Transosseous Osteosynthesis: Theoretical and Clinical Aspects of the Regeneration and Growth of Tissue

795 Pages·1992·48.576 MB·English

by  Professor Dr. Gavriil A. Ilizarov (auth.)

Gavriil A.llizarov
Transosseous
Osteosynthesis
Theoretical and Clinical Aspects
of the Regeneration and Growth of Tissue
Editorial Assistance by
Stuart A. Green
With 656 Figures in 3100 Separate Illustrations
Some in Color
Springer-Verlag
Berlin Heidelberg New York
London Paris Tokyo
Hong Kong Barcelona
Budapest
Professor Dr. Gavriil A. llizarov
Scientific Center
of Reconstructive Orthopaedics
and Traumatology
U. Klimova 41-38
640020 Kurgan, USSR
Editorial Assistant:
Stuart A. Green, M.D.
Rancho Los Amigos Medical Center
7601 East Imperial Highway
Downey, California 90242, USA
ISBN- 13: 978-3-642-84390-7 e-ISBN- 13: 978-3-642-84388-4
DOl: 10.1007/978-3-642-84388-4
Library of Congress Cataloging-in-Publication Data. Ilizarov, Gavriil Abramovich, 1921.
Transosseous osteosynthesis: theoretical and clinical aspects of the regeneration and growth
of tissue 1 Gavriil A. Ilizarov ; editorial assistance [and translation] by Stuart A. Green.
p. em. Includes bibliographical references and index.
ISBN-13:978-3-642-84390-7 1. Bones-surgery. 2. Bone regeneration. 3. Internal
fixation in fractures. I. Green, Stuart Alan. II. Title. [DNLM: 1. Bone and Bones
Surgery. 2. Bone Regeneration. 3. Fracture Fixation, Internal-methods. WE 185 128t]
RD684.I45 1992 617.4'71-<1c20 DNLM/DLC for Library of Congress 91-4844 CIP
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Preface
This volume deals with the transosseous external fixation techniques
that I have been developing over the course of the past 40 years.
During this time, our research in medicine, biology and engineering
has led to the evolution of more than 800 unique, highly effective
methods of treatment that extend beyond the realm of traumatology
and orthopedics. The book features a comprehensive theoretical
and clinical description of the biologic laws governing the depen
dence of the shape-forming processes of bones and joints upon the
adequacy of blood supply, as well as a delineation of the effect of
tension-stress upon the genesis and growth of tissues. I have in
cluded our latest data on tissue growth and regeneration during
transosseous osteosyntheses.
The book summarizes the biomechanical principles of applica
tion of my apparatus; clinical cases selected from more than 25000
patients illustrate the management of some of the most complex
disorders of the locomotor system.
New solutions to many therapeutic problems are described. In
particular, severe limb trauma with large defects of bone, vessels,
nerves and skin can be managed without resort to transplantation.
Radical debridement surgery can be followed by a one-step restora
tion of the missing tissue, thus decreasing the likelihood of a serious
wound infection or an amputation.
Other applications described in this monograph include techni
ques for: aligning and lengthening limbs; increasing stature; thicken
ing and reshaping the tibia; lengthening and shaping upper and
lower limb stumps to provide, for example, fingers or a foot; elonga
tion of the spine; normalization of the pelvis, and the treatment of
benign bone tumors. Specific chapters focus on fracture manage
ment, the percutaneous and operative care of foot pathologies, hand
surgery, and the treatment of diseases and disorders of the hip.
The ability to induce growth in blood vessels has been successful
ly exploited to treat limb circulation problems, including such severe
pathology as obliterating endarteritis.
It is my sincere hope that this book will prove valuable to mus
culoskeletal researchers, traumatologists, orthopedic surgeons, neu
rosurgeons, angiologists, biomechanical engineers, and, indeed, all
those interested in the genesis of bone and soft tissues.
G. A. Ilizarov
Contents
Introduction
1 Historical Background of Transosseous Osteosynthesis . . 3
References ...................................... , 46
2 The Apparatus: Components and
Biomechanical Principles of Application . . . . . . . . . . . . .. 63
3 The Tension-Stress Effect on the Genesis
and Growth of Tissues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
4 The Influence of Blood Supply and Loading
Upon the Shape-Forming Processes
in Bones and Joints ............................... 257
5 Osteogenesis and Hematopoiesis. . . . . . . . . . . . . . . . . . . . . 279
Clinical Methods
6 Lengthening of Upper and Lower Limb Segments ...... 287
7 Correction of Deformities of Long Tubular Bones
with Simultaneous Limb Lengthening ................ 329
8 The Treatment of Fractures:
Theoretical Considerations, Experimental Studies,
and Clinical Applications of the Apparatus. . . . . . . . . . . . 369
9 Pseudarthroses and Defects of Long Tubular Bones ..... 453
10 The Treatment of Pseudarthroses
Complicated by Osteomyelitis
and the Elimination of Purulent Cavities. . . . . . . . . . . . . . 495
Treatment of Disorders of the Foot
11 Nonoperative Correction of Foot Deformities .......... 547
12 Operative Correction of Foot Deformities ............. 583
vm
Contents
Treatment of Disorders of the Hand
13 Treatment of Diseases and Injuries of the Hand ........ 637
Treatment of Disorders of the Hip
14 Fractures of the Femoral Neck ...................... 671
15 Pseudarthrosis of the Femoral Neck ................. 687
16 Hip Dislocations .................................. 701
17 Coxa Vara ....................................... 727
18 Coxarthrosis ..................................... 751
19 Coxa Vara with Congenital Pseudarthrosis ............ 763
20 Defects of the Proximal Femur ..................... 773
SUbject Index ........................................ 797
Introduction
1 The Historical Background
of Transosseous Osteosynthesis
Patients who either sustain long bone fractures or undergo ortho
pedic procedures are often disabled for many months, or even years.
They may experience delay in osseous consolidation. Conventional
methods of promoting bone union frequently do not work; indeed,
some techniques can cause serious pathologic changes. To make
matters worse, protracted delays in healing compromise the function
of the limb, thereby disabling the patient permanently.
Altered functional capacity has been shown to accompany 6.0%-
1 [27,28,286] 20.3% of tibial shaft fractures 1 and 16.2%-69.0% of femoral shaft
2[21,37,38,142,288,480] fractures2. The most frequently cited causes of disability in cases of
long bone fracture include delayed consolidation, pseudarthrosis,
3 [29,33,37,38, 111] malunions, and joint contractures3• For this reason, any technique
that reduces both temporary and permanent disability following an
injury should assume great socioeconomic importance, since trauma
victims are frequently unproductive during convalescence.
How can delays in consolidation and a significant proportion of
unsatisfactory results be explained? Are problems with healing a
consequence of the method of treatment or the result of unfavorable
biologic factors - either local or generalized?
Obviously, the choice of an inappropriate method of treatment
will cause a bad outcome. Yet we know from experience that
problems with consolidation occur even when well-established
methods are used. Often, we blame an unsatisfactory result on the
poor general health of the patient. Many studies, however, have
demonstrated that most problems with osseous healing occur in
4 [361,490,519] 5 [519] otherwise healthy individuals4• As Timofejev5 put it: "The most
striking cases of ununited fractures occur in healthy and sound in
dividuals". He concludes: "There are some patterns of non-union for
which we cannot understand the nature of the phenomenon in any
6 [120] way." Likewise, Epstein6 found that only six of 225 patients with
delayed consolidation had generalized diseases.
Equally intriguing is the matter of non-union of only one of two
bones fractured at the same level in the same patient. For example,
Schneider, in 1956, reported the case of a 35-year-old female physi
cian from Novosibirsk who sustained a closed both-bone fracture of
the forearm:
Closed reduction ... turned out to be ineffective. Open reduction, which
gave good position ... wasn't successful either. Stimulation therapy was
performed ... [but] no consolidation was achieved. A second operation
was performed ... on the radius [with] a tibial autograft fixed into a slot.
[Serial] X-rays showed good position of the fragments ... and callus for
mation. But now, 6-7 months postoperatively, we see no consolidation of
the radius while the ulna, which wasn't touched during the second opera
tion, is well consolidated.
4 The Historical Background of Transosseous Osteosynthesis
It is hard to imagine that the physiologic processes that heal soft
tissues without difficulty would selectively fail to unite bone. Indeed,
we consider it unlikely that anything but a severe disturbance in a
patient's general health will suppress the reparative capacity for
tissue healing in general, and bone in particular. It is possible,
however, for an altered state of health to retard wound healing
somewhat, slowing the process.
The first step of healing - whether bone or soft tissue - results in
a sort of primary adhesion. In general, cutaneous soft tissue wounds
that are sutured heal by first intention, whereas bone usually unites
by second intentionl. Since the healing of both bone and soft tissues 1 [71,87, 107-109,214,215,218,
starts with the same processes, it would seem possible to bring the 261,356,505,515,540]
stages of osseous consolidation closer to the characteristics of pri
mary healing as seen in clean, repaired postoperative wounds.
For centuries, bone was thought to lack the capacity for healing
by first intention. This perspective was based upon methods of
treatment that could not provide the biomechanical conditions nec
essary for swift osseous consolidation.
More recently, investigators have searched for means of stimu
lating osseous union. In our view, however, efforts at promoting
healing without adequate fragment fixation can be compared to a
construction site with two teams of workers - one team building, and
the other tearing down what the first team assembles. In the end, the
construction site is full of misused building materials after a lot of
wasted time and labor. This picture is seen in a hypertrophic non
union, where redundant bone tissue fails to overcome the destruc
tive effect of fragment mobility. The same can be said for bone
growth stimulators used without stability.
We consider the unfavorable biomechanical environment to be
the principal cause of non-unions and pseudarthroses. To ensure the
optimum biologic environment for bone healing, we strive for the
following objectives:
- Preservation of the blood supply of the fracture site and the limb
as a whole
- Preservation of the osteogenic tissue - periosteum, endosteum,
bone marrow - during osteosynthesis and postoperative care
- Functional activity of the muscles and joints of the limb
- Early patient mobilization
The main mechanical factors important to promote healing include:
- Complete anatomic reduction of fragments
- Rigid fixation
It should be pointed out that all of the aforementioned factors play
a role in promoting rapid healing and a satisfactory outcome. In our
view, neither a cast nor skeletal traction, nor, for that matter, many
types of internal fixation, provide the entire complex of conditions
needed for rapid osseous healing by first intention.
The Significance of Congruent Reduction and Contact 5
1.1 The Significance of Congruent Reduction and Contact
Surgeons have long known that wound surfaces need mutual contact
to heal rapidly. Indeed, modern surgery would not exist were it not
for this general principle. We believe that bone tissue responds in the
same way. In some locations - patella, femoral neck, olecranon - a
lack of mutual contact (in interfragmentary compression) precludes
healing. In other places, suboptimal reduction slows the pace of
union. Only precise and complete repositioning of fresh fracture
fragments will promote rapid osteosynthesis. Complete reduction
and close contact of congruent fragment ends provides a large
contact area - the conditions needed for firm "primary adhesion." In
this situation, direct consolidation of a fracture begins at the initial
stage of fracture healing; a minimal amount of callus is required.
When dealing with soft tissues, we use sutures to obtain complete
and firm contact. With bone, suturing is not possible. Yet, if we fail
to bring the surfaces together congruently, spikes on fragment sur
faces can act as spreaders, creating gaps between the bone ends that
must be filled in with tissue that does not immobilize the fragments
until fully ossified. The greater the gap between the bone ends, the
larger the volume of new bone needed for bridging. A significant
fracture gap also separates the corresponding periosteal and endo
steal surfaces, both of which are important for osteogenesis.
The requirements outlined above were well known to nineteenth
1 [201,549] century authorsl, since they recognized the difference between pri
mary and secondary healing. Nevertheless, the requirements were
not considered obligatory by those who advocated nonoperative
2 [229, 230] methods of fracture treatment. For example, Itskova2 found that
reduction was complete in only 53% of tibial fractures treated with
casts and 83% treated with skeletal traction. Even in the anatomical
ly reduced group, some displacement occurred in 29% of patients.
3 [398] In another study, Novikova3 reviewed the results of fracture treat-
ment in 14282 patients. Of this large group, only 2238 (15.6%) had
fractures that united in an anatomic position. Studies by other au
thors have suggested that anatomic reduction is achieved in 18%-
4 [78, 397, 465, 478] 60% of displaced fractures treated by closed means4. Moreover,
secondary displacement occurs in 30%-64% of accurately reduced
5 [110, 173, 180,545,563] fractures5•