Minimally Invasive Technology in Orthopedic Trauma

The application of minimally invasive technology in orthopedic trauma is one of the widely promoted techniques.

Under the technical guidance of the General Hospital of Northern Theater Command, the Second Ward of the Orthopedics Department at No. 968 Hospital of the Joint Logistic Support Force has gradually mastered this technology and applied it clinically: minimally invasive closed reduction for tibial fractures.

Fractures of the distal one-third of the tibia are among the hardest to heal. Because of the scarce surrounding soft tissue and poor blood supply (especially the anteromedial tibia, covered only by subcutaneous fat and skin), nonunion, exposed internal fixation plates, and bone exposure after tibial fractures are troublesome problems for orthopedic surgeons.

Typical Case Analysis

Patient: Male, 46 years old. Admitted 2 hours after falling, with swelling, pain, and deformity of the left lower leg. Physical examination showed no signs of neurovascular injury.

Diagnosis: Left tibiofibular fracture (Grade 8-10 disability).

Surgical Options

Based on the patient's condition and fracture severity, the team weighed the most suitable plan: plate fixation or intramedullary nail fixation?

Option 1: Plate and Screw Fixation

Under anesthesia, the skin, subcutaneous tissue, and fat layer are incised and retracted, muscles bluntly dissected to the fracture site, severely contused tissue excised, and local hematoma removed. The fracture is manually reduced anatomically and fixed with instruments. Plate and screws are placed on the tension side (not the compression side). After drilling, screw length is measured and each screw fixed; the incision is then irrigated and sutured.

Option 2: Intramedullary Nail Fixation

Intramedullary nailing is more favorable for fractures with poor blood supply, because the nails do not interfere with blood supply at the fracture site, cause less damage, and speed recovery. Their fixation stability is somewhat lower than plates, but they allow slight movement of the fracture ends during healing.

• Central fixation of intramedullary nails conforms to normal physiological mechanics, ensuring good stability, whereas plate fixation is eccentric.
• Nailing requires no incision or only a small one at the fracture site, causing minimal damage to local blood supply and favoring healing.
• Plate fixation involves extensive incision and dissection, causing significant secondary damage.
• Patients with intramedullary nails can get out of bed earlier, with higher safety and better bone healing, compared to later ambulation with plates.

Surgical Process

• Phase 1: Localization under C-arm fluoroscopy, reamer drilling, traction reduction, guide wire insertion, and sequential reaming after opening the medullary cavity at the proximal fracture end.
• Phase 2: Insertion of the intramedullary nail, and screwing in all locking nails after measurement.
• Phase 3: Intraoperative real-time display of reduction and fixation via C-arm fluoroscopy.
• Phase 4: Postoperative limb appearance shows only a few small incisions for nail insertion and locking nails.
• Phase 5: Postoperative rest and recovery.

Precautions

After intramedullary nailing, the hematoma organization phase begins, with a local inflammatory response forming granulation tissue. New blood vessels grow at the fracture ends and osteoblasts proliferate, promoting healing and ossification.

Recovery time depends mainly on the speed of bone healing, generally 3-6 months. Intensive care of the injured site is required. During recovery, patients may take bone-healing drugs as prescribed, such as Huoxue Zhitong Capsules, Biqi Capsules, Xianling Gubao Capsules, Calcium Carbonate D3 Tablets, and Alfacalcidol Soft Capsules.

The fracture becomes relatively stable only after healing. It is important to avoid premature weight-bearing and refrain from running and deep squats. Normal weight-bearing and activity can resume only after complete healing.