Articles

The International Journal of Lower

A New Approach to the Extremity Wounds

9(2) 70­–73
© The Author(s) 2010
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Deformity of the Knee Using Ilizarov’s DOI: 10.1177/1534734610371559

http://ijlew.sagepub.com

Principle of Distraction Histogenesis:

A Preliminary Communication

Kulshrestha Gaurav, DNB1 and Jog Vilas, MS2

Abstract
Fixed flexion deformity (FFD) of the knee causes significant patient disability and is challenging to orthopedic surgeons
because of its complexity. A prospective study was conducted using Ilizarov’s principles of distraction neohistogenesis and
differential distraction and Ilizarov’s ring fixator for the correction of this deformity in cases with soft-tissue contracture.
This was done without any concurrent bony procedures. A prospective, uncontrolled study of 26 patients (39 knees) was
conducted over a 4-year period with prior approval from the local institutional review board. Patients with FFD of the
knee without bony ankylosis were treated with knee-spanning 4-ring Ilizarov’s frame and gradual differential distraction. All
patients showed complete correction of deformity without any significant complications. The results of this uncontrolled
study permit the observation that soft-tissue distraction across a joint using Ilizarov’s principle results in soft-tissue
lengthening and correction of joint deformity caused by contractures. This technique needs further detailed examination.

Keywords
fixed flexion deformity, knee, Ilizarov distraction histogenesis

Soft-tissue contractures and secondary fixed flexion defor-
mities of the knee joint can cause significant limb length
discrepancy, gait abnormality, and disability. In most
instances, these fixed flexion deformities are complex and
multiplanar and pose a challenge to orthopedic surgeons.1,2
Different techniques have been used to manage this defor-
mity. The chosen techniques depend on the affected muscle
groups, severity of contracture, age of the patient, and include
soft-tissue release, skeletal traction, casting techniques, and
supracondylar extension osteotomy.1-7
Ilizarov, popularized the concept of distraction osteo-
genesis.8,9 He discovered that by carefully severing a bone
without severing the periosteum around it and then hold-
ing the separate halves fixed slightly apart, it was possible
for bone to grow and fill the designed gap. Ilizarov
designed a ring fixator that would hold the severed bones
in place by a framework. Few previous studies have used
this principle for the correction of fixed flexion deformity
(FFD) of the knee joint. However, all included bony oste-
otomies followed by gradual distraction use different types of
external fixators such as Ilizarov’s ring fixator, Orthofix,
and Wagner’s fixator.10-15
This report presents findings from a prospective study of
controlled, gradual, soft-tissue distraction across the knee
joint using Ilizarov’s external ring fixator for correction of
FFD of the knee secondary to soft-tissue contractures. The
study design was open and uncontrolled and was carried out
in a hospital setting.
It was hypothesized that gradual controlled differential
distraction by Ilizarov’s method will cause neohistogenesis,
lengthening of the contractured muscles and the neurovas-
cular structures, thereby correcting the deformity and may
also provide for remodeling of the articular surfaces, with
improvement in the arc of movement.
Materials and Methods
A prospective study was conducted from August 2003
to July 2007, in which patients in the age group of 11 to
15 years, receiving treatment for FFD of the knee joint were
enrolled after taking written informed consent from their
1
DNB Orthopaedics, Amrita Institute of Medical Sciences, Kochi, India
2
Bharati Vidyapeeth Medical College, Pune, India
Corresponding Author:
Kulshrestha Gaurav, Department of Neurosurgery, Amrita Institute of
Medical Sciences, Elamakkara P.O. Kochi, Kerala 682 026, India
Email: gkkulshrestha@gmail.com

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Gaurav and Vilas 71
guardians. The study was cleared by the institutional review
board for this hospital. For each case, a detailed history and
clinical examination was done. The components of defor-
mity, angle of FFD, arc of movement, severity of contractures,
local skin condition, distal neurovascular status, and associ-
ated comorbidities were noted. Both patient and guardians
were counseled about the long duration of treatment, pos-
sibility of repeat surgeries, care of the frame, and frame
adjustment. Only those patients and families with high
levels of motivation and compliance were included in the
study on account of the long and testing process that accom-
panies this treatment option. In each patient, a standard
4-ring knee spanning Ilizarov’s construct was made with
hinges placed anteriorly and laterally to accommodate the
deformity. Motors (graduated distractor rods) were applied
only posteriorly. Postoperatively, differential distraction
was started 48 hours after surgery. Patients were discharged
on the fifth postoperative day after training patients’ carers
in daily differential distraction and pin site care. Patients
were reviewed weekly till the deformity was corrected.
Frame adjustment was done as required. After deformity
correction, further distraction was stopped, and construct
was maintained in situ for 3 weeks after which the frame was
removed. After frame removal, correction was maintained
with appropriate orthoses. Distraction was not continued
beyond 12 weeks in any of the patients. All the patients
were followed up for a period of 24 months—fortnightly
for the first 3 months, thereafter trimonthly till 1 year, and
biannually in the next year. At each follow-up, they were
assessed for recurrence or increase in residual FFD and
orthosis compliance.
The primary objectives of the study were to study the
correction achieved with this technique and the duration of
treatment. The secondary objectives included assessment of
complications, patient compliance, arc of movement, and
recurrence of deformity or loss of correction.
Results
As shown in Table 1, a total of 26 patients (39 knees) were
included in the study. There were 9 patients with unilateral
and 9 patients with bilateral post–polio residual paralysis
(PPRP) FFD knee, 4 patients had bilateral congenital web-
bing of the knee, 4 patients presented with triple deformity.
Of these 1 was secondary to burns contracture,1 was a
posttubercular knee infection, and 2 were of PPRP (see
Table 1).
In all, 7 knees had a FFD of 30° to 60° as presented in
Table 2. Of these, the duration of distraction was 6 weeks in
6/7 and 8 weeks in 1/7 knees, 28 knees had 60° to 90° FFD,
20 of which were caused by PPRP. Of these, 17 knees
needed 10 weeks for correction, and 3 took 12 weeks. In all
the 5 knees with congenital webbing and 3 knees with triple
deformity, distraction was carried out for 12 weeks. Of the
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Table 1. Number and Characteristics of Patients
Number of Number of
Deformity Patients Knees
PPRP with FFD knees bilateral   9 18
PPRP with FFD knees unilateral   9   9
Congenital webbing of   4   8
  knees (bilateral)
Triple deformity knee   4   4
Total 26 39
Abbreviations: PPRP, post–polio residual paralysis; FFD, fixed flexion
deformity.
Table 2. Details of Deformities in Patients Included
Degree Triple Congenital
of FFD PPRP deformity Webbing Total
30°-60°   7 — —   7
60°-90° 20 3 5 28
90°-120° — 1 3   4
Total 27 4 8 39
Abbreviations: FFD, fixed flexion deformity; PPRP, post–polio residual
paralysis.
4 knees with FFD of 90° to 120°, distraction was continued
in 2 for 12 weeks and had to be abandoned in 2 (cases of
congenital webbing) because of complications.
All 27 knees with PPRP in both the groups (30°-60° and
60°-90° FFD) achieved full correction at the time of implant
removal. All 3 patients with triple deformity of 60° to 90°
achieved full correction, whereas one with 90° to 120° FFD
had a residual deformity of 10°, which was acceptable to
the patient and left as such. Of the 5 knees with congenital
webbing with 60° to 90° FFD, 3 (60%) achieved full correc-
tion, and 2 (40%) had residual deformities of 15° and 20°,
respectively. All the 3 knees with congenital webbing and
FFD of 90° to 120° had residual deformity—20° in 1 case,
whereas in the other patient, there was a fracture of the shaft
of the femur during frame adjustment for the left side, and
further treatment was abandoned.
During the postoperative period, pin-tract infection
occurred in 2 cases (5.12%), which were treated with oral
antibiotics. There was no wire breakage observed. How-
ever, bending of the connecting rods, as mentioned in
previous studies, was noted in 27 knees, requiring changing
of rods in 2 cases. There was no distal neurovascular com-
plication in any of the patients.
It was observed that with this technique all knees with
30° to 60° of FFD achieved full correction, whereas 26
(92.85%) of the 28 knees with FFD of 60° to 90° achieved
full correction. All the 4 cases of FFD of 90° to 120° had
residual deformities of 10° to 20°. The mean arc of move-
ment was 45.38° preoperatively and 41.5° postoperatively.
72 The International Journal of Lower Extremity Wounds 9(2)
All participants were followed up till 24 months after the
procedure. There was no increase in residual deformity in
any, and all were ambulating with appropriate orthoses.
Discussion
FFD of the knee, arising from varied etiologies, can have
crippling sequelae affecting the ambulation and bipedal gait
of the patient. Different methods have been used to correct
this deformity, which may frequently be multiplanar.1,2
Contractures of 15° to 20° or less in young children may be
treated with posterior hamstring lengthening and capsulot-
omy. Severe knee flexion contractures in growing children
can be treated by the division of the iliotibial band and
hamstring tendons, combined with posterior capsulotomy.
Skeletal traction after surgery is maintained through a pin in
the distal tibia; a second pin in the proximal tibia pulls ante-
riorly to avoid posterior subluxation. Long-term use of a
long leg brace may be required to allow the joint to remodel.
Supracondylar extension osteotomy of the femur may be
required as a second-stage procedure in older patients near
skeletal maturity or as the primary treatment for more severe
contractures.10,11
Each of these methods has its own complications,
such as decrease in motor power, incomplete correction,
delayed union, nonunion, implant failure (in bony proce-
dures), neurovascular complications, and extensive operative
procedures, at times needing multiple surgeries. Even then,
complete correction is limited by the severity of the con-
tracture, and there may be recurrence.
Ilizarov’s principle of distraction osteogenesis states
that slow, steady distraction of a recently cut bone (securely
stabilized in an external fixator) leads to the formation of
new bone “regenerate” within the widening gap. Distraction
histiogenesis is a biological phenomenon that can be used to
induce the formation of new bone and soft tissue. The dis-
traction force is applied with an external fixator, such as the
Ilizarov circular ring fixator or a uniplanar fixators.8,9
In this study, we have tried to analyze the efficacy of
Ilizarov’s principle of distraction histogenesis and technique
of differential distraction to treat knee flexion deformity
arising from soft-tissue contractures based on a postulate
that gradual distraction will cause stretching and thereby
lengthening of the contractured tissues, including the neu-
rovascular bundle, and gradually correct the deformity.
Previous reported studies with this technique have involved
primary supracondylar femoral osteotomy and then gradual
deformity correction using external fixators.12,13,15-17
In our study, the preoperative deformity ranged from
50° to 110°, with a mean FFD of 74.35°. The duration of
distraction needed was 6 to 12 weeks, increasing with the
severity of deformity, and it was more in patients with triple
deformity and congenital webbing. Patients with PPRP
needed distraction for a mean of 9.25 weeks, and those with
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triple deformity and congenital webbing needed distraction
for a mean of 12 weeks. In a similar study by Bosse et al,16
wherein the mean knee flexion contracture was 72.5° pre-
operatively, the mean total fixator time was 14.5 weeks.
A total of 33 of the 39 knees achieved full correction at
the end of distraction. Patients with triple deformity and
congenital webbing and with greater degree of FFD had
residual deformity, ranging from 10° to 20°; however, at the
follow-up at 24 months, there was no increase in residual
deformity, and all were ambulating with appropriate ortho-
ses. In the study by Bosse et al,16 all knees were corrected to
full extension ±5°; at follow-up, the mean contracture was
20.5°. Martin13 used distal hamstring release and femoro-
tibial external fixation in the treatment of knee contractures;
87% had complete extension or residual flexion contracture
of less than 10°. Zouari et al17 used supracondylar femoral
extension osteotomy for knee flexion contracture correction
in poliomyelitic conditions. In their study, although com-
plete extension of the knee was achieved peroperatively in
all cases, recurrence was observed in 5.74%. They observed
that osteotomy was not possible if the flexion contracture was
greater than 30°, because of excessive tension on the vaculo-
nervous bundles, and in children younger than 12 years
of age. Complications included septic arthritis (3.44%)
and transient paralysis of the common fibular nerve
(2.3%).17
The mean arc of movement remained the same irrespec-
tive of the deformity and correction. Similar observations
were made by Bosse, Zouri, and Herzenberg and col-
leagues.12,16,17 Postoperatively, the amplitude gained in
knee extension corresponded to the amplitude lost for
flexion.16 Although the average total arc of motion was
essentially unchanged after treatment, the functional posi-
tion of the arc improved substantially.12 We report that
functional and sustainable correction of FFD of the knee is
achieved without needing bony procedures and recurrent
soft-tissue release surgeries, thus, also avoiding the associ-
ated morbidities and costs.
To the authors’ knowledge, this is the first study that
uses purely soft-tissue distraction through Ilizarov’s ring
fixator without soft-tissue release or bony procedure for
correction of knee FFD. We are aware that the reported
study was uncontrolled and the sample size small. We are
also aware that there is a degree of patient selection; this
report should inform future controlled observations of the
reported findings.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
Gaurav and Vilas 73
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