İlizarov Surgery and Applications in Traumatology

Dr.Mehmet KOCAOGLU

Use of external fixator for the fractures was first performed by Malgaigne in 1853 ^3,7 (Figure-18.1).

Figure-18.1: Malgaigne’s Treatment method for fractures.

If we look at ancient books, it is seen that the same materials for osteosyntesis are also used for fractures with soft tissue defect. Need for the treatment of gunfire injuries at battle site in the Second World War helped the development of external fixators. Hoffmann from Switzerland, and Mc Kibbin and Anderson from U.S.A described both design and tecniques. American Academy of Trauma Surgery accepted external fixation as a part of trauma surgery and also emphasized that this technique needs a special training and a surgeon that treats at least 200 cases can have enough experience ^1,7.
Ilizarov, a Russian orthopaedic surgeon, described his technique in Italy at the AO meeting in 1981 for the first time to western countries. Surgeons from western countries distrusted at the beginning. The technique and external fixators that were used since 1950 were different than they were used to until that time.²⁰. With these technique, not only the fixation of the fragment but also controlled motion and gliding of fragments was possible, which provided anatomic reposition. İlizarov described many techniques for the operations, and creativity of the surgeon became an important part of treatment. Therefore, many national and international educational meetings are organised to improve Ilizarov surgical technique ²⁰ .
This technique has many advantages such as; minimal trauma, no need to open the fracture site, optimal biomechanical stability (eliminates rotational and binding forces, allows pure compressive forces), posibility to reconstruct large bone defects, correction of deformities, providing early joint motion, keeping the blood supply of the bone, and minimal blood loss during the operation. It also has some disadvantages like the need for a long learning curve, the effect of surgeon creativity on the treatment result, the risk of pin tract infection, more than one outpatient clinic control, unsuitability for inharmonious patient. ^{3,5,6,7,9,10,15,17,20}.
Ilizarov’s ideas and technique changed the treatment indication in modern travmatology ^3,7,9,15,20 Indication of Ilizarov’s technique are: (for more information you can examine section 3)
· Pilon tibia and tibial plateau fractures with intraarticular extension (especially with open fractures and/or soft tissue injury)
· Fractures with serious burns
· Intraarticular fractures that need arthrodesis
· Infected cases
· Periarticular fractures that extend to diaphysis
· Unstabile diaphysial factures
· Fractures with major bone defect
· Serious pediatric injuries

18.1-TİBİAL FRACTURES
Ilizarov emphasizes that tibial fractures heal 25% faster than conventional methods and have 94-100% consolidation rate. According to Ilizarov, in bone healing:
1. Stability
2. Keeping the blood supply of bone
3. Keeping extremity function are very important^3,10,15,17 .
When Ilizarov classified the tibial fractures, he emphasized the injury to the intramedullary blood supply of the bone more than the configuration of the fracture (Figure-18.2). According to that, in first degree fracture displacement is minimal and consolidation takes 40-50 days. In 2. degree transverse fractures there is 50% displacement and consolidation takes 50-60 days; in 3. degree fractures there is 50-75% displacement, the intrameullary blood supply is damaged and consolidation takes 60-80 days. On the other hand if there is 100% displacement in fractures, the nutritional artery is damaged and the consolidation can take longer than 90days ^15,17.


Figure-18.2: İlizarov’s tibial fracture classification.

In original Russian technique, Ilizarov frame is reconstructed during the operation ¹⁵. However, several experienced surgeons from Italy and U.S.A. prefer to build the frame preoperatively in order not to lose time^3,8,10. The size of the ring should be determined by using X-rays and the non injuried extremity. There should be at least two-finger width between extremity and the frame ^3,8 . If the fracture line is not on the proximal third of the tibia, a 5/8 ring should be preferred in order to keep the knee motion. If carbon rings are used, the frame should be constructed with a circular ring preoperatively and at the end of operation the posterior part of the proximal ring should be cut with gigli saw. (Figure-18.3-4). Ilizarov classified tibial fractures according to the anatomical localization and the shape of the fracture line, thereby he also described the place of rings (Figure-18.5,18.12).

Figure-18.3: keeping free the posterior part of the knee is important for the knee flexion for Ilizarov external fixator applied patients.

Figure-18.4: Lateral view of knee of patient in figure -18.3

Figure-18.5: Ilizarov’s tibia fracture classification according to anatomic localization and fracture line.


Figure-18.6: fixation with K wire in a case that doesn’t need reposition.

Figure-18.7:Application of olive K wires in A2 Tibial fracture with oblique fracture line. Olive K wires provide not only reposition but also increase the rate of consolidation by doing interfragmanter compression

Figure-18.8:Schematic design of reposition with olive K wire.

Suggested application order:
· Before starting the operation anestesiologist has to be warned about avoiding muscle relaxant like curare so that the surgeon can know if there is a false placement of K wire, as it can pass through a nerve which is indicated by contraction of the muscle. In which case the wire will be pulled out and replaced.
· K wire should be paralled to the tibial plateau proximally and joint line distally.^3,10(Figure-18.6).
· While fixing the proximal K wire to the ring, attention should be given so that tibial anatomic axis is perpendicular to ring and parallel to the rods^3,23 (Figure-18.6).
· While distal second K wire is fixed to the ring, fluroscopy in lateral plane is done to see that tibial sagittal plane and rods are parallel to each other.
· Anteroposterior fluroscopy is done to centralize the bone in the frame, thereby preventing the pressure of the rings on the soft tissue.

·An olived k wire is used to fix the rings to the bone if reduction is needed. Otherwise, plain K wires are used (Figure-18.6-8).
· Interfragmantairy compression can be achieved using olived K wires in case of A2, B2, C2 oblique fractures according to İlizarov classification ^{5,10,15,17,23} (figure-18.7).
· In original Russian technique osteosynthesis is done with K wires only, but in the Italian modification, K wires and Schanz screw combinations can be used. (Figure-18.9-11).

Figure-18.9: Schanz screw and K wire hybrid application.

Figure-18.10:Different hybrid applicationtechniques.

Figure-18.11:Clinical example for Schanz screw application.

· Proximally the fibular head and distally the lateral malleolus should be fixed with olived K wire.

During the distal K wire tensioning, an assistant should hold the ankle joint in maximum dorsiflexion.¹⁷
· Before ending the operation AP and lateral X-Ray (ankle and knee joint should be seen) should be taken and the alignment should be confirmed.
· After the dressing of pins (Figure-18.13-14), posterior part of the leg (where there is larger muclce bulk) should be supported with compresive dressing in order to avoid edema.

Figure-18.12: Ring application according to tibial fracture line.

Application of ring for fractures in tibia, as seen above^5,10.

Figure-18.13:After the dressing of pin, placement of pads.


Figure-18.14: View of plantar area in the same case.

Application of bifocal compression- distraction osteogenesis technique is needed to speed up the consolidation in tibial fractures with bone defect^15,17,24 (Figure-18.15-21).


Figure-18.15: Bifocal compression-distraction technique.

· If the defect is more than 4-5 cm, gradual shortening should be preferred instead of acute compression (Figure-18.16-17), as acute shortening more than 5 cm cause arterial torsion that results in circulatory problems of the limb^,15,20,24 .

figure-18.16: A case of tibial fracture with defect .

figure-18.17: Preoperative lateral radiograph of the same case.

figure-18.18: Radiograph of consolidation that is achieved by using compression –distraction technique in which shortening is treated with proximal lengthening.


figure-18.19:Clinical image with external fixator on.

figure-18.20:Image after the removal of the external fixator.


figure -18.21 Function after removal of fixator

figure -18.22: Application of brace keeping the ankle in neutral position.

· Brace keeping the ankle in neutral position should be added in postoperative period. (figure -18.22).

18.1.1-Tibial Plateau Fractures :
According to literature there is no definitive treatment method for the tibial intraarticular plateau fractures ( Schatzker Tip IV ve V ; Hohl Tip V ) ^3,17,22, as these kind of fractures are usually due to high energy trauma, with large soft tissue defects and loss of joint integrity. Using implants with open reduction and internal fixation may cause deep soft tissue infections in these fractures . ^19,20.
· If a large soft tissue area is involved in injury with /without a defect, debridement, mechanichal irrigation and a knee spanning external fixator application should be done as an emergency ²⁰(figure-18.23).
· If at that point there is dead space antibiotic impregnated cement should be used as a spacer.
· 3-7 days later the defect can be closed with flaps and restoration of articular surface with osteosynthesis should be performed.

Figure-18.23: Unilateral external fixator combined with a circular one for tibia plateau fractures with soft tisue defect.
· positioning of wires should be planned with preoperative CT views ²² .

Figure -18.24: Olived K-wires and screw fixation.

· Aa a definitive mean of osteosynthesis, classical Ilizarov type external fixator as well as hybrid systems that allow fixation of the diaphysis with Schanz screws and articular surface with multiple K wires, can be used. We prefer classical Ilizarov type external fixator in our department. ³ (figure-18.24-27).
· In order to take advantage of ligamentotaxis you should add a temporary femoral ring to the external fixator for the reduction of articular surface; 2 K wires can be used for the fixation of femur and also tibia at the ankle joint^15,17 .
· If anatomic reduction is achieved after the distraction, osteosynthesis can be achieved with the help of olived k wires (figure-18.28 A ve B).


Figure-18.28 A: figure-18.28 B:

· Some authors suggest placing the K wires at least 15 mm away from the joint in order to prevent septic arthritis as a complication¹⁶.

In our clinical practice, we have not encountered septic arthritis as a complication although we placed K wires closer than 15 mm to the joint line in 22 cases.

Figure-18.24: preoperative AP radiograph of a case with tibial plateau fracture.


Figurel-18.25: preoperative lateral radiograph of the case.

figure-18.26: Radiograph of the case in figure-18.24 and 25 after the application of Ilizarov type external fixator.


Figure-18.27 A: AP radiograph after the removal of external fixator.


figure-18.27 B: lateral radiograph after the removal of external fixator.

· If reduction of the joint is not achieved, a Weber clamp and elevator should be used. If there is bone defect after the elevation of plateau, bone grafting should be applied to the defect area. ^17,19(figure-18.29).


Figure-18.29: Schematic diagram showing the use of Weber clamp and elevator for the restoration of joint surface.

· Postoperatively ROM exercises should be started and weight bearing should be started at 6 weeks. Then weight bearing can be increased gradually ^3,17.

18.1.2-Pilon fractures of tibia :
· Intraarticular fractures of distal tibia metaphysis are generally high energy/impaction fractures that cause cancellous bone loss (AO type C) (figure-18.30). They make up 5-10% of all tibia fractures and have an indication for treatment with Ilizarov ‘s method ^{2,10,15,16,17,25}. Soft tissue necrosis, infection, and nonunion are common complications of these fractures if treated with conventional methods. ²⁵.
· Before the operation articular surface should be examined with CT scan and the way that K wire will pass throught should be planned. (figure-18.31).
· The success of the Ilizarov method depends on ligamentotaxis and indirect reduction. ^1,25 (Figure-18.32).


Figure-18.30: A case of tibial pilon fracture with cancellous bone loss.


Figure-18.31: K wire pathway determination with CT scan .

· If reduction is not achieved after the placement of K wires and ligamentotaxis open reduction should be done with a small incision and if necessary augmentation of osteosynthesis can be done with screws ^2,3,25 .


Figure-18.32: Osteosynthesis with K wires as seen on CT scan.


Figure-18.33: Augmentation with screws when restoration of intraarticular surface is inadequate.


Figure-18.34: Dynamic examination with fluoroscope.

· Following osteosynthesis, if instability is seen on dynamic examination especially in the sagittal plane (or fragment is smaller than 2 cm) talus and calcaneus are fixed with K wires to the ring, thereby providing stability. (Figure-18.34-35).


Figure-18.35: Placing additional the K wires through the calcaneus.

·If ankle joint is also taken into the frame, non weight bearing ankle motion is allowed after 6 weeks of distraction.
· 8-10 weeks after the operation, partial weight bearing is allowed and at 12-16. week patient should be able to give full weight with a crutch ^3,25.

18.2-Femoral fractures
Especially unilateral external fixators used for unstable femur fractures cause loss of reduction (varus position) when weight bearing is started, as load transfer is from the medial side but unilateral external fixator is applied on the lateral side and is not able to provide enough strength. ^5,6,12,13,15 (Figure-18.36-38).


Figure-18.36 figure-18.37
Schematic diagram comparing the medial support in circulair and unilateral external fixator.

Ilizarov method is indicated especially in open fractures and bone defects. Catagni et all classified these fractures in four types according to localization. ^6,17.

Figure-18.38: Providing medial support with L connection plate in Ilizarov type external fixator.

18.2.1. Proximal femoral fractures: (Figure-18.39)
· Frame is composed of 2 90 degree pelvic rings or with one 90 degree and one 120 degree pelvic ring ⁶ (Figure-18.40).

Figure-18.39: Schematic diagram of the ring for proximal femoral fracture

· Medial support should be provided. ^5,6,15,17 (figure-18.38).
· Proximal pelvic ring should be placed on the level of the lesser trochanter and a ring should be placed at an average of 3 cm away from the fracture line. (Figure-18.40).
· Distal femoral ring is at the level of the femoral condyle (Figure-18.40).
· The reference K wire should be applied from the lateral to the medial side on the femoral condyle perpendicular to the anatomic axis (Figure-18.40).
· After the control of the rotation a Shanz screw should be applied from the posterolateral to anteromedial on the greater trochanteric line ⁶ (Figure-18.40).

Figure-18.40: Circular ring application for proximal femoral fractures.
· Device should be centralized to the thigh according to soft tissue.
· In the original Russian technique proximal fragment is fixed with multiple K wires ^10,15,17 (Figure-18.41). But our clinical experience show that fixation with multiple K wires cause varus posture in time because of the abductor muscle force (despite prophylactic 20 degree valgus position at the beginning), so Schanz screws are placed.

Figure-18.41: Use of multiple K wires in original Russian technique.
· Two Shanz screws are fixed to the proximal pelvic ring.

·It is important to place the Shanz screw in posterolateral and anteromedial direction for knee range of motion

· K wires placed to distal ring can hinder knee range of motion. To prevent this, we use two Shanz screws from posteromedial and posterolateral sides ⁶ .
· Patient can walk with full weight bearing starting from the first dat postoperatively. Knee and hip joint exercises should start immediately.

·For consolidation of the bone, 2x0.25 mm/day compression should be applied.

18.2.2-diaphyseal femur fractures:
· First circle should be placed 5-6 mm away from the fracture line ^6,10,17 (Figure-18.42).

Figure-18.42: Frame placement for femoral diaphyseal fractures

· The frame which is closer to the knee can be smaller than the others not to disturb the patient
· Application technique and postoperative care is explained in the previous section.

18.2.3-Distal femoral fractures:
· Although it depends on the length of the distal segment, it should consist of 2 rings (Figure-18.43).
· Proximal part should consist of 2 rings. One at the subtrochanteric region and one 5-6 cm proximal to the fracture line. ^6,10,17,18 .
· If distal fragment is short for 2 level fixation; after the fixation of the femur, knee is spanned with an initial ring on the proximal tibia connected with hings centered at the center of rotation of the knee to allow for range of motion.

Figure-18.43: Construction of frame for distal femoral fractures

Figure -18.44: Femur bipolar fracture after gun shot injury

Figure -18.45: preoperative clinical image of the same patient

Figure -18.46: postoperative clinical image of the same patient

Figure-18.47: lateral image of the same patient after the operation

Figure -18.48: Clinical image of the same patient after removal of the external fixator

Figure-18.49: Functional lateral image of the same patient after removal of external fixator

18.2.4-Femoral fractures with bone loss:
· The aim of the treatment is to restore the integrity of the femur and maintain the normal axis.

· Strategy for these kind of fractures is; fixation of the fragment with 2 circular rings as proximal and distal block and fixation of the transport segment with one circular ring ^6,17 (Figure -18.50).

Figure -18.50: Application of the frame for the femoral fractures with bone loss
· Subtrochanteric osteotomy is performed for segment transport^7-10 (Figure -18.51).

· In cases where bone defect is more than 4 cm, in order to shorten the treatment time the target zone is compressed 3-4 mm /day

· If there is no sign of infection at the docking site, bone grafting can be done⁶ .

Figure -18.51 Restoration of bone loss with segment transport

18.2.5-Femoral intercondylar fractures:
These are generally high energy trauma associated with open fracture and soft tissue problems ^14,16 .
· As in tibial plateau fractures, temporary knee spanning external fixator should be applied as soon as possible

· Before the definitive osteosynthesis, CT scan should be done to examine the articular surface.

· Vessel injuries are common in these kind of fractures ,therefore angiographic evaluation should be done.
· Especially for the fracture C2-3 according to AO/ASIF classification ligamentotaxis is not enough. Open reduction with lateral incision and temporaray fixation with multiple k wires should be done. Then with cannulated screws the number of fragments should be decreased to two ^6,14,16 (Figure-18.52).

Figure-18.52: Decrease the number of fragments with help of cannulated screws
· Popliteal fossa is supported on a roll, keeping the knee in 30-40º flexion ^8,14.
· Rotation is corrected with patella anteriorly.
· Distal fragment fixation should be done first with multiple olived K wires (figure-18.53).

Figure -18.53:Distal fixation with olived K wires

· On the sagittal plane, recurvatum is corrected with an anterior Shanz screw applied to the proximal fragment. (Figure-18.54).

Figure -18.54: correction of the recurvatum with anterior Shanz screws.
· as it is not possible to apply the fixator along the mechanical axis, the 5-7 degrees of difference between anatomic and mechanichal axis should be kept in mind. ¹⁴ (Figure-18.55).

Figure -18.55: attention to 5-7 degrees of differance between anatomic and mechanichal axis .
·After reduction, the external fixator is fixed to the proximal fragment with Shanz screws for osteosynthesis. ^14,16 (Figure-18.56).
· Active physical therapy should start immediately in postoperative period. (Figure-18.57). In order to avoid instability, the knee range of motion of the should not exceed 0- 90 degrees for the first 6 weeks postoperatively. In our experience, if the patients have 0-90 degrees motion during external fixator period, they achieve full range of motion afterwards.

Figure-18.56: Fixation of proximal fragment with shanz srews after reduction

· After the radiological callus formation, (generally 6 weeks) progressive weight bearing should start.
· The most common complication after the intraarticular distal femoral fractures is knee joint stiffness. Most of the patients improve the range of motion from 0-45 to 0- 90 degrees with physical therapy after removal of the external fixator. But in resistant cases, operation like quadricepsplasty may be required.
· Surgeon must be alert about septic arthritis due to pin tract infection as it is an intraarticular fracture. Proper antibiotics should be given according to the aspiration and culture antibiograms.

18.3-Humerus fractures
Osteosynthesis with transosseous method in upper extremity has some characteristic issues due to close anatomic relations. ¹¹
· Patient should be placed in supine position and scapula should be elevated with a pillow.
· In that position, shoulder and elbow motion should be checked to see if 80 degrees of shoulder abduction with 90 degrees of elbow flexion is possible.
· Hand should not be covered, to see excitation of the neural structures during K wire application.

Figure-18.57: Using the CPM to keep the knee range of motion.

Figure-18.58: fixation of proximal humerus fractures with K wires as per original Russian technique
· In original Russian technique for the proximal fractures osteosynthesis should be done with K wires, omega ring should be used ^10,15,17 (Figure-18.58).
· Accoding to the Lecco clinic in Italy, osteosynthesis with small Shanz screws and small pelvic ring is enough. The second technique was developed after the diffuculties seen in the first technique ¹⁷ (Figure-18.59).
· On the 1/3 diaphyseal fracture, for osteosynthesis both Russian and Italians suggest K wires. But in our clinic we also use Shanz screws.

Figure-18.59: Technique developed by Italian Lecco clinic; osteosynthesis of proximal humerus fractures with Shanz screws.

In this way, we avoid the neurovascular structures . We also cut the medial side of the ring to provide comfort while patient is in neutral position.

· For the fixation of distal humerus, K wires can be used. Kenan clinic (USA) emphises that most stable fixation of distal humerus is with 2 cross Shanz screws from medial and lateral condyles (figure-18.60). But in our clinic to avoid ulnar nerve palsy, we explore the ulnar nerve through an incision and then perform the osteosynthesis.

Figure-18.60: Fixation of distal humerus with two cross Schanz screws

·If carbon ring is used at the elbow joint level, at the end of operation carbon ring is cut to provide the elbow joint motion. If metalic ring is used 5/8 rings are preferred.
· Interfragmantary compression must be done with olived K wires.
· For the tuberculum majus fractures, compression ability of olived K wires can be used. (Figure-18.62).

Figure-18.61: Correction and prevention of translation with olived K wires.

Figure-18.62: Compression on isolated tuberculum majus fractures with olived K wires

· To benefit from reduction with distraction for the proximal humeral intraarticular fractures, first K wire should be applied to acromion (Figure-18.63).

Figure-18.63: Application of K wire to acromion for the reduction of proximal humeral intraarticular fracture using distraction

· For the distal humeral intraarticular fractures, fixation with multiple K wires and rings must be performed after open reduction through lateral and medial mini incisions ¹¹ (Figure-18.64).

Figure-18.64: Reduction with olived K wires in distal humeral intraarticular fractures.

18.4-Forearm fractures

· Due to different anatomic structures, it is the most diffucult area for transosseous osteosynthesis ^10,17 .
· Surgeon should perform this technique in the forearm after at least 200 cases in other areas ¹ .
· During the insertion of K wires, muscles at that region must be kept at maximum length by an assistant ^10,17.
· Due to high number of complications such as nerovascular damage and muscle contractures, western orthopedists have developed Shanz screw application to proximal ulna. (Figure-18.65).

Figure-18.65: Shanz screw application in the forearm .

· Patient should be in supine position with forearm in radiolucent table and elbow in 90 degrees of flexion.

· If just one of the forearm bones is broken, only that bone should be fixed.
· Fixation with K wires before the rotational correction is the most common mistake done by the surgeons .

· Skeletal traction from the metacarps and olecranon will help reduction and fixator application ^1,4,17.
· For the two bone fractures proximal and distal radio-ulnar joints should be fixed at neutral position with transfixation wires. ²¹ (Figure-18.66).

figure-18.66:
· For Montegia fracture dislocation, first of all osteosynthesis of ulna should be done and reduction of radial head should be done. Then, radial head can be fixed with an olived K wire. 1 mm compression every week will improve bone healing²¹. (Figure-18.67).
·Elevation of the limb after the operation will help to prevent the edema. Physical therapy such as active joint exercises and finger stretching should start early.

Figure-18.67: Application of frame for the Monteggia type fracture dislocation cases

· After the second week as the pain decreases, weight bearing exercices should be started and normal daily use of the extremity should be the aimed ⁴ .
· After the removal of the external fixator, restoring pronation and supination should be the primary aim of physical therapy ⁴.
·Radiological consolidation on forearm occurs later than clinical healing. Therefore, when the pain diasappears, we loosen the rods and check for any movement at the fracture site. If there is no movement, we can remove the external fixator ^1,4 .

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