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SurgicalSurgical fracturefracture treatmenttreatment, ,
fixationfixation typestypes
III. III. ExternalExternal SkeletalSkeletal FixationFixation
dr. Varga Attila
HistoryHistory of of ExternalExternal
FixationFixation
••AlreadyAlready usedused atat thethe end of end of thethe 19th 19th centurycentury
••GainedGained popularitypopularity duringduring//afterafter II WWII WW
••WidespreadWidespread useuse delayeddelayed ((missingmissing standardsstandards))
••WidelyWidely usedused atat presentpresent ((biologicalbiological osteosynthesisosteosynthesis))
AdvantagesAdvantages
•• MinimallyMinimally invasiveinvasive
•• RobustRobust mechanicalmechanical environmentenvironment
•• EffectiveEffective inin infectedinfected areasareas asas wellwell
•• DynamizationDynamization atat a a laterlater stagestage of of healinghealing
•• HighlyHighly customizablecustomizable (PMMA/APEF)(PMMA/APEF)
DisadvantagesDisadvantages
•• OutsideOutside of of weightweight bearingbearing axisaxis
•• Pin Pin tractstracts areare infectioninfection risksrisks
•• SomeSome systemssystems areare notnot „„flexibleflexible”” inin useuse (K(K--E)E)
•• SomewhatSomewhat limited limited rangerange of of orthopedicorthopedic situationssituations
•• CanCan injureinjure patientpatient//ownerowner
IndicationsIndications
•• TIBIATIBIA
•• RADIUS & ULNARADIUS & ULNA
•• HUMERUS & FEMURHUMERUS & FEMUR ((withwith restrictionsrestrictions))
•• ShearingShearing injuryinjury, , GunshotGunshot traumatrauma
•• SomeSome mandibularmandibular fracturesfractures
•• VeryVery smallsmall patientspatients
•• MatureMature patientspatients/ / ImmatureImmature patientspatients ((growthgrowthplateplate!!)!!)
TibiaTibia & & RadiusRadius//UlnaUlna
•• ESF most ESF most applicableapplicable toto
–– shaftshaft fracturesfractures
–– highlyhighly comminutedcomminuted diaphysealdiaphyseal fracuresfracures
HumerusHumerus & & FemurFemur
•• Less Less appropriateappropriate thanthan R & UR & U
–– OnlyOnly unilateralunilateral framesframes
–– ThickThick softsoft tissuetissue coveragecoverage (pin (pin tracttract infectioninfection))
–– BiggerBigger mobilitymobility of of softsoft tissuestissues (ex (ex femoropatellarfemoropatellar
liglig, , quadricepsquadriceps etcetc))
ShearingShearing injuriesinjuries
•• ESF ESF providesprovides easyeasy accessaccess toto thethe woundwound thusthus
facilitatesfacilitates dailydaily managementmanagement
•• RigidRigid fixationfixation a major a major advantageadvantage inin thethe casecase of of
articulararticular injuriesinjuries
ShearingShearing injuriesinjuries
ShearingShearing injuriesinjuries
ShearingShearing injuriesinjuries
ShearingShearing injuriesinjuries
GunshotGunshot traumatrauma
GunshotGunshot traumatrauma
GunshotGunshot traumatrauma
GunshotGunshot traumatrauma
MandibularMandibular fracturesfractures
DebridementDebridement
FixateurFixateur externeexterne
VeryVery smallsmall & & ImmatureImmature patientspatients
•• VeryVery smallsmall
–– MinimallyMinimally invasiveinvasive
–– PreservingPreserving softsoft tissuetissue & & bloodblood supplysupply
–– YorkshireYorkshire radiusradius, , footfoot, , carpuscarpus//tarsustarsus, MC/MT, MC/MT
•• ImmatureImmature
–– MUST NOTMUST NOT bridgebridge activeactive growthgrowth plateplate
–– LimbLimb elongatingelongating operationsoperations
BridgingBridging a a jointjoint
•• OnlyOnly maturemature animalsanimals!!!!
•• WhenWhen extra extra placeplace is is requiredrequired toto insertinsert pinspins
•• TemporaryTemporary fixationfixation!!!!
•• KeepKeep jointjoint inin functionalfunctional angleangle!!!!
•• SupportingSupporting a a „„weakweak”” internalinternal fixationfixation
LimbLimb correctioncorrection osteotomyosteotomy
ElementsElements of an ESF of an ESF systemsystem
•• FixationFixation pinspins
•• FixationFixation columncolumn ((connectingconnecting columncolumn//rodrod))
The The differentdifferent systemssystems
•• KK--E E systemsystem
•• SecurosSecuros, , ImexImex--SKSK
•• SynthesSynthes--AesculapAesculap
•• PMMA/APEFPMMA/APEF
•• ManuflexManuflex
KirschnerKirschner--EhmerEhmer systemsystem
•• ElementsElements
•• DisadvantagesDisadvantages
–– no no potentialpotential forfor usingusing smallersmaller//largerlarger pinspins
–– difficultydifficulty toto useuse positivepositive profileprofile pinspins
–– frequentfrequent failurefailure//looseningloosening of of clampsclamps
–– overcomplexovercomplex framesframes toto protectprotect weakweak frameframecomponentscomponents
–– StraightStraight connectingconnecting bar bar makesmakes idealideal pin pin placementplacementdifficultdifficult
SecurosSecuros systemsystem/ IMEX/ IMEX--SK SK systemsystem
•• ElementsElements
•• AdvantagesAdvantages toto KK--E E systemsystem
–– BetterBetter strengthstrength and and versatilityversatility
–– PositivePositive profileprofile pinspins
SecurosSecuros systemsystem
IMEXIMEX--SK SK systemsystem
IMEXIMEX--SK SK systemsystem
PMMA/APEFPMMA/APEF
•• ElementsElements
PMMA/APEFPMMA/APEF
•• AdvantagesAdvantages
–– easeease of of useuse
–– no no preoppreop planningplanning//preassemblypreassembly
–– minimalminimal riskrisk of pin/bar of pin/bar looseningloosening oror failurefailure
–– FREEDOMFREEDOM of of placingplacing pinspins��pin pin locationlocation notnot
subservientsubservient toto connectingconnecting bar bar positionposition
–– EasilyEasily combinedcombined withwith otherother typestypes
PMMA/APEFPMMA/APEF
•• DisadvantagesDisadvantages
–– SingleSingle useuse
–– PostopPostop adjustmentadjustment notnot easyeasy
–– DynamisingDynamising notnot easyeasy↔↔KK--EE
ManuflexManuflex
•• ElementsElements
ClassificationClassification of of framesframes
•• UnilateralUnilateral ((typetype I)I)–– typetype IaIa
–– typetype IbIb
–– typetype I I tietie--inin configconfig (IM pin)(IM pin)
•• BilateralBilateral ((typetype II)II)
•• MultiplanarMultiplanar ((typetype III)III)--exex. a . a unilateralunilateral//typetype IaIa addedadded toto a a bilateralbilateral
•• CircularCircular//IlizarovIlizarov
•• StrengthStrength & & stiffnessstiffness:: typetype IaIa < < typetype IbIb << typetype I I tietie--inin < < typetype II < II < typetype III)III)
ClassificationClassification of of framesframes
•• UnilateralUnilateral ((typetype I)I)
–– typetype IaIa
–– typetype IbIb
–– typetype I I tietie--inin configconfig (IM pin)(IM pin)
ClassificationClassification of of framesframes
•• BilateralBilateral ((typetype II)II)
•• MultiplanarMultiplanar ((typetype III)III)
--exex. a . a unilateralunilateral//typetype IaIa addedadded toto a a bilateralbilateral
•• CircularCircular//IlizarovIlizarov
Pin Pin TypesTypes
•• SmoothSmooth pinspins ((KK--wirewire, , SteinmannSteinmann pinspins))
–– CheapCheap butbut minimalminimal resistanceresistance toto pulloutpullout
–– InsertedInserted inin an an angleangle (70 (70 degreesdegrees))
•• PositivePositive profileprofile threadedthreaded pinspins
–– More More expensiveexpensive
–– IncreasedIncreased pinpin--bonebone interfaceinterface ( ( pinpin--looseningloosening))
–– No No needneed forfor angulationangulation
–– PreservesPreserves corecore diameterdiameter
–– Less Less proneprone toto pin pin breakagebreakage
Pin Pin TypesTypes
•• NegativeNegative threadedthreaded pinspins
–– BiggerBigger pinpin--bonebone interfaceinterface
–– ProneProne toto pin pin breakagebreakage ((notnot recommendedrecommended))
•• FullFull pinspins
–– BetterBetter strengthstrength & & stabilitystability
–– HarderHarder toto findfind safesafe softsoft tissuetissue „„corridorscorridors””
–– DemandsDemands more more carefulcareful alignmentalignment
•• HalfHalf pinspins
Pin Pin InsertionInsertion
•• MOST IMPORTANTMOST IMPORTANT: : correctcorrect limblimb alignmentalignment
•• MM--LL alignmentalignment and torsion!!(and torsion!!(valgusvalgus//varusvarus, ,
abnormalabnormal stressesstresses onon adjacentadjacent jointsjoints))
•• SomeSome CRANCRAN--CAUDCAUD malalignmentmalalignment cancan be be
toleratedtolerated ((elbowelbow//carpuscarpus,,stiflestifle//tarsustarsus cancan
accomodateaccomodate))
Pin Pin InsertionInsertion
•• ReleasingReleasing softsoft tissuestissues ((preventprevent windupwindup))
•• PrePre--drillingdrilling pin pin holesholes((decreasedecrease heatheat necrosisnecrosis))
•• PinsPins shouldshould be min 0,5be min 0,5--1 cm 1 cm fromfrom jointjoint surfacesurface
and min 2 cm and min 2 cm fromfrom fracturefracture lineline ((fissuresfissures!)!)
•• TwoTwo corticescortices engagedengaged
•• Begin Begin withwith proxprox//distdist onesones��alignmentalignment
Pin Pin InsertionInsertion
--controllingcontrolling heatheat--
•• AdverseAdverse reactionsreactions:: local local thermalthermal boneboneinjuryinjury++excessiveexcessive locallocal stressstress
•• PinPin--bonebone interfaceinterfaceaffectedaffected��necrosisnecrosis��fibrousfibrous connectiveconnectivetissuetissue��micromovementmicromovement of pinof pin��boneboneresorptionresorption��pinpin--looseningloosening
•• TrocarTrocar pointspoints of of pinspins dontdont facilitatefacilitate egressegress ofofbonebone shardsshards��impactionimpaction��HEATHEAT
•• >50rpm>50rpm�� thermalthermal necrosisnecrosis minimizedminimized
Pin Pin InsertionInsertion
•• LargerLarger pinspins �� greatergreater pinpin--bonebone interfaceinterface ((dondon’’ttexceedexceed 30%)30%)
•• MoreMore pinspins �� increaseincrease strengthstrength ((maxmax 33--4 per 4 per segmentsegment))
•• StifferStiffer pinspins �� more more eveneven loadload sharingsharing
•• SofterSofter pinspins �� exertsexerts more more stressstress onon nearnear cortexcortex��stressstress��resorptionresorption
Pin Pin InsertionInsertion SummarySummary
•• AtAt leastleast 3 3 pinspins per per fragmentfragment
•• NearNear/far/far fromfrom fracturefracture sitesite
•• LargestLargest possiblepossible pinspins ((dontdont exceedexceed 30%)30%)
•• StiffStiff pinspins
•• PositivePositive profileprofile threadedthreaded pinspins
•• IfIf usingusing smoothsmooth pinspins 70 70 degreesdegrees!!
BoneBone healinghealing
•• FactorsFactors affectingaffecting bonebone healinghealing
–– AgeAge & & generalgeneral healthhealth
–– LocationLocation & & typetype of of fracturefracture
–– SurroundingSurrounding softsoft tissuetissue damagedamage
–– ObtainedObtained degreedegree of of fragmentfragment appositionapposition
–– MechanicalMechanical environmentenvironment providedprovided byby ESFESF
•• PrimaryPrimary bonybony unionunion
–– RigidRigid internalinternal fixationfixation + + closeclose contactcontact of of fragmentsfragments
BoneBone healinghealing
•• SecondarySecondary bonebone healinghealing
–– FractureFracture gapsgaps + + somesome interfragmentaryinterfragmentary
motionmotion
–– ESF is ESF is goodgood exampleexample asas interfragmentayinterfragmentay
comprcompr. . usuallyusually isis notnot appliedapplied (ESF (ESF preservespreserves
bloodblood supplysupply, , importantimportant forfor 2ndary 2ndary unionunion))
PrimaryPrimary and and secondarysecondary bonybony
unionunion
BoneBone healinghealing
TRAUMATRAUMA
Soft tissue and bonedamage
HEMATOME
BoneBone healinghealing
HEMATOME
FIBRIN STABILIZATION
CYTOKINES
MESENCHYMAL CELL PROLIFERATION
VASCULARISATION
DifferentiationDifferentiation of of mesenchymalmesenchymal
cellscellsSmall amount of interfragmentary strain
And high O2 environment
Osteoblasts
More strain
And lower O2 environmentChondroblasts
Large amount of strain
And low O2 environment
Fibroblasts
CallusCallus FormationFormation
•• OutsideOutside of of calluscallus has has bestbest mechanicalmechanical & & biologicalbiological environmentenvironment
–– most most resistantresistant toto bendingbending forcesforces (less (less strainstrain))
–– periostealperiosteal bloodblood supplysupply maintainsmaintains highhigh O2 O2 environmentenvironment
•• FractureFracture endsends underunder highhigh strainstrain + + lowlow O2 O2 tensiontension (more (more chondrochondro//fibroblastsfibroblasts))
•• OuterOuter edgeedge of of calluscallus givesgives most most infoinfo ononsecondarysecondary calluscallus formationformation!!
CallusCallus FormationFormation
•• Limited Limited amountamount of of strainstrain helpshelps bonybony unionunion
((maxmax 2% of 2% of fracturefracture areaarea))
•• ExcessExcess strainstrain leadsleads toto chondrochondro//fibroblastfibroblast
formationformation + + lowlow O2 O2 envenv ��NONUNION!NONUNION!
•• AxialAxial forcesforces promotepromote ����bendingbending//twistingtwisting
forcesforces hinderhinder bonybony unionunion
PostopPostop XrayXray
•• AAAA=AAAA=alignmentalignment, , appositionapposition, , apparatusapparatus, , activityactivity
•• AreAre therethere adequateadequate numbernumber of of pinspins//segmentssegments??
•• Pin Pin sizesize correctcorrect??
•• AreAre pinspins properlyproperly centeredcentered, , safesafe distancedistance awayawayfromfrom skinskin//fracturefracture lineslines??
•• DoesDoes frameframe configconfig matchmatch fracturefracture typetype//patientpatientsizesize??
PostopPostop XrayXray
•• AmountAmount of of externalexternal calluscallus is is inverselyinversely
proportionalproportional toto thethe rigidityrigidity of of thethe frameframe
•• OsteomyelitisOsteomyelitis:: roughrough//irregularirregular calluscallus marginsmargins
•• PinPin--looseningloosening:: 1mm 1mm radiolucentradiolucent areaarea aroundaround
pinpin
PostopPostop XrayXray
•• ResorptionResorption//lacklack of of bridgingbridging calluscallus indicatesindicates
delayeddelayed//nonnon--unionunion
��reexplorationreexploration��bonebone graftinggrafting��newnew fixationfixation
•• GeneralizedGeneralized lossloss of of bonebone densitydensity indicatesindicates stressstress
protectionprotection��stagedstaged dynamizationdynamization
PostopPostop XrayXray
•• IdeallyIdeally fracturesfractures fillfill upup withwith bonebone densitydensity
materialmaterial afterafter 66--8 8 weeksweeks
•• RechecksRechecks atat 77--10 10 daysdays, 6, 6--8 8 weeksweeks thenthen everyevery 33--4 4
weeksweeks
•• 77--10 10 daysdays recheckrecheck
–– PartiallyPartially weightweight bearingbearing
–– SomeSome edemaedema
–– MildMild painpain onon pin sitepin site
PostopPostop XrayXray
•• 66--8 8 weeksweeks recheckrecheck
–– UsuallyUsually healedhealed byby thisthis timetime
–– WeightWeight bearingbearing
–– PainPain free pin free pin sitessites ((otherwiseotherwise looseningloosening))
–– XraysXrays ((evaluateevaluate AAAAsAAAAs))�� decisiondecision�� more more timetime, ,
removalremoval, , interventionintervention oror dynamizationdynamization
ESF ESF cancan be be removedremoved
•• AnimalAnimal is is weightweight bearingbearing
•• SufficientSufficient bonybony calluscallus bridgingbridging thethe fracturefracture gapgap
((densitydensity�� adjacentadjacent bonebone))
•• IfIf severesevere lamenesslameness butbut goodgood calluscallus�� findfind reasonreason
((oftenoften looseloose pin!)pin!)
More More timetime neededneeded
•• WeightWeight bearingbearing butbut calluscallus notnot completelycompletely
bridgedbridged
•• BridgingBridging calluscallus of of insufficientinsufficient radiodensityradiodensity ((tootoo
stiffstiff frameframe?)?)
ComplicationsComplications
•• SoftSoft tissuetissue impalementimpalement:: musclesmuscles, , nervesnerves ((cancan
be be severesevere, , „„windwind--upup””) ) tendonstendons, , vesselsvessels
•• ESF ESF faliurefaliure:: frameframe faliurefaliure, pin , pin breakagebreakage, , pinpin
looseningloosening
•• InfectionInfection:: osteomyelitisosteomyelitis, , sequestrationsequestration, ,
major/minor pin major/minor pin tracttract infectionsinfections
Pin Pin breakagebreakage and and looseningloosening
•• Pin Pin breakagebreakage:: negativenegative threadedthreaded pinpin?, ?, reassessreassess
frameframe strengthstrength//rigidityrigidity
•• Pin Pin pulloutpullout:: smoothsmooth pinspins insertedinserted parallelparallel
•• PramaturePramature pin pin looseningloosening:: veryvery commoncommon
complicationcomplication, , oftenoften poorpoor placementplacement!!
–– IfIf goodgood bonebone unionunion processprocess�� removeremove looseloose pin(s) = pin(s) =
dynamizationdynamization
–– IfIf frameframe is is notnot stabilestabile anymoreanymore�� reviewreview ESFESF
Pin loosening
Pin tract drainage
Infection
Instability
OsteomyelitisOsteomyelitis and and sequestrumsequestrum
•• ESF is a ESF is a veryvery effectiveeffective methodmethod toto managemanage
ongoingongoing osteomyelitisosteomyelitis comingcoming fromfrom otherother typetype
of of fixationfixation methodmethod ((internalinternal!)!)
•• SequestrumSequestrum�� resultresult of of thermalthermal necrosisnecrosis ((poorpoor
techniquetechnique, , calcaneuscalcaneus!)!)
–– RemoveRemove pin and drill out pin and drill out tracttract, , draindrain freelyfreely
Major pin Major pin tracttract infectioninfection
•• CommonCommon complcompl. . causescauses prematurepremature pin pin
looseningloosening
•• BacterialBacterial colonizationcolonization of of pinpin--skinskin interfaceinterface
•• PainPain
•• PurulentPurulent dischargedischarge
•• Pin Pin looseningloosening
Minor pin Minor pin tracttract infectioninfection
•• ToTo somesome degreedegree itsits normalnormal ((wherewhere thickthick softsoft
tissuetissue))
•• BacterialBacterial contaminationcontamination of of thethe pinpin--skinskin surfacesurface
•• Limited Limited granulationgranulation tissuetissue formationformation
•• LightLight serousserous dischargedischarge
•• LackLack of of painpain
•• No pin No pin looseningloosening
ThankThank YouYou!!
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