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C H A P T E R
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The Ilizarov Method
The Ilizarov Method
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Stuart A. Green, M.D.
In 1951, Gavriil A. Ilizarov, a surgeon working in Kurgan, they have developed therapeutic strategies that allow a
Siberia, developed a circular external skeletal fixator that surgeon to achieve the following:
attached to bone segments with tensioned transfixion
wires.18 His device was a modification of other external Percutaneous treatment of all closed metaphyseal and
fixators, popular at the time in the then Soviet Union, that diaphyseal fractures, as well as many epiphyseal
followed the principle of connecting Kirschner wire fractures
(K-wire) bows together with threaded rods. By encircling Repair of extensive defects of bone, nerve, vessel, and soft
the limb with solid rings, Ilizarov could attach two or more tissues without the need for grafting—and in one
tensioned wires to limb segments for enhanced fixation. operative stage
Moreover, his frame proved springy enough to permit axial Bone thickening for cosmetic and functional reasons
micromotion, yet stable enough to limit translational Percutaneous one-stage treatment of congenital or trau-
movement. Initially, the device was used for fracture matic pseudarthroses
management. By adding hinges to the threaded connector Limb lengthening or growth retardation by distraction
rods, Ilizarov could gradually correct deformities in any epiphysiolysis or other methods
plane. Correction of long bone and joint deformities, including
When Ilizarov began using his fixator for limb length- resistant and relapsed clubfeet
ening, he performed the standard Z osteotomy, followed Percutaneous elimination of joint contractures
by gradual distraction and bone grafting of the resultant Treatment of various arthroses by osteotomy and reposi-
osseous defect. During the course of a lower extremity tioning of the articular surfaces
stump lengthening, Ilizarov observed new bone formation Percutaneous joint arthrodesis
within the distraction gap of an individual who slowly Elongating arthrodesis, a method of fusing major joints
distracted his own frame. Pursuing and extending his without concomitant limb shortening
observations, Ilizarov developed an entire system of Filling in of solitary bone cysts and other such lesions
reconstructive orthopaedics and traumatology based on a Treatment of septic nonunion by the favorable effect on
bone’s capacity to form new osseous tissue within a infected bone of stimulating bone healing
surgically created gap under appropriate conditions of Filling of osteomyelitic cavities by the gradual collapsing of
osteotomy, soft tissue preservation, external fixation, and one cavity wall
distraction.23 Lengthening of amputation stumps
Management of hypoplasia of the mandible and similar
conditions
Ability to overcome certain occlusive vascular diseases
without bypass grafting
GENERAL INDICATIONS Correction of achondroplastic and other forms of dwarfism
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With the Ilizarov method, osseous fixation is achieved with
tensioned smooth Kirschner transfixion wires attached to FRACTURE MANAGEMENT
an external fixator frame. The apparatus consists of a small zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
number of components that can be assembled into an
unlimited number of different configurations. Ilizarov and Ilizarov’s fixator is first and foremost a system for acute
his group never use plates and screws, intramedullary fracture management; most patients treated with the
nails, or even threaded external fixation pins; nevertheless, apparatus in Russia have worn the frame for the reduction
605
Copyright © 2003 Elsevier Science (USA). All rights reserved.

606 SECTION I • General Principles
and fixation of displaced long bone fractures. When used in the care of displaced articular fractures requiring
for acute limb trauma, the Ilizarov apparatus allows reduction and stabilization, especially in locations in
anatomic repositioning of fracture fragments in a circular which extensive internal fixation has proved risky, such as
external skeletal fixator that is axially dynamic yet at the lower end of either the tibia or the humerus. After
minimally invasive. A frame applied to a short, oblique, all, the usual method of managing such injuries includes
unstable tibial fracture, for example, might require only reduction and stabilization with K-wires, followed by the
eight K-wires for reduction, approximation, and stabiliza- application of more extensive internal fixation compo-
tion. Stiffness is imparted to the bone-fixator configuration nents. With the Ilizarov method, the K-wires used for
by tensioning the wires to about 100 to 130 kg at the time reduction are left in place and attached to an external
the frame is applied.1 Acute fracture fragments are reduced skeletal fixator, which is secured to intact bone elsewhere
by a number of strategies, the details of which are beyond on the limb, minimizing the amount of hardware at the site
the scope of this chapter. In principle, one or two rings are of injury. Closed diaphyseal fractures are treated in circular
attached perpendicular to each major bone fragment (each fixators only if well-controlled studies demonstrate that
with at least one pair of crossed wires). The fracture is the Ilizarov apparatus is clearly superior to other methods
reduced and compressed by adjusting the position of the of care.
rings with respect to one another. Ilizarov’s techniques will find their greatest applications
Ilizarov’s method was ideally suited for both the Soviet in the field of traumatology for post-trauma reconstruction
style of medical care under the Communist regime and the dealing with nonunions, malunions, post-traumatic osteo-
labor-intensive medical care system that, as of this writing, myelitis, and residual limb shortening.
has replaced it, for the following reasons: To understand how the Ilizarov techniques work, it is
important to understand the features of his method that
1. Implants for internal fixation of unstable fractures are
encourage bone formation within the distraction gap of a
sometimes made of low-quality metals or have limited
cortical osteotomy.21, 22, 30 The biologic principles that are
availability.
required for optimizing neoosteogenesis include the fol-
2. Periodic shortages of antibiotics—especially the
lowing:
second- and third-generation cephalosporins com-
monly used for surgical prophylaxis in the Western c Maximal preservation of marrow blood supply with a
world—require that such medications be reserved for percutaneous ‘‘corticotomy-osteoclasis’’ instead of an
open fractures and established cases of sepsis, rather open transverse osteotomy.
than as prophylactic coverage for clean implant surgery. c External skeletal fixation stable enough to eliminate
3. Despite a high initial cost for the apparatus, all parts shear at an osteotomy or fracture site, yet springy
except the K-wires are reusable, resulting in substantial enough to allow micromotion in the bone’s mechan-
long-term savings. ical axis.
4. The labor-intensive application of circular transfixion c A delay (latency) after surgery of about 1 week
wire external fixation constitutes no particular problem (although this could be more or less, under certain
in a nation with a federalized health care system. circumstances) before commencement of distraction
Likewise, the high physician-to-population ratio in for limb lengthening or opening a wedge.
many areas of Russia permits a ‘‘team’’ of three surgeons c A distraction rate of 1.0 mm/day, modified, if
to be available for frame application, a measure that necessary, by the characteristics of regenerate bone
greatly speeds up the operation. formation in the distraction gap.
5. Russian physicians and surgeons are well trained in c Distraction in frequent small steps—at least four
topographic anatomy, which reduces the likelihood of times daily (0.25 mm every 6 hours)—instead of in a
complications from inadvertent impalement of neu- single step.
rovascular structures. c Physiologic use of an elongating limb—a measure
6. Full disability insurance, equal to a worker’s wages, that promotes rapid ossification of the newly formed
permits protracted time off work without concern for bone. (Obviously, the fixator must be comfortable for
loss of job or other such problems and allows a more the patient and permit an adequate range of joint
leisurely approach to post-traumatic therapeutics. Also, motion.)
in a socialized medical system, frequent clinic visits and c A period of neutral fixation after distraction to permit
a prompt return to the operating room for a wire the regenerate bone to strengthen, with this period
exchange incur no added expense. lasting at least as long as the time needed for limb
7. Image intensification fluoroscopy is not available in lengthening or correction of a deformity, and possibly
general hospitals in Russia, making ‘‘closed’’ intramed- longer.
ullary nailing—the standard of care for many fractures
in Western countries—all but impossible.
For orthopaedic traumatology as practiced in Western EXPERIMENTAL BACKGROUND
countries, the rather time-consuming application of circu- zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz
lar transfixion wire external fixation will probably never
supplant the simpler half-pin frames used to stabilize the To confirm the importance of these measures, Ilizarov and
types of injuries commonly thought to require external co-workers performed a series of experiments utilizing a
fixation, such as type II and type III open fractures. canine tibia model and the Ilizarov transfixion wire-
Ilizarov’s methods of fracture treatment will find a place circular external skeletal fixator.21, 22

CHAPTER 21 • The Ilizarov Method 607
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Presentation
FIGURE 21–1. An experimental design to study the effect of fixator stability on new bone formation during
distraction. Open transverse osteotomies were performed in the tibias of dogs that were in external fixators of
differing stabilities. The configuration for the first group consisted of two rings loosely affixed to bone with wires.
The second group wore more stable fixators of two rings secured to the bone with tensioned wires. The third
group of animals were stable in a four-ring frame, each ring of which was affixed to bone with a pair of tension
wires. (From Ilizarov, G.A. Clin Orthop 238:250, 1989.)
In the first group of experiments, an open transverse

osteotomy of the midtibia was performed, followed by
application of a circular external fixator in three configu-
rations of progressively increasing stability. In the first
configuration, a two-ring frame was applied with a pair of
loosely attached wires at each ring level. In the second
configuration, a two-ring frame was also used, but a pair of
crossed wires was fixed with tension to each ring. The
third (most stable) fixation consisted of a four-ring frame,
with each ring affixed to bone with a pair of tensioned
crossed wires (Fig. 21–1).
Following a 5-day delay after fixator application, the
osteotomy sites were distracted at a rate of 0.125 mm every
6 hours. Ilizarov and co-workers21 observed that the
unstable frame with loosely attached wires led to a fibrous
nonunion with, in some cases, full-shaft width displace- Print Graphic
ment at the osteotomy site (Fig. 21–2). The more stable
two-ring configuration with tensioned wires led to patchy
areas of bone and cartilage formation but ultimately
resulted in a pseudarthrosis in most cases (Fig. 21–3). The
Presentation
most stable configuration (four rings) led to direct
osteogenesis without intervening cartilage formation
(Fig. 21–4).
As part of that study, Ilizarov and co-workers21 used the
same rate of distraction and the four-ring fixator configu-
ration to study a second variable: preservation of blood
supply (Fig. 21–5). Three types of osteotomy were
performed in this series:
1. Open transverse osteotomy with transection of the
bone marrow and nutrient vessels
2. Open transverse osteotomy with transection of only
one third of the bone marrow
FIGURE 21–2. The animals maintained in unstable two-ring fixators
3. Closed osteoclasis using the apparatus and a curved developed fibrous nonunions with focal areas of hemorrhage and fibrous
wire to crack the bone, using the mechanical advantage tissue formation in the distraction gap. (From Ilizarov, G.A. Clin Orthop
gained by the apparatus 238:257, 1989.)

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FIGURE 21–3. The animals with two-ring configurations secured to bone FIGURE 21–4. The most stable configuration (four rings) led to direct
with tension wires demonstrated the formation of cones of bone attached osteogenesis in the distraction gap without intervening cartilage forma-
to the endosteal canal and areas of cartilage formation in the distraction tion. (From Ilizarov, G.A. Clin Orthop 238:258, 1989.)
gap. (From Ilizarov, G.A. Clin Orthop 238:257, 1989.)
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Presentation
FIGURE 21–5. A study to define the effect of preservation of blood supply. The canine tibia was used in a stable
four-ring configuration (each ring was affixed to bone with crossed tension wires). In the first group of dogs,
the osteotomy was performed with open technique, transecting the marrow and nutrient artery. In the second
group of dogs, an open osteotomy-corticotomy was performed, but only one third of the marrow was
transected by the osteotome. In the third group of dogs, the osteotomy was performed by a closed osteoclasis
technique using tension developed by the apparatus. The study demonstrated that the best quality of bone
formation was associated with the maximal preservation of blood supply. (From Ilizarov, G.A. Clin Orthop
238:250, 1989.)

FIGURE 21–6. Ilizarov’s experiments to

evaluate the influence of marrow pres-
ervation on bone formation during
lateral distraction of a cortical frag-
ment. In the dogs in group 1, a segment
of cortex was separated from the tibia Print Graphic
using a rotary cutter that limited pene-
tration of the bone, whereas the dogs
in group 2 underwent the identical
cortex-splitting procedure, but the
marrow was traversed by an osteotome.
The best osteogenesis occurred in ani- Presentation
mals with maximal preservation of the
marrow. (From Ilizarov, G.A. Clin Or-
thop 238:252, 1989.)
The researchers observed that the greater the preserva-

tion of bone marrow, the better the quality of new bone
formation within the distraction gap.
In the second series of experiments, Ilizarov’s group
widened canine tibias instead of lengthening them (Fig.
21–6). A split-off segment of tibia, constituting approxi-
mately 40% of the bone’s length and 30% of the cortical
circumference, was moved laterally (after a 3-day delay
following osteotomy) by an Ilizarov apparatus modified for
lateral traction. In half the animals, the bone was cut with
a rotary cutter that limited damage to the marrow, whereas
in the other half, the marrow was transected with an
osteotome. The new bone that formed was parallel to the
lateral distraction vector (i.e., perpendicular to the bone’s
mechanical axis) (Fig. 21–7).21 As with longitudinal
lengthening, damage to the marrow decreases new bone
formation. Print Graphic
In the third experiment, also using the canine tibia,
bone was lengthened, after either open osteotomy or
closed osteoclasis, at three different rates of distraction
(0.5 mm, 1.0 mm, and 2.0 mm) in combination with
a second variable: the frequency of distraction (1 step/day, Presentation
4 steps/day, or 60 steps/day in an autodistractor). It was
learned that a rate of distraction of 0.5 mm/day often led
to premature osseous consolidation (Fig. 21–8),22 whereas
a distraction rate of 2.0 mm/day resulted in damage of
periosseous soft tissue and suboptimal new bone forma-
tion. The best results were achieved with a distraction of
1.0 mm/day. Ilizarov and co-workers20 also observed that
the more highly fractionated the distraction frequency, the
better the outcome. Thus, distraction at 60 steps/day
resulted in a better quality of bone formation than 4
steps/day which, in turn, produced better neoosteogenesis
than distraction at 1 step/day (Fig. 21–9).22 Likewise, the
periosseous soft tissues—including the nerves, fascia, FIGURE 21–7. Neovascularization takes place during lateral distraction of
blood vessels, muscles, and skin—responded more favor- a split-off cortical bone fragment. (From Ilizarov, G.A. Clin Orthop
ably to a highly fractionated distraction, which mimicked 238:266, 1989.)

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FIGURE 21–8. A canine experiment to evaluate the effect of the rate of
distraction. In this animal, distraction at a rate of 0.5 mm/day in four divided
steps led to premature consolidation of the bone in the distraction gap. A
secondary fracture occurred at the lower end of the distraction gap between
the newly formed bone and the original distal shaft fragment. (From Ilizarov,
Presentation G.A. Clin Orthop 239:268, 1989.)
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Presentation
FIGURE 21–9. A, Distraction at 1.0 mm/day in 60 steps with an autodistractor results in excellent bone formation in the widening distraction gap. The
growth zone of the distraction regeneration is a dark band that zigzags across the center of the newly formed bone. B, Distraction at a rate of
1.0 mm/day in 4 steps results in satisfactory bone formation. C, Distraction at a rate of 1.0 mm in 1 step (following open osteotomy) results in poor
quality of the newly formed bone. (A–C, From Ilizarov, G.A. Clin Orthop 239:268, 1989.)

anatomic considerations limit the surgeon’s ability to insert

wires crossing at 90° within the bone. For this reason,
transfixion wires usually end up crossing each other at a
more acute angle, thereby diminishing fixator stability. To
overcome this problem, the surgeon must either use more
than two wires at each plane of fixation or insert additional
wires away from—or oblique to—the ring’s plane of
fixation. For added stability, Ilizarov’s fixation system also
utilizes beaded wires to prevent the bone from sliding
along the wire.
INSERTING TRANSFIXION WIRES

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When inserting wires, an important technical principle is
to avoid necrosis of tissues at the time of insertion.
Necrosis of the soft tissues can be caused by either
wrapping up of tissues, excessive tension, or thermal
Presentation injury from heat build-up during drilling.8, 9, 11, 17
With transfixion wires, a spinning bayonet point may
wrap up soft tissues, causing necrosis (Fig. 21–14).
Therefore, the surgeon should push transfixion wires
straight through the tissue to the bone before turning on
the drill. If the wire misses the bone, the surgeon should
withdraw it completely and reinsert it rather than
redirecting it within the limb’s tissues.
At times, when inserting a transfixion wire with a
motorized chuck, wire flexibility may cause the wire to
bend, reducing accuracy of placement. For this reason,
whenever inserting a wire, manually grasp the wire close to
its tip to stabilize it. Because a spinning wire can wrap up
surgical gloves, hold the wire with a wet 2 × 2-inch gauze
pad (Fig. 21–15).
When inserting transfixion wires into bone with a
FIGURE 21–10. Under optimal conditions of distraction and stabilization, power drill, the dense cortical bone, by offering substantial
osteoblasts possess elongated organelles, with stretched-out endoplasmic
reticulum forming parallel rows (upper arrow) and elongated mitochon-
resistance to the wire point’s progress, may cause heat
dria (lower arrow). (From Ilizarov, G.A. Clin Orthop 238:270, 1989.) build-up, which hardens the bone even more, resisting
additional progress of the wire point. For this reason, the
drill should be stopped every few seconds, using a
the natural process of growth (Figs. 21–10 and 21–11).22 stop-start action to advance the wire slowly through hard
Moreover, with a 60 step/day autodistractor (85 µm every osseous tissue. Furthermore, complete intracortical inser-
24 minutes), changes within the elongating tissues took on tion of a wire—not accompanied by the ‘‘feel’’ of crossing
histologic and electron microscopic features characteristic the marrow to encounter a second cortex—is especially
of cellular growth during embryonic, fetal, and neonatal prone to excessive heat build-up, thermal damage, and the
life (Fig. 21–12).22 possibility of wire hole osteomyelitis.
Clearly, Ilizarov discovered a previously hidden biologic As soon as a transfixion wire’s point penetrates a bone’s
plasticity of osseous tissue. With his techniques, a surgeon far cortex, the surgeon should not continue drilling,
can create a sort of growth plate anywhere in bone that because the spinning wire tip might damage tissues on the
ossifies in both the proximal and the distal directions from limb’s opposite side. Instead, the surgeon should grasp the
a central growth zone during distraction (Fig. 21–13).22 wire with pliers and hit the pliers with a mallet to drive
Consolidation of the entire regenerate region takes place the wire through (Fig. 21–16).
during the neutral fixation period that follows distraction. A most important principle when using any transfixion
implant: if the tip of a wire (or pin) emerges from the
opposite side of a limb either smoking or too hot to be
TRANSFIXION WIRES comfortably held between the surgeon’s fingertips, then
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz the wire should be withdrawn, cooled, and reinserted
elsewhere. With transfixion wires, it is necessary to check
Transfixion wire external fixators use smooth K-wires for the range of motion to make sure that no undue tension
attachment to bone; therefore, fixation is not secure unless occurs during the anticipated range required while the
two or more wires are used at each level of fixation. For fixator is on the limb. If necessary, a wire should be
maximal stability, the two wires should cross each other at reinserted if movement of an adjacent joint causes skin
a right angle at each plane of fixation.1 Unfortunately, tension around a wire.

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Presentation
FIGURE 21–11. A, Resting fascia has a wavy shape under light
microscopy. B, Distraction of fascia at a rate of 1.0 mm in one step
produces pulled-out collagen fibers and areas of focal homogeni-
zation (arrows). C, Distraction at a rate of 1.0 mm/day in four steps
results in retention of the wavy shape of collagen fibers but with a
few patches of focal homogenization. Numerous fibroblasts are seen
in the lower portion of the field. (A–C, From Ilizarov, G.A. Clin
Orthop 239:272, 1989.)
Certain important techniques of transfixion wire inser- flexor and extensor muscle groups. For example, when the
tion ensure maximal functional limb use and joint surgeon is inserting a wire from anterolateral to postero-
mobility: medial in the distal femoral metaphysis, the knee should
be flexed to 90° before the wire is inserted through the
c Avoid impalement of tendons.
quadriceps; the wire is then pushed straight down to the
c Avoid (whenever possible) transfixing synovium.
femur before drilling. The wire is driven through the bone
c Penetrate muscles at their maximal functional length.
with a power drill. As soon as the wire point emerges
This last rule—critically important for a successful through the far cortex, the surgeon should stop drilling,
long-term application—means that the position of a extend the knee, and hammer the wire through the limb’s
nearby joint must change as a wire passes through the opposite side.
When inserting a wire into the lower leg, the surgeon
should plantar flex the foot when transfixing the anterior
compartment, invert the foot when inserting wires into the
peroneal muscles, and dorsiflex the foot during triceps
surae impalement.
When a wire is being inserted near a tendon, a sim-
ple technique helps the surgeon avoid tendon transfixion.
First, palpate the worrisome tendon to determine its exact
course and location. Next, holding the transfixion wire
Print Graphic in one hand (do not attach the wire to a drill), palpate
the position of the tendon with the other hand, and
poke the wire through the skin down to, but not quite
touching, the bone. Then, wiggle the structure ordinar-
ily moved by the tendon in question. For example,
Presentation
dorsiflex and plantar flex the ankle when a wire is in-
serted near the tibialis anterior tendon. If the wire tip has
impaled the tendon, the wire will move as the involved
part is put through a range of motion. If this occurs,
FIGURE 21–12. During elongation of a limb, the nerves and Schwann cells
take on the histologic characteristics seen during fetal and embryonic withdraw the wire and reinsert it in a slightly different
growth. A Schwann cell (arrows) is seen in the two developing axons (A). position.
(From Ilizarov, G.A. Clin Orthop 238:272, 1989.) Once wires are in place, after the final frame configu-

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Presentation
FIGURE 21–13. A, Electron micrograph of the central (growth) zone of the distraction regenerated bone. Fibroblast-like cells appear in a relatively avascular
central zone, forming collagen fibers that are oriented parallel to the tension-stress vector of elongation. Osteoblasts appear in the vascularized spaces
between the collagen fibers and form bone directly on the collagen molecules. The newly formed bone condenses into trabeculae proximally and distally.
B, Anteroposterior and lateral projection radiographs of a 32-year-old woman with 4 cm of tibial shortening following an injury incurred while skiing.
C, A distal tibial and fibular corticotomy was performed using the Ilizarov technique. Distraction started on postoperative day 7. The rate was 0.25 mm
every 6 hours. D, Progressive ossification of the distraction gap occurred during the neutral fixation period that followed elongation. (A–D, From Ilizarov,
G.A. Clin Orthop 238:262, 1989.)
ration is established, it is important to put the adjacent

joints through a range of motion to be sure that the wires
do not interfere with joint motion by causing excessive
soft tissue tension at the end of either flexion or
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extension. When transfixion wires are used, bending the
wire for ring attachment may cause excessive soft tissue
damage, as the wire, being very narrow, concentrates
pressures over a small area. For this reason, transfixion
wire fixator systems use special strategies to ensure that a Presentation
wire is not bent during frame attachment. The original
Ilizarov equipment uses washers, posts, and other
hardware to achieve this goal. Other circular fixators use
other techniques. In any case, the principle of not
FIGURE 21–14. The bayonet point of an Ilizarov wire can wrap up soft
bending a wire when attaching it to a frame is a critical tissues, a possible source of deep sepsis. When inserting a wire, push the
element to successful tensioned wire external fixation implant straight through the tissues down to bone before the wire starts
(Fig. 21–17). to spin.

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FIGURE 21–15. To stabilize a wire, grasp it with a moistened 2 × 2-inch

gauze sponge.
Presentation
PIN TECHNIQUES
Many circular fixator systems permit supplementary
fixation with threaded pins. This technique is especially
helpful for proximal femur mountings, because transfixion
wires in this region must exit through the buttocks—a
situation requiring special beds and chairs for the
patient. Also, a high rate of wire sepsis occurs in this
region. For these reasons, the Ilizarov method has been
modified for the proximal femoral mounting to include
half pins for fixation. At Rancho Los Amigos Medical FIGURE 21–17. A, When, following insertion, a wire is off the plane of a
Center, we have had excellent success with configurations ring, do not bend the wire to the ring. (This creates undue soft tissue
that use half pins in many different locations,9, 10, 12, 15 tension.) B, Instead, build up hardware to secure the wire where it lies.
based on the observation of DeBastiani and associates5 that
good regenerate bone forms in a distraction gap if one
follows Ilizarov’s biologic principles of marrow preserva- external fixator configuration when the frame is used for
tion, stability, latency, and distraction. many, if not all, Ilizarov-type applications. Numerous
These observations suggest that half pins may be experienced surgeons have started using half pins in place
substituted for transfixion wires at one or both ends of an of wires in many Ilizarov-type fixator configurations (Fig.
21–18).
The use of pins made from a titanium alloy rather than
stainless steel has led to a reduction in implant site sepsis
at Rancho Los Amigos Medical Center.10, 15 This observa-
tion has been made with respect to other orthopaedic
implant systems as well, including total joint implants and
intramedullary nails. To elucidate the mechanism of
titanium tissue tolerance, Pascual and co-workers added
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powdered stainless steel, pure titanium, titanium alloy, and
cobalt chromium to mixtures of bacteria and viable human
polymorphonuclear leukocytes.29 The investigators then
measured respiratory burst activity (a measure of intracel-
lular bacterial killing by white blood cells [WBCs]) at
Presentation various times after the beginning of incubation. They
found that titanium and, to a lesser extent, cobalt
chromium, resulted in only a slight inhibition of normal
respiratory burst activity when compared with the inocu-
lum that did not contain any metallic powder. Stainless
FIGURE 21–16. After the bone is penetrated with a wire, drive the point steel, on the other hand, caused a marked reduction in
of the wire through the skin on the opposite side of the limb with pliers respiratory burst activity, suggesting interference with a
and a mallet. critical step in the bactericidal activity of human WBCs.

This inhibition of a vital cellular function probably has the

effect of reducing host resistance to implant site sepsis.
The toxic effect of steel on cellular function may be
related to the elution of certain metallic ions—perhaps
nickel or chromium—from the implant’s surface. The use
of titanium pins does not completely eliminate pin site
sepsis; the effect is to reduce the incidence of pin tract
infections by about 50%.15 Moreover, I have noted that
when implant site infections do occur around titanium
pins, the problem stays localized to the immediate
environment around the implant. Extensive cellulitis that Print Graphic
extends for many centimeters around the pin hole (a
common phenomenon when stainless steel pins are used)
occurs rarely, if at all, with titanium alloy implants.
Despite a substantial reduction in the rate of implant
site sepsis during the past two decades, pin and wire site Presentation
infections remain the principal drawback to the use of
external skeletal fixation. Moreover, many additional
problems commonly associated with external fixation,
such as undue pain and decreased limb usage while in the
frame are often secondary consequences of implant-skin
interface sepsis.
Two strategies designed to further reduce implant site
sepsis have been developed; both involve coating the FIGURE 21–19. Irrigate the drill bit with cooled irrigating solution.
implants. Because pin site infections are often associated
with implant loosening, any technology that reduces the
possibility of loosening should also decrease the incidence
of pin infections. Based on this logic, hydroxyapatite
(HA)-coated pins have been developed that reproduce the
osseous integration that occurs with HA-coated total joint
implants.3 Clinical studies have confirmed the lower rate
of pin site sepsis associated with HA-coated implants.28 A
comparable reduction in pin site sepsis may be associated
with the use of titanium pins and wires, rather than those
made of stainless steel.
The second technique designed to reduce pin or wire
site sepsis involved coating the implants with an antimi-
crobial substance. So far, silver is the only such substance
that has been extensively tested. Proponents of silver-
coated pins claim a reduced pin site infection when such
implants are used.31
A threaded pin—especially a modern one with self-
cutting flutes at the tip—can wrap up soft tissues in the
thread’s grooves. For this reason, surgeons should always
Print Graphic use a trochar and sleeve to insert threaded pins into bone.
Surgeons should not use a power drill to insert a
threaded pin directly into bone, because heat build-up at
the pin’s point could cause a thermal injury to the bone.
Instead, the bone hole should be predrilled with a sharp
Presentation fluted drill bit and a drill sleeve and the pin inserted by
hand.
When drilling, the surgeon should stop the drill every
few seconds to allow the cutting tip to cool down. The heat
generated by drilling not only damages the bone but also
‘‘work hardens’’ osseous tissue, which then resists further
advancement. A worthwhile practice is to irrigate the
exposed portion of the drill bit to cool it and conduct heat
away from the tip (Fig. 21–19).
If much resistance is encountered during drilling, check
FIGURE 21–18. A, Ring-gripping clamps, called Rancho Cubes, are used the drill bit tip between the fingertips for excessive
to secure pins to Ilizarov rings. B, A Rancho swivel assembly is used to temperature. If the tip cannot be comfortably held for 15
secure a nonperpendicular pin to a ring. or 20 seconds, the implant should not be left in the bone

until it passes through the skin in an improved position

(Fig. 21–21).
If the interface tension exists on the insertion side of a
limb, snap off the wire’s blunt end obliquely to create a
point, and advance the wire to just below the skin surface
Print Graphic by the pliers-mallet method on the limb’s far side. Tap the
wire back through the skin after making a position
adjustment.
Presentation
MOUNTING STRATEGIES
Juxta-articular Mountings
FIGURE 21–20. The bone in the flutes of a drill bit should be white, never
black or brown (a sign of thermal injury to bone).
One might wonder why we should be concerned with the
composition of the wire available when the preceding
section recommended the use of half pins for external
hole, as there will be necrotic (thermally injured) bone in
fixation. I have come to the conclusion that in certain
communication with the pin’s bacteriologic environ-
anatomic locations, wire mounts are actually superior to
ment—a setup for chronic osteomyelitis. Instead, the pin
pin mountings, regardless of the material from which the
(wire) should be inserted elsewhere. Likewise, the bone in
implant has been fabricated. In general, wires provide
the drill bit’s flutes should be white, never black or brown,
better fixation in the juxta-articular regions of a long bone,
which is a sign of burned bone (Fig. 21–20).
whereas half pins are generally superior for diaphyseal
locations.
Threaded pins are less than ideal for fixation of
THE IMPLANT-SKIN INTERFACE cancellous bone near a joint surface for several reasons.
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz First, threads do not hold well in spongiosa, especially if
any degree of osteopenia is present. Second, even when a
After inserting a wire or pin but before attaching it to the threaded pin achieves initial stability in a juxta-articular
frame, check the skin interface for evidence of tissue fragment, the passage of time frequently leads to loosen-
tension while the limb is in its most functional position— ing, because the loss of a very small volume of bone
that is, with the knee extended and the ankle at neutral. around the implant diminishes fixation more rapidly than
Interface tension creates a ridge of skin on one side of a a comparable loss of bone volume around a threaded
wire or pin. Incise the ridge to enlarge the skin hole implant secured in cortical bone. Third, once the fixation
around either a transosseous pin or an olive wire. Close the of a half pin in a cancellous bone has been decreased by
enlarged hole with a nylon suture on the side of the wire resorption of osseous tissue from around the implant, a
opposite the released ridge. substantial hole has been created in the bone fragment that
When the ridge of skin is adjacent to a smooth wire, limits the anatomic options for additional or subsequent
slowly withdraw the wire (with pliers and a mallet) until fixation.
its tip drops below the skin surface. Allow the skin to shift On the other hand, when a wire is used to secure
to a more neutral location, and advance the wire again juxta-articular fragments, the bone hole is tiny, and the
Print Graphic
Presentation
FIGURE 21–21. The wire-skin interface. A, Tension on the skin is caused by a transfixion wire. To correct the situation, withdraw the wire to below
skin level, allow the skin to shift to a neutral position, and (B) drive the wire forward. The arrow points to the original wire hole.

loosening that does occur becomes established without complete repositioning of the moving ring by adjusting the
creating a very large hole. Furthermore, multiple cross lengths of the struts. In this manner, the gradual reduction
wires can be placed in a fairly small fragment, thereby of a displaced fracture, or the correction of a deformity, or
creating a trampoline effect that supports the bone. Also, limb elongation or compression in its own axis can be
in most locations, there are no muscle bellies surrounding accomplished with ease, provided the exact relationship
juxta-articular bone. For the most part, such fragments are between the rings and their respective bone fragments are
adjacent to either tendons or neurovascular structures that known, as well as the precise position of the rings with
can, with care, be avoided during wire placement. respect to each other.
Moreover, most of these neurovascular structures are either The reduction-repositioning system must be used with
anterior or posterior to the articular bone fragments, a computer program that details the precise amount of
leaving the mediolateral corridor for safe wire insertion. lengthening or shortening of each strut required to
The clinical techniques of fracture reduction and gradually move a bone fragment into position. With such
deformity correction with circular external fixation by a program, it is also possible to designate a particular
Ilizarov’s methods require that the surgeon understand the neurovascular bundle as being at risk of stretch injury if
relationship between the moving bone fragment’s initial the bone fragment is moving too rapidly from its initial to
position and its final position with respect to the stationary final position. With this information, combined with a
bone fragment that serves as the frame of reference for the parameter that defines the maximum tolerable stretch of
reduction maneuver. There are four ways that the moving the structure at risk, the computer program can tell the
fragment can change position to effect a reduction: clinician how fast the struts can be lengthened without
angulation, translation, rotation, and axial shortening or causing injury to that structure.
lengthening. With the classic Ilizarov fixator configuration, To use the spatial frame successfully, several parameters
separate assemblies are used to achieve each one of these must be entered into the computer, including a numerical
displacements, although angulation and shortening can description of the exact relationship of the fragments to
often be combined in one maneuver by placing the hinge their respective rings in all planes, as well as precise
axis at a distance from the edge of the bone along the line measurements defining both the initial and final position
that divides the deformity angle in half, the bisector line. In of the moving fragment with respect to the stationary
some cases, translation can also be corrected with the same fragment. This particular feature of the system has proved
mechanism that realigns angulation and shortening, but to be most troublesome to surgeons comfortable with the
only in situations in which the translational offset is in the classic Ilizarov reduction techniques, in which errors in
same plane as the angulation and shortening. In all other measurement are correctable without much difficulty by
cases, separate assemblies must be constructed to elimi- using the proper correction assemblies, even when they are
nate the different deformities. added to the fixator long after it was applied to the patient.
Taylor realized that regardless of the number of Nevertheless, the system is popular with surgeons who
assemblies needed to reduce or align bone fragments, the have become familiar with its features.
moving bone makes a single pathway from its displaced
position to its reduced position. In some situations, the
pathway may be a straight line, and in other cases, the
pathway may be spiral or otherwise curved, but the nature Hybrid Mountings
of that path can be determined in advance by noting the
three-dimensional location of the starting position of the For more substantial fragments that include not only the
fragment with respect to a frame of reference, and articular end of the bone but also the metaphyseal region,
mathematically comparing that position with the final various combinations of pins and wires have proved
position. Indeed, it is not necessary to consider the entire successful for mount external fixation. The stability of
moving fragment to define the pathway. Instead, a single these mounting strategies has been studied by Calhoun
point on the moving fragment may be used as a substitute and associates.3 They analyzed a number of different pin
for the whole fragment as long as the relationship of the and wire combinations to determine the amount of
point to the rest of the fragment remains unchanged as the stability available as one converts from an all-wire
fragment moves through space from its starting position to mounting technique to one that uses only half pins. Using
its final position. two crossed tension wires as the standard, Calhoun and
Likewise, if the moving fragment is secured to a ring (or associates learned that the popular T configuration
block of rings) and the stationary fragment is secured to (consisting of a transfixion wire and perpendicular half
another ring or block of rings, then the rings can be pin) is not as stable as two tension wires crossed at 90°.
considered as part of their respective fragments. Therefore, Indeed, Calhoun and associates3 learned that whenever a
correction of the deformity or displacement via the rings wire is removed from a circular fixator mounting plan, it
will correct the osseous deformity as well. Indeed, this is a should be replaced by two half pins. Thus, stability
basic Ilizarov concept. The unique feature of the method comparable with that produced by two tensioned wires at
that considers the pathway that the moving bone fragment 90° to each other requires one wire and two half pins in a
must take as the route to alignment of the fragments is the reasonable geometric configuration.
application of engineering principles to the problem of At Rancho Los Amigos Medical Center, we are fond of
deformity correction and fracture fragment reduction. using certain configurations in the periarticular and
Connecting the ring surrounding the moving fragment to epiphyseal-metaphyseal regions of bones that, in our
the ring of the stationary fragment with six struts allows for clinical experience, have proved to be stable. The first of

FIGURE 21–22. The H mounting. A,

Print Graphic With parallel counterpulling beaded
wires. B, With crossed counterpulling
beaded wires.
Presentation
these mountings is what we call the H mounting, plane, so the crossing angle between them cannot be too
consisting of two counterpulling olive wires at about the great. This configuration is especially valuable in the distal
same level and a single half pin, which is either radius, calcaneus, and scapula (Fig. 21–23).
perpendicular to the two wires or at some angle between The T mounting, consisting of a single wire and a
60° and 120° to the wires (Fig. 21–22A). Alternatively, the perpendicular half pin (Fig. 21–24), is not particularly
wires can be crossed with respect to each other (see Fig. stable, as noted by Calhoun and associates.3 The T mount,
21–22B). Usually, the wires are placed in the coronal however, can be considered stable if the wire also passes
Print Graphic
Presentation
FIGURE 21–23. The H mounting of wrist (A), calcaneus (B), and

scapula (C).

Print Graphic Print Graphic
Presentation Presentation
FIGURE 21–24. The T mounting. FIGURE 21–26. The A mounting.
through an intact bone. For example, transfixing the distal It is often possible to use titanium half pins in
radius and ulna with a single wire would then require only juxta-articular regions, especially if the bone is of good
a single half pin to complete the mounting of the distal quality. In relatively stable situations, two half pins at right
radius fragment. Of course, the radius cannot be length- angles will suffice—a V configuration (Fig. 21–28). In
ened when it is fixed to the ulna, but such a configuration other cases, more stability can be achieved by employing
is useful in bone transport cases and similar mounting three half pins in a W configuration (Fig. 21–29). We have
needs (Fig. 21–25). developed a mounting configuration for the distal femur
Another strategy we often use is the A mounting, in that secures the condyles without synovial penetration. We
which two half pins are inserted at the same or nearly the first insert K-wires in the coronal plane from distal to
same transverse level in the bone, with the angle between proximal, crossing each other 6 mm apart. We next
them measuring from 60° to 120°. A single wire employ a cannulated drill bit to enlarge the K-wire tracts,
(preferably an olive wire) is then inserted perpendicular to drilling from proximal to distal. The 6-mm threaded half
the line bisecting the angle between the half pins (Fig. pins are inserted into the drilled holes from the proximal
21–26). (The crossed implants make up the letter A within to the distal direction. A supplementary half pin is added
the bone.) This mounting is useful for a proximal tibial for additional fixation (Fig. 21–30).
fixation (Fig. 21–27).
TECHNIQUES
Corticotomy
To preserve both the periosseous and the intraosseous soft
tissues at the time of osteotomy, Ilizarov developed
techniques for percutaneous osteotomy of a bone without
transecting the marrow’s nutrient vessels. The procedure is
called a corticotomy if performed in the metaphyseal region
of a bone and a compactotomy if accomplished in the
Print Graphic diaphysis.26 Through an incision no wider than a narrow
osteotome, a small periosteal elevator (or ‘‘joker’’) is used
to elevate the periosteum as far around the bone in both
directions as possible. Next, a starting notch is made in the
bone’s near cortex, followed by progressive intracortical
Presentation
advancement of the osteotome, first on one side of the
bone and then on the other. Because the osteotome tends
to jam as it advances, the surgeon must twist or wiggle the
blade within the bone’s cortex to make room for further
advancement. One should not be overly concerned if the
osteotomy crosses the marrow on occasion. Instead,
distraction can be delayed 2 to 3 days beyond the planned
latency interval.
FIGURE 21–25. The T mounting in the ulna for bone transport. The opposite cortex is cracked by rotating the os-

FIGURE 21–27. A mountings in the

Print Graphic proximal and distal tibia. A, Photograph
of the configuration. B, Radiograph of
the configuration.
Presentation
teotome 90° within the cortical cuts on both sides of the corticotomy, the rods must be reattached to their original
bone or, alternatively, by performing a closed osteoclasis in position—and at their original length—thereby reestab-
torsion by counterrotation of the rings attached to each lishing the precorticotomy alignment of the bone. To
bone segment. (The distal fragment should always be ensure correct alignment, the surgeon should count the
rotated externally, as internal rotation might unduly holes in the rings, making note of the position of each
stretch the peroneal nerve in the leg or the radial nerve in connecting rod before removing it. Short, threaded sockets
the arm.) can be used between a ring and the threaded rods
Because the object of a corticotomy is to create a connected to it, or one-hole posts can serve the same
nondisplaced fracture, it is important to restore the bone to function. The sockets or post can be detached from one
its precorticotomy alignment immediately after completing ring before corticotomy and reassembled afterward.
the procedure. To accomplish this, the external fixator
must already be secured to the limb before the bone is
osteotomized. Obviously, an intact external fixator would Latency
prevent torsional osteoclasis of a bone’s far cortex.
Therefore, the surgeon must disconnect from the rings all There is a latency (delay) before distraction commences,
longitudinal rods traversing the corticotomy level. After the purpose of which is to allow the first stage of fracture
FIGURE 21–28. The V mounting. FIGURE 21–29. The W mounting.

FIGURE 21–30. The W mounting

for the distal femur avoids trans-
synovial pins or wires. A, Radio- Print Graphic
graph of the mounting. B, Photo-
graph of the pin configuration.
Presentation
healing to begin. During distraction, corticotomy site transport wires. Usually two crossed wires are used for this
fracture healing tries to ‘‘catch up’’ with the distracting purpose; if only one wire is used, the transported segment
bone ends but under most circumstances does not may twist on that wire’s axis. As the transport ring is
consolidate the regenerate bone within the distraction gap gradually moved along the fixator frame, the transport
until the neutral fixation period after elongation. wires cut through soft tissues by causing necrosis ahead of
Generally speaking, the delay is 5 to 7 days, but this can the wires; the skin and tissues heal behind the wires. In
be lengthened or shortened under certain circumstances. this manner, transport wires cut through soft tissues as a
When the corticotomy is oblique, the latency should be hot wire cuts through ice. Because the transport wires’
shortened by 1 to 2 days because oblique corticotomies movements are gradual, there is little pain associated with
heal more rapidly than transverse ones. Latency should be the transport process; nevertheless, the area of focal
prolonged if (1) the osteotome seems to have crossed the necrosis at the wire’s leading surface often becomes
marrow canal during corticotomy, (2) there has been infected, as one might expect with any wire causing soft
considerable comminution at the site of corticotomy (delay tissue damage by compression. The inflammation sur-
should be 3 or 4 days), (3) there has been substantial rounding the necrotic area causes patient discomfort. A
displacement of the major fragments during corticotomy, serous or purulent discharge often accompanies the
and (4) fragments were counterrotated (during torsional process. Usually the inflammation stops once bone
osteoclasis of the posterior cortex) more than 30°. transport has been completed; nevertheless, I maintain
If the bone is of poor quality—either extremely dense patients on oral antistaphylococcal antibiotics as soon as
or osteopenic—the latency interval should be increased up soft tissue inflammation appears during the course of bone
to 14 days, especially if the soft tissues surrounding the fragment transportation.
bone are also of suboptimal quality. When planning to move a bone segment through a limb
by way of transport wires, the surgeon must consider both
the initial and the final positions of the transport wires, as
Distraction well as the path the wires will cut through soft tissues.
With longitudinal bone segment movement, the transport
After latency, the corticotomy gap is usually distracted 0.25 wires generally move parallel to neurovascular structures
mm every 6 hours. This rate and frequency may be altered, and tendons; thus, little likelihood for transection of such
depending on the clinical circumstances. For an adult with structures exists. However, one should recognize the
dense bone and suboptimal surrounding tissues, a more danger of a proximally moving transport wire entering the
appropriate rate and frequency would be 0.25 mm every 8 bifurcation of a nerve or vessel.
to 12 hours.
Directional Wires
Transport Wires
One or more directional wires may be used to pull a bone
Wires that move a major bone segment through tissues by segment through soft tissues. For this purpose, olive wires,
firmly securing the segment to a movable ring are called kinked wires, or twisted wires can be used. The technique

involves the following: One or two wires are driven outlined later can be put into effect. In some cases it may
obliquely through bone, exiting the soft tissues on the be sufficient to introduce a curette into a false synovial
limb’s opposite side. The tips of the wires are curved with cavity through a stab incision to débride the bone ends.
pliers; by grasping the proximal end of the wire with pliers Ilizarov claims that compression of a synovial pseudar-
and striking the pliers with a hammer, the surgeon can throsis for 2 weeks—enough time to cause necrosis of
back out the wire until the tip is under the skin. fibrocartilage and an inflammatory reaction—may be
Once the tip is within the soft tissues, the wire is slowly sufficient to stimulate healing.
wiggled and advanced (with pliers and a hammer) until If the radiographs demonstrate a pencilin-cup appear-
the tip moves up the limb. Usually the wire point emerges ance of the pseudarthrosis, in which only one side of the
somewhere in the region of the skeletal defect. Thereafter, nonunion is showing proliferative changes while the other
the surgeon may have to bend the wire in another fragment appears to have the same contour that was
direction, withdrawing the wire below the skin line, and present immediately after the injury, the side of the
advance the wire through the skin farther along the limb. nonunion demonstrating no progress toward healing may
The process of tip protrusion, wire bending, retraction, be nonviable. In some cases a bone scan will clarify the
and advancement may have to be repeated to achieve the issue, demonstrating lack of circulation in osseous tissue of
optimal final wire position. It may be helpful to rotate questionable viability. If bone scans are to be used in this
the wire 180° so that the curve points away from the limb. manner, it is important to obtain a three-phase study, with
The wire’s curved end readily passes through the skin an initial scan taken shortly after injection of the
without the point’s scratching intact skin near the exit hole. radionuclide so that the nonviable bone end can be more
As a trick to help determine the direction of the wire’s readily distinguished from any surrounding periosteal
curve, one can bend the proximal end to a right angle, tissue reaction. If substantial doubt remains about the
pointing in the same direction as the tip’s curve. viability of the osseous tissue in question, the surgeon
In most instances the longitudinal directional wires should explore the wound. Likewise, if there is persistent
used for compression-distraction osteosynthesis emerge or recurrent drainage from the site of the nonunion,
through the skin adjacent to the target segment. The wires débridement of nonviable and marginally viable osseous
are then secured with nuts into the groove of threaded rods tissue is necessary, in accordance with the principle
for progressive traction (after the usual latency interval). described earlier in this chapter. Thereafter, the skeletal
Unfortunately, longitudinal directional wires end up at defect must be closed by the technique of bone transport.
a rather oblique angle to the bone’s mechanical axis as the In the absence of nonviable tissue, several strategies can be
transport process nears completion. For this reason, the applied to nonunions. These are discussed in the sections
directional wires may become progressively less effective in that follow.
achieving the final stages of interfragmentary compression.
When this occurs, the patient must return to the operating
room for removal of the directional wires and application Transverse Nonunion without Shortening
of an additional ring and transverse wires as the defect
closes. Hypertrophic nonunions without shortening and in good
Problems with treating nonunions and pseudarthroses axial alignment have long been treated with external
seem to arise more frequently at the site of original skeletal fixation, as well as a variety of other methods. In
pathology than at the region of elongation. Atrophic many cases a percutaneous or open fibular osteotomy or a
nonunions do not magically unite because a transfixion slice fibular ostectomy may be necessary to promote
wire external fixator has been applied to a limb. For this union. In these situations, the strategy of axial compres-
reason, Ilizarov’s group in Kurgan has developed numerous sion usually ensures union, especially if the nonunion is
strategies to encourage bone healing at a site of a likely hypertrophic (Fig. 21–31).
delayed union, whether due to limited bone contact, A two-ring, three-ring, or four-ring configuration can be
atrophic bone ends, or related difficulties.19, 20, 27 applied, depending on the intrinsic stiffness of the fracture
configuration. (The more stable the nonunion, the fewer
the rings.) If the limb shortening is less than 1.5 cm, no
MANAGEMENT OF NONUNIONS lengthening will be necessary.
Although individual nonunion patterns require treatment Transverse Nonunion with Shortening
strategies tailored to the patient, certain general therapeu-
tic strategies can be applied to common nonunion In some situations a transverse nonunion with a
configurations. As a rule, the principles described later satisfactory mechanical alignment of the bone may be
apply to cases in which both bone ends are viable—that is, accompanied by shortening because of traumatic bone
both sides of the nonunion demonstrate proliferative loss or a healed fracture elsewhere in the bone. In these
changes on roentgenographic evaluation. If the nonunion situations the surgeon might be inclined to compress the
has characteristics of a true synovial pseudarthrosis (i.e., nonunion while performing a lengthening corticotomy
formation of a false joint cavity lined with synovium and elsewhere on the limb. Such a treatment plan is not
filled with synovial fluid), then the cavity must be entered necessary; instead, the principle of monolocal consecutive
surgically and the fibrocartilaginous ends of the bone compression-distraction osteosynthesis can be applied. By
scraped down to osseous tissue before the treatment plans this technique, a nonunion site is first compressed for 2

A B
A B
FIGURE 21–31. A, A transverse nonunion of the tibia without shortening
or angulation. B, Compression of a transverse nonunion of the tibia with FIGURE 21–33. A, An oblique hypertrophic nonunion of the diaphysis
a stable four-ring configuration. without shortening or angulation. B, Treatment with olive wires that
provide interfragmentary compression while the fixator acts as a
compressor.
weeks and then gradually distracted (Fig. 21–32). The

compression stimulates neoosteogenesis, and the distrac-
longitudinal compression causes the bone fragments to
tion stimulates the formation of regenerate bone in the
slide past each other, leading to limb shortening. When
elongating gap. The standard frequency of distraction
there is an oblique nonunion line, it is necessary to achieve
(0.25 mm every 6 to 12 hours) is used. Bone will fill the
side-to-side (transverse) compression combined with com-
distraction gap. If necessary, the hypertrophic nonunion
pression in the bone’s mechanical axis (Figs. 21–33 and
may have to be realigned gradually so that the mechanical
21–34). Such side-to-side compression can be achieved in
axes of both the proximal and the distal fragments are
a number of ways:
collinear.
1. Olive wires traversing the fracture site from opposite
directions, applying interfragmentary compression by
Oblique Nonunion without Shortening way of the apparatus.
2. Rings applied close to the fracture site, achieving
In situations in which the fracture line is oblique rather transverse compression toward and away from longitu-
than perpendicular to the bone’s mechanical axis, simple dinal plates in the configuration.
FIGURE 21–32. A, A transverse hyper-

trophic nonunion of the tibial shaft
and the concomitant shortening else-
where in the bone (arrow). B, Man- Print Graphic
agement was by compression of the
hypertrophic nonunion for 2 weeks,
followed by distraction to overcome
shortening. C, Distraction of a hyper-
trophic nonunion results in new bone
formation if the osteogenic process Presentation
has been stimulated.
A B C

3. ‘‘Arched wires,’’ a technique frequently used for fracture neously restore the bone’s mechanical axis and achieve
reduction whereby transfixion wires are passed through side-to-side compression (Fig. 21–35). To achieve this
a bone segment and slightly curved in the direction the goal, it is necessary to construct the frame with the rings
surgeon wishes to translate the bone segments. The closest to the nonunion site sliding along the apparatus
wires are then tightened to straighten them, thereby during distraction, while at the same time applying
moving the bone segment toward the concavity of the transverse traction to the bone ends. To accomplish this,
curve of the wires. Side-to-side interfragmentary com- the sliding mechanism that connects the innermost rings
pression must be combined with axial compression in to the apparatus can be made with either a buckle (which
the bone’s mechanical axis. slides along the plate) (Fig. 21–36) or, alternatively, a
bushing that has a nut on either side of it; the bushing will
slide along any threaded rod (Fig. 21–37). Because the
Oblique Nonunion with Shortening bushing has a tapped hole in its side, it can be used to
connect a ring to the rod while allowing a translation
This common pattern of nonunion can occur anywhere movement in the ring.
along the length of the bone. Although the surgeon’s Once the distraction has been completed, final adjust-
inclination might be to attempt side-to-side compression ment in the ring position should be made to allow
with the bone as it lies, a far more acceptable strategy is to restoration of the bone’s mechanical axis. Finally, axial
distract the limb to overcome shortening, while at the compression combined with side-to-side compression
same time using the rings of the apparatus to simulta- should achieve union.
FIGURE 21–34. A, A 45-year-old woman

with an oblique nonunion of the distal
tibia. There had been a previously
attempted plating followed by serious
infection, with a skin slough. The
Print Graphic wound is now closed as a result of skin
grafting. B, A lateral projection radio-
graph of the reduction with counter-
pulling olive wires. C, The apparatus
seen from the frontal plane. The coun-
terpulling olive wires are attached to the
Presentation three-hole post, projecting downward
from the middle ring. D, The final result
shows consolidation.

FIGURE 21–35. A, Oblique nonunion

with shortening. B, Straight longitu-
dinal distraction will increase the Print Graphic
gap. C, If the distraction is combined
with simultaneous transverse com-
pression, the fracture site will be
reduced. Transverse and axial com-
pression are continued until union.
Presentation
A B C
Angulated Nonunion without Shortening tion’’ can be used, using a plate on the deformity’s convex
side stabilized to the proximal and distal rings with twisted
When a nonunion is angulated, the surgeon should restore plates and effecting a pushing action on the rings adjacent
the bone’s mechanical alignment as nearly perfectly as to the site of nonunion. With either configuration, it is
possible before compression. The technique employed necessary to calculate the rate of correction at the point
follows the principles of deformity correction. A hinge (or
pair of hinges) is placed in the fixator configuration with
the axis of the hinge located over the apex of the deformity
(Fig. 21–38). (In most cases two hinges are used, with the
axis of the hinges forming an imaginary line that passes
through the deformity’s apex.) Frequently the apex of the
deformity is somewhat difficult to ascertain. Standard
radiographs in the anteroposterior and lateral projections
often demonstrate a deformity in two planes—for exam-
ple, with the apex posterior on the lateral projection and
lateral on the anteroposterior projection. A thoughtful
analysis of such a deformity, however, reveals that the
deformity, or any deformity for that matter, can exist in
only one plane, with the apex posterolateral. To best
determine the plane of the deformity, it may be necessary
to obtain radiographs of the limb at several oblique Print Graphic
projections, with the projection demonstrating the maxi-
mal angular deformity being the one that most truly
represents the deformity’s plane; moreover, the plane of the
deformity is perpendicular to the radiographic projection
Presentation
that shows the bone to be straight. Obviously, rotation,
translation, or other axial deviations can be included with
an angular deformity, but the angular deformity itself can
exist in only one plane.
When there is good bone contact and hypertrophic
changes on both sides of the nonunion line, the fixator is
applied with a pair of rings on the proximal fragment and
a pair of rings on the distal fragment; each fragment’s rings
are perpendicular to that fragment’s mechanical axis.
Hinges are placed between the proximal and the distal ring
clusters, and the nonunion site is compressed for 2 weeks,
thereby increasing the deformity slightly. After the prelim-
inary compression, the deformity is gradually corrected,
FIGURE 21–36. The apparatus used for simultaneous elongation and
utilizing a threaded distractor on the concave side. Usually, side-to-side compression when treating an oblique hypertrophic non-
twisted plate and post assemblies are used to accomplish union with shortening. The 17-hole plates allow sliding of buckle
the distraction. If the nonunion is stiff, a ‘‘push configura- assemblies that push or pull the middle two rings.

Print Graphic
Presentation
FIGURE 21–37. A, Another configuration to provide simultaneous elongation and transverse compression. In this case, bushings slide along threaded
rods during lengthening and simultaneously provide a fixation point for transverse compression of the third and fourth rings in the configuration.
B, Pretreatment and post-treatment radiographs of the same patient (a hypertrophic nonunion of the distal tibia 8 months after an open fracture).
of either distraction or push to correspond to an Angulated Nonunion with Shortening

opening of the base of the deformity at a rate of
1.0 mm/day in divided segments. When the deformity is In many nonunions, shortening without translation may
fully corrected, the nonunion site will have a wedge accompany the angulation. In this situation the deformity
configuration with triangular regenerate bone filling the can be corrected while limb length is simultaneously
gap (see Fig. 21–38B). restored by using a distraction wedge technique. The
FIGURE 21–38. A, Angulated non-

union without shortening. B, The
treatment of an angulated hypertro-
Print Graphic phic nonunion without shortening
involves the placement of a hinge
(black dot) at the apex of the defor-
mity. The rings of the apparatus are
applied perpendicular to the me-
chanical axis of their associated seg-
Presentation ments. Gradual distraction (after ini-
tial compression) should result in a
triangle of regenerated bone in the
widening gap.
A B

regenerate bone within the distraction gap will become Nonunion with Rotational Malalignment
trapezoidal, with its length corresponding to the amount
of limb elongation (Figs. 21–39 and 21–40). To achieve If there is a rotational deformity combined with angula-
this goal, the apex of the hinges for deformity correction is tion, displacement, or shortening, the rotation should be
placed at a distance away from the bone, which can be corrected last. A gradual twist distributed over the entire
determined by making acetate cutouts and rotating the length of the regenerate is more satisfactory than rotation
fragments around a thumbtack hinge. through the corticotomy site that tears at the healing tissue
(Fig. 21–43). Another important point: Whenever a
rotational correction must be made, it is easier to correct
Angulation Nonunion with Translation the rotary deformity once the mechanical axis of the bone
without Shortening has been restored to normal, as the surgeon will be dealing
with a problem in only one plane. When correcting a
Many angulated nonunions display some element of rotational malalignment, be sure that the bone segments in
translation; if the angular deformity is corrected, the axes question are in the center of the configuration rather than
of the proximal and distal fragments will not be collinear. in the more customary eccentric location. If this step is not
Such a residual displacement can often be corrected in a taken, the bone fragments will rotate around an imaginary
single maneuver based on Ilizarov’s concept of a transla- axis in the center of the configuration, thereby becoming
tional hinge. The apex of the hinge must be located at the displaced with respect to each other when the rotation is
intersection point of two lines that follow the edge of the completed. This principle must be considered whenever a
bone fragments on the deformity’s convex side. A simpler fixator is initially applied to correct the deformity.
method is to make cutouts of the fracture, placing each Obviously, a derotation assembly should be included in
cutout on a separate sheet of clear acetate or x-ray film, the configuration.
and to perform the rotation through a thumbtack hinge. It
is usually necessary to correct the angulation before
correcting the displacement (Fig. 21–41). Segmental Defects
SEGMENTAL DEFECTS WITHOUT
Angulated Nonunion with Translation SHORTENING
and Shortening When a segmental defect is present, angulation, transla-
tion, and rotation can be easily corrected at the time the
When there is angulation, translation, and shortening, fixator is in place, as the soft tissues in the defect will be
alignment of the bone fragments can be restored utilizing sufficiently pliable to allow restoration of the bone’s
a translational hinge, but the apex of the hinge must be mechanical axis.13 Thus, the frame configuration for
displaced from the convex edge of the deformity by a segmental defect management is actually quite a bit
distance that corresponds to the amount of shortening simpler than one applied to correct a deformity, because all
present. One can use Ilizarov’s formula or cutouts for this the rings can be in a straight line. If, after the fixator is
correction. The shortening must be corrected before the applied, an axial displacement, angulation, or rotation is
translation, lest one bone fragment block repositioning of noted, the correction should be done on the operating
the other (Fig. 21–42). table while the patient is still anesthetized. Because the
FIGURE 21–39. A, Angulated hypertro-

phic nonunion with shortening. B,
Correction of the problem with a hinge
(black dot) in the configuration located Print Graphic
at some distance from the apex of the
deformity. The rings of the apparatus
are applied perpendicular to the me-
chanical axis of their associated seg-
ments. Gradual distraction leads to the
formation of a trapezoidal regeneration Presentation
that simultaneously achieves deformity
correction and lengthening.
A B

Print Graphic
Presentation
FIGURE 21–40. A, A clinical photograph of a patient with a failed ankle arthrodesis. B, Radiographic appearance of the patient. Note the valgus angulation
of the failed tibiotalar arthrodesis site. C, The apparatus used for correction of the deformity. The distal rings are perpendicular to the hindfoot axis, and
the proximal rings are perpendicular to the tibial axis. A lateral distraction assembly is effecting a slow correction. D, A gradual realignment of the talus
under the tibia has occurred. E, A clinical photograph of the patient 1 month after removal of the fixator.
strategy for defect treatment usually involves corticotomy fragment makes circumferential contact with the endosteal
and bone transport, the intercalary transported segment surface of the receptacle fragment. As it turns out,
must be in perfect alignment with the target fragment however, this process of invagination is at odds with the
before the corticotomy is performed or the fragments will principle of collinearity between the fragments, because a
not be aligned at the completion of bone transport. point carved in the cortex of the intercalary fragment
When planning the solution to the problem of a would probably become displaced as it penetrated into the
segmental defect, the final contact point between the target fragment. Nevertheless, it is surprising how often
intercalary and the target fragments must be considered jagged fragment ends are left after a post-traumatic skeletal
before the two bone ends meet. The most stable configu- deficiency, whether because of an absolute loss of bone
ration occurs when one fragment invaginates into the other at the time of initial injury or as a consequence of
until firm contact between the exterior surface of the inner débridement.

When the skeletal defect follows a segmental resection is appealing, I have found that immediate compression of
of infected osseous tissue, it is advisable to square off the a segmental defect larger than 2.5 cm distorts the
bone ends to create a transverse point of contact (Fig. surrounding soft tissues, making wound closure difficult
21–44). Bear in mind, however, that there is a significant and leading to edema distal to the area of compression,
incidence of long delays in bone healing when two possibly because of distortion and kinking of lymphatic
seemingly parallel bone surfaces come together. For one vessels. For this reason, it is wiser to leave a segmental
thing, the bone ‘‘carpentry work’’ is seldom perfect, so defect and the surrounding soft tissues at full length and
contact is usually made at a high point on one or the other close the defect by the technique of bone transport.
of the cut bone surfaces. Also, it is likely that cutting the When extensive segmental débridement of nonviable
bone with an oscillating saw may damage viable bone bone is required, one end of the residual osseous tissue can
several cell layers into the tissue. For this reason, it is safer be fashioned into a point while the other side is made
to use an osteotome (or chisel), followed by careful rasping trough shaped. After transport of an intercalary bone
of the cut surfaces and then by roughing up the smooth segment, the point is impaled into the trough, ensuring
surface of the cut bone ends with a curette or rongeur after good bone contact and stability (Figs. 21–45 and 21–46).
squaring off bone fragments. In any event, if there is
delayed union at the point of contact between the
intercalary and the target segments, a small cancellous PARTIAL SEGMENTAL DEFECT WITHOUT
bone graft can be packed around the region to promote SHORTENING
healing. A method of dealing with a partial segmental defect (i.e.,
In some situations a surgeon might be tempted to resect when one cortex is long enough to achieve contact, but
abnormal bone, immediately compress the site of pathol- there is substantial deficiency of the remaining cortical
ogy, and compensate for the resultant shortening by limb bone) is to use the method of splinter fragment transport.
elongation through healthy tissues. Although this proposal With this technique, a lengthwise split is created in the
FIGURE 21–41. A, Nonunion associ-

ated with angulation and translation.
B, In some cases, the deformity can
be corrected with a distractional
hinge (black dot). The center of rota-
tion is placed along a line at the
intersection of the cortices, along the A B
convex side of the deformity. Gradual Print Graphic
correction results in simultaneous
correction of the deformity and elim-
ination of the translation. C, An
alternative strategy for dealing with
angulated displaced nonunions. Se-
quential elimination of, first, the Presentation
angulation and, second, the transla-
tion results in elimination of the
deformity.

Print Graphic A B
Presentation
C D
FIGURE 21–42. A, A nonunion associated with angulation, translation, and shortening. B, In some cases, a translation hinge (black dot) placed with its axis
at a distance from the point of intersection of the convex edge of the fracture fragments results in correction of angulation, shortening, and translation.
C, An alternative strategy is sequential correction of the deformity, with angulation corrected first, followed by correction of shortening, and, as the last
step, correction of translation (D).
Print Graphic
Presentation
A B
FIGURE 21–43. A, Nonunions that combine rotation, angulation, and displacement, with and without shortening. B, In both cases, rotation is corrected
last; moreover, the axes of the bone fragments must be collinear and in the center of the configuration before malrotation is corrected, lest gradual
counterrotation of the fragments result in axial displacement of one with respect to the other.

A B
Print Graphic
Presentation
C
FIGURE 21–44. A, A partial skeletal defect can be converted to a complete transverse skeletal defect for reconstruction by the bone transport method.
B, With a complete transverse defect, a corticotomy through healthy bone is followed by gradual transport of the intercalary segment toward the target
segment. New bone forms in the distraction gap. C, Crossed directional wires can be used in place of a transport ring to move an intercalary bone segment
through a limb.
cortex involving approximately half of the cortical circum- is lengthened through the corticotomy site, moving the
ference. The split fragment is then drawn longitudinally intercalary and target fragments together as a unit away
across the defect, after an appropriate delay, until it makes from the corticotomy gap (Figs. 21–48 and 21–49).
contact with the target bone on the other side of the gap In situations requiring lengthening in limb segments
(Fig. 21–47). with paired bones, both bones will be short (Fig. 21–50A).
In the lower leg, after completing the bone transport to
eliminate a tibial defect, it will be necessary to osteotomize
SEGMENTAL DEFECT WITH SHORTENING
the fibula to restore limb length. If the surgeon performs
When a segmental defect is accompanied by shortening, the bone transport before limb elongation, an osteotomy
the problem can be overcome by performing a bone of the shortened fibula will have already healed before
transport procedure identical to the one described in the elongation commences (see Fig. 21–50B), necessitating a
preceding section. However, after contact and compression return trip to the operating room for a repeat fibular
between the intercalary and the target fragments, the limb osteotomy. A wiser strategy is to lengthen the limb,

Print Graphic
Presentation
FIGURE 21–45. A, Pretreatment and post-treatment radiographs of a 5-cm skeletal defect. There is also a cavitary osteomyelitis around the lower pin
in the upper segment (on the left). The radiograph on the right shows the tibia after the fixator has been removed. B, A corticotomy performed through
the area of cavitary osteomyelitis (which was not draining at the time). C, Appearance at the beginning of distraction. D, Appearance at approximately
1.5 cm of bone transport. Note the new bone forming in the corticotomy gap. E, Appearance at 3.0 cm of bone transport. F, Appearance at the
completion of bone transport. Note the elimination of the cavity. G, Further maturation of the bone in the distraction gap at the end of treatment.
H, Appearance of the patient at the completion of treatment.

Print Graphic
Presentation
A B
FIGURE 21–46. A, With a substantial skeletal defect, it is possible to create two corticotomies in bone, transporting the first intercalary segment at a rate
of 2.0 mm/day and the second at a rate of 1.0 mm/day. Each corticotomy gap widens at a rate of 1.0 mm/day with this strategy. B, Another strategy for
dealing with a large skeletal defect. Proximal and distal corticotomies are performed, and the two intercalary segments are moved toward each other.
The defect closes at the rate of 2.0 mm/day, but each corticotomy site opens at the rate of only 1.0 mm/day.
through a tibial corticotomy and fibular osteotomy, Septic Nonunions

before bone transport to prevent premature union of the
fibular osteotomy. Thereafter, the bone transport of the External skeletal fixation has long been a weapon in the
tibia should be continued until the gap is closed (see Fig. surgical assault on septic nonunions. The fixator, by virtue
21–50C). of its rigidity, permits control of limb length and
Obviously, when paired bones are lengthened, both alignment without the need for hardware traversing the
ends of both bones must be secured to the frame, or one site of sepsis. A stable biomechanical environment pro-
or the other end will subluxate or dislocate from its motes both osseous healing and immune function simul-
anatomic position. taneously.
Print Graphic
Presentation
FIGURE 21–47. A method of eliminating a partial skeletal defect using

‘‘slivers.’’ A cortical fragment (curved arrow) is separated from one bone
segment and is gradually drawn across the wound (straight arrows). FIGURE 21–48. A segmental defect accompanied by shortening.

Print Graphic
Presentation
FIGURE 21–49. A, Roentgenogram of the leg of a 21-year-old man with a 7.5-cm tibial defect and 2.5-cm of limb
shortening (note fibular overlap), resulting in a true tibial defect of 10 cm. B, Roentgenographic appearance during
bone transport. Note the corticotomy site (C) and the transported intercalary segment. The shortening has not yet been
overcome (note fibular overlap). C, Appearance at the completion of bone transport and restoration of limb length.
Note that the fibular overlap has been eliminated. New bone is forming in the distraction gap. D, Appearance toward
the end of fixation. A small cancellous bone graft has been placed between the distal tibia and the distal fibula because
of the atrophy of the bone ends in this region. E, Final radiographic appearance. Note the 10 cm of regenerated bone
in the proximal tibia and the small bone graft in the distal interosseous space. F, The clinical appearance of the skin
during bone transport. The wires cut through the skin, with necrosis ahead of the wire and healing behind.

DÉBRIDEMENT principle, an external fixator should not be removed from

a patient with an infected nonunion until the fracture is
Débridement of nonviable tissues remains the hallmark of united.24
osteomyelitis surgery. An equally important principle, and In another common pattern of post-traumatic sepsis,
one that is often overlooked, is the need for elimination of there may be nonviable bone within and surrounded by
residual cavities (actually, hard wall abscesses) within living osseous tissues. Such a sequestra incontinuity is
infected bone. fairly common in patients with septic nonunions treated at
In certain septic nonunions, infection may persist in the the Problem Fracture Service at Rancho Los Amigos
absence of nonviable bone. In these cases false movement Medical Center. For this reason, I explore every septic
at the septic focus leads to persistent drainage. An nonunion with wound drainage, often to find a sequestra
infection in which drainage is motion related rather than in continuity requiring débridement, even if radiographs
necrosis related is often called a fistulous pseudarthrosis to fail to demonstrate areas of nonviable bone. Sequestra in
distinguish it from post-traumatic osteomyelitis, in which continuity is the most difficult to diagnose with standard
nonviable bone, usually in the form of sequestered radiographic, tomographic, scintigraphic, and other non-
fragments, is present. If osseous healing in such motion- invasive studies. At times, the lack of callus from one or
associated infections leads to bone union, the sepsis is another side of a fracture site—especially where an
usually eradicated. If, however, immobilization of the experienced eye would ordinarily expect to see callus—
focus of infection is only temporary—the result of stable may be a tipoff to the presence of sequestra in continuity.
external fixation—and not accompanied by osseous union, Equally often, however, radiographs do not provide this
drainage may reappear shortly after the fixator is removed type of information. Unfortunately, wound exploration
and false motion starts again. Therefore, as a general may potentially devitalize additional bone as the perios-
FIGURE 21–50. A, A skeletal defect

with shortening accompanied by
union of the fibula. B, Simultaneous
corticotomy of the tibia and fibula,
followed by bone transport to close
the tibial defect, results in premature
union of the fibula before length is
restored, necessitating a second fibu- A B
lar corticotomy. C, A more appropri- Print Graphic
ate strategy is to perform simulta-
neous corticotomies of the tibia and
fibula but lengthen the limb before
transporting the intercalary segment.
In this manner, fibular shortening
will be overcome during the initial Presentation
portion of tibial corticotomy gap
distraction. Completion of the bone
transport eliminates the residual tib-
ial defect.

teum is elevated during the course of exposure. For this applied. The defect is closed by bone transport, incorpo-
reason, the surgeon should carefully limit subperiosteal rating the principles outlined previously in the sections
dissection, choosing instead the extraperiosteal route to dealing with bone transport with and without shortening.
the bone in question.
An infected nonunion draining to the surface points to
PROBLEMS WITH THE REGENERATE BONE
a septic focus through an open sinus. Enlarging the sinus
opening usually leads to an obvious sequestrum. During Ilizarov’s method includes the creation of ‘‘regenerate’’ new
débridement, I do not excise the sinus tract, because its bone during elongation of the osteotomized segments.
epithelialized granulation tissue is a natural response to the Dealing with the regenerate bone is a new experience for
infection rather than a source of sepsis. Likewise, healthy most orthopaedic surgeons. The regenerate bone in a
granulation tissue, noted for its beefy red color and distraction gap can ossify too rapidly, limiting distraction,
friability, should be left in place. Grayish-brown granula- or more commonly, it may mature too slowly, prolonging
tion, on the other hand, probably represents reactive tissue the period of fixator application.
overwhelmed by microorganisms and calls for débride- Ordinarily the distraction gap shows small hazy patches
ment. of calcification, often within the first 2 weeks after cortical
Densely collagenized fibrous tissue surrounding bone osteotomy of a long bone. One should not be concerned if
fragments probably has little potential for new bone no calcification appears within the gap, which is slightly
formation once the limb has been stabilized; indeed, such less than 1.0 cm wide by the end of the second
avascular tissue may inhibit host defenses. For this reason, postoperative week (5 days predistraction fixation, fol-
I resect dense avascular or hypovascular collagenized lowed by 9 days of distraction at a rate of 1.0 mm/day).
fibrous tissue. It is often difficult to determine where this Distraction should continue at a slightly slower rate for
reactive tissue ends and normal periosteum, nerves, 2 more weeks. By the fourth week after surgery, some
tendons, or fascia begin. As an aid to the resection, calcification should be visible within the distraction gap. If
consider the following: First, the dense fibrous tissue not, one should reverse the distraction and begin com-
represents the end-stage of biologic material that started as pressing the gap over 2 to 3 days. Then, after a brief rest
granulation tissue. Thus, the pathologic process leading to of 3 or 4 days, distraction should be commenced once
avascular fibrous tissue formation must be at least several again. Usually bone will form during the second distrac-
months old. Second, the dense fibrous tissue requiring tion interval.
débridement is usually located within the original perios- At any point during elongation, when the quality of
teal sleeve. Hence, it is often necessary to define the neoosteogenesis within the distraction gap causes concern,
location and extent of the preinjury periosteal envelope the distraction can be stopped or reversed briefly in what
before débridement. With this objective in mind, one can has been called an accordion procedure. Ideally, the
find the periosteum where it is adherent to normal bone regenerate bone should appear on radiographs as longitu-
(i.e., beyond the extent of distorted anatomy) and trace dinal striations attached to both cortical fragments with a
this periosteum toward the center of the infected region. A clear ‘‘growth zone’’ in the center.
large curette aids in the separation of periosteum from Once elongation or correction has been completed, the
proliferative tissues lining its inner surface. fixator is left in place for at least as long as the time spent
Once bone and soft tissue débridement is complete, the during elongation or deformity correction. This period of
surgeon may be left with a sizable segmental defect ‘‘neutral fixation’’ after correction often taxes the pa-
requiring osseous and soft tissue reconstruction. Since the tient’s—and the surgeon’s—tolerance. Ilizarov recom-
mid-1980s, numerous strategies have evolved to deal with mends ‘‘training the regenerate’’ by compressing the frame
such post-traumatic tissue deficiencies. These have always slightly (0.25 mm twice a week) toward the end of the
included one or another method of bone grafting to neutral fixation period. This maneuver is used both for the
compensate for the loss of osseous tissue. Likewise, skin regenerate bone in a distraction gap and for any areas of
defects are usually eliminated by a cutaneous graft, tardy bone healing at a fracture or nonunion site.
transposition or musculocutaneous free flaps, or gradual The fixator can be removed if the site of nonunion is
closure by secondary intention. Osseous defects longer united and the regenerate is mature and demonstrates the
than 10 cm seem beyond the limit of cancellous bone following:
grafting; for this reason, microvascular free osseous
1. No defects or ‘‘shark bites’’ along the regenerate bone’s
transfers have gained popularity. For some bones, espe-
edge on three sides of the distraction zone
cially the weight-bearing tubular bones of the lower limb,
2. Complete ossification of the radiolucent central growth
the transplanted osseous tissue (usually the fibula or iliac
zone of the regenerate bone
crest) may fail to incorporate or may refracture when
3. Uniform radiographic density of the regenerate bone
subjected to unprotected weight bearing.7
(in both projections) that appears, to the surgeon’s eye,
The techniques already described for reconstructive
to be halfway between the density of the adjacent
surgery of uninfected nonunions developed by Ilizarov are
normal bone’s cortex and that of its marrow canal
ideally suited for eliminating skeletal defects after débride-
ment of infected or nonviable osseous tissues, without the Before removal of either a pin or a wire fixator, one
need for bone grafting or free microvascular transfers.14, 32 should loosen the frame 1 to 2 mm every 1 to 2 days,
After débridement, the mechanical axes of the bone reversing distraction, and allow it to ‘‘float’’ on the limb to
fragments are aligned collinearly, and a corticotomy is test osseous stability. When a transfixion wire fixator has
performed through healthy tissue after the frame is been used for limb elongation, the wires are usually bent

toward the center of the limb segment. If the threaded element of the frame to impede movement of the limb
connecting rods are loosened, the rings above and below segments. If adjustments are necessary, the fixator should
the distraction region may not be secure enough for be stabilized with a temporary strut before any important
patient comfort. Also, if the frame must be restabilized structural elements of the frame are moved.
because the limb is not ready for fixator removal, the wires Pin or wire tips can catch on clothing and bedding,
will be loose. For these reasons, it is often necessary to even when they are properly covered or curled into the
reapply tension to the wires if ring positions are altered at frame. To avoid this, one can cover the external fixator
the end of the neutral fixation period. with a double-thickness stockinette.
The expanded indications for external fixation currently
coming from Russia will present remarkable therapeutic
opportunities and an entirely new constellation of difficul-
COMPLICATIONS ties as surgeons attempt reconstructions to a degree never
before thought possible. With time, surgeons in Western
Researchers at Ilizarov’s institute summarized the compli- nations will learn of the best use for circular wire external
cations associated with 3669 fixator applications during fixators in restorative traumatology.
the period from 1970 to 1975.6 Analyzing wire tract
infections, they found an 8.3% rate of purulent soft tissue
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to bacterial invasion: the intact skin. 280:23–30, 1992.
An important principle designed to prevent pin or wire 2. Caja, V.L.; Moroni, A. Hydroxyapatite coated external fixation pins:
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Ilizarov external fixator. Bull Hosp Jt Dis 52:21–26, 1992.
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two year follow up in patients treated by the Ilizarov technique. Clin Orthop 280:281–288, 1992.
Orthopedics 12:497–514, 1989. 30. Tajana, G.F.; Morandi, M.; Zembo, M.M. The structure and
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C H A P T E R

Copyright © 2003 Elsevier Science (USA). All rights reserved.

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In the first group of experiments, an open transverse

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FIGURE 21–6. Ilizarov’s experiments to

The researchers observed that the greater the preserva-

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anatomic considerations limit the surgeon’s ability to insert

INSERTING TRANSFIXION WIRES

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Copyright © 2003 Elsevier Science (USA). All rights reserved.

ration is established, it is important to put the adjacent

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FIGURE 21–15. To stabilize a wire, grasp it with a moistened 2 × 2-inch

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This inhibition of a vital cellular function probably has the

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until it passes through the skin in an improved position

Copyright © 2003 Elsevier Science (USA). All rights reserved.

Copyright © 2003 Elsevier Science (USA). All rights reserved.

FIGURE 21–22. The H mounting. A,

FIGURE 21–23. The H mounting of wrist (A), calcaneus (B), and

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FIGURE 21–24. The T mounting. FIGURE 21–26. The A mounting.

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FIGURE 21–27. A mountings in the

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FIGURE 21–28. The V mounting. FIGURE 21–29. The W mounting.

Copyright © 2003 Elsevier Science (USA). All rights reserved.

FIGURE 21–30. The W mounting

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weeks and then gradually distracted (Fig. 21–32). The

FIGURE 21–32. A, A transverse hyper-

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FIGURE 21–34. A, A 45-year-old woman

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FIGURE 21–35. A, Oblique nonunion

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of either distraction or push to correspond to an Angulated Nonunion with Shortening

FIGURE 21–38. A, Angulated non-

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FIGURE 21–39. A, Angulated hypertro-

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FIGURE 21–41. A, Nonunion associ-

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Copyright © 2003 Elsevier Science (USA). All rights reserved.

through a tibial corticotomy and fibular osteotomy, Septic Nonunions

FIGURE 21–47. A method of eliminating a partial skeletal defect using

Copyright © 2003 Elsevier Science (USA). All rights reserved.

Copyright © 2003 Elsevier Science (USA). All rights reserved.

DÉBRIDEMENT principle, an external fixator should not be removed from

FIGURE 21–50. A, A skeletal defect

Copyright © 2003 Elsevier Science (USA). All rights reserved.

Copyright © 2003 Elsevier Science (USA). All rights reserved.