innovations in fracture repair
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Innova&onsinFractureRepair
May12,2016
Adam Strom, DVM, MS, DACVS-SA
Outline
1. Pathophysiologyoffracturehealing2. Biomechanicsofplate/screws3. Historyoflockingplate4. Minimallyinvasiveplate
osteosynthesis(MIPO)5. Currentuses/research6. Thefuture
Fracturehealing:Inthepast…
• AnatomicReduc&onandRigidFixa&on– Extensivesurgicaltrauma
• Disturbanceoffracturehematoma(FH)• Devasculariza&onofbonefragments• TraumatosurroundingsoV&ssues
– Interfragmentarystrain– Riskofnonunionorimplantfailure
Fracturehealing
• Goals– Encouragehealing– Stabilizefracture– Minimizepain– Returnappearance
• Length• Rota&on/axialalignment• Jointsurfacealignment
– Earlyreturntofunc&on!!!
Fracturehealing
• Primarybonehealing(directorendosteal)– Rigidfixa&on– Strain<2%– Minimalcallus– Skips&ssuedifferen&a&on– RepairviaHaversianosteones
Primaryhealing
• Contacthealing– <0.01mm– Strain<2%
• Gaphealing– Gap<1mm– Strain<2%
Secondaryhealing
• Secondarybonehealing(indirectorendochondral)– Lessstableenvironments– Stepwisechangein&ssue
• Eachstepdecreasesstrain
Strain
• Changeinlength/Originallength(ΔL/L)– ie:5µmgapwith0.2µmdisplacement=4%strain(0.2/5)
• Increasedstrainpreventscertain&ssuesfromforming.
Straincont.
• Strainreduc&on– Increasedgaplength(comminu&on,reduc&on,resorp&on)
• ie:7µmgapwith0.2µmdisplacement=2.8%strain(0.2/7)
– Decreaseddisplacement• ie:5µmgapwith0.1µmdisplacement=2%strain(0.1/5)
Straincont.
• Strainvariesbetweensimilarsimpleandcomminutedfractures
Internalfixa&on
• Openanatomicreduc&onwithinternalfixa&on(ORIF)– Primarybonehealing– Mayrequirewideexposure– Ar&cularreconstruc&on– Pre-contouringofplate
• Biologicinternalfixa&on– SupportfromtheboneandsoV
&ssues&llpresent– Minimallyinvasiveorclosed
reduc&on– Minimiza&onofimplants
Biologicfixa&oncont.
• Openbutdonottouch(OBDNT)
• Minimallyinvasivepercutaneousosteosynthsis(MIPO)
Platebiomechanics
• Platefunc&ons1. Compression2. Neutraliza&on3. Buhress4. +/-Bridging
Platebiomechanicscont.
• DynamicCompressionPlates(DCP)– Eccentricholes–axialcompression
– Compressionofplatetoboneviascrew
– Nega&ves• Lossofrigidreduc&ond/tplatecontour
• Periostealcompression
Platebiomechanicscont.
• LimitedContact-DCP(LC-DCP)– Reducedcontactwithperiosteum
– Decreasedweaknessatscrewholes
Platebiomechanicscont.
• Lockingplates– Fixedanglescrews– Screwslockedintoplate– Internalfixator
• ShorterdistancethanESF–increasedrigidity
• Nopintracts– Nointerfragmentarycompression
Biomechanicscont.
• Indica&ons– Diaphysealfractures– Comminutedfractures– Osteopenicbone– Riskofinfec&on
• Contraindica&ons– Simplefractures– Intraar&cular
• Cost
Biomechanicscont.
• Screwposi&on
• ScrewNumbers
• Screwdepth
• Drillguideandtorquelimit
History
• PointContact-Fixa&on(PC-FIX)
• LessInvasiveStabiliza&onSystem(LISS)
• LockingCompressionPlate(LCP)
LockingCompressionPlate(LCP)
• LCPprinciples– Compression
– Bridging– Combina&on
LockingCompressionPlate(LCP)
• Combina&onhole– 200°captureoflockinghead.
– Lockingpor&onissmallestpor&onofhole
Screws
• Types– Cor&cal,cancellous– Selftapping– Selfdrillinglocking
• Lockingscrewspull-out– Widercore,smallerthreads– Monocor&calpurchase
LCPscrewplacement
• Rela&onshipbetweenangleofscrewinser&onandstabilityofplate
• Screwsinsertedatdifferentangles(0,5,10°)
• Testedun&lfailure• Significantstabilitydecreaseat>10º
LCP
• Currentlyavailableinsizes1.5,2.0,2.4,2.7,3.5mmandup
• Canbeusedondogsaslihleas1kg
LCP
LCP
LCP
AdvancedLockingPlateSystem(ALPS)
• Titaniumplates• Lockingandstandardscrews• Minimalplatefootprint• Bendingin3planes
• Needforbiomechanicalliterature
TheFuture
• Specificplates– PHILOS
• Tibial– TOMO-Fit
• Shoulder
• Computerguidedsurgery
…andpresent:Biologicalosteosynthesis
• PreservesoV&ssue&vascularintegrity• Remotemanipula&onofmainfragments• Restorelength&3-Dbonealignment
Alignment
…andpresent:Biologicalosteosynthesis
• BonegraVsnotnecessary• Limitedhardware
vs.
Biologicosteosynthesis
• Results:– Increasedcallusproduc&on– Acceleratedradiographicunion– Earliergaininbiomechanicalstrength– Earlierreturntofunc&on
KinastC,BolhofnerBR,MastJW,andGanzR.Subtrochantericfracturesofthefemur.Resultsoftreatmentwiththe95degreescondylarblade-plate.CORR1989Jan;(238):122-30.HeitemeyerU,KemperF,HierholzerG,etal(1987)Severelycomminutedfemoralfractures:treatmentbybridging-plateosteosynthesis.
ArchOrthopTraumaSurg;106(5):327–330.JohnsonAL,SmithCW,SchaefferDJ.Fragmentreconstruc&onandboneplatefixa&onversusbridgingplatefixa&onfortrea&nghighlycomminuted
femoralfracturesindogs:35cases(1987–1997).JAmVetMedAssoc;213(8):1157–1161,1998.RozbruchSR,MiillerU,Gau&erE,etal.TheEvolu&onofFemoralShaVPla&ngTechniqueCORR1998;354(195-208)
GrundnesOetal.,ActaOrthopScand,1993,64,3,340-342
MIPO
• Tibialfracturesin10animals(6K9and4Fel.)– Pre-surgicalplanning– Medialproximalanddistal
incisons,tunneling– 2-4screwsateachend
• MeanSX&me59min• Nosecondprocedures• Goodtoexcellentoutcome
inall
• Indirectbiologicalapproaches:• OBDNT(OpenButDoNotTouch)• MIO(MinimallyInvasiveOsteosynthesis)
BiologicalOsteosynthesis
MIP(P)O(MinimallyInvasive(Percutaneous)PlateOsteosynthesis)
• GroupI:Anatomicalreduc&on(n=39)• GroupII:Bridging-plateosteosynthesis(n=32)
HeitemeyerU,KemperF,HierholzerG,etal(1987)Severelycomminutedfemoralfractures:treatmentbybridging-plateosteosynthesis.ArchOrthopTraumaSurg;106(5):327–330.
Bridging-plateosteosynthesisfor71comminutedfemoralshaVfractures
Conven&onal(n=24) Biological(n=23)Clinicalunion(mos) 5.4 4.2Delayedornonunion 16.6% 0%
Infec&on 20.8% 0%BonegraV 10 0
Conven&onalvs.Biologicalpla&ng:47subtrochantericfracturesofthefemur
KinastC,BolhofnerBR,MastJW,andGanzR.Subtrochantericfracturesofthefemur.Resultsoftreatmentwiththe95degreescondylarblade-plate.CORR1989Jan;(238):122-30.
• ORIF(n=22)• ESF(n=25)• Nodifferencesin:
– Hospitaliza&on– Timetounion
• Complica&ons:– ORIF18%– ESF4%
• Conclusion:– Closedreduc&on>Openreduc&on
DudleyM,JohnsonAL,OlmsteadM,etal.Openreduc&onandboneplatestabiliza&on,comparedwithclosedreduc&onandexternalfixa&on,fortreatmentofcomminuted&bialfractures:47cases(1980–1995)indogs.JAmVetMedAssoc;211(8):1008–1012,1997
ORIFvs.closedreduc&onwithESF47&bialfracturesindogs
– GroupI:Anatomicreconstruc&on(n=20)– GroupII:Bridgingplatefixa&on(n=15)– Nodifferencesin
• Hospitaliza&on• Alignment• Complica&ons
– Bridging-platefixa&on:• Shorteropera&ve&mes• Faster&mestoradiographicunion
JohnsonAL,SmithCW,SchaefferDJ.Fragmentreconstruc&onandboneplatefixa&onversusbridgingplatefixa&onfortrea&nghighlycomminutedfemoralfracturesindogs:35cases(1987–1997).JAmVetMedAssoc;213(8):1157–1161,1998.
Anatomicreduc&on/platefixa&onvs.bridging-platefixa&onin35femoralfracturesindogs.
• Alignmentrestoredandsimilartocontralateral&biae
Prospec&veEvalua&onofMIPOin36TibialFracturesin28Dogsand8Cats
GuiotLP,DéjardinLM.Prospec&veEvalua&onofMinimallyInvasivePlateOsteosynthesisin36Nonar&cularTibialFracturesinDogsandCats.VetSurg40(2011)171–182.
• Meanhealing&me36/45days
GuiotLP,DéjardinLM.Prospec&veEvalua&onofMinimallyInvasivePlateOsteosynthesisin36Nonar&cularTibialFracturesinDogsandCats.VetSurg40(2011)171–182.
Prospec&veEvalua&onofMIPOin36TibialFracturesinDogsandCats
• Minorcomplica&ons(11%)• Majorcomplica&on(3%)
GuiotLP,DéjardinLM.Prospec&veEvalua&onofMinimallyInvasivePlateOsteosynthesisin36Nonar&cularTibialFracturesinDogsandCats.VetSurg40(2011)171–182.
Prospec&veEvalua&onofMIPOin36TibialFracturesinDogsandCats
MIPO–clinicaloutcome
• Tibialfractures(36)
• Healing&me– ORIF87d.*– MIO36to45d.#
• Complica&ons– ORIF18%(severe)*– MIO2.8%(severe)#– MIO8.5%(minor)#
*Dudley,JAVMA 1997#MSU36consecu&vecases
677616
6 w
eeks
MIPO
MIPO
MIPO
MIPO
MIPO–clinicaloutcome
• Humeralfractures(10)
• Healing&me– ORIF68*to140d.^– MIO38d.#
• Complica&ons– ORIFupto38%– MIO0%#
*Kirkby,JAAHA2008;^Moses,AusVetJ2002#MSU10consecu&vecases
694109
4 w
eeks
MIPO• Techniqueapplicabletoalllongbones
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