My blog posts the past two weeks have described the pioneering work of Dr. Gavriil Ilizarov, who made lemonade out of lemons when confronted with problematic fractures and limited resources in the Russian hinterlands. His external fixators (pins placed into the bone and then secured to one another by a metal scaffolding outside the skin) are most often applied to the leg bones. These are the bones that are quite vulnerable to high-energy, devastating damage. Motorcycle injuries and war wounds are common causes. If it were not for external fixators, which can correct alignment and stabilize fracture fragments to allow for healing, many of these severely injured limbs would have to be amputated.
The techniques that Ilizarov perfected can also be applied to upper extremity bone problems. Take for example, this young man who broke his wrist when he was ten. He was casted, the fracture healed, and he resumed normal activities. A problem, however, was lurking.
The injury had destroyed the growth plate in the larger of his two forearm bones. Over his teenage years, the adjacent. uninjured bone naturally grew longer while the previously broken one remained its ten-year-old length. By the time he finished growing, the length discrepancy between the two bones limited motion caused pain and a displeasing appearance. (The red line on the X-ray indicates the bone’s normal length.)
Rather than using bicycle spokes as Ilizarov had done originally, I placed sturdy steel pins in the bone and attached them to an expandable external frame. Then I cut the bone midway between the pins. The rest of the treatment was totally Ilizarovian. For the first ten days, we left everything alone. The bone-forming cells were probably thinking, “Hey, here’s a fracture, the bone ends are together and are not moving on each other. Healing this is going to be a piece of cake.” And so the bone-forming cells went to work.
After ten days, the patient began using a screwdriver six times a day to barely lengthen the fixator for a total daily gain of just a millimeter–less than a sixteenth of an inch. Over weeks, the bone ends gapped progressively farther apart. Most importantly, the distraction happened so slowly that the bone forming cells had no cause for alarm. “Wow, this seems to be taking a long time, but everything is in order. Let’s carry on.”
After five weeks, the bone was appreciably longer and a whispy cloud of new bone was present in the gap. At seven weeks, the bone had been restored to its appropriate length, and more bone was evident in the gap. Now it was just a matter of patience while the new bone consolidated, which it did over several months. At that point the fixator came off and the pins came out.
Over more months, the new bone continued to strengthen and remodel and eventually closely resembled its uninjured mate in the opposite forearm.
As with the cases I described in two recent posts, here again patience was rewarded. Only one operation (insert the pins and cut the bone) was required. There was no need for a bone graft from the patient’s hip or leg or from a cadaver. And finally the patient had resolution of pain, deformity, and disability. Thank you, Dr. Ilizarov.
Next week I will describe how the Ilizarov technique can be applied to make short people taller.
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