Ilizarov              Dr.Abhishek chachan               Mahatma gandhi hospital               sitapura, jaipur           ...
Historical review  Gavriil Abramovich   Ilizarov( 15 june 1921 – 24 july   1992) Russian physician,   known for inventin...
Historical review   Ilizarov was born in the Azerbaijan   In 1944 he was sent to a rural hospital in    Kurgan Oblast in...
Priciples of Illizarov    DISTRACTION OSTEOGENESIS. This refers to the    induction of new bone between bone surfaces tha...
Indications of Illizarov   In treating of bone infections   In Poliomyelitis Sequelae (in limb lengthening and    correc...
Instruments and their use   Primary components – That join skeleton to    finished frame       Transosseous wires      ...
Instruments and uses   Secondary components – Used to construct    frame     Threaded and telescopic rods     Connectin...
Instruments used in ilizarov
Wire fixation bolt   Cannulated   Cannulated with    threaded head   Slotted
Wire fixation buckle   Allows mechanical    derotation or angular    corrections
Telescopic rod   Provide stability when    long distance must be    spanned between    rings   Allows lengthening
Hinge ( Male and female)
Threaded socket   Inerconnect threaded    rods   Stabilize two rings    together
Wires   Trocar- Cancellous bone   Bayonet – Cortical bone   Olive wires
Dynamometric wire tensioner
Biomechanics   Tensioned wires (1.5 and 1.8) achieve rigidity    equal to half pins.   And retain elasticity and low axi...
Biomechanics   Tension in soft tissues also determine the    tension to be applied to wire   In Lengthening its safer to...
Biomechanics   Number of wires       More the number/ring more stable is        the fixator   Wire spread       90/90 ...
Biomechanics   Wires are self stiffening     Wires derive increasing rigidity with increasing      deflection     On re...
Biomechanics   Wire diameter       Increase diameter increases tension   Optimum wire     1.5 mm for children     1.8...
Biomechanics of Ring   Stability of assembly     Number     Size     Position of rings   Closer the middle two rings ...
Biomechanics   Reduction of 2 cm of radius of rings       77% rise in axial stiffness under 100 N load   Only torsional...
Biomechanics of Fulcrum   In deformity correction Olive wires are used as    fulcrum to prevent slippage of wires
Biomechanics of hinges
Biomechanics of Hinges   Central hinge    causes distraction    on concave side    and compression    on convex side.
Biomechanics Hinges   Fulcrum on the convex    side   Hinge at apex of    deformity – distraction    on convex side
   Hinge placed more    laterally results in    lengthening along    with angular    correction
Factors affecting stability of fixator   I Apparatus related (Extrinsic) factors     Spread between crossing wires appro...
Factors affecting stability of fixator   II. Intrinsic factors-     Area of tissue contact between the bone ends.     M...
Histology of distraction             osteogenesis   FIZ – Fibrous interzone   PMF- Primary    mineralization front   MC...
Histology   Latency period – similar to fracture healing   1 week after distraction-       Fibrous interzone fills cort...
   3 weeks of distraction       New bone differentiates to microcolumn formation        {MCF} with maximum diameter of 2...
   During the 6 weeks after frame removal, the    osteogenic area remodels into cortex and    medullary canal   Blood fl...
Factors affecting osteogensis   Stability of bone fragments   local or regional blood supply   Latency period   Rate a...
Anatomic considerationsFEMUR- When inserting wires into the femur, there  are several basic problemsFirst, the bulk of the...
   Insert the first olive wire from anteromedial to posterolateral two    fingerbreadths lateral to the femoral artery. I...
TIBIAThe proximal ring for a tibial mounting usually incorporates . a wire that passes through the fibular head and into t...
   HUMERUS   The Proximal And Distal Ends Of The Bone Can Be Secured With Three    Wires Each   Through The Proximal Hu...
FOOT   Before Inserting Wires Into The Calcaneus,    Consider The Diameter Of The Wires,Number ,    The Angles Between, T...
   Next, consider the direction from which the wires are    to be inserted. When correcting an equinus, insert both    ol...
Precautions   Corticotomy complete – Confirm    fluoroscopically   Distraction no more than 2-4 mm   Angulation no more...
Radiographic classification of              regenerate   Normotrophic   Hypertrophic and   Hypotrophic
Normotrophic   Early radiodense bone formation b/w 21 to 28 days   At this point bone ends have distracted approx 14 mm ...
Radiologic evaluation of callus
Hypertrophic   Regenerate appears    radiologically before 20    days   Cross sectional diameter    of regenerate exceed...
Hypertrophic   Factors     Young patient     More active patients     Good local blood supply ( Humerus)
Hypotrophic   Radioloigcal new bone appears after 30 days   Or if bone column has multiple breaks   Or regenerate has h...
Hypotrophic   Type A   Spotty radiodensities    after day 50    indicating poor    vascularity
Hypotrophic   Type B   Hourglass    configuration –    distraction rate too fast
Hypotrophic   Type C   Irregular bone columns    indicate instability or    vascular disruption
Hypotrophic   Type D   Focal failure of bone    formation indicate local    vascular injury or    periosteal damage if  ...
Timing of Frame Removal   Depends on the condition of the limb and pathology invovled   X Ray: Ideally the regenrate bon...
Clinical applications   Non unions and deformity correction   Bone transport   Fractures   Limb lengthening
Non union   Hypertrophic non-unions have a vital blood    supply from each bone end and a dense    collagenous interface....
Bone transport   Intercalary defects resulting from     trauma,     infection,     tumor, or     prosthetic replaceme...
Limb lengthening   The Ilizarov method allows the surgeon to perform    complex and extended lengthening of both congenit...
   The rate of healing is directly proportional to the length    of the distraction gap —   the greater the lengthening,...
Complications   Complications can involve the     pin tracks     bones     Joints     neurovascular structures     M...
   Inflammation surrounding pin tracks is common    as a result of     mechanical or thermal damage     Cellulitis    ...
   Osseous complications may involve     premature or delayed consolidation     non-union     axial deviation     lat...
   During the lengthening, motion of the joint may    be temporarily or permanently lost as a result of     muscle contr...
   Nerves and vessels may be damaged     directly by pins or osteotomes or     Indirectly by the actual stretching.   ...
Advantages of Ilizarov over         Cantilever type Ex fix   Elastic allow axial micromotion, and controls    shear stres...
Ilizarov, Dr abhishek chachan,Mahatma gandhi hospital,Sitapura, jaipur,india
Ilizarov, Dr abhishek chachan,Mahatma gandhi hospital,Sitapura, jaipur,india
Ilizarov, Dr abhishek chachan,Mahatma gandhi hospital,Sitapura, jaipur,india
Ilizarov, Dr abhishek chachan,Mahatma gandhi hospital,Sitapura, jaipur,india
Ilizarov, Dr abhishek chachan,Mahatma gandhi hospital,Sitapura, jaipur,india
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Ilizarov, Dr abhishek chachan,Mahatma gandhi hospital,Sitapura, jaipur,india

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Ilizarov, Dr abhishek chachan,Mahatma gandhi hospital,Sitapura, jaipur,india

  1. 1. Ilizarov  Dr.Abhishek chachan Mahatma gandhi hospital sitapura, jaipur Rajasthan, INDIA
  2. 2. Historical review Gavriil Abramovich Ilizarov( 15 june 1921 – 24 july 1992) Russian physician, known for inventing the Ilizarov apparatus
  3. 3. Historical review Ilizarov was born in the Azerbaijan In 1944 he was sent to a rural hospital in Kurgan Oblast in Siberia In 1951, he developed a revolutionary technique and called it a RING FIXATOR .
  4. 4. Priciples of Illizarov DISTRACTION OSTEOGENESIS. This refers to the induction of new bone between bone surfaces that are pulled apart in a gradual, controlled manner. The distraction initially gives rise to NEOVASCULARISATION which is what actually stimulates new bone formation. In addition, there is simultaneous histogenesis of muscles, nerves and skin; in bone diseases (osteomyelitis , fibrous dysplasia, pseudo-arthrosis) this new bone replaces pathological bone with normal bone.
  5. 5. Indications of Illizarov In treating of bone infections In Poliomyelitis Sequelae (in limb lengthening and correction of deformities) In treating of malunited fractures and non-unions To correct deformities of the limbs, both congenital and acquired In treating badly comminuted fractures (multiple fragments) in the limbs Lengthening of limb stumps, foot stumps and fingers To increase height (for dwarfs)
  6. 6. Instruments and their use Primary components – That join skeleton to finished frame  Transosseous wires  Rings  Wire fixaion bolts
  7. 7. Instruments and uses Secondary components – Used to construct frame  Threaded and telescopic rods  Connecting plates  Hinges and posts  Nuts and bolts
  8. 8. Instruments used in ilizarov
  9. 9. Wire fixation bolt Cannulated Cannulated with threaded head Slotted
  10. 10. Wire fixation buckle Allows mechanical derotation or angular corrections
  11. 11. Telescopic rod Provide stability when long distance must be spanned between rings Allows lengthening
  12. 12. Hinge ( Male and female)
  13. 13. Threaded socket Inerconnect threaded rods Stabilize two rings together
  14. 14. Wires Trocar- Cancellous bone Bayonet – Cortical bone Olive wires
  15. 15. Dynamometric wire tensioner
  16. 16. Biomechanics Tensioned wires (1.5 and 1.8) achieve rigidity equal to half pins. And retain elasticity and low axial stiffness. Should not exceed 50% of yield strength of wire Maximum limits  90 kg for 1.5 mm wire  130 kg for 1.8 mm wire
  17. 17. Biomechanics Tension in soft tissues also determine the tension to be applied to wire In Lengthening its safer to tension wires to 80 -90 Kg Increasing wire tension from 90-130 increases bending and axial stiffness but lowers torsional stiffness
  18. 18. Biomechanics Number of wires  More the number/ring more stable is the fixator Wire spread  90/90 ideal- Anatomical constraints  45/135 configuration less stable in flexion Off centering  Higher axial stiffness and lower torsional stiffness. Olive wires  increase bending, axial and torsional stiffness
  19. 19. Biomechanics Wires are self stiffening  Wires derive increasing rigidity with increasing deflection  On releasing deflection load, wires spring back to its original axially tensioned position  Allows axial micromotion
  20. 20. Biomechanics Wire diameter  Increase diameter increases tension Optimum wire  1.5 mm for children  1.8 mm for adults
  21. 21. Biomechanics of Ring Stability of assembly  Number  Size  Position of rings Closer the middle two rings to the fracture more stable is the configuration
  22. 22. Biomechanics Reduction of 2 cm of radius of rings  77% rise in axial stiffness under 100 N load Only torsional stiffness increased with increasing ring diameter Ilizarov recommends minimum of 2 cm between skin and ring to accomadate edema as blood flow increases
  23. 23. Biomechanics of Fulcrum In deformity correction Olive wires are used as fulcrum to prevent slippage of wires
  24. 24. Biomechanics of hinges
  25. 25. Biomechanics of Hinges Central hinge causes distraction on concave side and compression on convex side.
  26. 26. Biomechanics Hinges Fulcrum on the convex side Hinge at apex of deformity – distraction on convex side
  27. 27.  Hinge placed more laterally results in lengthening along with angular correction
  28. 28. Factors affecting stability of fixator I Apparatus related (Extrinsic) factors  Spread between crossing wires approaching 90/90  Increase in wire diameter and tension  Increase in number of rings  Decreased ring size (wire span distance of 2-3cm around the limb)  Close positioning of center rings to fracture or nonunion site.  Use of olive (stop) wires.
  29. 29. Factors affecting stability of fixator II. Intrinsic factors-  Area of tissue contact between the bone ends.  Modulus of elasticity of tissue between bone ends  Length of gap between bone ends.  Tension of soft tissue surrounding bone  Mechanical configuration and interlock between bone ends
  30. 30. Histology of distraction osteogenesis FIZ – Fibrous interzone PMF- Primary mineralization front MCF – microcolumn formation HBS – Host bone surface
  31. 31. Histology Latency period – similar to fracture healing 1 week after distraction-  Fibrous interzone fills corticotomy gap (6-7 mm) By 2nd week-  Osteoblasts appear on each side of FIZ and collagen bundles fuse with osteoid like matrix  Later in 2nd week Osteoid mineralizes (Primary Mineralization Front)  New bone forms at two cut surfaces of corticotomy.
  32. 32.  3 weeks of distraction  New bone differentiates to microcolumn formation {MCF} with maximum diameter of 200 microns. FIZ persists throughout distraction After distraction FIZ ossifies, MCF unifies bridging the gap At the conclusion of distraction, the FIZ ossifies, creating one zone of MCF and completely bridging the gap During this 6-week consolidation period
  33. 33.  During the 6 weeks after frame removal, the osteogenic area remodels into cortex and medullary canal Blood flow peaks 7 times normal during first 4 weeks of distraction Then Decreases but remains elevated 3 times normal for next 3 months
  34. 34. Factors affecting osteogensis Stability of bone fragments local or regional blood supply Latency period Rate and rhythm of distraction Function of limb Timing of frame removal
  35. 35. Anatomic considerationsFEMUR- When inserting wires into the femur, there are several basic problemsFirst, the bulk of the soft tissues causes difficulties, especially posteriorly, in the buttock.Second, the neurovascular bundles,especially the superficial femoral artery,can be damaged during wire insertion.Third, the sciatic nerve prevents direct AP wire insertion.
  36. 36.  Insert the first olive wire from anteromedial to posterolateral two fingerbreadths lateral to the femoral artery. Insert a second olive wire from back to front, 15° medial to the first wire. The posterior olive on this wire prevents the entire frame from displacing anteriorly while the patient lies in bed. A third wire is often inserted between the first two. To stabilize a hip during femoral lengthening.especially a hip that might sublux or dislocate,it may be necessary to insert wires into the supraacetabular or iliac portion of the pelvis. Leave these wires in place (not allowing movement) until lengthening is complete. Thereafter, the wires are removed and hip motion is commenced. For the distal femur, insert wires into either the transverse or the coronal plane. When selecting the transverse plane, cross the wires at an angle of no less than 60°. Likewise, insert olives from both directions for enhanced stability
  37. 37. TIBIAThe proximal ring for a tibial mounting usually incorporates . a wire that passes through the fibular head and into the tibia to prevent subluxation of the proximal tibia fibula joint during lengthening or deformity correction. A second wire through the tibia crosses the fibula wire, paralleling the medial face of the tibia. A third transverse drop wire is inserted across the tibia into the location used for skeletal traction. Additional wires are inserted as needed for greater stability. Distally, the fibula must usually be incorporated into the configuration with a distal fibulotibial wire.
  38. 38.  HUMERUS The Proximal And Distal Ends Of The Bone Can Be Secured With Three Wires Each Through The Proximal Humerus, Abduct The Arm 90° and externally rotate it 20°. Drive olive wires from both the anterior and posterior directions. The third wire is a drop wire off the plane of the ring. In the distal humerus, insert olive wires crossing in the frontal plane, one from the lateral supracondylar ridge and one from the medial supracondylar ridge A drop wire (perpendicular to the bones axis) completes the configuration Insert the wires into both epicondyles, exiting the humerus proximally at the medial and lateral supracondylar ridges. Take care not to transfix either the ulnar or radial nerves. A third wire straight across from one supracondylar ridge to the other completes the mounting. After all wires are in place, flex and extend the elbow: there should be no block in either direction.
  39. 39. FOOT Before Inserting Wires Into The Calcaneus, Consider The Diameter Of The Wires,Number , The Angles Between, The Direction Of Insertion, The Plane Of The Wires. diameter of the wires is determined by the age the amount of osteoporosis and degree of deformity influence the number of wires selected-more then 2 wire
  40. 40.  Next, consider the direction from which the wires are to be inserted. When correcting an equinus, insert both olive wires from the posterior part of the heel toward the forefoot. When correcting a cavus or calcaneus deformity, insert the olive wires from the forepart of the foot toward the heel. When correcting a forefoot adduction deformity, keep both olive wires on the medial side of the heel. When a valgus of the heel is being corrected, place the olive on the lateral side of the foot. In combined deformities such as talipes equinovarus, the position of the olives is determined by the nature of the pathology
  41. 41. Precautions Corticotomy complete – Confirm fluoroscopically Distraction no more than 2-4 mm Angulation no more than 20-30 degrees
  42. 42. Radiographic classification of regenerate Normotrophic Hypertrophic and Hypotrophic
  43. 43. Normotrophic Early radiodense bone formation b/w 21 to 28 days At this point bone ends have distracted approx 14 mm apart Definite columns of longitudinally oriented new bone extends from each corticotomy surface towards central transverse radiolucent area measuring approximately 4 mm As distraction proceeds columns of new bone elongate maintaining central radiolucent band Following distraction new bone bridges centrally & proceeds to homogenous appearance
  44. 44. Radiologic evaluation of callus
  45. 45. Hypertrophic Regenerate appears radiologically before 20 days Cross sectional diameter of regenerate exceeds that of corticotomy surface Rate of distraction must be increased
  46. 46. Hypertrophic Factors  Young patient  More active patients  Good local blood supply ( Humerus)
  47. 47. Hypotrophic Radioloigcal new bone appears after 30 days Or if bone column has multiple breaks Or regenerate has hourglass appearance Factors  Vascular deficits  Local scarring or swelling which constricts new tissue formation  Lack of function or weight bearing by the patient
  48. 48. Hypotrophic Type A Spotty radiodensities after day 50 indicating poor vascularity
  49. 49. Hypotrophic Type B Hourglass configuration – distraction rate too fast
  50. 50. Hypotrophic Type C Irregular bone columns indicate instability or vascular disruption
  51. 51. Hypotrophic Type D Focal failure of bone formation indicate local vascular injury or periosteal damage if peripheral
  52. 52. Timing of Frame Removal Depends on the condition of the limb and pathology invovled X Ray: Ideally the regenrate bone should be remodelled with cortex and medullary canal of equal cross section diameter to the host bone Q.C.T: Quantitave C.T. scanning of central osteogenic area density must be 60% of opposite normal bone is satisfactory for removal of frame Clinical test for frame dynamization: prior to removal the wire tension is gradually reduced to minimum and patient allowed for full wt bearing,if new bone supoorts full load without pain or deformity,then device can be safely removed
  53. 53. Clinical applications Non unions and deformity correction Bone transport Fractures Limb lengthening
  54. 54. Non union Hypertrophic non-unions have a vital blood supply from each bone end and a dense collagenous interface. Bone formation can be stimulated by primary distraction Atrophic non-unions, with thin, non-reactive bone ends, are treated initially with compression and then with distraction
  55. 55. Bone transport Intercalary defects resulting from  trauma,  infection,  tumor, or  prosthetic replacement can be treated with transport of a segment of bone within the limb
  56. 56. Limb lengthening The Ilizarov method allows the surgeon to perform complex and extended lengthening of both congenital and acquired short limbs Rate and quality of bone formation can be influenced by certain factors  Amount of lengthening that is attempted,  the site of the lengthening,  the selection of the bone to be lengthened,  and the number of sites of lengthening within the bone
  57. 57.  The rate of healing is directly proportional to the length of the distraction gap — the greater the lengthening, the longer the time needed for treatment Metaphyseal sites generally heal faster than diaphyseal sites. The femur has been shown to heal faster than the tibia And tibiae lengthened at two sites heal faster than those lengthened at only one site Older patients tend to heal more slowly, with greater delays occurring after the age of twenty years
  58. 58. Complications Complications can involve the  pin tracks  bones  Joints  neurovascular structures  Mental status
  59. 59.  Inflammation surrounding pin tracks is common as a result of  mechanical or thermal damage  Cellulitis  abscess or  local osteomyelitis.
  60. 60.  Osseous complications may involve  premature or delayed consolidation  non-union  axial deviation  late bending  fracture
  61. 61.  During the lengthening, motion of the joint may be temporarily or permanently lost as a result of  muscle contracture  arthrofibrosis, or  damage to the cartilage.
  62. 62.  Nerves and vessels may be damaged  directly by pins or osteotomes or  Indirectly by the actual stretching. Regional edema is common; Painful neurapraxia is less common; and Reflex sympathetic dystrophy, and compartment syndrome are rare
  63. 63. Advantages of Ilizarov over Cantilever type Ex fix Elastic allow axial micromotion, and controls shear stress Multilevel multiplanar fixator, distribute stresses more evenly across fracture - 3 dimensional correction is possible intraop and post op. Stable- allow immediate weight bearing Better in osteoporotic bone Pins are thin and does not cause much damage to tissues

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