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Ilizarov External Fixation SURGICAL PRINCIPLES, NURSINGIMPLICATIONS Wendelyn A. Valentine, RN; Patricia A. Williams, RN; Wilda L. Tafoya, RN

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ancho Los Amigos Medical Center (RLAMC), Downey, Calif, a teaching and research facility affiliated with the University of Southern California, Los Angeles, is frequently involved in innovative orthopedic procedures diretted toward increasing the patient’s function. Recently, orthopedic surgeons at RLAMC began using the Ilizarov external fixation system for lengthening limbs, filling bone defects, correcting bone deformities such as dwarfism and congenital bowing defects, and treating problem fractures. Physicians in the problem fracture service, one of more than 20 surgical services at RLAMC, evaluate and treat mainly patients who have had poor results from previous surgeries. For many years, the standard technique in the United States to treat problem fractures has been to use external metal frames with thick pins inserted through the skin into the bone. These devices often caused infection and required bone grafting as an additional procedure.

Stimulating New Bone Growth

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he Ilizarov technique, developed in the Soviet Union by Gavriil Ilizarov, MD, has been used in that country since 1951. The principle underlying the Ilizarov technique is to stimulate new bone growth through the use of an external fixating device and a surgical corticotomy (ie, a percutaneous osteotomy). Dr Ilizarov’s research in orthopedics and trauma led to the discovery of a biological principle called the law of tension-stress.’ He found that gradual 1530

traction on living tissues stimulates their growth and regeneration. The regenerative processes depend on an adequate blood supply and the stimulating effect of weight bearing. According to Dr Ilizarov, the tension produced by the external fixation device is identical to the stresses that promote rapid growth in childhood? The Ilizarov external fixation device facilitates treatment of many injuries and diseases of the legs and arms. Longitudinal rods connect the half

Wendelyn A. Valentine

Wendelyn A . Valentine, RN, BSN, CNOR, CRRN is a clinical nurse educator, Rancho Los Amigos Medical Center, Downey, CaliJ:She earned an associate degree in nursing from the State University of New York at Albany and a bachelor of science degree in nursing from California State University, Dominguez Hills Carson. Patricia A . Williams,RN,MS, was a staffnurse/ OR nurse I4 Rancho .Los Amigos Medical Center,

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and full circular rings that are attached to the bone with smooth, tensioned wires (Fig 1). The apparatus can stabilize bone in all planes, allowing enough axial motion to stimulate new bone growth at a fracture site and eliminate the need for bone grafting. For limb lengthening, a corticotomy is performed to preserve the periosteal and endosteal bone blood supplies,which promote rapid healing of the bone. The corticotomy is performed with a narrow osteotome through a small skin incision, which causes minimal soft tissue trauma and promotes rapid healing. Five to seven days postoperatively, elongation is started by adjusting the fixator nuts along the longitudinalrods 0.25 mm every six hours or about 1 mm per day. All of the surrounding soft tissues are gradually lengthened during the elongation process. Although the apparatus is awkward, it does not interfere with circulation and allows the patient to use the limb as opposed to spending weeks in a cast. Weight bearing is essential to the development and hardening of newly formed bone and,

therefore, is encouraged as tolerated? Usually only one leg is corrected at a time. In some cases, an arm and a leg may be corrected simultaneously, which does not contraindicate using the extremity. Patients often use a cane or crutches for balance.

Patricia A . William

WildaL. Tafoya

Downey, Calij when this article was written. She earned an associate degree in nursing from Cerritos College, Norwalk, Car8 a BS degree in criminology from California State Universiiy, Fresno; and a MS degree in criminaljustice from California State Universitl:Long Beach

Downey, Calg She earned her associate degree in nursing from Cerritos College, Norwalk, Gal$

WildaL. Tafoya,M, is a staff nurse/OR nurse 11 and the primaly nurse in the problem fracture service, Rancho Los Amigos Medical Center,

Equipment

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t RLAMC, four complete sets of Ilizarov fixation trays have been purchased. Each set is divided into four trays according to weight (Figs 2-5). All four trays are sterilized. The larger instrument rings, rods, and plates are recycled with smaller items such as posts, washers, nuts, and bolts. One nurse scrubs for all the Ilizarov procedures at RLAMC. This primary scrub nurse fills out individual inventory control sheets at the end of the case so that the equipment can be replaced as needed. An unsterilized clinic tray is used during followup visits to make any necessary adjustments or revisions. The clinical tray consists of a tackle box filled with various sizes of bolts, rods, posts, hinges,

The authors acknowledge Betty Mowely, RN, former director, surgical services, Rancho Los Amigos Medical Center (RLAMC), Downey, Calij and Maureen Habel, RN,MEd, director, nursing education, RLAMC, for their contributions, and Annette Hurd, RN, staff nurse/OR nurse, RLAMC, for her contributions to the case study. 1531

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Fig I. Model showing wires through the bone and connected to the half and full circular rings. Rods placed parallel to each other and in line with the longitudinal axis of the bone connect the rings. and nuts (Fig 6).Wrenches, pliers, and wire cutters are added along with colored tape and extra pin covers. The primary scrub nurse is responsible for restocking the tray.

Preoperative Phase

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he surgical team at RLAMC works together to ensure that patients understand the surgical procedure and the postoperative course. Communication between the patients, their families, and members of the interdisciplinary team is essential. The primary perioperative nurses attend preoperative clinical and conference sessions with all interdisciplinary team members. This opportunity to meet and assess surgical candidatesallows the nurses to develop a specific care plan for each

individual. In the preoperative clinic, the patient has the opportunity to work with the surgical team in assembling the external fixator. Ring selections are based on the size of the patient’s operative extremity. A rule of thumb is that the rings need to be 2 to 3 cm larger than the involved limb with the exception of the tibia. The tibia requires a 2-cm posterior variance and a 1-cm anterior variance because edema is minimal in this area. Other factors considered are the patient’s size, bone quality, and the presence of other orthopedic and soft-tissue problems. Patient and family teaching is an important focus in preoperative interventions. The nurse shows the patient how to care for the fixator postoperatively. The nurse also discusses postoperative pain control. Concerns of family members and home adaptations must be addressed. 1533

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Fig 2. Ilizarov fixation set is divided into four trays based on weight. Tray I. Sponge stopper clips (a); three-, seven-, and four-hole connecting plates (b);cannulated, center hole, and slotted wire-fixation bolts (c); 20-mm and 40-mm threaded sockets, 10-mm,16-mm, and 30-mm bolts (d); two-hole, 45-mm twisted connecting plates (e); three-hole, 65-mm twisted connecting plates 0;and 13-mm open-end wrench (g). Tray also contains fixator wires (h) and dynamometric wire tensioner (0.

Fig 3. Tray 11. Seven-, 11-,and 17-hole plates (a); 40-mm to 200-mm sizes of threaded and partially threaded rods (b); multiple wire-fixation clamp fc); detachable wire-fixation clamps (d); telescopic rod (e); assorted supports and end posts @; hex nut (8);and assorted washers (h). 1534

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Fig 4. Tray 111. Nuts (a); 10-mm bolts (b); 16-mm bolts (c); 30-mm bolts (d); threaded sockets (e); hinge and post ends, feminine 0; hinge and post ends, male (g); long connecting plates (h); assorted sizes threaded rods and detachable wire-fixation buckles (I); short connecting plates and twisted plates 0); assorted pliers, open-end wrenches, socket wrenches, wire cutters (k); pin clips and stoppers (5); slotted washers (m);assorted washers (n); and wire-fixation bolts (0).

Fig 5. Tray IV. Arches with holes (a); femoral rings (b); 5 / 8 ring (c); half rings (d); graduated telescopic rods (e); dynamometric wire tensioner 03;open-end, box-end wrenches (g); support connectors (h); wire fixation sets (i); and wires 0). 1535

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Fig 6. The clinical tray consists of a tackle box filled with unsterilized bolts, rods, posts, hinges, and nuts. The clinical tray is used during follow-up visits to make any necessary adjustments or revisions.

Preoperative teaching is done by the primary scrub nurse. He or she explains correct turning, coughing, and deep breathing exercises and asks the patient to demonstrate the exercises. He or she answers questions about the surgery and the recovery period. During this initial patient-family contact, the nurse identifies and corrects any patient knowledge deficits or misconceptions and allays potential fears. These initial interactions also set the stage for a positive surgical experience. If the patient sees a familiar face in the preoperative holding area, it may decrease his or her anxiety. After the patient is admitted to the preoperative holding area on the day of surgery, the primary circulating nurse checks the surgical consent form and determines that all laboratory work and xrays are available. During a brief visit with the patient, the nurse verifies the patient’s identity and assesses any potential problems not previously noted. Patients always have an intravenous (IV) line

inserted and usually receive IV cefazolin sodium (Ancefs). While the patient is being premedicated, the nurses make a final safety check of all equipment and supplies.

Intraoperative Phase

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fter transporting the patient to the operating room, the nurses place the patient in a supine position on the OR bed and apply safety straps. Applying warm blankets helps the patient relax and decreases the chance of hypothermia during the procedure. X-ray shields are used to cover the patient’s genital areas. All other OR staff must wear xray aprons to protect against radiation exposure from the image intensifier (C-arm) used during the procedure. During anesthesia induction, the circulating nurse ensures that the room is quiet, which promotes a smooth anesthesia induction. He or she carefully applies the electrosurgical grounding 1537

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Fig 7. The scrub nurse helps assemble the Ilizarov fixator in the OR.

pad on the patient, and preps the operative extremity with povidone-iodine solution. During this phase, a key role of the circulator is to prevent physical injury to the patient and to ensure that the surgical team maintains aseptic technique. It is essential that the camera, x-ray machine, image intensifier, and other equipment used during the procedure are properly draped because they may cross the sterile area. The circulating nurse also monitors and controls traffic in the room, which can be considerable for a new procedure such as this. The scrub nurse helps the residents assemble the rings and the frame of the Ilizarov fixator (Fig 7). Because the Medical Center is a teaching facility, residents perform a significant amount of the work under the direct supervision of the attending physicians. When the fixation wires are inserted, surgeons determine the direction and location to avoid any neurovascular structures. Some wires have a stopper to add stability to the limb. If two wires are used, they are inserted at a 90-degree angle superior or inferior to the top or bottom of the ring. The surgeon inserts 1.5 rnm or 1.8 rnrn wires

with a Maxidriver'" using fluoroscopy to determine correct placement. He or she examines the skin for tension at pin sites and releases it, if present. Pin or wire sites are covered with sponges held in place by plastic clips. The rings are repositioned to accommodate the correct placement of the wires. When attaching the wires to the rings, the surgeon takes care not to bend them. He or she attaches the wires with nuts and bolts and tightens them with a dynamometric wire tensioner. He or she cuts off the ends of the wires, turns ends toward the ring, and covers them with special plastic tips. Wire tensioning is a crucial part of the intraoperative procedure and the postoperative follow-up. Loss of wire tension decreases stability, causes pain, and can evoke an inflammatory response around the wire insertion sites leading to infection.4 Threaded rods are placed parallel to each other and in line with the longitudinal axis of the bone connecting the transport and stabilizing rings. A hinge on the frame is used to correct varw or valgus deformity. An additional rod serves as a distractor force. When the Ilizarov device is used for limb I539

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lengthening, the surgeon performs a corticotomy after inserting the wires and attaching them to the frame. This is done through a 1 cm longitudinal incision as close to the growth plate as possible. Bone loss caused by trauma, removal during debridement of osteomyelitis, or resection for malignancy can be treated. If a segment of bone is missing, a corticotomy is performed through the bone at some distance from the area of bone loss. Ideally, this is done through healthy bone and confirmed by fluoroscopy. It is followed postoperatively by gradual distraction of the corticotomy site and simultaneous closure of the skeletal defect. Variations to this technique can be made depending on the individual orthopedic need of the patient.

Postoperative Phase

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he anesthesiologistor nurse anesthetist help the circulating nurse transfer the patient to the postanesthesia care unit (PACU). The patient’s affected limb is elevated. If there are no complications, the patient is transferred to the surgical unit after approximately two hours. The patient may experience severe pain during the first 24 hours after surgery. Meperidine hydrochloride(DemeroP) or morphine sulfate are usually given intramuscularly during the first postoperative days, with a gradual decrease to oral oxycodone hydrochloride ([email protected])or acetaminophen with codeine. Propoxyphene hydrochloride (Darvons) is prescribed at discharge. Nursing management during the postoperative period includes elevating the affected extremity, performing range-of-motion and neurological checks, and may involve regular turning of the fixator nuts beginning from the fifth to seventh postoperative day. Following evaluation by a physical therapist, the patient may be allowed to walk with the use of crutches from one to seven days postoperatively. The pin sites are left untouched until checked by the physician. Patient pin care consists of cleaning the pin site with soap and water or hydrogen peroxide. Patients must notify the physician if any redness or drainage occurs. At the end of the first week, patients are taught

Fig 8. Case study. X-rays show bilateral bowing deformities of the femur after surgeon performed corticotomy and initial distraction.

to turn the fixator nuts 0.25 mm every six hours. Usually, the direction of the turn and the magnitude of the distraction are indicated on the fixator with colored tape on the rods and fingernail polish marked on the nuts to be turned. The success of the procedure depends on the distraction turns being performed every six hours. Skipping only one or two distraction steps may lead to premature bone union and surgical failure. If the patient experiences unusual pain during distraction or develops signs of neurological impairment such as numbness or tingling, the physician must be notified. Patients are taught which signs and symptoms to look for. Weekly x-rays help surgeons determine whether a patient’s leg is distracting at the proper rate.

Case Study

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29-year-old female (Ms B) with a pronounced side-to-side limp and intolerable pain in both knees was selected for the Ilizarov procedure. At the time of admission, she was 4 feet, 5 inches tall and weighed 141 pounds. X-rays showed bilateral bowing deformities of 1541

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Fig 9. Case study. X-rays (left)show new bone forming during distraction process. Process straightened leg (right) and formed new bone. the femurs (Fig 8). The probable etiology of the varus deformities was rickets, a nutritional deficiency of vitamin D. Ms B was one of many children and, before the family’s move to the United States, had received no treatment for her disability. After her initial evaluation, Ms B had a series of corrective osteotomies, was fitted for orthopedic shoes, and participated in an in-home program of strengthening exercises. Increasing lower extremity joint swelling and pain, coupled with her physical deformities, however, prevented her from participating in normal activities. A week before surgery, the OR nurses met with Ms B to plan her perioperative care. The nurse explained the procedure using written materials and photographs. The patient was aware one leg would be operated on at a time, necessitating special shoes with lifts for the other leg for balance. In the preoperative clinic, the surgeon explained the procedure, including risks and benefits. Teaching focused on a thorough explanation of preoperative procedures and the importance of

postoperative position changes and deep breathing and coughing routines. On the day of surgery, the OR nurses greeted Ms B in the preoperative holding area. She expressed her concerns by talking about her family and her hopes for a successful outcome while holding tightly to the nurse’s hand. A preoperative check of the chart showed that the consent form was complete and that all reports from preoperative tests were available and within normal limits. After Ms B was anesthetized, the surgeon placed the first fixation wires in the distal tibia. The leg was divided into four equal quadrants using landmarks at the medial malleolus and the medial tip of the proximal tibia. He placed the wires from lateral to medial and included oblique pins for a total of five wires in the distal tibia. The wires were fixed to the rings and tensioned to 130 lbs of pressure. Wires were placed in the proximal tibia and tightened in the same way as the distal wires. The surgeon then performed the corticotomy using fluoroscopy. 1543

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Fig 10. Case study. Patient (leji) shortly after Ilizarov fixator was applied. Patient (right) after the lengthening procedure was completed. Note the special shoe on patient’s right foot.

The surgery went without incident; however, Ms B developed cardiac arrhythmias and was taken to the surgical intensive care unit for observation. Postoperatively, Ms B had an uneventful recovery. The OR nurses answered her questions about mobility and pain management. They discussed with her ways to adapt to the cumbersome device, including crutches, a walker, and a wheelchair. For pain management, they recommended a program of scheduled medication, elevating the leg, applying warmth, and using techniques such as guided imagery and relaxation. Seven days postoperatively, Ms B was able to use the wheelchair and walker with minimum assistance. She walked with a steady gait but tired easily. 1544

Before discharge, Ms B expressed considerable anxiety about physical barriers that would, in effect, keep her homebound. The solution involved installing a ramp in front of the patient’s home and using a wheelchair for transportation. Both of these problems were brought to the attention of the social worker and physical therapist. Before Ms Bs discharge, the unit nurse repeated the instructions on apparatus distraction and adjustment. Ms B had minimal difficulty with this important step and continued distraction every six hours for approximately two months. She maintained regular x-ray appointments and clinic visits until her fixator was removed six months later (Fig 9). Ms B is scheduled for surgery on her other leg. With this patient, the nurses’ preoperative

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assessment and postoperative follow-up contributed greatly to a successful surgical outcome (Fig 10).

Summary

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he role of the perioperative nurse in caring for a patient with an innovative procedure such as the Ilizarov device is challenging. Because of the problem fracture, the patient usually has had multiple unsuccessful surgical experiences and may express considerable concern and anxiety. As perioperative patient advocates, nurses must encourage patients to be their own spokespersons and to ask questions when they do not understand. The patient advocacy role becomes even more important when the patient undergoes a new procedure. It is our experience with this procedure that both patients and professional staff have many questions during the postoperative period. It is essential that the perioperative nurse establish a communication climate among the patient and members of the interdisciplinary team that promotes collaboration and problem solving on behalf of the patient undergoing this unique surgical procedure. 0 Notes 1. G A Ilizarov, “The tension-stress effect on the genesis and growth of tissues. Part I: The influence of stability of fixation and soft-tissue preservation,” Clinical Orthopaedics and Related Research 238 (January 1989) 249-281. 2. Bid. 3. D Paley, “Current techniques of limb lengthening,” Journal of Pediatric Orthopedics 8 (January/February 1988) 73-92. 4. Ibid; Ilizarov, “The tension-stress effect on the genesis and growth of tissues. Part I: The influence of stability of fixation and soft-tissuepreservation,” 249281; G A Ilizarov, “The tension-stress effect on the genesis and growth of tissues. Part 11: The influence of the rate and frequency of distraction,” Clinical Orthopaedics and Related Research 239 (February 1989) 263-285; S A Green, “Ilizarov orthopedic methods: Innovations from a Siberian surgeon,” AORN Journal 49 (January 1989) 215-230.

Checklist Helps Ease Monitoring Administrators at Wayne County Memorial Hospital, Honesdale, Pa, wanted to improve management of the endoscopy room connected with the same-day surgery unit. As a result, Linda Tietjen, RN, director of quality assurance, along with the surgical case review committee, developed a checklist of quality assurance and risk management monitors. These included providing the same level of care for patients treated in the endoscopy room as for patients admitted to the hospital and providing the same quality assurance monitoring and evaluation process for that room as for other areas of the hospital. The checklist helps staff members identify dayto-day problems that occur in the room, including unusual incidents, patient complaints, medication errors, need for additional testing, and patients who need to return to the endoscopy room for repeat procedures within 48 hours. After a procedure is completed, one of the nurses or the physician fills out the checklist. If the endoscopy room nurse determines that a quality assurancdrisk management standard has not been met, he or she flags that chart for review by the surgical case review committee. Most patients’ charts meet the standards, but if one goes to committee for review, the committee determines whether the quality of care was acceptable. It also reviews the patient’s medical record to see whether the findings support the diagnosis. A physician reviewer may ask the attending physician to respond to details of the review. Staff members who work in the endoscopy room also keep a log of all patients having endoscopy procedures, according to the March 1990 issue of Same-Day Surgery. They identify patients whose charts are sent to the committee so problems can be tracked.

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Ilizarov external fixation. Surgical principles, nursing implications.

The role of the perioperative nurse in caring for a patient with an innovative procedure such as the Ilizarov device is challenging. Because of the pr...
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