OSTEOSYNTHESIS (osteosynthesis; grech, osteon a bone + synthesis connection) — operational connection of fragments of a bone. It is applied at treatment fresh, not accrete, incorrectly accrete changes (see) and nearthroses (see), for connection of a bone after it osteotomies (see). The purpose O. — to provide fixing of the compared fragments, having created conditions for their bone union, recovery of an integrity and function of an extremity.
In 1873 J. Lister made connection of fragments of a patella by means of a bone seam that it is possible to consider one of the first operations O. In 1875 N. V. Sklifosovsky and I. I. Nasilov applied to connection of fragments the, original method — « Russian lock » (see). Heavy septic complications in the postoperative period and an unsatisfactory outcome forced to refuse operational treatment of changes temporarily. After implementation in practice of an asepsis and antiseptics and a x-ray method of a research interest in operational treatment of changes renewed. In 1892 the English surgeon W. A. Lane applied metal plates to O., in 1902 the Belgian surgeon A. Lambott used screws with the same purpose. E. Lekser in 1909 made an osteosynthesis by means of intramedullyarno the entered bone pin. In 1893 B.H. Kuzmin, and later I. K. Spizharny, V. I. Razumovsky, P. A. Herzen, etc. applied an intra bone metal nail at treatment of a nearthrosis of a hip. At the XII congress of the Russian surgeons (1912) V. I. Geydroyts and at the XVII congress of the Russian surgeons (1925) G. F. Petrashevskaya from I. I. Grekov's clinic reported about the observations on operational treatment of fractures of bones. Abroad in 1912 intra bone fixing by a metal core was applied by Grovs (E. W. N of Groves). To G. Schone in 1913 and a little later Kirchner (M. of Kirschner) in the same purposes spokes used. In 1931 Smith-Petersen (M. of N. Smith-Petersen) suggested to make O. of fractures of a neck of a hip a three-blade nail from stainless steel. Since 1932 in the USSR B. A. Petrov and A. V. Kaplan began to apply this method (the union of fragments was observed at 70 — 90% of patients). G. Kiintscher's message on the congress of the German surgeons in 1940 about treatment of diaphyseal changes by intradermal O. by means of a long core from stainless steel was of great importance. After the Great Patriotic War this method was especially widely applied by Ya. G. Dubrov (1946), F. R. Bogdanov (1949), M. O. Friedland (1952), I. L. Krupko (1954), H. N. Priorov (1959), etc. Favored to development of a metalosteosynthesis sovr, prophylactic and fight against operational shock, methods of the general anesthesia and the prevention inf. complications, and also improvement of the operational equipment, emergence of fixers from stainless steel and alloys (see. Orthopedic tools ).
Distinguish two main types of O. — submersible (introduction of the fixer of a bone directly in a zone of a change) and outside (Extra focal) — by means of the spokes which are carried out to fragments through skin and fixed in any device (see. Distraktsionno-kompressionnye devices ). Submersible O. depending on an arrangement of the fixer in relation to a bone happens intradermal (intramedullary), bone and chreskostny. To intra bone O. apply different types of cores (pins, nails), to bone O. — various plates with screws and for chreskostny — screws, spokes. Quite often apply a combination of several views of the Lake.
Fixers for submersible O. shall be manufactured from biologically, chemically and physically inert materials. As a rule, apply metal designs from stainless steel, a vitalliya, titanium, sometimes from a bone and inert plastic. Metal fixers, as a rule, after an union of a change delete. There were attempts to create fixers from the so-called resolving metals and alloys (magnesium, magnesium and cadmium) — an ostheosynthesitis, «paralyuman-2», an electron, dau-metal, etc. Such fixers at a wedge, check were not repaid yet since it turned out that in an organism they quickly enough become brittle and cease to fix fragments.
Cores for intra bone O. can be continuous or hollow, in cross-section to have a form of a leaf of a clover, round, ploskoovalny, trihedral, tetrahedral, hemispherical, U-shaped, zhelobovaty, etc. Of diaphyseal fractures of a femur in the USSR Kyuncher's nails, Dubrova, shtykoobrazny cores of TsPTO, a tube with a continuous longitudinal cut, and also fixers with the pulling together and compressing device are most often applied to O. (Fishkin, Pavlik's nail, Akhalaya, Krupko's nail screw, Shadin's screws, a corkscrew of Sivash, etc.).
Distinguish the closed and open intra bone Island. At the closed O. after comparison of fragments by means of special devices into the marrowy canal of the broken bone on the conductor through a small section far from the place of a change enter a metal long hollow core under X-ray inspection of the corresponding diameter. The conductor is deleted and the wound is sewn up. At an open intramedullary osteosynthesis, to-ry apply much more often, bare a zone of a change, fragments reponirut in an operational wound and into the marrowy canal of the broken bone enter a metal core (fig. 1).
Open O. does not demand the special equipment for reposition of fragments, technically more simply and more well closed, however at the closed way the zone of a change is not bared, danger of an infection decreases, soft tissues around fragments are less damaged. O.'s stability depends on features of a change, type of the fixer and depth of its introduction to fragments. The best fixing is reached at diaphyseal fractures of long tubular bones, cross and slanting with a small bevel, at a thickness nailing, corresponding to diameter of the marrowy channel. Steady O. of a fracture of a hip can be provided with the thick nail (8 — 12 mm) entered into a bone after preliminary drilling of the marrowy channel (fig. 2). At unstable O. there can be mutual kachatelny movements of fragments leading to shift them on width, length and the periphery to disturbance of an axis of a bone at the level of a change and as a result to failure of union. Unstable O. is possible at introduction too thin nailing, to - ry easily migrates, is bent and can break at the level of not accrete change as a result of metal fatigue over time.
The most often intra bone O. a long metal core is applied at changes of a diaphysis of a femur. For O. at nek-ry types of changes there are special fixers, napr, a three-blade nail Smith-Petersen for O. of fractures of a neck of a femur, the screw with the closed springing device (fig. 3), etc. for a constant compression according to J. Charnley. Lakes of a neck of a femur usually carry out in the closed way by means of special napravitel (Kaplana, Petrov-Yasnov, etc.) under rentgenol, control. The fixer at the same time lead quite often through a hip joint with implementation him to a wall of an acetabular hollow (so-called transarticulary O.). It increases stability of fixing of a fracture of neck of a hip.
Bone O. is applied at changes of various localization and a look: splintered, slanting, spiral, cross, circumarticular and intra joint changes regardless of a form and a bend of the marrowy channel. In the majority fixers for bone O. represent various form and a sheet gage, connected to a bone by means of screws. Many sovr, plates have the special, pulling together (compressing) devices, including fixed, offered by Deynis (D. Danis, 1938) and X. S. Rakhimkulov (1959), and removable — compression detorsionnye Kaplan's plates — Antonova (fig. 4), Demyanov, Tkachenko, etc. After bone O. quite often in addition apply a plaster bandage. Müller (M. of Muller) and soavt, biomekhanichesk developed reasonable devices for stable bone O., a so-called set of the joint-stock company (The Association for the Study of Osteosynthesis). Similar set is created in Czechoslovakia by Paul-di. The system of the joint-stock company is based on use of the massive plates having a large number of openings (8 — 12), and screws with persistent cutting (fig. 5). After O. by means of a set of the joint-stock company the plaster immobilization is applied seldom that is connected with sufficient stability in a zone of a change. However O. long massive plates is followed by an exposure of a bone on a big extent that breaks its trophicity and can be the cause of delay of consolidation; the removals of screws remaining later numerous openings weaken a bone. Bone O. at slanting and spiral changes can be made by means of a circular okhva-tyvayushchey fragments of a metal wire, metal tapes, special half rings and rings of stainless steel. This type of O., especially wire as the independent method is seldom applied because of short fixing; usually it serves as addition to other views of the Lake. Bone O. soft suture material (catgut, silk, lavsan, etc.) it is applied extremely seldom since threads cannot resist to muscular draft and repeated shift of fragments even at an additional plaster immobilization. Nek-ry fixers represent a combination of bone and intra bone designs, napr, the tee beam of Klimov, an angular beam of Vorontsov (fig. 6, 7), Kalnberz, Novikov, Senpo's fixers, etc.
Chreskostny O. is carried out by means of screws, bolts, spokes, etc. At the same time fixers carry out in the transverse or kosopoperechny direction through walls of a bone tube in a zone of a change. The special type of chreskostny O. represents a bone seam. At the same time in fragments drill channels and through them carry out ligatures (silk, catgut, wire), to-rye then tighten and connect. The bone seam is applied at fractures of a patella, an elbow shoot. At chreskostny O., as a rule, apply a plaster bandage. The early cast removal can lead to shaking and a vykhozhdeniye of screws, shift of fragments and formation of a nearthrosis.
A specific place is held by outside O.'s method by means of distraktsionno-compression devices (see). This method gives the chance, without baring a zone of a change, Reponirovat fragments and to strongly fix them (Extra focal O.). The method does not demand a plaster immobilization, patients with devices on the lower extremities can go with full load.
For connection of small bone fragments, and more often at change of a bone apply so-called ultrasonic O. to connection of transplants (see. Ultrasonic therapy ).
At O. the wrong choice of a method of fixing of fragments or incorrectly chosen fixer, a failure to provide of stability of reponirovanny fragments, insufficient observance of an asepsis and antiseptics, ill-treatment of soft tissues, excessive radicalism during the processing of open changes, etc. can lead to complications. The most frequent complications of operation O. are failure of union of fragments, superficial suppuration in the field of an operational wound and septic complications — osteomyelitis (see), phlegmons (see). In the past at production of submersible fixers for O. from low-quality steel or other metals it was observed so-called metalloz as a result of chemical interaction of metal with fabrics and liquids of an organism.
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A. V. Kaplan.