Minimally invasive plate osteosynthesis (MIPO) of periprosthetic femoral fractures with percutaneous cerclage wiring for fracture reduction: tips and technique

Minimally invasive plate osteosynthesis (MIPO) of periprosthetic femoral fractures with percutaneous cerclage wiring for fracture reduction: tips and technique Jonna N.1, Manohar U.2* DOI: https://doi.org/10.17511/ijphr.2015.i1.03 1 Nagesh Jonna, Associate Professor, Department of Orthopedics, Rajiv Gandhi Institute of Medical Sciences, Kadapa, Andhra Pradesh, India. 2* U Rama Manohar, Assistant Professor, Department of Orthopedics, Rajiv Gandhi Institute of Medical Sciences, Kadapa, Andhra Prades, India.


Introduction
We describe percutaneous cerclage wiring and minimally invasive plate osteosynthesis ( In general, cerclage wiring alone provides insufficient mechanical strength to maintain stable fixation; however, when used as an adjunct with an internal splint such as a plate, nail, or stem of a prosthesis, reliable stability can be achieved. From a biomechanical point of view, certain fractures even benefit from the "loose-lock stability" of cerclage wires or cables as a result of the relative instability promoting fracture healing by secondary fracture healing [5]. Recent evidence has refuted the historical argument that cerclage wiring may strangle the periosteal blood supply. In a cadaveric study using liquid contrast gelatin and three-dimensional computed tomography, one of us (T.A) and colleagues found no significant difference between the observed disruption of deep femoral arteries and perforating arteries, independent of the location of wiring or spacing between wire loops [6].
The technique with which the cerclage wiring is executed may have a greater impact than any potential effects from strangulation.
Open cerclage wiring requires extensive surgical dissection with a resultant disruption of the blood supply and evacuation of the hematoma. Regardless of whether an open or percutaneous technique is used, a major concern with cerclage wire application is soft-tissue interposition, especially of major neurological and vascular structures, as has been previously reported.
It is the purpose of this article to describe the Step 1: Preoperative Planning and Assessment of the Length, Alignment, and Rotation of the Extremity: A well-developed preoperative plan and assessment of the length, alignment, and rotation of the extremity are critical.

Jonna N. et al: Minimally invasive plate osteosynthesis (MIPO)
A well-developed preoperative plan is essential. It is critical to assess the length, alignment, and rotation of the extremity. We prefer to do so with both lower extremities draped into the field so that the contralateral lower limb can be used as a clinical template for these assessments.
Alternatively, to measure the length and alignment and rotation of the extremity using Step 2: Prepare the Tunnel : After making the appropriate incision, use the tunneling device anterior and posterior to the femur to create a softtissue tunnel.
Step  If cables or wires are used for the primary purpose of fixation, they should be tightened securely around the plate-bone interface and be deployed with complementary instrumentation for whichever cable system is chosen.
Step 5: Place and Fix the Submuscular Plate: Verify the alignment and length of the plate with intraoperative images and precontour the plate to fit the lateral aspect of the femur as necessary.
The length of the plate should allow for at least four locking screws proximal to the fracture site and three locking screws distal to the fracture site. More important than the number of screws on each side of the fracture is spreading the screws over a longer distance using a longer plate. Step 6: Closure and Postoperative Rehabilitation: Encourage an immediate range of motion to aid in postoperative recovery.

Results
In our original study 18 patients with periprosthetic femoral shaft fracture (mean age, seventy-four years; range, forty-seven to eighty-four years) were treated with the described percutaneous cerclage wire and MIPO techniques. One patient died two months postsurgery, leaving nine patients who were followed for a mean of 13.2 months (range, twelve to eighteen months).
Four patients sustained a spiral fracture pattern; three, an oblique fracture; and two, a wedge fracture.Closed reduction was successful in all but one case, and took a mean of 24.4 minutes (range, seven to forty-five minutes). The mean total operative time was 103 minutes (range, seventyfive to 140 minutes). Blood loss was <100 ml in all cases. All fractures united at a mean of eighteen weeks (range, sixteen to twenty weeks).
No hardware failures were observed; one plate bent 100, but the bending did not progress and the fracture healed uneventfully at sixteen weeks.
Seven of the nine patients were able to return to their previous level of mobility. During the application of the percutaneous cerclage wires, there were no vascular or nerve injuries and none of the patients returned with any wound complications.

Discussion and Conclusion
It is important to understand that this is a technically demanding procedure with the potential In some patients, a suction drain may be inserted but this is not required for all cases.
Close the iliotibial band with a number-1 absorbable suture, followed by routine subcutaneous and skin closure as desired.
Beginning on the second day postsurgery, encourage the patient to move the hip and knee. Generally, patients can be instructed to bear partial weight (20 to 40 lb (10 to 20 kg)) and walk with assistive devices for the first six 2012. [Crossref] 02. Goetze O. (Subcutaneous wire suture in oblique tibial fractures). Arch Klin Chir. 1933;177;445-9. [Crossref] Public Health Review -International Journal of Public Health Research 2015;2(1)