Tension-belt Osteosynthesis: Treatment, Effects & Risks

Tension-belt osteosynthesis is a surgical procedure for reduction and fixation of dislocated fractures that pass through joints. This is a commonly used and reliable method in surgical and orthopedic care.

What is tension-belt osteosynthesis?

Tension-belt osteosynthesis is a surgical procedure for reduction and fixation of dislocated fractures that pass through joints. It is used, for example, in ankle fractures. Tension-belt osteosynthesis is a procedure from the field of internal fixation of special fracture fragments using foreign material. The basis of tension chord osteosynthesis originated from engineers in the field of reinforced concrete construction. The effect of this technique was scientifically substantiated by Friedrich Pauwels, and the concept of the procedure was subsequently first presented and performed by orthopedists and surgeons in 1958. Tension-belt osteosynthesis is used in the field of surgery and orthopedics. It is used to treat fractures (broken bones) that occur in the region of a joint, and the fracture fragments (broken pieces) are separated from each other by the tensile force of a tendon. These fractures are treated with the help of a wire sling under traction. The purpose of this is to anchor the fracture fragments to each other until they fuse together again. Such fractures are usually caused by falls or direct external force on the bone. In combination with increased muscle tension, this can lead to a bony avulsion of a tendon. The increased muscle tension occurs reflexively, for example, in a fall, for self-protection to intercept if possible.

Function, effect, and goals

When trauma results in a fracture, the following characteristics are crucial for treating it using tension-belt osteosynthesis. The fracture is in the region of a joint and may involve portions of the articular surface. An avulsed partial fragment is under the traction of a muscle connected to the fracture by a tendon. The fragments are dislocated and thus spaced apart by the pull of the tendon. If these characteristics are present in a fracture, the fracture is surgically treated with cribbing wires or Kirschner wires and wire slings. The wires are usually made of chromium-cobalt-molybdenum alloys, surgical steel or titanium alloys. Typical fractures of this type are, for example, the olecranon fracture (elbow joint) and a fracture of the patella (kneecap). However, fractures in the area of the malleoli (inner and outer ankle on the foot) of the upper ankle joint or bony avulsions in the area of the metatarsus are also treated with tension-belt osteosynthesis. These are fixed with wire slings, but not under traction. If a fracture with dislocated fracture fragments is treated surgically with tension-belt osteosynthesis, the surgeon must first align all the fracture fragments with each other in order to restore the anatomical shape and thus the axis-correct function of the joint. The crib wires or Kirschner wires must then be inserted as parallel to each other as possible to avoid locking the joint function. Starting in the area of the tendon insertion, the cribbing wires are inserted and pass perpendicularly through the course of the fracture in the immediate vicinity of the joint surface. The surgeon must take care that the wires do not perforate the tissue. The wires are not inserted under imaging. The surgeon uses palpation to orient the joint structures. Once the crib wires are in place, they are bent over at their ends and firmly anchored in the far cortex. An imaging check can then confirm the correct position. The application of the wire cerclage now applies a uniform tension to the crib wires and ensures that the fracture fragments do not move away from each other, even under muscular tension. The wire sling is fixed in place by twisting the helix in different directions. The resulting wire swirls are shortened to 7-10mm at the end using pliers. The wire ends of the cribbing wires are shortened to 5-7mm and bent over by about 90°. Finally, the affected joint is moved under the anesthesia in its complete function to exclude functional disorders. A final check by X-ray shows once again the position and course of the wires. If the wires are in the right place and the joint can move freely, the operation has been successful.A Redon drain is placed proximal to the treated fracture to drain fluid and blood. A sterile and dry dressing is applied under light compression. On the first postoperative day, light physiotherapeutic range-of-motion exercises can usually be started in a pain-oriented manner. On the second postoperative day, the Redon drain is removed. The clear advantage of tension-belt osteosynthesis is the reliable result and the low cost of the material. In addition, the patient can freely move the affected limb postoperatively and can thus prevent risks such as thrombosis or muscle atrophy.

Risks, side effects, and hazards

After inpatient discharge from the hospital, further treatment and regular checkups should be performed by a specialist. Important here are the complete wound control, thread pulling after about 14 days, X-ray control after 4 and 8 weeks and intensive physiotherapeutic movement exercises. The following risks should always be weighed up despite the reliable and frequently used method. Every treatment with an osteosynthesis procedure of this type is associated with a surgical intervention and thus anesthesia. Especially in geriatric patients, swallowing difficulties, cardiovascular problems or respiratory disturbances may occur. Therefore, material removal is no longer performed in older patients and is kept as minimally invasive as possible in younger patients. Side effects such as wound healing disorders, pain, infections and functional limitations can occur postoperatively. Furthermore, wire loosening or breakage can occur due to overloading or material failure. This should be detected and resupplied as soon as possible with regular monitoring by imaging techniques, since it can lead to displacement of the fracture fragments and thus to malposition of the joint. If the fracture fragments grow together in a malposition, permanent impairment and discomfort may result.