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| ORIGINAL ARTICLE |
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| Year : 2018 | Volume
: 4
| Issue : 1 | Page : 11-19 |
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Accordion maneuver: A bloodless tool in ilizarov
Ranjit Kumar Baruah, Sourav Patowary
Department of Orthopaedics, Assam Medical College, Dibrugarh, Assam, India
| Date of Web Publication | 3-May-2018 |
Correspondence Address:
Dr. Sourav Patowary
Department of Orthopaedics, Assam Medical College, Dibrugarh - 786 002, Assam
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jllr.jllr_25_17
Purpose: Accordion maneuver (AM) is a “Bloodless Tool” to stimulate bone healing as described by Professor Ilizarov by a mechanism called transformation osteogenesis. It has been underdescribed in literature. Furthermore, there is lack of standard protocol for AM. We report our cases where this Bloodless Tool was used and discuss the strategies for its use in various conditions. Materials and Methods: We reviewed our cases that underwent AM during 1994−2015, through this retrospective study. In nonunion, initial compression or distraction was decided by the status of nonunion. In hypertrophic (stiff) nonunion, the first maneuver was distraction followed by compression in one cycle and the sequence was reversed in atrophic (mobile) nonunion. In hyporegenerate, distraction was discontinued, stability restored, and AM was performed with compression first. Results: Twenty-three patients were included. In 15 cases monofocal, 7 cases bifocal, and in 1 case trifocal osteosynthesis was done with Ilizarov. AM was done for hypertrophic nonunion in 6 cases, atrophic nonunion in 15 cases, and hyporegenerate in 5 cases. In 3 cases, AM was done for both hyporegenerate and docking site nonunion. In all the cases of nonunion, union was achieved and in all the cases of hyporegenerate, bone formation improved. Conclusions: Transformation osteogenesis with AM is a bloodless tool in Ilizarov. To achieve desired results, protocol for the maneuver should be based on type of pathology between the fragments.
Keywords: Accordion maneuver, compression-distraction, docking site nonunion, hyporegenerate, nonunion
How to cite this article:
Baruah RK, Patowary S. Accordion maneuver: A bloodless tool in ilizarov. J Limb Lengthen Reconstr 2018;4:11-9 |
| Introduction | |  |
Accordion maneuver (AM) is the “Bloodless stimulation” of bone healing as described by Professor Ilizarov. It comprises of alternate compression and distraction which converts the scar tissue at the fracture nonunion site into tissues capable of neo-osteogenesis.[1] Apart from nonunion, a modified form of this tool can be used in hyporegenerate developed in bone transport and at docking site after acute docking or after internal bone transport.[2] There is a paucity of literature explaining the protocol and rationale for use of AM in various conditions.
We report our cases where AM was used to manage nonunion or hyporegenerate or induce union at docking site with satisfactory result. We revisit the technique and attempt to explain its rationale and biomechanics involved in the background.
| Materials and Methods | | |
We retrospectively review our cases that underwent AM during 1994−2015. These were done in a tertiary teaching institute and the records were retrieved from the department database. Approval for conducting this study was obtained from the institutional ethics committee. For classification of open fractures, Gustilo−Anderson classification[3] was used. Infected nonunions were classified according to H. Rosen's classification[4] and aseptic nonunions were classified according to Muller's classification.[5] Based on radiographic appearance, infected nonunions were further classified into atrophic and hypertrophic, similar to Muller's types. Patients were included in the study with these inclusion criteria: (1) Cases of nonunion (both atrophic and hypertrophic) that underwent AM over Ilizarov and (2) Cases of hyporegenerate detected during bone transport with Ilizarov in various conditions where AM was done. Exclusion criteria were: (1) Cases whose complete data could not be retrieved from department database and (2) Cases lost to follow-up. Criteria used to decide the use of AM has been shown in [Table 1]. | Table 1: Criteria used to decide use of accordion maneuver in case of nonunion and hyporegenerate
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Protocol used for maneuver
In nonunion, initial compression or distraction was decided by the status of nonunion. In hypertrophic (Stiff) nonunion, the first maneuver was distraction followed by compression in one cycle and the sequence was reversed in atrophic (Mobile) nonunion. The maneuver (either compression or distraction) was performed at the rate of 0.25 mm twice a day for 7 days followed by rest for 3−4 days, and then the opposite maneuver was carried out in the same rate for 7 days and this too followed by rest for 3−4 days. These maneuvers constituted a cycle and each cycle was performed twice. After two cycles of AM, final compression was done at the rate of 0.25 mm on every 3rd day for 1 month. In hyporegenerate, before starting AM, distraction was discontinued. Stability of the system was assessed and if required, extra wires were added. Compression was done first and after 2 cycles of AM X-ray was done to evaluate the status of the regenerate. After successful maneuver, distraction was again started at previous rate (0.25 mm/6 h).
Radiographic assessment of nonunion was done at monthly intervals, starting at the end of one month of final compression following two cycles of AM, till union was achieved. Union was established if there was bridging bone across fracture site in entire cross section of orthogonal views.[8] Before fixator removal, dynamization was done by loosening threaded rods, one at a time at weekly intervals. Clinical union was confirmed by the absence of pain on weight bearing during dynamization. Hyporegenerate was assessed radiographically at the end of two cycles of AM. It was considered normotrophic if radiodense new bone appeared, continuity of bone columns was seen, cross-sectional diameter of regenerate is equal to width of bone at corticotomy site, and central radiolucent band of regenerate was around 4 mm or less.[7] The outcome of Ilizarov treatment was assessed according to Association for the Study and Application of the Method of Ilizarov (ASAMI) bone and functional result criteria.[9] Records of all the cases are summarized in [Table 2].
| Results | | |
A total of 23 patients were included in the study, of which 18 were male and 5 were female. The mean age was 34.87 years (16−76 years). Bones involved were femur in 11 cases, tibia in 10 cases, and humerus in 2 cases. Ten of the 23 patients had open fractures. Duration at which Ilizarov treatment was undertaken varied considerably among the cases with maximum being 15 years. In 20 cases, prior surgical interventions were done before Ilizarov. In 15 cases monofocal, 7 cases bifocal, and in 1 case trifocal osteosynth-esis was done with Ilizarov. AM was done for hypertrophic nonunion in 6 cases, atrophic nonunion in 15 cases, and hyporegenerate in five cases. In three cases, AM had to be done for both hyporegenerate and docking site nonunion. In all the cases of nonunion, union was achieved and in all the cases of hyporegenerate, the bone was regenerated. Bone and functional results of all patients according to ASAMI criteria are shown in [Table 3] and [Table 4]. Nineteen of the 23 patients had excellent bone results and 16 patients had excellent and good functional results. | Table 3: Outcome according to Association for the Study and Application of the Method of Ilizarov bone results criteria
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 | Table 4: Outcome according to Association for the Study and Application of the Method of Ilizarov functional results criteria
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| Discussion | | |
Two types of osteogenesis are seen in Ilizarov methodology, distraction and transformational osteogenesis.[10] Transformational osteogenesis is used for healing nonunions and hardening hyporegenerate in bone transport. It mechanically stimulates pathologic bony interfaces to induce osteogenesis and regenerate normal bony continuity. This is accomplished by AM as it alternately gives compression and distraction like an accordion.[1],[11] In an experimental study, Claes et al. in 2008 concluded that temporary cyclic distraction and compression can enhance bone healing by producing increased bone volume that has higher bending rigidity.[12] AM is a powerful tool described in Ilizarov techniques for delayed and nonunion and also in hyporegenerates.[11]
Rationale of accordion maneuver in nonunion
Deciding to start with compression first or distraction first depends on the quality of tissue anticipated between the fragments at the nonunion site. In stiff, (Hypertrophic) nonunion, thick fibrous, fibrocartilaginous tissue with good blood supply is expected. It is biologically active. Distraction is started first to initiate neo-osteogenesis followed by compression to consolidate the new bone.[13],[14],[15] Conversely, in mobile (Atrophic) nonunion, loose fibrous/connective tissue is present at the nonunion site which is avascular and biologically not active.[13],[14] Therefore, compression is done first to crush the tissue to create inflammation and subsequent neovascularization that is conducive for neo-osteogenesis. Distraction creates columnar fibrovascular tissues that arise from the crushed tissue on fracture surface. Repeated distraction stimulates production of osteoblast and helps collagen bundles to consolidate within a bony matrix.[11]
Rationale of accordion maneuver in hyporegenerate
AM has also been used to enhance osteogenesis in hyporegenerate or hypotrophic regenerate formation which may be seen in bone transport. Poor regenerate formation may be due to technical factors, patient factors, or combination of both. The technical factors could be traumatic corticotomy, initial diastasis, instability of the apparatus, and too rapid distraction. The patient factors are infection, malnutrition, metabolic, reduced vascularity, reduced walking etc. Role of AM in hyporegenerate has been described by Paley in 1991. He compared formation of bone in the distraction area to a group of soldiers marching at different rates. In time, the slowest fall behind the rest. To prevent them from falling further and further behind, the group in front must turn around and return to the slow ones regroup, and start marching again. In the distraction area, the trabeculae on opposite sides of widening interzone get farther and farther apart. It is important to bring them together again and redistract them apart at a slower rate.[2] In our study, distraction was discontinued and stability of the system was checked. Compression was done first to bring the trabeculae together followed by distraction to constitute a cycle of AM, and was performed twice.
Protocol of accordion maneuve
The suggested protocol for this maneuver in nonunion is compression for 10 days, followed by distraction up to 10 mm−20 mm, at the rate of 0.25 mm twice a day, which is followed by rest for 7−10 days, and then slow compression again up to 7 mm−10 mm. After a rest period for 5−7 days, distraction is performed for second time.[1] Kulkarni suggested protocol for AM in hypertrophic nonunion as distraction 0.5 mm/day for 20 days, followed by rest for the next 20 days, and finally compression.[16] In the present study, AM was done for hypertrophic nonunion in six cases and atrophic nonunion in 15 cases. In all the cases, cycle of AM was performed twice and nonunions healed. Others have used AM but have not described the technique. Makhdom found favorable result in 3 out of 4 cases of hyporegenerate with AM and protocol followed was 0.25 mm distraction in morning, followed by 0.25 mm compression early PM, and then distraction of 0.25 mm late PM (0.25 mm of lengthening/day). They mentioned AM as a noninvasive strategy for absent or delayed callus formation in cases of limb lengthening.[19] Krishnan et al. successfully treated 2 cases of hyporegenerate with AM, where distraction was discontinued, reversed, and restarted at a reduced rate (0.25 mm/12 h, instead of 0.25 mm/6 h).[20] In the present study, the cycle AM was performed twice and after X-ray confirmation on status of the regenerate, distraction is done again at previous rate (0.25 mm/6 h). All the five cases of hyporegenerate have been successfully treated. El-Sayed et al.[21] and Hatzokos et al.[22] have successfully treated 19 out of 25 and 6 out of 8 cases, respectively, of hyporegenerate with AM; however, they have not mentioned details of the protocol they followed.
Various studies using AM for nonunions and hyporegenerate have been shown in [Table 5] with comparison to the present study, in terms of indication for AM, protocol for maneuver, and outcome. | Table 5: Accordion maneuver used in various studies, showing indication for accordion maneuver, protocol for maneuver, and outcome
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| Conclusions | | |
AM is a bloodless stimulation of bone healing. It is a useful tool to address nonunions and hyporegenerate with successful outcome. We describe the rationale and protocols for different nonunion types and poor regenerate formation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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