Q U I C K
R E F E R E N C E
G U I D E
11
L i m b Re c o n s t r u c t i o n S y s t e m
Part A: General Principles
Part B: Correction of Deformities
By Prof. M. Saleh and Dr. S. Nayagam
PA R T
A :
G E N E R A L
P R I N C I P L E S
INTERMEDIATE SIZE BONE DEFECT:
BONE TRANSPORT
a) Intermediate size distal defect with shortening.
Limb Reconstruction System with 3 clamps applied.
b) Proximal metaphyseal osteotomy between clamp 1 and 2,
followed by transport with clamp 1 and 3 locked to the
rail and clamp 2 moved distally.
c) Lengthening to restore the original limb length. Clamp 2
and 3 locked to rail and clamp 1 moved proximally.
(a)
(b)
(c)
LARGE BONE DEFECT: BIFOCAL TRANSPORT
Central Defect
a) Large central bony defect and Limb Reconstruction
System in place.
b) Proximal and distal metaphyseal osteotomies
performed.
c) Simultaneous proximal and distal transport with clamps
1 and 4 locked to rail and clamp 2 moved distally and
clamp 3 proximally until segments meet.
(a)
(b)
(c)
Peripheral Defect
a) Large peripheral bony defect and Limb Reconstruction
System in place.
b) Two osteotomies performed in longer bone fragment.
c) Simultaneous proximal transport with clamps 1 and 4
locked to rail and clamps 2 and 3 moved proximally until
segments meet.
(a)
(b)
(c)
SMALL BONE DEFECT:
COMPRESSION-DISTRACTION
a) Small distal bone defect and Limb Reconstruction System
in place.
b) Immediate compression between clamps 2 and 3 to close
defect. Proximal osteotomy performed between clamps 1
and 2.
c) With clamps 2 and 3 locked to rail to maintain
compression, clamp 1 is moved proximally to restore
original limb length by Callotasis.
(a)
(b)
(c)
FRACTURES ASSOCIATED WITH MAJOR SOFT
TISSUE DEFECTS: COMPRESSION-DISTRACTION
a) Fracture with major soft tissue defect and exposed
bone. Limb Reconstruction System in place.
b) Debridement and resection of sufficient bone to allow
soft tissue closure; distal stabilization; proximal
osteotomy.
c) Proximal distraction (lengthening) to restore original
bone length.
(a)
(b)
(c)
LENGTHENING
Monofocal Lengthening
a) Shortening and Limb Reconstruction System in place.
b) Proximal metaphyseal osteotomy.
c) Distraction (lengthening) with clamp 1 locked to rail and
clamp 2 free to move.
(a)
(b)
(c)
Bifocal Lengthening
a) Extreme shortening in the limb, with the Limb
Reconstruction System in place.
b) Proximal metaphyseal osteotomy between clamps 1 and
2 and distal metaphyseal osteotomy between clamps 2
and 3.
c) Simultaneous lengthening at each osteotomy site, with
clamp 2 locked to the rail and clamps 1 and 3 free to
move, restoring original limb length.
(a)
(b)
(c)
GENERAL TECHNIQUE
Screw Insertion
Assemble clamp templates on rail. Insert first screw in
usual manner. Second screw to be inserted will be most
distal one.
Identify center of bone at most distal seat of distal clamp,
using trocar inserted in screw guide.
HA-Coated OsteoTite Bone Screws are strongly
recommended for all limb reconstruction procedures.
Use second trocar and screw guide to check that screws
sited in outer seats of middle clamp will penetrate center
of bone.
Check that satisfactory screw insertions can be achieved
at chosen sites in proximal and distal clamps.
Insert most distal screw using standard technique.
Insert remaining screws.
Use screw seats 1, 2 and 4 (starting from proposed
osteotomy site) in proximal clamp.
Use screw seats 1 and 5 in middle and distal clamp.
Tension Osteotomy
Remove rail with template clamps and screw guides;
apply rail with definitive clamps.
Lock clamps into position on rail. Place compressiondistraction unit between proximal and middle clamps.
With middle clamp loosened, apply distraction.
Perform osteotomy using drill bit in corresponding drill
guide. Connect holes with osteotome.
Distract osteotomy to confirm complete.
Bring both segments together and lock middle clamp.
Replace periosteum, suture if possible, and close incision
with single suction drain.
PA RT B : C O R R E C T I O N O F D E F O R M I T I E S
BASIC CONSIDERATIONS
BISECTOR
LINE
When hinge of monolateral fixator is on bisector line,
after correction there is no translation (a).
When hinge is at level of deformity, after correction there
is some residual translation (b).
When monolateral fixator is on convex side of deformity,
correction will distract osteotomy.
When on concave side, compression will occur at
osteotomy.
CORA
CORA
(a)
(b)
PROTOCOL FOR USE OF MICROMETRIC
CORRECTION CLAMPS
Fixator on Convex Side of Deformity
a) Distract osteotomy according to principles of Callotasis.
b) Reduce soft tissue tension by shortening acutely by
4-5 mm.
c) Correction is performed until tension is felt.
d) Repeat (b) and (c) until correction complete.
Fixator on Concave Side of Deformity
Distract osteotomy according to principles of Callotasis.
Correction is performed. As fixator is on concave side,
angular correction will close distraction gap and
simultaneously reduce soft tissue tension.
MICROMETRIC SWIVELLING CLAMP
Apply LRS with swivelling clamp, using template and
screw guides. Osteotomy: at least 15 mm from nearest
bone screw, as near as possible to level of hinge.
Immediate on-table Correction
Loosen micrometric swivelling clamp on rail; loosen
outer two clamp locking screws; perform correction,
allowing clamp to slide on rail.
Late Correction through Callus Manipulation
See Protocol for use of Micrometric Correction Clamps,
above.
MULTIPLANAR CLAMP
Bolt B
Assemble template and set angulator to plane of
deformity. Tighten bolt A. Set hinge of angulator to angle
of deformity with distractor.
Mark position of CORA and bone screws on patients
limb.
Hold assembly at correct distance from skin and adjust
position so that hinge is at same level as either apex of
deformed bone or bisector line of CORA.
Insert bone screw through straight clamp template into
longer bone segment, at 90 to axis.
Bolt A
Adjust distance between rail and skin to 2-3 cm.
Insert screw guide and trocar through multiplanar clamp
template. Check is at 90 to axis, in correct plane. If not,
adjust position. Tighten bolt B.
Insert second screw through multiplanar clamp template.
Bolt B
Insert all screws. In an adult, always use three screws per
clamp.
Remove screw guides and templates, apply rail with
definitive clamps. Tighten firmly all clamp locking
screws, perform osteotomy through apex of deformity.
For correction, follow Protocol for use of Micrometric
Correction Clamps described above.
THE OF-GARCHES T-CLAMP
The OF-Garches T-Clamp may be used for lengthening,
angular correction or a combination of the two. Gradual
or immediate angular correction is possible.
Gradual Correction
(T)
Determine pre-operatively distance L shown opposite by
drawing mechanical axis of both deformed and corrected
tibia.
Perform complete tibial osteotomy just below insertion
of patellar tendon, and a fibular osteotomy. Place
compression-distraction unit in concavity of deformity
and distract osteotomy according to principles of
Callotasis, to amount equal to distance L above.
While distracting, clamp axis locking nut (T) should be
tightened and straight clamp locking screw (L) loosened.
(L)
(L)
(T)
Change position of removable locking pin, and with
clamp axis locking nut (L) loosened and straight clamp
locking screw (T) tightened, distract to correct angular
deformity. When correction complete, tighten clamp axis
locking nut.
THE ACUTE CORRECTION TEMPLATES
Compatible with either adult or pediatric limb reconstruction
system, they may be used to correct acutely an angular or
rotational deformity, or combination of the two.
Angulation Templates
Allow correction in two planes. Two hinges on each
clamp, one for alignment in coronal plane, the other in
sagittal plane.
Rotational Templates
The template consists of two components: an arc and a
template clamp.
3 arc sizes for different sizes of limb (60 mm, 100 mm,
130 mm).
Example Application Showing Use of Angulation and
Rotational Templates in a 20 Varus and 25 Internal
Rotation Deformity.
25
Choose correct size arc, so that distance between rail and
bone is equal to radius of arc selected.
Attach template clamp (N.B. Use correct locking hole for
arc size).
Lock to arc at correct rotational position for screw
insertion (in this case 25).
Attach angulation template; adjust to reflect varus
deformity; tighten hinge locking screws.
Hold rail 3-4 cm from skin; advance spacing screws in
both clamp templates until they touch skin.
Insert screw at 90 to bone axis, just proximal to apex of
deformity.
Insert trocar through screw guide in clamp template on
arc, down to bone.
If template has been set up correctly, trocar will point
towards center of bone, 90 to axis of distal femur. If OK,
insert second screw. If not, adjust clamp until trocar
points to center of bone.
Insert remaining screws, always 3 in each clamp in adults.
Perform osteotomy at apex of deformity; remove rail, and
manipulate limb so that both pairs of bone screws are
parallel.
Apply LRS rail with standard straight clamps, and tighten
clamp locking screws.
Spacing screw
The Orthofix Quality System has been certified to be in compliance with the
requirements of:
Medical Devices Directive 93/42/EEC, Annex II - (Full Quality System)
International Standards EN 46001/ISO 9001
for orthopaedic external fixator systems including bone screws, nails and wires,
sterile external and internal fixation systems.
See Operative Manual 1 General Application Instructions and
appropriate Operative Manual prior to use.
T H E
O R T H O F I X
G R O U P
Orthofix Inc
Novamedix Services Ltd
250 East Arapaho Road
7 Viscount Court, South Way,
Richardson, Texas
Andover, Hants
75081 USA
SP10 6NW, England
Tel. 1 972 9188300
Tel. 44 1264 334212
Fax 1 972 9188356
Fax 44 1264 334007
Orthofix Ltd
Novamedix Distribution Ltd
Northfield House
Julia House
Northfield End
3 Themistocles Dervis Street
Henley-on-Thames
Nicosia, Cyprus
Oxon RG9 2JG, England
Tel. 35 72 450964
Tel. 44 1491 413131
Fax 35 72 475194
www.orthofix.com
Fax 44 1491 412929
Orthofix Srl
Orthosonics Ltd
Via delle Nazioni, 9
Bremridge House
37012 Bussolengo
Bremridge,
Verona, Italy
South Devon TQ13 7JX, England
Tel. 39 0456767030
Tel. 44 1364 652426
Fax 39 0456767135
Fax 44 1364 653589
Inter Medical Supplies Ltd
Intavent Orthofix Ltd
Julia House
Burney Court
3 Themistocles Dervis Street
Cordwallis Park
Nicosia, Cyprus
Maidenhead,
Tel. 35 72 450964
Berks SL6 7BZ, England
Fax 35 72 475194
Tel. 44 1628 594500
Fax 44 1628 789400
DMO Srl
Collin Orthofix
Via dellAgricoltura, 50
19, Rue de la Gare
37012 Bussolengo
94230 Cachan, France
Verona, Italy
Tel. 33 (0)1 49083800
Tel. 39 0456767028
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PG LRS E0
01-11/99
