Illizarov and Principle of Distraction Osteogenesis

Introduction

 Gavril Ilizarov developed this technique in 1950s

Basis of the technique

 Produce a careful fracture of bone, followed by a short wait before the young callus is
gradually distracted via a circular or unilateral external fixator.

Advantages

 Effective and reliable treatment for some of the most challenging conditions in orthopaedics
o Infected non-union of long bones
o Malunion
 The Ilizarov external fixator has a high modularity
o Can be constructed to correct any deformity or to address any mechanical problems

Indication

 Trauma
o Non union
o Bone lengthening
o Bone defect
 Deformity correction
o Trauma
o Developmental disorder
o Congenital eg CTEV
o Infection
o Tumor
o Metabolic disorder
 Joint stiffness
o Gradual soft tissue distraction
Basic science of distraction osteogenesis

 Definition
o Generate new bone and soft tissue(nerve, muscle and skin) in response to gradual
increases in tension
o Base on the principle of tension-stress

 Tension stress principle

o Callus distraction, or callotasis, is perhaps the single most important application of
the tension-stress principle
o First careful osteotomy performed through bone
o Followed by slow controlled tension applied through soft tissues
o Stimulated increased proliferative and metabolic activity in all tissue types
1. Bone formation (callotasis)
 Bone regenerate then consolidated proximally and distally, furthest
away from the central area of regenerate bone
 Centre area remains highly active in regenerate production
(intramembranous ossification).
2. Angiogenesis
 In addition to new bone formation, the tension-stress effect
promotes intense angiogenesis increased regional perfusion of the
limb being treated
3. New muscle, fascia, nerve and skin tissue growth
 Muscle tissues tolerate lengthening well, but increasing limb length
by 30% or more produces histological changes
 The newly formed tissues were noted by Ilizarov to be similar in
structure to embryonic and foetal equivalents

Factors important for the optimal production of new tissues

 Stable configuration of the frame

o To prevent excessive motion
 Excessive motion lead to bleeding within the bone regenerate causing cyst
and cartilaginous formation leading to non union
 Little disturbance to surrounding soft tissue
o Preserve the periosteal and endosteal blood supply
 Rate and frequency of distraction
Key factors in the Ilizarov method/Phases of distraction osteogenesis

 Stable frame construct and fixation

 Low energy corticotomy
o Preservation of periosteum
o Preservation of marrow
 Latent period
 Low rate of distraction (0.5–1mm daily)
 Consolidation

Phases of DO

 Corticotomy
 Latent phase
 Distraction phase
 Consolidation phase
Technique

1. Fixation of two or more segments of bone

 Types of wire
o Wires of 1.8mm diameter
o Olive wire - push or pull bone segments into place
 Technique
o Driven through the bone at low speed to avoid thermal damage to the bone
that would promote infection of pin sites
o Avoid tethering of soft tissue
o All the wires are attached onto a circular frame
o They are secured by clamping them onto the frame with slotted and
cannulated bolts.
o One end is secured as tightly as possible to the frame, then the opposite end
tensioned before being secured onto the frame.
2. Corticotomy performed percutaneously
 A small incision is made
 Incise and elevate the periosteum to allow multiple drill holes to be made across
the bone.
 Drill at low speed to avoid thermal damage to the periosteal tissues.
 An Ilizarov osteotome is used to complete the osteotomy
 Repair the periosteum
 Endosteal and marrow blood supply are largely preserved
3. Latent period of 7-10 days
 Allow the bone to start healing prior to correction
4. Low rate of distraction
 Distraction of the osteotomy begins at 1mm or day with small (usually 0.25 mm)
increments spaced out evenly throughout the day.
 Regenerate bone is formed
 Frequency and rate of distraction
 Too rapid and aggressive
o Fibrous tissue formation at regenerate site (fibrous non union)
o Regenerate may be thin with an hourglass appearance
o Abnormal soft tissue function - nerve and muscle
o Pain
 Too slow
o Premature consolidation of regenerate
5. Closed follow up and monitoring
 Monitor with repeated radiographs to assess the regenerate
o Ensure the correction is proceeding as planned
o Watch out for premature consolidation
o Malalignment of the bone
 Watch out for pin site infection
6. Consolidation
  When the desired length is reached, a second wait follows, which allows the
regenerate column to consolidate and harden.
 Once the cortices of even thickness are seen in the regenerate on x-ray, the fixator
is ready to be removed.
 Using these techniques 1 cm of mature bone can be ‘regenerated’ in 40 day

How to improve the IEF stability?

 Ring
1. Increase number of rings (including ‘dummy’ rings)
2. Reduce the diameter of ring (near to the bone: at least 2 cm clearance for swelling)
3. Placement of the two central rings close to the fracture site
4. Increase spacing btw the adjacent rings in the same segment
 Wire
1. Bigger diameter pin or wire (1.8mm in adult;1.5 mm in children)
2. Increase number of pins
3. Increase the tension of the wire (130newton in adult, 110newton in children)
4. Wires or pin crossing at 90 degrees (increase the cross angle of wire)
5. Use opposing olive wire
 Pin
1. Increase diameter
2. Hydroxyapatite coating
3. Increase crossing angles (multiplanar)
4. Decrease distance of external construct to bone
5. Near and far positions (Fig. 15.2)
6. Increase number
 Attachments:
1. Use ‘slotted’ bolts – high surface area of contact with wire
2. Build ring to wire, if necessary – decrease bend on wire

Physiotherapy

 Throughout treatment, physiotherapy is important to preserve joint movement and avoid

contractures.

Weightbearing

 Weightbearing is permitted and this assists the consolidation process

Complications of illizarov

 Pin site infection

 Pain with distraction
 Poor regenerate formation
 Delayed union at docking site
 Regenerate fracture or deformity after frame removal
Consent and risks

 Duration of treatment must be emphasized (c.40 days/cm)

 Pain: post-surgical, chronic dull ache during distraction is common
 Pin site problems: inflammation; soft tissue infection; osteomyelitis
 Joint stiffness or subluxation
 Soft tissue contractures
 Vascular injury
 Neurological injury: perioperative; postoperative stretching
 Premature/delayed/non-union
 Hardware failure
 Late bowing
 Fracture
 Deep vein thrombosis/pulmonary embolism

Preop planning

Acute vs gradual correction

 Acute
– Mild deformity
– Opening or closing wedge
– Plate and screws
– Intra-medullary (IM) nail
– External fixation
 • Gradual
– More severe deformity
– Less risk of neurological damage
– Potential for revision of correction protocol
– Distraction osteogenesis
– Circular frame e.g. Ilizarov or hexapod type (e.g. Taylor Spatial Frame)
– Monolateral fixator: on convex side - distraction at osteotomy site