Guidelines for surgical approaches for minimallyinvasiveplateosteosynthesis in cats
Schmierer, Philipp A ; Pozzi, Antonio
Abstract: OBJECTIVES: Minimallyinvasiveplateosteosynthesis (MIPO) is one of the most recent fix- ation techniques that embody the concept of biological osteosynthesis. Several studies evaluating MIPO in dogs have been published in the recent years. However, there are few clinical reports of MIPO in cats and no description of the surgical approaches. The purpose of our study was to describe the safe corridors for plate insertion in cats using the MIPO technique. METHODS: The surgical approaches for the humerus, radius-ulna, femur and tibia were developed after reviewing the described techniques and surgical approaches for MIPO in dogs, while considering any relevant anatomical difference between dogs and cats. Following the MIPO approaches, the limbs were anatomically dissected and the relationship be- tween proximal and distal positions of the implants and neurovascular structures was noted. RESULTS:
Most closed humeral shaft fractures can be successfully managed nonsurgically. However, fractures for which closed treatment is unsuccessful are stabilized using either plates or intramedullary nails. There are shortcomings associated with each technique, including the potential complications of nonunion, infection, shoulder pain, and radial nerve injury. Minimallyinvasiveplateosteosynthesis (MIPO), an innovative alternative treatment, is gaining in popularity. This technique is based on the anterior humeral shaft providing a relatively safe surface for plate application, and limited open exposures proximally and distally allow percutaneous insertion of the necessary implant. More than 40 articles have been published regarding MIPO, and it compares favorably to other available forms of treatment with excellent functional outcomes and a lower rate of iatrogenic radial nerve injury. Larger randomized controlled trials comparing this method with other accepted techniques, including nonsurgical management, are necessary to better define the role of MIPO in the management of humeral shaft fractures.
I, Dr.P .Keerthivasan., solemnly declare that this dissertation tilted
“PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME OF DISTAL RADIUS FRACTURE MANAGED BY MINIMALLYINVASIVEPLATEOSTEOSYNTHESIS” is a bonaﬁde work done by me at Tirunelveli Medical College from August 2013 onwards under the guidance and supervision of Prof.ELANGOVAN CHELLAPPA, M.S.ORTHO, D.ORTHO, Professor and Head of the Department, Department of Orthopaedics, Tirunelveli Medical College, Tirunelveli.
and Ex-Fix lowest. IMN often leads to mal-alignment deformities. LCP is stronger than DCP to fix the proximal tibial fractures with the additional benefit of being minimallyinvasive 1 . Earlier techniques emphasized precise anatomical reduction and absolute rigid fixation to achieve mechanical stability. However extensive surgical exposure and soft tissue stripping often resulted in devitalisation of fracture fragment and soft tissue complications. Minimallyinvasiveplateosteosynthesis (MIPPO) in extra-articular proximal tibia fractures showed a promising result with minimal complications 2,3 . Improvements in surgical technique and implant design of IML have resulted in more acceptable outcomes with lesser commonly encountered apex anterior and/or valgus deformities. Using a variety of the reduction techniques such as an ideal starting point and insertion angle, polar screws, unicortical plates, a universal distractor, alternative positioning of patient and approaches minimizes Article History:
AO plating techniques. Locking capability is important for fixed angle constructs in osteopenic bone or multifragmentary fractures where screw purchase is compromised. These screws do not rely on plate to bone compression to resist patient load, but function similarly to multiple, small, angled blade plates. The fixation of this implant can be done in both MinimallyInvasivePlateosteosynthesis or routine open reduction technique.
The use of intramedullary nailing is limited because of disadvantages, such as difficulties in the control of fracture fragments, especially those extending metaphyseally, distal locking problems, and impingement syndrome. 4,5 Further- more, this indication is not greatly preferred because of changes in the physio-anatomy of geriatric bones. Classic plate-screw osteosynthesis has disadvantages, such as extensive soft tissue dissection and impaired vascularity of the fragments. 6 However, in recent years, there has been increased use of the minimallyinvasiveplateosteosynthesis (MIPO) method, especially in the femur and the tibia, fol- lowed by humerus shaft and humerus proximal fractures and many successful results have been reported in literatüre. 6–10
3 Institute of Science and Technology, Federal University of Alfenas, Campus Poços de Caldas, Alfenas, Minas Gerais, Brazil
*Corresponding author: firstname.lastname@example.org
Citation: Filgueira FGF, Minto BW, Chung DG, Prada TC, Rosa-Ballaben NM, Campos MGN (2019): Platelet-rich plasma, bone marrow and chitosan in minimallyinvasiveplateosteosynthesis of canine tibia fractures – a randomized study.
Background: In this study, we performed a meta-analysis to identify whether minimallyinvasiveplateosteosynthesis (MIPO) was superior to conventional fixation techniques (CFT) for treating humeral shaft fractures.
Methods: A systematic literature search was conducted up to February 2016 in ScienceDirect, Springer, MEDLINE, and PubMed databases for relevant papers that compared the outcomes of MIPO with CFT, such as open reduction with plateosteosynthesis (ORPO) and intramedullary nail (IMN) for treating humeral shaft fractures. Meta-analysis was performed with Review Manager 5.0 software.
Zichao Xue 1 , Chaolai Jiang 1 , Chuanzhen Hu 2 , Hui Qin 1 , Haoliang Ding 1 and Zhiquan An 1*
Background: Humeral shaft fractures are generally managed with the conventional posterior open reduction and internal fixation (ORIF) or minimallyinvasiveplateosteosynthesis (MIPO). This study was aimed at comparing the outcomes of these surgical techniques in terms of the vascular integrity of the mid-distal humeral shaft.
Conclusion: The present evidence indicates that compared to ORIF, MIPO had advantages in functional outcomes, operation time, blood loss, postoperative pain, and fracture union time for the treatment of PHFs. However, the MIPO technique had a higher rate of axillary nerve injury and longer radiation time compared to ORIF.
Keywords: Minimallyinvasiveplateosteosynthesis (MIPO), Open reduction – internal fixation (ORIF), Proximal humeral fractures, Meta-analysis
Initially, K-wires were inserted to the uppermost hole of plate for temporary fixation of this LPP plate under C-arm guidance. Then we applied distal part of the long plate to the distal humerus while protecting the radial nerve. Compression screw in the uppermost proximal compression hole was inserted so that this anatomical LPP could reduce the fracture displacement easily. Con- sequently, compression screw in the distal part of the plate was inserted. If long oblique fracture was present or middle part of the fracture was unstable after prox- imal and distal compression screw insertion, additional locking or compression screw was inserted by using locking or compression drill sleeves at the middle part of the plate. In the earlier period of LPP group, no add- itional locking or compression screw at the middle part of the LPP plate developed two metal failure. After 2 failure, we always tried to insert additional positional screw in the middle part of plate of the unstable frac- tures (Figs. 4, 5). Step by step, proximal or distal locking screw were inserted. Finally, the status of fracture
All major and minor complications were documented at follow up.
Surgical technique : Surgical procedures were performed by a senior consultant in 5 cases, junior consultant in 19 cases and a post graduate registrar in 2 cases. In all cases surgery was performed in supine position with the use of an image intensifier. Fracture reduction was achieved manually in all but 2 cases where a femoral distractor was used. A curvilinear incision of 3 to 4cms was made at the medial end of distal tibial metaphysis protecting the saphenous vein. A subcutaneous or extra periosteal tunnel was prepared with the use of a periosteal elevator for subsequent plate insertion. After insertion of the implant, the position of the bone fragments and the plate was checked with an image intensifier. One screw was inserted in each of the main fragments and the position of the fracture and plate were checked again. Fixation was then completed with the insertion of a planned number of screws (a minimum of 3 to 4, 3.5 mm locked screws on either side of the fracture were considered sufficient. The different plates used were L.C.P. in 22 cases and D.C.P. in 3 cases.
In the MIPO group, 5/43 patients experienced compli- cations and 4/43 patients experienced complications in the ORIF group (Table 4). No patients developed wound infection and nonunion after one year of follow-up in both groups. In 3 patients (group MIPO, 2 patients, type B and C; group ORIF, 1 patient, type B), the fracture collapsed after 3 months, leading to a varus malalignment. These patients developed loss of reduction and underwent reoperation either by reosteosynthesis combined with cancellous grafting or by joint replace- ment. One patient in the MIPO group presented with clinical signs of axillary injury, which was characterized by poorly localized posterior shoulder pain, parenthesis over the lateral aspect of the shoulder, and deltoid muscle weakness. Axillary nerve injury was confirmed on electromyography examination. However, there was no functional impairment when the patient was assessed at one year follow-up. One plate in the MIPO group and two plates in the ORIF group were removed due to subacromial impingement after radiographs confirmed fracture union at about 5 months. In the ORIF group, one patient underwent reoperation to change a perforated screw 3 months after the initial operation.
Materials and methods: 20 patients with distal femur fractures were evaluated in between July 2011 to November 2013. Radiographs of knee were taken in AP &
Lateral views. AO/Muller type B and C3 were excluded from the study. All the patients were operated under spinal/epidural anaesthesia and the patient position was supine with knee in 60-70 degrees flexion. Distal femur was exposed using modified lateral approach (minimallyinvasive) and the fracture was reduced by indirect reduction techniques. We used locking compression plate to fix the fracture. Post operative radiographs were taken to assess the reduction and implant position.post operative rehabilitation was started from the 1 st post operative day. Patients were followed up at every 4-6 weeks interval to assess fracture union, limb length, alignment, knee range of movements and functional outcome. Hammer et al grading was used to assess union and the knee society scoring system was used to assess the functional outcome.
The present study directly compared MIPPO and MIPTENO. The results revealed that mini-
mally invasive surgical had a low rate of com- plications when treating displaced midshaft clavicle fractures. For simple midshaft clavicle fractures, the MIPPO and MIPTENO groups showed no significant difference in osseous healing. MIPPO could be more suitable for wedge type comminuted midshaft clavicle fra- ctures, maybe leading to faster osseous heal- ing, possibly because the plate is more stable than TEN. Finally, both approaches led to good functional outcomes at the last follow-up.
66 points for 4-part fractures were reported . Those results are slightly better than our results of a mean CMS score of 60.9 points.
Range of motion seems to be very important especially for older people in order to manage their activities of daily living. For this reason, in older patients, perhaps it is more important to restore range of motion than strength. Surprisingly, only a few studies specifically report on range of motion after plating . However, in this study, abduction and anterior flexion were found to be significantly better in the Humerusblock group than in the PHILOS plate group.
No cases reported infection postoperatively which was better compared to concha et al study which reported 2 cases of infection.
Postoperative iatrogenic radial nerve palsy was reported in 2 cases which was higher compared to Deepak S et al study and Hadhoud MM. et al. one case recovered by 6 months followup & one case did not show recovery at 1 year for which tendon transfer to be planned subsequently. These nerve injury occurred earlier in the study probably due to plate offset and unicortical drilling with chance of drill bit slippage into the neural structures posteriorly. Hence plate position should be visualized digitally and radiologically before drilling. Take care to be in the proper intermuscular plain and the plate advanced gently in close contact to bone over the anterior surface in a proximal to distal direction to protect
the most efficient method to reduce strain at the bone- implant interface. In order to reduce stress-shielding in plates, long implants fixed with few locking head screws are currently used. However, it is less effective and leads to a relatively large surface implant. An intramedullary im- plant is in line with the weight-bearing axis while plates feature an excentric position. Earlier weight bearing might be possible after nail osteosynthesis. In elderly osteopor- otic patients, fixing implants are usually not removed after fracture healing. Since metal is much more rigid than bone, there is a risk for stress rising at the plate end and bone absorption under the plate . This causes add- itional structural bone weakening with an increased risk for a subsequent fracture. The use of a retrograde nail in combination with lag screw fixation might offer an option in certain pilon fractures (AO/OTA 43 C1-2), since in these patients, the main treatment goal should be the res- toration of function over restoration of an exact anatomy.
Conclusions: Compared to MIPPO, IMN had a significantly low risk of wound complications and associated with limited time for reunion. Although the pooled functional outcomes of the two groups were controversial due to different evaluating scores, IMN was the preferred surgical technique than MIPPO for treating distal tibial fractures.
Keywords: Distal tibial fractures, Minimallyinvasive percutaneous plateosteosynthesis, Intramedullary nail, Meta-analysis
Keywords: Minimallyinvasive percutaneous plateosteosynthesis, early stage, delayed stage, fracture
Distal tibial metaphyseal comminuted fracture is a complicated comminuted distal tibial me- taphyseal fractures. Traditional treatment me- thods mainly adopt the open reduction and plate fixation, but the clinical treatment effect is not good. There are many disadvantages for the traditional treatment methods, including intra-operative striping, large trauma, heavy tis- sue damage, destruction of blood supply in fracture, serious interference of the internal environment, infection, delayed union and non- union, and the other postoperative complica- tions. Therefore, the traditional methods would be gradually replaced [1-3]. With the more and more requirement of modern medicine for the