Name: surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling
Uploaded: 2015-01-05T14:00:00.000+00:00
Duration: 15 min 11 s
Description: Watch this Scientific Journal Video about Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling at JoVE.co

This article is dedicated to the specialist in pediatric surgery, Professor Dr. R.T. Carbon (Erlangen, Germany) with heartfelt gratitude for his educational impact. We thank the Radiological Institute of the Erlangen University Hospital (Director: Prof. Michael Uder) for providing the X-rays and CT scans.

注:以下程序进行批准的部门负责人，并满足其他所有机构的要求。 1.术前计算机断层扫描注:整个胸壁的螺旋CT采取以下的地方标准协议开始之前。 <img alt="图1" src="/files/ftp_upload/52124/52124fig1highres.jpg" /> 图1:术前CT扫描。 （一）轴向视图显示斜和纵向裂缝。（二）矢状面视图显示前后脱位或胸骨扭结。（三）冠状图给出了一个概述了斜和纵向裂缝。（四）容积再现技术（VRT）给出了一个概述在整个前胸壁显示肋骨骨折，胸骨柄和黄sterni骨折<ol><li>扫描胸壁受伤。检查完成前胸壁，包括检查软组织，软骨和骨骼。 <ol><li>寻找骨折在柄，胼sterni和相邻肋I至VII两侧。寻找软骨的破坏。要知道软骨破坏和胸肋分离不要错过不稳定的任何原因。 </li><li>执行三维评价。通过评估具体每个轴向，冠状面和矢状画面看到整个胸壁的三维图像重建的作案。 </li></ol></li><li>找准骨折: <ol><li>采取从上胸骨边缘（jugulum）到骨折的距离。用于测量矢状视图。 </li><li>万一斜形骨折或多个裂缝的同时测量的距离来jugulum，颅和骨折的尾边缘。取的那些边缘之间的距离。另外使用的冠状图像可能是在这种情况下有帮助。 </li></ol></li><li>确定presternal软组织的厚度。评价和测量presternal软组织的厚度在断裂的点。 </li><li>估计可能的手术切口的长度，在中线进行。 注:基本方法需要至少60毫米加presternal软组织的厚度，以获得适当的访问的横向断裂。 <ol><li>万一斜形骨折或多个裂缝的添加头部和裂缝的基本方法的尾边缘之间的距离。 注意:有可能是必要的肥胖患者较长切口，如果有伤痕，在确定的区域或由于其他原因。 </li></ol></li></ol> 2.手术治疗<img alt="图2" src="/files/ftp_upload/52124/52124fig2highres.jpg" /> 图2:手术方法。 （一）定位在背部可以访问到耳鼻喉科愤怒前胸壁和两个车桥;胸管已经插入双边在这种情况下，（二）绘制的地标，例如jugulum和胸锁关节（以上）的中线被识别，并且进行该切口之后。胸肌从前壁胸骨切开。一个raspatory插入subperiostally。（三）的做法给予完全访问发现的任何骨折。在这种情况下，两个横向裂缝被示出。 2.1）初始手术过程: <ol><li>在全身麻醉下以下的本地标准，同时患者插管执行操作。将患者在仰卧位置。休息臂上的臂板，它必须放置小于90°，​​以所述主体的中线并与地面水平的板。如果插入胸管的必要，这可能是有用的。 </li><li>申请前的防腐剂去除浅表的土壤，垃圾，饰品和短暂的微生物普天代理。离开头发在手术部位的地方只要有可能。 <ol><li>展开消毒后的地方标准。开始从干净的区域，通常是手术和/或切口部位，并继续在同心时尚最干净的区域。让消毒液完全干燥自然。确保该消毒液保持与皮肤的时间所需的时间接触，制造商推荐的。 </li></ol></li><li>固定至少要在jugulum，肚脐和两侧腋中线免费访问。马克解剖标志，如两侧胸锁关节，上胸骨缘在jugulum，下缘胸骨剑突和，第七肋骨两侧以及使用无菌笔脐部。 <ol><li>现在画出中线jugulum和脐之间并测量在步骤1.2标记骨折的头部和尾部边缘。加入一半的基本方法颅和行吟诗人ř半尾到胸骨的裂缝区域的边缘。 </li></ol></li><li>仔细检查中线骨折（S）和正确的位置，然后执行正中切口尊重解剖层的软组织。 </li><li>由垂直切口沿所述血肿的长度除去presternal血肿和洗出尽可能用0.9％盐水。 </li><li>谨慎带走胸肌两侧，从中线到胸骨，同时尊重解剖层的边缘开始。要知道，从较小的船只出血和阻止他们。确定骨折。 </li><li>暴露胸骨肋间缘，两者的，头部和断裂的尾部。纵向沿着胸骨的前缘执行胸骨骨膜的切口。小心翼翼从横向骨和胸骨的后表面使用升高或raspatory设备解剖骨膜。 注:准备很CLOSE到在此过程中的骨是非常重要的，以防止伤害到相邻的胸廓血管和纵隔。 </li><li>暴露骨折并清除骨折谨慎。一般胸骨血肿将出现在这个时候，洗出尽可能用0.9％盐水。 </li></ol><img alt="图3" src="/files/ftp_upload/52124/52124fig3highres.jpg" /> 图3:手术安全性（一）测量胸骨厚度和插入一个升降装置（B，C）深度有限的钻探。 <ol start="9"><li>测量胸骨用钝刀厚度。不要使用常见的"很多"，因为可能的胸骨受伤。制备钻孔机与胸骨厚度的长度的钻头或更短，如果不明确。 </li><li>通过提高向后郁闷片段与elevato减少碎骨这可以通过在步骤2.1.7中所示的相同的方法骨膜下被插入ř设备。装配侧向脱臼片段应该是横向压缩。用尖头镊子球，韦勒钳或压线，如果必要的。 </li></ol><img alt="图4" src="/files/ftp_upload/52124/52124fig4highres.jpg" /> 图4:在板的固定选项（一）横向断裂在语料库sterni:固定用尖头球镊子和锁定螺丝（B）斜骨折在柄:减少与压缩导线，第一板已被固定，但（。 c）多路横形骨折;固定使用压缩线的柄（上图）和尖头镊子球（下图）的板块。 2.2）横向骨折和胸骨体斜骨折: <ol><li>使用笔O符号胸骨中线ř电灼。 </li><li>插入一个小尖镊子球使用肋间胸骨的后表面旁边的断裂，再次保持非常封闭的胸骨骨。先用郁闷片段的肋间。 <ol><li>把纵向盘子旁边中线和针对性球forcipes修复它。 注:该板的至少三个螺孔应覆盖头部和尾部主要片段。如果一个骨折，一个七，八孔板提供正确的固定。使用更长的板是必要的，多处骨折，其中较长的距离需要被固定。 </li></ol></li><li>与锁定螺钉固定板，钻孔用钻孔导向件和钻头的每个孔作为选择下步骤2.1.9从而保证深度有限的钻井和每一个安全锁定固定螺钉到板上。再次，修复每个主片段具有至少三个螺钉。 </li><li>把第二板对T的另一面他中线并重复步骤2.2.2-2.2.3。 </li></ol> 2.3）纵向裂缝，斜柄骨折和胸肋分离: <ol><li>降低了断裂下步2.1.10所示。 </li><li>插入一个小尖球钳上使用肋间隙每侧胸骨的后表面旁边的断裂，再次保持非常靠近胸骨骨。把横板从肋骨到肋骨，缩小与它的碎片胸骨和针对性球forcipes修复它。将至少有三个螺丝孔每个横向骨折。 注:如果一个骨折，一个七，八孔板提供正确的固定。使用长板通常为多处骨折成为必要。 </li><li>固定板锁定螺丝;使用钻引导和钻下步2.1.9从而保证有限的深度钻孔的选择。再次，固定各主片段具有至少三个螺钉。 </li><lI&gt;对于每一个受伤的水平接骨，重复步骤 2.3.1-2.3.3。 </li></ol><img alt="图5" src="/files/ftp_upload/52124/52124fig5highres.jpg" /> 图5:手术结果（一）长的平行板，每个片段固定3个螺丝（B）术后胸部X线显示纵向胸骨板和三横板固定斜柄断裂，第二肋和骨折胸肋分离。在右侧第三肋。（三）的X射线的横向视图显示两个平行板固定位于胸骨语料库骨折的正确位置。 <ol start="5"><li>仔细检查所有板的正确位置。检查前胸壁有足够的稳定性。寻找任何出血停止。排除胸膜病变。如果胸膜病变显示或怀疑，插入胸管插入PL采用腋路患侧eural腔。 </li><li>如有必要，将皮下引流。将管在胸骨前面，经皮从伤口的下边缘转移约5厘米远。 </li><li>关闭伤口尊重解剖层次。缝合切口骨膜保持胸骨的血液供应。建议胸肌中线逼近，以确保与软组织植入物的适当范围。 </li><li>采取手术治疗后胸部X射线，以排除气胸血胸和。附加侧视图将会显示胸骨片段和植入物的位置。 </li></ol>

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D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+utility+of+3-D+CT+scan+in+the+diagnosis+and+evaluation+of+sternalfractures.">The utility of 3-D CT scan in the diagnosis and evaluation of sternalfractures.</a> J. Trauma. 60 (3), 635-636 (2006).</li><li>Alkadhi, H., Wildermuth, S., Marincek, B., Boehm, T. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+and+time+efficiency+for+the+detection+of+thoracic+cage+fractures:+volume+rendering+compared+with+transverse+computed+tomography+images.">Accuracy and time efficiency for the detection of thoracic cage fractures: volume rendering compared with transverse computed tomography images.</a> Comput. Assist. Tomogr. 28 (3), 378-385 (2004).</li></ol>

The first author has a consultant agreement with Synthes CMF. No funds were received in connection to the presented study. The coauthors are not involved in any conflict of interest.

虽然大多数胸骨骨折的保守治疗，有时手术内固定成为必要。胸骨解剖学和前胸壁的稳定性是由一个稳定的固定采用锁定接骨板恢复。使用非常纤细板（1.5毫米或2.0毫米厚度）提供一方面和高便利性的适当的稳定性，另一方面12的患者。非常好的结果也描述为任何锁定板中的应用，例如LCP系统或用于其它骨像颈椎或远端半径6,27开发板。 锁定板被认为是提供一个生物固定的优点是功能性作为内部固定器与板和骨9之间显著减少摩擦。这种内部固定器上的前胸骨表面的定位提供了fr的凸面的足够的固定acture并因此降低牵引力的断裂。在同一时间每个呼吸运动导致压缩到内部胸骨皮质和断裂从而刺激骨愈合。每个螺丝需要锁定牢固，以使内部固定器的效率。 正如我们推荐每个片段具有至少三个螺钉的固定，也可能会出现的情况下非常短的片段的限制。可能的解决方案是那些片段的桥接和使用特殊的板，它允许纵向和横向固定集于一身的。在将来，"T"或"H"形的板可以是在这些情况下有帮助。 一些外科医生显示不愿上胸壁操作，可能是由于在这个特定区域一个缺乏经验。有需要一种用于胸骨稳定1,12一种简单而安全的方法。上述方法代表一种可能的站ndard并减少并发症的风险的手术操作由一个精确的术前计划，软组织的骨膜下剥离和深度限定钻孔由于。那里在于使用的任何其他板不提供深度有限钻孔（ 表1）的可能性的差异，而术前计划，制剂的步骤，并且可以类似地执行该手稿的描述方式减少骨折。 作为三维重建的CT扫描允许骨折胸骨和伴随骨折诊断灵敏度高，外科医生被详述有关损伤28,29的信息。的CT显示的特定位置和断裂的方向以及任何错位。这一重要信息，简化的预期手术方法术前计划，如图步骤1.1-1.5。此外，它允许所述numbe的精确规划r和应用于固定，如图中的步骤2.2-2.3板的设计。 CT扫描的可能局限在于困难展示undislocated骨折和软骨的破坏，虽然他们可能有助于胸壁的不稳定性。 骨膜下剥离和深度有限的钻探是手术安全性最重要的两个步骤。 减少胸骨片段到其解剖位置通常就必须一个方法来胸骨后壁。这个过程可能会伤害纵隔器官，周围血管和胸骨的血液供应7,18。执行围绕胸骨严格骨膜下剥离所示步骤2.1.7将并发症的风险降到最低。这表明横向错位，可以有自己的碎片骨折的移动非常紧密的内部乳腺血管。在这种情况下，医生需要知道的任何伤害吨Ø这些船只可能导致严重出血。在这个特定区域中的出血被识别时，外科医生需要通过肋间的方法来内乳容器立即停止。肋间肌肉的解剖和吊具在受影响的肋间插入提供了一个快速和适当的访问受损血管。 钻孔太深要尽量避免，因为它可能会导致危及生命的伤害到纵隔。这确保了深度有限钻孔结合胸骨厚度的测量和对应的长度12的钻头的选择。 总结讨论程序和可能的限制，具有低轮廓锁定钛板进行前胸骨电镀是可以预料的成功，如果进行术前规划由计算机断层摄影，subperiostal夹层，和深度有限钻孔。

胸骨骨折是罕见的，发生在大约3-8％的创伤受害者1。通常情况下，这些裂缝是由钝性外伤引起的。最能保守了足够的合并骨折的治疗。有些骨折显示经久不愈，甚至缺乏整合了假关节的连续发展和持久的痛苦不稳定2,3。在这种情况下，手术的稳定，必须考虑。尊重不同创伤机制负责胸骨骨折等的直接影响到前胸壁或躯干的屈曲压缩损伤，一个主要的稳定的骨折，应考虑4-6。可能的手术治疗指征有:严重或持续性疼痛;呼吸衰竭或依赖机械通气;移动，重叠或影响骨折，以及畸形或胸骨不稳定;驼背的姿势和限制躯干7的移动。 有必要保留每胸骨片段在正确的位置，而中和剪切力以胸骨，以便恢复解剖学形状和前胸壁的正常功能。在这种情况下前胸骨电镀提供了最好的稳定性，因此越来越多地在大多数情况下使用。用导线的板而不是稳定的优势已经在胸骨倒闭被描述后正中8。由于其在生物内固定的优点利用锁定板增益重要性。锁定板的原理是螺纹螺钉头与板的螺纹螺钉孔之间的固定。由此锁定板充当内固定有一个最小板状骨接触保持骨膜血液供应板9下面的优点。 然而，许多外科医生reluc坦进行胸骨接骨因可能出现的并发症。在术前计划困难，严重伤害到纵隔器官或执行方法的失败可能的原因10。仅病例报告或小系列被描述为每个步骤。 表1示出不同的手术方法和选择路径描述和分析它们。 <table border="0" cellpadding="0" cellspacing="0"><tbody><tr><td> OP-技术 </td><td> 年 </td><td> 笔者 </td><td> 研究 </td><td> 患者手术数 </td><td> 结果 </td></tr><tr><td colspan="6"> 锁定钢板固定 </td></tr><tr><td> 3.5 / 4.0毫米定角板（LCP） </td><td> 2010 </td><td> Gloyer 等 。 [10] </td><td>外伤性脱位manubriosternal和胸骨骨折接骨s的3.5 / 4.0定角板（LCP） </td><td> 3 </td><td>没有任何功能限制，无痛苦</td></tr><tr><td>锁定钢板（TiFix） </td><td> 2010 </td><td> Queitsch 等人[3] </td><td>创伤后胸骨不愈合的治疗锁定胸骨接骨板（TiFix）。 </td><td> 12 </td><td>整合在所有情况下</td></tr><tr><td>低调钛板（Matr​​ixRib） </td><td> 2013 </td><td>舒尔茨-德罗斯特等人[11] </td><td>胸骨骨折内固定手术:锁定钢板固定以低调的钛金板 - 通过深度有限的钻探手术安全</td><td> 10 </td><td> 12周后盘整在所有情况下，无错位，患者满意度1.4，在随访无并发症</td></tr><tr><td> SternaLock </td><td> 2005年</td><td> Wu 等人 。 [12] </td><td>胸骨骨折不愈合:目前治疗审查和僵化固定的新方法</td><tD&gt; 2 </td><td>功能转归良好</td></tr><tr><td colspan="6"> 钢丝 </td></tr><tr><td>不锈钢丝</td><td> 2002年</td><td> Athanassiadi 等人 [1] </td><td>胸骨骨折100例回顾性分析</td><td> 2 </td><td>功能转归良好</td></tr><tr><td>不锈钢丝</td><td> 2002年</td><td> Potaris 等人[13] </td><td> 239例胸骨骨折管理</td><td> 4 </td><td>功能转归良好</td></tr><tr><td>胸骨线，植骨</td><td> 2002年</td><td>昆斯等人[15] </td><td>胸骨非工会:病例报告</td><td> 2 </td><td>一名患者与非工会</td></tr><tr><td>钢丝</td><td> 2009年</td><td>阿卜杜勒·拉赫曼等人 [16] </td><td> Comminutes胸骨骨折 - 一个胸骨钢丝固定:2例报告</td><td> 2 </td><td>功能转归良好</td></tr><tr><td>钢丝</td><td> 2009年</td><td>赛因切利克等人[17] </td><td>胸骨骨折和相关的伤害效果</td><td> 2 </td><td>功能转归良好</td></tr><tr><td colspan="6"> 非锁定钢板 </td></tr><tr><td>蚂蚁。 6孔钢板，植骨</td><td> 2004年</td><td>邦尼等人[18] </td><td>胸骨骨折:前镀理由</td><td> 3 </td><td>个人resons 12个月后取出钢板</td></tr><tr><td>蚂蚁。颈椎板的4个孔</td><td> 2009年</td><td>奇里亚科等 。 [6] </td><td>早期修复外伤孤立胸骨骨折unsing一个制版系统</td><td> 6 </td><td>一个盘子取出的胸骨疼痛</td></tr><tr><td>用3个螺丝板对骨折eachs方</td><td> 1993年</td><td> Kitchensens和Richardson [19] </td><td>胸骨骨折内固定开放</td><td> 2 </td><td>克OOD功能结局</td></tr><tr><td> T形压缩钢板，非锁定螺丝</td><td> 2006年</td><td>的Al-Qudah [20] </td><td>手术治疗胸骨骨折</td><td> 4 </td><td> 2板拆除没有命名的原因</td></tr><tr><td>两个8孔三分之一管板; H-板</td><td> 2006年</td><td> Kälicke 等人[21] </td><td>外伤性脱位manubriosternal </td><td> 2 </td><td>没有任何功能限制，无痛苦</td></tr><tr><td colspan="6"> 其他设备 </td></tr><tr><td> 2螺纹斯氏针，胸骨线</td><td> 2005年</td><td>莫利纳[22] </td><td>评估和手术技术修复孤立的胸骨骨折</td><td> 12 </td><td>在一名患者销钉迁移</td></tr><tr><td>布朗特主食</td><td> 2011 </td><td> Abdelhalim萨尔瓦多易卜拉欣等人 。 [23] </td><td>外伤性脱位manubriosternal:一种新的满足稳定postreduction的HOD </td><td> 1 </td><td>功能转归良好</td></tr><tr><td>钛下颌骨板</td><td> 2007 </td><td> Richardson 等 。 [24] </td><td>胸壁骨折内固定手术:一个了解prcedure？ </td><td> 35 </td><td>拆除3板（1心脏手术，1点击感，1个保险的原因） </td></tr></tbody></table> 表1:固定选项-选择小径从哈斯顿7 改性。 最近公布的调查通常描述了一个好的结果11成功前电镀。 利用低轮廓锁定钛板的保证了适当的稳定具有高患者的舒适度。另外，这些板块的固定提供了手术安全性，为深入钻探有限使用12。 因此，这个马努斯CRIPT描述一个选项，以在一步一步的指导，采用低剖面锁定钛金板前胸骨电镀稳定不同类型的胸骨骨折。另外，术前计划被描述一步一步来。 诊断，评估和计划: 任何病人住进了急诊科，主要是通过执行ABCDE-规则，从高级创伤生命支持，ATLS 25众所周知管理。从而危及生命的伤害，应检测，并立即处理或排除。之后，需要全患者的详细调查，以被执行以检测任何伤害。如果患者从痛苦中遭受的胸部，甚至显示了一个不稳定的胸壁有矛盾呼吸运动，胸骨骨折需要被排除。 任何病人怀疑胸骨骨折接受了胸部螺旋CT。在上下文中的可疑伴随陪审团，所有患者被全身多层螺旋CT检查。 CT数据的三维重建可以详细描述了6断裂的形态。受影响的区域需要被描述，以及断裂的方向和片段的可能的错位。 作为手术治疗指征不稳定前胸壁需要考虑以及骨折移位和七天以上7,12一个持久的，痛苦的不稳定。曾经为胸骨骨折手术作出决定，任何伴随损伤重估应该执行，为了把身体多处受伤的治疗以适当的顺序。 以下方案示出了用于外科手术治疗的（分离的）胸骨骨折，由此需要在这一点上，以强调在大多数类型骨折的保守治疗的可能性的一个可能的标准。在CA伴随肋骨骨折额外的考虑，这是这里没有显示，本身成为必要。

<table><tbody><tr><td>MatrixRIB</td><td>DePuySynthes CMF</td><td></td><td></td></tr><tr><td>LCP Forefood/Middlefood 2.4/2.7</td><td>DePuySynthes CMF</td><td></td><td>only compression wires are employed</td></tr></tbody></table>

surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method.
This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture&#8217;s morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures.
Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels.
Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.

术前将进行计算机断层扫描提供了整个胸骨和肋骨相邻的详细调查。使用CT数据的不同的窗口允许骨骼的详细分析以及肋条的相邻软骨和周围的组织。应检测受伤前胸壁的所有骨折。轴向的图片显示伤软组织窗口和胸肋关节破坏软骨。此外，骨窗口显示胸骨的纵向和斜向裂缝，而横向裂缝在该平面内很少发现。冠状重建从图片中手术治疗了类似的观点，以一个描述断裂的方向。在关系到中线的片段的错位可正确地进行说明。矢状视图显示片段的前脱位 - 后方向。胃角sterni的可能中断，synchondrosis柄和胼sterni之间最好的显示在这个平面上。这些步骤示于图1a - ð。 下面的步骤1.2-1.4允许的手术方法简明的规划。仰卧位允许全面进入前胸壁和两个车桥（ 图2a）。标志着标简化了中线的识别中所示步骤2.3（ 图2b）。 可以毫无问题地到达胸骨和相邻肋的所有受伤部位，同时执行一个中位数的方法按照以上（ 图2c）中提到的步骤。 执行胸骨骨膜纵向沿着胸骨的前边缘的切口和插入的电梯装置，所述后表面允许任何脱臼片段的减少和防止伤及相邻的内部胸椎血管和mediastiNUM在图4a所示。此外，深度有限钻孔可以进行通过胸骨厚度的测量，在第一个（ 图3a）和一钻头的与相应的长度的选择（ 图3b，c）所示 。 的尖头球镊子的插入可能难以在某些情况下， 例如，在该柄。在这些情况下，向前方放置压缩电线（长度=最大胸骨厚度）将有助于减少骨折和临时固定板（ 图4a - 三）。 使用至少三个螺钉各片段的固定通常显示一个适当的镇定横向以及用于倾斜和纵向裂缝（ 图5a，b）中 。定影分离肋胸骨可以通过胸骨-肋软骨电镀以及导致稳定结合26（ 图5b）进行。 此时，前胸壁的所有不稳定的部分是固定的板。前胸壁出现与生理呼吸运动稳定胸肋结合。尊重解剖层次获得最精确的伤口缝合;伤口并发症通常是罕见的。 术后采取胸部X光在两个平面显示正确的减少骨折和植入物的正确定位而进行给药（ 图5c）。 6个星期的随访通常显示周围骨折的第一愈伤组织和12周后的整合通常可以观察到。

Watch this Scientific Journal Video about Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling at JoVE.co

Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

Here we present a method to stabilize sternal fractures by using locked titanium plates in a low profile design. Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates provides a safe surgical way.

胸骨骨折内固定手术:术前设计和安全的手术技术采用锁定钛板和深度钻探有限公司

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the ...

surgical-fixation-sternal-fractures-preoperative-planning-safe

Universidad San Sebastian

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JoVE Journal

Medicine

62.8K 次观看.  University Hospital Erlangen. Here we present a method to stabilize sternal fractures by using locked titanium plates in a low profile design. Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates provides a safe surgical way.

视频: Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

Creating Rigidly Stabilized Fractures for Assessing Intramembranous Ossification, Distraction Osteogenesis, or Healing of Critical Sized Defects

Assessing modes of skeletal repair is essential for developing therapies to be used clinically to treat fractures. Mechanical stability plays a large role in healing of bone injuries. In the worst-case scenario mechanical instability can lead to delayed or non-union in humans. However, motion can also stimulate the healing process. In fractures that have motion cartilage forms to stabilize the fracture bone ends, and this cartilage is gradually replaced by bone through recapitulation of the developmental process of endochondral ossification. In contrast, if a bone fracture is rigidly stabilized bone forms directly via intramembranous ossification. Clinically, both endochondral and intramembranous ossification occur simultaneously. To effectively replicate this process investigators insert a pin into the medullary canal of the fractured bone as described by Bonnarens4. This experimental method provides excellent lateral stability while allowing rotational instability to persist. However, our understanding of the mechanisms that regulate these two distinct processes can also be enhanced by experimentally isolating each of these processes. We have developed a stabilization protocol that provides rotational and lateral stabilization. In this model, intramembranous ossification is the only mode of healing that is observed, and healing parameters can be compared among different strains of genetically modified mice 5-7, after application of bioactive molecules 8,9, after altering physiological parameters of healing 10, after modifying the amount or time of stabilization 11, after distraction osteogenesis 12, after creation of a non-union 13, or after creation of a critical sized defect. Here, we illustrate how to apply the modified Ilizarov fixators for studying tibial fracture healing and distraction osteogenesis in mice.

This article describes a method for stabilizing long bone fractures that is based on the application of modified Ilizarov external fixators 1-3. After application of the fixators and creation of the bone injury, healing can be assessed, distraction osteogenesis can be performed, or non-union or critical sized defect can be created and used to study therapeutic interventions.

建立评估膜内骨化硬性稳定骨折，牵张成骨，或临界中小企业缺损愈合

Assessing modes of skeletal repair is essential for developing therapies to be used clinically to treat fractures. Mechanical stability plays a large role ...

科研

医学

Adjustable Stiffness, External Fixator for the Rat Femur Osteotomy and Segmental Bone Defect Models

The mechanical environment around the healing of broken bone is very important as it determines the way the fracture will heal. Over the past decade there has been great clinical interest in improving bone healing by altering the mechanical environment through the fixation stability around the lesion. One constraint of preclinical animal research in this area is the lack of experimental control over the local mechanical environment within a large segmental defect as well as osteotomies as they heal. In this paper we report on the design and use of an external fixator to study the healing of large segmental bone defects or osteotomies. This device not only allows for controlled axial stiffness on the bone lesion as it heals, but it also enables the change of stiffness during the healing process in vivo. The conducted experiments have shown that the fixators were able to maintain a 5 mm femoral defect gap in rats in vivo during unrestricted cage activity for at least 8 weeks. Likewise, we observed no distortion or infections, including pin infections during the entire healing period. These results demonstrate that our newly developed external fixator was able to achieve reproducible and standardized stabilization, and the alteration of the mechanical environment of in vivo rat large bone defects and various size osteotomies. This confirms that the external fixation device is well suited for preclinical research investigations using a rat model in the field of bone regeneration and repair.

One constraint of preclinical research in the field of bone repair is the lack of experimental control over the local mechanical environment within a healing bone lesion. We report the design and use of an external fixator for bone repair with the ability to change fixator stiffness in vivo.

可调节刚度，外固定支架的大鼠股骨截骨和节段性骨缺损模型

The mechanical environment around the healing of broken bone is very important as it determines the way the fracture will heal. Over the past decade there ...

Establishment of a Segmental Femoral Critical-size Defect Model in Mice Stabilized by Plate Osteosynthesis

The use of tissue-engineered bone constructs is an appealing strategy to overcome drawbacks of autografts for the treatment of massive bone defects. As a model organism, the mouse has already been widely used in bone-related research. Large diaphyseal bone defect models in mice, however, are sparse and often use bone fixation which fills the bone marrow cavity and does not provide optimal mechanical stability. The objectives of the current study were to develop a critical-size, segmental, femoral defect in nude mice. A 3.5-mm mid-diaphyseal femoral ostectomy (approximately 25% of the femur length) was performed using a dedicated jig, and was stabilized with an anterior located locking plate and 4 locking screws. The bone defect was subsequently either left empty or filled with a bone substitute (syngenic bone graft or coralline scaffold). Bone healing was monitored noninvasively using radiography and in vivo micro-computed-tomography and was subsequently assessed by ex vivo micro-computed-tomography and undecalcified histology after animal sacrifice, 10 weeks postoperatively. The recovery of all mice was excellent, a full-weight-bearing was observed within one day following the surgical procedure. Furthermore, stable bone fixation and consistent fixation of the implanted materials were achieved in all animals tested throughout the study. When the bone defects were left empty, non-union was consistently obtained. In contrast, when the bone defects were filled with syngenic bone grafts, bone union was always observed. When the bone defects were filled with coralline scaffolds, newly-formed bone was observed in the interface between bone resection edges and the scaffold, as well as within a short distance within the scaffold. 
The present model describes a reproducible critical-size femoral defect stabilized by plate osteosynthesis with low morbidity in mice. The new load-bearing segmental bone defect model could be useful for studying the underlying mechanisms in bone regeneration pertinent to orthopaedic applications.

Although mouse models are invaluable tools for bone tissue engineering, models of long bone defects are sparse. This need motivated development of the present protocol which uses a locking plate with four screws and a dedicated jig to perform and stabilize a reproducible, femoral, critical-size defect with low morbidity.

在小鼠节段性股临界尺寸缺陷模型的建立接骨板稳定

The use of tissue-engineered bone constructs is an appealing strategy to overcome drawbacks of autografts for the treatment of massive bone defects. As a ...

An Intramedullary Locking Nail for Standardized Fixation of Femur Osteotomies to Analyze Normal and Defective Bone Healing in Mice

Bone healing models are essential to the development of new therapeutic strategies for clinical fracture treatment. Furthermore, mouse models are becoming more commonly used in trauma research. They offer a large number of mutant strains and antibodies for the analysis of the molecular mechanisms behind the highly differentiated process of bone healing. To control the biomechanical environment, standardized and well-characterized osteosynthesis techniques are mandatory in mice. Here, we report on the design and use of an intramedullary nail to stabilize open femur osteotomies in mice. The nail, made of medical-grade stainless steel, provides high axial and rotational stiffness. The implant further allows the creation of defined, constant osteotomy gap sizes from 0.00 mm to 2.00 mm. Intramedullary locking nail stabilization of femur osteotomies with gap sizes of 0.00 mm and 0.25 mm result in adequate bone healing through endochondral and intramembranous ossification. Stabilization of femur osteotomies with a gap size of 2.00 mm results in atrophic non-union. Thus, the intramedullary locking nail can be used in healing and non-healing models. A further advantage of the use of the nail compared to other open bone healing models is the possibility to adequately fix bone substitutes and scaffolds in order to study the process of osseous integration. A disadvantage of the use of the intramedullary nail is the more invasive surgical procedure, inherent to all open procedures compared to closed models. A further disadvantage may be the induction of some damage to the intramedullary cavity, inherent to all intramedullary stabilization techniques compared to extramedullary stabilization procedures.

This protocol describes an osteosynthesis technique using an intramedullary locking nail for standardized fixation of femur osteotomies, which can be used to analyze normal and defective bone healing in mice.

髓内锁钉股骨截骨标准化固定用于分析正常和有缺陷的骨愈合小鼠

Bone healing models are essential to the development of new therapeutic strategies for clinical fracture treatment. Furthermore, mouse models are becoming ...

A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an increased use of mouse models in orthopedic research was noted, most probably because mouse models offer a large number of genetically-modified strains and special antibodies for the analysis of molecular mechanisms of fracture healing. To control the biomechanical conditions, well-characterized osteosynthesis techniques are mandatory, also in mice. Here, we report on the design and use of a closed bone healing model to stabilize femur fractures in mice. The intramedullary screw, made of medical-grade stainless steel, provides through fracture compression an axial and rotational stability compared to the mostly used simple intramedullary pins, which show a complete lack of axial and rotational stability. The stability achieved by the intramedullary screw allows the analysis of endochondral healing. A large amount of callus tissue, received after stabilization with the screw, offers ideal conditions to harvest tissue for biochemical and molecular analyses. A further advantage of the use of the screw is the fact that the screw can be inserted into the femur with a minimally invasive technique without inducing damage to the soft tissue. In conclusion, the screw is a unique implant that can ideally be used in closed fracture healing models offering standardized biomechanical conditions.

This protocol describes a minimally invasive osteosynthesis technique using an intramedullary screw for standardized stabilization of femur fractures, which can be used to analyze endochondral bone healing in mice.

标准化生物力学条件下小鼠软骨骨折愈合的微创模型分析

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an ...

Treatment of Facial Deformities using 3D Planning and Printing of Patient-Specific Implants

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve better results, even in the less experienced hand, or continue without it. As technology develops and becomes more user-friendly, we believe it is time to allow the surgeon the option to plan his/her operations and create his/her own patient-specific surgical guides and fixation plates allowing him full control over the process. We present here a protocol for 3D planning of the operation followed by 3D planning and printing of surgical guides and patient-specific fixation implants. During this process we use two commercial computer-assisted design (CAD) software. We also use a fused deposition&#160;modeling printer for the surgical guides and a selective laser sintering printer for the titanium patient-specific fixation implants. The process includes computed tomography (CT) imaging acquisition, 3D segmentation of the skull and facial bones from the CT, 3D planning of the operations, 3D planning of patient-specific fixation implant according to the final position of the bones, 3D planning of surgical guides for performing an accurate osteotomy and preparing the bone for the fixation plates, and 3D printing of the surgical guides and the patient-specific fixation plates. The advantages of the method include full control over the surgery, planned osteotomies and fixation plates, significant reduction in price, reduction in operation duration, superior performance and highly accurate results. Limitations include the need to master the CAD programs.

As technology develops and becomes more user-friendly, planning of operations and patient-specific surgical guides and fixation plates should be performed by the surgeon. We present a protocol for 3D planning of orthognathic skeletal movements and 3D planning and printing of patient-specific fixation plates and surgical guides.

使用患者特定植入物的 3D 规划和打印治疗面部畸形

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

胸腰椎后凸畸形患者改良后椎柱切除术

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

Combination of Anatomical Plates and Rotator Cuff Reinforcement for Minimally Invasive Treatment of Greater Tuberosity Fractures of the Humerus

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

Here, we present a protocol to utilize anatomical plates alongside rotator cuff reinforcement in a minimally invasive surgery to efficiently treat humerus greater tuberosity fractures, promising quicker healing and improved stability.

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. ...

Arthroscopic Repair of Medial Meniscus Posterior Root Tear with Adjustable Titanium Plate Fixation

Medial meniscus injury is one of the most prevalent knee disorders, with posterior root tears occurring in approximately 10% to 21% of affected individuals. A posterior root tear disrupts the meniscus's continuous annular structure, compromising its ability to absorb pressure and protect the knee's articular cartilage. If left untreated, this can result in increased stress on the cartilage, leading to conditions such as varus deformity and accelerated joint degeneration. Partial removal (resection) of the medial meniscus further exacerbates these issues, often leading to quicker joint deterioration. Repairing medial meniscus posterior root tears (MMPRTs) plays a crucial role in restoring the meniscus's structural integrity and improving knee biomechanics. Studies have shown that compared to partial medial meniscectomy or conservative treatments, repairing MMPRTs enhances clinical outcomes and significantly delays the onset of arthritis. This article details a surgical procedure that uses a single-suture, double-loop, adjustable titanium plate fixation technique under arthroscopy for effective MMPRT repair.

This article describes a surgical approach to repairing a medial meniscus posterior root tear (MMPRT) using a single-suture, double-loop, adjustable titanium plate internal fixation under arthroscopy.

Medial meniscus injury is one of the most prevalent knee disorders, with posterior root tears occurring in approximately 10% to 21% of affected ...

<meta charset="utf8"></head><body>胸腰椎爆裂性骨折矢状面调整螺钉系统技术

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the indication for surgical treatment of neurologically intact TL fractures remains under debate, studies have demonstrated that posttraumatic malalignment may lead to a deterioration in the patient&#39;s quality of life. For burst fractures with malalignment or fragments in the spinal canal, a reduction technique using ligamentotaxis is commonly used to improve long-term outcomes.
The sagittal adjusting screw (SAS) system is a monoaxial screw system with a fixed head and concave sliding saddle that allows lordotic sliding of the rod in the sagittal plane after screw insertion. SAS also has a percutaneous option and has been used for TL spine fractures. Notably, the SAS only allows motion on the sagittal plane, allowing both secure fixation and angular reduction. The SAS has certain advantages over the conventional Schanz screw system or normal mono-/multiaxial pedicle screws for TL spine fracture treatment. In addition, specialized trauma reduction devices are available for the SAS system. In this video protocol, we discuss the indication for the SAS system in TL burst fracture and describe a technique of TL burst fracture reduction and fixation using the SAS system. Additionally, we describe our recent case series with radiological evaluation, including regional kyphotic angle and percent loss of anterior vertebral body height, to evaluate the newly introduced trauma reduction device.

<meta charset="utf8"></head><body>使用矢状对位螺钉和创伤复位装置对胸腰椎爆裂性骨折进行微创治疗

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.