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Board Review Surgery

Current Concepts In Fixation-An Overview

Stanley Kalish, DPM

Stanley R Kalish, DPM discusses principles of fixation and various options available for fixation with screws and plates.

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Goals and Objectives
  1. Recognize types of screws now available for external and internal fixation
  2. Review the advantages and disadvantages of traditional versus locking plates
  3. Explain the underlying principles of internal and external fixation
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  • CPME (Credits: 0.5)

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    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • Stanley Kalish, DPM

    Senior Staff Surgeon
    Dekalb Medical Center
    Atlanta, GA

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    Stanley Kalish Stanley R Kalish, DPM has disclosed that he receives Honorarium/Expenses, is a Consultant to and serves on the Speaker's Bureau for Pfizer and Merck. He will be speaking on the investigational products dalbavancin and telavancin.

  • Lecture Transcript
  • Male Speaker: We’re going to talk about current concepts of fixation. In dealing with current concepts of fixation, I can’t possibly cover external fixation so you’ll excuse me for saving that for Superbones West. And maybe the external fixation course that we’re doing on triple arthrodesis later this weekend. Traditional fixation options are AO fixation and that has been replaced with cannulated screws. There are now fixation options for hammertoes and Smart Toes and PRO-TOE. I’m not going to talk about that. I’m going to kind of just talk about fixation options with screws, medial column beam screws for flatfoot correction, for triple arthrodesis, for Charcot, current concepts in locking plates which I’m going to spend some time on. And I’m not going to talk at all about external fixation and retrograde nails. But understand that these are the fixation options that are here for you. The support is huge if you go out into our wonderful exhibition area, we’ve got probably 65 exhibitors. They are here because we have had conversations with them and continue to develop ideas and concepts to fixate the foot and the ankle in both internally and externally. And this never was 30 years ago. We were always there borrowing information from the orthopedic surgeon. And in this situation, we have developed concepts based on foot surgery. And you can, the younger residents and students who are here, you should be actively involved with these companies and taking your ideas as you get more experience to develop new concepts in fixation. So how did this all started? It started in Davos, Switzerland in the ‘70s and myself and Dalton McGlamry, and Guido and John Ruch and John Buckholtz, and just a whole bunch of people, Chuck Gudas, we went to the AO area in Davos, Switzerland and we learned the concept of internal fixation. When we came back and looked at some of the stuff we were doing, you have to understand that our fixation techniques were poor. They were noncompressive and there was a high incidence of nonunion. Our osteotomies were inappropriate. They were central in the middle of bones with the diaphysis, does not heal well. And now mostly all of our osteotomies are metaphyseal in nature. We used a lot of Kirschner wires. And even the early bunion procedures, we didn’t even do anything. We just impacted the bone and wrapped it tightly with a bandage and kept the patient nonweightbearing for seven or eight weeks. Here, you see some of the young people who have become educators in the background fixing in the 1970s in Davos, Switzerland, understanding that the incidence of nonunion in the orthopedic literature in certain cases is up to 40% in triple arthrodesis. And in 2003, when we evaluated all our studies, we had done over 5,000 triple arthrodesis, our incidents in nonunion was about 3.5%. Now, 10 years after that, I’m sure it’s in the same realm, maybe a little bit better with some of the improvement in orthobiologics and in bone stimulation and the application of internal bone stimulators. The principles have basically not changed at all. The principles of internal fixation and external fixation remain the same. There are certain things that are changing as you can see some of the material just presented is highly technical, highly sophisticated to make us get closer to that area of perfection as surgeons. But again, most importantly, anatomically is preservation of the vascular supply, anatomical reduction of the fracture or the osteotomy, because why go in there and cut the bone and create something that is not perfect. You might as well just treat it conservatively. Rigid immobilization, early functional use of the limb, the prevention of what we all know as cast disease, osteopenia and osteoporosis, and weakness and loss of vertical and horizontal trabeculations, kind of like a nonweightbearing astronaut phenomena of the bone when you keep these people nonweightbearing forever. What we saw, we saw a lot of disasters and we were using cerclage wires. We didn’t understand what the term elevatus meant. We didn’t realize that our patients, when they develop these dorsiflexory elevated osteotomies that they were going to have problems.

    [05:09]

    And they’re going to get shortening, and they’re going to get transfer lesions and they’re going to get stress fractures of the adjacent metatarsal. All because of the inappropriate preparation both mentally, mechanically for these patients prior to surgery to determine what the foot was, what it look like on x-ray and what we wanted to do surgically to correct it. Without that information, you wound up with disasters like this, very commonly. And so this concept of interfragmental compression and splintage, and is very classical picture of the concept of compression with over drilling either by the leg development of the screw and cannulated screw certainly, or over drilling of a fully cortical screw. Understand the cortical screw is the most perfect device, the most simple device invented. And it’s the one we should turn to almost all the time when we can, especially when we’re purposefully creating osteotomies. And if we purposefully correct or create osteotomies, then we can apply a simple technique. We don’t need all these fancy techniques. And Muller, who I spent some time with and all the grandmasters of AO would be interested to know the $16 billion they got for their company. They didn’t even give a hoot about money. And again, Muller, who was an interesting fellow, wild man on his own, said that compression does not exert any mystical osteogenic effect on bone. Of course, it’s not mystical, it’s actual. You’re helping the body help itself. And you’ve heard me over 30 years talk about that. So here were some of the first things we did back then. We actually used trauma screws. And now, with companies that are out there like Vilex and Rite, and OsteoMed, and all the companies that support us, we have built devices that are not so prominent. That 3.5 and 4.0 trauma screw, at the end of the big toe just doesn’t work. You always have to remove it, it’s always coming through the skin and it’s always painful. This is one of our first interphalangeal fusions that we did with a 3.5 trauma screw. And here was one of the first Kalish osteotomies done with trauma screws back 25 years ago. It worked. And again, the concepts have changed because we have asked for help. How do we make our jobs easier? And early base wedge or the 4.0 lag screw and there’s now much better ways to do that with IOL loops and, in some cases, with cannulated screws, in some cases, with small locking plates. Our first 6.353 screw triple, I never saw this in the orthopedic literature, didn’t exist until we published our textbook and started to talk about all of the triple arthrodesis we used with 65 and 70 screws. So we should be really proud of what we’ve developed. Now, what’s come up, what do we got? We’ve got cortical bone screws, miniature screws from 1.5 to 8.0. We have cancellous bone screws. We understand the difference between them and the pitch of how they’re used in different types of bones. We have cannulated screws. We have medial beam screws that can be used, long beam screws for Charcot, for first ray stabilization and the medial column stabilization. We have headless screws. We have absorbable screws. We have magic pins, FFS screws, and we have our traditional K wires with IOL loop cerclage wiring. And so, here, is the gold standard, as I said, the cortical bone screw. Whenever you have the option and look at your osteotomy, create an osteotomy that will simply use two cortical bone screws. Don’t create all of these. I’ve been reading all these triple osteotomies and I agree with CORA and Akin, all the concepts of angulation. I don’t like to cut a metatarsal bone more than once. I don’t like multiple osteotomies at all. I think you have a disaster in the making. Here cancellous bone screws here, larger ones. And again, some of the systems that are self-tapping and self-drilling makes your life a lot easier. The application of a bone screw in hallux valgus surgery shouldn’t take you more than five minutes to do if you’re looking for time saving. Well, I could put a K wire and fasten it, not necessarily. The screws are low profile, there are headless versus headed screws, which has better compression in bunion surgery which is a track this morning, you need a screw that has a head.

    [10:00]

    Don’t use headless screws. Headless screws will crack that cortical, that thin cortical surface especially in the long arm Kalish type osteotomy and Austin type of osteotomy because you will crack the bone with headless screws. So you need a low profile head for that operation. I don’t use a lot of absorbable screws. But here you see some of the original ideas that we had in hallux valgus surgery and look at the thread pattern. Now, when we’re doing an osteotomy that cuts the bone straight down the middle and comes up with a long dorsal arm, the dorsal wing is very thin. We don’t need screw threads across that. That’s the area that has to be over drilled or legged. And the rest of the metatarsal should have additional screws. The original ones were like so. And here, you see some of the modifications that have come out and look at the difference with this large titanium Synthes screw versus some of the other screws developed by smaller companies that we have that actually are adapted to the operations that we’ve come up with. And particularly, this first screw that you see has got threads that adapt to the long dorsal arm osteotomy with a short leg, because the dorsal surface is short. So why don’t you have many threads below that purchasing the metatarsal, and that’s exactly what we developed. And other companies who have come up, and I never used this. I would never use this. I don’t like this. I like a few but I think that this is, in this particular situation for bunion surgery, a screw that’s got disaster written all over it for simple bunion surgery. And that’s why I never use this but kind of nice to break off pin. I don’t use the propeller screw. I love the ABI. They’re great but not for bunion surgery. There’s a great screw for real foot and trauma surgery, but it’s not a bunion screw. And then there are those unclassified systems of bone screws like the IO FiX system. The IO FiX system is kind of interesting in the sense that basically it’s like a stop sign. You put a post down and you put cement around the post, and then there’s a hole in the middle of the post. At the right angle, you change that angle, you actually move your hand up and down and get exactly where you need to get an opposing compression of the joint for arthrodesis. This is kind of a really neat screw that we’ve used over the years especially in triple arthrodesis setting here the post, screwing the post in to the navicular, and then angulating in the direction by being able to bend that wire, the screw in the proper direction to get into the talus. And verification to see that you have good compression. Very, very interesting technique and very, very nice and fun to use the IO FiX system. The screws or the plate is kind of a combination. Don’t think when you hear about all these fancy-dancy institutions. The institutions don’t make the results, the surgeons working in the institutions. I’ve got a fixer who just came in, came from a great hospital, world famous hospital. People come from all over the world to go here. And yet, when I see results like this, I have to say, it’s never the hospital that you have to blame, it’s the surgeon. This is a Charcot surgery that was a complete failure that we will change and turn around probably with a retrograde nail and maybe even a frame and combination. Cerclage wire, still used. I’ll talk a little bit in a few minutes about the IOL loop for nonunion first metatarsal osteotomies, but of simple technique of the two wires wrapped around in the figure of eight. You get compression across particularly the most common nonunion fracture in the body is fifth metatarsal, a Jones fracture and good compression with a simple inexpensive device. Many of you, I know many of our residents who are all over the world, all over the country, they don’t have all these fancy devices. They don’t have IO FiX systems. They don’t have locking plates. They don’t have all of the sophisticated equipment that you have. And so a simple K wire and a simple piece of wire that they may have to go into the backroom and put an autoclave for you is what you need to treat these fractures appropriately. The concept of the plate is to resist all bending, rotational, ensuring forces on a fracture of osteotomy, and we know that. The very thought of a plate usage is because the ideal interfragmentary compression screw that I talked about, the cortical bone screw, is not possible.

    [15:00]

    Why in heck would you want to put all the sophisticated expensive stuff in there if you could put a simple good compression screw in? Well, with trauma, you don’t have a choice. You can pick your friends, you can’t pick your relatives. Okay. And so with trauma, whatever it is, you have to have the equipment to do it. With standard plates versus locking plates, there are lots of plates that are available that now we have the addition of the locking plate. Because the only way to get compression out of a plate prior to this was to use a dynamic compression type plate and kind of over drill and get compression through the plate, very brilliant idea. Works great. But it didn’t work great in fibula fractures, where you have distal osteoporosis, so what the Germans referred to as the rotten tomato. And so you didn’t have good compression distally. But you did get fracture healing. And sometimes you have to use a posterior plate or you have to use a spoon plate, or an antiglide plate in order to do that. Now, those plates are basically archaic. They’re not needed anymore with the locking plate advantage. Conventional plate and screw combination is especially important. Many of you do Lapidus type fusions. And pull Lapidus through me out of the joint disease dining rooms, and not my most favorite person. And yet, the concepts with Lapidus fusion is still used today and are still a very, very popular surgical condition for hallux valgus, and hypermobile type hallux valgus. Here, with conventional plates, you have dynamic compression, neutralization, buttressing and antiglide. And then, we came up with this new concept of locking screw. What do you do when the bone is of poor quality? What do you do when you need a plate but you want a plate that’s not going to fail? And you have multiple fragments. Now, the Russians would say, “The heck with the plates, put on a small wireframe, an Ilizarov frame.” What a plate does is it works as a splint. Splintage is a French word, bears load from one fragment to the other temporarily taking on the mechanical function of the bone. That’s what a plate does. Traditional plate, the load is transferred from the bone to the plate at the bone-plate interface. In a locking plate, the plate is not even connected to the bone as far as its space. The load is transferred from the bone to the plate of the lock screw heads in the plate, that is a second cortex. The lock threads are set in cortex. In traditional situation, both cortices have to be purchased for stability. In a locking plate which you could use for Lapidus, or you can use for failed operations, base wedge and disasters in trauma, locking plates act as a second cortex and act as internal-external fixator. What a plate doesn’t do, gentlemen, is it doesn’t compress unless it’s a design plate or DCP, dynamic compression plate. Or unless you prebend the plate, otherwise you pop open opposite side. Locking plates with non-locking oval screws can be eccentrically drilled. And so there are differences. And so here is the major difference here and you see the basic type of locking screw and locking compression plates where the threads are in the holes of the plate acting as a second cortex. A plate for every potential, for foot and ankle application, but not every operation need a plate. So here’s your external fixator. And here’s your locking plate, basically an internal to external fixator. In a conventional plate, the screws can toggle but you need compression. You need compression between the plate and the bone, that's part of the ability and you need bicortical purchase. You can have unicortical purchase. Even if you’re using cancellous screws, that’s why they failed. In a conventional plate, if you have a load that’s less or equal to the compression force of the plate on the bone, it’s stable. If you have a load that’s greater than that, it’s unstable and the screws begin to toggle around in the bone. Conventional plate, when it fails, the bending load is greater than the pull-out strength of the screw, the screw just pulls out, big deal. But when you have a locking plate, and you have a failure, there’s no compression there. There’s no compression between the plates. But when you have a failure, you get compression. The plate comes down to the bone and the screws can’t toggle.

    [20:01]

    So what happens is, you get major fracture with the locking plate. Here, the bending force is, again, with a locking plate, and look what happens when you fail. Don’t think locking plates, “Oh, they’re the [indecipherable] [20:17], they're the cat’s meow.” They can cause great problems with failure. When one screw just comes out, with the locking plate, the whole damn bone falls apart. Alright. So here’s some conventional versus locking, and then we’re going to go on to complications of hallux valgus since I have my helper right here. You’re doing a great job, by the way. Here’s a conventional versus locking plate, five months postoperative. What’s happening? The screw is failing. This is bad? Not if the bone is healed, who cares? Osteogenesis is a race between the failure of the fixation device when they’re healing a bone. Very famous quote. Okay. When you’re postoperatively, bone reabsorption, not a big deal. The fracture was healed. If you have to, you take the screws out, the metal out. Screw failure backing out, but not necessarily a total failure. With a locking plate, the entire construction is based on the integrity of the plate, it’s a second cortex. If you have three screws and each screw has a value arbitrarily of 10 Newtons, you got 30 Newtons of pressure from a locking plate screw. If you weigh at the interface between the plate and the screw, that’s 20 a piece. You get 90 Newtons of pressure coming out of standard three-hole locking plate. That’s incredible. The failure is not dependent on that. And of course, I don’t have time to talk with your low profile calcaneal plates, which are locking plates and non-locking plates, made by a whole host of companies that are excellent for the treatment of calcaneal fractures. There’s no time for external fixation today. Maybe in Vegas, advances in fixation have made better results, maybe and maybe not. Advances in fixation have made for less complications, maybe and maybe not. Advances in fixation increase bone healing, maybe but maybe not. Can we talk? Absolutely. We’re here all week for you guys. I had so much fun. My son is a captain of baseball team. They are in L.A. and this guy comes up to him and says, “Can I be your co-captain, my little daughter is on the team?” And Michael looked at him and said, “Oh, you can be the water boy.”