Ilizarov Principles Research Articles

The history of Ilizarov

This review describes the life and works of Gavril Abramovich Ilizarov. The authors attempt to explain Ilizarov’s motivation and the key stages of his career which brought him to international acclaim. The article also discusses the key principles of Ilizarov’s methods and how these can be clinically applied.

Complications of Ilizarov Fixator in 105 Cases

Abstract Objective: The objective of this descriptive study was to assess the complications of locally made Ilizarov fixator. Study Design: Descriptive study. Place and Duration of Study: This study was con-ducted in Combined Military Hospital Quetta and Combined Military Hospital Rawalpindi over a period of 3 years from January 2007 till January 2010. Patients and Methods: One hundred five patients requiring Ilizarov fixator fixation for various indica-tions were studied. We included all the patients who required Ilizarov fixation as a definitive means of tre-atment. Locally made Ilizarov fixator was used and Schanz screws were inserted without pre drilling. Records were kept in microsoft access database. Results: Male population dominated our sample by 95 (90.5%) with mean age of 32.16 years. Road traffic accident was most common aetiology affecting tibia in 77 (73.33%) cases. Average fixator time was 17.9 weeks, minimum 7 and maximum 48. We achieved satisfactory union in 102 (97.14%) patients with out-come graded as excellent in 69 patients (65.71%), good in 27 (25.71), fair in 6 (5.71%) and poor in 3 (2.85%) as per ASAMI criteria. Total complications were 78 (74.38%), infection in 33 (31.42%) cases, of which 17 (16.2%) were minor pin tract infections and 16 (15.3%) were major infections which require curet-tage. We had joint stiffness in 16 (15.3 %) patients. We had limb shortening of more than 2.5 cm in 5 (4.76%) patients and valgus or varus deformity of more than 7 degree deformity in 19 (18.09%). 1 (0.95%) patient had progressive dislocation of the knee joint, while Schanz screw breakage was observed in 1(0.95%) patient. Conclusion: Complications encountered can be redu-ced by observing Ilizarov principles. Pin tracts must be cleaned as per standard protocols, joint stiffness can be minimized by vigorous range of motion exercises and weight bearing. Neurovascular injuries are avoided by respecting their planes. Although complications are common, still this is an effective tool for treating com-plex skeletal disorders which at time require amputa-tions. Keywords: Pin tract infections, joint stiffness, Ilizarov fixator.

Limb lengthening combined with deformity correction in children with the Taylor Spatial Frame

It is difficult to replicate the regular rate and rhythm described by Ilizarov while lengthening with the Taylor Spatial Frame. The purpose of the study was to examine whether this breach of Ilizarov's principles has any deleterious effect on the ability of children to make healthy regenerate bone. A retrospective case-control study was performed comparing pediatric patients undergoing primarily lengthening with Taylor Spatial Frame rings and struts, and patients undergoing lengthening with Taylor Spatial Frame rings and Ilizarov clickers. Fifteen patients had primarily lengthening with Taylor Spatial Frame rings and struts, and six patients had lengthening with Taylor Spatial Frame rings and Ilizarov clickers. Statistically, there was no significant difference between the two groups in terms of age, latency, pre-operative bone length percentage, and average length gained. The lengthening index for the strut group (1.79 months/cm) was significantly different from the clicker group (1.33 months/cm) with P=0.012. For a pediatric patient with lower extremity long bone deformities in multiple planes, the Taylor Spatial Frame is an excellent option. However, the surgeon should anticipate a slightly longer duration of treatment with the Taylor Spatial Frame compared to Ilizarov frames and plan his/her fixation accordingly. For the straightforward lengthening of pediatric long bones without significant concomitant deformity, our results indicate that the Ilizarov method appears to be superior to the Taylor Spatial Frame struts and should still be considered the gold standard.

Circular Fixation for the Nonplantigrade Charcot Foot

Diabetes-associated neuropathic osteoarthropathy (Charcot foot) is increasingly being recognized as a destructive disease process that frequently leads to severe disability and is responsible for a severe negative impact on health-related quality of life. In addition, this diabetes-specific disease process creates a similar negative impact on the health care system by consuming health care resources for multiple surgical procedures, often leading to lower extremity amputation and premature death. There is growing interest among orthopedic foot and ankle surgeons to address surgical correction of the acquired deformities, with a goal of improving walking independence, which appears to reverse the impaired quality of life of affected individuals. Reconstructive surgery in this patient population is fraught with a substantial potential for unique complications, as many of the patients are morbidly obese, have large wounds overlying substantial bony deformity, have impaired immunity due to diabetes, and have underlying chronic osteomyelitis with poor bone quality. This review is focused on the applications of the principles of Ilizarov for providing surgical stabilization following correction of deformities. This application is best reserved for patients who are at the highest risk for complications or have failed with standard orthopedic methods of internal fixation.

Ilizarov principles of deformity correction

Ilizarov frames provide a versatile fixation system for the management of bony deformities, fractures and their complications. The frames give stability, soft tissue preservation, adjustability and functionality allowing bone to realise its full osteogenic potential. It is important that we have a clear and concise understanding of the Ilizarov principles of deformity correction to best make use of this fixation system. In this review article, the history of Ilizarov frame, the basic sciences behind it, the mechanical principles governing its use and the clinical use of the fixation system are discussed.

Bone Gap Management Using Linear Rail System (LRS): Initial Observations in a National Orthopaedic Hospital

Background: Vascularized fibular grafting, free fibular graft, tibia profibula synostosis, amputation with a good prosthesis and Ilizarov technique are some of the suitable options for managing bone gaps that result from trauma or treatment of tumours, bone infection, congenital pseudoarthrosis and repeated failed osteosynthesis with shortening. We opted for the use of linear rail system (LRS) in the treatment of such cases. Objective: To study the effectiveness of the linear rail system (LRS) in the management of bone gaps.Method: Via lateral approach to the femur through previous surgical scars, the broken plate and screws as well as the broken intermediary nails were removed for case 1 and 3 respectively. Fibrolysis was effected and the bone ends trimmed. The gaps required on table to be bridged to achieve limb equality was 10 and 9cm respectively. The linear rail system device was applied, corticotomy performed in the supracondylar region of the femur and distraction commenced after a latency of 10 days. Case 2 haddebridement of his gunshot wound with a defect of 10cm created on table. LRS was applied and corticotomy effected. Distraction was commenced after latency of 7 days.Results: Case 3 has completed his treatment, his device is removed after consolidation of 7cm of his regenerate. Case 1 and 2 have completed their distraction phase and are awaiting consolidation of 10cm regenerate each.Conclusion: The linear rail system (LRS) appears to be an effective tool in the management of bone gap using the Ilizarov principle of distraction osteogenesis. It is simpler, more cosmetically acceptable to patients and less technically challenging and gives same result as the Ilizarov circular frame.Key words: Bone gap, linear rail system, distraction osteogenesis.

Limb lengthening and deformity correction in children using hexapodal external fixation: Preliminary results for 36 cases

Limb deformities in children can be corrected using different techniques, notably external fixation following the Ilizarov principles. However, correction can be difficult in cases of multiple deformities. In 1994, Charles Taylor developed a new computer-assisted hexapodal external fixator system to treat these pathologies, the Taylor Spatial Frame. The objective of this study was to evaluate the results obtained with this technique in treating lower-limb deformities in children. Thirty-six patients were included in this prospective study, with a mean age of 11.1 years. The etiologies were distributed into six groups: congenital pathologies in 17 cases, fractures in five cases, post-traumatic pathologies in two cases, postinfectious sequelae in three cases, achondroplasia in three cases, and other causes in the last six cases. A total of 67 deformities in the three spatial planes were found in the entire group of patients. The procedure consisted of lengthening, correcting the axis, or both simultaneously. All the patients were managed with the same protocol: placement of an external fixator, AP and lateral X-rays, and planning of the correction using dedicated software. In this group of 36 patients, the fixator was worn for a mean 183 days; when lengthening was performed, a mean 4.3cm was gained with a healing index of 38.2 days/cm. Of the 67 initial deformities, 91% were corrected. The most frequently encountered complications were a superficial infection in 22.2% of the cases; one deep infection was also noted as well as three bone regenerate fractures. Use of this computer-assisted fixation system seems effective in treating complex deformities of the limbs in children, and allows treating several deformities simultaneously.

Managing Flexion Knee Deformity Using a Circular Frame

Knee flexion deformity can cause marked physical disability. Acute correction, whether nonoperative or operative, may lead to serious complications. We treated 50 patients (71 knees) between 1994 and 2002 with the Ilizarov external fixator. The deformity was gradually corrected using Ilizarov principles. Of the 50 patients, 29 were affected unilaterally and 21 bilaterally. In 15 patients, there were associated deformities. In no patient did we surgically release soft tissues; in two patients with arthrodesed or congenitally fused knees, we performed osteotomy before distraction. All patients were assessed clinically and radiographically. We assessed knee flexion angle, range of motion, stability, presence of pain, and healing index. After a minimum followup of 1 year (mean 3.7 years; range, 1-8 years), 18 of 20 of the preoperatively nonambulatory patients having bilateral surgery could walk at last followup. Complications included pin tract infection in all patients, knee subluxation in three patients, and fracture related to treatment in seven patients. We believe gradual correction using a circular frame an effective method to treat flexion knee contractures. In patients with bilateral deformities, improvement in functional activity may be expected in most patients. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Calcanisation of tibia using Ilizarov fixator in crush injuries of hindfoot: a new method

Crush injuries of the foot are one of the most difficult and challenging tasks for a trauma surgeon to manage in terms of limb salvage and provision of a painless functional foot. Injuries to the foot, especially the hindfoot, account for almost 24.6% of all the warfare injuries in Afghanistan, of which more than 70% end in amputation for various reasons. We devised a method using the principles of Ilizarov's distraction osteosynthesis to salvage limbs with bony defects in the hindfoot which otherwise were candidates for amputation. The procedure is done in two stages. Initially, the ring fixator is applied for the soft tissue reconstruction and infection control, and the next stage consists of percutaneous "inverted L"-shaped osteotomy in the posterior half of the lower tibia. The study included 32 patients with hindfoot crush injuries involving talus, calcaneum, a combination of both, or even involving the adjacent tarsal bones. All these crush injuries were classified using the Gustilo and Anderson classification. The postoperative functional assessment of the feet was done using the Maryland Foot Score system with a minimum follow-up of four years. We had good results in 53%, fair in 34% and failure in 13% of our cases. The complications of this procedure were the same as with the use of the ring fixator elsewhere in the body. This method provides a technique to salvage the foot and produce a painless, stable, fused foot in one of the most difficult settings of a hindfoot crush injury.

Humeral diaphyseal aseptic non-unions: An algorithm of management

Successful operative treatment of a humeral shaft non-union may be a challenge for the surgeon. Several treatment options have been reported over the years. A systematic review of the literature was performed. Twenty-three retrieved articles (level of evidence IV) fulfilled our inclusion criteria and dealt with aseptic diaphyseal humeral non-union managed by plating, intramedullary nailing and external fixation based on Ilizarov's principles. Despite an obvious superiority of plating in the treatment of humeral shaft non-unions, there is no doubt that intramedullary nailing as well as external fixation devices have a role. An algorithm of management of the humeral shaft non-unions following a rational approach is suggested.

An Introduction to the Taylor Spatial Frame for Foot and Ankle Applications

The Taylor Spatial Frame (TSF; Smith & Nephew Memphis, TN) is an advanced orthopaedic modality that uses the Ilizarov priciples to correct deformities via an external hexapod. Typically, it is used to correct severe deformities that are not amenable to other methods of acute correction or fixation. Historically, these complex deformities have been corrected with the Ilizarov principles and components. Currently, advances in deformity planning, hardware, and software analysis have made correcting severe foot and ankle deformities much easier. This article gives an overview of the indications and contraindications of the TSF, it reinforces the basic principles of deformity planning, and it introduces the different designs of the TSF available.

A Novel Technique for Closing Difficult Diabetic Cleft Foot Wounds With Skin Grafting and a Ring-Type External Fixation System

Treatment of central metatarsal head plantar forefoot ulceration with or without associated underlying osteomyelitis and gangrene usually require resection of the associated central metatarsal rays. Despite various modifications of central metatarsal ray resection, the resultant cleft foot deformity represents a significant challenge to the foot and ankle surgeon. In this regard, the authors present a novel approach using a ring-type external fixation system that uses the principles of Ilizarov to narrow the forefoot cleft followed by application of a split-thickness skin graft over the remaining soft-tissue defect. When compared with previously reported techniques, the authors approach allows precise narrowing of the forefoot, postoperative weightsharing, decreased time frame of actual external fixation device application, and rapid healing via split-thickness skin graft application about the remaining cleft foot deformity, which has the added benefit of producing additional scarring and contracture over time during the skin graft maturation process.

Equinovarus Deformity Correction With the Taylor Spatial Frame

The Ilizarov method has gained much popularity over the years in the treatment of fractures, limb-length discrepancy, nonunion , bone defects , deformity (malunion), soft-tissue contracture, and osteomyelitis . More recent developments have been made in designing a multiplane external fixator, the Taylor Spatial Frame (Smith & Nephew, Memphis, TN), to treat these complex deformities. This versatile device allows gradual deformity correction using a system of 6 articulated struts, tibial rings, a foot-plate, half-pins and wires. The use of this system requires an understanding of basic Ilizarov principles and technique. The Taylor Spatial Frame corrects both osseous and soft-tissue deformities. Treatment of equinovarus is well suited for gradual correction. At our institution, we routinely use circular external fixation for correction of complex forefoot, hindfoot, ankle, and tibia deformities. Judicious use of the Taylor Spatial Frame allows for correction of deformity and preservation of limb length. Our goal in the treatment of equinovarus deformities is to achieve a painless, plantigrade, and functional foot. In this article, we share our surgical approach in treating equinovarus deformity contractures with the Taylor Spatial Frame.

Ilizarov external fixator: acute shortening and lengthening versus bone transport in the management of tibial non-unions

Eighteen patients with tibial shaft non-unions were treated by the Ilizarov method between March 1995 and September 2001 by the senior author. Three subgroups of six patients each were treated by either acute shortening and lengthening, bone transport or simple stabilisation with a frame. All aspects of non-union, infection, shortening, deformity and bone loss were addressed by using Ilizarov principles. There were 10 cases of infected non-unions in the entire series. Bone resection in the shortening group was between 3 and 6 cm (median 4.6) compared to 3-7.5 cm (median 5.9) in the bone transport group. Union was achieved in all the patients with the average time to union at 12.1 months, 17.2 months and 8.0 months, respectively. The bone transport group required additional bone grafting in five patients (83.3%) prior to union compared to one (16.7%) in the acute shortening group.

Compass elbow hinge: short-term results in five adolescents

The Compass Elbow Hinge (Smith and Nephew, Memphis, Tennessee, USA) was developed in the late 1990s as a mean of treating elbow contractures, utilizing Ilizarov's principles of distraction histeogenesis and a circular frame external fixator. Subsequent reports were published on its use for treating elbow ankylosis and instability in adults. Since 1999 five paediatric patients (aged from 12 to 15 years) have been treated by this device in our institute. The indications were post-traumatic elbow stiffness in four patients and elbow ankylosis following septic arthritis in one patient. Application of the elbow hinge was accompanied by open soft tissue contracture release, both anteriorly and posteriorly. Elbow mobilization and physiotherapy were commenced immediately postoperatively. The hinge was removed after 6-8 weeks. Follow-up ranged from 5 to 36 months. Complications were limited to simple pin track infection in three patients, and transient ulnar neuropraxia in one. The Compass Elbow Hinge (Smith & Nephew) application was successful in improving the arc of motion in three patients out of five.

THE GIESSEN-MAINZ-FRANKFURT PROCEDURE: A NEW METHOD FOR COMPLEX PELVIC RECONSTRUCTION FOR BLADDER EXSTROPHY

In bladder exstrophy primary reconstruction remains the gold standard worldwide. Despite various types of osteotomies the permanent correction of pubic diastasis remains a challenge. In maxillofacial surgery callus distraction is a routine treatment for hypoplastic mandibles. Originally described by Ilizarov, this method provides stable and true bone lengthening after gradual distraction of an osteotomy site as long as the periosteum remains intact. In cooperation with the departments of maxillofacial surgery and orthopedics we used this technique to correct pubic diastasis and facilitate phallic reconstruction in a 4 1/2-year-old boy with bladder exstrophy who had previously undergone continent diversion. Three-dimensional computerized tomography was used to create a stereolithography model and mock surgery was performed. Based on this model bilateral osteotomies of the superior and inferior segments of the pubic bones were done, preserving the periosteum. Pins were inserted and a multidirectional external fixation device was mounted. Distraction was started on day 5 postoperatively. The distraction rate was 1 mm. daily and immobilization time was 28 days. The distraction progress was monitored by sonography. The device was removed 6 weeks postoperatively. Radiography of the pelvis 2 years postoperatively revealed that the distance between the pubic bones had decreased from 6 to 3 cm. (50%). Simultaneously the slanting angle normalized from 24 to 35 degrees due to upward rotation of the inferior pubic rami. Mineralization in the newly formed bones was excellent. Visible penile length had increased significantly. To our knowledge we describe the first use of the basic Ilizarov principle of callus distraction for permanent complex pelvic reconstruction for bladder exstrophy in a 4 1/2-year-old boy. After subperiostial osteotomies approximation of the symphysis and rotation of the inferior pubic rami were achieved with a device commonly used in maxillofacial surgery. Approximation of 1 mm. daily for 28 days resulted in significant penile lengthening. At a followup of 2 years there were stable pelvic ring reconstruction and normal mineralization of the newly formed bones. In contrast to the standard techniques of osteotomies for correcting pubic diastasis, the Giessen-Mainz-Frankfurt procedure provides true bone growth with a stable decrease in diastasis. Successful penile reconstruction was facilitated 1 year postoperatively. This method may also be useful in primary and secondary bladder reconstruction.

The Ilizarov method in infected nonunion of fractures

Thirty patients with infected non-union of long bones were treated with radical resection of the necrotic bone and bone transport or compression/distraction osteosynthesis. Non-union, infection, deformity, bone gap and shortening were all addressed simultaneously using the Ilizarov principles. There were 15 cases with bone loss ranging from 4 to 12 cm (median bone gap of 7 cm), 10 cases of stiff non-union (six of which had an associated deformity) and five cases of mobile non-union. The median time in the Ilizarov frame was 150 days. Median follow up time after frame removal was 23.5 months. Bone grafting at the docking site was only required in three cases (10%). There were three cases of refracture (10%) and three cases of recurrence of infection (10%). The bone result was excellent in 21 patients (70%), good in three (10%), fair in none (0%) and poor in six (20%). The functional results were excellent in eight patients (26.7%), good in 12 (40.0%), fair in three (10%) and poor in seven (23.3%). It is difficult to precisely define the indications for preservation and reconstruction of severe injuries. The surgical team has to take into account the length, disability, complications and cost of treatment. Patients must be aware of the limitations of functional results and the possible difficulty of return to work despite the reconstructive attempt.

Bone Transport Osteogenesis for Limb Salvage

Six dogs with osteosarcoma of the radius were treated by local resection and limb salvage using bone transport osteogenesis. One case is described in detail. Although the initial learning curve is steep for this technique, strict adherence to oncologic surgical technique and the principles of Ilizarov can lead to a successful outcome. Bone transport shows promise as an alternative to cortical allografts for reconstruction of large bone defects after tumor resection in the canine radius.

Reconstruction of a neocondyle using transport distraction osteogenesis

The process of slow bone expansion by distraction osteogenesis in conjunction with functional remodeling can also be used for the reconstruction of a neomandible and neocondyle. This is the technique of transport distraction osteogenesis. A transport disc is surgically created adjacent to the area of a discontinuity defect, and the transport disc is advanced by the process of distraction osteogenesis, using the Ilizarov principles. The mandible therefore acts as the bony template for reconstruction such that the neomandible created from the distraction process has the same size and shape as the native mandible covered by gingiva. This allows for enhanced prosthetic reconstruction. A reverse-L osteotomy of the ramus can also be performed to create a transport disc to reconstruct a neocondyle. Because the leading edge of the transport disc becomes enveloped by a fibrocartilagenous cap, the ramal transport disc can be moved superiorly to create a new articulation. Patients are encouraged to open and close their mouths during the distraction process, such that the transport disc remodels to form a neocondyle. This technique was successfully used to treat patients with degenerative joint disease, condylar resorption, and bony ankylosis.

The Ilizarov Method: Orthopedic and Soft Tissue Applications

The Ilizarov method has broad applications for the generation of bone and soft tissue via an external fixator composed of small pins, tensional wires, rings, hinges and distractors. The success of the technique depends on adherence to Ilizarov's principles of tension-stress phenomenon: preservation of the tissues' blood supply, frequent distraction in small increments, and full function of the extremity.