Therapeutic exercise in osteosynthesis of the tibia. Stages and technique of osteosynthesis of the tibia with a pin Possible consequences of injury

Hello! I want to tell my story of a broken leg) On May 26, 2018, a fracture was accidentally received. The diagnosis that was made in the hospital: a closed fracture of both bones of the lower leg in the lower third with displacement of the fragments. The hospital insisted on hospitalization, but I signed a refusal, after that I was put in plaster, and then I realized that I could not get to the fifth floor home, and therefore I decided to stay in the hospital.

In the morning, when going around the doctors, they suggested an operation, because. the fracture is quite complex and it would take 2-3 months to walk in a cast and it’s not a fact that the bones have grown together as expected. Surgery was scheduled for May 31st. On the appointed day, in the morning they brought me to the operating room, put spinal anesthesia, I stopped feeling below the waist right there, plus the anesthesiologist probably put sleeping pills, because. I slept through most of the operation. 30 minutes before the end, I woke up, of course there was no pain, but I felt all the manipulations that took place behind the screen: how something was being hammered, sawed, screwed. In total, everything took about two hours, after which I was taken back to the ward. They told me to drink more (to get all the anesthesia out as quickly as possible) and not raise my head from the pillow during the day. At first, I felt very good, I thought that the worst was over, as it turned out in vain)) In the evening, the anesthesia went away and blood pressure began! The pains were such that I didn’t know where to put myself, no painkillers helped absolutely. The night passed in agony, there was no question of any sleep. In the morning I let go a little, it became easier. They took him for an x-ray to make sure everything went as expected)

This is the design that now flaunted in my leg) On the same day, the surgeon came for an examination, said that you can stand on crutches and give a leg load of up to 20 kg. Plus, physiotherapy (magnet), therapeutic exercises were prescribed.

I moved with the help of these crutches, very comfortable. Plaster was no longer applied after the operation, but it was necessary to wear elastic bandages on both legs and drink Xarelto (1 month) in order to avoid thrombosis, which very often occurs after surgery on the lower extremities.

On the fourth day after the operation, I was discharged home. I got up to the fifth floor quite briskly (in about ten minutes). And at home, as they say, the walls are treated) I processed the seams myself with the help of an antiseptic and applied Kosmopor plasters (very convenient to use).

A week after discharge, she began to get out of the house. They took me for a walk, but the weakness after such sorties was very strong, and in the evening my leg swelled more than usual.

Well, otherwise I can’t say that rehabilitation was very difficult for me ... After 20 days after the operation, I could walk down the street on crutches with an emphasis on both legs, I even swam in the river and lake three times) I really went into the water with the help of friends, but she swam herself (in the water her leg felt healthy). Exactly one month later, she switched to one crutch, and after a month and a half she began to walk without them. Yes, at first I was scared that I would break something five, but the fear quickly passed, because it's such a thrill to feel like a full-fledged person again). The lameness remained for quite a long time .. Yes, even now, sometimes with a very long walk, I can begin to limp, but this is almost not evident to anyone.

In general, summing up all of the above: I am very glad that I agreed to this operation, because. rehabilitation takes much less time.

a) Indications for osteosynthesis of the tibia with a pin:
- Relative readings: fractures of the middle third of the diaphysis of the tibia.
- Contraindications: fractures of II and III types, fractures in children (damage to the growth zone), acute or chronic osteomyelitis, fractures involving the articular surfaces of the tibia.
- Alternative activities: conservative treatment, traction, external fixation, fixation with plates, pin osteosynthesis without canal reaming or osteosynthesis with a locking rod.

b) Preoperative preparation. Patient Preparation: Prophylactic perioperative antibiotic therapy is possible.

in) Specific risks, informed consent of the patient:
- (7% of cases)
- Delayed union/nonunion (less than 5% of cases)
- Wrong union
- Nerve damage (often peroneal)
- Development of the closed space syndrome
- Removing clips

G) Anesthesia. Spinal, epidural or general anesthesia.

e) Patient position. Lying on your back, a special trauma table, a mobile x-ray machine.

e) Access. Median incision over the tendon of the patella.

and) Operation steps:
- Patient position
- Skin incision
- Opening of the medullary canal
- Guide rod introduction
- Reaming of the medullary canal
- Pin installation
- Skin suturing, drainage installation

h) Anatomical features, serious risks, surgical techniques:
- When cutting the patellar ligament, especially from the proximal side, do not deepen the incision to the venous plexus present here.
- Warning: do not perforate the cavity of the knee joint with an awl
- In the distal bone, insert the pin exactly in the midline, especially in the anteroposterior projection.
- Advance the guidewire tip to the end of the medullary canal just above the distal articular surface of the tibia.

and) Measures for specific complications. Infection of the medullary canal: remove the pin, stabilize the fracture with external fixation, install a lavage drain with an active suction system.

to) Postoperative care after osteosynthesis of the tibia with a pin:
- Medical care: remove the active drain on the 2nd day. Careful postoperative monitoring is required.
- Warning: do not miss the beginning of the development of the syndrome of the closed space.
- Partial weight bearing on the limb is allowed after 5 days, full weight bearing - 10 days after surgery.
- Activation: immediately, in the first days without load on the injured limb.
- Physiotherapy: a gradual increase in the range of motion in the knee and ankle joints.
- Disability period: 6-10 weeks.

l):
1. Position of the patient
2. Skin incision
3. Opening of the medullary canal
4. Introduction of the guide rod
5. Reaming of the medullary canal
6. Pin installation
7. Skin suturing, drainage installation

1. Patient position. The patient is in the supine position with supports placed under bent knees. The lower extremities are located in such a way as not to impede the reposition and fixation of the fracture.

2. skin incision. The skin is dissected just distal to the lower edge of the patella, directly above its tendon, which is divided along the fibers with blunt scissors.

3. Opening of the medullary canal. After longitudinal division of the tendon of the patella into two equal parts, they are bred to the sides with blunt retractors. Then the cavity of the medullary canal is opened with an awl, carried out in the area of the tuberosity of the tibia.

The entry hole should be located over the medullary canal dilatation (eg, slightly medial to the tibial tuberosity) as proximal as possible without damaging the anterior tibial articular surface. First, the awl is inserted at a right angle, and then, after passing through the cortical layer, it moves in an oblique direction into the cavity of the medullary canal.

4. Guide rod introduction. A 3-mm flexible rod with a spherical curved tip is inserted into the cavity of the medullary canal, which moves distally to the distal epiphysis of the tibia through the fracture site under constant X-ray control. Then, a flexible rod with a drilling tip is inserted along the guide rod, and the channel cavity expands to 8-10 mm.

5. Reaming of the medullary canal. The length of the expansion of the canal cavity depends on the fracture site. Currently, the desire for a complete cleaning of the cavity of the medullary canal is giving way to a trend towards abandoning this stage of the operation.

6. Pin installation. After expanding the cavity of the medullary canal, a pin is inserted into it with the help of a special guide. The length of the pin is determined before the operation, and its diameter must correspond to the diameter of the expanded channel. The introduction of the pin is performed by rotational movements of the guide and is controlled by the marks applied to the pin.

Careful control of pin advancement avoids additional displacement of bone fragments. If the fracture is unstable, additional fixation may be used (not shown here).

7. Skin suturing, drainage installation. Active drainage can be placed in the medullary canal. Separate sutures are placed on the patellar tendon, subcutaneous tissues and skin. If postoperative bleeding occurs, the drain is disconnected from the suction system, at least temporarily.

An alternative method of internal fixation of fractures of the diaphysis of the tibialis is bone osteosynthesis along the AO.

However, it is advisable to limit its use to cases of comminuted fractures of the upper and lower thirds and oblique fractures with a large plane of the upper thirds of the tibial shaft. Open fractures of I, II degree of severity are not a contraindication for bone fixation.

The skin incision is made strictly directly 1 cm outward from the crest of the tibia! bones (Fig. 11.40). In the lower third of the leg, the incision line goes around the medial ankle. The periosteum is separated no more than 1-2 mm from the fracture line. Cushion-shaped or oblique fractures are reduced (preferably indirectly) and the fragments are held with repositioning clamps. The key moment of the operation is the introduction of 2-3 tightening interfragmentary screws. The screws must be inserted perpendicular to the fracture plane, in case of a complex fracture configuration - to the “averaged” plane. Deviation from the perpendicular direction by more than 20° leads to displacement of the fragments (Johner et al., 1983). If in qualities! If an interfragmentary lag screw is used with a full length cortical screw, then the diameter of the hole in the adjacent cortical layer must be at least equal to the outside diameter of the screw thread. In the distant cortical layer, the diameter of the hole for the screw is 0.1-0.2 mm larger than the diameter of its body. To cut threads in a remote hole, a tap is used, the shape of the threaded part of which exactly matches the shape of the screw. We do not recommend using self-tapping screws as tightening screws AO (Switzerland).

Under these conditions, the screw in the process of twisting creates compression between fragments and, therefore, is responsible for the stability of osteosynthesis.

The “Achilles heel” of such a system is the screw-threaded hole connection, the margin of safety of which is exhausted as the screw is tightened and the degree of compression increases. To protect this connection and improve the functional properties of osteosynthesis, it is necessary to additionally use a narrow straight 3.5 mm neutralization (protective) plate, accurately modeled according to the shape of the bone contact surface. The plate is placed on the medial or lateral surface of the tibia and is fixed to each of the main fragments (fragments) with at least two, and in the upper third of the diaphysis - with three screws. The heads of the screws must be in the holes in the plate in a neutral position. To do this, you must use the universal drill guide when drilling the screw hole. Inaccurate insertion of screws into the plate hole can lead to uncontrolled displacement of fragments, loss of fixation stability, destruction of the screw itself, or a decrease in its safety margin due to the development of prestresses in the structure.

To fix the plate to each of the fragments, it is acceptable to use self-tapping screws or pre-threading in both cortical bone layers using a tap. Additional passage of the tightening interfragmentary screw through the plate significantly improves the quality of fixation (Fig. 11.41).

At all stages of internal fixation, and especially during drilling, the wound is irrigated with an antiseptic solution. Before closing the wound, it is necessary to perform drainage

tubular drainage. The fascia is sutured only if there is no danger of developing a compartment syndrome. Good adaptation of the skin without significant disruption of its microcirculation is achieved using a single or continuous suture according to Donati or in the modification of Allgover. Bed rest is prescribed for 2-3 days after the operation. The limbs are elevated. The vacuum drain is removed after 24-48 hours. The possibility of early active movements from the first days after surgery is the main advantage of stable osteosynthesis.

From 3-5 days, walking with crutches with a partial load of up to 10 kg (limb weight) is recommended. The sutures are removed on the 12-14th day. X-ray control is required after 6, 12 weeks. In the absence of radiological and clinical signs of instability, the presence of adhesions, it is recommended to increase the weight load, which is brought to a full load, usually by 12-16 weeks after surgery.

Surgical treatment of extra-articular fractures of the proximal tibia

In accordance with the classification of AO, the proximal tibia is understood to be its segment located in a conditional square, the upper side of which is a line drawn through the articular surfaces of the tibial condyles between the two extreme points of the external and internal condyles. Damage localized in the conditional square can be intra-articular or extra-articular. Both those and others are often combined with neurovascular damage. In the treatment of extra-articular proximal tibia fractures, it is necessary to solve two problems:

1) restoration of correspondence between the axis of the diaphysis and the plateau;

2) creating adequate stability.

To stabilize a “high” metaphyseal fracture of the tibia, significant interfragmentary compression is required, taking into account the large length of the lever and the weight of the limb segment below the fracture. The use of interfragmentary lag screws for this purpose is not possible for transverse and near-transverse fractures. Therefore, the problem of interfragmentary compression is solved with the help of the plate itself, which in this case is used as a compression plate. However, the absence of a rigid connection between the straight plate and the element through which it is connected to fragments leads to a significant eccentricity of the axial compressive force, the emergence of a bending moment in addition to the force acting along the axis (X. A. Yanson, 1975). The consequence of this is the formation of a wedge-shaped gap between the fragments, a decrease in the area of their contact with each other, loss of stability, and a change in the axis of the leg. Therefore, in the osteosynthesis of extra-articular fractures of the proximal tibia, many authors recommend the use of two straight plates at once, which undoubtedly increases the trauma. More biological, in our opinion, are the angle plates proposed by JSC in 1959 for osteosynthesis of the femur. Their use allows, due to the presence of a rigid connection between the blade and the bone part, to transfer the axial compressive force within the cores of the segment sections, which makes it unnecessary to use another plate.

The relative disadvantage of using corner plates is more complex

shins without impression (pure splitting without reduction in bone volume) and impression (crushing of the bone with a decrease in its volume) and with a combination of splitting and impression.

Surgical treatment of injuries of the tibial plateau is aimed at reconstructing the articular surface, damaged ligaments and menisci, restoring the axis of the segment, creating adequate stability and, therefore, prerequisites for early functional treatment.

A sufficient view of the surface of one of the condyles gives an arcuate external or internal access, which begins in the projection of the joint gap laterally or medially and, curving, continues down 0.5-1.0 cm outward from the tuberosity and crest of the tibia. If it is necessary to examine the plateau from both sides, then a straight longitudinal median anterior incision is made in the area of the knee joint with economical separation of the skin-subcutaneous flaps to the sides. The ligaments supporting the patella are dissected parapatellar and separated from the joint capsule. The latter is cut transversely on both sides of the patellar ligament, below and parallel to the meniscus. The meniscus is retracted upward. To isolate the lateral surface of the tibia, the extensor muscles must be separated from the lateral condyle. However, in this case, it is necessary to minimally devitalize bone fragments, leaving their connection with soft tissues. In the case of very complex bicondylar lesions, extended exposure of the tibial plateau can be obtained by Z-cutting the patellar ligament and lifting upward the patella, pterygoid ligaments, both menisci, and joint capsule. In these cases, at the end of the operation, the suture of the crossed ligament is supplemented by the imposition of an unloading wire loop between the tendon of the quadriceps femoris muscle and the tuberosity of the tibia.

For incomplete intra-articular plateau fractures without impression, a 3.5 mm narrow straight, T-shaped or L-shaped base plate is used. The plate is accurately modeled and fixed to the main (distal) fragment on the side of the injury with three to four cortical screws. A control X-ray is taken and, after making sure that the articular surfaces are congruent and there are no angular deformities, fixation is completed by introducing two or three interfragmentary compression spongy screws (Fig. 11.44, a, b). In the case of a frontal orientation of the fracture plane, stabilization is achieved with the help of two or three spongy screws implanted in the anterior-posterior direction (Fig. 11.44, c, d).

With an incomplete intra-articular impression fracture, the depressed fragment is repositioned, replacing the defect formed in the metaphysis with spongy bone. The need for bone grafting is already determined during preoperative planning. The graft must be taken from the donor site before the fracture is exposed. If there is a central impression without splitting, then reposition and thrombosis of the cancellous bone of the defect are made through a window in the cortical layer of the condyle. Stabilization is achieved by inserting one or two cancellous screws parallel to the plateau (fig. 11.45.1, 11.45.2). The results of reposition should be confirmed by control radiographs. In the case of a combination of depression with splitting, access to the depressed area of the bone, its reposition and replacement of the metaphyseal defect with a spongy graft are possible from the side of the fracture itself. After reposition, the fracture is temporarily fixed with Kirschner wires. The latter are injected from the side of the injury, perforating the skin on the opposite side and leaving the ends of the wires above the bone no more than 1-2 mm. This technique makes it possible to further remove the wires by traction at their distal ends and allows you to freely place the plate on the broken condyle for the final

stabilization. The results of reposition control radiographically. If the articular surfaces are congruent and there is a correspondence between the axis of the diaphysis and the plateau of the tibia, then the fragments are fixed with a base plate and interfragmentary spongy screws (Fig. 11.46, 11.47). In the presence of concomitant injuries of the menisci and ligaments, identified visually and with the help of stress tests after stabilization of bone injuries, the operation must be completed with the restoration of these anatomical structures.

Features of surgical treatment of complete intra-articular fractures of the proximal tibia are determined by the nature of the destruction of the plateau and metaphysis. If the intraarticular and metaphyseal components of the fracture are not comminuted (simple in AO), then reposition and temporary fixation with Kirschner wires do not present great difficulties. Final stabilization is achieved with a special lateral tibial head support plate (LTHBF). This design has a special shape of the proximal part in accordance with the anatomy of the upper end of the tibia and is more rigid and durable compared to the T- and L-plates, as it combines the properties of support, neutralization and compression (Fig. 11.48). If, with a complete intraarticular fracture, there is a comminuted destruction of one condyle in combination with a simple metaphyseal component of the fracture, then at the first stage of the intervention it is advisable to reposition and temporarily fix with wires to the metadiaphysis of the condyle with an intact articular surface. Usually it turns out to be the internal condyle of the tibia. Further actions of the surgeon until the final stabilization are similar to those described for an incomplete intra-articular fracture with splitting and impression. At the final stage, fixation is achieved using an LTHBF plate or (less often) two plates (T- and L-shaped in combination with "/3" tubular) (Fig. 11.49).

In the presence of comminuted destruction of the articular surfaces of both condyles, reposition and fixation present the greatest difficulties. At the first stage, it is necessary to reconstruct the plateau and temporarily fix the fragments with Kirschner wires, and then fill the metaphyseal defect with cancellous bone. The next step is temporary fixation of the metaepiphysis to the diaphysis with wires with the restoration of the correct axial relationships. After the control radiography, the Kirschner wires are replaced with external fixation with one or two plates, as described above.

A special approach is required for comminuted plateau fractures in combination with comminuted metaphyseal destruction, often extending to the tibial shaft. As a rule, such injuries are accompanied by significant soft tissue injury. The choice in these cases is only the reconstruction of the plateau with fixation with two or three spongy screws and the application of an external fixation device outside the damage zone, that is, with overlapping of the knee joint. After 2-3-4 weeks, after the improvement of soft tissue trophism, it is necessary to remount the device in order to free the knee joint or replace the external fixation with an internal one.

From 3-5 days of the postoperative period, after the pain syndrome has decreased, it is necessary to start active and passive movements in the knee joint. After 4, 8, 12 weeks, control radiographs are performed. The beginning of weight loading with a positive radiological and clinical picture is possible with simple intra-articular injuries after 8-10 weeks from the moment of surgery, and with comminuted, impression plateau fractures - after 12-16 weeks.

Rice. 11.40. Access to the tibial shaft: 1 cm outward from the crest, below the medial malleolus

Rice. 11.41. Comminuted fracture of the lower third of the tibial shaft, fixed with lag screws and a neutralization plate:

a, b - type of fracture before surgery; c, d - condition after bone osteosynthesis.

Arrows indicate three lag screws that create interfragmentary compression and, consequently, fixation stability. One of the screws is inserted perpendicular to the fracture plane through the plate, the other two are outside it.

Rice. 11.42. Radiographs of the patient M., 37 years old. Diagnosis - closed uncomplicated comminuted fracture of the proximal metaphysis of the right tibia, subcapitate fracture of the fibula:

a - before surgery; b - osteosynthesis with an angular compression plate;

c - after 16 weeks - fusion

Rice. 11.43. Patient B., 33 years old, senior foreman, was hit by a car on 05.10.95. Diagnosis - concomitant injury, open I degree multi-comminuted fracture of the upper third of the right tibia, fracture of the upper third of the fibula (a), contusion of the soft tissues of the lower leg at the level of the fracture, closed craniocerebral injury, concussion of the brain, fracture of the sternal end of the right clavicle. Produced toilet wound shin, superimposed damped skeletal traction for the calcaneus. As the wound healed, pain decreased, swelling of the limb, the patient began to move in the knee joint, bringing their volume to 90°. 40 days after the injury, an operation was performed - osteosynthesis with an angular bridge-like plate with limited contact with the placement of the implant along the medial surface of the tibia (b). By this time, pathological mobility in the fracture zone remained, the clinical test was negative. The contact surface of the fragments is isolated extraperiosteally. The formed fibrous regenerate was not destroyed. The extraosseous part of the plate is neutrally fixed to the distal fragment with four cortical screws. The wound was drained with two tubular drains for 48 hours. There was no additional immobilization. 5 days after the operation, the patient walked with crutches, placing his foot on the floor. After 6 weeks - periosteal fusion and full range of motion in adjacent joints. The beginning of support on the leg was recommended, which was brought to full by 10 weeks after the operation. 122 days after the injury and 82 days after the operation, he began to work. After 17 weeks, union of the fracture was observed (c). The construct was removed 7 months after osteosynthesis (d). Schwarzberg result after 1 year - 3.0 (excellent)

Rice. 11.44. Osteosynthesis in incomplete intra-articular fractures without articular surface impression: a, b - the fracture line is oriented in the sagittal plane; c, d - the fracture line is located frontally

Rice. 11.45.2. clinical observation. Treatment of a depressed fracture of the lateral condyle of the left tibia: a - computed tomography; b - osteosynthesis with raising the depressed fragment of the condyle

Rice. 11.45.1. Stages of osteosynthesis for an impression fracture of the lateral condyle of the tibia without splitting:

a - type of fracture before surgery; b - raising the depressed fragment through the window in the external condyle of the tibia;

c - condition after bone grafting and insertion of a position screw

Rice. 11.46. Stages of osteosynthesis for an incomplete intra-articular fracture with splitting and impression: a - type of fracture before surgery; b - reposition with replacement of the defect with spongy bone, temporary fixation with Kirschner wires; c - final result

>is. 11.45.1.

Rice. 11.45.2.

Rice. 11.47. Clinical observation of osteosynthesis of an impression comminuted fracture of the lateral condyle of the right tibia in patient L., 25 years old, with a supporting T-shaped plate and compressing spongy screws:

a - before surgery; b - 12 weeks after osteosynthesis - restoration of function

Rice. 11.48. Use of the lateral tibial head support plate for complete intra-articular fractures of the proximal tibia:

a - front view; b - side view.

Rice. 11.49. Osteosynthesis with an L-shaped and a third-tubular plate of a complete intra-articular fracture of the proximal segment of the tibia with comminuted destruction of the lateral condyle

Osteosynthesis is used only in case of unsuccessful closed reposition of fragments (“irreducible”), as well as in patients whose fragments cannot be kept in the correct position under a plaster cast (“irrepressible”). When starting the operation, one should keep in mind the likelihood of both general and local (skin necrosis, suppuration) complications. It can be undertaken only when it is possible to accurately compare the fragments, create close contact between them and reliably immobilize. Due to frequent complications, osteosynthesis on the lower leg is rarely resorted to, guided by strict indications.

Surgical access to the tibia.

Apply anteroexternal, anterior, posterior-internal and posterior accesses. Convenient for the production of internal osteosynthesis is the anteroexternal access. The tibia is exposed at all levels with a slightly arched anterolateral incision 10 to 15 cm long. The reference point for incision is the tibial crest; the beginning and end of the incision should be on the ridge, and in the middle part should be 0.5-1 cm outward from it.

The skin flap is not formed. Then, with one incision, all tissues are dissected to the bone (Fig. 57). The periosteum is exfoliated in limited areas - only at the site of the installation of the structure. It is necessary to strive to ensure that the fragments are associated with the surrounding tissues as much as possible.

Intramedullary osteosynthesis.

Indications.

Osteosynthesis of the tibia is carried out throughout its diaphyseal part. For fractures in the upper third, the length of the central fragment should be at least 8 cm, and for fractures in the lower third, at least 10 cm. . In view of the fact that surgical interventions on the lower legs are often complicated by tissue necrosis and secondary suppuration, the choice of indications for the use of this method is strictly approached.

Contraindications are the general serious condition of the victim (blood loss, shock, etc.), the presence of abrasions in the area of the proposed operation, pustular skin diseases. Intraosseous fixation with a rod should not be used for multi-comminuted fractures, when it is not possible to reliably immobilize the fragments.

Technical equipment.

To perform the operation, you need: 1) rods for fixing the tibia; 2) single-pronged hooks; 3) bone forceps; 4) hooks for extracting the rod; 5) nozzle.

Grooved rods from the Osteosynthesis set are used. The length of the required rod is determined by measuring the distance from the intended insertion site to the ankle joint, which is done on a healthy leg.

Methodology.

For fractures at the border of the upper and middle thirds in the middle third, the nail is inserted from the proximal fragment through the metaphysis of the tibia or through the area above the tuberosity of the tibia. The 2nd insertion method does not require bending of the pin, and it can be of a larger diameter. For fractures in the lower third, it is better to insert the nail through the inner ankle. It is advisable to drive the rod through a short fragment, which gives a more reliable fixation.

With the introduction of a curved rod into the medullary cavity, immobilization is achieved by fixing it at 3 points, and when introduced through the platform above the tuberosity of the tibia, along the entire length.

The introduction of the rod through the metaphysis of the tibia.

Anesthesia is intraosseous. The fracture site is exposed by anteroexternal surgical access. Fragments are lifted with hooks; if there is an interposition of soft tissues, it is eliminated. They try not to damage the periosteum at the ends of the fragments. The second arcuate incision is made above the tuberosity of the tibia 3–4 cm long. The place for the insertion of the pin is chosen at the level of the tuberosity, retreating from it medially by 1.5 cm. In this place, the periosteum is cut longitudinally, and a channel equal to the diameter of the pin is drilled in the cortical layer , at an angle of 30° to the length of the bone. This direction of the channel ensures the correct insertion of the pin.

The rod is driven into the canal made until it stands 0.5 - 1 cm from the bone marrow cavity of the central fragment. Fragments are compared and held in the correct position with bone forceps. The rod is hammered into the peripheral fragment so that it stands at the site of insertion from the bone by 1 cm. At the time of driving the rod, make sure that diastasis does not form between the fragments (Fig. 58, a).

The introduction of the rod through the inner ankle.

Anesthesia is intraosseous. Fragments are exposed by anterolateral surgical access. The 2nd longitudinal incision, 3 cm long, is carried out over the inner ankle. With a drill in the ankle, a channel is made at an angle of 30 °, through which the nail is inserted into the peripheral fragment, and then into the central one.

The introduction of the rod through the platform above the tuberosity of the tibia.

The operation is performed according to the same plan as the previous one. The difference is as follows. The limb is bent at the knee joint up to 90°. An arched skin incision is made from the top of the patella to the tuberosity of the tibia, after which the ligament of the patella is cut longitudinally, a platform is found above the tuberosity of the tibia, in which a hole is made in the bone marrow cavity along a straight line and length of the bone with an awl. Through this hole, a straight rod is driven first into the central and then into the peripheral fragments (Fig. 58b).

postoperative treatment.

After the operation, for 10-12 days (until the sutures are removed), the limb is fixed with two lateral plaster splints, and then with a circular plaster cast up to the upper third of the thigh. With a satisfactory general condition of the patient on the 2nd day for a limited time, he is allowed to rise with the help of crutches. Provided that a strong fixation of fragments is achieved and in the presence of their good end stop, a dosed load on the limb is allowed 3–4 weeks after the operation.

Osteosynthesis with plates.

Osteosynthesis with plates with preliminary compression by a contractor is especially indicated for fixing fragments in the upper and lower thirds of the tibia; in the absence of trauma to the skin, it can also be used in the middle third.

In osteosynthesis of fragments of the tibia, the plates of Ankin, Demyanov, Kaplan-Antonov, Kalnberz, Polyakov, Sivash, Tkachenko and others are used.
An anteroexternal surgical incision is made 12-15 cm long. The outer surface of the tibia is exposed. The skin is cut with a slightly arcuate approach, 0.5 cm away from the tibial crest. The skin flap is not formed. The subcutaneous tissue and periosteum are dissected longitudinally, which are sparingly exfoliated only in the area where the plate is established. When fixing fragments in the upper or lower third of the plate, they bend, give them the shape of a bone in these places, or level the place for their setting in the fragments with a chisel.

The plate is installed in such a way that its center is at the fracture site. After osteosynthesis, the periosteum and subcutaneous tissue are sutured with rare catgut sutures. Sparse silk or nylon sutures are applied to the skin so that there is no tension on it.

Stable osteosynthesis with Tkachenko's plates makes it possible not to use external immobilization and, 3 weeks after the operation, to start dosed loading on the operated limb (Fig. 59).

Osteosynthesis with screws.

Osteosynthesis with screws is used for oblique and helical fractures of the tibia. Sometimes during the operation it turns out that it is impossible to fix the fragments with 2 screws due to a small extension of the fracture line or the presence of additional cracks and fragments. In the 1st case, fixation can be limited to one screw, in the 2nd, a plate with an additional hole in the center is used. In this case, after comparing the fragments, the plate is placed on the tibia. The 1st screw is passed through the central hole, thereby fixing the fragments at the fracture site, and then the structure is fixed with 6 screws on the central and peripheral fragments.

Osteosynthesis is the most common and effective method of treating injuries of bones and joints in modern conditions. Now there are different types of it. Most often, such treatment is required to restore the tubular bones of the limbs. In the past, the most popular method of treating such injuries, along with plastering, was the use of transosseous fixation devices. But they are bulky and uncomfortable, in addition, they often cause wound infections. Therefore, intramedullary osteosynthesis is now considered more effective for restoring the integrity of tubular bones.

What is osteosynthesis

For the treatment of bone injuries, not gypsum, but surgical intervention is now increasingly used. The operation of osteosynthesis provides more efficient and faster bone fusion. It consists in the fact that bone fragments are combined and fixed with metal structures, pins, knitting needles or screws. Osteosynthesis, depending on the method of applying these devices, can be external and submersible.

The second method is divided into intramedullary osteosynthesis - fixation of the bone with the help of rods inserted into the medullary canal, extramedullary, when the fragments are combined with the help of plates and screws, and transosseous - performed by special external devices of a pin design.

Method characteristic

For the first time, the idea of intraosseous fixation of fragments was proposed by the German scientist Kushner in the 40s of the XX century. He was the first to perform intramedullary osteosynthesis of the femur. The rod he used was shaped like a shamrock.

But only by the end of the century the technique of intramedullary osteosynthesis was developed and began to be widely used. Rods and other implants for blocking osteosynthesis have been developed, which allow you to firmly fix bone fragments. Depending on the purpose of use, they differ in shape, size and material. Some pins and rods allow them to be inserted into the bone without reaming the canal, which reduces the invasiveness of the operation. Modern rods for intramedullary osteosynthesis have a shape that repeats the bends of the bone canal. They have a complex structure that allows you to firmly fix the bone and prevent the displacement of fragments. Rods are made of medical steel or titanium alloys.

This method is devoid of many disadvantages and complications of external structures. Now it is the most effective way to treat periarticular fractures, damage to the tubular bones of the lower leg, thigh, shoulder, and in some cases even joints.

Indications and contraindications for use

Such an operation is performed with closed fractures of the femur, humerus, tibia. These lesions may be transverse or oblique. It is possible to use such an operation in the development of a false joint due to improper bone fusion. If the injury is accompanied by damage to soft tissues, it is desirable to postpone osteosynthesis, since there is a high risk of infection of the fracture site. In this case, the operation is more difficult to perform, but it will also be effective.

Intramedullary osteosynthesis is contraindicated only in complex open fractures with extensive soft tissue damage, as well as in the presence of an infectious skin disease in the place where the pin should be inserted. Such an operation is not used in elderly patients, since due to degenerative-dystrophic changes in the bone tissue, the additional introduction of metal pins can cause complications.

Some diseases can also become an obstacle to intramedullary osteosynthesis. These are arthrosis in a late stage of development, arthritis, blood diseases, purulent infections. Surgery is not done for children due to the small width of the bone canal.

Kinds

Intramedullary osteosynthesis refers to intraosseous surgery. In this case, the fragments are repositioned and fixed with a pin, rod or screws. According to the method of introducing these structures into the bone canal, intramedullary osteosynthesis can be closed and open.

Previously, the open method was most often used. It is characterized by the fact that the damaged area of the bone is exposed. Fragments are compared manually, and then a special rod is inserted into the bone marrow canal, which will fix them. But more effective is the closed method of osteosynthesis. It only takes a small incision to do it. Through it, by means of a special conductor, a rod is inserted into the bone channel. All this happens under the control of the x-ray machine.

The pins in the channel can be installed freely or with blocking. In the latter case, they are additionally reinforced on both sides with screws. If osteosynthesis is performed without blocking, this increases the load on the bone marrow and increases the risk of complications. In addition, such fixation is not stable with oblique and helical fractures or with rotational loads. Therefore, the use of rods with blocking is more efficient. Now they are produced already with holes for screws. Such an operation not only firmly fixes even multiple fragments, but does not lead to compression of the bone marrow, which preserves its blood supply.

In addition, the operation differs in the way the rod is inserted. It can be introduced with a preliminary reaming of the medullary canal, which leads to injury. But recently, special thin rods are most often used, for which it is not necessary to further expand the channel.

There are even less common types of intramedullary osteosynthesis. Fragments can be fixed with several elastic rods. One straight and two rods bent opposite to each other are inserted into the bone. Their ends are bent. With this method, a plaster cast is not required. Another method was proposed in the 60s of the XX century. The medullary canal is filled with pieces of wire so that it fills it tightly. It is believed that in this way it is possible to perform a more durable fixation of fragments.

When choosing the type of osteosynthesis, the doctor focuses on the patient's condition, the type of fracture, its location and the severity of concomitant tissue lesions.

Open osteosynthesis

Such an operation is more common, as it is simpler and more reliable. But, like any other operation, it is accompanied by blood loss and violation of the integrity of soft tissues. Therefore, after open intramedullary osteosynthesis, there are more complications. But the advantage of using this method is the possibility of using it in complex treatment in conjunction with various devices for transosseous fixation. Separate open intramedullary osteosynthesis is now used very rarely.

During the operation, the fracture area is exposed and bone fragments are compared manually without the use of devices. This is precisely the advantage of the method, especially in the presence of many fragments. After comparing the fragments, they are fixed with a rod. The rod can be inserted in one of three ways.

With direct injection, it is necessary to expose another section of the bone above the fracture. In this place, a hole is punched along the medullary canal and a nail is inserted into it, with its help comparing the fragments. With retrograde introduction, they begin with the central fragment, comparing it with the rest, gradually hammering the nail into the medullary canal. It is possible to insert the rod along the conductor. In this case, it also starts from the central fragment.

With intramedullary osteosynthesis of the femur, the alignment of the fragments is usually so strong that a cast is not required. If an operation is performed on the lower leg, forearm or humerus, then it usually ends with the imposition of a plaster splint.

Closed osteosynthesis

This method is now considered the most effective and safe. After its implementation, no traces remain. Compared to other osteosynthesis operations, it has several advantages:

slight soft tissue damage;
little blood loss
stable fixation of bones without intervention in the fracture zone;
short operation time;
rapid recovery of limb functions;
no need for gypsum limb;
Can be used in osteoporosis.

The essence of the method of closed intramedullary osteosynthesis is that a pin is inserted into the bone through a small incision. The incision is made away from the fracture site, so complications are rare. Previously, with the help of a special apparatus, the reposition of bone fragments is done. The entire process of the operation is controlled by radiography.

Recently, this method has been improved. The fixing pins have holes on each end. Screws are inserted into them through the bone, which block the pin and prevent it and bone fragments from moving. Such blocked osteosynthesis provides more efficient bone fusion and prevents complications. After all, the load during movement is distributed between the bone and the rod.

The fixation of the fracture site using this method is so strong that the next day it is possible to give a dosed load on the injured limb. Performing special exercises stimulates the formation of callus. Consequently, the bone fuses quickly and without complications.

A feature of blocked intramedullary osteosynthesis is its higher efficiency compared to other methods of treatment. It is indicated for complex fractures, combined injuries, in the presence of many fragments. Such an operation can be used even in obese patients and patients with osteoporosis, since the pins that fix the bone are firmly attached in several places.

Complications

Negative consequences of intramedullary osteosynthesis are rare. They are mainly associated with the poor quality of the fixation rods, which can corrode or even break. In addition, the introduction of a foreign body into the medullary canal causes its compression and impaired blood supply. Bone marrow destruction can occur, causing a fat embolism or even shock. In addition, straight rods do not always correctly match the fragments of tubular bones, especially those that have a curved shape - the tibia, femur and radius.

Recovery after surgery

After closed intramedullary osteosynthesis, the patient is allowed to move after 1-2 days. Even with shin surgery, you can walk with crutches. In the first few days, severe pain in the injured limb is possible, which can be relieved with painkillers. The use of physiotherapy procedures that will accelerate healing is shown. Be sure to perform special exercises, first under the guidance of a doctor, then on your own. Recovery usually takes 3 to 6 months. The operation to remove the rod is even less traumatic than the osteosynthesis itself.

The effectiveness of bone fixation depends on the type of injury and the correctness of the method chosen by the doctor. Fractures with smooth edges and with a small number of fragments grow best. The efficiency of the operation also depends on the type of rod. If it is too thick, there may be complications due to compression of the spinal cord. A very thin rod does not provide a strong fixation and may even break. But now such medical errors are rare, since all stages of the operation are controlled by special equipment, which provides for all possible negative aspects.

In most cases, patients' feedback on the operation of intramedullary osteosynthesis is positive. After all, it allows you to quickly return to normal life after an injury, rarely causes complications and is well tolerated. And the bone grows together much better than with conventional methods of treatment.