Large bone defect of tibia treatment using

Ilizarov ring fixator - study of 47 cases.

A. Chandrasekaran, M.S., Ph.D.,Senior Consultant Orthopedic Surgeon,

Accident Care Clinics,Chennai 600021 & 600056 INDIA

acortho@gmail.com

This work is possible because of the institution’s free block

My sincere thanks to Founder Chancellor Ayya, Chancellor Shri. R. Venkatachalam

With teachers

With teachers

Definition

Large bone defect 3 to 5 centimeters with

soft tissue environment • secondary to infection, • radiation, • congenital deformity or deficiency.

AO classification

Bone defect

Primary bone loss• Open fractures and

bone loss• Gunshot injuries• Osteoclastic tumors

Secondary bone loss• After tumor resection• Infection• Nonunion

Bone defects caused by high energy injuries, bone loss, infected non unions, non unions- Hans C. Pape et al OCNA 1-4 Jan 2010

Defect Pseudarthrosis

Classification

a. Pseudarthrosis- defectb, c. Diastasis defect with

anatomical shorteningd. Diastasis defect without

anatomical shortening

Defects of lower limb bones. Shevetsov et al, BI Churchill Livingstone 2000-261

Ilizarov circular fixator – apparatus limb

Ilizarov ring fixator system

16 Times more rigid than other fixators

NEMKOV Transosseous compression distraction apparatus. Mechanics and strength of material 1977:47-50

Apparatus Limb

• In large gap and during distraction osteogenesis provides stability both in static and dynamic conditions, hence “APPARATUS LIMB.”

Makushin V.D., Kuftyrev L.M. (1983)

28 January 2011 SCORE 2011

Biomechanics - Wire limb

Stability and rigidity All the stresses are

taken by the wires Micro movement Ossification follows

first order of kinetics

Biomechanics of fracture healing and distraction osteogenesis using Ilizarov ring fixator system – a finite element analysis – A. Chandrasekaran, PhD thesis, SRU 2004

Evaluation• Soft tissue envelope• Infection both active and dormant• Joint contracture and range of motion• Nerve function: sensation, motor• Vasculature: perfusion, angiogram?• Location and size of defect• Hardware• General health of the host• Psychosocial resources

Soft tissue envelope

Everyone expect a functional recovery

Materials and methods• Sri Ramachandra University and Accident care Clinic• April 1996 to April 2015- • Retrospective and prospective study• forty(47) patients were treated, female-9 male -38 • The age group was between 3yrs to 70 yrs.• The gaps(defects) measured 3cms – 20 cms.• They were followed up periodically till they went back to their original position.

Etiology• Trauma - 39• Residual polio - 02 • Tumours - 02• Congenital - 02 • Post infective dislocation of hip - 01• Acute osteomyelitis - 01

EtiologyExternal fixation - 24plate osteosynthesis - 05Ilizarov fixator - 03Intramedullary nail - 04free fibular graft - 02allograft - 01Others - 08

Gap

3-5 cm -185-10cm -2310-15cm -0515-20cm -01

Procedures done

Distractional osteosynthesis -06 Osteotomy and transport -31 Osteotomy lengthening -05 Tibofibular synostosis - 03 Sequesterectomy stabilisation -01

Articular defects -04

Bone healing by Ilizarov technique

• Closed distractional osteosynthesis• Lengthening one of the fragments• Bilocal gradual distraction-compression

osteosynthesis• Defects of articular ends• Tibiofibular synostosis Defects of lower limb bones. Shevetsov et al, BI Churchill Livingstone 2000-

Closed distractional osteosynthesis

Lengthening one of the fragments –auto distractor

Segmental internal bone transportation

Segmental internal bone transportation

Segmental internal bone transportation

Segmental internal bone transportation

•Locomotor apparatus of man is actually constructed with a minimum of material for the maximum resistance to stress (Pauwels 19 65)

Infected Nail Management

Infected Nail – Trifocal Osteosynthesis

Infected Nail – Tibiofibular synostosis

Infected Nail- Trifocal Osteosynthesis

Infected Nail- Trifocal Osteosynthesis

Infected tibia /nail removal

X ray and Te99

Compression distraction osteosynthesis

Bowing of fibula

Infected Plate Osteosynthesis- Segmental Transport

Infected Plate Osteosynthesis- Segmental Transport

Infected Plate Osteosynthesis – Segmental Transportation

BMAC in very large gap

• 25 years male • Traffic accident 2yrs 6mths back• Lost other limb above knee• Allograft failed• 20 cm gap

Allograft

After allograft removal

• 20 cm gap• Tibialisation of fibula• Segmental transfer• Membrane induced

osteogenesis

Internal segmental transportation

Rapid transportation

BMAC - Stem cells infiltrated

Thanks to Mr. Abhaikumar, Tricell, Chennai.

Corticotomy through regenerate – II stage

Stage II

After completion

18 months follow up

18 months follow up

What HE needs is a good prosthesis

Tumor – Defect of the articular ends

Tumor – Defect of the articular ends

Should we fuse the ankle when the knee is fused ?

Complications- septic arthritis

• Wire in the joint and knee fusion

Complications- early fusion

Complications –subsidence and deformity of regenerate

Complications

• Shortening

Tibio fibular synostosis - amputation

Observation

• Edges need not be excised• Transport more than 5 cm requires osteotomy

at 2 levels or internal bone transport• Average healing time for 1 cm is 1.8 months –

variable.• Will require few adjustments till completion• No bone graft at docking site

Complications

• Septic arthritis -1• Non union -2• Knee stiffness -2• Delayed regenerate -1• Shortening -2• Amputation -1• Deformity -2

Results • union, • pain, • stiffness of a joint,• Shortening and• return back to the job.

Results

excellent - 14good - 24fair - 06poor - 02in progress - 01

Summary

• Large bone defects are uncommon• Mostly they are young• Part of multiple skeletal injuries/poly trauma• Undergone many procedures• Physically and financially exhausted• Almost always infected

Summary

• Remove implants and sequestrum• Need not resect the ends• Stabilise the bone by Ilizarov fixator• Create contact• Mobilise them early with maximum weight

bearing• Expect complications• How many joints can be fused?

Conclusion

• Limb salvage is most challenging, with lot of inherent problem technical, social and financial

• Try to save the limb till a sensitive foot prosthesis could be made.

• Ilizarov bone transport construction is faster, safer, less expensive and easier to perform.

“Personal experience remains the best teacher”