CC BY
47
Гений Ортопедии № 2, 2016 г.
© Barawi Omer Ali Rafiq, 2016. УДК 616.717.4-001.5-089.227.84 DOI 10.18019/1028-4427-2016-2-36-39
Лечение дефектов плечевой кости по методу Илизарова
Omer Ali Rafiq Barawi
Школа Медицины, Университет Sulaimani, Региональное Правительство Курдистана, Ирак
Management of bone defect of humerus by Ilizarov method
Omer Ali Rafiq Barawi
School of Medicine-University of Sulaimani-Kurdistan Regional Government of Iraq
INTRODUCTION
The treatment of posttraumatic diaphyseal bone defects (BD) calls for a number of techniques including bone transport techniques , shortening, compression- distraction at the fracture site, shortening followed by lengthening in a corticotomy distant from the site and segmental bone transport [1]. The earliest treatment for these problems included
amputation or shortening where as more recent treatments have included bone lengthening, bone grafting, Titanium mesh cage packed with allograft and distraction osteogenesis [2]. The French technique of bone grafting within induced membranes, otherwise known as the Masqulet technique, offers a viable alternative with minimal complications [3].
PATIENTS AND METHODS
Between Feb.2010 and Feb.2014, 10 patients with bone loss and upper arm shortening were treated by segmental bone transport using Ilizarov method, the amount of bone loss in the humeri ranging from (3cm-9cm), average 6 cm, male to female ratio is 7/3. Their age ranged from 20-60 years (average 37.8 years). Number of previous operations ranged from 2-6 operations (average 3.6 operations).
The causes were trauma in 9 cases as they were treated by multiple operations of open reduction and internal fixation and bone graft, while one of the cases was a complication of bone elongation causing delayed union of distraction site (Table 1).
External fixation index 34.8 days/cm, bony results, Table 2 showing 6 cases excellent and 4 cases good depending on four criteria (union, infection, deformity and upper limb length discrepancy). Recommended by Paley et al [4, 5, 6].
An excellent result was one with union, no infection, axial deviation <5°, no limb length discrepancy. A good result was union, no infection, axial deviation between 5° and 15° and limb length discrepancy < 3 Cm. A poor result was nonunion, refracture, axial deviation >15° or limb length discrepancy >3 cm.
Functional results 7 cases excellent and 3 cases good. The functional results based on 3 criteria as recommended by Cattaneo et al., which are range of motion of shoulder and elbow, functional activities such as perineal care, sports ,brushing teeth and face washing and patient satisfaction.
An excellent result was one with improved or unchanged range of movement, improved functional activities and satisfaction. A good result was with no change or < 10° loss of preoperative range of movement, with maintained functional activities and satisfaction. A poor result was one with loss of range of movement by < 10°, deteriorated functional activities or dissatisfaction [4, 5, 6].
Table 1
Preoperative patient data
Case Age Gender No. of previous operations Bone loss in Centimeters Type of operation
1 б0 Female 5 9 O.R.I.F.&B.G
2 28 Female 2 9 Bone elongation
3 20 Male 3 4 O.R.I.F.&B.G
4 35 Male 4 5 O.R.I.F.&B.G
5 40 Male 4 5 O.R.I.F.&B.G
6 42 Male 3 5 O.R.I.F.
7 32 Male 3 7 O.R.I.F.
8 б2 Male 4 4 O.R.I.F.
9 29 Male 6 5 O.R.I.F.
10 30 Female 2 6 O.R.I.F.
Note: O.R.I.F. - open reduction and internal fixation by plate and screws. B.G. - bone graft.
Q Barawi Omer Ali Rafiq. Management of bone defect of humerus by Ilizarov method // Гений ортопедии. 2016. № 1. С. 36-39.
Table 2
Results
Case Lengthening in cm External fixation index, Days/cm Bone status at last follow up Functional status at last follow up
1 9 40 Excellent Excellent
2 8 40 Good Good
3 4 30 Good Good
4 5 35 Excellent Excellent
5 5 36 Good Excellent
6 6 35 Excellent Excellent
7 6 37 Good Good
8 4 31 Excellent Excellent
9 5 33 Excellent Excellent
10 6 31 Excellent Excellent
COMPLICATIONS
Pin tract infection 4 cases 3 of them treated by oral antibiotics and proper hygiene, while one of them treated by replacing the pin with another pin.
DISCUSSION
Inferior subluxation of gleno-humeral joint one case and treated by physiotherapy.
Intraoperatively, I didn't expose the docking site of two of the cases for removal of the false joints as the failed implants were removed before their presentation to me, the limbs were protected by braces, similar to the study done by T. Liu et al [7]. While in the remaining 8 cases, refreshing
of nonunion sites done till capillary cortical bleeding seen from the fragments, Paprika sign, which is considered as the endpoint of resection [8]. The reason for refreshing the fragments is that as a part of removal of implant failure I refreshed the exposed fragments also (Fig. 1).
Fig. 1. (a, b): Plain radiograph of left humerus of 60 years old lady, A.P. & Lateral views, showing non-union & implant failure
Fig. 1. (c): Plain radiograph of left humerus of the same patient after removal of the failed implant & fixation by two intramedullary K-wires & Ilizarov frame
Fig. 1. (d, e): The same patient after bifocal bone transportation & removal of fixators & using brace
Fig. 1. (f, g, h): The same patient holding a chair or her bag
Гений Ортопедии № 2, 2016 г.
Fig. 1. (i, j): Plain radiograph of the same patient showing well corticalised distraction sites & well united compression site
Regarding case No. 4, there was nonunion of docking site so I did Accordion Procedure for her, which is shortening for 3 days daily 3 mm i.e. 1mm/8 hours thus totally 9 mm will be shortened, then stop for 10 days and
restart elongation 0.25mm/12 hours thus within 18 days the shortened 9 mm will be compensated [9].
Case No. 2. She was 28 years old, her chief compliant was discrepancy of upper arms 9 cm, so both elbows were not at the same level that was the sequel of pyogenic osteomyelitis of proximal humerus during her childhood, I started bone elongation using Ilizarov frame 9 days after starting of distraction, she developed wrist drop, her radiograph showing malaligned distal fragment, compressing the radial nerve in spite of stopping distraction and waiting for 6 weeks no improvement of wrist drop, confirmed by Electromyography and Nerve conduction Study, so exploration of the radial nerve done with adjustment of external fixator frame, the distraction is restarted, 4 days after the operation 1 mm/day till equalization of the limb done but it was ended by delayed union, so proximal to distraction site a corticotomy done for distraction of new corticotomy site and compression of the non-union site (Fig. 2). Wrist drop disappeared 50 days after exploration of the radial nerve.
All the 10 cases had been cases of fracture of the humerus treated by surgical intervention, they are prone to nonunion and bone defect this is in favour that most diaphyseal fractures of humerus heal without surgical intervention [10].
Fig. 2. (a): Plain radiograph of left humerus of a 28 years old lady, 9-cm shortening as sequel of osteomyelitis, corticotomy of the middle part of the humerus
Fig. 2 (b, c): Plain radiograph of the same patient with malaligned distal fragment causing wrist drop
Fig. 2. (d): Plain radiograph of left humerus of the same patient with distraction of corticotomy site & no evidence of union
Fig. 2. (e): Plain radiograph of left humerus of the same patient, corticotomy done in the proximal part of the left humerus
Fig. 2. (f): Distraction started to fill the gap & compensate for shortening
Fig. 2. (g, h): Plain radiograph of left humerus of the same patient, even there is some overlap of the fragments at the compression site
Fig. 2. (i): Plain radiograph of the same patient showing evidence of union at the compression site
Fig. 2. (j, k , l): The same patient after removal of the Ilizarov frame ,well equalized humeri (as there were 9-cm shortening),scar tissues of her childhood operations for infection, she can use her hand holding her bag
CONCLUSION
Fig. 2. (m, n): Plain radiograph of the same patient, showing well corticalised distraction site & well united docking site
Segmental Bone Transport is a very successful method for treating bone defects in humerus to control infection,
stimulate osteogenesis at docking (non-union) site and to compensate for any shortening.
REFERENCES
1. Bone transport techniques in posttraumatic bone defects / S. Rigal, P. Merloz, D. Le Nen, H. Mathevon, A.C. Masquelet; French Society of Orthopaedic Surgery and Traumatology (SoFCOT) // Orthop. Traumatol. Surg. Res. 2012. Vol. 98, N 1. P. 103-108.
2. Molina C.S., Stinner D.J., Obremskey W.T. Treatment of traumatic segmental long-bone defects // JBJS Reviews. 2014. Vol. 2, N 4. P. el.
3. Woon C.Y, Chong K.W., Wong M.K. Induced membrane - a staged technique of bone-grafting for segmental bone loss: a report of two cases and a literature review // J. Bone Joint Surg. Am. 2010. Vol. 92, N 1. P. 196-201.
4. Ilizarov treatment of tibial nonunions with bone loss / D. Paley, M.A. Catagni, F. Argnani, A. Villa, G.B. Benedetti, R. Cattaneo // Clin. Orthop. Relat. Res. 1989. N 241. P. 146-165.
5. Reconstruction of segmental bone defects due to chronic osteomyelitis with use of external fixator and an intramedullary nail / M. Kocaoglu, L. Eralp, H.U. Rashid, C. Sen, K. Bilsel // J. Bone Joint Surg. Am. 2006. Vol. 88, N 10. P. 2137-2145.
6. Lengthening of the humerus using the Ilizarov technique. Description of the method and report of 43 cases / R. Cattaneo, A. Villa, M.A. Catagni, D. Bell // Clin. Orthop. Relat. Res. 1990. N 250. P. 117-124.
7. Callus distraction for humeral nonunion with bone loss and limb shortening caused by chronic osteomyelitis / T. Liu, X. Zhang, Z. Li, W. Zeng, D. Peng, C. Sun // J. Bone Joint Surg. Br. 2008. Vol.90, N 6. P. 795-800.
8. Distraction osteogenesis using a monolateral external fixator for infected non-union of the femur with bone loss / S. Arora, S. Batra, V. Gupta, A. Goyal // J. Orthop. Surg. (Hong Kong). 2012. Vol. 20, N 2. P. 185-190.
9. Catagni M.A., Guerreschi F., Lovisetti L. Distraction osteogenesis for bone repair in the 21st century: lessons learned // Injury. 2011. Vol. 42, N 6. P. 580-586.
10. Nonunion of the humerus after failure of surgical treatment. Management using the Ilizarov circular fixator / VR. Patel, D.K. Menon, R.D. Pool, R.B. Simonis // J. Bone Joint Surg, Br. 2000. Vol. 82, N 7. P. 977-983.
Рукопись поступила 28.03.2016.
Information about author:
Barawi Omer Ali Rafiq - School of Medicine-University of Sulaimani-Kurdistan Regional Government of Iraq.
