NEW DIRECTION IN
TRAUMATOLOGY AND ORTHOPAEDICS
from a two-dimensional
to a THREE-DIMENSIONAL REPRESENTATION
(in bone reduction and fragments fixation)
Artificial Intelligence in Traumatology and Orthopedics..
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Pichkhadze is a leading specialist in the area of the creation of the biomechanical foundations of osteosynthesis in Russia and other countries.
In 1983 he developed a new biomechanical classification of long−bone and pelvic fractures (Atlas of long−bone and pelvic fractures, London, 2002, in two languages) and also a biomechanical concept of bone fracture fixation.
This classification makes it possible to systematize all fractures with due account of leverage properties of bone fragments, and the concept allows to optimize the quality of fragment fixation with all known constructions.
I.M. Pichkhadze is the author of more than 300 scientific papers, and 85 inventions and rationalization proposals, many of which have been introduced into series production. He has been awarded VDNKH (All−Union Exhibition of Achievements of the National Economy) medals. He is the author of ORTHO computer system (1984), which makes it possible to optimize the whole process of surgery and to calculate the degree of firmness of fracture fixation following osteosynthesis. The present brochure includes unique constructions and new apparatuses for external fixation and plates for osteosynthesis created on the basis of Pichkhadze’s theoretical work.
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BIOMECHANICAL
CLASSIFICATION OF LONG BONE
AND PELVIS FRACTURES BY PICHKHADZE
BIOMECHANICAL CONCEPT OF FRACTURE FIXATION
BY PICHKHADZE
Example diagnosis
Unified classification of closed and open injuries of limb segments and of bone fractures:
based on Gustilo R.B. and Anderson J.T. (1976, 1984), & АО/OTA classification schemes Е. Muller et all. (1990, 1996),
(in the modified by Pichkhadze I.M., 2020)
Regeneration of bone tissue in conditions of stable fixation
by PICHKHADZE
SUBCUTANEOUS – SUPRAOSSEOUS –
TRANSOSSEOUS OSTEOSYNTHESIS SYSTEM
BY PICHKHADZE
EXTERNAL FIXATION
BY PICHKHADZE
INTRODUCTION
BONE FRACTURES MUST BE CURED IN A NEW WAY
THE CREATION OF SPATIAL INFLEXIBILITY WHILE FIXING BONE FRAGMENTS IN THREE-DIMENSIONAL COORDINATES IS A GUARANTEE OF THE QUALITY OF THE TREATMENT FOR BONE FRACTURES AND THEIR COMPLICATIONS
Modern world... modern technologies... open new opportunities to humankind, but in this same world a mere accident can at any moment rudely interfere with the familiar course of everyday life, deprive one of hope, ruin one’s peace of mind. The number of traumas and their variety is increasing. This calls for a new quality of treatment for traumas and orthopedic diseases. Unfortunately a man cannot fully realize what has happened and how long the recovery will take. On the international market of medical equipment
there is now a huge number of different devices to treat traumas. Numerous firms which offer metal structures for trauma therapy adopt an aggressive marketing policy, which is unjustified from the medical point of view. All this makes the problem of common standards while determining the tactics of treatment for traumas more pressing. A coherent system for evaluating the nature of injuries is required in order to select a proper fixative in case of fractures of the same type and to prognosticate a satisfactory result of the treatment. It is also important that this system should enable the same approach to acute injuries as well as to complications, including infected ones.
Professor I. M. Pichkhadze has created a universal biomechanical classification base of both bone fractures and principles of their fixation. This allows to classify injures accurately, preventing ambiguous diagnosis. It also becomes possible to reliably encode diagnoses, thus simplifying statistical data processing and also making it possible to check the adequacy and quality of treatment, to analyze injuries, and to select a suitable fixative for a particular fracture. The unified ideology of fragment fixation now leaves no room for a loose interpretation of the diagnosis, which has a positive effect on the quality and duration of treatment. On this basis it has become possible to develop new fixatives.
The biomechanical classification of limb and pelvic fractures by prof. I. M. Pichkhadze was published in 1983. The classification is based on the biomechanical characteristics of fragments in a given fracture and analyze available metal structures in relation to their application to different traumas. The unified approach also makes it possible to analyze performed osteosynthesis in retrospect.
The main principle of fragment differentiation is whether bone fragments have leverage properties or not. This factor determines the tactics of the treatment and the selection of a device for osteosynthesis. As most classifications of long bone fractures, Pichhkadze’s classification distinguishes monofocal and polyfocal fractures depending on the number of total interruptions of transverse section of the bone.
But he also brings the biomechanical meaning into these terms. What determines the number of “levels of fracture” is the number of fragments but not the number of splinters. The number of fragments in the case of a bone fracture is always more than one, i.e. if there is one fracture level there are two fragments, as in the case of monofocal fractures. In the case of polyfocal fractures, for example, in the case of “two-level fractures” the number of fragments is three, and so on. And every fragment — a level of bone fragment — must be identified as either possessing leverage properties or not, i.e. whether it will influence the fracture zone stability. Such a classification makes it possible to evaluate not only acute traumatic injuries but also their complications. Pichkhadze distinguishes four systems of interaction of a fixative and bone fractures in his classification, and these regulate the selection of devices and optimize the treatment tactics.
NEW FIXATIVES FOR OSTEOSYNTHESIS PROF. PICHKHADZE HAS SUCCEEDED IN CREATING A UNIVERSAL BIOMECHANICAL CLASSIFICATION BASE FOR BOTH BONE FRACTURES AND PRINCIPLES OF THEIR FIXATION. THIS HAS MADE IT POSSIBLE TO PROVIDE PRECISE CLASSIFICATION OF INJURIES PREVENTING AMBIGUOUS INTERPRETATION OF DIAGNOSIS, AND ALSO A CLEAR IDEA OF THE INTERACTION OF BONE TISSUE AND A FIXATIVE IN ORDER TO PROVIDE ITS OPTIMAL ARRANGEMENT AND ENSURE RELIABLE OSTEOSYNTHESIS. ALL THIS MAKES IT POSSIBLE TO REDUCE THE TERMS OF TREATMENT AND TO SIGNIFICANTLY INCREASE THE PERCENTAGE OF POSITIVE OUTCOMES.
On the basis of his biomechanical concept of fragment fixation I.M. Pichkhadze has created fundamentally new systems of external fixation:
- Pichkhadze’s apparatus model III APMBF-01 for monopolar, bipolar and polypolar fixation with the capability for bone reduction in three orthogonal planes (Registration certificate FS 0226204/1428-05 of March 15, 2005, patent of Russian Federation 2143240).
- Pichkhadze’s apparatus model I for the treatment of intra- and periarticular fractures (inventor’s certificate 534231).
- Pichkhadze’s apparatus model II for intraarticular and polyfocal fractures (patent 1301395).
- Pichkhadze’s construction for subcutaneous -supraosseous
tran-sosseous osteosynthesis (inventor’s certificate 1824720 A1 of 22.09.1988 and others).
- “Device for osteosynthesis” 1991 (patent 1699445).
- “Device for combined osteosynthesis of proximal humerus
fragments” 2003 (patent 2208415).
- “Assembly for combined supraosseous and intramedullar osteosynthesis of the proximal femur” 2003 (patent 2206290).
PICHKHADZE’S APPARATUSES of MODEL II
Pichkhadze’s apparatus model I is intended for the treatment of intra- and periarticular fractures of long bones. It happily combines a capability of providing a targeted stepby- step closed (i.e. without incisions) elimination of fragment displacement with quite firm fixation until complete union of the fracture has been achieved.
Pichkhadze’s apparatus model II is intended for the treatment of polyfocal intra- and periarticular diaphyseal fractures of long bones.
The apparatuses have several advantages in comparison with ones of other constructions. They can be used to treat non-, uni- and bileveral injures of long bones. They are easy to adjust to every individual patient. To achieve this, it is enough to remove unused parts (arcs-attachments and nails-fixatives) during or before surgery, and to perform/external osteosynthesis. The main distinguishing feature of these apparatuses is the combination of an extensive scope for repositioning, and reliable fragment stabilization.
The apparatuses make it possible to perform precise closed repositioning of fragments in intra- and periarticular fractures and in diaphyseal fractures of long bones as well. The apparatus construction allows to move fragments in any direction in three-dimensional space, and to neutralize all 6 degrees of freedom of each fragment with due account for its biomechanical characteristics. The range of the reposition movements of the apparatus exceeds what is practically needed, in case of inaccuracy in its assembly. It is possible to insert pins next to the fracture line and to reposition even small fragments. The apparatuses make it possible to perform all known versions of pin insertion with the creation of a crossing in various planes at different angles.
During the treatment the tension of each separate pin can be graduated. After the apparatuses have been installed, a good access for open surgery and dressing remains. The apparatuses enable early development of movements in the injured and adjacent joints. It is easy to replace a pin in them or insert an additional one. The weight of the full set is only 1.5 kg. A physician who has a good knowledge of the biomechanical concept of fragment fixation will not find it difficult to choose the right apparatus.
PICHKHADZE’S APPARATUSES of MODEL I
PICHKHADZE’S APPARATUS MODEL III
Pichkhadze’s apparatus model III is intended for monopolar , bipolar and polypolar fixation with the possibility of bony reduction in three orthogonal planes.
The speediest fracture union is achieved with the most precise bone reduction and stable fragment fixation for the duration of treatment. Maximum stability in fracture zone is achieved by using the combination of the biomechanical concept of fragment fixation and external osteosynthesis.
Pichkhadze’s multifunction apparatus model III for bone reduction was created for this express purpose as well as for monopolar and polypolar fixation in long-bone and pelvic fractures.
The apparatus is assembled in pin, rod and pin-rod arrangements.
The set consists of semi-rings, rings, straight and special pins, reposition studs which are fastened to the bearing beam with special brackets. It is easy to orient the construction in relation to the fragments and create levels of fixation on it. Fixation can be carried out in any order, e.g. an intermediate level of fixation can be created after the basic ones. Apparatus model III happily combines the possibility of a targeted successive bone repositioning in three orthogonal planes and quite firm fixation of fragments with due account of the biomechanical nature of the fracture until its complete union has been achieved.
The apparatus is intended for treating fresh open and closed limb and pelvic fractures. It can also be successfully used to cure longstanding injures — pseudarthrosises, including ones complicated by chronic osteomyelitis, and orthopedic diseases of the relevant regions. Pichkhadze’s apparatus III has several advantages compared with ones of other constructions. It is the most general apparatus for the treatment of skeleton bone fractures and their complications, and orthopedic diseases as well. It provides the largest range of repositioning of each bone fragment in closed bone reduction, and the greatest spatial stability of ragments.
The apparatus is light and comfortable for both the patient and the surgeon. It is resistant to corrosion as it is made of titanium alloy. The apparatus is easy to assemble individually during surgery with due account of the nature of the fracture. It is possible to prepare before surgery its preassembled units, which are easily adjusted to the individual case.For this purpose it is enough to select the appropriate parts during or before the operation, and to perform external osteosynthesis. The range of the reposition movements of the apparatus exceeds what is practically needed in case of inaccuracy in its assembly during surgery.
The construction allows to achieve fragment stability, i.e. to neutralize all 6 degrees of freedom of each fragment with due account of its biomechanical characteristics. The apparatus enables early development of movement in the injured and adjacent joints due to high rigidity of fixation of fragments of different shapes and sizes. The size of the apparatus varies depending of its assembly but does not exceed 450 mm x 270 mm x 240 mm. The weight of the apparatus does not exceed 3 kg.
PICHKHADZE’S CONSTRUCTION FOR SUBCUTANEOUS — SUPRAOSSEOUS — TRANSOSSEOUS OSTEOSYNTHESIS.
PROF. PICHKHADZE’S APPARATUSES AND CONSTRUCTIONS PROVIDE THE SURGEON WITH A WIDE RANGE OF FIXATION OPTIONS IN VARIOUS TYPES OF FRACTURES, ENSURE COMFORT FOR THE PATIENT, AND GUARANTEE HIGH QUANTITY AND RELIABILITY OF OSTEOSYNTHESIS.
Pichkhadze’s construction for subcutaneous — supraosseous-transosseous osteosynthesis is intended for the treatment of fresh closed long-bone fractures. It provides early development of full range of movement in the joints adjacent to the injured one.
The construction consists of a bearing plate, attached brackets, cortical and metaphyseal fixatives. By means of an original set of instruments for plate installation it is possible to apply compression at the site of the fracture. Open and semi-open fracture reduction is performed in one step. The construction has several advantages compared with others: it provides stable fixation in osteosynthesis of diathyseal and metaphyseal long-bone fractures with a minimum number of screws.
The construction can be placed extraosseously, close to the bone, subcutaneously, i.e. at a distance from the bone in soft tissues, and externally, as an external fixation device.
The possibility of locating it at a distance from the bone in soft tissues makes it possible to maintain blood flow to bone fragments. The construction can be used both as an internal fixative and as an external fixation device, and also in the combination of subcutaneous — supraosseous and transosseous osteosyntesis at the same time. When necessary, internal parts of the fixative are easily linked up with the parts of Pichkhadze’s apparatus model III.Stable fixation provided with this construction makes it possible to
avoid plaster fixation, to start exercise and movement development in the very first days after surgery. Screws with
an original cortical thread firmly fix the construction into the bone. Offset brackets are also firmly fixed on the plate by means of threaded connection, and the section of the plate and the alloy composition allow the plate to carry the necessary load in long-bone osteosynthesis . The plates and screws are made of strong titanium alloy which allows them to carry a heavy load. The construction is easy to assemble individually during surgery with due account of the biomechanical nature of the fracture. Post-operative care
is facilitated significantly, the development of movement in adjacent joint can start early, patients can return to an active lifestyle early after surgery, and the injured limb can start regaining its load-carrying early too.
«ORTHO» COMPUTER SYSTEM IS A NEW WORD IN THE DEVELOPMENT OF TRAUMATOLOGY IN THE 21ST CENTURY.
Pichkhadze’s fundamental theoretical ideas and unique constructions for fracture treatment created on their basis are a new stage in the development of traumatology and orthopedics.
Modern medicine has added the broadest possibilities of computer technology to the physician’s knowledge and professional insight. Having created a biomechanical approach to the classification and fixation of bone injures, Prof. Pichkhadze has systematized the latest ideas on the subject, thus making it possible to choose individual treatment for every patient with the help of the «ORTHO» computer system, which was developed with technical assistance from Moscow State University, the Bauman Moscow State Technical University, the Kurchatov Institute, and the Federal Space Agency’s Mission Control Centre (TsUP). The «ORTHO» system allows the traumatic surgeon to diagnose the nature of the fracture and the size ofbone defects and deformation with utmost precision. It helps to choose the best arrangement of the apparatuses and other constructions for fragment fixation with due account of the biomechanical approach, and to calculate the degree of firmness of osteosynthesis. The system helps optimize the quality of closed bone reduction, taking into account the technical capabilities of the apparatus chosen by the surgeon.
