Asian Biomedicine Vol. 7 No. 6 December 2013;885-892 DOI: 10.5372/1905-7415.0706.254 Clinical report
Ilizarov apparatus in Cambodia: a review of its history and versatility in a resources poor region. With case illustrations
Rupert Wharton, Suzanne Zeidler, James Gollogly, Cheng Ngiep Ou, James Aird Children’s Surgical Centre, Phnom Penh, Cambodia
Background: The Ilizarov apparatus is a versatile external fixation system that can be used for a variety of indications in orthopaedic and reconstructive surgery to provide stability, bone transport, and correct angular deformities. The Children’s Surgical Centre is a non-governmental hospital in Phnom Penh, Cambodia providing free elective surgery to Cambodian nationals. The Ilizarov apparatus has been used in our centre since 2005. Objective: We described the frame’s use in our centre and discuss its impact on our patient population. Methods: This is an analysis of care series with six illustrated examples. Results: The apparatus is well tolerated by patients. Its use results in higher rate of unions. Conclusion: Ilizarov apparatus is associated with higher rates of unions. This external fixation is suitable for areas where access to healthcare is impeded by distance.
Keywords: Developing world surgery, external fixator, Ilizarov, orthopaedics, reconstructive surgery, ring fixator
The Children’s Surgical Centre (CSC) is a non- apparatus was fitted, dating back to the first frame governmental hospital based in Phnom Penh, application in 2005. Cambodia, specialising in limb reconstruction. Surgery We have selected illustrative cases for each is offered free of charge to both adults and children. indication, to demonstrate the Ilizarov frame’s In 2010, a total of 2,631 patients presented with limb versatility in Cambodia. problems, and 1,487 operations were performed. The Ilizarov frame has been used in our centre since 2005. Results Despite limited training in its use and equipment, the Treatment of tibial malunion surgeons have had significant success in treating Patient 1 challenging conditions for which there are limited A 25-year-old man (Sal-5227) presented with alternative treatments in Cambodia. a malunion of the tibia, following fall from a tree in The surgeons at the Children’s Surgical Centre 1995 when he was a child. At that time there was learned to use this device during week long visits from little orthopaedic care available in Cambodia and he international surgeons. Many of the patients treated received no treatment. When in 2005 he presented to would have otherwise required amputation as few CSC, he was treated initially with osteotomy and other treatment modalities were available locally. With intramedullary nailing, which resulted in an infection the use of Ilizarov frames, most patients have and subsequent non-union. Six months later, his nail functional limbs with no need for prostheses. was removed and an Ilizarov frame was applied. Fifteen weeks later, bony union was achieved, the Materials and methods frame was removed and the patient was able to walk The study was submitted to the local ethics board, unaided. and consent was duly given. A retrospective analysis was conducted of all patients on whom an Ilizarov Treatment of chronically infected non-union of tibia Patient 2 A 35-year-old man (ngo-9653) presented in Correspondence to: James Gollogly, Children’s Surgical Centre, January 2007 with an open fracture of the tibia and Phnom Penh, Cambodia. E-mail: [email protected] exposed bone sustained in an accident 3 months 886 R. Wharton, et al.
previously. He had been unable to afford the fees in a flap and an Ilizarov frame was applied. The frame local hospital, and had therefore had no treatment. At was removed 7 months later following bony union with CSC he underwent debridement, a fascio-cutaneous a good functional outcome.
Figure 1. A: Presentation of the malunion of tibia, B: Intramedullary fixation of tibia and subsequent application of Ilizarov, C: Solid healing on X-ray images and ability of patient to stand after removal of frame. Vol. 7 No. 6 Ilizarov apparatus in Cambodia 887 December 2013
Figure 2. A: Exposed bone in 3 month old tibial fracture, B: Ilizarov frame on leg and compressing tibial fracture, C: Healed fracture in Ilizarov frame
Treatment of growth plate arrest Treatment of congenital pseudarthrosis of the tibia Patient 3 Patient 4 A 16-year-old girl (chh-7948) presented in A 10-year-old girl (5587s) presented with a February 2006 with a 30-degree valgus deformity at pseudarthrosis of her right tibia, which had been the left knee. At the age of 8, she had been involved present from birth but untreated, as her mother was in a motor vehicle accident, and subsequently suffered unaware that any treatment was available in growth plate arrest of the lateral femoral condyle. Cambodia. When she finally was referred to CSC in In October 2006, she underwent supracondylar 2004, she had a severe deformity of her tibia, a short osteotomy to correct the deformity, and had a modified leg, and walked with a limp. She was initially treated Ilizarov frame applied, which used some struts from with excision of the pseudarthrosis and bridge fixation a Taylor Spatial Frame, because of a lack of hinges with the ipsilateral fibula. This treatment failed and a being available. The frame was adjusted 3 times and year later in November 2005, she underwent more was removed after five months with significant extensive debridement of the pseudarthrosis and then correction of the valgus deformity and restoration of application of an Ilizarov frame, allowing the equal leg length. pseudarthrosis to be compressed whilst simultaneously 888 R. Wharton, et al.
lengthening the tibia more proximally. Six months later, and when seen in 2007, she walked with a normal this resulted in a united fracture with equal leg lengths gait.
Figure 3. A: Clinical and X-ray pictures of presenting deformity, B: Clinical and X-ray pictures of modified Frame, C: Final clinical pictures after deformity correction Vol. 7 No. 6 Ilizarov apparatus in Cambodia 889 December 2013
Figure 4. A: Congenital pseudarthrosis of tibia, treated initially with ipsilateral fibular onlay graft, B: Clinical and x ray pictures of Ilizarov frame with distraction proximally, and compression of the pseudarthrosis, C: Healed and lengthened tibia at end of treatment
Bone lengthening/Bone transport the 20 cm leg. The patient can walk without any Patient 5 assistance, and is happy to have avoided an amputation. A 27-year-old woman (hoe-15732) presented in February 2009, with an advanced giant cell tumour of Upper limb application the distal femur. This was treated with excision of Patient 6 the entire distal femur leaving a bone defect of A 14-year-old boy (che-15077) with multiple approximately 20cm, so an Ilizarov frame was applied hereditary exostoses presented with a 90-degree fixed to the femur and tibia bridging the gap. In addition, flexion contracture at the right elbow in November osteotomies of the proximal femur and tibia were 2008. X-ray revealed multiple exostoses and a short conducted within the boundaries of the frame, so that ulna, with associated radial head dislocation. A decision the distal femur and proximal tibia could be slowly was made to lengthen the ulna, so a mid-ulnar approximated. Seven months later, the bone ends were osteotomy was performed in December 2008, and an in contact and a knee fusion was performed and Ilizarov frame was applied for lengthening. The ulna stabilised with a Steinman pin. The circular fixator was restored to length and although the radial head was changed to a monolateral fixator for the final remained dislocated he was able to flex his elbow from stages of consolidation and all hardware was removed 80 to 120 degrees, giving him a useful range of motion. by August 2010. The treatment corrected 17 cm of 890 R. Wharton, et al.
Figure 5. A: Clinical and X-ray picture of bone tumor of knee, B: Extensive Ilizarov frame to allow bone transport, C: Lengthening of the femur and tibia, D: Clinical and X-ray picture just before removal of ex-fix Vol. 7 No. 6 Ilizarov apparatus in Cambodia 891 December 2013
Figure 6. A: Clinical and X-ray pictures of initial deformity. B: Clinical and X-ray pictures of Ilizarov lengthening of ulna. C: Clinical and X-ray pictures of forearm after lengthening
Discussion with internal fixation met with limited success, and Patient group our treatment of chronic infected non-unions was This selection of patients highlights the advanced particularly challenging. The use of a circular external nature of pathology presenting to CSC in Cambodia. fixator system that has the potential to compress a This is because of a variety of factors, which include non-union site has allowed us to achieve significantly lack of facilities for complex surgery in centres other higher rates of union [3]. In our experience, the Ilizarov than Phnom Penh, transportation challenges, lack of apparatus has been well tolerated by patients, and been affordable health care and treatment by traditional very useful in achieving successful treatment. medicine practitioners who lack basic knowledge of many of the conditions they encounter. Traditional Conclusion Khmer medicine is generally more accessible to many The Ilizarov apparatus is a system of external of our patients, who only seek help from orthodox fixation of bones, using intraosseus or periosseus pins medical services if traditional medicine fails to resolve and external rings, which can be used to treat many the problem and then often after much delay[2]. limb deformities. In Cambodia, where access to healthcare resources is limited by distance and poverty, Use of the Ilizarov apparatus at Children’s many patients present late. We have described the Surgical Centre versatility of the Ilizarov system by detailing a range Since starting to use the Ilizarov apparatus in 2005, of interesting and varied indications for its use in our centre has benefited from its versatility. Prior to patients presenting to our centre over a six-year period. obtaining the apparatus, our treatment of non-unions 892 R. Wharton, et al.
Acknowledgement osteosynthesis in traumatology and orthopedics. The authors would like to thank the staff at CSC Probl Rehab Surg Traumatol Orthop. 1962; 8:4-21. for their help with identifying patients and charts that 2. Collins W. Medical practitioners and traditional qualified for this study and the donors who help finance healers: a study of health seeking behavior in the hospital. The authors have no conflict of interest Kampong Chhnang, Cambodia. Presentation at to declare. Phnom Penh, Centre for Advanced Study, 2000. 3. Spiegelberg B, Parratt T, Dheerendra SK, Khan WS, References Jennings R, Marsh DR. Ilizarov principles of deformity 1. Ilizarov GA. A decade of experience in the application correction. Ann R Coll Surg Engl. 2010; 92:101-5. of the author’s apparatus for compression