Minimally Invasive Techniques in Orthopedic Trauma
Curr Trauma Rep
Minimally Invasive Techniques in Orthopedic Trauma
M. Thaeter 0 1 2
P. Kobbe 0 1 2
E. Verhaven 0 1 2
H.-C. Pape 0 1 2
0 Harald Tscherne Research Laboratory for Orthopaedic Trauma, Aachen University Medical Centre , Pauwelsst. 30, 52074 Aachen , Germany
1 Department of Orthopaedic Surgery, St. Nicolaus Hospital , Hufengasse 4, 4700 Eupen , Belgium
2 Department of Orthopaedic Trauma, Aachen University Medical Centre , Pauwelsst. 30, 52074 Aachen , Germany
Purpose of Review This review focuses on the evolution of minimally invasive techniques in orthopedic surgery and provides an overview of the evidence-based knowledge of the last decade. Recent Findings Implants and surgical techniques for minimally invasive osteosynthesis in periarticular, spinal and pelvic fractures underwent rapid improvement. They show adequate healing along with low complication rates and satisfactory outcome. Computer-assisted insertion of implants and navigation offer new possibilities and are particularly advantageous in difficult anatomical regions, such as the pelvis or spine. Summary The treatment purpose in minimally invasive orthopedic surgery consists of anatomic reconstruction and
Minimally invasive surgery; Trauma; Orthopedics; Extremity; Spine; Pelvis
After anesthesia and asepsis, the introduction of minimally
invasive surgery (MIS) is called the third patient-friendly
revolution in surgery. Due to shorter duration of in-hospital
treatment and better cosmetic results, arthroscopic surgical
techniques have widely replaced open surgery in articular surgery.
Implants and surgical techniques for minimally invasive plate
osteosynthesis (MIPO) and minimally invasive percutaneous
plate osteosynthesis (MIPPO) in periarticular fractures
underwent rapid improvement and demonstrate adequate
healing along with low complication rates.
Computerassisted minimally invasive insertion of implants and
navigation offer new possibilities and are particularly advantageous
in difficult anatomical regions, such as the pelvis or spine.
Yet, randomized clinical trials are missing to prove the
advantages of minimal invasive surgery [
during the past decade, a large number of these high quality
randomized controlled trials and meta-analyzes detected
significant advantages over open surgery—based in particular on
blood loss, soft-tissue trauma, pain-associated parameters, and
Through continuous development of arthroscopic and
minimally invasive surgical techniques, instruments, and implants
paired with sophisticated digital navigation technologies,
minimally invasive trauma surgery will be reaching gold
standard of treatment in the near future.
The purpose of this review is to give an overview of the
current possibilities and limitations of minimally invasive
treatment in trauma surgery.
The majority of injuries in orthopedic surgery are diaphyseal
or periarticular fractures of the limb. The concept of Babsolute
anatomical stability^, where each fragment either from the
articular or metaphyseal area was supposed to be subject for
anatomical reduction and stabilization using rigid implants
has been associated with poor long-term biological effects.
As a result of large incisions and vast deperiostation,
complications such as infection, delays in consolidation, and
nonunion occurred [
]. These findings lead to the Bbiological
(bridging) plate osteosynthesis^ concept and initiate a
remarkable development of new surgical techniques, e.g., indirect or
closed reduction and MIPO, and implants, e.g., bridging
plates, Limited Contact-Dynamic Compression Plate
(LCDCP), or unidirectional and recently multidirectional angular
screw stability [
]. A certain (relative) instability degree can
be useful for accurate and fast healing. The advantages of
ameliorated bone vascularization, callus formation [
consolidation, shorter operative time, less blood loss, and
decreased infection rate have made these minimally invasive
techniques a state-of-the-art treatment. By increased resilience
to mechanical stress, implant insertion and removal allow
earlier patient rehabilitation [
For most diaphyseal fractures, minimally invasive surgical
treatment is routinely applied. For acute displaced clavicle
shaft fracture, MIPO is an equally effective and safe treatment
method when compared to open plating with interfragmentary
screw fixation [
] providing better cosmetic results and patient
satisfaction. In view of shorter surgical and fluoroscopy time,
intramedullary nailing may offer an alternative [
options on the adult humeral shaft fracture include external
fixation, open reduction and internal fixation (ORIF), MIPO,
and ante-/retrograde intramedullary nailing. MIPOs using the
dual approaches show an excellent bony union decreasing the
risk of iatrogenic radial nerve palsy compared to ORIF [
While plating remains an option in some type of fracture, e.g.,
periprosthetic fractures, medullary nailing after drilling out the
medullary cavity is the method of choice in treatment of
fractures of the femur shaft. Most nails can be positioned in an
anterograde or retrograde direction and allow immediately
full-weight bearing [
The treatment of complex periarticular fractures of the long
bones remains particularly challenging. In proximal humeral
fractures, a recent multicenter study and a meta-analysis
provide evidence that both intramedullary nailing and MIPO
through the deltoid-splitting approach are safe and effective
in enabling an early return of shoulder function [
choice of treatment option in distal radius fracture should
results from an individual decision mainly based on complexity
and stability of the fracture and the patient’s age. For stable
fractures, functional treatment after closed reduction or
percutaneous fixation using the Kapandji technique should be
performed. The use of fixed angle intramedullary devices in
extra-articular or simple intra-articular distal radius fractures
is gaining popularity, limiting soft tissue dissection and tendon
irritation while affording adequate stability for early wrist
motion. Systematic reviews reveal excellent functional outcomes.
However, the mean complication rate of 17.6 % for
intramedullary nailing is higher, notably because of the
propensity to cause a transient neuritis of the superficial branch of
the radial nerve [
A recent meta-analysis compared two common surgical
treatments for intertrochanteric fractures of the proximal
femur reveals advantages of the percutaneous compression plate
(PCCP) with less need of transfusion, reduced hospital stay,
and fewer incidences of implant-related complications
compared to intramedullary nail (IMN) fixation [
]. MIPO in
distal femur fracture fixation is safe, efficient [
associated with less implant failure and nonunion compared to
] while its higher risk of rotational malalignment
remains despite existing techniques for control of axes and
]. While rates of malunion remain still
improvable, the advantages of minimally invasive surgery in
treatment of distal tibial fractures with its principles of the gentlest
possible soft-tissue handling and avoidance of unnecessary
dissection become undisputable [
]. Through a distal
anterolateral approach, concomitant distal fibular fracture can be
treated at the same level using MIPO-technique [
The important role of minimally invasive surgery in spinal
fractures is undisputed. Vertebral compression fractures that
may be caused by bone-weakening conditions (such as
osteoporosis or spine cancer in the elderly) or by minor trauma
injury are commonly treated by minimally invasive vertebral
augmentation procedures such as vertebroplasty and
kyphoplasty. These surgeries show high success rates in terms
of improving the patient’s pain, early rehabilitation, and
fracture stabilization, avoiding more aggressive and larger open
spinal fusion surgery [
Atlantoaxial instabilities caused by different types of
fractures (especially odontoid fractures including nonunion,
transverse ligament ruptures, or unstable Jefferson fractures),
tumors or infections requiring reduction and stabilization of the
atlantoaxial joint underwent a continuous development of
surgical techniques and strategies.
Still remaining a challenging procedure for the surgeon C1
lateral mass and C2 pedicle screw combined as a fixateur
interne described by Harms using a posterior incision has been
widely accepted as it provides sufficient biomechanical
stability by offering the possibility of reduction (Fig. 1) and
vertebral fusion while minimizing the risk of an injury to the
vertebral artery. In case of insufficient screw channel size, isthmal
screws can be inserted (Fig. 1, right). Preoperative CT- or
MRI-angiography is recommended to assess potential
anatomical variations of the artery trajectories.
Computernavigated posterior atlantoaxial fixation with the Magerl
screw technique is a true minimal invasive option (Fig. 2).
While allowing adequate reduction, vertebral fusion however
cannot be performed. This technique seems promising for
immunocompromised patients (e.g., diabetes and cancer) by
reducing the risk of wound infection.
The invasive open dorsal approach for traumatic fractures of
the thoracic or lumbar spine (AO type A3/A4, B, and C injuries)
is increasingly replaced by the use of percutaneous systems as the
development of reduction tools compensates its major drawback:
the limited ability to reduce the fracture (Fig. 3). The advantages
of percutaneous systems become especially evident in
multiFig. 2 (left, center, right)
atlantoaxial fixation with the
Magerl screw technique
segmental dorsal stabilization: shorter operation time, reduced
blood loss and soft-tissue trauma and lower rates of wound
infections allow early patient mobilization and shorten the length of
hospital stay. There is no difference in the accuracy of pedicle
screw positioning and the restoration of sagittal balance as a
major goal of spinal fracture treatment. Nevertheless, mid- and
long-term functional outcomes seem not to be influenced by a
percutaneous dorsal approach [
]. In osteoporotic bone,
additional stability can be achieved by cement augmentation. Both
pain reduction and less screws loosening have been described to
]. In terms of intense reduction possibilities and spinal
cord decompression, the open approaches still remain superior to
the percutaneous systems although minimally invasive
decompression is also a viable option [
27 , 28
In case of severe destruction of the vertebral bone, patients can
benefit from anterior column reconstruction, preventing a
progressive loss of reduction by maintaining the physiological load
distribution (Fig. 4, center and right). While requiring single-lung
ventilation, thoracoscopic techniques replace open thoracotomy
and thoracophrenolumbotomy and avoid extensive soft tissue
dissection and rib resection (Fig. 4; left) [
]. The use of
computer-aided 3D imaging has proven its value by improving
image quality for the anatomical landmarks, especially the
complex atlantoaxial region, safety, and accuracy compared to
conventional fluoroscopy [
Pelvic ring injuries represent a therapeutic challenge to the
orthopedic surgeon. Surgical stabilization is indicated in
unstable injury patterns (with or without radiographic
dislocation). Also, it is recommended with failing nonsurgical
management. The indication is largely based on fracture
classification, associated injuries, and the patient’s physiological
status. Open reduction and internal fixation is routinely applied
but minimally invasive percutaneous plate- or screw fixation
] as well as the anterior fixation of the pelvic ring with
addressed compression tools is gaining popularity. The
internal use of the anterior fixator (Fig. 5) as a definitive treatment
in hemodynamically stable patients provides a novel approach
by eliminating the disadvantages of difficult nursing care and
pin-infections, especially in obese patients, and allowing the
patient to sit upright and even in prone position. In case of
Fig. 4 (left, center, right)
thoracoscopic vertebral body
replacement Th12 after minimally
invasive dorsal instrumentation
vertical instability (egg APC 3), posterior stability has to be
recovered previously by reduction and fixation with either
iliosacral screws or posterior plating of spinopelvic fixation
33, 34, 35
Operative treatment of acetabular fractures remains one of
the most challenging sections in trauma surgery. Since minor
articular gaps may lead to posttraumatic arthritis, precise
reduction is essential in order to avoid poor functional outcome.
Open reduction and internal fixation is considered the gold
standard of treatment, especially in displaced fractures
involving the weight-bearing surface or the posterior wall. For
acetabular fractures in the elderly as well as less- or undisplaced
fractures in patients aiming for an early return activity,
percutaneous techniques with cannulated screws [
] or minimally
invasive plate osteosynthesis (MIPO) using preshaped 3D
] are on a rise. Although long-term outcomes are
limited, most advanced treatment methods including
minimally invasive fixation under computer-assisted navigation [
and 3D printing, simulating the plate preflex and screw length
], are promising to improve surgical accuracy and safety
and to shorten the operation time.
Discussion and Conclusion
The treatment purpose in minimally invasive orthopedic
surgery consists of anatomic reconstruction and stabilization of
the articular surface, length, axis, and rotation with minimal
soft-tissue trauma. For the metaphyseal-diaphyseal area, this
concept is implemented through intramedullary implants or
plate osteosynthesis fixated only distally and proximally from
the fracture site, bridging the fracture area and leading to
biological advantages. Better knowledge in metallurgy and
biomechanics paired with advanced instruments, techniques,
imaging, and navigation results in improved possibilities for the
treatment of truncal and cervical injuries. Combining less
invasiveness and stability, this development leads to higher
potential for immediate post-operative full weight bearing,
which is particularly beneficial to elderly patients [
Furthermore, by minimizing additional insults (Bsecond
hits^), modern minimal invasive techniques will contribute
to the concept of damage control orthopedic surgery for
severely injured and polytraumatized patients.
Although demanding, minimally invasive techniques
appear to warrant the effort to master the learning curve.
Compliance with Ethical Standards
Conflict of Interest Drs. Thaeter, Kobbe, Verhaven, and Pape declare
no conflicts of interest relevant to this manuscript.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
Papers of particular interest, published recently, have been
Of major importance
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