Pseudarthrosis and osteomyelitis treatment with external fixators
(Ilizarov method)

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Dr. Alexander Kirienko

Surgeon

Specialist in Orthopedics and Traumatology

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PSEUDOARTROSIS

Pseudoarthrosis is the failure to consolidate a bone fracture approximately 6 months after the event (3 to 6 months is referred to as delayed consolidation). It is a late complication brought about by the interruption of the physiological healing processes of the fracture.

Depending on the shape that the two bone stumps take at the end, at the fracture line, we distinguish two types of pseudoarthrosis:

  • Atrophic:
    the apices of the two bone segments are thinned to the extent that they completely avoid contact;
  • Hypertrophic:
    the end tract of bone segments widens into an elephant's foot where the two stumps touch but are not welded together.
CAUSE
  • Failure to weld:
    there is a failure of bone callus formation, the bone fails to produce the bone tissue needed to weld the fragments together.
  • Development of a "false joint":
    due to the absence of the weld, the area affected by the fracture becomes mobile and unstable, behaving like an artificial joint.

Diagnosis is made by examination of the specialist aided by radiological investigations (X-ray(RX), CT, MRI) in assessing the degree of failure of bone consolidation.

  • Stability problems:
    excessive opportunity for movement of bone fragments prevents proper formation of the bone callus
  • Inadequate conservative or surgical treatment
  • Insufficient vascularization:
    the fracture site has a reduced vascular supply resulting in a shortage of oxygen, cells, and growth factors
  • Infections
  • Patient's own factors that adversely affect vascular microcirculation:
    advanced age, smoking (nicotine), anemia, cortisone therapies, diabetes, nutritional deficiencies, unbalanced diet

The Ilizarov method involves the use of an external fixator that stabilizes the bone and stimulates tissue regeneration through gradual distraction of bone segments.

  1. Osteotomy:
    an incision is made to fracture the bone in a controlled manner, preserving the vasculature and periosteum.

  2. Fixator application:
     Kirschner wires and screws are inserted into the bone, which are connected to metal hoops that form the outer “cage” of the fixator. The hoops will be connected to each other by threaded rods.

  3. Osteogenic Distraction:
     Bone segments are gradually pushed away through the device, thus stimulating histogenesis, or regeneration of bone tissue.

  4. Gradual correction:
     daily lengthening of the threaded rods connecting the circles is provided, spacing the bone fragments and stimulating regeneration of new tissue.

  5. Bone regeneration:
     the bone responds to this gradual distraction by creating new cells and tissue, lengthening the limb or healing the fracture.

  6. Movement and Loading:
     The patient can load on the limb during treatment, as the fixator provides stability and stimulates consolidation.

OSTEOMIELITE

Osteomyelitis is an infection of the bone caused by pathogens (the most common being staphylococcus aureus and, more rarely mycetes or clostridia).
Children and the elderly are most frequently affected but it can be developed by anyone.
Depending on location and onset it can be:

  • Acute osteomyelitis, results from direct aggression of a pathogen or spread by blood from adjacent infected soft tissue
  • Spinal osteomyelitis, which develops gradually, causes persistent back pain that worsens with movement and is not relieved by rest.
  • Chronic osteomyelitis, results from treated osteomyelitis without resolution of the infectious picture. Sometimes, it is undetectable for a long time and does not produce symptoms for long periods. It causes bone pain, recurrent infections in the soft tissues over the bone with pus secretion.
CAUSES
  • Hematogenic:
    bloodborne transfer of the pathogen
  • Direct invasion by pathogen:
    through open fractures, postoperative wounds, or synthetic means that pierce bone
  • Secondary to contiguous infection
  • Associated with peripheral vascular problem
The risk of disease occurrence increases in case of:
  • Smoke
  • Chronic diseases with circulation disorders (diabetes, peripheral arterial disease, renal failure, sickle cell anemia..)
  • Recent injury or orthopedic surgery
  • Diseases requiring intravenous drug administration or application of a catheter
  • Weakening of the immune system
  • Injections of substances through non-sterile devices or non-disinfected skin

The Cierny-Mader classification provides a guideline for the treatment of osteomyelitis, depending on the severity and extent of the disease:

  • Osteomyelitis type I (spinal canal):
    start with targeted antibiotic therapy then, if needed, surgery with thorough cleansing.
  • Osteomyelitis type II (cortical bone):
    surgical removal of the infection by debridement and use of flaps or advanced closure techniques to fill spaces in the treated tissue.
  • Osteomyelitis types III and IV:
    require surgical treatments with extensive bone resections and, in severe cases, external fixators. Implantation of prostheses may be necessary to fill bone loss, bone grafts or bone substitutes (Pmma, polymethylmethacrylate) are used, in combination with techniques such as Masquelet's, ordistractional osteogenesis by external fixation. In extreme cases, amputation may be used.

Distractional osteogenesis by external fixation (Ilizarov method)

The consequences of osteomyelitis can involve bone loss, deformity of the bone segment, and even shortening of the affected limb. The Ilizarov method restores normal anatomical function or structure through the use of a structure attached to the bone, which provides the bone with a fixed support that guides it through the process of recomposition and subsequent recalcification.

  1. Osteotomy:
    an incision is made to fracture the bone in a controlled manner, preserving the vasculature and periosteum.

  2. Fixator application:
     Kirschner wires and screws are inserted into the bone, which are connected to metal hoops that form the outer “cage” of the fixator. The hoops will be connected to each other by threaded rods.

  3. Osteogenic Distraction:
     Bone segments are gradually pushed away through the device, thus stimulating histogenesis, or regeneration of bone tissue.

  4. Gradual correction:
    daily lengthening of the threaded rods connecting the circles is provided, spacing the bone fragments and stimulating regeneration of new tissue.

  5. Bone regeneration:
     the bone responds to this gradual distraction by creating new cells and tissue, lengthening the limb or healing the fracture.

  6. Movement and Loading:
     The patient can load on the limb during treatment, as the fixator provides stability and stimulates consolidation.

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06 35528500

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