Article

Effects of Ligation of Lateral Intermuscular Septum Perforating Vessels on Blood Supply to the Femur

Article

Effects of Ligation of Lateral Intermuscular Septum Perforating Vessels on Blood Supply to the Femur

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... A meticulous surgical technique that preserves the femoral blood supply is needed. Recently, Grob et al. [25] studied the effect of ligation of the lateral intermuscular septum perforating vessels (LISP vessels) on the blood supply of the femur in a cadaveric injection study. All LISP vessels between the greater trochanter and lateral femoral condyle were identified and ligated laterally, about 2 cm above the intermuscular septum, and the periosteum was not destroyed or peeled off the bone. ...
... Using the results of this study and previous reports of vascular supply of the femur [8,25], we developed safety guidelines for passing cerclage wiring around the femur. The principle of passing the wire passer around the femur is to start the wire passer from the side close to the structures at risk including the femoral vessels and the sciatic nerve then move towards the safe area. ...
... The principle of passing the wire passer around the femur is to start the wire passer from the side close to the structures at risk including the femoral vessels and the sciatic nerve then move towards the safe area. The direction of the tip of the wire passer can be controlled using the handle outside the patient without visualising the posteromedial, medial or anteromedial [25] of the femur. Based on our results and our clinical and technical experience, there are two reasons given for insertion of the wire passer starting from posterior of the femur. ...
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Introduction: Cerclage wiring for reduction of complex femoral shaft fractures can create iatrogenic vascular injury. Objective: To describe the anatomical relation of blood vessels to the femur and develop a technical guide for safe passage of cerclage wire. Materials and methods: CT lower-limb angiographs (CTA) of 80 patients were reviewed and analysed to identify the superficial femoral artery (SFA) and the deep femoral artery (DFA) as well as the relation of those arteries to the femoral cortex. The total length of the femur was measured and divided into eight equal segments (seven levels). At each level, the medial half of the femur was divided into eight sectors labelled A through H and the position of the SFA and DFA was recorded. The shortest distance between the femoral cortex and the SFA and DFA at each level was measured. The data was analysed using STATA version 10.0. Results: The average total femoral length from the tip of greater trochanter to lateral joint line was 402.98 ± 26.16 cm. The average distances from the SFA to the femur (d1) for levels 1 through 7 were 37.20 ± 5.0, 32.09 ± 4.74, 27.13 ± 4.19, 27.71 ± 5.46, 23.71 ± 4.40, 13.63 ± 3.59 and 10.08 ± 3.09 mm, respectively. The average distances between the DFA and the femur (d2) for levels 1 through 3 were 26.70 ± 4.13, 14.76 ± 3.27 and 9.58 ± 3.79 mm, respectively. The position of the SFA is located in sectors B through E at levels 1-3 and in sectors E through H at levels 4-7 and the position of the DFA located in sectors B through F at levels 1-3. Conclusion: Cerclage wiring should be started from the posterior intermuscular septum at the linea aspera. The safe area is the proximal half (midshaft) of the femur where the SFA and DFA lie at a safe distance from the femur. Between the midshaft and the distal 1/4, insertion of the passer must be done meticulously with the tip kept close to posteromedial cortex. Below the distal 1/4, the tip of the passer should be kept close to the posterior cortex to avoid injury to the SFA and the sciatic nerve.
... 12 The blood supply to and from the vastus lateralis is via branches of the lateral circumflex femoral artery and vein, mainly from the descending branch 10 and branches from the deep femoral artery which perforate the lateral intermuscular septum. 13,14 Branches from these main vessels form an anastomosing 15,16 network. Most distally, the geniculate network contributes as well. ...
... Most distally, the geniculate network contributes as well. 16 Femoral nerve branches innervate vastus lateralis. In many individuals, they split before entering the muscle in its anterior proximal portion. ...
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A density model of neurovascular structures was generated from 28 human vastus lateralis muscles isolated from embalmed cadavers. The intramuscular portion of arteries, veins and nerves was dissected, traced on transparencies and digitised before adjustment to an average muscle shape using Procrustes analysis to generate density distributions for the relative positions of these structures. The course of arteries, veins and nerves was highly variable between individual muscles. Nevertheless, a zone of lower average neurovascular density was found between the tributaries from the lateral circumflex femoral and the deep femoral arteries. While the area with the lowest density was covered by the iliotibial tract and would therefore not be suitable for biopsies, another low‐density area was located in the distal portion of vastus lateralis. This was just anterior to the iliotibial tract, in a zone that has been described as a good needle biopsy site. The reported complication rates of needle biopsies (0.1‐4%) are in the range of expectations when simulated based on this model. It is concluded that the optimal human vastus lateralis biopsy site is in the distal portion of the muscle, between ½ and ¾ of the length from the greater trochanter to the lateral epicondyle, just anterior to the iliotibial band. This article is protected by copyright. All rights reserved.
... However, studies have shown that the blood supply of the bone cortex is constituted by centrifugal, circumferential, and large longitudinal vessels, not only in the periosteum but also in the medullary canal, which are not completely destroyed by the use of cerclage wires [23,26]. A cadaveric injection study showed that ligation of the perforating vessel about 2 cm above the lateral intermuscular septum did not change the medullary perfusion due to the rich vascular anastomosis [27]. Given that periosteal devascularization is caused by periosteal stripping near the lateral intermuscular septum or linea aspera, complications may be prevented with percutaneous cerclage wiring, which does not violate the periosteum excessively. ...
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IntroductionAchieving adequate reduction is difficult when performing minimally invasive plate osteosynthesis (MIPO) in elderly patients with simple distal femur fracture. This study aimed to evaluate the elderly patients who had undergone percutaneous wiring-assisted reduction with MIPO for simple distal femur fractures to determine the effect of this technique on reduction quality and fracture union.Materials and methodsBetween January 2009 and September 2017, 56 patients (56 femurs) with displaced simple distal femur fractures treated with MIPO at three trauma centers were finally enrolled. The MIPO technique with percutaneous cerclage wire reduction was performed in 25 patients (Group A). Among them, 12 patients had a simple spiral metaphyseal fracture (Group A*). In comparison, MIPO without percutaneous cerclage wire reduction was performed in 31 patients (Group B). Among them, seven patients had a simple spiral metaphyseal fracture (Group B*). Medical records containing surgical records were retrospectively reviewed to investigate demographic data, comorbidities, complications, operative time, and fluoroscopic time. Radiographs were evaluated for assessing the quality of the reduction and fracture union.ResultsThe mean fracture union time of Group A* was 21.7 weeks, which was significantly shorter than that of Group B* (28.6 weeks). The mean coronal and sagittal angulation in Group A* was 0.6° and 0.7°, respectively, which were significantly lesser than those in Group B* (2.4° and 3.2°, respectively). Mean translation in Group A* was 1.43 mm, which was significantly shorter than that in Group B* (3.81 mm). Nonunion occurred in two patients in Group B.Conclusion Surgical treatment of simple spiral distal femur fractures with percutaneous cerclage wiring-assisted reduction and the MIPO technique in elderly patients resulted in better reduction and faster union time. Therefore, this technique could be a good solution if used in accordance with the indication.
... It appears likely that the bone cement in the femoral cavity led to a lowering of the blood supply to the distal femoral medullary cavity. This could have been due to injury of the intramedullary and metaphyseal blood vessels and nutrient arteries [8][9][10][27][28][29] and elevated intraosseous pressure in the distal femur. [9][10][11] Further analysis of the radioactivity data at the various time points showed that the blood supply and metabolic activity in the experimental distal femur gradually improved over time. ...
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Objective A rabbit model was used to evaluate the effects of bone-cemented hip arthroplasty on distal femoral blood flow and metabolism relative to that of the non-cemented contralateral leg. Methods The marrow cavity of the right hind femur was filled with bone cement. At each of the following time points, rabbits were randomly selected to receive an injection of one dose of 99mTc-methylene diphosphonate and then immediately scanned using a gamma camera: immediately postoperatively and at 4 and 8 weeks postoperatively. A BL-410 model biofunction experimental system was used to analyze the acquired images and determine the radioactive counts of each hind leg. Results The X-ray and photographic images of the right femoral bones confirmed successful filling of the marrow cavity with bone cement. The radioactive counts were significantly lower in the experimental than control legs at each time point. The ratio of the radioactive count of the experimental to control leg increased considerably at each time point, but each ratio was <1. Conclusion Blocking the proximal femoral medullary cavity with bone cement was associated with significant lowering of the blood circulation of the femur and marrow, decreasing the distal femoral blood flow and bone metabolic rate.
Article
Purpose Helical plates potentially avoid the medial neurovascular structures of the thigh. Two plate designs (additional medial 90°-helical plate in double plate constructs for geriatric patients and 180°-helical plate for single plating in young patients) are potential alternatives to widely used standard straight plates. Aims: (1) Assess the distances to adjacent anatomical structures which are at risk after applying medial 90°- and 180°-helical plates in MIPO-technique to the femur. (2) Compare these distances with medial straight plates, and (3) correlate measurements performed during anatomical dissection with CT-angiography. Methods MIPO was performed in ten cadaveric femoral pairs using either a 90°-helical 14-hole-LCP (group1) or a 180°-helical 15-hole-LCP-DF (group2). Using CT-angiography, distances between femoral arteries and plates as well as distances between plates and perforators were evaluated. Following, specimens were dissected, and distances determined again. All plates were removed, and all measurements were repeated with straight medial plates (group3). Results Closest overall distances between plates and femoral arteries were 15mm(11-19mm) in group1, 22mm(15-24mm) in group2 and 6mm(1-8mm) in group3 with a significant difference between group1 and group3(p<0.001). Distances to the nearest perforators were 24mm(15-32mm) in group1 and 2mm(1-4mm) in group2. Measurement techniques (visual after surgery and CT-angiography) showed a strong correlation of 0.972(p<0.01). Conclusions Inserting 90°- and 180°-helical plates in MIPO technique is safe, however, attention must be paid to the medial neurovascular structures with 90°-helical implants and to the proximal perforators with 180°-helical implants. Helical implants can avoid medial neurovascular structures compared to straight plates although care must be taken during their distally insertion. Measurements during anatomical dissection correlate with CT-angiography.
Chapter
Die periprothetische Femurfraktur stellt mit steigender Inzidenz die dritthäufigste Ursache für eine Revision nach Hüft-TEP dar. In der Mehrzahl der Fälle kommt es durch die Fraktur zu einer Lockerung des Femurschaftes, was üblicherweise den Wechsel auf einen Revisionsschaft erfordert. Detailliert beschrieben und bebildert ist die operative Technik, insbesondere auch bei problematischer Knochenqualität (Vancouver B3), sowie verschiedene Zugangswege einschließlich der minimal invasiven Erweiterung des vorderen Hüftzuganges. Das postoperative Management, Ergebnisse, Komplikationsmöglichkeiten und ein Fallbeispiel runden das Kapitel ab.
Article
Background: Femoral component revision is the treatment of choice for Vancouver type B2/B3 periprosthetic femur fractures (PFFs). The purpose of this study was to report the clinical outcome of revision total hip arthroplasty with the use of a modified extended trochanteric osteotomy (ETO) in PFF treatment. Methods: A total of 43 cases between 2000 and 2014 were analyzed. Clinical and radiographic evaluation was performed with a mean follow-up of 40 months. Patient survival after revision surgery, complications, radiographic outcomes, and quality of life and hip function were assessed. Results: Merle d'Aubignè and Postel score averaged 15, and mean postoperative Harris hip score was 70. Radiographic evaluation revealed that the ETO and fractures healed in all but 1 patient within 9 months. Component stability and apparent osseointegration were not coincident with healing of the osteotomy and fracture sites proximal to the inserted stem. Six patients (15%) developed postoperative complications, which included the following: 1 nonunion with progressive subsidence, 2 hip dislocations, 2 deep infections, and 1 breakage of the modular junction of the revision stem. Conclusion: The modified ETO with a lateral approach to the hip for the treatment of PFF is compatible with fracture healing, a low dislocation rate, and good clinical results. However, component stability and apparent osseointegration are coincident with fracture healing only in the distal aspect of the inserted stem. Absence of proximal osseointegration might lead to poor osseous support resulting in inadequate fatigue strength at the junction of the dual modular revision stem.
Article
Trochanteric intramedullary nailing has gained widespread acceptance and popularity among orthopedic trauma surgeons. Whereas some simple fracture patterns are easily reduced and nailed, others may present a major challenge for the surgeon. Anatomical reduction and optimal placement of the intramedullary implants are the most important factors for fracture healing and good functional outcome. Closed anatomical reduction is to be achieved before the nail is inserted. However, especially in inter- and subtrochanteric fractures, a limited open or even open reduction technique may be necessary to achieve an adequate reduction. This article focuses on a structured and practical approach to various reduction techniques based on characteristic displacement patterns. The authors describe in detail their favored reduction techniques with tips and tricks for problem-solving. Furthermore, a non-systematic review of the current literature is provided with a critical appraisal of the described techniques and alternative methods.
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Background The aim of this cadaveric study was to compare a polyaxial (NCB®, Zimmer) to a fixed-angle monoaxial locking plate (PERILOC®, Smith & Nephew) in comminuted fractures of the distal femur regarding stability of the construct. Up to date there is no published biomechanical data concerning polyaxial plating in cadaveric distal femurs. Methods Fourteen formalin fixed femora were scanned by dual-energy x-ray absorptiometry. As fracture model an unstable supracondylar comminuted fracture was simulated. Fractures were pairwise randomly fixed either with a mono- (group A) or a polyaxial (group B) distal femur plate. The samples were tested in a servohydraulic mechanical testing system starting with an axial loading of 200 N following an increase of 200 N in every step with 500 cycles in every sequence up to a maximum of 2 000 N. The end points were implant failure or relevant loss of reduction. Data records included for each specimen time, number of cycles, axial load and axial displacement. Statistical analysis was performed using the exact Wilcoxon signed rank test. Results The mean donor age at the time of death was 75 years. The bone mass density (BMD) of the femurs in both groups was comparable and showed no statistically significant differences. Five bones failed before reaching the maximum applied force of 2000 N. Distribution curves of all samples in both groups, showing the plastic deformation in relation to the axial force, showed no statistically significant differences. Conclusions Operative stabilization of distal femur fractures can be successfully and equally well achieved using either a monoaxial or a polyaxial locking plate. Polyaxial screw fixation may have advantages if intramedullary implants are present.
Article
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Background: LISS, the newest surgical method, makes it possible to completely regain knee function after knee fractures. We share our experience of the most frequently occurring errors during LISS-based treatment and ways of avoiding them. Material and methods: Our sample consisted of patients treated with the LISS method between 2007 and 2012 in the Department of Orthopedics and Traumatology of the 4th Military Hospital in Wroclaw, Poland. We analysed the patients' radiographic records. Results: We analysed follow-up radiographs of 28 patients with fractures of the distal femur. We identified the following seven errors in reduction and fixation of fractures of the distal femur occurring during treatment using the LISS method: 1. Valgus or varus fracture fixation. 2. Malrotation of the fracture fragments. 3. Fixation in malrotation in the sagittal plane. 4. Non-axial placement of the LISS plate in the sagittal plane. 5. The use of K wires not recommended in the LISS method. 6. Screws penetrating into the joint. 7. Drilling holes for unicortical screws. Conclusions: 1. The most common errors in the treatment of fractures of the distal femur by LISS method relate to inadequate reduction of the fracture. 2. Intraoperative fluoroscopy should be used at all stages of the surgical procedure. 3. The surgical technique recommended by the creators of the LISS method must be strictly followed.
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We report early results using a second generation locking plate, non-contact bridging plate (NCB PH((R)), Zimmer Inc. Warsaw, IN, USA), for the treatment of proximal humeral fractures. The NCB PH combines conventional plating technique with polyaxial screw placement and angular stability. Prospective case series. A single level-1 trauma center. A total of 50 patients with proximal humeral fractures were treated from May 2004 to December 2005. Surgery was performed in open technique in all cases. Implant-related complications, clinical parameters (duration of surgery, range of motion, Constant-Murley Score, subjective patient satisfaction, complications) and radiographic evaluation [union, implant loosening, implant-related complications and avascular necrosis (AVN) of the humeral head] at 6, 12 and 24 weeks. All fractures available to follow-up (48 of 50) went to union within the follow-up period of 6 months. One patient was lost to follow-up, one patient died of a cause unrelated to the trauma, four patients developed AVN with cutout, one patient had implant loosening, three patients experienced cutout and one patient had an axillary nerve lesion (onset unknown). The average age- and gender-related Constant Score (n = 35) was 76. The NCB PH combines conventional plating technique with polyaxial screw placement and angular stability. Although the complication rate was 19%, with a reoperation rate of 12%, the early results show that the NCB PH is a safe implant for the treatment of proximal humeral fractures.
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The torsion of both femora was evaluated in 110 patients who had been treated by intramedullary nailing for unilateral femoral shaft fractures. The anteversion (AV) angle was measured by ultrasound, using a tilted-transducer technique. True torsional deformity, defined as an AV difference of 15 degrees or more between sides was found in 21 patients, but only eight had complaints related to the deformity. Three patients had reoperations for troublesome external torsional deformities. Of 26 patients with AV differences of 10 degrees to 14 degrees, defined as possible torsional deformity, three had complaints, but none had serious problems. AV differences of up to 29 degrees were observed in symptom-free patients, and no patients with AV differences below 10 degrees had complaints. Static and dynamic nailing showed almost equal tendencies to lead to torsional deformity. We conclude that torsional deformities are usually established during the operation. Many patients tolerate abnormal torsion, but efforts should be made to reduce and stabilise the femoral shaft fracture with an AV difference of less than 15 degrees.
Book
Part of the highly regarded Master Techniques in Orthopaedic Surgery series, Relevant Surgical Exposures, Second Edition, is a concise, lavishly illustrated reference designed to assist today’s orthopaedic surgeons in a crucial task: choosing and executing the exposure necessary for a given procedure. It presents successful, widely used exposures for hand and wrist, forearm, elbow, humerus, shoulder, pelvis, hip and acetabulum, femur, knee, tibia and fibula, foot and ankle, and spine, all in step-by-step detail. Fully revised with new exposures, anatomic dissections, and illustrations throughout, as well as a section on preferred exposures for trauma, this Second Edition is ideal for orthopaedic surgeons at all levels of experience. • Presents approximately 100 preferred exposure techniques of surgical masters, illustrated with full-color, sequential, surgeon’s-eye view photographs, as well as superb drawings by noted medical illustrators. • Virtually every chapter is enhanced by exceptional anatomic dissections of unexcelled quality. • Includes substantial additions to the shoulder, hip and acetabulum, knee and leg, as well as many more exposures for minimally invasive procedures in all areas. • Features enhanced and expanded full-color drawings throughout. • Provides the up-to-date guidance you need to master both well-established exposures and recent exposures for minimally invasive procedures. • Contains practical guidance, pearls, and tips from Dr. Bernard Morrey and his son, Dr. Matthew Morrey, as well as other leading orthopaedic surgeons.
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Background: Minimally invasive treatment of diaphyseal femur fractures (DFF) with closed reduction and intramedullary nailing is a well established procedure. However, a femoral malrotation after intramedullary nailing is considered to be a substantial problem. Studies have described femoral malrotation (FMR) in 17-35 % after this procedure. Computed tomography (CT) of both femora is accepted as an objective, reproducible measurement method to determine a postoperative femoral malrotation. An anatomic reposition of the centreline of the femur remains of high importance since a malrotation > 15° can lead to a significant limitation of the range of motion (ROM) and to clinical symptomatic constraints. Patients/material and methods: Between July 2007 and December 2011 patients with unilateral DFF were treated with closed reduction and intramedullary nailing. Exclusion criteria were defined as bilateral or prior treatment for femoral fractures, open epihyseal plate or pregnancy. In all cases a postoperative CT scan of the femora was conducted to analyse a femoral malrotation. The indication for a correction was posed in cases of a malrotation > 15°. The data were not randomised and evaluated retrospectively. Results and conclusion: In total 94 patients with unilateral DFF were included. 21 female and 73 male with an average age of 33.15 ± 14.04 years (range 14-94). In the postoperative CT scan an average FMR of 11.58 ± 9.41° (range 0-44°) was determined. In 15 cases (15.95 %), 10 male (13.7 %) and 5 female (23.81 %) a FMR > 15° (average: 23.66 ± 5.74°) was noticed. A subsequent surgery with a correction in average of 17.53 ± 6.83° was performed. After the correction the malrotation averaged 6.07 ± 5.61°. The results support the existing data that the treatment of DFF with closed reduction and intramedullary nailing may lead to a significant femoral malrotation despite a precise intraoperative monitoring. The data demonstrate that nearly 15 % of all patients appear after closed reduction and intramedullary nailing with a femoral malrotation greater than 15°. A routinely utilised postoperative CT scan provides additional information to discover an occult malrotation. Conclusion: In spite of diligent attendance to the femoral torsion intraoperatively in DFF a significant femoral malrotation may result after closed reduction and intramedullary nailing. To prevent a limitation of ROM and clinical constraints a routinely performed postoperative CT scan with a adequate surgical correction is recommended.
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An especially low-odor embalming technique was developed over a 30-years-period using a totoal of 977 complete cadavers, numerous cadavers after autopsy, and in vitro series of fresh beef. The color, consistency, and transparency of the tissue were very well preserved. The technique met high standards of preservation without releasing harmful substances into the environment. Concentrations of formaldehyde in room air remained under the limit of detection by Dräger capillaries. The efficacy for disinfection of the method was confirmed by bacteriologic tests. None of the cadavers or samples developed molds.
Article
Background Periprosthetic femur fractures in elderly patients are a challenging surgical procedure. The aim of this study was a prospective evaluation of minimally invasive implantation of non-contact bridging (NCB-DF®) plates. Patients and methods A total of 30 osteosynthesis procedures in 29 patients (average age 76 years and mean ASA 2.9) with complex femur fractures were registered, 19 fractures were periprosthetic and osteoporosis was present in 17 bones. In 25 patients a minimally invasive percutaneous procedure was performed using a standardized technique. An x-ray examination and clinical follow-up were performed after 6, 12 and 24 weeks. Results The early complications (14% in total) included 1 plate breakage after 16 weeks as well as 3 minor revisions for screw length correction. The x-ray follow-up after 24 weeks showed a secondary extension deficit of 10° and 15° in the knee joint in 2 patients, respectively. Conclusion The NCB-DF® implantation using a standardized minimally invasive technique in periprosthetic femur fractures is a safe alternative in elderly patients. In this very sensitive population the early revision rate within the first 24 weeks is noticeable lower compared to similar procedures.
Zusammenfassung Zwölf langstreckige Stück-und Trümmerfrakturen des Oberschenkels, die den metaphysären (siebenmal proximal, fünfmal distal) und gleichzeitig auch den diaphysären Bereich betrafen, wurden mit extrem langen Kondylenplatten (16 bis 20 Loch) osteosynthetisch versorgt. Die Kondylenplatten wurden über einen proximalen und einen distalen Zugang eingebracht, der Musculus vastus lateralis in allen Fällen im Frakturbereich vollständig unversehrt belassen. Nach typischer Vorbereitung des Klingenlagers mit dem Plattensitzinstrument wurden die Kondylenplatten mit der Klinge auf den Operateur zeigend hinter dem Musculus vastus lateralis eingeschoben, und anschließend unter Drehung der Platten um 180° sowie leichter Kippung der Kondylen bzw. des Trochantermassivs eingeschlagen. Im langstreckigen Frakturbereich wurden keinerlei Schrauben, insbesondere keine Zugschrauben, eingebracht. Zehn der zwölf Frakturen heilten problemlos, in zwei Fällen mußte eine Knochenspanplastik durchgeführt werden. Die Analyse der Operationen und des klinischen und röntgenologischen Heilverlaufs zeigte drei wesentliche Beobachtungen. Bei weitgehend intaktem Weichteilmantel kommt es nach Wiederherstellung der Beinlänge durch Extension zu einer erstaunlich guten indirekten Reposition der Fragmente. Im Heilverlauf kommt es zu einer raschen medialen Abstützung über Kallusheilung. Das Remodelling des Knochens ist homogener als nach Plattenosteosynthesen mit mehreren Scharauben im Frakturbereich, um die es häufig zu erheblichen Dichteunterschieden des Knochens kommt. Die Technik der “durchgeschobenen” Platte für langstreckige Mehrfragmentfrakturen ist die Weiterentwicklung der Brückenosteosynthese, sie kann für sehr langstreckige Frakturen empfohlen werden, bei denen keine Marknagelung durchgeführt werden kann.
Article
Malalignment has been frequently reported after intramedullary stabilization of distal tibia fractures. Nails have also been associated with knee pain in several studies. Historically, plate fixation has resulted in increased risks of infection and nonunion. Our purposes were to compare plate and nail stabilization for distal tibia shaft fractures by assessing complications and secondary procedures. We hypothesized that nails would be associated with more malalignment and nonunion. Randomized, prospective study. Level I trauma center. One hundred four skeletally mature patients with extra-articular distal tibia shaft fractures with a mean age of 38 years (range, 18-95 years) and mean Injury Severity Score of 13.5 (range, 9-50). The majority had high-energy injuries. Patients were randomized to a reamed intramedullary nail (n = 56) or a large fragment medial plate (n = 48). Forty fractures (39%) were open. Twenty-eight (27%) had concomitant fibula fractures that were stabilized. Malunion, nonunion, infection, and secondary operations. The two treatment groups were evenly matched with respect to age, gender, Injury Severity Score, fracture pattern, and presence of open fracture. Six patients (5.8%) developed deep infection with equal numbers in the two groups. Eighty-three percent of infections occurred after open fracture (P < 0.001). Four patients (7.1%) developed nonunion after nailing versus two (4.2%) after plating (P = 0.25) with a trend for nonunion in patients who had distal fibula fixation (12% versus 4.1%, P = 0.09). All nonunions occurred after open fracture (P = 0.0007); the primary union rate for closed fractures was 100%. Primary angular malalignment of 5° or greater occurred in 13 patients with nails (23% of all nails) and four with plates (8.3% of all plates; P = 0.02 for plates versus nails). Six additional patients experienced malalignment after immediate weightbearing against medical advice. Valgus was the most common deformity (n = 16). Malunion was more common after open fracture (55%, P = 0.04). Eighty-five percent of patients with malalignment after nailing did not have fibula fixation. Eleven patients underwent 15 secondary procedures after plating, five of which were for prominent implant removal. This was not significantly different from patients treated with nailing: 10 patients had 14 procedures and five for prominent implant removal. High primary union rates were noted after surgical treatment of distal tibia shaft fractures with both nonlocked plates and reamed intramedullary nails. Rates of infection, nonunion, and secondary procedures were similar. Open fractures had higher rates of infection, nonunion, and malunion. Intramedullary nailing was associated with more malalignment versus plating. Fibula fixation may facilitate reduction of the tibia at the time of surgery. The effect of fibula fixation on tibia healing deserves further study. Economic assessment and functional outcomes data for this population will help to enhance our treatment decision-making.
Article
This study evaluated the anatomic relationship between the femur and the vessels that arise from the deep femoral artery, that is, the perforating arteries and the nutrient artery. Blue silicone dye was injected through the common femoral artery in 20 fresh human cadavers. An anteromedial and a posterolateral dissection were performed to identify the femoral perforating arteries and the nutrient artery of the femur. The length of the femur and the distances between the tip of the greater trochanter and the perforating arteries and nutrient artery were measured. This study showed that a reliable, clinically applicable topographic relationship exists between the femur and the perforating arteries and the nutrient artery.
Article
This study was designed to evaluate the incidence of femoral malrotation in bilateral femoral shaft fractures. All closed bilateral femoral shaft fractures in patients aged 18 or over treated between April 2000 and December 2009 were included in the current study. All patients received a postoperative CT-scan to estimate femoral antetorsion and leg length. All bilateral fractures were treated with intramedullary nailing on a radiolucent table. Retrospectively, all patients were analyzed according to the following parameters: (1) femoral antetorsion of both limbs and antetorsion difference in degrees, (2) femoral length discrepancy (cm), (3) incidence of femoral malrotation >15°, (4) revision rate due to femoral malrotation. A total of 24 patients (11 [45.8%] female; 13 [52.8%] male) with bilateral femoral shaft fractures were included in this study of average age 38 years (median 38 years, range 18-74 years). Clinically relevant malrotation (greater than 15°) was found in 10 cases (41.2%), whereas in 4 cases (40%) a revision surgery was required. Bilateral femoral shaft fractures are associated with a high incidence of clinically relevant femoral malrotation over 15°. Measurement of intraoperative femoral antetorsion in bilateral femoral shaft fractures is quite difficult and currently only feasible postoperatively.
Article
To determine the incidence of rotational malalignment in distal femoral and proximal tibial fractures using computed tomography (CT) scanograms following indirect reduction and internal fixation with the minimally invasive percutaneous osteosynthesis (MIPO) technique. Prospective Cohort. Level I Trauma Centre. A total of 27 consecutive subjects, and 14 proximal tibia and distal femur fractures.Intervention: All patients underwent indirect reduction and internal fixation with a MIPO plating system. A CT scanogram to measure rotational malalignment between the injured and non-injured extremity was then undertaken. Femoral anteversion angles and tibial rotation angles between the injured and non-injured extremities were compared. Malrotation was defined as a side-to-side difference of >108. A total of 14 postoperative tibias and 13 femurs underwent CT scanograms. Three females and 11 males with an average age of 38.1 years sustained proximal tibia fractures and six females and seven males with an average age of 55.8 years sustained distal femur fractures. The difference between tibial rotation in the injured and the non-injured limbs ranged from 2.7 to 40.08 with a mean difference of 16.28(p = 0.656, paired T-test). Fifty percent of the tibias fixed with MIPO plates were malrotated >108 from the uninjured limbs. The difference between femoral anteversion in the injured and non-injured limbs ranged from 2.0 to 31.38 with a mean difference of 11.58 (p = 0.005, paired T-test). A total of 38.5% of the distal femurs fixed with MIPO plates were malrotated >108 from the uninjured limb. Following fixation of distal femoral and proximal tibial fractures, the incidence of malrotation was 38.5% and 50%, respectively. The difference of the mean measures was significant for femoral malrotation; however, statistical significance could not be demonstrated for tibial malrotation.The incidence of malrotation following MIPO plating in this study is much higher than that quoted in previous studies.
Article
The Less Invasive Stabilization System (LISS) is an internal fixator, which combines closed reduction of the diaphysis or metaphysis of distal femur fractures with locked unicortical screw fixation. In a retrospective consecutive study, 50 patients with Association for the Study of the Problems of Internal Fixation/Orthopaedic Trauma Association (AO/OTA) type 33-A1 to 33-C3 fractures were treated with the LISS between January 1999 and December 2003. Final results were assessed using the functional score of Neer after a median follow-up of 29 months (15-48 months). Fifteen male and 16 female patients were followed up. The mean age was 49 years (17-90 years). Deep wound infection was seen in one patient (3%) and malpositioning with cutting-out of the proximal screws was in two patients (6%). All other fractures healed uneventfully without bone graft requirements after a mean of 12 weeks (7-20 weeks). A revised osteosynthesis was performed for correction of a valgus deformity of 20 degrees after 4 months. There was no difference in leg length exceeding 2 cm. One patient had a valgus deformity of 10 degrees combined with a rotational deformity of 10 degrees. Range of motion of the knee joint was >120 degrees in 15 patients (48%); 12 (39%) had a range of motion between 90 degrees and 120 degrees and 4 (13%) between 70 degrees and 90 degrees. The function according to the Neer score was excellent in 15 (48%), good in 10 patients (32%), and fair in 6 patients (20%). The mean Neer score was 80 (60-100). The LISS promotes early mobilization and rapid rates of bony and clinical healing without bone grafting with low rates of infection.
Article
This review is primarily concerned with those features which have direct clinical relevance and it is fortunately possible to treat fractures successfully without a complete understanding of the cellular mechanisms involved without at the same time relying entirely on empiricism. A number of factors influence the healing which can be identified from both clinical and experimental work and may be taken into consideration to put treatment on a more rational basis. It is with these observations that we shall be particularly concerned and cellular mechanisms will be discussed only if they appear to have clinical implications. Such an account must necessarily include details of the healing process as it is modified by contemporary methods of treatment but first it is necessary to consider that events that occur in the healing of a simple fracture in an unsplinted longe bone.
Article
In a prospective randomised trial between September 89 and June 90 one hundred patients with per- and subtrochanteric fractures were consecutively treated by Gamma-nail or DHS. The average age of both groups was about 80 years. The operation time for Gamma-nailing was longer than for DHS-implantation and also the postoperative blood loss was higher in the Gamma-nail-group. We found no difference of intraoperative blood loss, of perioperative letality and in duration of hospital care. 90% of Gamma-nail-patients and 80% of DHS-patients were successfully able to walk four days after operation with full weight bearing on the operated limb. Six patients (12%) with DHS had to be reoperated within 6 weeks. Three patients with unstable fractures got cranial perforation of the cephalic screw after mobilisation. The other three patients had soft tissue complications. Five patients (10%) of the Gamma-nail-group were reoperated, one case because of missed distal locking, one because of cranial perforation of the cephalic screw after varus dislocation of the proximal fragment. One patient suffered intraoperatively a proximal femur shaft fracture which was corrected during operation. In one case a wound hematoma was evacuated, an other patient needed secondary wound closure. Despite technical imperfection of implant and instruments, we conclude that the Gamma-nail allows a very high percentage early and full weight bearing immediately after operation. So we consider that in the treatment of unstable pertrochanteric fractures of geriatric patients, the Gamma-nail has proven to be more efficient than the DHS.
Article
Trauma centers treat more and more patients who have sustained multiple injuries during high energy accidents. The techniques of internal fixation of such fractures may be dictated by the concomitant soft tissue trauma, rather than by the bony injury. Three stages of soft tissue injuries are recognised: Stage I delineates compromised soft tissues which may be treated with standard techniques of internal fixation, provided that further devialization by surgery is avoided. Stage II implies partial, non-circumferential destruction of soft tissues, requiring alternative techniques of internal fixation to prevent (mainly septic) complications. In stage III, the soft tissues about the fracture site are destroyed and need early, specific soft tissue reconstruction. Indirect reduction without further devascularization of bone, aiming at perfect alignment rather than anatomical reduction of extraarticular fractures, optimal rather than maximal internal fixation as well as the inclusion of soft tissue reconstructive procedures into the armamentarium of the orthopaedic surgeon, require an intellectual and technical reorientation but can be shown to improve the results of the treatment of fractures with concomitant soft tissue injury.
Article
The technique of bridging plate osteosynthesis in closed comminuted fractures of the femoral shaft is described. With regard to clinical and radiological results as well as to complications in the postoperative course a group of 17 fractures stabilized by the bridging technique is compared with a group of 16 femoral fractures fixed by plate osteosynthesis after anatomical reduction.
Article
The longitudinal endosteal blood supply is interrupted by fractures while the transverse blood supply conveyed by the periosteum sustains viability on both sides of the fracture site. The intact periosteum seals the fracture gap and the periosteal vessels revascularize the distal fragment. The integrity of the periosteum is of vital importance in determining the rate of healing of a fractured tibia.
Article
The normal circulation of the tibia, a typical mammalian long bone, consists of the afferent vascular system carrying arterial blood and the efferent vascular system carrying venous blood. The link between these 2 systems in compact bone is the intermediate vascular system, composed of thin walled vessels of capillary size within the smallest bone canals. Compact bone, unlike the soft tissues, has no true capillary network. The flow of blood through the cortical canals appears to have a resting level and a stimulated level. The difference between the 2 represents the potential for increased blood supply which may be on a physiologic basis, or on a pathologic basis in response to fracture. Blood flow through cortex as a whole is normally centrifugal, i.e., from medulla to periosteum. The 3 primary components of the afferent vascular system of a long bone are the principal nutrient artery, the metaphyseal arteries, which anastomose freely to form the medullary arterial supply to all areas of the cortex, and the periosteal arterioles, which appear to enter a long bone only under the protection of fascial attachments, to supply the outer third of cortex where they enter. In bone undergoing repair, the components of the afferent vascular system increase functionally above their resting levels. Additionally, there is an extraosseous blood supply, derived from the periosseous soft tissues, to furnish blood initially to periosteal callus and subsequently to necrotic cortex which has been isolated from its normal medullary arterial supply. The extraosseous supply is facultative and transitory. It regresses as the medullary arterial supply, after partial suppression by a fracture or by surgery, is able to regenerate. After reduction of a fracture, the 2 factors essential for achievement of osseous union are blood supply and stabilization. Devascularized bone becomes necrotic, and must be revascularized or replaced before it can enter into any of the processes of repair. Since the tibia does not ordinarily have a deficiency in blood supply, the clinical problems encountered in the treatment of tibial fractures are chiefly attributable to difficulties in establishing adequate stabilization.
Article
1. 1. During 23 procedures of femoral artery reconstruction the respective roles of the deep femoral artery and branches of the still patent superficial vessel in collateral circulation were evaluated by recording arterial pressure below the femoral occlusion before and after interruption of these vessels. 2. 2. The importance of the deep femoral artery was confirmed. 3. 3. The deep femoral artery is the main source of collateral circulation in occlusions confined to the adductor canal and those extending to the common femoral artery bifurcation. 4. 4. In blocks of median length, collaterals leaving the still patent superficial trunk are of main value in some cases, the deep femoral artery or both in others.
Article
A study was done to determine the number, size, direction, exact site and position of the nutrient foramina in human long bones. The position of all nutrient foramina observed was on the flexor aspect and was more or less around a fixed area, but the exact spot varied considerably. Two foramina were much more frequent in the femur, clavicle and humerus than in the other long bones. Three and four nutrient foramina have also been observed in few femora, clavicles and ulnae. Absence of a foramen has been observed in few humeri and radii. Variations have been observed in the direction of nutrient foramina only in lower limb bones. The nutrient foramina in long bones have been described as being directed towards the elbow and away from the knee. Our observations support this assumption except in 0.5% femora, 3.5% tibiae and 9.5% fibulae. Periosteal, muscular and vascular theories are discussed for the normal and abnormal direction of the foramina; the vascular theory offers the best explanation of all reported anomalies as well as of the normal fashioning of the nutrient canals.
Twelve extensive segmental and comminuted fractures of the femur affecting the metaphyseal areas (7 times proximal, 5 times distal) and the diaphysis were treated with extremely long condylar plates (16 to 20 holes). The condylar plates were inserted via a proximal and a distal incision leaving the Musculus vastus lateralis intact at the fracture site in all cases. Following standard preparation of the blade position using the seating chisel, the condylar plate was inserted behind the musculus vastus lateralis with the blade pointing towards the surgeon. The condyles or the trochanteric area were tilted slightly and the plate was turned 180 degrees and driven home. No screws were inserted in the area of the fracture, in particular, lag screws were not used. Ten out of 12 fractures healed without problems, in 2 cases bone grafting was necessary. Three main observations resulted from analysis of the operations and subsequent clinical and radiographical assessments. In the presence of relatively intact soft tissue covering, an astonishingly good reduction of the fragments was achieved after restoration of leg length and extension. In the healing process, callus formed rapidly and provided medial support. The bone structure was found to be more homogeneous than in the case for plate fixation involving several screws at the fracture site around which considerable fluctuations in bone density frequently occur. The application of condylar plates behind the musculus vastus lateralis by only proximal and distal incision for osteosyntheses of extensive multifragmental fractures is a further development of bridge-plating and can be recommended for long fractures.
Article
Lower extremity ischemia is a common disorder that in the majority of cases is associated with occlusion of the superficial femoral artery. The deep femoral artery is recognized as an important collateral pathway to the genicular arterial system, thus accounting for the appearance of symptoms only after its involvement in the disease process. Surgical exposure of the deep femoral artery is often necessary in vascular reconstructive procedures. Furthermore, because it supplies the bulk of the thigh musculature, plastic surgeons have shown great interest in the muscular branches of the deep femoral artery when designing procedures that incorporate myocutaneous flaps. This article gives a detailed account of the embryology, anatomical relations, important variations, and branches of the deep femoral artery. Recommendations for the surgical exposure of this artery at different levels are also presented.
Article
The nutrient foramina of 10 dry cadaveric specimens of human radius, ulna, humerus, femur, and tibia are described. The point of nutrient artery entrance relative to bony surface and distance from proximal articular margins are recorded. The relative risks for intraoperative injury to the nutrient artery during exposure and placement of internal fixation devices in these five long bones are described. The clinical relevance of avoiding injury to the nutrient artery and further compromising existing osseous injury is discussed. Suggestions regarding placement of internal fixation devices are offered.
Article
The role of the periosteal and intraosseous blood supply to the femur and the proximal tibia was investigated to improve the operating technique for transplantation of allogenic vascularized femoral diaphyses and knee joints in humans. Altogether 48 limbs were injected with gelatin, red latex milk, or Revertex and macroscopically prepared; 41 limbs were studied for the variation and division of the truncus profundo-circumflexus. In 200 femurs and 200 tibias the location of the nutrient foramen was determined. The arteries supplying the periosteum of the distal femur and the proximal tibia have defined nutritive areas. The following technique should be followed: If the femoral artery alone is prepared as the vascular pedicle, the optimal section for resection of the femur in knee joint transplantations is 6 to 12 cm above the level of the femur condyles and 5 to 7 cm below the tibial plateau. For the transplantation of femoral diaphyses, the deep femoral artery can be used if the lateral femoral circumflex artery is protected. The Proximal line of resection is defined between the greater and lesser trochanter. For shorter grafts one must consider the number and location of nutrient foramens. For longer grafts the distal branches of the femoral artery must be respected as the intraosseous blood supply reaches distally down to the level of about 8 cm above the femoral condyles. In all these operations of the variation of the truncus profundo-circumflexus and the trifurcation of the popliteal artery must be considered.
Article
A cadaveric arterial injection study was performed to study the effects of percutaneous and conventional surgical plating techniques on femoral vascularity. Sixteen-hole dynamic condylar screw and condylar buttress plates were applied on the proximal and distal shafts, respectively, of intact femora in ten human cadavers. On one side, the plate was inserted using a lateral conventional plate osteosynthesis (CPO) technique with elevation of the vastus lateralis muscle to expose the shaft. On the contralateral side, the plate was inserted percutaneously beneath the muscle using a minimally invasive plate osteosynthesis (MIPPO) technique. After plating, blue silicone dye was injected through the common femoral artery. A dissection was then performed to identify the femoral perforating arteries (PAs). The pattern of periosteal filling of the injected dye was analyzed. The MIPPO technique maintained the integrity of the PAs and exhibited superior periosteal perfusion. The results of this study indicate that the MIPPO technique maintains femoral vascularity and perfusion better than the CPO technique.
Article
Proximal and distal femur fractures have traditionally been treated with open reduction and internal fixation through a standard lateral approach. New, "minimally invasive" internal fixation techniques, however, have been developed in an effort to devascularize the bone less than the traditional method. The purpose of this study was to determine whether a minimally invasive percutaneous plating technique better preserves bone vascularity relative to the traditional method by comparing the effect of the two approaches on the blood supply of the distal femur using silicone arterial dye injection in a cadaveric model. Ten fresh human cadavers underwent lateral conventional plate osteosynthesis (CPO) through a standard lateral approach on one side and minimally invasive plate osteosynthesis (MIPO) through two three-centimeter incisions on the contralateral side. After injection of silicone dye, a dissection was performed bilaterally to identify the femoral perforating and nutrient arteries. All MIPO specimens showed intact perforating and nutrient arteries, whereas the CPO specimens had a variable incidence of vessel disruption. The MIPO group demonstrated better periosteal perfusion in each of the cadavers and improved medullary perfusion in 70 percent of the MIPO specimens compared with the CPO specimens. A percutaneous minimally invasive plating technique disrupts the femoral blood supply less than the traditional open method. Such minimally invasive methods may be more advantageous biologically than the traditional method.
Article
Bridge-plating with its advantages in terms of vascularity and bone healing is a well established procedure today in the treatment of comminuted femoral fractures. Bridge-plating means that the fracture site is not interfered with during the operative procedure. This paper introduces a surgical technique in which the plate is inserted through isolated proximal and distal incisions only, behind the vastus lateralis. Alignment is secured by the plates, the fracture site remains untouched, fixation and screw insertion is restricted to the proximal and distal main fragments. Longitudinal femoral fractures extending right into the trochanteric and or condylar areas are the main indication for minimally invasive plate fixations with angled blade plates or condylar screws since fractures which are restricted to the diaphyseal area are mostly treated by nailing today. The surgical trauma resulting from plating by proximal and distal incisions only is less than that associated with conventional techniques. Indirect reduction of femoral fragments is much easier since the integrity of the surrounding muscles and soft tissue is preserved, the fragments often being reduced simply by traction. Adjustment of rotation is an essential aspect requiring careful attention. For special indications, namely comminuted fractures affecting a large part of the femur and extending into the trochanteric or condylar areas, insertion of the plate via proximal and distal incisions only is a further development in bridge-plating which minimizes surgical trauma and operation time.
Article
A cadaver arterial injection study was performed to analyse the vascular supply to the femur and to study the effects of two surgical plating techniques on femoral vascularity. A 16-hole LC-DCP was applied on the intact femora of five fresh human cadavers. On one side, the plate was inserted using a conventional lateral plate osteosynthesis (CLPO) technique with elevation of the vastus lateralis muscle to expose the shaft. On the contralateral side, the plate was inserted percutaneously beneath the muscle using a minimally invasive plate osteosynthesis (MIPO) technique. After plating, blue silicone dye was injected through the common femoral artery. Cadaveric dissection was then performed to identify the femoral perforating arteries (PAs) and the nutrient artery (NA) of the femur. The pattern of periosteal filling and medullary perfusion of the injected dye was analysed and the topography of the PAs and NA was determined. CLPO placed the PAs and NA of the femur at risk. MIPO maintained the integrity of the PAs and NA and was associated with superior periosteal and medullary perfusion. The results of this study indicate that MIPO is superior to the CLPO in maintaining arterial femoral vascularity and perfusion.