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Ilizarov surgery, a minimally invasive surgical procedure named after Professor Gavril Abramovich Ilizarov who discovered the working principle of Limb Lengthening Surgery. According to this principle, which he referred to as " The law of tension stress" the biological tissue can grow under mechanical tension. Prof. Ilizarov, first used this technique in 1950 in Kurgan, the Siberian city of former Soviet Union to treat World war II afflicted patients. He accidently discovered the process of "Distraction Osteogenesis" that causes lengthening of bone, while treating one of his patients who was supposed to compress the frame and he mistakenly moved it in the opposite direction causing it to separate further. Dr ilizarov observed callus(bony healing tissue) formation in the cut and separated ends of the bone.
Since then, Ilizarov technique has offered hope for patients with
Injuries associated with bone loss, here this technique is utilized to make up for the bone loss and fill the bone gaps as big as 8 inches.
Congenital abnormalities of the limbs.
Patient with acquired problems concerning limbs such as due to Polio, infection in bone, malunited fracture, surgical removal of benign or malignant tumor of bone, dysplasia and destruction of the hip joint.
For cosmetic reasons, to increase height.
Ilizarov surgery has been used extensively to treat patient with above problems with high success rate. It is a safe surgery, though complex and calls for highly skilled and experienced surgeon. Patient also need to be tolerant as it requires prolonged time, regular follow up and good care of the frame. This technique also work wonders for patients who had failed rod implants or bone grafting surgeries initially or had severe infections. Ilizarov surgery involves natural bone lengthening process.
Q1 What are the indications for Ilizarov surgery?
A1 Ilizarov surgery is indicated for the following:
Birth defects of the lower limbs that need both lengthening and correction of angular deformities.
Reconstruction surgery to fill the large bone gaps created as a result of trauma, tumor or infection
Contraction of the joints
Non-Union of fracture
Mal-Union of fracture
Dwarfism, for lengthening
Few acute fractures
Distraction of joints
Q2 What are the benefits of Ilizarov technique over other techniques in Limb reconstruction surgery?
A2 Ilizarov technique offers several advantages over other techniques for limb reconstruction surgery, as mentioned below:
Distraction Osteogenesis principle, the basis of this technique, works well in both young and mature bones which means equally effective in both adults and children. It pulls the bone parts apart resulting in new bone formation which can be used for limb lengthening and overcoming bone loss due to trauma, infection or tumor.
Modular structure of the apparatus: Ilizarov external frame can be customized as per the individual patient's needs.
Increased stability and even distribution of stress across the bone gap, due to the circular frame of the apparatus..
The shape and strength of the frame enables weight bearing all through the treatment which helps the patient in
Prevent joint stiffness
Build muscle strength
Minimially Invasive surgery- During the surgery, bones are connected to the rings of the frame by means of wire and no other skin incisions are required thereby diminishing chances of bleeding, infection and damage to the neighbouring soft tissue.
As compared to other techniques used for limb reconstruction surgery, studies have shown it to reduce treatment time, primary disability and treatment cost.
Q3 What is the structure of the Ilizarov device?
A3 Ilizarov device is a metal frame that encircles the limb and it is attached to the underlying bone with the help of pins put inside through the bone and the limb.The external rings are connected to each other through rods and hinges that in turn allow the patient and the doctor to move the position of the bone.
Q4 What are the causes of limb shortening?
A4 The causes of limb shortening can be summarized as follows:
Congenital short Femur, referred to as Proximal focal femoral Deficiency
RTA(Road Traffic Accidents) or Trauma are responsible for a huge number of malunited fractures accompanied with shortening.
Trauma to the distal Femur, its fracture resulting in damage to its growth plate.
Severe infections such as Osteomyelitis, Septic arthritis of the hip, Fulminating meningococcemia, an infection resulting in growth retardation as it destroys growth plates in various sites.
Neurological causes such as Cerebral Palsy
Bone diseases such as Osteogenesis Imperfecta, Rickets, hypophosphatemia
Residual Paralytic Poliomyelitis
Surgical removal of benign and malignant tumor of bone
Dysplasia and destruction of the hip joint
Q5 What are the repercussions of inequality of limb?
A5 Shortening of the upper limb does not cause significant problems. Difference can only be made out once it exceeds15%. Mild to moderate shortening does not call for surgery in the arm. Significant shortening of humerus, especially if accompanied with the elbow joint can result in lack of reach so much so that riding a two wheeler may seem difficult. In contrast, the shortening of bones(Radius and Ulna) in forearm, however small, is an absolute indication for limb lengthening surgery as it affects the Radio-Ulnar joints adversely. Loss of movement of the forearm, especially for the activities such as like tightening of the screws are affected to a large extent.
Unlike shortening in the upper limb, lower limb shortening cannot be accepted. Even insignificant difference in limb length may lead to several problems such as difficulty in walking making it stressfull, excessive pressure on the weight bearing joints predisposing them to early arthritic changes and result in backache as well.
Q6 What are the indications for wearing shoe raise or adaptive footwear?
A6 Discrepancy of 2 to 2.5 cm can be made up for by wearing shoe raise. However, shoe raise for a discrepancy beyond that is not acceptable since it is heavy and may lead to fall while walking.
Q7 What are the stages of limb lengthening?
A7 Limb lengthening has four stages:
1.Distraction- This stage commences 5 to 7 days after surgery. Most favourable distraction(controlled pulling apart of bone's cut ends) is done at a rate of 1mm/day, 0.25 mm every 6 hrs, until the required length is procured. For eg. for lengthening of 5 cm, time would be 50 days for distraction.
2.Consolidation (Hardening)- This phase involves the hardening of the newly formed soft bone. This time is twice the amount of time taken for distraction. Time is nearly 1 month for each 1 cm of lengthening. Therefore for 5 cm, time would be approximately 5 months. During this time external fixator remains at its place and only removed once the newly formed bone is strong enough to permit its removal.
3. Removal of the external fixator or frame Xrays and clinical examination are the usual methods carried out to evaluate the strength of the new bone in order to decide the best time to remove the frame. The best time for removal of the frame is when the xray shows that the newly formed bone has bridged the gap completely and cortex has been formed at the lengthened region. Then connecting rods of the external fixator are removed under General anesthesia and the strength of the bone is clinically examined. The external frame is completely removed only when the bone is considered solid enough to do so. Eventually, cast or brace is applied on the surgical site for another 4 to 6 weeks.
4. Rehabilitation Limb rehabilitation is initiated after the cast or brace is taken off. range of motion and strengthening exercises are advised as part of physiotherapy. This stage last for couple of months.
Q8 How much time does the surgery take?
A8 The surgery usually takes around 3 to 5 hrs. However, it may vary from patient to patient.
Q9 How much is the duartion of hospital stay?
A9 The hospital stay is generally 5 days. It may differ from patient to patient.
Q10 What does Ilizarov method of surgery involve?
A10 Ilizarov method is generally used to correct limb deformities. The Ilizarov technique is based on the principle of Distraction Osteogenesis. According to this principle, the concerned bone, is strategically cut(osteotomy) into two, pulled apart in a controlled manner(distraction) with the help of an external device commonly referred to as Ilizarov apparatus named after the doctor who used it for the first time.
This device consists of metal rings, rods and wires that encircles the limb in such a way so as to pull apart the broken ends of the bone in a controlled manner usually at the rate of 1mm/day and this stimulates the formation of new bone naturally over a period of time and so its nerve and blood supply. The best part of this technique is that it permits a person to lead a normal life despite a fracture.
Q11 When to go for lengthening process?
A11 Age of the person and the amount of difference are taken into account in order to decide the right time to go for lengthening. Generally, difference of 5 cm or more calls for limb lengthening surgery or if there are chances of discrepancy of 5 cm or more at skeletal maturity(when growth stops) which is around 16 yrs for boys and around 14 yrs for girls. Even though there is no minimal age for the limb lengthening, children less than 5 yrs are rarely considered for the limb lengthening, unless there is specific indication to do so. The idea behind this is that firstly the child should have the weight bearing capacity and should be able to cooperate in following the presecribed exercise regimen.
For few exceptional cases, discrepancy of 3 or 4 cm is also taken into consideration for limb lengthening. Discrepancy, less than 5cm, combined with angular deformity requiring correction, are corrected simultaneously with the help of an external fixator.
Q12. Which type of anesthesia is given?
A12 The surgery is done under General anesthesia.
Q13 How much can a bone be lengthened?
A13 Although still not completerly determined, many researchers based on their experience advocate that an increase of 20% to 25% of the original length of the bone, at any given time yield better resuts as compared to increased lengthening. i.e., beyond 25%. Many doctors recommend that in order to meet the expectation of greatly increased length one should go for 2 to 3 legthening procedures, each with 20% increase in length rather than single lengthening surgery with 30% to 40% increase.
Q14 What is osteotomy?
A14 Osteotomy is the surgical cutting of the bone so as to shorten, lengthen or reallign it. Ilizarov surgery is also characterized by osteotomy followed by Distraction Osteogenesis. Here, the metaphysis, part of the bone with the highest metabolic turnover, is cut thereby stimulating the fastest formation of new bone tissue. Great care needs to be exercised during surgery in order to protect the soft tissue and blood supply to the bone.
Q15 What is Distraction Osteogenesis?
A15 Distraction Osteogenesis is a surgical technique or a process that is characterized by gradual progressive separation of the cut segments of the bone and stimulating the formation of the new bone which fills the bone gap through natural bone healing. This principle of new bone formation through controlled pulling apart of cut bone segments has been extensively used in Orthopedic surgery and Oral and Maxillofacial surgery, reconstructive surgery involving skeletal deformities.
It is initiated 5 to 7 days after surgery, at a rate of 1mm/day by adjusting the external fixator or frame 3 to 4 times(every 6hrs) in a day in increments of 0.25mm.
Q16 What is latency phase of Ilizarov surgery?
A16 The latency phase is the time between the osteotomy(surgical cutting of bone) and the lengthening or distraction phase. It is usually 7 to 10 days.
Dr (Prof.) Raju Vaishya
MBBS,MS (Orthopedics),MCh(Orthopedics),FRCS(General Surgery)
Indraprastha Apollo Hospital, New Delhi
Dr Nikhil Agarwal
MBBS, MS(Ortho), MCh(Ortho)
Consultant Orthopedic Surgeon
Wockhardt Hospital, Mumbai
Saket, New Delhi
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