Vascular complications after the treatment with Ilizarov external fixators

Use of external fixators in developing countries: a short socioeconomic analysis

The use of external fixators (EFs) dates back to 377 BC Hippocrates’ time, and it has a wide range of orthopaedic applications. External fixator has expanded its use in the management of fractures and other musculoskeletal conditions. It is widely used all over the world to manage complex musculoskeletal injuries. It has many advantages as compared to internal fixation in some trauma scenarios. However, the cost of the external fixators presents a dilemma to the healthcare system in developing countries. The goals of this review article are to explain the importance of EFs in developing countries in managing fractures, to determine the problems encountered at present during external fixation by developing countries, to identify solutions that could be used to address these issues, expand the use of external fixation into other domains of treatment, the impact of COVID-19 pandemic on fracture management based on existing literature. In conclusion, EFs are very expensive, researches have been conducted to overcome these barriers in developing countries. However, there are limitations in implementing in developing countries. It is important to have affordable and clinically acceptable EFs available in developing countries.

Vascular Complications during Ilizarov Fixator Surgery to the Femur: Two Case Reports with the Introduction of a Method for Determining the Safe Vascular Corridor around the Femur

Aim

To perform an in-depth review of the safe vascular corridor around the femur in order to decrease possible vascular injury.

Background

Despite regular use of half pins in the femur, there is no region entirely safe for percutaneous pin placement. Damage to a major nerve or vessel must be avoided at all costs. Vascular complications during Ilizarov fixator surgery to the femur are rare but serious.

Case description

Of 306 cases of Ilizarov fixation to the femur in the period from 2002 to 2016, two cases had vascular complications. The first case developed a delayed superficial femoral artery (SFA) pseudoaneurysm and the second case sustained an early deep femoral artery (SFA) injury.

Conclusion

The in-depth review of the vascular anatomy around the femur with relevance to the placement of half pins indicates that the femoral shaft segment greatest at risk to lead to a vascular injury lies between the two points: 8 and 24 cm proximal to the adductor tubercle.

How to cite this article

Khanfour AA, Khanfour AA. Vascular Complications during Ilizarov Fixator Surgery to the Femur: Two Case Reports with the Introduction of a Method for Determining the Safe Vascular Corridor around the Femur. Strategies Trauma Limb Reconstr 2019;14(2):106–110.

Biomechanical assessment of a novel bone lengthening plate system - a cadaveric study

BACKGROUND

Although many types of external fixators have been developed for distraction osteogenesis, all have some drawbacks. We recently developed a novel bone lengthening plate to overcome these problems. The purpose of this study is to conduct biomechanical analyses using cadavers to assess the stability of the bone lengthening plate in relation to distraction length and femoral bone mineral density.

METHODS

We used human cadaveric femurs (n=18) to assess the effects of distraction length and bone mineral density on the biomechanical stability of the bone lengthening plate. After establishing control (n=6, 0mm lengthening) and experimental groups (n=12, 30 mm lengthening), we measured biomechanical stability (structural stiffness, ultimate load, and displacement) under a compressive load. The experimental group was subdivided into a group with normal bone mineral density (n=6) and a group with osteoporosis (n=6), and the biomechanical stability of these groups was compared.

FINDING

Structural stiffness differed significantly between the control (417.6 N/mm) and combined experimental groups (185.6 N/mm, p=0.002). Ultimate load also differed significantly between the control (1327.8 N) and combined experimental (331.4 N, p=0.002) groups. Bone mineral density was unrelated to structural stiffness (p=0.204), ultimate load (0.876), or displacement (0.344). In all cases, failure of the bone lengthening plate occurred at the longitudinal connectors, such as the connecting columns between the upper and lower plates, and the lengthening shaft of the bone lengthening plate.

INTERPRETATION

The biomechanical stability of the bone lengthening plate was affected by the lengthening length but not by bone mineral density. In addition, biomechanical stability during lengthening was most strongly influenced by the longitudinal connectors.

Surgical membranes as directional delivery devices to generate tissue: testing in an ovine critical sized defect model

Purpose

Pluripotent cells residing in the periosteum, a bi-layered membrane enveloping all bones, exhibit a remarkable regenerative capacity to fill in critical sized defects of the ovine femur within two weeks of treatment. Harnessing the regenerative power of the periosteum appears to be limited only by the amount of healthy periosteum available. Here we use a substitute periosteum, a delivery device cum implant, to test the hypothesis that directional delivery of endogenous periosteal factors enhances bone defect healing.

Methods

Newly adapted surgical protocols were used to create critical sized, middiaphyseal femur defects in four groups of five skeletally mature Swiss alpine sheep. Each group was treated using a periosteum substitute for the controlled addition of periosteal factors including the presence of collagen in the periosteum (Group 1), periosteum derived cells (Group 2), and autogenic periosteal strips (Group 3). Control group animals were treated with an isotropic elastomer membrane alone. We hypothesized that periosteal substitute membranes incorporating the most periosteal factors would show superior defect infilling compared to substitute membranes integrating fewer factors (i.e. Group 3>Group 2>Group 1>Control).

Results

Based on micro-computed tomography data, bone defects enveloped by substitute periosteum enabling directional delivery of periosteal factors exhibit superior bony bridging compared to those sheathed with isotropic membrane controls (Group 3>Group 2>Group 1, Control). Quantitative histological analysis shows significantly increased de novo tissue generation with delivery of periosteal factors, compared to the substitute periosteum containing a collagen membrane alone (Group 1) as well as compared to the isotropic control membrane. Greatest tissue generation and maximal defect bridging was observed when autologous periosteal transplant strips were included in the periosteum substitute.

Conclusion

Periosteum-derived cells as well as other factors intrinsic to periosteum play a key role for infilling of critical sized defects.

"Asymmetric scalloping of the regenerate": a radiological sign of pseudoaneurysm in distraction osteogenesis

Pseudoaneurysm formation is an uncommon but well-recognised and important complication in limb reconstruction surgery. Postoperative diagnosis is usually clinical or an incidental finding. We present an 11-year-old girl, who underwent two-stage limb lengthening with a circular fixator, for a previously treated pseudoarthrosis of the tibia. During the lengthening plan, a concave defect was noted on one side of the regenerate, which was found to be due to extrinsic compression by a pseudoaneurysm. Normal regenerate formation was seen after selective embolisation of the pseudoaneurysm. This concave appearance on one side of the regenerate has previously been described secondary to a difference in stability on the two sides of the osteotomy, when a monolateral fixator is used, but not due to extrinsic compression by a pseudoaneurysm. The authors propose that this radiographic appearance of “asymmetrical scalloping” on one side of the regenerate may represent a radiological sign of a pseudoaneurysm formation and should provoke investigation for the same.

Rupture of Pseudo aneurysm of Popliteal vessels due to pin migration of External Fixator- A Rare Case Report

External fixators for fracture stabilization or limb lengthening cause complications such as pseudoaneurysm, acute ischemia, bleeding, compartment syndrome, and arterio venous fistula. This is a report of a patient who sustained open fracture of both bones of the right leg and the recovery period was complicated by a rare complication where migration of the proximal pin of external fixator into the popliteal vessels and caused rupture of pseudoaneurysm with popliteal vessels injury after a trivial trauma.

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.

Testing of a new one-stage bone-transport surgical procedure exploiting the periosteum for the repair of long-bone defects

BACKGROUND

A recently proposed one-stage bone-transport surgical procedure exploits the intrinsic osteogenic potential of the periosteum while providing mechanical stability through intramedullary nailing. The objective of this study was to assess the efficacy of this technique to bridge massive long-bone defects in a single stage.

METHODS

With use of an ovine femoral model, an in situ periosteal sleeve was elevated circumferentially from healthy diaphyseal bone, which was osteotomized and transported over an intramedullary nail into a 2.54-cm (1-in) critical-sized diaphyseal defect. The defect-bridging and bone-regenerating capacity of the procedure were tested in five groups of seven animals each, which were defined by the absence (Group 1; control) or presence of the periosteal sleeve alone (Group 2), bone graft within the periosteal sleeve (Groups 3 and 5), as well as retention of adherent, vascularized cortical bone chips on the periosteal sleeve with or without bone graft (Groups 4 and 5). The efficacy of the procedure was assessed qualitatively and quantitatively.

RESULTS

At sixteen weeks, osseous bridging of the defect was observed in all twenty-eight experimental sheep in which the periosteal sleeve was retained; the defect persisted in the remaining seven control sheep. Among the experimental groups 2 through 5, significant differences were observed in the density of the regenerated bone tissue; the two groups in which vascularized bone chips adhered to the inner surface of the periosteal sleeve (Groups 4 and 5) showed a higher mean bone density in the defect zone (p < 0.02) than did the other groups. In these two groups with the highest bone density, the addition of bone graft was associated with a significantly lower callus density than that observed without bone graft (p < 0.05). The volume of regenerate bone (p < 0.02) was significantly greater in the groups in which the periosteal sleeve was retained than it was in the control group. Among the experimental groups (groups 2 through 5), however, with the numbers studied, no significant differences in the volume of regenerate bone could be attributed to the inclusion of bone graft within the sleeve or to vascularized bone chips remaining adherent to the periosteum.

CONCLUSIONS

The novel surgical procedure was shown to be effective in bridging a critical-sized defect in an ovine femoral model. Vascularized bone chips adherent to the inner surface of the periosteal sleeve, without the addition of morselized cancellous bone graft within the sleeve, provide not only a comparable volume of regenerate bone and composite tissue (callus and bone) but also a superior density of regenerate bone compared with that after the addition of bone graft.

Femoral artery and vein injury after cerclage wiring of the femur: a case report

Iatrogenic injuries to the vascular system are a rare but serious complication of primary and revision hip arthroplasty. These injuries usually occur during screw or retractor placement at the acetabulum or proximal femur. Although vascular injury during the passage of cerclage wires is a fear of all surgeons, its occurrence is yet to be described. This case report describes an unusual injury to the femoral artery and vein by a cerclage wire passed around the femoral midshaft during revision total-hip arthroplasty. It underscores the need for diligent comparison of preoperative and postoperative vascular examinations and emergent vascular surgery consultation when needed to avoid disastrous complications.

[Constituted adult equine from the ankle: surgical treatment by Ilizarov external fixator]

INTRODUCTION

Ilizarov's external fixator indications are classically used in children to lengthen the lower limbs. This technique is used for adults to gradually correct articular limitations, especially in the knee, ankle and foot.

METHOD AND RESULTS

We report a case of a 53-year-old patient with distal microangiopathy of the lower limbs leading to amputation of the toes and a bilateral, direct, irreducible, isolated equine feature? from the back foot to 0/50/60 degrees? on retraction of the Achilles tendon. The aim of patient management was to regain walking ability. Because of vascular and cutaneous fragility, the classical surgical treatment was contra-indicated. Progressive reduction by Ilizarov's external fixator was tried. Dorsal inflection was obtained by twice-daily screwing until a radiological angle of 90 degrees was obtained between the tibia and talus. At ten weeks post-surgery, the dorsal voluntary inflection ankle amplitude was symmetrical to 0/10/60 degrees. The patient walked with orthopaedic shoes compensating for the few degrees of residual equine.

DISCUSSION

Correction of adult equine without osseous deformation by Ilizarov's external fixator should be considered when conventional surgery is contra-indicated.

The use of circular wire external fixation in the treatment of salvage ankle arthrodesis

The authors retrospectively reviewed their experience with circular wire external fixation in the treatment of salvage ankle arthrodesis during the past 9 years. The results of 43 cases in a difficult patient population are presented with an average follow-up of 27.0 months. Thirty-three patients (80.5%) went on to achieve a solid fusion or stable pseudarthrosis. A minimum of a 4-ring frame construct was applied for an average of 96.1 days. The major complication rate was 51.2%, including 3 below-knee amputations (7.3%), 7 unstable nonunions (17.1%), 7 cases of osteomyelitis and/or deep-space infection (16.3%), 3 malunions (7.3%), and 2 tibial stress fractures (4.7%). The incidence of complications occurred similarly in patients with Charcot arthropathy, failed total ankle arthroplasty, septic fusion, posttraumatic deformity, or avascular necrosis of the talus, whereas it was relatively higher in patients who were diabetics, smokers, or had an increased body mass index. In addition, the incidence of a nonunion tended to increase with longer follow-up, suggesting that early presumption of a solid union may be erroneous. Based on our defined criteria of a stable, well-aligned fusion without severe pain or activity restrictions, 28 patients (68.3%) had a good result. Circular wire external fixation can be a viable treatment for complex ankle salvage pathology; however, it is difficult to predict the prospects of success or failure.

External fixators for elective rearfoot and ankle arthrodesis. Techniques and indications

Since its introduction to the western hemisphere in the mid 1980's, Gavriel Ilizarov's ring fixator system has been studied extensively and shown to be a superior mechanical construct for stabilizing limb segments. This newfound form of external fixation has radically changed many elements of foot and ankle reconstruction, providing a modular device that can accommodate the complex limb deformities while performing multiple tasks. This article summarizes the authors' experience with compression arthrodesis of the rearfoot and ankle using external fixation.