General Principles of Osteosynthesis 1

81 We agree with the views expressed by the illustrious speaker Mr. Denis who claimed that osteosynthesis is a necessary procedure in the face of the failure of conservative or non-surgical treatment. Now, there are no hard-and-fast criteria that tell us what we should understand by a failure or an insufficiency. What for some is an adequate result, for others is unacceptable because it causes anatomical or functional abnormalities, it frequently leads to sequelae, stiffness or atrophy, it requires a long recovery period, etc. Nonetheless, in our opinion the field of osteosynthesis is becoming larger and larger as surgeons feel more confident regarding the safety of the technical solutions it proposes and the benignancy of its operative procedures. As they compare the results they achieve with the different techniques they employ, surgeons have become increasingly critical of their work and nowadays tend to reject procedures that in the past they considered satisfactory. As far as the pathology and treatment of fractures is concerned, not all cases are alike. We know that many fractures can be kept perfectly reduced throughout the osteointegration period, which tends to be fairly short. However, in other cases either reduction is difficult to maintain and there is a risk of secondary displacement or integration takes such a long time that it inevitably leads to atrophy and stiffness. Lastly, there are other cases in which not even an intermediate degree of reduction and coaptation can be achieve with non-surgical procedures. Osteosyntesis is especially useful in the last two cases, i.e. either to obtain reduction and containment that would be impossible with any other technique or to secure an active degree of early mobility that protects the limb from undesirable sequelae. If we had to define the current status of osteosynthesis, we should say that it is going through a renaissance, both in terms of the techniques and principles used. We unquestionably recognize the essential role played by the modern proponents of osteosynthesis, especially Sir Arboutnot Lane and Albin Lambotte, and would not like to be taken to belittle them if we said that they established a number of principles of osteosynthesis and developed a number of rules that, naturally, could not be the true principles or the final techniques since, even today after so many years, both the techniques and principles of internal fixation are in permanent evolution and improvement. The use of flawed principles and inappropriate materials that often acted as aggressive chemical agents interfering with the integration process, as well as the nonchalance and ineptitude displayed by surgeons on some occasions led to a series of disasters and, consequently, to a campaign against osteosynthesis and to the fear of applying internal fixation techniques that most of us have all experienced. However, only the list of the terrible sequelae of osteosynthesis – normally the result of a poor technique and ignorance about the procedure – was generally presented. The equally terrible sequelae provoked by conservative or closed techniques, even when well applied, tended to be ignored. Not enough emphasis was placed on the inability of the latter to address the problems inherent in a large number of cases either. The undeniable truth is that osteosynthesis has outlived all the criticism leveled against it and has overcome its crisis; that is the reason why we said that it was going through a renaissance. Modern fixation materials, the way in which they are used depending on the type of fracture and anatomical region at issue, as well as a better knowledge of bone biology and the evolution of the integration process and the bone reactions of the various anchor points have all worked the miracle. The onslaught of prejudice that threatened with demolishing osteosynthesis eventually disappeared. As a result of the recent developments, surgical techniques have improved and it is no longer thought that a single general method or technique can be applied to all cases; on the contrary, the most suitable mechanical solutions are being developed for each anatomical region and for each fracture type within them, always in line with the general biological characteristics, with those specific to each particular and with the function of the involved skeletal segment. As regards osteosynthesis, we must emphasize as energetically as possible that success and prognosis are based upon the ability of harmonizing two types of principles that although not incompatible can sometimes prove difficult to bring together: 1.o) Mechanical principles, derived from the shape of the fracture and its fragments, from its texture (either cortical or cancellous) and the muscular and gravitational forces acting upon them; and 2.o) Biological principles derived from the bone’s vitality, its nutritional paths, the reactions of the integration bone tissue and the anchor points for bone General Principles of Osteosynthesis1