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Treating Bone Deformities With Circular External Skeletal Fixation

Treating Bone Deformities With Circular External Skeletal Fixation

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Vol. 21, No. 6June 199920TH ANNIVERSARY
Refereed Peer Review
FOCAL POINTKEY FACTS
#
Circular external fixation usingthe Ilizarov method is a novelsurgical option for correctingangular limb deformities andlengthening deformed bonesof companion animals.
Treating BoneDeformities withCircular ExternalSkeletal Fixation
North Carolina State University 
Denis J. Marcellin-Little, DEDV 
ABSTRACT:
The Ilizarov method of circular external fixation has remarkable benefits in treat-ing bone deformities. It relies on unique external fixation devices and distraction osteogenesis.Rings placed around the limbs are interconnected with threaded rods and fixed to the boneusing small-diameter wires under tension. The angle and distance between rings can bechanged, leading to change in the shape of the bone. With distraction osteogenesis, new boneforms at the osteotomy site when it is slowly distracted after surgery.
L
imb deformities in dogs are most frequently caused by abnormal bonegrowth but can also be a consequence of fracture malunion, joint contrac-ture, or polyarthritis. Abnormal bone growth may be secondary to physealinjuries, dwarfism, hypertrophic osteodystrophy, multiple cartilaginous exos-toses, or hyperparathyroidism.
1–4
The most common angular limb deformitiesare antebrachial, representing 0.74% of all bone problems.
5
Limb deformities incats are rare. Tarsal hyperextension and torsion have been reported in kittens,
6
but the prevalence, cause, and pathogenesis of these problems are unknown.Bone deformities of the tarsus, carpus, and extremities also occur in Scottish-foldcats with osteodystrophy.
7
Conventional treatment options for limb deformities include conservativemanagement
8
; physeal resection with fat grafting
9
; physeal stapling
10
; transverse,oblique, cuneiform, or dome osteotomies (transsection of bone)
8,11
; ostectomies(removal of a fragment of bone) with or without fat grafting
12,13
; and stabiliza-tion with external coaptation,
8,11
bone plates,
14
or conventional external fixa-tors.
15,16
The major drawback of all of these methods is that the shape of thebone cannot be changed after surgery. Limb alignment is determined while thepatient is anesthetized and not bearing weight, making the cosmetic and func-tional results of surgery less predictable. Because bone shape and length are set atthe time of surgery, additional surgeries may be necessary to treat incomplete de-formity corrections and recurrent deformities in growing dogs. To address thisissue, adjustable fixation techniques have been attempted, with bone movementmade possible by the use of rubber bands or adjustable connecting bars on exter-nal fixators.
17–20
The results of these methods have been unpredictable.
19
CE
V
I
The Ilizarov circular externalfixation method involves placingrings around the limbs; the ringsare fixed to the bone with wiresthat are 1- to 1.5-mm in diameterand under 0 to 90 kg of tension.
I
Joint malformations (except jointsubluxations) and degenerativejoint disease secondary to growthdeformities cannot be correctedwith circular external fixators(CEFs); growth deformitiesshould be treated before irrevers-ible joint damage occurs.
I
Mild angular deformities withlength deficits can be treatedwith CEFs; severe angulardeformities are ideally treatedwith hinged CEFs.
I
Following a delay of 2 to 7days after osteotomy, the siteis distracted 0.5 to 2 mm daily,in two to four steps, until thedeformity is corrected 2 to 8weeks later.
 
Circular external fixators (CEFs) represent a new surgical method for treating bone deformities in hu-mans and companion animals.
21
23
CEFs are also calledring fixators, fine-wire fixators, or Ilizarov fixators (inhonor of the surgeon who developed their applicationmethod and popularized their use in humans in theSoviet Union in the 1950s).
24
Originally developed forfracture repair, the use of CEFs in treating bone defor-mities has increased over time. Ilizarov introduced sev-eral unique concepts: (1) Bone fixation is provided by small-diameter wires that are under tension and con-nected to rings surrounding the limbs; (2) rings con-nected by articulated threaded rods can be assembledin unlimited configurations; and (3) the bone can begradually distracted after osteotomy, and bone healing will occur within the resulting gap
a phenomenoncalled
distraction osteogenesis 
. The combination of dis-traction osteogenesis and the limitless geometric flexi-bility of CEFs allows bone deformities to be correctedprogressively and precisely in a few weeks after surgicalplacement of the frame and osteotomy of the de-formed bone. This article presents the applications of CEFs in treating limb deformities in companion ani-mals.
DIAGNOSIS AND TREATMENT PLANNINGClassification of Bone Deformities
 A precise understanding of the pathologic process isnecessary to treat bone deformities using CEFs. Bonedeformities may be classified as unifocal (i.e., abnormalbone shape in one location; Figure 1) or multifocal(i.e., abnormal bone shape in multiple locations; Figure2). Unifocal deformities are common in dogs and in-clude premature physeal closures in the first few weeksafter physeal injury as well as fracture malunions. Uni-focal deformities originate at the intersection of twolines representing the center of the long axis of theproximal and distal parts of the limb (Figure 1). Prema-ture physeal closures of a single bone (e.g., femur) orpaired bones (e.g., radius and ulna) as well as mal-unions are treated with corrective osteotomy of the af-fected bones. In puppies with significant remaininggrowth potential, premature physeal closures of onepaired bone (e.g., ulna) are treated with ostectomy of the restricting bone (e.g., ulnar ostectomy). After a few  weeks of growth, premature physeal closures of pairedbones often become multifocal deformities when thebone with less growth potential impairs growth of thebone with more growth potential. Multifocal deformi-ties also result from metabolicbone diseases and chondrodys-plastic dwarfism. Multifocal de-formities are treated with correc-tive osteotomies of the affectedbones.
Components ofBone Deformities
Bone deformities have severalcomponents, including angula-tion, length deficit, rotation,and translation. It is importantto identify and specifically treateach of these components.
Angulation 
 Angulation can be measuredon both the animal and radio-graphs. Angular deformities may be overestimated if measured ona weightbearing limb becausethe deformity may cause jointinstability. Angular deformitiesmeasured on radiographs may be underestimated if linear trac-tion is placed on the extremities(e.g., by taping the foot). Angu-lation can be measured on ra-
Small Animal/Exotics20TH ANNIVERSARY
Compendium 
June 1999
CIRCULAR EXTERNAL FIXATORS
I
ILIZAROV
I
PREMATURE PHYSEAL CLOSURES
Figure 1AFigure 1BFigure 1CFigure 1—
(
 A 
) Craniocaudal and (
B
) mediolateral radiographic views of the antebrachiumof (
C
) an 11-month-old Siberian husky with a malunion secondary to an untreated SalterII fracture of the distal radial physis. A unifocal bone deformity is visible. Two lines aredrawn on the radiographs, in the center of the paw and in the center of the antebrachium.These lines intersect at the distal radial physis, which is the origin of the deformity.
 
diographs by comparing lines drawn in the center of the proximal and distal parts of the normal and affectedlimbs (Figure 1).The general alignment of the limb should be evaluat-ed in the medial-to-lateral (ML) and cranial-to-caudal(CC) directions. Most deformities have ML and CCcomponents, which means that most deformed bonesare angled in a valgus or varus direction and are bowed. As a general rule, the ML component of the deformity is more critical than is the CC component because, un-like the hip and shoulder joints, distal joints move only in the CC direction. Within limits, a dog with a bowedradius can correct for the deformity by flexing or ex-tending its elbow or carpus, but a dog with a valgus de-formity of the carpus cannot adjust the position of itslimb to compensate. However, these compensationsonly partially correct angular deformities.
Length Deficit 
The length deficit present in a deformed bone shouldbe determined by comparing the lengths of affectedand opposite limbs on ML and CCradiographic pro- jections. The ML radiographic view is often more use-ful than the CC view because the limb is more likely tobe parallel to the radiographic cassette with the MLview. If both limbsare abnormal, a littermate may beused for comparison. In antebrachial growth deformi-ties, the length deficit of both the radius and ulnashould be measured; the length deficit is generally larg-er in the bone that had the original growth problem. When radiographs taken at different times are available,length deficit should be measured for each time becausevariations can help indicate the cause of deformity. When angulation is present in a limb, the functionallength of the limb is less than the anatomic length of allbone segments.
Rotation 
Rotation of a deformed limb should be determinedduring the orthopedic examination by comparing thedirections of the planes defined by flexion and exten-sion of the joint above and below the deformity (Figure3). Rotation cannot be reliably determined radiographi-cally.
Translation 
Translation within a bone is the displacement of abone segment in relation to the rest of that bone per-pendicular to the long axis. Translation may be presentin the absence of angulation or rotation, creating an
S
-shaped bone. Although rare in animals, translation may be present in fracture malunion or nonunion.
Compendium 
June 199920TH ANNIVERSARYSmall Animal/Exotics
LIMB ALIGNMENT
I
COMPENSATION
I
ANTEBRACHIAL GROWTH DEFORMITIES
Figure 2
(
 A 
) Craniocaudal and (
B
) mediolateral radiographic views of the antebrachium of (
C
) a 6-month-old Irish wolfhound with a bilaterally abnormal distal ulnar physeal growth. A multifocal bone deformity is present; the radius is curved throughout its length.
Figure 2AFigure 2BFigure 2CFigure 3
Determination of therotational deformity of a bone ina 6-month-old Boston terrier.Comparing the plane of flexionand extension of the proximal joint (
 A 
) with the plane of flex-ion and extension of the distal joint and extremity (
) deter-mines the degree of rotation of alimb segment. This dog has 65
˚
of external rotation (
arrow 
).

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