30 May 2014

The methods of Dr. Ilizarov from the Research Institute for Experimental and Clinical Orthopaedics and Traumatology in Kurgan - Rusia are accepted and carried out for 20 years at the Special Hospital for Orthopaedics and Traumatology "St. Erazmo" - Ohrid. These methods allow successful treatment of the most torpid problems from the field of orthopaedics and traumatology which were often considered as unsolvable or whose final results were uncertain or a compromise. These methods brought in new postulates and opened new views not only in orthopaedics but also in the basic biological sciences. By the acceptance of these methods the hospital's main aim was: in the most suitable way and most rationally to help those patients whose invalidity interrupted their normal life, removed them for a long period of time or permanently from public life, as individuals who work, with unforeseeable consequences in the psychophysical sphere.
	Chronology of the introduction of Dr Ilizarov's methods   Pseudoarthritis   Correction of deformities   Fractures   The essence of Ilizarov's methods   Social and economic implications   Plans for the method   Presentation - common expirience with Ilizarov methods
	Chronology of the introduction of Dr Ilizarov's methods
	The beginning of our familiarization with the basic principles of Ilizarov's methods was from professional literature dating from the period 1976-1977. The originality of the idea, the approach to the problems and the results previously confirmed experimentally drew the hospital's attention, for during its routine work it came across identical problems every day, problems which were difficult to solve or impossible to be solved at all. The solution was: either to accept their approach to the problems together with all their risks, or to agree with partial, not always adequate, and very often forced solutions with which neither the hospital nor the patients were always completely satisfied. The hospital chose: the longer and harder way respecting all known and unknown risks. There came a period of a number of years filled with skepticism and attention. That was also a period of intensive studying of the theoretical postulates of Ilizarov's methods. Unable to supply original apparatus according Ilizarov, in 1981 the first apparatus they constructed themselves was applied in the hospital marking the beginning of practical work. The next goal of the hospital was to establish as close as possible contacts with the Kurgan Research Institute for experimental orthopaedics and traumatology and especially with Prof. doc. G. A. Ilizarov. Our idea was to get deeper to the heart of the methods, i.e. to get to know the work techniques in detail. This contact was made in 1983 for the first time when Prof. Ilizarov visited the hospital. His visit opened a new era in the working process of the hospital. Besides the detailed introduction of the institute profile in Kurgan and presentation of an impressive plead successfully treated orthopaedic and traumatological problems, Prof. doc. G. A. Ilizarov in the hospital also practically demonstrated his work by operating patients. In the years 1984 and 1986 he visited the hospital again. This strengthened the formerly set basis for professional collaboration between the two institutions even more. The problems that could be solved with mutual programs were also accepted. His invitation for professionals from the hospital to stay in Kurgan for further education and development of his methods was also accepted and accomplished three times. His stay was used not only for education (theory and practice by mutual work, operations on patients) but also for organizing a professional meeting in September 1986 this meeting was attended by orthopedists and traumatologists from Belgrade, Zagreb, Ljubljana, Sarajevo and Skopje. Then they constitute a group that would work within the framework of YUOT and would deal with objectivization of Ilizarov's methods here, and exchange experiences related to the problems solvable by these methods. The registration of the group under the name of YUOT was the next activity. As a coordinator of this group they appointed the Special Hospital for Orthopaedics and Traumatology  Ohrid. That was also a special credit for all past efforts concerning the acceptance of Ilizarov's methods. An this meeting they suggested that the hospital in Ohrid become a center with a wider Yugoslav meaning for the application of Ilizarov's principals, which was also accepted. In order to justify its trust and respect in the professional and medical circles the Special Hospital for Orthopaedics and Traumatology - Ohrid, towards the end of the seventies, made a distribution of professional work according individual problems, i.e. created multidisciplinary teams for strict direction of personnel to individual problems. In this context, in 1982 they created a group at the Hospital that would study the methods and details of the techniques of work. In addition to the orthopedists, in this group they also included a physiatrist and a neurologist.
	Pseudoarthritis
	Pseudoarthritis (false joints, difficult healing after bone fractures or congenital false joints). Modern transport means, the expansion of transport traumatisms and the growing number of developing anomalies increase the problem of false joints. The former methods of treatment of sue patients did not completely solve problem. This especially applies to the infected pseudoarthritis, which is increasing along side with the osteosynthesis shorter or deformed extremity as a consequence. In addition to the two well-known components that are present in these cases of pseudoarthritis (difficult healing and infections), Ilizarov himself also adds the problems of shortening and deformation of the extremity. Respecting his principles, the approach to this problem was significantly changed. This enabled curing of pseudoarthritis, elimination of the infection, correction of the axis and saving, i.e. reaching of normal length of the extremity, all in one or two phases with minimal multilateral undertakings on the altered extremity. The final results from the treatment of such patients completely justify the orientation of the hospital to apply Ilizarov's methods.
	Correction of deformities
	The deformities of the extremities, of any kind of genesis, have a negative effect on the statics of the complete locomotor apparatus. No matter whether they are acquired (most often post traumatic) or congenital deformities of the skeleton, Ilizarov's method, which is based on successive and gradual solving of the problem, gives extraordinary results, which from experience, are also proven by the Special Hospital for Orthopaedics and Traumatology-Ohrid.
	Fractures
	Fractures (broken, traumatological or pathological) are the next symptomatic regions of application of his methods. This especially applies to two difficult problems in the orthopaedics and traumatological practice: pathological fractures and open fractures. The work principle is dynamic extra focal fixation (osteosynthesis). Despite the hidden dangers that this problem brings with itself, Ilizarov's method found its place and is increasingly being transformed from an alternative to a dominant method in the solving of this problem. This does not exhaust indications for application of Ilizarov's principles. We have merely listed the most frequent, and at the same time the most therapeutically resistant problems.
	The essence of Ilizarov's methods
	Based on present knowledge in the field of biomechanics, Prof. dr. G. A. Ilizarov " was making his own system for treating not only the problems from the field of orthopaedics and traumatology, but also from the field of vascular and plastic surgery (treatment of obstructive vascular illnesses from the type of Birger) or replacement of defects on soft tissues (muscles, fascia, blood vessels and nerves) and covering defects with skin covers without using transplantations on these tissues. The adoption and adaptation of natural (biological) laws, and not their rejection, are used as basic regular laws.
	The basic principles on which Ilizarov's study is based, and at the same time his most striking advantages compared to the classical methods, are the following:
	•  Minimal traumatization of the soft tissues (small skin cut during operation, from 1 to 2 cm, no division of muscles and injury on blood vessels and nerves), there is no deperiostation of the bone; •  Corticotomy (cutting only the corticortal layer of the bone arid protection of the bone and medular contents which are also the source of osteogenetic potential); •  Sparing of vascular elements extra and intraosal; •  Rigid dynamic fixation (osteosynthesis), achieved by net-like transfixation of the bone segment using thin needles placed in cases when there is overstraining; •  Early mobilization of neighboring joints; •  Total load on the operated extremity from the first, i.e. the second post operative day. This frees the patient from long-lasting stay in bed or carrying plaster. Practically, this means that the patient whose extremity is being elongated, if it is done using one of the classical methods, would have to undergo at least three big operations (elongation, spongioplastics plus osteosynthesis and removal of osteosynthetic materials). We have to emphasize that this kind of undertaking is conditioned by the pathology, age and working technique, and making of longer elongations would not be possible. In addition o this, the patient would have to be tied to bed for months subject to all risks of repeated operations and long-lasting stays in bed or limited locomotion of neighboring joints. Using Ilizarov's method, when the patient can move around with total strain on the extremity from the very first day, all previously mentioned risks are brought to a minimum, making it possible to work on adult patients and to achieve considerably longer elongations.
	To conclude, we can freely say that the method of transosal synthesis together with the apparatus for skeletal transfixation, according Ilizarov, opens wide horizons in the overcoming of the problems of invalidity in an extremely rational manner.
	Social and economic implications
	Knowing the material conditions in our economy and in general, especially in the medical field, the application of Prof. Dr. G. A. Ilizarov's method significantly rationalizes the material expenses for the treatment of orthopaedic and traumatology patients. It is well known that this treatment is among one of the most expensive and one of the longest being connected with a number of material expenses which are not to be disregarded. This method not only allows shortening of the time needed for hospitalization, but also allows repeated usage of a large number of comprising parts of Ilizarov's apparatus on a larger number of patients. On the other hand, the caused invalidity, most often, from the epidemic of traffic traumatism and its consequences causes a great problem, for it burdens the economy funds. Most often they are patients who are at the beginning or are in their late working stage. A fast treatment and a fast return of the patient to work is an imperative of every modern treatment. This method not only allows fast medical and professional rehabilitation, but it also allows clinical treatment of patients for whom it was previously thought that they could only be treated under strict and complete hospitalization. We feel that the collaboration with the renowned institute for experimental and clinical orthopaedics and traumatology in Kurgan opened for us, among the first in Europe, new knowledge in solving problems that only till yesterday seemed very difficult and insoluble. For the first time in the worldwide orthopaedics practice these problems became solvable. Problems such as liquidation of shortening of extremities, above 50% of the original length of the extremity, and more, on children as well as on adults, were treated using bloodless means without surgery. For the first time it was possible without transplantation of bone to treat significant defects on the skeleton, false joints, to regulate growth, to thicken the bone and to treat a number of congenital illnesses. All this provides grounds for lowering of invalidity up to six times. For the first time, using the biological potentials of the bone tissue, there was success in influencing the process of remodeling the bone into the desired direction. The respect that the Special Hospital for Orthopaedics and Traumatology from Ohrid gained abroad for using this method is confirmed by the visit of the "Kalo" Institute in France, where our team demonstrated practical application of compressive and destructive apparatus according to Ilizarov on their patients. We believe that we are one of the many, and certainly among the first centers in Europe who incorporated Ilizarov's methods in their every day routine work. The system of clinical treatment of patients by the given method that we are using, allows restoration of working capabilities on a significant number of ill people and lowers the expenses compared to hospital treatment. The affirmation of this method is significant not only from the medical point of view, but from a social and economic aspect as well.
	Plans for the method
	The professional team working on this problem plans the following:
	•  To follow actively everything new that comes out of the Kurgan institute; •  To increase frequency of mutual meetings between professionals from the Institute in order to evaluate past activities, exchange experiences on certain thematic problems and organize joint activities on given programs; •  Working out of previously set problems, problems that need clinical approbation (meaning, first of all, the problem on deformation of the spinal column); •  Complex statistic analysis for our past work; •  Introduction of new scientific methods on patients treated by the method (angiography, computer tomography, subtle laboratory analyses concerning fig general reaction of the organism treated by the method of Ilizarov, pato-hystic and chemical analyses etc.); •  Clinical application of an automatic distracter; •  Multidisciplinary activities by including institutions that deal with basic biological activities; •  Detailed examination of the biochemical characteristics of the system apparatus-bone.