Evolution of minimally invasive plate osteosynthesis (MIPO) in the femur

Problems with conventional open reduction and internal plate fixation of distal femoral fractures are well established. These problems have been associated with extensile exposures of the fracture site. "Biological plating", like intramedullary nail fixation, of distal femoral fractures preserves the soft tissues about the fracture, and is associated with early fracture consolidation and low rates of infection. Anatomical restoration of the articular surface continues to be the main goal in the treatment of these fractures regardless of the stabilization technique. Submuscular plating techniques, which provide for closed reduction of the diaphyseal/metaphyseal component of the fracture, have improved significantly.     

Minimally invasive plate osteosynthesis (MIPO) in the treatment of the femoral shaft fracture where intramedullary nailing is not indicated

The aim of this study was to examine the results of minimally invasive plate osteosynthesis (MIPO) of the femoral shaft fracture in patients where intramedullary nailing is contraindicated and evaluate the proper number of the screws for stable fixation. This was a retrospective study of 36 closed femoral shaft fractures which underwent MIPO using a conventional 4.5 broad dynamic compression plate (DCP) with 14-18 holes fixed with three or four screws in the proximal and distal fragments. Thirty-three fractures had bony union in 21.0 weeks (range, 12-28 weeks), two had delayed union that required bone graft and union at 28 and 32 weeks. Malalignment occurred in five cases. Sixty-two fragments were fixed with three screws--40 in cluster and 22 in separated positions. Ten fragments were fixed with four screws--eight in cluster and two separated. Broken screws were found in three cases; all were in the group with three screws fixed in cluster group. MIPO of the femoral shaft fracture is an alternative treatment in the patient where intramedullary nailing is contraindicated. Malalignment is the common complication that must be carefully evaluated intraoperatively. We recommend using at least three separated screws in each fragment to reduce the risk of screw breakage.     

骨段撑开转移治疗骨缺损国外进展

节段性骨缺损是下肢开放性骨折中较严重的损伤,传统的治疗包括:采用外固定支架稳定骨折、应用游离组织移植修复软组织缺损创面以及用带血管或不带血管的骨移植修复骨缺损.骨段撑开转移是治疗骨缺损的一种新方法.适宜治疗3～12 cm的骨干缺损,仅需行少量松质骨移植以促进局部骨愈合.而常规治疗方法植骨量较大.因而,供骨区并发症较少.而且,不需行游离组织移植修复创面.缺点是相对复杂,治疗时间长.当病例选择适当以及对技术掌握完善时,对某些骨缺损病例的治疗,才能充分发挥其优越性.     

Osteofibrous dysplasia treated with distraction osteogenesis: a report of two cases

We treated two patients with osteofibrous dysplasia of the tibia using en bloc marginal excision of the lesion and bone transport, a distraction osteogenesis procedure. In one patient, we had performed curettage procedures twice, each time followed by local recurrence and deformity. In contrast, with marginal excision and bone transport using an Ilizarov apparatus, the disease healed. In the other patient, we performed marginal excision and bone transport as the first procedure, which resulted in a healed lesion. In patients with osteofibrous dysplasia requiring treatment by an open method, curettage frequently is followed by local recurrence and deformity. We now prefer marginal excision of the lesion to avoid long-term failures, as in our first case. Distraction osteogenesis has proven useful for restoring structure and function in the affected limb.     

Minimally invasive plating osteosynthesis (MIPO) of middle and distal third humeral shaft fractures

OBJECTIVE: To evaluate the clinical, radiographic, and functional outcomes of middle and distal third humeral shaft fractures treated with the minimally invasive percutaneous osteosynthesis (MIPO). DESIGN: Prospective, single-center, nonconsecutive clinical series study. SETTING:: Skeletal trauma center of a university teaching hospital. PATIENTS: Thirteen patients who were seen from May 2004 to October 2005 with an average age of 38.1 years (range, 25 to 60 years) form the basis of this study. Patients were obtained from a surgical database of 1 surgeon. INTERVENTION: The middle and the distal third humeral shaft fractures were reduced by closed means and fixed with long narrow 4.5-mm dynamic compression plates introduced through 2 small incisions away from the fracture sites and placed on the anterior aspect of the humerus. MAIN OUTCOME MEASUREMENTS: Time to fracture healing and functional assessments were assessed at an average follow-up of 12.5 months (range, 7 to 19 months) for the affected shoulders and elbows using the UCLA and Mayo elbow performance scoring systems, respectively. RESULTS: All fractures united with a mean healing time of 16.2 weeks (range, 12 to 32 years). There were no nonunions, radial nerve palsies, or implant failures. The UCLA scoring system showed excellent results in 7 cases (53.8%) and good results in 6 cases (46.2%). Thirteen patients had excellent results of their elbow function when assessed with the Mayo elbow performance scoring system. CONCLUSION: Closed reduction and internal fixation of middle or distal third humeral shaft fractures using MIPO is a safe and effective surgical treatment method and an alternative option to open techniques.     

微创治疗小儿骨囊肿31例报告

[目的]回顾性地总结小儿骨囊肿的临床和X线特点,微创治疗的结果,为今后诊治提供参考。[方法]将既往医院诊治的资料完整的小儿骨囊肿31例进行临床分析,找出其一定的规律性。[结果]该病好发于长管状骨干骺端,最多见于股骨、肱骨近端,X线片、CT扫描可明确诊断,少数骨囊肿诊断困难时,可行MRI检查或骨穿刺活检确诊。[结论]31例12岁以下骨囊肿患儿,均采用囊肿穿刺引流、激素灌注术、自体骨髓血移植术治疗,取得了满意的治疗效果。     

Minimally invasive plate osteosynthesis for osteofibrous dysplasia of the tibia: a case report

Osteofibrous dysplasia occurs most frequently in the tibia and may result in deformity and pathological fracture. We report one such case in a 6-year-old girl who underwent minimally invasive plate osteosynthesis using a locking compression plate. The varus deformity of the tibia was manually corrected, and the plate was inserted without extensive surgical exposure. At 20-week follow-up, the fracture had healed completely, and she had returned to normal daily living. At 3-year follow-up, radiographs showed no progression of the varus deformity. Minimally invasive plate osteosynthesis is useful for treatment of pathological fractures caused by osteofibrous dysplasia. It preserves blood flow at the fracture site, leading to good bone healing and stability to prevent further deformity and an early return to daily activity.     

两种术式治疗胫骨中段闭合性骨折的疗效比较

[目的]比较微创钢板固定( MIPO)和交锁髓内钉两种方法治疗闭合性胫骨干骨折的临床疗效.[方法] 2007年3月～2010年6月,采用MIPO技术治疗45例胫骨中段闭合性骨折,与前期采用髓内钉治疗的43例进行比较.对两组的手术时间、出血量、术中透视次数、骨折愈合时间、临床疗效及并发症进行对比分析.[结果]所有病例均获随访12 ～ 24个月,平均18.7个月.在41例AO分型4-2 -A型骨折中,两组在手术出血量、骨折愈合时间、临床疗效及术后并发症方面的差异均无统计学意义(P＞0.05).在47例4 -2 - B/C型骨折中,钢板组在手术时间、术中透视次数、畸形愈合率以及临床效果评价方面均优于髓内钉组(P＜0.05),而手术出血量、骨折愈合时间及并发症发生率差异无统计学意义(P＞0.05).[结论]髓内钉与MIPO技术治疗4-2 -A型胫骨闭合性骨折均可取得满意的临床疗效;但MIPO技术是治疗4-2 - B/C型骨折更为理想的手段.     

MIPPO结合NCB万向锁定板在老年股骨转子间骨折的运用

目的探讨运用MIPPO(微侵入钢板插入技术)结合NCB万向锁定板在老年股骨转子间骨折的治疗效果。方法运用MIPPO结合NCB万向锁定板对2013年7月至2015年10月收治的35例老年转子间骨折患者进行治疗,男21例,女14例;右髖16例,左髖19例;年龄为68~92岁,平均年龄83.5岁,Evans分型Ⅰ型2例,Ⅱ型5例,Ⅲ型11例,Ⅳ型10例,Ⅴ型7例。术前对患者均行骨盆正蛙位X光片和CT扫描,记录患者的手术时间、术中出血量、并发症情况、骨折愈合时间及末次随访时髖关节Harris评分等,初步分析该方法治疗老年股骨转子间骨折疗效和经验。结果本组患者手术时间平均为50.2 min(40~65 min),术中出血量平均为180 m L(150~230 m L)。35例患者术后均获得平均15.6个月(12~39个月)随访,1例出现术后内固定松脱后再行半髖置换治疗,34例术后均获得骨性愈合,平均愈合时间7.8个月(6~9个月)。术后末次随访时34例患者髖关节Harris评分平均为84.5分(75~90分)。结论 MIPPO结合NCB万向锁定板对于老年股骨转子间骨折治疗是有效、可靠的治疗方法,特别对于骨质疏松型股骨转子间骨折,微创MIPPO结合NCB万向锁定板可以达到更好的复位和早期稳定,是对老年股骨转子间骨折微创治疗方法的有益探索。     

Minimally invasive percutaneous plate osteosynthesis (MIPPO) technique applied in the treatment of humeral shaft distal fractures through a lateral approach

The minimally invasive percutaneous plate osteosynthesis (MIPPO) technique through the anterior approach has been successfully used in the treatment of humeral shaft fractures and has gained satisfactory clinical outcome. An anatomical study and a preliminary clinic report were performed to evaluate the feasibility of applying the MIPPO technique in the treatment of humeral shaft distal fractures through the lateral approach. This study was done on 14 arms from seven fresh cadavers. The results of this study showed that it is possible to treat humeral shaft distal fractures by using the MIPPO technique through the lateral approach. The results of using the MIPPO technique through the lateral approach in the treatment of humeral shaft fractures in 22 patients were also reviewed.

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Résumé  L’ostéosynthèse par plaques par voie mini-invasive (technique MIPPO), après abord antérieur est utilisée avec succès dans le traitement des fractures diaphysaires humérales et permet d’obtenir un bon résultat clinique. Une étude anatomique et une étude clinique préliminaires ont été réalisées pour évaluer la faisabilité de l’utilisation de la technique MIPPO dans le traitement de ces fractures distales par voie latérale. Cette étude a été réalisée sur 14 membres supérieurs de 7 cadavres frais. Les résultats de cette étude montrent qu’il est possible de traiter la fracture de l’humérus distal en utilisant la technique MIPPO par voie latérale. Cette technique, transposée chez 22 patients présentant une fracture de ce type a également été réalisée et évaluée.

     

微创钢板接骨技术治疗复杂胫骨远端骨折49例临床分析

目的探讨微创钢板接骨技术(MIPO)治疗复杂胫骨远端骨折的临床效果。方法对49例复杂胫骨远端骨折采用MIPO技术治疗,术后3个月均行膝踝关节功能Johner-Wruhs疗效评定标准评价疗效。结果 49例均获8～16个月随访,术后复查X线片示骨折对位、对线佳,骨折均愈合,无钢板、螺钉断裂和松动,术后3个月Johner-Wruhs疗效评定:优29例,良17例,可3例,优良率为93.88%。结论应用微创钢板接骨技术能达到最低限度的伤害,减少对软组织的剥离,以及减少骨折端和骨折碎片的骨膜剥离,血供得以保护,降低骨折不愈合和感染率,膝、踝关节功能得到较好的恢复,为复杂胫骨远端骨折的治疗提供了安全可靠、有效的方法之一,值得在临床骨科进一步推广。     

锁定加压钢板微创固定治疗肱骨干骨折的初步报告

目的探讨锁定加压钢板(LCP)经肱骨前侧入路微创穿皮固定治疗肱骨干骨折的方法及疗效。方法2004年2月-2005年1月间,使用LCP经肱骨前侧入路微创穿皮固定治疗肱骨干骨折17例,男12例,女5例;年龄18-75岁(平均48岁)。根据AO分型:A型3例,B型10例,C型4例。结果经14-25个月(平均19．1个月)随访,17例患者全部愈合。骨折愈合时间为9-14周(平均11．3周)。末次随访时,肩关节前屈135°-180°(平均174°),后伸20°-40°(平均38°),外展70°-90°(平均87°);肘关节前屈115°-135°(平均133°),后伸-10°-0°(平均-1°);手臂肩残疾问卷表(DASH)评分6-44分(平均11分)。术后3例出现并发症:1例GustiloⅢB型开放性骨折发生浅表感染,经保守治疗后痊愈;1例术后出现一过性桡神经麻痹,3个月后症状完全消退;另有1例出现明显的肩肘关节功能障碍。无继发骨折移位及内固定物失效或断裂。结论LCP经肱骨前侧入路微创穿皮固定治疗肱骨干骨折可以提供稳定的固定,骨折愈合率较高,神经血管结构相对安全;更适合于粉碎性或骨质较差的肱骨干骨折。     

Percutaneous cerclage wiring and minimally invasive plate osteosynthesis (MIPO): a percutaneous reduction technique in the treatment of Vancouver type B1 periprosthetic femoral shaft fractures

Background

Periprosthetic femoral fractures (PPFs) associated at or near a well-fixed femoral prostheses (Vancouver type-B1) present a clinical challenge due to the quality of the bone stock and instability of the fracture.

Objectives

The purpose of this study was to present a novel reduction technique and analyze clinical and radiographic outcome in patients with Vancouver type-B1 fractures treated with percutaneous cerclage wiring for fracture reduction and maintenance of reduction with minimally invasive plate osteosynthesis (MIPO) utilizing a locking compression plate (LCP).

Methods

Between March 2007 and December 2008, ten consecutive patients with spiral, oblique or wedge Vancouver type-B1 were treated with closed percutaneous cerclage wiring using a new cerclage passer instrument (Synthes^?) through small 2–3?cm incisions for reduction and maintenance of reduction. Internal fixation with MIPO was obtained utilizing a long LCP Synthes^? bridging the fracture. The reduction time, fixation time and operative time were recorded. The rehabilitation protocol consisted of partial weight bearing as tolerated. Clinical and radiographic outcomes included evidence of union, return to pre-injury mobility, and surgical complications were recorded.

Results

There were three men and seven women with an average age of 74?years (range 47–84?years) at the time the fracture occured. The average follow-up was 13.2?months. One patient died 2?months after surgery due to cardiovascular problems and was excluded. The average reduction time with percutaneous cerclage wiring was 24.4?min (range 7–45?min). The average fixation time was 79?min (range 53–100?min). The average operative time was 103?min (range 75–140?min). Blood loss was minimal and only two patients needed a blood transfusion. All fractures healed with a mean time to union of 18?weeks (range 16–20?weeks). There was one implant which bent 10° in the post-operative period but went on to heal uneventfully within 16?weeks. There was no evidence of loosening of any implants. Seven patients returned to their previous level of mobility. Two patients required a walker. There were no implant failures, wound complications or infections.

Conclusions

Percutaneous reduction of spiral, oblique or wedge-type B1 PPFs with percutaneous cerclage wiring combined with minimally invasive locking plate osteosynthesis provided satisfactory reduction, adequate stability and healing in nine patients. Our early results suggest that this reduction technique and fixation may be a useful solution for this growing challenge in orthopaedics. The authors caution that this technique must be done carefully to avoid serious complications, e.g., vascular injury.     

Minimally invasive plate osteosynthesis for proximal humerus fractures: functional results of treatment

Proximal humeral fractures can safely and effectively be treated with minimally-invasive plate osteosynthesis (MIPO). Twenty-one patients treated with MIPO for 2-, 3-, and 4-part proximal humerus fractures were treated at a mean 6.8 days (range, 1-24 days) after injury and followed for a mean of 24 months (range, 5-38 months). All fractures healed by 8 weeks postoperatively, with reductions "good" in 18 (86%) of patients and "fair" in 3 (14%). There were no infections or nerve or vascular injuries. One patient had loss of reduction that healed but required hardware removal. The neck-shaft angle was measured intraoperatively and at final follow-up, with mean (SD) of 139° (9.3; range, 123°- 156°) and 138° (8.9; range, 123°- 159°), respectively. Mean (SD) displacement from the most superior aspect of the humeral head articular surface to the top of the greater tuberosity was 4.3 (10) mm. Mean (SD) active range of motion was 143° (35.04; range, 80°- 180°) for forward flexion, 118° (46.8; range, 45°- 180°) for elevation, and 33° (19.2; range, 10°- 65°) for external rotation. The mean Disability of the Arm, Shoulder, and Hand (DASH) score was 25.95 (range, 0-80). Excluding patients with associated injuries, a statistically significant difference (P<.05) was found in the DASH scores for those patients with greater tuberosity displacements between 3 mm and 8 mm and those patients with greater tuberosity displacement greater than 8 mm inferior to the articular surface. Clinical outcomes depended upon reduction of the greater tuberosity, which is facilitated by the MIPO technique.     

Effectiveness of sonography assisted minimal invasive plate osteosynthesis (MIPO) compare with fluoroscope assisted in femoral shaft fracture: A cadaveric study

IntroductionA minimal invasive plate osteosynthesis (MIPO) has an advantage of biological soft tissue preservation that consists of preserving bony blood supply, fracture hematoma and less soft tissue damage which leads to decreasing of infection rate and rapid bone healing. However, the radiation exposure is still a disadvantage of this technique. A sonography that provides dynamic real time imaging may be used as an alternative technique for assisting MIPO. The aim of this study was to compare the effectiveness of MIPO in femoral shaft fracture between the sonography assisted and the fluoroscopy assisted.MethodsTwenty-eight cadaveric limbs were subjected to create femoral shaft fracture. Then, sonography assisted reduction with temporary external fixation and MIPO were performed. Images of the sonography and the fluoroscopy were recorded including before reduction, after reduction and after MIPO in order to identify fracture displacements in anteroposterior and mediolateral directions. Moreover, the anterior and posterior distances from edge of the bone to the plate were measured to confirm plate position. The effectiveness of this technique was defined as the proper plate position and acceptable alignment after fixation. All distances from the sonography and the fluoroscopy were also analyzed and compared using Pearson correlation and Bland-Altman method to assess the agreements between two tests.ResultAll of the subjects were met the criteria for acceptable alignment. We found only three femoral shaft fracture (11%) operated with MIPO by sonography assisted that showed slipped plate off femoral bones. According to Pearson correlation, there were good to excellent agreements in term of measuring fracture displacement before (Pearson Correlation >0.7) and after reduction (Pearson Correlation >0.7) between these two tests. There was moderate agreement regarding to evaluation of plate position (Pearson Correlation 03.–0.7). When we compared two methods of measurement using Bland-Altman plot, there were no statistical significant difference (P < 0.05).ConclusionImages from the sonography could provide visualization of the fracture during reduction and MIPO as accurately as the radiography. Thus, the sonography assisted MIPO in femoral shaft fracture can be done effectively comparing with radiographic assisted.