Minimal Invasive Osteosynthesis Research Articles

Open Reduction and Internal Fixation with Plate and Screw versus Triplanar External Fixation in the Surgical Treatment of Calcaneal Fractures: A Retrospective Cohort Study.

Background: The treatment of displaced intra-articular calcaneal fractures (DIACF) is debated. This study compares open reduction and internal fixation (ORIF) with minimally invasive osteosynthesis (MIOS). Methods: We conducted a retrospective study on 70 patients with DIACF treated between January 2018 and September 2022, divided into ORIF (n = 50) and MIOS (n = 20) groups. Functional outcomes were assessed using the Maryland Foot Score (MFS) and the Creighton-Nebraska Health Foundation Assessment Scale (CNHFAS). Radiographic outcomes, complication rates, and reintervention rates were evaluated. A chi-square analysis examined the correlation between Sanders classification and treatment choice. Results: The chi-square analysis indicated no significant correlation between the complexity of the fracture and the type of treatment chosen (χ2 = 0.175, p = 0.916). Additionally, the Cochran-Armitage test for trend showed no significant trend in the choice of treatment based on fracture complexity (statistic = 0.048, p = 0.826). A Kaplan-Meier analysis showed a longer time to reintervention for MIOS (p = 0.029). Complication rates were similar, with specific complications varying between groups. Quality-of-life outcomes were comparable. Conclusions: ORIF is preferable for high-demand patients due to better anatomical outcomes, while MIOS suits high-risk patients by reducing reinterventions and complications. Further randomized trials are needed to confirm these findings.

Techniques and results of reconstruction of femoral head fractures: An Update

A narrative review of the literature was conducted to examine the data on femoral head fractures, with a particular focus on their management, complications and clinical outcomes.A PRISMA strategy was used. Medline and Scopus library databases were queried using pre-defined MeSH terms and Boolean operators. Quality of evidence was evaluated based on OCEBM and GRADE systems. The 50 eligible articles that met the predefined inclusion criteria reported on 1403 femoral head fractures. A detailed analysis of the surgical approaches used was performed in 38 articles with 856 fractures.Most fractures were treated surgically (90,8 %) with preferred anatomical reconstruction in 76,7 % of all operatively treated cases. Posterior approaches were the most common (52.5 %). This was evenly split between surgical hip dislocation and the classic Kocher-Langenbeck approach. 70.5 % of surgically treated cases achieved excellent or good result according to Thompson-Epstein criteria. Highest rate of excellent results showed minimal invasive osteosynthesis and surgical hip dislocation. Major late complications were avascular necrosis (10.8 %), post-traumatic arthritis (16.2 %) and heterotopic ossification (20.8 %). Secondary THA was necessary in 6.9 %. Highest rate of major complications was joined with anterior approach (77 %), lowest rate from frequently used approaches surgical hip dislocation (37.8 %).Conservative treatment recedes into the background. The Ganz flip osteotomy with surgical hip dislocation allows safe treatment of all types of fractures and should be considered the first choice, offering the lowest rate of complications and one of the best functional outcomes. Reconstruction of Pipkin Type III fractures should be reserved for very young patients due to high rate of major complications.

Double Pre-Bending of an Intramedullary Nail Is the Minimal Invasive Osteosynthesis Solution for Dia-Metaphyseal Fractures of the Radius in Children: Technical Note and Case Series.

Whereas in paediatric traumatology for diaphyseal fractures of the radius (intramedullary nail), as well as metaphyseal fractures (K-wire), minimal invasive methods for osteosynthesis were established as gold standard, the ideal osteosynthesis of fractures of the dia-metaphyseal area remains controversial. In this article, the author describes his own minimal invasive technique, using an intramedullary nail that must be pre-bent twice to achieve a stable reduction, with three-point support. The material used for this new surgical technique is an ordinary intramedullary nail. If not available, the operation can also be performed with a sufficiently lengthy K-wire. The intramedullary nail needs to be pre-bent twice, which follows a standardised procedure. A small case series is included to visualise the scope of this minimal-invasive method.

A review of minimally invasive fracture stabilization in dogs and cats.

ObjectiveTo summarize and discuss peer‐reviewed studies on minimally invasive osteosynthesis (MIO) of long bone, physeal, and articular fractures in dogs and cats.Study DesignInvited review.MethodsA critique of literature was performed to assess MIO feasibility, outcomes, and complications through PubMed, Scopus, and CAB abstracts research databases (2000–2020).ResultsMore than 40 MIO articles have been published in the last 15 years, but most studies had small numbers, lacked control groups, and used limited outcome measures. Studies generally showed that MIO was feasible in dogs and cats with low complication rates. The current evidence does not demonstrate superior bone healing or functional outcomes with MIO when compared to standard methods. Although treatment principles, case selection, and techniques varied depending on the anatomical location, there were no salient differences in complication rates among long bones, physeal, and articular fractures treated by MIO.ConclusionThe current available evidence and the personal experience of the authors support MIO as a promising fracture management modality. MIO can yield excellent outcomes when applied in carefully selected cases, performed by surgeons experienced in the technique. We cannot, however, conclude that MIO is superior to open fracture stabilization based on the available evidence in veterinary literature. Randomized controlled studies are warranted to prospectively compare MIO with other osteosynthesis techniques and thereby validate its role in fracture management for dogs and cats.

Perceptions of minimally invasive osteosynthesis: A 2018 survey of orthopedic surgeons.

To report perspectives of minimally invasive osteosynthesis (MIO) techniques in veterinary surgical practice in 2018. Electronic questionnaires. Diplomates and residents of the American College of Veterinary Surgery and European College of Veterinary Surgery and members of the Veterinary Orthopedic Society. Survey questions pertaining to MIO and minimally invasive plate osteosynthesis (MIPO) were sent electronically to the sample population. Questions assessed training, current caseload, benefits, and limitations of MIO and MIPO. Two hundred fifty-six veterinary surgeons completed questions pertaining to MIO, and 238 veterinary surgeons completed questions pertaining to MIPO. With regard to MIO, only 16% of respondents reported that they performed MIO regularly or exclusively, and 62% wanted to perform more MIO than they were currently undertaking. Tibial fractures were most commonly selected for MIO/MIPO stabilization techniques in both cats and dogs. Challenges in achieving adequate fracture reduction were identified as the greatest limitations of MIO/MIPO techniques. Forty-three percent of respondents felt there were not enough MIPO training opportunities. Currently, MIO/MIPO techniques are performed infrequently, with a large proportion of respondents revealing that they would like to perform more in the future. There is also evidence that additional training opportunities would be welcomed for MIPO. The results of our survey provide evidence that, despite the benefits of MIO and MIPO compared with more traditional fracture stabilization approaches, significant barriers must be overcome before the techniques are likely to be more widely adopted.

TALUS FRACTURES - CLINICAL OUTCOMES - CLOSED REDUCTION AND MINIMAL INVASIVE OSTEOSYNTHESIS VERSUS OPEN REDUCTION AND INTERNAL FIXATION

The purpose of this paper is to evaluate and compare the clinical outcomes of closed reduction with minimal invasive osteosynthesis with the ones of open reduction with internal fixation in talus fractures. In this study we used the Bucharest University Hospital, Department of Orthopaedics and Traumatology database. We retrospectively reviewed the records of 65 patients with 70 talus fractures, 5 of them were bilateral) managed in our department between 2010-2013. The 65 patients were divided into two groups. In the first group, there were 26 patients with 27 talus fractures who were treated by closed reduction under C-arm control followed by minimal invasive osteosynthesis. We compared the results with the ones of the second group of 39 patients who had 43 talus fractures who were treated by open reduction with internal fixation. The mean age was 32.5 years (range: 22-79) for the first group and 35.1 years (range: 20–85). The gender distribution was 15 males/11 females for the first group and 27 males/12 females for the second group. The average follow-up was 4 years (range 2-7.3years). To evaluate properly the clinical outcome, we determined the American Foot and Ankle Score at 3,6,12 months and every year after that and we recorded the complications for each case: avascular necrosis, tibiotalar osteoarthritis and talocalcanean osteoarthritis. By groups, the complications were: for Group 1: avascular necrosis – 2, tibiotalar osteoarthritis – 1, talocalcanean osteoarthritis - 3, and for Group 2: avascular necrosis – 4, tibiotalar osteoarthritis – 1, talocalcanean osteoarthritis – 4. Group 1 had an average value of the American Foot and Ankle Score at of 85.6 +/- 9.2 (extremes: 54-96) at 3 months, of 89.4+/-8.9 (extremes:61-97) at 6 months and of 94.5 +/-8.8 (extremes: 64-100) at 1 year, while in Group 2 the average value for the American Foot and Ankle Score was 73.9 +/- 9,6 (extremes: 50-91) at 3 months, 82.1+/-7,6 (extremes: 55-90) at 6 months and of 89.5 +/-8,7 (extremes: 60-94) at 1 year. Talar fractures are most commonly followed by complications as osteoarthritis of the adjacent joints and avascular necrosis of the talus. Tibiotalar and talocalcanean osteoarthritis are well tolerated by patients, and the postoperative recovery is considerably faster in the case of closed reduction with minimally invasive osteosynthesis.

Minimally Invasive Osteosynthes of Periprosthetic Fractures in the Lower Extremity

Periprosthetic fractures (PPF) of the lower extremity are increasing as the population ages, as the number of joint replacement increases, and patients remain active. The management of PPFs is challenging because of implant and cement obstruction within the bone, poor bone quality, and limited availability of bone stock for screw purchase. Historically, they have been associated with high rates of nonunion, infection, and fixation failure. Minimally invasive osteosynthesis (MIO) has reduced complications and improved union rates compared to conventional open plating of fractures. This paper reviews the principles of treatment, implant choices, and technical challenges of MIO for PPF in the lower extremity. In recent series, PPF for the lower extremity has shown reduced complication rates, improved union, and early mobilization compared prior open treatment. MIO for PPF is technically challenging but promising method of treatment for PPF.

Minimally invasive lag screw fixation of sacroiliac luxation/fracture using a dedicated novel instrument system: Apparatus and technique description.

To describe a novel Sacroiliac Luxation Instrument System (SILIS™) and its application in minimally invasive osteosynthesis (MIO) of sacroiliac luxations/fractures (SIL/F). The SILIS was designed to provide stable SIL/F reduction and accurate sacral screw placement while reducing personnel exposure to ionizing radiation during intraoperative fluoroscopy. Descriptive, proof of concept cadaveric study. A right SIL and a left SIL/F were created on a Labrador Retriever that had died of natural causes. Bilateral sacroiliac lag screw fixation was performed under fluoroscopic guidance with the SILIS, which consists of dedicated reduction and fixation instruments rigidly linked to table-bound 6-axis arms. Throughout surgery, the SILIS facilitated and maintained stable reduction and allowed accurate placement of a custom designed drill guide over the sacral body without the surgeon's manual holding of any reduction or fixation instruments. The surgical team was therefore able to step away from the C-arm when acquiring fluoroscopic images, thus reducing exposure to radiation. Dorsoventral and craniocaudal screw deviation from an ideal trajectory ranged from 0.9° to 3.8°. Both screws were fully located within the sacral body. The SILIS addresses limitations associated with MIO of SIL/F, including maintenance of reduction throughout surgery along with reliable and accurate sacral screw placement. Distance from the X-ray source is the most effective protection against radiation. Use of the SILIS allows the surgical team to move away from the C-arm during fluoroscopy, thereby reducing personnel exposure to dangerous direct and back-scattered ionizing radiation.

Treatment of Proximal Humerus Fracture with Minimally Invasive Osteosynthesis (MIO)

Treatment of Proximal Humerus Fracture with Minimally Invasive Osteosynthesis (MIO)

Treatment strategy for tibial plateau fractures: an update.

Tibial plateau fractures are complex injuries produced by high- or low-energy trauma. They principally affect young adults or the ‘third age’ population.These fractures usually have associated soft-tissue lesions that will affect their treatment. Sequential (staged) treatment (external fixation followed by definitive osteosynthesis) is recommended in more complex fracture patterns. But one should remember that any type of tibial plateau fracture can present with soft-tissue complications.Typically the Schatzker or AO/OTA classification is used, but the concept of the proximal tibia as a three-column structure and the detailed study of the posteromedial and posterolateral fragment morphology has changed its treatment strategy.Limb alignment and articular surface restoration, allowing early knee motion, are the main goals of surgical treatment. Partially articular factures can be treated by minimally-invasive methods and arthroscopy is useful to assist and control the fracture reduction and to treat intra-articular soft-tissue injuries.Open reduction and internal fixation (ORIF) is the gold standard treatment for these fractures. Complex articular fractures can be treated by ring external fixators and minimally-invasive osteosynthesis (EFMO) or by ORIF. EFMO can be related to suboptimal articular reduction; however, outcome analysis shows results that are equal to, or even superior to, ORIF. The ORIF strategy should also include the optimal reduction of the articular surface.Anterolateral and anteromedial surgical approaches do not permit adequate reduction and fixation of posterolateral and posteromedial fragments. To achieve this, it is necessary to reduce and fix them through specific posterolateral or posteromedial approaches that allow optimal reduction and plate/screw placement.Some authors have also suggested that primary total knee arthroplasty could be an option in specific patients and with specific fracture patterns.Cite this article: Prat-Fabregat S, Camacho-Carrasco P. Treatment strategy for tibial plateau fractures: an update. EFORT Open Rev 2016;1:225-232. DOI: 10.1302/2058-5241.1.000031.

The influence of the operation technique and implant used in the treatment of periprosthetic hip and interprosthetic femur fractures: a systematic literature review of 1571 cases.

A systematic literature review on periprosthetic/interprosthetic fracture fixation after hip arthroplasties was performed to summarize available clinical data. Operation techniques and implants used were evaluated as possible risk factors for outcomes. MEDLINE and Cochrane databases were searched. Articles describing patients with postoperative periprosthetic femur fractures sustained around a hip arthroplasty and with interprosthetic fractures treated with plates, nails, screws and/or cerclage were included. Considered articles were from 2000 or newer. Eligible abstracts were screened by two independent persons and discrepancies were resolved by consensus. Absolute numbers of complications and/or reoperation events along with their corresponding rates were calculated according to operation technique and type of implant. Relative risks of having a complication and/or a reoperation according to the operation technique and the type of implant used were estimated. Available data from 49 prospective and retrospective studies were analyzed. Of 1574 fractures, 81.7% were treated with plating. For 83.0% of all fractures, an open approach was applied. The overall complication rate was 14.3%. Fixation failure and nonunion were most often reported (fixation failure: 4.4%; nonunion: 3.9%). Nonunion and refracture occurred more often after open approaches than after minimal invasive osteosynthesis (nonunion: 4.5 vs. 0.0%, p=0.001; refracture: 3.8 vs. 0.6%. p=0.024). The relative risk for nonunion was 11.9 (95% CI 4.5-31.5) times higher (p<0.0001) for non-locking plates (13.0%) than for locking plates (1.1%). The clinical evidence of published studies dealing with periprosthetic/interprosthetic fractures after hip arthroplasty is generally low. This literature search suggested higher rates of nonunion and refracture after an open approach and a higher risk of nonunion for non-locking plates compared to locking plates. Based on the available clinical evidence, no treatment recommendations can be given.

CORR Insights(®): Reamed Intramedullary Nailing has an Adverse Effect on Bone Regeneration During the Distraction Phase in Tibial Lengthening.

Where Are We Now? How does periosteal and endosteal blood supply contribute to bone healing? It is a question posed by philosophers and scientists as far back as the 17th and 18th centuries—from Jean-Baptiste Du Hamel, to John Hunter, and Bernhard Heine. The problem of new bone formation in fracture healing has been well evaluated: 70% to 75% of the centrifugal blood supply of the cortex derives from the nutrient artery and the epiphyseal arteries and 25% to 30% from the periosteum, as long as the muscle coverage is intact. Intramedullary reaming will destroy the intramedullary arterial network of vascularization. Cortical defects will be filled with 70% bone formation from the medullary cavity and 30% from the periosteum. An endosteum does not exist. The periosteal bone healing appears with a delay of 5 days to 7 days [3-5, 9, 10]. The conclusion is clear: Any lengthening without intramedullary reaming will result in earlier bone formation. The amount of biomechanical load transfer, however, remains unclear. Where Do We Need To Go? The question that still needs to be answered is quite obvious: How can we combine the most biomechanically stable fixation with the least traumatization of the vascular network? But there are other gaps in the knowledge as well. What is the best fixation for the bone after having made the osteotomy? How can we achieve a stable fixation of the fragments allowing at the same time load transmission inducing bone formation? How can we avoid destroying the vascularization? Fracture fixation interaction and its mechanical and biological consequences are complicated and not yet fully understood. Alternative treatments include principle external fixation and intramedullary nailing. The external fixation diminishes the axial load acting on the mesenchymal tissue, leaves, however, the intramedullary vascularization intact. Nailing allows axial loading, but destroys the intramedullary vascular network. Therefore, one important question remains: Is intramedullary reaming in a more atraumatic way [6]—such as including the material of the implant, titanium, or stainless steel—a viable option [1, 2, 6]. The transcutaneous nailing technique might offer a way to achieve a stable fixation by a minimal invasive osteosynthesis even in open fracture treatment, a situation comparable to the osteotomy [7]. How Do We Get There? We have to combine different methods, based on a profound knowledge on the effects of each therapy. We should: (1) Study all possibilities for the osteotomy, as opposed to cutting the nutrient artery of the bone; (2) avoid reaming in the first phase of bone formation during lengthening; (3) study bone formation dependent on the revascularization using polychromatic fluorescent labels; and (4) define the first phase for revascularization and the second phase for axial loading. In terms of biomechanics, we can study all phases of load transfer by a gait analysis and choose the osteosynthesis appropriate to guarantee stability. One option, developed by Labitzke [8], is a spiral intramedullary nail, called the Endo-Helix, which can be introduced percutaneously by a stich incision and a drill hole in the tibial bone. The nail would find its way along the compact bone of the tibial tube and will not destroy any vasculature.

Outcome of Minimaly Invasive Plate Osteosynthesis (MIPO) Technique with Locking Compression Plate in Distal Tibial Fracture Management

Background: Distal tibial fractures including tibial pilon present a challenge as to their best method of management due to subcutaneous location of larger portion of tibia, paucity of soft tissue coverage and precarious blood supply of distal leg. MIPO (Minimal invasive plating osteosynthesis) has evolved as a newer concept to treat distal tibial fractures with minimal articular comminution and minimal soft tissue damage. It works on Biological fixation principle which assists physiological process of bone healing wisely with minimal operative intervention. Method: A prospective study for the management of distal tibial fractures by MIPO technique by using pre-contoured metaphyseal LCP (locking compression plate) was done, in 20 patients, between January 2012 and October 2013. Fractures were classified as per AO system and patients were followed and scored according to TEENY and WISS clinical scoring criteria. Result: Among 20 patients operated, there were 15 males and 5 females with a mean age of 38.95yrs (range from20-67yrs). 17 patients sustained extra-articular fractures (type A), 02 partial-articular fractures (type-B) and 01 total-articular fracture (type-C). High energy trauma (road traffic accident) predominated causing 13 fractures. Average trauma surgery interval was 12 days (02-22days). Patients were followed minimum for 6 months (range 06-18 months). Superficial wound infections were seen in 02 cases, surgical wound breakdown with implant exposure in 01 case and prominent hardware in 01 case. 17 patients (85%) had excellent/good outcome and 03 cases with complications had fair (02 cases) to poor (01 case) outcome. Conclusion: MIPO is an effective and safe technique for the management of distal tibial fractures without intra-articular comminution and minimum soft tissue damage. It preserves bone biology by maintaining balance between devascularisation and mechanical perfection. Further studies with longer follow-up and large sample size are warranted.

The Tibial Pilon Fractures: Are there Problems?

decade [2]. These fractures may be caused by falls, road accidents or sport injuries. TPF may be produced by two different dynamics: shear-stress injuries, which separate bone fragments, and compression injuries, which compress and impact bony matter. The mechanism is the implosion of the tibial plafond caused by axial compression between the talus and the distal tibial articular surface, with or without horizontal torsion [3]. It is often associated with significant degloving of the soft tissue surrounding the bone, while the skin, capsule and ligaments are partly spared. The aim of operative treatment is to anatomically reduce the fracture fragments to restore the congruity of the joint surface and promote bony union with minimal disruption of the soft tissue envelope [4]. So the TPF are always complex. Its complexity is related to the number of bone fragments, the decomposition of the bone fragments and the lesion of the neighboring soft tissues. Muller’s AO classification is the more complete and universally accepted system: it characterizes Type A (not articular), type B (partially articular) and type C (completely articular) fractures. TPF can also be classified by Ruedi and Allgower classification that includes three type of fracture depending on the displacement of articular surface, metaphyseal and injury extent of fractures [5]. The treatment of this type of fractures is a very timely topic, since there is no real consensus on the unique methods of treatment, which must take into account not only the stabilization of bone but also soft tissue which frequently leads to complications. Non operative management, such as cast immobilization, is reserved only for nondisplaced articular fractures, patients who have surgical controindications because of medical co-morbidities, or patients with low demand such as those who are nonambulatory. Surgical treatments are varied and different: minimally invasive osteosynthesis (MIO), open reduction and internal fixation (ORIF), minimally invasive plate osteosynthesis (MIPO), esternal fixation (EF), external fixator combined with limited invasive internal fixation (LIFEF), ilizarov treatment. Operative fixation of TPF has presented a significant challenge to the orthopaedic surgeon as the extensive soft tissue damage associated with such injuries makes surgical intervention hazardous. Advantages of minimally invasive osteosynthesis of pilon fractures compared to conventional open reduction and osteosynthesis, include protection of the soft tissue and no further disturbances of circulation-ideal prerequisites for undisturbed bone healing. Ruedi and Allogower [5] believed that anatomical restoration of the articular surface was fundamental surgical point. They considered essential: the restoration of the length and axis of fibula or tibia, the reconstruction of the distal end of the tibia, the filling of the defect resulting from im paction, using cancellous autografts, the support of the medial side of the tibia by plating to prevent a late varus deformity. White et al. say that provided surgery is performed expeditiously by experienced orthopedic trauma surgeons, most tibial pilon fractures can be stabilized by primary ORIF within a safe and effective operative window with relatively low rates of wound complications, a high quality of reduction, and functional outcomes that compare favorably with the published results for all other reported surgical treatments of these severe incurie [6]. A retrospective study by Watson et al. has shown that there is a significantly higher complication rate with the use of open plating techniques in AO type C fractures of the distal tibia, and this is probably related to the amount of dissection and stripping of soft tissues needed to achieve reduction and plate fixation [7].

Minimal-invasive Osteosynthesen von Pilonfrakturen

The primary aim of minimally invasive osteosynthesis (MIO) is the anatomical reconstruction of the distal tibial articular surface, with preservation of the soft tissue to allow early functional postoperative management. This should lead to a normal bone healing and recovery without arthrosis. Fractures type Rüedi I + II or AO43-B1, -B2, AO43-C1, -C2, rare and relative indications are fractures of type AO43-B3 and -C3 fractures without IIb and III° soft tissue injuries. It may also be used as an additional technique for osteosynthesis with external fixators. Severe comminuted fractures of the pilon with closed or open II and III° soft tissue damage. Severe soft tissue damage (III°). An intensive preoperative analysis of conventional X-rays and CT images is necessary to support the indication for MIO of pilon fractures. The first step is reduction of the fracture with axial traction, in some cases with a distractor or external fixator. The definitive reduction is performed with K-wire joysticks or reduction clamps. The key step is the intraoperative X-ray control of the reduction in various planes, if possible with 3D reconstruction. An alternative is also arthroscopic control of the articular reduction. All manipulations are performed via small incisions. After incision of the skin, all layers of soft tissue are smoothly divided with scissors allowing the soft tissue including vessels and nerves to be moved out of the working channel. All instruments and implants (e.g., K-wires, drill sleeve, screws) are introduced between the opened scissor branches. After lag screw osteosynthesis with 3.5 or 4.5mm conventional screws, the articular block is reduced to the diaphysis and fixed with a minimally invasively inserted plate. Under X-ray control in two planes, the plate is adjusted into position and preliminarily fixed with K-wires. The screws are inserted using the minimally invasive technique. Immediate mobilization starting on day1 with partial weight bearing (sole contact or 12-15kg) for 4-6weeks, postoperative protection with orthesis or split cast for 2-5days depending on degree of swelling, early functional physiotherapy, thrombosis prophylaxis with heparin until complete mobilization. Full weight-bearing depending on fracture type after 6-8weeks. Advantages of minimally invasive osteosynthesis of pilon fractures compared to conventional open reduction and osteosynthesis, include protection of the soft tissue and no further disturbances of circulation-ideal prerequisites for undisturbed bone healing. In 129patients after osteosynthesis of pilon fracture, no reoperations were necessary when using MIO, but reoperation was necessary with other techniques in 17.6% of all patients. In addition, no infections were observed with MIO vs. 13.4% of patients with other techniques. The average Olerud/Molander Score was 95points for the MIO group vs. 58.91 points for all patients treated, while MIO plus an external fixator received a score of 50points. The average Ankle Hindfoot Score was 64.9points, for MIO 87.5points, and for operations consisting of MIO plus an external fixator 58points.

Morphometric analysis of anatomical implant forms for minimally invasive acetabular fracture osteosynthesis

Introduction: Anatomical implants enable minimally invasive osteosynthesis (MIO) and represent ideal complements of computer-assisted surgical workflows. This 3D morphometric study analyzes anatomical implant forms (AIF) for acetabular fracture osteosynthesis (AFO).Materials and Methods: Three-dimensional pelvis models were created from clinical CT data of 99 European-Caucasian patients (50 females, 49 males). The mean age of the patients was 60.1 years (range: 20–89; SD 10.8). Definition of a referential region of interest (ROI) corresponding to an AIF for AFO was followed by automated ROI computation for each of the 198 hemipelvises. Three-dimensional statistical modeling and analysis of the resulting 198 homologous ROIs consisted of thin-plate spline transformation, generalized Procrustes fit, and principal component analysis.Results: The mean ROI length was 18.2 cm (range: 16.1–20.1 cm; SD 0.76). The first principal component (PC1) mainly modeled the ROI length, which correlated well with body height (r = 0.325; p < 0.001). PC1 comprised 47.4% of the overall ROI form variation. PC2 primarily influenced the ROI curvature in the anterior-posterior (inlet) view. Curvatures were more pronounced in female patients compared to males (p < 0.001). There was no gender-specific ROI size variation. PC1-4 contained 80.2% of the total ROI form variation. Left and right ROI forms displayed symmetry.Conclusion: This 3D morphometric study demonstrates the feasibility of anatomical implants for minimally invasive acetabular fracture osteosynthesis. Implant size/length is by far the most important variable of form variation. The necessity of gender-specific implant forms requires further investigation. The non-fractured, contralateral hemipelvis can be used for preoperative surgical planning. Ultimately, the plate design will depend on prospective implant fit tests based on the required fit as defined by the clinician.

Tibial pilon fractures: Which method of treatment?

A comprehensive review of the existing literature, related to treatment options and management principles of pilon fractures was performed, and its results are presented. The identified series advocate in favour of a number of different treatment strategies and fixation methods. Decision making was mostly dependent on the severity of the local injury, the fracture pattern, the condition of the soft tissues, patient's profile and surgical expertise. External fixation and conservative treatment did not provide sufficient articular congruence in many cases. Internal fixation allowed excellent restoration of joint congruity in Rüedi type I and II fractures. A staged approach, consisting of fibular plating and temporary bridging external fixation, later substituted by an internal minimal invasive osteosynthesis or by a definitive external fixation, was favourable for Rüedi type III fractures. Closed pilon fractures with bad soft tissue conditions (Tscherne ≥ 3) or open pilon fractures are regarded as contraindication of open reduction plate fixation. Anatomic reduction of the fracture, restoration of joint's congruence, reconstruction of the posterior column, with minimal soft tissue insult, were all highlighted as of paramount importance.

Suprakondyläre Femurfraktur bei Kniearthrodese

We present a 65 year old patient who complained of pain in the right supracondylar femur region after minor trauma. He previously underwent arthrodesis of the knee and had had several operative treatments for a septic hip endoprosthesis on the same side. The MRI showed a fracture of the supracondylar femur, which was successfully treated by partial intra- and extramedullary minimal invasive osteosynthesis.

Distal femoral fractures

Techniques of operative treatment of supra- and intercondylar fractures have changed in recent years. These changes refer to reduction techniques and implant selection. Operative approach concepts, which remained unchanged for several decades were critically evaluated and modified to a minimal invasive osteosynthesis [MIO]. This included for intraarticular fractures a trans-articular joint reconstruction and a retrograde plate osteosynthesis (TARPO). This technique result in better operative visualization and management of intraarticular comminution, saver fracture healing and better functional outcome. For extraarticular fractures a minimally invasive percutaneous plate osteosynthesis (MIPPO) via stab incisions only or retrograde intramedullary nailing is available. Beside that new strategies and techniques for the avoidance of axial malalignment, rotational deformities and leg length discrepancies are described, as well as a new plate generation (LISS: less invasive stabilization system), which behaves more like an internal fixator. The complex nature of combined fractures and soft tissue injuries of the distal femur and proximal tibia needs special attention and specific management. Distal femoral and proximal tibial fractures in young patients are usually caused by a high energy trauma. They are complicated by a high rate of systemic and local injuries to cartilage, ligaments and skin. The patients in this group with severe injuries need a detailed treatment algorithm, because the surgeon's individual skill, enthusiasm and wishful thinking frequently led to unsatisfactory results. A decision making scheme is presented specifically addressing timing and treatment modalities.

Aktueller Stellenwert der minimal-invasiven Chirurgie bei der Frakturversorgung

Minimal invasive osteosynthesis (MIO) should belong nowadays in the armentarium of each trauma surgeon. The tendency to minimize the invasivity of every operation is a logical development considering the goal of each surgeon to reduce the iatrogenic damage caused by the operation. The term 'MIO" stands for this criteria: Fracture zone not opened, reduction by indirect manoeuvres or percutaneously by joy-sticks, small approaches for the application of the implants, intraoperative assessment of the reduction by imaging (fluoroscopy, arthroscopy, endoscopy, etc.). Long time before the definition of "minimal invasive surgery" some technologies in trauma surgery as external fixator or intramedullary nailing already fulfilled these criteria. In the nineties of the 20th century first cases of percutaneously inserted plate osteosynthesis have been reported. This technique got a widespread acceptance under the term of MIPO (minimal invasive plate osteosynthesis) during the last five years, especially pushed with the new angular stable screw-plate systems (LISS, LCP). The main problem of the MIPO-technique is and remains the reduction (no direct manipulation possible) and their intraoperative assessment (no direct visualisation). The balance between the degree of invasivity and the achieved quality of reduction and stability is often difficult to define and must be related to several factors (localisation and type of fracture, local soft tissue conditions, quality of the bone, age and wishes of the patient, available implants, experience of the surgeon, etc.). New technologies as improved imaging, intraoperative navigation and percutaneous reduction tools will help to further reduce the invasivity of fracture surgery in the future.