Connecting broken bones using surgery has made it possible to speed up both the treatment process and the rehabilitation of patients with complex fractures. For the first time, such a procedure as bone osteosynthesis was performed back in the 19th century, but due to the occurrence of very serious purulent complications, doctors were forced to stop doing it. Attempts were resumed after the introduction of antisepsis and asepsis into treatment practice.

What is osteosynthesis?

Doctors suggest osteosynthesis for many patients with complex fractures. joining bone fragments through surgery. It is usually prescribed for the treatment of complex joints, improperly fused or fresh non-united fractures. Using osteosynthesis, the aligned fragments are fixed. Thus, ideal conditions are created for their fusion, as well as restoration of the integrity of the limb.

There are two main types of osteosynthesis:

• submersible (extraosseous, intraosseous, transosseous);
• external (extrafocal).

There is also ultrasonic osteosynthesis. connection of small bone fragments.

Operations are performed using different fixators. For submersible intraosseous osteosynthesis, nails and pins are used, for extraosseous osteosynthesis, plates with screws are used, and for transosseous osteosynthesis, pins and screws are used. These fixatives are made from chemically, biologically and physically neutral materials. Metal structures made of vitalium, stainless steel, titanium are mainly used, and much less often - from inert plastics and bone. Metal fixators are usually removed after the fracture has healed. The Ilizarov apparatus on the leg is used for external osteosynthesis. Thanks to it, the bone fragments are firmly fixed after comparison. Patients can move normally with full weight bearing.

Indications

Osteosynthesis surgery is indicated as the main method of recovery for:

• such a fracture that cannot heal without the help of a traumatologist;
• damage with the possibility of perforation of the skin (when a closed fracture can turn into an open one);
• fracture complicated by damage to a large artery.

Contraindications

• if the patient feels unwell;
• there are open extensive injuries;
• if the affected area becomes infected;
• if there are pronounced pathologies of any internal organs;
• with progression of systemic bone disease;
• The patient has venous insufficiency of the limb.

Types of plates

The plates used during surgery are made from various metals. Titanium plates are recognized as the best, since this material has an interesting feature: when exposed to air, a film instantly forms on it, which will not interact in any way with the tissues of the body. In this case, there is no need to worry about the development of metallosis. That is why many people do not remove such plates, but leave them for life.

Submersible intraosseous osteosynthesis

Another name for the operation is intramedullary osteosynthesis. It can be open or closed. In the first case, the fracture zone is exposed, after which the fragments are compared, and a mechanical rod is inserted into the medullary canal of the damaged bone. Open osteosynthesis does not require the use of special equipment to connect fragments; this technique is much simpler and more accessible than closed surgery. However, this increases the risk of soft tissue infection.

Closed intramedullary osteosynthesis is characterized by the fact that fragments are compared, after which a small incision is made far from the fracture site. Through this incision, using a special apparatus, a rather long metal hollow rod of the appropriate diameter is inserted into the medullary canal of the damaged bone along a guide. After this, the conductor is removed and the wound is sutured.

Submersible bone osteosynthesis

The method of connecting bone fragments is used for various fractures (comminuted, helical, periarticular, oblique, transverse, intra-articular), regardless of the bend and shape of the medullary canal. The fixators that are used for such operations are presented in the form of plates of different thicknesses and shapes, connected to the bone with screws. Many modern plates have special bringing together devices, including removable and non-removable. After the procedure, a plaster cast is often applied.

For helical and oblique fractures, bone osteosynthesis is usually performed using metal bands and wires, as well as special rings and half-rings made of stainless steel. This method of connecting bone, especially wire, is rarely used as an independent method due to not very strong fixation and most often serves as an addition to other types of osteosynthesis.

For this operation, soft ones (silk, catgut, lavsan) are very rarely used, because such threads are not able to withstand muscle traction and displacement of fragments.

Submersible transosseous osteosynthesis

Such surgical reposition is carried out using bolts, screws, knitting needles, and these fasteners are carried out in an oblique transverse or transverse direction through the bone walls at the site of injury. A special type of transosseous osteosynthesis is a bone suture - this is when channels are drilled in the fragments and ligatures (catgut, silk, wire) are passed through them, which are then tightened and tied. A bone suture is used for fractures of the olecranon or patella. Transosseous osteosynthesis involves the application of a plaster cast.

External osteosynthesis

This reposition is carried out using special devices (Ilizarov, Volkov-Oganesyan devices). This allows you to compare fragments without exposing the fracture site and firmly fix them. This technique is carried out without applying a cast, and the Ilizarov apparatus on the leg allows the patient to walk with full load.

Complications

Serious complications may occur after the operation. Leads to them:

• incorrect choice of technique for fixing bone fragments;
• instability of juxtaposed bone fragments;
• rough handling of soft tissues;
• incorrectly selected retainer;
• non-compliance with asepsis and antiseptics.

Such complications contribute to its suppuration or complete nonunion.

Since long massive plates are used for submersible bone osteosynthesis, and for this purpose the bone is exposed over a large area, its blood supply is often disrupted, which leads to slow fusion. Removing the screws leaves numerous holes that weaken the bone.

Conclusion

So, we have examined such a technique as osteosynthesis. the most modern way to connect bone fragments after a fracture. Thanks to it, the process of treatment and rehabilitation of patients is significantly accelerated. Osteosynthesis is carried out using various fixators. Titanium plates are considered the most durable, and they don’t even need to be removed.

With complete bone fractures, there are mainly three problems:

• How to correctly combine all the fragments, returning them to their original position.
• How to make sure that the fragments do not move when there is load on the injured area.
• How to ensure rapid healing of all damaged bone and soft tissues.

Restoring the status quo (original anatomical disposition) of bone fragments is called reposition. For simple and moderate fractures, in most cases it is possible to limit the fracture to closed reduction, that is, without opening the fracture zone, after which plaster immobilization is performed. But sometimes the nature of the injury is such (for example, there are many fragments and there are displacements) that open access to the area of ​​damage and more reliable fixation of the fragments is required (fixation in some cases can be accomplished using the closed reduction method). And then a surgical operation called “osteosynthesis” is performed.

What is osteosynthesis?

Osteosynthesis in surgery is a method of reposition (open or closed), in which all bone fragments are fixed using metal structures (pins, screws, knitting needles, rods, nails, etc.) or using modern technologies (for example, one of them is ultrasound osteosynthesis).

Today, new life has been literally breathed into trauma medicine, and many standard approaches are undergoing changes. Thus, until recently, the only reliable method of treatment for elderly people over 65 years of age was considered to be (unipolar or total) hip joint replacement. But this operation is performed in older patients mainly using a cement method (that is, parts of the prosthesis are glued to the bone with a special polymer glue), which does not ensure 100% reliability of the endoprosthesis and leads to its premature loosening and the need for revision surgery. But endoprosthetics are very expensive, and are unaffordable for older people who do not have citizenship and an insurance policy from the country that adopted them. Osteosynthesis today for hip fractures is quite successfully used in those patients who do not have late coxarthrosis.

In the picture: Operation osteosynthesis for a femoral neck fracture.

Osteosynthesis at the dawn of its development also often led to complications:

• an inflammatory infectious process could develop at the site where the metal is attached to the bone;
• the structures reacted with surrounding tissues, became oxidized and damaged;
• sometimes a reaction of rejection was observed.

But today, medicine uses new materials (for example, titanium alloys) that are durable, practically do not enter into biochemical reactions, and are maximally compatible with human tissues.

Indications for osteosynthesis

This method of treating fractures is used for complex or old, improperly healed fractures. The absolute indications for osteosynthesis, that is, without taking into account any “what if...”, are the following situations:

• The surgeon sees, based on the x-ray, that this fracture will not heal without surgery or will heal incorrectly.
• This situation occurs especially often with comminuted fractures of long bones, as well as with articular fractures accompanied by damage to the articular surface.
• Fragments with their edges can damage blood vessels and nerves, skin and muscle fibers.

Relative indications for osteosynthesis, that is, not necessarily requiring such an operation, are:

• impossibility of performing closed reduction;
• unstable fractures of tubular and flat bones;
• delayed osteogenesis;
• deformations of the limbs, face and skull;
• jaw fractures.

Contraindications to osteosynthesis

Contraindications to osteosynthesis are:

• Inoperable condition (heart disease, hypertension, anemia, weakened immune system, etc.).
• Fractures complicated by direct infection.
• The presence of infectious and aseptic processes (bone tuberculosis, osteomyelitis, syphilis, osteonecrosis, etc.).
• Severe diseases of organs and blood vessels.
• Epilepsy, cerebral palsy and other diseases of the central nervous system with convulsive symptoms.
• Late stage osteoporosis (50% or more bone loss).

Types of osteosynthesis

The classification of osteosynthesis methods is carried out according to the time of its implementation and the method of introducing fastening elements - clamps.

Primary and delayed osteosynthesis

• Primary osteosynthesis is an operation performed immediately after a fracture, if it was not preceded by any other surgical intervention. Recommended for displaced, comminuted and oblique fractures, for patients without serious concomitant diseases and contraindications. Provides high results and quick recovery.
• Delayed osteosynthesis - performed some period after the injury. The reason for the delay may be the serious condition of the patient. Also, delayed osteosynthesis is resorted to in case of unsuccessful previous treatment or repeated displacements. The effectiveness of the operation depends on the volume of intervention, the physical status of the patient and other factors.

External and submersible osteosynthesis

External hardware transosseous osteosynthesis

We have already encountered this technique using the Ilizarov apparatus as an example.

With this method, no surgical incision is made: the bone fragments are first reduced and then fastened with knitting needles or nails drawn from the outside through the bone in the transverse direction.

The method can be combined with a previously performed osteotomy, does not require plaster immobilization, and allows the patient to walk, leaning on the sore leg. It can provide high-quality fusion with a neat bone suture: the fragments are first separated using a distraction mode, and then, when the callus is formed, they are brought together and compression is created in the fracture zone to strengthen the suture.

In addition to the Ilizarov DKA, there are also joint-type Volkov-Oganesyan, Obukhov, Gudusuari, etc. devices.

Transosseous osteosynthesis is used:

• for fractures of the limbs;
• joint injuries;
• valgus-varus deformity of the legs;
• lengthening of limbs;
• in maxillofacial medicine (for congenital and acquired defects of the face and skull).

Immersion osteosynthesis

With the submersible method, bone fragments are reduced and fastened using extraosseous, intraosseous and transosseous methods, after which, in some cases, the diseased area is immobilized. With stable osteosynthesis using retrograde pins, locknuts and other methods of reliable fixation, immobilization is not required.

Bony osteosynthesis

This is a minimally invasive method in which, after reposition, fixing flat plates located along the bone canal are attached to the combined bone fragments using fasteners.

Initially, there was discomfort due to the friction of the plates on the surface of the bones. Nowadays, the technique has undergone significant modernization, which makes it possible to remove the contact of the plate with the bone:

• Entire systems are used, consisting of an implant plate with angular stability and special screws with threads on the heads, which allows them to be attached not only to bone fragments, but also to the plate itself.
• Not only screws and screws are used as metal elements of osteosynthesis, but also wire, rings, half rings, tape and even lavsan or silk threads.

Intraosseous osteosynthesis

This method of fixation is also called intramedullary. Its essence is the introduction of fixing rods directly into the bone canal after reposition.

There are two methods of intraosseous surgery: closed and open:

• With the closed method, an incision is made at a distance from the fracture zone, through which a fixator (pin or nail) is inserted under X-ray control. The fixator is brought to the fracture line and inserted into the bone cavity. The method is not used for complex multi-fragment fractures, as well as for difficult access.
• With open intraosseous osteosynthesis, the surgeon opens the area of ​​injury, combines bone fragments, and then inserts a rod into the canal and fixes them.

Transosseous osteosynthesis

The surgeon inserts the fixative into the bone canal of both fragments in the transverse direction or at an oblique angle. The method can only be used for oblique and vertical fractures. At the same time, the same reliable fixation is not always ensured as with external percutaneous hardware osteosynthesis: under the influence of load, displacement of fragments can occur. For example, this is possible if the fragments being fastened do not allow the use of fundamental rods and many screws. Therefore, during transosseous osteosynthesis without the use of distraction compression devices, immobilization using plaster casts or splints may be required.

Side effects of osteosynthesis

All methods of metal osteosynthesis discussed above involve the introduction of fixing structures that are foreign to human tissues. Even despite the use of soft, inert modern materials, the following are possible after surgery:

• Prolonged pain, increased local temperature.
• Inflammatory processes in the fracture zone (periostitis, myositis, vasculitis), swelling.
• The possibility of damage to the bone by metal fasteners under full load: this is caused by the higher rigidity of the wire or rod in relation to the loose porous bone structure in a number of diseases (osteoporosis, osteonecrosis, osteomyelitis).
• Development of osteonecrosis in areas of the bone, around metal structures (a long-term consequence of chronic periostitis in combination with vascular pathologies).

However, there is an innovation that allows you to avoid such complications.

Ultrasonic osteosynthesis - what is it?

This is truly a living example of how you can create using the destructive power of sound waves. Presumably, the ultrasonic method was used by ancient civilizations, connecting granite blocks without any seams or mortars, for example, during the construction of the Egyptian pyramids.

With ultrasonic synthesis (USS), bone fragments or bone areas after resection are connected (welded) using ultrasound, thereby creating a bone mass (conglomerate) to fill empty canals and restore bone areas.

Modern traumatologists and surgeons are increasingly using plates for osteosynthesis in their practice, as they perform the supporting function of the bone during a fracture and contribute to the rapid healing of fragments during complex therapy. For fractures of the pelvic joint, plates are selected, the working length of which is selected individually for each person and does not leave the person disabled.

What is osteosynthesis?

A method of treating an injured bone by connecting and fixing its fragments. There are two forms of it:

• Internal (submersible). A type of operation using prostheses that are attached to both affected surfaces of the bone inside the human body. How implants are used: plates, wires, wires, pins and screws.
• Bony osteosynthesis. Fixation occurs over tubular or flat bone. During the operation, the fragments are manually compared, then the bone is fixed.

Osteosynthesis with plates is an internal subtype of the bone form, performed using shunting or compression parts. It is attached over the patient’s bone, subcutaneously. For fixation, spongy screws are used, which are screwed into round, oval or slotted holes at an angle located in the plate. During the operation, the plate is modeled to match the feature of the bone, thereby creating its compression.

Indications

It is recommended to operate on all fractures with bone displacement, since this avoids the formation of callus and maintains full range of motion. Unlike conservative methods, in most cases a person will be able to restore motor skills immediately after surgery. In terms of healing time, such injuries heal 30-40% faster, since with the help of plates the fragments are in close contact.

Indications for osteosynthesis are:

This type of surgery is necessary for displaced bone fractures.

• all fractures with displacement of bone fragments;
• danger of damage to the vascular bed or nerves (with such fractures, osteosynthesis over the bone is not always possible; therefore, a pin is often used);
• secondary destruction of fragments;
• improperly healed fracture.

Contraindications

Contraindications for surgery are divided into two groups - relative and absolute. Conditional conditions include pregnancy, mental disorders of the patient, diabetes mellitus, liver cirrhosis, anemia, obesity, bronchial asthma, chronic pyelonephritis or glomerulonephritis. Absolute contraindications are:

• open fracture due to risk of infection;
• severe somatic diseases in which a person may not undergo surgery (myocardial infarction, acute renal failure, stroke, tuberculosis);
• severe blood loss leading to shock;
• allergic reactions to metal;
• severe osteoporosis.

Types of plates and selection rules for osteosynthesis

Derivatives for osteosynthesis are classified by contact area:

Compression-blocking plates may be used for the operation.

• full;
• partial;
• spot.

They are also classified according to screw holes into the following types:

• compression - LC-DCP;
• blocking - LISS;
• compression-blocking - LCP.

Different types of plates are made from different materials. Steel and titanium plates are popular; the characteristics of the materials from which they are made are presented in the table below:

When choosing a plate, you need to look not only at its characteristics and alloy, but also at the company that produces it. We must try to choose designs from companies that have proven themselves and have become leaders in the field of quality and reliability of structures.

Externally, bone fragments can be connected using the Ilizarov apparatus.

Next, it is necessary to determine the complexity of the operation and what material will be most suitable, what the length of the plate will be and what screws will be used for osteosynthesis. Osteosynthesis with miniplates is used to hold bone fragments without compression. Miniplates are effective in cases of displaced fragments, false joints, non-union of fractures or prolonged fusions. External transosseous osteosynthesis is an operation performed using the Ilizarov apparatus.

After selecting the plate, you need to select the screws. Like metal structures, they are made of titanium. And depending on the damage, a certain screw is required. For example, compression screws are used for transverse diaphyseal fractures of the forearm to tighten the fragments, and locking screws are used for surgery in the hip joint because it provides reliable fixation and angular stability. Often in traumatology, fastening of plates with a cannulated screw, which is self-tapping, is used, which attracted the attention of traumatologists.

“I love what I do, and I do what I can!” (c)

Well, sportsman, how did you train? Not bad? Glad to hear! While there is time for recovery, I will talk about one topic that my readers touched on in their messages - we are talking about designs used in traumatology and orthopedics. Let me explain: where they are used, whether they need to be removed and when it is better to leave them in place. So, let's go.

External osteosynthesis

Today about structures used for osteosynthesis; This is the name for operations whose purpose is to heal a broken bone. Osteosynthesis can be external or submersible. External - extrafocal fixation, used mainly in the treatment of open fractures, when there is a risk of wound suppuration if metal is installed there, for example: the Ilizarov apparatus, which even that grandmother at the entrance heard about.

Immersion osteosynthesis

We are more interested in submersible: extramedullary, intraosseous. Bone osteosynthesis is a plate that is placed at the fracture site and fixes the fragments together with screws.

Intraosseous osteosynthesis involves the introduction of rods into the bone marrow canal, fixing the fragments relative to each other and allowing them to heal.

Fastener materials

Now I’ll tell you about the materials from which the clamps are made. Typically, this is a medical alloy: cobalt-chromium-molybdenum or titanium alloys, such as BT-6. This is a fairly strong elastic alloy that has all the necessary characteristics. But in our time of brilliant optimization and import substitution, a large number of companies are appearing offering cheaper metal structures, in the manufacture of which other titanium alloys are used, when only wire can be made from them. Sometimes such a plate can be bent by hand or even broken. Unfortunately, we cannot check every batch, so just as you prefer to play rugby in Nike or Canterbury boots, or fight in Shoyoroll gis, we also give preference to the fixatives of certain brands in our work. (Until they pay me for advertising, I won’t name them).

The designs of these companies are somewhat more expensive, but we are confident that they will fulfill their purpose. I would also like to note that modern fixators make it possible to perform MRI (magnetic resonance imaging) without risk to the patient’s health. The only thing is that when performing research in the area of ​​​​installation of the retainer, the result will not be informative due to the distortion of the image around the metal.

Didn't fall asleep? The fun begins.

Bone fusion

A fracture heals from 6 weeks to 3 months (and some bones take up to 5 months), while fusion occurs, the fixator must perform its function - I want to make a reservation right away: the plate or pin does not heal, does not accelerate the healing of the fracture, but only dehydrates the fragments, which allows the bones grow together It is customary to remove metal no earlier than after a year.

It is believed that it is during this time that the bone is rebuilt, and it acquires its maximum strength. But I will say this: sometimes removing the retainer is more difficult than putting it in there. Therefore, at the moment, indications for the planned removal of fixators have been compiled:

1. pain and discomfort caused by the fixator;
2. aesthetic component (sometimes the retainer is visible under the skin, for example, on the collarbone);
3. urgent requirement of the patient;
4. requirement of the employer (there are structures in which a person with a structure in the body can be given a commission).

Urgent indications:

1. presence of infection in the area;
2. the need to install another clamp or another system in this area;
3. migration and structural failure.

In general, the metal fixator, having fulfilled its function, can be removed. But sometimes the doctor realizes that removing the fixator will lead to serious injury to surrounding tissues and bone structures and recommends leaving the fixator.
Therefore, Tin Woodman, before you remove something from yourself, ask yourself whether it bothers you or not. And then consult a specialist. And remember: the longer you wear metal, the more difficult it is to remove.

Who am I telling all this to? He has already left to pump the banks...

Osteosynthesis is a type of surgery that is used for bone fractures. Plates for osteosynthesis are needed to ensure that the elements of the damaged bone structure are fixed in a stationary state. Such devices provide strong, stable fixation of bone fragments until they completely heal. Fixation, which is carried out promptly, ensures stabilization of the fracture site and proper bone fusion.

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 dissolve in the patient’s body.

The fixing devices are located inside the body, but on 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 fixation devices

The operation is performed in order to connect all the fragments.

During surgery, surgeons can change the plate using 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 heal correctly. For osteosynthesis to be successful, you need:

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

The disadvantage of osteosynthesis with plates is that the periosteum can be damaged during fixation, which can provoke osteoporosis and bone atrophy, since blood circulation in this area will be disrupted. To avoid this, they produce clamps that have special notches and allow them to reduce pressure on the surface of the periosteum. To perform the intervention, plates that have different parameters are used.

Types of fixing plates for osteosynthesis

The variety of plates allows you to choose the optimal one for each case.

Plate clamps are:

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

Shunts are used for fractures of the comminuted and multi-fragmented type, when the fragments are displaced, as well as for certain types of fractures inside the joint. In other cases, compressive types of clamps are used. The 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 you to reduce the area of ​​contact with the periosteum. Plates that provide angular screw stability are effective for osteosynthesis. The thread promotes rigid and durable fixation in the holes of the devices. The fixator in them is installed epiperiosteally - above the bone surface, which avoids its pressure on the periosteum area. For plates with angular screw stability, contact with the bone surface occurs:

• PC-Fix - point;
• LC - limited.

The following types of plates are distinguished:

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

Fastener parameters

The choice of fixator depends on the type of injury.

With external osteosynthesis, surgical intervention is performed using implants with various parameters. There are different widths, thicknesses, shapes and lengths of the plate in which the screw holes are made. The large working length helps 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 external osteosynthesis needs to be used. The plates provide bone fixation in such parts of the body as:

• brush;
• shin;
• forearm and shoulder joint;
• collarbone;
• hip joint area.