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Clinical And Functional Assessment Of Patients With Use Of Ilizarov External Fixator In Acute Trauma

*Pankaj Kumar   #G. K. Singh  ж M.P.Singh **Suraj Bajraacharya

*Asst. Prof. Department of Orthopaedics, BP Koirala Institute of Health Sciences, Dharan, Nepal
#Professor, Department of Orthopaedics, BP Koirala Institute of Health Sciences, Dharan, Nepal
жHead of Department, Department of Orthopaedics, BP Koirala Institute of Health Sciences, Dharan, Nepal
**Post graduate trainee, Department of Orthopaedics, BP Koirala Institute of Health Sciences, Dharan, Nepal

Address for Correspondence

Dr Pankaj Kumar,
Asst. Prof, Department of Orthopaedics
BP Koirala Institute of Health Science, Dharan, Nepal
Ph No. 00977-25-525555-3260®,2016(Off)
Fax no.977-25-520251


Aims and Objective: To determine the clinical effectiveness of Ilizarov external fixation for the acute treatment of the supracondylar femur, tibial plateau, upper fourth and distal fourth tibial fractures.
Study Design: Descriptive Study.
Setting: A tertiary care hospital.
Patients and Methods: 55 grade IIIB fractures of 20 distal fourth femur  C3 (14),  C2 (6), 12 distal fourth tibia of  C1.1 (6),  C1.3 (6), 12 upper fourth Tibia of A2 (8)  and A3 (4) fractures according to AO classification and 11 Tibial plateau fractures  of Schatzker type VI (5) ,  V(5),  IV(1)  followed up to 12-52 months were studied.
Intervention- Ilizarov hybrid external fixator till sound union and physiotherapy.
Main Outcome measure-Clinical and functional outcome at > 52 months.
Results: Supracondylar fracture united at 39.00±9.15, distal fourth tibial fractures 31.1667±8.3046, upper fourth tibia 24.00±5.2915 and Tibial plateau tooks 15.545±4.160 weeks to unite and were significantly different (p-0.00).  The extensor lag of 5°to 10° (12.222±3.49) and ROM at knee in type C2 (110°±10°), (72.85°±36.38°) in type C3 supracondylar fracture of femur, in type IV tibial platue 130°±00, type V 124°±8.94° , type VI 125°±7.0711°, distal fourth fracture tibia of type C1.1 (50°±0.00), type C1.3 (43° ±5.7755) and in the upper fourth tibial were no restriction of movement.
Conclusion: Functional results were better in upper fourth, distal fourth tibial fractures but in only type VI tibial platue fractures and 50% cases of only type C3 supracondylar fractures.
Key words:  Ilizarov hybrid external fixator, supracondylar, tibial plateau, upper fourth and distal fourth fracture, Clinical and Functional outcome.

J.Orthopaedics 2006;3(1)e5


The use of circular external fixator for acute trauma of the upper and lower extremities is common in Russia and part of Western Europe and increasing in North America.1 Metaphysical fractures may have extension into the articular and diaphyseal regions, greatly increases the complexity of their management. 2 The presence of Gustilo type I or II open wound does not alter basic treatment guidelines. However, a type III wound, especially III B, favors stabilization with an external fixator. Less exposure is needed if performing a limited open reduction and external fixation, decreasing the amount of soft tissue dissection and limiting local vascular injury. Stabilization of short periarticular fragments is possible with a circular external fixator. Because the wires are tensioned and supported circumferentially, a “trampoline” of fixation is provided.2 Fixation is rigid enough to allow early motion and partial weight bearing.  The comminuted fractures are one the most difficult to treat with open reduction and internal fixation. The distal fragment is usually small and many times fragmented. This versatile external fixator is an excellent tool for these fractures. Skin conditions are bad and more complicated when the fracture is open as in many cases. Open reduction and stabilization are very difficult or impossible. This ring fixator with its inherent advantage is useful. The spectrum of injuries to the tibial plateau is so great that no single method of treatment has proven uniformly successful. Despite improvement in imaging technique and less invasive surgical methods, the management of tibial plateau fractures remains controversial.3 The purpose of this study is to clinical and functional assessment of patients after application of ilizarov external fixator in acute trauma.

Material and Methods :

Total 55 open grade IIIB fractures of age between 18 to 58 years (36.9±10.76), of 24 male and 6 female, 20 cases of distal fourth fractures of femur of fourteen   type C3, six  type C2  , 12 distal fourth fracture of tibia and fibula  of six  C1.1 and  six  C1.3 and 12 upper fourth Tibia and fibula  of A2  eight and A3  four, according to AO classification, 11 Tibial plateau fractures of Schatzker type VI five, type V five, one type IV fractures were treated at BPKIHS, Dharan, NEPAL during August 2000 to August 2004 and followed up to 12-52 months, were studied. INCLUSION CRITERIA-All open grade IIIB tibial plateau fracture, upper fourth, lower fourth and supracondylar fracture of femurs with intraarticular extension,  EXCLUSION CRITERIA-All fractures with extensive soft tissue loss excluded from study. Initial resuscitation, splintage and primary care for the wound was provided in the emergency room. Any bony fragments that were protruding out were covered with sterile dressing. The patients were then taken to the operating room and treated by pulse lavage and debridement of wound and fixation of fracture accordingly. All tibial pleatue, all proximal fourth fractures and all lower fourth fractures of tibia and fibula (Reversed Hybrid), treated with Ilizarov hybrid fixator using two Ilizarov 5/8 rings and AO External fixator and all supracondylar of femur treated with two ring in lower fragments using 5/8 ring in lower most and in proximal fragments using one 5/8 ring and proximal most using Italian arc at required distance and connected with threaded rods. We were used schanz pin in proximal fragments of supracondylar fracture. Acute shortening were done in supracondylar and distal fourth fractures after removal of loose detached small fragments. Acute shortening were helped in primary and delayed primary closure of wound. In all cases we used image intensifier for accuracy of reduction. Every attempt was made to cover the exposed part of bone with soft tissue; however flap coverage was not needed in any cases. Initial first 48 hours we teach the patients and patient attendant how to clean the wire and rings. Usually we teach them pin tract cleaning minimum twice a day regularly with betadine solution or sprit. All patients were made to stand with support after 48 hours, in all cases of Tibial plateau fractures knee mobilization started within heels of pain and partial weight bearing after 3 months and full weight bearing after 6 months after clinicoradiological assessment, in all cases of upper fourth and lower fourth tibial fractures toe touching were permitted as per the stability of the fixation diagnosed radiologically. Partial weight bearing with support was started within 2 weeks of fixation and for supracondylar fracture of femur knee mobilization started within heels of pain and weight bearing (either partial or full) started according to clinicoradiological assement. Wounds were inspected at the interval of 48 –72 hours and repeat debridement was done whenever required. Split thickness grafting was performed within 3 weeks of primary surgery.   We did secondary bone grafting in all cases of supracondylar fractures. Clinical and radiological feature assessed the progress of bony union at 6 weeks interval till union was sound. The radiological assessment of bony union by good evidence of bridging periosteal and endosteal callus formation as seen by the obliteration of the fracture line. The clinical assessments of the union were mainly based on complete absence of pain and tenderness at the fracture site. Satisfactory wound healing and good amount of endosteal and periosteal callus formation were taken as the criteria for removal of fixator. Clinical and functional assessments were done after union by asking the question, ever have you pain on walking, getting out of chair, going up, going down, pain at rest and needs support of cane and stability was checked by physician. Our aim was to determine the clinical effectiveness and safety of Ilizarov external fixation for the acute treatment of severely comminuted extra-articular tibial fractures, tibial plateau and supracondylar fractures of the distal femur.

Results :

Time to union was significantly different between fracture types (p-0.00). Supracondylar fracture united at 39.00±9.15 weeks whereas distal fourth tibial fractures took 31.1667±8.3046 weeks to unite. Fractures of upper fourth tibia united at 24.00±5.2915 and Tibial plateau took 15.545±4.160 weeks to unite.

The extensor lag of 5°to 10° (12.222±3.49) were seen only in supracondylar fractures.  The ranges of movement at knee in C2 type supracondylar fracture were (110°±10°) and (72.85°±36.38°) in type C3.  Knee movements in type IV tibial platue were 130°±00, type V 124°±8.94° and type VI 125°±7.0711°.Range of movement of distal fourth fracture tibia of type C1.1 (50°±0.00), type C1.3 (43° ±5.7755) and in the upper fourth tibial fractures there was no restriction of knee movements.

40% of supracondylar fractures had 4 cm and 40% had 1.5 cm shortening and in distal fourth tibial fracture 30% had 1cm of shortening. They are managing to walk with shoes rising.  One patient of type VI tibial plateau had pin tract dermatitis that was successfully treated by dermatologist. One case of distal fourth tibia develops 10º of equines she is managing to walk with high heel sandal. Despite of pin tract infection nothing alters our results.                     

In the type VI tibial platue fractures pain on walking only in 20% of cases, whereas type IV and V it was in above 80% of cases. There was no different seen in walking with support, getting out of chair, going up but in going down again there was no problem in type VI but 100% problem in type IV and V fractures. Pain at rest was observed in one out of five cases in type V fractures.

In supracondylar fractures of femur problems in 100% of cases in all type of function was observed in C2 type of fractures.50% cases of C3 fractures had problem in pain on walking, walking with support and pain at rest, whereas no cases had any problem in getting out of chair, going up and going down.

In (33%) fracture of distal fourth of tibia of C1.1 type had pain on walking. In none of the other cases were problems in any function.

In upper fourth of tibia only A2 type fractures were treated in which 8 out of 12 had pain on walking? No other functions were compromised.

Discussion :

The Ilizarov method of fixation device can be used to correct limb length discrepancies, manage open and closed fractures, nonunion, and bony or soft tissue deformities.  Early aggressive debridement of nonviable tissues, stabilization with an Ilizarov external fixator, and either primary or delayed primary closure followed by early mobilization and weight bearing is an alternative treatment method of these injuries.4Acute shortening, using the Ilizarov technique followed by progressive lengthening, is one of the methods used to deal with complex fractures combined with severe soft tissue injuries.5 Despite technical difficulties and problems associated with pin-tract infections, the Ilizarov external fixator may be the preferred technique in open tibial fractures because of high union rates, the use of thin K-wires with minimal traumatic effect, and more successful functional results.6 The most frequent complication was pin-tract infections. This study suggests that the hybrid external fixator in standard configuration have stiffness characteristics similar to those of the conventional Ilizarov fixator when used to treat metaphyseal and shaft fractures of the tibia.7 Functional result were better in upper fourth and distal fourth tibial fractures and in type VI tibial platue fractures only. Kumar A, Whittle AP compared with other series, and they believed it is appropriate for treatment of these complex tibial fractures (Schatzker Type VI) especially those with a poor soft-tissue envelope.8  Roberts CS, Dodds JC et al showed that most dramatic improvements in the stability of hybrid frames used for proximal tibial fractures result from addition of an anterior, proximal half-pin.9 This hybrid frame is easy to apply, versatile, and significantly less expensive than other commercially available adaptors and frames.10 This hybrid frame allows immediate functional stabilization of tibial diaphyseal fractures and postoperatively allows ease of fracture gap closure and compression.  For optimum fixator stiffness in hybrid fixators, at least three femoral arches and four half-pins must be used. However, it should be remembered that, hybrid fixator models had less axial and bending stiffness than standard Ilizarov fixator model.

According to Arazi M et al mean range of flexion of the knee in supracondylar fracture of femur, at the final follow-up were 105 degrees (35 to 130º) with compared to our study ranges of movement at knee in C2 type supracondylar fracture were type (110°±10°) and (72.85°±36.38°) in type C3.11 50% of cases of only type C3 supracondylar of femur will give good functional result.  Application of the Ilizarov external fixator is slightly more complicated than traditional large pin fixator and requires more attention to detail intraoperatively and postoperatively, but can be a versatile tool in the management of complex tibial shaft fractures.12

Using this technique, we found some advantages. First, there is no need for free and local flaps.5 Second, it permits definitive treatment using an external fixator device, enabling the possibility of early functional loading. Third, Functional results were better in upper fourth and distal fourth tibial fractures but in only type VI tibial platue fractures and 50% cases of only type C3 supracondylar fractures were better in terms functional results.  On the basis of our experience, we suggest adopting this method for functional limb salvage after extensive complex high-energy injuries. This fixator is safe and versatile, effective in providing stability and allowing early rehabilitation, although the indications for its use are very–very specific.13

Reference :

  1. Ilizarov Ga.Experimental studies of bone elongation .In: coombs R, Green S, Sarmiento A, eds. External fixation and functional bracing. London: Orthotext; 1989: 375

  2. Chapman WM. Chapman Orthopedic surgery.Philadelphia, PA:Lippin cott William and Wilkins: Edn third.

  3. Rockwood AC, Green PD .Fractures in adults. Philadelphia, PA:Lippin cott Raven: Edn third.

  4. Yildiz C, Atesalp AS, Demiralp B, Gur E. High-velocity gunshot wounds of the tibial plafond managed with Ilizarov external fixation: a report of 13 cases. J OrthopTrauma.200 Jul; 17(6):421-9.

  5. Lerner A, Fodor L, Soudry M, Peled IJ, Herer D, Ullmann Y. Acute       shortening: modular treatment modality for severe combined bone and soft tissue loss of the extremities.  J Trauma. 2004 Sep; 57(3): 603-8.

  6. Inan M, Tuncel M, Karaoglu S, Halici M. Treatment of type II and III open tibial fractures with Ilizarov external fixation. Acta Orthop. Traumatol Turc. 2002; 36(5):390-6

  7. Lundy DW, Albert MJ, Hutton WC. Biomechanical comparison of hybrid           external      fixators. J Orthop Trauma. 1998 Sep-Oct; 12(7): 496-503.

  8. Kumar A, Whittle AP. Treatment of complex (Schatzker Type VI) fractures of the tibial plateau with circular wire external fixation: retrospective case review. J Orthop Trauma. 2000 Jun-Jul; 14(5):339-44.

  9. Roberts CS, Dodds JC, Perry K et al. Hybrid external fixation of the proximal tibia: strategies to improve frame stability. J Orthop Trauma. 2003 Jul; 17(6):415-20

  10. Remiger AR, Miclau T, Neuer W. A simple technique for creating hybrid                fixators using a modified AO single adjustable clamp.  J Orthop Trauma, 1997 Jan; 11(1): 54

  11. Arazi M, Memik R, Ogun TC, Yel.  Ilizarov external fixation for severely comminuted supracondylar and intercondylar fractures of the distal femur.  J Bone Joint Surg Br. 2001 Jul; 83(5): 663-7.

  12. Tucker HL, Kendra JC, and Kinnebrew TE. Management of unstable open and closed tibial fractures using the Ilizarov method. Clin Orthop. 1992, Jul ;( 280): 125-35.

  13. Ong CT, Choon DS, Cabrera NP, Maffulli N.  The treatment of open tibial fractures and of tibial non-union with a novel external fixator. Injury. 2002 Nov; 33(9): 829-34.


This is a peer reviewed paper 

Please cite as : Pankaj Kumar:Clinical And Functional Assessment Of Patients With Use Of Ilizarov External Fixator In Acute Trauma

J.Orthopaedics 2006;3(1)e5





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