Ilizarov External fixator

1. Central Seminar
Lecture Hall # 05, 23
rd
April, 2013

2. Ilizarov External Fixator
Chairperson:
Prof. M. Ishaq Bhuyian
Head, Orthopaedics
Speaker:
Dr. Abdullah-al-mamun
Junior Consultant, Orthopaedics

3. Objectives:
History of the invention of Ilizarov
Principles of Ilizarov
Components and procedure of application
Care of the apparatus, Rehabilitation and Removal of
Ilizarov.
Indications
Advantages and disadvantages
Our experiences in EMCH

4. PROF. GABRIEL ABRAMOVITCH ILIZAROV
(1921-1992)

5. History
Professor Gavril Abramovich Ilizarov was born in the Caucasus, in
the Soviet Union in 1921.
He was sent, without much orthopedic training, to look after injured
Russian soldiers in Kurgan,Siberia in the 1950s. With no equipment
he was confronted with crippling conditions of unhealed, infected,
and malaligned fractures.
With the help of the local bicycle shop he devised ring external
fixators tensioned like the spokes of a bicycle. With this equipment
he achieved healing, realignment and lengthening to a degree
unheard of elsewhere.
His Ilizarov apparatus is still used today as one of the distraction
osteogenesis methods.

6. 1954 published his first article
on Transosseous Osteosynthesis.

7. 1967. At this time he successfully treated an infected, non-union
fracture sustained by the Olympic high jump champion Valery
Brumel.
Professor Ilizarov’s methods were brought to the west in 1981 by
an Italian doctor, Prof. A. Bianchi-Maiocchi.
he headed the world’s largest orthopaedic hospital. This is the
Kurgan All-Union Scientific Centre for Restorative Orthopaedics
and Traumatology.
Professor Ilizarov continued working in this field of orthopaedics
for 41 years until his death in 1992 at the age of 71.

8. Kurgan the city

9. Principles of Ilizarov
Law of tension stress
Distraction osteogenesis
Mechanical induction of new bone formation
Neovascularization
Stimulation of biosynthetic activity
Activation and recruitment of osteoprogenitor cells
Intramembranous ossification

10. Law of tension stress
Ilizarov developed the law of tension-stress, which describes the
process of new bone and soft tissue regeneration under the
effect of tension-stress caused by slow and gradual distraction.
His biological principles can be summarized as follows:
Minimal disturbance of bone and soft tissues
Delay before distraction
Rate and rhythm of distraction
Site of lengthening
Stable fixation of the external fixator
Functional use of the limb and intense physiotherapy.

11. Distraction Neo-histogenesis
Distraction osteogenesis, also called callus distraction, callotasis
and osteodistraction is a surgical process used to reconstruct
skeletal deformities and lengthen the long bones of the body.
A corticotomy is used to fracture the bone into two segments,
and the two bone ends of the bone are gradually moved apart
during the distraction phase, allowing new bone to form in the
gap.
When the desired or possible length is reached, a consolidation
phase follows in which the bone is allowed to keep healing.
Distraction osteogenesis has the benefit of simultaneously
increasing bone length and the volume of surrounding soft
tissues.

12. Distraction Osteogenesis

13. Neo-vascularisation

16. Equipments

17. Equipments

18. procedure
Wires of 1.5 mm or 1.8 mm diameter are passed percutaneously
(through the skin) through bones by means of a drill.
The protruding ends of these wires are then fixed to rings with
special "wire-fixation" bolts.
These rings in turn are connected and fixed to one another by
threaded rods.
Once it is fixed, the Ilizarov frame affords a stable support to the
affected limb.
A CORTICOTOMY is then performed; it is an osteotomy (cutting the
bone) where the periosteum of the bone is preserved.
Adjustments in the rods produce compression or distraction as
desired between the bone ends, and simultaneously, deformities are
also corrected.
The ring fixator is removed at the end of the treatment.

19. Procedure…

20. Procedure…

21. Procedure…

22. After care of the apparatus

23. After care of the apparatus
The postoperative management of a patient requires
frequent contact and close monitoring by the surgeon.
Deformities and contractures cannot be allowed to
persist or progress.
The patient must be encouraged to bear weight on the
lengthening limb.
Pin- or wire-site sepsis should be treated aggressively;
osteolysis around an implant suggests that additional
transosseous fixation is needed.
Adequate physiotherapy is essential.

24. Physiotherapy
The patient has to participate in a proper program of
exercises, mobilization and ambulation.
In fact Ilizarov's original technique requires the patients
to stay in hospital and participate in at least two hours of
therapy in various forms every day.
In our circumstances, the services of a physiotherapist
are not always available. The only recourse in such
cases is for the surgeon himself to supervise the therapy
for the patient.
Achieving length or correcting a deformity at the cost of
decreased motion, mobility or function is certainly not a
worthwhile goal.

25. Living with Ilizarov…

26. Removal of Apparatus
A month too late is better than a day too early.
The x-rays must show at least three cortices; i.e. out of
four cortices (anterior, posterior, medial and lateral) in
AP & lateral projections, at least three should be fully
ossified, with a sharp outline of the cortical bone.
Finally before actually removing the frame the patient
may be administered a 'stress test‘ and asked to use the
limb in a functional manner ( weight bearing for the lower
limb and functional activities for the upper limb).
If the patient is able to do this the frame can then be
removed with confidence.
 Actual removal of the fixator is usually done under
anesthesia.

27. advantages
No skin incision is made as in a conventional operation.
Incidents of haemorrhage, tissue trauma and infection
are much fewer.
minimally invasive as only wires fix the bones to the
rings and there is very little soft tissue damage.
The Ilizarov fixator is very versatile; the cylindrical shape
of the fixator allows deformities to be corrected
simultaneously in 3 dimensions.
The patient remains mobile throughout the course of the
treatment. Intensive physiotherapy is instituted early; as
a consequence, problems of joint stiffness and
contractures are rare. Further, the patient's stay in the
hospital is considerably reduced.

28. Disadvantages
Mechanical
Distraction of fracture site
Inadequate immobilization
Pin-bone interface failure
Weight/bulk
Refracture (pediatric
femur)
Biologic
Infection (pin track)
Neurovascular injury
Tethering of muscle
Soft tissue contracture

29. Indications…
Limb lengthening
Deformity Correction.
Infected Non-unions.
Congenital Pseudarthrosis.
Treatment of Joint Contractures e.g. resistant congenital
talipes euino varus, post burns contractures, post-
traumatic stiffness
Fixation of complex fractures
Bone transport & Osteomyelitis (treatment of missing
bone in the limb, due to various causes)
Arthrodesis (fusion or joining of two bones across a joint)
Peripheral Vascular Disease like Thrombo-angitis
obliterans

30. Non-unions
Nonunion is permanent failure of healing following a
broken bone.
Nonunion is a serious complication of a fracture and may
occur when the fracture moves too much, has a poor
blood supply or gets infected.
Patients who smoke have a higher incidence of
nonunion.
In some cases a pseudo-joint (pseudarthrosis) develops
between the two fragments with cartilage formation and
a joint cavity.

31. Non-unions

32. Non-unions…
Ilizarov revolutionized the treatment of recalcitrant
nonunions demonstrating that the affected area of the
bone could be removed, the fresh ends "docked" and the
remaining bone lengthened using an external fixator
device.
The time course of healing after such treatment is longer
than normal bone healing.
Usually there are signs of union within 3 months, but the
treatment may continue for many months beyond that.

33. Non-union

34. Infected non-union
Ilizarov is a golden method for the management of
nonunion osteomylitis for both achieving union and
eradication of infection, however generous, careful
sequential debridement and hardware/dead tissue
removal and bone grafting is also an option for some
selected cases.

35. Osteomylitis burns in the fire of regeneration
Activate biosynthetic process, increasing local resistant
to infection.
Three ways to correct INU:
Controlled osteogenesis, filling of cavities by newly formed tissue
Resection of infected bone and subsequent intercalary bone
lengthening
Gradual bone transport of one wall of the cavity.
Infected non-union…

36. Deformity correction
Treating Neglected club with Ilizarov

37. Deformity correction
Treating Cubitus Varus with Ilizarov

38. Deformity correction
Treating Cubitus Varus with Ilizarov

39. Open Fracture and Bone Loss

40. Difficult fractures

41. Limb lengthening
Limb lengthening and reconstruction techniques can be used to
replace missing bone and lengthen and/or straighten deformed
bone segments.
The procedures may be performed on both children and adults
who have limb length discrepancies due to birth defects,
diseases or injuries.
The regenerated bone is normal and does not wear out.
The muscles, nerves and blood vessels grow in response to the
slow stretch like they do during a growth spurt or in pregnancy.
 The actual procedure is minimally invasive and requires only
one or two nights in the hospital.
Literature says successful limb lengthening upto 18 cm.

42. Limb lengthening

43. Limb lengthening

44. Buerger’s disease
In Buerger’s disease Arterial reconstructive surgery is
not feasible and sympathectomy has limited role.
Progression of the disease invariably leads to
amputation.
Ilizarov’s method increases the vascularity of the
ischaemic limb. Ilizarov’s method is an excellent and
cheap procedure in treatment of Buerger’s disease.

45. Burger’s disease…

46. Our experiences
In EMCH, we regularly do Ilizarov surgery in the
orthopedic department.
Our patients are mostly suffering from Non-union and
Complex fractures.
We also treat congenital limb deformities by this surgical
techniques.

47. Infected non union

48. Infected non union

50. Difficult fractures

52. Difficult Fractures

53. Difficult Fractures

54. Congenital pseudoarthrosis

56. Congenital pseudoarthrosis of Tibia

57. Congenital pseudoarthrosis

58. Limb lengthening

59. Limb lengthening

60. Take home Message
Ilizarov is a compression-distraction device that can do
osteogenesis.
Infection Non-union and Congenital deformity corrections
are one of the golden indications.
You can be taller even after 18 yrs with this.
Wearing Ilizarov is not a fancy style. It returns painful
discomfort.
Physiotherapy is essential.