Wagner / Frigg AO Manual of Fracture Management: Internal Fixators

Concepts and Cases using LCP and LISS
1. Auflage 2006
ISBN: 978-3-13-257991-0
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 888 Seiten, ePub

This is the first compendium of principles of using locking compression plates in fracture management. With more than 100 cases from world-leading surgeons, including the inventors of the technique, this book will guide orthopedic trauma surgeons, general orthopedists, and residents through applications of the internal fixator technique. Intraoperative photos and illustrations and an interactive DVD containing additional cases, animations, and videos make this AO Manual an indispensable reference.

Michael Wagner, Richard Buckley

Zielgruppe

Ärzte

Autoren/Hrsg.

Wagner, Michael

Frigg, Robert

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Chirurgie Orthopädie- und Unfallchirurgie

Inhaltsverzeichnis

Concepts
1 Background and methodological principles
2 Surgical reduction techniques
3 Techniques and procedures in LISS and LCP
4 Pitfalls and complications
Cases
5 Shoulder girdle
6 Humerus
7 Radius and ulna
8 Pelvic ring and acetabulum
9 Femur
10 Tibia and fibula
11 Calcaneus

Leseproben

Forewords

Thomas P Rüedi

For almost 40 years AO compression plate fixation providing absolute stability—as introduced by Maurice Müller—was the gold standard in operative fracture treatment. In the 1980s the locking intramedullary nail opened up new perspectives for the stabilization of diaphyseal fractures. As an internal splint this device provides relative stability, which allows rapid fracture healing with abundant callus formation. Perren and Tepic showed in the early nineties that, thanks to locking head screws (LHS) providing angular stability, the longitudinal stabilizer, eg, a plate could be kept at a distance from the bone similar to the external fixator and without interfering with periosteal or cortical vascularity. This innovative, quite different and biologically gentle as well as less invasive fixation principle was called “internal fixation”. Clinically, it was applied as the PC-Fix (point contact fixator) and LISS (less invasive stabilization system).

The actual breakthrough for the new internal fixator principle occurred however, when Michael Wagner as clinician, together with the engineer Robert Frigg, designed and developed the so-called “combination hole”. The idea and new design of the screw hole—a combination of the dynamic compression unit for standard cortex screws with a threaded hole for the LHS—could be introduced in any of the existing plates and required only a few additional instruments. The new and very versatile locking compression plate system—LCP—with its three different possibilities of applications and functions found immediately wide acceptance and has revolutionized operative fracture fixation in a similar way to the original compression plate and twenty years later the interlocking in-tramedullary nail.

It seemed therefore logical that Michael Wagner should also pioneer the collection of LCP and LISS cases for a book that addresses not only the basic principles, attributes, and different applications of the new implants but also highlights the pearls and pitfalls of the internal fixators in the clinic. Together with the contributions of other enthusiastic but also critical users the authors share experiences with these devices and gives valuable, practical recommendations to newcomers. The best stabilization system is of little use if the vascularity of the soft as well as hard tissues are not carefully respected. An entire chapter has therefore been dedicated to the most difficult and demanding challenges of any fracture treatment—the fracture reduction.

The editors, Michael Wagner and Robert Frigg, and the coauthors have to be complimented for a most comprehensive and attractive book on the clinical applications of the new internal fixator principles with the LISS and LCP, which are introducing interesting possibilities and opportunities especially in articular fractures as well as providing new hopes for severely osteoporotic patients.

The team at AO Publishing has again displayed its ability to produce, together with Thieme Verlag, a most attractive book that will find numerous readers and thereby help to improve patient care.

Thomas P Rüedi, MD, FACS
Founding Member of the AO Foundation
Davos, April 2006

Stephan M Perren

Fracture treatment has undergone a fascinating evolution. Early in the last century the main goal of treatment was to reach solid union. Then stable fixation and functional postoperative treatment successfully eliminated fracture disease. Now we can take advantage of restoring function while inducing prompt and safe healing and reducing the risk of biological complications.

In the early days the excessive external immobilization of the neighboring articulations too often resulted in damage to the articulations and even worse to the soft tissues and blood supply. In my own “pre AO” experience I observed a high incidence of what was later called fracture disease (Sudeck's or reflex dystrophy). Swelling, pain, patchy bone loss, and stiff articulations were accepted as the natural consequence of fracture. It is interesting to note that each generation was (and is!) blinded by the “state-of-the-art”.

In the late fifties the visionary Maurice E Müller and his colleagues effected a worldwide change in the fight against fracture disease. They studied and advocated precise reduction and compression fixation so that fracture healing could take place in a mechanically neutral environment. Dystrophy became a very rare incident and fracture healing showed a fascinating histology: direct healing. The price paid for focusing on mechanical advantages was that this approach did not induce early healing and so implants could not be removed earlier than one to two years postoperatively. This was not a major problem in view of the fact that the implants were mechanically protecting the fracture. Still, the observation of late union was a strong indicator that there was room for improvement. Considerable damage to the soft tissues and blood supply to bone in the hands of the less experienced resulted in complications due to a disregard for biology.

The promoters of stable internal fixation had to face harsh criticism, mainly focused on the complications of such treatment like infections and refractures. A close collaboration including clinical input, documentation, biomechanical research, and basic development allowed the AO to overcome these difficulties by defining the principles of treatment and offering thorough teaching.

From the outset less stable fixation like the more flexible version of the intramedullary nail and also external fixators, both resulting in indirect healing, were integral parts of the AO technology. But it took a long time to amalgamate observations of biological reactions to the more flexible techniques and observations relating to compression plating. As always, some ideas were not new; we mention the basic contributions to compression technology by Lambotte and Danis and those of Kuntscher to nailing. Still, to bring a new method to bear on a large scale not only requires innovative and sound ideas and ingenious individual surgical skill, but also an integrated approach to improvement and teaching to allow others to achieve similar results.

In the late eighties while studying the potential of internal fixators the team of the AO Research Institute came across a more flexible plate fixation that took advantage of locked screws. The point contact fixator (PC-Fix), which is the proof of concept of the internal fixator, was born. Animal studies showed an astonishing early solid bridging of the fractures (10 weeks) and good local resistance to infection. Furthermore, the opportunity to take advantage of monocortical threaded bolts was demonstrated. Clinical studies with exceptionally high follow-up showed low complication rates in respect to infection (Norbert P Haas, Alberto Fernandez). History repeats itself as a rule: again there were pioneers: Boitzy, Weber, and Heitemeyer (bridge plating) and we also pay tribute to Granowski (Zespol fixator). It took 40 years from the first bridge plates and nearly twenty years from successful use of the PC-Fix for the advantages of the internal fixator to be generally accepted. The difference between “me too” and leadership is rooted in basic insight and early commitment.

A new era started with great respect to biology: the era of the internal fixator. Insistence on precise reduction was replaced by restricting the aim of surgery to adequate alignment to restore the original relative positions of the two joint bearing surfaces of the long bone. Approximate alignment without touching the intermediate fragments became acceptable. The main ingredients for successful internal fixator technology still are sufficient stability for early functional treatment and, now, sufficient instability for the induction of prompt healing. The strain theory allowed definition of the degree of instability which is tolerated and the degree which induces healing.

When the bone is dead and/or infected as a result of the accident (and hopefully not of the surgery) there is a clear indication for good reduction and absolute stability and similarly precise reduction and absolute stability is a requirement for intraarticular fractures!

Living bone is able to react once it is given the chance to do so. Creating the proper biological and mechanical environment is the prerequisite. The future will show whether additional stimulation offers an advantage for fresh fractures. One may question whether stimulation will be tolerated without causing damage in desperate clinical cases such as chronic and infected nonunions. Let's not forget that it took supernatural power to revive Lazarus, in other words, I think that stimulating nearly dead cells is equally challenging.

Without perfect closure of the fracture gap it is now possible to follow the repair process within the gap radiologically. We can now pinpoint those cases that require the long-term presence of the implant to avoid refracture. Some of the observations of delayed healing are not an indication of less satisfactory healing, but they are a consequence of improved visualization.

While the LISS is a further refinement of the PC-Fix, the LCP combines a stripped version of both the LC-DCP and PC-Fix with a threaded conical locking system to reduce jamming at removal. The LCP offers a convenient way of making the transition from conventional compression techniques to the internal fixator. As the two principles of plate screws, namely, screws that press the plate to the bone and those that keeping the plate elevated are incompatible, it is advisable to...

Über Autor(innen)

Michael Wagner, Richard Buckley