Yusuf ÖZTÜRKMEN, Cemal DOĞRUL, Mahmut KARLI

Alt ekstremite psödoartrozlarında Ilizarov yöntemi ve tedavi sonuçları

Amaç: Alt eksremite psödoartrozlannın tedavisinde kullanılan llizarov yönteminin sonuçlan değerlendirildi. Çalışma planı: Çalışmaya llizarov yöntemiyle tedavi edilen 46 hasta (34 erkek, 12 kadın; ort. yaş 39; dağılım 28-69) alındı. Sekiz olguda (%17) femur, 38 olguda (%83) tibia tutulumu vardı. Ortalama psödoartroz süresi 1.6 yıl (dağılım 6 ay-4.8 yıl) idi. Yedi olguda hipertrofik (%16), 39'unda atrofik (%84) psödoartroz görüldü. Tedavi öncesinde geçirilen ortalama ameliyat sayısı 1.4 (dağılım 0-4); ortalama kemik kaybı 7.4 cm (dağılım 3-12 cm), ortalama kısalık 6.8 cm (dağılım 0-12 cm), ortalama kemik defekti 5.2 cm (dağılım 3-12 cm) idi. Olguların 16'smda (%34) bifokal, 30'unda (%66) monofokal uygulama yapıldı. Olgular ortalama 22.6 ay (dağılım 9-54 ay) süreyle izlendi. Sonuçlar: Dört olgu (iki monofokal, iki bifokal) dışında tüm olgularda (%92) kaynama sağlandı. Cihazda ortalama kalış süresi 208 gün (dağılım 93-750 gün) iken, bifokal grupta 286 gün (dağılım 140-496 gün), monofokal grupta ise 162 gün (dağılım 98-296 gün) idi. Paley ölçütlerine göre 26 olguda mükemmel, 12 olguda iyi, dört olguda orta, dört olguda kötü kemiksel sonuç alındı. Fonksiyonel sonuçlar 25 olguda mükemmel, 14 olguda iyi, üç olguda orta, dört olguda kötü idi. Yirmi sekiz olguda çivi dibi enfeksiyonu, üç olguda refleks sempatik distrofi görüldü; bifokal uygulamalı üç olguda cihaz çıkartıldıktan sonra yeniden kırık oluştu. Dört olguda ayak bileği sertliği, bir olguda geriye dönen peroneal sinir lezyonuna bağlı düşük ayak oluştu. Segment kaydırma olgularının dördünde (%25) hedef bölgede kaynama geciktiği için spongioz greftleme yapıldı. Üç olguda 7 derecenin üzerinde angülasyonla kaynama sağlandı. Monofokal uygulama yapılanlarda, kısalığın l cm'in üzerinde olmadığı görüldü. Bifokal uygulama yapılan defekt psödoartrozlarmda, uygulama sonrası hiç defekt kalmadı. Rezidüel kısalık ortalama 1-5 cm (dağılım 0-4 cm) idi. İyileşme indeksi ortalama 52 gün/cm bulundu. Çıkarımlar: llizarov yöntemiyle eklem kontraktürleri, angüler, translasyonel ve rotasyonel deformiteler, kısalık, kemik defektleri gibi tüm sorun ve eksiklikler aynı anda giderilemektedir.

Anahtar Kelimeler:

Tibia kırıkları, Kemik uzatma, Femur kırıkları, Kırık tespiti, Ilizarov tekniği, Eksternal fiksatörler, Psödoartroz

Results of the Ilizarov method in the treatment of pseudoarthrosis of the lower extremities

Objectives: We evaluated the results of the llizarov method in the treatment of pseudoarthrosis of the lower extremities. Methods: Forty-six patients (34 men, 12 women; mean age 38.6 years; range 28 to 69 years) were treated by the llizarov method for femoral (11=8, 17%) and tibial (n=38, 83%) pseudoarthrosis. The mean duration of the disease was 1.6 years (range 6 months to 4.8 years). Pseudoarthrosis was hypertrophie in seven patients (16%) and atrophie in 39 patients (84%). The mean number of previous opera-tions was 1.4 (range 0 to 4); the mean bone loss was 7.4 cm (range 3 to 12 cm); the mean shortening was 6.8 cm (range 0 to 12 cm); the mean size of the defect was 5.2 cm (range 3 to 12 cm). Applications were monofocal in 30 patients (66%) and bifocal in 16 patients (34%). The mean follow-up was 22.6 months (range 9 to 54 months). Results: Union occurred in all patients (92%) but four (2 monofo-cal, 2 bifocal). The fixator was applied for a mean of 208 days (range 93 to 750 days), which was 162 days (range 98 to 296 days) for monofocal, and 286 days (range 140 to 496 days) for bifocal applications. According to the Paley's criteria, the results for bone healing and function were excellent in 26 and 25 patients, good in 12 and 14 patients, fair in four and three patients, and poor in four patients, respectively. Pin tract infections developed in 28 patients, and reflex sympathetic dystrophy in three patients. Refracture occurred after the removal of the frame in three patients who received bifocal treatment. One patient developed transient per-oneal nerve palsy with drop foot. Equinus rigidity of the ankle was seen in four patients. Cancellous bone grafting was performed in four patients (25%) in whom delayed healing was observed at the target site following segmental bone transport. Three patients had union with a residual deformity of more than 7 degrees. In the monofocal group, none of the patients had a residual shortening of more than 1 cm. Following bifocal applications, no bone defects were observed; the mean residual length discrepancy was 1. 5 cm (range 0 to 4 cm), and the healing index was 52 days/cm. Conclusion: The llizarov technique may simultaneously be successful in the treatment of joint contractures, angular, rota-tional, and translational deformities, shortening, and bone defects.

Keywords:

Tibial Fractures, Bone Lengthening, Femoral Fractures, Fracture Fixation, Ilizarov Technique, External Fixators, Pseudarthrosis,

PDF

___

1. Frank DJ, Miller EH. Complications of treatment of fractures and dislocations of the tibia and fibula. In: Epps CH, editor. Complications in orthopaedic surgery. Vol. 1, 3rd ed. Philadelphia: Lippincott; 1994. p. 587-93.
2. Cornell CN, Lane JM. Newest factors in fracture healing. Clin Orthop 1992;(277):297-311.
3. Tuncay İ. Uzun kemik psödoartrozlarında Ilizarov metodu ile tedavi [Uzmanlık Tezi]. İstanbul Üniversitesi İstanbul Tıp Fakültesi Ortopedi ve Travmatoloji Anablim Dalı: İstanbul; 1997.
4. Goulet JA, Templeman D. Delayed union and nonunion of tibial shaft fractures. Instr Course Lect 1997;46:281-91.
5. Gülşen M. Ilizarov yönteminin biyolojik temelleri. In: Çakmak M, Kocaoğlu M, editörler. Ilizarov cerrahisi ve prensipleri. 1. baskı, İstanbul: Doruk Grafik Matbaası; 1999. s. 5-15.
6. Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattaneo R. Ilizarov treatment of tibial nonunions with bone loss. Clin Orthop 1989;(241):146-65.
7. LaVelle DG. Delayed union and nonunion of fractures. In: Canale ST, editor. Campbell's operative orthopaedics. 9th ed. St. Louis: Mosby; 1998. p. 2614-6.
8. Göğüş A, Kabukluoğlu YS, Küçükkaya M, Kuzgun Ü. Alt ekstremite defekt psödoatrozlarının segmenter kemik transportu tekniği ile tedavi sonuçları. Acta Orthop Traumatol Turc 1996;30:347-51.
9. Kocaoğlu M, Çakmak M, Baştürk S, Tuncay Ü. Uzun kemiklerin psödoartroz tedavisinde Ilizarov metodu ve klinik sonuçlarımız. Acta Orthop Traumatol Turc 1996;30:120-4.
10. Green SA, Jackson JM, Wall DM, Marinow H, Ishkanian J. Management of segmental defects by the Ilizarov intercalary bone transport method. Clin Orthop 1992;(280):136-42.
11. Green SA. Skeletal defects. A comparison of bone grafting and bone transport for segmental skeletal defects. Clin Orthop 1994;(301):111-7.
12. Cierny G 3rd, Zorn KE. Segmental tibial defects. Comparing conventional and Ilizarov methodologies. Clin Orthop 1994;(301):118-23.
13. Marsh DR, Shah S, Elliott J, Kurdy N. The Ilizarov method in nonunion, malunion and infection of fractures. J Bone Joint Surg [Br] 1997;79:273-9.
14. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop 1989;(238):249-81.
15. Ilizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop 1989;(239):263-85.
16. Paley D, Chaudray M, Pirone AM, Lentz P, Kautz D. Treatment of malunions and mal-nonunions of the femur and tibia by detailed preoperative planning and the Ilizarov techniques. Orthop Clin North Am 1990;21:667-91.
17.Mayo KA, Benirschke SK. Treatment of tibial malunions and nonunions with reamed intramedullary nails. Orthop Clin North Am 1990;21:715-24.
18. Robinson CM, McLauchlan G, Christie J, McQueen MM, Court-Brown CM. Tibial fractures with bone loss treated by primary reamed intramedullary nailing. J Bone Joint Surg [Br] 1995;77:906-13.
19. Giannoudis PV, MacDonald DA, Matthews SJ, Smith RM, Furlong AJ, De Boer P. Nonunion of the femoral diaphysis. The influence of reaming and non-steroidal anti-inflammatory drugs. J Bone Joint Surg [Br] 2000;82:655-8.
20. Aronson J, Harrison BH, Stewart CL, Harp JH Jr. The histology of distraction osteogenesis using different external fixators. Clin Orthop 1989;(241):106-16.
21. de Pablos J, Barrios C, Alfaro C, Canadell J. Large experimental segmental bone defects treated by bone transportation with monolateral external distractors. Clin Orthop 1994;(298): 259 - 65 .
22. Claes L, Laule J, Wenger K, Suger G, Liener U, Kinzl L. The influence of stiffness of the fixator on maturation of callus after segmental transport. J Bone Joint Surg [Br] 2000;82: 142-8.
23. Shevtsov VI. Bone defects management by means of transosseous osteosynthesis after Ilizarov GA. In: Çakmak M, Kocaoğlu M, editors. Eksternal fiksatörler. İstanbul: Damla Matbaacılık; 1995. s. 111-6.
24. Alonso JE, Regazzoni P. The use of the Ilizarov concept with the AO/ASIF tubular fixateur in the treatment of segmental defects. Orthop Clin North Am 1990;21:655-65.
25. Saleh M, Rees A. Bifocal surgery for deformity and bone loss after lower-limb fractures. Comparison of bone-transport and compression-distraction methods. J Bone Joint Surg [Br] 1995; 77:429-34 .
26. Saleh M, Royston S. Management of nonunion of fractures by distraction with correction of angulation and shortening. J Bone Joint Surg [Br] 1996;78:105-9.
27. Schwartsman V, Choi SH, Schwartsman R. Tibial nonunions. Treatment tactics with the Ilizarov method. Orthop Clin North Am 1990;21:639-53.
28. Tucker HL, Kendra JC, Kinnebrew TE. Tibial defects. Reconstruction using the method of Ilizarov as an alternative. Orthop Clin North Am 1990;21:629-37.
29. Catagni MA, Guerreschi F, Holman JA, Cattaneo R. Distraction osteogenesis in the treatment of stiff hypertrophic nonunions using the Ilizarov apparatus. Clin Orthop 1994;(301): 159-63 .
30. Song HR, Cho SH, Koo KH, Jeong ST, Park YJ, Ko JH. Tibial bone defects treated by internal bone transport using the Ilizarov method. Int Orthop 1998;22:293-7.
31. Başbozkurt M. Psödoartrozların Ilizarov yöntemi ile tedavisi. In: Çakmak M, KocaoĞlu M, editörler. Ilizarov cerrahisi ve prensipleri. 1. baskı, İstanbul: Doruk Grafik Matbaası; 1999. s. 129-36.
32. Ateşalp AS, Başbozkurt M, Erler E, Şehirlioglu A, Tunay S, Solakoğlu C, et al. Treatment of tibial bone defects with the Ilizarov circular external fixator in high-velocity gunshot wounds. Int Orthop 1998;22:343-7.
33. Paley D, Maar DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma 2000;14:76-85.
34. Kocaoğlu M, Eralp L, Çınar M, Çakmak M. Eksternal fiksatör kullanımında yeni seçenek:İntramedüller çivi eksternal fiksatör kombine kullanımı. In: Alpaslan AM, editör. 17. Ulusal Ortopedi ve Travmatoloji Kongre Kitabı; 24-9 Ekim 2001; Antalya, Türkiye.İstanbul: Turgut; 2001.s. 363-4.
35. Cattaneo R, Catagni M, Johnson EE. The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov. Clin Orthop 1992;(280):143-52.
36. Hosny G, Shawky MS. The treatment of infected non-union of the tibia by compression-distraction techniques using the Ilizarov external fixator. Int Orthop 1998;22:298-302.