Bone loss is rare in Clinical practice. To treat them is to prevent amputation and putting them back to their routine, It requires lot of dedication and car from both the patient and the treating surgeon. This is a ppt presentation in last week symposium, SRMC & RI, Chennai.

1. Large bone defect of tibia
treatment using
Ilizarov ring fixator -
study of 47 cases.
A. Chandrasekaran, M.S., Ph.D.,
Senior Consultant Orthopedic Surgeon,
Accident Care Clinics,
Chennai 600021 & 600056 INDIA
acortho@gmail.com

2. This work is possible because of the
institution’s free block
My sincere thanks to Founder Chancellor Ayya,
Chancellor Shri. R. Venkatachalam

3. With teachers

4. With teachers

5. Definition
Large bone defect 3 to 5 centimeters with
soft tissue environment
• secondary to infection,
• radiation,
• congenital deformity or deficiency.
AO classification

6. Bone defect
Primary bone loss
• Open fractures and
bone loss
• Gunshot injuries
• Osteoclastic tumors
Secondary bone loss
• After tumor resection
• Infection
• Nonunion
Bone defects caused by high energy injuries, bone loss, infected non unions, non
unions- Hans C. Pape et al OCNA 1-4 Jan 2010

7. Defect Pseudarthrosis
Classification
a. Pseudarthrosis- defect
b, c. Diastasis defect with
anatomical shortening
d. Diastasis defect without
anatomical shortening
Defects of lower limb bones. Shevetsov
et al, BI Churchill Livingstone 2000-261

8. Ilizarov circular fixator – apparatus limb

9. Ilizarov ring fixator system
16 Times more rigid than other fixators
NEMKOV Transosseous compression distraction apparatus. Mechanics and strength of
material 1977:47-50

10. Apparatus Limb
• In large gap and during
distraction osteogenesis
provides stability both in
static and dynamic
conditions, hence
“APPARATUS LIMB.”
Makushin V.D., Kuftyrev L.M. (1983)

11. 28 January 2011 SCORE 2011
Biomechanics - Wire limb
Stability and rigidity
All the stresses are
taken by the wires
Micro movement
Ossification follows
first order of kinetics
Biomechanics of fracture healing and distraction osteogenesis
using Ilizarov ring fixator system –
a finite element analysis – A. Chandrasekaran, PhD thesis, SRU 2004

12. Evaluation
• Soft tissue envelope
• Infection both active and dormant
• Joint contracture and range of motion
• Nerve function: sensation, motor
• Vasculature: perfusion, angiogram?
• Location and size of defect
• Hardware
• General health of the host
• Psychosocial resources

13. Soft tissue envelope

14. Everyone expect a functional recovery

15. Materials and methods
• Sri Ramachandra University and Accident care Clinic
• April 1996 to April 2015-
• Retrospective and prospective study
• forty(47) patients were treated, female-9 male -38
• The age group was between 3yrs to 70 yrs.
• The gaps(defects) measured 3cms – 20 cms.
• They were followed up periodically till they went
back to their original position.

16. Etiology
• Trauma - 39
• Residual polio - 02
• Tumours - 02
• Congenital - 02
• Post infective dislocation of hip - 01
• Acute osteomyelitis - 01

17. Etiology
External fixation - 24
plate osteosynthesis - 05
Ilizarov fixator - 03
Intramedullary nail - 04
free fibular graft - 02
allograft - 01
Others - 08

18. Gap
3-5 cm -18
5-10cm -23
10-15cm -05
15-20cm -01

19. Procedures done
Distractional osteosynthesis -06
Osteotomy and transport -31
Osteotomy lengthening -05
Tibofibular synostosis - 03
Sequesterectomy stabilisation -01
Articular defects -04

20. Bone healing by Ilizarov technique
• Closed distractional osteosynthesis
• Lengthening one of the fragments
• Bilocal gradual distraction-compression
osteosynthesis
• Defects of articular ends
• Tibiofibular synostosis
Defects of lower limb bones. Shevetsov et al, BI Churchill Livingstone 2000-

21. Closed distractional osteosynthesis

22. Lengthening one of the fragments –auto
distractor

23. Segmental internal bone transportation

24. Segmental internal bone transportation

25. Segmental internal bone transportation

26. Segmental internal bone transportation
•Locomotor apparatus of man is actually constructed with a minimum
of material for the maximum resistance to stress (Pauwels 19 65)

28. Infected Nail Management

29. Infected Nail –
Trifocal Osteosynthesis

30. Infected Nail – Tibiofibular synostosis

31. Infected Nail- Trifocal Osteosynthesis

32. Infected Nail- Trifocal Osteosynthesis

33. Infected tibia /nail removal

34. X ray and Te99

35. Compression distraction
osteosynthesis

36. Bowing of fibula

37. Infected Plate Osteosynthesis-
Segmental Transport

38. Infected Plate Osteosynthesis-
Segmental Transport

39. Infected Plate Osteosynthesis –
Segmental Transportation

40. BMAC in very large gap
• 25 years male
• Traffic accident 2yrs 6mths back
• Lost other limb above knee
• Allograft failed
• 20 cm gap

41. Allograft

42. After allograft removal
• 20 cm gap
• Tibialisation of fibula
• Segmental transfer
• Membrane induced
osteogenesis

43. Internal segmental transportation

44. Rapid transportation

45. BMAC - Stem cells infiltrated
Thanks to Mr. Abhaikumar, Tricell, Chennai.

46. Corticotomy through regenerate – II
stage

47. Stage II

48. After completion

49. 18 months follow up

50. 18 months follow up

51. What HE needs is a good prosthesis

52. Tumor –
Defect of the articular ends

53. Tumor –
Defect of the articular ends
Should we fuse the ankle when the knee is fused ?

54. Complications- septic arthritis
• Wire in the joint and knee fusion

55. Complications- early fusion

56. Complications –
subsidence and deformity of regenerate

57. Complications
• Shortening

58. Tibio fibular synostosis - amputation

59. Observation
• Edges need not be excised
• Transport more than 5 cm requires osteotomy
at 2 levels or internal bone transport
• Average healing time for 1 cm is 1.8 months –
variable.
• Will require few adjustments till completion
• No bone graft at docking site

60. Complications
• Septic arthritis -1
• Non union -2
• Knee stiffness -2
• Delayed regenerate -1
• Shortening -2
• Amputation -1
• Deformity -2

61. Results
• union,
• pain,
• stiffness of a joint,
• Shortening and
• return back to the job.

62. Results
excellent - 14
good - 24
fair - 06
poor - 02
in progress - 01

63. Summary
• Large bone defects are uncommon
• Mostly they are young
• Part of multiple skeletal injuries/poly trauma
• Undergone many procedures
• Physically and financially exhausted
• Almost always infected

64. Summary
• Remove implants and sequestrum
• Need not resect the ends
• Stabilise the bone by Ilizarov fixator
• Create contact
• Mobilise them early with maximum weight
bearing
• Expect complications
• How many joints can be fused?

65. Conclusion
• Limb salvage is most challenging, with lot of
inherent problem technical, social and
financial
• Try to save the limb till a sensitive foot
prosthesis could be made.
• Ilizarov bone transport construction is faster,
safer, less expensive and easier to perform.
“Personal experience remains the best teacher”