LARGE BONE DEFECT

HOW TO MANAGE IT

ISMAIL MARYANTO
RSO - FK UNS
Bone graft massive
Congenital Pseudo arthrosis Tibia
 Introduction

• Limb Length discrepancy become cosmetic ,

psychologic & orthopaedics problem because of
gait pattern changes & finally degeneratif
changes
• Ilizarov method have speciality in large bone
defect ( > 5 cm )
• Distraction Osteogenesis 1 mm/day (usually
divided every 6 hours)
(Bucholz R.W.2006)
 Introduction
• Tibia was the most suitable for Ilizarov
method because its anatomical features
providing save wire insertion
• Tibia the most often suffered open fractures &
bone loss because its location subcutaneously
 Indications
• Lengthening Extremity
• Congenital Pseudoarthrosis Tibia
• Refractory Non Union
• Bone Loss Fracture
• Benign Bone Tumour
• Infected Non Union
• Lengthening Stump Amputat
• Multiplanar Deformity that failed with soft
tissue release
 Protocol

• Rate of distraction : 1mm - 1,5mm / day

• Rhytm of distraction : 0,25 mm / 6 hours
• Gap. Initial gap at corticotomy not exceed 2 mm
• Latency Period.
Minimal medulla damage : 1 day
Some damage of medulla : up to 10 days
 Procedure
• Osteo/ CORTICOtomy, external fixation
• Latent phase : 7 days ( Callus formation)
• Days 8th : Callus distraction 1 mm/24 hours
divided in 0,25 mm/6 hours
corticotomy
 Maintenance
• Medication with antiseptic at pin insertion
• Clean wire with alcohol every day
• Distract 3-4 times / day
 Turning
• 8 mm rod, 360º ~ 1,2 mm
• 6 mm rod, 360º ~ 1 mm
• Maximum 1 mm/day divided in 3-4 times
• Too fast : inhibit mineralization/scar tissue
• Too slow : premature consolidation
 Physioterapy
• ROM exercise soon after surgery
• Partial Weight Bearing
 Time to remove

• Desired length
distraction
• Callus consolidation
3-6 months
 Complication
• Pin track infection
• Pain
• Joint stiffness
• Vascular/Nerve Injury
 Gavriil Abramovich Ilizarov says :

•After apply this device

…………...............
• The problem has just begun
 Problem alat Ilizarov
• Alat harus dibuat tailor-made, setiap orang
tidak sama ukurannya
• Harga alat impor sangat mahal
• Di-assembly dulu sebelum op, dari bagian
yang terpisah untuk disterilkan, untuk
mengurangi waktu op
 Problem Kehidupan sehari hari
• Perawatan lama, harus telaten, melibatkan
seluruh keluarga, harus dididik untuk perawatan
luka yang benar,
• pemutaran : ARAH harus tepat , tidak salah arah
Kompressi atau distraksi,
• WAKTU : sesuai jadwal yang ditetapkan (ukuran
Rod 6 mm sehari 4 x 90 ⁰, sedangkan bila ukuran
rod 8 mm sehari 3 X 90  saja)
• ADL terganggu selama pemanjangan dan selama
maturasi yg 2x masa distraksi
 Problem penderita
• Penderita Datang dengan kondisi jaringan
sudah infeksi dan fibrosis / bekas dukun shg
vaskularisasi daerah tsb tidak baik
• Sebagian besar ekonomi rendah, sulit untuk
disuruh kontrol tiap bulan ke RSO krn harus
charter mobil
• Pasien enggan latihan jalan mandiri dengan
kruk, ingin tampak sakit, manja, dan lebih
senang dilayani minta braankart
 Problem operasi
• Perlu perencanaan model simulasi gambar
mengenai apa yang akan dikerjakan dan
rencana distraksinya , panjang rod tersedia
• Operasi : sulit dan cukup lama
• Instrumen prae op harus dicek siap
kelengkapannya
 Distraction osteogenesis
• Diperkenalkan pertama oleh Codivilla 1904
• Fase laten : sesudah osteotomi (7 hari)
• Fase Distraksi : sehari 1 mm – 1,5 mm dibagi
dalam beberapa waktu, sebulan 1 inch
• Fase konsolidasi / maturasi kallus : perlu 2x
lamanya fase distraksi
Qurrota ayyun 5 yo. girl , came to
Soeharso Hospital with complaint:
 Clinical
Galeazzi Sign
Radiographic
PA
 PA
• kesan heterogenitas mencolok & keragaman
derajat sel serta chondrosit fenotype
Post Operation 2 month follow up
 6 Month Follow-up
6 month follow up
 Second Stage

Performing Illizarov at Femur &

Achiles Tendo lengthening to corection equinus
 2 month follow up
LLD : 3 cm
Good Function of the ankle
 Sumarni 12 th
( Osteochondroma ulna- Madelung deformity)
Post op 2 mg
Ronsen Bulan Ke-2
3 bulan . 4 bulan
5 bulan 7 bulan
.
Burhanudin 12 th