Internal Fixation

Pure Metals: Titanium, Zirconium Uses of wire: Alloys: Stainless steel (Fe, Cr, Ni, C, Mo), Vitallium (Co, Cr, Mo) 20-22 gauge- thick cortical bone, o Mo adds inertness to stainless steel malleolar fractures, tension banding Never mix metals; will get galvanic erosion 24-26 gauge - 1st metatarsal Dorsal Loop technique- loop through cortex dorsally 26-28 gauge - lesser metatarsals, Purchases only 1 cortex phalanges (mostly proximal phalanx Can get dorsiflexed metatarsal because only fixating dorsally of hallux) Intraosseous Loop- dorsal and plantar OR medial and lateral 30 gauge - delicate situations Purchases 2 cortices; more stable 1st & 5th metatarsals = perpendicular to the shaft, 2nd-4th metatarsals = 45 to shaft Circlage Wiring- completely encircles a long bone Good to use in adjunct with other forms of internal fixation Need long oblique fracture in order to work ONLY GIVES SPLINTAGE Staples- indications include triple arthrodesis, fusion, TN/CC joint Types: o Osteoclasps- put perpendicular to fracture with hope they come together and create compression o Memory Compression- made from nickel-titanium alloy At body temperature, the tips of the arms come close to each other to create compression o Oss Staple- similar to memory compression, but an electrical current causes arms to close Kirshner Wires- most common form of internal fixation (offers splintage) Diameter: 0.028, 0.035, 0.045 (2-5 mets; FF sugery), 0.054, 0.062 (1st ray, hallux) Indications: fracture, healing, tendon transfer, maintenance of proper alignment, fusion, arthroplasty, Keller, spaces of joint, maintains length, transverse fracture of metatarsal For K-wire to get compression must be combined with: tension bands, stainless steel wires, wire loops, screws, etc Threaded K-wires: core is NOT the diameter, so they are weaker o Offers mild resistance to distraction Static compression: screw causes the compression Dynamic compression: bodies forces combined with internal fixation, create compression Tension banding- use in 5th metatarsal fracture Tension band + wiring = dynamic compression

Principals of Internal Fixation

Purpose of internal fixation = to hold a fracture stable until sufficient healing has occurred to allow normal loading Requirements for optimal healing: Detriments to optimal healing: Adequate blood supply Disruption of blood supply via trauma or aggressive surgery Need biologic activity Gap between bone fragments Mid-diaphysis has a higher rate of non-union and Destabilizing forces: tension (transverse fx), shear, bending delayed union (metaphysic better for healing) (oblique fx), rotatory (spiral fx) Anatomic reduction,stability of osseous fragments Soft tissue interposition, Non-anatomic reduction Devices which splint: External Bandages, casts, etc o Indication = non displaced fracture (fracture that is inherently stable) o Problem is you are also splinting the skin and get soft tissue atrophy K-wires: limited stability / compression, may neutralize shearing or bending force External fixators (also compress) Buttress- transfers stress to plate rather than affected Plates: compressive force, internal splint (also compress) region ORIF (Open reduction internal fixation) AO: Arbeitsgemeinschaft fur Osteosynthesfragen (society of Primary bone healing: when bone heals in stable osteosynthesis) position ASIF: American Society for Internal Fixation NOT primary goal, but side affect of the goal o Believed best outcome from osteotomies/fractures are when: Rehabilitation of soft tissue: movement of muscles i.) Preservertion of Blood supply on/off weightbearing ii.) Anatomic reduction Fixated bone and while bone is healing you must iii.) Stabilize the fracture to retain anatomic maintain movement of soft tissue reduction iv.) Rehabilitate the soft tissue WHY INTERNALLY FIXATE? To hold bone in anatomic position and hope it heals in that alignment! Appleton Page | 1

Bone Screws
Purpose of fixation device: hold a fracture/ osteotomy stable until sufficient healing has occurred to allow normal loading Compression increases the force of friction between two surfaces, therefore increasing the resistance to movement; enhance stability Screws create compression by: Screw Anatomy: NOT PROPERTIES! Design of the screw Shaft: part that does not have threads Technique of insertion o Fully threaded does not have a shaft Two types of bone Core: Central area between threads Cortical: hard, more compact, may only have 2-3mm cortex o Inner solid area o Screw: NARROW PITCH (3mm), NARROW THREAD Pitch: distance between threads DIAMETER o Different pitches dependent on which Cancellous: spongy bone, more volume type of bone you are inserting it in o Screw: WIDE PITCH, WIDE THREAD PATTERN Thread diameter: outer diameter of screw Holding Power: depends on # of threads imbedded in bone Head of screw Ratio of major to minor diameter (thread surface area) o If you have thread diameter of 1 and core diameter 0.75, you are left with .25 of thread surface to grab into bone Compressive or LAG effect: achieve a compressive effect by with screw being partially threaded or fully threaded Fully threaded- as screw penetrates the bone, you want the head to compress the proximal cortex to the distal cortex o You want the under surface of the head to grab the proximal cortex and pull it toward the distal cortex o Get compressive effect by neutralizing the threads in the proximal cortex Partially threaded- important that all the threads are across the osteotomy Screw Design: under surface of the head should pull the proximal cortex to the distal cortex Bone surface needs to be contoured to the same size and shape as the screw head: COUNTERSINK o Countersinking- reason is to evenly distribute the forces under the head to prevent stress riser Standard Screw Sequence: 1) Temporary Fixate put in anatomic position 2) Dill Pilot Hole 3) Countersink 4) Measure 5) Tap 6) Overdrill 7) Screw insertion New trends: Material: titanium, cobalt chromium (Vitalium) Low contour heads: good for small bone of the foot Cannulation- central core is hollow, allows you to place guide pin across the osteotomy o Cannulated Sequence: 1) Reduce fracture 2) Guide Pin (measure length thats needed) 3) Countersink 4) Screw insertion Self tapping (rare) Self reaming (many new screws are self drilling, no need to drill a pilot hole) Range of screw sizes: 2.0, 2.5, 3.0 = CORTICAL 3.5 = MIXED 4.0, 4.5, 6.5 = CANCELLOUS To get max compression you generally may want 2 screws in an oblique osteotomy 1st screw inserted perpendicular to the fracture to get max compression 2nd screw inserted perpendicular to the long axis of the metatarsal to give you max resistance What if only 1 screw? You split the difference! Lapidus: NOT going cortex-cortex, going from cortex to medullary bone, use a larger screw size (4.0, 4.5, 6.5) for cancellous bone Clinical Applications of Compression Internal Fixation Appleton Page | 2

Compression Applictions of Compression Internal Fixation

Primary bone healing is when you get bone healing with out callus formation, that step is skipped. Primary bone healing is an outcome of compression fixation Internal (compression ) Fixation instrumentation Cannulated screw systems, Plates, staples Bone clamps, wires, guide pins, external fixation Counter Sink - Purpose is that you want the head of the screw flush with the cortex of the bone. The counter sink also prevents a stress riser Depth Gauge Determine length of the total screw, 2mm increments in the standard AO Always the next highest screw: ex) if you measure with the depth gauge 15mm you want to use a 16mm screw Standard bunion surgery the screw sizes are standard 14, 16, 18mm long TAP- Cuts thread pattern (Same pitch as the screw being utilized) A tap needs to create the exact same thread pattern as the screw you are going to put in. If you are using a 2.7 bone screw you are going to use a tap that is 2.7 Narrower pitch = more threads this screw is designed for cortical bone as opposed to a screw with wide pitch (increased space btw the threads) is more used for cancellous bone. LAG screw fixation: thread takes purchase in the far cortex only Tightening causes compression- As the head of the screw hits the dorsal cortex and the narrow threads grab the plantar cortex, thats how you get compression. Fully threaded screw- overdrill the near cortex (create a gliding hole) o Thread pattern up the entire length of the screw. We have to do something to avoid the threads grabbing in the proximal section. This is called overdrilling in the near cortex and create a glide hole. o This is what the lag technique is. You dont want the threads to grab anything in the meduallary canal. partially threaded screw; Lag screw (no threads proximally to grab anything) o Wwide threads are going to grab the cancellous bone and when the head of the screw hits the cortex thats how you get the compression. Screw Driver- two finger tightness **Basic Drill Sequence:** 1) Pilot hole : taking a drill bit going from cortex to cortex 2) Glide hole ( overdrill): if using a fully threaded screw and dont want to grab the near cortex; need to overdrill. 3) Counter sink: prevent the screw from being prominent and prevents the stress riser. 4) Measure: 5) Tap: 6) Screw insertion: 7) *Creation of glide hole Intra-Operative Complication Alternative stabilization technique If you get a problem you need to know how to salvage o 4 hole box loop with monofilament wire (springer) o Remember that non compression staples, k wire , monofilament wire dont give interfragmental compression give splintage only! Tension Banding Fixation- A device which will exert a force equal in magnitude but opposite in direction to the bending force Plate: Function- Plates have been made to facilitate different fracture designs Neutralization (protection): plate that is applied to the bone to protect static interfrag. compression Buttress Compression Tension band Locking Neutralization- Protection of interfragmental compression, Resist torsion, bending and shearing forces Compression- Transverse and short oblique fractures, static compression Buttress- Prevents Axial deformity as a result of shearing or bending Appleton Page | 3

External Fixation
Purpose: to anchor multiple osseous fragments together through use of wires and rods in order to provide longitudinal support Decrease need for extensive soft tissue dissection Provides post-op adjustment and earlier return to weight bearing and range of motion Mode of Fixation: compression, neutralization, distraction Neutralization- maintain length and alignment of segment as well as resists external deforming forces Distraction- pull segments away from each other slowly (1mm/day), resulting in controlled lengthening of the bone o Fracture reduction through ligamentotaxis Ilizaraov Prinicples: Tension-stress effect- bone could be lengthened through callous distraction, if performed at a proper rate of distraction both osseous and soft tissue will respond o Distraction @ 1mm / day Stages of distraction: o Latency- osteotomy & corticotomy o Distraction- turn at 4X / day o Consolidation- take 2X as long as distraction (4w for distraction, 8w for consolidation) Under optimal conditions during distraction, bone forms via intramembranous ossification Under unstable conditions during distraction, bone forms via enchondral ossification Basic Frame Components: Pins: connects bone to rest of the frame o Stiffness of pin = radius to the 4th power (small diameter increase will greatly increase stiffness) o Thread designs- constant diameter (purchase on near & far cortex; stress focused to these areas), short thread, self drilling, conical taper Conical Taper: obtain purchase on near and far cortex but allow for RADIAL preload Distributes stress in all areas rather than in specific areas like constant diameter Pin Designs: stress highest at pin-bone interface on insertion, thread-shank junction = pins weakest segment Longer thread design = stress riser more distally from bone or away from interface Shorter thread design = stress riser to far cortex External Fixator Types: Monolateral / Half pin- uniplanar correction o Lacks stability in the sagittal plane! Therefore cannot have any weightbearing o Monolateral frame mechanics: Stacking of rods gives more stability and rigidity Delta frame configuration adds resisitance to deformation into 2 planes Need to spread pins apart, otherwise fixation will be deformed Circular (Ilizarov)- circular or partial rings connected by rods o Provide provide compression and distraction o Biplanar correction; allows for sagittal plane stability but allows axial rotation Hybrid- combines circular and monolateral configurations into one frame o Indication: tibial plateau fracture, pilon fractures, ankle fusion Taylor-Spatial frame- for reduction of complex TRIPLANE deformities with utilization of computer programs o Indication: fixation of fractures, limb lengthening, arthrodesis, soft tissue lengthening Complications: infection, edema, hematoma, drainage, pin tract infection, scar, pain, wire breakage, non-union, stress fracture, joint dislocation / subluxation Pin tract infections: Dahls Classification o Grade 0 clear fluid NaCl cleansing with topical abx o Grade 1 slightly red fluid - NaCl cleansing with topical abx o Grade 2 red/tender yellow drainage PO abx with TD pin care o Grade 3 red/painful/purulent definitive PO abx o Grade 4 radiolucency with purulence removal of pin/possible IV abx o Grade 5 sequestrum removal of pin/debridement of pin tract and IV abx

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Peripheral Nerve Surgery

Degree of Myelin: A- : (largest and fastest!), A- : (fibers that concern us), A-delta & C (both last to be affected by diseas) Types of Receptors Meissner Corpuscle: A- fibers, VIBRATION, dermis of glabrous skin (no hair) Pacinian Corpuscle: A- fibers, VIBRATION, deep layers of dermis, both hairy and glabrous skin Ruffini Endings: A- fibers, PRESSURE, dermis, hairy and glabrous skin Receptor # of fibers # of receptors Merkel Cells: A- fibers, PRESSURE, epidermis of glabrous skin 1 1 Pacinian Receptor-Nerve Fiber Relationship 1-9 1 Meissner Merkel receptor: damage to ONE nerve fiber leads to greatest area of defect 1 4-5 Merkel Mortons Neuroma: interdigital perineural fibrosis Not a true perineural fibrosis Nerve compression involving the common digital nerves of the lesser toes Most often 3rd interspace (80-85%) Intense pain in the forefoot with burning, tingling, or numbness that radiates to the toes Etiology: predominantly in women, 88% of cases in the range of 30-86 yrs occur in women Treatment: (Conservative) o Change shoe gear, padding, orthoses, PT, and corticosteroid injections o Alcohol injection therapy- 4% sclerosing ETOH solution Treatment: (Surgical) o Endoscopic decompression of intermetatarsal neuroma Small incision dorsally Advantage = minimal incision, paitents can go to work immediately, less tissue trauma EDIN 1 involves 3 incisions, EDIN 2 now involves 2 incisions o KobyGard by Osteomed: smaller incision, only 1 incision, complication = scarring, stump neuroma Stump Neuroma Individuals develop stump neuroma because there has been an injury to the nerve, and the nerve tries to repair itself Transplant the nerve into a muscle to prevent the release of nerve growth-factor Can transplant nerve into the ABductor muscle belly Peripheral Neuropathy: Patterns of neuropathy in diabetics: ENTRAPMENT NEUROPATHY (2nd most common) Mechanism of action: blood glucose taken directly into nerve is metabolized to fructose and then sorbitol o Sorbitol is hydrophilic and causes the nerve to swell o When the nerve swells in anatomic small spaces such as carpal/tarsal tunnels, pressure leads to tingling, pain, and decreased sensation Nerve Ablation: Principle of radiofrequency ablation: sends electrical impulse through a probe and generates heat Parameters that determine the radiofrequency lesion size: temperature, electrode geometry, time until thermal equilibrium is reached Takes the foot 60 seconds to generate heat Peripheral Nerve Injuries Seddens Classification:** o Neuropraxia: interruption in conduction of the impulse down the nerve fiber and recovery takes place Without wallerian degeneration o Axonotmesis: involves loss of the relative continuity of the axon and its covering of myeline, but preservation of the connective tissue framework of the nerve (encapsulating tissue, epineurium, perineurium are preserved) WALLERIAN DEGENERATION o Neurotmesis: not only the axon, but the encapsulating connective tissue lose their continuity WALLERIAN DEGENERATION Sunderland System: 1st degree- compression or ischemia, complete recovery in 2-3 weeks 2nd degree- injury to axon, supporting structures intact, wallerian degeneration occurs (1mm/day) 3rd degree- endoneurium disrupted, epineurium & perineurium intact 4th degree- interruption of all neural and supporting elements, epineurium intact 5th degree- complete transaction with loss of continuity 6th degree- mixture of injuries, nerve has had a disordered self repair with a lateral neuroma Mechanism of Repair: proximal cut end- sprouting collateral buds @ the proximal node of Ranvier, releasing nerve growth factor Neurotube: Porous (provides O2 rich environment), Flexible (to accommodate for movement/tendon gliding), Corrugated (resist occlusive force of surrounding tissue), Bioabsorbable (eliminates the need for removal at a subsequent operation) Appleton Page | 5

Surgery of the Rheumatoid Foot

Pathophysiology Autoimmune Disease: circulating autoimmune complexes deposited in the synovium (in the recess of the joints )- leads to synovial hypertrophy PANNUS: synovium that has undergone a transformation. o Leads to destruction at the articular cartilage and the subchondral bone Poststatic dyskinesia = Pain upon movement after period of rest. o Duration allows you to separate DJD from inflammatory joint disease (DJD no more than 30m) More prominent in young females Joints that are most commonly effected: MPJs and proximal IPJs (clinically see HAV and hammer toes) Extra-articular manifestations in patients with connective tissue disorders o Prone to vasculitis (during procedure can end up with necrosis, Neuropathy Radiographic: first change you see is osteoporosis; Either side of the joint only (medially surrounding the joint) = Juxta-articular osteoporosis Erosions on either side of the joint = Marginal erosions. (in the recesses). Earliest erosive change = 5th MPJ MPJ and IPJ subluxation, and eventually full dislocation; from ligaments losing their insertions Fibular deviation in the foot Progression:eroding the cartilage on either side of the joint. o With less and less cartilage, the bones move closer together and can eventually fuse. Clinical and Pharm concerns NSAIDS, programs of rest or therapeutic exercise., Immunomodulators (DMARDS), Corticosteroids. possible atlanto-axial subluxation when hyperextend the neck during anesthesia (before hand x-rays of the neck) Surgical Options: Synovectomy (more useful in the rearfoot) Take the joint out (all or part of it); mostly replacement of 1st MPJ. Arthrodesis; take out the joint and fuse the bones together Joint salvage; perform an osteotomy to decreases the mechanical stress in the joint, perhaps you can slow down the progression of the disease. Indications = PAIN Classical incisions: 1. Clayton Procedure: Transverse on the dorsum of the foot 2. Hoffman Procedure: Straight across the bottom of the foot. - With a Fowler modification: Took a wedge out of skin, subQ, and everything else. - Purpose: when you close the skin, you would bring the forefoot down allow rapid excess right down to the bone, run the risk of severing nerves, blood vessels, tendons Linear incision: 1. Remove all met heads. -The only way to reset everything and correct the problem is to take all the met heads out. 2. Fuse 1st MPJ and take out the lesser metatarsal heads (Keeps the lesser digits in place) 3. Certain rules with met head removal: -maintain the met parabola (2,1,3,4,5 with 1 and 3 about the same length) 2nd at reference point -take a bit more off plantarly than dorsally: prevents plantar shelf from persisting after surgery. -Angle mets 1 and 5 a little bit instead of cutting them completely transversely. -K wire driven thru 1-4 Complications: GOAL = Relief of pain, not to make foot look like it never had RA - Infection, At risk because of CT dz, medication puts at risk, patients need to be prophylaxed , Delayed wound healing, skin sloughing if multiple incisions, vasculitis can lead to skin sloughing, foot = shorter, recurrence

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