I thought it would be beneficial for people to see an essay regarding post-op care for leg lengthening from an orthopedic surgeon with specialty training in Ilizarov. The author of this essay is Dr. Mangal Parihar, an orthopedic surgeon who specializes in Ilizarov techniques.
Post-Op Care in the Ilizarov Methodby Dr. Mangal PariharBackgroundIn conventional orthopedic surgery, the manipulation of bones or other tissue is done only during the actual operative procedure, usually there is no active manipulation of the tissues during the post-op period. In contrast, with Ilizarov surgery, the manipulation of the tissues really begins only a few days after the actual surgical procedure. Looked at in this way, it becomes easy to understand, why the post-op period is so important in the Ilizarov Method. It is really a temporal extension of the surgical procedure and therefore needs the same high level of care and monitoring that we apply during the actual surgery. One could go as far as to say that the post-op period is probably more important than the time spent in the operation theater. It is a well known fact that the Ilizarov method is not without complications. Most of these can be prevented by diligent post-op care, and those that do occur can be treated successfully if recognized early and appropriately treated. In this chapter I will present a widely accepted postoperative plan with the emphasis on prevention of complications by preemptive actions. The post-op period may be arbitrarily divided into three periods, and during these three periods one lays emphasis on different aspects of care.
The Early Post-op period (the Latent Phase)The early post operative period extends from the time the patient comes out of surgery till the beginning of distraction. Even before the patient comes out of the OT one needs to confirm that the operative plan has been carried out correctly by proper 'final' x-rays of the part. Relying on 'eyeballing' skills or the small localized views are notoriously imprecise. The pinsites and the corticotomy sites are apt to bleed and this can be prevented by external tamponade in the form of large dressing pads compressing the skin around these areas. All the connection bolts in the frame must be tight. the wires cut and bent smoothly so as not to snag on clothing, and Schanz screws cut as short as possible with the cut ends covered by tape. Finally the ROM of the joints proximal and distal to the fixator must be checked again to ensure that their movements are not impeded by any of the wires, and if needed surgical releases must be performed around the offending wires.
Pain reliefPain relief is very often not given due importance in our (Indian) circumstances. The importance of keeping the patient free of pain, during the entire length of treatment cannot be overemphasized. This is even more vital in the early post-op period, because the patient with pain is not going to be very cooperative in the physiotherapy and mobilization. Pain also will cause the adoption of protective postures such as flexion of the knee, plantarflexion of the ankle, which later develop into contractures one of the commonest 'complications' of the Ilizarov method. Adequate doses of non-steroidal anti-inflammatory and or narcotics must be used. The use of NSAIDs is generally discouraged because of possible, unproved deleterious effects on regenerate formation; but for a short while they can be used.
Limb PositioningProper limb positioning taught early on minimizes the chances of contractures developing later. The commonest cause of a flexion deformity is the tendency to keep a pillow lengthwise under a tibial frame. This causes flexion at the knee. This should be prevented by repeatedly correcting the tendency and keeping an pillow only under the distal most ring in the frame thus allowing the knee to remain fully extended at all times. The other point to be remembered is the necessity of passive dorsiflexion splints for the ankle. This can be easily done by using a strap or bandage around the plantar aspect to the forefoot which is attached to the frame and keeps the foot in a neutral position. In patients undergoing significant tibial lengthening, this splint is required all through the day, and especially in the night. To prevent hip flexion contractures, especially in patients with a femoral frame, the patient has to be taught to lie prone for a few hours a day, and to extend the hip by taking the leg off the edge of the bed.
Distraction Phase-
Discussion: It is during the distraction phase that most of the complications of the treatment will occur, and consequently the surgeon has to be constantly on the lookout for the known complications. Follow-up Frequency: During the distraction phase, the patient should be seen at least every two weeks. At these visits one should perform a detailed clinical examination covering the points noted below as well as X-ray studies.
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Follow-up Checklist (Clinical): Distance moved on the threaded rods compared to previous visit. The threaded rods are marked with tape when distraction is begun. At every visit, the length of threaded rod visible beyond the tape is compared to the previous visit. This gives us a direct reading of the amount of distraction that the patient has performed during the intervening period. Normally, (at 1 mm per day) this should equal the number of days since the last visit. This is also used to keep a check that the distraction at bone (checked radiologically) is keeping up with the distraction at the distraction rods.
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ROM of Adjacent Joints: The amount of active and passive movements at the joints above and below the fixator is recorded at every visit. A decrease from previously recorded range of motion is the first sign of an evolving contracture, and calls for increased efforts on the part of the patient and the surgeon to intensify physiotherapy, hands-on stretching, and if needed the additional use of a splint. At times, in spite of all efforts the range of motion may deteriorate severely. In such cases a decision may have to be made to abandon the goal of treatment, and concentrate on regaining the lost range of motion, by intensive, inpatient physiotherapy. Occasionally the frame may need to be modified, into a contracture correcting configuration, and bony elongation postponed to a second stage of lengthening. Congenital shortening and deformities are especially prone to developing contractures in contrast to post traumatic problems.
Neurological ExaminationEMG monitoring of patients undergoing lengthening has shown that up to 80% of patients undergoing lengthening show electromyographic changes of neural injury, in spite of no clinical signs. This fact must be remembered especially when large lengthenings are being planned. The patient must have a proper evaluation of the motor and sensory function distal to the fixator. If the damage is noticed only after the motor weakness has occurred, the chances of recovery are diminished. The usual sequence of events in neurological injury during distraction is hyperesthesia in the nerve distribution, hypoesthesia, anesthesia, motor weakness, complete palsy. If recognized early (hyperesthesia, hypoesthesia) and treated appropriately, function is completely regained.
Pinsites for Signs of Inflammation/InfectionPinsites should be cleaned with sterile saline (boiled & cooled water would do as well) and cotton swabs on a daily basis. Use of antiseptic lotions to cover the pinsites is favored by many surgeons, but is not necessary. In fact the only area where any gauze dressings are required is for Schanz pins in the upper thigh, where bulky dressings are used to reduce the motion between the pin-skin interface. The patient is given instructions to increase the frequency of pin-site cleaning if there is any increased discharge. If there is any redness and pain around a pin-site associated with increased or purulent discharge the patient can start a course of antibiotics. Utilizing these guidelines, most centers report very few instances of serious pin-site complications. Another frequent worry for the patient as well as the surgeon is that of bathing and washing the fixator. This is completely safe, provided that the limb and the fixator is thoroughly dried and the pinsites cleaned again after the bathing.
Stability of Frame & ComponentsLike all mechanical components, the Ilizarov frame is liable to loosen. Therefore at every visit a check is made to ensure that the various bolts and nuts are adequately tight. Though it does not happen often, wires may loosen. The patient with loose wires complains of pain at the pin site, especially on weight bearing. This may need re-tensioning of the wire/s. If a frame is demonstrably unstable on the limb, i.e. physical movement can be visualized between the frame held by one hand and the limb in the other, further fixation of the frame by means of additional pins or wires is usually required. Fixator instability should not be brushed aside, because an unstable fixator will prevent weight bearing ambulation, with resultant deleterious effects on development and ossification of the regenerate. When a patient wearing a fixator stops walking a vicious cycle of osteoporosis, reduced anchorage of implants in bone, loss of fixation, pin-site sepsis, pain, further decrease in walking; is set up. This can be very difficult to treat when established, and is therefore best prevented.
AmbulationPractically every patient needs to be taught weight bearing ambulation after the fixator is put on. It is not enough to tell them to bear full weight. There is a natural wariness to bear full weight on a limb that has just been operated, which is compounded by the pain in the early phase of treatment. Therefore it is mandatory that the patient be taught and his ambulation supervised till the surgeon is certain of his ability to bear a fair amount of weight on the limb. The other facet to this is the pattern of gait. The tendency is to walk with the limb gingerly held in front of the body with the ankle in plantarflexion. This prevents proper weight bearing, and promotes an ankle plantarflexion and knee flexion contracture. The patient has to learn to progress in the proper sequence of heel strike to toe-off.
Follow-up Checklist (X-rays)Distraction gap increasing as desired & progressive Correction of deformity. The first few days of distraction does not result in distraction of the corticotomy site, especially in patients with congenital conditions. This is because the first 2 to 3 mm is spent in overcoming tight musculature and fascial structures. Beyond that, the distraction that is measured on the rods and the distraction gap should equal the number of days of distraction. In other words, if the patient has distracted the apparatus for 10 days, we should be able to see 10 threads on the distraction rod, and 10 mm increase in the distraction gap. One must ensure a fixed tube-film and limb-film distance between successive examinations, otherwise the magnification factors could allow errors to creep in to the measurements. In cases where angular correction is being performed, sequential x-rays must confirm a decrease in angular deformity. This necessitates reproducible placement of the limb for the AP and Lateral projections. Very often this can only be achieved by the surgeon himself being present to confirm the positioning of the limb. At the end of the distraction phase, before the distraction is actually stopped, limb length equality and correction of the various mechanical axes should be confirmed by means of a full length standing film.
Quality of RegenerateThe rhythm and more so the rate of distraction are not fixed numbers. 1 mm per day in four equal fractions is only the recommended average. There are frequently cases that require a slower rate, or occasionally a faster rate. This can only be adjusted if one is looking closely at and monitoring the quality of regenerate at the distraction gap. The distraction gap should show shadowy streaks of linear ossification by the end of three weeks. This ossification should show progressive improvement over subsequent x-ray examinations. To be able to compare the opacity of the gap from one examination to the next, one must ensure the same exposure factors are used. In cases with more than one corticotomy, each corticotomy should be evaluated with an x-ray centered on that particular corticotomy. A regenerate with a transverse diameter larger than the diameter of the parent bone could be very likely due to instability in the frame, rather than increased bone formation; and the rate of distraction should be increased in such cases only after a careful examination has ruled out instability.
PhysiotherapyMuch is spoken about physiotherapy and it's importance in the Ilizarov method. Unfortunately, this is infrequently translated into practice. One just has to look at many cases with iatrogenic problems to realize that lack of physiotherapy lies at the root of the majority of these. The patient has to participate in a proper program of exercises, mobilization and ambulation. This cannot be stressed enough. Lack of proper physiotherapy can turn even the technically excellent surgery into a poor result, and nowhere is this more true than in the subspecialty of Ilizarov surgery. In fact Ilizarov's original technique requires the patients to stay in hospital and participate in at least two hours of therapy in various forms every day. In our circumstances, the services of a physiotherapist are not always available. The only recourse in such cases is for the surgeon himself to supervise the therapy for the patient. Achieving length or correcting a deformity at the cost of decreased motion, mobility or function is certainly not a worthwhile goal.
Consolidation PhaseAt the end of distraction, Ilizarov recommends "training the regenerate'. Simply put, this involves overlengthening the limb by 7 to 10 mm and then compressing this back to the proper length in a gradual fashion. This ensures a larger cross sectional area of regenerate to participate in the consolidation. The fixator has to be neutralized to ensure that the weight bearing stresses will be transferred to the newly formed osseous tissue. Neutralization is achieved by reversing (compressing) the rings at a rate of 0.25 mm an alternate days till the rings no longer move towards each other. At this point there is no more tension in the system, and most of the weight bearing forces are transmitted through the bone. This procedure may render the wires relatively lax, and they may need to be tensioned if the patient complains of pain or instability can be demonstrated. At this time a monthly follow up will usually suffice. During the consolidation phase the risk of complications is reduced markedly, and the patient's functional abilities increase. Movement and ambulation are encouraged to ensure a speedy consolidation of the regenerate.
Removal of the Fixator and Post fixator removalA month too late is better than a day too early. This is a useful thing to remember at a time when even the most cooperative patient is usually becoming impatient for the frame to be removed. The ability of the regenerate for unprotected weight bearing must be ensured prior to taking off the frame. The x-rays must show at least three cortices; i.e. out of four cortices (anterior, posterior, medial and lateral) in AP & lateral projections, at least three should be fully ossified, with a sharp outline of the cortical bone. Finally before actually removing the frame the patient may be administered a 'stress test'. in which all the uprights connecting the proximal and distal segments of bone are disconnected and the patient asked to use the limb in a functional manner (weight bearing for the lower limb and functional activities for the upper limb). If the patient is able to do this the frame can then be removed with confidence. Actual removal of the fixator is usually done under anesthesia. In adults, though it is possible to do without it, it is not recommended as the removal of half pins is quite painful. In case a removal is done without anesthesia, one must remember to loosen the wire fixation bolts thus releasing wire tension prior to cutting the wire. Ensure that the limb does not drop suddenly when the last wires are cut. Remember to inject local anesthetic at the side of the olive when removing olive wires.
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Post Fixator Removal: If Schanz pins had been used, the patient should be protected weight bearing for a period of six weeks to allow for some repair of the pin tracts in the bone. Use of braces or casts is usually not necessary if the plan outlined above has been followed, but when in doubt it is always safer to put the patient in a snugly fitting cast or brace as required. In certain cases, namely congenital pseudarthrosis of the tibia, residual significant deformity, and a small cross sectional area of regenerate the limb needs long term protection in the form of a plastic brace. Strenuous activity and contact sports should be avoided till such time as all four cortices are seen clearly and the medullary cavity has recanalised.
Link:
http://www.wheelessonline.com/ortho/post_op_care_in_the_ilizarov_methodDoctor Parihar's website:
http://www.ilizarov.in/about-us/dr-mangal-parihar.htmlEducation background: Dr. Mangal Parihar did his MBBS and MS (Orth) from Seth G S Medical College and KEM Hospital, Mumbai, respectively. He did his fellowship in Total Joint Arthroplasty with Dr. C S Ranawat at the Hospital for Special Surgery, New York, USA. He also took post-doctoral fellowship in Ilizarov Techniques with Dr. Dror Paley at the Maryland Center for Limb Lengthening and Reconstruction, Baltimore, USA. Dr. Parihar has also visited Dr. Derek McMinn of Birmingham for training in hip resurfacing. Furthermore, he also took some specialized training at Blackburn Royal Infirmary, Blackburn, England.
Doctor Parihar's youtube channel (very interesting videos here, including his commentary on surgeries you can see he and his team perform):
http://www.youtube.com/user/mangalparihar
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Topic: Post-Op Care in the Ilizarov Method (Read 11352 times)