Reconstructive surgery based on Ilizarov technique is an example of a breakthrough technology in medicine that first appeared in Russia. Dr Alexander Aleksandrovich Artemiev told a Russian electronic magazine about the advantages and prospects of the method. Here we publish a shortened version of the interview.
Dr Artemiev, MD, is a leading expert of the Clinical Hospital on the Yauza, has carried out more than 1.5 thousand surgeries to correct deformations and shortenings of the lower limbs with the use of the Ilizarov technique. He actively promotes it, and in June 2017, he will highlight this issue at the Eurasian Orthopedic Forum (EOF).
What is your assessment of the role and place of the Ilizarov technique in traumatology and orthopaedics? It is often said that this is the past ages.
For many years I have been using and promoting external transosseous osteosynthesis based on the Ilizarov technique — and indeed, I meet many opponents. Formally, it is truly “past ages,” but only because it was invented in the middle of the last century. However, to date only a basis of the first apparatus has survived — the rings, which make it recognizable. The modern apparatus is the fruit of collective creativity of several doctors’ generations. The main thing is not even the device itself, but the discovery that Dr Gavriil Abramovich Ilizarov made. The said “Ilizarov effect” is as follows: it is a general biological property of tissues to respond to dosed stretching by growth and regeneration. Someone once invented a wheel, and since then it has been an integral element of machines and mechanisms. Ilizarov has invented such a “wheel” for traumatology and orthopaedics. It is an outstanding, compelling achievement, which has been recognized and developed in 60 countries of the world. Its potential has not been fully unleashed, though.
It is no secret that in many industries we focus and rely on foreign technologies and equipment. As far as medicine is concerned, the Ilizarov apparatus and technique is the only domestic medical technology that has been recognized all over the world. This is a calling card of Russia in medical circles. Among the other branches, I can site as an analogy the first artificial Earth satellite created in the Soviet Union. Another example is the Kalashnikov assault rifle, but the designation of the Ilizarov apparatus is quite different, creative. For more than two years my father, Alexander Anatolievich Artemiev, was the chief traumatologist of our army in Afghanistan in the 80s. He implemented it in gunshot wounds treatment, saved lives and preserved hands and feet in hundreds of young men. It is a pity that Ilizarov had not invented his device ten years earlier. Perhaps, we could have won in the Great Patriotic War with much fewer losses.
When correcting deformities of limbs, different types of osteosynthesis are used. What are the advantages of the Ilizarov technique as compared to them?
The possibilities of the Ilizarov technique are much wider. There are fewer counterindications. For example, a plate cannot fix a deformation greater than 15 degrees. And the apparatus can fix any large deformation, it is created for this end — as a super-cross-country SUV, capable of traveling where other machines cannot. And there is no need for complex preoperative planning, while in the case of internal osteosynthesis with the use of suprabone plates, one should calculate in advance the course of the surgery taking into account a variety of factors, and it is not always possible to achieve the desired result without complications. The apparatus can also bring the limb axis to an ideal position in almost 100% of the cases. When using the Ilizarov technique, the complication rate is considerably lower. Already in 5-7 days after the surgery, the patient starts walking, he independently manipulates the apparatus, and the shape of the legs is gradually being adjusted. The doctor only needs to perform clinical and X-ray monitoring in time to understand when the desired result is achieved.
The Ilizarov technique has no alternatives in cases of severe mechanical injuries and gunshot wounds, which are accompanied by extensive soft tissue damage, when the use of plates and pins is counterindicative because of inflammation or osteomyelitis risks. Due to this specificity, the Ilizarov apparatus is widely used in military hospitals, but, unfortunately, it is used less and less in civilian healthcare.
How do you assess the condition of reconstructive and, in particular, aesthetic orthopaedics of limbs in Russia and globally?
First of all, let’s define the terminology. Reconstructive surgery is a general concept; aesthetic surgery is only a small part of it. Confusion in terms is due to the fact that the legs are one of the few organs whose shape is directly related to the function. The shape of the ear does not affect the sense of hearing, the shape of the nose does not affect the breathing function — they are corrected mainly for aesthetic reasons. The shape of legs is quite a different thing. If the limbs are deformed, the joints experience increased and uneven loads. This significantly increases the risk of deforming knee joint arthrosis in the age of 40-50, especially against the background of age-related and hormonal changes, weight gain, microtraumas, pregnancy in women, and other factors.
Therefore, a surgery to correct the crooked legs at a young age can significantly reduce or even completely eliminate the risk of arthrosis development. An indicative fact: every year several hundreds of thousands of people in the world undergo a rather serious surgical operation — knee joint arthroplasty. I am sure that 70% of them could avoid this operation if they underwent corrective osteotomy 5-10 years ago. Corrective osteotomy is a surgery aimed at restoring the normal position of the mechanical axis of a lower limb. To make it absolutely clear — it is a surgical operation to straighten limbs. Hence the error: the legs were crooked, now they become straight — this means aesthetics. I will put it differently: the legs were crooked, now they become straight — this means prevention. But, unfortunately, many doctors — not only in Russia, but also abroad — either are unaware of the possibilities of preventing knee and ankle arthrosis, associated with deformities, or do not pay enough attention to this area.
Corrective osteotomy can be performed by different methods. I would like to cite here a famous Italian orthopaedist, Maurizio Catagni, who was the first in the world to appreciate the possibilities of the Ilizarov technique in the treatment of gonarthrosis (arthrosis of the knee) and characterize it as a fast, simple, safe and effective one.
Apart from correcting the shape of legs, the Ilizarov technique is also used to increase height. How much the patient’s height can be increased?
About 5-7 cm can be added to the height. For example, with the least expenditure of energy, time and resources of the body, last year we operated a 22-year-old man who is engaged in bodybuilding. His height has increased from 190 to 196 cm. It is planned to apply to make an entry for him in the Guinness Book of World Records as the tallest man whose legs were lengthened. The surgical operation was carried out simultaneously with the correction of shins.
What difficulties do the doctors using the Ilizarov technique face in aesthetic surgery of limbs?
A serious problem is that people with pathology of limbs do not have reliable information. Basically they are looking for information on the Internet, on forums. There are many myths circulating, including complications, there are even specific words: ‘slope’, ‘medial’ and ‘subsidence’, which are not used in medicine.
Why the doctors do not provide patients with reliable information?
Unfortunately, very many orthopaedic traumatologists and rheumatologists are not familiar with the peculiarities of transosseous osteosynthesis; they do not know the indications for its application. Therefore, for example, in cases of knee pain anti-inflammatory drugs, hormone therapy or arthroplasty are most often prescribed. While the corrective osteotomy by the Ilizarov technique is similar to a tooth filling, prosthetic implant is like a dental crown or a bridge. A tooth does no longer exist. But while a man has 32 teeth, there are only two knee joints.
By and large, osteotomy and arthroplasty solve different problems; in order to prevent the development of arthrosis, you must first restore the mechanical axis of the limb and reduce load on the joint, thereafter, based on the indications, perform a sanative arthroscopy, and only in a few years, if the disease progresses, arthroplasty should be considered.
What, in your opinion, can help solve the problem of keeping doctors updated and developing the Ilizarov technique?
One should bring together medical professionals of different specialties: orthopaedic traumatologists, rheumatologists, rehabilitation specialists, and radiologists, even physicians from polyclinics. It is necessary to conduct interdisciplinary training, which has long been a “gold standard” in the world of medicine. Speaking of my specialty, an interesting example is the Eurasian Orthopedic Forum, where it is possible to present and compare different points of view.
The forum is also interesting due to participation of doctors from the Asian countries, where the varus deformity of the legs is an ethnic distinction. As a consequence, arthrosis develops in the population much more often than, for example, in Europe. This has been repeatedly proved by results of scientific research. Recently, the interest in this issue has increased significantly among specialists from China, Korea and Japan. Therefore, in my opinion, it would be promising to develop our direction jointly by the EAEU (Eurasian Economic Union) countries, in order to not only improve the quality of care for patients with limb deformation in Russia and the CIS (Commonwealth of Independent States), but also contribute to the development of medical tourism in Russia.
The full version of the interview can be seen at Medvestnik.