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V.I.Shevtsov, V.D.Makushin, L.M.Kuftyrev "Controlled Transosseous Osteosynthesis../'
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CONTROLLED TRANSOSSEOUS OSTEOSYNTHESIS WITH ILIZAROV APPARATUS FOR MULTIPLE PSEUD ARTHROSES OF LONG BONES
V.I.Shevtsov, V.D.Makushin, L.M.Kuftyrev
(Russian Scientific Ilizarov Center "Restorative Traumatology and Orthopaedics";
General Director - V.I.Shevtsov, M.D.)
Management of multiple pseudarthroses in ong bones is a difficult task for restorative surgery, since it calls for a number of traumatic interventions comprising fragment reposition, application of various intra-extramedullary metal fixators independently or in combination with free bone grafting. However, such treatment do lot always guarantee successful osteosynthesis md complete rehabilitation. Chronic infection in )seudarthrotic area often extends treatment time.
In 1951 G. A. Ilizarov proposed his ipparatus and brand new method to decrease ;urgical trauma and improve rehabilitation of jatients with the said pathology. The method is )ased on controllability of plastic and regenera-ion tissue potential under stable fixation of bone ragments in the apparatus and stimulation by fension stress known in literature as the "Ilizarov jffect"
Ilizarov apparatus design with its cross-rossing wires, from the mechanical standpoint, rovides better fixation in terms of rigidity and alance in comparison with other apparatuses dth monoplane wires or half-pins fixed either to rched fulcrums or to monolateral longitudinal •ames. Such constructions being to a certain xtent springy do not ensure stable fixation of one fragments, therefore they often necessitate iditional means of fixation. Consequently, early mb loading is impossible in full value for a
relatively long time. Construction peculiarities of Ilizarov apparatus allow to assembly its parts into various groups according to treatment and rehabilitative tasks. The apparatus allows to control in a closed manner fragment position in any type of pseudarthrosis management regardless of displacement and fracture type. With the use of compression, distraction or their combination surgeon is able to solve complex orthopaedic problems minimizing the number the number of treatment stages and amount of surgery.
Chronic osteomyelitis in remission or its weak form is not a contraindication against controlled transosseous osteosynthesis. Small sequestra in interfragmental gap are exterminated or restructured under compression stress that eliminates the need for sequestrectomy.
By the moment, the literature gives insufficient data demonstrating rehabilitation tactics for patients with multiple pseudarthroses in long bones. That's why we want to share our experience in the management of the said pathology with Ilizarov method of transosseous osteosynthesis on the basis of the discovered by him general biological regularities of reparative tissue regeneration.
We studied the results of rehabilitation in 53 patients with multiple location of pseudarthroses in long bones.
Of them 14 cases were female, 39 were male. The bulk of the patients were young workable people. Multiple pseudarthroses make 6% of all cases of the said pathology, according to our data.
Fifty three patients admitted for treatment had 107 pseudarthroses, 25 of them were in the upper third of one or more segments, 50 cases in the middle and 32 cases in the lower third of segment.
According to location of pseudarthroses the patients were distributed as follows: double tibial pseudarthroses - 6; triple ones - 1; in both forearm bones - 5; both tibial bones - 12; both tibiae - 7; both femurs - 1. Pseudarthroses of humerus and one of the forearm bones in one limb were in 4 patients, the ones in different limbs - in 3 patients. Combination of humeral and femoral pseudarthroses were in 3 cases and there were 2 cases of humeral and tibial pseudarthroses. In one patient pseudarthroses were in one of the forearm bones and in tibia. Pseudarthroses in femur and tibia at one side (5) and opposite sides (3) were in 8 patients.
Latency of pseudarthroses was from 6 months to 8 years; in the majority of cases (38) it exceeded 2 years. In 36 patients multiple pseudarthroses appeared after open fractures while in 17 cases they appeared after closed fractures or intervention in bones. Thirty six patients had been operated elsewhere before admission to our clinic, 32 of them were operated with the usage of various metal fixators and bone plastics independently or in combination. After multiple attempts to eliminate pseudarthroses and osteomyelitic process half of the patients were proposed to amputate limb.
Pseudarthroses were aggravated wi1 trophic ulcers (10 cases), eczema (1), extensiit-] skin scars (50), anatomic limb shorteni)in (35),different types of fragment displacemdn (38), contractures and ankyloses of adjacent joi^r (43). Twenty eight patients had broken forei bodies in pseudarthrotic area (metal rods, platte< allograft, wires). In 24 cases pseudarthroses w&t complicated with weak chronic osteomyelitis.(ir Thirteen patients used canes or crutclx for walking. Thirty patients had additional me^ for fragment fixation (cast - 13 cases, orthopae devices - 17 cases). Five patients couldn't w,-e without additional help. g
Variability and severity of the patholc^ were the reasons for persistent disability.
Methodology should be taken \± consideration when viewing the problem e multiple pseudarthroses from the standpoint! controlled transosseous osteosynthesis. 1 following issues are solved during rehabilitate of patients with the said pathology: *
- elaboration of feasible treatment tactics, choc of type and sequence of I
osteosynthesis;
- technical performance of osteosynthesis u correct choice of frame assemblies dur< treatment; s
- forecast of treatment time depending duration of the problem;
- determination of the amount of preoperat preparation of patient consider aggravating factors;
- post-operative management.
Preoperative preparation for cases multiple pseudarthroses in one or two upper 1 segments is made according to general rules,
V.I.Shevtsov, V.D.Makushin, L.M.Kuftyrev "Controlled Transosseous Osteosynthesis..."
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Treatment is generally performed on the it-patient basis and patients remain at home to clinic for fragment fixation checks and dressing. Being with the family patient lives his :>rmal life that has a positive effect on his state.
Highly stable fragment fixation for steosynthesis of humerus and forearm bones lables men to do farming (driving tractors, ding horse, etc.) and women to run household ooking, domestic animal care, milking cows, c.).
Osteosynthesis for pseudarthroses of both rearm bones is especially interesting since irgeon encounters a number of non-standard tuations. Osteosynthesis is quite easy when both ¡eudarthroses are at the same level and fragment ids are cross-cut. That calls for monolocal teosynthesis with longitudinal compression and ^responding Ilizarov apparatus assembly.
The task is more difficult when fragments one bone are cross-cut and fragments of the tier are oblique. In such cases osteosynthesis is ade with longitudinal compression in one bone d side-to-side compression in the other one. ree wires are driven through metaphyseal areas • basic rings and at the ends of fragments the res are driven in such a way as to provide lependent manipulation with each bone.
Even more complex case is when there is lislocation in one of radioulnar joints, persis-t pronation and shortening of one bone. Such lation demands several consecutive stages.
First, an apparatus is applied to correct ?ular and rotational deformities and to set the ies. After the segment axis is corrected and les are set a defect in one of the bones omes apparent. At the final stage of osteos-
ynthesis bone fragments are fixed and defect of the second bone is filled.
In pseudarthroses of both segments of the lower limbs patients should be prepared for active motion after frame application since many patients follow the tradition and "tune" themselves to postoperative bed rest. This group of patients needs constant care before treatment. The lack of active motion affects their morale due to physical disability. That's why a great deal of attention should be paid preoperatively to motion control, positive attitude and assurance in the final result. We recommend everyday physical therapy with instructor like change position in bed, active an passive articular motion, soft tissue massage.
Small trauma caused by transosseous osteosynthesis allow to use it, as a rule, simultaneously for multiple pseudarthroses in one and/or different segments. In the last case according to patient's wish osteosynthesis can be made consecutively i.e. initially the apparatus is applied to one segment and after the patient gets used to the frame and active articulation is restored apparatus is applied to another segment. Using the technology of controlled transosseous osteosynthesis the following complex of treatment tasks should be solved: 1.Restoration of bone integrity. 2.Restoration of limb length. 3.Elimination of osteomyelitis. 4.Correction of anatomic and functional changes and disorders.
A special care should be given to correct choice of frame assembly providing permanent and rigid fixation of bone fragments throughout treatment period.
Bloodless treatment was used in 38 patients without large sequestra and foreign bodies, with congruent fragment ends and
sufficient contact area for longitudinal, side-to-side compression or their combination. In such cases closed monolocal compressional osteosynthesis was applied (51).
Indications for closed monolocal distrac-tional osteosynthesis were hyperplastic pseudar-throses (6) with stiff, "springy" pathological mobility and anatomical shortening under 5 cm.
In cases when pseudarthroses were accompanied with fixed angular deformity of bone fragments (19) caused by monolocal wedge-shaped bone defect a closed monolocal combined compression-distractional osteosynthesis was used.
Most frequently (11) in such cases a method of directed horizontal traction was applied when the main correcting force was driven against the deformity apex close to fragment ends and auxiliary force was applied through distraction at the rods of the frame. Segment deformities were corrected in 7 cases by traction of the additional rings with crossing wires driven close to deformity apex transported perpendicularly to biomechanical axis of limb, in 3 cases - by tightening wires with stoppers and in one case - by tightening a bent wire. The basic principle for reposition was biomechanical centering of the distal fragment to the proximal one. In 15 cases with pseudarthrosis and incon-gruent fragment ends, large sequestra and fragment shortening over 5 cm, fragment ends were openly realigned and the longer fragment was osteotomized for further lengthening.
Function of the adjacent joints, specifically knee or elbow in 12 patients was recovered employing hinges assembled of standard parts fixed trough rods to the main frame including additional ring with wires on the distal fragment.
For mild equinus position of foot elastic ba were used in 8 cases and 18 cases with persis contractures and foot deformities were trea with the corresponding frame assembly thro skeletal traction of metatarsal bones. Dm treatment all the patients underwent a cours( motion therapy and physioprocedures on artici area.
Stable fixation of bone fragments in fn from the first days enabled the patients to self-service, make active and passive artic exercises and put loading on limb that impro trophicity, eliminated articular stiffness
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consequently favored prompt rehabilitation.
Tactical principles of osteosynthesis*, multiple pseudarthroses in one segment (femi] tibia) are hardly different from those for sing pseudarthroses. However, the apparatus assen, must ensure independent systems between br rings for osteosynthesis at non-union a (pseudarthroses). Shape of fragment ends, typ^ callus formation and supposed amount ] rehabilitative measures influence the choict "subsystems" for compression, distraction ort combination and the type of osteosynthes open or closed. The status of the second of paired bone - its deformity, integrity, alignu in joints - is also important.
A clinical example (fig. 1).
Patient M., 39 years old was admitte the clinic for multiple (triple) pseudarthrosi the left tibia. Three years earlier he hs multiple fracture of his left tibia in a accident. Bone plates and intramedullary plastics with cast had been applied. No conso tion occurred, pseudarthroses appeared. He c walk only with crutches and detachable splint as fixator.
Fig 1. X-rays of patient M.: left - before treatment; middle - during osteosynthesis, right - 2 years after treatment
Clinically and roentgenological^ there Was pathological "springy" mobility in mid-tibia and locking plates at the ends of fragments.
Ilizarov apparatus of four rings was applied in a closed manner with crossing wires driven through each tibial fragment. Stable ation and sustaining compression at the gment junctions were performed for 5 months, of them - on the out-patient basis. Complete nsolidation, articular function and supportabi-ity were stated after apparatus removal.
Follow-up in two years demonstrated no •ecurrence of pseudarthroses.
In diaphyseal pseudarthroses of forearm )ones at the same or different levels osteosynthesis is made in each of the bones, though basic dngs in metaphyseal regions are common for both bones.
Patients with pseudarthroses in the same egments of lower limbs are the hardest to cure.
Controlled transosseous osteosynthesis has certain advantages in such cases since it can be performed simultaneously in two segments and thus shorten rehabilitation process. Main tactical principles of osteosynthesis are largely determined by anatomic and functional features of the pathology. The basic requirement is application of frames with increased strength of bone fragment fixation to ensure functional treatment after surgery. Osteosynthesis in the same segment on both sides can be made either by one or two teams of surgeons. We prefer to work in two teams for the less time needed for procedure.
Fig 2a. Patient K. X-rays of the right femur (before, during and 2 years after the treatment)
Another clinical example (fig.2).
Patient K., 47 years old was admitted to the clinic for pseudarthroses of both humeri, persistent knee extension contracture. Trauma occurred 2 years earlier. Intramedullary osteosynthesis had been performed twice for fractures of femurs with further cast fixation for 8 months.On admission: the patient couldn't walk indepen-
&dently. She could stand for a while with crutches and additional support. There was valgus (10°) - antecurvatum (30°) in the right femur and varus (30°) in the left one. In the middle of both femurs there was stiff (5°) pathologic mobility. Range of motion in the right knee was 70° (180 -110°) and 110° (+80 - 170°) in the left one.
Fig 2b. Patient K. X-rays of the left femur (before, during and 2 years after treatment)
Roentgenogram cross-cut fragment ends with moderate femurs extension, metal rods in bone marrow canals of both femurs and inter-fragmental gap of 0,2-0,3 cm. The patient underwent concurrent closed osteosynthesis with Ilizarov frames for both femurs after removal of the rod from the left femur. The segmental deformities were gradually corrected within 13 days. From the first days she did active exercises and initially stood up 3 times a day. In two weeks she became completely ambulant with crutches and in 1,5 months - with two canes.
From the right femur the frame was removed 2,5 months while from the left femur, wlj combined monolocal compression-distractiof osteosynthesis was performed, the apparatus v removed in 5 months. Solid bone consolidati was achieved.
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Fig 2c. Patient K. during treatment
Full ROM in the knee was restored wit a year. On a 3-year follow-up: no complaints, disability.
Small surgical trauma allows to perfc simultaneous osteosynthesis for multiple pseu(
V.I.Shevtsov, V.D.Makushin, L.M.Kuftyrev "Controlled
id 'hi
hroses in two segments of the same limb.
^atients tolerate apparatus application relatively
;asy, their general state is not aggravated. The itii
>rocedure is regularly made with one team consecutively and the upper limbs can be treated )n the out-patient basis. A specific technique is elaborated each time depending on anatomic and functional changes, patient's age, occupation, ethology location, shape of fragment ends, their ength and displacement, pathologic mobility, ype of callus formation, presence of foreign x>dies, state of soft tissue and accompanying :rophic disorders.
This is shown by the next clinical example (fig.4).
Patient C., 35 years old was admitted for pseudarthroses in the lower right femur and upper right tibia. He had gotten an open right tibia fracture and closed right femur fracture in a road accident. Initial treatment had included primary surgical treatment of tibial wound, fragment fixation with a catgut thread and cast immobiliza-:ion. Skeletal traction by femoral condyles had 3een kept for 40 days followed by cast fixation br 6 months. No consolidation had happened. ?emoral and tibial osteosynthesis with Ilizarov ipparatus had been made without consolidation.
On admission to our clinic the patient was unbulant with crutches without right leg veightbearing. Shortening of the right leg was 1 :m in the femur. There was 65° varus in the ower right femur with stiff pathologic mobility vithin 15° and valgus (150°)-recurvatum (170°) ill in the same area.
Roentgenogram demonstrate cross-cut ragment ends of femoral fragments, unevenly paque interfragmental gap of 0,2-0,3 cm;
Osteosynt hesis..." 25
oblique-transverse ends of tibial fragments and interfragmental gap of 0,6-0,8 cm.
Fig 3. X-rays of Patient C. (left - before, middle - during treatment, right - the result in 3 years )
The patient underwent closed compres-sional osteosynthesis of the right femur and tibia with Ilizarov apparatus. Fixation in femur lasted for 90 days.
Deformity correction in tibia took 55 days, fixation lasted 180 days.
Fragment consolidation and limb support-ability were reached.
On follow-up in 1 year and 2 months: no complaints, the patient is ambulant without crutches, no disability.
Remarkable is the fact that psychogenic disorders rapidly disappear in patients who had lost hope for recovery. This is explained by atmosphere of psychological trust, everyday activity (possibility of self-service) and expansion of contacts.
Average period of frame fixation made 127+-8 days for management of multiple pseudarthroses in one limb. For the patients with pseudarthroses of the same segments and different segments of the same or different limbs this time makes correspondingly 138, 143 and 155 days.
We encountered the following complications during treatment: mild pin tract infection (6 patients), aggravation of chronic osteomyelitis (1 patient), temporary paresis of peroneal nerve (1 patient). The complications were not severe, they were corrected during treatment and didn't have much effect upon its final result.
Analysis of close anatomic and functional outcomes demonstrated the following.
Bone fragment consolidation was reached in all 53 patients, purulent process was eliminated
in 94,7%, function of the adjacent joints wi restored in 46 patients and significantly improv( in 7. Of 21 patients with 2-7 cm limb shortenin it was completely eliminated in 19 and in tu cases the amount of residual shortening was and 3 cm.
Long-term follow-up of 1 to 6 years we: studied in 50 patients, of them 49 sustained tl achieved level of rehabilitation and one patie^ had to undergo treatment for regenerate fractui that occurred after falling. Forty nine persons ^ all studied are actually healthy and employed i different spheres.
Positive anatomic and functional results i the treatment demonstrate high efficacy ^ controlled transosseous osteosynthesis wiij Ilizarov apparatus for multiple pseudarthroses long bones.
Therefore, transosseous osteosynthesis № certain advantages before traditional surgici techniques for the treatment of multiple pseu arthroses of long bones in various combinatioi These advantages are:
- concurrent controlled osteosynthesis thi shortens treatment time;
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- wide range of non-traumatic technique providing highly functional treatment allows i simultaneously rehabilitate the patients;
- high efficacy of treatment and social rehabilita tion.
