Central SeminarLecture Hall # 05, 23rd April, 2013

Ilizarov External Fixator

Chairperson: Prof. M. Ishaq Bhuyian

Head, Orthopaedics

Speaker:

Dr. Abdullah-al-mamun

Junior Consultant, Orthopaedics

Objectives:

History of the invention of Ilizarov Principles of Ilizarov Components and procedure of application Care of the apparatus, Rehabilitation and Removal of

Ilizarov. Indications Advantages and disadvantages Our experiences in EMCH

PROF. GABRIEL ABRAMOVITCH ILIZAROV(1921-1992)

History

Professor Gavril Abramovich Ilizarov was born in the Caucasus, in the Soviet Union in 1921.

He was sent, without much orthopedic training, to look after injured Russian soldiers in Kurgan,Siberia in the 1950s. With no equipment he was confronted with crippling conditions of unhealed, infected, and malaligned fractures.

With the help of the local bicycle shop he devised ring external fixators tensioned like the spokes of a bicycle. With this equipment he achieved healing, realignment and lengthening to a degree unheard of elsewhere.

His Ilizarov apparatus is still used today as one of the distraction osteogenesis methods.

1954 published his first article on Transosseous Osteosynthesis.

1967. At this time he successfully treated an infected, non-union fracture sustained by the Olympic high jump champion Valery Brumel.

Professor Ilizarov’s methods were brought to the west in 1981 by an Italian doctor, Prof. A. Bianchi-Maiocchi.

he headed the world’s largest orthopaedic hospital. This is the Kurgan All-Union Scientific Centre for Restorative Orthopaedics and Traumatology.

Professor Ilizarov continued working in this field of orthopaedics for 41 years until his death in 1992 at the age of 71.

Kurgan the city

Principles of Ilizarov

Law of tension stress Distraction osteogenesis Mechanical induction of new bone formation Neovascularization Stimulation of biosynthetic activity Activation and recruitment of osteoprogenitor cells Intramembranous ossification

Law of tension stress

Ilizarov developed the law of tension-stress, which describes the process of new bone and soft tissue regeneration under the effect of tension-stress caused by slow and gradual distraction.

His biological principles can be summarized as follows: Minimal disturbance of bone and soft tissues Delay before distraction Rate and rhythm of distraction Site of lengthening Stable fixation of the external fixator Functional use of the limb and intense physiotherapy.

Distraction Neo-histogenesis

Distraction osteogenesis, also called callus distraction, callotasis and osteodistraction is a surgical process used to reconstruct skeletal deformities and lengthen the long bones of the body.

A corticotomy is used to fracture the bone into two segments, and the two bone ends of the bone are gradually moved apart during the distraction phase, allowing new bone to form in the gap.

When the desired or possible length is reached, a consolidation phase follows in which the bone is allowed to keep healing.

Distraction osteogenesis has the benefit of simultaneously increasing bone length and the volume of surrounding soft tissues.

Distraction Osteogenesis

Neo-vascularisation

Equipments

Equipments

procedure Wires of 1.5 mm or 1.8 mm diameter are passed percutaneously

(through the skin) through bones by means of a drill. The protruding ends of these wires are then fixed to rings with

special "wire-fixation" bolts.

These rings in turn are connected and fixed to one another by threaded rods.

Once it is fixed, the Ilizarov frame affords a stable support to the affected limb.

A CORTICOTOMY is then performed; it is an osteotomy (cutting the bone) where the periosteum of the bone is preserved.

Adjustments in the rods produce compression or distraction as desired between the bone ends, and simultaneously, deformities are also corrected.

The ring fixator is removed at the end of the treatment.

Procedure…

Procedure…

Procedure…

After care of the apparatus

After care of the apparatus

The postoperative management of a patient requires frequent contact and close monitoring by the surgeon.

Deformities and contractures cannot be allowed to persist or progress.

The patient must be encouraged to bear weight on the lengthening limb.

Pin- or wire-site sepsis should be treated aggressively; osteolysis around an implant suggests that additional transosseous fixation is needed.

Adequate physiotherapy is essential.

Physiotherapy

The patient has to participate in a proper program of exercises, mobilization and ambulation.

In fact Ilizarov's original technique requires the patients to stay in hospital and participate in at least two hours of therapy in various forms every day.

In our circumstances, the services of a physiotherapist are not always available. The only recourse in such cases is for the surgeon himself to supervise the therapy for the patient.

Achieving length or correcting a deformity at the cost of decreased motion, mobility or function is certainly not a worthwhile goal.

Living with Ilizarov…

Removal of Apparatus A month too late is better than a day too early. The x-rays must show at least three cortices; i.e. out of

four cortices (anterior, posterior, medial and lateral) in AP & lateral projections, at least three should be fully ossified, with a sharp outline of the cortical bone.

Finally before actually removing the frame the patient may be administered a 'stress test‘ and asked to use the limb in a functional manner ( weight bearing for the lower limb and functional activities for the upper limb).

If the patient is able to do this the frame can then be removed with confidence.

Actual removal of the fixator is usually done under anesthesia.

advantages

No skin incision is made as in a conventional operation. Incidents of haemorrhage, tissue trauma and infection are much fewer.

minimally invasive as only wires fix the bones to the rings and there is very little soft tissue damage.

The Ilizarov fixator is very versatile; the cylindrical shape of the fixator allows deformities to be corrected simultaneously in 3 dimensions.

The patient remains mobile throughout the course of the treatment. Intensive physiotherapy is instituted early; as a consequence, problems of joint stiffness and contractures are rare. Further, the patient's stay in the hospital is considerably reduced.

Disadvantages

Mechanical Distraction of fracture site Inadequate immobilization Pin-bone interface failure Weight/bulk Refracture (pediatric

femur) Biologic

Infection (pin track) Neurovascular injury Tethering of muscle Soft tissue contracture

Indications…

Limb lengthening Deformity Correction. Infected Non-unions. Congenital Pseudarthrosis. Treatment of Joint Contractures e.g. resistant congenital

talipes euino varus, post burns contractures, post-traumatic stiffness

Fixation of complex fractures Bone transport & Osteomyelitis (treatment of missing

bone in the limb, due to various causes) Arthrodesis (fusion or joining of two bones across a joint) Peripheral Vascular Disease like Thrombo-angitis

obliterans

Non-unions

Nonunion is permanent failure of healing following a broken bone.

Nonunion is a serious complication of a fracture and may occur when the fracture moves too much, has a poor blood supply or gets infected.

Patients who smoke have a higher incidence of nonunion.

In some cases a pseudo-joint (pseudarthrosis) develops between the two fragments with cartilage formation and a joint cavity.

Non-unions

Non-unions…

Ilizarov revolutionized the treatment of recalcitrant nonunions demonstrating that the affected area of the bone could be removed, the fresh ends "docked" and the remaining bone lengthened using an external fixator device.

The time course of healing after such treatment is longer than normal bone healing.

Usually there are signs of union within 3 months, but the treatment may continue for many months beyond that.

Non-union

Infected non-union

Ilizarov is a golden method for the management of nonunion osteomylitis for both achieving union and eradication of infection, however generous, careful sequential debridement and hardware/dead tissue removal and bone grafting is also an option for some selected cases.

Osteomylitis burns in the fire of regeneration Activate biosynthetic process, increasing local resistant

to infection. Three ways to correct INU:

Controlled osteogenesis, filling of cavities by newly formed tissue Resection of infected bone and subsequent intercalary bone

lengthening Gradual bone transport of one wall of the cavity.

Infected non-union…

Deformity correction

Treating Neglected club with Ilizarov

Deformity correction

Treating Cubitus Varus with Ilizarov

Deformity correction

Treating Cubitus Varus with Ilizarov

Open Fracture and Bone Loss

Difficult fractures

Limb lengthening

Limb lengthening and reconstruction techniques can be used to replace missing bone and lengthen and/or straighten deformed bone segments.

The procedures may be performed on both children and adults who have limb length discrepancies due to birth defects, diseases or injuries.

The regenerated bone is normal and does not wear out. The muscles, nerves and blood vessels grow in response to the

slow stretch like they do during a growth spurt or in pregnancy. The actual procedure is minimally invasive and requires only

one or two nights in the hospital. Literature says successful limb lengthening upto 18 cm.

Limb lengthening

Limb lengthening

Buerger’s disease

In Buerger’s disease Arterial reconstructive surgery is not feasible and sympathectomy has limited role.

Progression of the disease invariably leads to amputation.

Ilizarov’s method increases the vascularity of the ischaemic limb. Ilizarov’s method is an excellent and cheap procedure in treatment of Buerger’s disease.

Burger’s disease…

Our experiences

In EMCH, we regularly do Ilizarov surgery in the orthopedic department.

Our patients are mostly suffering from Non-union and Complex fractures.

We also treat congenital limb deformities by this surgical

techniques.

Infected non union

Infected non union

Difficult fractures

Difficult Fractures

Difficult Fractures

Congenital pseudoarthrosis

Congenital pseudoarthrosis of Tibia

Congenital pseudoarthrosis

Limb lengthening

Limb lengthening

Take home Message

Ilizarov is a compression-distraction device that can do osteogenesis.

Infection Non-union and Congenital deformity corrections are one of the golden indications.

You can be taller even after 18 yrs with this. Wearing Ilizarov is not a fancy style. It returns painful

discomfort. Physiotherapy is essential.