Treatment of Distal Tibial Fractures with Ilizarov Methodology

Maurizio A. Catagni
Ilizarov Unit, Lecco Hospital, Italy

INTRODUCTION
Without a doubt, the treatment of tibial fractures, with transosseous osteosynthesis, is one of the most
important chapters in the methodology proposed by Ilizarov. The high incidence and variety of these
fractures may, at times, present difficulties in choosing a treatment method. There are currently many
treatment methods available. Optimal treatment should include anatomic reduction, stable fixation, and
early function (weight bearing).
Transosseous osteosynthesis may have a “relative” indication in the treatment of a simple, closed
diaphyseal fracture, while it is absolutely indicated for the treatment of an open, comminuted,
contaminated diaphyseal fracture and for the treatment of open fractures in the multiply injured patient.
Based upon our clinical experiences, we propose the following clinical classification for treating these
fractures:
- Open, intra-articular, tibial fractures that require open reduction with minimal internal fixation may also
be treated with the Ilizarov apparatus as well as closed fractures with unacceptable displacement of
fragments.
- Fractures for which the Ilizarov apparatus is highly recommended include: closed, comminuted
fractures; open fractures with or without articular involvement; and open fractures with bone loss.
- The advantages of using the Ilizarov apparatus compared to traditional external fixation, casts, or
internal fixation:
1. Stability
The previous biomechanical studies clearly show that the Ilizarov apparatus, using external, circular,
transosseous fixation in a standard assembly of four rings with two wires crossing between 45° (and 90°)
per ring segment, provides greater stability than a unilateral fixator does. The elasticity of the wires used
in the apparatus allows for axial movement. These compressive movements favour the rapid
consolidation of the fracture callus.
2. Preservation of Blood Supply
Closed, transosseous fixation respects the vascularity of the fracture segments and soft tissues and so
contributes to a more rapid consolidation of the fracture. Furthermore, by avoiding opening the fracture,
the risk of infection and subsequent osteomyelitis is minimized.
3. Maintenance of Function
When a patient with a tibial fracture is treated with the Ilizarov apparatus, he is allowed to weight bearing
from the first postoperative day on. Progressive weight bearing is encouraged over the next two to three
weeks until the patient is full weight bearing on the extremity.
Weight bearing adds the positive effects of compression forces on the fracture site and also increases the
venous and lymphatic return preventing swelling and disuse osteopenia.
Other methods of stabilizing fractures that respect the vascularity of the fracture site such as cast
treatment often do not provide great stability and so early weight bearing cannot always be permitted.
Internal fixation of fractures, with plates and screws, achieves early stability but at the cost of bone
vascularity. Early motion of the joints is allowed but weight bearing in not permitted.
Intramedullary nailing of tibia fractures allows early weight bearing at the cost of the intramedullary
blood supply and, in open fractures, increases the risk of infection.
Traditional external fixation respects the vascularity of the fracture segments and allows early motion of
the joints but, early Weight bearing is not always permitted. Problems related to the larger half pins are
frequently encountered and fixation may provide insufficient mechanical stability.
The Ilizarov method involves a non-invasive procedure without the problems of blood loss and need for
transfusion, while providing stability and allowing weight bearing.
Difficulties may be encountered using the Ilizarov method during the closed reduction of fractures. This
may require a longer operative time but such difficulties are quickly overcome if the surgeon follows the
assembly techniques which will be presented here. Furthermore, as with most other surgical techniques,
operative time decreases as the surgeon’s experience increases.
The risks of vascular injury caused by wire penetration are no greater than with conventional surgery. If a
vascular lesion is produced during the procedure, simply remove the wire which caused the bleeding and
apply direct pressure with a compressive bandage for several minutes. (An Ilizarov wire is no larger than
a venipuncture needle).
When we first began using the Ilizarov method for treating fractures, we encountered several difficulties
including psychological problems with patients and pain with frequent dressing changes to wires sites.
Increased surgical experience enables the assembly of a more stable, painfree frame and allows easier
dressing changes.
The advantages of the Ilizarov system include stability, preservation of vascularity, immediate joint
motion, immediate weight bearing, minimal operative risk, and minimal blood loss.
The disadvantages include: difficulties for the surgeon in assembling of the frame and performing closed
reductions and difficulties for the patient with dressing changes and with wearing the frame.

CLASSIFICATION
The Ilizarov apparatus can be applied to almost all fractures of the tibia. We will describe the apparatus
in detail for its application in the following types of tibial fractures:

Proximal: Non-displaced intra-articular

Displaced intra-articular
Complex
Diaphysial: Simple
With a third (butterfly) fragment
Segmental
With bone loss
Distal: Metaphysial
Epiphysial
Pylon

DISTAL METAPHYSIAL FRACTURES (Fig. 5.34)

The preassembled frame consists of four rings: a block of two rings for each fragment. Fixation begins
with the usual proximal and distal reference wires and reduction is accomplished using olive wires.
Strengthening of the frame is achieved with other wires or with half-pins in a hybrid configuration (Fig.
5.34). In open fractures with less difficult reductions, it may be possible to avoid the use of olive wires.
Diagram for the introduction of wires and half pins:
a) H.T. osteosynthesis. Reduction takes place with the two olive wires inserted from opposite positions.
The half pins stabilize the reduction.
b) Mixed osteosynthesis with an interfragmentary compression screw (H.A.) (1 = open reduction which
is sometimes provisional, 2 = centralization, 3 = fixation).

DISTAL EPIPHYSIAL FRACTURES (Fig. 5.36)

The preassembled frame consists of three rings. After closed reduction, the proximal and distal reference
wires are placed, and the frame is further stabilized with wires and half-pins in a hybrid configuration. In
comminuted fractures, stability is improved with a temporary wire through the calcaneus attached to a
half ring which prevents movement of the ankle joint (Fig. 5.36). This wire can be removed
approximately one month after callus formation becomes visible.
CASE REPORT: Distal metaphysial fracture

Fig. 5.37 (From the Ilizarov Unit - Lecco Hospital)

A.C., 30 year-old male
a) Distal, metaphysial fracture of the right tibia combined with multiple metatarsal fractures.
b) Closed reduction of the tibial fracture and stabilization with the external fixator. This is
performed as an emergency procedure (intraoperative radiographs). The metatarsal fractures are
reduced by open reduction.
c) Radiographic examination.
d) Radiographic examination prior to removal of the apparatus.
e) Eleven months follow-up: there was a complication of reflex sympathetic dystrophy of the foot.
CASE REPORT: Distal metaphysial fracture

Diagram 5.38a
Diagram for the introduction of wires and half pins:
a) H.T. osteosynthesis. Reduction takes place with the two olive wires inserted from opposite sides. The
half pins stabilize the reduction.
b) Mixed osteosynthesis with an interfragmentary compression screw (H.A.) (1 = open reduction, which
is sometimes temporary, 2 = centralization, 3 = fixation).

CASE REPORT: Distal metaphysial fracture

Fig. 5.39 (From the Ilizarov Unit - Lecco Hospital)

T.C., 29 year-old male
a) Open, distal, metaphysial fracture of the right tibia. Minimal internal fixation with one cortical screw
and stabilization with a 3-ring Ilizarov frame. This is performed as a delayed primary procedure.
b) Radiographs 2 months after injury.
c) Radiographic exam of the fracture 4 months after injury.

MALLEOLAR FRACTURES (Fig. 5.40)

Indications and Operative Technique
Transosseous osteosynthesis of the tibial and fibular malleolar segments is especially indicated in open
fractures with or without dislocation. Thorough preoperative planning is important to identify the exact
placement of the transosseous wires, with or without olives, in order to exert the maximum
interfragmentary compression.
The apparatus must be extended to the proximal third of the tibia and to the hindfoot and\or the forefoot.
This is of particular importance if an ankle arthrodesis is to be achieved. A complete ring may be used at
the level of the distal tibia if greater fixation is required.
According to the H.A. technique, the apparatus is applied after an internal osteosynthesis has been carried
out according to the AO technique. The apparatus allows greater stability of the fragments during partial
weightbearing (Fig. 5.40-5.41).
CASE REPORT: Comminuted malleolar fracture

Fig. 5.42 (G. Pinto - Coimbra Hospital). From Operative Principles of Ilizarov
F.G., 68 year-old male.
a) Open fracture-dislocation of the right ankle joint with a comminuted lateral malleolar fracture.
b) Reduction of the dislocation. Stabilization using the Ilizarov method with repair of the deltoid
ligament. Duration of treatment was three months.
c) Radiographic follow-up after four months.

PYLON FRACTURES (Fig. 5.43-5.44)

When the tibial pylon is fractured, it is absolutely necessary to reapproximate the intra-articular
fragments to reconstruct the articular surface. The Ilizarov apparatus makes it possible to perform this
reduction. A preconstructed frame consists of a block of two rings for the tibia connected to a foot frame
with threaded rods and an intermediate ring.
The proximal block is fixed to the tibia. The distal ring of this proximal block is placed 3-4 cm proximal
to the fracture site. The foot frame is fixed with two wires in the heel and two wires in the forefoot (Fig.
5.43-5.44-5.45). Distraction is performed between the tibial block and the foot frame, inducing a kind of
ligamentotaxis. The fracture is reduced surgically, restoring the joint anatomically. The fracture
fragments are further stabilized with olive wires or screws (Fig. 5.46). After
wound closure, the intermediate ring and wires are applied at the level of the fracture for further
stabilization. Distraction is maintained between the foot and the tibia, preventing stress to the joint
surface. Distraction is removed after one month and the connecting rods are substituted with hinges. This
allows a range of motion of the ankle joint. After another 15 days, the foot frame is removed and
progressive weightbearing is begun until the fracture is healed. At that time the frame is removed.

CASE REPORT: Pylon fracture

CASE REPORT: Pylon fracture
Fig. 5.48 (From the Ilizarov Unit - Lecco Hospital)
P.R., 29 year-old male
a) Comminuted fracture of the right tibial pylon.
b) Reduction after 10 days is performed with opposite olive wires while stabilization is achieved with an
external ring fixator which is extended onto the foot.
c) The fixation on the foot is removed, while the entire fixator is removed one month later. Ankle joint
mobility is painful and is limited to 100- 125 degrees of plantar flexion which made surgical

CASE REPORT: Pylon fracture

Fig. 5.49 (G.B. Benedetti - F. Argnani - Bergamo Hospital)
C.G., 43 year-old male
a) Comminuted fracture of the right pylon with detachment of the medial malleolus. Percutaneous
osteosynthesis allowed passive motion.
Weightbearing was not permitted.

CASE REPORT: Pylon fracture

Fig. 5.50 (From the Ilizarov Unit - Lecco Hospital)
P.B., 53 year-old male
a) Comminuted, open fracture of the left tibial pylon.
b) Urgent transosseous osteosynthesis after wound debridment. Active range of motion of the ankle was
possible from the day after surgery on.
Weight-bearing with crutches was allowed eight days following surgery. During the early postoperative
period, a slight valgus persists with unacceptable reduction of the posterior malleolus.
c) After the correction of the valgus deformity by compressing the anteromedial rod, the posterior
fragment was reduced with an olive wire tensioned anteriorly.
d) After partial weightbearing on crutches for 30 days, full weightbearing began. The apparatus was
removed 60 days after surgery. At three months, the anatomical reconstruction of the tibial pylon
seemed to be enhanced by active motion. Disuse ostoeporosis was not present.

CASE REPORT: Pylon fracture

Fig. 5.51 (M. Raschke - Wirchow Klinikum - Berlin)
S.K.H., 39 year-old, suicide attempt.
a) Distal, intra-articular tibial pylon fracture.
b) Transfixion for better soft tissue management.
c) Open reduction, internal fixation of the fibula (first step).
d) Open reduction, internal fixation, restoration of the joint surface (second step).
e) Additional support with the Ilizarov apparatus.
f) Osseous consolidation after 16 weeks of treatment.

CASE REPORT: Distal metaphysial and pylon fractures

Fig. 5.52 (M. Raschke - Wirchow Klinikum - Berlin)
a) 48 year-old female sustained multiple injuries with multiple fractures. The patient sustained a tibia
fracture on the right and a tibial pylon fracture on the left. The patient had also sustained grade 2 (and 3)
burns of 30% of the body involving both legs and lower abdomen. In this situation of soft tissue injuries
along with the complex pylon fracture, it is recommended that minimal invasive procedures are used to
minimize further soft tissue injury.
b) Stabilization of the pylon was performed using composite rings combined with plating of the fibula
and percutaneous screw fixation of the distal tibia. The soft tissues went on to heal and full weightbearing
was allowed at four weeks.
c) The fracture healed at 16 weeks and the frame was removed after two weeks of dynamization.