Minimally Invasive Reduction and Fixation in Orthopedic Trauma

Abstract

In China, approximately, 4.41 million individuals sustain fractures every year. With the rapid development of economy, industrialization, and urbanization as well as the aging of the Chinese population, it is predictable that the number of traumatic fractures will inevitably increase dramatically in the near future. According to the nation-wide data on the clinical epidemiology of orthopedic trauma during 2010−2011, fractures occurring in young and mid-aged patients reached 72%, representing the predominant injuries, and the corresponding percentage of fractures in elderly people was 14.7%.[1] Most of the fractures require operative treatment. Open reduction and internal fixation (ORIF) via a large incision was once a commonly used method in the treatment of traumatic fractures, which remains an important choice of treatment algorithm for fractures. However, ORIF is often associated with relatively extensive invasion and increased incidence of infections and nonunion of the fractures. Minimally invasive surgery (MIS) has gained its popularity in many specialties in the last two decades or so, due to its minimal invasion, fewer complications, quick recovery, and the reduced expense.[234] In the field of orthopedic trauma, minimally invasive reduction and fixation, which is the ultimate goal that patients and surgeons have been in persistent pursuit of for a long time, has been achieved, benefiting from sustained attention and the emerging of various new concepts and techniques. Among them, biological osteosynthesis (BO) is one of the currently and widely applied concepts in the management of orthopedic trauma. BO has gained considerable popularity since its advent for fracture management and subsequent successful application in basic research and clinical application. The techniques of less invasive stabilization system for long bone fractures, the internal compression fixation technique via a minimally invasive incision for displaced intra-articular calcaneal fractures,[56] and other percutaneous reduction and fixation techniques,[78] all embody the advantages and successful application in the treatment of traumatic fractures following BO concept. During the procedure of minimally invasive treatment of fractures, the key success factor is minimal or closed reduction, namely ensuring the satisfactory reduction of the fracture before skin incision and fixation. It is impossible to achieve the minimally invasive fixation (MIF) before desired reduction is accomplished. If anatomical or satisfactory alignment could not be achieved before skin incision, limited open reduction and even complete open reduction should be performed in some complex cases. For the pursuit of anatomical or at least satisfactory alignment, Hippocrates invented the famous Hippocrates’ traction table. With societal progress and technological development, especially with the application of X-rays in medical practice, fracture could be reduced accurately and safely with the aid of this revolutionary affordable technique. Afterward, researchers and surgeons continuously invented and developed creative tools for fracture reduction. Currently, the most commonly used tool for fracture reduction is the traction table for fractures of the lower limbs,[9] using a boot as upholder for pulling force and perineal post for resistance. However, there are some weaknesses existing in the traction table-based reduction technique. The biggest limitation is the inconsistency between the direction of generated traction force and that of the muscle contraction in the lower limbs. As a result, in case of young adult patients with significantly displaced or old fracture, a larger force and prolonged traction are required to reduce the fracture, leading to stretch injury of the foot, pudendal nerve trauma, perineal ulcers, peroneal nerve palsy, and even compartment syndrome.[1011] Second, skin traction is performed during fracture reduction procedure by the traction table, which onl