The Basic Principles of External Fixation Using the Ilizarov Device Leonid N. Solomin
Leonid N. Solomin
The Basic Principles of External Fixation Using the Ilizarov Device
Leonid N. Solomin R. R. Vreden Russian Research Institute of Traumatology and Orthopaedics 8 Baykova Str. Saint Petersburg, Russia, 195427 E-mail: solomin
[email protected] This book is intended for those, who got connected with the External Fixation and still have a desire to learn it in such a way as to improve it. Thanks are due to Prof. J. Tracy Watson, Djoldas Kuldjanov, MD, and Dr. Evgeny Tchekashkine for translating and editing some chapters of this book.
Original title:
Osnovy qreskostnogo osteosinteza apparatom G. A. Ilizarova © 2005 “Morsar AV”, Saint Petersburg, 2005 Graphics: E. Chukhonina, L. Arsentjev, K. Guzenko
Library of Congress Control Number: 2007937660 ISBN 978-88-470-0512-9 Springer Milan Berlin Heidelberg New York e-ISBN 978-88-470-0513-6 Springer is a part of Springer Science + Business Media springer.com © Springer-Verlag Italia 2008 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the Italian Copyright Law in its current version, and permission for use must always be obtained from Springer. Violations are liable for prosecution under the Italian Copyright Law. The use of general descriptive names, registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Cover design: Simona Colombo, Milan, Italy Typesetting with LATEX: PTP-Berlin Protago-TEX-Production GmbH, Germany. www.ptp-berlin.eu Printer: Grafiche Porpora, Cernusco/Naviglio, Italy Printed in Italy Springer-Verlag Italia S.r.l.,Via Decembrio 28, I-20137 Milan
To the memory of my parents
Forewords
This book is the first comprehensive text on the Ilizarov method to come from Russia since Professor Ilizarov passed away in 1992.The text covers both acute traumatic reconstruction with the Ilizarov method and orthopaedic reconstruction with the Ilizarov techniques. The authors unique method of cross-sectional anatomy evaluation improves the safety of pin and wire insertion. The text is well illustrated for ease of understanding and numerous case examples are presented demonstrating the results of different treatment methods. Dr. Solomin helps the reader advance along the learning curve of these complicated methods while learning from the author’s extensive experience and avoiding the pitfalls of treatment. Dr. Solomin’s work is a testament to the Ilizarov method’s versatility and utility in the first generation after Professor Ilizarov’s death.This book will serve as a new foundation for the next generation of orthopaedic surgeons interested in limb reconstruction using circular external fixation. Dror Paley, MD, FRCSC Director, Rubin Institute for Advanced Orthopedics Co-Director, International Center for Limb Lengthening Sinai Hospital of Baltimore Balitmore, Maryland, USA
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Forewords
Dr. Solomin’s monograph “Basic principles of external fixation using the Ilizarov device” is one of a number of domestic and foreign texts testifying to the steady growth of interest from orthopaedic surgeons in the problems of achieving a reliable osteosynthesis and in finding a way to really control the bone regeneration process. A convenient classification of external fixation devices, unification of the terminology used, a description of the equipment (some of which is original), and a presentation of the biomechanical basis of external fixation will be useful in practice not only for beginners, but also for those who have some experience of the use of the Ilizarov apparatus. In the manual the reader will find not only an analysis of the basis of external fixation, but also the author’s original approach in this field. The manual includes an atlas of transosseous element insertion. The concepts of “safe positions”, where there are no main vessels and nerves, and “reference positions”, that are used to decrease pin-induced joint stiffness and pin-tract infections, are described. The coordinates derived from the “Method for the Unified Designation of External Fixation” allow data to be precisely transferred to the operation table. Certainly,no book can include all possible clinical situations in orthopaedic practice.Nevertheless,this manual is different from others in being easy to read. Consequently the execution of each method of external fixation can be readily grasped. Furthermore, as stated above, the perfectly prepared illustrations will be of significant benefit to the orthopaedic surgeon. Prof. Vladimir I. Shevtsov Director, Russian Ilizarov Scientific Center “Restorative Traumatology and Orthopaedics” Kurgan, Russia
Forewords
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I am pleased to present this book to experts on external fixation and to those who are taking only their first steps in this field. Having been engaged in the development of external fixation for a long time, I am certain that its potential in rehabilitative treatment is practically unlimited. However, external fixation is highly technical and it is necessary to have a full command of it! A perfunctory knowledge of the method together with its negligent implementation will not satisfy the aspirations of the doctor, will bring suffering to the patient, and will throw a shadow on the authors who are responsible for the method. I regret that the “Method for the Unified Designation of External Fixation” is only now becoming the standard language of orthopaedic surgeons. If it had been developed and introduced earlier, it would have been possible to avoid many of the criticisms (sometimes justified) of the training in the method resulting from “individual” perceptions of the information in articles, instructional lectures, and manuals. It is necessary to note, that the device assemblies for combined (hybrid) external fixation, developed by the author, complement the original Ilizarov devices, the efficiency of which has been confirmed over decades. The clever design, the high-quality illustrations, the wide range of pathological conditions considered for application of external fixation, and the style of presentation of the material are great advantages of this manual. I am sure that it will prove to be of great interest to orthopaedic surgeons in many different countries. Prof. Viktor K. Kalnberz Riga, Latvia
Table of Contents
Contributors 1
General Aspects of External Fixation 1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2 Historical Background and Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 Advantages and Disadvantages, Indications and Contraindications . . . . . . . . . . . . . . . . 1.4 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.5 General Terms for External Fixation Constructs . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6 Biomechanical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6.1 Relationship between the Transosseous Elements and the Surrounding Tissues . . . 1.6.2 Control of Bone Fragment Position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6.2.1 Moving the External Supports with the Transosseous Modules Fixing the Bone Fragments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6.2.2 Moving the Transosseous Elements Relative to the External Supports; External Supports and Modules Remain Immobile . . . . . . . . . . . . . . 1.6.3 Control of Bone Fragment Rigidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6.3.1 Material from which the Elements are Manufactured . . . . . . . . . . . . . 1.6.3.2 Number of Transosseous Elements . . . . . . . . . . . . . . . . . . . . . . . . 1.6.3.3 Diameter and Type of Transosseous Elements . . . . . . . . . . . . . . . . . 1.6.3.4 Wire Tension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6.3.5 Levels of Transosseous Element Insertion . . . . . . . . . . . . . . . . . . . . 1.6.3.6 Plane of Orientation of the Transosseous Elements . . . . . . . . . . . . . . 1.6.3.7 Distance from the Bone to the External Support . . . . . . . . . . . . . . . 1.6.3.8 External Support Geometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.6.3.9 Number of Connecting Rods . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7 Internal Contradictions in External Fixation: Combined External Fixation (CEF) . . . . . . 1.7.1 Method for the Unified Designation of External Fixation (MUDEF) . . . . . . . . . . 1.7.2 Use of Different Types of External Support and Transosseous Elements . . . . . . . 1.7.3 Reference Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7.4 Minimum Number of External Supports and Transosseous Elements . . . . . . . . . 1.7.5 Module Transformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.7.6 Computer Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8 Method for the Unified Designation of External Fixation (MUDEF) . . . . . . . . . . . . . . . 1.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8.2 Symbols Used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8.3 Coordinates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8.4 Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8.5 Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8.6 Designation of Transosseous Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8.7 Designation of K-wires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8.8 Designation of Half-Pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1.8.9 Designation of the External Support Frame . . . . . . . . . . . . . . . . . . . . . . . . 1.8.10 Designation of the Whole Device . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.8.11 Additional Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9 Atlas for Insertion of Transosseous Element Reference Positions . . . . . . . . . . . . . . . . . 1.9.1 Upper arm (L. N. Solomin, R. E. Inyushin) . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.2 Ulna (L. N. Solomin, P. N. Kulesh) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.2.1 Mid-position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.2.2 Supination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.2.3 Pronation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.3 Radius (L. N. Solomin, P. N. Kulesh) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.3.1 Mid-position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.3.2 Supination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.3.3 Pronation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.4 Femur (L. N. Solomin, M.V. Andrianov) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.9.5 Tibia (L. N. Solomin, D.A. Mykalo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.10 Preoperative Preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11 Principles of Frame Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11.1 Identification of Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11.2 Identification of the Optimal Levels for Locating the External Supports . . . . . . . 1.11.3 Identification of the Possible Transosseous Elements on the Basis of Safe Positions and Reference Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11.4 Identification of Transosseous Elements Best Suited to the Particular Clinical Situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11.5 Selection of the Type and Size of External Support for Every Level of Transosseous Element Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11.6 Marking of the Selected Levels and Positions on the Segment for Transosseous Element Placement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.11.7 Transosseous Element Insertion and External Support Installation . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Specific Aspects of External Fixation 2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . 2.2 Fractures of the Humerus . . . . . . . . . . . . . . . 2.2.1 Proximal Humerus (11-) . . . . . . . . . . . 2.2.2 Diaphyseal Fractures (12-) . . . . . . . . . . 2.2.2.1 Proximal Third . . . . . . . . . . . 2.2.2.2 Middle Third . . . . . . . . . . . . 2.2.2.3 Distal Third . . . . . . . . . . . . . 2.2.2.4 Radial Nerve Injury . . . . . . . . 2.2.3 Distal Humerus (13-) . . . . . . . . . . . . . 2.3 Fractures of the Forearm . . . . . . . . . . . . . . . . 2.3.1 Proximal Forearm (21-) . . . . . . . . . . . . 2.3.2 Diaphyseal Fractures (22-) . . . . . . . . . . 2.3.2.1 Ulnar Diaphysis . . . . . . . . . . 2.3.2.2 Radial Diaphysis . . . . . . . . . . 2.3.2.3 Diaphysis of the Radius and Ulna 2.3.3 Distal Forearm (23-) . . . . . . . . . . . . . . 2.4 Fractures of the Femur . . . . . . . . . . . . . . . . . 2.4.1 Proximal Femur (31-) . . . . . . . . . . . . . 2.4.2 Diaphyseal Fractures (32-) . . . . . . . . . . 2.4.2.1 Proximal Third . . . . . . . . . . . 2.4.2.2 Middle Third . . . . . . . . . . . .
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2.5
2.6 2.7 2.8
2.9
2.10 2.11
2.12
2.13
2.4.2.3 Distal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.3 Distal Femur (33-) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4.4 Patella (91.1-) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fractures of the Tibia and Fibula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5.1 Proximal Tibia and Fibula (41-) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5.2 Diaphyseal Fractures (42-) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5.2.1 Proximal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5.2.2 Middle Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5.2.3 Distal Third . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5.3 Distal Tibia and Fibula (43-) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5.4 Ankle Injuries (44-) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.5.5 Chronic Ankle Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Compound Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Malunited Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Basic Principles of Correction of Long-Bone Deformities . . . . . . . . . . . . . . . . . . . . . . 2.8.1 Inequality in Length of the Extremities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8.2 Angular Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8.3 Rotational Deformities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.8.4 Technical Tips and Tricks for the Humerus and Forearm . . . . . . . . . . . . . . . . . Aesthetic Correction of the Lower Extremities (A.A. Artemiev, O.A. Kaplunov, L. N. Solomin) 2.9.1 Shape of the Legs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.9.2 True Bow-Legs (Varus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.9.3 Volume and Contour of the Lower Legs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.9.4 Growth and Length of the Lower Extremities . . . . . . . . . . . . . . . . . . . . . . . . 2.9.5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nonunions, Pseudoarthroses and Long-Bone Defects . . . . . . . . . . . . . . . . . . . . . . . . . Combined Strained Fixation of the Long Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.1 Equipment for CSF and Principles of Application . . . . . . . . . . . . . . . . . . . . . . 2.11.2 Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.3 Femur . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.4 Tibia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.5 Forearm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.5.1 Ulna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.5.2 Radius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.5.3 Both Forearm Bones (Combinative Fixation) . . . . . . . . . . . . . . . . . . . 2.11.6 Clavicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.6.1 External Fixation of the Clavicle . . . . . . . . . . . . . . . . . . . . . . . . . . 2.11.7 Postoperative Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pelvic Injuries (A.V. Runkov, L. N. Solomin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.12.1 Insertion of Transosseous Elements into the Pelvic Bones . . . . . . . . . . . . . . . . . 2.12.2 Principles of Assembly of External Devices for Fixation of Pelvic Injuries . . . . . . . 2.12.3 Surgical Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.12.4 Osteosynthesis in Stable and Partially Stable Pelvic Injuries . . . . . . . . . . . . . . . . 2.12.5 Osteosynthesis in Vertical Unstable Pelvic Injuries . . . . . . . . . . . . . . . . . . . . . 2.12.6 External Fixation of Fractures of the Acetabulum . . . . . . . . . . . . . . . . . . . . . . 2.12.7 Postoperative Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.12.8 External Fixation of Malunited Pelvic Fractures . . . . . . . . . . . . . . . . . . . . . . . Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.13.1 Forefoot Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.13.2 Midfoot Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.13.3 Hindfoot Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.13.3.1 External Fixation of Talus Fractures . . . . . . . . . . . . . . . . . . . . . . . . 2.13.3.2 External Fixation of Calcaneal Fractures . . . . . . . . . . . . . . . . . . . . .
XIII
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165 168 171 172 175 178 178 179 179 183 184 188 190 198 201 201 204 209 209 218 220 220 223 225 228 228 236 237 241 243 244 246 246 248 249 251 253 253 256 256 260 260 260 263 266 268 269 274 274 275 277 277 277
XIV
Table of Contents
2.13.4 Correction of Foot Deformities . . . . . . . . . . . . . . 2.14 Large Joint Pathology . . . . . . . . . . . . . . . . . . . . . . . . . 2.14.1 Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.14.2 Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.14.3 Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.14.4 Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.14.5 Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.14.6 Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.15 Infectious Complications of Long-Bone Fractures . . . . . . . . 2.16 External Fixation in Children, the Elderly and the Senile . . . 2.17 General Principles of Patient Management in the Postoperative 2.17.1 Position in Bed . . . . . . . . . . . . . . . . . . . . . . . . 2.17.2 Anaesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . 2.17.3 Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.17.4 Exercise Therapy . . . . . . . . . . . . . . . . . . . . . . . 2.17.5 Physio- and Pharmacotherapy . . . . . . . . . . . . . . . 2.17.6 Biomechanical Device State . . . . . . . . . . . . . . . . 2.17.7 Outpatient Treatment . . . . . . . . . . . . . . . . . . . . 2.17.8 Device Removal . . . . . . . . . . . . . . . . . . . . . . . . 2.18 Mistakes and Complications of External Fixation . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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279 283 283 285 288 289 291 298 301 303 305 306 306 306 307 307 307 309 319 320 326 331
3
Appendix 1: Method for the Definition of “Reference Positions” for the Insertion of Transosseous Elements 333 3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 3.2 Main Principles for the Determination of Positions with Minimum Displacement of Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 333 3.2.1 Skin Displacement Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334 3.2.2 Fascia Displacement Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 3.2.3 Muscle Displacement Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 3.3 Determination of Positions with Minimum Soft-Tissue Displacement . . . . . . . . . . . . . . . . 335 3.3.1 Femur (L. N. Solomin, M.V. Andrianov) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 3.3.2 Upper Arm (L. N. Solomin, R. E. Inyushin) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335 3.3.3 Lower Leg (L. N. Solomin, D. A. Mykalo) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337 3.3.4 Forearm (L. N. Solomin, P. N. Kulesh) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
4
Appendix 2: Method for Rigidity Testing of External Fixation Assemblies (L. N. Solomin, P. I. Begun, V. A. Nazarov) 4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Indications and Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3 General Theoretical Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.1 Transosseous Module Classification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.2 Method for the Unified Designation of External Fixation . . . . . . . . . . . . . . . 4.3.3 Modelling the Displacing Forces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.4 Primary Standard for Rigidity of Transosseous Modules . . . . . . . . . . . . . . . . 4.4 Experimental Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1 Investigating Rigidity of the Transosseous Modules of the First (M1) and Second (M2) Order . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1.1 Longitudinal Rigidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1.2 Rotational Rigidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1.3 Transverse Rigidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1.4 Transverse Rigidity in the Frontal Plane when Modelling Abduction and Adduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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4.4.2
Index
Investigating the Rigidity of Third-Order Modules (M3) . . . . . . . . . . . . . 4.4.2.1 Rotational Rigidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.2.2 Transverse Rigidity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.2.3 Transverse Rigidity in the Frontal Plane when Modelling Abduction Adduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Contributors
M.V. Andrianov R. R. Vreden Russian Research Institute of Traumatology and Orthopaedics 8 Baykova Str. Saint Petersburg Russia, 195427
P. N. Kulesh R. R. Vreden Russian Research Institute of Traumatology and Orthopaedics 8 Baykova Str. Saint Petersburg Russia, 195427
A.A. Artemiev State Institute of Advanced Medical Studies Ministry of Defense of the Russian Federation 7 Cherkizovskaja Str. Moscow Russia, 141280
D.A. Mykalo R. R. Vreden Russian Research Institute of Traumatology and Orthopaedics 8 Baykova Str. Saint Petersburg Russia, 195427
P. I. Begun The State Electrotechnical University 5 Popova Str. Saint Petersburg Russia, 195007
V.A. Nazarov Marshal Novikov Str., 3–131 Saint Petersburg Russia, 195427
R. E. Inyushin R. R. Vreden Russian Research Institute of Traumatology and Orthopaedics 8 Baykova Str. Saint Petersburg Russia, 195427
A.V. Runkov Ural Scientific Research Institute of Traumatology and Orthopaedics 7 Bankovsky Str. Ekaterinburg Russia, 620014
O.A. Kaplunov The Orthopaedic Center of City Clinical Hospital No. 3 45 Sovietskaja Str. Volgograd Russia, 400005
L. N. Solomin R. R. Vreden Russian Research Institute of Traumatology and Orthopaedics 8 Baykova Str. Saint Petersburg Russia, 195427
1 General Aspects of External Fixation
1.1
Introduction
External fixation is a method for treating bone and joint injuries as well as for correcting skeletal deformities by attaching bones to an external device that stabilizes the injured limb. Additionally, it allows manipulation of the limb segments to achieve restoration of length and alignment. A synonym for external fixation is “external osteosynthesis”. In contrast, internal osteosynthesis employs devices implanted under the skin and muscle. External braces, cast splints and orthotic devices are not considered external fixators.“Extrafocal osteosynthesis”, “compression osteosynthesis” and “distraction osteosynthesis”are not synonymous with external fixation. These concepts can be utilized with either internal or external osteosynthesis.The concepts represented by these terms can be applied separately or in combination. For example, an external fixator can be used to apply compression and distraction at the same time. The term “transosseous osteosynthesis” is commonly used in the Russian-speaking literature.
1.2 Historical Background and Classification The first external fixator was described by the American J. Emsberry in 1831. In 1843, the French physician Malgaigne introduced a device for treating fractures of the patella and olecranon (Fig. 1.2.1). This resembled a clamp and was known as the Malgaigne fixator. The widespread practical use of external fixation was popularized by the Belgian surgeons Clayton Park-
Fig. 1.2.1. Malgaigne fixator
hill (1898) and Albin Lambotte (1902). In the 1930s, 1940s, and 1950s other surgeons such as Roger Anderson, Raul Hoffman, Robert and Jean Judet, and Jacques Vidal continued the development of external fixation devices by improving the clamp, pin and bar technologies. In the former Soviet Union a 30-year period of intensive development occurred beginning in the 1950s thanks to the efforts of G.A. Ilizarov, K. Sivash, O. Gudushauri, V. Kalnberz, M. Volkov, O. Oganesyan, V. Demianov and S. Tkachenko. Various types of external fixation device are shown in Fig. 1.2.2. Currently more than 1,000 external fixation devices are available in the orthopaedic marketplace. All of the external fixator devices have similar components and can be divided into six frame types (Table 1.1). Types I and II are single-plane. All the other frame types are multiplane. Only console transosseous elements (halfpin constructs) can be fixed in monolateral (type I) and sectorial (type II) external supports. The mounting of frame types IV–VI is based on wires or pins, or wires and pins in combination. All the above features are important for determining the biomechanical, clinical and performance features of each type of external fixation device. The constructions mentioned as examples of circular devices (type V) are the usual members of this group. The majority of these devices are used in the clinic as hybrid constructions with sectorial, semicircular, and circular external supports. External fixation techniques can be classified according to the following characteristics: • Insertion of transosseous elements to treat injury to bone (fracture, nonunion) and soft tissues: intrafocal, extrafocal. • Biomechanical condition between bone fragments (neutral, compression, distraction): combined (consecutive, alternating, synchronous). • Zones of mechanical influence on bone fragments: monolocal, bilocal, polylocal. • Quantity and quality of zones of osteogenesis (bone formation): monolocal, bilocal, polylocal. These techniques are discussed in later chapters devoted specifically to all aspects of external fixation.
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1 General Aspects of External Fixation
a
b
c
d
e
f
g
h
i
Fig. 1.2.2a–i. Fixation devices. a Lambotte, b Hoffman-Vidal, c Ilizarov, d Kalnberz, e Volkov-Oganesyan, f Demianov, g Tkachenko, h Gudushauri, i Sivash
1.2 Historical Background and Classification
3
j
k
l
m
n
o
p
q
r
Fig. 1.2.2j–r. j Lee, k Barabash, l Synthes, m Biomet, n OrthoFix, o Stryker, p Taylor spatial frame, q SUV-frame, r Poli Hex
4
1 General Aspects of External Fixation
Table 1.1. Principal types of external fixation device Type
Examples
Features
I. Monolateral
Lambotte, Hoffmann, AO/ASIF, Wagner, Afaunov, Sushko
1. Built only on pins that capture both cortices but do not pass completely through the bone (console transosseous elements, known as half-pins) 2. All transosseous elements are installed in one plane and on one side 3. The free ends of the pins are fixed to longitudinal connecting bars
II. Bilateral
Charnley, Hoffmann, Vidal-Adrey, Roger-Anderson, Key, Hey-Groves, Gryaznukhin
1. Built on through-and-through Steinmann pins or K-wires 2. All transosseous elements are inserted in one plane and pass through both cortices (true transfixation pins) 3. The transosseous elements are joined using longitudinal connecting bars on each side, thus forming the “frame”
III. Sectorial (arch)
AO/ASIF, SKID
1. Pin placement is limited to sector ˛ (0
