Minimally Invasive Techniques in Orthopedic Trauma

Role of Augmentation in the Fixation of Osteoporotic Fractures

Introduction

Osteoporotic fractures present a significant challenge due to the compromised bone quality, leading to complications in traditional fracture fixation methods. Augmentation techniques have emerged as a valuable approach to enhance the stability of fracture fixation in osteoporotic patients.

Aim

This review explores the various augmentation methods used in fracture management, including polymethylmethacrylate (PMMA) and calcium phosphate cements, as well as novel injectable materials. Additionally, the role of biomechanical augmentation techniques, such as locked plating and hybrid fixation, is discussed in enhancing fixation strength. Clinical applications in vertebral, proximal femur, and upper extremity fractures are examined, with a focus on the effectiveness of augmentation in improving patient outcomes. Despite the benefits, augmentation presents challenges, such as the risks associated with cement leakage and the economic burden on healthcare systems. The review also highlights future directions, including the development of bioactive and biodegradable materials, as well as innovations in minimally invasive techniques.

Conclusion

Overall, augmentation plays a crucial role in addressing the limitations of traditional fixation in osteoporotic bone, offering promising solutions to improve fracture management.

Principles of Minimally Invasive Reduction and Nail Fixation for Subtrochanteric Femur Fractures

Subtrochanteric femur fractures have a reputation as difficult orthopaedic injuries to treat. Strong deforming forces, including the hip musculature and high physiologic forces, must be counteracted to obtain and maintain reduction. Adding to the complexity is a wide variety of fracture morphologies that must be recognized to execute an appropriate surgical plan. The challenging nature of this injury is demonstrated by nonunion rates of 4% to 5%, but some series have reports of up to 15% and malunion rates of 10% to 15%. Improved outcomes have been shown to be dependent on appropriate reduction and stable fixation, which can be achieved with less surgical insult. The treating surgeon must have a thorough understanding of the injury characteristics and reduction techniques to appropriately execute minimally invasive techniques for these difficult fractures.

Interprosthetic femoral fractures managed with modern distal femoral locking plates: 10 years' experience at a UK major trauma centre

INTRODUCTION

Interprosthetic femoral fractures (IFF) are rare but increasing with an ageing population. Operative management is challenging and there is currently a paucity of outcome data in literature. The purpose of this study was to evaluate outcomes of IFFs managed with modern distal femoral locking plates, in a larger sample size than previously published.

METHOD

This retrospective study reviewed 49 closed IFFs in 48 patients at a major trauma center from 2009 to 2019 occurring between previous total hip arthroplasty (n=38), hemi hip arthroplasty (n=3), dynamic hip screw (n=6) or cephalomedullary nail (n=2) and total knee arthroplasty. They were managed with Minimally Invasive Plate Osteosynthesis (MIPO) employing modern biological fixation techniques and stabilised with VA-LCP Condylar (Synthes; n=28) or Peri-Loc (S&N; n=21) plate. Clinical and radiographic outcomes were measured.

RESULTS

The majority of fractures were in female patients (80%), who were elderly (average 83 years), and comorbid (55% ASA grade 3 or 4). Most fractures were Pires type IIA and OTA/AO type 33A. Average plate spanning femur was 16 holes, with average working length of 6 holes. 86% had unrestricted weight bearing immediately post operatively. 31 fractures reached radiological (n=25) or clinical (n=6) union. 13 patients died with 2 lost to follow up. There were 3 non-unions, with implant failure occurring before 4 months in all 3. We present a union rate of 91% (n=31/34).

CONCLUSION

IFFs are occurring with increasing frequency in a frail elderly population. In patients with IFFs, MIPO and biological fixation techniques using modern distal femoral locking plates can achieve high rate of union when combined with immediate unrestricted weight bearing postoperatively.

Minimally Invasive Osteosynthesis of Transtrochanteric Fractures with Dynamic Hip Screw (DHS)

The method presented here consists of a minimally invasive surgical technique for osteosynthesis of transtrochanteric fractures with Dynamic Hip Screw (DHS) 135°. It is indicated in the treatment of 31-A1 and 31-A2 fractures (Arbeitsgemeinschaft für Osteosynthesefragen Classification - AO) that meet the prerequisites required for using DHS. The surgery is performed, preferably, before 48 hours after the fracture. With the use of the same instruments as the traditional surgical technique and the aid of the C-arm, a closed reduction of the fracture and implantation of the DHS is performed by a 2-cm surgical incision, through dissection of the underlying tissues, with minimal bleeding and damage to the soft parts. In the immediate postoperative period, the patient is encouraged to orthostatism and walk with full load, which anticipates hospital discharge and favors early functional rehabilitation. Outpatient return is scheduled at 2, 6, 12 and 24 weeks postoperatively, with radiographic evaluation to assess fracture healing.