This article is dedicated to the specialist in pediatric surgery, Professor Dr. R.T. Carbon (Erlangen, Germany) with heartfelt gratitude for his educational impact. We thank the Radiological Institute of the Erlangen University Hospital (Director: Prof. Michael Uder) for providing the X-rays and CT scans.

NOTE: The following procedures were approved by the head of department and meet all other institutional requirements.
1. Pre-operative Computed Tomography
NOTE: A helical computed tomography of the entire chest wall is taken following the local standards before the protocol begins.
<img alt="CT scan images showing various anatomical views, including chest and spine cross-sections." src="/files/ftp_upload/52124/52124fig1highres.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Preoperative CT-Scan. (a) Axial view shows oblique and longitudinal fractures. (b) Sagittal view shows anterior-posterior dislocation or sternal kinking. (c) Coronal view gives an overview over oblique and longitudinal fractures. (d) Volume rendering technique (VRT) gives an overview over the entire anterior chest wall showing rib fractures, manubrium and corpus sterni fracture
<ol>
	<li>Scan the chest wall for injuries. Inspect the complete anterior chest wall including examination of soft tissue, cartilage and bones.
	<ol>
		<li>Look for bone fractures at the manubrium, corpus sterni and adjacent ribs I to VII on both sides. Look for cartilage disruption. Be aware of cartilage disruption and sternocostal separation not to miss any cause of instability.</li>
		<li>Perform a three dimensional evaluation. See the whole chest wall in the modus of three dimensional reconstructed pictures by evaluating each axial, coronal and sagittal picture in detail.</li>
	</ol>
	</li>
	<li>Pinpoint the fracture:
	<ol>
		<li>Take the distance from the upper sternal edge (jugulum) to the fracture. Use the sagittal view for measuring.</li>
		<li>In case of oblique fracture or multiple fractures measure both distances to jugulum, the cranial and the caudal edge of the fractures. Take the distance between those edges. The additional use of the coronal pictures might be helpful in this case.</li>
	</ol>
	</li>
	<li>Determine the thickness of presternal soft tissue. Evaluate and measure the thickness of presternal soft tissue at the point of the fracture.</li>
	<li>Estimate the length of the possible surgical incision, performed in the midline. 
	NOTE: The basic approach needs to be at least 60 mm plus thickness of presternal soft tissue to get a proper access to a transverse fracture.
	<ol>
		<li>In case of oblique fracture or multiple fractures add the distance between the cranial and the caudal edge of the fractures to the basic approach. 
		NOTE: There might be a need of a longer incision in obese patients, if there are scars in the determined region or for other reasons.</li>
	</ol>
	</li>
</ol>
2. Surgical Treatment
<img alt="Surgical procedure on abdominal area; incision, tissue exposure, retractor use; medical anatomy." src="/files/ftp_upload/52124/52124fig2highres.jpg" data-altupdatedat="1747911167000" data-alt="Figure 2"> 
Figure 2: Surgical approach. (a) Positioning on the back gives access to the entire anterior chest wall and both axles; chest tube were already inserted bilaterally in this case. (b) After drawing the landmarks such as jugulum and sternoclavicular joints (above) the midline is identified and the incision performed. Pectoral muscle was dissected from the anterior sternum. A raspatory is inserted subperiostally. (c) The approach gives full access to any fracture identified. In this case two transverse fractures are shown.
2.1) Initial surgical procedures:
<ol>
	<li>Perform the operation under general anesthesia following the local standards while the patient is intubated. Place the patient in a supine position. Rest the arms on an arm board which must be placed less than 90° to the midline of the body and level the board with the floor. This might be useful if insertion of a chest tube becomes necessary.</li>
	<li>Remove superficial soil, debris, jewelry and transient microbes before applying antiseptic agents. Leave hair at the surgical site in place whenever possible.
	<ol>
		<li>Commence disinfection following the local standards. Start from the cleanest area, usually the operative and/or incision site and proceed in a concentric fashion to the least clean area. Allow the disinfectant solution to dry completely naturally. Ensure that the antiseptic solution remains in contact with the skin for the required period of time as recommended by the manufacturer.</li>
	</ol>
	</li>
	<li>Secure free access at least to the jugulum, the umbilicus and the axillary midline on both sides. Mark anatomical landmarks such as sternoclavicular joints on both sides, the upper sternal edge at the jugulum, the lower sternal edge and xiphoid, the seventh rib bilaterally and the umbilicus using a sterile pen.
	<ol>
		<li>Draw the midline now between jugulum and umbilicus and mark the cranial and caudal edge of the fractures as measured in step 1.2. Add half of the basic approach cranial and the other half caudal to the edges of the fractured region of sternum.</li>
	</ol>
	</li>
	<li>Double check the correct position of the fracture(s) and of the midline, then perform the midline incision respecting the anatomical layers in soft tissue.</li>
	<li>Remove presternal haematoma by a vertical incision along the length of the haematoma and wash out as much as possible with 0.9% saline.</li>
	<li>Cautiously take away the pectoral muscle bilaterally, beginning from the midline to the margin of the sternum whilst respecting the anatomical layers. Be aware of bleeding from smaller vessels and stop them. Identify the fracture.</li>
	<li>Expose the intercostal margin of the sternum, both, cranial and caudal of the fracture. Perform an incision of the sternal periosteum longitudinally along the front edge of the sternum. Cautiously dissect the periosteum from the bone laterally and on the posterior surface of the sternum using an elevatory or raspatory device. 
	NOTE: Preparation very close to the bone during this procedure is very important to prevent injuries to the adjacent internal thoracic vessels and the mediastinum.</li>
	<li>Expose the fracture and clear the fracture cautiously. Usually retrosternal haematoma will appear at this time, wash out as much as possible with 0.9% saline.</li>
</ol>
<img alt="Surgical procedure sequence: orthopedic implant placement, tools, incision process, medical operation." src="/files/ftp_upload/52124/52124fig3highres.jpg" data-altupdatedat="1747911167000" data-alt="Figure 3"> 
Figure 3: Surgical safety. (a) Measuring the sternal thickness and insert an elevator device. (b, c) Depth limited drilling.
<ol start="9">
	<li>Measure the thickness of the sternum with a blunt instrument. Do not use a common “lot” due to possible retrosternal injuries. Prepare a drilling machine with a drill of the length of sternal thickness or shorter if not clear.</li>
	<li>Reduce the bone fragments by elevating the posteriorly depressed fragments with an elevator device which can be inserted through the same subperiosteal approach shown in step 2.1.7. Assemble the laterally dislocated fragment should be by lateral compression. Use a pointed ball forceps, weller clamp or compression wires if necessary.</li>
</ol>
<img alt="Surgical technique diagrams; orthopedic plate fixation on bone fracture." src="/files/ftp_upload/52124/52124fig4highres.jpg" data-altupdatedat="1747911167000" data-alt="Figure 4"> 
Figure 4: Fixation options of the plates. (a) Transverse fracture at corpus sterni: fixation with a pointed ball forceps and locked screws. (b) Oblique fracture at manubrium: reduction with compression wires , the first plate has been fixed yet. (c) Multiple transverse fracture; fixation of the plate using compression wires at the manubrium (above) and pointed ball forceps (below).
2.2) Transverse fractures and oblique fractures of sternal body:
<ol>
	<li>Mark the midline of the sternum using a pen or electrocautery.</li>
	<li>Insert a small pointed ball forceps to the posterior surface of the sternum using the intercostal space next to the fracture, again keeping very closed to the sternal bone. Use the intercostal space of the depressed fragment first.
	<ol>
		<li>Put a longitudinal plate next to the midline and fix it with the pointed ball forcipes. 
		NOTE: At least three screw holes of the plate should cover the cranial and the caudal main fragment. In case of a single fracture, a seven or eight-hole plate offers the correct fixation. Using longer plates is necessary in multiple fractures, where a longer distance needs to be fixed.</li>
	</ol>
	</li>
	<li>Fix the plate with locked screws, drilling each hole using a drilling guide and the drill as chosen under step 2.1.9 thus ensuring depth limited drilling and a secured locked fixation of each screw to the plate. Again, fix each main fragment with at least three screws.</li>
	<li>Put a second plate on the other side of the midline and repeat the steps 2.2.2-2.2.3.</li>
</ol>
2.3) Longitudinal fractures, oblique manubrium fractures and sternocostal separation:
<ol>
	<li>Reduce the fracture as shown under step 2.1.10.</li>
	<li>Insert one small pointed ball forceps to the posterior surface of the sternum on each side using the intercostal space next to the fracture, again keeping very close to the sternal bone. Put a transverse plate from rib to rib, bridging the sternum with its fragments and fix it with the pointed ball forcipes. Place at least three screw holes laterally of each fracture. 
	NOTE: In case of a single fracture, a seven or eight- hole-plate offers the correct fixation. The use of longer plates usually becomes necessary for multiple fractures.</li>
	<li>Fix the plate with locked screws; use a drilling guide and the drill as chosen under step 2.1.9 thus ensuring depth limited drilling. Again, fix each of the main fragments with at least three screws.</li>
	<li>For osteosynthesis of each injured level, repeat steps 2.3.1-2.3.3.</li>
</ol>
<img alt="Surgical stabilization and X-ray of rib fractures showing fixation plates in thoracic surgery procedure." src="/files/ftp_upload/52124/52124fig5highres.jpg" data-altupdatedat="1747911167000" data-alt="Figure 5"> 
Figure 5: Operative results. (a) Long parallel plates, each fragment was fixed with 3 screws. (b) Postoperative chest x-ray showing longitudinal sternal plate and three transverse plates fixing oblique manubrium fracture, sternocostal separation of second rib and fracture of third rib on the right side. (c) Lateral view of x-ray shows correct position of two parallel plates fixing a fracture located at sternal corpus.
<ol start="5">
	<li>Double check the correct position of all plates. Examine the anterior chest wall for sufficient stability. Look for any bleeding and stop it. Rule out pleural lesions. If a pleural lesion is indicated or suspected, insert a chest tube into the pleural cavity on the affected side using an axillary approach.</li>
	<li>Insert a subcutaneous drainage if necessary. Place the tube in front of the sternum and percutaneously divert about 5 cm away from the lower edge of the wound.</li>
	<li>Close the wound respecting the anatomical layers. Suture the periosteal incisions to preserve sternal blood supply. Approximation of the pectoral muscle to the midline is recommended to ensure a proper coverage of the implants with soft tissue.</li>
	<li>Take a chest x-ray after surgical treatment to rule out pneumothorax and hemothorax. The additional lateral view will show the position of the sternal fragments and of the implants.</li>
</ol>

<ol>
	<li>Athanassiadi, K., Gerazounis, M., Moustardas, M., Metaxas, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sternal+fractures:+retrospective+analysis+of+100+cases.">Sternal fractures: retrospective analysis of 100 cases.</a> World J. Surg. 26 (10), 1243-1246 (2002).</li><li>Severson, E. P., Thompson, C. A., Resig, S. G., Swiontkowski, M. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transverse+sternal+nonunion,+repair+and+revision:+a+case+report+and+review+of+the+literature.">Transverse sternal nonunion, repair and revision: a case report and review of the literature.</a> J. Trauma. 66 (5), 1485-1488 (2009).</li><li>Queitsch, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+posttraumatic+sternal+non-union+with+a+locked+sternumosteosynthesis+plate+(TiFix).">Treatment of posttraumatic sternal non-union with a locked sternumosteosynthesis plate (TiFix).</a> Injury. 42 (1), 44-46 (2011).</li><li>Fowler, A. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Flexion-compression+injury+of+the+sternum.">Flexion-compression injury of the sternum.</a> J. Bone Joint Surg Br. 39 (3), 487-497 (1957).</li><li>Bailey, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracic+hyperextension+injury+with+complete+'bony+disruption'+of+the+thoracic+cage:+Case+report+of+a+potentially+life-threatening+injury.">Thoracic hyperextension injury with complete 'bony disruption' of the thoracic cage: Case report of a potentially life-threatening injury.</a> World J. Emerg Surg. 7 (1), 14 (2012).</li><li>Ciriaco, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Early+surgical+repair+of+isolated+traumatic+sternal+fractures+using+a+cervical+plate+system.">Early surgical repair of isolated traumatic sternal fractures using a cervical plate system.</a> J. Trauma. 66 (2), 462-464 (2009).</li><li>Harston, A., Roberts, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fixation+of+sternal+fractures:+a+systematic+review.">Fixation of sternal fractures: a systematic review.</a> J. Trauma. 71 (6), 1875-1879 (2011).</li><li>Fawzy, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sternal+plating+for+primary+and+secondary+sternal+closure;+can+it+improve+sternal+stability.">Sternal plating for primary and secondary sternal closure; can it improve sternal stability.</a> J. Cardiothorac Surg. 4, 19 (2009).</li><li>Murphy, W. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> AO Principles of Fracture Management. , 25-165 (2000).</li><li>Mayberry, J. C., Ham, L. B., Schipper, P. H., Ellis, T. J., Mullins, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surveyed+opinion+of+American+trauma,+orthopedic,+and+thoracic+surgeons+on+rib+and+sternal+fracture+repair.">Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair.</a> J. Trauma. 66 (3), 875-879 (2009).</li><li>Gloyer, M. A., Frei, H. C., Hotz, T. K., K&#228;ch, K. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Osteosynthesis+of+traumatic+manubriosternal+dislocations+and+sternal+fractures+with+a+3.5/4.0+mm+fixed-angle+plate+(LCP).">Osteosynthesis of traumatic manubriosternal dislocations and sternal fractures with a 3.5/4.0 mm fixed-angle plate (LCP).</a> Arch. Orthop. Trauma Surg. 131 (9), 1261-1266 (2011).</li><li>Schulz-Drost, S., Mauerer, A., Grupp, S., Hennig, F. F., Blanke, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+fixation+of+sternal+fractures:+locked+plate+fixation+by+low-profile+titanium+plates--surgical+safety+through+depth+limited+drilling.">Surgical fixation of sternal fractures: locked plate fixation by low-profile titanium plates--surgical safety through depth limited drilling.</a> Int. Orthop. 38 (1), 133-139 (2014).</li><li>Wu, L. C., Renucci, J. D., Song, D. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sternalnonunion:+a+review+of+currenttreatments+and+a+newmethod+of+rigidfixation.">Sternalnonunion: a review of currenttreatments and a newmethod of rigidfixation.</a> Ann. Plast. Surg. 54 (1), 55-58 (2005).</li><li>Potaris, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+sternal+fractures:+239+cases.">Management of sternal fractures: 239 cases.</a> Asian Cardiovasc. Thorac. Ann. 10 (2), 145-149 (2002).</li><li>Coons, D. A., Pitcher, J. D., Braxton, M., Bickley, B. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sternal+nonunion,+case+report.">Sternal nonunion, case report.</a> Orthopedics. 25, 89-91 (2002).</li><li>Abdul-Rahman, M. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comminuted+sternal+fracture&#8212;a+sternotomy+wire+fixation:+report+of+2+cases.">Comminuted sternal fracture&#8212;a sternotomy wire fixation: report of 2 cases.</a> Heart Surg. Forum. 12 (3), E184-E186 (2009).</li><li>Celik, B., Sahin, E., Nadir, A., Kaptanoglu, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sternum+fractures+and+effects+of+associated+injuries.">Sternum fractures and effects of associated injuries.</a> Thorac. Cardiovasc. Surg. 57 (8), 468-471 (2009).</li><li>Bonney, S., Lenczner, E., Harvey, E. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sternal+fractures:+anterior+plating+rationale.">Sternal fractures: anterior plating rationale.</a> J. Trauma. 57 (6), 1344-1346 (2004).</li><li>Kitchens, J., Richardson, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Open+fixation+of+sternal+fracture.">Open fixation of sternal fracture.</a> Surg. Gynecol. Obstet. 177 (4), 423-424 (1993).</li><li>Al-Qudah, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Operative+treatment+of+sternal+fractures.">Operative treatment of sternal fractures.</a> Asian Cardiovasc. Thorac. Ann. 14 (8), 399-401 (2006).</li><li>Frangen, T. M., M&#252;ller, E. J., Muhr, G., Hopf, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Traumatic+manubriosternal+dislocation.">Traumatic manubriosternal dislocation.</a> Arch. Orthop. Trauma Surg. 126 (6), 411-416 (2006).</li><li>Molina, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+and+operative+technique+to+repair+isolated+stemal+fracture.">Evaluation and operative technique to repair isolated stemal fracture.</a> J Thorac Cardiovasc Surg. 130 (2), 445-448 (2005).</li><li>El Ibrahimi, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Traumatic+manubriosternal+dislocation:+A+new+method+of+stabilization+postreduction.">Traumatic manubriosternal dislocation: A new method of stabilization postreduction.</a> J. Emerg. Trauma Shock. 4 (2), 317-319 (2011).</li><li>Richardson, J. D., Franklin, G. A., Heffley, S., Seligson, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Operative+fixation+of+chest+wall+fractures:+an+underused+procedure.">Operative fixation of chest wall fractures: an underused procedure.</a> Am. Surg. 73 (6), 591-596 (2007).</li><li>M&#252;nzberg, M., Mahlke, L., Bouillon, B., Paffrath, T., Matthes, G., W&#246;lfl, C. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Six+years+of+Advanced+Trauma+Life+Support+(ATLS)+in+Germany:+the+100th+provider+course+in+Hamburg.">Six years of Advanced Trauma Life Support (ATLS) in Germany: the 100th provider course in Hamburg.</a> Unfallchirurg. 113 (7), 561-566 (2010).</li><li>Schulz-Drost, S., Syed, J., Besendoerfer, M., Carbon, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sternocostal+Dislocation+Following+Open+Correction+of+Pectus+Excavatum-'Stairway+Phenomenon':+Complication+Management+by+Means+of+Sternocostal+Locking+Titanium+Plate+Osteosynthesis.">Sternocostal Dislocation Following Open Correction of Pectus Excavatum-'Stairway Phenomenon': Complication Management by Means of Sternocostal Locking Titanium Plate Osteosynthesis.</a> Thorac Cardiovasc Surg. 62 (3), 245-252 (2013).</li><li>Ergene, G., Tulay, C. M., Anas&#305;z, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sternal+fixation+with+nonspecific+plate.">Sternal fixation with nonspecific plate.</a> Ann Thorac Cardiovasc Surg. 19 (5), 364-367 (2012).</li><li>Kehdy, F., Richardson, J. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+utility+of+3-D+CT+scan+in+the+diagnosis+and+evaluation+of+sternalfractures.">The utility of 3-D CT scan in the diagnosis and evaluation of sternalfractures.</a> J. Trauma. 60 (3), 635-636 (2006).</li><li>Alkadhi, H., Wildermuth, S., Marincek, B., Boehm, T. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Accuracy+and+time+efficiency+for+the+detection+of+thoracic+cage+fractures:+volume+rendering+compared+with+transverse+computed+tomography+images.">Accuracy and time efficiency for the detection of thoracic cage fractures: volume rendering compared with transverse computed tomography images.</a> Comput. Assist. Tomogr. 28 (3), 378-385 (2004).</li></ol>

The first author has a consultant agreement with Synthes CMF. No funds were received in connection to the presented study. The coauthors are not involved in any conflict of interest.

Although most of the sternal fractures are treated conservatively, sometimes a surgical fixation becomes necessary. The sternal anatomy and the stability of the anterior chest wall are restored by a stable fixation employing a locked plate osteosynthesis. Using very slim plates (1.5 mm or 2.0 mm thickness) provides a proper stability on the one hand and high convenience for the patient on the other hand12. Very good results are also described for the application of any locked plate, for example LCP System or plates developed for other bones like the cervical spine or the distal radius6,27.
Locked plates are considered to provide the advantage of a biological fixation to be functional as an internal fixator with significantly reduced friction between plate and bone9. The positioning of such an internal fixator on the anterior sternal surface provides a sufficient fixation of the convex surface of the fracture and thus reducing traction forces to the fracture. At the same time each respiratory movement induces compression to internal sternal cortex and to the fracture thus stimulating bone healing. Each screws needs to be locked securely to enable the efficiency of the internal fixator.
As we recommend the fixation of each fragment with at least three screws, there could be limitations in case of very short fragments. Possible solutions are the bridging of those fragments and the use of special plates, which allow longitudinal and transverse fixation rolled into one. In the future, &#8220;T&#8221; or &#8220;H&#8221;-shaped plates could be helpful in those situations.
Some surgeons show a reluctance to operate on the chest wall, probably due to a lack of experience in this particular region. There is a need for a simple and safe method for sternal stabilization1,12. The above described method represents one possible standard and reduces the risk of complications due to the operative procedure by a precise preoperative planning, subperiosteal dissection of soft tissue, and depth limited drilling. There lies the difference in the use of any other plates not providing the possibility of depth limited drilling (Table 1), whereas the preoperative planning, the steps of preparation, and reduction of the fracture could be performed analogously to the described way of this manuscript.
As a three dimensional reconstructed CT scan allows the diagnosis of fractures to sternum and concomitant fractures with high sensitivity the surgeon gets detailed information about the injury28,29. The CT shows the particular position and the direction of the fracture as well as any dislocation. This important information simplifies the preoperative planning of the intended surgical approach as shown in steps 1.1-1.5. Furthermore, it allows a precise planning of the number and design of the plates which should be employed for fixation as shown in the steps 2.2-2.3. A possible limitation of a CT scan lies in difficulties showing undislocated fractures and disruption of cartilage although they could contribute to the instability of the chest wall.
The subperiosteal dissection and the depth limited drilling are the two most important steps for surgical safety.
Reducing the sternal fragments to their anatomic position usually necessitates an approach to the posterior wall of the sternum. This procedure may injure mediastinal organs, surrounding vessels and the sternal blood supply7,18. Performing strictly subperiosteal dissection around the sternum as shown in step 2.1.7 will minimize the risk of complications. Fractures which show a lateral dislocation, could have their fragments move very closely to the internal mammary vessels. In those cases the surgeon needs to be aware of any injury to those vessels which could cause severe bleeding. At the time a bleeding in this particular region is identified, the surgeon needs to stop it immediately through an intercostal approach to the internal mammary vessel. The dissection of intercostal muscles and the insertion of a spreader in the affected intercostal space provides a quick and proper access to the injured vessel.
Drilling too deep has to be avoided, as it may cause life-threatening injuries to the mediastinum. This is ensured by depth limited drilling in combination with the measurement of the sternal thickness and the choice of a drill bit of corresponding length12.
Summarizing the discussed procedure and possible limitations, performing anterior sternal plating with low profile locked titanium plates is to be expected successful, if a preoperative planning by computed tomography, subperiostal dissection, and depth limited drilling is performed.

Sternal fractures are rare and occur in about 3-8% of all trauma victims1. Usually, these fractures are caused by blunt trauma. Most can be treated conservatively with a sufficient consolidation of the fracture. Some fractures show prolonged healing or even a lack of consolidation with the consecutive development of a pseudarthrosis and persistent painful instability2,3. In these cases surgical stabilization has to be considered. Respecting the different trauma-mechanisms responsible for sternal fractures such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, a primarily stabilization of the fractures should be considered4-6. Possible indications for surgical treatment are: severe or persistent pain; respiratory failure or dependency on mechanical ventilation; shifted, overlapping or impacted fractures, as well as deformity or instability of the sternum; hunched posture and restricted movement of the trunk7.
There is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum in order to restore anatomical shape and normal function of the anterior chest wall. In this context anterior sternal plating provides the best stability and is therefore increasingly used in the majority of cases. The advantage in stability by using a plate instead of wires has already been described in sternum closure after median sternotomy8. The use of locked plates gains importance due to their advantages in biological internal fixation. The principle of a locked plate is the fixation between the threaded screw head and the threaded screw hole of the plate. Thereby the locked plate acts as an internal fixator with the advantage of a minimized plate-bone contact preserving the periosteal blood supply below the plate9.
However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications. Difficulties in preoperative planning, severe injuries to mediastinal organs or failure of the performed method may be possible reasons10. Only case reports or small series are described for each procedure. Table 1 shows different surgical methods and a selection of trails describing and analyzing them.
<table border="0" cellpadding="0" cellspacing="0">
	<tbody>
		<tr>
			<td>OP-technique</td>
			<td>Year</td>
			<td>Author</td>
			<td>Study</td>
			<td>Number of patients with surgery</td>
			<td>Outcome</td>
		</tr>
		<tr>
			<td colspan="6">locked plate fixation</td>
		</tr>
		<tr>
			<td>3.5/4.0 mm fixed angle plate (LCP)</td>
			<td>2010</td>
			<td>Gloyer et al. [10]</td>
			<td>Osteosynthesis of traumatic manubriosternal dislocations and sternal fractures with a 3.5/4.0 fixed angle plate (LCP)</td>
			<td>3</td>
			<td>no functional restrictions, no pain</td>
		</tr>
		<tr>
			<td>locked plate (TiFix)</td>
			<td>2010</td>
			<td>Queitsch et al. [3]</td>
			<td>Treatment of posttraumatic sternal non-union with a locked sternum-osteosynthesis plate (TiFix).</td>
			<td>12</td>
			<td>consolidation in all cases</td>
		</tr>
		<tr>
			<td>low profile titanium plate (MatrixRib)&#160;</td>
			<td>2013</td>
			<td>Schulz-Drost et al. [11]</td>
			<td>Surgical fixation of sternal fractures: locked plate fixation by low-profile titanium plates - surgical safety through depth limited drilling</td>
			<td>10</td>
			<td>after 12 weeks consolidation in all cases, no dislocation, patient satisfaction 1.4, no complications in follow up</td>
		</tr>
		<tr>
			<td>SternaLock</td>
			<td>2005</td>
			<td>Wu et al. [12]</td>
			<td>Sternal nonunion: a review of current treatments and a new method of rigid fixation</td>
			<td>2</td>
			<td>good functional outcome</td>
		</tr>
		<tr>
			<td colspan="6">Steel wires</td>
		</tr>
		<tr>
			<td>Stainless steel wires</td>
			<td>2002</td>
			<td>Athanassiadi et al. [1]</td>
			<td>Sternal fractures: retrospective analysis of 100 cases</td>
			<td>2</td>
			<td>good functional outcome</td>
		</tr>
		<tr>
			<td>Stainless steel wires</td>
			<td>2002</td>
			<td>Potaris et al. [13]</td>
			<td>Management of sternal fractures of 239 cases</td>
			<td>4</td>
			<td>good functional outcome</td>
		</tr>
		<tr>
			<td>Sternal wire, bone graft</td>
			<td>2002</td>
			<td>Coons et al. [15]</td>
			<td>Sternal non union: Case report</td>
			<td>2</td>
			<td>one patient with non union</td>
		</tr>
		<tr>
			<td>Steel wires</td>
			<td>2009</td>
			<td>Abdul Rahman et al. [16]</td>
			<td>Comminutes sternal fracture - a sternotomy wire fixation: report of 2 cases</td>
			<td>2</td>
			<td>good functional outcome</td>
		</tr>
		<tr>
			<td>Steel wires</td>
			<td>2009</td>
			<td>Celik et al. [17]</td>
			<td>Sternum fractures and effects of associated injuries</td>
			<td>2</td>
			<td>good functional outcome</td>
		</tr>
		<tr>
			<td colspan="6">non locking plate</td>
		</tr>
		<tr>
			<td>Ant. 6 hole plate, bone graft</td>
			<td>2004</td>
			<td>Bonney et al. [18]</td>
			<td>Sternal fractures: anterior plating rationale</td>
			<td>3</td>
			<td>plate removal after 12 months for personal resons</td>
		</tr>
		<tr>
			<td>Ant. Cervical plates with 4 holes</td>
			<td>2009</td>
			<td>Ciriaco et al. [6]</td>
			<td>Early repair of isolated traumatic sternal fractures unsing a plate system</td>
			<td>6</td>
			<td>one plate removed for sternal pain</td>
		</tr>
		<tr>
			<td>Plate with 3 screws on eachs side of fracture</td>
			<td>1993</td>
			<td>Kitchensens and Richardson [19]</td>
			<td>Open fixation of sternal fractures</td>
			<td>2</td>
			<td>good functional outcome</td>
		</tr>
		<tr>
			<td>T-shaped compression steel plate, non-locking screws</td>
			<td>2006</td>
			<td>Al-Qudah [20]</td>
			<td>Operative treatment of sternal fractures</td>
			<td>4</td>
			<td>2 plates removed no reasons named</td>
		</tr>
		<tr>
			<td>two 8 hole one-third tubular plates; H-plate</td>
			<td>2006</td>
			<td>K&#228;licke et al. [21]</td>
			<td>Traumatic manubriosternal dislocation</td>
			<td>2</td>
			<td>no functional restrictions, no pain</td>
		</tr>
		<tr>
			<td colspan="6">other devices</td>
		</tr>
		<tr>
			<td>2 threaded Steinmann pins, sternal wires</td>
			<td>2005</td>
			<td>Molina [22]</td>
			<td>Evaluation and operative technique to repair isolated sternal fractures</td>
			<td>12</td>
			<td>pin migration in one patient</td>
		</tr>
		<tr>
			<td>Blount staples</td>
			<td>2011</td>
			<td>Abdelhalim El Ibrahimi et al. [23]</td>
			<td>Traumatic manubriosternal dislocation: A new method of stabilization postreduction</td>
			<td>1</td>
			<td>good functional outcome</td>
		</tr>
		<tr>
			<td>Titanium mandibular plates</td>
			<td>2007</td>
			<td>Richardson et al. [24]</td>
			<td>Operative fixation of chest wall fractures: an understood prcedure?</td>
			<td>35</td>
			<td>3 plates removed (1 cardiac surgery, 1 clicking sensation, 1 insurance reasons)</td>
		</tr>
	</tbody>
</table>
Table 1: Fixation options &#8211; a selection of trails. Modified from HARSTON7.
Recently published surveys usually describe the successful anterior plating with a good outcome11.
The use of low-profile-locked titanium plates guarantees a proper stabilization with high patient comfort. Furthermore the fixing of those plates provides surgical safety, as depth limited drilling is used12.
Hence, this manuscript describes one option to stabilize different types of sternal fractures in a step-by-step guidance for anterior sternal plating using low profile locking titanium plates. In addition, preoperative planning is described step by step.
Diagnosis, Assessment, and Plan:
Any patient admitted to the emergency department primarily is managed by performing the ABCDE-rules, known from the Advanced Trauma Life Support, ATLS25. Thereby life-threatening injuries should be detected and immediately treated or ruled out. Afterwards, a detailed survey of the whole patient needs to be performed to detect any injury. If the patient suffers from pain in the chest or even shows an unstable chest wall with paradox respiratory movements, a sternal fracture needs to be ruled out.
Any patient with suspected sternal fracture receives helical computed tomography of the thorax. In context with suspected concomitant injuries, all patients are examined by a whole body multi-slice CT. A three-dimensional reconstruction of CT data can describe the fracture&#8217;s morphology in detail6. The affected region needs to be described as well as the fracture&#8217;s direction and possible dislocation of the fragments.
As indications for surgical treatment the unstable anterior chest wall needs to be considered as well as fracture displacement and a persistent, painful instability of more than seven days7,12. Once the decision for surgery of the sternal fracture is made, a reassessment of any concomitant injury should be performed, in order to put the treatment of multiple injuries in an appropriate sequence.
The following protocol shows one possible standard for surgical treatment of (isolated) sternal fractures whereby the possibility of a conservative treatment in most types of fractures needs to be emphasized at this point. In case of concomitant rib fractures additional considerations, which are not shown here, become necessary.

<table><tbody><tr><td>MatrixRIB</td><td>DePuySynthes CMF</td><td></td><td></td></tr><tr><td>LCP Forefood/Middlefood 2.4/2.7</td><td>DePuySynthes CMF</td><td></td><td>only compression wires are employed</td></tr></tbody></table>

surgical fixation of sternal fractures: preoperative planning and a safe surgical technique using locked titanium plates and depth limited drilling

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the anterior chest wall or the flexion-compression injury of the trunk, there is a need to retain each sternal fragment in the correct position while neutralizing shearing forces to the sternum. Anterior sternal plating provides the best stability and is therefore increasingly used in most cases. However, many surgeons are reluctant to perform sternal osteosynthesis due to possible complications such as difficulties in preoperative planning, severe injuries to mediastinal organs, or failure of the performed method.
This manuscript describes one possible safe way to stabilize different types of sternal fractures in a step by step guidance for anterior sternal plating using low profile locking titanium plates. Before surgical treatment, a detailed survey of the patient and a three dimensional reconstructed computed tomography is taken out to get detailed information of the fracture&#8217;s morphology. The surgical approach is usually a midline incision. Its position can be described by measuring the distance from upper sternal edge to the fracture and its length can be approximated by the summation of 60 mm for the basis incision, the thickness of presternal soft tissue and the greatest distance between the fragments in case of multiple fractures.
Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates prevents injuries to mediastinal organs and vessels.
Transverse fractures and oblique fractures at the corpus sterni are plated longitudinally, whereas oblique fractures of manubrium, sternocostal separation and any longitudinally fracture needs to be stabilized by a transverse plate from rib to sternum to rib. Usually the high convenience of a patient is seen during follow up as well as a precise reconstruction of the sternal morphology.

The preoperatively performed computed tomography provides a detailed survey of the whole sternum and the adjacent ribs. Using different windows of the CT data allows a detailed analysis of the bones as well as the adjacent cartilage of the ribs and the surrounding tissue. All fractures of the injured anterior chest wall should be detected. Axial pictures show injuries to cartilage in soft tissue window and disruption of sternocostal joints. Furthermore, the bone window shows longitudinal and oblique fractures of sternum, whereas transverse fractures are rarely detected in this plane. Coronal reconstructed pictures describe the fracture&#8217;s direction from a similar point of view to the one during surgical treatment. The dislocation of the fragments in relationship to the midline can be described properly. The sagittal view shows the dislocation of fragments in the anterior &#8211; posterior direction. A possible disruption of angulus sterni, the synchondrosis between manubrium and corpus sterni is shown best in this plane. These steps are shown in Figure 1a-d.
Following the steps 1.2-1.4 allows a concise planning of the surgical approach. The supine positioning allows full access to anterior chest wall and both axles (Figure 2a). Marking the landmarks simplifies the identification of the midline as shown in step 2.3 (Figure 2b).
All injured parts of the sternum and the adjacent ribs can be reached without problems while performing a median approach following steps mentioned above (Figure 2c).
Performing an incision of the sternal periosteum longitudinally along the front edge of the sternum and inserting an elevator device to the posterior surface allows the reduction of any dislocated fragment and prevents injuries to the adjacent internal thoracic vessels and the mediastinum as shown in Figure 4a. Moreover, depth limited drilling can be carried out by measurement of the sternal thickness at first (Figure 3a) and the choice of a drill bit with the corresponding length (Figure 3b, c).
The insertion of a pointed ball forceps might be difficult in some cases, e.g., at the manubrium. In those cases anteriorly placed compression wires (length = maximum sternal thickness) will help to reduce the fracture and fix the plate temporarily (Figure 4a-c).
The fixation of each fragment using at least three screws usually shows a proper stabilization for transverse as well as for oblique and longitudinal fractures (Figure 5a, b). Fixing separated ribs to the sternum can be performed by sterno-costal plating as well leading to a stable conjunction26 (Figure 5b).
At the time, all unstable parts of the anterior chest wall are fixed by plates. The anterior chest wall appears as a stable sternocostal union with physiologic respiratory movement. Respecting anatomical layers obtains the most precise wound closure; wound complications are usually rare.
Postoperatively taken chest x-rays in two planes show the correct reduction of the fracture and the correct positioning of the implants which were administered (Figure 5c). The 6 week follow up usually shows first callus surrounding the fracture and after twelve weeks consolidation usually can be observed.

Watch this Scientific Journal Video about Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling at JoVE.co

Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

Here we present a method to stabilize sternal fractures by using locked titanium plates in a low profile design. Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates provides a safe surgical way.

Different ways to stabilize a sternal fracture are described in literature. Respecting different mechanisms of trauma such as the direct impact to the ...

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63.4K Views.  University Hospital Erlangen. Here we present a method to stabilize sternal fractures by using locked titanium plates in a low profile design. Performing subperiosteal dissection along the sternum while reducing the fracture, using depth limited drilling, and fixing the plates provides a safe surgical way.

Video: Surgical Fixation of Sternal Fractures: Preoperative Planning and a Safe Surgical Technique Using Locked Titanium Plates and Depth Limited Drilling

Creating Rigidly Stabilized Fractures for Assessing Intramembranous Ossification, Distraction Osteogenesis, or Healing of Critical Sized Defects

Assessing modes of skeletal repair is essential for developing therapies to be used clinically to treat fractures. Mechanical stability plays a large role in healing of bone injuries. In the worst-case scenario mechanical instability can lead to delayed or non-union in humans. However, motion can also stimulate the healing process. In fractures that have motion cartilage forms to stabilize the fracture bone ends, and this cartilage is gradually replaced by bone through recapitulation of the developmental process of endochondral ossification. In contrast, if a bone fracture is rigidly stabilized bone forms directly via intramembranous ossification. Clinically, both endochondral and intramembranous ossification occur simultaneously. To effectively replicate this process investigators insert a pin into the medullary canal of the fractured bone as described by Bonnarens4. This experimental method provides excellent lateral stability while allowing rotational instability to persist. However, our understanding of the mechanisms that regulate these two distinct processes can also be enhanced by experimentally isolating each of these processes. We have developed a stabilization protocol that provides rotational and lateral stabilization. In this model, intramembranous ossification is the only mode of healing that is observed, and healing parameters can be compared among different strains of genetically modified mice 5-7, after application of bioactive molecules 8,9, after altering physiological parameters of healing 10, after modifying the amount or time of stabilization 11, after distraction osteogenesis 12, after creation of a non-union 13, or after creation of a critical sized defect. Here, we illustrate how to apply the modified Ilizarov fixators for studying tibial fracture healing and distraction osteogenesis in mice.

This article describes a method for stabilizing long bone fractures that is based on the application of modified Ilizarov external fixators 1-3. After application of the fixators and creation of the bone injury, healing can be assessed, distraction osteogenesis can be performed, or non-union or critical sized defect can be created and used to study therapeutic interventions.

Assessing modes of skeletal repair is essential for developing therapies to be used clinically to treat fractures. Mechanical stability plays a large role ...

Adjustable Stiffness, External Fixator for the Rat Femur Osteotomy and Segmental Bone Defect Models

The mechanical environment around the healing of broken bone is very important as it determines the way the fracture will heal. Over the past decade there has been great clinical interest in improving bone healing by altering the mechanical environment through the fixation stability around the lesion. One constraint of preclinical animal research in this area is the lack of experimental control over the local mechanical environment within a large segmental defect as well as osteotomies as they heal. In this paper we report on the design and use of an external fixator to study the healing of large segmental bone defects or osteotomies. This device not only allows for controlled axial stiffness on the bone lesion as it heals, but it also enables the change of stiffness during the healing process in vivo. The conducted experiments have shown that the fixators were able to maintain a 5 mm femoral defect gap in rats in vivo during unrestricted cage activity for at least 8 weeks. Likewise, we observed no distortion or infections, including pin infections during the entire healing period. These results demonstrate that our newly developed external fixator was able to achieve reproducible and standardized stabilization, and the alteration of the mechanical environment of in vivo rat large bone defects and various size osteotomies. This confirms that the external fixation device is well suited for preclinical research investigations using a rat model in the field of bone regeneration and repair.

One constraint of preclinical research in the field of bone repair is the lack of experimental control over the local mechanical environment within a healing bone lesion. We report the design and use of an external fixator for bone repair with the ability to change fixator stiffness in vivo.

The mechanical environment around the healing of broken bone is very important as it determines the way the fracture will heal. Over the past decade there ...

Establishment of a Segmental Femoral Critical-size Defect Model in Mice Stabilized by Plate Osteosynthesis

The use of tissue-engineered bone constructs is an appealing strategy to overcome drawbacks of autografts for the treatment of massive bone defects. As a model organism, the mouse has already been widely used in bone-related research. Large diaphyseal bone defect models in mice, however, are sparse and often use bone fixation which fills the bone marrow cavity and does not provide optimal mechanical stability. The objectives of the current study were to develop a critical-size, segmental, femoral defect in nude mice. A 3.5-mm mid-diaphyseal femoral ostectomy (approximately 25% of the femur length) was performed using a dedicated jig, and was stabilized with an anterior located locking plate and 4 locking screws. The bone defect was subsequently either left empty or filled with a bone substitute (syngenic bone graft or coralline scaffold). Bone healing was monitored noninvasively using radiography and in vivo micro-computed-tomography and was subsequently assessed by ex vivo micro-computed-tomography and undecalcified histology after animal sacrifice, 10 weeks postoperatively. The recovery of all mice was excellent, a full-weight-bearing was observed within one day following the surgical procedure. Furthermore, stable bone fixation and consistent fixation of the implanted materials were achieved in all animals tested throughout the study. When the bone defects were left empty, non-union was consistently obtained. In contrast, when the bone defects were filled with syngenic bone grafts, bone union was always observed. When the bone defects were filled with coralline scaffolds, newly-formed bone was observed in the interface between bone resection edges and the scaffold, as well as within a short distance within the scaffold. 
The present model describes a reproducible critical-size femoral defect stabilized by plate osteosynthesis with low morbidity in mice. The new load-bearing segmental bone defect model could be useful for studying the underlying mechanisms in bone regeneration pertinent to orthopaedic applications.

Although mouse models are invaluable tools for bone tissue engineering, models of long bone defects are sparse. This need motivated development of the present protocol which uses a locking plate with four screws and a dedicated jig to perform and stabilize a reproducible, femoral, critical-size defect with low morbidity.

The use of tissue-engineered bone constructs is an appealing strategy to overcome drawbacks of autografts for the treatment of massive bone defects. As a ...

An Intramedullary Locking Nail for Standardized Fixation of Femur Osteotomies to Analyze Normal and Defective Bone Healing in Mice

Bone healing models are essential to the development of new therapeutic strategies for clinical fracture treatment. Furthermore, mouse models are becoming more commonly used in trauma research. They offer a large number of mutant strains and antibodies for the analysis of the molecular mechanisms behind the highly differentiated process of bone healing. To control the biomechanical environment, standardized and well-characterized osteosynthesis techniques are mandatory in mice. Here, we report on the design and use of an intramedullary nail to stabilize open femur osteotomies in mice. The nail, made of medical-grade stainless steel, provides high axial and rotational stiffness. The implant further allows the creation of defined, constant osteotomy gap sizes from 0.00 mm to 2.00 mm. Intramedullary locking nail stabilization of femur osteotomies with gap sizes of 0.00 mm and 0.25 mm result in adequate bone healing through endochondral and intramembranous ossification. Stabilization of femur osteotomies with a gap size of 2.00 mm results in atrophic non-union. Thus, the intramedullary locking nail can be used in healing and non-healing models. A further advantage of the use of the nail compared to other open bone healing models is the possibility to adequately fix bone substitutes and scaffolds in order to study the process of osseous integration. A disadvantage of the use of the intramedullary nail is the more invasive surgical procedure, inherent to all open procedures compared to closed models. A further disadvantage may be the induction of some damage to the intramedullary cavity, inherent to all intramedullary stabilization techniques compared to extramedullary stabilization procedures.

This protocol describes an osteosynthesis technique using an intramedullary locking nail for standardized fixation of femur osteotomies, which can be used to analyze normal and defective bone healing in mice.

Bone healing models are essential to the development of new therapeutic strategies for clinical fracture treatment. Furthermore, mouse models are becoming ...

A Minimally Invasive Model to Analyze Endochondral Fracture Healing in Mice Under Standardized Biomechanical Conditions

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an increased use of mouse models in orthopedic research was noted, most probably because mouse models offer a large number of genetically-modified strains and special antibodies for the analysis of molecular mechanisms of fracture healing. To control the biomechanical conditions, well-characterized osteosynthesis techniques are mandatory, also in mice. Here, we report on the design and use of a closed bone healing model to stabilize femur fractures in mice. The intramedullary screw, made of medical-grade stainless steel, provides through fracture compression an axial and rotational stability compared to the mostly used simple intramedullary pins, which show a complete lack of axial and rotational stability. The stability achieved by the intramedullary screw allows the analysis of endochondral healing. A large amount of callus tissue, received after stabilization with the screw, offers ideal conditions to harvest tissue for biochemical and molecular analyses. A further advantage of the use of the screw is the fact that the screw can be inserted into the femur with a minimally invasive technique without inducing damage to the soft tissue. In conclusion, the screw is a unique implant that can ideally be used in closed fracture healing models offering standardized biomechanical conditions.

This protocol describes a minimally invasive osteosynthesis technique using an intramedullary screw for standardized stabilization of femur fractures, which can be used to analyze endochondral bone healing in mice.

Bone healing models are necessary to analyze the complex mechanisms of fracture healing to improve clinical fracture treatment. During the last decade, an ...

Treatment of Facial Deformities using 3D Planning and Printing of Patient-Specific Implants

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve better results, even in the less experienced hand, or continue without it. As technology develops and becomes more user-friendly, we believe it is time to allow the surgeon the option to plan his/her operations and create his/her own patient-specific surgical guides and fixation plates allowing him full control over the process. We present here a protocol for 3D planning of the operation followed by 3D planning and printing of surgical guides and patient-specific fixation implants. During this process we use two commercial computer-assisted design (CAD) software. We also use a fused deposition&#160;modeling printer for the surgical guides and a selective laser sintering printer for the titanium patient-specific fixation implants. The process includes computed tomography (CT) imaging acquisition, 3D segmentation of the skull and facial bones from the CT, 3D planning of the operations, 3D planning of patient-specific fixation implant according to the final position of the bones, 3D planning of surgical guides for performing an accurate osteotomy and preparing the bone for the fixation plates, and 3D printing of the surgical guides and the patient-specific fixation plates. The advantages of the method include full control over the surgery, planned osteotomies and fixation plates, significant reduction in price, reduction in operation duration, superior performance and highly accurate results. Limitations include the need to master the CAD programs.

As technology develops and becomes more user-friendly, planning of operations and patient-specific surgical guides and fixation plates should be performed by the surgeon. We present a protocol for 3D planning of orthognathic skeletal movements and 3D planning and printing of patient-specific fixation plates and surgical guides.

Technological advancements in surgical planning and patient-specific implants are constantly evolving. One can either adopt the technology to achieve ...

Modified Posterior Vertebral Column Resection for Patients with Thoracolumbar Kyphotic Deformity

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may cause severe thoracolumbar kyphotic deformity, often accompanied by intractable low back pain or compression of the spinal cord, leading to severe neurological symptoms or even paralysis. If conservative treatment cannot relieve the symptoms or correct the deformities, surgical treatment is usually needed. For severe kyphotic deformity, reconstruction of the physiological curvature and rigid fixation determine the prognosis of the patients. Osteotomy and orthopedics are the standard procedure for deformities with severe compression of the front and middle column, but the trauma to the patients is high, with a long operation time and massive blood loss. To avoid these disadvantages, we have developed a modified technique to remove the diseased vertebra unilaterally. In this technique, we use a modified trephine to resect the vertebral columns like in the pedicle screw technique by adding a locking instrument that can restrict the trephine to lower the risk of osteotomy and shorten the surgery time and blood loss.

We describe a modified technique for resecting the posterior vertebral column unilaterally based on a modified trephine for patients with thoracolumbar kyphotic deformity.

Old compression vertebrae fracture or congenital kyphoscoliosis with abnormal vertebral body development and other diseases that invade the spine may ...

Combination of Anatomical Plates and Rotator Cuff Reinforcement for Minimally Invasive Treatment of Greater Tuberosity Fractures of the Humerus

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

Here, we present a protocol to utilize anatomical plates alongside rotator cuff reinforcement in a minimally invasive surgery to efficiently treat humerus greater tuberosity fractures, promising quicker healing and improved stability.

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. ...

Arthroscopic Repair of Medial Meniscus Posterior Root Tear with Adjustable Titanium Plate Fixation

Medial meniscus injury is one of the most prevalent knee disorders, with posterior root tears occurring in approximately 10% to 21% of affected individuals. A posterior root tear disrupts the meniscus's continuous annular structure, compromising its ability to absorb pressure and protect the knee's articular cartilage. If left untreated, this can result in increased stress on the cartilage, leading to conditions such as varus deformity and accelerated joint degeneration. Partial removal (resection) of the medial meniscus further exacerbates these issues, often leading to quicker joint deterioration. Repairing medial meniscus posterior root tears (MMPRTs) plays a crucial role in restoring the meniscus's structural integrity and improving knee biomechanics. Studies have shown that compared to partial medial meniscectomy or conservative treatments, repairing MMPRTs enhances clinical outcomes and significantly delays the onset of arthritis. This article details a surgical procedure that uses a single-suture, double-loop, adjustable titanium plate fixation technique under arthroscopy for effective MMPRT repair.

This article describes a surgical approach to repairing a medial meniscus posterior root tear (MMPRT) using a single-suture, double-loop, adjustable titanium plate internal fixation under arthroscopy.

Medial meniscus injury is one of the most prevalent knee disorders, with posterior root tears occurring in approximately 10% to 21% of affected ...

Technique of Sagittal Adjusting Screw System for Thoracolumbar Burst Fractures

Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device

Thoracolumbar (TL) burst fracture is one of the most common indications for minimally invasive percutaneous pedicle screw fixation. Although the indication for surgical treatment of neurologically intact TL fractures remains under debate, studies have demonstrated that posttraumatic malalignment may lead to a deterioration in the patient&#39;s quality of life. For burst fractures with malalignment or fragments in the spinal canal, a reduction technique using ligamentotaxis is commonly used to improve long-term outcomes.
The sagittal adjusting screw (SAS) system is a monoaxial screw system with a fixed head and concave sliding saddle that allows lordotic sliding of the rod in the sagittal plane after screw insertion. SAS also has a percutaneous option and has been used for TL spine fractures. Notably, the SAS only allows motion on the sagittal plane, allowing both secure fixation and angular reduction. The SAS has certain advantages over the conventional Schanz screw system or normal mono-/multiaxial pedicle screws for TL spine fracture treatment. In addition, specialized trauma reduction devices are available for the SAS system. In this video protocol, we discuss the indication for the SAS system in TL burst fracture and describe a technique of TL burst fracture reduction and fixation using the SAS system. Additionally, we describe our recent case series with radiological evaluation, including regional kyphotic angle and percent loss of anterior vertebral body height, to evaluate the newly introduced trauma reduction device.

The sagittal adjusting screw (SAS) system has been widely used for thoracolumbar (TL) spinal trauma. Percutaneous options and specialized trauma reduction devices are also available for the SAS system. We describe a technique for reducing TL burst fractures using an SAS system and a newly introduced trauma reduction device.

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