Learning From Failures in Orthopedic Trauma E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 487

Veröffentlichungsjahr: 2019

Beschreibung

Numerous advances in basic research, surgical techniques, practice, and patient care have revolutionized surgery over the last 60 years and made the field with its many subspecialties more diverse but also more complex.

The surgical profession places high demands on surgeons who must often make the right split-second decisions. This can easily lead to misjudgments or mistakes.

Learning From Failures in Orthopedic Trauma—Key Points for Success is the first book of its kind to give surgeons the opportunity to learn from failures without making them themselves.

Based on the Spanish book Errores en la Osteosíntesis by Rafael Orozco Delclós, this publication offers real case examples that have been collected over the past 25 years. It is an essential and valuable resource as it specifically examines the reasons and responses to surgical error in real cases from different anatomical regions of the body, thus helping surgeons avoid the most frequent errors in osteosynthesis.

The collection of more than 70 cases will help surgeons recognize and avoid common failures, start reflecting in action, present failures as positive learning opportunities, and bring that knowledge into their daily practice.

The book is divided into 9 sections that analyze different types of failures. Key features are:

• Analysis of failures to help surgeons avoid making mistakes that lead to those errors
• More than 20 detailed and illustrative case-based chapters that analyze failures and offer tips to successfully prevent those mistakes
• More than 1,100 x-rays, clinical images, and illustrations

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

Miquel Videla Cés, J Miquel Sales Pérez, Joan Girós Torres, Roberto Rivero Sosa

Learning From Failures in Orthopedic Trauma

Key Points for Success

More than 1,100 high-quality x-rays, clinical photographs, and illustrations

Library of Congress Cataloging-in-Publication Data is available from the publisher.

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Great care has been taken to maintain the accuracy of the information contained in this publication. However, the publisher, and/or the distributor, and/or the editors, and/or the authors cannot be held responsible for errors or any consequences arising from the use of the information contained in this publication. Contributions published under the name of individual authors are statements and opinions solely of said authors and not of the publisher, and/or the distributor, and/or the AO Group.

The products, procedures, and therapies described in this work are hazardous and are therefore only to be applied by certified and trained medical professionals in environments specially designed for such procedures. No suggested test or procedure should be carried out unless, in the user’s professional judgment, its risk is justified. Whoever applies products, procedures, and therapies shown or described in this work will do this at their own risk. Because of rapid advances in the medical sciences, AO recommends that independent verification of diagnosis, therapies, drugs, dosages, and operation methods should be made before any action is taken.

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Restrictions on use: The rightful owner of an authorized copy of this work may use it for educational and research purposes only. Single images or illustrations may be copied for research or educational purposes only. The images or illustrations may not be altered in any way and need to carry the following statement of origin “Copyright by AO Foundation, Switzerland”.

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Copyright © 2020 by AO Foundation, Clavadelerstrasse 8, 7270 Davos Platz, Switzerland

Distribution by Georg Thieme Verlag, Rüdigerstrasse 14, 70469 Stuttgart, Germany, and Thieme New York, 333 Seventh Avenue, New York, NY 10001, USA

1 2 3 4 5 6

ISBN: 978-3-13-243456-1

e-ISBN: 978-3-13-243457-8

Foreword

Nikolaus L Renner, Dr med

Head of the Department of Traumatology

Cantonal Hospital Aarau

Tellstrasse 25

5001 Aarau

Switzerland

The success of the AO is attributed, among other things, to the classical four pillars instrumentation (ie, development of new implants and instruments for their application as well as for fracture reduction), research, education, and documentation. Pure documentation, however, is useless if the results are not thoroughly analyzed and discussed and if the ensuing discussion does not lead to recommendations for actual changes in the treatment of future patients.

When the AO was founded by a group of 13 Swiss surgeons, they named their association Arbeitsgemeinschaft für Osteosynthesefragen, which was translated as Association for the Study of Internal Fixation (ASIF), that has evolved into a tight-knit community fostering a special AO spirit which was noticed by outsiders right from the beginning. In a quite simplistic way this is also called today the “family spirit” of the AO Foundation, which is much too trivial, though. Surgeons are quite often “alpha individuals” and tend to be loners. To create an environment that allows to admit failures and to discuss them at eye level amongst peers was 60 years ago unthinkable and as disruptive as the revolutionary treatment that was propagated by the group. Yet, it was at least as important for the success of the AO as the classical four pillars. From this perspective, this book is closing a gap since it mirrors a tradition that has been living on in the AO from its beginning but has never before been put down in writing in such a comprehensive way.

Learning from failures appears to be natural and easy. In practice, though, when an operation does not lead to the desired outcome, the main reason for the failure is not always obvious. Quite often there are different factors contributing to the failure and it is thus the editors’ merit to provide categories according to which failures can be classified. This is a very helpful starting point for the analysis. If the reader browses only through the table of contents, however, she or he will completely miss the pearls. The real benefit for the reader comes by carefully reading through every illustrative case in each chapter which was diligently selected and analyzed by the authors. Although the failure may be often quite obvious for the more experienced surgeon, he or she will still learn and gain valuable insights from the carefully documented solutions.

Failures can never be completely avoided. First and foremost they have an impact on our patients’ lives but are always also a humbling experience for the surgeon. The editors and authors have to be complimented on addressing this sensitive topic and on breaking it up into easily digestible morsels. This book should thus help surgeons to analyze their own failures and prevent them and others from repeating the same mistakes.

Nikolaus L Renner

Preface

This book has been published thanks to the sponsorship of the AO Foundation whose interest in the topic was sparked by Rafael Orozco Delclós’ Errores en la Osteosíntesis, the first Spanish book on the topic of surgical failures, published in 1993.

Miquel Videla Cés, J Miquel Sales Pérez, Joan Girós Torres, and Roberto Rivero Sosa, the editors of Learning From Failures, were Orozco Delclós’ colleagues. They shared his interest in surgical failures, be it their own or those of other surgeons, and in learning how to prevent them. The editors have therefore collected cases, documented, and jealously guarded them for this edition.

While reviewing the failures published back in 1993, the editors found that some failures in incorrectly applying the principles of fracture fixation have persisted and are still made today, but the main difference is the evolution in implants to treat fractures. They therefore believe it is essential to insist on teaching the basic principles of fracture fixation and the fundamentals of the AO techniques.

The operative treatment of fractures, for instance, is a highly valuable but difficult therapeutic procedure and carries with it great responsibility.

Failure is human; we all make mistakes because human beings are imperfect or to quote Seneca, “errare humanum est”.

Surgeons ought to strive to learn all possible outcomes for each intervention with the resources available to them; however, they have a right to fail on the one condition that they recognize any such failure, make an effort to understand the reasons behind the failure, and then correct it with the means available to them. No surgeon has the right to repeat that failure, though. By investigating the causes of certain unsatisfactory results, surgeons can learn more about the possibilities and limitations of a technique they use. If their documentation is in order, their radiological dossier complete, and their self-criticism objective, they will quickly discover how they can improve their results [1].

We can all make mistakes by misjudging criteria and technique. Patients understand that surgeons and doctors in general are no gods but just human beings. They expect the surgeon to show empathy, understanding, and, above all, honesty.

Failure is always educational as long as it is fully understood and corrected. It is important to recognize failures, whether due to omission, technique, diagnosis, reasoning, or simply ignorance. “If we shut the door to all errors, truth will be shut out,” said Rabindranath Tagore.

This book is an update on the 1993 work in Spanish on the failures that can occur owing to a lack of respect for the evolution of the fundamental principles of the AO techniques and compounded by the appearance of new implants.

We apologize for those images that do not meet the highest quality standards, as they were taken at critical moments in the emergency department. We decided to include them, though, as they serve the purpose of teaching and because “a picture is worth a thousand words”.

Miquel Videla Cés, MD

J Miquel Sales Pérez, MD, PhD

Joan Girós Torres, MD, PhD

Roberto Rivero Sosa, MD

1 Müller ME. Prólogo. In: Orozco Delclós R. Errores en la Osteosíntesis, Barcelona: Masson; 1993:VII–VIII.

Acknowledgments

Learning From Failures in Orthopedic Trauma is the result of many years of reflecting on and documenting how to best treat fractures and their complications. It owes its existence to the invaluable collaboration of the true “protagonists”, namely the patients who suffered one or more failures and underwent rescue surgery until a satisfactory outcome was achieved.

When the idea for this project was conceived, it soon developed into a book project to pay homage to the work of R Orozco Delclós and his team from Barcelona in teaching about resolving mistakes and failures in internal fixation. From the very beginning, Jaime Quintero played a key role as a facilitator between the editors, the AOTrauma Education Commission, and AO Education Institute.

This special book would not have been possible without the effort, dedication, and support of an extensive list of contributors. We are very pleased to have been able to work together with such a dedicated group of authors from different backgrounds who are also AO experts.

While there have been many people involved in the project to thank, we would especially like to mention the following group and individuals:

• Members of the AOTrauma Education Commission for recognizing the value of this project as a valid teaching tool and for approving this publication.

• Urs Rüetschi who pushed us to go beyond the impact of just an image of a failure, encouraging us to analyze the failure more in depth and look for the resolution to each problem. This was a task that at first seemed impossible to us.

• The many colleagues from around the world who provided excellent cases and images.

• Nikolaus Renner for writing the foreword to this book.

• Katalin Fekete, Project Manager for this book, for the overall planning and management of this project as well as her guidance, support, and expertise.

• Carl Lau, Manager Publishing, for providing expert advice and support throughout the production process, and Robin Greene for enabling extensive resources to prepare this publication and make it into an invaluable publication.

• Irene Contreras for her fantastic linguistic and cultural support and liaising; Marcel Erismann and Roman Kellenberger for their excellent graphic work, Amber Parkinson and Jecca Reichmuth for their invaluable editorial advice, and the entire Publishing team for their help and professional support.

• Tom Wirth at nougat GmbH for the graphic design and aesthetic aspects of the book which aids the audience in reading and understanding the content.

• Our hospital colleagues (physicians and other staff) for their unconditional daily support, for their understanding and help in facilitating the reflective discussions and enforcing the teaching character of the cases presented in this book.

• And last but not least, our families for their loving support and unwavering faith and encouragement throughout this project. To produce and publish the book Learning From Failures in Orthopedic Trauma, we spent much time away from our families and without their understanding this book would not have been possible.

Miquel Videla Cés, MD

J Miquel Sales Pérez, MD PhD

Roberto Rivero Sosa, MD

Joan Girós Torres, MD PhD

Contributors

Editors

Miquel Videla Cés, MD

Clinical Professor, University of Barcelona

Head of Trauma Unit

Service of Orthopedic Surgery and Traumatology

Consorci Sanitari Integral

Hospital de Sant Joan Despí Moisès Broggi

C. Jacint Verdaguer 90

08970 Sant Joan Despí, Barcelona

Spain

Joan Girós Torres, MD, PhD

Clinical Professor, University of Barcelona

Senior Consultant, Orthopedic Surgery and Traumatology Department

Service of Orthopedic Surgery and Traumatology

Consorci Sanitari Integral

Hospital de Sant Joan Despí Moisès Broggi

C. Jacint Verdaguer 90

08970 Sant Joan Despí, Barcelona

Spain

J Miquel Sales Pérez, MD, PhD

Clinical Professor, University of Barcelona

Head of the Orthopedic Surgery and Traumatology Department

Service of Orthopedic Surgery and Traumatology

Consorci Sanitari Integral

Hospital de Sant Joan Despí Moisès Broggi

C. Jacint Verdaguer 90

08970 Sant Joan Despí, Barcelona

Spain

Roberto Rivero Sosa, MD

Consultant, Orthopedic Surgery and

Traumatology Department

Service of Orthopedic Surgery and Traumatology

Consorci Sanitari Integral

Hospital de Sant Joan Despí Moisès Broggi

C. Jacint Verdaguer 90

08970 Sant Joan Despí, Barcelona

Spain

Authors

Terry S Axelrod, MD, MSc, FRCSC

Professor, Division of Orthopaedics

Department of Surgery

Sunnybrook Health Sciences Centre

University of Toronto

Room MG 371

2075 Bayview Ave.

Toronto, ON M4N 3M5

Canada

Reto Babst, Prof Dr med

Vorsteher Department Chirurgie

Chefarzt Unfallchirurgie

Klinik Orthopädie und Unfallchirurgie

Luzerner Kantonsspital

6000 Lucerne 16

Switzerland

Suthorn Bavonratanavech, MD

Chief of Orthopedic and Trauma Network, BDMS.

Senior Director of Bangkok Orthopedic Center

Bangkok Medical Center

2 Soi Soonvijai 7

New Petchaburi Rd.

Bangkok, 10310

Thailand

Christopher A Becker, Dr med

Ludwig Maximilians University Munich

Department for General, Trauma- & Reconstructive Surgery

Marchioninistrasse 15

81377 Munich

Germany

Frank J P Beeres, Dr med, PhD

Leitender Arzt, Klinik Orthopädie und Unfallchirurgie

Luzerner Kantonsspital Luzern

Spitalstrasse

6000 Luzern 16

Switzerland

Jordi Bertrán Padrós, MD, PhD

Trauma and Orthopaedic Surgeon

Unión de Mutuas

Josep Tarradellas 110

08029 Barcelona

Spain

Jaroslaw Brudnicki, MD, PhD

Senior Assistant

Department of General Surgery Orthopaedic and Politrauma

University Hospital of Jagiellonian University Cracow

Szpital Uniwersytecki

ul. Mikołaja Kopernika 36

31-501 Kraków

Poland

Arancha Capel Agundez, MD

Trauma Unit

Doce de Octubre

University Hospital

Av. Andalucía s/n

28045 Madrid

Spain

Matej Cimerman, MD

Professor, Director of Traumatology

University Clinical Centre Ljubljana

Zaloška 7

1000 Ljubljana

Slovenia

Peter A Cole, MD

Professor

University of Minnesota

Chairman of Orthopedic SurgeryRegions Hospital

Department of Orthopaedic Surgery

Regions Hospital

640 Jackson Street

Mail Stop 11503L

St. Paul, MN 55101

USA

Anthony J Dugarte, MD

389 E270th St

Euclid, OH 44132

USA

Christian Kammerlander, PD Dr med

Vice Director

Ludwig Maximilians University Munich

Department for General, Trauma- & Reconstructive Surgery

Marchioninistrasse 15

81377 Munich

Germany

Anze Kristan, MD, PhD

University Medical Centre Ljubljana

Zaloška cesta 7

1525 Ljubljana

Slovenia

Björn-Christian Link, Dr med

Leitender Arzt

Klinik für Orthopädie und Unfallchirurgie

Luzerner Kantonsspital Luzern

Spitalstrasse

6000 Lucerne 16

Switzerland

José Juan Mendoza Vera, MD

Servicio de Traumatologíade Fremap Barcelona

Carrer dels Madrazo 8-10

08006 Barcelona

Spain

Josep M Muñoz-Vives, MD

Consultant Orthopaedic Trauma Surgeon

Fundació Althaia

C/ Dr. Joan Soler, 1-3

08243 Manresa, Barcelona

Spain

Rodrigo Pesántez, MD

Professor

Avenida 9# 116-20

Bogotá

Colombia

Jaime Quintero, MD

Assistant Professor

Hospital Universitario Clinica San Rafael

Ortopedia y Traumatologia

Carrera 8 No.17-45 Sur

Bogotá

Colombia

Pol Maria Rommens, Dr med, Dr h.c.

Professor, Director Department of Orthopaedics and Traumatology

University Medical Center

Johannes Gutenberg-University

Langenbeckstrasse 1

55131 Mainz

Germany

Bianka Rubenbauer, Dr med

Ludwig Maximilians University Munich

Department for General, Trauma- & Reconstructive Surgery

Marchioninistrasse 15

81377 Munich

Germany

Eladio Saura-Sánchez, Dr med

Associate Professor Miguel Hernandez University

Chief of Traumatology Unit

University Hospital of Elche

Camino de la Almazara 11

03203 Elche

Spain

Francisco Saura-Sánchez, Dr med

Hip and Foot Unit

Hospital General Universitario Santa Lucia

30202 Santa Lucia, Cartagena

Spain

Mariano Saura-Sánchez, Dr Eng

Associate Professor, Mechanical Engineering

Polytechnic University of Cartagena

30202 Cartagena

Spain

Juan Carlos Serfaty Soler, MD

Head of the Department of Traumatology and Orthopedic Surgery

MC Mutual

Calle Copérnico 58

08006 Barcelona

Spain

Fabian Sommer, Dr med

Ludwig Maximilians University Munich

Department for General, Trauma- & Reconstructive Surgery

Marchioninistrasse 15

81377 Munich

Germany

Matevž Tomaževič, MD

Orthopaedic trauma consultant

University Medical Center Ljubljana

Department of Traumatology

Zaloška cesta 2

1000 Ljubljana

Slovenia

In Memoriam

Abbreviations

3D

three-dimensional

ABCDE

airway, breathing, circulation, disability, exposure/examination

AP

anteroposterior

ARI

AO Research Institute

ATLS

advanced trauma life support

BMD

bone mineral density

BMI

body mass index

CT

computed tomography

DCP

dynamic compression plate

DCU

dynamic compression unit

DEXA

dual energy x-ray absorptiometry

DHS

dynamic hip screw

ETC

early total care

HLS

head of the locked screw

IM

intramedullary

IS

iliosacra

ISS

Injury Severity Score

K-wire

Kirschner wire

LAP

locking attachment plate

LC-DCP

limited-contact dynamic compression plate

LCP

locking compression plate

LFN

lateral femoral nail

LHS

locking head screw

LISS

less invasive stabilization system

LISS DF

less invasive stabilization system-distal femur

MIPO

minimally invasive plate osteosynthesis

NPWD

negative-pressure wound dressing

NPWT

negative-pressure wound therapy, also called vacuum-assisted wound closure (VAC)

PC-Fix

point contact fixator

PFN

proximal femoral nail

PFNA

proximal femoral nail antirotation

PHILOS

proximal humerus internal locked system

PMMA

polymethylmethacrylate

UTN

unreamed tibial nail

VAC

vacuum-assisted wound closure, see negative-pressure wound therapy (NPWT)

WHO

World Health Organization

Online AO Educational Content

Abundant online educational offerings from across AO are accessible on https://lff.aoeducation.org or through the QR codes printed on this page. Also included are the journal references linked to PubMed. Using a QR code scanner on a mobile device, readers will be taken to a microsite containing supplemental content curated by the book editors specifically for that chapter topic.

Links to supplemental AO educational content include:

• Webinars and webcasts

• Lectures

• Teaching videos

• AO/OTA Fracture and Dislocation Classification

As the array of online AO educational resources evolves and develops, the offerings in the microsite will be reviewed and updated by the book editors. This will ensure that readers are linked to the latest in AO education.

https://lff.aoeducation.org/assets.html

Table of Contents

Foreword

Preface

Acknowledgments

Contributors

Abbreviations

Online AO Educational Content

Table of contents

Section 1—Introduction to internal fixation

1.1The evolution of internal fixation over the last 20 years

Joan Girós Torres

Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

Section 2—Breaches of AO principles

2.1General considerations on violation of AO principles

J Miquel Sales Pérez

Joan Girós Torres, Roberto Rivero Sosa, Miquel Videla Cés

2.2Osteosynthesis in unreduced fractures

Joan Girós Torres, Rodrigo Pesantez, Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

2.3Principles of stability, selection of implants, and the combination of absolute and relative stability

Reto Babst, Frank Beeres, Jaroslaw Brudnicki, Matej Cimerman, Joan Girós Torres, Björn Link, Roberto Rivero Sosa, J Miquel Sales Pérez, Matevž Tomaževič, Miquel Videla Cés

2.4Biology management (including soft-tissue management)

Jordi Bertrán, Jaroslaw Brudnicki, Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

Section 3—Implant-related issues

3.1Implant selection issues

Miquel Videla Cés

Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez

3.2Type of implant related to biomechanical principles

Joan Girós Torres, Christian Kammerlander, Roberto Rivero Sosa, Bianka Rubenbauer, J Miguel Sales Pérez, Fabian Sommer, Miquel Videla Cés

3.3Implant size, prebending, molding, and shape adapted to the fractured bone

Reto Babst, Frank Beeres, Joan Girós Torres, Björn Link, Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

3.4Anatomical implants: ready-to-wear versus custom-fit

Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

3.5Designs and techniques of intramedullary nailing

Suthorn Bavonratanavech, Joan Girós Torres, Josep Muñoz Vives, Roberto Rivero Sosa, Pol M Rommens, J Miquel Sales Pérez, Miquel Videla Cés

3.6Failures due to guided targeting and implant assembly

Arancha Capel Agúndez, Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

Section 4—Surgical team

4.1Determining factors for failures relating to the surgical team

J Miquel Sales Pérez

Joan Girós Torres, Roberto Rivero Sosa, Miquel Videla Cés

4.2Insufficient preparatory planning, including alternatives

Matej Cimerman, Joan Girós Torres, Anze Kristan, Roberto Rivero Sosa, Pol M Rommens, J Miquel Sales Pérez, Miquel Videla Cés

4.3Lack of anatomical knowledge

Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez, Juan Carlos Serfaty Soler, Miquel Videla Cés

4.4Insufficient asepsis protocols

Matej Cimerman, Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez, Bastian Sluga, Miquel Videla Cés

4.5Proficiency and experience

Jordi Bertrán Padrós, Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

4.6Accumulation of failures

Terry Axelrod, Suthorn Bavonratanavech, Matej Cimerman, Joan Girós Torres, Anze Kristan, Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

Section 5—Postoperative management

5.1General considerations in postoperative management of internal fixation

Roberto Rivero Sosa

Joan Girós Torres, J Miquel Sales Pérez, Miquel Videla Cés

5.2Physiotherapy

Matej Cimerman, Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez, Matevž Tomaževič, Miquel Videla Cés

5.3Implant removal

Peter A Cole, Anthony J Dugarte, Joan Girós Torres, Jose Mendoza-Vera, Roberto Rivero Sosa, J Miquel Sales Pérez, Eladio Saura-Sanchez, Francisco Saura-Sanchez, Mariano Saura-Sanchez, Miquel Videla Cés

Section 6—Patient compliance

6.1Failures unrelated to the healthcare team but related to patient compliance

Roberto Rivero Sosa

Reto Babst, Christopher A Becker, Frank Beeres, Joan Girós Torres, Christian Kammerlander, Björn Link, Bianka Rubenbauer, J Miquel Sales Pérez, Miquel Videla Cés

Section 7—Failure recognition and timing

7.1Early recognition of failures

Joan Girós Torres

Jordi Bertrán Padrós, Roberto Rivero Sosa, J Miquel Sales Pérez, Juan Carlos Serfaty Soler, Miquel Videla Cés

Section 8—The learning circle

8.1The learning circle: tips and tricks to minimize failures

Jaime Quintero

Section 9—Bizarre failures

9.1Difficult to classify

Miquel Videla Cés

Joan Girós Torres, Roberto Rivero Sosa, J Miquel Sales Pérez

Appendix

Glossary

AO/OTA Fracture and Dislocation Classification

Gustilo-Anderson Classification of Open Fractures

Section 1

Introduction to internal fixation

Section 1

Introduction to internal fixation

1.1 The evolution of internal fixation over the last 20 years

Joan Girós Torres

Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

Every day we know more and we understand less.

Albert Einstein

An elderly professor at medical school who taught the history of medicine used to say that the breakneck speed at which modern medicine was evolving meant that any surgical technique would become obsolete within 30 years. This does not appear to have happened with the techniques proposed by the founding fathers of the AO: Maurice E Müller, Robert Schneider, Hans Willenegger, Martin Allgöwer, Walter Bandi, et al (Fig 1.1-1). An exhaustive review of documented and clinically controlled cases has shown that current techniques following their foundational principles have evolved thanks to a better knowledge of the biological response of bone to the materials used for fracture fixation.

Even today, anatomy, stability, biology, and mobilization are still the four fundamental AO principles. They evolved in response to findings from different scientific investigations and clinical observations. The progressive changes in surgical approaches and methods have been based on clinical and laboratory research and resulted in new discoveries that have led to the development of new implants and instruments. The strategy for fracture fixation is dynamic and follows the principles, methods, and techniques of internal fixation.

The progressive evolution of the implants available today is the result of a long-standing collaboration between the AO Research Institute (ARI) and Synthes.

The less invasive stabilization system (LISS) was developed from the point contact fixator (PC-Fix) system while the locking compression plate (LCP) system and anatomically preshaped implants combine the old versions of limited-contact dynamic compression plate (LC-DCP), PC-Fix, and LISS. The “fusion” of the holes of the LC-DCP and LISS plates into a combination hole (combi-hole), developed by Wagner and Frigg [Frigg, 2001; Gautier et al, 2003], allows the use of locking head screws (LHS) (internal fixator) or alternatively, the conventional cortex screws (with dynamic compression).

Fig 1.1-1    Founders of the AO (from left to right):

Maurice E Müller, Martin Allgöwer, Walter Bandi, Robert Schneider, Hans Willenegger.

Co-founders of the AO:

Ernst Baumann, Fritz Brussatis, August Guggenbühl, Willy Hunziker, Walter Ott, René Patry, Walter Schär, and Walter Stähli.

From the biomechanical point of view, the LCP is used as an internal fixator that provides angular stability and does not require perfect premolding of the LCP or pressure on the cortical bone. Biologically, since no close contact or pressure on the cortical bone exists, the periosteal circulation will be less compromised.

The LCP system can be used as:

• A conventional plate using only the dynamic compression unit (DCU) in the space for conventional screws.

• A purely internal fixator only using the space for blocked screws, ie, LHS without dynamic compression.

• A combination of the two previous principles in case of limited indications, which requires strict and meticulous planning. Correct indications are segmental fractures with:

– A simple fracture pattern that would benefit from stabilization by interfragmentary compression techniques and absolute stability criteria.

– A multifragmentary fracture pattern that should be treated by applying a splint to stabilize the fracture lines, using relative stability criteria and with the implant acting as an internal fixator

Both situations are treated with the same implant but have a different function and stability criteria.

The basic AO principles (Fig 1.1-2) of fracture fixation established by the founders had the main goal of restoring form and function:

Fig 1.1-2    The AO principles contributing to successful fracture healing are of equal importance without any order of preference.

• Reduction and fixation of the fracture to restore its anatomical relationships, ie, restoration of the form.

• Stabilization by fixation as required by the characteristics of the fracture and the injury.

• Preservation of bone and soft-tissue vascularization through careful manipulation and gentle reduction techniques, ie, respect for the biology requiring a high level of care and technical ability as well as science.

• Early and safe mobilization of both the injured part and the patient, ie, restoration of function.

These principles still embody the AO philosophy. However, new implants now allow surgeons to reduce the surgical approaches and damage to surrounding tissues. The reduced surgical approaches and minimally invasive techniques emphasize the biological needs of the different bone segments, the preservation of the fracture hematoma, and the adjacent soft tissues, all important aspects for fracture healing. The new anatomical implants used as internal fixators or conventional implants make it necessary for us to reformulate or be more explicit in the evolution of the AO principles:

Reduction and fixation

Reduction and fixation of the fracture to restore anatomical relationships. Direct or indirect atraumatic reduction and fixation techniques are obligatory. The fracture of a bone results in the loss of its rigidity. This can be temporarily reestablished by osteosynthesis while union definitively restores it. Anatomical reduction is:

• Essential in intraarticular fractures to restore joint congruity, reconstruct the anatomy, expand the compression surface, and obtain a maximum friction coefficient, which are all factors favoring stability.

• Essential in metaphyseal or diaphyseal fractures of a simple transverse or oblique type, if interfragmentary compression techniques are used with absolute stability criteria.

• Not essential in multifragmentary fractures of long bones. Instead axial alignment should be obtained while respecting the length and degree of torsion between diaphysis and metaphysis, ie, functional reduction.

Stabilization by fixation

Fracture fixation providing absolute or relative stability depends on the personality of the fracture, the type of patient, and what the injury requires.

• Compression method principle of absolute stability:

– Mandatory in joint fractures, achieved through interfragmentary compression.

– May be indicated in simple transverse or oblique diaphyseal and metaphyseal fractures with little soft-tissue compromise, optimal bone quality, with the aim that the bone contributes to its own stability.

– Biomechanically, the loading forces during activity pass mainly through the bone and to the least possible degree through the implant. Absolute stability is the absence of micromovement between the bone fragments which has a positive effect on vascularization because the blood vessels can cross the fracture site more easily and promote primary fracture healing.

• Internal fixator method or intramedullary nailing follow the principle of relative stability:

– Most of diaphyseal fractures with a multifragmentary pattern must be treated with methods with elastic fixation that provide relative stability and secondary fracture healing.

– Fixation with relative stability aims to maintain the reduction and still keep the mechanical stimulation for fracture repair by callus formation.

– With relative stability, the bone fragments displace in relation to each other when physiological load is applied across the fracture. Displacement increases with the applied load and decreases with the rigidity of the fixation device.

– Generally, a fixation method is considered flexible if it allows controlled interfragmentary movement under physiological load.

– Locked intramedullary nailing is generally accepted as the standard treatment for diaphyseal long-bone fractures. The limitations of nailing are related to the fracture type, location, and pattern.

– Another method that provides relative stability is the internal fixation with extramedullary bridging plates with a splint protection function.

Preservation of bone and soft-tissue vascularization

Preservation of blood supply to the bone and the surrounding soft tissues. This is achieved through careful manipulation and gentle direct or indirect reduction techniques, using appropriate surgical approaches. Whenever possible, indirect reduction will reduce the surgical trauma. Iatrogenic osteonecrosis, on the other hand, is the result of careless surgical access and rough handling of bone fragments.

With the development and increased use of minimally invasive surgical methods for the fixation of fractures, it is paramount that surgeons are equipped with anatomically preshaped implants and excellent anatomical knowledge.

Early and safe mobilization

Early, safe, and painless active mobilization of the injured part and of the patient is critical. Restoring function is key: “Life is movement and movement is life”.

Evolution is an ongoing process. Methods, techniques, and new implants will undergo further development to help facilitate our work as surgeons. However, the general basic principles of the AO technique will remain.

Key points to remember

• “A good osteosynthesis is not the one performed with original implants but the one that follows the AO principles,” said Hans Willenegger [Frigg, 2001].

• Anatomy, stability, biology, and mobilization are still the fundamental AO principles. They are all equally important and are not listed in order of preference.

• Surgeons must never forget that a fracture is a soft-tissue injury with a broken bone.

• “Improved surgical techniques may be more important than new implants and prosthesis,” said R.K. Marti in his lecture [Gautier et al, 2003; Marti, 2008].

References and suggested reading

Bandi W, Müller ME, Allgöwer M, et al.Technique of Internal Fixation of Fractures. Berlin Heidelberg: Springer-Verlag; 1965.

Buckley R, Moran C, Apivatthakakul T.AO Principles of Fracture Management. 3rd ed. Stuttgart New York: Thieme; 2017.

Frigg R. Locking Compression Plate (LCP). An osteosynthesis plate based on the Dynamic Compression Plate and the Point Contact Fixator (PC-Fix). Injury. 2001 Sep;32 Suppl 2:63–66.

Frigg R. Development of the Locking Compression Plate. Injury. 2003 Nov;34 Suppl 2:B6–10.

Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury. 2003 Nov;34 Suppl 2:B63–76.

Leunig M, Hertel R, Siebenrock KA, et al. The evolution of indirect reduction techniques for the treatment of fractures. Clin Orthop Relat Res. 2000 Jun(375):7–14.

Marti RK. Osteotomies for posttraumatic deformities. Lecture presented at: Meeting commemorating AO Spain’s 37th anniversary and the AO’s 50th; October 2008; Segovia, Spain.

Mast J, Jakob RP, Ganz R.Planning and reduction technique in fracture surgery. Berlin: Springer-Verlag; 1989.

Müller M, Allgöwer M, Schneider R, et al.Manual of Internal Fixation. 2nd ed. Berlin Heidelberg New York: Springer Verlag; 1979.

Müller ME, Allgöwer M, Schneider R, et al. Manual of Internal Fixation: techniques recommended by the AO-ASIF Group. 3rd ed. Berlin Heidelberg: Springer-Verlag; 1991.

Orozco Delclós R.Errores en la Osteosíntesis. Barcelona: Masson; 1993. Spanish.

Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002 Nov;84(8):1093–1110.

Perren SM. Backgrounds of the technology of internal fixators. Injury. 2003 Nov;34 Suppl 2:B1–3.

Rozbruch SR, Muller U, Gautier E, et al. The evolution of femoral shaft plating technique. Clin Orthop Relat Res. 1998 Sep (354):195–208.

Rüedi TP, Murphy WM.AO Principles of Fracture Management. 1st ed. Stuttgart New York: Thieme; 2000.

Schatzker J. Changes in the AO/ASIF principles and methods. Injury. 1995;26:B51–B56.

Sommer C. Locking Compression Plate. Injury. 2003 Nov; 34 Suppl 2:B4–5.

Wagner M. General principles for the clinical use of the LCP. Injury. 2003 Nov; 34 Suppl 2:B31–42.

Wagner M, Frigg R.Internal Fixators—Concepts and Cases Using LCP and LISS. New York: Thieme; 2006.

Willenegger H. Principios y filosofia. AO bases teóricas y principios prácticos des tratamiento quirúrgico de las fracturas [Principles and philosophy. The AO theoretical basis and practical principles of surgical fracture treatment]. Lecture presented at: AO conference; 1981; Spain.

Section 2

Breaches of AO principles

Section 2

Breaches of AO principles

2.1 General considerations on violation of AO principles

J Miquel Sales Pérez

Joan Girós Torres, Roberto Rivero Sosa, Miquel Videla Cés

Why things are as they are and not otherwise?

Evangelista Torricelli

A fracture is usually a combination of bone and soft-tissue injuries, and the fundamental objective of fracture treatment is to completely restore the function of the injured limb.

Before widespread acceptance of surgical fracture treatment, the so-called fracture disease, ie, chronic complex regional pain syndrome, caused by the combination of prolonged immobilization, circulatory disorders, inflammation, and pain could be commonly observed during nonoperative treatment. The absence of weight bearing or physiological stimulus led to joint stiffness, muscle and skin atrophy, and circulatory dysfunction. Nonoperative treatment of fractures also led to a higher number of unions with malpositioned fragments, delayed unions, nonunions, and malunions.

The treatment of fractures has made significant progress through the development of osteosynthesis techniques. Osteosynthesis has fulfilled its objectives when there is no need for external fixation, and early, active, and pain-free mobilization of the muscles and joints is possible. This fun- damental principle of the AO and its achievement is possible through a stable, long-lasting osteosynthesis of the bone fragments during the period necessary for the union of the fracture.

The founders of the AO established, from the beginning, the goal of achieving early pain-free active mobilization after performing an anatomical reduction with stable fixation of the bone fragments while preserving their vascularization. Thus, the stabilization of the anatomical reduction, especially in joint fractures, achieves biomechanical conditions that lead to direct bone healing without callus formation, via remodeling of the Haversian canals and the blood vessels, while respecting the blood supply of bone and soft tissues to obtain early and pain-free functional restitution.

This goal of osteosynthesis was based on the mechanical principle of stability and on the biological criteria related to vascularization so as to aid uneventful bone healing. The mechanical and biological criteria are closely related, and an acceptable union cannot result if there is imbalance between them. The principles for internal fixation are still valid after decades of research and application, but they have evolved leading to a better understanding of the biological and biomechanical aspects of the injury.

At present these principles and their interrelationship (Fig 2.1-1) remain valid and they must be followed but not necessarily in a set order. The importance that was first given to the mechanical concept has been counteracted by the concepts of respect for biology and understanding stability and the way these concepts are applied to the type and site of the fracture.

Fig 2.1-1    Graphical representation of how the AO principles interrelate.

The interrelationship of the principles has implications for the expected clinical and radiographic results, although other factors, eg, infection or bearing too much weight too quickly, may affect the evolution of the fracture and the functional restoration.

The application of internal fracture fixation was a real rev- olution in fracture treatment, but it has not resolved all the problems. The presentation of complications such as delayed consolidation and pseudarthrosis did not disappear com- pletely and others such as infection appeared with significant repercussion during the evolution of cases treated with osteosynthesis. For this reason, great efforts have been made to improve the osteosynthesis procedure, minimize compli- cations, and improve the results of the treatment.

The interaction between bone and implant have led to new plate designs to avoid devitalization of soft tissue and bone through contact and pressure of the implant on the perios- teum and the bone. If the bone-implant contact is reduced, bone necrosis occurs less often. The anchoring of plates and screws with new designs allows their use in osteoporotic bone. And plates that have been premolded to fit the anatomy of the bone can be applied to fractures in specific sites. A better knowledge of fracture healing has enabled surgeons to better understand the role that soft tissue plays in healing. The use of indirect reduction, without devascularization of the bone fragments, also improves soft-tissue care.

The vascular change in the bone and in the injured soft tis- sue caused by the fracture has led to surgical changes. Min- imally invasive osteosynthesis enables preservation of the fracture hematoma which is essential for the regenerative process of fracture healing. Biology also plays a crucial role in the healing process and respecting it is vital to the healing of the fracture and soft tissues to achieve good function as early as possible.

The principles have been further developed in recent decades due to new issues that surgeons face, like the demographic shift throughout the world and the needs of a rapidly growing older population. There has generally been a large increase in the number of osteoporotic fractures in the elderly, high-energy trauma patients. Lately, surgeons have also seen an increase in the number of periimplant or periprosthetic fractures, ie, fractures that occur proximal or in relation to other osteosynthesis implants or prostheses applied previ- ously due to prior injuries or degenerative diseases.

In osteosynthesis, many factors need to be considered to obtain the expected result. We should remember that despite the indication and availability of implants, the implant is only a means of carrying out principles already described many years ago by the founding AO members. On occasion, in a single traumatic bone injury, various solutions may be offered using different implants, which is acceptable as long as the established principles are fulfilled. Ignorance or violation of the recognized principles of surgical fracture treatment is not only a cause of suboptimal results but in practical terms, a guarantee of failure of treatment. The technical expertise and prior experience of the surgeons must also be considered, which improves with each case treated or studied.

This chapter presents real examples of the violation of three of the principles mentioned: fracture reduction, osteosynthesis stability, and respect for vascularization, which also make the fourth principle of early active and pain-free mobilization impossible. The selection of the cases has sought to provide an array of the most thought-provoking educa- tional examples so that we can discuss the difficulties involved in remedying the injury and each of the AO principles.

Understanding the reason behind a failed osteosynthesis leads to reflection on which of the principle(s) has or have not been respected; on many occasions the errors are multiple or combined. The reasoning behind the causes and understanding the mechanisms behind the unexpected outcome can help avoid repeated similar failures. The solution provided and explained in each case also helps surgeons understand how to correct the problem and can help them with the planning of future cases.

The authors’ fundamental aim in presenting these cases is to reflect on and discuss why and how surgeons do what they do. This is the educational value of these cases and the revised solutions.

Key points to remember

• Osteosynthesis is the surgical procedure by which the bone fragments are stabilized using implants. The goal of osteosynthesis is to restore the anatomy of the bone, to achieve sufficient and lasting stability between the bone fragments while the healing callus is formed, allowing immediate function without pain.

• Osteosynthesis is based on the interrelationship of mechanical stability and biological vascularization.

• Violation of the principles of fracture reduction, stability of osteosynthesis, and not respecting vascularization makes pain-free mobilization impossible:

– Ignorance of or noncompliance with the principles of osteosynthesis lead to failures of the internal fixation.

– An implant is only a means to fulfill certain functions to treat the fracture and not the end in itself.

– The main objective in the treatment of fractures is the application of the basic principles of stability while altering the vascularization as little as possible.

References and suggested reading

Buckley R, Moran C, Apivatthakakul T.AO Principles of Fracture Management. 3rd ed. Stuttgart New York: Thieme; 2017.

Gautier E, Sommer C. Guidelines for the clinical application of the LCP. Injury. 2003 Nov;34 Suppl 2:B63–76.

Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453–458.

Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug;24(8):742–746.

Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am. 1990 Feb;72(2):299–304.

Kfuri M, Schatzker J. Revisiting the Schatzker classification of tibial plateau fractures. Injury. 2018 Dec;49(12):2252–2263.

Luo CF, Sun H, Zhang B, et al. Three-column fixation for complex tibial plateau fractures. J Orthop Trauma. 2010 Nov;24(11):683–692.

Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium — 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007 Nov–Dec;21(10 Suppl):S1–133.

Matthews SJ, Nikolaou VS, Giannoudis PV. Innovations in osteosynthesis and fracture care. Injury. 2008 Aug;39(8):827–838.

Meinberg EG, Agel J, Roberts CS, et al. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018 Jan;32 Suppl 1:S1–s170.

Miclau T, Martin RE. The evolution of modern plate osteosynthesis. Injury. 1997;28 Suppl 1:A3–6.

Müller M, Allgöwer M, Schneider R, et al.Manual of Internal Fixation. 2nd ed. Berlin Heidelberg New York: Springer Verlag; 1970.

Müller ME, Allgöwer M, Schneider R, et al.Manual of Internal Fixation: techniques recommended by the AO-ASIF Group. 3rd ed. Berlin Heidelberg: Springer-Verlag; 1991.

Müller ME, Nazarian S, Koch P, et al.Classification AO des fractures. 1: Les os longs [AO Fracture Classification. 1 Long bones]. Berlin: Springer-Verlag; 1987.

Müller ME, Nazarian S, Koch P, et al.The comprehensive classification of fractures of long bones. Berlin Heidelberg: Springer-Verlag; 1990.

Orozco Delclos R, Sales JM, Videla M.Atlas of internal fixation: fractures of long bones; classification, statistical analysis, technique, radiology. Berlin Heidelberg: Springer-Verlag; 2000.

Perren SM. Evolution of the internal fixation of long bone fractures. The scientific basis of biological internal fixation: choosing a new balance between stability and biology. J Bone Joint Surg Br. 2002 Nov;84(8):1093–1110.

Rozbruch SR, Muller U, Gautier E, et al. The evolution of femoral shaft plating technique. Clin Orthop Relat Res. 1998 Sep(354):195–208.

Sales JM, Videla M, Forcada P, et al.Atlas de Osteosintesis. Fracturas de los huesos largos. Vias de acceso quirúrgico. 2nd ed. Barcelona: Elsevier Masson; 2009.

Schatzker J, McBroom R, Bruce D. The tibial plateau fracture. The Toronto experience 1968–1975. Clin Orthop Relat Res. 1979 Jan-Feb(138):94–104.

Schatzker J, Tile M.The rationale of operative fracture care. 3rd ed. Berlin New York Tokyo: Springer; 1987.

Séquin R, Texhammar R.AO/ASIF Instrumentation. Manual of Use and Care. Berlin Heidelberg New York: Springer-Verlag; 1981.

Tscherne H, Oestern HJ. [A new classification of soft-tissue damage in open and closed fractures (author’s transl)]. Unfallheilkunde. 1982 Mar;85(3):111–115. German.

2.2 Osteosynthesis in unreduced fractures

Joan Girós Torres, Rodrigo Pesantez, Roberto Rivero Sosa, J Miquel Sales Pérez, Miquel Videla Cés

The last thing you know is where to start.

Isaac Newton

The displacement of a fracture can be considered a conse- quence of the action of deforming forces due to the trauma caused by the bone injury. The reduction of a fracture aims to return the bone to its original anatomical shape and regain its normal functions. Osteosynthesis counteracts the deforming forces on the fracture like the muscular action between agonist and antagonist muscles (eg, biceps and triceps), for instance. The reduction of the fracture creates stability by load transmission on the bone-implant interface until consolidation of the fracture.

The principle of anatomical fracture reduction has evolved in recent years into the concept of functional reduction, as it has become clear that not all fractures require a strictly anatomical reduction to achieve adequate functional out- come for the patient.

There is consensus that fractures occurring at an articular site should be differentiated from those in a diaphyseal site due to their different mechanical needs. This is logical because in articular fractures an exact correction of the articular regions is needed to achieve good functional outcome. Any alteration to the articular surfaces will cause joint incongruity resulting in a decreased range of motion and subsequent sequelae of an arthritic degenerative type, especially in those articulations most subjected to load bearing. The anatomical reduction of the articular surface represents the essential condition for the complete functional restitution of a fractured joint.

Thus, the concept of anatomical reduction and interfrag- mentary compression and osteosynthesis providing absolute stability to the fracture site can still be found today in the treatment of articular fractures. In this case, joint congruity is achieved and the surfaces of the fracture site have the maximum contact possible so when compressed there exists maximum friction between the fragments, with the bone achieving its own stability. Compression between fragments is the main cause of stability of a reduced fracture. Inter-fragmentary compression can also be obtained by using traction screws or with anatomically preshaped or molded plates placed to apply compression, for instance. Biome-chanically, it is ideal if the load-bearing forces pass mainly through the bone and only to the least possible degree through the implant. The anatomical reduction creates stability and the osteosynthesis reinforces it by compressing the site and neutralizing it or guiding the forces. It permits optimal functioning with early mobilization that favors joint cartilage regeneration and avoids an articular incon- gruity that would otherwise lead to evolution towards an arthritic process. Interfragmentary compression neither influences the speed of callus formation nor causes resorption or bone necrosis, but it does favor stability and revascularization of the fracture site. Anatomical reduction is essential for normal joint function in articular fractures. The consolidation of a joint fracture, with anatomical re- duction and compression, occurs directly by first intention, without formation of bone callus visible radiographically. If a bone callus appears in the control x-rays, this denotes a loss of stability.

Moreover, articular fractures with impaction are not reduced by closed methods and articular depressions are not filled with fibrocartilage; they should be filled with autogenous bone graft.

If the articular fracture is not reduced anatomically, it tends towards instability. The pressures exercised by the load are not distributed physiologically, but concentrate in other areas and the implant must absorb a large part of the load bearing, possibly failing due to fatigue. The formation of the healing callus will be delayed or it will not form and will evolve towards pseudoarthrosis. If the surgeon does not restore the anatomy, the articular function will be compro- mised and will progress towards definitive sequelae.

In diaphyseal fractures, the function requires a correct align- ment of the bone and limb, and a recovery of the bone length and its rotation to achieve correct limb function. Metaphyseal and diaphyseal axial displacements must be reduced to prevent articular overloading. This reduction in diaphyseal fractures, understood as a functional reduction, is not rec- ommended so as to avoid unnecessary surgical access that may devascularize the bone fragments and affect the vascularization of the soft tissues necessary for fracture healing.

In multifragmentary diaphyseal fractures with various intermediate fragments, manipulation of the fragments to achieve better reduction provides no benefits radiologically, if alignment, rotation, and length of the bone are respected. Consolidation of the fragments will benefit from controlled movement at the fracture site through periosteal and end-osteal consolidation and will have a radiographically visible callus. It is therefore advisable not to approach the site and to respect the fracture hematoma. In cases of intramedullary nailing with comminution at the fracture site, it will be necessary to stabilize the reduction by locking the nail to avoid collapse and consequent loss of nail length. If plates are used to treat diaphyseal fractures with comminution at the fracture site, they must be applied, wherever possible, through approaches that respect the fracture hematoma and act by bridging the site to also achieve the consolidation favored by the hematoma.

In simple diaphyseal fractures, there is a greater indication for a more closed approach to the site, with osteosynthesis performed using internal fixation such as with the intra- medullary nail which acts by bearing the load in a stable way. If contact of the bone fragments exists, greater stability and thus improved transmission of load bearing will result until the fracture’s consolidation. In simple factures where plate osteosynthesis through minimal surgical approaches with preservation of vascularization is considered, an osteosynthesis with absolute stability criteria may be indi- cated. In cases where the fracture occurs in areas that do not permit a stable intramedullary fixation, the osteosynthesis should be extramedullary with plates respecting the site and the soft tissues through anatomical approaches. Fracture site compression is indicated if its vascularization can be respected, but it requires greater technical expertise. Diaphyseal radial and ulnar fractures constitute an excep- tion to the foregoing concept, as they are considered articular fractures and require anatomical reduction to reestablish the combined movement between both bones in pronation and supination maneuvers and in the mobility of the prox- imal and distal joint regions to recover forearm functionality without sequelae.

CASE 1

Case description

A 28-year-old woman who was hit by a car sustained a contusion in her left knee and presented with an isolated tibial plateau fracture. The fracture was stabilized by external fixation on the day of the accident (AO/OTA 41C3.1) (Fig 2.2-1).

A computed tomographic scan was performed along with a three-dimensional reconstruction to obtain additional images and assess the fracture (Fig 2.2-2).

Subsequently, surgical intervention was indicated and internal fixation with plate and screws performed to obtain stability. The immediate postoperative x-rays showed a tibial plateau fracture that was not reduced but stabilized with two proximal cannulated screws and a proximal plate over the proximal tibia (Fig 2.2-3).

Eight months later, the patient presented with a varus angulated pseudarthrosis of the proximal tibia and a clinical reduction in mobility with a range of -20–80° (Fig 2.2-4).

Fig 2.2-1a–b    Initial x-rays after external fixation show the tibial plateau fracture.

Fig 2.2-2a–i    Preoperative computed tomographic (CT) scans of the tibial plateau fracture.

a–bAP views.

c–dLateral views.

e–fCoronal views.

g–iThree-dimensional reconstruction in AP and lateral views.

Fig 2.2-3a–c    X-rays taken immediately postoperatively following internal fixation. They show the lack of reduction of the fracture and the osteosynthesis performed during the intervention.

Analysis of failure and reflection

Despite studying the fracture preoperatively, the surgeon responsible did not fully understand the fracture to be able to plan how to ap- proach and correct it. Instead she or he performed surgery to treat the fracture. After it was fixed without reduction, patient monitoring was continued; however, the surgeon failed to recognize her or his own inability to understand the principles for treatment of tibial plateau fractures until the fracture showed a lack of consolidation with varus deviation.

The surgeon should have reflected on what should have been done differently: she or he should have tried to understand the anatomy of the fracture, classify it based on the images available, and select the appropriate surgical tactic to approach, reduce, and stabilize this tibial plateau fracture adequately. Continuing without correcting the basic error, which in this case is a lack of anatomical reduction in a joint fracture fixed with osteosynthesis, can never improve the prog- nosis of an injury, and it will progress towards complications and sequelae.

Final outcome

The patient was subsequently treated with an intraarticular oste- otomy of the tibial plateau and bone substitutes to correct the defect (Fig 2.2-5). The fracture was fixed with a one-third tubular plate medially and a proximal tibial locking compression plate (Fig 2.2-6). The patient was allowed partial weight bearing with crutches according to pain tolerance from the first day and immedi- ate functional rehabilitation was initiated (Fig 2.2-7). She managed to achieve a full range of mobility and the alignment of her lower limbs was reestablished (Fig 2.2-8).

Fig 2.2-4a–e    Radiological study of the fracture at 8 months.

a–bX-rays in AP and lateral views showing a varus deviation of the proximal tibia.

c–eComputed tomographic scans presenting a varus pseudarthrosis of the proximal metaphysis of the tibia. The lateral view (e) shows the deviation of the fracture in antecurvatum.

Fig 2.2-5a–c    Intraoperative photographs of the surgical correction. With the aid of the distractor, alignment of the limb is achieved, followed by reduction of the fracture, filling of the bone defect with bone substitute, and then stabilization of the fracture site with a new osteosynthesis.

Fig 2.2-6a–c    X-rays of the reduction and stabilization taken during the refixation.

aIntraoperative x-ray obtained with the image intensifier of the reconstruction.

b–cRadiographic aspect of the reconstruction in AP and lateral views.

Fig 2.2-7a–d    Postoperative AP and lateral control x-rays during the period of partial weight bearing.

a–bX-ray checks of the joint region during the postoperative period.

c–dX-ray checks of the osteosynthesis in AP and lateral views during the postoperative period.

Fig 2.2-8a–h    Final postoperative AP and lateral clinical and x-ray controls.

a–bFinal appearance of the lower limbs in AP and lateral views. Complete extension of the joint.

c–dMobility in flexion obtained at the final follow-up.

e–fFinal control x-rays of the reconstruction and of the osteosynthesis performed.

g–hDetail of the joint region and of the proximal tibial metaphysis.

CASE 2

Case description

A 54-year-old woman suffered a ski accident and presented with a pertrochanteric fracture of the left hip (AO/OTA 31A1) (Fig 2.2-9) without other traumatic injuries.

A trochanteric nail was planned, using a hip fracture nail system that combines the principles of a compression hip screw with an intra- medullary nail. The postoperative control x-ray showed a lack of reduction at the fracture site and rotation of the proximal fragment, but the surgeon decided to trust the implant and continue with the planned fracture treatment (Fig 2.2-10).

Fig 2.2-9a–b    Preoperative x-rays showing a simple trochanteric fracture with a rare fracture pattern that indicates a high-energy trauma despite it being a simple trochanteric fracture.

Fig 2.2-10a–b    Postoperative x-rays at 2 months.

Analysis of failure and reflection

We cannot expect an implant that bears all the weight to improve the reduction of a fracture that we have not managed to achieve by either indirect or direct reduction maneuvers.

When a right femur is treated, torque maneuvers in a clockwise direc- tion of the screw situated in the femoral head cause anterior rotation and flexion of the femoral neck; the secondary displacement occurs in extension and in posterior rotation. The topographic anatomy of the proximal femur causes a rotational displacement of the head and neck of the left femur (Fig 2.2-11). In the right femur, clockwise torque causes a rotation and a subsequent extension that contribute to the impaction and reduction of the fracture [Mohan et al, 2000].

Fig 2.2-11    In the left femur, clockwise torque maneuvers of the screw situated in the femoral head cause anterior rotation and flexion of the femoral head.

Final outcome

One year after the fracture, no cut-out has taken place despite the lysis phenomena around the femoral head screw and the proximal migration at the femoral head and neck. In the fracture healing process, the still poor callus formation has stabilized the fracture. Despite a reduced quality of life, the patient is able to walk with crutches (Fig 2.2-12). Eventually, the patient will be able to walk without crutches.

“Patients heal despite the surgeon.”

Fig 2.2-12    Postoperative x-ray check at 1 year after the fracture. Although the fracture presents poor callus formation, bone resorption exists around the femoral head screw but there is no cut-out.

Case description

A 75-year-old woman presented after falling from standing height on a public road. She did not present with any other traumatic symptoms (ie, the assessment of the patient being checked for airway, breathing, circulation, disability, exposure/examination (ABCDE) following advanced trauma life support was fine). X-rays taken upon admission showed an intertrochanteric fracture of the left hip (AO/OTA 31A2) (Fig 2.2-13).

The surgeon decided on a sliding hip screw system (eg, dynamic hip screw [DHS]) with a stabilizing plate and performed the intervention with trust in the implant (Fig 2.2-14).

Three months after the intervention, the patient was allowed to bear weight and ambulate using forearm crutches; clinically, the pain was remitting (Fig 2.2-15). The control x-ray showed impaction of the fracture with the implant acting with dynamic stability driving the impact through it. The radiographic signs of consolidation had started when the fracture impacted with a certain valgus position that was beneficial to its stability.

Fig 2.2-13a–b    Preoperative x-rays in AP and axial views showing a simple intertrochanteric fracture.

Fig 2.2-14a–b    Postoperative x-rays in AP and axial views showing the unreduced fracture. Despite the lack of reduction, the surgeon decided to leave the implant in place.