Gavriil Abramovich Ilizarov (June 15, 1921, Bialowieza Bialystok Voivodeship of the Second Commonwealth (now Podlaskie Voivodeship of Poland) - July 24, 1992, Kurgan) - an outstanding Soviet orthopedic surgeon, inventor, doctor of medical sciences (1968), professor. Academician of the Academy of Sciences of the USSR (1991; corresponding member 1987). Hero of Socialist Labor (1981). Honored Inventor of the USSR (1985). Honored Doctor of the RSFSR (1965). Honored Scientist of the RSFSR (1991). Laureate of the Lenin Prize (1978).
Compression-distraction apparatus (Ilizarov apparatus, Shevtsov-Matsukatov apparatus) is a medical apparatus intended for long-term fixation of bone tissue fragments, as well as for its compression (“compression”) or stretching (“distraction”), that is, for carrying out the so-called “ transosseous osteosynthesis. " The device is used to treat injuries, bone fractures, congenital deformities of bone tissue. It is also used in "aesthetic" operations in anthropometric (orthopedic) cosmetology for lengthening and straightening legs. The device is a metal "ring" on which are attached "spokes" passing through the bone tissue. The rings are connected by mechanical rods, allowing them to change their orientation at a speed of the order of one millimeter per day. The compression and distraction apparatus was first developed by the Soviet surgeon G. A. Ilizarov (copyright certificate No. 98471 of 06/09/1952).
Using the Ilizarov apparatus, limbs are lengthened, various deformities of the limbs are corrected, fragments of bone are fixed during fractures. The device is constantly being improved and it finds new applications in the treatment of various bone ailments.
The history of the creation of the apparatus by a doctor G. A. Ilizarov
Since ancient times, injuries have occurred in people's lives, for example, broken legs, arms, and so on. Doctors could treat relatively minor fractures, but when a person broke bones unsuccessfully, they did not know what to do. And they tied around the perimeter of the bed, and drove the wire into the bone, and wrapped the leg with magic sheets, but nothing helped. As a result, the fracture did not heal well, not to mention its appearance.
So it was almost to this day. The solution in the middle of the 20th century was found by Gabriel Abramovich Ilizarov. He first proposed his device as a means to treat severe fractures. Subsequently, his invention made it possible not only to effectively treat fractures, but also to lengthen bones, correct leg curvature, and heal many other complex diseases.
In the Kurgan specialized research institute dealing with orthopedics and traumatology, they talk about the history of the invention of this device like this. First, Ilizarov conducted experiments on broken shovel cuttings, piercing them with ordinary knitting needles. As a result, a real medical device for treating fractures was gradually invented. Its essence is as follows. Iron spokes pierce the bone. Further, these spokes are fixed on iron rings, and the rings themselves are interconnected by several bolts. Thus, the leg was fixed and had the opportunity to grow together better.
What is a modern Ilizarov apparatus?
For several decades, constant work has been ongoing to improve the apparatus. At present, the varieties of this design have both similarities and differences with the original sample. Now, instead of knitting needles, rods made of inert materials such as titanium or carbon fiber are often used. Rigid rings were replaced by semicircles, plates and triangles. The device has become much lighter and smaller. It is increasingly used not only for the treatment of fractures, but also with the aim of lengthening the limbs. To do this, a very slow stretching of the bone is initiated, which creates tension in it and surrounding tissues. As a result, bone marrow is gradually forming - a new tissue, due to which the limb becomes longer.
Usually, the proportions of the patient’s body are measured before surgery. This is done in order to find out how much bones can be enlarged without significant violation of the ratio of individual parts of the body. Lengthen or lower legs, or hips. It’s not possible at the same time. The doctor decides with the patient what exactly to lengthen.
The Ilizarov apparatus contains 30 parts. Parts are produced at the pilot plant of our center and can be delivered at cost in the required quantity.
The main supports of the apparatus:
- One-piece rings (Fig. 2a).
- Half rings (Fig.2b).
- Arcs with holes (Fig. 2c).
Rings and half rings are made in 11 sizes depending on their inner diameter from 100 to 160 mm every 10 mm, and then 180-200-220 and 240 mm. The width of the plane of the ring support is 15 mm. The ring is the main support of the Ilizarov apparatus and is used in the treatment of bone pathology of the upper and lower extremities.
Half rings can be interconnected with the help of strips, brackets and screw rods. In addition, to enhance the stiffness of the fixation of the support, they can be interconnected with a lining on top of each other.
Arcs as the main supports are used mainly in the proximal limbs, have 7 sizes depending on the radius of the inner surface of the arches. Moreover, in terms of radius, they are 80-90-100-110-120-140 and 160 mm. The width of the plane of the arcs is 30 mm. The material for the manufacture of external supports is steel 20x13 GOST 563272.
The employees of the biomechanical research laboratory conducted a study on identifying the dependence of the deformation of the rings and arcs of the apparatus on their stiffness and the tension force of the spokes. The rings and arcs of all diameters are examined with a tensile force of spokes from 10 to 170 kg every 20 kg. It was revealed that the stiffness of the arcs is 5 times lower than the stiffness of the rings. The forces arising in the rings of the Ilizarov apparatus, from the action of the tension force of the spokes and the forces of compression and distraction, significantly depend on the layout of the apparatus, on the angle of intersection of the spokes, on the radius of the rings, on the number of rods and their location. The greatest margin of safety of the rings occurs when the angle of intersection of the spokes is 90 ° and the symmetrical arrangement of 4 rods.
Additional external supports of the Ilizarov apparatus (Fig. 3a - c).
Brackets with a threaded shank and a threaded hole (Fig. 3a) are 2, 3, and 4 hole. Designed for fastening and tensioning knitting needles, creating articulated joints, derotational nodes and systems for controlling the position of fragments, segments, fragments. The strips are flat, screw-like and radial with the number of holes from 2 to 10 (Fig. 3b. Most often they are used to connect the supports of different diameters, connect the rods, connect the supports installed in different planes, create the appropriate supports taking into account the anatomy of the segment and to increase the circumference of the half ring when installing them in the proximal extremities. Beams without and with threaded shanks are most often used to connect the main external supports (rings, arches), fasten the knitting needles with the help of special fixators and a dist action rods, reinforcing the rigidity of fixing the supports and nodes when arranging apparatuses with pathology requiring a lot of effort.
Washers: cushioning, grooved, grooved. They are used to correct the position of the spokes, carried out in different planes, fasten the spokes and other mounting options for the device (Fig. 4).
Threaded couplings and bushings (Fig. 5) are designed to facilitate installation of the device for orthopedic pathology, namely: to lengthen the rods, attach additional supports (brackets, straps), followed by the installation and fastening of knitting needles or devices to perform the corresponding medical task.
Continuous-threaded rods are designed to connect the main supports of the Ilizarov apparatus and to mount various functional reposition units in order to eliminate the displacement of fragments along the width, periphery, as well as the installation of articulated and other joints. In length, they are available in 6 sizes: 60, 80, 100, 120, 150 and 200 mm.
Telescopic rods are made in 4 sizes, depending on the length: 190, 220, 290, 380 mm. They are designed to connect the main supports located at a great distance from each other. Connecting them with the main external supports, the fixation stiffness is significantly enhanced and are most often used when lengthening the limbs, eliminating deformations and re-installing the apparatus at the stage of changing the fixation stiffness of fragments (Fig. 6).
Threaded rods with a hole and a distraction groove are used in cases where it is necessary to move osteotomized fragments to replace defects, reposition of bone fragments in case of incorrectly fused and old fractures. The length of these rods ranges from 40 to 120 mm every 10 mm.
At the stages of the development of parts, various special fixators were used, which are presented in Figure 7.
At present, bolts are used with special fixators with a groove or hole , they are intended for fastening and tensioning the spokes to the main or auxiliary supports. With the help of special fixing bolts, you can not only fasten, but also pull the needles, as shown in the following figures.
In addition to the details described above, keys (end and open-end spanners), round pliers, wire cutters, and wire tensioners (Fig. 8) are necessary for applying the apparatus to tension the base and reposition-fixation spokes.
In addition, bolts, nuts, and a set of chisels are required to perform compactotomy and corticotomy.
The spokes (Fig. 9) are the connecting link between the bone and the external supports of the apparatus. To perform transosseous osteosynthesis, spokes 1.5 and 1.8 mm in diameter are most often used. To increase the rigidity of fixation, 2.0 mm needles can be used. When applying the method of transosseous osteosynthesis for fractures and pathology of small tubular bones, spokes 1.0 mm in diameter are used. The length of the spokes can be from 250 to 400 mm. Carrying the knitting needles through the metaphysical department is not difficult and for this purpose spokes with trihedral sharpening are most often used. In order to reduce the morbidity when conducting knitting needles through the diaphyseal sections of the bone, use knitting needles with a special sharpening, most often in the form of a spear. Studies were carried out with the needles coated with platinum, silver, graphite, but they have only historical, and not practical significance. Currently, spokes with various coatings are used to stimulate bone formation.
To enhance the rigidity of fixation of bone fragments, to achieve their exact reposition, as well as to move osteotomized fragments in order to replace bone defects, needles with thrust pads in the form of bayonet-shaped, corkscrew-shaped bending, soldering from silver solder or stop due to flattening of the knitting needle are used. The location of the thrust pads can be at different distances from the tip of the spokes. In case of fractures of the bones of the pelvis, collarbone, sternum, the persistent sites are located at a distance of 1.5 - 2.0 cm from the tip of the spoke. In case of fractures of the neck and trochanteric region of the femur, the thrust pads are located at such a distance that prevents penetration of the end of the spoke into the hip joint. Most often, persistent pads are located in the middle of the spokes, which are called repositional-fixation.
The spokes in relation to the medullary canal and the cortical layer of the bone can be transmedullary, transcortical, paraossal, while they can pass through both or one semicircle of the limb. Currently developed techniques for intramedullary introduction of needles.
Ilizarov’s apparatus refers to compression-distraction mechanisms. And therefore, its direct purpose is distraction or stretching and compression or compression, and, of course, long-term fixation of individual bone fragments.
Any fracture involves the displacement of the edges of the bone, as the muscles pull them in different directions. The use of the Ilizarov apparatus for fracture of the extremities reduces the risk of displacement of the bone edges to a minimum. The device reliably fixes not yet joined fractures and pseudoarthrosis, without requiring additional immobilization with plaster.
Together with the therapy of pseudoarthrosis and not yet fused fractures, this device is applicable with a positive effect if necessary, correction of limb length.
In case of a limb fracture, the installation process of the Ilizarov apparatus occurs as follows: Using a drill, the spokes of the apparatus carry two pieces through each bone fragment in the fracture region, while the spokes are crossed at an angle of ninety degrees. Each pair of knitting needles in each bone fragment is fixed with a ring or half ring with a special key.
The reduction in compression force occurs due to deformation of the spokes.
The tension of the spokes is constantly monitored and regulated daily. With skillful manipulation of the moving rods, any displacements of bone fragments along the axis, angular deformations are eliminated and a closed reposition of bone fragments is performed.
The process of lengthening the legs using the Ilizarov apparatus is a phased process. The first stage is the application of an apparatus to the patient, the second stage is osteometry (bone dissection), the third stage is the fixation of bone fragments using the Ilizarov apparatus. About seven days after this operation, a gradual process of distraction begins, that is, lengthening of the legs.
Limb lengthening occurs at a rate of one millimeter per day. The speed of stretching directly depends on the individual sensitivity of the portability of the procedure. Elongation by five centimeters occurs in about fifty to seventy-five days. After a period of lengthening, a period of fixation begins. And its duration, as a rule, exceeds the stretching period by half.
At least thirty days later, an operation begins to lengthen the second limb. All operations of this nature are performed under general anesthesia. Already on the second day the patient can walk with crutches. The rehabilitation period should be accompanied by walking and swimming.
The curvature of the limbs is also corrected using the Ilizarov apparatus. An operation is performed to dissect the bone at the site of its deformation. Then, the bone is fixed in the correct position using the Ilizarov apparatus.
The installation of the apparatus consists in introducing the rods and passing the spokes through the bones. Correction of the curvature of the lower extremities can take place gradually, with daily correction, or at the same time, that is, correction is carried out during a surgical operation. Daily correction is carried out by patients on their own.
The Ilizarov apparatus is removed after the fusion of bones in the correct position.
Since the modern Ilizarov apparatus has small overall dimensions, full-fledged movements are available to the patient almost immediately after the operation.
Advantages and disadvantages
The advantage of using the Ilizarov apparatus is the fact that it can significantly reduce the time of bone fusion during fractures and minimize the risk of developing a false joint at the fracture site. Moreover, a partial load is allowed on the injured limb already on the second day after the operation and the installation procedure of the device.
The disadvantages of using the Ilizarov apparatus include facts such as:
- with rings it is inconvenient to lie and sit;
- in places of punctures, scars of a point character remain, after removal of the apparatus;
- while using the device there are swelling and pain that interferes with sleep.
Removing the Ilizarov apparatus is carried out exclusively by a specialist. The device is removed, as a rule, without anesthesia and anesthesia.
The wounds that remain after removal of the Ilizarov apparatus heal quickly enough. In order to speed up the healing process, you can use disinfectants. Scars remain at the sites of removal, but they are usually small in size and practically invisible.
Take the bone.
Stainless steel knitting needles are passed through the bones. One end of the spoke is sharpened trihedrally, the other end of the spoke is inserted into the cartridge of the guide vane. All this looks like a drill is drilling a hole in the bone, and the spoke is like a drill.
Then the spokes are attached to the rings. The final rigidity of this design is given by threaded rods. In general, as you can see, everything is simple, factory-like. Reminds the Soviet children's designer.
Then, a fracture is made surgically (and in some cases two, depending on how much the limb needs to be lengthened). Despite the anesthesia, during the strokes of the chisel on the bone, it gives you so well in the spine (I recall that spinal anesthesia anesthetizes only the lower half of the body), so this is hellishly unpleasant.
Distraction. The purpose of this stage is to lengthen the Ilizarov apparatus and, accordingly, to lengthen the bone. The process is elementary - several times a day, the nurse turns the nuts on your device, the nuts spinning forward along the thread of the rod, push the rings, they in turn push the knitting needles, and the knitting needles push the bones. Feeling after the "twist" is not the most pleasant, you feel your leg stretched to the limit of the string. I note that there are special electronic boxes that automatically and very smoothly do a twist (and as usual, many tales go around as the electronics failed, the boxes went crazy and literally tore apart the limbs). In the fracture between bone fragments, a jelly-like substance is formed, which hardens every day, so you can not lose time. Distraction stage is not very pleasant - but bearable.
Regeneration. The sweet stage, when compared with the service, you become a scoop, and report the days to demobilization. The extension is completed, and the main thing is to help the bone to heal as quickly as possible. To do this, you intensively eat calcium-containing products, go to physical therapy, attend a massage, and recover in a pressure chamber. Nothing hurts already, the device becomes a native integral part of you.
Removing the device. A solemn moment for which you are preparing and waiting as a climax, before which you worry like before an important exam. Someone removed under anesthesia, someone like that, always comes out differently. Control x-ray, the doctor gives the green light to the removal of the apparatus. Unscrewing all the nuts, removing all the rings, only the knitting needles remain in the leg. This feeling of lightness cannot be conveyed - it is so unusual that having lost 3-5 kilogram load, the leg itself takes off. The needles are bite with ordinary nippers and pulled out with pliers. Then the limb is plastered, and the next day they are released on all four sides.
Recovery. It would seem all over. But a new life begins - you learn to walk, struggle with shyness, endure pain, learn to be a new person.