Lengthening of short bones by distraction osteogenesis--results and complications

We performed bone lengthening surgery on 12 metacarpals and 14 metatarsals of 15 patients. The mean age for metacarpal and metatarsal lengthening was 14.5 (10-21) and 17.5 (10-25) years, respectively. We used a unilateral or a circular external fixator. The mean healing index of the metacarpals and metatarsals was 1.6 (1.1-2.3) and 1.6 (1.0-2.0) months/cm, respectively. The mean increase in metacarpal and metatarsal length was 17.6 (13-26) and 24.3 (20-30) mm, respectively. The functional scores of the metatarso-phalangial (MTP) joint of lengthened metatarsals for the lesser toe were excellent in 12 and good in two cases based on the American Orthopaedic Foot and Ankle Society (AOFAS) scoring system. Complications were seen in six of the metatarsal lengthening cases including four angulations, one subluxation and one non-union. We conclude that the periosteum must be protected with percutaneous osteotomy and lengthening should be performed at a rate of 0.25 mm twice a day and should not exceed 40% of the original bone length (or >20 mm).

Plating after lengthening (PAL): technical notes and preliminary clinical experiences

INTRODUCTION

Shortening the period of time for the external fixator after limb lengthening decreases the complication rate and increases the patient satisfaction.

MATERIAL AND METHOD

We describe the plating after lengthening (PAL) as a new technique on five patients with limb length discrepancy (1 femoral, 4 tibial) who had lengthening procedure with Ilizarov technique. The mean amount of lengthening was 50 mm. The mean lengthening period was 100 days (5-135 days). When the lengthening period ended, the locking compression plate was applied percutaneously by using the technique of minimal invasive plate osteosynthesis, and the Ilizarov external fixator was removed.

RESULTS

The fixator-free period was achieved at the beginning of the consolidation phase, except in two patients, which were delayed for plating because of pin-tract infection. No complication was encountered except in one patient who had limited flexion of knee joint. There was no need for blood transfusion.

DISCUSSION

The PAL, which shortened the period of time for the external fixator, was an easy and safe method for the fixation of the bone after limb lengthening.

[Treatment of the tibial bone defects by traumatic sequels with the Ilizarov method in children]

INTRODUCTION

Tibial bone defects are usually results of: high energy trauma, infections, bone tumors, and are associated to soft tissue lesion. The most successful way to fill bone defects is the use of autologous bone grafting with adequate blood supply and soft tissue coverage.

PURPOSE

To evaluate the clinical and functional outcome of post-traumatic bone defects treated with vascularized bone allograft, fibular tibialization, and bone transport with Ilizarov method.

MATERIAL AND METHODS

Retrospective longitudinal study with 12 patients, from October 2000 to November 2005, with a 33.6 months follow up average.

RESULTS

Seven male and five female, all of them treated previously in other institutions were included in the study. We found excellent clinical and functional results in five patients, good results in five and bad in two, with an average of surgical procedures of three.

COMPLICATIONS

Pseudoarthrosis, fibular fusion and non union.

DISCUSSION

Postraumatic bone defects can be treated successfully using different techniques: Vascularized bone graft, tibialization, end bone transport with Ilizarov method. Bone transport allows filling of bone defect with adequate soft tissue coverage and length discrepancy management.

CONCLUSIONS

These choices of treatment are different solutions with post-traumatic bone defects in patients candidate for amputation.

Juvenile dermatomyositis with bilateral progressive knee flexion contracture

Juvenile dermatomyositis is a multisystem, inflammatory vasculopathy that primarily affects muscles and skin. Calcinosis is one of the most debilitating complications affecting patients with juvenile dermatomyositis. Calcifications resulting from calcinosis frequently are located on the elbows, knees, and other joints and can cause considerable disability with severe pain, joint contractures, skin ulcers, and muscle atrophy. Many therapies for calcinosis have been reported including diltiazem, probenecid, and alendronate. We report a patient surgically treated for bilateral knee flexion contractures with the Ilizarov technique. At 2.5 years' followup, the patient had full extension of both knees with 0 degree to 50 degrees flexion and was walking independently. The Ilizarov technique provides an important option for correcting knee flexion contractures secondary to calcinosis in juvenile dermatomyositis.

Femoral lengthening using the Ilizarov technique

The Ilizarov method allows the surgeon to perform extended lengthening of both congenital and acquired short limbs. The technique can be difficult, time consuming and is associated with many complications. Generally, the number of complications and failures of lengthenings increases in proportion to the length of the distraction and the severity of the preoperative problems. The rate of major complications decreases substantially as the experience of the surgeon increases.

Treatment of delayed union or non-union of the tibial shaft with partial fibulectomy and an Ilizarov frame

We reviewed 28 patients treated with partial fibulectomy combined with an Ilizarov compression frame for a non-infected tibial delayed union or non-union. Patient data, time to referral, type of fracture (open or closed), type of non-union (atrophic or hypertrophic) and period of treatment were recorded. Neither time to referral, type of fracture or type of non-union did adversely affect the duration of treatment. Only smoking was found to have a negative influence on the healing time. There were no major complications associated with the treatment and all fractures united except one. We conclude that partial fibulectomy combined with an Ilizarov frame is a reliable method for the treatment of tibial delayed and non-union.

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.

Patellar tendon lengthening for patella infera using the Ilizarov technique

Patella infera can cause knee pain and lead to patellofemoral osteoarthritis. Treatment is usually unsatisfactory. We describe a case of severe patella infera after operative treatment for fracture of the patella. We used Ilizarov external fixation and gradual lengthening of the patellar tendon. The patellar height was restored and the patient's symptoms were much improved.

Neglected, open, multiple carpal-metacarpal fracture dislocations of the hand--an unusual entity and its management

A rare case of neglected, open, multiple carpal-metacarpal fracture dislocations complicated by wound infection, soft-tissue contractures, and Sudeck's dystrophy is reported. Satisfactory cosmetic and functional results at 2 years were achieved with staged distraction using Ilizarov's fixator to stretch soft tissues and gain length, followed by open reduction and internal fixation.

Ilizarov frame fixation without bone graft for atrophic humeral shaft nonunion: 28 patients with a minimum 2-year follow-up

OBJECTIVES

To evaluate the outcomes of patients with atrophic humeral shaft nonunion (HSNU) treated by Ilizarov frame fixation without the use of bone graft.

DESIGN

A retrospective review of 28 consecutive patients treated in 1 center between 1996 and 2002.

SETTING

Tertiary referral center.

PATIENTS AND METHODS

We studied 28 consecutive patients: 12 male and 16 female. Of the patients, 21 had been previously operated (15 by internal fixation using compression plates, 3 by intramedullary nailing, and 3 by external fixation), and 9 of those 21 patients also had failed revision procedures; 7 patients had been treated nonoperatively from the time of injury to the time of the index procedure for HSNU. Mean age at the time of the index operation was 44 years (16-73 years).

INTERVENTION

Removal of the previous fixation device, excision of fibrous tissue at the HSNU site, opening of the intramedullary canal, excision of avascular bony ends, and stabilization fixation and compression of the humerus with an Ilizarov circular frame (proximal semicircular ring) using smooth 1.8-mm K-wires. No bone graft was used. The mean postoperative follow-up was 76 months (24-174 months).

MAIN OUTCOME MEASUREMENTS

Radiologic union using plain radiographs. Clinical and functional outcome using the Lammens system, which evaluates pain, range of shoulder and elbow movements (and their limitations), and humeral alignment and union. Patient subjective outcomes were assessed using a 4-point patient satisfaction questionnaire.

RESULTS

Bony union was achieved in all 28 cases after a mean of 4.1 months (3.4-5.7 months). There were 6 superficial pin tract infections (which resolved with antibiotics) and 1 transient radial nerve palsy (which resolved at 2.5 months). One patient refractured his humeral shaft following a fall, but the fracture successfully united 5.7 months later after a further Ilizarov frame application. All patients had good or excellent functional outcomes and range of shoulder and elbow movements as rated by the Lammens scoring system.

CONCLUSIONS

Ilizarov circular frame fixation without bone graft is a reliable method for the treatment of atrophic nonunion of the humerus, even after failed previous surgery.

Treatment of Achilles tendon calcinosis in juvenile dermatomyositis with external ilizarov fixator

Calcinosis is a devastating complication of juvenile dermatomyositis and a challenging therapeutic problem. We report the use of an external Ilizarov fixator for the treatment of Achilles tendon calcinosis causing severe disability in a young girl with juvenile dermatomyositis.

Cross-sectional anatomy in postdistraction osteogenesis tibia

BACKGROUND

Although the early period of distraction osteogenesis has been extensively investigated, there are few data describing the appearance of medium-term bone regeneration.

METHOD

We investigated 10 adults with magnetic resonance imaging scans. Seven of them underwent bone transport, and three had tibial lengthening. The mean follow-up was 28 months after removal of the external fixator. The values were compared with those of the contralateral tibia, which acted as a control.

RESULTS

All of the cases with bone transport had an increase in the volume of the whole tibia of 15.3%-50.8%. The diameters of the regenerated segments increased significantly (P < 0.0001) in all cases. The mean signal intensity in the regenerate decreased significantly in seven cases (P < 0.0001), which suggested a rise in the content of unhydrated tissue, such as bone and collagen. The cross-sectional area of the transported segment increased in all cases (P < 0.01). Finally, in the patients who underwent bone transport, the docking site was seen to be obstructed by unhydrated tissue.

CONCLUSIONS

Contrary to previous claims, the postdistraction osteogenesis of tibia consists of areas with potentially different biomechanical properties. Recognition of these changes is essential not only for appropriate preoperative counseling but also for considering treatment modalities in case of fracture.

Treatment of massive tibial bone loss due to chronic draining osteomyelitis: fibula transport using the Ilizarov frame

This article affirms the value of the application of the Ilizarov frame for gradual transport of the ipsilateral fibula to replace massive tibial bone loss following chronic refractory osteomyelitis.

Outcome of Ilizarov ankle arthrodesis

BACKGROUND

Many operative techniques have been described for ankle arthrodesis, with varying fusion rates. In revisions, the fusion rate is lower than in primary arthrodesis. Recent reports have described good results after Ilizarov ankle arthrodesis. However, descriptions were qualitative, with none using an accepted score. We describe our experience with this technique and functional outcomes in our patients.

METHODS

Seventeen patients (average age 48 years) had primary or revision unilateral ankle arthrodesis using the Ilizarov technique at two centers. Diagnoses included post-traumatic arthritis and Charcot arthropathy. Three patients had talar osteonecrosis. Time in the frame averaged 15 weeks and in a cast 4 weeks. Followup averaged 6 years. Outcome was assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale.

RESULTS

All ankles achieved solid fusion. The average AOFAS score was 65 out of 86 possible. Based on this, results were defined as excellent in three patients, good in eight, fair in four, and poor in two. Minor complications were common, all resolving with local treatment. No deep infection developed. One fusion malunited in 8 degrees of varus.

CONCLUSIONS

The Ilizarov external fixator has numerous advantages applicable to ankle fusion, including: stable fixation, respect for soft tissues, and the possibility of postoperative alignment 'fine-tuning'. Additionally, the ability to direct forces through or around skeletal elements allows varying of the load through the skeletal elements, allowing early weightbearing. The Ilizarov technique, with its high union rate, may be considered for any ankle arthrodesis but is especially useful in complex cases such as revisions, talar osteonecrosis, soft-tissue compromise, and infection. Early weightbearing is an added benefit.

Evaluation of management of tibial non-union defect with Ilizarov fixator

BACKGROUND

Tibial bone defect lead to limb shortening and functional deficit and needs proper treatment. There are various treatment modalities for bone defect in long bone to restore length and function of the limb, i.e. bone grafting, vascularised bone graft, allograft and bone transport. Bone transport can be done through fixators (uniplaner or ring) and intramedullary nail system. This study was conducted on management of tibial non-union with Ilizarov external fixator.

METHOD

This descriptive study was performed on 58 patients in Agency Headquarter Hospital, Bajawar and Lady Reading Hospital, Peshawar, from January 2000 to January 2006. Patients of either gender with age between 9 to 58 years, having nonunion (clean and infected nonunion) in tibia with defect of 2 to 7cm due to trauma or firearm injury were included in the study. These patients were followed up upto one year. Outcome measures were according to the classification of Association for the Study and Application of the Method of Ilizarov (ASAMI), which is based on radiological (defect filling) and clinical (functional) findings.

RESULTS

Out of 58 patients, 44 (75%) were male and 14 (25%) were female. Mean age was 30 years (9 to 58 years). 38 (65.52%) patients had infected non-union while 20 (34.48%) had clean non-union. Right tibia was involved in 32 patients (51.17%) and left was involved in 26 (44.83%) patients. The cause of initial trauma was road traffic accident in 27 patients (46.55%), firearm injury in 23 patients (39.65%) and a simple fall in 8 patients (13.79%). The length of average bone defect was 2.90 cm (200-7.00 cm). Radiological results were excellent in 33 (58.89%) patients, good in 12 (20.68%) patients, fair in 8 (13.79%) patients and poor in 5 (8.62%) patients. The clinical results were excellent in 33 patients (56.89%), good in 18 patients (31.05%), fair in 4 (6.89%) patients and poor in 3 patients (5.17%).

CONCLUSION

Ilizarov ring fixator is excellent treatment modality for tibial non-union with a defect, regarding bone union, deformity correction, infection eradication, limb length achievement and limb function but this needs prolonged learning curve for fresh orthopedic surgeons.

Treatment of non-union of the forearm using distraction-compression osteogenesis

BACKGROUND

The goal of the study is presentation broad abilities like gives Ilizarov method in the treatment of posttraumatic nonunion the of forearm with concomitant shortening and axis deformity, in minimally invasive technique, with contemporary axis correction and lengthening .

MATERIAL AND METHODS

. Authors present 6 patient operated on with the use of Ilizarov method, in years 2001-2005 , suffer from vital nonunion of the forearm - 6 cases radius; 1 case ulna and radius. In all cases with nonunion concomitant shortening of the radius from 2 to 3 cm and valgosity of radius with deformity in sagittal plane in 4 patients (2antecurvation, 2 retrocurvation). All patients had restricted rotation ROM of forearm and restriction of wrist motion . Author's modification of Ilizarov apparatus (with mini-Schanz's half-pins, which permitted rotation of forearm) was used in most of patients. In 3 cases monofocal slow correction with lengthening within nonunion was performed. In 2 cases bifocal, one-step slow correction of deformity and compression within nonunion with lengthening was performed. In 1 remaining case compression of ulna nonunion and compression with deformity correction of radius nonunion were performed. Distraction and correction start in 7 postoperative day in rate from 0,25 to 1 mm/day and correspondingly from1 to 2o/day.

RESULTS

Time of correction and distraction was average 63,3 days (40 - 90 days) . Total time of stabilization was average 25,4 weeks (20 - 35 weeks). Bone union was obtained in all patients. In all cases considerable recovery of limb function was achieved. All patients had superficial pin-tract infection . One patient had staphylococcal pin-tract infection of soft tissues, which retreat after 3-weeks guided antibiotic therapy.

CONCLUSION

The Ilizarov method permit for contemporary axis correction and/or distraction or compression. There is the method of choice in the treatment of nonunion of forearm with concomitant shortening and axis deformity.

The results of treatment of bone defects and non-union within the femoral shaft with shortening of femur using Ilizarov method

BACKGROUND

The non-union within the femur with shortening of the limb as a consequence of trauma is an indication to choose external stabilisation as a method of treatment for that reason, that healing of the bone and surrounded soft tissues is disordered.

MATERIALS AND METHODS

Authors discuss the results of treatment of 16 patients with post-traumatic bone defect and pseudarthroses with femur shortening. The injury was located in femur shaft in 8 cases, distal epiphysis in 5 cases and proximal epiphysis in 3 cases. 11 patients were treated in one stage, 4 patients were treated in two stages and 1 was held in three stages. First operation was made for achievement of union in place of bone loss or pseudarthrosis- the second and third- for elongation and correction of the axis of the femur. The follow-up consisted of 10 patients. In most cases subjective and objective improvement was achieved.

RESULTS

The bone union was reached in 15 patients and in 1 case pseudarthrosis was observed. Patients who were considered to have next procedures due to remaining femur shortening or other limb deformity didn't see necessity of following treatment.

CONCLUSION

The results of the current study indicated that Ilizarov's method can be successfully used in most patients with post-traumatic bone defect and pseudarthrosis with femur shortening. The method allows to reach the bone union, correct the deformity and lengthen the limb as well, what need mostly multi-stage treatment.

Chipping and lengthening technique for delayed unions and nonunions with shortening or bone loss

Autologous bone graft is usually necessary for reconstruction of nonunions with shortening or bone loss. We developed a new technique to reconstruct such nonunions or delayed unions without bone grafting by chipping and lengthening of bone at the original fracture site. Five in six nonunions with shortening or bone loss could be successfully united without bone graft by using our method. The chipping and lengthening technique, which requires neither bone grafting nor change in the anatomy of muscles, is a useful technique for delayed unions and nonunions accompanied by shortening or bone loss.

Correction of severe recurrent clubfoot using a simplified setting of the Ilizarov device

BACKGROUND

Severe recurrent clubfoot deformities are challenging to treat. The Ilizarov method offers a safer alternative; however, the management of the device is complex.

METHODS

A simplified standard setting of the Ilizarov device was used to treat 29 patients (35 feet) with a mean age of 14 years with severely stiff recurrent clubfoot deformities and large scars caused by one or more previous surgeries. This simplification involved a correction in two stages: first a gradual correction of the equinus, varus, cavus, and adduction deformities and later an acute correction of the supination deformity. All feet underwent percutaneous Achilles tenotomy and plantar fasciotomy; 11 feet required an additional midfoot osteotomy. The final outcome was scored as good (complete correction and no pain); fair (partial correction with plantigrade foot and occasional pain); or poor (nonplantigrade foot and continuous pain during walking).

RESULTS

After a mean followup of 56 months, the results were good in 27 feet (77%), fair in five feet (14%), and poor in three feet (9%). Early complications were complete dislocation of the first metatarsophalangeal joint in two feet and partial dislocation of the distal tibial epiphysis in two feet. Late complications were recurrence of the deformity (11 feet), spontaneous ankylosis (16 feet), and symptomatic foot and ankle arthritis (7 feet). Arthrodesis was performed in 13 feet at an average of 21 months after the index surgery to treat symptomatic arthritis or correct disabling residual deformities.

CONCLUSIONS

The Ilizarov device allowed correction of all the complex deformities of severe recurrent clubfoot with minimal operative intervention. Complications were numerous but manageable and for the most part did not compromise overall patient satisfaction in this very difficult to treat clinical condition.

Treatment of grade IIIB opens tibial fracture by Ilizarov hybrid external fixator

OBJECTIVE

We evaluated the results of patients who were treated with Ilizarov hybrid external fixator for type IIIB open tibial fractures.

MATERIALS AND METHODS

35 Gustilo grade IIIB tibial fractures of age between 18 to 42 years (22 male and 13 female) in which 12 distal fourth tibia (D/4) of C1.1 (6), C1.3 (6), 12 upper fourth Tibia (U/4) of A2 (8) and A3 (4) according to AO classification and 11 Tibial plateau fractures of Schatzker type VI (5) , V(5), IV(1) . All tibial plateau, proximal fourth fractures and lower fourth fractures of tibia and fibula (Reversed Hybrid), treated with Ilizarov hybrid fixator using two Ilizarov 5/8 rings and AO External fixator were followed up to 12-52 months.

RESULTS

D/4 fractures were united at 31.16678.3046 wks, U/4 at 24.005.2915 and Tibial plateau at 15.5454.160 weeks (p-0.00). ROM in tibial plateau type IV 130 degrees +/- 00, type V 124 degrees +/- 8.94 degrees, type VI 125 degrees +/- 7.0711 degrees, D/4 of type C1.1 (50 degrees +/- 0.00), type C1.3 (43 degrees +/- 5.7755) whereas full ROM in U/4 fractures. Pin tract infection occurred in 21% of cases. Pain on walking in 20% of cases of type VI tibial plateau fractures and 80% of cases of type IV and V. Problem free in rest of parameter of function of VI and 100% problem in IV and V. Pain at rest observed in 20% of cases in type V. In 66.67% U/4 fractures had pain on walking but no other functions were compromised. In 33% D/4 fractures of C1.1 type had pain on walking only and had 1cm of shortening.

CONCLUSION

On the basis of our experience, we suggest adopting this method for functional limb salvage after extensive complex high-energy injuries. This fixator is safe and versatile, effective in providing stability and allowing early rehabilitation, although the indications for its use are very relatively specific.

Surgical outcomes after treatment of fractures in femur and tibia in pycnodysostosis

Pycnodysostosis is a rare hereditary disease, characterized by systemic bone sclerosis. The most important orthopedic problem in this condition is the recurrent pathological fracture of long bones. In this paper, the surgical results for fractures of six limbs (three femurs and three tibias) in five cases of pycnodysostosis are reported. Five limbs achieved fracture union and union is developing in one tibia after intramedullary nail (IM) nailing or Ilizarov external fixation (IEF), although fracture line tends to persist for longer periods of time. One femoral fracture was treated by IM nailing, and one femoral and one tibial fracture were treated by IEF leading to final bone union. One femoral and one tibial fracture were initially treated by IEF, and were treated by IM nailing after re-fracture. One tibial fracture was initially treated by IEF leading to a failure of union, and was converted to IM nailing. All cases are able to walk; one case requires a single crutch. Infection was noted in two limbs after IM nailing following IEF. Fixation with IM nail was effective in preventing re-fracture as well as in alignment correction. Although the surgical technique is more difficult, IM nailing in the initial surgery may be a better choice for achieving successful union while reducing the risk of re-fracture or infection.

Spiral and oblique fractures of distal one-third of tibia-fibula: treatment results with circular external fixator

INTRODUCTION

Spiral and oblique fractures of distal 1/3 of tibia-fibula are relatively common fractures of long bones. Due to their types, aetiology, limited coverage and blood supply, these fractures often lead to union and soft tissue problems.

MATERIALS AND METHODS

Twenty-seven patients with spiral and oblique fractures of distal 1/3 of tibia-fibula were treated with circular external fixator (CEF) between January 1997 and August 2000. All the fractures were closed. The type of fractures based on AO classification were A1 (n = 8), A2 (n = 6), B1 (n = 11) and C1 (n = 2).

RESULTS

The mean framing time was 14.1 +/- 1.8 weeks (range, 12 to 19 weeks), and the mean treatment time was 18.8 +/- 2.2 weeks (range, 15 to 24 weeks). The patients were followed up for 36 to 78 months (mean follow-up time: 51.9 +/- 10.4 months). The results were evaluated for shortness, angulation, rotation, ankle stiffness, pain and infection. After removal of the frames, 11 patients had ankle pain and stiffness, and 3 patients had loss of range of motion in the ankle even after rehabilitation. None of the patients suffered any complications such as shortness, angulation, rotational deformity and infection, and none had loss of motion in the knee.

CONCLUSIONS

CEF might be a preferable alternative treatment for distal tibia-fibula fractures due to its easy application, fewer major complications such as shortness and angulation, early mobilisation and shorter treatment time.

Acute peg in hole docking in the management of infected non-union of long bones

The Ilizarov method has been studied extensively in the management of non-union of long bones. In most cases this involves filling of defects present primarily or after débridement by bone transport. Acute docking over gaps longer than 2 cm has not been adequately studied, however. The purpose of this paper is to report the efficacy of acute peg in hole docking as a bone graft-sparing modality in the management of infected non-union of long bones.

Acute correction of proximal tibial deformities in adolescents using Ilizarov external fixator: focal-dome versus straight-cut osteotomy

Straight-cut osteotomy was compared with focal-dome osteotomy in two similar groups of patients with proximal tibial deformities. Acute correction of deformity was carried out for 27 patients with a total of 36 bone segments. Ilizarov external fixator was used in all cases. No significant difference was found between the two groups in terms of bone healing, external fixation time and stability of osteotomy. The follow-up ranged from 24 to 63 months. In this study, the focal-dome osteotomy was not found to be superior to straight-cut osteotomy, which is simpler to perform and more versatile for deformity correction.

Ilizarov treatment of infected nonunions of the distal humerus after failure of internal fixation: an outcomes study

OBJECTIVE

To report the functional outcomes of Ilizarov treatment of infected nonunion of the distal humerus.

DESIGN

Prospective case series.

SETTING

Tertiary referral center.

PATIENTS

Between July 1998 and August 2003, 6 consecutive patients (age 33 to 73 years) were referred to us with an infected nonunion of the distal humerus following failure of open reduction and internal fixation. The average time from initial injury to presentation with the nonunion was 27 months (range, 6 to 99 months). The average number of prior surgeries was 2.8 (range, 1 to 4).

INTERVENTION

Hardware removal, ulnar nerve neurolysis, 1 stage debridement, autogenous bone grafting, and application of an Ilizarov external fixator with acute compression in the operating room followed by slow gradual compression (0.25-0.50 mm per day) for several weeks postoperatively.

MEASUREMENTS

Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; SF-12 Physical Component Scale (PCS); Brief Pain Inventory; quality-adjusted life years.

RESULTS

All patients attained bony union. One patient refractured 3 weeks after removal of the external fixator following a fall and ultimately underwent total elbow arthroplasty. At an average follow-up of 4.1 years (range, 2 to 7 years), none of the remaining 5 patients had undergone any additional surgery on their arm and all were free of infection. For these 5 patients, significant improvements were seen in standardized DASH scores (42% initially to 78% at follow-up, P = 0.017), worst pain intensity ratings (5.4 initially to 0.8 at follow-up, P = 0.007), and SF-12 PCS scores (37 initially to 44 at follow-up, P = 0.041). On average, the pretreatment to posttreatment improvement was equivalent to 3.8 quality-adjusted life years.

CONCLUSIONS

Ilizarov treatment of infected distal humeral nonunions that have failed internal fixation restores function, decreases pain, and improves quality of life. The Ilizarov method should be considered a primary treatment option for this disabling and difficult clinical problem.

Functional outcome after lengthening with and without deformity correction in polio patients

Poliomyelitis is one of the causes of limb length discrepancy. The aim of lengthening and deformity correction in such patients is to improve the functional mobility of the patient. This study aims to find out whether or not improvement of limb length inequality with or without deformity correction affects or improves ambulation. This prospective study included 32 skeletally mature patients managed using the Ilizarov technique and external fixation for limb lengthening with or without deformity correction. Functional Mobility Scale scoring was used for assessment of ambulation before lengthening and at the final follow-up. The average duration of follow-up was 2 years and 9 months. Lengthening alone did not change the Functional Mobility Scale score. While lengthening associated with deformity correction improved the mobility scale at 5 m only (in the house), it had no effect on the 50 and 500 m score.

Soft tissue Ilizarov correction of congenital talipes equinovarus--5 to 10 years postsurgery

The aim of this study was to address concerns regarding maintenance of correction of foot deformity after soft tissue Ilizarov distraction in relapsed clubfeet. We retrospectively reviewed the results of Ilizarov surgery of 19 rigid clubfeet in 14 children. The postoperative follow-up was at least 5 years (range, 5-10 years). All patients were assessed using the International Clubfoot Study Group score. This is a comprehensive scoring system published in 2003, incorporating morphological, functional, and radiological assessments. Patient and parent satisfaction was also assessed. Using the International Clubfoot Study Group score, 14 of the 19 feet managed by the Ilizarov soft tissue distraction technique were graded good or excellent. Only 1 patient experienced recurrence of the deformity. Subjectively, 13 of the 14 children in the study were satisfied with the result of the treatment. The study confirms that the short-term good results reported previously are maintained at least 5 years after the operation. There are no other similar studies with a minimum 5-year follow-up.

High recurrence after calf lengthening with the Ilizarov apparatus for treatment of spastic equinus foot deformity

Both gastrocnemius recession and Achilles tendon lengthening lead to scarring in the calf and have high reported recurrence rates when performed under the age of 8 years. Triceps surae lengthening by external fixation seemed to be a valuable alternative. Twelve calf lengthenings have been performed with an Ilizarov device with a mean correction of 27 degrees. No calcaneal gait was observed, but there was a slow continuous loss of dorsiflexion over the observation period. The Ilizarov technique has a higher recurrence rate than most operative procedures for calf lengthening, but carries virtually no risk in producing calcaneus. The technique cannot be recommended for routine clinical use and may only be an alternative for selected cases.

Reconstruction of juxta-articular huge defects of distal femur with vascularized fibular bone graft and Ilizarov's distraction osteogenesis

BACKGROUND

We evaluate the effect of reconstructing huge defects (mean, 15.8 cm) of the distal femur with Ilizarov's distraction osteogenesis and free twin-barreled vascularized fibular bone graft (TVFG).

METHODS

We retrospectively reviewed a consecutive series of five patients who had cases of distal femoral fractures with huge defects and infection that were treated by the Ilizarov's distraction osteogenesis. After radical debridement, two of the five cases had free TVFG and monolocal distraction osteogenesis, and another two cases had multilocal distraction osteogenesis with knee fusion because of loss of the joint congruity. The other case with floating knee injury had bilocal distraction osteogenesis and a preserved knee joint. The mean defect of distal femur was 15.8 cm (range, 14-18 cm) in length.

RESULTS

The mean length of distraction osteogenesis by Ilizarov's apparatus was 8.2 cm. The mean length of TVFG was 8 cm. The average duration from application of Ilizarov's apparatus to achievement of bony union was 10.2 months (range, 8-13 months). At the end of the follow-up, ranges of motion of three knees were 0 to 45 degrees, 0 to 60 degrees, and 0 to 90 degrees. Two cases had knee arthrodesis with bony fusion because of loss of the joint congruity. There were no leg length discrepancies in all five patients. In addition, three patients had pin tract infections and one case had a 10 degree varus deformity of the femur.

CONCLUSIONS

Juxta-articular huge defect (>10 cm) of distal femur remains a challenge to orthopedic surgeons. Ilizarov's technique provides the capability to maintain stability, eradicate infection, restore leg length, and to perform adjuvant reconstructive procedure easily. In this study, we found that combining Ilizarov's distraction osteogenesis with TVFG results in improved patient outcome for patients with injuries such as supracondylar or intercondylar infected fractures or nonunion of distal femur with huge bone defect.

Proof of concept of a simple computer-assisted technique for correcting bone deformities

We propose a computer-assisted technique for correcting bone deformities using the Ilizarov method. Our technique is an improvement over prior art in that it does not require a tracking system, navigation hardware and software, or intraoperative registration. Instead, we rely on a postoperative CT scan to obtain all of the information necessary to plan the correction and compute a correction schedule for the patient. Our laboratory experiments using plastic phantoms produced deformity corrections accurate to within 3.0 degrees of rotation and 1 mm of lengthening.

Distraction osteogenesis to improve limb function in congenital bilateral humeroradioulnar synostosis

Congenital bilateral humeroradioulnar fusion of the elbow is rare. Many patients tolerate unilateral elbow stiffness very well, but bilateral fixed elbows are very disabling. We report the management of a 13-year-old patient using the Ilizarov technique. The left elbow was ankylosed in 70 degrees flexion. It was gradually lengthened through an osteotomy across the fused elbow and flexed through the regenerate to 110 degrees. This has improved the function of the left arm.

The Ilizarov method for the treatment of resistant clubfoot: is it an effective solution?

The resistant clubfoot deformity presents a significant challenge. Several corrective procedures have been described, with the goal to provide a pain-free, plantigrade foot. The Ilizarov method of external fixation and gradual distraction has been reported as an alternative to conventional techniques. Previous reviews have concluded that this method can provide satisfactory correction and outcome. This study presents a review of 21 resistant clubfeet in 17 patients, who had undergone previous surgery, treated with Ilizarov external fixation and gradual distraction by 1 of 2 surgeons. Outcome measures were graded based on function and presence of residual deformity: (a) excellent (painless, plantigrade foot, with no functional limitations); (b) good (plantigrade foot in a patient able to ambulate long distances with mild pain; (c) fair (mild residual deformity, required bracing, and/or had some functional limitations but an active life); and (d) poor (significant residual deformity, pain, and activity limitations). Radiographic measures of the talocalcaneal and talo-first metatarsal angles were compared preoperatively and postoperatively. At an average follow-up of 6.64 years (range, 2.25-10.50 years), 9.5% (2) achieved an excellent result; 4.8% (1), good; 33.3% (7), fair; and 52.4% (11), poor. All 11 of the feet graded poor required revision surgery at an average of 5.63 years postoperatively (range, 2.67-10.2 years). Only the talo-first metatarsal angle displayed a clinically and statistically significant correction. We conclude that the Ilizarov method for treatment of resistant clubfoot deformities results in poor outcome associated with residual or recurrent deformity, often requiring revision surgery.

Complications of Ilizarov leg lengthening: a comparative study between patients with leg length discrepancy and short stature

The Ilizarov technique has been used to treat severe limb length discrepancy and short stature. However, complications of this treatment are frequent. Between 1984 and 2001, 57 patients (94 tibias) had an Ilizarov procedure for limb lengthening. Twenty patients had limb discrepancy and 37 had short stature. Their mean age was 20.2 years (range 15-34). The average limb lengthening was 8.37 cm (range 3.2-14.7), which was equivalent to 26% (range 9.2-60%) average tibial lengthening. A total of 90 complications were observed. Thirty-three unplanned procedures were required during the lengthening programme. Two patients stopped the lengthening programme. There was no difference in the complications in leg lengthening using Ilizarov technique between the group of patients with leg length discrepancy and the group with short stature. A good knowledge of the Ilizarov technique is necessary to perform a lengthening programme with a low rate of complications.

[Ilizarov reconstruction of the distal radius after resection of a giant-cell tumor: a case report]

We present a case of Ilizarov reconstruction after en bloc resection of the distal radius. An 8-cm resection was required to remove a giant-cell tumor. Reconstruction was based on the ascension technique using an Ilizarov external fixator after corticotomy of the proximal fragment of the radius. Satisfactory reconstruction with formation of a neoarticulation between the radius and the carpus was achieved. Satisfactory wrist function was achieved and the patient was recurrence free at five years. The arguments leading to this therapeutic option are discussed.

Osteitis

Infections of the locomotive system appear in many different forms such as acute inflammation of joints or bone following injury or surgical or chronic processes, often lasting for years. They demand an exact treatment plan not only to remove necrotic tissue but also for reconstruction of defects. A special problem is infection following alloplastic reconstruction of joints or spine. Multiple surgical procedures are required to hinder reinfection, restore function, and assure acceptable patient quality of life.

Treatment of relapsed idiopathic clubfoot by complete subtalar release combined with the Ilizarov method

This study presents the clinical and radiographic outcomes of 6 feet (4 patients) with relapsed idiopathic clubfoot that were treated with a combination of subtalar release and the Ilizarov method. The mean patient age at the time of the surgery was 7.4 years (range, 4.5-10.5 years), and the mean follow-up was 5.1 years (range, 2.0-7.3 years). All cases achieved a plantigrade foot, better walking ability, and parental satisfaction with the result. Ankle joint range of motion increased from a mean of 17 degrees (range, 10-30 degrees) preoperatively to 45 degrees (range, 35-65 degrees) at final follow-up. The talocalcaneal angle improved from a mean of 26 degrees (range, 15-34 degrees) preoperatively to 55 degrees (range, 47-65 degrees) at follow-up. The mean tibiocalcaneal angle improved from 95 degrees (range, 87-115 degrees) preoperatively to 80 degrees (77-83 degrees) at follow-up, whereas the talometatarsal angle improved from a preoperative mean of -19 degrees (range, -35 to -10 degrees) to 3.5 degrees (range, -5 to 7 degrees) at follow-up. Recurrence was observed in only 1 foot with forefoot adductus, caused by a pin tract infection and early fixator removal. These cases suggest the Ilizarov method combined with subtalar release are beneficial for the treatment of relapsed idiopathic clubfoot.

Preliminary results of the use of Ilizarov fixation in clavicular non-union

Although clavicular fractures are common, nonunion of clavicle is a rare complication. Clavicular nonunion that occurs due to insufficient stabilization is usually painful and necessitates operative treatment. Seven cases with oligotrophic clavicular nonunion that developed after a conservative process were treated with Ilizarov between January 2000 and December 2002. In all of them, the middle one-third of the clavicle was affected. Details of the cases regarding sex, age information, reason of fracture, previous treatment methods that were applied, nonunion area, nonunion, and duration of frame application were recorded. Two of the cases were female and five of them were male with age mean of 27.1 (19-32 years). Five of these cases had right clavicular injury and two of them had left clavicular injury. Mean nonunion duration was 18 months (range was 6-36 months). All nonunion were fixed and went through acute compression by means of Ilizarov's external fixators without grafting. The duration between the frame application and union was mean 2.7 months (range was 2.5-3.5 months). Mean follow-up period was 31 months (range was 22-48 months). Cases were evaluated in accordance with the Constant Scoring system. They were able to return to their normal daily activities in 10-15 days. All of them regained full shoulder movement and extension ability. Patients have also been evaluated by using Dash-Score. Union existed for all patients and none of them had any complaints of pain after treatment. Since circular external fixator allows acute compression, early shoulder movements, and requires no such additional procedure as grafting, it is an alternative method which can be used in treating nonunion of clavicle.

Two-Stage Reconstruction in Congenital Pseudarthrosis of the Forearm Using the Ilizarov Technique and Vascularized Osteoseptocutaneous Fibula

The authors present nine patients with congenital pseudarthrosis of the forearm. The reconstruction was carried out in two stages. At the first stage, Ilizarov's device was applied to the forearm in order to lengthen the affected extremity and to eliminate deformity. At the second stage, the bone defect was replaced a with free vascularized fibula osteoseptocutaneous graft. All patients had complete survival of the transferred fibula grafts. Bone consolidation was achieved in 4 to 6 months after the reconstruction.

Patient-based outcomes after Ilizarov surgery in resistant clubfeet

We present the results of clinical evaluation and patient-based outcomes after Ilizarov surgery in resistant clubfeet (grade D clubfeet, Dimeglio-Bensahel system). This is a retrospective study of 26 resistant clubfeet in 23 children who were managed by the Ilizarov technique. The average age of the patients at the time of the operation was 9 years and the average follow-up period was 47 months. A calcaneal or mid-foot osteotomy followed by bony distraction was undertaken in nine feet and a soft-tissue distraction, with or without soft-tissue release, was undertaken in 17 feet. Clinical evaluation of the degree of correction of the deformity and functional evaluation, using patient-based questionnaires, were used in assessing the outcome in these patients. Patient-based outcomes give useful information about the functional status following surgery, complementing the objective assessment by the surgeon. Clinical evaluation revealed stiff, plantigrade feet in nine patients and a recurrent deformity after initial correction in the remaining 14 patients. The patient-based outcomes were good to excellent in 52% for satisfaction, 57% for cosmesis, 48% for walking and 73% for teasing (made fun of because of the shape of foot), showing that the functional results were better in these patients in spite of a poor surgical outcome.

Combined Iliazarov and Free Flap for Severe Recurrent Flexion–Contracture Release

This article discusses the treatment of recurrent flexion-contracture of the knee after circumferential burns involving the entire limb. A two-team approach to surgery is used: the orthopedic team widely excises the scar tissue and releases tendons, muscles, and adjacent soft tissue that limit joint movement. The microsurgery team covers the exposed popliteal neurovascular elements with a latissimus dorsi free flap. However, full range of the knee is still limited by the short neurovascular bundle. Therefore, the orthopedic team applies a circular hinged Iliazarov external-fixator-frame to achieve gradual correction, until full range of the knee is achieved. Intensive physiotherapy and continuing use of extension splints for additional 6 months until the scars are deemed stable compliment the treatment regimen and prevent the recurrence of contractures. Between the years 2002 and 2003, we treated four patients (totaling five knee joints) with recurrent severe flexion-contractures after circumferential burns of the entire lower extremity. A significant limitation was caused by the abnormal scarring, which left the patients confined to a wheelchair. In all our patients, previous attempts to release the flexion-contracture failed. With the aforementioned technique, within 3 months after the procedure, all patients were able to walk. We encountered one major complication (ie, drop foot). At follow-up, all patients enjoyed a full range of motion and were able to walk. The strength of our approach comes from combining a free muscle flap with an Iliazarov external fixation and a detailed postoperative rehabilitation plan.

Treatment of Gustilo grade III B supracondylar fractures of the femur with Ilizarov external fixation

Twenty patients who had been treated with Ilizarov external fixation for a Gustilo grade IIIB supracondylar fracture of the femur were functionally assessed 12 to 52 months after treatment. Fourteen fractures were type C3 and 6 were type C2 according to the AO classification. Fractures were united at an average of 39 +/- 9 weeks. There was a final knee extension deficit of 5 degrees to 10 degrees (12.2 degrees +/- 3.5 degrees) and flexion reached 110 degrees +/- 10 degrees in type C2 and 73 degrees +/- 36 degrees in C3 supracondylar fractures. Forty percent of the supracondylar fractures had 4cm shortening and 40% had 1.5 cm. Pin-track infection occurred in 21%. Half of the C3 fracture cases had problems with pain on walking, needed support and had pain at rest, whereas no patients had difficulty getting out of a chair, going up and down stairs. However, all C2 type fractures had problems with all types of function.

The use of the Ilizarov method as a salvage procedure in infected nonunion of the distal femur with bone loss

We reviewed 13 patients with infected nonunion of the distal femur and bone loss, who had been treated by radical surgical debridement and the application of an Ilizarov external fixator. All had severely restricted movement of the knee and a mean of 3.1 previous operations. The mean length of the bony defect was 8.3 cm and no patient was able to bear weight. The mean external fixation time was 309.8 days. According to Paley's grading system, eight patients had an excellent clinical and radiological result and seven excellent and good functional results. Bony union, the ability to bear weight fully, and resolution of the infection were achieved in all the patients. The external fixation time was increased when the definitive treatment started six months or more after the initial trauma, the patient had been subjected to more than four previous operations and the initial operation had been open reduction and internal fixation.

[Central bone transport system optimizes reconstruction of bone defects. Results of 40 treatments]

BACKGROUND

This article describes the results, experiences, and advantages of a bone transport system with one single rope or a fully implantable distraction nail for the treatment of bone defects that totally avoids soft tissue cross traction.

METHODS

40 patients with bone defects were treated by central bone transport systems. 30 post-traumatic defects (12 aseptic, 18 post-septic) and 10 defects after resection of bone tumors (2 benign, 8 malignant). Thirty defects were located at the tibia and ten at the femur; the mean defect size was 10.1 cm; 36 central rope systems and 4 motorized distraction nails were used. The follow-up examination took place after an average of 2.4 years.

RESULTS

All defects were totally bridged. The mean distraction time was 131 (57-208) days and the mean time of external fixation 283 (126-326) days. The time of partial load bearing was 466 (302-594) days and the healing index was 47 (33.1-60.4) d/cm. In 34 patients autologous bone grafting at the docking site was performed, and in 30 patients the external fixator was replaced by internal stabilization. The mean leg length discrepancy compared to the contralateral side was 4+/-3 mm, and the leg axis deviation from the center of the knee joint was 1.5+/-7.0 degrees . There were 1.8 complications per patient on average (15 pin tract infections with replacement, 2 premature consolidations).

CONCLUSIONS

In contrast to conventional methods reduced pin tract infections offer better conditions for internal fixation. Control of length and axis can be optimized, immobilization of the patients is reduced, and the comfort of treatment is significantly improved.