Ilizarov Circular Fixator Research Articles

Bone Transport for Large Segmental Tibial Defects Using Taylor Spatial Frame versus the Ilizarov Circular Fixator.

Bone transport has become the gold standard for treating large segmental tibial bone defects. The technique for application the Ilizarov circular fixator (ICF) has a long learning curve and is associated with many complications. There are few clinical studies on bone transport via the Taylor spatial frame (TSF). The main purpose of this study was to compare the radiological and clinical and outcomes of bone transport by using the TSF and the ICF. There were 62 patients included in this retrospective study from June 2011 to June 2021 and distributed to two groups according to the fixation method: a TSF group consisting of 30 patients and an ICF group consisting of 32 patients. Demographic information, surgical duration, external fixation times, external fixation index, final radiographic results, complications, and clinical outcomes were recorded and examined. The clinical outcomes were assessed using the ASAMI criteria during the most recent clinical visit. Then, statistical analysis such as independent-samples t tests or chi-Square test was performed. The mean surgical duration in the TSF group was 93.8 ± 7.3 min, which was shorter than that in the ICF group (109.8 ± 1.4 min) (p < 0.05). Compared to the ICF group (10.2 ± 2.0 months), the TSF group (9.7 ± 1.8 months) had a shorter average external fixation time (p > 0.05). The external fixation index was 1.4 ± 0.2 m/cm and 1.5 ± 0.1 m/cm in the two groups. Moreover, there was no significant difference between the two groups. At the last follow-up visit, the medial proximal tibial angle (MPTA) and posterior proximal tibial angle (PPTA) in the TSF group were 88.1 ± 12.1° and 80.9 ± 1.3°, respectively. The MPTA and PPTA in the ICF group were 84.4 ± 2.4° and 76.2 ± 1.9°, respectively. There were statistically significant differences between the two groups (all p < 0.05). The complication rate was 50% in the TSF group and 75% in the ICF group. Moreover, the ASAMI score between the two groups was no statistically significant difference (p > 0.05). No statistically significant difference was found in clinical outcomes between the use of Taylor spatial frame and Ilizarov circular fixator for treating large segmental tibial bone defects. However, TSF is a shorter and simpler procedure that causes fewer complications and improves limb alignment.

Evaluation of Radiological and Functional Outcomes of Closed Complex Mid-shaft Tibia Fractures Treated with Primary Definitive All Wire Ilizarov Ring Fixator: A Prospective Study at Tertiary Care Centre of Nepal.

Introduction: Closed complex tibial shaft fractures are frequently encountered fractures in lower limb injuries. Various surgical methods for these fractures include primary or delayed fixation with intramedullary nails, minimal invasive plates, and primary definitive external stabilization using ring fixators. We conducted this study to evaluate the radiological and functional outcomes of primary definitive fixation of these fractures using an all-wire Ilizarov circular fixator. Objectives: The objectives of this study were to evaluate the radiological and functional outcomes of primary definitive fixation of closed complex tibial mid-shaft fractures in patients with compromised soft tissue status. Methodology: We defined Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) 42-B1 to AO/OTA 43-C3 fractures as complex tibial shaft fractures for this prospective observational study, and evaluated all 26 patients for the functional and radiographical progression according to ASAMI classification. Results: Twenty-six patients were stabilized with an all-wire circular ring fixator. The union time on average was 27.61 weeks. Among all patients, 7 (37.5%) cases had minor pin tract infections, and one (2.7%) patient landed a non-union, which required bone graft. Conclusion: With the use of an all-wire Ilizarov circular frame, there is a good mean time to union, fewer chances of re-operations, and good functional outcomes without any major complications.

Functional Outcome of Ilizarov Technique in Managing Proximal Tibial Fracture in Combined Military Hospital, Rawalpindi

Background: Tibial plateau fractures involve injuries affecting the major weight-bearing joint and result in functional impairment which can be prevented by implying competent treatment techniques including dual column plating, assisted reduction, internal fixation with plating and Ilizarov circular fixator. The objective of this study was to evaluate the functional outcome of Ilizarov technique in treating closed tibial plateau fractures.&#x0D; Methodology: A Quasi experimental study was conducted in the Orthopedic department of Combined Military Hospital, Rawalpindi from 30th July 2019 to 29th January 2020. A total of 100 patients with tibial plateau fractures of Schatzker type III to VI, 20 to 60 years of age of either gender were included. In all patients, Ilizarov technique was performed. Data were entered in SPSS 22. Descriptive analysis was done for quantitative variables and percentages were calculated for qualitative variables. Chi square test was applied to determine association of variables with functional outcome.&#x0D; Results: Mean age of patients was 37.42 ± 8.94 years. Out of 100 patients, 70% were males and 30% were females, 76% patients managed with Ilizarov technique in treating closed tibial plateau fracture had excellent functional outcome, 15% good outcome, 5% fair and 4% poor outcome. Functional outcome with respect to age, gender, BMI and DM showed statistically significant difference with p value 0.017, 0.016, 0.004 and 0.001 respectively.&#x0D; Conclusion: Functional outcome of Ilizarov technique in treating closed tibial plateau fracture is significantly better.&#x0D; Keywords: Ilizarov Technique, Orthopedic Fixation Devices, Tibial Fractures

Outcomes of intralesional osteotomy and distraction osteogenesis for limb length equalization in Ollier's disease.

Limb length discrepancy and deformities resulting from Ollier's disease are challenging to treat and have increased complications. We aimed to assess the safety of intralesional osteotomy for distraction osteogenesis and report the results of guided growth as a method of deformity correction in such conditions. We retrospectively reviewed 13 patients (eight boys and five girls), 28 segments (12 femora and 16 tibias), treated using Ilizarov circular ring fixator in one center. Nine patients had an oblique plane deformity, whereas four had a coronal plane deformity. Femoral shortening ranged from three to 11 cm. Tibial shortening ranged from 3.5 to 12 cm. Intralesional osteotomy was carried out in all patients, and guided growth (hemiepiphysiodesis) was used in seven segments (25%). The median age was 11 years (6-14 years) at surgery, with a median follow-up of 4.5 years (3-18 years). The median achieved lengthening in the femur was 7 cm (5-11 cm) and in the tibia was 5 cm (3-9 cm). The average Bone Healing Index (BHI) for the femur was 32 days/cm (28-38 days/cm), and for the tibia was 36 days/cm (28-40 days/cm). Before frame removal, the mechanical axis was restored to the knee joint center in all cases. Normal radiographic bone regeneration was evident in all cases. Hemiepiphysiodesis successfully corrected the angular deformities. Intralesional osteotomy for distraction osteogenesis is well-tolerated and reliable in Ollier's disease. Radiological normal bone was formed at the distraction site. Guided growth is also a reproducible method for deformity correction in Ollier's disease, similar to other conditions.

The Role of Chlorhexidine in the Prevention of Pin Tract Infection as Compared to Povidone-Iodine in Patients Managed by Ilizarov Circular Fixator

Objective: To compare the efficacy of Chlorhexidine in the prevention of pin tract infection as compared to Povidone-iodine antiseptic. Study Design: Prospective, single blinded randomized trial. Study Setting and Duration: Liaquat University of Health Science (LUMHS), Jamshoro between July 2018 to November 2020. Methodology: All patients who underwent Ilizarov external fixation as per indications were eligible for the study. Individuals with a previous history of osteomyelitis were excluded from the study. Pin sites were cleansed with normal saline using clean applicators. In the group chlorhexidine, the antiseptic was applied on the pin skin interphases (1% chlorhexidine). Similarly, 10% povidone iodine was applied to patients in group C. The control group was cleansed with normal saline. Pin sites were either dressed daily or weekly. The primary outcome was the rate of pin site infection days. Results: Chlorhexidine group had significantly lesser pin-site infections as compared to the povidone-iodine group with a frequency of 13 (39.39%) and 19 (63.33%), p=0.04, respectively. The mean pin tract infection rate days ± SD were significantly lower in the chlorhexidine group as compared to the povidone-iodine group (1.35 ± 2.26 vs 3.54 ± 4.30, p=0.041). Similarly, the mean duration to onset of pin site infection was also significantly higher in the chlorhexidine group compared to povidone-iodine and control groups. Conclusion: Patients who used Chlorhexidine as the cleansing agent had significantly fewer pin-site infections as compared to the povidone-iodine group. Keywords: Chlorhexidine, Ilizarov fixator, fracture, Povidone-iodine

Optimal time-dependent levels of weight-bearing for bone fracture healing under Ilizarov circular fixators

It is known that weight-bearing exercises under Ilizarov circular fixators (ICF) could enhance bone fracture healing by mechano-regulation. However, interfragmentary movements at the fracture site induced by weight-bearing may inhibit angiogenesis and ultimately delay the healing process. To tackle this challenge, a computational model is presented in this study which considers the spatial and temporal changes in mechanical properties of fracture callus to predict optimal levels of weight-bearing during fracture healing under ICF. The study takes sheep fractures as example and shows that the developed model has the capability of predicting patient specific, time-dependent optimal levels of weight-bearing which enhances mechano-regulation mediated healing without hindering the angiogenesis process. The results demonstrate that allowable level of weight-bearing and timings depend on fracture gap size. For normal body weights (BW) and moderate fracture gap sizes (e.g. 3 mm), weight-bearing with 30% BW could start by week 4 post-operation and gradually increase to 100% BW by week 11. In contrast, for relatively large fracture gap sizes (i.e. 6 mm), weight-bearing is recommended to commence in later stages of healing (e.g. week 11 post-operation). Furthermore, increasing ICF stiffness (e.g. using half pins instead of pretension wires) can increase the level of weight-bearing significantly in the early stages up to a certain time point (e.g. week 8 post-operation) beyond which no noticeable benefits could be achieved. The findings of this study have potential applications in designing post-operative weight bearing exercises.

A probabilistic approach for modelling bone fracture healing under Ilizarov circular fixator

Bone fracture treatments using Ilizarov circular fixator (ICF) involve dealing with uncertainties about a range of critical factors that control the mechanical microenvironment of the fracture site such as ICF configuration, fracture gap size, physiological loading etc. To date, the effects of the uncertainties about these critical factors on the mechanical microenvironment of the fracture site have not been fully understood. The purpose of this study is to tackle this challenge by using computational modelling in conjunction with engineering reliability analysis. Particularly, the effects of uncertainties in fracture gap size (GS), level of weight-bearing (P), ICF wire pretension (T) and wire diameter (WD) on the fracture site mechanical microenvironment at the beginning of the reparative phase of healing was investigated in this study. The results show that the mechanical microenvironment of fracture site stabilised with ICF is very sensitive to the uncertainties in P and GS. For example, an increase in the coefficient of variation of P (COVP ) from 0.1 to 0.9 (i.e., an increase in the uncertainty in P) could reduce the probability of achieving a favourable mechanical microenvironment within the fracture site (i.e., Probability of Success, PoS) by more than 50%, while an increase in the coefficient of variation of GS (COVGS ) from 0.1 to 0.9 could decrease PoS by around 30%. In contrast, an increase in the uncertainties in T and WD (COV increase from 0.1 to 0.9) has little influence on the fracture site mechanical microenvironment (PoS changes <5%).

Role of the Ilizarov non-free bone plasty in the management of long bone defects and nonunion: Problems solved and unsolved.

Ilizarov non-free bone plasty is a method of distraction osteogenesis using the Ilizarov apparatus for external fixation which originated in Russia and was disseminated across the world. It has been used in long bone defect and nonunion management along with free vascularized grafting and induced membrane technique. However, the shortcomings and problems of these methods still remain the issues which restrict their overall use. To study the recent available literature on the role of Ilizarov non-free bone plasty in long bone defect and nonunion management, its problems and the solutions to these problems in order to achieve better treatment outcomes. Three databases (PubMed, Scopus, and Web of Science) were searched for literature sources on distraction osteogenesis, free vascularized grafting and induced membrane technique used in long bone defect and nonunion treatment within a five-year period (2015-2019). Full-text clinical articles in the English language were selected for analysis only if they contained treatment results, complications and described large patient samples (not less than ten cases for congenital, post-tumor resection cases or rare conditions, and more than 20 cases for the rest). Case reports were excluded. Fifty full-text articles and reviews on distraction osteogenesis were chosen. Thirty-five clinical studies containing large series of patients treated with this method and problems with its outcome were analyzed. It was found that distraction osteogenesis techniques provide treatment for segmental bone defects and nonunion of the lower extremity in many clinical situations, especially in complex problems. The Ilizarov techniques treat the triad of problems simultaneously (bone loss, soft-tissue loss and infection). Management of tibial defects mostly utilizes the Ilizarov circular fixator. Monolateral fixators are preferable in the femur. The use of a ring fixator is recommended in patients with an infected tibial bone gap of more than 6 cm. High rates of successful treatment were reported by the authors that ranged from 77% to 100% and depended on the pathology and the type of Ilizarov technique used. Hybrid fixation and autogenous grafting are the most applicable solutions to avoid after-frame regenerate fracture or deformity and docking site nonunion. The role of Ilizarov non-free bone plasty has not lost its significance in the treatment of segmental bone defects despite the shortcomings and treatment problems encountered.

Experimental study on the effects of different disinfectants in preventing pin-site infection after using Ilizarov circular external fixators

The present study aimed to investigate the effects of different disinfectants in preventing pin-site infection. A total of 32 healthy New Zealand white rabbits were selected as the research subjects. The rabbits were placed in an Ilizarov 3/4 circular external fixator for a period of time after feeding. They were then divided into four groups of eight animals each. After surgery, pin-site nursing was performed twice a day with a different disinfectant for each group (chlorhexidine gluconate alcohol disinfectant, Maokang iodine, 75% alcohol and physiological saline). Each pin site’s surrounding conditions were visually observed daily, and bacterial culture of the pin-site secretions was promptly performed. The changes of C-reactive protein (CRP) and white blood cell upon the first day, first week, second week, fourth week, and sixth week after the operation were compared, as were infection statuses and morphological changes in the surrounding tissue at the sixth week post operation. The differences in the CRP and white blood cell values and infection rates among the four groups were found to be statistically significant (P &lt; 0.05), but the difference in infection levels among the four groups was not statistically significant (P&gt;0.05). In addition, the difference in the pathologically inflammatory cells among the four groups at the sixth week post operation was statistically significant (P &lt; 0.05).It was concluded that the effect of chlorhexidine gluconate alcohol disinfectant in preventing pin-site infection was superior compared to the other three disinfectants.

Ilizarov segmental bone transport of infected tibial nonunions requiring extensive debridement with an average distraction length of 9,5 centimetres. Is it safe?

ObjectivesTo evaluate the results of one stage radical debridement and segmental bone transport with circular fixator in the treatment of infected tibial non-union requiring extensive debridement with an average defect size of 8 cm and distraction length of 9,5 cm. DesignRetrospective study. SettingLevel I trauma centre at an academic university hospital. PatientsThirty patients with infected tibial non-union with an average of 2,9 previous failed operations after a mean 12,5 months post-injury were treated consecutively. The mean age was 39,5 years (R:16–68). After radical debridement and irrigation, all patients were treated with segmental bone transport using Ilizarov circular fixator. All patients except 3, managed with an open docking protocol without bone grafting. In 2 patients a planned ankle arthrodesis with transport was done. Main outcome measurementsBone union, resolution of infection, external fixation index (EFI), external fixation time (EFT), bone and functional results for this big defect size. ResultsUnion and eradication of infection was achieved in all patients. Mean follow-up was 32,5 months (R: 12–72 mo.) The average bone defect after debridement was measured 8.1 cm (R, 6–15). The total distraction length to restore the debridement defect and previous LLD was 9,5 cm (R, 6–15). The mean external fixation time was 13,7 months; the mean external fixation index was 1,49 mo./cm. One non-union, one refracture and one late valgus deformity was managed successfully with plating or nailing and all were healed uneventfully at the completion of the treatment. According to Paley & Maar and Katsenis criteria, the bone results were excellent in 24 and good in 6, functional scores were excellent in 21, good in 7, and fair in 2 patients. Minor complications were 1,36 per patient, major complications were 0,4 per patient and permanent complications were 0,2 per patient in the study group. ConclusionIn the management of large post-infectious bone defects requiring an average 9,5 cm distraction; segmental bone transport is safe in terms of union and eradication of infection. The EFI, EFT, complications, bone and functional results do not differ from the other published studies with smaller defect size.

One-stage debridement and two-stage Ilizarov bone transport technology for post-traumatic lateral malleolus defect

To explore the effectiveness of one-stage debridement and two-stage Ilizarov bone transport technology in repairing post-traumatic lateral malleolus defect. Between June 2013 and December 2016, 7 patients with bone defect of lateral malleolus were treated. There were 5 males and 2 females with an average age of 45.9 years (range, 35-60 years). There were 6 cases of traffic accident injury and 1 case of strangulation injury. All patients had extensive soft tissue injury and lateral malleolus bone exposure. There were 4 cases of Gustilo type ⅢB and 3 case of Gustilo type ⅢC. The time from injury to admission was 3-10 hours (mean, 6.3 hours). Through one-stage thorough debridement, exploration and repair of vessels and nerves, external fixation of scaffolds and coverage of wounds, free fibulas were removed in 3 cases at one-stage and fibulas were resected in 4 cases after expansion. The bone defects ranged from 4.5 to 15.0 cm in length (mean, 8.2 cm). The Ilizarov circular external fixators were used to transport with fibula osteotomy for repairing bone defect of lateral malleolus when the wound healing. During fibular osteotomy, the stents were adjusted 2-4 times (mean, 2.8 times) and the external fixators were removed after 10-16 months (mean, 12.8 months). The nail tract infection occurred in 2 cases during transporting and was controlled after symptomatic treatment. All patients were followed up 24-48 months (mean, 32.9 months). The shape of lateral malleolus was close to normal without obvious varus or valgus deformity. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot score was 86-92 (mean, 90.3), and 5 cases were excellent and 2 cases were good. X-ray film showed that there was no obvious widening of the gap between the ankle points and no sign of absorption of the lateral malleolus. The one-stage debridement combined with two-stage Ilizarov bone transport technology can maintain the stability of ankle joint structure and obtain better effectiveness in repairing post-traumatic lateral malleolus defect.

Ilizarov External Fixation: Percutaneous Gigli Saw Versus Multiple Drill-hole Osteotomy Techniques for Distraction Osteogenesis

IntroductionMany different methods and variations have been employed to perform osteotomy for deformity correction, bone lengthening, and segmental bone transport. Currently, multiple drill-hole (MDH) and Gigli saw osteotomies are the two most preferred ones, being favoured over other techniques. Our objective is to compare the modified healing index (mHI) of these two commonly used procedures.MethodologyThis retrospective study was conducted at the department of Orthopedics, Liaquat University of Medical and Health Sciences, Jamshoro, Pakistan. The study population consisted of all skeletally mature patients who underwent tibial bone osteotomy for bone lengthening or bone transport using Ilizarov circular fixator from June 2016 to September 2018. We excluded patients with metabolic bone disease and patients who underwent osteotomy for deformity correction. Preoperative and operative patients’ demographics and clinical data were gathered through a review of medical record and mHI was calculated to compare the effectiveness of osteotomy techniques.ResultsA total of 50 patients, 74% males and 26% females 26% with a mean age of 33.14 ± 12 years were included in the study. Of the 50 patients, 23 (27 osteotomies) had undergone MDH osteotomy (group I), whereas 27 patients (37 osteotomies) had a Gigli saw osteotomy (group II). The overall mHI of both groups was 1.60 ± 0.34 month/cm (range 1.0-2.5 month/cm). When we compared the mHI of both techniques, the mean mHI was 1.72 ± 0.33 month/cm (range 1.2 - 2.5 months/cm) in MDH group and 1.54 ± 0.36 month/cm (range 1.0-2.5 month/cm) in the Gigli saw group. The healing index was significantly lower in the Gigli saw group. None of our patients showed nonunion at the osteotomy site. However, the problems of incomplete osteotomy in two cases and bone fractures in four cases were seen in MDH osteotomy.ConclusionAccording to our results, percutaneous Gigli saw osteotomy technique by two small incisions minimizes the local soft tissue trauma and periosteal disruption around the osteotomy more than the multiple drill holes osteotomy, resulting in better consolidation following distraction osteogenesis.

The Effects of Dynamic Loading on Bone Fracture Healing Under Ilizarov Circular Fixators.

Early weight bearing appears to enhance bone fracture healing under Ilizarov circular fixators (ICFs). However, the role of early weight bearing in the healing process remains unclear. This study aims to provide insights into the effects of early weight bearing on healing of bone fractures stabilized with ICFs, with the aid of mathematical modeling. A computational model of fracture site was developed using poro-elastic formulation to simulate the transport of mesenchymal stem cells (MSCs), fibroblasts, chondrocytes, osteoblasts, osteogenic growth factor (OGF), and chondrogenic growth factor (CGF) and MSC differentiation during the early stage of healing, under various combinations of fracture gap sizes (GS), ICF wire pretension forces, and axial loads. 1 h of physiologically relevant cyclic axial loading followed by 23 h of rest in the post-inflammation phase (i.e., callus with granulation tissue) was simulated. The results show that physiologically relevant dynamic loading could significantly enhance cell and growth factor concentrations in the fracture site in a time and spatially dependent manner. 1 h cyclic loading (axial load with amplitude, PA, of 200 N at 1 Hz) increased the content of chondrocytes up to 37% (in all zones of callus), CGF up to 28% (in endosteal and periosteal callus) and OGF up to 50% (in endosteal and cortical callus) by the end of the 24 h period simulated. This suggests that the synergistic effect of dynamic loading-induced advective transport and mechanical stimuli due to early weight bearing is likely to enhance secondary healing. Furthermore, the study suggests that relatively higher PA values or lower ICF wire pretension forces or smaller GS could result in increased chondrocyte and GF content within the callus.

Primary ilizarov external fixation in open grade III type C distal femur fractures: Our experience

IntroductionOpen comminuted distal femur fractures are notorious for septic or aseptic non-union. The recommended fixed angle distal femur locking plate in such situations can lead to a septic non-union due to its extensive approach and further periosteal stripping. Supracondylar nails, though have a minimally invasive approach, are not suitable for type C2 and C3 (AO/ASIF) fractures. A monolateral fixator as damage control followed by plating may be recommended. But if wound healing is delayed it results in difficult articular reduction, poor alignment and a stiff knee. We therefore used ilizarov circular external fixators (ICEF) for such open fractures (type C1, C2 and C3) and analysed its radiological and functional outcomes. Materials and methods25 male patients, with a mean age of 31.04 ± 6.62 years (range, 22–44 years), with open grade III type C distal femoral fractures were treated with ICEF. There were 7 fractures of type C1and C3 each, 11 were of type C2. Articular reduction and compression was achieved with inter-fragmentary screws through minimal open technique by extending the open wound and then stabilising the fracture with ICEF. The main outcomes evaluated were union, range of motion, final shortening, Knee Society scoring and ASAMI scoring system for radiological and functional outcomes. ResultsThe mean follow-up period was 19.12 ± 1.14 months. All fractures except two united at a mean period of 30 ± 3.02 weeks, without the need of bone grafts. The bony assessment (according to ASAMI score) was excellent in 8 cases (33.33%), good in 9 cases (37.5%) and fair in 5 cases (20.83%), while there were 2 poor clinical end results. The functional results were excellent in 6 cases (25%), good in 9 cases (37.5%) fair in 6 cases (25%) poor in 3 cases (12.5%). The complications included shortening, extension lag and pin tract infections. ConclusionWith the encouraging results, the use of ICEF with minimal internal fixation in grade III open comminuted distal femur fractures as a primary definitive treatment is a valuable alternative.

Treatment of infected non-unions with segmental defects with a rail fixation system

We conducted this study to evaluate the use of rail fixation system in infected gap non-union of femur and tibia as an alternative to the established Ilizarov circular fixator technique. Prospective study. The study was done in the Department of Orthopaedic surgery in a medical school and level I trauma center to which the authors are/were affiliated. Between June 2010 and June 2015, 40 patients with infected gap non-union of femur and tibia were treated with the rail fixation system. Patients who were willing to undergo surgery and participate in the post-operative rehabilitation were included in the study. After radical debridement, the system was applied and corticotomy done. For closure of bone gap, acute docking and distraction was done in 18 cases and segmental bone transport in 22 cases. Early mobilization of patient was done along with aggressive physiotherapy. Bone and functional results were calculated according to ASAMI scoring system, and complications were classified according to Paley classification. The mean follow-up period was 22.56 months (range 8–44). Bone union with eradication of infection was achieved in all but 1 case (97.5%). Bone results were excellent in 57.5%, good 40%, fair 0% and poor in 2.5% cases, while functional result was excellent in 32.5%, good 65%, fair 0% and poor in 2.5% cases. The rail fixation system is an excellent alternative method to treat infected gap non-union of femur and tibia. It is simple, easy to use and patient-friendly.

Compression distraction for the management of complex femoral nonunion

Background Complex nonunion is defined as established nonunion of at least 6 months’ duration with one of the following criteria: infection, bone defect or shortening of more than 4 cm, deformity, and an attempt to achieve union that failed to heal after at least one supplementary surgical intervention such as bone graft. Internal fixation methods are limited in their ability to deal with infection, bone defect, or shortening, and they involve extensive dissection around the fracture site for realignment of severe deformity. The Ilizarov method of compression distraction is particularly valuable in these complex cases. Patients and methods Between January 2004 and December 2010, 52 patients were treated for complex femoral nonunion using Ilizarov circular fixator. A monofocal treatment confined to the nonunion site (simple stabilization of the nonunion with compression and then stimulation of healing by distraction) was used in 23 patients; four of them had infected nonunion. Bifocal compression distraction technique with corticotomy (compression of the nonunion with distraction at the corticotomy) was used in 29 patients; 10 of them were infected. Results Bone healing was identified radiologically as callus bridging three cortices in 48 patients after a mean of 6.3 (4–12) months. Twenty patients of 23 treated using the monofocal technique had a mean healing time of 5.6 (4–9) months. Totally, 28 patients of 29 treated with bifocal compression distraction had healing after a mean of 6.8 (4–12) months. Using the criteria proposed by Paley and Maar, 30 patients had excellent functional results, 15 patients had good results, two had fair results, and five had poor results. The bony results were excellent in 35 patients, good in eight, fair in four, and poor in five. Conclusion Both monofocal and bifocal compression distraction techniques are effective in the treatment of complex femoral nonunion. Less treatment time is achieved for monofocal cases (mean: 5.6 months). In bifocal cases, acute shortening and lengthening has a much lower treatment time (mean: 5.5 months) compared with bone transport (mean: 9.3 months) and should be used when possible.

Ilizarov Fixator in the Management of Benign, Malignant and Complicated Cases of Bone Tumours

Objective: evaluate the Ilizarov fixator in the management of bone tumours regarding the duration and the ease of the procedure, the outcome and the complications. Methods: This study was done at the Department of Orthopedic surgery in Ain Shams University Hospitals. 15 patients with benign or malignant tumours were treated by resection followed by bone and soft tissue reconstruction and Ilizarov circular fixator in January 2012-April 2013 and followed up till July 2014. Results: Follow-up was done with a mean period of 21.7 (14-28) months. Adjustment of the frame was done as required. As regards malignant tumours, the disease free survival has a mean of 22.8 (12-30) months. 2 patients developed local recurrence. The overall survival was a mean of 25.8 (13-30) months. 1 patient died as a result of chemotherapy. The MSTS score was 50% to 100% with a mean value of 84.6%. ASAMI-bone score was excellent in 53% of the cases, good in 2 cases, fair in 1 case but poor in 4 cases. ASAMI-function score was excellent in 53% of cases, good in 33% of cases, fair in 1 case and poor in 1 case. The adverse effects were 7 problems, 5 obstacles and 6 complications according to Paley’s classification. Conclusion: Biological reconstruction using Ilizarov circular fixator should be considered safe and effective in the management of benign and low grade malignant tumours, and a salvage treatment in case of failure of other methods of limb salvage.

Bone transport for the management of severely comminuted fractures without bone loss.

This study aims to provide a new method for treatment of severely comminuted fractures without bone loss using the well-known technique of bone transport. Sixteen patients suffering from severely comminuted fractures with closed soft tissue injury were prospectively treated using bone transport by Ilizarov circular fixator. There were 14 male and 2 female patients. The mean age was 36.5 years (27–45). There were 13 proximal tibial metaphyseal fractures, one tibial diaphyseal fracture and two femoral distal metaphyseal fractures. All patients had closed soft tissue. The mean length of the comminution gap was 50.3 mm (40–64). Fracture healing occurred in 15 patients. The mean healing time was 23.4 weeks (14–30). No bone stimulating procedures were needed for either the fracture or distraction site. Using the IOWA knee and ankle score for assessment of the 15 patients who completed treatment: the functional outcome for the knee was excellent in 11 patients, good in three and fair in one. The ankle score was excellent in 12 patients, good in two and fair in one. According to Paley and Maar’s, bone results were excellent in 14 patients, good in one patient and poor in the patient who had failure of the procedure. The results achieved in this work are encouraging to keep on applying this technique to treat fractures that meet the following criteria: metaphyseal, with total circumferential comminution involving more than 4 cm of the bone length.

The effect of 2 different surgical methods on intracompartmental pressure value in tibial shaft fracture: An experimental study in a rabbit model.

Intracompartmental pressure (ICP) monitoring is a widely used modality, particularly after intramedullary nailing of tibial shaft fractures. It was hypothesized that ICP value in fracture fixed with Ilizarov circular fixator (ICF) might be lower than in fracture fixed with intramedullary pin (IMP). The present study is a comparison of ICP value in tibial fractures in a rabbit model fixed with ICF and IMP. Twenty male New Zealand White rabbits were randomly divided into 2 groups of equal size: ICF group (Group 1) and IMP group (Group 2). Under anesthesia, half of proximal part of the right tibia of all rabbits was fractured. Tibial fractures were fixed with ICF in Group 1 and IMP in Group 2. ICP values were monitored at 6-hour intervals for 48 hours. There was statistically significant difference in ICP value between groups (p<0.001). While there was statistically significant increase in ICP values 24 hours post surgery, there was statistically significant decrease during second 24 hours following surgery. Most importantly, ICP values of ICF group were significantly lower than those of IMP group at 30, 36, and 42 hours post surgery (p<0.05). At 24th hour after fixation, ICP values measured in ICF group were lower compared with those of IMP group. These results indicate that use of ICF in tibial fractures provides additional decompression in the anterior compartment. In light of these findings, ICF may be preferable for treatment of tibial fractures with high risk for compartment syndrome.

Ilizarov fixator in management of nonunited and infected tibial shaft fractures

Background: Management of nonunion with bony defect and infection in long bones is a challenging problem for orthopedic surgeons. Objectives: Evaluation of Ilizarov circular fixation method of treatment for the management of nonunited and infected fractures of tibia. Materials and Methods: This prospective study was conducted in a tertiary care hospital of eastern region of India on 30 subjects in a time span of 3 years after taking clearance of the Institutional Ethical Committee and informed consent of the patients. Results: All the patients had infected nonunion before undergoing Ilizarov procedure. Following initial injury, 22 patients were treated with external fixation and 8 cases were treated with internal fixation. At the time of presentation, 18 patients had infected gap nonunion, 5 patients had infected hypertrophic and 2 patients had atrophic nonunion. The Ilizarov fixator was kept for an average period of 303.7 days. Based on Association for the Study and Application of Methods of Ilizarov scoring system, bony and functional results were assessed. The bony result was excellent in 16 patients, good in eight, fair in four and poor in two. The functional result was excellent in 10 patients, good in 16, fair in two, poor in two. Conclusion: Ilizarov ring fixator still remains an excellent treatment modality for tibial nonunion with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.