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