Svetlana Ilizarov

Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method.

Objectives To evaluate the potential for limb salvage using the Ilizarov method to simultaneously treat bone and soft-tissue defects of the leg without flap coverage. Design Retrospective study. Setting Level I trauma centers at 4 academic university medical centers. Patients/Participants Twenty-five patients with bone and soft-tissue defects associated with tibial fractures and nonunions. The average soft-tissue and bone defect after debridement was 10.1 (range, 2–25) cm and 6 (range, 2–14) cm respectively. Patients were not candidates for flap coverage and the treatment was a preamputation limb salvage undertaking in all cases. Intervention Ilizarov and Taylor Spatial Frames used to gradually close the bone and soft-tissue defects simultaneously by using monofocal shortening or bifocal or trifocal bone transport. Main Outcome Measurements Bone union, soft-tissue closure, resolution or prevention of infection, restoration of leg length equality, alignment, limb salvage. Results The average time of compression and distraction was 19.7 (range, 5–70) weeks, and time to soft-tissue closure was 14.7 (range, 3–41) weeks. Bony union occurred in 24 patients (96%). The average time in the frame was 43.2 (range, 10–82) weeks. Lengthening at another site was performed in 15 patients. The average amount of bone lengthening was 5.6 (range, 2–11) cm. Final leg length discrepancy (LLD) averaged 1.2 (range, 0–5) cm. Use of the trifocal approach resulted in less time in the frame for treatment of large bone and soft-tissue defects. There were no recurrences of osteomyelitis at the nonunion site. All wounds were closed. There were no amputations. All limbs were salvaged. Conclusions The Ilizarov method can be successfully used to reconstruct the leg with tibial bone loss and an accompanying soft-tissue defect. This limb salvage method can be used in patients who are not believed to be candidates for flap coverage. One also may consider using this technique to avoid the need for a flap. Gradual closure of the defect is accomplished resulting in bony union and soft-tissue closure. Lengthening can be performed at another site. A trifocal approach should be considered for large defects (>6 cm). Advances in technique and frame design should help prevent residual deformity.

Repair of tibial nonunions and bone defects with the Taylor Spatial Frame.

Objective: To investigate the outcomes of tibial nonunions and bone defects treated with the Taylor Spatial Frame (TSF) using the Ilizarov method. Design: Retrospective. Setting: Limb Lengthening and Deformity Service at an academic medical center. Patients: Thirty-eight consecutive patients with 38 tibial nonunions were treated with the TSF. There were 23 patients with bone defects (average 5.9 cm) and 22 patients with leg-length discrepancy (LLD) (average 3.1 cm) resulting in an average longitudinal deficiency (sum of bone defect and LLD) of 6.5 cm in 31 patients (1-16). The average number of previous surgeries was 4 (0-20). At the time of surgery, 19 (50%) nonunions were diagnosed as infected. Intervention: All patients underwent repair of the nonunion and application of a TSF. Patients with bone loss were additionally treated with lengthening. Infected nonunions were treated with 6 weeks of culture-specific antibiotics. Main Outcome Measurements: Bony union, time in frame, eradication of infection, leg-length discrepancy, deformity, Short Form-36 (SF-36) scores, American Academy of Orthopaedic Surgeons (AAOS) lower-limb scores, and Association for the Study of the Method of Ilizarov (ASAMI) bone and functional results. Results: Bony union was achieved after the initial treatment in 27 (71%) patients. The presence of bone infection correlated with initial failure and persistent nonunion (P = 0.03). The 11 persistent nonunions were re-treated with TSF reapplication in 4, intramedullary rodding in 3, plate fixation in 2, and amputation in 2 patients. This resulted in final bony union in 36 (95%) patients. The average LLD was 1.8 cm (0-6.8) (SD 2). Alignment with deformity less than 5° was achieved in 32 patients and alignment between 6° and 10° was achieved in 4 patients. Significant improvement of Short Form-36 (SF-36) scores was noted in physical role (P = 0.03) and physical function (P = 0.001). AAOS lower-limb module scores significantly improved from 56 to 82 (P < 0.001). ASAMI bone and functional outcomes were excellent or good in 36 and 34 patients, respectively. The number of previous surgeries correlated inversely with the ASAMI bone (P = 0.003) and functional (P = 0.001) scores. Conclusions: One can comprehensively approach tibial nonunions with the TSF. This is particularly useful in the setting of stiff hypertrophic nonunion, infection, bone loss, LLD, and poor soft-tissue envelope. Infected nonunions have a higher risk of failure than noninfected cases. Treatment after fewer failed surgeries will lead to a better outcome. Internal fixation can be used to salvage initial failures.

Correction of tibial deformity with use of the Ilizarov-Taylor spatial frame.

The Ilizarov-Taylor Spatial Frame (TSF; Smith and Nephew, Memphis, Tennessee) is a powerful tool for correcting tibial deformity1-6. A specialized feature of the TSF is its virtual hinge, which allows for the simultaneous gradual correction of multiplanar deformities and limb-lengthening through one osteotomy site. The power of the spatial frame lies in its precise control over the final limb length and alignment and in its ability to correct a residual deformity. The stability of this multiplanar circular fixator permits early weight-bearing and provides an ideal environment for both new-bone formation and soft-tissue healing. The classic principles of the Ilizarov method are followed to ensure proper frame application. The TSF web-based software is user-friendly and has greatly simplified the planning of the correction of an oblique plane deformity by utilizing standard anterior-posterior and lateral radiographic measurements. Computer-generated schedules and easy-to-read struts have greatly simplified patient involvement, which is crucial to the success of this technique. ### Preoperative Planning Patients are evaluated clinically by a history and physical examination including observation of gait. Special attention is directed toward the assessment of leg length, mechanical axis deviation, and rotational alignment (Fig. 1). An erect bipedal 51-in (130-cm) radiograph in the frontal plane is made. If there is a leg-length discrepancy, then blocks are placed under the affected foot to level the pelvis, and the block height is recorded. Accurate limb lengths are measured in this way. Sagittal deformity about the knee is evaluated with a 36-in (91-cm) lateral radiograph made with the knee in full extension. Routine anteroposterior and lateral radiographs of the tibia are made as well. Ankle deformity should be evaluated with the x-ray beam centered on the ankle. Mechanical axis deviation is determined with use of the malalignment test7,8 (Fig. 2). The lateral distal femoral angle, …

Knee arthrodesis with simultaneous lengthening using the Ilizarov method.

Objective: To determine whether knee arthrodesis with simultaneous lengthening using the Ilizarov method for a nonreconstructable knee joint with bone loss and infection is a successful salvage procedure. Design: Retrospective review of patients. Setting: University hospital-based orthopaedic practice. Patients: From 1999 to 2001, 4 consecutive patients with a nonreconstructable knee joint, bone loss, and infection after trauma underwent knee arthrodesis with simultaneous lengthening. Intervention: Arthrodesis of the knee with simultaneous limb lengthening through an osteotomy of the tibia and/or femur and the use of an Ilizarov frame. External bone stimulation was used at the knee arthrodesis site and the lengthening sites. Application of this device began during the early distraction phase and continued until frame removal. Main Outcome Measures: Bony union at the arthrodesis and bone lengthening sites, alignment of the lower extremity, limb length discrepancy, infection, pain, and outcome scales (SF-36 scores and American Academy of Orthopaedic Surgeons lower limb modules). Results: Bony union of the knee arthrodesis and lengthening sites and good alignment were achieved in all 4 patients. Mean amount of lengthening was 5.4 cm (range 2.5-11.5 cm). Average time in frame was 11 months (range 6-17 months). Limb length discrepancy after treatment averaged 1.8 cm (range 0.6-3.7 cm). Mean duration of follow-up after frame removal was 35 months (range 28-48 months). At follow-up, infection had not recurred, pain was not present, and assistive devices were not needed for ambulation. Average SF-36 scores improved in all 8 categories, and the average American Academy of Orthopaedic Surgeons lower limb modules improved from a mean of 33 (range 11-37) to a mean of 68 (range 51-76). Conclusion: Knee arthrodesis with simultaneous lengthening can be performed successfully using the Ilizarov method. It enables surgeons to optimize limb length during knee arthrodesis. The use of external fixation and the avoidance of internal implants may be advantageous in the presence of or history of infection. The Ilizarov frame provides stability that allows weight bearing during treatment.

Limb Salvage Reconstruction of the Ankle with Fusion and Simultaneous Tibial Lengthening Using the Ilizarov/Taylor Spatial Frame

Despite early appropriate treatment with modern orthopedic trauma surgery protocols, distal tibia and ankle injuries do not uncommonly result in posttraumatic ankle arthritis. Ankle fusion offers reliable pain relief and improved function for many of these patients [1]. Ilizarov reconstruction with ankle arthrodesis has been used successfully to treat the more complex ankle pathology in many cases as an alternative to amputation [2–7]. These complex fusions can be limb salvage undertakings, as the treatments are often complicated by the presence of bone loss, osteomyelitis, associated deformity, and a poor soft tissue envelope with compromised healing potential. Most of these patients had failed multiple previous surgeries including open reduction with plates and screws, attempted ankle fusion, total ankle replacement, and external fixation with limited internal fixation. Various techniques for achieving complex ankle fusion have been reported including fixation with crossed lag screws, a fixed angle plate and screws, retrograde intramedullary nailing, and external fixation [8–16]. Although all of these methods can be used to obtain bony union, bone loss remains a challenging problem in these patients. Leg length inequality commonly results in altered gait and symptomatic malalignment of the pelvis and spine. Large shoe lifts are difficult to manage and poorly tolerated, and compliance is low. The use of structural allografts with internal or external fixation has been advocated to reestablish length [17–19]. Problems with graft collapse, infection, and nonunion accompany this technique. Proximal tibial lengthening provides an alternative means of equalizing leg lengths and improving function and self-perception. The need to implant large devitalized bone graft at a compromised healing site is obviated by the use of the patients own bony regenerate at a separate lengthening site. This technique allows for bony contact at the fusion site without intervening graft that is thought to facilitate union. In cases of severe bone loss, acute shortening to obtain bony contact at the fusion site may not be possible, and bone transport may become necessary. The use of circular fixation for ankle fusion was first described by Ilizarov [20]. The rationale for using the Ilizarov frame is to provide fixed angle stable fixation of the bone fragments, a percutaneous approach that is particularly useful in the presence of poor skin, and avoid the use of internal implants in the presence of infection. Using these frames, chronic deformity can be corrected with reduced risk of soft tissue complications, compression can be maintained throughout the postoperative period, and limb function is preserved through early weight bearing and physical therapy. The Taylor spatial frame (TSF) is a newer version of the Ilizarov fixator and has greatly simplified our ability to combine fusion with gradual simultaneous deformity correction and/or lengthening. Lengthening at a proximal osteotomy site can be done at the time of ankle fusion or staged a few weeks later as the clinical situation dictates. Staged lengthening requires returning to the operating room (OR) for frame modification and osteotomy. In complex ankle arthrodesis, it is not uncommon to be faced with having to close a large defect that is not amenable to bone grafting. The Ilizarov/TSF can be used to simplify this otherwise daunting problem by performing a gradual shortening with or without simultaneous lengthening or bone transport.

Humeral lengthening and deformity correction in Ollier's disease: distraction osteogenesis with a multiaxial correction frame

A case of Olliers disease with deformity and shortening of the humerus is presented. Lengthening of 9 cm and deformity correction of 50 degrees were accomplished with excellent functional and cosmetic results. Unique features of this case were the use of a multiaxial correction monolateral frame and the formation of normal bone within the region of diseased Olliers bone.

Lengthening and reconstruction of congenital leg deficiencies for enhanced prosthetic wear.

Congenital limb deficiencies with severe shortening and/or deformity can be difficult to fit with a prosthesis. We report two patients in whom gradual lengthening and deformity correction with the Ilizarov/Taylor spatial frame was used to improve prosthesis fit, comfort, and gait.Congenital limb deficiencies with severe shortening and/or deformity can be difficult to fit with a prosthesis. We report two patients in whom gradual lengthening and deformity correction with the Ilizarov/Taylor spatial frame™ was used to improve prosthesis fit, comfort, and gait.