Orthopedic Hardware and Procedures. John Park
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1 Orthopedic Hardware and Procedures John Park
2 Background Orthopedic Hardware Hardware frowned upon Often used by orthopedists
3 Fracture Management
4 External fixation Materials Plaster of Paris Fiberglass
5 External fixation Materials Plaster of Paris
6 External fixation Materials Plaster of Paris Original casting materials took 2-3 days to harden Improved to 6 hours Around 1800, British diplomat in Turkey observed use of Gypsum First Plaster of Paris bandages introduced in 1850 s Drawbacks: burns, heavy, not waterproof
7 Plaster External fixation
8 External fixation Materials Fiberglass
9 External fixation Materials Fiberglass Fiberglass bandages introduced in early 1970 s Benefits: lighter, harder 1990 s: waterproof (with special underwrap = $$$)
10 Fiberglass External fixation
11 Casting vs Splinting Splinting Non-circumferential 2 layers of fixation with elastic outer wrap Allows flexibility in fixation to accommodate soft tissue swelling Immobilize joints proximal and distal to fracture Usually 3-14 days before switch to cast
12 Splint Casting vs Splinting
13 Splint Casting vs Splinting
14 Splint Casting vs Splinting
15 U-Splint Casting vs Splinting
16 Casting vs Splinting U-Splint With posterior slab
17 U-Splint Casting vs Splinting
18 Ulnar gutter Splint Casting vs Splinting
19 Coaptation Splint Casting vs Splinting
20 Coaptation Splint Casting vs Splinting
21 Coaptation Splint Casting vs Splinting
22 Coaptation Splint Casting vs Splinting
23 Finger splints Casting vs Splinting
24 Finger splints Casting vs Splinting
25 Casting vs Splinting Casting Circumferential Immobilize joints proximal and distal to the fracture Usually removed at 4 weeks for radiographs OOP Total length of immobilization usually 6 weeks
26 Cast Casting vs Splinting
27 Casting vs Splinting Short vs Long Arm Casts
28 Long Leg Casts Casting vs Splinting
29 Casting vs Splinting Spica Cast (aka-hip spica)
30 Thumb spica cast Casting vs Splinting
31 Casting vs Splinting Casting Bivalving Allows immediate application of cast with flexibility to accommodate soft tissue swelling
32 Bivalved cast Casting vs Splinting
33 Bivalved cast Casting vs Splinting
34 Bivalved cast Casting vs Splinting
35 Bivalved cast Casting vs Splinting
36 Bivalved cast Casting vs Splinting
37 Cast Fracture!! Casting vs Splinting
38 Casting vs Splinting Cast window Allows ability to monitor skin without loss of fixation
39 External fixator External fixator Minimally invasive Rigid fixation The closer the bars are to the body part, the stronger the construct will be
40 External fixator External fixator Pin Clamp Bar
41 External fixator Mexican external fixator
42 Mexternal fixator External fixator
43 External fixator External fixator
44 Internal fixation
45 But first
46 Nomenclature External fixation By definition, minimally invasive Internal fixation Can be either minimally or maximally invasive
47 Nomenclature ORIF Commonly used to describe the application of any type of internal fixation to fracture This is INCORRECT
48 Nomenclature ORIF Describes an open surgical procedure where the fracture site is directly visualized and reduced by the surgeon Internal fixation is then applied across the reduced fracture Thus OPEN Reduction/Internal Fixation
49 ORIF Nomenclature
50 ORIF Nomenclature
51 ORIF Nomenclature
52 NOT ORIF Nomenclature
53 Nomenclature CRPP Closed Reduction/Percutaneous Pinning Should be used when fracture is not directly visualized but is reduced and fixation applied into the bone
54 CRPP Nomenclature
55 CRPP Nomenclature
56 CRPP Nomenclature
57 Wires and Pins
58 Wires Kirschner wire (K-wire)
59 Wires Kirschner wire (K-wire) Fracture fixation Intraoperative joysticks for fx reduction Guides for screw placement Traction
60 Kirschner wire (K-wire) Wires
61 Kirschner wire (K-wire) Wires
62 Pin Steinmann pin Fracture fixation Guides for screws External fixation Traction
63 Steinmann pin Pin
64 Steinmann pin Pin
65 Steinmann pin Pin
66 Steinmann pin Pin
67 Steinmann pin Pin
68 Pin Traction pin Traction bow 2.5cm posterior and inferior to tibial tubercle
69 Traction with K-wire Pin
70 Screws
71 Screws Come in various sizes (length, thickness) Basic types Cortical Cancellous
72 Cortical Screws
73 Cancellous Screws
74 Screws Cortical Screw Cancellous Screw
75 Screws Cortical Screw Cancellous Screw
76 Screws Cortical Screw Cancellous Screw
77 Screws Cortical Screw Cancellous Screw
78 Screws Types of cancellous screws Fully-threaded Partially-threaded (Lag)
79 Screws Cancellous Fully-threaded
80 Screws Cancellous Partially-threaded (Lag)
81 Screws Cancellous Principle of lagging
82 Screws Cancellous Principle of lagging
83 Screws Cancellous Principle of lagging
84 Screws Cancellous Principle of lagging
85 Screws Cancellous Principle of lagging
86 Screws Cancellous Principle of lagging
87 Screws
88 Screws
89 Screws
90 Bad Lag Screws Screws
91 Screws Specific screw uses Interfragmentary Plate fixation Syndesmotic Locking Derotation
92 Screws Specific screw uses Interfragmentary
93 Screws Specific screw uses Interfragmentary
94 Screws Specific screw uses Interfragmentary
95 Screws Specific screw uses Interfragmentary
96 Screws Specific screw uses Plate fixation
97 Screws Specific screw uses Syndesmotic
98 Screws Specific screw uses Syndesmotic
99 Screws Specific screw uses Syndesmotic
100 Screws Specific screw uses Locking
101 Screws Specific screw uses Locking
102 Screws Specific screw uses Locking
103 Screws Specific screw uses Dynamization Removal of distal locking screw(s) to allow compression at fracture site with weight-bearing
104 Screws Specific screw uses Derotation
105 Screws Specific screw uses Derotation
106 Screws Specific screw uses Derotation
107 Screws Specific screw uses Derotation
108 Screws Special screws Headless Interference Dynamic Hip Screw (DHS)
109 Screws Headless-compression with single screw Herbert Acutrak variable pitch
110 Screws Headless Herbert
111 Interference Screws
112 Interference Screws
113 Interference Screws
114 Interference Screws
115 Interference Screws
116 Screws Dynamic Hip Screw Large lag screw attached to side plate Allows dynamic compression of fx with weight-bearing
117 Internal Fixation Devices
118 Intramedullary fixation Femur rod Tibia nail Humerus nail Flexible nail
119 Intramedullary fixation Principles Maintains alignment of fracture fragments Does not strip periosteum Minimally invasive Bone entry site Small stab incisions for locking screws Can allow for dynamic compression (dynamization)
120 Intramedullary fixation Approaches Anterograde Femur Tibia Humerus Radius Ulna Retrograde Femur only
121 Femur rod Intramedullary fixation
122 Femur rod Intramedullary fixation
123 Femur rod Intramedullary fixation
124 Femur rod Intramedullary fixation
125 Intramedullary fixation Femur rod retrograde
126 Femur rod Intramedullary fixation
127 Femur rod Intramedullary fixation
128 Femur rod Intramedullary fixation
129 Femur rod Intramedullary fixation
130 Femur rod Intramedullary fixation
131 Femur rod Intramedullary fixation
132 Femur rod Intramedullary fixation
133 Intramedullary fixation Femur rod Fractured locking screw
134 Tibia - nail Intramedullary fixation
135 Tibia - nail Intramedullary fixation
136 Tibia - nail Intramedullary fixation
137 Tibia - nail Intramedullary fixation
138 Special Fixation
139 Special Fixation Tension band wiring Wiring pattern converts tensile force of pull of muscle/ligament into a compressive force across fracture
140 Tension band wiring Special Fixation
141 Tension band wiring Special Fixation
142 Tension band wiring Special Fixation
143 Tension band wiring Special Fixation
144 Special Fixation Cerclage wiring Looped wire provides stabilization in conjunction with more rigid fixation Used for fracture management and in spinal instrumentation
145 Cerclage wiring Special Fixation
146 Arthroplasties
147 Arthroplasties Joint replacement Total arthroplasty Replaces both sides of articulation Hemiarthroplasty Resurfacing replaces only 1 surface Unipolar replaces only 1 side of articulation Bipolar replaces both surfaces but only 1 side of articulation
148 Total arthroplasty Arthroplasties
149 Arthroplasties Total arthroplasty Cemented Non-cemented Hybrid Cement on femoral side only
150 Arthroplasties Total arthroplasty Cemented Non-cemented Hybrid Cement on femoral side only
151 Arthroplasties Total arthroplasty Cemented Non-cemented Hybrid Cement on femoral side only
152 Arthroplasties Hemiarthroplasty Resurfacing
153 Arthroplasties Hemiarthroplasty Unipolar Prosthetic head articulates directly with acetabulum
154 Arthroplasties Hemiarthroplasty Bipolar
155 Arthroplasties Hemiarthroplasty Bipolar Small femoral head articulates with metal cup (lined with polyethylene) which fits into native acetabulum
156 Arthroplasties Knee arthroplasty TKA (cemented, non-constrained)
157 Arthroplasties Knee arthroplasty TKA (cemented, constrained)
158 Arthroplasties Knee arthroplasty Unicondylar knee replacement Younger patients, usually medial, done to buy time
159 Arthroplasties Revision arthroplasty Primary arthoplasty removed due to infection or failure Tip-off = long stem
160 Revision arthroplasty Arthroplasties
161 Revision arthroplasty Arthroplasties
162 Plates
163 Calcaneal plate Tibial condylar plate Blade plate Reconstruction plate Dynamic compression plate (DCP) LISS plate
164 Plates Multiple functions Compression Rigid fixation Apply compression across fracture Neutralization Hold fragments in place Used in conjunction with lag screws Buttress Fracture reduced, but used to lock-in frags Used in tibial plateau
165 Plates Types of plates Dynamic compression plate Allows compression across fracture Can be any of the 3 types
166 Plates Types of plates Dynamic compression plate Locking Compression plate
167 Plates Types of plates Dynamic compression plate Low Profile Reduced contact with periosteum may increase blood flow to fracture
168 Plates Types of plates Dynamic compression plate Low Profile
169 Plates Types of plates Tubular plates Aka 1/3 tubular Looks like DCP Areas of limited ST Dist fib, ulna
170 Plates Types of plates Blade plate Blade attached to side plate Blade through large frags
171 Plates Types of plates Reconstruction plate Aka Recon plate Very malleable, cut to length
172 Plates LISS plate Less Invasive Stabilization System Contoured to specific bone Reduced ST injury Distal femur, prox tib
173 Spinal Fixation
174 Spinal Instrumentation Rod Laminar hooks Pedicle screw
175 Spinal Instrumentation Rod Laminar hooks Pedicle screw Cerclage wire laminar or spinous process Cross-link
176 Spinal Instrumentation 5 basic types Distraction/Compression Segmental instrumentation Derotation or coupled systems Pedicle screw (Translational) systems Anterior instrumentation
177 Distraction/Compression Harrington rods 1950 s Allows distraction of concave margin of curvature Ratcheted rod with opposed laminar hooks
178 Segmental Luque rods Smooth rod with multiple wires which pull spine to rod Distributes force over many segments (Galveston technique) (Luque rectangle)
179 Coupled systems Cotrel-Dubousset Aka CD rod Hooks on rods Allows compression and distraction on same rod
180 Pedicle screw Pedicle screws 50-75% into body Does not rely on intact posterior elements (ideal after posterior decompression)
181 Posterior instrumentation In practice, use combinations that work best for each curve
182 Anterior Instrumentation Allows very strong lateral forces Actually lateral fixation Bad results when anterior Same principles Screw purchase slightly weaker because body is mostly cancellous bone
183 Anterior Instrumentation Interbody devices Interbody cage Main function is to restore disc height PLIF Posterior Lumbar Interbody Fusion
184 Anterior Instrumentation Interbody devices Interbody cage Main function is to restore disc height PLIF Posterior Lumbar Interbody Fusion
185 Anterior Instrumentation Interbody devices Interbody cage Main function is to restore disc height PLIF Posterior Lumbar Interbody Fusion
186 Anterior Instrumentation Interbody devices Interbody cage Main function is to restore disc height PLIF Posterior Lumbar Interbody Fusion
187 Anterior Instrumentation Interbody devices Interbody cage Main function is to restore disc height PLIF Posterior Lumbar Interbody Fusion
188 Take Home Points Non-circumferential = Splint Circumferential with split = Bivalved Thin wire that s bent = K-wire Thicker pin not bent = Steinmann pin Screw with naked shank = Lag screw Screw across fx = Interfragmentary screw
189 Take Home Points If open surgery = ORIF If K-wires only = CRPP Femur = rod Tibia = nail Plate = plate Tension bands and syndesmotic screws are allowed to break
190 Take Home Points 1 side of joint = hemiarthroplasty Both sides = total (beware the bipolar!) Rods, hooks, pedicle screws, cross links
191 References Taljanovic MS, et al. Joint arthroplasties and prostheses. Radiographics 2003; 23(5): Taljanovic MS, et al. Fracture fixation. Radiographics 2003; 23(6): Foster MR. A functional classification of spinal instrumentation. The Spine Journal 2005; 5: Calder SJ, et al. Unipolar or bipolar prosthesis for displaced intracapsular hip fracture in octogenarians. JBJS (Br) 1996; 78B(3): Roberts CC, Chew FS. Radiographic imaging of hip replacement hardware. Seminars in Roentgenology 2005; 40(3): Miller TT. Imaging of knee arthroplasty. Eur J Radiology 2005; 54(2):
192 References Gausepohl T, et al. Fine thread versus coarse thread A comparison of maximum holding power. Injury Int J Care Injured 2001; 32: SD1-7
193 Web Site Credits html en.wikipedia.org/wiki/cast
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