My Experiences with Ilizarov system
-
Upload
l-prakash -
Category
Health & Medicine
-
view
1.190 -
download
2
Transcript of My Experiences with Ilizarov system
My Experiences with the Ilizarov system
Dr L.Prakash M.S. (orth), M.Ch Orth (Liverpool)
My Experiences with Ilizarov system I am not an expert
Ilizarov surgeon. I have never been
to Kurgan or Russia. I have never been
formally trained in this system under anyone.
I LEARNED this system, rather than being TAUGHT
But, I experimented a lot with this
Learnt from my mistakes
Conducted 63 workshops on Ilizarov
Introduced this system to Malaysia, Singapore, Srilanka, and Bangladesh
I conducted experimental studies Studied
biomechanics Read the
literature Attended and
conducted workshops
And continue learning even now
I even wrote a book in 1991
This talk will focus on Biomechanics of bone healing Logic behind original Ilizarov
principles
This talk will focus on
Prakash bangles for paediatric use. Recent experiments in material research Do’s and dont’s of this system
Blood supply to the bone
Is either medullary or cortical Nutrient artery perfuses the medulla Periosteal vessels supply cortical bone.
When a fracture occurs:
Periosteum is torn Medullary integrity is disturbed. A fracture haematoma collects and stops when
the internal pressure equals systolic BP
Now starts the fracture healing
Haematoma resolution Deposition of soft callus Maturation of the callus Calcification or hard callus Consolidation Remodelling
Fracture haematoma is like colostrum for a new born.
Periostal integrity is essential for microvascular transport of callus and other factors stimulating bone healing
We surgeons open the fracture converting a simple one to COMPOUND.
We then suck away all the valuable haematoma.
What good would a haematoma do inside a suction bottle??
We then cut the periosteum, thereby disturbing the blood supply. We dill holes right across disturbing the medullary supply
Else we ream the medulla totally removing the valuable marrow
IS THERE ANY consequence OTHER THAN THIS??
Lanyon and Rubin ( 1984) demonstrated that cyclic axial loading increases callus formation and maintained good bone mass.
Woolf and Wright (1981) and Goodship & Kenwright (1985) demonstrated shortened fracture healing times in animals, with intermittent cyclic axial dynamization.
An Ilizarov system is an intrinsically dynamic system giving beneficial compression-distraction micromovements, in the vertical axis, while providing outstanding stability in both torsional and angular deformations.
This allows almost immediate weight bearing and indirectly helps blood flow and vascularisation
But all these beneficial effects are retained only as long as you use only K-Wires and tension them. Even a single Shanz screw screws up the biomechanics
The magic of original Ilizarov
Original
Original
Original
What do these have in common??
The gasket of one and the spoke of the other were the contents of original Ilizarov
This is not an Ilizarov assembly
See the Shanz pins sticking out!!!
This is not an Ilizarov assembly
See the Shanz pins sticking out!!!
This is certainly not an Ilizarov assembly
See the Shanz pins sticking out!!!
This is not an Ilizarov assembly either!!!
In my opinion there are only three MAGIC
COMPONENTS in Ilizarov Tensioning of wires
Corticotomy
Controlled distraction
A 1.8 mm K wire, tensioned at 80 kg is stronger than a 7mm
Stienman pin and yet inherently elastic compared to a stiff pin.
Originally G A Ilizarov never used anything except pins.
Thin pins, thicker pins, but all pins capable of being
tensioned.
By substituting Shanz screws for K-wires, we loose the Magical
advantage of INHERENT DYNAMISM
Tensioning
My design of tensioner
If we do not respect the original concepts of the designer, the
results will decidedly be inferior!!
It is essential to understand the difference between a stretched wire and a stiff pin. Elasticity is of paramount importance which helps Woolf’s law.
What is the difference
What is the difference
THIS is the difference
The shock absorber
Intrinzic Dynamism An Ilizarov fixator is multiaxially intrinzically
dynamic, because of tensioned wires
This is another design of my tensioner
You mess up when you change Substitution of wires by Shanz pins
totally alters the frame biomechanics.
The intrinzic telescoping, that augments Woolfe’s law is screwed.
How I began doing Ilizarov fixations It was probably in
the year 1988 when I was showing off a some TKR X-rays at the Madras Orthopaedic Club, when a close friend Dr R.Gopalakrishnan showed some of his Ilizarov X-rays. This was the first time that we had seen this and a distraction or elongation appeared simply Miraculous
Everyone gave him a standing ovation. During drinks session, my colleague jokingly told me that Ilizarov was not simple carpentry like TKR, and one needed to be trained in Russia to do it!
I was a little drunk and boasted that nothing was impossible if one tried hard enough. I even put my foot in my mouth and said that un assisted, I would perform a surgery and show the instrumentation during the next meeting.
Then came the real troubles At that time the
fixators were not commercially available.
ASAMI had been just born, and Paley was a 30 year old budding surgeon
Unless you bought the set from Russia, you could not perform the operation.
I located the catalogues and saw the photos. They had cleverly avoided mentioning the dimensions.
I decided to make my own Ilizarov systems
I made rings with 8mm holes as 8mm SS bolts were easily available
Just by looking at the drawings and some X-rays, I fabricated a set and used it on a 23 year old with hypertrophic non union.
I cut the fibula and compressed the fracture
I was surprised at the result, and had an X-ray to boast at the next meeting.
And this led to my making rings & bolts, for myself and my friends. I have the dubious distinction of being the first person to introduce 8mm rings in India.
And it was with this system that I conducted numerous workshops in India and abroad.
The Prakash Bangle fixator
One of the disadvantages of the Ilizarov system was its heavy weight, and thus could not be used on very small children.
That was the era when closed tenotomies and gradual stretching were gaining popularity
Dr B.B.Joshi of Bombay had developed a Joshi fixator, which produced consistent results in club feet in his centre.
I purchased the Joshi system, but was a tad unhappy at the lack of tensioning of the wires,
I modified it and made my bangle fixator
Principles The wires used are
thinner. 1.2 and 1.4 mm dia
Wires are tensioned to provide dynamic elasticity
Assembly is extremely light weight to enable use in even small children
Principles Compliance is
relatively high with children even as young as two months old
Distraction of soft tissue contractures is easier than bone distraction
Though 90/90 wire displacement may not be possible, a fairly stable and dynamic construct can be achieved
Components
Bangles available in sizes from 70 mm to 100 mm
Each bangle has 8 loose junctions to attach to both wires and distracters
Components Distractors provide 0.2 mm
elongation per quarter turn L rods, Z rods, U rods and straight
rods are available in various designs and sizes to enable a versatile construct
Prakash CTEV fixator can be used for conditions other than club feet Paediatric lengthening Congenital pseudoarhrosis of Tibia Paediatric deformities
Congeital pseudoarthrosis of tibia
Congeital pseudoarthrosis of tibia
Congeital pseudoarthrosis of tibia
Congeital pseudoarthrosis of tibia
Congeital pseudoarthrosis of tibia
Club feet
Club feet
Follow up
Another club feet
And one more infant
progress
Excellent results with minimum tissue trauma
Prakash bngles are versatile
Can be used up to adolosence
Other exmples
Examples
And a few more examples
My experiences with Ilizarov have been dependant on the phases of my life. 1990 to 1995- -
Ilizarov surgeon 1995 to 2001- Knee
and revision joint referral surgeon
2002 to 2013 - Convict prisoner doing orthopaedic management without resources inside a prison
May 2013 to the present - Back to action, but still struggling to find the ground
Developments in the last four months 1, Carbon composite
rings 2, Light weight
titanium aluminium alloy
3, Highly cross linked polymer composites
4, Edge drilled featherlite rings
5, Tensioner variants
My current experiments Highly cross
linked HDPE rings
My current experiments Carbon
reinforced plastic
Recent work in rings Aluminium Titanium featherlite
rings
Each ring lesser than 50 grams
Rings with both top and edge holes
Assembled frames are Extraordinarily light
This one with 8 half rings weighed just above half kg
Few recent experiences Neuropathic foot with
equinocavovarus
Partial correction after Knenerman osteotomy
Fairly rapid mobilization
The ulcers have healed
Foot has revascularised!!
Compliance is high and a well stretched tight frame is painfree allowing walking and weight bearing on next day!
Smith’s fracture, plastered after reduction.
In six weeks, the the fracture malunited.
A simple frame with three wires was applied
Ligamentotaxis provided a perfect reduction
Movements at one week
Results are comparable to ORIF with fewer complications and no scar
Questions, Questions and Questions If this is
such a wonderful method, why is it not popular?
Questions, Questions and Questions What is the
reason for decline in the number of cases where this system is currently being used?
Why have surgeons moved away from this system??
1980 to
1995
1996 to
2005
2005 to
1010
2010 to
1015
020406080
100120Series3
Answers Deviation
from original design.
Gilding the lilly
Ease of use of internal fixation devicesBad workman bringing disrepute to the tools
Commercial considerationsPlates are cheaper
Preoperative planning and preparation The
Japaneese calligraphist
Adequate pre op planning
Is there a role of Ilizarov in primary closed fractures? What is
distant control of fractures?
Rings 50mm above and below the fracture without disturbing the haematoma
Ideal indications
Segmental fractures
Grossly comminuted fractures
Intra-articular fractures
Other conditions where Ilizarov is unbeatable
Congenital pseudoarthrosis of tibia
All hypertrophic non unions
Other conditions where Ilizarov is unbeatable
Segmental bone loss
Infected non unions
Misconceptions Long
learning curve
Difficult procedure
Misconceptions Time
consuming
Needs training at a specialized centre
The future of Ilizarov
Ultra-light rings
Wires with higher elasticity
The future of Ilizarov
Light weight bits and nuts
Design improvements in tensioners
The future of Ilizarov
Design improvements in corticotomy chisels
Better understanding of the biomechanics
Thank You