morten schultz larsen odense university hospital · 2018. 8. 20. · forsinket orif y ekstern...
TRANSCRIPT
![Page 1: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/1.jpg)
Morten Schultz LarsenOdense University Hospital
![Page 2: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/2.jpg)
Objectives
Distale tibiaBehandling og resultater -historiskModerne behandlingsprincipperResultater
Proksimale tibiaModerne behandlingsprincipperMekaniske betragtningerResultater
![Page 3: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/3.jpg)
Hvorfor intern osteosyntese ?
Anatomisk reposition af ledfladenStabil fiksationTidlig mobiliseringMere acceptabel for patienterne
![Page 4: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/4.jpg)
Fungerer fint ved lav energi frakturer
Ruedi og Allgöwer (1969): 84 cases74% good results, 5% deep infectionSki injuries
Bourne 1983:McFerran 1992:Teeny 1993:Bhattacharyya 2006:
44% good results34% infection37% infection47% complication
Disse resultater har andre ikke kunnet reproducere
![Page 5: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/5.jpg)
Hvad gik galt ?
Skinnen ?Stabiliteten ?Bløddele ?
Omfang af skaden (høj ernergi eller lav energi)Tilstand ved operationBehandling ved operation
![Page 6: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/6.jpg)
Nyere behandlingsprincipper
Small wire cirkulær ekstern fiksation + skruerMinimal invasiv, indirekte reposition
Minimal invasiv plate osteosyntese (MIPO)Anatomiske skinner, vinkelstabile skruer, indirekte reposition
Forsinket ORIFEkstern fiksation 10-20 dageAnatomiske skinner, vinkelstabile skruer, ÅBEN reposition
![Page 7: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/7.jpg)
Minimal invasiv plate osteosyntese (MIPO) med indirekte reposition
Ekstra artikulære, simple intra artikulære Gode bløddele
![Page 8: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/8.jpg)
Forsinket ORIF
Pilon frakturer (AO 43 C)Temporær ekstern fiksationAfvente afhævning 10 – 20 dageAntero – lateral incisionÅben, anatomisk reposition af ledfladeStabil osteosyntese af begge søjlerTidlig mobilisering
![Page 9: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/9.jpg)
J Orthop Trauma 21 (3) 2007
![Page 10: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/10.jpg)
To pins højt på tibia (langt væk fra frakturen)
En pin lateralt i calcaneusEn pin i 1. metatars
Evt. suppleret meden pin medialt i calcaneusog/eller 4. metatars
Lav en trekant med barrerneIngen skinne på fibula !!
Temporær ekstern fiksator
![Page 11: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/11.jpg)
J Orthop Trauma 21 (3) 2007
![Page 12: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/12.jpg)
J Orthop Trauma 21 (3) 2007
![Page 13: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/13.jpg)
Analyse af fraktur
Anterolateral fragment (Chaput)Medial fragmentPosterior fragment (Volkmann)Central depression
![Page 14: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/14.jpg)
Behandling inden final osteosyntese
ElevationPunkter bullaeDaglig skiftningPindhuls plejeRynke testRense og skylle pin huller ved fjernelse
![Page 15: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/15.jpg)
Lejring
![Page 16: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/16.jpg)
J Orthop Trauma 21 (3) 2007
![Page 17: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/17.jpg)
J Orthop Trauma 21 (3) 2007
Ekstensor retinaculum
![Page 18: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/18.jpg)
J Orthop Trauma 21 (3) 2007
Tibialis anterior
![Page 19: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/19.jpg)
J Orthop Trauma 21 (3) 2007
![Page 20: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/20.jpg)
J Orthop Trauma 21 (3) 2007
![Page 21: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/21.jpg)
Osteosyntese
Skinne på fibula –genskab længdeAnatomisk reposition af ledflade
Posteriore fragmentCentral depressionAnterolaterale fragmentMediale fragment
En eller to skinner
![Page 22: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/22.jpg)
J Orthop Trauma 21 (3) 2007
![Page 23: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/23.jpg)
J Orthop Trauma 21 (3) 2007
![Page 24: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/24.jpg)
J Orthop Trauma 21 (3) 2007
![Page 25: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/25.jpg)
Andre resultaterStudy Cases Superficial DeepLeonard 2009 30 2 0Yih-Shiunn Lee 2009 88 5 1Bahari 2007 42 2 1Sirkin 2004 30 5 1Helfet 2007 44 2 2
Små retrospektive undersøgelser
Ingen randomiserede, prospektive, eller blot sammenlignende undersøgelser
![Page 26: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/26.jpg)
Proksimale frakturer
![Page 27: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/27.jpg)
Moderne behandling
Small wire cirkulær ekstern fiksation + skruer
Minimal invasiv, indirekte repositionMinimal invasiv plate osteosyntese (MIPO)
Anatomiske skinner, vinkelstabile skruer, indirekte reposition
Double plating – two incisionsAnatomiske skinner, vinkelstabile skruer, og/eller traditionelle skinner
![Page 28: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/28.jpg)
Hvis bløddelene er kompromitteretElevationEvt. temporær ekstern fiksationAfvente 10-20 dage
![Page 29: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/29.jpg)
MIPO – Anatomiske skinner og vinkelstabile skruer
AO type 41 A og B (en søjle stabil)
![Page 30: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/30.jpg)
MIPO – Anatomiske skinner og vinkelstabile skruer
AO type 41 A og B (en søjle stabil)Også med diafysær fraktur (Schatzker 6)HUSK bløddele !!!Minimal invasiv teknik med en lateral eller medial incision
![Page 31: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/31.jpg)
Lateral incision
Tuberculum Gerdy
![Page 32: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/32.jpg)
Biomekaniske begrænsninger
Vinkelstabile skruer kan ikke holde en ustabil søjle
Biomekaniske test○ J Orthop Trauma. 2007
May;21(5):301-6
Kliniske studier○ J Trauma. 2004 Aug;57(2):340-6○ Knee. 2008 Mar;15(2):139-43
![Page 33: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/33.jpg)
Pitfall – postero-medialskæringsfraktur
![Page 34: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/34.jpg)
Pitfall – postero-medialskæringsfraktur
![Page 35: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/35.jpg)
Pitfall – postero-medialskæringsfraktur
![Page 36: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/36.jpg)
Double plating –two incisions
To mindre frilægningerPrimært for repositionenSkinnen kan placeres med minimal invasiv teknik
![Page 37: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/37.jpg)
Double plating – two incisions
To mindre frilægningerStabil osteosyntese af begge søjler
2 skinnerLøft af deprimeret ledflade gennem frakturenBonegraft
![Page 38: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/38.jpg)
Double plating – two incisions
To mindre frilægningerStabil osteosyntese af begge søjler
2 skinnerSkåne bløddele – kan bruge minimal invasiv teknik
![Page 39: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/39.jpg)
![Page 40: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/40.jpg)
![Page 41: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/41.jpg)
![Page 42: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/42.jpg)
AUTHOR UPDATE 2009:
We continue to use both surgical techniques for the fixation of displaced bicondylar tibial plateau fractures, and we have found the two techniques to be complementary rather than mutually exclusive.
2006
Conclusions: Both techniques provide a satisfactory quality of fracture reduction. Because percutaneous reduction and application of a circular fixator results in a shorter hospital stay, a marginally faster return of function, and similar clinical outcomes and because the number and severity of complications is much higher with open reduction and internal fixation, we believe that circular external fixation is an attractive option for these difficult‐to‐treat fractures.
![Page 43: Morten Schultz Larsen Odense University Hospital · 2018. 8. 20. · Forsinket ORIF y Ekstern fiksation 10-20 dage y Anatomiske skinner, vinkelstabile skruer, ÅBEN reposition. Minimal](https://reader035.vdocuments.net/reader035/viewer/2022081403/6090a4611e106764887aea63/html5/thumbnails/43.jpg)
Summary Skinneosteosyntese kan anvendes til både proksimale og distale tibia frakturer hvis:
Man venter til bløddelene er i ordenIncisionerne placeres korrektRepositionen kan gøres anatomiskOsteosyntesen kan gøres stabil nok til at ubelastede bevægelser kan påbegyndes inden for en uge