Planning and Reduction Technique in Fracture Surgery PDF

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Planning and Reduction Technique in Fracture Surgery J.Mast R.Jakob R.Ganz Planning and Reduction Technique in Fracture Surgery Foreword by H. Willenegger With 130 Figures in 782 Separate Illustrations ~ Springer Jeffrey Mast, MD, Associate Clinical Professor Department of Orthopedic Surgery Wayne ...

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Planning and Reduction Technique in Fracture Surgery

J.Mast R.Jakob R.Ganz

Planning and Reduction Technique in Fracture Surgery Foreword by H. Willenegger

~

With 130 Figures in 782 Separate Illustrations

Springer

Jeffrey Mast, MD, Associate Clinical Professor Department of Orthopedic Surgery Wayne State University, Hutzel Hospital 4707 St. Antoine Blvd., Detroit, MI 48201, USA Roland Jakob, MD Department of Orthopedic Surgery University of Berne, Inselspital CH-3010 Berne, Switzerland Reinhold Ganz, MD, Professor Director, Department of Orthopedic Surgery University of Berne, Inselspital CH-3010 Berne, Switzerland

Illustrations by Jan Piet Imken Illustrator, Laboratory for Experimental Surgery CH-7270 Davos Platz, Switzerland

ISBN-13: 978-3-642-64784-0 DOl: 10.1007/978-3-642-61306-7

e-ISBN-13: 978-3-642-61306-7

Library of Congress Cataloging-in-Publication Data Mast, J. (Jeffrey) 1940- Planning and reduction technique in fracture surgery / J.Mast, R.Jakob, R.Ganz. Bibliography: p. Includes index. 1. Fractures-Surgery. I. Jakob, Roland. II. Ganz, R. III. Title. [DNLM: 1. Fractures-surgery. WE 175 M423p) RD101.M365 1989 61T.15-dc19 DNLM/DLC 88-24958 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. © Springer-Verlag Berlin: Heidelberg 1989 Softcover reprint of the hardcover 1st edition 1989

Printed on acid-free paper

"I get by with a little help from my friends" "The Beatles" (by John Lennon and Paul McCartney, 1967)

VII

Foreword

During the past 30 years, the Study Group for the Problems of Osteosynthesis (AO) has made decisive contributions to the development of osteosynthesis as a surgical method. Through close cooperation among specialists in the fields of orthopedic and general surgery, basis research, metallurgy, and technical engineering, with consistently thorough followup, it was possible to establish a solid scientific background for osteosynthesis and to standardize this operative method, not only for the more obvious applications in fracture treatment, but also in selective orthopedics where hardly any problems relating to bone, such as those with osteotomies can be solved without surgical stabilization. Besides the objective aim, the AO was additionally stimulated by a spirit of open-minded friendship; each member of the group was recruited according to his professional background and position, his skills, and his talent for improvisation. Against this backdrop without even mentioning the schooling program well known throughout the world I should like to add some personal and general comments. This book is written for clinicians, instructing them how to perform osteosynthesis with special reference to plating in all its varieties and in strict accordance with the biomechanical and biological aspects and facts. From this point of view, the chapter on preoperative planning merits particular emphasis. Not only is it conductive to optimal surgery, it will also contribute to self-education and may found a school. Preoperative planning thus appears as a leitmotif throughout the whole book. The theme is illustrated with a number of fascinating details and suggestions concerning fracture repair and the different kinds of osteotomies, always closely linked with further fundamental concepts: minimal disturbance of blood flow, minimal hardware, optimal stability. I perused with special interest the chapter on plate fixation. All plates (straight and angled) were implanted with the patient on a conventional operating table without X-ray control, even in the case of a segmental fracture, shortening, or comminution. For such cases, the AO distractor is the instrument of choice; the reduction can be achieved without external traction, avoiding the need for both the traction table and the technically demanding insertion of an interlocking nail. Following the precepts outlined, the results are convincing, provided that the specific problems of the plate, which is in eccentric position, are taken into consideration. The AO distractor simplifies the reduction of a fracture to be treated by intramedullary nailing. In certain cases, the plate itself can be used as a reduction instrument, for instance by applying the plate first at the proximal part of

VIII

the fractured bone. This simple and effective procedure is demonstrated in different situations and will be stimulating for anyone familiar with the art of plating. The great importance of any simplification of osteosynthesis should not be underestimated, as it is not only in developing countries that operating rooms may not be adequately equipped. Having discovered this for myself in the course of my travels in various countries, I always carry the AO distractor in my luggage and have often found it useful. In addition to discussing external fixation and the minidistractor, the remaining chapters refer to a number of combinations of internal and external fixation. Finally, the authors describe a remarkable selection of tricks used to adapt the classical AO implants to many different purposes. Every devotee of the art of surgery will especially like this well-illustrated closing chapter. This expertly written and stimulating book is a valuable addition to the orthopedic literature and merits the widest possible distribution. Berne, October 1988

Prof Hans Willenegger, M. D. hon., D. V. M. hon.

IX

Preface

This book is the product of an AO fellowship awarded to one of us (JM) in 1979. This invitation to study in Switzerland allowed the three of us to meet and subsequently become friends. Over the ensuing years the very positive contact between us stimulated the development of a surgical approach based on the classical tenets of AO surgical philosophy but altered by the realization that the anatomic repair of certain high-energy injuries to bone and soft tissue requires excellent judgement and a few reliable tricks. The acceptance of the interlocking intramedullary nail has highlighted the fact, well appreciated in the classical orthopedic literature, that living bone will heal. Healing of viable bone occurs by means of callus formation, gap healing, or "soudure autogene", depending on the circumstances of contact and stability. In the case of the interlocking nail, given the right starting point, correct alignment in the frontal and sagittal planes is restored because of the location of the implant in the intramedullary canal of the proximal and distal main fragments. Realignment of the fracture in the horizontal plane (rotation) and correction of any residual displacement (shortening and lengthening) must be the concern of the surgeon at the time of the operation; the implant itself does not bring about the restoration of these relationships. The anatomic reduction of intercalary displaced diaphyseal fragments, however, is not so important as long as they do not interfere with function. These fragments remain viable by virtue of their connections to the adjacent soft tissue, and healing of the bone may be expected to occur with "functional aftercare". In contrast, regardless of the state of reduction or contact, dead bone heals only when the time necessary for revascularization of the necrotic fragments has passed and when infection has not intervened. We have observed that the same outcome can be achieved by plate fixation of a comminuted fracture. The plate, however, must be applied in such a way as to minimize the disruption of blood flow in the fracture zone and to maximize mechanical stability. We have used on many occasions a technique which can be described, simply, as the "interlocking plate" method. Thus, when internal fixation of bone is indicated, a prime consideration must be to preserve the remaining vascularity. On the other hand, as we have learned, healing of a fracture in a position compromising function, or in association with contractures or dystrophies that compromise use, is also unacceptable. Therefore it is not enough to be the guardian of the vitality of the fracture zone; one must also be concerned with the axial relationships of the extremity and the early restora-

x tion of movement. Stable fixation with a reduction restoring normal spatial relationships is also a goal. How to accomplish these objectives simultaneously is the central concern of this book. We have pushed one another along through clinical application of the methods that are described. Problems, results, and novel applications of the principles have been shared informally, and some early reports on success of the methods in the clinical setting have been generated. In the end, it was accepted that a book on the subject should be written. For purposes of expedience one of us (JM) became the writer and the other two provided criticism, ideas, and illustrative cases. Thus, although the result is a composite product, it is expressed in one person's style. In some instances this approach is a compromise, as like orthopedic surgeons in general we differ in our preferences, our special interests, and our general approach. Nevertheless, we have tried to set out clearly the methods by which we treat certain fractures. We hope that the techniques discussed will be fully understood and also applied, with the end result of satisfaction for both patient and surgeon. We would like to thank the following individuals for their help with the preparation of the manuscript and the many illustrations: David Roseveare, our copyeditor at Springer-Verlag, for refining the crude extracts that he received; Jan Piet Imken for patiently revising and re-revising illustrations to ensure clarity and accuracy; Slobodan Tepic for his technical assistance; Theres Kiser, Gerold Huber, and Lottie Schwendener from Switzerland and Ronnie Constantino from Melbourne, Florida for their exceptional photographic work; Polly Barnes from Mainstream Studio for her proofreading and typing skills; Fellow surgeons Brett Bolhofner, Keith Mayo, Joel Matta, Raymond White, Philip Anson, Christian Gerber, Diego Fernandez, Balz Isler, Peter Ballmer, Fred Baumgartel, Hans Jaberg, Hans Ueli Staubli, Stephan von Gumpenberg, and other friends and colleagues for cases and support. Lastly, the writer thanks the staff at Melbourne Orthopedic Clinic, Florida, including Dan King and Glenn Bryan, for allowing him a little time for this project. We are also grateful to Phillip G. Spiegel for his support and encouragement. Berne and Detroit, October 1988

Jeffrey Mast Roland Jakob Reinhold Ganz

XI

Contents

Chapter 1: Rationale . . . . . . . . . . . . . . . . . . . . . . . . . ..

1

Chapter 2: Anticipation (Preoperative Planning)

11

Fractures and Post-traumatic Residuals . Osteotomies . . . . . . . . . . . . . . . . The Goals of Planning . . . . . . . . . . Preoperative Planning by Direct Overlay Technique: The Making of a Jigsaw Puzzle . . . . . . . . . . . . Preoperative Planning of an Acute Fracture Using the Sound Side: Solving the Jigsaw Puzzle. . . . . . . . . . . . . . . . . . . . . . . ..

11 12 15

Chapter 3: Reduction with Plates

48

.....

Using a Straight Plate as a Reduction Aid . . . . . . . . . Reduction of a Distal Third Oblique Fracture of the Tibia by Means of an Antiglide Plate . Fractures of the Fibula Forearm Fractures .. Acetabular Fractures . Using the Angled Blade Plate as a Reduction Tool. Proximal Femur . Summary . . . . . . . . . . . . . . . . .

16 16

50

51 53 54 54

56 57 57

Chapter 4: Reduction with Distraction .

130

The Femoral Distractor . . . . . . . . . The External Fixator in Reduction and Internal Fixation of Os Calcis Fractures The Minidistractor Summary . . . . . . . .

131

Chapter 5: Substitution . . . . . . . . . . .

201

Combined Internal and External Fixation Composite Fixation . Summary . . . . . . . . . . . . . . . . . . .

201 203

139 141 143

205

XII Chapter 6: Tricks

228

Tricks with Instruments . Tricks with Implants

228 230

References . . .

251

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

XIII

Glossary

Absolute stability: In a fracture treated by internal fixation with physiologic activity there should be no motion between fracture fragments until healing has occurred. This is best achieved through the use of interfragmentary compression. Antiglide plate: A plate used to reduce an oblique fracture indirectly through interference between the plate and the undisplaced main fragment. Buttress plate: A plate employed to support the fractured bone in the area of the metaphysis, usually used in conjunction with lag screws. Direct reduction: The repositioning of bone fragments individually under direct vision with an instrument. Dynamic compression: The fracture fragments are not only compressed by the prestress of the implant, but also subjected to additional compression which results from harnessing forces generated at the level of the fracture when the skeleton comes under physiologic load. Indirect reduction: The blind repositioning of bone fragments through distraction accomplished with an instrument (distractor) or an implant. Instability: Movement between fracture fragments at any time resulting from the application of fixation which leads to a loss of reduction. Interference reduction: A forced repositioning of a bone fragment or fragments achieved by means of conflict between the bone and an anatomically contoured implant. Interfragmentary compression: Prestressing an implant increases friction between the fracture fragments and this improves the stability of the internal fixation. Neutralization plate: A plate used to protect lag screw fixation from torsional and bending movements. Preload (prestress): This is achieved by tensioning an implant and reciprocally compressing the bone or fracture surfaces, before the patient actively subjects the implant to load or stress. Relative stability: In a fracture treated by internal fixation with physiologic activity there is motion between the fracture fragments although the reduction is maintained throughout, until healing has occurred. Static interfragmentary compression: The tension applied to an implant results in compression at the fracture interface. Tension band: An implant loaded in tension against the bone, which is under reciprocal compression load.

1

Chapter 1: Rationale

This book is written with the purpose of sharing with you various techniques that will facilitate your efforts to obtain a successful result in the operative treatment of difficult extremity fractures. The primary objective in these challenging operations is to apply the basic principles of stable fixation with the least possible disturbance of the soft tissues. Unquestionably, the correct application of the AOI ASIF techniques has benefited thousands of patients. In mUltiple international conferences, orthopedic surgeons have learned the practical aspects of the use of compression, neutralization, and splintage in fracture surgery. These basic principles outlined in the AO manual [25] remain the foundation for the successful application of the methods to be discussed. Satisfaction of this prerequisite, allied with a better knowledge of the instrumentation and a desire to maintain the viability of the surgical zone, gives us the ability to enhance our results. Logically, then, functional treatment can be extended to fractures with severe comminution, emphasizing the biologic rather than the purely mechanical principles. This book will discuss the means of achieving fracture reduction with the least motor input and the least devitalization of a living tissue - bone - and yet produce an internal fixation that is mechanically sound and conservatively applied. The postoperative X-ray is the visual statement of the surgical intervention. By analyzing the results of our prior cases we can follow the evolution of the sophistication of our technique, a direct expression of increased understanding and improved skills. Similarly, it is interesting to compare the editions of the Manual of Internal Fixation [25] from 1963 to 1979. Comparing the reduction and fixation montages for various fracture types the different editions, the reader sees the evolution of the system. This development was assisted by critical review of the results of fixation; in AO clinics, in courses, and in review of the materials in the AO Documentation Center (Bern, Switzerland). What are the requisites for reduction? In general, these depend on the specific bone and on the anatomic location of the fracture in that bone. In the diaphysis, we must be faithful to the axis of extremity by restoring the bony shaft so as not to leave residual angulations in the frontal or sagittal planes. In the horizontal plane, rotational alignment must be correct. In young adults or active individuals, we should avoid shaft displacements and shortening or lengthening, particularly in the lower extremities. However, the anatomic reduction of each fracture surface is not critical, nor should it be the absolute goal in this region, especially if the trade-off for anatomicity is the devitalization of the fracture zone [2, 9, 12].

2

Fig. 1.1, pages 5-7 Fig. 1.2, page 8

In the metaphysis the same principles hold true. However, we often must introduce bone or a suitable substitute into metaphyseal areas which have lost substance due to the impaction of cancellous bone by axial forces transmitted from the articular surface. In the epiphysis, anatomic reduction requirements are more severe. The articular surface and its subchondral supporting system demand accurate repositioning of displaced fragments so that the joint surfaces remain smooth and congruent. Likewise, the distribution of the soft tissue that corresponds to the anatomic segments of bone influences the surgical approaches and tactics used to obtain a reduction. For example, indirect reductions in diaphyseal femur fractures are logical because of the extensive muscular envelope which surrounds the bone. If a plate is to be used, the surgical approach must be conservative, taking care to preserve soft tissue attachments to all of the fragments. Obviously, this favors traction reduction and intramedullary fixation in this area as only one end of the bone is exposed. In contrast, in fractures involving the joint surface, the bone is more easily accessible because of the relatively thin soft tissue envelopes surrounding it (the exceptions being the acetabulum and the glenoid), and a direct reduction followed by internal fixation may be possible. Nevertheless, reduction and stable fixation of fractures remains a difficult task. Knowledge of all the tricks in the fracture surgeon's repertoire is necessary. The variations in technique presented in this book will hopefully offer alternative and useful solutions for problem fractures. The bone surgeon develops, with time and experience, a sense of balance, a sense of the relationship of implants to the ...