Ilizarov apparatus: scope and features of application

To create optimal conditions for fastening bone fragments of a limb segment, compressing or stretching bones, and anatomically correct fusion, it is proposed to use a special design - the Ilizarov apparatus. This is a kind of corset for bones. Widely used in many areas of clinical medicine - traumatology, outpatient, pediatric orthopedics. The Ilizarov apparatus is also successfully used in the beauty and health industry - in anthropometric cosmetology for the correction of congenital or acquired deformities of the limbs, for the correction of the hips and legs for aesthetic purposes.

How the device works

The compression-distraction method of treatment was developed in the early 50s by the traumatologist-orthopedist of the regional hospital of the city of Kurgan G. A. Ilizarov, later he was awarded the academic title of professor, doctor of medical sciences.
The technique is based on the use of a device located outside the patient’s body, comparable to a kind of tunnel, in the center of which there is a limb that needs to be assembled and fused. The dynamic design for transosseous (external) osteosynthesis, named after the author of the invention, at that time consisted of 2 rings connected by movable rods and 4 X-shaped intersecting stainless steel spokes fixed on ring supports.

Subsequently, the design was constantly improved, but the principle remained unchanged - with the help of special wires passed through the middle sections of the damaged bone, rigid fixation is ensured, eliminating any displacement. In order to be able to influence the course of therapy, the structure is fastened with mechanical movable rods, allowing dosed adjustment of the level of impact on the affected area, providing a given compression or stretching of the bone area. Early modifications were bulky, heavy, and caused a lot of inconvenience to patients. Design innovations made it possible to obtain a lightweight, reliable, small-sized, universal and multifaceted design that provides the greatest rigidity of fixation:

• The steel wires of the Ilizarov apparatus, which are the connecting element between the outer ring supports and bone tissue, were replaced with high-strength titanium or carbon fiber rods. To enhance rigidity, they are equipped with special sharpening, soldering or thrust pads. The greatest rigidity is provided by knitting needles with a diameter of 2 mm, but 1.5 or 1.8 mm are more often used;
• triangles, half-rings or individual arcs are used as support instead of inconvenient one-piece rings. To give greater rigidity to the support, the parts are connected to each other using additional fasteners; they can even overlap each other;
• the presence of a relatively small number of standardized parts allows, in addition to the basic model for the treatment of deformations and damage to long tubular bones (Ilizarov apparatus on the leg, arm - usually the lower leg and forearm), to complete options for almost any bone, incl. metacarpal, metatarsal and phalanges.

For each specific clinical case, doctors individually select parts and, depending on the nosological form, localization of the pathology, and assigned tasks, install their own special type of design. The Ilizarov apparatus, which includes standardized components and parts, has no analogues at the moment.

Path to glory

The road of the Ilizarov apparatus to all-Union, and later to worldwide fame, was not easy. Until the end of the 1960s, apart from the inventor himself and literally a few progressive orthopedists, no one used his device. The devices were not mass-produced; the few existing copies were made for specific needs. But in 1968, Ilizarov was lucky with a patient. After an accident, an all-Union athlete, the best of the Soviet jumpers, Valery Brumel, came to him.

Brumel underwent 30 operations on his leg, which was literally pieced together, but until it fell into the hands of Ilizarov, it was of little use.

Ilizarov was the first doctor to promise Brumel not a wheelchair or crutches, but a return to sports. And he kept his promise. With the help of a miracle device, he straightened the injured leg, making it equal to the healthy one, and Brumel returned to his sporting life.

Of course, he never repeated his previous record of 228 centimeters, but he jumped 209 centimeters, and this is a very good result.

Valery Brumel, photo - Championship.

In what cases is surgery using the device indicated?

The design feature of the device allows you to fix bone fragments in a given position, creating optimal mechanical and medical-biological conditions for their rapid fusion. When assembled, it serves as a frame that solves a number of problems in various fields of medicine. Operation with the Ilizarov apparatus restores the natural integrity of the skeletal system and is indicated for bloodless treatment:

• severe fractures of the chest, pelvic, and various parts of the spinal column;
• closed comminuted, comminuted, multi-fragmented fractures along the diaphysis (central section of the tubular bone), metaphyseal (periarticular) fractures;
• fresh and old dislocations, open fractures;
• building up the missing section of bone in the presence of defects formed as a result of diseases, the destructive action of tumors, osteomyelitis, after removing small fragments of injured bone unsuitable for regeneration;
• congenital malformations of the skeleton - shortening, deformation of the limbs, clubbed hands, clubfoot;
• true o- or x-shaped curvature of the legs with rickets;
• pseudarthrosis of any localization, acquired bone changes due to arthritis, arthrosis, infectious diseases;
• joint contractures, solitary bone cysts, slowly healing or improperly fused bones.

Advantages and disadvantages

The installation operation is used strictly as prescribed by a doctor and is indicated for adults and children . The operating principle, purpose, device and installation procedure are identical. Manufacturers produce device kits in several sizes:

• 8 sizes for shoulder, forearm, hand and lower leg - with inner diameter of rings from 80 to 225 mm;
• 5 sizes for the hip – diameter from 120 to 180 mm.

A complete set of parts allows you to assemble a large number of options. For small patients, it is recommended to purchase a set of parts made of titanium. This material is resistant to corrosion, biologically absolutely harmless, and the weight of a titanium device is less than its steel counterpart. Its main advantages include the ability to obtain a readable, without visualization distortion, image on X-rays, NMR and computed tomography and to control the treatment process due to the fact that the titanium alloy does not exhibit magnetic properties.

Treatment with the Ilizarov apparatus allows:

• compare and reliably record fragments as accurately as possible;
• maintain normal blood supply;
• resist the force of muscles approaching the diseased bone from different sides and pulling it in diametrically opposite directions, causing shifts;
• protect the combined fragments and the juxtaposed bone from displacement, divergence of edges, additional trauma, and malunion;
• due to the ability to accurately fix and regulate the length of the bone, prevent its shortening during fusion;
• correct congenital changes - stretch a limb that is unequal in length, correct its shape;
• minimize the risk of formation of pseudarthrosis (false joint) at the fracture site;
• begin to move painlessly as early as possible, without waiting for complete consolidation of the fracture, which allows you not to lose the motor and supporting function of the joints, and prevent muscle contracture. The ability to walk with the Ilizarov apparatus literally a week after its installation appears due to a design feature that allows the weight to be distributed over the entire area of ​​the supporting frame.

The disadvantages of treatment with the device in comparison with the positive effect are not significant; they mainly boil down to the following:

• extra weight is felt;
• the device causes discomfort – it interferes with sleep, sitting and lying down normally;
• immediately after installation, swelling and pain appear;
• At the entry points, pinpoint scars remain on the skin and can persist for a long time.

Links[edit]

1. ^ abcdefghi Spiegelberg B., Parratt T., Dhirendra S. K., Khan V. S., Jennings R., Marsh D. R.. (2010). "Principles of Ilizarov deformity correction". Annals of the Royal College of Surgeons of England
   .
   92
   (2): 101–5. DOI: 10.1308/003588410X12518836439326. PMC 3025247. PMID 20353638 .CS1 maint: uses the authors parameter (link)
2. ^ abcd Svetlana Ilizarova (2006). "The Ilizarov method: history and scope." In S. Robert Rosebruch; Svetlana Ilizarova (ed.). Limb Lengthening and Reconstruction Surgery. CRC Press. pp. 3–6. ISBN 0849340519.
3. ^ abcd Svetlana Ilizarova (2006). "The Ilizarov method: history and scope." In S. Robert Rosebruch; Svetlana Ilizarova (ed.). Limb Lengthening and Reconstruction Surgery. CRC Press. pp. 15–16. ISBN 0849340519.
4. Paley, Dror; Kovelman, Harry F; Herzenberg, John E (October 1993). "Ilizarov Technology". In Stauffer, Richard (ed.). Advances in Operative Orthopedics: Volume 1 (PDF). Mosby Inc., pp. 243–287. ISBN 978-0-8151-7939-9. Archived from the original (PDF) on March 19, 2012. Retrieved January 14, 2012.
5. Ed Woolley (December 13, 2015). "How Comrade Ilizarov saved my leg". Observer
   . Retrieved December 13, 2015.

How to install the Ilizarov apparatus

Technically, installing the Ilizarov apparatus is a complex task, requiring the trauma surgeon to have mathematical precision of movement, understanding of the engineering design, and the ability to quickly make decisions. The operation is performed in an equipped trauma department exclusively by an experienced specialist. He will need to study in advance the nature of the bone fragments and their location using x-rays and assemble the required version of the device from the parts. They are pre-prepared - sterilized by boiling using distilled water. To numb the area of ​​the body during surgery, local anesthesia is administered. Depending on the severity of the condition and the extent of the procedure, the patient may be prescribed general anesthesia. The place where the needles are inserted is disinfected.

The patient is positioned on the operating table so as to provide free access to the site of application of the guide device. So, if the Ilizarov apparatus is installed:

• on the hand - use a side table and place the sore limb on it;
• on the leg (tibia fracture) - the bed is created using a fixator, on a standardized Beler splint, which has special hip and knee notches at both ends, ensuring peace and relaxation of the muscles;
• on the thigh - place a pillow under the buttock on the side of the healthy part of the body so that the operated area of ​​the thigh hangs without tension.

Assembly is carried out directly during the operation; for this, the surgeon performs the following actions:

• the needles are brought to the designated section of the bone at a right angle to its longitudinal axis, taking into account the topography of the vessels and nerves;
• to maintain sterility, the needles are held with a dry cloth, balls and rubber plugs treated with an alcohol solution are put on them, with the help of which the needles are attached to the patient’s skin;
• the doctor brings the needles to the bone, piercing the soft tissue, and using an electric drill, drills holes in a given fragment with them, the needles are inserted in mutually intersecting directions;
• to avoid burns, often stop drilling;
• Having passed the knitting needles through the bone, he assembles the apparatus - puts on support rings, secures the knitting needles to them with special holders, tightens the nuts on the connecting rings installed parallel to each other, ties and rods;
• checks the correct position and fastening, then proceeds to tensioning the spokes - one end is tightly secured with a clamp, the other is first pulled out using a spoke tensioner.

The apparatus is adjusted by rotating the nuts on movable rods (bars) that hold metal support rings that transmit the load to the bones. By changing the distance between them, we achieve:

• Compression effect - tightening the nuts and bringing the rings closer together.
• Stretching of bone fragments - increasing the distance between the rings with arches and weakening the compression.

Treatment of patients with congenital or post-traumatic shortening of the phalanges of the fingers and metatarsal bones is provided by installing a mini-device on the finger. It is divided into a basic and dynamic part and consists of several (from 1 to 5) cantilever spokes fixed in a support. They are passed through the lower end of the metatarsal or metacarpal bone, the central section of the main phalanx of the finger, the nail and middle phalanges.

The installation scheme is the same for all indications and injured parts of the body - the manipulations are identical in cases where the Ilizarov apparatus is applied for a bone fracture and when cosmetic changes are performed. Depending on the location of the problem area and the complexity of the disease, a different number of semicircles and arcs can be used, serving as the main supporting and regulatory elements. Lengthening with the Ilizarov apparatus is a step-by-step procedure, including:

• Installation of the device on a solid limb in need of correction.
• Osteotomy is an orthopedic operation in which the bone is cut.
• Fixing the ends in the desired position with a guide device.
• Gradual lengthening of the limb - distraction begins after 7 days, when the bone begins to grow.
• Fixation period. Correction of the second leg begins no earlier than a month from the start of the operation.

This is how the shape of the bone is adjusted.

When to use

The Ilizarov apparatus is mainly prescribed for open fractures. “When the fracture is open, it cannot be fixed with a plate or a pin inserted there. Because this place is most likely infected - dirt around the wound, etc. And if you put an implant there, there is a high risk that it will fester. As a result, osteomyelitis may develop, and it may even lead to sepsis and death. The Ilizarov apparatus allows you to work not in the area of ​​the fracture itself, but above and below it. Doctors fix the bone with knitting needles on rings and align the fragments relative to each other in the correct position. All this is recorded, and the person walks in the device exactly as long as it takes for the bone to heal,” says the orthopedic traumatologist, head. Trauma Department, Ph.D. Andrey Naimann .

Questions and Answers Can bones stick together on their own?

Duration of wearing the device

There is no clear answer to the question: how long do you wear the Ilizarov apparatus? The period is determined individually and depends primarily on the rate of bone tissue growth. The duration of wearing consists of the period of connection of fragments, elongation and the period of pressure. There are restrictions on the rate of dilation - bone traction: 1 mm / day. Having reached the required length of the bone or having carried out immediate fixation of the fragments, wait until the bones are strengthened and acquire their natural density. By time, on average:

• the traction period lasts 20-30 days - with an extension of 2 cm, 50-75 - with an extension of 5 cm;
• the fixation period is at least 1-2 months, but usually extends to 4-6 months. for comminuted fractures, 5-8 during orthopedic surgery.

The process should be constantly monitored to minimize the risks of improper fusion and the development of complications. If the fracture has healed sufficiently, after this time the Ilizarov apparatus must be removed.

What to consider

Any fractures are fixed using the Ilizarov apparatus. Often, of course, we are talking about open ones, but closed ones can also be effectively treated with the help of such a device.

However, it is worth understanding that it is necessary to properly care for the structure. After all, you have to wear it not for a day or two, but in some cases for six months. “The disadvantage of this method of treatment is that the needles are passed through the bone and percutaneously, they can fester, inflammation begins, and as a result, streaks form. And you should take very careful care of the structure - constantly change the cotton balls at the entry and exit points of the knitting needles, wash it and do it at the time of dressing,” says the orthopedist.

An orthopedic device developed by the surgeon, director of the Kurgan Research Institute of Experimental and Clinical Orthopedics and Traumatology Gavriil Ilizarov. Photo: RIA Novosti/Igor Vinogradov

Rules for wearing the device

After a successful operation, the patient is discharged to continue treatment on an outpatient basis. Before discharge, they are taught the rules of wearing and caring for the device. You are allowed to begin loading the limb on the second day after the application of the pins and to move independently, leaning on the sore leg and using crutches for support while walking, within a week. To eliminate the risk of suppuration and inflammation, it is important to adhere to sanitary standards and certain hygiene rules:

• daily disinfect open areas of the knitting needles and all parts of the device - wipe with a cloth moistened with medical or other high-quality alcohol, avoiding contact of the solution with the skin;
• change napkins every 2 days, after 2 weeks - every 7 days;
• When a doctor prescribes antibiotics, strictly adhere to the prescribed dosage; if symptoms (pain, swelling, redness, purulent discharge) do not disappear, immediately notify the attending physician.

In case of displacement or deformation of the spokes, urgent medical attention is required. Ignoring the problem is fraught with irreversible consequences.

Causes of fractures

Bone fractures are divided into traumatic and pathological .

Traumatic bone fractures occur as a result of external mechanical influences. A broken leg and a broken arm most often occur when a person is hit or falls. A rib fracture, like a collarbone fracture, often occurs as a result of an unsuccessful jump and fall. A fracture of the heel bone (the so-called “skydiver’s injury”), as a rule, occurs when landing unsuccessfully on one’s feet from a height.

Others, pathological fractures , are caused by weakness and fragility of the bone itself. These include, for example, bone fractures in older women suffering from osteoporosis (a common injury in this disease is a hip fracture).

1 Treatment of fractures

2 Treatment of fractures

3 Treatment of fractures

Basics of rehabilitation after removal of the device

The removal procedure must be carried out by the same doctor who installed the device. In most cases, it does not cause significant pain and anesthesia is not required. How to remove the Ilizarov apparatus:

• Dismantling of supporting supports, rings, clamps.
• Biting one end of the knitting needle and pulling it out of the bone.
• Treating puncture sites with disinfectants.
• Applying a plaster cast.

After removal, it is recommended to gradually increase the load, because bone thickness, strength and density decreased. Wearing heels is prohibited (allowed only after six months). The arm, leg after the Ilizarov apparatus and other joints need to restore normal blood circulation, which will provide nutrition to the limb and accelerated regeneration. The rehabilitation period should include:

• massage, hydromassage;
• therapeutic exercises;
• hydrogen sulfide baths, swimming, walking.

How long does the treatment process take?

Most often, the Ilizarov apparatus is installed on the limbs, although modern medicine also allows the use of this treatment method in correcting spinal curvature and more. You will have to wear the device for a certain number of months (minimum two). The duration of wearing the device largely depends on the specific diagnosis and the complexity of bone correction. In addition, the rate at which the patient regenerates bone tissue plays a role. This process is quite individual for everyone.

In case of complex splinter fractures of the legs, sometimes the devices have to be worn for 4 months, six months, and sometimes up to 10 months. When performing orthopedic treatment with bone lengthening, it lasts more than six months.

Why and in what cases are complications possible?

Immediately after installation, some patients experience swelling and pain. They are not caused by the Ilizarov apparatus itself - the pain is a consequence of damage to small formations (vessels, nerve columns) by a metal needle (during its penetration into soft tissue), the exact localization of which cannot be determined during the operation.

Serious disadvantages of the technique include the occasional inflammatory processes of soft tissues at puncture sites. This may be a consequence:

• failure to comply with hygiene rules while wearing the device;
• harmful bacteria entering the wound during surgery;
• receiving a burn while drilling a bone that needs fusion.

In this case, a course of antibiotics will be required. To avoid such a complication, it is recommended to cool the needles during the operation and use a low-speed drill. It is advisable to use a special sterile cover with elastic bands at the ends, which is placed over the device and protects the needles from infection (dust, dirt).

Patient care requirements

When installing the Ilizarov apparatus, constant monitoring of the patient’s condition and regular examination are required.

While wearing the device, an infectious process may develop . Therefore, it is necessary to disinfect its surfaces and maintain aseptic conditions. Disinfection of the knitting needles is carried out using an alcohol solution. It is necessary to wipe them not only along their entire length, but also to treat the skin in places of contact with them. To prevent bacterial contamination from above, the device is covered with a bandage that is tightly secured.

It should also be borne in mind that the process of bone change can be quite painful, so it is necessary to support the patient’s treatment with antibiotics, anti-inflammatory and painkillers.

During fixation, the hand swells and turns red in the first days; at this time, an increase in local temperature may also be observed.