FAQ – Kirienko

How is the Ilizarov fixation device removed?

Removal of the apparatus can be carried out progressively (so as to favour reinforcement and maturity of the bone callus) in outpatient clinic under local anaesthesia.

What recommendations must be followed after removal of the device?

Maximum care must be taken during this delicate phase of treatment. The lengthened bone or limb recently healed of the fracture or pseudoarthrosis is still week and fragile for the first month or two after removal of the metallic structure.

For treatment of the lower limbs, initially crutch-assisted weight-bearing with a maximum weight of 7-9 kg is permitted; such load may be progressively increased, adding 1-2 additional kgs daily. Subsequently, total weight-bearing may be attempted after one month when the second radiographic follow-up examination after removal of the device is carried out.

In the case of upper limbs, the treated limb must be kept at rest; all physical activity must be avoided, as must accidental falls, or strong muscular contractions.

Brumel fu sottoposto al trattamento con la metodica di Ilizarov, riportò la guarigione dell’osteomielite e il ripristino della simmetria degli arti.

Physio-kinesiotherapy

Physio-kinesiotherapy may be initiated after complete healing of the bone, which normally takes place 1-2 months after removal of the Ilizarov fixation device.

Functional normality occurs progressively, in keeping with the time required for limb oedema to subside and improvement of joint motility to occur, the latter of which is diminished during the period of treatment with the Ilizarov device.

After some months, a growing range of joint movement is observed, comparable to that present prior to treatment.

Post-operative care

Approximately 7-10 days after hospital discharge, the first out-patient examination is performed and the wound is medicated. Thereafter, follow-up examinations are carried out every two weeks, while radiographic control is carried out monthly.

In cases of lengthening and correction of deformities, radiographic follow-up must be performed every two weeks. Such rigorous clinical and radiographic monitoring helps to prevent complications and gives a more accurate forecast of healing time.

What is the duration of treatment prior to removing the Ilizarov fixation device?

Treatment duration varies in relation to the gravity of the disorder to be treated and the subjective response of the patient but, on average, takes approximately 4-6 months.

Care of Ilizarov’s external fixation device

The limb carrying this fixation device must not be allowed to get wet as this would pose the risk of superficial infection of the soft tissues around the wires. Therefore, the patient may not take a bath or shower without first accurately protecting the limb with a waterproof covering. Hygiene of the affected limb can be carried out using a damp sponge with a little soap. As for the device itself, the wires can be kept clean with cotton wool imbued with alcohol solution.

Special clothing and footwear are recommended. Helpful suggestions and details regarding the former shall be enclosed.

For lower limb treatment, crutches shall be required and should be prescribed by the Physiotherapist in charge of the case.

Two 10mm spanners shall be required for periodic adjustment of the device. In addition, a bottle of red nail polish for plotting the movement of the bolts to be tightened at the prescribed times.

For lengthening procedures, the fixation device shall be subjected to progressive action by utilizing the wrenches through loosening and subsequent tightening of the nuts according to detailed instructions pertaining to the case in hand, during pre-established intervals 4-6 times a day.

Such a phase may continue over a long period of time and could cause pain due to stretching of the skin and muscles. In any case, such pain can be controlled with appropriate pharmaceutical intervention

Potential complications

Potential Complications

Infection of the soft tissues around the tramites of the trans-osseous wires that manifests as local pain at the site of insertion, redness, swelling, increase in local temperature and fever;
Abundant serous secretion and consequent soaking of the gauze dressing;
Breakage of the trans-osseous wires accompanied by the sensation of internal rupture of a guitar string, onset of pain of variable intensity;
Loss of mechanical stability of the various junctions between the metal parts due to loosening of the bolts of the fixation device;
Itching;
Disturbed limb sensation;
Perception of squeaking noise around the wires bought on by movement;

In the event of any of the above-mentioned complications, reference should be made to Dr. Kirienko for information and advice on the correct line of action to adopt.

What are the treatment indications?

What are the Treatment Indications?

An example of use of the Ilizarov external fixation device is for the treatment of serious cases of infection (osteomyletis), a common phenomenon after serious trauma to the limbs, for which no other form of treatment guarantees sure healing with complete anatomical and functional restoration.

Such a technique may also be used successfully for congenital (present from birth) malformations or shortening of the limbs, and in cases of dwarfism or short stature.

In post-traumatic bone loss, is a bone graft carried out or is application of the fixation device sufficient?

In cases of diaphyseal bone loss, the device is applied and the bone stumps are guided into contact with one another, then a surgical fracture is performed (osteotomy) in the “healthy” part of the bone. Function is permitted. The subsequent phase would be to apply distraction force until the necessary length has been achieved. This process must be slow and gentle for best results a too forceful or rapid distraction tension causes pain and will arrest the regenerative process.

By application of the Ilizarov device, is it possible to correct mal-consolidation without resorting to osteotomy?

In cases of mal-consolidation due to deviation of the mechanical axis of diaphyseal fractures, or fractures adjacent to the joints, application of an expertly-applied fixation device and precisely and progressively-dosed distraction and compression forces can correct the axial defect without surgical intervention.

Can post-traumatic joint rigidity be resolved by use of the fixation device?

With the Ilizarov technique, excellent lengthening is achieved of the capsular-ligamentous and muscular structures, not only in cases of acquired rigidity but also in cases of congenital rigidity since the aforesaid structures, when subjected to traction and gradually guided to correct function will regenerate.

Timing is an essential factor. If one thinks about the training necessary for a ballerina to perform the splits, well, a rigid joint must be similarly trained.

With regard to the consequences of congenital deformities in the adult such as club foot, equine foot, or congenital cavo-varus foot. Is morphological and functional reintegration possible?

The Ilizarov apparatus, made up of 25 components, poses various assembly options, like a child’s erector set.

Assembly of the apparatus for a case of club foot in the adult is fashioned in such a way that the combined action of distraction and compression forces that are appropriately directed to the diseased part, will correct the deformities of each individual bone in order to achieve normal morphology over time.

What is the treatment technique for non-consolidated fractures (atrophic and hypertropic pseudoarthrosis)?

The principle constituting the basis for the process of tissue regeneration is applied, eliminating the possibility of abnormal movement by means of stabilization.

Therefore, by directing a load onto its axis, function favours nutrition of the bone. Fibro-chondroid tissue is replaced by regenerated tissue that is rich in vessels. Fusion and, if necessary, lengthening is achieved. Congenital pseudoarthrosis is treated in the same manner.

What does healing of bone infection (Osteomyelitis) mean?

By healing, one means the definitive resolution of the infected nidus. Surgical cleaning of the infected nidus is performed as well as lengthening of the farthermost part from the infection site, without bone grafting.

Everyone is familiar with the Brumel case (record man of the High Jump) who sustained a leg fracture which developed osteomyelitis. Brumel underwent numerous sequestrectomy operations that led to significant shortening of the limb.

Brumel then underwent treatment with the Ilizarov method; his osteomyelitis was healed and he obtained restoration of limb symmetry.

What is an Ilizarov external fixation device?

The Ilizarov external fixation device was created and perfected in Russia by Professor Gavril Abramovich Ilizarov during the period between 1951 and 1992. The Ilizarov method consists in applying a cylindrical structure to the pathological limb constituted by steel bows to which the extremities of wires or screws are connected, the latter of which are then inserted into the bone.

How is the Ilizarov external fixation device used?

The Ilizarov external fixation device is used for stabilizing bone fragments, hence determining consolidation of the traumatic lesions (or results of fractures or pathological malformations). It may be necessary, depending on the type of pathology present, to act on the structure of the device in order to modify the altered spatial orientation of the bony segments.

For example, if the case in hand involves an arm or a leg with deformities and therefore with angulation and translation ad latus of the bony stumps, it is possible to correct their position in both cases by utilizing a simple spanner, slowly and progressively during the course of days so that the two bone stumps can be realigned.

In some cases of trauma, there is a resulting shortening of the limb due to loss of bone substance. With the Ilizarov fixation device, it is possible to achieve lengthening after having performed an osteotomy (surgical resection of bone), which gives rise to the formation of a coagulation that can be lengthened. Given time this coagulation acts as a bone regenerator (precursor of bone substance) and finally transforms into normal bone, promoting healing.

How is the limb lengthening process carried out in the child and in the adult?

Lengthening of a limb in a child or an adult is based on the same theoretical principles: that the interrupted bone is subjected to measured force in terms of intensity and direction. Once absolute stability of the bone segments has been obtained, a regenerative process is established, not only of the bone tissue, but also the soft parts (blood vessels, nerves, tendons, muscles), vascular integrity is maintained, allowing complete functionality.

Stability is obtained by means of application of trans-osseous wires and external bows that are connected to each other by rods; function is established, for example of the lower limb, simply by ambulation. The Ilizarov technique completely respects vascular integrity.

The surgically-interrupted bone segment (Osteotomy) is subjected to continuous distraction force of approximately 1mm per day. Active mobilization and ambulation is prescribed. The gradually increasing distance between the epiphysis and the metaphysis is where bone tissue is formed, known as â€œregenerated bone.

Maximum lengthening achieved by means of this method was 52cm.
Both in the child and the adult, it is advisable to execute interruption of the bone segment in a highly vascularised area such as the metaphysis.

How is Ilizarov’s external fixation device applied?

In order to apply Ilizarov’s external fixation device, with the patient under anaesthesia, steel wires are introduced into the pathologic limb, which are then fixed in tension by circular structures made of steel.

These steel rings are then externally connected by threaded rods, hence forming a sustaining cylindrical framework around the limb.

In fact, the former basically constitutes the essence of treatment and can be likened to an “open plaster”, allowing access and monitoring of the skin and/or eventual existing lesions. The structure moreover allows correction, when necessary, of axial defects, but offers, at the same time, stability and support and the feasibility of crutch-assisted weight-bearing, hence movement.

How long is the stay in hospital?

Depending on individual cases, the hospital stay may vary from 3 to 7 days.

This period includes pre-operative preparations, the surgical procedure under general anaesthesia or an epidural, followed by the post-operative hospital stay.

Constant observation and monitoring are guaranteed during hospitalisation by the department’s team of specialists.

What needs to be done before the procedure?

The following tests need to be carried out: blood tests; diagnostic instrument and imaging tests; specialist examinations and finally, an anaesthesia evaluation.

The examinations and tests required for the procedure can be carried out at the Day Hospital a few days before being admitted and usually take one day.