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骨科英语:Minimally invasive techniques in the management of orthopedic trauma  

2015-12-27 20:26:15|  分类: 骨科英语 |  标签: |举报 |字号 订阅

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Summary
Surgery is a double-edged sword. It is removing lesions at the same time, also must have a negative impact on the body. Therefore, whether doctors or patients always hope to minimize the surgical injury to get the best treatment. The pursue of doctors and patients led to the emergence and development of minimally invasive surgery. Minimally invasive surgery (MIS) is the trend of development of modern surgery.The application of minimally invasive techniques in treating orthopaedic trauma includes two aspects: On the one hand, minimally invasive techniques is an effective means of damage control orthopaedics in the treatment of patients with serious multiple traumatic injuries, aiming to reduce surgical morbidity, improve postoperative care and rehabilitation; On the other hand, minimally invasive technique is widely used in the treatment of fractures around the joints, pelvic and acetabular fractures, spine fracture,with advantages of minor operation injury,smaller incision, less muscle rupture, lower bone blood supply damage, better local hematoma protection, rapid fracture recovery. 

Minimally invasive techniques

Minimally invasive technology is an effective means of damage control orthopedics, also an effective method for treatment of fracture.
Its research,application and popularization in the field of orthopaedic trauma are well demonstrated in the development of current osteosynthesis.
Arthroscopy, a method developed in the middle of the last century, could be regarded as a typical paradigm.

Damage control surgery

Damage control surgery(DCS), defined as initial control of hemorrhage and contamination followed by intraperitoneal packing and rapid closure, allows for resuscitation to normal physiology in the intensive care unit and subsequent definitive re-exploration.
Damage control orthopedics(DCO):Based on the concepts of damage control surgery, the application of the same principles to the management of the multiply-injured patient with associated fractures of the long bones and pelvic fractures was named “damage control orthopaedics”.

Damage control orthopedics
The first involves early temporary stabilisation of unstable fractures and the control of haemorrhage and, if indicated, decompression of intracranial lesions. 
The second stage consists of resuscitation of the patient in the intensive care unit and optimisation of his condition. 
In the third stage, delayed definitive management of the fracture is undertaken when the patient’s condition allows.
The favoured technique for achieving temporary stability of the fractured pelvis or a fracture of a long bone is external fixation. This is an expedient and minimally invasive method and can be used very efficiently to accomplish early stabilisation of the fracture and to control the additional biological stresses posed by prolonged surgical procedures. 
The delayed definitive procedure for the stabilisation of fractures of long bones, in particular fracture of the femur, is usually intramedullary nailing and this is carried out when the condition of the patient is stable and optimised.
The practice of delaying definitive surgery in damage control orthopaedics is an attempt to minimise the second hit, the additional burden of the surgical procedure, on the already traumatised patient.
External fixation is an effective and adaptable modality that has various applications for the stabilisation of the musculoskeletal system. A common use of external fixation is for the expeditious, temporary stabilisation of long bone fractures in the setting of a patient unsuitable for immediate and definitive operative care which is now generally known as DCO. 
Logan found knowledge of component cost was low among physicians at varying levels of experience and training.Consistent with previous investigations, even commonly used orthopaedic devices and components fall within a knowledge gap and, as with our analysis, physicians underestimated the cost of components.
Whether external fixation can safely be converted to intramedullary nailing without increasing rates of infection has been a topic of debate for some time with conflicting results available in the literature.

AO Principles
In 1958, AO formulated four basic principles, which have become the guidelines for internal fixation.
Anatomic reduction:Fracture reduction and fixation to restore functional anatomical relationships. 
Stable fixation:Stability by rigid fixation or splintage, as the personality of the fracture and the injury requires. 
Preservation of blood supply:Preservation of the blood supply to soft tissue and bone by careful handling and gentle reduction techniques. 
Early mobilization:Early and safe mobilization of the part and patient.

BO Principles
Biological osteosynthesis is characterized by the preservation of bone and soft tissue vascularity and relative rather than absolute fixation. Reduction of fractures should be achieved by using soft tissue traction while obtaining axial and rotational alignment and the correct length.
In this respect intramedullary nailing can well meet these requirements when used to treat the shaft fracture of a long tubular bone.
In some intraarticular and metaphyseal fractures which may need open reduction and internal fixation, there still indirect surgical reduction and limited internal fixation combined with external fixator.

Evolution in operative technique
Plating, common and effective in managing diaphyseal or metaphyseal fractures, can now be accomplished with minimally invasive surgery(MIS). 
For the past several years, the concept of minimally invasive plate osteosynthesis (MIPO) has been widely accepted and its technique increasingly used.
As more clinical experiences have been collected, MIPO has technically evolved into minimally invasive percutaneous plate osteosynthesis (MIPPO).
In the past decades, the principles of fracture management have been changed from mechanical approach to fracture care to methods considering first of all the biological aspect of the injury.
Now clinically intramedullary nailing has been the choice of treatment for long bone fracture as long as it is not contraindicated.
Intramedullary nailing is a mature technique and widely used in clinical practice but still has some complications harmful to fracture healing, such as infection.Insertion of the nail,especially the reamed one, can damage the intramedullary blood supply to some extent, and the fracture healing may therefore be affected and even inhibited.
External fixator is the other alternative of fracture fixation when close reduction is concerned.
The screws for fixation are inserted into the cortexes away from the fracture site without disturbing the biological environment of the fracture.This procedure well follows the principle of MIS.Simple manipulation and easy regulation are its main advantages.
Clinically, external fixator is widely used to manage open fractures, especially those with soft tissue problems .The fixator can be used as a temporary fixation and afterwards replaced with internal fixation when conditions permit.
However, external fixator has some constant short-comings,inadequate stability and pin track irrigation and loosening.

Improvement in implants
In the past decade the implants for fixation have been modified, improved and renewed.Their applications well meet the needs of MIS in osteosythesis.
A point contact plate is utilized to reduce the compression on the cortex beneath the plate, so that the range of necrosis and osteoporosis induced by rigid plating can be reduced and fracture healing improved.
A locking compression plate (LCP) is extremely useful in the treatment of complicated, especially osteoporotic diaphyseal or metaphyseal fracture with MIS.
Based on the mechanism of locking plate is introduced subcutaneously or beneath the muscle layers and fixed in place,the less invasive stabilization system (LISS) has come out, providing an effective and stable fixation for fractures about the knee joint.
Thus, LISS can well bridge the articular component and the shaft, without disturbing the metaphyseal fragments whose blood supply can well be preserved to facilitate fracture healing.

Digital technology applied in traumatic orthopaedics

Thanks to the development of high technology, the effectiveness, practicability and precision of MIS in the management of fractures have been improved progressively. 
The coming out of computer assisted orthopaedic surgery (CAOS) makes it possible to introduce a plate or a screw precisely and quickly with less exposure of both the surgeon and the patient to radiation. In addition, it makes some risky operations can be accomplished safely.

Medical image processing and 3D modeling technology
Computer aided design and manufacturing technology
Surgical planning and virtual simulation technology
Computer-assisted reduction system  and Computer-assisted orthopaedic surgery

Summarization and prospect
Because of the multiplicity of musculoskeletal trauma, any kind of method cannot be expected to use a single device to treat all kinds of fractures. We still need  on the way to modify the present implants or to innovate in designing new implants.
Minimally invasive technique is not a concept that it possesses lower operational risk, more easy operation procedure, and smaller incision. It will be popularized and changed continuously with the time goes on. The surgeon should be timely grasp the concept and operation indications, learn and improve surgical methods. 
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