Sample Report: Ilizarov Frame Application
Preoperative Diagnoses
1. Malunion, left radius and ulna.
2. Unequal arm lengths.
3. Planned removal of deep implants, left radius and ulna.
Postoperative Diagnoses
1. Malunion, left radius and ulna.
2. Unequal arm lengths.
3. Planned removal of deep implants, left radius and ulna.
Operative Procedures
1. Osteotomy/osteoplasty, left radius and ulna.
2. Insertion of prophylactic intramedullary nails, left radius and ulna.
3. Iliac crest bone grafting of osteotomy site, left radius and ulna.
4. Application, Ilizarov multiplanar external fixator, left forearm.
Indications: The patient has a longstanding malunion of the radius and ulna with dorsal plate on both bones. The deformity is angulation with apex radial on the ulna and apex dorsal on the radius. He has full supination and no pronation. In addition, he has marked shortening of the left forearm. Prior to surgery we discussed treatment options, being correction of deformity with internal fixation using plates or IM rods or a combination of both versus lengthening of the forearm in addition to the deformity correction.
Description of Operation and Findings: After general anesthesia, the left upper extremity was prepped and draped free in the usual manner. Tourniquet was placed on the left arm. The tourniquet was elevated after the arm was prepped in the usual manner. The dorsal ulnar incision was made and carried down to the ulnar plate. All of the screws were removed and the plate was removed from the ulna. Dorsal radial incision was also made and careful dissection to avoid injury to any neurovascular structures, in particular superficial branch of the radial nerve, was done. We then removed the screws and plate. There was one lag screw that was removed separately on the ulna. With both wounds exposed, it was now time to do the osteotomy. We chose to begin with the ulna.
The ulna was osteotomized by making multiple drill holes and then using an osteotome to complete the osteotomy. The osteotomy had been acutely corrected out of its apex radial bow. We then inserted Foresite nails by Smith & Nephew into the ulna using a 4-mm nail. In order to prepare the bone for this, we reamed the proximal segment first, using a combination of cannulated drills as well as the hand reamers. We then did the distal segment, working from the osteotomy site, in a similar manner but also using the flexible reamer. We then passed a guidewire down to the end and measured the length of the bone, then chose a 24 cm x 4 mm Foresite nail. The distal ulna had a separate bow from another malunion that was present, and in passing the nail we reamed a false channel in that, exiting at the second malunion site. We, therefore, had to bend the tip of the rod in order to negotiate around that malunion site. This allowed the intramedullary nail to pass into the distal ulna. We locked the rod proximally from posterior to anterior in the ulna.
Next, we osteotomized the radius at its apex and acutely corrected its apex dorsal bow. We then inserted Foresite nails into the radius. We straightened out the bow but also straightened out the normal radial bow. We, therefore, extracted the nail and bent the nail so that it had an apex radial bow to it.
While I was inserting the rod, the co-surgeon obtained a bone graft from the iliac crest. We had previously prepped and draped the right iliac crest, and we did a limited exposure on the tuberosity of the ilium in order to get the bone graft. After performing a couple of find holes, we removed sufficient bone for the grafting. The wound was closed in layers at the hip.
The next step was to bone graft the site of the radius and ulnar osteotomies. The bone graft was inserted and packed around the osteotomies, with the most important around the ulnar one because of its distraction. The ulna must have been shorter overall than the radius, since it did distract apart in order to maintain the length of the two bones to each other. The interval was packed with cancellous bone. No cortical bone was used. The radius was also packed.
In neither the ulna nor the radius did we distract the interosseous membrane border of the bone, in order to avoid damaging the vascularity to the bone on that side, as well as to minimize the risk of a crossunion between the bones. At all times this dissection was subperiosteal at most in that region.
After completing the bone grafting with the rod in place for both bones, we were ready to close the wounds. The radius rod was inserted from Lister tubercle and should be noted was reamed in the same manner as described for the ulna, using a combination of cannulated drill, flexible drill, and hand reamers. We reamed this from the fracture site but also from the Lister tubercle. A single locking screw was inserted into the radius from its radial aspect, getting two cortices of fixation. The rods were buried within the bone. At this time we closed the wound, which was done in layers. The two main wounds, as well as the smaller one used for the rod insertion, were closed.
After completing the closure and obtaining radiographs demonstrating that the alignment was corrected with both rods, we proceeded with application of the Ilizarov multiplanar external fixator. This involved putting a transradial ulnar wire distally and proximally. Proximally we inserted one wire from the neck of the radius, through the ulna as well, transfixing the two bones but being careful to avoid injury to the radial nerve and the ulnar nerve. The patient was not paralyzed and we did not see any muscle twitches in passing this wire in what was presumed a safe anatomic plane. In addition to that, a half pin was added to the top ring in the ulna alone. Distally, the two radioulnar wires were used. None of the wires or half pins touched the intramedullary implant.
After completing the fixation of the two-ring frame, which was bent at the elbow to allow for elbow flexion, the procedure was completed. Final radiographs were obtained. Sterile dressing was applied, and the arm was secured to an IV pole for elevation and maintained that way in the postoperative period. A drain was used in both the radial and ulnar wounds to minimize swelling.
The compartments were wide open through the incision in order to allow sufficient room for swelling. In the recovery room, the patient was examined and found to be neurologically completely intact for radial, median, and ulnar nerves, including both the proximal and distal motor branches. I was very satisfied with the final position and outcome.