a nail is inserted intraosseously into the humerus, the distal fragment often slides off the nail under the influence of the weight of the forearm. To prevent fragments from slipping, screw nails are used or a plaster cast is applied.

If osteosynthesis is performed ineptly, errors are possible: 1) insertion of the rod to an insufficient depth, which does not provide good fixation of fragments; 2) insufficiently accurate reduction of the fracture with rotation of the peripheral fragment to the sides; 3) penetration of the end of the rod into the joints; 4) damage to large vessels and nerves; 5) diastases between bone fragments; 6) major tissue trauma and wound infection; 7) the use of fixators that do not provide strong fastening of fractures.

What is osteosynthesis

Characteristics of the method

Indications and contraindications for use

Intramedullary osteosynthesis is contraindicated only in complex open fractures with extensive soft tissue damage, as well as in the presence of an infectious skin disease in the place where the pin needs to be inserted. This operation is not used in elderly patients, since due to degenerative changes in bone tissue, additional introduction of metal pins can cause complications.

Kinds

Previously, the open method was most often used. It is characterized by exposing the damaged area of the bone. The fragments are compared manually, and then a special rod is inserted into the medullary canal to fix them. But the closed method of osteosynthesis is more effective. It only requires a small incision. Through it, a rod is inserted into the bone canal using a special guide. All this happens under the control of an X-ray machine.

When choosing the type of osteosynthesis, the doctor is guided by the patient’s condition, the type of fracture, its location and the severity of associated tissue damage.

Open osteosynthesis

Closed osteosynthesis

This method is now considered the most effective and safe. After it is carried out, there are no traces left. Compared to other osteosynthesis operations, it has several advantages:

minor soft tissue damage;
little blood loss;
stable fixation of bones without intervention in the fracture zone;
short operation time;
rapid restoration of limb functions;
no need to cast the limb;
Possibility of use for osteoporosis.

Complications

Recovery after surgery

What is osteophyte: causes and treatment of marginal bone growths

Bone growths on joints are called osteophytes, and a similar phenomenon in general is osteophytosis. Often they do not make themselves felt until they become extensive, causing long-term constant or short-term, but intense pain and limited mobility. They are usually detected during a comprehensive examination after radiography.

Osteophytes can be localized on:

Joints of the hands and feet;
Spine;
Large joints of the upper or lower extremities.

Most often, osteophytosis occurs after injuries such as moderate and severe limb fractures, as a side effect of joint pathologies caused by degenerative changes in tissues and their destruction (arthrosis and arthritis of various types).

In some cases, osteophytes occur during a long-term inflammatory process in bone tissue. Metastases from other organs affected by cancer also sometimes contribute to the development of osteophytosis. Diabetes mellitus is another factor that provokes osteophytosis.

Often osteophytes are also called bone spurs; they can form from almost any bone tissue. Typically, these growths have a cone- or spike-shaped shape; if they are extensive, the mobility of the joints is significantly limited.

In addition, osteophytes can cause severe pain if nerves are pinched. The range of human movements is sharply limited depending on their location - it becomes difficult to squat, bend, turn or move a limb to the side.

In this case, osteophytosis requires treatment, usually surgery.

What it is

Osteophytes are bone growths that are so named because of their appearance. Literally translated from Greek, this medical term means “bone process.” Sometimes you can find another name for osteophytes - exophyte. In fact, exophyte and osteophytes are the same thing.

Osteophytes can be single or multiple, resembling spines, cones, hills, tubercles or processes. Their structure is the same as bone tissue.

The following types of osteophytes are distinguished:

Compact;
Spongy;
Metaplastic;
Osteochondral.

Osteophytes and osteophytosis can be successfully treated, including with folk remedies at home. If treatment is ineffective, they are removed.

The different types of osteophytes are discussed in more detail below.

Compact osteophytes

Bone tissue contains the so-called compact substance. Osteophytes of this type are its derivatives. The compact substance is indispensable in the formation of bones; in fact, it is their main part. This substance performs the following functions:

Protective – compact substance is the outer layer of bones. It is very durable and can withstand heavy loads.
Nutritional – reserves of various minerals, including calcium and phosphorus, are stored here.
Construction – up to 80% of the human bone skeleton consists of compact bone substance.

The compact layer is homogeneous in structure, it is especially dense in the middle sections of long and short tubular bones - fibula, tibia, femur, radius, ulna, humerus, foot bones and phalanges of the fingers.

Compact osteophytes most often form on the metatarsal bones of the foot or on the phalanges of the fingers of the upper and lower extremities.

Because the growths form at the ends of long bones, they are also called marginal osteophytes.

Spongy osteophytes

This type of osteophyte is formed from spongy bone tissue. These tissues have a special cellular structure formed from partitions and plates. The spongy substance is loose and not as dense as the compact one. It is this substance that forms the epiphyses - the marginal sections of the tubular bones.

The ribs, sternum, wrists, and vertebrae are entirely made of spongy tissue. Inside these bones there is red marrow, which is directly involved in the process of hematopoiesis.

If very heavy loads are placed on the spongy tissue, the formation and growth of osteophytes begins.

Osteochondral osteophytes

This type occurs when the structure of the cartilage tissue changes. In a healthy joint, all surfaces are covered with a cartilage layer. It performs very important functions: thanks to cartilage, the sliding of articular elements relative to each other during movement is ensured, and not friction, which would otherwise destroy bone tissue. In addition, cartilage serves as a shock absorber.

But if a disproportionate load is regularly placed on the cartilage tissue, if an inflammatory process occurs in the joints and degenerative changes occur, the cartilage loses its density and elasticity. It dries out and begins to deform.

Then the bone tissue, the mechanical impact on which increases, begins to grow. The formation of osteophytes in this case is a protective reaction of the body - in this way it tries to increase the area of the joint and distribute the load. In this case, osteophytes of the hip joint often develop.

The location of osteochondral osteophytes is large joints, knee or hip.

Why does osteophytosis occur?

Disruption of metabolic processes in the body is the very first and most common cause of the formation of osteophytes. Often this phenomenon is a consequence of excessive stress on the joints, which causes the destruction of cartilage. Injuries of various origins can also cause the development of osteophytes.

It is obvious that treatment of osteophytes should first of all be aimed at eliminating the root cause.

Their formation can be prevented if you treat the disease, which can become an impetus for this, and treat injuries in a timely and complete manner

Treatment of osteophytes

Identification of osteophytes in itself is not enough to begin treatment. It is imperative to establish the reason for their appearance. It is believed that if the growths do not cause pain and do not reduce mobility, then their treatment is not necessary.

If there is severe pain due to pinched nerves, then it is necessary to remove them surgically. Surgery is never performed just to eliminate osteophytosis. First of all, the main problem in the joints and bones is eliminated. What type of surgery will take place and on what scale depends on the degree of joint damage.

For example: osteophytosis of the knee joint was diagnosed, treatment with conservative methods, as well as treatment with folk remedies, did not bring results, surgery is indicated. In this case, it is first necessary to correctly align the elements of the knee joint and, if necessary, remove damaged parts of bones and cartilage. If required, completely worn-out cartilage is removed and replaced with mosaic grafts, and damaged bones are replaced with titanium implants.

Thus, osteophytosis is a consequence of other pathologies or injuries in a fairly advanced form. Its treatment is only a stage in the complex therapy of the main disease.

If a patient is diagnosed with a dangerous bone fracture, in which separate pieces of hard tissue have formed, he needs to undergo osteosynthesis. This procedure allows you to correctly compare the fragments using special devices and devices, which will ensure that the pieces do not move for a long time. All types of surgical reduction preserve the functionality of movement of the segment axis. The manipulation stabilizes and fixes the damaged area until healing occurs.

Most often, osteosynthesis is used for fractures inside joints, if the integrity of the surface has been compromised, or for damage to long tubular bones or the lower jaw. Before proceeding with such a complex operation, the patient must be carefully examined using a tomograph. This will allow doctors to draw up an accurate treatment plan, choose the optimal method, set of instruments and fixatives.

Types of procedure

Since this is a very complex operation that requires high precision, it is best to carry out the manipulation on the first day after the injury. But this is not always possible, so osteosynthesis can be divided into 2 types, taking into account the time of execution: primary and delayed. The latter type requires more accurate diagnosis, because there are cases of formation of a false joint or improper fusion of bones. In any case, the operation will be performed only after diagnosis and examination. For this purpose, ultrasound, x-ray and computed tomography are used.

The next method of classifying the types of this operation depends on the method of introducing fixing elements. There are only 2 options: submersible and external.

The first is also called internal osteosynthesis. To carry it out, use the following clamps:

knitting needles;
pins;
plates;
screws.

Intraosseous osteosynthesis is a type of submersible method in which a fixator (nails or pins) is inserted under X-ray control into the bone. Doctors perform closed and open surgery using this technique, which depends on the area and nature of the fracture. Another technique is bone osteosynthesis. This variation makes it possible to connect the bone. Main fasteners:

rings;
screws;
screws;
wire;
metal tape.

Transosseous osteosynthesis is prescribed if the fixator needs to be inserted through the wall of the bone tube in the transverse or oblique transverse direction. For this, an orthopedic traumatologist uses knitting needles or screws. The external transosseous method of repositioning fragments is carried out after exposing the fracture zone.

For this operation, doctors use special distraction-compression devices that stably fix the affected area. The fusion option allows the patient to recover faster after surgery and avoid plaster immobilization. Separately, it is worth mentioning the ultrasound procedure. This is a new method of osteosynthesis, which is not yet used so often.

Indications and contraindications

The main indications for this treatment method are not that extensive. Osteosynthesis is prescribed to a patient if, along with a bone fracture, he is diagnosed with pinched soft tissue that is pinched by fragments, or if a major nerve is damaged.

In addition, complex fractures that are beyond the power of a traumatologist are treated surgically. Typically these are injuries to the femoral neck, olecranon or displaced patella. A separate type is considered a closed fracture, which can turn into an open one due to perforation of the skin.

Osteosynthesis is also indicated for pseudarthrosis, as well as if the patient’s bone fragments have separated after a previous operation or they have not healed (slow recovery). The procedure is prescribed if the patient cannot undergo a closed operation. Surgical intervention is performed for injuries to the collarbone, joints, lower leg, hip, and spine.

Contraindications for such manipulation consist of several points.
For example, this procedure is not used when an infection is introduced into the affected area.
If a person has an open fracture, but the area is too large, osteosynthesis is not prescribed.
You should not resort to such an operation if the patient’s general condition is unsatisfactory.

venous insufficiency of the extremities;
systemic hard tissue disease;
dangerous pathologies of internal organs.

Briefly about innovative methods

Modern medicine differs significantly from earlier methods due to minimally invasive osteosynthesis. This technique allows fragments to be fused using small skin incisions, and doctors are able to perform both extraosseous and intraosseous surgery. This treatment option has a beneficial effect on the fusion process, after which the patient no longer needs cosmetic surgery.

A variation of this method is BIOS - intramedullary blocking osteosynthesis. It is used in the treatment of fractures of tubular bones of the extremities. All operations are monitored using an x-ray installation. The doctor makes a small incision 5 cm long. A special rod, made of titanium alloy or medical steel, is inserted into the medullary canal. It is fixed with screws, for which the specialist makes several punctures (about 1 cm) on the surface of the skin.

The essence of this method is to transfer part of the load from the damaged bone to the rod inside it. Since during the procedure there is no need to open the fracture zone, healing occurs much faster, because doctors are able to maintain the integrity of the blood supply system. After the operation, the patient is not put in plaster, so the recovery time is minimal.

There are extramedullary and intramedullary osteosynthesis. The first option involves the use of external devices of a spoke design, as well as the combination of fragments using screws and plates. The second allows you to fix the affected area using rods that are inserted into the medullary canal.

Femur

Such fractures are considered extremely serious and are most often diagnosed in older people. There are 3 types of femur fractures:

at the top;
in the lower part;
femoral diaphysis

In the first case, the operation is performed if the patient’s general condition is satisfactory and he does not have impacted injuries to the femoral neck. Typically, surgery is performed on the third day after injury. Osteosynthesis of the femur requires the use of the following instruments:

three-bladed nail;
cannulated screw;
L-shaped plate.

Before the operation, the patient will undergo skeletal traction and an x-ray. During the reposition, doctors will accurately compare the bone fragments, and then fix them with the necessary instrument. The technique for treating a midline fracture of this bone requires the use of a three-bladed nail.

In type 2 fractures, surgery is scheduled on the 6th day after the injury, but before that the patient must undergo skeletal traction. For fusion, doctors use rods and plates, devices that will fix the affected area externally. Features of the procedure: it is strictly forbidden to perform it on patients in serious condition. If fragments of hard tissue can injure the hip, they should be immediately immobilized. This usually occurs with combined or fragmented injuries.

After such a procedure, the patient is faced with the question of whether it is necessary to remove the plate, because this is another stress for the body. Such an operation is urgently necessary, if fusion does not occur, its conflict with any joint structure is diagnosed, which causes contracture of the latter.

Removal of metal structures is indicated if the patient had a fixator installed during surgery, which over time developed metallosis (corrosion).

Other factors for plate removal surgery:

infectious process;
migration or fracture of metal structures;
planned step-by-step removal as part of recovery (the stage is included in the entire course of treatment);
playing sports;
cosmetic procedure to remove a scar;
osteoporosis.

Options for upper limb surgery

The operation is performed for fractures of the bones of the extremities, so the procedure is often prescribed to fuse the hard tissues of the arm, leg, and hip. Osteosynthesis of the humerus can be performed using the Demyanov method, using compression plates, or Tkachenko, Kaplan-Antonov fixators, but with removable contractors. Manipulation is prescribed for fractures on the diaphysis of the humerus if conservative therapy is not successful.

Another surgical option involves treatment with a pin, which must be inserted through the proximal fragment. To do this, the doctor will have to expose the broken bone in the damaged area, find the tubercle and cut the skin over it. After this, an awl is used to make a hole through which the rod is driven into the medullary cavity. The fragments will need to be accurately compared and the inserted element advanced to the full length. The same manipulation can be performed through the distal piece of bone.

If a patient is diagnosed with an intra-articular fracture of the olecranon, it is best to undergo surgery to install metal structures. The procedure is performed immediately after the injury. Osteosynthesis of the olecranon requires fixation of the fragments, but before this manipulation the physician will need to completely eliminate the displacement. The patient wears the cast for 4 weeks or more, as this area is difficult to treat.

One of the most popular methods of osteosynthesis is Weber fusion. To do this, the specialist uses a titanium knitting needle (2 pieces) and wire, from which a special loop is made. But in most cases, the mobility of the limb will be permanently limited.

Lower limb

Separately, we should consider various fractures of the dyphyseal bones of the leg. Most often, patients come to a traumatologist with problems of the tibia. It is the largest and most important for the normal functioning of the lower limb. Previously, doctors carried out long-term treatment using plaster and skeletal traction, but this technology is ineffective, so now they use more stable methods.

Osteosynthesis of the tibia is a procedure that reduces rehabilitation time and is a minimally invasive option. In the event of a fracture of the diaphysis, the specialist will install a locking rod, and treat intra-articular damage by inserting a plate. External fixation devices are used to heal open fractures.

Ankle osteosynthesis is indicated in the presence of a large number of comminuted, helical, rotational, avulsion or comminuted fractures. The operation requires a mandatory preliminary X-ray, and sometimes a tomography and MRI are needed. The closed type of injury is fused using an Ilizarov apparatus and needles are inserted into the damaged area. In case of foot fractures (usually the metatarsal bones are affected), the fragments are fixed using the intramedullary method with the introduction of thin pins. In addition, the physician will apply a plaster cast to the damaged area, which should be worn for 2 months.

Patient rehabilitation

After the operation, you need to carefully monitor your well-being and, at the slightest negative symptoms, contact a specialist (acute pain, swelling or fever). These symptoms are normal in the first few days, but they should not appear until several weeks after the procedure.

Other complications after surgery that require urgent medical consultation:

arthritis;
fat embolism;
osteomyelitis;
gas gangrene;
suppuration.

Rehabilitation is a significant stage of the entire course of therapy. To prevent the muscles from atrophying and blood to flow into the damaged area, you should start doing physical therapy on time, which is prescribed the day after surgery.

After a week, the patient will need to begin to move actively, but in case of a fracture of the lower limb, he must use crutches.