The skin incision is made 1 cm outward from the anterior crest of the tibia, in accordance with the lines of Langer. In the supramallear region, the incision line is extended in an arc anterior to the medial malleolus. The edges of bone fragments are treated with a raspator. The periosteum is separated no more than 1-2 mm from the fracture line. If necessary, use internal access, and for access to the fibula - lateral.

After reposition, spiral fractures and fractures with anterior torsion wedge are held with a repositioning clamp. Fractures with a posterior torsion wedge are more complex and sometimes require temporary intraoperative pin fixation. Typically, fixation begins with the insertion of 3.5 mm or 4.5 mm cortical lag screws. Later, a fracture-neutralizing plate is added. Depending on the plane of the fracture, the lag screw may pass through the hole in the plate.

Torsion wedge fractures require the use of a lag screw in combination with a neutralization plate. The neutralization plate must be bent and twisted exactly to the shape of the lateral surface of the tibia. To achieve the required degree of bending, a bending press is used, twisting is performed with bending keys or bending tongs. To fix the plate at the level of the metaphysis, 6.5 mm spongy screws with threads along the entire length are used. At the level of the diaphysis, 4.5 mm cortical screws are used.

Postoperative treatment

Postoperative treatment after internal fixation includes a complex of active and passive movements, special mechanical splints are used for constant passive movement.

During the first 3-4 months. body weight load should be limited to 10 kg, depending on the severity of the fracture in each case and the degree of osteoporosis, as well as the nature of the damage to the cartilage tissue.

If ligaments, tendons, and menisci are sutured, then an intraoperative check of flexion and extension in the knee joint is mandatory. For a period of 4-6 weeks, splints with a fixed angle of mobility in the joint can also be used, which facilitates the healing of damaged structures.

Application of inserts with angular stability

The use of plates with angular stability has some peculiarities. This is due to the design features of the plates, and the new possibilities that these features provide.

Traditional plates provide stability of fixation due to the frictional force between the plate and the bone, for this, direct anatomical reduction is performed, extensive bone exposure is performed to provide access and achieve a good view of the fracture zone, the plate is pre-modeled according to the shape of the bone.

Blocking the screws in the plate by tapered threads in the head of the screw and the corresponding plate in the holes minimizes the pressure of the plate on the bone and does not necessarily mean that the plate must be in contact with the bone.

In LCP, the distance between the screws is greater than in LC-OCP, which reduces the load on the plate. The longer working length of the insert, in turn, reduces the load on the screws, so fewer screws need to be driven through the insert. It is possible to use monocortical and bicortical fixation. The choice is made depending on the quality of the bone. It is important to drive the screw into the threaded portion of the plate holes at the correct angle to ensure blocking.

Tribological studies have shown that stability is affected by several factors, both in compression and in torsion. The axial load tolerance and resistance to torsional forces are determined by the working length of the insert. If the nearest holes to the fracture line in both fragments are left empty, then the structure becomes twice as flexible under the influence of compression and torsion forces. The introduction of more than three screws into each of the two main fracture fragments does not lead to a significant increase in strength, either under axial load or torsional load. The closer to the fracture zone additional screws are localized, the stiffer the structure becomes during compression. The resistance to torsional forces is only determined by the number of screws inserted. The farther the plate is from the bone, the less stable the structure.

In case of fractures of the lower limb, it is enough to insert two or three screws on both sides of the fracture line. For simple fractures with a small interfragmentary gap, one or two holes can be left free on both sides of the fracture line to stimulate spontaneous union, accompanied by the formation of a bone callus. In multi-comminuted fractures, it is necessary to introduce screws into the plate holes closest to the fracture zone. The distance between the plate and the bone should be small. To ensure sufficient axial rigidity of fixation, long plates are used.

The AO system of LCP implants with combined holes can be used, depending on the fracture, as a compression plate, as an internal fixator with locking, or as an internal fixator combining both techniques.

A combination hole plate can also be used, depending on the fracture, according to the traditional fixation technique, fracture bridging technique, or a combination technique. Combining both types of screws makes it possible to apply both internal fixation techniques. When an LCP plate is used as a compression plate, the surgical technique is similar to that of conventional plates, where appropriate instruments and screws can be used. Overlapping of the fracture zone with a bridge plate is carried out using both open and minimally invasive approaches.

Compression: indications are simple transverse or oblique fractures of the metaphysis and diaphysis of the tibia with minor damage to the soft tissues.

Bridge plate or non-slip splinting: indications are comminuted and multicomminuted fractures of the tibia. The system consists of an implant and a broken bone. Stability depends on the strength of the plate and how securely the plate is anchored in the bone. LCP uses bi- and monocortical self-drilling and self-tapping locking screws, but bicortical screws are recommended for osteoporosis.

Combined technique:

multisegmental fractures with a simple fracture at one level and a comminuted fracture at another; accordingly, a simple fracture will be fixed with interfragmentary compression, and a comminuted one will be splinted with a bridge plate;

in osteoporosis, a simple fracture will be fixed with a simple lag screw through the plate, but the remaining neutral screws will be lockable.

Screw selection. There are 4 types of screws used:

normal spongy;

ordinary cortical;

lockable: self-drilling and self-tapping screws.

Conventional screws are inserted when they need to be inserted at an angle to the plate to avoid penetration into the joint, or when interfragmentary compression with eccentric screw insertion is chosen.

Self-tapping screws are mainly used as monocortical screws, with excellent bone quality. If, due to the small depth of the medullary cavity, the self-tapping screw abuts against the opposite cortical layer, then it immediately breaks the thread in the bone and continues at least beyond the opposite cortical layer.

Self-tapping screws are used in all segments when bicortical fixation is planned. The protruding part of a self-tapping screw is shorter than that of a self-drilling screw, since the latter has a cutting tip. For good fixation in both cortical layers, even a self-tapping screw should protrude slightly from the bone.

In osteoporosis, the cortical layer is thinned, the working length of the monocortical screw decreases, and, accordingly, the fixation of even a blocked screw is poor.

This can lead to instability. This is especially pronounced when subjected to torsional forces. Bicortical fixation is recommended for all osteoporotic bones. It should be noted that when tightening the screw, the surgeon cannot feel the quality of the bone, since the head of the screw is blocked in the conical hole of the plate.

Insertion through the skin of short monocortical screws into the distal holes of the plate, if the plate is not axial, can lead to poor adhesion to the bone. If this happens, then you need to replace the screw with a longer one, or insert a regular screw at an angle.

Choice of length.

When choosing the length of a conventional plate, surgeons sometimes chose a plate that was smaller than necessary to avoid additional soft tissue damage associated with a large approach. The introduction of LSR is possible from small incisions, which minimizes these injuries.

The concept of the plate overlap coefficient is introduced. Empirically, it has been found that for comminuted fractures, it should be 2-3, i.e., the length of the plate should be 2-3 times longer than the fracture. For simple fractures, the coefficient will be 8-10.

The density of the screws in the plate is an indicator of the filling of the holes in the plate with screws. Empirically, it is determined in the range from 0.5 to 0.4, showing that less than half of the holes in the plate are occupied by screws. With comminuted fractures, not a single screw is inserted into the fracture zone, but more than half of all holes can be occupied in the main fragments.

Number of screws.

From a mechanical point of view, 2 monocortical screws in each fragment are enough to fix a simple fracture in the LCP. In practice, this is possible only with excellent bone quality and the surgeon's confidence that all screws are inserted correctly. The instability of one of the screws will lead to loosening of the entire structure. Accordingly, at least 3 screws must be inserted into each fragment.

The order of insertion of screws.

If the plate is used to achieve compression, then it is achieved by inserting a conventional screw in an eccentric position. It is possible to fix one fragment to the plate with lockable screws, and then achieve compression by inserting the screw in an eccentric position or using a special compression device. Osteosynthesis is supplemented with screws with blocking.

Reposition technique.

The basic principles of reposition are also preserved with the new technology of internal fixation - anatomical reposition and stable fixation of the articular surface, restoration of the axis and length of the limb, correction of rotational deformity. Reposition can be open or closed; from a biological point of view, closed reduction is preferable. For the lower limb, limb length restoration is carried out mainly by traction: manual, on an orthopedic table, skeletal traction or distractor. Angular deformity is assessed using radiographs in two projections, rotational deformity is determined by clinical signs.

The advantage of closed, indirect reposition is the minimization of soft tissue damage and devascularization of bone fragments, which results in a more natural course of fusion and active involvement of bone fragments that have retained blood supply in the process of callus formation. Technically closed reduction is much more difficult to perform, which requires careful preoperative preparation.

Offset on the plate.

Incorrect use of conventional or lockable screws may result in the loss of previous reduction results. Thus, the X-ray control data dictates which type of screw should be inserted into which hole to avoid displacement on the plate.

Minimally invasive stabilization system

Indications for use: periarticular fractures, intraarticular fractures, fractures of the proximal part of the diaphysis.

The plate has a given anatomical shape. The screws lock into the tapered holes of the plate and provide angular stability to the structure. A special guide ensures accurate insertion of screws through punctures in the skin.

External curved or direct access is recommended. The length of the incision should be sufficient to insert the plate. The tibialis anterior is displaced by 30 mm, 5 mm away from the anterior tibial spine.

If there is a fracture involving the articular surface, then it should first be restored using compression screws. Closed reposition is performed, external fixator, distractor, Shants screws are effective.

The plate is connected to a radiolucent guide and, moving it along the bone, is inserted under the anterior tibial muscle. The position of the plate is controlled by palpation. Knitting needles carry out preliminary fixation of the proximal end of the plate. With the help of an image intensifier tube, the position of the plate is checked; it should stand so that the screws inserted through it fall into the center of the diaphysis. A scalpel puncture is made through the distal foramen, which can be made slightly larger than needed to insert the screw to visualize the plate and avoid damage to the superficial peroneal nerve, which runs approximately at the level of the 13th foramen of the plate. A sleeve with a trocar is inserted along the guide of the distal opening of the plate. Then, instead of them, a stabilizing bolt is inserted through which a 2-mm spoke is inserted. Check the reposition and position of the plate before inserting the locking screws. A pin is inserted into hole E along the guide to make sure that the screw that will be inserted through this hole does not go into the area of ​​the neurovascular bundle in the popliteal fossa. EOP control. If necessary, change the position of the plate or introduce a shorter screw.

The screws are inserted based on the biomechanical principles of external fixation. 4 or more screws must be inserted into each main fragment. More screws need to be inserted for osteoporotic bones. Using a tightening device, the reposition is corrected on the plate, and the proximal fragment is fixed.

Start with the proximal segment. First, a 5-mm self-drilling screw is inserted along the guide into the proximal hole II, having previously made a hole with a scalpel and trocar. Final blocking is possible when the screw head is level with the plate. The holes of the guide, through which the screws are inserted, are closed with plugs.

The proximal screw of the distal fragment is inserted, then the rest of the screws are fixed.

The plate can be removed only after complete fusion and restoration of the bone marrow cavity. The procedure is the reverse of the order in which the plate is installed.

Features of damage to the ankle joint are determined mainly by the mechanism of injury. Knowledge of the regularities of the occurrence of damage under the influence of various mechanical influences is a necessary condition for their correct diagnosis and treatment.

Fractures caused by the direct impact of force are only 3-7%. At the same time, the complexity of the structure of the ankle joint leads to the fact that some of its elements are damaged indirectly.

The mechanism of damage to the ankle joint is described based on the movements of the foot or, more precisely, the direction of the forces applied to it at the time of injury.

The whole infinite variety of injuries to the ankle joint from the indirect impact of force consists of the following elements, described in the form of pathological movements of the foot relative to the conditionally immobile tibia:

Around the sagittal axis

pronation,

supination;

Around the vertical axis

external rotation = eversion,

internal rotation = inversion;

around the frontal axis

bending,

extension.

The terms "abduction" and "adduction" in relation to the mechanism of damage to the ankle joint in publications are used in different senses: firstly, to denote abduction and adduction of the forefoot, and then they are synonymous with eversion and inversion, and secondly, to denote abduction and adduction of the heel, i.e. in the meaning of pronation and supination. Therefore, they speak of both “abduction-pronation” and “abduction-eversion” injuries, denoting “pronation-eversonic”.

The described possible components of the injury mechanism can be combined in a variety of ways, both simultaneously and sequentially in time, which leads to an infinite variety of damage options.

Patterns of the occurrence of injuries of different structures of the ankle joint are best considered on the example of the pronation and supination mechanism.

When the foot is tucked inwards, tension occurs on the external collateral ligaments of the ankle joint. This leads either to their rupture or to an avulsion fracture of the lateral malleolus, the plane of which is perpendicular to the direction of the tearing force and, therefore, horizontal. The fracture level is not higher than the horizontal section of the ankle joint fissure. The talus is free to move medially and, if the impact continues, it presses on the inner malleolus and "breaks" it in an obliquely upward direction. The course of the fracture plane: from the outside from the bottom - inside and up. If the traumatic force continues to act, then the talus, having lost support in the form of an inner ankle, freely moves inwards. After the cessation of exposure, the foot can, due to the elasticity of the soft tissues, return to its previous position or remain in the position of subluxation or dislocation medially.

Osteosynthesis is a surgical method of bone treatment (comparison and fusion of fragments). It can be external and internal, from which various methods of execution appeared: transosseous, external, intraosseous, transosseous. The affected bone is fixed with screws and plates, pressing the fragments to each other. After the operation, the patient is prescribed medications, procedures and exercises to develop the joints. Recovery after surgery lasts up to 6 months.

Many people experience bone fractures, but not everyone manages to avoid serious consequences. To save a person from a complex lesion of bone structures and return to normal life, they resort to surgical restoration by performing osteosynthesis.

The essence of osteosynthesis, and what is this procedure

Osteosynthesis is the fixation of bone fragments formed as a result of a severe injury with a metal structure. In this way, specialists create conditions under which the damaged bone grows together correctly and quickly.

Factors under which osteosynthesis is inevitable:

• when simple therapeutic techniques are useless;
• treatment was unsuccessful;
• studies show a complex fracture that can only be repaired by osteosynthesis.

The bone structures are connected by metal implants containing fixators that prevent displacement. The type of fixation structure depends on the location of the fracture and its complexity.

Scope of osteosynthesis

Today, osteosynthesis is carried out in all surgical clinics, since the effectiveness of the method has been scientifically proven. Thanks to the procedure, the integrity is restored:

During osteosynthesis, the functionality of bone structures and joints is restored, fixing the fragments and comparing them in their natural position, which speeds up the patient's rehabilitation and improves treatment. At the end of therapy, people can walk, exercise without abuse, serve themselves.

Indications for osteosynthesis

Hips and other structures have 2 types of indications, differing in the speed of rehabilitation and the nature of the lesion:

As a result of treatment, the risk of injury to nearby tissues and structures is reduced. The affected area returns to movement even before the patient has fully recovered.

Types of osteosynthesis

There are quite a few directions of osteosynthesis, but they were combined and carried out according to 2 methods:

• Submerged bone osteosynthesis. It is divided into 3 types: intraosseous, extraosseous and transosseous. Then the fixing element, selected based on the individual characteristics of the fracture, is inserted into the bone;
• External compression osteosynthesis, also known as the Ilizarov operation. It does not require exposure of the affected area, since the needles are inserted through the bones perpendicular to the bone axis.

Types of bone treatment with metal structures according to osteosynthesis methods, see the photo.

Therapy is carried out only by highly qualified surgeons after a detailed determination of the complexity of the pathology by X-ray, MRI, CT or ultrasound scanning. As a result of the data obtained, the type of osteosynthesis to be performed is determined and a suitable implant is selected.

Transosseous surgery technique

In case of complex injuries with the preservation of the functionality of the ligaments, a transosseous type of osteosynthesis is performed, which does not require the opening of tissues. Thanks to the procedure, injured ligamentous, cartilaginous and bone tissues are regenerated in a natural way. Typically, surgery is performed for open fractures:

• knee;
• tibia;
• shins.

The most common type of metal structures used for correction is, but due to the individual characteristics of the fracture, Tkachenko, Gudusuari, Akulich devices can be used.

They consist of the following elements:

• crossed spokes;
• fixing rods;
• rings.

Before prosthetizing the patient, the structure is assembled, starting from the localization of inert fragments found on an x-ray or magnetic resonance image. Insertion of plates and spokes should only be done by a qualified technician, as there are several types of structural elements that require mathematical precision.

The duration of the rehabilitation period after the operation of the transosseous type is up to 3 weeks. There are no contraindications.

Bone treatment method

The very name of the procedure - the bone type of osteosynthesis - indicates the installation of a metal structure on the bone surface, which implies opening the tissue.

This type is suitable for the treatment of periarticular, patchwork, comminuted, transverse injuries. During the procedure, the plate elements fix the fragments in the right places with special screws and other fixators used for hardening.

The composition of the metal structure includes:

• tapes;
• half rings and rings;
• wire;
• corners.

For the manufacture of the implant, only high-quality materials are used: composite, titanium, stainless alloys.

Technology of intraosseous osteotomy

The operation of intraosseous intramedullary osteosynthesis is performed by the method of open or closed surgery.

The closed type is carried out in several steps:

• with the help of a guide device, fragments of bones are connected;
• a metal rod of a hollow sample is introduced into the medullary canal.

The fixators, advanced through the entire affected bone, are introduced into the tissue through a small diameter incision. The installation of the implant is performed by controlling the process with the help of X-ray equipment, and then the conductive device is removed and the wound is sutured.

Open therapy is performed without a guide. The affected area is cut using special equipment, the fragments are compared and fixed with a metal structure. According to the principle of the method, it is simple, compared with the closed type, but at the same time, the risk of infection, blood loss and injury to soft tissue structures increases.

Blockable synthesis

The technique of blocked closed intramedullary osteosynthesis is used to treat the middle of tubular bones. Then the screw elements block the plate in the medullary canal. The technology is suitable for the treatment of young people. Before examining the patient, the state of the bone tissue is assessed and, if even minor degenerative-dystrophic disorders are detected, another method is selected.

Note! Bones with degenerative pathologies will not withstand the weight of the metal structure, which will cause additional injuries.

The forearms or lower legs are covered with a splint, which ensures the immobilization of the site, the surgical treatment of the thigh does not require any additional fixing devices.

How the bone is treated by blocking osteosynthesis, see the photo:

Hip fractures are the rarest. Often they occur in lovers of extreme entertainment and athletes. Then various fixing materials are used, such as spring screws, three-blade type nails.

Contraindications to blocked synthesis:

• age up to 16 years;
• acute arthritis;
• underdeveloped anomalous medullary canal (up to 3 mm.);
• arthrosis in the last stages of development, affecting bone density;
• diseases of the hematopoietic system;
• infectious ulcers.

Synthesis of the femoral neck, which does not have displaced fragments, is performed in a closed way, but to improve the effect, an additional element is introduced into the hip joint and fixed in the acetabulum.

The quality of bone tissue fastening by a blocking method depends on:

• specialist qualifications;
• the quality of the metal structure used;
• injury.

Smooth and oblique bone fractures respond better to therapy. It is also important to choose the right thickness of the rod, since the thin material will quickly fail.

In transosseous therapy, fixation screws and bolts are used that protrude slightly from the bone tissue (greater than the diameter of the bone). Their cap presses the bone segments, providing a compression type of osteosynthesis. The method is widely used for helical fractures resembling a spiral.

Oblique fractures of the olecranon, brachial condyle, patella are cured by bone suture technology. Then the fragments are tied together with a tape made of flexible stainless steel or rounded wire:

1. Drill holes in the bone.
2. They stretch the tape into them.
3. Fix the adjoining bone fragments.
4. Pull and fasten the plate.

After the bones have been fused, the hardware is removed to prevent atrophy resulting from bone compression. In most cases, the course of treatment with this method lasts no more than 3 months.

Note! Elbow and knee therapy rarely ends successfully with a conservative treatment method, therefore, in 95% of cases, suture osteosynthesis is used. It is important to carry out the operation in a timely manner, since its delay leads to complete or partial immobilization of the joints.

Maxillofacial osteosynthesis

Osteosynthesis of the jaw corrects congenital developmental anomalies and acquired pathologies using the distraction-compression method.

An orthodontic metal structure is made individually depending on the characteristics of the fracture, fixing the masticatory apparatus and creating a measured distribution of pressure on the tissues, ensuring their adjoining and fusion. To restore the shape of the jaw, they resort to a combination of metal elements.

Osteosynthesis with ultrasound

Ultrasonic bone osteosynthesis is used for seamless bone fusion, because under the influence of waves that are safe for the patient's health, the fragments stick together, creating a conglomerate to fill empty channels. The effectiveness of therapy is not inferior to the installation of metal structures, but the procedure is expensive and is not performed in all medical centers.

Installation of plates with angular stability

Angular stability plates function as internal retainers. The screw plates achieve stability by connecting to the bone tissue and transferring part of the load from the screw and bone attachment to the screw and plate. This factor makes it possible to perform osteosynthesis for people with minor bone weakness.

Possible Complications

Usually, after osteosynthesis, there are no negative consequences, however, if the treatment is carried out incorrectly (by unqualified specialists) or as a result of the individual characteristics of the body, the following complications develop:

• embolism, arthritis;
• osteomyelitis;
• soft tissue infection;
• bleeding (internal).

With closed therapy, the risks of complications are reduced to zero, and with open therapy, they are possible. To prevent their occurrence, anticoagulants, antibiotics and antispasmodics are prescribed. After 3 days, the tablets can be canceled if the patient's condition is stable.

rehabilitation period

The duration of the rehabilitation period for each patient is different, because the speed of therapy is influenced by many factors:

• general condition of the body;
• the presence or absence of complications (temperature, infections);
• the complexity of the fracture;
• age;
• the location of the broken bone;
• type of osteosynthesis used.

After surgical therapy, the goal of doctors is to prevent inflammation, complications, and restore joint and bone tissues. Assign mud, therapeutic baths, UHF, recovery exercises, electrophoresis.

Treatment of the elbow during the first 3 days causes intense pain, but the patient needs to develop the arm, despite the sensations. The doctor prescribes various types of exercises: arm extension, rotation, extension / flexion of the elbow. The knees and joints of the pelvis, hips are restored on special training structures. The intensity of the loads is constantly increasing. Thus, joints, muscle and ligamentous tissues are developed.

Segments treated by the transosseous method are restored in 2 months, and other types of immersion therapy are regenerated up to six months. Drug therapy is prescribed based on the patient's well-being, and physical exercises and loads are performed until the metal structure is removed.

The cost of osteosynthesis and clinics where to carry out the therapy

It is difficult to estimate the cost of the operation without a preliminary examination by a doctor, since the price is affected by the level and comfort of service, the complexity of the fracture, the type of osteosynthesis used, and the cost of the metal structure. On average, or an elbow costs about 40,000–50,000 rubles, and a tibia reaches 200,000 rubles. For the removal of metal structures after the rehabilitation of osteosynthesis, they pay additionally, but less (up to 35,000 rubles). Some patients are given the opportunity to receive treatment free of charge if the nature of the damage allows them to wait 5-6 months for surgery.

Table 1. Overview of clinics and costs of operations

Clinic	The address	The cost of the procedure Rs.
Seline Clinic in Bolshoi Kondratievsky Lane	Moscow, Bolshoi Kondratievsky lane, 7
European MC on the street. Shchepkina	Moscow, st. Shchepkina, 35	150 000
SPGMU them. I.P. Pavlova	Saint Petersburg, st. Leo Tolstoy, 6–8	22 000
VCEiRM them. A.M. Nikiforov Ministry of Emergency Situations of the Russian Federation on Ak. Lebedev	Saint Petersburg, st. Academician Lebedeva, 4/2	54 000
Medeor Medical Center on Gorky Street	Chelyabinsk, Gorky street, 16	45 000
Clinic "Semya" on Voznesenskaya street	Ryazan, Voznesenskaya street, 46	24 000

The most expensive treatment is in private clinics, but there is also more comfortable service, individual rooms with air conditioning, TV and the Internet. Public hospitals have less pleasant conditions, but the quality of therapy and the qualifications of doctors in both types of medical centers is the same.

How to perform osteosynthesis with a locking rod, see the video:

Osteosynthesis is a type of surgical intervention that is used for bone fractures. Plates for osteosynthesis are needed so that the elements of the damaged bone structure are fixed in a stationary state. Such devices provide a strong, stable fixation of bone fragments until they are completely fused. Fixation, which is carried out promptly, provides stabilization of the fracture site and proper bone union.

Plates as a way to connect bone fragments

Osteosynthesis is a method of surgical operation, during which fragments of bone structures are connected and fixed with special devices in the area of ​​the fracture.

Plates are fixing devices. They are made from different metals that are resistant to oxidation inside the body. The following materials are used:

• titanium alloy;
• stainless steel;
• molybdenum-chromium-nickel alloy;
• artificial materials that are absorbed in the body of the patient.

Fixing devices are located inside the body, but from the outside of the bone. They attach bone fragments to the main surface. To fix the plate to the bone base, the following types of screws are used:

• cortical;
• spongy.

Efficiency of fixing devices

The operation is carried out in order to connect all the fragments.

During surgical intervention, surgeons can change the plate by bending and modeling - the device adapts to the bone with its anatomical features. Compression of bone fragments is achieved. A strong, stable fixation is provided, the fragments are compared and held in the required position so that the bone parts grow together correctly. For osteosynthesis to be successful, you need:

• anatomically clearly and correctly compare bone fragments;
• fix them firmly;
• to provide them and the tissues that surround them with minimal trauma, while maintaining normal blood circulation in the fracture sites.

Lack of osteosynthesis with plates - it is possible to damage the periosteum during fixation, which can provoke osteoporosis and bone atrophy, since blood circulation in this area is disturbed. To avoid this, fixators are produced that have special cutouts and allow reducing pressure on the surface of the periosteum. To perform the intervention, plates are used that have different parameters.

Types of fixation plates for osteosynthesis

A variety of plates allows you to choose the best for each case.

Plate clamps are:

• Shunting (neutralizing). Most of the load is provided by the fixator, as a result of which such undesirable consequences as osteoporosis or a decrease in the effectiveness of osteosynthesis at the fracture site can occur.
• Compressive. The load is distributed by the bone and the fixator.

Shunting devices are used for fractures of the comminuted and multi-comminuted type, when fragments are displaced, as well as for certain types of fractures inside the joint. In other cases, compression types of clamps are used. Holes in the fixing device for screws are:

• oval;
• cut at an angle;
• round.

To avoid damage to the periosteum, LC-DCP plates are produced. They allow to reduce the area of ​​contact with the periosteum. Plates that provide angular screw stability are effective for osteosynthesis. The thread contributes to a rigid and durable fixation in the holes of the fixtures. The latch in them is installed epiperiosteally - above the bone surface, which avoids its pressure on the periosteum. For plates with angular screw stability, contact with the bone surface occurs:

• PC-Fix - spot;
• LC - limited.

There are such types of plates:

• narrow - holes are located in 1 row;
• wide - double-row holes.

Retainer options

The choice of fixator depends on the type of injury.

With external osteosynthesis, surgical intervention is performed using implants with different parameters. There are different widths, thicknesses, shapes and lengths of the plate in which the screw holes are made. The large working length helps to reduce the load on the screws. The choice of a plate fixator depends on the type of fracture and the strength properties of the bone for which plate osteosynthesis is to be applied. The plates provide bone fixation in such parts of the body as:

• brush;
• shin;
• forearm and shoulder joint;
• collarbone;
• region of the hip joint.

Osteosynthesis- connection of bone fragments. The purpose of osteosynthesis is to ensure a strong fixation of the matched fragments until they are completely fused.

Modern high-tech methods of osteosynthesis require a thorough preoperative examination of the patient, a 3D tomographic examination for intra-articular fractures, a clear planning of the course of surgical intervention, an image intensifier tube during the operation, the availability of sets of tools for installing fixators, the ability to choose a fixator in the size range, appropriate training of the operating surgeon and the entire operating team.

There are two main types of osteosynthesis:
1) Internal (submersible) osteosynthesis- This is a method of treating fractures with the help of various implants that fix bone fragments inside the patient's body. Implants are pins, plates, screws, wires, wires.
2) External (transosseous) osteosynthesis when bone fragments are connected using distraction-compression devices for external fixation (the most common of which is the Ilizarov apparatus).

Indications

Absolute indications for osteosynthesis are fractures that do not fuse together without surgical fastening of fragments, for example, fractures of the olecranon and patella with divergence of fragments, some types of fractures of the femoral neck; intra-articular fractures (condyles of the femur and tibia, distal metaepiphyses of the humerus, radius) fractures in which there is a risk of perforation by a bone fragment of the skin, i.e. transformation of a closed fracture into an open one; fractures accompanied by interposition of soft tissues between fragments or complicated by damage to the main vessel or nerve.

Relative indications are the impossibility of closed reposition of fragments, secondary displacement of fragments with conservative treatment, slowly healing and non-united fractures, false joints.

Contraindications to internal osteosynthesis are open fractures of limb bones with a large area of ​​damage or contamination of soft tissues, local or general infectious process, general serious condition, severe concomitant diseases of internal organs, severe osteoporosis, decompensated vascular insufficiency of the limbs.

Osteosynthesis with pins (rods)

This type of surgical treatment is also called intraosseous or intramedullary. The pins are then inserted into the internal cavity of the bone (medullary cavity) of long tubular bones, namely their long part - the diaphysis. It provides strong fixation of fragments.

The advantage of intramedullary osteosynthesis with pins is its minimal trauma and the ability to load a broken limb within a few days after surgical treatment. Non-blocking pins are used, which are rounded rods. They are introduced into the medullary cavity and wedged there. This technique is possible with transverse fractures of the femur, tibia and humerus, which have a bone marrow cavity of a sufficiently large diameter. If it is necessary to fix the fragments more firmly, reaming of the spinal cavity with the help of special drills is used. The drilled spinal canal should be 1 mm narrower than the pin diameter in order to firmly wedged it.

To increase the fixation strength, special locking pins are used, which are provided with holes at the upper and lower ends. Through these holes, screws are inserted that pass through the bone. This type of osteosynthesis is called blocked intramedullary osteosynthesis (BIOS). Today, there are many different nail options for each long bone (proximal humeral nail, universal humeral nail for retrograde and antegrade placement, femoral nail for transtrochanteric placement, long trochanteric nail, short trochanteric nail, tibial nail).

Also, self-locking intramedullary pins of the Fixion system are used, the use of which allows you to minimize the time of the surgical intervention.

With the help of locking screws, a strong fixation of the pin is achieved in the areas of the bone above and below the fracture. Fixed fragments will not be able to move along the length, or rotate around its axis. Such pins can also be used for fractures near the end of the tubular bones and even for comminuted fractures. For these cases, pins of a special design are made. In addition, pins with blocking can be narrower than the medullary canal of the bone, which does not require reaming of the medullary canal and contributes to the preservation of intraosseous circulation.

In most cases, blocked intramedullary osteosynthesis (BIOS) is so stable that patients are allowed dosed load on the injured limb on the next day after surgery. Moreover, such a load stimulates the formation of callus and fracture healing. BIOS is the method of choice for fractures of the diaphysis of long bones, especially the femur and tibia, since, on the one hand, it least disrupts the blood supply to the bone, and on the other hand, it optimally accepts axial load and reduces the use of canes and crutches.

Plate osteosynthesis

Bone osteosynthesis is performed using plates of various lengths, widths, shapes and thicknesses, in which holes are made. Through the holes, the plate is connected to the bone with screws.

The latest development in the field of external osteosynthesis are plates with angular stability, and now also with polyaxial stability (LCP). In addition to the threads on the screw, with which it is screwed into the bone and fixed in it, there are threads in the holes of the plate and in the head of the screw, due to which the head of each screw is firmly fixed in the plate. This method of fixing the screws in the plate significantly increases the stability of osteosynthesis.

Plates with angular stability have been created for each of the segments of all long tubular bones, having a shape corresponding to the shape and surface of the segment. The pre-bending of the plates is of great help in repositioning the fracture.

Transosseous osteosynthesis with external fixation devices

A special place is occupied by external transosseous osteosynthesis, which is performed using distraction-compression devices. This method of osteosynthesis is used most often without exposing the fracture zone and makes it possible to reposition and stable fixation of fragments. The essence of the method is to pass wires or rods through the bone, which are fixed above the skin surface in an external fixation apparatus. There are various types of devices (monolateral, bilateral, sector, semicircular, circular and combined).

Currently, preference is increasingly given to rod external fixation devices, as the least massive and providing the greatest rigidity of fixation of bone fragments.

External fixation devices are indispensable in the treatment of complex high-energy injuries (for example, gunshot or mine injuries), accompanied by massive defects in bone tissue and soft tissues, with preserved peripheral blood supply to the limb.

Our clinic performs:

• stable osteosynthesis (intramedullary, osseous, transosseous) of long tubular bones - shoulder, forearm, thigh, lower leg;
• stable osteosynthesis of intra-articular fractures (shoulder, elbow, wrist, hip, knee, ankle joints);
• osteosynthesis of the bones of the hand and foot.

Osteosynthesis is an intervention aimed at connecting fragments of damaged bone tissue. It is performed using fixation devices and orthopedic structures.

The operation of osteosynthesis is prescribed for fractures of bones and false joints. The main point of the procedure is to eliminate the mixing of fragments and fix them in the correct anatomical position. Due to this, the process of tissue regeneration is accelerated and the functional indicators of the therapy are improved.

Classification of fracture treatment methods

The classification of surgical intervention is based on several criteria. Depending on the time of the intervention, delayed and primary reposition are distinguished. In the latter case, professional medical care is provided to the patient within a day after the fracture. Delayed reduction is carried out after 24 hours after the injury.

Depending on the method of intervention, the following types of osteosynthesis are distinguished:

• outer;
• submersible;
• ultrasonic.

The first 2 types of surgery are traditional and are often used to treat fractures. Ultrasonic osteosynthesis is considered an innovation in this area and is a process of chemical and physical impact on damaged bone structures.

External bone fusion

External or extrafocal osteosynthesis is characterized by the possibility of intervention without exposing the fracture zone. During the procedure, specialists use metal knitting needles and nails. Pins for osteosynthesis are passed through the broken elements perpendicular to the bone axis.

The technique of extrafocal compression-distraction osteosynthesis involves the use of guide devices:

• Ilizarov;
• Gudushauri;
• Tkachenko;
• Akulich.

The devices consist of rings, crossed spokes and fixing rods. The assembly of the structure is carried out after studying the nature of the fracture and analyzing the location of the fragments. When approaching or removing the rings fixed on the spokes, compression or distraction of bone tissue elements occurs. Bone fragments are fixed in such a way that the natural mobility of the articular ligaments is preserved

Transosseous osteosynthesis according to Ilizarov is prescribed not only for fractures. The operation is also shown:

• for limb lengthening;
• for arthrodesis of joints;
• for the treatment of dislocations.

Indications for external type surgery

Guide vanes are used in the following types of surgery:

1. Osteosynthesis of the tibia. During the procedure, the doctor connects the distal and proximal bone fragments with a metal pin. The structure is fixed with screws. To insert the screws, an incision is made in the skin, and holes are drilled in the bones.
2. Osteosynthesis of the leg. The intervention is performed with or without reaming the bone. In the latter case, the risk of soft tissue damage is minimized, which is important in traumatic shock. In the first case, a more dense fixation of the fragments is provided, which is important in case of damage to the false joints.
3. Osteosynthesis of the humerus. The procedure is resorted to only with closed fractures, when it is not possible to reposition the fragments with the help of external fusion. To fasten the fragments, pins, plates with screws or rods are used.

For the treatment of a fracture of the jaw bones, osteosynthesis according to Makienko is performed. The operation is performed using AOC-3 equipment. In case of a transverse fracture, the needles are placed on both sides of the zygomatic bone to the nose. Before the intervention, the doctor compares the fragments of bone tissue.

Extra-ocular treatment of fractures, carried out according to the Makienko method, does not make it possible to completely restore the jaw bones.

Osteosynthesis with wires is a difficult task even for an experienced traumatologist. During the intervention, the doctor requires precise movements, an understanding of the design of the guiding device and the ability to make quick decisions during the operation.

Submersible bone fusion

Internal osteosynthesis is the fusion of bone fragments using a fixing element inserted directly into the area of ​​damage. The device is selected taking into account the clinical picture of the injury.

In surgery, this type of operation is carried out according to three methods:

• on the bone;
• intraosseously;
• transosseously;

The separation is due to differences in the place of fixation of the devices. In severe cases, specialists combine the methods of surgery, combining several types of treatment.

Intraosseous (intramedullary) method

Intraosseous osteosynthesis is performed by open and closed methods. In the first case, the fragments are connected using X-rays. Fixing devices are inserted into the middle part of the tubular bone. The method of open intervention is considered the most common. The essence of the operation is to expose the fracture site, compare the fragments and insert a metal rod into the bone marrow canal.

Intraosseous osteosynthesis is more often performed in the following forms:

1. Osteosynthesis of the hip. Intramedullary osteosynthesis of the femur is more popular than the external type of intervention. Fracture of the femur is more often observed in old age or in people involved in professional sports. The main task of the operation in this case is to put the person on his feet in a short time. To fasten the debris, spring-loaded screws, U-shaped clamps and three-blade nails are used.
2. Osteosynthesis of the femoral neck. The operation is prescribed for young patients whose bones are well supplied with blood. The procedure is carried out in several stages. First, the fragments are compared to give the fragments of bone tissue the correct anatomical position. Then, a small incision (up to 15 cm) is made on the skin near the injured area.
3. Osteosynthesis of the ankles. Intraosseous osteosynthesis is performed only for old injuries, in which there are non-united bone tissues. If the damage was received recently, then surgical intervention is prescribed no earlier than 2 days from the moment of damage.
4. Osteosynthesis of the clavicle. The operation is performed with the patient in the supine position. A roller is placed in the space between the shoulder blades and the spine. The intervention begins with a dissection of the skin layer and subcutaneous tissue, parallel to the lower edge of the clavicle. Screws are used to hold the bones in the correct position.

Bony (extramedullary) method

Extramedullary osteosynthesis is prescribed for any type of bone damage, regardless of the location of the fracture and its features. For treatment, plates of various shapes and thicknesses are used. They are fixed with screws. Plates for performing osteosynthesis are equipped with removable and non-removable mechanisms.

Bone osteosynthesis with plates is prescribed in the following cases:

• for minor injuries
• in displaced fractures.

Additionally, as fixing elements can be used:

• tapes;
• half rings;
• corners;
• rings.

Structural elements are made of metal alloys - titanium, steel.

Transosseous method

The operation is carried out using bolts, spokes and screws. Designs are introduced in the oblique or transverse direction through the tubular bones in the area of ​​damage. It is advisable to apply the technique for the following types of intervention:

• osteosynthesis of the patella;
• osteosynthesis of the olecranon.

Operations of this type should be carried out urgently, since conservative treatment rarely gives positive results. Untimely provision of medical care in the future may affect the ability of the joint to bend and unbend.

Fixation can be weak or absolute. In the first case, slight mobility between bone fragments is allowed, which is not accompanied by pain. Absolute fixation is characterized by the absence of micromovements between fragments of bone tissue.

Ultrasonic method

Ultrasonic osteosynthesis was developed in 1964. The essence of the technique lies in the effect of electrical oscillations generated by the generator on the damaged area. Ultrasonic osteosynthesis provides fast fixation of fragments and reduces the effect of toxic adhesive on the wound surface.

The essence of the operation is the filling of the pores and channels of the fragments with a biopolymer conglomerate, due to which strong mechanical bonds are formed between the damaged elements. Ultrasonic osteosynthesis has one significant drawback - the possibility of developing atrophic processes in tissues located in the border zone with the polymer.

Complications after surgery

Complications after osteosynthesis performed by a closed method are observed in rare cases. After open operations, the following consequences occur:

• infection of soft tissues;
• inflammation of bone structures;
• hemorrhage;
• embolism;
• arthritis.

For preventive purposes, after the intervention, antibacterial drugs and anticoagulants are prescribed.

rehabilitation period

Rehabilitation after osteosynthesis depends on several factors:

• the complexity of the operation;
• fracture location;
• techniques of osteosynthesis and view;
• the patient's age and general health.

Recovery measures are developed by a specialist individually in each case. They include several therapeutic approaches:

• physiotherapy exercises;
• physiotherapy baths;
• mud treatment.

After fusion of the bones of the arm or leg, a person may experience discomfort for several days. However, it is necessary to develop an injured limb or body part.

In the first days, therapeutic exercises are carried out under the supervision of a doctor. It performs circular and extensor movements of the limb. Subsequently, the patient performs a physical education program on his own.

To restore the patella or hip joint, special simulators are used. With their help, a gradually increasing load is created on the damaged area. The purpose of rehabilitation is to strengthen the ligaments and muscles. The development of the damaged area with a simulator is complemented by massage.

On average, the recovery period after the submersible type of intervention is 3-6 months, after the external one - 1-2 months.

Mobilization period

Mobilization occurs from the 5th day after the operation, with the patient feeling normal. If the patient does not feel pain in the damaged area, then against the background of the positive dynamics of the treatment, its activation begins. The motor mode for the operated area is increased gradually. The gymnastic program should include light exercises, which are performed gradually at the beginning of the rehabilitation period, and then more actively, until minor pain appears.

In addition to gymnastics, to restore the motor functions of the damaged area, patients are recommended to exercise in the pool. The procedure is aimed at improving blood supply, accelerating the recovery processes at the fracture site. You should remember the following rules:

• classes in the water begin no earlier than 4 weeks after the operation;
• the water temperature in the pool should be 30–32 degrees;
• the duration of classes does not exceed 30 minutes;
• repetition frequency of each exercise 10 times.

After clinical confirmation of fracture consolidation, the fixing devices installed during extracortical osteosynthesis are removed. Full restoration of previous functions in case of fracture of the forearm, clavicle or olecranon occurs after 1 year. The rehabilitation period for a fracture of the femur, lower leg - up to one and a half years.

Few have heard about the concept of osteosynthesis and know what it is. The main point of the procedure is the restoration of bone structures after a fracture. The operation is performed in various ways - without opening the damaged area or using an immersion technique. Doctors of private clinics practice ultrasonic osteosynthesis. The method of treatment and rehabilitation measures after it are determined by the attending physician, depending on several factors: the age of the patient, the severity of the injury and the location of the injury.