Original Article
European Journal of Trauma
The Ilizarov Ring External Fixator in Complex Open Fractures of the Tibia Ebrahim Hasankhani, Mahamad Taghi Payvandi, Ali Birjandinejad1
Abstract Introduction: Complex open fracture of the tibia particularly with bone defect and infection is one of the major problems in orthopedic surgery. There are many available alternatives in the management of these fractures. Aim: The purpose of this study is to evaluate the results and efficacy of the Ilizarov ring external fixator in treating complex open fractures of the tibia. Materials and Methods: We treated 25 patients with complex open fracture of the tibia using the Ilizarov ring external fixator between March 1999 and February 2002. The open fractures were type IIIA, type IIIB , and type IIIC in 19, 9, and 4 patients, respectively. There were 11 patients with bone loss ranging from 3 to 9 cm (average bone loss 5 cm), and 10 patients with infection. There were 11 one-level tibial transports, 5 bone graftings at the docking site, 6 internal fixations with bone grafting because of pin tract infection. Results: Results were divided into bone and functional categories [according to the association for the study and application of the method of Ilizarov (ASAMI) classification]. The bony results were excellent in 18 patients (56.2%), good in 4 (12.5%), fair in 3 (9.4%), and poor in 7 (21.9 %). The functional results were excellent in 7 (21.9%) patients, good in 14 (43.7%), fair in 4 (12.5%), and poor in 7 (21.9%). Conclusion: The Ilizarov ring external fixator is an effective a salvage procedure in the treatment of complex open fractures of the tibia as it allows for the simultaneous treatment of bone loss, infection, non-union, and deformity.
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Key Words Ilizarov ring external fixator · Complex open fractures · Tibia Eur J Trauma 2006;32:63–8 DOI 10.1007/s00068-005-0031-6
Introduction Complex open fracture of the tibia, particularly with bone defect and consequent infection, is one of the major problem in orthopedic surgery. There are various alternatives available in the management of these fractures. Bone defects are treated by various methods including cancellous bone grafting, Papineau-type cancellous bone grafting, vascularised fibular grafts, and internal bone transport with an external fixator [1–8]. Infected fractures are treated by alternative available methods; these include extensive debridement with local soft-tissue rotational flaps, packing the defect with antibiotic impregnated beads, Papineau-type cancellous bone grafting, tibia fibular synostosis, cancellous allograft in fibrin sealant mixed with antibiotics, and free microvascular soft-tissue and bone transplants [4]. The Ilizarov ring external fixator is a simple method for treating the complex open fractures of the tibia and permits orthopedic surgeons to easily manage the associated bone defect and infection simultaneously. The purpose of this study is to evaluate the result and efficacy of the Ilizarov ring external fixator in treating complex open tibial fractures (type III Gustilo classification with or without bone defect and infection).
Mashad university of Medical Sciences, Department of Orthopaedic and Spine, Shahid Kamiab Hospital, Mashad, Khorasan 9187944615, Iran.
Received: August 15, 2004; revision accepted: June 30, 2005.
European Journal of Trauma 2006 · No. 1 © Urban & Vogel
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Hasankhani E, et al. The Ilizarov in Open Tibial Fractures
Figures 1a to 1c. a) A 45- year-old woman with open type III B fracture of left leg due to pedestrian accident. b) Debridement, reduction and application of Ilizarov system with a good union after 6 months. c) After 8 months and removal of Ilizarov apparatus.
Materials and Methods Thirty-two patients with complex open fracture of the tibia were treated by Ilizarov ring external fixator between March 1999 and February 2002. There were 24 males and 8 females with ages ranging from 18 to 50 years (mean: 32 years). There were 19 open type III A (Gustilo classification), 9 type III B and 4 type IIIC fractures. In all of
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these, type III C fracture arteriography was performed before application of Ilizarov. Three of them had arterial repair and one needed below-knee amputation. All fractures were at high risk. High-risk fractures include cases in which there is significant comminution at the site of the fracture, bone loss, extensive soft-tissue injury, and infection. All patients were given prophylaxis against tetanus and short-term, broad-spectrum antibiotics (1 g of Cefazolin and Gentamicin 3–5 mg/kg of body weight every 24 h in three divided doses) intravenously. Antibiotic therapy was maintained postoperatively for 72 h. The same antibiotic regimen was used at each subsequent operative intervention. At the emergency operation, wound excision was carried out with copious irrigation. A standard operative protocol was followed. Wound debridement was performed as soon as possible after admission to the hospital. As part of the debridement protocol, a minimum of 10 l of saline solution was used for irrigation. Thorough debridement and excision of all necrotic and suspect bone fragments followed this procedure. After debridement, in patients in whom wounds were closed primarily, the ring external fixator was applied. Patients in whom wounds were allowed to heal by secondary intention (split-thickness skin-grafting, delayed primary closure, fasciocutaneous flap, gastrocnemius or soleus flaps, free flaps) the hybrid ring external fixator was applied, and after soft tissue healing replaced by ring external fixator. Plastic surgeons were included in the treatment team
European Journal of Trauma 2006 · No. 1 © Urban & Vogel
Hasankhani E, et al. The Ilizarov in Open Tibial Fractures
Figures 2a to 2d. a) A 32-year-old man with open type III B fracture of tibia due to motorcycle accident. b) After debridement and Ilizarov system application. c) One-level osteotomy for bone defect reconstruction. d) Bone graft and internal fixation for docking site after 5 months.
when needed. Early coverage of the exposed bone was achieved by local flaps or free-tissue transfer within 15 days of injury. The Ilizarov frame was assembled preoperatively for all patients. On average, four rings were used. The technique is as follows: two pairs of pins are placed in the proximal tibia and two pairs in the distal tibia and each pin is fixed to an appropriate ring. The intermediate rings can be used for bone transport if needed.
European Journal of Trauma 2006 · No. 1 © Urban & Vogel
Corticotomies were performed in the proximal metaphases of tibia in three cortexes. The technique is as follows: a longitudinal skin incision of about 2 cm is made over the area of corticotomy and then the periosteal incision is made just medial to the tibial crest. The periosteum is elevated from the cortex carefully, and the medial, lateral, and posterior cortexes are broken with a sharp narrow osteotom. The lateral end of the posterior
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Hasankhani E, et al. The Ilizarov in Open Tibial Fractures
cortex is used as a hinge and is broken by manipulation to produce a greenstick fracture. The periosteum is sutured and the skin is closed. Postoperative radiographs were taken to assess the reduction and placement of the wires. Ambulation and exercises were begun as soon as pain permitted to prevent contractures and stiffness of joints. There were 11 patients with bone defect ranging from 3 to 9 cm (average bone defect 5 cm), and 10 patients with infection. There were 11 one-level corticotomies for tibial transport (Figures 1 and 2), 5 bone graftings at the docking site, and 6 internal fixations and bone graftings because of removal of Ilizarov system for pin track infections. Additional procedures include wire exchange (because of pin site infection), frame adjustments for alignment, debridement of necrotic and infected softtissues and bone and soft-tissues coverage (skin graft) (Table 1). The mean time of Ilizarov apparatus removal was 21 weeks (12–32 weeks). Results The results were divided into bony and functional results according to the protocol of the ASAMI (Table 2). The bony results were determined according to four criteria: union, infection, residual deformity, and limb length discrepancy. The functional results werebased on fivecriteria:limping, stiffness of either the knee or the ankle, sympathetic dystrophy, pain that resulted in reduced activity or disturbed sleep, inactivity (inability to return to previous activities). Union was achieved in all cases. Bone grafting was necessary in five cases, and bone grafting + internal fixation was required in six cases. Infection (11 cases) was effectively controlled by drainage, antibiotic therapy, and antiseptic dressings. Five patients had a residual deformity of more than 7º, and 2 patients had a shortening of more than 2.5 cm. Twelve patients returned to their previous work, 10 required a change from previous work and 3 did not return to any work till now. Seven patients had significant pain, which resulted in reduced activity. Ten patients had a noticeable limp. Ten patients had stiffness of either the knee (4 cases) or the ankle (6 cases). According to the ASAMI protocol the bony results were excellent in 18 patients (56.2%), good in 4 (12.5%), fair in 3 (9.4%) and poor in 7 (21.8%), and the functional results were excellent in 7 (21.9%), good in 14 (43.8%), fair (12.5%), and poor in 7 (21.8%) (Table 3).
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Table 1. Clinical data of 32 patients with complex open tibial fractures treated by Ilizarov ring external fixator. Data
Number of patients
Type of fracture Type III A Type III B Type III C
19 9 4
Sex Female Male
8 24
Side of fracture Left Right
12 20
Bone loss (in cm) 3 4 5 7 9
3 3 3 1 1
Other treatments Bone graft Bone graft- internal fixation One level osteotomy
5 6 11
Complications Infection Residual deformity Shortening more than 2/5 cm Returned to previous work Changed work Unable to work Significant pain Noticeable limp Stiff joint
11 5 2 19 10 3 7 10 10
Discussion The treatment of open type III fractures of the tibia particularly when associated with bone defect and infection is difficult and a major problem for orthopedic surgeons. In this study, we found that the Ilizarov ring external fixator is an excellent method for open type III fractures of the tibia especially with comminution, infection, and bone loss. The basic principles of the Ilizarov ring external fixator method are stable fixation, a low energy osteotomy with gradual distraction and bone formation by intramembranous ossification. In open type III fractures without bone loss or infection, the advantages of Ilizarov system are, principally, the minimal surgical trauma and bleeding, the early weight-bearing, the lack of deep infections, and the possibility of performing progressive corrections during the treatment [9, 10].
European Journal of Trauma 2006 · No. 1 © Urban & Vogel
Hasankhani E, et al. The Ilizarov in Open Tibial Fractures
Table 2. Classification of the results according to the modified association for the study and application of the method of Ilizarov ASAMI classification. ADL: activities of daily living. Bony result
Functional result
Excellent
Bone union, no infection deformity < 7º LLD < 2.5 cm
Ability to perform previous activities of daily living (ADL), no pain or mild pain No limp, no soft tissue sympathetic dystrophy Knee or ankle joint contracture < 5º Loss of ankle or knee motion < 15º
Good
Bone union Failure to meet one of the other criteria
Almost all ADL with minimal difficulty No pain or mild pain Failure to meet one of the other criteria
Fair
Bone union Failure to meet two of the other criteria
Most ADL with minimal difficulty No pain or mild pain Failure to meet two of the other criteria
Poor
Nonunion or refracture Failure to meet three of the other criteria
Significantly limited ADL Significantly pain requiring narcotics Failure to meet three of the other criteria
With this method the patient can leave the hospital after a few days, with a decrease in hospital costs. When the open type III fractures of the tibia are associated with bone loss and infection, there are various methods of treatment including cancellous bone grafting, Papineau type bone grafting, vascularised fibular graft and bone transport [1, 3, 5–8, 11, 12], and extensive debridement with local soft-tissue rotational flaps, packing the defect with antibiotic impregnated beads, tibiofibular synostosis, and free microvascular soft-tissue and bone transport[13]. None of the above mentioned techniques afford the surgeon the ability to correct deformities, eliminate prolonged preoperative and postoperative antibiotic therapy, regenerate new bone without the use of bone graft, progressiveTable 3. Bony and functional results of 32 patients with complex open tibial fractures treated by Ilizarov ring external fixator. Grade
Excellent Good Fair Poor Total
Bony results
Functional results
Number of patients
Percent (%)
Number of patients
Percent (%)
18 4 3 7 32
56.2 12.5 9.4 21.9 100
7 14 4 7 32
21.9 43.8 12.5 21.8 100
European Journal of Trauma 2006 · No. 1 © Urban & Vogel
ly lengthen the extremity, transport internal bone for filling the defect, and allow weight bearing during the treatment period simultaneously. This study and many other studies confirm that all of these capabilities are possible with application of the Ilizarov ring external fixator [3, 12, 14, 15, 21]. Recently, many orthopedic surgeons have reported alternative methods of stabilization of open tibial fractures. In these reports, there is a high complication rate with external fixator (not Ilizarov) compared to internal fixation (intramedullary nails) after long-term followup of fractures [16]. Mohit Bhandari et al. [17] systematically reviewed the effect of alternative methods of open tibial fracture fixation (plate, usual external fixator, intramedullary nails). This study showed that intramedullary nails offer benefit over external fixators (not Ilizarov) and plates in the treatment of open tibial fractures. Bone et al. [16] reported good results (union, alignment, infection) in a study of 27 open tibial fractures treated with intramedullary nails. In these studies all of the reported cases were open tibial fractures with low risk, contrary to our high-risk cases, and also they did not compare the intramedullary nails with ring external fixator (Ilizarov). This study showed that with the Ilizarov ring external fixator, the unstable fracture, soft-tissue defect, infection, and bone loss are managed successfully with one device and method simultaneously [18]. Progressive bone histogenesis after corticotomy and bone transport helps to eradicate bone infection and to reconstruct bone defect [19]. We treated 11 cases of bone loss and 10 cases of infection successfully in this study. Although the classical Ilizarov method called for healing of docking site by gradual and prolonged compression [14], as many other surgeons we found that supplementation with autogenous bone graft accelerates and facilitates healing [15]. In our series 11 patients had autogenous bone grafting at the docking site in order to shorten the length of treatment, and bone union was obtained in all patients. We recommend bone grafting at the docking site in order to obtain union, to shorten external fixation time and to avoid refractures. Many studies have reported that conventional management is successful in the treatment of bone defects measuring less than 6 cm, but is connected with a high rate of complications [1, 19, 20]. We treated 11 patients with bone defects ranging from 3 to 9 cm successfully by Ilizarov method with less complication.
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Hasankhani E, et al. The Ilizarov in Open Tibial Fractures
Conclusion The Ilizarov ring external fixator is most effective and could be used as a salvage procedure in the treatment of complex open fractures of the tibia. It has the advantages of minimal surgical trauma and bleeding, early weightbearing and allows for the simultaneous treatment of bone loss, infection, non-union and deformity. References 1. 2.
3.
4.
5.
6. 7. 8.
9. 10. 11.
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Banic A, Hertel R. Double vascularised fibulas for reconstruction of large tibial defects. J Reconstr Microsurg 1993;9A:421–28. Christian EP, Boss MJ, Robb G. Reconstruction of large diaphyseal defects without free fibular transfer, in grade-III B tibial fractures. J Bone Joint Surg Am 1989;71:994–1004. Dendrinos GK, Kontos S, Lyrisis E. Use of the Ilizarov technique for treatment of nonunion of the tibia associated with infection. J Bone Joint Surg Am 1995;77A(6):835–46. Gordon L, Chiu EJ. Treatment of infected non-unions and segmental defects of the tibia with staged microvascular muscle transplantation and bone-grafting. J Bone Joint Surg Am 1988;70:377–86. Green SA, Jackson JM, Wall DM, et al. Management of segmental defects by the Ilizarov intercalary bone transport method. Clin Orthop 1999;280:136–42. Green S. Skeletal defects: a comparison of bone grafting and bone transport for segmental skeletal defects. Clin Orthop 1994; 301:111–17. Papineau LJ, et al. Chronic osteomyelitis: open excision and grafting after saucerization. Int Orthop 1979;3:165–76. Schapiro MS, et al. Treatment of tibial defects and non-union using ipsilateral vascularised fibular transposition. Clin Orthop 1993;296:207–12. Fleming B. A biomechanical analysis of Ilizarov external fixator. O.I.C. Medical press, Florence, 1989; pp 195–201. Ilizarov GA. Transosseous osteosynthesis. Springer, Berlin Heidelberg, New York, 1990. Lalit M, Manish C, Jashan V. The Ilizarov method in infected nonunion of fractures. J Inj 2000;34:509–17.
12. Marsh DR, Shah S, Elliot J. the Ilizarov method in non-union, malunion and infection of fractures. J Bone Joint Surg Br 1997;79B:273–79. 13. Hosny G, Shawky MS. The treatment of infected nonunion of the tibia by compression–distraction techniques using the Ilizarov external fixation 1998;22:298–302. 14. Cattaneo R, Catagni M, Johnson EE. The treatment of infected non-union and segmental defects of tibia by the method of Ilizarov. Clin Orthop 1992;280:143–52. 15. Cierny G, Zorn KE. Segmental tibial defects, comparing conventional and Ilizarov method. Clin Orthop 1994;301:111–17. 16. Bone LB, et al. Prospective study of union rate of open tibial fractures treated with intramedullary nails. J Othop Trauma 1994;8(4):359–61. 17. Mohit Bhandari, et al. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br 2001;83:62–7. 18. Terry Canale S. Campbell´s operative orthopaedics. Mosby. 10th edn. 2003; pp 2767–73. 19. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: part I: the influence of stability of fixation and soft-tissue preservation. ClinOrthop 1989;238–249. 20. Chew WYC, Low CK, Tan SK. Long-term result of free vascularised fibular graft. Clin Orthop 1995;311:258–61. 21. Pavolini B, Maritato M, Turelli L. The Ilizarov fixator in trauma. J Orthop Sci 2000;5:108–113.
Address for Correspondence Ebrahim Hasankhani Mashad University of Medical Sciences Department of Orthopaedic and Spine Shahid Kamiab Hospital, Mashad Khorasan 9187944615, Iran Phone (+98/511)6061281, Fax -8549234 e-mail:
[email protected]
European Journal of Trauma 2006 · No. 1 © Urban & Vogel
