Turchányi Béla Head of Department of Traumatology and Hand Surgery

Transcription

1 Kenézy Gyula Hospital Department Turchányi Béla Head of Department of Traumatology and Hand Surgery Debrecen Trauma and Hand Department

2 Ligament, bone and joint replacement. Metals and plastics in the trauma surgery. Biological osteosynthesises. 2

3 Red blood cell White blood cell bone marrow neurons bone Test-tube baby? Stem cell cartilage liver skin Facts? Legends? Present? Future? cardiac muscle 3

4 Indications of tissue replacement Injury (skin burn, tendon, nerve, bone, joint, spinal cord) Tumors (wherever, whatever) Degeneration (heart, eye lens, teeth ) Infection (liver) Congenital deficiencies (limbs ) Esthetics (silicon ) 4

5 Tissue/organ/replacement according to source Autolog (e.g.: skin right-left?, foot-hand) Homolog (stem cell, heart, kidney, lung, liver, eye lens, bone, joint, cartilage, tendon ) Heterolog /xenolog/ (tendon, heart!) Synthetic (heart, silicon, bone) 5

6 Advantages - disadvantages Autolog Your own is best, but the removed tissue is missing from the donor area» possibilities for purchase are limited Tissue /stem cell culture - tissue engineering Homo-xenolog: no limitation of available tissue immune reactions: graft-host Synthetic: Immune response is minimal (allergy?) Size, amount is unlimited» expensive! Anything that does not infiltrate or reorganize will eventually genera inflammation, and rejection! 6

7 After tissue transplantion: Inflammatory phase (days) Revascularisation degeneration (weeks) Regeneration (months) Remodellation (quarter years) 7

8 Skin replacement Only your own!!! Face transplantation is SciFi See separate chapter! 8

9 Tendon ligament replacement fresh injuries It is possible to make a tendon or ligament suture: sharp injuries of flexor and extensor tendons of fingers & toes ulnar collateral lig. tear of I. MP joints some carpal ligament injuries collateral ligaments of elbow MCL of knee tear of lateral & medial ankle lig. There is no chance for suture after 7-10 days of injury. 9

10 Tendon ligament replacement Basic principles: fiber fasciculus Bradytrophy - ischemia tolerance Special hystological structure longitudinal filaments endotenon the traditional techniques of the surgical stiches fail Healthy tendon could not tear! Primary augmentation Movements & of the joint have the same degree of importance the stability 10

11 Kleinert Kessler stich-technic 11

12 Tendon ligament replacement Primary augmentation 12

13 Tendon ligament replacement scar tendon ligament Autolog Own is the best Free transfer Pedicled transfer Tendon - muscle /insertion-origin/ transfer Heterolog? Synthetic? 13

14 14 Synthetic ligaments Proper indication?

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16 Instability of shoulder coracobrachialis + caput br. biceps subscapularis 16

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18 F N 18

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20 rotation + sliding hinge 20

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25 5 mm α Varus instability α > 15 o Table drawer test 25

26 Peroneus tendon 26

27 . 27

28 Hyaline cartilage replacement 28

29 hyaline 2 cm 29

30 Mosaic plasty (Hangody) Outside the knee? 30

31 Replacement of knee & hip by TEP is the most popular procedure of orthopedic surgery 31

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34 Other surgical solutions for arthrosis: -arthrodesis -interpositional arthroplasty 34

35 Bone replacement osteogenetic /own bone/ osteoinductive conserved /synthetic bone+f/ *bone lengthening!, osteoconductive /synthetic, conserved bone/ 35

36 Lengthening of own bone 36

37 Lengthening device combined with an IM nail 37

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39 Limited possibilites 39

40 Autologous harvesting: iliac-crest Block Spongiosa-chips 40

41 Bone source Own bone /is the best!/ BUT (iliac crest, hip, metaphysis of large bones, local) In septic cases! Limited Pain Risk of infection 41

42 Bone source Own bone (hip, metaphysis of large bones, local) Secondary defect 42

43 Bone source conserved bone Femur heads related to hip replacement frozen /- 26 o C / liofilized synthetic 43

44 autolog/heterolog bone augmented by Platelet Derivated Factors 44

45 Corals? Xenolog grafts? CaCO 3 Bovin bone 45

46 Synthetic bone 46

47 Composition of synthetic bone 47

48 Injectable synthetic bone 48

49 Pathological fracture of humerus 49

50 Special mixtures: Synthetic & autologue bonegraft + active cell elements Autologue bonemarrow aspirate + synthetic bone 50

51 Bone healing usually occurs within Bone strength 6-8 weeks fracture Indirect healing Healthy bone Direct healing months 51

52 Biomechanical aims: Absolute stability near the joints Relative stability at the diaphysis 52

53 Plate or nail:

54 Biological osteosynthesis Osteoinductive Osteoconductive Use material with elasticity similar to bone Implantology, metallurgy Layered plates, metals Controlled deformation Absorbable? Synthetic? Inexpensive??? 54

55 Plates Extraosseally implantable (for example, in addition to already implanted prosthesis) For intraarticular fractures Cannot be implanted wherever! 55

56 Plates damage blood supply of the bone to a lesser degree than IM nails! 2/3 1/3 56

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60 IM nails are: minimal invasive and, biomechanicaly optimal 60

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63 Stainless steel (St) or titanium(ti)? The fixation /metal should be strong enough / St ++, (alloy) Ti - elastic enough / St?, Ti - tissue friendly / St +, Ti ++ inexpensive / St +, Ti - Implantable / St +, Ti + osteoconductive / St -, Ti + simple to remove?! / St +, Ti 63

64 anatomical reposition of joint surfaces proper (near anatomical length, alignment, axis) fixation of meta-, and diaphysis weight bearing or motion stabile fixation of fragments possibility for minimal invasive technique (no further damage of blood supply of tissues) minimize duration of surgery minimize xray consumption during operation reduced risk of infection biocompatible (resorbable) fixation materials cheap 64

65 Bioretec Activa pin & screw by kind permission of Tamás Kassai MD Developed in Finland lactic/glycolic acid copolymer (PLGA). Bio-absorbable (2 years) Mainly for children 2 mm diameter pins AO KFI spongious screw 65

66 Bioretec Activa Pin rotatinal stability, ribbed surface Self locking effect: Become swollen on the 1. p.op. day 66

67 Bioretec Activa Screw cannulated, require proper predrilling 67

68 Bioretec Activa pin & screw 68

69 Epyphyseolysis Salter Harris IV. of lateral hum. cond. Bioretec ACTIVA PIN +PDS 69

70 Bioretec Activa Pin 70

71 4 weeks after surgery 0/20/130 o of motions NO FURTHER INTERVENTION 71

72 Separation of radial head 72

73 Separation of radial head Intra op. situation 73

74 Separation of radial head Open reduction, predrilling by K wire, then ACTIVA PIN 74

75 Bioretec activa pin 75

76 p. op 3 w. p. op w. p. op.

77 10 weeks p. op. 77

78 The Future Today 78

79 Take home massage: Degenerated tendons should be augmented Tendons require special suture technic Bone transplantation can be osteoconductive, osteoinductive & osteogenetive Biological ostheosynthesis is only an idea Expectations: stability, elasticity and biocompatibility 79

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