Prof. Dr. Ulrich Holz
Founding Member of IGOF
Minimally Invasive Techniques in Fracture Treatment
Unlike in abdominal, thoracic and spinal surgical endoscopic procedures, keyhole surgery has a limited scale of application in fracture treatment.
The term Minimal Invasive Surgery marks out a wide range of surgical techniques. It is wrongly understood by many people just as a surgery with small skin incisions.
What is the goal of Minimal Invasive Surgery?
- Preservation of vascular supply
- Avoidance of tissue necrosis
What are the techniques?
- Indirect reduction
- Little detachment of soft tissues
These techniques easily work with conservative treatment and intramedullary nailing.
With plate osteosynthesis little detachment of tissues can be achieved by a clear cut surgical approach through anatomical pathways (open, controlled), or by small skin incisions and then undermining the tissues in anatomical pathways (or tunnelling). (keyhole, not completely under vision)
What was wrong since osteosynthesis became the predominant treatment of fractures?
The paramount promotion of plate osteosynthesis even for shaft fractures caused a huge amount of complications such as infection, non union and sometimes bone loss.
Biological techniques in fracture care, such as conservative treatment and intramedullary nailing have been neglected for quite some time, when plating was “en vogue”.
Now the pendulum is swinging back.
I.m.nailing with closed reduction and very small skin incisions approaches has clearly shown its advantages in the management of shaft fractures and with interlocking nails the range of indication could successfully be extended to the treatment of metaphyseal fractures as well.
Correctly performed i.m. nailing meets the criteria of Minimal Invasive Surgery
The domain of plate osteosynthesis is articular fractures and some metaphyseal fractures.
Minimal invasive techniques in plate osteosynthesis are
- Endoscopy in articular fractures
- Indirect reduction(Traction, push screw, joy stick)
- Locked plates as bridging plates
When does minimal invasive fracture treatment work?
Fractures which can be reduced by closed manipulation
- Joy stick
- Push screw
When does minimal invasive fracture treatment not work?
- Complex articular fractures
- Open fractures 2° and 3°
- Irreducible fractures
Problems with minimal invasive plate osteosynthesis
- Reduction may be incomplete
- The plate shifts over the soft tissues and may destroy muscles and vessels (no visual control during insertion)
- Bone may be devastated
- Metal removal (plate and locked screws) is often difficult and the implant has to be exposed completely. (After this, the incision is as big as with traditional approaches)
Minimal Invasive Surgery in fracture care is only fulfilled, when tissues and blood supply are preserved. This is not guaranteed simply by using a small skin incision.