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© Группа авторов, 2000
Одновременное полисегментарное удлинение нижней конечности по методу Илизарова
Polysegmental simultaneous lengthening of lower limb using the
Ilizarov technique
Нами пролечено 76 больных с укорочением и сопутствующими деформациями длинных трубчатых костей. Деформации бедренной и большеберцовой костей, особенно деформации стопы, являлись одним из основных компонентов нарушения статико-динамической функции нижней конечности наряду с ее укорочением от 4 до 15 см, которое отмечалось в 100% случаев. Укорочение бедра и голени имело место у 51 больного, двустороннее укорочение - у 25 больных. У 55% больных отмечалась порочная установка стопы с наличием эквинусной, вальгусной деформации или конской стопы. Во всех случаях послеоперационный период протекал без осложнений. При создании оптимальных механических и биологических условий остеогенеза характер и динамика силовых параметров в системе "аппарат-конечность", особенно измеренных в противоположных направлениях, имеют большое значение. Ближайшие результаты лечения изучены у 100% больных, отдаленные - у 79%. Во всех случаях результаты оцениваются положительно.
Ключевые слова: деформация, полисегментарное удлинение, метод Илизарова.
We have treated 76 patients with shortening and associated deformities of long bones. Femur and tibia deformities and especially those of the foot were one of the main components of statodynamic function disturbance of lower limb alongside with its shortening from 4 to 15 cm, which observed in 100% cases. Femur and tibia shortening happened in 51 patients, bilateral tibia shortening in 25 patients. 55% of patients had faulty foot position with equinus, cavus or varus. Postoperative period in all the cases was runnung smoothly. Providing optimal mechanical and biological conditions for osteogenesis the character and dynamics of force parameters in the system apparatus-extremity have a great significance especially by contrary directions of attempts. The nearest results of treatment have been studied with 100% of patients and the long-term results with 79% and in all the cases were estimated as positive. Keywords deformity, polysegmental lengthening, the Ilizarov technique.
S. Bozinovski, N. Razmoski, T. Petrovski, S. Nedeski
S. Bozinovski, N. Razmoski, T. Petrovski, S. Nedeski
Special hospital for orthopaedic surgery and traumatology, Ohrid Republic of Macedonia
INTRODUCTION
Discovered by Ilizarov, the tension stress effect of biological tissue, stimulating the genesis, is widely used for formation of bone regeneration in the direction planned in advance and diversed in configuration and length. This discovery led to find out new decisions of treatment of bone shortening with or without associated deformities. The essence of the developed treatment techniques now consists in the guided modelling of tissue structures under conditions of Distractional osteosynthesis by multifunctional and multicomponental apparatus with universal character.
tissue genesis is theoretical basis for working out methods of Distractional osteosynthesis. G.A. Ilizarov stated that decreasing of unit pressure metaepiphyseal growth plates both sufficient increase brings about slowing down the rate of longitudinal limb growth, there are optimal indications of pressure on the cartilaginous plate which revealed by comparatively high growth rate. Methods of partial corticotomy with sparing attitude towards soft and bone tissues are the result of improving of femur and tibia surgical lengthening, which in conditions of stable fixation made prerequisites for simultaneous lengthening of both limb segments at several levels.
Biological law according which tension stress is a factor stimulating and sustaining soft and bone
MATERIALS AND METHODS
Covering a long path from first attempt of lengthening bone through skeletal traction, to the automatic distraction with modern apparatus for transosseous osteosynthesis, the surgical lengthening of the lower limb has been actively developed over a period of more than 70 years. At present surgical lengthening uses two different principles:
1. Wagner method - Three surgical interventions are necessary: meta or diaphyseal osteotomy, distraction using the Wagner apparatus, bone plastics using bone grafts on the newly formed bone defect with fixation by metal plate and screws, removal of plate after consolidation of bone fragments.
2. Ilizarov method - In this method, progressive distraction of the bone after partial corticotomy, stimulates regeneration of bone tissues.
This surgical technique is less traumatizing and practically does not damage the osteogenic tissues. Bone grafts are not used, and there is no necessity for additional fixation. Optimal distraction rate preserves full volume of blood supply in fragments under lengthening and does not disturb enervation of the limb. Rigid fixation of bone fragments at any part of the limb gives an opportunity for functional loading during the treatment.
In this article, the treatment of 76 patients (152 tubular bone segments and 40 corrections of the foot deformity); 50 males and 26 females; aged average 15+/-10 (from 8 to 39 years of age); operated between 1987 and 1997, are subdevided according to etiology of shortening (Table 1).
Table 1
Percentage of shortening Etiology of shortening
7% Tuberculosis of bones and joints
6% Residual polio
35% Trauma
Percentage of shortening Etiology of shortening
17% Congenital shortening
25% Development diseases (Dischondroplasio, Chondrodystrophy)
10% Hematogenic osteomyelitis
Table 2.
Associated pathology: Percentage:
Foot deformities 55%
Varus, valgus or recurvation of ankle 21%
joint
Flexion contracture or ankylosis of 10%
the hip joint in malposition
Subdivision of 76 patients
Majority of patients had a total limb shortening of more than 5 cms. Femur and tibia shortening: 51 patients and bilateral tibia shortening: 26 patients. The average shortening of the femur was 8 cms (from 4 to 14 cms) and the average shortening of the tibia was 6,2 cms (from 3 to 12,5 cms). A majority cases showed an accompanying pathology of the adjacent joints or foot (Table 2).
Diaphyseal deformities of long bones were found in 59 patients (33 femur, 26 tibia).
In the Ilizarov technique, following classification of transosseous osteosynthesis is used:
The whole period of treatment after the surgical includes the period of distraction, fixation with Ilizarov frame and functional rehabilitation. The duration of distraction depends on the amount of lengthening, the selected technique for distractional osteosynthesis, the dynamics of reparative process, the neuromuscular system in the lengthening limb and the functional position of the adjacent joints.
Simultaneously with femoral lengthening malposition of hip joint was corrected, and the axis of limb became even. In 40 cases together with tibial lengthening surgery on the foot was done (corrective osteotomies, arthrodesis of foot and foot correction).
The average rate of distraction in Monolocal distractional osteosynthesis was 1,2 mm per day in femoral lengthening, and 1 mm per day in tibial lengthening. The average increase of distractional osteosynthesis was 1,5 times in tibia and 1,9 times in the femur. In both tibial and femoral lengthening the rate of distraction was not more than 1,5 mm daily. The consolidation of fragment is obtained during the fixation period with the Ilizarov apparatus. Giving fuctional load on the operated limb, without additional fixation, helps to obtain good bone regeneration. The period of fixation depends on: the etiology, the amount of lengthening, the level of segmental corticotomy and or complications during lengthening. The period of distraction using bilocal osteosynthesis in femur or tibia can be reduced by 1,5-2 times period of distraction, and period of fixation reduces in 1,1-1,3 times.
In table 3 and 4 the percentage of lengthening of bone segment with Ilizarov apparatus in monolocal distractional osteosynthesis depending on the level of osteotomy (corticotomy) and the etiology of the shortening is shown.
Table 3.
% of lengthening
Level of osteotomy Congenital shortening Acquired shortening
Proximal metaphyses 14±1,2 13,2±1,1
Diaphyses 17,1±1,5 11,6±1,5
Distal metaphyses 17,2±1,7 12,7±2,1
Table 4. Period of fixation
Level of osteotomy Congenital shortening Acquired shortening
Proximal metaphyses 54 days 46 days
Diaphyses 49 days 45 days
Distal metaphyses 72 days 79 days
Table 5.
% of lengthening
Character of osteotomy Congenital shortening Acquired shortening
Partial corticotomy 15,4±2,2 16,7±1,7
Osteotomy 16,6±1,4 15,6±2,3
Fragmental osteotomy 16,9±2,1 16,4±2,1
Table 6. Period of fixation (days)
Character of osteotomy Congenital shortening Acquired shortening
Partial corticotomy 35 42
Osteotomy 59 63
Fragmental osteotomy 75 65
COMPLICATIONS
In complications being observed during lengthening, following observations were made:
■ Purulent inflammations: 5 cases
■ Subluxation of the knee: 1 case
■ Paresis of peroneal: 2 cases
■ Angulation deformity of segments: 4 cases
■ Extension contracture of the knee joint: 42 cases
■ Contracture of the ankle joint: 2 cases
Comparative analysis of gained data of literature showed that it became possible not only to reduce the number of complications, but even to eliminate such complications as infected hematoma, sepsis, thrombosis and thromboembolism and others with the help of the technique of osteotomy, elaborating the stability of osteosynthesis, and using the method of quantitative control for the lengthening.
CONCLUSION
The analysis of results of treatment allows the conclusion that the complex of techniques of distractional osteosynthesis after Ilizarov gives the opportunity for individual and differential treatment of the patients, depending on the degree of shortening and accompanying deformities.
Methodical principles of controlled distractional
osteosynthesis which makes possible to unite the stages of treatment of orthopaedic cases, to influence on speed of distraction and terms of reconstruction of bone regenerate, is a real way for reducing of period of treatment in patients with shortening of lower limbs.
REFERENCES
1. Barabas A.P. Formiranje na koskeno tkivo pri nadomestuvanje na defekti po Ilizarov // Zbornik na trudovi od sesojuznata konferencija. - Kurgan, 1984. - S.76-79
2. Barabas A .P., Svesnikov A.A., Larionov A.A. Anatomofunkcionalna procenka na vaskularizacijata na ekstremitetot, pri fokalno diskretno rastegnuvanje na tkivata // Ortopedija i traumatologija. - 1985. - Br. 9. - S.9-12.
3. Barabas A. P., Hanes G.S., Sbrodova L.I. Koagulacioniot sistem na krvta pri nadomestuvanje na masivni koskeni defekti i nestabilna osteofiksacija // Ortopedija i traumatologija. - 1982. - Br.7. - S.38-41
4. Gudusauri 0.N. Kompresivno-distrakcionata osteosinteza pri lekuvanje na povredi i zaboluvanje na lokomotorniot sistem // Ortopedija i traumatologija. - 1971. - Br.2. - S.l-7
5. Ilizarov G.A. Transosalnata kompresivna osteoisinteza so aparat na avtorot: Disertacija za kandidat na med. Nauki. - Perm, 1968. -483 s.
6. Ilizarov G.A. Nekoi prasanja od teorijata i praktikata na kompresivno-distrakcionata osteosinteza // Mezunaroden simpozium za transosalna osteosinteza. - Kurgan, 1970. - S.14-19
7. Ilizarov G.A. Osnovni principi na kompresivno-distrakcionata osteosinteza // Ortopedija i traumatologija. - 1971. - Br.ll. - S.7-14
8. Ilizarov G.A. Moznosti za upravuvanje so regenerativnite i formoobrazuvacki procesi na koskenoto i mekite tkiva // Zbornik na naucni trudovi. - Kurgan, 1982. - S. 5-15
9. Li A.D., Lavrisheva G.I. Znacenje na kompleksot na optimaini bioloski i mehanicki uslovi vo regenerativnite procesi pri transosalna osteosinteza. -Zbornik na naucni trudovi. - Kurgan, 1984. - S. 8-49
10. Ilizarov G.A., Irjanov J.M., Petrovskaja N.V. Ultrastrukturelni karakteristiki na distrakcionata dijastaza na elongirana koska // Zbornik na naucni trudovi. - Odesa, 1988. - S.24-26
11. Cara J.A., Forriol F., Canadell J. Bone lengthening after conservative oncologic surgery // J. Pediatr. Orthop. - 1993. - Part B 2. - P. 5761.
12. Ciemy G. 3 rd, Zom K.E. Segmental tibial defects. Comparing conventional and Ilizarov methodologies // Clin. Orthop. - 1994. - N 301.
- P.118-123
13. Marsh J.L., Prokuski L., Biermann J.S. Chronic infected tibial nonunions with bone loss. Conventional techniques versus bone transport // Clin. Orthop. - 1994. - N 301. - P.139-146
14. Ilizarov treatment of tibial nonunions with bone loss / D. Paley, M.A. Catagni, F. Argani et al // Clin. Orthop. - 1989. - N 241. - P.146-165
15. Paley D. Bone transport: The Ilizarov treatment for bone defects // Tech. Orthop. - 1989. - N 4. - P.80-93
16. Treatment of congenital pseudoarthrosis of the tibia using the Ilizarov technique / D. Paley, M. Catagni, F. Argani et al. // Clin. Orthop.
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Рукопись поступила 25.06.99.
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Russian Ilizarov Scientific Centre for Restorative Traumatology and Orthopaedics runs international training courses on the Ilizarov method
The program includes lectures, hands-on workshop and discussion of clinical cases, real-life surgeries, purchase of original Ilizarov fixators at 10% discount for the course participants.
1. Introduction course on transosseous osteosynthesis after Ilizarov Duration - 5 days
Course fee (total) - 1000 USD Participants: physicians
2. Management of long bone fractures and their sequelae, elimination of deformities and limb lengthening
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3. Provision of surgeries for management of fractures and orthopaedic pathology with application of Ilizarov fixator
Duration - 5 days
Course fee - 150 USD per day
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Course fee - 150 USD per day Participants - physiotherapists
Discount is possible for large groups. The course date can be agreed upon.
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