It all begins in the Siberian steppe, in Kurgan, over 2,000 km east of Moscow. There the Soviet doctor GavriiI Ilizarov he works in the department of General Surgery of the regional hospital, when in 1954 he publishes the first cases of patients with fractures treated with the circular fixator, which he designed and developed. Rings connected by longitudinal bars that form a cylindrical exoskeleton, parallel to the segment to be treated, on which thin metal wires are applied that grip the bone. To stabilize and reduce the fracture, the innovative idea is to act on the abutments by distancing them gradually during the consolidation of the tissue, to stimulate their growth and recover their original shape.
Kurdan’s wizard and the strange idea
“Quack”, he is addressed in academic circles. Then the initial skepticism turns into amazement, because the number of people treated by the “Wizard of Kurgan” increases. Among them the Soviet Valeriy Brumel, high jump champion, world record holder for years. In the West, several luminaries are incredulous: “Lengthen the bone in adults? Not even if they were children. Impossible.” And they leave for Siberia. But overcoming the Iron Curtain is a complicated undertaking, many give up. Italian does not fail Carlo Mauri, climber from Lecco. After a fall his leg does not heal and that Russian doctor remains the only possibility. The meeting with Ilizarov will solve the problem, will mark the beginning of a beautiful friendship and will contribute to the spread of the method.
The hundred years of Ilizarov
Until today. “It is the technique that more than any other realizes the biological and clinical principles of Orthopedics – explains the professor Marco Massobrio, orthopedist and past president of Sife, the Italian Society of External Fixation – a technique that established itself after 1980 and is constantly evolving thanks to the knowledge of materials and the clinic. “The progress and evolution of this technique will be discussed at national congress scheduled for 28 and 29 October at the University of Rome “Tor Vergata”, which celebrates the hundredth anniversary of the birth of the inventor of the technique, Graviil Ilizarov.
Professor, what is an external fixator?
“It is a device that stabilizes the bone thanks to wires or screws and their external anchoring, with a minimum grip on the skeletal segment. It allows to treat fractures without resorting to plaster casts or internal synthesis. Fracture results are treated, congenital and post-traumatic deformities, loss of bone substance, shortage of stature “.
What are the potential of the technique?
“It guarantees mechanical stability by opposing the displacements of the bone in the three planes of space (sagittal, frontal and rotatory, ed) and respects its vitality. An aspect not taken for granted with other means of synthesis. It is irreplaceable in the treatment of open fractures, infections bone loss, tissue loss and limb elongation “.
How long does it stay in place?
“It depends on the type of pathology, intervention and age of the patient. Generally months. However, in selected cases, internal synthesis can also be associated, simultaneously or subsequently with external fixation, so as to remove the equipment early, when has completed its function of gradual correction of the deformity or at the end of the elongation. A method called ancillary or auxiliary use of external fixation “.
Are there any contraindications?
“In conditions of urgency, or necessity, external fixation does not present any, because it stabilizes the fractured patient with a modest surgical trauma. In elective interventions, such as the treatment of deformities, the most important aspects are the person’s tolerance and cooperation , which must be prepared and followed appropriately. A lot of patience is needed, which however is supported by the evidence of the result. To obtain the formation of new tissue with the methods of bone lengthening or transport, there is a first and short waiting phase after the application of the fixator, followed by the lengthening time, which proceeds at the speed of one millimeter a day. Finally the consolidation, which lasts about 2-3 times the lengthening period. Previously it was believed that the age over 35- 40 years was a contraindication, due to the changes in the periosteum (the covering sheath, ed.) Which thins over time. Today it is thought that the limit for osteogenic surgery nesis in distraction should be related to the patient’s general clinical condition “.
What are the complications?
“Infections of wires and screws, breakage and loosening of the implant. But they are not frequent, thanks to the specific study of the anatomy that establishes the right positioning of the means of synthesis. In addition, the patient is taught the daily cleaning of skin procedures. and programmed access to dedicated centers is recommended “.
What topics will be discussed at the congress?
“Three main themes. Ample space for Damage control (damage control, ed), an emergency method for the treatment of fractures in relation to the patient’s clinical condition. The term comes from the United States Navy, from war protocol of a ship that is about to sink and relieves itself of any load in order to arrive in port. The principle is the same, do everything immediately to save the person and the damaged skeletal segment, even without definitive therapy. It has precise rules and indications , which is important to know in order to improve interdisciplinary collaboration in those cases where bone pathology is associated with brain, lung and heart problems “.
What about the other sessions?
“They concern the upper limb, often underestimated in the application of external fixation. In fact, the arm, forearm and hand find a great benefit from this technique, which reduces surgical exposure and preserves the mobility of the limb, which is essential for recovery. precocious. And then the hexapodal systems “.
“They can be considered the evolution of traditional circular external fixation devices. They are formed by two rings firmly connected to the bone segments and by six telescopic rods called struts, or actuators, which connect the rigid supports together. Tools that meet production needs. mechanical industry, applied in robotics and lent to orthopedics “.
Why is this an interesting area?
“For the application of computerized methods, already in use. Today the hexapodal fixators allow you to manually transfer the correction values intended for each of them to the struts, thanks to the calculation of the software in which the deformity or fracture data were loaded . The program elaborates them, provides the resulting vector and the temporal plane. By changing the length of the telescopic rods, it becomes possible to modify the spatial orientation of the support rings and obtain the alignment of the connected bone segments. The advantage of computerized management of fixators hexapodalics is to proceed with the correction with a single gradual maneuver, instead of a subsequent sequence according to the three planes of space. We will thus have a minor surgical trauma, a reduced radiographic exposure, a greater precision “.
What are the developments?
“The application of automation and remote control to the computerized management of hexapodal fixators is being studied. It is achieved by inserting existing micromotors into the struts and using dedicated apps for smartphones”.
What advantages would they give?
“Correction by adjusting the struts would no longer be manual, according to the instructions received from the computer program, but performed directly from the App, which can also be controlled remotely and capable of programming times and changes, evaluated by the doctor, with the patient alert and self conscious”.
Are they already available?
“These stepper motors are used in other research fields, not in medicine. A first and partial attempt at experimentation has been made by some companies. But it is necessary that computerized hexapodalic external fixation systems have greater diffusion before introducing more advanced methods. This is one of the tasks of a scientific society such as SIFE, created for the dissemination and development of external fixation “.