|Year : 2015 | Volume
| Issue : 1 | Page : 40-42
A comment on a work using Ilizarov methodology
Department of Orthopaedics, Thanjavur Medical College, Thanjavur, Tamil Nadu, India
|Date of Web Publication||8-Jan-2015|
Department of Orthopaedics, Thanjavur Medical College, Thanjavur, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumaravel S. A comment on a work using Ilizarov methodology. Med J DY Patil Univ 2015;8:40-2
I reviewed this work on Ilizarov method which I worship, titled "Ilizarov fixator in management of nonunited and infected tibial shaft fractures." Reading this work one can appreciate its basic step by step approach and its openness. However, I do have a few differences in opinion which I will be mentioning later.
Introduction of the Work
It is a statistically significant work on 30 infected fractures (18 gap nonunions) of tibia treated with Ilizarov circular fixation. Just because the center is a medical college with advanced facilities, such study in patients from a rural background of a developing country is not easy. This is due to the poor acceptance of the Ilizarov ring.  Showing Ilizarov patients walk along with their X-rays are needed for the consent from a new patient.  In one sentence, the authors describe the final aim of treatment of a nonunion is to achieve a "leg without deformities." The versatile nature of Ilizarov allows this.
| The Step by Step Approach|| |
The success of this paper is that it provides a general know-how about the things one may need in any set up. These include selection of cases, their relevant investigation, preanesthetic checkup, removal of the existing failed devices, measurement of both the legs, doing culture and sensitivity for choosing the antibiotics. An ideal interval of 2 weeks is allowed before the patient is taken up for a definitive application of an autoclaved preassembled apparatus. Careful description of, first, passing the reference wires taking care of the anatomical cuts to fix the ring to the limb and second, maintaining the plane of the rings parallel to the ground are few examples. Details like corticotomy in most cases or acute docking of the fracture site without corticotomy in four cases are also explained. Clinical and radiological evidence, the ability to walk without pain and calcification and re-canalization of the regenerate are accepted methods of assessing fracture union are reiterated in the paper. Vital things such as dynamometric-tension, timing of the corticotomy, postoperative mobilization of joints, supplementation of Calcium, and Vitamin C. Re-tensioning of wires, tightening of nuts, and clamps are also reiterated. Careful release of the tension in all the wires before cutting the wires is one another useful point.
| Openness of the Paper|| |
Though the findings in the work concur with what is already known, one needs to read its limitation part. Here, the authors accept the small sample size and a short follow-up period (affecting Association for the Study and Application of the Methods of Ilizarov scoring system). They have also accepted the need for additional procedures like tendo calcaneus lengthening and bone augmentation. They have accepted a changing periodicity of X-rays that is, once in every 2 weeks initially during bone transport and later once in 6-8 weeks during the consolidation phase that is, 12-38 in number (average 21). This is comparable to other series as they have included bone transport cases also.  For similar cases, we have used diagnostic electric stimulation to assess fracture healing, provided the patient gives consent.  This is only a suggestion. It does not take away the credit of doing such a work, which is tedious and needs commitment. Declaration of a longer treatment period, wire infection in all cases, poor bony and functional results and failure of union in two of their patients is few examples of their openness. Surprisingly, they did not see complications such as premature consolidation, nonreporting of patient in time, and aneurysms.
| Where we Differ|| |
The authors have hammered the corticotome in a fan-shaped manner to cut the medial, lateral and far cortex. In practice, this can be difficult. Instead, I have in the initial period, after the medial and lateral cuts dismantled and turned the distal assembly laterally to complete the far cortex cut (as the author already does rotate the rings on the both side of corticotomy after removing the connecting rods between; by a crackling noise confirms completion of corticotomy). Also to reduce the energy level of hammering, predrilling along the line of corticotomy can help. Presently, I pass a Gigli-wire (Staan Bio-med Engineering Private Limited, 190-A, Bharathiar Road, Ganapathy, Coimbatore - 641006, Tamil Nadu, India) using a right angled artery forceps around the proposed site of corticotomy and cut the bone.  This method first thought to reduce tissue regeneration as it cuts the endosteum, produce abundant and proportionate regenerate.  The authors have started to distract the corticotomy on the 3 rd to 5 th day which we feel they could have postponed to 7 th to 10 th day. During the ring removal, after cutting the wires instead of removing the connecting rods and rings one by one, the entire anterior nuts can be removed and the rings can be opened.
I sincerely hope these comments will help the reader to understand the paper better.
| References|| |
Kulkarni GS. Biomechanics of Ilizarov ring fixator. In: Kulkarni GS, editor. Text Book of Orthopaedics and Trauma. 1 st
ed. New Delhi: Jaypee Brothers; 1999. p. 1490.
Illiterate patients: Greater care and caution required in the Indian context. In. M .K .Bajpai Ed: Med Law Cases Doct 2012;5:180-81.
Schiedel FM, Buller TC, Rödl R. Estimation of patient dose and associated radiogenic risks from limb lengthening. Clin Orthop Relat Res 2009;467:1023-7.