SIGN Symposium - Sept. 2014 Taylor Spatial Frame: Clinical Applications John E. Herzenberg, MD, FRCSC Director, ICLL Sinai Hospital, Baltimore, Maryland Clinical Prof. – Univ. Maryland Disclosures: Research and institutional support from: Smith Nephew Orthofix Ellipse Example: Deformity only. No LLD. Options: Internal or external fixation Internal Fixation External Fixation Example: Deformity plus LLD Options: external fixation only! Gavriel Ilizarov Professor Ilizarov and Carlo Mauri smoking in the O.R. Charlie Taylor J. Charles Taylor: Spatial Frame • Patent filed 1996 • Awarded 17/3/1998 • Expires17/3/ 2015 Phillipe Moniot, 1985 (13 years before JCT): First patent on a hexapod Ilizarov device TSF vs Ilizarov • hardware is easier than Ilizarov • computer based correction • versatile for complex deformities • learning curve is acceptable Which is more accurate: Ilizarov or TSF? • N= Ilizarov (79) TSF (129) • Goal of correction achieved (all cases): Ilizarov 56% TSF 91% Hexapod “Stewart” Platform (1965) 2/3 Ring Baltimore Center – 2014 TSF = most common fixator for limb lengthening and deformity correction. Exceptions: - most straight lengthening we use internal lengthening nails (femurs > age 8-10; tibias > age 14-16) - very small children may need Ilizarov frames 2 y.o. boy Congenital Pseudarthrosis of Tibia (Hypertrophic type) CPT (HNU) 2 weeks Post-op 4 weeks Post-op TSF: Advantages • Preconstruction not required • No need for special constructs for rotation/translation/angulation • Easily reprogrammed during treatment • Able to mix ring sizes and orientations • Able to do multilevel corrections 48 year-old woman s/p ORIF for tibia fx (motorcycle) • hypertrophic non-union • valgus - procurvatum deformity • broken hardware Origin Origin CP CP Apply Reference Ring to distal segment. centering bolts overlapped AP frame offset centering bolts overlapped Lateral view frame offset Add fixation… Completed fixation Post-op radiographs Final Pre-op Final Step 16 y.o. with varus and 3 cm LLD from growth arrest Medial compartment osteoarthritis Early post-op 2/3 ring 2/3 ring End of correction: Mechanical axis passes through the Fujisawa point 12 year old girl with knee fusion following severe trauma: double level oblique plane deformities TSF strategy: 2 frames 3 rings procurvatum valgus valgus recurvatum TSF strategy: Distal reference for femoral deformity. Proximal reference for tibial deformity. Apexes = origins Reference ring During treatment At frame removal At follow-up Three-level Deformity Correction 17 y.o. boy Fibular Hemimelia s/p lengthening Has valgus, hyperpronatted foot and LLD Intraoperative Images Elevating periosteum off tibia + fibula Kirschner wire to prevent proximal migration of gigli saw Osteotomy of fibula and tibia Postop Radiographs Initial postop Distraction at osteotomy site Angular correction at osteotomy Final Post-op • 18 yo male, genu varum, also wants height 2 weeks post-op PRE-OP POST-OP • 39 year old x-ray tech, s/p HTO for knee pain --• BAD COMBO • Varus tibia + valgus femur 2 weeks post-op 6 weeks 4 months post-op post-op Final post-op 35 year old man previous open tibia fracture. Now has stiff nonunion & ankle equinus contracture Strategy: Two level deformity Double level treatment TSF for mal-non-union TSF for ankle equinus contracture Residual program to achieve 10° of dorsiflexion initial after running residual program Consolidation phase – TSF struts changed to Ilizarov struts (better x-ray access and more dynamic) Equinus Contracture 16 y.o. girl Bilateral Radial Club Hand s/p centralization, 16 y.o. girl Radial Club Hand s/p centralization, relapse PLAN: Ilizarov Wrist Reconstruction + Lengthening GSW: Oblique Plane Malunion Humerus Distal Reference Ring U-Osteotomy 14 y.o. girl with diastrophic dysplasia – Equinovarus foot after many operations Early regenerate bone Post-op Pre-op 17 y.o. spina bifida girl with supinated forefoot NOTE: “stacked” metatarsals U-plate with tapped ends Is the Ilizarov Fixator obsolete? TSF = Fixator of choice for most limb lengthening and deformity correction. EXCEPTIONS: small children needing baby Ilizarov frames TSF: Disadvantages • • • • Internet access required Expensive ~10,000 $ per frame If reused 10 times, then cost = 1,000 $ per frame Learning curve 25th Annual Baltimore Limb Deformity Course August 27-31, 2015 www.deformitycourse.com TSF in the Developing World: Is it realistic? Francel ALEXIS, MD Chief of Orthopedics Haiti Adventist Hospital No Disclosures HUEH residents, Port au Prince, Teaching Seminar, Adventist, 2012 TSF: Deformity Correction Is it useful in austere environments in the Developing World? Requirements: • skilled surgeon • internet access • time and commitment • cooperative patients • TSF program at HAH • Used regularly at HAH since 2010 n = 90 • Used rings/struts are donated from USA surgeons; reused (recycled) Some TSF cases done at Haiti Adventist Hospital… Distal Tibia Malunion in 14 y.o. boy [neglected for 10 years] Valgus + LLD Neglected Blount’s in 27 y.o. man • Bilateral Blount’s R>L • Never treated • He had to quit school because of this deformity • 45° deformity Before After Second side… Bilateral Neglected Clubfoot • 14 y.o. girl • Unable to wear normal shoes • Difficulty walking Miter Frame TSF Genu Valgum Hypophosphatemic Rickets • • • • 14 y.o. girl Unable to stand and walk Mostly crawling Unable to go to school, have friends and live a normal life Severe Genu Valgum/Rickets Left side, then right side.. left right No External Rotation, L. arm (Brachial Plexus Palsy) Unable to externally rotate the left arm since birth. Pre and final Neglected Right Clubfoot in Adult Woman “Ponsetaylor” TSF Neglected Right Clubfoot in Adult Before After Unilateral Blount Disease • • • • • 22 y.o. young man Familial Hypophosphatemic rickets Severe genu valgum Unable to stand Has to crawl Immediate Post-Op After Correction During treatment, after removal… Happy patient! TSF in the Developing World… It can be done! 25th Annual Baltimore Limb Deformity Course August 27-31, 2015 www.deformitycourse.com
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