The treatment of high tibial osteotomy non-union with the Ilizarov external fixator

To evaluate the results of the Ilizarov external fixator in the treatment of non-union post–high tibial osteotomy (HTO). Five non-unions, in four patients, following HTO were treated by Ilizarov fixation. Clinical outcome was assessed pre- and post-operatively by the Knee Society Clinical Rating System (KSCRS). Radiological analysis assessed bone healing pre- and post-operatively and measured proximal tibial alignment. All cases healed with a mean time of 25 ± 3 weeks (Mean ± SD) (range, 24–30 weeks) in the fixator. The clinical and radiological outcome improved in all cases. Four knees were initially in excessive varus and underwent correction of alignment, as measured by medial proximal tibial angle (MPTA), from 75.5° ± 8.4° (mean ± SD) to 90.2° ±  2.7° (normal range, 85°–90°). One patient was in excessive valgus and had a correction of MPTA from 100° to 87°. The KSCRS knee score improved from 35.6 ± 10.8 to 86.6 ± 13.9 (mean ± SD) (normal score = 100) and the functional score from 37.8 ± 11.8 to 85.4 ± 10.5 (mean ± SD) (normal score = 100). The Ilizarov technique is a minimally invasive method that produces excellent clinical, radiological and functional outcomes.     

Management of paediatric tibial fractures using two types of circular external fixator: Taylor spatial frame and Ilizarov circular fixator

Background

The use of circular fixators for the treatment of tibial fractures is well established in the literature. The aim of this study was to compare the Ilizarov circular fixator (ICF) with the Taylor spatial frame (TSF) in terms of treatment results in consecutive patients with tibial fractures that required operative management.

Method

A retrospective analysis of patient records and radiographs was performed to obtain patient data, information on injury sustained, the operative technique used, time duration in frame, healing time and complications of treatment. The minimum follow-up was 24 months.

Results

Ten patients were treated with ICF between 2000 and 2005, while 15 patients have been treated with TSF since 2005. Two of the 10 treated with ICF and 5 of the 15 treated with TSF were open fractures. All patients went on to achieve complete union. Mean duration in the frame was 12.7 weeks for ICF and 14.8 weeks for the TSF group. Two patients in the TSF group had delayed union and required additional procedures including adjustment of fixator and bone grafting. There was one malunion in the TSF group that required osteotomy and reapplication of frame. There were seven and nine pin-site infections in the ICF and TSF groups, respectively, all of which responded to antibiotics. There were no refractures in either group.

Conclusion

In an appropriate patient, both types of circular fixator are equally effective but have different characteristics, with TSF allowing for postoperative deformity correction. Of concern are the two cases of delayed union in the TSF group, all in patients with high-energy injuries. We feel another larger study is required to provide further clarity in this matter.

Level of evidence

Level II—comparative study.     

Ilizarov外固定架治疗创伤性马蹄足

目的探讨应用Ilizarov外固定支架治疗创伤性马蹄足的疗效。方法2003年2月～2005年8月应用Ilizarov外固定架治疗17例创伤所致马蹄足患者。将组装好的Ilizarov外固定架按照Ilizarov的穿针固定原则安装在患侧小腿和足部。术后3d开始转动螺纹杆上的螺母,第1周旋转螺母2～4圈/d,4次/d;1周后旋转螺母1～2圈/d,4次/d,分别逐渐缩短和延长前、后螺纹杆,矫正马蹄足畸形。用伊氏架将踝关节固定在中立位2～3个月。去除外固定架后让患者逐渐增加负重量直至完全负重。不负重时穿戴支具保持踝关节处于中立位至少3个月。结果17例患者均得到随访,平均随访10个月(7～14个月)。术后4～6周踝关节恢复到中立位。平均带外固定架14.5周(10～16周)。无血管、神经损伤。3例各1处针道轻度感染,对症处理后感染消失。1例诉矫正过程中疼痛,术后10周去除外固定架,去除外固定架后6周时僵直在跖屈20°。1例去除外固定架4个月后僵直在跖屈10°。1例小腿前后肌群损伤严重合并胫骨骨缺损重建术后踝关节矫正到中立位后1.5个月行踝关节融合术,融合术后3个月去除外固定架。其余14例达到0°全足负重,行走时无明显足下垂。2例负重时疼痛。踝关节背伸肌群功能存在的患者,踝关节可主动背伸10°。结论Ilizarov外固定架是治疗创伤性马蹄足的微创技术。     

The Ilizarov fixator in trauma: a 10-year experience

We reviewed the clinical results of 332 fractures treated with the Ilizarov external fixator between 1984 and 1993. The locations of the involved bones were: tibia, 247 (including 28 with tibial pylons); femur, 47; humerus, 21; forearm, 12 and calcaneus, 5. The clinical outcomes of this series were retrospectively evaluated by radiological and clinical rating systems. In the tibial fractures, results in 71.1% were categorized as excellent or good, without deep infection; 63.3% of the tibial pylon fractures, mostly open, also showed excellent or good results. In the femoral fractures, which were mostly localized at the metaphysis or distal epiphysis, 72% showed excellent or good results, but the patients com-monly complained of knee stiffness. Limitations of range of movement (ROM) in the elbow and the wrist were common in patients with forearm fracture, but ROM was regained after physical therapy. According to the clinical results of the present study, we believed that Ilizarov external fixation was best indicated for tibial fractures, because of its advantage of allowing early weight-bearing. Ilizarov external fixation was also best indicated for: (1) open fractures, (2) comminuted fractures, (3) intra-articular fractures, and (4) fractures with bony defect. Received for publication on Oct. 12, 1998; accepted on Sept. 7, 1999     

Ilizarov技术同期治疗感染性胫骨大段缺损并小腿软组织缺损

目的探讨Ilizarov技术同期治疗感染性胫骨大段骨缺损并小腿软组织缺损的疗效。方法回顾性分析2012-01—2014-05应用Ilizarov技术同期治疗8例感染性胫骨骨缺损并软组织缺损。均为胫骨骨折术后感染,清创后小腿软组织缺损位于胫前内外侧,面积平均为30.4(24~91)cm2,胫骨缺损长度平均为9.5(6~13)cm。7例胫骨中远段缺损采用胫骨结节下方截骨向远端骨搬运修复,1例胫骨近段缺损采用胫骨远端截骨向近端骨搬运修复,软组织缺损修剪成椭圆形后直接拉拢缝合。术后10 d开始骨段搬运,速度为1 mm/d,分4次完成。结果术后延长段切口及创面均一期愈合。所有患者均获随访17~36个月,平均23个月。延长段骨自然愈合,愈合时间为210~496 d,平均271 d;愈合指数3.4~4.0 d/mm,平均3.7 d/mm。对接点2例行二期植骨后愈合,其余6例均自然愈合,愈合时间170~308 d,平均236 d。去除外固定架后5个月疗效根据ASAMI评价标准评定:优6例,良2例。结论Ilizarov技术简便、疗效良好,是同期修复感染后大段胫骨缺损并软组织缺损的可靠方法。     

Salvage of infected total knee arthroplasty with Ilizarov external fixator

Background:

Knee arthrodesis may be the only option of treatment in cases of chronic infected total knee arthroplasty (TKA) with concomitant irreparable extensor mechanism disruption, extensive bone loss or severe systemic morbidities. Circular external fixation offers possible progressive adjustment to stimulate the bony fusion and to make corrections in alignment. We evaluated the results of knee arthrodesis with one or two stage circular external fixator for infected TKA.

Materials and Methods:

16 cases of femoro-tibial fusion were retrospectively evaluated. Male-to-female ratio was 10:6. Mean age of the patients was 62.2 years. Cierney-Mader classification was used for anatomical and physiological evaluation while the bone stock deficiency was classified into mild, moderate and severe. Surgical technique involved either single or two stage arthrodesis using circular external fixator.

Results:

Union was achieved in 15 patients (93.75%). The mean duration for union (frame application time) in these patients was 28.33 weeks (range 22 to 36 weeks). Analysis showed that in the group with frame application time of less than 28 weeks, the incidence of mild to moderate bone deficiency was 83.33%, while in the frame application time more than 28 weeks group the incidence was 20% (P-value 0.034). Similarly the incidence of Cierney-Mader 4B (Bl, Bs, Bls) was found to be 33.33% in the group of frame application time of less than 28 weeks, while it was 90% in the group with frame application time more than 28 weeks (P-value 0.035).

Conclusion:

Circular external fixator is a safe and reliable method to achieve knee arthrodesis in cases of deep infection following TKA. Severe bone stock deficiency and Cierney- Mader type B host are likely risk factors for prolonged frame application time. We recommend a two-stage procedure especially when there is compromised host or severe bone loss.     

Two stage reconstruction of septic non-union of the humerus with the use of circular external fixation

Achieving quiescence in chronic osteomyelitis remains challenging. Wide resection of all infected and necrotic tissues improves the chances of achieving remission of the disease. Extensive debridement however decreases the already compromised bone stock that increases the complexity of reconstruction. We report on the outcome of eight patients with Cierny and Mader stage IV chronic osteomyelitis of the humerus who underwent debridement followed by bone graft and circular fixator application as a second stage procedure. Resolution of infection and humeral shaft union was achieved in all patients. Our study finds that two-stage reconstruction of stage IV chronic osteomyelitis with the use of circular external fixation is effective in achieving infection control and union in these complex cases.     

改良Ilizarov外固定器治疗复杂踝关节骨折脱位

目的 :应用改良Ilizarov外固定器治疗复杂的踝关节骨折脱位。方法 :对 2 4例复杂踝关节骨折脱位采用手法复位 ,闭合穿针改良Ilizarov外固定器固定进行治疗。结果 :本组2 4例中优 12例 ,良 10例 ,差 2例 ,总优良率 91.67%。骨折的平均愈合时间为 7.5周。结论 :应用改良Ilizarov外固定器治疗复杂踝关节骨折脱位疗效满意 ;应用橄榄针穿针弹性固定下胫腓联合分离 ,符合生物学固定的原则 ,是治疗下胫腓联合分离的一种有效方法。     

Management of shotgun-induced fractures of the humerus with Ilizarov external fixator

Abstract We retrospectively reviewed 11 shotgun-induced open humeral fractures treated with immediate application of Ilizarov type ring external fixation. Eight patients had grade III A and three had grade III B open fractures. No patient had associated neurovascular injury. All fractures were stabilized with Ilizarov external fixator immediately after meticulous debridement and irrigation under emergent conditions. Complete bony union occurred in all patients in 14–44 weeks (mean, 21 weeks). One patient required a second intervention to adjust the external fixator rings. Two patients required a rotational fasciocutaneous flap to handle the soft tissue coverage problem. Superficial pin tract infection was present in eight patients; however none of them had deep infection or osteomyelitis. A good to excellent result was achieved in 10 patients according to the rating system of Smith and Cooney. Immediate Ilizarov external fixation is a safe method of obtaining a functional limb in the treatment of shotgun-induced open humeral fractures with severe soft tissue damage.     

Versatility of Ilizarov external fixator in management of foot and ankle deformity

Abstract Traditional methods of correcting foot deformities may be difficult to apply in some conditions, especially in presence of other lower limb problems. This study discusses the versatility of Ilizarov external fixator (IEF) in such cases. It was performed in 34 foot deformities in 33 patients, treated with IEF between 1997 and 1999. The average age of the patients was 15 years. The aetiology of foot deformity was recurrent congenital talipes equinovarus (n=10), neglected congenital talipes equinovarus (n=3), poliomyelitis (n=9), post-traumatic deformity (n=6), post-burn deformity (n=1), arthrogryposis multiplex congenita (n=2), and cerebral palsy, fibular hemimelia and tibial hemimelia (1 case each). Unconstrained IEF was applied for the foot in all cases. The leg construct was applied according to the target: foot deformity alone or associated with other leg problems. IEF construct was extended to the femur in cases with flexion knee deformity and hinges were added. Follow-up continued until overcorrection was maintained for the same period of correction followed by an appropriate cast for 8 weeks. The mean time for deformity correction and Ilizarov stabilisation was 16 weeks, and follow-up period was 23.1 months. The results were good in 31, fair in 2 and bad in 1. Additional procedures were performed, most often in the same operating time. Primary arthrodesis was done for 5 feet and for one revision of failed previous arthrodesis. Open corrective osteotomy for arthrodesis was performed in 2 cases. Two females were treated for flexion knee with bloodless technique. Wire-site infections, wire cut-through a calcaneum and metatarsals and fracture post-IEF removal were observed. Although it is technically difficult, IEF can be considered an effective and versatile way of treating foot and other associated lower limb problems through one-reconstruction attack.     

Custom made Ilizarov ring fixator for fracture care in morbidly obese patients

Background  Fracture care in obese patients is becoming an everyday problem because the prevalence of obesity in European countries has tripled since the last 20 years. Patients and method  With the use of a custom made Ilizarov ring fixator with a ring diameter of 300 to 340 mm, fracture stabilization in three morbidly obese patients was performed. The patients’ body mass index (BMI) ranged from 59 to 89. There were one proximal tibia fracture and two pilon fractures. The tibia fracture was stabilized with a 340-mm frame and the pilon fractures were stabilized by primary ankle arthrodesis with 300-mm frames. Primary ankle arthrodesis was performed because polyneuropathy and Charcot arthropathy were present in one patient and in the other patient because time from injury to referral was too long for reconstruction. Results  All patients were able to fully weight bear. Frame removal after fracture correction and consolidation was performed only in the patient with the tibial fracture (patient BMI 89). The other patients died during the treatment because of decompensated comorbidities. Conclusion  The Ilizarov technique is a good fixation modality for stabilizing fractures of the lower limb in morbidly obese patients. Associated medical comorbidities are the limitations of successful fracture care. Financial Disclaimer: The authors have received nothing of value.     

Use of the Ilizarov apparatus to improve alignment in proximal humeral fractures treated initially by a unilateral external fixator

One of the recommended methods for the management of displaced unstable proximal humeral fractures is the unilateral external fixator. In polytrauma cases this method may be especially useful for the stabilisation of these fractures. However, problems may arise if the fracture is fixed in a malaligned or distracted position. Conversion of the treatment concept to other modalities is difficult because of the problem of pin tract infection. The Ilizarov apparatus provides an useful method in such situations, as it allows distraction, translation and compression without the need for further anaesthesia and additional fixation.     

Accordion technique combined with minimally invasive percutaneous decortication for the treatment of bone non-union

BackgroundA variety of approaches have been used to treat oligotrophic or atrophic non-union. Conventional methods are often associated with great operative trauma, increased blood loss, a risk of re-infection, higher medical costs, and complications at the donor site. This study aimed to assess the clinical efficacy of the accordion technique combined with Minimally Invasive Percutaneous Decortication (MIPD) for these types of bone non-union.MethodsFrom January 2010 to December 2015, 20 patients with long bone aseptic non-unions of the lower extremities without bone defects who were treated with the accordion technique combined with MIPD. The limb-length discrepancy (LLD) was less than 2 cm in all patients. None of the patients received autogenous bone grafts during follow-up. All surgeries were performed by the same surgeon, and the modified Application of methods of Ilizarov (ASAMI) criteria were used to evaluate the operative effectiveness.ResultsA total of 20 patients were included in this study, and 1 patient was lost during follow-up. Fifteen of these patients presented with oligotrophic non-unions, and 5 patients presented with atrophic non-unions. The average follow-up period in these patients was 12.1 months (range: 8–42 months). The alternative compression and distraction procedure was repeated 1–3 times. Blood loss was 30 to 250 ml during surgery. Ultimately, bone union was achieved in 19 patients and failed in 1 patient. The fractures healed within 4–8 months (average time: 5.9 months), and fracture healing was considered excellent in 19 patients and poor in 1 patient. Postoperative function was evaluated as excellent in 9 patients, good in 6 patients, fair in 4 patients, and poor in 1 patient.ConclusionThe accordion technique combined with MIPD, which is a simple, minimally invasive procedure that does not require autologous bone grafting, resulted in a high bone union rate and good postoperative function.     

Treatment of unstable distal radius fractures with Ilizarov circular, nonbridging external fixator

Unstable distal radius fractures remain a challenge for the treating orthopaedic surgeon. We present a retrospective follow-up study (mean follow-up 12.5 months) of 20 patients with 21 unstable distal radius fractures that were reduced in a closed manner and stabilized with a nonbridging Ilizarov external fixator. Subsequent insertion of olive wires for interfragmentary compression was performed in cases with intra-articular fractures. According to the overall evaluation proposed by Gartland and Werley scoring system 12 wrists were classified as excellent, 6 as good, 2 as fair and 1 as poor. Grade II pin-tract infection in distal fracture fragment was detected in 3 wires from a total of 78 (3.8%) and in 4 half pins out of a total of 9 (44.4%). Pronation was the most frequently impaired movement. This was restricted in 4 patients (19%) in whom a radioulnar transfixing wire was applied. Symptoms of irritation of superficial sensory branch of the radial nerve occurred in 3 patients with an olive wire applied in a closed manner in the distal fragment.Ilizarov method yields functional results comparable to that of other methods whilst it avoids wrist immobilization, open reduction and reoperation for implant removal. The method is associated with a low rate of major complication and satisfactory functional outcome.     

A comparative evaluation of the time to frame removal for tibia fractures treated with hexapod and Ilizarov circular frames

IntroductionTraditional Ilizarov and hexapod frames have different biomechanical properties and there is limited literature regarding their effect on time to fracture union or time to frame removal.MethodsTibial fractures managed with a circular frame at a tertiary limb reconstruction referral centre between 2011 and 2018 were retrospectively identified from a prospectively maintained database. They were classified into three treatment groups; Ilizarov style, Taylor Spatial Frame (TSF) and TrueLok Hex (TL-Hex). Data were extracted from electronic patient records and digital radiographs. The primary outcome was time to frame removal, which was seen as an indicator of clinical and radiological fracture union. Odds ratios were calculated with the clinical significance set at 30 days.Results274 patients (median age 49 years, 36% female) were included in the analysis. 8.4% Ilizarov, 10.5% TSF and 13.5% TL-Hex frames required further surgery to aid fracture healing (p = 0.38). 30% of patients had open fractures. Median time to removal for Ilizarov, TSF & TL Hex frames was 167, 198 and 185 days respectively. There was a significant difference between Ilizarov and hexapod frames. Both TSF (OR 2.2, p<0.003) and TL-Hex (OR 1.8, p<0.04) had a significantly increased time to removal of 30 days or more compared with Ilizarov frames.The time to frame removal in metaphyseal fractures was significantly shorter for Ilizarov frame fixation than hexapod frames (p = 0.04). Open fractures were significantly more likely to require at least 30 days extra time to removal than closed fractures (OR 3.3, p<0.001). There was no significant difference in the time to frame removal between fracture location, age or sex.ConclusionIlizarov frames have demonstrated a reduced time to frame removal in the management of tibial fractures than hexapod frames. Differences in the time to frame removal, an indicator of time to fracture union, may be due to the different mechanical properties of the frame, or early disruption of the fracture haematoma through secondary frame manipulation and fracture reduction, increased proportion of metaphyseal fractures treated with Ilizarov, or patient selection. The healing time was comparable across the tibia. Pooled meta-analyses may be able to further quantify these associations.     

Ilizarov fixator pin site care: The role of crusts in the prevention of infection

Pin site infection is one of the most common local complications after procedures using the Ilizarov fine wire fixator. In this study, the rate of infection was investigated in two groups of patients, representing two consecutive case series, undergoing fracture stabilisation or lower limb reconstruction using an Ilizarov fine wire fixator. Both groups received identical Russian-style pin site care, except in the first Group A where the crusts of dried exudate were removed at the time of pin site cleaning; while in the subsequent Group B, the adherent crusts were retained during cleaning. Pin site infection was diagnosed if the site was painful and inflamed or discharging. The first infected pin site while the fixator remained in situ was considered the outcome of interest. Group A consisted of 59 patients and Group B of 33 patients. A lower proportion of patients in Group B (12/33 – 36%) developed a pin site infection compared to Group A (36/59 – 61%) (p = 0.023). However, once infection had developed, a greater proportion of patients in Group B required more than one course of antibiotics to treat the infection when compared to patients in Group A (p = 0.005). No patient required hospitalisation for intravenous antibiotics or wire change in Group B (0/33), whereas 3/59 patients required hospitalisation in Group A; but this did not reach statistical significance (Chi-squared test, p = 0.18). Retention of adherent crusts during Ilizarov fixator pin site care significantly protects against the development of pin site infection, but renders subsequently infected pin sites more refractory to treatment. This study therefore suggests that crusts should be retained as long as a pin site remains uninfected. Retained crusts may act as a physical barrier to bacterial contamination (‘biological dressing’).     

Masquelet技术与Ilizarov技术治疗成人胫骨慢性骨髓炎的早期临床疗效比较

目的 比较Masquelet技术与Ilizarov技术治疗成人胫骨慢性骨髓炎清创后大段骨缺损的早期临床疗效.方法 回顾性分析2011年1月至2015年5月我院收治的45例成人胫骨慢性骨髓炎病人资料,Masquelet技术治疗的27例纳入Masquelet组,男20例,女7例,骨缺损长度为(8.9±2.2)cm;Ilizarov技术治疗的18例纳入Ilizarov组,男12例,女6例,骨缺损长度为(8.3±2.1)cm.收集并比较两组病例的骨愈合时间、完全负重时间、术后并发症情况及末次随访时的Iowa膝关节评分、Iowa踝关节评分、SF-36量表得分.结果 45例病人的随访时间为12～38个月,平均(21.5±6.5)个月.Masquelet组与Ilizarov组的骨愈合时间分别为(20.85±4.31)周、(28.86±6.47)周,完全负重时间分别为(23.17±6.93)周、(32.87±6.79)周,两组间比较,差异均有统计学意义(t=4.944,P<0.0001;t=4.636,P<0.0001);两组末次随访时的Iowa膝、踝关节评分及SF-36量表总得分均较术前明显改善,但两组间比较,差异均无统计学意义(P均>0.05).结论 Masquelet技术与Ilizarov技术均可有效地解决成人胫骨慢性骨髓炎清创后大段骨缺损问题,但Masquelet技术能显著缩短治疗周期,完全负重时间早,是一种简单有效的手术方法.     

Relationship between locking-bolt torque and load pre-tension in the Ilizarov frame

The wire-bolt interface in an Ilizarov frame has been mechanically tested. The optimal torque to be applied to the frame locking-bolts during physiological loading has been defined. The set-up configuration was as is used clinically except a copper tube was used to simulate bone. The force-displacement curves of the Ilizarov wires are not altered by locking-bolt torque. The force in the bone model at which pre-tension is lost increases as the locking-bolts are tightened to 14 Nm torque, but decreases if torque exceeds 14 Nm. Thus, 14 Nm is the optimal locking-bolt torque in frame. The relationship between pre-tension versus load for different locking-bolt torques arises because at low and high clamping torques poor wire holding and plastic deformation respectively occur. Wire damage was seen under light and electron microscopy. Clinically, over or under-tightening locking-bolts will cause loss of pre-tension, reduction in frame stiffness and excessive movement at the fracture site, which may be associated with delayed union.     

Knee arthrodesis with the Ilizarov external fixator as treatment for septic failure of knee arthroplasty

Background  

The authors report the results of femoral–tibial fusion with an Ilizarov circular external fixator following septic loosening of knee prosthesis.     

Treatment of type IIIA open fractures of tibial shaft with Ilizarov external fixator versus unreamed tibial nailing

Introduction The aim of this study was to compare the radiographic results and clinical outcome of unreamed tibial nailing (UTN) and Ilizarov external fixation (IEF) for the treatment of type IIIA open fractures of the tibia. Materials and Methods Sixty-one patients with open type IIIA tibial shaft fractures were treated with an IEF (n = 32) or UTN (n = 29). Both groups were compared for union time, secondary outcomes of nonunion, infections, mechanical failure of the implant, and malunion. Results The average time-to-bone healing was 19 weeks (range 14–23 weeks) for IEF and 21 weeks (range 16–36 weeks) for UTN; it was significantly shorter in the IEF group (P = 0.039). One patient had refracture in the IEF group. Malunion occurred in four patients for each group. Posttraumatic osteomyelitis occurred in two patients in the IEF group and in three patients in the UTN group. In the IEF group, additional surgical procedures were indicated in three cases including sequestrectomy (n = 1), and pin replacement (n = 2). In the UTN group, seven patients needed additional surgery including bone grafting (n = 3), nail exchanged (n = 1), and posttraumatic osteomyelitis (n = 3). Conclusion The results of the current study showed that IEF technique had a notable incidence of pin-tract infection, joint contracture, and shorthening related to treatment of the delayed union. The UTN technique had the disadvantage of a posttraumatic osteomyelitis and delayed union requiring additional surgery. We believe that the decision to use IEF or UTN should be made on a case-by-case basis.