Treatment of distal femoral fractures in elderly diabetic patients using minimally invasive percutaneous plating osteosynthesis (MIPPO)

The aim of this study was to evaluate the results of minimally invasive percutaneous plate osteosynthesis (MIPPO) of distal femoral fractures in elderly diabetic patients with osteoporotic bone. Thirteen supracondylar or intercondylar femoral fractures were treated by MIPPO with a locked plate without bone grafting. All fractures healed, with only one delayed union in a patient who had deep infection. Results were evaluated using Schatzker and Lambert's criteria; all patients had excellent, moderate or good results except one with a poor result. Minimally invasive percutaneous locked plating provided favorable results in the treatment of distal femoral fractures in this geriatric population.     

Indirect reduction and bridge plating of supracondylar fractures of the femur

Between October 1995 and December 1998, 16 patients with A-O type A3, C2 or C3 supracondylar femoral fractures were treated by open reduction and internal fixation using indirect reduction and bridge plating. Seven (44%) patients had open fractures. The patients were followed for a mean of 46 months (range 24-71). All fractures healed. The average time for fracture healing was 18.5 weeks (range 12-28). Four primary bone grafts and three secondary bone grafts were performed. By using the modified Schatzker rating scale, the result of 13 patients (81%) were rated as excellent or good. Complications included two implant failures that were due to full weight bearing before bone healing, and one superficial delayed wound healing. No deep infections were found in this series. The open fracture group needed longer time to heal and had a higher rate of receiving bone grafts. We conclude that indirect reduction and bridge plating with a 95 degrees dynamic condylar screw (DCS) or condylar blade plate can produce favourable results for complex distal femoral fractures. We suggest primary bone grafts or early secondary bone grafts for comminuted open fractures using an indirect reduction technique.     

Effects of percutaneous and conventional plating techniques on the blood supply to the femur

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. Received: 10 July 1997     

Double plating of unstable proximal tibial fractures using minimally invasive percutaneous osteosynthesis technique

BACKGROUND: Double plating of proximal tibial fractures with traditional open osteosynthesis gives a stable fixation, but may be complicated by wound healing problems. Minimally invasive methods have been recommended to decrease the wound complication rates. We report the efficacy of double plating of proximal tibial fractures using a minimally invasive percutaneous technique. PATIENTS AND METHODS: 23 proximal tibial fractures in 23 patients (mean age 54 (36-78) years) were treated with double plating using a minimally invasive percutaneous technique. Functional and radiographic results were evaluated by a modified Rasmussen scoring system. RESULTS: All fractures healed. The average time for fracture healing was 19 (10-32) weeks. 21 patients had excellent or good clinical and radiographic results. 2 patients had a fair clinical result because of associated knee injuries. Complications included 1 case of shortening (1 cm) and 2 cases of mild malalignments (varus less than 10 degrees ). There was 1 case of superficial infection that healed after removal of the plate. No deep infections occurred. INTERPRETATION: Double plating using minimally invasive percutaneous technique can provide favorable results in the treatment of proximal tibial fractures.     

Ipsilateral hip and distal femoral fractures

We tried to find the trauma mechanism and treatment rationale of ipsilateral concomitant hip and distal femoral fractures involving the articular surface. Between 1988 and 1995, 15 cases of ipsilateral hip (confined to neck or trochanteric areas of the femur) and distal (confined to supra- and intercondylar area of the femur) femoral articular fractures were collected. The hip fractures consisted of 10 trochanteric fractures and five neck fractures, which were managed with reduction and fixation in 14 (Knowles' pin in eight, DHS in four and standard Gamma nail in two), and primary bipolar hemiarthroplastry in one. The distal femoral articular fractures were open in 11; these were managed with radical debridement, implantation of Septopal chains and immediate internal fixation, followed by prophylactic autogenous bone grafting 6 weeks later in the recent six cases (five Judet plates, four dynamic condylar screws and two condylar plates). The other four closed distal femoral fractures were managed with early reduction and internal fixation (two Judet plate, one dynamic condylar screw and one condylar plate). The union time was 20.3 (12-48) weeks for proximal fractures and 23.7 (12-36) weeks for distal fractures. Early infection developed in three cases. Nonunion of a femoral neck fracture developed in one case. The other complications were implant failure in one, coxa vara in one, refracture in one, delayed union in one and knee stiffness in one.     

Percutaneous plate stabilization of proximal tibial fractures

BACKGROUND: Despite various treatment methods, proximal tibial fractures are common injuries associated with poor outcomes and high rates of complications. To improve this, a percutaneous plating technique was performed to treat proximal tibial fractures. METHODS: Twenty-four proximal tibial fractures (17 proximal fractures [AO 41] and 7 proximal shaft fractures [AO 42]) were treated using percutaneous plating with either or both sides without bone graft. One was an open fracture. RESULTS: All fractures healed. The average time for fracture healing was 16.5 weeks (range, 8-24 weeks). Complications included one case of shortening (1 cm) and two cases of malalignments; one valgus of 6 degrees and one varus of 5 degrees. There was one case of superficial infection that was healed after removal, but no patient showed deep infection. Results were evaluated by the modified Rasmussen scoring system. Most patients had excellent or good results; only one patient had fair results. CONCLUSION: Minimally invasive percutaneous plating can provide favorable results in the treatment of proximal tibial fractures.     

Minimally invasive percutaneous plate osteosynthesis (MIPPO) using the DCS in proximal and distal femoral fractures

In a prospective study, 14 cases of supracondylar or subtrochanteric fractures or osteotomies were stabilized with a dynamic condylar screw (DCS) inserted using a minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. The technique consisted of 4 major steps: 1) placement of the guide wire under fluoroscopic control and condylar screw insertion through a stab incision; 2) plate insertion beneath the vastus lateral muscle; 3) engagement of the condylar screw to the plate using a modified T-handle and, 4) plate fixation to the shaft using percutaneously inserted self-cutting screws. Between October 1994 and December 1995, 14 cases in 12 patients met the inclusion criteria. There were 11 acute fractures (6 subtrochanteric, 5 supracondylar) and 3 corrective osteotomies. Nine fractures were closed, and 2 were open. One 97-year-old patient died 6 weeks after trauma. There were no infections and 12 of 13 cases healed without a second procedure. There was 1 implant failure (plate screw breakage), which required repeat fracture fixation. At follow-up, there were 2 varus deformities above 5 degrees, 2 shortenings over 20 mm, and 1 rotational deformity of 20 degrees. According to the Neer score, there were 6 excellent, 1 satisfactory, 3 unsatisfactory results and no failures. The results of this technique compare favourably with those of other series of osteosynthesis of subtrochanteric or supracondylar femoral fractures treated with internal fixation without the added morbidity associated with an extensive approach or autogenous bone grafting. However, the surgical technique is demanding, and care must be taken to restore the axial alignment.     

Minimally invasive plate osteosynthesis: does percutaneous plating disrupt femoral blood supply less than the traditional technique?

OBJECTIVES/HYPOTHESIS: 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. STUDY DESIGN/METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

Double plating of unstable proximal tibial fractures using minimally invasive percutaneous osteosynthesis technique

Background?Double plating of proximal tibial fractures with traditional open osteosynthesis gives a stable fixation, but may be complicated by wound healing problems. Minimally invasive methods have been recommended to decrease the wound complication rates. We report the efficacy of double plating of proximal tibial fractures using a minimally invasive percutaneous technique.

Patients and methods?23 proximal tibial fractures in 23 patients (mean age 54 (36–78) years) were treated with double plating using a minimally invasive percutaneous technique. Functional and radiographic results were evaluated by a modified Rasmussen scoring system.

Results?All fractures healed. The average time for fracture healing was 19 (10–32) weeks. 21 patients had excellent or good clinical and radiographic results. 2 patients had a fair clinical result because of associated knee injuries. Complications included 1 case of shortening (1?cm) and 2 cases of mild malalignments (varus less than 10°). There was 1 case of superficial infection that healed after removal of the plate. No deep infections occurred.

Interpretation?Double plating using minimally invasive percutaneous technique can provide favorable results in the treatment of proximal tibial fractures.     

Minimally invasive plate fixation in femoral shaft fractures

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.     

股骨远端骨折的手术治疗

目的　评价不同内固定材料治疗股骨远端骨折的临床疗效。方法　应用L形髁钢板 ,动力加压钉板 ,股骨远端解剖钢板和逆行股骨髁上交锁髓内钉等 4种内固定材料治疗股骨远端骨折 53例 ,其中随访 1 2个月以上者 44例 (平均随访 1 7月 ) ,采用X线检查及膝关节KSS评分评估治疗结果。结果　本组 44例患者 ,6例骨折对位欠佳 ,5例出现内固定松动、断裂 ,其中 2例发生骨折不愈合 ,无一例发生感染。各内固定组的优良率分别是 ,L形髁钢板 71 4% ,动力加压钉板 1 0 0 % ,解剖钢板 88 9% ,逆行交锁钉 89 5 % ,各组间优良率无显著差异。结论　 4种内固定都能起到较好治疗效果 ,手术适应症选择得当和内固定材料的规范操作是关键。逆行股骨髁上交锁髓内钉适用于粉碎性骨折 ,解剖钢板适用于骨骺未闭合青少年骨折 ,动力加压钉板适用于“T”形和“Y”形骨折 ,L形髁钢板不作为治疗首选 ,可作为其他方法的补充选择     

Anwendung der Klingen- und der dynamischen Schraubplattenosteosynthese

Osteosynthesis in fracture treatment and in some reconstructive procedures with blade plates or dynamic screw systems was the standard procedure for several decades. In this review, the current options and concepts using blade plate osteosynthesis, stabilization of proximal and distal femur fractures and reconstructive procedures with the dynamic hip screw or the dynamic condylar blade are discussed. On the basis of a literature review, the present indications, results and region-specific complications are reported and discussed. Blade plates are used mainly in the context of reconstructive procedures, as well as in the treatment of pseudoarthroses. The Pauwel procedure in femoral neck non-unions is one of the best known indications. In contrast, the dynamic hip screw is the gold standard for stabilization of femoral neck and most pertrochanteric fractures, whereas the dynamic condylar screw is still an alternative to internal fixators for proximal and distal femoral fracture fixations.     

经皮DCS微创固定治疗股骨远端严重粉碎性骨折

目的探讨应用经皮动力髁螺钉（dynamic condylar screw，DCS）微创固定技术治疗股骨远端严重粉碎性骨折的临床价值。方法2005年5月至2007年6月，采用经皮DCS微创固定技术治疗33例股骨髁间和／或股骨髁上的严重粉碎性骨折患者，术后早期进行功能锻炼。结果全部病例获得6～24个月随访，平均14个月。无感染、骨折不愈合、内固定松动、折断等并发症发生。结论应用经皮DCS微创固定技术治疗股骨远端严重粉碎性骨折，可以减少骨折部位血运破坏，降低不愈合率，同时固定坚强、有效，可以早期功能锻炼，值得临床推广应用。     

微创经皮钢板内固定治疗胫腓骨骨折的体会

目的报道以生物学内固定及间接复位技术为基础，微创经皮LC-DCP钢板内固定治疗胫腓骨骨折的临床疗效。方法应用间接复位技术，通过建立胫骨内侧皮下隧道，采用LC-DCP钢板内固定治疗胫腓骨折28例。结果全部病例获得随访，时间为10～18个月(平均15个月)。X线片见骨痂为4～7周(平均4．6周)，骨愈合时间为12～18周(平均12．8周)。全部病例Ⅱ期骨愈合，无骨不愈合或延迟愈合，无钢板松动等并发症，其中15例已拆除钢板，无再骨折现象发生。结论微创经皮LC-DCP钢板内固定治疗胫腓骨骨折符合生物学固定的原则，疗效满意。     

Non-union in lateral locked plating for distal femoral fractures: A systematic review

IntroductionThis study aims to identify patient and intra-operative factors that contribute to non-union in locked lateral plating for distal femoral fractures.MethodsSystematic searches of English-language articles in Ovid Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were undertaken in February 2018 according to the PRISMA guidelines. The search terms were (fracture or fracture*) AND (distal femur or distal femoral) AND (malunion or non-union). Eligible studies published at any time reported non-union rates and compared patient and intraoperative factors in patients who underwent locked lateral plating for traumatic distal femoral fractures. The quality of included papers was assessed using The Journal of Bone and Joint Surgery levels of evidence (Wright et al., 2003), and further appraised using the Downs and Black score (Downs and Black, 1998).ResultsEight studies investigating 1380 distal femoral fractures were found to satisfy the inclusion and exclusion criteria. These studies analysed a variety of patient and intra-operative factors that may contribute to non-union. These include high BMI, open fracture, comminution, fracture infection, stainless steel plate material, shorter working length, open reduction and internal fixation when compared with minimally invasive plate osteosynthesis, high construct rigidity scores and purely locking screw constructs.ConclusionThis review has identified multiple factors which potentially contribute to non-union including stainless steel plate material, high construct rigidity scores and purely locking screw constructs. These findings may reflect that overly rigid plating constructs can contribute to non-union. However, they should be taken in the context of heterogeneity amongst included studies, with further research necessary to support these findings.     

动力髁钉板在儿童股骨下段骨折中的应用

目的 探讨动力髁钉板治疗儿童股骨下段骨折的治疗效果。方法 开放复位动力髁螺钉（dynamic condylar screw），DCS内固定治疗儿童股骨下段骨折11例。结果 11例均在2～5个月愈合，无内固定松动、断裂情况，患肢膝关节功能恢复满意。结论 DCS治疗儿童股骨下段骨折具有骨折复位好、固定可靠、可早期活动关节及骨折愈合率高等优点，是一种治疗儿童股骨下段骨折的有效方法。     

经关节入路微创钢板固定技术治疗股骨远端C型骨折

目的探讨经关节入路微创钢板固定(MIPPO)技术治疗股骨远端C型骨折的临床疗效。方法2002年4月～2005年2月,应用MIPPO技术治疗股骨远端C型骨折14例,按AO/ASIF分类：C1型3例,C2型6例,C3型5例。先行关节内骨折切开复位、松质骨螺钉固定,再行髁上部分骨折间接复位、经关节内切口插入髁支撑钢板或LISS钢板桥接固定骨折。结果12例患者获得10～32个月(平均18．4个月)随访,骨折均获愈合,愈合时间10周～12个月,平均4．6个月。按Kolmert和Wulff的评价标准：优4例,良5例,可2例,差1例,优良率为75%。结论应用MIPPO技术治疗股骨远端C型骨折实现了微创操作,具有创伤小、软组织干扰少、骨折愈合快等优点,疗效满意。     

Distal fractures of the femur

Supracondylar femoral fractures still present a challenge to the treating surgeon. The incidence of delayed and non-unions is reduced due to the minimally invasive plating techniques, but establishing a correct axis and good function is still a problem. During the last few years new implants have been developed to allow less difficult operative techniques in minimally invasive surgery. The Less Invasive Stabilization System (LISS) is a percutaneous plating system with monocortical self-drilling screws. The screws are inserted with an aiming guide and form a stable angle with the plate. The distal femoral nail allows placement of a spiral blade in the nail, thereby enhancing the interlocking stability.     

Helical plating of the proximal humerus

The ideal treatment for fractures of the proximal humerus has not been definitively agreed upon. Several recent reports have described a technique of helical plating for proximal humeral fractures, in which the proximal plate is placed laterally on the greater tuberosity, and spirals 90 degrees distally to lie on the anterior surface of the humeral shaft. The purpose of this study was to evaluate the feasibility of helical plating using a less invasive surgical approach and placing screws percutaneously in the distal plate. Dissection of 10 cadaveric upper extremity specimens was performed, using an extended anterolateral acromial approach followed by percutaneous helical plating. With the plate secured, the neurovascular structures which crossed the anterior humerus superficial to the plate were exposed and identified. Only the musculocutaneous nerve crossed anterior to the plate and was at risk for percutaneous screw placement. The nerve location was found in a consistent location among the specimens. The danger zone for the nerve location was found to be at an average of 13.5 cm from the greater tuberosity (99% CI: 12.2-14.8 cm). Though clinical experience is necessary to validate this plating technique, it appears that avoiding this danger zone in which the musculocutaneous nerve crosses will allow safe percutaneous screw placement and permit minimally invasive plating of these fractures.     

微创张力带固定治疗横断型髌骨骨折

目的探讨微创张力带固定治疗横断型髌骨骨折的适应征和临床效果。方法回顾性分析1997年6月～2005年6月间应用微创张力带法治疗横断型髌骨骨折(闭合性或污染较轻的开放性骨折)38例,其中经皮穿刺克氏针钢丝张力带固定26例,经皮穿刺空心钉张力带固定12例。对骨折复位程度、关节活动度及膝关节功能进行分析。结果所有手术操作顺利。所有患者获6个月～6．5年(平均32个月)的随访。骨折愈合时间6～12周,平均7．7周；无内固定失败及创伤性关节炎等并发症发生。临床效果评定采用胥少汀式髌骨张力带固定术后评价标准,骨折复位程度：优21例,良11例,中6例,优良率为84．2%。全部病例膝关节活动度均在正常范围内,膝关节功能评价均为优良,其中优34例,良4例。结论微创张力带固定治疗横断型髌骨骨折临床效果优良。该技术主要适用于闭合性横断型髌骨骨折和创口较小且污染较轻的髌骨骨折,对于骨折块不超过3个且位置尚可的粉碎骨折也可酌情使用。