内固定技术讲解教材.ppt

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1、Minimally invasive surgery is this the future? Suthorn Bavonratanavech M.D,What evidence do we have ,What is MIS or MIO ,What are the indications ,Is MIPO solve the problem ,What are problems in the past ,Stable Osteosynthesis (1959,Biological Osteosynthesis (Mast, Ganz 1989,MIO,History“ of MIO,Clin

2、ical approval of the concept 1989 - 1996 Femur: Kleining, Heitemeyer, Mast, Kinast, Baumgrtel, Bolhofner, Wenda, Strmer, Hoentzsch,Bast, Krettek (MIPPO 1996) Distal Tibia: Helfet (MIPO,30 years,Definitions MIO,Small incisions Big enough to deal with an articular fracture Small at the level of the fr

3、acture if necessary and minimal at the shaft,Minimally invasive,Caring of soft tissue,MIPO VS. conventional plating,Rapid bone healing ,bone graft Less infection Less post op pain Less bleeding no matching of blood Early recovery Cosmesis,Disadvantages of MIPO,C-arm dependent Difficulty in reduction

4、 Malalignment Technical demanding Instruments,implants,MIPO,What happen after introduce plate under the muscle ?How much damage to the blood supply to the bone ,A cadaver injection study of minimally invasive VS. conventional plate osteosynthesis,Farouk Osama, Krettek Christian, Miclau Theodore, Sch

5、andelmaier Peter, Guy Pierre, and Tscherne Herald,Minimally Invasive vs.Conventional Plating (Farouk et al., JOT, 1999,Marked difference: 70% No difference: 30% p 0.002,MIPO,Medullary perfusion,CLP,Marked difference: 50% Moderate: 33% Mild: 17% p 0.001,Periosteal perfusion,Conclusion from study,MIPO

6、 has better preservation of PAs, NA, Periosteal filling & Medullary perfusion. This study support the clinical results using MIPO technique in complex femoral fracture,Which technique for reduction ,Direct reduction Indirect reduction,Different bone formation between anatomical and indirect reductio

7、n,Direct anatomical reduction,Indirect reduction ,no touch,Indirect reduction and bone healing,The fracture gaps were bridged more regularly and sequestra were rarely observed Callus took place much earlier A higher breaking strength in mechanical test from increase cross section 2.5 times,The blood

8、 supply to even the smaller fragment was well maintained Almost complete mineralised after 5-6 weeks compare to anatomical reduction was only just beginning,Indirect reduction and bone healing,Indirect reduction is more favorable in multifragmentary fracture,What are the problem in the past with con

9、ventional plating technique ,Plate fixation has a bad reputation from poor surgical technique and bad soft tissue handling,Soft tissue problem,Bone healing problem,Evolution of Plate Osteosynthesis,70-80,80-90,90-2000,But we forget with the technique that has least disturbance of the soft tissue,Goa

10、l of operative fracture treatment is stable fixation,Select the technique that will preserve the blood supply to the bone because only living bone will heal,What I have changed ,If you believe that close IM nailing is a great advanced in operative treatment of fracture Why not doing closed extramedu

11、llary plating ,Do you need this exposure,Why do you have to expose fracture site if you do not need to do that ,Why do you have to make a long incision if you do not need to do that ,Gun shot wound,35 yrs old male,Plate has antecurvature to adapt with the femoral bowing. Do not apply the wrong curve

12、,Midshaft Femoral Fracture,When LCP is used curved plate is recommended for long plate The chance of missing locking screw is less Support the thigh with towel to reduce the fracture,Proximal part of the plate is contoured to match the metaphyseal flare of proximal femur using condylar blate as the

13、template,Post op X ray 8 months,90 years old chinese male fell from the last step of stair and sustained pain and deformity at left thigh. He has transferred to the hospital 3hrs after accident,31 A1 stable type,Use 5 mm longer screw so you can feel the end of the screw,Use the short barrel side pla

14、te and introduce the plate with the barrel face outward and rotate,Side plate has to parallel with the shaft of femur,Admission 3 hrs after accident at 4 PM Operation perform 4 hrs after admission 8 PM Anesthetic time 80 min Operative time 50 min Return to ward at 11PM Start to sit and move at 8 AM

15、next day Ambulation in the gym on following day,Misunderstanding,Make the smallest incision possible Relative stability is not stable Too much radiation exposure Prolong operative time It have more malalignment,It is not necessary to look at the fracture as well as the hole of the plate to insert th

16、e screws,How to locate the plate hole ,Never use C arm to find the plate hole Use another plate with the same length Make a stab incision and use hemostat to locate the hole,Small incisions Indirect reduction Aligning length, axis, rotation Precontouring of plate Shifting of plate in preexisting cav

17、ities Fixation of plate on each side No exposure of fracture-site,Minimally invasive plate,No attempts to achieve anatomical reduction No interfragmentary compression Stab incision for screw-insertion Only few screws No screws at fracture site Plate as a bridging function only No bone-graft is neces

18、sary,Minimally invasive plate,Review of the AOs Minimally Invasive Plate Osteosynthesis (MIPO) book. “This book is well produced, eminently readable and the illustrations are clear and appropriate to the text. It should be a standard reference text in theatres and hospital libraries.” N Geary, the J

19、ournal of Bone and Joint Surgery British Volume, Vol 89-B, Issue 10, 1412,Please consider MIPO for your next plating case,I hope that I will be able to convince you,Thank you for your attention,Can we use MIPO in case we want to have absolute stability Yes we can,24 yrs old lady with 4 months pregnancy sustained closed femoral shaft fracture 3 weeks ago. She stayed in ICU for 2 weeks on respirator because of ARDS and then one week later transfer to BH hospital,Closed femoral shaft fracture 3 weeks ago,You do not need extensive exposure for absolute stability