Objectives: History of the invention of Ilizarov Principles of Ilizarov Components and procedure of application Care of the apparatus, Rehabilitation and Removal ofIlizarov. Indications Advantages and disadvantages Our experiences in EMCH
History Professor Gavril Abramovich Ilizarov was born in the Caucasus, inthe Soviet Union in 1921. He was sent, without much orthopedic training, to look after injuredRussian soldiers in Kurgan,Siberia in the 1950s. With no equipmenthe was confronted with crippling conditions of unhealed, infected,and malaligned fractures. With the help of the local bicycle shop he devised ring externalfixators tensioned like the spokes of a bicycle. With this equipmenthe achieved healing, realignment and lengthening to a degreeunheard of elsewhere. His Ilizarov apparatus is still used today as one of the distractionosteogenesis methods.
1954 published his first articleon Transosseous Osteosynthesis.
1967. At this time he successfully treated an infected, non-unionfracture sustained by the Olympic high jump champion ValeryBrumel. Professor Ilizarov’s methods were brought to the west in 1981 byan Italian doctor, Prof. A. Bianchi-Maiocchi. he headed the world’s largest orthopaedic hospital. This is theKurgan All-Union Scientific Centre for Restorative Orthopaedicsand Traumatology. Professor Ilizarov continued working in this field of orthopaedicsfor 41 years until his death in 1992 at the age of 71.
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 theprocess of new bone and soft tissue regeneration under theeffect 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, callotasisand osteodistraction is a surgical process used to reconstructskeletal 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 apartduring the distraction phase, allowing new bone to form in thegap. When the desired or possible length is reached, a consolidationphase follows in which the bone is allowed to keep healing. Distraction osteogenesis has the benefit of simultaneouslyincreasing bone length and the volume of surrounding softtissues.
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 withspecial "wire-fixation" bolts. These rings in turn are connected and fixed to one another bythreaded rods. Once it is fixed, the Ilizarov frame affords a stable support to theaffected limb. A CORTICOTOMY is then performed; it is an osteotomy (cutting thebone) where the periosteum of the bone is preserved. Adjustments in the rods produce compression or distraction asdesired between the bone ends, and simultaneously, deformities arealso corrected. The ring fixator is removed at the end of the treatment.
After care of the apparatus The postoperative management of a patient requiresfrequent contact and close monitoring by the surgeon. Deformities and contractures cannot be allowed topersist or progress. The patient must be encouraged to bear weight on thelengthening limb. Pin- or wire-site sepsis should be treated aggressively;osteolysis around an implant suggests that additionaltransosseous fixation is needed. Adequate physiotherapy is essential.
Physiotherapy The patient has to participate in a proper program ofexercises, mobilization and ambulation. In fact Ilizarovs original technique requires the patientsto stay in hospital and participate in at least two hours oftherapy in various forms every day. In our circumstances, the services of a physiotherapistare not always available. The only recourse in suchcases is for the surgeon himself to supervise the therapyfor the patient. Achieving length or correcting a deformity at the cost ofdecreased motion, mobility or function is certainly not aworthwhile goal.
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 offour cortices (anterior, posterior, medial and lateral) inAP & lateral projections, at least three should be fullyossified, with a sharp outline of the cortical bone. Finally before actually removing the frame the patientmay be administered a stress test‘ and asked to use thelimb in a functional manner ( weight bearing for the lowerlimb and functional activities for the upper limb). If the patient is able to do this the frame can then beremoved with confidence. Actual removal of the fixator is usually done underanesthesia.
advantages No skin incision is made as in a conventional operation.Incidents of haemorrhage, tissue trauma and infectionare much fewer. minimally invasive as only wires fix the bones to therings and there is very little soft tissue damage. The Ilizarov fixator is very versatile; the cylindrical shapeof the fixator allows deformities to be correctedsimultaneously in 3 dimensions. The patient remains mobile throughout the course of thetreatment. Intensive physiotherapy is instituted early; asa consequence, problems of joint stiffness andcontractures are rare. Further, the patients stay in thehospital is considerably reduced.
Indications… Limb lengthening Deformity Correction. Infected Non-unions. Congenital Pseudarthrosis. Treatment of Joint Contractures e.g. resistant congenitaltalipes euino varus, post burns contractures, post-traumatic stiffness Fixation of complex fractures Bone transport & Osteomyelitis (treatment of missingbone in the limb, due to various causes) Arthrodesis (fusion or joining of two bones across a joint) Peripheral Vascular Disease like Thrombo-angitisobliterans
Non-unions Nonunion is permanent failure of healing following abroken bone. Nonunion is a serious complication of a fracture and mayoccur when the fracture moves too much, has a poorblood supply or gets infected. Patients who smoke have a higher incidence ofnonunion. In some cases a pseudo-joint (pseudarthrosis) developsbetween the two fragments with cartilage formation anda joint cavity.
Non-unions… Ilizarov revolutionized the treatment of recalcitrantnonunions demonstrating that the affected area of thebone could be removed, the fresh ends "docked" and theremaining bone lengthened using an external fixatordevice. The time course of healing after such treatment is longerthan normal bone healing. Usually there are signs of union within 3 months, but thetreatment may continue for many months beyond that.
Infected non-union Ilizarov is a golden method for the management ofnonunion osteomylitis for both achieving union anderadication of infection, however generous, carefulsequential debridement and hardware/dead tissueremoval and bone grafting is also an option for someselected cases.
Osteomylitis burns in the fire of regeneration Activate biosynthetic process, increasing local resistantto infection. Three ways to correct INU: Controlled osteogenesis, filling of cavities by newly formed tissue Resection of infected bone and subsequent intercalary bonelengthening Gradual bone transport of one wall of the cavity.Infected non-union…
Deformity correctionTreating Neglected club with Ilizarov
Deformity correctionTreating Cubitus Varus with Ilizarov
Deformity correctionTreating Cubitus Varus with Ilizarov
Limb lengthening Limb lengthening and reconstruction techniques can be used toreplace missing bone and lengthen and/or straighten deformedbone segments. The procedures may be performed on both children and adultswho 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 theslow stretch like they do during a growth spurt or in pregnancy. The actual procedure is minimally invasive and requires onlyone or two nights in the hospital. Literature says successful limb lengthening upto 18 cm.
Buerger’s disease In Buerger’s disease Arterial reconstructive surgery isnot feasible and sympathectomy has limited role. Progression of the disease invariably leads toamputation. Ilizarov’s method increases the vascularity of theischaemic limb. Ilizarov’s method is an excellent andcheap procedure in treatment of Buerger’s disease.
Our experiences In EMCH, we regularly do Ilizarov surgery in theorthopedic department. Our patients are mostly suffering from Non-union andComplex fractures. We also treat congenital limb deformities by this surgicaltechniques.
Take home Message Ilizarov is a compression-distraction device that can doosteogenesis. Infection Non-union and Congenital deformity correctionsare one of the golden indications. You can be taller even after 18 yrs with this. Wearing Ilizarov is not a fancy style. It returns painfuldiscomfort. Physiotherapy is essential.
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