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Minimally invasive osteosynthesis

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Abstract

Minimally invasive osteosynthesis (MIO) involves the application of implants for fracture stabilization without making an extensive surgical approach to expose the fracture site. The bone segments are reduced using indirect reduction techniques (without direct manipulation of the bone at the fracture site ). This chapter considers case selection and preoperative considerations; principles of specific fixation methods using minimally invasive osteosynthesis. Reduction techniques for minimally invasive fracture surgery; Minimally invasive application of a plate to the humerus; Minimally invasive application of a plate to the radius; Minimally invasive application of a plate to the femur; Minimally invasive application of a plate to the tibia.

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Figures

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15.1 A tibial fracture in a dog has been reduced with an intramedullary pin and a plate placed through the insertion skin incisions. Note that the insertion skin incisions are small and expose only two or three plate holes. Additional screws can be placed through stab incisions.
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15.2 (a) A cannulated screw is inserted percutaneously to stabilize a condylar fracture following reduction with vulsellum forceps. (b) Percutaneous K-wires have been used to manage a proximal tibial physeal fracture with MIO.
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15.3 Photographs of cadaveric radii injected with blue latex and India ink to evaluate extraosseous blood supply in specimens that underwent (a) minimally invasive plate osteosynthesis (MIPO) and (b) open reduction and internal fixation (ORIF). There is markedly improved preservation of periosteal vasculature and less extravasation with MIPO when compared to ORIF. (Reproduced from with permission from )
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15.5 A temporary two-ring circular fixator was applied to a radius for reducing a mid-diaphyseal fracture. A broad 3.5 mm limited contact dynamic compression plate was used in MIPO fashion for definitive fracture fixation.
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15.6 (a–d) Serial fluoroscopic images of cross pin placement for a distal tibial physeal fracture in a cat. Use of fluoroscopy greatly facilitates accurate insertion point, insertion length and pin trajectory.
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15.7 Preoperative (a) mediolateral and (b) craniocaudal radiographs of a highly comminuted mid-diaphyseal humeral fracture due to a gunshot injury in a dog. Postoperative (c) mediolateral and (d) craniocaudal radiographs. A pin–plate construct was used in MIPO fashion to stabilize the fracture.
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15.8 Preoperative (a) craniocaudal and (b) mediolateral radiographs of a short oblique distal diaphyseal antebrachial fracture in a dog. Postoperative (c) craniocaudal and (d) mediolateral radiographs. A plate was applied to the radius in MIPO fashion to stabilize the fracture. Note that MIPO techniques can still be adopted in non-comminuted injuries, provided accurate reduction can be achieved.
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15.9 Preoperative (a) craniocaudal and (b) mediolateral radiographs of a distal femoral Salter–Harris type II fracture in a dog. Postoperative (c) craniocaudal and (d) mediolateral radiographs. Percutaneously placed cross pins were used to stabilize the fracture.
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15.10 Skeletal traction applied to a humeral fracture for a MIPO technique. After securing the dog to the table, K-wires are inserted in the humeral condyle and in the proximal humerus and secured to traction stirrups (arrowheads). Application of longitudinal traction allows reduction of the fracture. (a) Following reduction a pre-contoured plate is introduced through a small incision, (b) then positioned appropriately over the bone. (c) Following tightening of the screws the plate is no longer visible in the incision. (Courtesy of GL Rovesti)
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15.11 A two-ring circular fixator can be utilized to apply distraction and to align the fracture fragment in different planes. Correction of rotational alignment can be performed by shifting the position of the distal wire about the circumference on the distal ring. The threaded bars are used to correct varus or valgus. Reduction is assessed during surgery by palpation, visual assessment of limb alignment and fluoroscopy. In large dogs the K-wires are tensioned to prevent wire deformation whilst applying traction.
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15.12 Sequential fluoroscopic (a–b) mediolateral and (c) craniocaudal images showing indirect reduction of a tibial fracture using an IM pin. The IM pin is advanced to the fracture site under fluoroscopic guidance. The fracture is then reduced and the IM pin is advanced into the distal fragment. Following reduction, the plate is inserted; reduction can be improved using the pre-contoured plate.
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15.13 (a) An IM pin has been inserted normograde, proximodistally, to reduce a tibial fracture. (b) An epiperiosteal tunnel is dissected more easily following reduction because the tissue layers are more normally positioned.
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15.14 Sequential fluoroscopic images showing indirect reduction of a femoral fracture using a pre-contoured plate. (a) The plate is slid into the epiperiosteal tunnel. (b) Pin stoppers, instruments similar to push-pull devices, are used to pull the bone fragments towards the plate. (c) Screws are applied to complete the fixation.
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15.15 Minimally invasive application of a plate to the humerus. Incisions are made (a) proximally and (b) distally. (c) Following reduction of the fracture and creation of an epiperiosteol tunnel a pre-contoured plate is applied. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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15.16 Sequential intraoperative photographs of MIPO application to a humeral fracture in a dog. (a) Two small incisions are made over the metaphyseal regions of the bone, and indirect reduction is first achieved with an intramedullary pin. (b) An epiperiosteal tunnel is made with long Metzenbaum scissors. (c) A pre-contoured plate is slid into the tunnel. Application of cortical screws will further aid reduction if the plate is contoured and positioned appropriately.
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15.17 Minimally invasive application of a plate to the radius. A craniolateral incision is made over the (a) distal and (b) proximal radius and an epiperiosteal tunnel is created from proximal to distal; (c) a pre-contoured plate can then be slid into the tunnel. Proximally, a craniomedial rather than a craniolateral approach can be used if desired. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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15.18 Sequential intraoperative photographs of MIPO application to an antebrachial fracture in a dog. (a) Two small incisions are made over the metaphyseal regions of the bone, and indirect reduction is first achieved with a temporary circular fixator. (b) A pre-contoured plate is slid into the epiperiosteal tunnel. (c) Application of cortical screws will further aid in reduction if the plate is contoured and positioned appropriately.
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15.19 Minimally invasive application of a plate to the femur. Incisions are made (a) proximally over the greater trochanter and (b) distally over the lateral aspect of the femoral metaphysis. (c) Following creation of an epiperiosteal tunnel, (d) a pre-contoured plate is applied to the bone. Linear alignment of the bone is best achieved using an IM. Great care is needed to ensure torsional alignment of the bone as the plate is applied. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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15.20 Sequential intraoperative photographs and fluoroscopic images of MIPO application to a femoral fracture in a dog. (a) Two small incisions are made over the metaphyseal regions of the bone, and indirect reduction is first achieved with an IM pin. (b) A pre-contoured plate is slid into the epiperiosteal tunnel. (c) Application of pin stoppers will further aid in reduction if the plate is contoured and positioned appropriately. (d) Intraoperative radiograph of indirect reduction achieved with an IM pin. Postoperative (e) craniocaudal and (f) mediolateral radiographs of the pin–plate construct. Ideally, the IM pin could have been seated more distally.
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15.21 Minimally invasive application of a plate to the medial aspect of the tibia. An incision is made (a) proximally and (b) distally. (c) Following creation of an epiperiosteal tunnel, a pre-contoured plate is slid into it and applied to the bone. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
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15.22 A push-pull device (arrowed) placed in the distal aspect of the plate allows the plate to be secured and its position checked with fluoroscopy. In addition, the push-pull device aids reduction of the fracture if a pre-contoured plate is used.

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