For long oblique and spiral fractures of the long diaphysis, we can usually fix them by open reduction followed by wire tying, but incisional reduction is more invasive and may damage the periosteum resulting in delayed healing or even non-healing of the fracture.
Today, we will teach you how to place a wire minimally invasively through a typical case. (Video of the surgery is at the end of this article.)
Typical case.
A female patient, 67 years old, presented to our hospital with a traumatic injury resulting in deformity, swelling and pain in the right thigh and limitation of movement. She was diagnosed with “comminuted fracture of the right lower middle femur” on radiographs.
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Post-traumatic radiograph: Comminuted fracture of the lower and middle segments of the right femur
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After the anesthesia took effect, a sterile towel was routinely disinfected and a kleenex needle was placed on the body surface for fluoroscopy to determine the appropriate site for wire binding of the fracture end.
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On the plane determined by fluoroscopy, small incisions of about 1.5 cm are made on the anterior and slightly posterior lateral thighs, respectively, and the wire is clamped with a medium-sized curved forceps
(It is recommended to use No. 5 tendon wire or the thickest absorbable wire, which is not easy to break, and pay attention to clip the wire with a few more folds, so that the other hemostatic forceps can be easily clamped).
Insert from the posterior lateral incision, touch the backbone and slide downward, and extend along the back of the backbone against the periosteum outward to the medial side of the broken end.
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Using another medium-sized curved forceps, enter from the small anterior incision, reach the bone surface and then extend backward along the medial aspect of the femur to the posterior medial aspect of the femur.
At this point, the first medium curved forceps can be touched. When the tip of the second curved forceps feels the tip of the first curved forceps, try to open the mouth to clamp and lift upward, and feel the first curved forceps move with it, indicating that the guide wire has been clamped.
Continue to pull the second curved pliers until the guide wire is pulled out from the front incision.
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After re-clamping the guidewire firmly, the curved clamp enters the anterior incision again, reaches the bone surface and goes deeper along the anterior side of the femur in the direction of the posterior lateral incision diagonally until the tip of the clamp with the wire sticks out of the lateral incision.
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Take a medium-sized wire and fold it in half and put it into the wire, pulling the other end of the wire to introduce the wire.
Sometimes the separation is not sufficient and the traction wire needs to be pulled with more force, so the traction wire needs to be thicker to prevent pulling off.
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While the assistant maintains the traction, use a vise to tighten the wire (be careful to hold it as far as possible to the top of the wire knot and lift it to tighten)
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Fluoroscopy shows the wire gradually tightening and bringing the fracture end closer to the reset.
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Another wire is placed at the distal fracture end for tying and repositioning as before, without forcing the fracture to be anatomically repositioned for fear of over-tightening and causing the wire to break.
For those who seek perfection, the wire can be tightened more and the repositioning will be more beautiful.
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The location of the nail entry point is viewed by fluoroscopy in the front and lateral position, slightly lateral to the midpoint of the intercondylar fossa and slightly anterior to the Blumensaat line in the lateral position. Avoid damage to the posterior cruciate ligament and penetration of the intramedullary nail out of the posterior cortex.
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After expansion of the medulla, the intramedullary nail is placed along the guide pin, taking care that the caudal end does not protrude from the intercondylar fossa and that the tip of the intramedullary nail is placed at the level of the lesser trochanter.
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The distal locking nail and the proximal locking nail are placed respectively after installing the sight.
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The steel wire is mainly used for resetting, and can be removed after fixing, by lifting and unscrewing it directly with a vise.
In this case, the first bundle of wires was left in place because it was broken from the middle part of the knot when it was unscrewed.
The fluoroscopic lateral fracture is well aligned and the locking nail is well positioned.
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Exterior view of the surgical incision shows only a few small incisions.
At the first intramedullary nailing case sharing competition in December 2020, Professor Cao Lidong of Ningwu County People’s Hospital in Shanxi demonstrated a minimally invasive wire-bound repositioning method, a technique that was originally created by Professor Cao Lidong as a minimally invasive wire fixation repositioning method.
This minimally invasive wire repositioning method can be well closed and reset long oblique diaphyseal fractures by placing wires through two small incisions of about 1.5cm, which is very practical for minimally invasive surgery in orthopedic departments of primary units lacking AO wire dressers and is worth promoting!
With the authorization of Prof. Cao Lidong, this simple and effective minimally invasive repositioning method is hereby promoted. Please enjoy the following case by Prof. Cao Lidong.
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A case of femoral condyle fracture
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Minimally invasive wire ligature repositioning
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Plates were placed and screws were screwed in after repositioning
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The fracture was well repositioned and the internal fixation plate was well positioned after the operation.
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Intraoperative incision appearance photo
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This is a spiral fracture of the middle and lower tibia, which was also repositioned by minimally invasive wire placement and plate placement.
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Intraoperative photograph of the incision.
Illustration of minimally invasive wire binding repositioning method
(Thanks to hand-drawn by Mr. Li Wenxiang of Zhengzhou Orthopedic Hospital!
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Click on the video below to watch the full minimally invasive wire binding technique ?
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Do you have any takeaways or confusion after reading this article?
Feel free to tell us in the comments section~
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