|Year : 2016 | Volume
| Issue : 3 | Page : 685-690
The role of the Ilizarov fixator in management of tibial defect
Mahmoud M Hadhoud, Ahmad I Zayda, Mohamed F Abdel Baky
Department of Orthopedic Surgery, Menoufia University, Shebin El Kom, Menoufia, Egypt
|Date of Submission||06-Apr-2015|
|Date of Acceptance||25-May-2015|
|Date of Web Publication||23-Jan-2017|
Mohamed F Abdel Baky
Department of Orthopedic Surgery, Menoufia University, Shebin El Kom, Menoufia
Source of Support: None, Conflict of Interest: None
The objective of this study was to evaluate the results of the Ilizarov technique in the treatment of tibial defect.
The incidence of tibial defect is increasing continuously in our country as a result of high-energy trauma, debridement of osteomyelitis, tumor resection, or congenital anomalies. Sometimes the defects are associated with major soft-tissue injuries that limit the functional outcome independent of the actual bone loss.
Materials and methods
This work was a prospective study of 30 patients with tibial defect treated by Ilizarov external fixator. All patients were evaluated both clinically and radiologically through routine follow-up visits, and all items of information concerning each patient were collected and recorded using the patient information sheet, and data were tabulated and evaluated.
In this study of 30 patients with tibial bone defect treated with Ilizarov external fixator, the results were five excellent patients, 19 good patients, four fair patients, and two poor patients (P < 0.05).
Treatment of tibial defect with Ilizarov yields satisfactory results.
Keywords: bone lengthening, Ilizarov technique, tibia, tibiae bone defect
|How to cite this article:|
Hadhoud MM, Zayda AI, Abdel Baky MF. The role of the Ilizarov fixator in management of tibial defect. Menoufia Med J 2016;29:685-90
|How to cite this URL:|
Hadhoud MM, Zayda AI, Abdel Baky MF. The role of the Ilizarov fixator in management of tibial defect. Menoufia Med J [serial online] 2016 [cited 2020 Apr 3];29:685-90. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/685/198755
| Introduction|| |
Bone is among the very few tissues in the human body that possesses the intrinsic capacity to heal spontaneously following injury. However, beyond a certain critical size defect, bone cannot heal by itself and outside intervention is required  .
Numerous techniques are available for the management of these defects, including the gold-standard autogenous bone grafts, allograft, bone-graft substitutes, vascularized fibular bone grafts, and systemic administration of anabolic agents. All these techniques, however, do have limitations  .
Elective limb shortening to overcome skeletal defects can simplify treatment and speed the recovery. However, only 2 cm of shortening can be done without clinical manifestation  . Moreover, elective limb shortening is not accepted by many patients  .
In 1952, Ilizarov developed the technique of distraction osteogenesis. In the treatment of bone defects with this technique, a cortical osteotomy is made through a healthy bone segment at some distance from the defect site. Components of the frame are attached with wires to the segment of bone between the corticotomy and the defect. Thereafter, steady traction is applied to the intercalary bone segment to elongate the corticotomy region while closing the original skeletal defect in the same time. New bone formation within the distraction gap forms according to the tension-stress effect. With this method, the limb length is maintained, deformity is corrected, and limb shortening is gradually overcome while the defect is being eliminated , .
Many authors have used this method for management of segmental skeletal defects and reported variable results. Some reported good results ,, , whereas others reported high complication rate with this method  .
| Materials and methods|| |
This work was a prospective study of 30 patients with tibial defect treated by Ilizarov external fixator between March 2012 and March 2015 with follow-up from 6 to 20 months. The inclusion criteria for the cases were selected based on the presence of bone defects, and one or more of the following criteria: stiff nonunion with long-lasting bony deformity, limb-length discrepancy, bad skin coverage, previous or present history of infection, one or more previously failed operations to achieve union, and patients with infection elsewhere in the body for whom internal fixation is risky. The exclusion criteria were patients with mental disease, severe damage to the tibial nerve, and patients who can be safely treated by the simple method of open reduction internal fixator and/or bone grafting.
Ages of the patients in this study ranged from 5 to 52 years, with a mean age of 28.8, and most of them were male (22 patients, 73.3%) (P > 0.05) ([Table 1]).
The etiology of the bone loss was trauma in 21 cases, osteomyelitis in six cases, and congenital pseudoarthrosis in three cases ([Table 2]). The fractures were open in 15 cases and closed in six cases. The bone loss in the closed fractures occurred as a complication of multiple surgical procedures resulting in nonunion or infected nonunion.
The left side defect after debridement (15 patients, 50%) was equal to right side defect after debridement (15 patients, 50%). The defect was located in the upper third in three cases, in the middle third in eight cases, in the distal third in 17 cases, and segmental in two cases ([Table 3]).
General examination was done to determine the patient's general condition and the presence of any medical disorders. All patients were evaluated for associated medical problems and were referred to the respective specialty departments and treatment was given, when necessary. Simultaneously, associated injuries were evaluated and treated.
All included patients were subjected preoperatively to personal history, pre-existing medical diseases, fracture etiology, and mechanism of injury, followed by preoperative investigations such as complete blood count, alanine transaminase enzyme, aspartate transaminase enzyme, urea, creatinine, blood sugar, and prothrombine time and activity. Thereafter, informed consent was taken from each case according to ethical and legal research guidelines.
The procedure was performed under spinal or epidural anesthesia.
The patient was in the supine position on a radiolucent table, and the image intensifier was draped and positioned for easy entry and withdrawal. Intraoperatively, the nonunion area was approached, and sinuses, sequestrate, and unhealthy soft tissue were debrided aggressively. The ends of the two main bone fragments were exposed. The fragment that was preoperatively marked out as a peg was sculpted into an invaginating end. The other bone end was converted into a receptacle for this peg. The two ends were fitted into each other.
Stability was tested in a preliminary manner by applying manual force in bending and shear. An invagination of at least 1 cm was achieved. It was also mandatory for the base of the peg to be more than one-third of the diameter of the receiving end in both anteroposterior and lateral planes.
The preassembled Ilizarov frame was affixed and compression was applied at the docking site. In all cases in which the tibia was operated, a preliminary fibular osteotomy was performed to allow docking to take place. In the lower-limb bones where acute docking caused a shortening of more than 2.5 cm, a corticotomy was done in the metaphysis to allow distraction osteogenesis and equalization of limb length. Postoperatively, any angulation at the docking site as calculated from the radiographs was corrected by differential compression and distraction of the rings. Distraction was started at the corticotomy site 7 days postoperatively and carried out four times a day in 6-h increments of 0.25 mm. The distraction was continued until the limb lengths were equalized. In all these series cases where distraction was done, consolidation of the regenerate was the determining factor in the removal of the fixator. The docking site union was assessed by stress testing along with radiologic melting of the peg (cortical continuity). In all, 19 patients were treated by a single-level transport with a five-ring apparatus or with four-ring constructs with a pulling wire, and two cases were treated by double-level transport. Compression at the nonunion site and then relengthening from a distant corticotomy were performed in eight cases, and alternative compression distraction technique was performed in one case.
Intraoperative and postoperative antibiotic regimen and postoperative control radiographs were performed routinely; all patients were followed up for at least 12 months.
Statistical data analysis
Statistical presentation and analysis of the present study was conducted with SPSS (Statistical Package for Social Sciences) version 20 on an IBM-compatible computer (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics such as percentage (%) and mean value were used.
| Results|| |
A total of 21 cases were treated by bone transport technique, eight cases were treated by acute closure, and one case was treated by alternative compression distraction technique. The end results were assessed according to the study by Cattaneo et al.  , based on union, elimination of infection, and function. All fractures united, and the union time ranged from 3 to 17 months, with an average of 8.5 months. The average duration of union for our group of patients was 11 months (ranging from 6 to 20 months) ([Table 4]).
The clinical follow-up results were evaluated using three parameters - union, infection, and function - according to the criteria of Cattaneo et al.  to have excellent, good, fair or poor results according to [Table 5].
Time to operation
For Ilizarov external fixator, the time to operation procedure ranged from 1 to 216 months.
Time of operative procedure
The time of operative procedure ranged from 45 to 120 min, with an average of 85 min.
The shortest period of hospital stay was 5 days; the longest period was 2 weeks, with an average of about 10 days.
According to the criteria of Cattaneo et al.  , we had five excellent patients, 19 good patients, four fair patients, and two poor patients ([Table 5]) (P < 0.05).
Most of the complications are minor. Pin-tract infections form the bulk of complications associated with Ilizarov external fixator. Although the infection is superficial and mild in most of the cases, infection increases the risk of wire loosening and, because of the weight borne by the external fixator, causes frame instability. Good care of pin sites and aggressive management of superficial infections is essential to prevent deep infections and septic arthritis. Insufficient pin care has been associated with a higher incidence of pin-tract complications. Muscle contracture and joint stiffness are significant problems, especially in patients in whom the fixator is applied for prolonged periods and in fractures near the joints. Early and vigorous range of motion activities helps in achieving a good functional outcome. Despite the appearance of these complications, it did not affect the end results,except in three cases. In the present study, the incidence of the complications in the first 20 cases (three per each patient) was higher than the incidence of complications in the next 10 cases (2.5 per each patient). This indicates that this technique has a learning curve, and most of the complications can be avoided with the improvement of the experience. Delayed union of the docking site is one of the common complications encountered with bone transport. In the present series, the union at the target site was achieved without the need for bone graft in 22 cases (73.3%), and bone graft was required in eight cases (26.7%).
| Discussion|| |
Many methods have been used to treat tibial defect - for example, radical debridement, local flaps, muscle flaps, bone grafting, tibiofibular synostosis, cancellous allograft, fibrin mixed with antibiotics, antibiotic beads, microvascular flaps, and vascularized bone transplants. All have improved results but none has been able to fully solve this clinical situation  . All of these factors must be addressed during treatment. In more complex cases with atrophic bone ends, soft-tissue loss, chronic osteomyelitis, or a combination of these, amputation may be the eventual outcome despite the current technique of internal and external fixation  . Most treatment methods that are highly successful at obtaining union cannot address all of these problems, and certainly not at the same time. Until recently, the approach taken by the ASIF group has been more comprehensive. Their treatment goals include the elimination of deformity, infection, and defects at the same time as obtaining union  .
The Ilizarov ring fixator gives an option of compression, distraction, and bone transport, and it is effective in the treatment of infected nonunion of the tibia where other types of treatment have failed  .
The infection was eradicated in all the infected cases without the need for prolonged antibiotics and without reactivation throughout the period of follow-up. The defects were eliminated in all the cases except one. The union was achieved in all the cases except one. The healing index (time in frame in months per centimeter of distraction) ranged from 0.6 to 2.7 months/cm with a mean of 1.6 months/cm. The length of the regenerated bone ranged from 0.5 to 17 cm, with a mean of 6 cm. The average number of operations per patient was 2.1 (ranging from 1 to 5). The angular deformity did not exceed 7.5°, except in one case. The leg length discrepancy did not exceed 2.5 cm, except in one case.
The results compare favorably with those using other techniques for reconstruction of bone defects. Goldstrohm et al.  treated 39 bone defects with lengthening and bone grafting. They had only a 61% success rate after lengthening of more than 5 cm. The average time to full weight bearing was 12.3 months. In our series, the success rate was higher (80%) and the average time to full weight bearing was shorter (9 months). Christian et al.  reported on eight cases with large soft tissue and segmental diaphyseal defects of the tibia treated with massive cancellous bone graft and free tissue transfer. The defects ranged from 6 to 14 cm, with a mean of 10 cm. Although all the tibia healed, two cases had a deep infection - one at the donor site on the posterior iliac crest and one at the recipient site that necessitated elevation of the flap and debridement of a portion of the cancellous bone. The infection recurred and second debridement was needed. In the present series, no donor-site morbidity was reported and the infection was eradicated in all the infected cases without recurrence. Plastic surgery was not required in all of our cases, except one. In our series, the infection was not reactivated in any of the infected cases, and no cases required amputation. This distraction osteogenesis has a higher success rate and fewer numbers of complications when compared with autogenous bone graft in the management of segmental skeletal defects. This is in agreement of Cierny and Zorn  who compared 21 patients with segmental tibial defects (mean size = 6.4 cm) treated with bone transport using the Ilizarov apparatus with 23 patients with tibial bone defects (mean size = 8.5 cm) treated with massive cancellous bone grafts and soft-tissue transfer. They found that the complication rate was high in the bone grafting group (60% for the bone-graft patients and 33% for the Ilizarov patients). Ilizarov patients averaged fewer hours in the operating room, hospital days, months of disability, units of blood, and adjunctive surgical procedures, resulting in cost savings. The authors concluded that Ilizarov in bone defect reconstruction was faster, safer, less expensive, and easier to perform. The results of our study are in agreement with other series involving the same technique. Dendrons et al.  treated 28 patients aged 18-74 years old from the infected nonunion of the tibia with radical resection of the necrotic bone and distraction osteogenesis. The sizes of the bone defects average 6 cm (range = 2-13 cm). They reported satisfactory bone results in 78.8% of the cases and satisfactory functional results in 64.3% of the cases. The infection was eradicated in all patients before removal of the fixator. The mean duration of treatment was 10 months. One of the advantages of this method is its ability to bridge soft-tissue defects without the need for major plastic surgery. In this series, the soft tissue was deficient in 14 cases. Only one of them required plastic surgery, whereas the other 13 cases were left open to drain. As the bone segment was transported, it carried its surrounding soft tissue with it; thus, coverage was achieved without plastic operations. This is in agreement with Paley and Maar  who reported on eight cases with soft-tissue defects in their series and were treated by soft-tissue transport in concern with bone transport. The timing of frame removal is a very critical point during management with Ilizarov external fixator. Premature removal of the apparatus may lead to major complications. We have one patient in our series who developed angular deformity of the regenerated bone because of premature removal of the fixator. Thus, we are in agreement with the study by Paley  that it is wise to leave the apparatus 1 month later rather than to remove it 1 day earlier ([Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]).
|Figure 2: Follow-up 3 months after treatment by Ilizarov external fixator.|
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|Figure 3: Preoperative clinical and radiological image in a 35-year-old male patient. Anteroposterior and lateral view (preoperative).|
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|Figure 5: Clinical and radiological images after refracture in a 5-year-old male patient. Anteroposterior and lateral view (preoperative).|
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|Figure 6: Closure of the nonunion gap with distraction of the corticotomy site.|
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| Conclusion|| |
Ilizarov external fixator in bone defect reconstruction was faster, safer, less expensive, and easier to perform. Distraction osteogenesis is a good solution for the segmental tibial defects. It is important to include the foot in the frame in a large distal to proximal transport (>5 cm) to avoid equinus deformity. Soft-tissue defects may close during bone transport without the need for major plastic surgery.
The complications are numerous, but they can be reduced with the improvement of the experience. Patient selection is very important. Stable fixation is a very important point during treatment with distraction osteogenesis. Bone graft at the docking site may be needed to enhance the union and shortens the time in fixation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Demetrious R, E Jones, D McGonagle, PV Giannoudis. Bone regeneration: current concepts and future directions (2011).
Nauth A, MD McKee, TA Einkorn, JT Watson, R Li, EH Schemitsch. Managing bone defects. J Orthop Trauma 2011; 25
Edwards, CC. Staged reconstruction of open tibial fractures using Hoffman external fixation; clinical decision and dilemmas. Clin Orthop 1983; 178
Cattaneo R, Catagni M, Johnson EE. Treatment of infected non-union and segmental defects of the tibia by method of Ilizarov. Clin Orthop Relat Res 1992; 2801
Ilizarov GA. The tension-stress effect on the genesis and growthof tissues: part I. The influence of the stability of fixation and soft-tissue preservation. Clin Orthop 1989; (238)
Green SA, Jackson JM, Wall DM, Marinow H, Ishkanian J. Management of segmental defects by the Ilizarov intercalary bone transport model. Clin Orthop 1992; 280
Murray J, Fitch R. Distraction histiogenesis; principles and indications. J Am Acad Orthop Surg 1996; 4
Dagher F, Rouzok S. Compound tibial fractures with bone loss treated by Ilizarov technique's. Bone Joint Surg 1991; 73B
Johnson EE, Urist MR, Finer M. Repair of segmental defects of the tibia with cancellous bone graft augmented by human bone morphogenetic protein. A preliminary report. Clin Orthop 1998; 236
Tahmasebi MN, Mazlouman SJ. Ilizarov method in the treatment of tibial and femoral infected non-unions in patients with high-energy trauma and battlefield wounds. Acta Medica Iranica 2004; 42
Paley D, Catagni MA, Argonne F, Villa A, Benedetti GB, Cattaneo R, et al.
Ilizarov treatment of tibial nonunion with bone loss. Clin Orthop 1989; 241
Goldstrohm GL, Mears DC, Swartz WM. The results of 39 fractures complicated by major segmental bone loss and/or leg length discrepancy. J Trauma 1984; 24
Christian EP, Boss MJ, Robb G. Reconstruction of large diaphyseal defects, without free fibular transfer, in grade-IIIB, tibial fractures. J Bone Joint Surg 1989; 71A
Cierny GIII, Zorn KE. Segmental tibial defects. Comparing conventional and Ilizarov methodologies, Clin Orthop 1994; 301
Dendrons GK, Kontos S, Lyritsis E. Use of the Ilizarov technique for treatment of non-union of the tibia associated with infection. J Bone Joint Surg 1995; 77A
Paley D, Maar DC. Ilizarov bone transport for tibial defects. J Orthop Trauma 2000; 14
Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop 1990; 250
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]