SurgicalSurgical fracturefracture treatmenttreatment, ,

fixationfixation typestypes

III. III. ExternalExternal SkeletalSkeletal FixationFixation

dr. Varga Attila

HistoryHistory of of ExternalExternal

FixationFixation

••AlreadyAlready usedused atat thethe end of end of thethe 19th 19th centurycentury

••GainedGained popularitypopularity duringduring//afterafter II WWII WW

••WidespreadWidespread useuse delayeddelayed ((missingmissing standardsstandards))

••WidelyWidely usedused atat presentpresent ((biologicalbiological osteosynthesisosteosynthesis))

AdvantagesAdvantages

•• MinimallyMinimally invasiveinvasive

•• RobustRobust mechanicalmechanical environmentenvironment

•• EffectiveEffective inin infectedinfected areasareas asas wellwell

•• DynamizationDynamization atat a a laterlater stagestage of of healinghealing

•• HighlyHighly customizablecustomizable (PMMA/APEF)(PMMA/APEF)

DisadvantagesDisadvantages

•• OutsideOutside of of weightweight bearingbearing axisaxis

•• Pin Pin tractstracts areare infectioninfection risksrisks

•• SomeSome systemssystems areare notnot „„flexibleflexible”” inin useuse (K(K--E)E)

•• SomewhatSomewhat limited limited rangerange of of orthopedicorthopedic situationssituations

•• CanCan injureinjure patientpatient//ownerowner

IndicationsIndications

•• TIBIATIBIA

•• RADIUS & ULNARADIUS & ULNA

•• HUMERUS & FEMURHUMERUS & FEMUR ((withwith restrictionsrestrictions))

•• ShearingShearing injuryinjury, , GunshotGunshot traumatrauma

•• SomeSome mandibularmandibular fracturesfractures

•• VeryVery smallsmall patientspatients

•• MatureMature patientspatients/ / ImmatureImmature patientspatients ((growthgrowthplateplate!!)!!)

TibiaTibia & & RadiusRadius//UlnaUlna

•• ESF most ESF most applicableapplicable toto

–– shaftshaft fracturesfractures

–– highlyhighly comminutedcomminuted diaphysealdiaphyseal fracuresfracures

HumerusHumerus & & FemurFemur

•• Less Less appropriateappropriate thanthan R & UR & U

–– OnlyOnly unilateralunilateral framesframes

–– ThickThick softsoft tissuetissue coveragecoverage (pin (pin tracttract infectioninfection))

–– BiggerBigger mobilitymobility of of softsoft tissuestissues (ex (ex femoropatellarfemoropatellar

liglig, , quadricepsquadriceps etcetc))

ShearingShearing injuriesinjuries

•• ESF ESF providesprovides easyeasy accessaccess toto thethe woundwound thusthus

facilitatesfacilitates dailydaily managementmanagement

•• RigidRigid fixationfixation a major a major advantageadvantage inin thethe casecase of of

articulararticular injuriesinjuries

ShearingShearing injuriesinjuries

ShearingShearing injuriesinjuries

ShearingShearing injuriesinjuries

ShearingShearing injuriesinjuries

GunshotGunshot traumatrauma

GunshotGunshot traumatrauma

GunshotGunshot traumatrauma

GunshotGunshot traumatrauma

MandibularMandibular fracturesfractures

DebridementDebridement

FixateurFixateur externeexterne

VeryVery smallsmall & & ImmatureImmature patientspatients

•• VeryVery smallsmall

–– MinimallyMinimally invasiveinvasive

–– PreservingPreserving softsoft tissuetissue & & bloodblood supplysupply

–– YorkshireYorkshire radiusradius, , footfoot, , carpuscarpus//tarsustarsus, MC/MT, MC/MT

•• ImmatureImmature

–– MUST NOTMUST NOT bridgebridge activeactive growthgrowth plateplate

–– LimbLimb elongatingelongating operationsoperations

BridgingBridging a a jointjoint

•• OnlyOnly maturemature animalsanimals!!!!

•• WhenWhen extra extra placeplace is is requiredrequired toto insertinsert pinspins

•• TemporaryTemporary fixationfixation!!!!

•• KeepKeep jointjoint inin functionalfunctional angleangle!!!!

•• SupportingSupporting a a „„weakweak”” internalinternal fixationfixation

LimbLimb correctioncorrection osteotomyosteotomy

ElementsElements of an ESF of an ESF systemsystem

•• FixationFixation pinspins

•• FixationFixation columncolumn ((connectingconnecting columncolumn//rodrod))

The The differentdifferent systemssystems

•• KK--E E systemsystem

•• SecurosSecuros, , ImexImex--SKSK

•• SynthesSynthes--AesculapAesculap

•• PMMA/APEFPMMA/APEF

•• ManuflexManuflex

KirschnerKirschner--EhmerEhmer systemsystem

•• ElementsElements

•• DisadvantagesDisadvantages

–– no no potentialpotential forfor usingusing smallersmaller//largerlarger pinspins

–– difficultydifficulty toto useuse positivepositive profileprofile pinspins

–– frequentfrequent failurefailure//looseningloosening of of clampsclamps

–– overcomplexovercomplex framesframes toto protectprotect weakweak frameframecomponentscomponents

–– StraightStraight connectingconnecting bar bar makesmakes idealideal pin pin placementplacementdifficultdifficult

SecurosSecuros systemsystem/ IMEX/ IMEX--SK SK systemsystem

•• ElementsElements

•• AdvantagesAdvantages toto KK--E E systemsystem

–– BetterBetter strengthstrength and and versatilityversatility

–– PositivePositive profileprofile pinspins

SecurosSecuros systemsystem

IMEXIMEX--SK SK systemsystem

IMEXIMEX--SK SK systemsystem

PMMA/APEFPMMA/APEF

•• ElementsElements

PMMA/APEFPMMA/APEF

•• AdvantagesAdvantages

–– easeease of of useuse

–– no no preoppreop planningplanning//preassemblypreassembly

–– minimalminimal riskrisk of pin/bar of pin/bar looseningloosening oror failurefailure

–– FREEDOMFREEDOM of of placingplacing pinspins��pin pin locationlocation notnot

subservientsubservient toto connectingconnecting bar bar positionposition

–– EasilyEasily combinedcombined withwith otherother typestypes

PMMA/APEFPMMA/APEF

•• DisadvantagesDisadvantages

–– SingleSingle useuse

–– PostopPostop adjustmentadjustment notnot easyeasy

–– DynamisingDynamising notnot easyeasy↔↔KK--EE

ManuflexManuflex

•• ElementsElements

ClassificationClassification of of framesframes

•• UnilateralUnilateral ((typetype I)I)–– typetype IaIa

–– typetype IbIb

–– typetype I I tietie--inin configconfig (IM pin)(IM pin)

•• BilateralBilateral ((typetype II)II)

•• MultiplanarMultiplanar ((typetype III)III)--exex. a . a unilateralunilateral//typetype IaIa addedadded toto a a bilateralbilateral

•• CircularCircular//IlizarovIlizarov

•• StrengthStrength & & stiffnessstiffness:: typetype IaIa < < typetype IbIb << typetype I I tietie--inin < < typetype II < II < typetype III)III)

ClassificationClassification of of framesframes

•• UnilateralUnilateral ((typetype I)I)

–– typetype IaIa

–– typetype IbIb

–– typetype I I tietie--inin configconfig (IM pin)(IM pin)

ClassificationClassification of of framesframes

•• BilateralBilateral ((typetype II)II)

•• MultiplanarMultiplanar ((typetype III)III)

--exex. a . a unilateralunilateral//typetype IaIa addedadded toto a a bilateralbilateral

•• CircularCircular//IlizarovIlizarov

Pin Pin TypesTypes

•• SmoothSmooth pinspins ((KK--wirewire, , SteinmannSteinmann pinspins))

–– CheapCheap butbut minimalminimal resistanceresistance toto pulloutpullout

–– InsertedInserted inin an an angleangle (70 (70 degreesdegrees))

•• PositivePositive profileprofile threadedthreaded pinspins

–– More More expensiveexpensive

–– IncreasedIncreased pinpin--bonebone interfaceinterface ( ( pinpin--looseningloosening))

–– No No needneed forfor angulationangulation

–– PreservesPreserves corecore diameterdiameter

–– Less Less proneprone toto pin pin breakagebreakage

Pin Pin TypesTypes

•• NegativeNegative threadedthreaded pinspins

–– BiggerBigger pinpin--bonebone interfaceinterface

–– ProneProne toto pin pin breakagebreakage ((notnot recommendedrecommended))

•• FullFull pinspins

–– BetterBetter strengthstrength & & stabilitystability

–– HarderHarder toto findfind safesafe softsoft tissuetissue „„corridorscorridors””

–– DemandsDemands more more carefulcareful alignmentalignment

•• HalfHalf pinspins

Pin Pin InsertionInsertion

•• MOST IMPORTANTMOST IMPORTANT: : correctcorrect limblimb alignmentalignment

•• MM--LL alignmentalignment and torsion!!(and torsion!!(valgusvalgus//varusvarus, ,

abnormalabnormal stressesstresses onon adjacentadjacent jointsjoints))

•• SomeSome CRANCRAN--CAUDCAUD malalignmentmalalignment cancan be be

toleratedtolerated ((elbowelbow//carpuscarpus,,stiflestifle//tarsustarsus cancan

accomodateaccomodate))

Pin Pin InsertionInsertion

•• ReleasingReleasing softsoft tissuestissues ((preventprevent windupwindup))

•• PrePre--drillingdrilling pin pin holesholes((decreasedecrease heatheat necrosisnecrosis))

•• PinsPins shouldshould be min 0,5be min 0,5--1 cm 1 cm fromfrom jointjoint surfacesurface

and min 2 cm and min 2 cm fromfrom fracturefracture lineline ((fissuresfissures!)!)

•• TwoTwo corticescortices engagedengaged

•• Begin Begin withwith proxprox//distdist onesones��alignmentalignment

Pin Pin InsertionInsertion

--controllingcontrolling heatheat--

•• AdverseAdverse reactionsreactions:: local local thermalthermal boneboneinjuryinjury++excessiveexcessive locallocal stressstress

•• PinPin--bonebone interfaceinterfaceaffectedaffected��necrosisnecrosis��fibrousfibrous connectiveconnectivetissuetissue��micromovementmicromovement of pinof pin��boneboneresorptionresorption��pinpin--looseningloosening

•• TrocarTrocar pointspoints of of pinspins dontdont facilitatefacilitate egressegress ofofbonebone shardsshards��impactionimpaction��HEATHEAT

•• >50rpm>50rpm�� thermalthermal necrosisnecrosis minimizedminimized

Pin Pin InsertionInsertion

•• LargerLarger pinspins �� greatergreater pinpin--bonebone interfaceinterface ((dondon’’ttexceedexceed 30%)30%)

•• MoreMore pinspins �� increaseincrease strengthstrength ((maxmax 33--4 per 4 per segmentsegment))

•• StifferStiffer pinspins �� more more eveneven loadload sharingsharing

•• SofterSofter pinspins �� exertsexerts more more stressstress onon nearnear cortexcortex��stressstress��resorptionresorption

Pin Pin InsertionInsertion SummarySummary

•• AtAt leastleast 3 3 pinspins per per fragmentfragment

•• NearNear/far/far fromfrom fracturefracture sitesite

•• LargestLargest possiblepossible pinspins ((dontdont exceedexceed 30%)30%)

•• StiffStiff pinspins

•• PositivePositive profileprofile threadedthreaded pinspins

•• IfIf usingusing smoothsmooth pinspins 70 70 degreesdegrees!!

BoneBone healinghealing

•• FactorsFactors affectingaffecting bonebone healinghealing

–– AgeAge & & generalgeneral healthhealth

–– LocationLocation & & typetype of of fracturefracture

–– SurroundingSurrounding softsoft tissuetissue damagedamage

–– ObtainedObtained degreedegree of of fragmentfragment appositionapposition

–– MechanicalMechanical environmentenvironment providedprovided byby ESFESF

•• PrimaryPrimary bonybony unionunion

–– RigidRigid internalinternal fixationfixation + + closeclose contactcontact of of fragmentsfragments

BoneBone healinghealing

•• SecondarySecondary bonebone healinghealing

–– FractureFracture gapsgaps + + somesome interfragmentaryinterfragmentary

motionmotion

–– ESF is ESF is goodgood exampleexample asas interfragmentayinterfragmentay

comprcompr. . usuallyusually isis notnot appliedapplied (ESF (ESF preservespreserves

bloodblood supplysupply, , importantimportant forfor 2ndary 2ndary unionunion))

PrimaryPrimary and and secondarysecondary bonybony

unionunion

BoneBone healinghealing

TRAUMATRAUMA

Soft tissue and bonedamage

HEMATOME

BoneBone healinghealing

HEMATOME

FIBRIN STABILIZATION

CYTOKINES

MESENCHYMAL CELL PROLIFERATION

VASCULARISATION

DifferentiationDifferentiation of of mesenchymalmesenchymal

cellscellsSmall amount of interfragmentary strain

And high O2 environment

Osteoblasts

More strain

And lower O2 environmentChondroblasts

Large amount of strain

And low O2 environment

Fibroblasts

CallusCallus FormationFormation

•• OutsideOutside of of calluscallus has has bestbest mechanicalmechanical & & biologicalbiological environmentenvironment

–– most most resistantresistant toto bendingbending forcesforces (less (less strainstrain))

–– periostealperiosteal bloodblood supplysupply maintainsmaintains highhigh O2 O2 environmentenvironment

•• FractureFracture endsends underunder highhigh strainstrain + + lowlow O2 O2 tensiontension (more (more chondrochondro//fibroblastsfibroblasts))

•• OuterOuter edgeedge of of calluscallus givesgives most most infoinfo ononsecondarysecondary calluscallus formationformation!!

CallusCallus FormationFormation

•• Limited Limited amountamount of of strainstrain helpshelps bonybony unionunion

((maxmax 2% of 2% of fracturefracture areaarea))

•• ExcessExcess strainstrain leadsleads toto chondrochondro//fibroblastfibroblast

formationformation + + lowlow O2 O2 envenv ��NONUNION!NONUNION!

•• AxialAxial forcesforces promotepromote ����bendingbending//twistingtwisting

forcesforces hinderhinder bonybony unionunion

PostopPostop XrayXray

•• AAAA=AAAA=alignmentalignment, , appositionapposition, , apparatusapparatus, , activityactivity

•• AreAre therethere adequateadequate numbernumber of of pinspins//segmentssegments??

•• Pin Pin sizesize correctcorrect??

•• AreAre pinspins properlyproperly centeredcentered, , safesafe distancedistance awayawayfromfrom skinskin//fracturefracture lineslines??

•• DoesDoes frameframe configconfig matchmatch fracturefracture typetype//patientpatientsizesize??

PostopPostop XrayXray

•• AmountAmount of of externalexternal calluscallus is is inverselyinversely

proportionalproportional toto thethe rigidityrigidity of of thethe frameframe

•• OsteomyelitisOsteomyelitis:: roughrough//irregularirregular calluscallus marginsmargins

•• PinPin--looseningloosening:: 1mm 1mm radiolucentradiolucent areaarea aroundaround

pinpin

PostopPostop XrayXray

•• ResorptionResorption//lacklack of of bridgingbridging calluscallus indicatesindicates

delayeddelayed//nonnon--unionunion

��reexplorationreexploration��bonebone graftinggrafting��newnew fixationfixation

•• GeneralizedGeneralized lossloss of of bonebone densitydensity indicatesindicates stressstress

protectionprotection��stagedstaged dynamizationdynamization

PostopPostop XrayXray

•• IdeallyIdeally fracturesfractures fillfill upup withwith bonebone densitydensity

materialmaterial afterafter 66--8 8 weeksweeks

•• RechecksRechecks atat 77--10 10 daysdays, 6, 6--8 8 weeksweeks thenthen everyevery 33--4 4

weeksweeks

•• 77--10 10 daysdays recheckrecheck

–– PartiallyPartially weightweight bearingbearing

–– SomeSome edemaedema

–– MildMild painpain onon pin sitepin site

PostopPostop XrayXray

•• 66--8 8 weeksweeks recheckrecheck

–– UsuallyUsually healedhealed byby thisthis timetime

–– WeightWeight bearingbearing

–– PainPain free pin free pin sitessites ((otherwiseotherwise looseningloosening))

–– XraysXrays ((evaluateevaluate AAAAsAAAAs))�� decisiondecision�� more more timetime, ,

removalremoval, , interventionintervention oror dynamizationdynamization

ESF ESF cancan be be removedremoved

•• AnimalAnimal is is weightweight bearingbearing

•• SufficientSufficient bonybony calluscallus bridgingbridging thethe fracturefracture gapgap

((densitydensity�� adjacentadjacent bonebone))

•• IfIf severesevere lamenesslameness butbut goodgood calluscallus�� findfind reasonreason

((oftenoften looseloose pin!)pin!)

More More timetime neededneeded

•• WeightWeight bearingbearing butbut calluscallus notnot completelycompletely

bridgedbridged

•• BridgingBridging calluscallus of of insufficientinsufficient radiodensityradiodensity ((tootoo

stiffstiff frameframe?)?)

ComplicationsComplications

•• SoftSoft tissuetissue impalementimpalement:: musclesmuscles, , nervesnerves ((cancan

be be severesevere, , „„windwind--upup””) ) tendonstendons, , vesselsvessels

•• ESF ESF faliurefaliure:: frameframe faliurefaliure, pin , pin breakagebreakage, , pinpin

looseningloosening

•• InfectionInfection:: osteomyelitisosteomyelitis, , sequestrationsequestration, ,

major/minor pin major/minor pin tracttract infectionsinfections

Pin Pin breakagebreakage and and looseningloosening

•• Pin Pin breakagebreakage:: negativenegative threadedthreaded pinpin?, ?, reassessreassess

frameframe strengthstrength//rigidityrigidity

•• Pin Pin pulloutpullout:: smoothsmooth pinspins insertedinserted parallelparallel

•• PramaturePramature pin pin looseningloosening:: veryvery commoncommon

complicationcomplication, , oftenoften poorpoor placementplacement!!

–– IfIf goodgood bonebone unionunion processprocess�� removeremove looseloose pin(s) = pin(s) =

dynamizationdynamization

–– IfIf frameframe is is notnot stabilestabile anymoreanymore�� reviewreview ESFESF

Pin loosening

Pin tract drainage

Infection

Instability

OsteomyelitisOsteomyelitis and and sequestrumsequestrum

•• ESF is a ESF is a veryvery effectiveeffective methodmethod toto managemanage

ongoingongoing osteomyelitisosteomyelitis comingcoming fromfrom otherother typetype

of of fixationfixation methodmethod ((internalinternal!)!)

•• SequestrumSequestrum�� resultresult of of thermalthermal necrosisnecrosis ((poorpoor

techniquetechnique, , calcaneuscalcaneus!)!)

–– RemoveRemove pin and drill out pin and drill out tracttract, , draindrain freelyfreely

Major pin Major pin tracttract infectioninfection

•• CommonCommon complcompl. . causescauses prematurepremature pin pin

looseningloosening

•• BacterialBacterial colonizationcolonization of of pinpin--skinskin interfaceinterface

•• PainPain

•• PurulentPurulent dischargedischarge

•• Pin Pin looseningloosening

Minor pin Minor pin tracttract infectioninfection

•• ToTo somesome degreedegree itsits normalnormal ((wherewhere thickthick softsoft

tissuetissue))

•• BacterialBacterial contaminationcontamination of of thethe pinpin--skinskin surfacesurface

•• Limited Limited granulationgranulation tissuetissue formationformation

•• LightLight serousserous dischargedischarge

•• LackLack of of painpain

•• No pin No pin looseningloosening

ThankThank YouYou!!

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