Techniques in Orthopaedics®

17(1):1–4 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 1: Strategies for Reconstruction of Periarticular and

Shaft Fractures of the Tibia

James J. Hutson, Jr., M.D.

Summary: The technical strategies to treat fractures of the tibia with Ilizarov fixators
are described. An Ilizarov fixator can be applied as a neutralization device after open
or pericutaneous reduction, as an active reduction device using universal hinge
mechanisms between fixation blocks, or as an external scaffold which incorporates
distraction/compression and the placement of pins and wires to apply force through
pivot points and levers. Periarticular fracture patterns are classified into five types:
Type 1, intact metaphysis; Type 2, simple sagittal or coronal fractures; Type 3,
moderate large fragment joint fractures; Type 4, comminution of the joint; and Type
5, severe crushing with bone loss. The concept of fixation blocks and orthogonal
placement of pins and wires is introduced. Key Words: Ilizarov fixator—Tibia
plateau pilon fracture.

The reduction and treatment of tibial fractures with
Ilizarov fixators should have as its endpoint, reconstruc-
tion of the joint surface, restoration of axial alignment,
anatomic rotational alignment, and restoration of limb
length. The fixation needs to be stable to allow functional
rehabilitation of the extremity and healing of the fracture.
There are multiple strategies for reducing the fracture
using the Ilizarov system and these varied techniques can
be used based on the configuration, location, and com-
plexity of the fracture. The severity of injury to the soft
tissue envelope will also affect the reduction method
applied to the fracture.
There are three construction methods used in the
treatment of fractures. The most basic is using the Il-
izarov fixator as a neutralization frame. The external
fixator is applied to maintain axial alignment, rotation,
and control force transmission across the fracture site.
This function is similar to using a neutralization plate
across an oblique or spiral fracture that has been re-
aligned with interfragmentary screws. The external fix-
ator is applied after axial alignment has been corrected
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
by manual reduction, internal fixation, or percutaneous
fixation. The system is usually used in low energy
periarticular fractures with limited large fragments at the
joint surface, (OTA C1 and C2 fractures). The fragments
are realigned with limited screws and small fixation
plates. These fractures are often associated with shaft
extension fractures with minimal to moderate displace-
ment (low energy soft tissue injury). To avoid plating
these injuries, a neutralization frame is applied spanning
the fracture. This allows the concept of limited internal
fixation to succeed. The only requirement of the limited
internal fixation is that the fracture fragments are main-
tained in a reduced position during healing. The limited
internal fixation does not have to maintain axial align-
ment and resist the deforming forces of weight transmis-
sion across the fracture zone. This is the function of the
neutralization frame. This strategy of reconstruction can
be applied to low energy tibial plateau, pilon, and spiral
shaft fractures. The neutralization frame has similar
function to percutaneous plates and fracture bracing in
the treatment of fractures. The neutralization frames are
usually simple frames with a single ring fixation block at
the periarticular fracture zone and a one or two-ring
fixation block on the tibial shaft. The frame also may be
used distally on the lower extremity as joint spanning
frames for pilon and ankle fractures. An advantage of the
Ilizarov system is that neutralization frames can be used

1
2 J.J. HUTSON JR

to compress the fracture site because the threaded rods

are parallel. This is in contrast to Roger Anderson type
frames (Synthes, Hoffman II), and universal joint frames
(Synthes, Orthofix, Biomet, ACE, and Quick Connect)
where the axial rods or bars have no threaded sections to
allow compression or have nonparallel alignment to the
fracture.
The second strategy of reduction is using universal
hinge connections between fixation blocks for reduction
of the fractures. This method is considered the most
practical method of reduction by orthopaedists and is
used widely in fracture care. The Hoffman II, Synthes,
Biomet, Orthofix, Quick Connect, and ACE external
fixator systems use this method to reduce and align
fractures. The technique is accomplished by applying
fixation blocks to the proximal and distal segments of the
fracture. The fracture is reduced by manipulation of the
fracture followed by tightening of the universal hinge
mechanisms. Traction on the extremity and application
of the fixation blocks in orthogonal alignment facilitates
the reduction and limits the zigzag alignment of the
external fixator. These universal hinge mechanisms have FIG. 1.1. Type 1 to Type 5 fracture patterns, which will determine
the strategy of reduction of periarticular fractures.
an “all or none” control of alignment of the frame. To
correct alignment in one axis requires loosening all axis
of alignment. Precision adjustment of alignment is diffi- This, combined with the manipulation of wires and pins
cult. The length and bulk of the universal mechanism on the rings, which allow positioning through the entire
(Orthofix, Biomet, Synthes) also produce long working 360° arc of a circle, produces an effective and adaptable
lengths across the zone of injury, which reduce the system that can be used for high-energy fractures of the
stiffness of the fixator. This strategy of reduction has had tibia. The technique can be unifocal or multifocal. Seg-
wide usage and success and can be considered for mod- mental fractures can be reduced systematically, bone loss
erate to midenergy fractures of the tibia. This method of can be reconstructed, and severely comminuted periar-
fixation is also used well in pilon fractures as joint ticular fractures can be reconstructed and stabilized. The
spanning fixators with limited internal fixation of the external scaffold system is the most difficult technique to
plafond. The Ilizarov ring sections can be used with master and requires an understanding of biomechanics,
Quick Connect rods or Hoffman II fixators using a Ilizarov reduction techniques, and an ability to preoper-
transition component (Miami Post, Howmedica) between atively plan the sequence of reduction. The Ilizarov
systems. After reduction of the fracture, the universal fixator system is the only external fixation system that
hinge systems function as neutralization frames. The has the adaptability to use the external scaffold tech-
Spacial Frame (Smith Nephew) also functions as a uni- nique, which separates it from other external fixation
versal hinge mechanism. The independent linkages must systems into a unique category.
all be loosened to manipulate fixation blocks proximal The technique of reduction will vary depending on the
and distal to the fracture. A computer program is used to location of the fracture. Type C periarticular fractures
adjust the alignment of the fracture and provides more will require reduction of the joint surface, as well as axial
precise correction of alignment compared with manual alignment of tibia. Tibial shaft and Type A periarticular
manipulation of fixation blocks. fractures will have intact distal and proximal joint sur-
The third strategy of reduction is using the Ilizarov faces and axial alignment will be the focus of fixation.
fixator as an external scaffold and manipulating the Segmental fractures will combine periarticular and shaft
fracture using reduction techniques that combine distrac- fracture reduction.
tion, lengthening/compression, rotation, translation, and Periarticular fractures can be grouped into five pat-
angular correction. The system utilizes the placement of terns, which will determine the strategy of reduction
wires and pins as pivot points and axis of rotation that (Fig. 1.1).
can be manipulated by lever arms to obtain reduction. Type 1: The joint surface is intact with nondisplaced

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 1
or minimally displaced fractures extending into the joint
surface. The metaphysis will have moderate fracturing
(OTA A2, C1) or comminution (OTA A3, C2). Percuta-
neous fixation with a Steinman pin or cannulated screw
can be placed across the fracture to create a unified
block. The ensuing reduction will require axial alignment
of the shaft to the metaphysis.
Type 2: The joint surface has displaced sagittal frac-
tures with minimal rotation and depression. Rarely the
fracture plane will be in the coronal plane, a fracture
pattern associated with fracture dislocation injuries. A
unified metaphyseal block can be constructed using a
percutaneous reduction with “joy sticks’ or large pelvic
reduction clamp, or a limited open reduction may be used
to reduce the fracture. If percutaneous methods fail to
reduce the fracture, then an open reduction is mandatory.
An incarcerated meniscus or cartilage fragment will be in
the fracture gap preventing reduction. A percutaneous
screw placed across the fracture will create a unified
metaphyseal block. The ensuing reduction will require
axial alignment of the tibia.
Type 3: The joint surface has large displaced intraar-
ticular fragments with sagittal and coronal fracture
planes, depression and rotation of the fragments (OTA
C2, C3). Reduction cannot be obtained by distraction
alone. Reduction will require bridging ligamentotaxis
combined with percutaneous reduction of the fragments
or limited open reduction of the fragments. Meniscal
injuries are associated with this fracture pattern. Limited
internal fixation using small fragment screws and Stein-
man pins are used to fixate the fragments. The fixation
may create a unified metaphyseal block allowing simpler
fixation methods to be used or the fracture may be
reduced, but unstable and a bridging external fixation
technique may be required to maintain alignment.
Type 4: The joint surface has comminution, trabecular
crushing, rotation, and depression of the fragments (OTA
C3). The joint surface cannot be reduced by percutane-
ous methods. Open reduction and limited internal fixa-
tion, bone grafting, and meniscal repair combined with
bridging ligamentotaxis and circular wire external fixa-
tion are needed to reconstruct these severe fractures.
Type 5: The joint surface has severe comminution and
crushing. There may be external contamination from
open wounds. The fragment size will not accept screws.
Small Steinman pins may be used as subchondral nails to
align the joint or the fragmentation may be unreconstruc-
table. There are no fragments in which a tensioned wire
can be placed safely or will increase the stability of the
fracture. The salvage reconstruction can be a joint span-
ning fixator or excision with arthrodesis reconstruction
3
and bone transport. These fractures are considered OTA
“C3⫹” or “C4” fractures.
The strategy of tibial shaft fracture reduction and
treatment is based on the fragmentation and devitaliza-
tion of the bone and soft tissues. Low and moderate
energy fractures can be treated using universal hinge
support rods between fixation blocks or an external
scaffold strategy can be used to reduce the fracture.
Increasing fragmentation will require multiple points of
fixation to achieve alignment and stability at the fracture
site. Preoperative planning is essential for complex frac-
ture patterns extending over the length of the tibia.
Segmental fractures may require multiple fixation
blocks. Severe comminution, devitalized bone or bone
loss will necessitate the incorporation of reconstructive
techniques to treat the fracture. Acute shortening to
create stable compressible fracture surfaces of viable
bone or intercalary bone transport can be used to recon-
struct bone loss and comminution. The Ilizarov fixator
system can be constructed to combine fracture reduction
and bone transport for these complex fractures. These
strategies can also be used to treat fractures with open
wounds and soft tissue loss utilizing soft tissue recruit-
ment from shortening or bone transport.
The tibia has anatomic parameters that are used to
facilitate reduction of fractures. The joint surface of the
tibial plateau forms a slight varus angle of 3° with the
shaft of the tibia. This may vary by several degrees, but
is a reliable parameter for aligning fractures. The joint
surface on the true lateral centered view will have a
posterior slope of approximately 7°. The shaft can be
considered a straight axis, although patients with a gentle
varus curve will be encountered when reducing tibia
fractures. The lateral fluoroscopic view of the tibia can
be aligned using the posterior cortex of the shaft, which
is close to a straight line. The anterior cortex has anterior
apex curve which is less reliable to use as a guide to
alignment. The joint surface of the plafond forms a right
angle with the shaft, and the dome of the talus is centered
on the distal tibial shaft. The lateral centered view will
show a centered talar dome and the metaphysis will form
a right angle with the shaft.
Rotation of the tibia is evaluated by comparing the
tibial tubercle and crest of the anterior shaft and the
position of the foot with the second toe aligned with the
tibial tubercle. Internal rotation may create “rotation
confusion.” An examination of the opposite extremity
before draping is invaluable in choosing the correct
rotation alignment. An additional indicator is the tension
lines on the skin which will increase at a 45° angle as the
malrotation increases toward internal or external rota-
tion. This technique may not be reliable when there are
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
4 J.J. HUTSON JR
soft tissue defects from trauma. It is essential in Ilizarov
reductions of the tibia to correctly establish rotational
alignment during the early stages of the reduction. Late
in the reduction sequence, when multiple planes of fix-
ation have been placed, correction of rotation can be
accomplished, but requires partial disassembly (“back
tracking”), or complex frame modifications. One advan-
tage of universal connecting rod systems is the ability to
correct rotation late in reduction. During the initial align-
ment phase of a reduction, always make the effort to
establish correct rotational alignment. Surgical crafts-
manship demands attention to detail with each step of the
reduction.
The reduction of the tibia using Ilizarov fixators is
based on the technique of placing horizontal reference
wires parallel to the joint surface, plateau, or plafond; or
placing fixation blocks orthogonal to the shaft of the tibia
or metaphysis. The reference wires can be placed
through the plafond and plateau or the wires can be
placed parallel to the knee or ankle joint in the femoral
condyles or calcaneus when incorporating joint distrac-
tion frames into a sequence of reduction. The plafond
reference wire will almost always be parallel to the ankle
joint. The tibial plateau wire may be parallel to the joint
or angled 3° varus to have the wire aligned 90° to the
axis of the shaft. Reduction of the tibial plateau and
proximal periarticular fractures will usually be con-
structed with a parallel joint wire. Tibial shaft fractures
and proximal distraction histogenesis fixation blocks will
use a 3° varus wire 90° to the shaft axis.
By basing fixation blocks on periarticular reference
wires and orthogonal shaft ring blocks, fractures of the
tibia can be efficiently aligned and reduced. Proximal
periarticular fractures of the tibia can be aligned with a
periarticular reference wire and a midshaft orthogonal
ring block. Tibial shaft fractures can be aligned by
proximal and distal reference wire or proximal and distal
orthogonal fixation blocks. The pattern of some tibial
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
shaft fractures may be aligned with a reference wire and
an orthogonal fixation block. Distal periarticular frac-
tures will usually be aligned with a tibial shaft orthogo-
nal half pin fixation block and a plafond or calcaneal
reference wire. With appropriate choice of fixation, and
accurate alignment of the fixation blocks, distraction
between the fixation blocks will produce correction of
length, alignment of rotation, and axial alignment, which
will be close to anatomic. The fracture reduction can be
further manipulated with multiple reduction techniques
to improve alignment, increase stability, gain control of
fracture fragments, and reconstruct bone and soft tissue
loss.
The techniques to improve reduction will include
manipulation of the wire or pin on the ring blocks to
change rotation, angulation, and translation, draw wire
and pin push-pull techniques, arch wire techniques, the
placement of open and percutaneous pins and screws,
open reduction and percutaneous reduction of joint frag-
ments, supplemental bone grafting, bone transport, acute
shortening, and manipulation of ring blocks through
connecting rods. The strategy of reduction will usually
be blocks of fixation proximal and distal to the fracture
will be distracted orthogonally and the fracture will be
manipulated locally to achieve reduction. Orthogonal
distraction is essential to reduce a fracture and is the key
to reconstructing anatomic alignment.
The techniques required to reduce and treat tibial
fractures with Ilizarov fixators will be illustrated in the
ensuing chapters. The reduction of each fracture will
have a unique course. The journal is a guide to the
strategy of reduction. As a surgeon gains technical skill
and knowledge of the system, the route to reduction will
very much resemble a soccer game, each step along the
way will be determined by the previous maneuver, and
the patient will have a reconstructed leg where there was
once chaos.
Techniques in Orthopaedics®
17(1):5–11 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 2: Safe Wire and Half Pin Placement in Tibia Fractures

James J. Hutson, Jr., M.D.

Summary: The anatomy of the proximal metaphysis, shaft, and distal metaphysis of
the tibia, and how it determines the safe pin and wire pathways when fixating the tibia
using Ilizarov fixators are described. Wire placement in the foot is described for
bridging frame applications for pilon fractures. The safe wire positions adjacent to the
knee and ankle joint are described. The lateral centered view is used to safely place
wires adjacent to the joint capsule. Unsafe wire and pin positions are illustrated and
techniques to avoid poor wire placement are described. Key Words: Ilizarov
fixator—Tibia—Fractures—Safe wire.

The placement of wires and half pins is determined by
two opposing factors. Fixation of the fracture and stiff-
ness of the Ilizarov fixator is opposed by safe soft tissue
wire and pin pathways, and tension on the skin and soft
tissues during flexion and extension of the joint. The
placement of each pin or wire must be considered,
balancing bone fixation against soft tissue injury. Failure
of fixation and unstable frames will lead to nonunion or
malunion of the fracture. Reckless pin and wire place-
ment will lead to nerve and artery injuries, binding of
muscles and tendons, deep fracture infection, and septic
arthritis. These complications can be disastrous and
cause poor outcome and possibly amputation. The pos-
terior tibial artery and nerve are the critical structures in
the lower extremity. No wire or half pin should ever be
placed in a position that can injure these vital structures.
Many high-energy tibial fractures will have only one
artery traversing the zone of injury. If there are mutilat-
ing injuries to the anterior or posterior compartments of
the leg, a preoperative angiogram should be obtained to
clearly delineate the surviving arterial branch. Wire and
pin pathways must not place at risk the surviving artery.
If you damage the artery, a vascular repair will be needed
that might not be successful, leading to limb loss.
Wires placed in the joint will cause septic arthritis.
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
Cadaver and volunteer studies have clearly defined the
location of the joint capsule on the tibial plateau and
plafond.2,3,7 The capsule is within 1 cm of the anterior
and midjoint. Posterior medially and laterally, the cap-
sule has inferior extension to approximately 14 mm and
wires placed through these areas must be placed exterior
to the capsule. The true centered lateral view should be
used to determine the position of wires below the tibial
plateau6 (Appendix 1, Fig. 1.).
The joint capsule is less expansive at the ankle joint
and wires should be placed 8 mm above the plafond. The
true lateral centered view should be used to evaluate pin
placement about the ankle.
The soft tissue anatomy of the tibial plateau defines an
arc of approximately 60° centered on the medial lateral
plane of the metaphysis5 (Fig. 2.1). Anteriorly, the pa-
tella tendon is an absolute no wire zone. Wires placed
adjacent to the tendon medially or laterally may clear the
tendon, but will bind the anterior skin and capsule
causing pain with motion, retarding motion of the knee.
The wire and half pin pathways should clear the patella
tendon by approximately 2 cm. The lateral and medial
condylar surfaces of the plateau in a 60° arc are the
preferred pathways for tensioned wires. The wires are
placed as divergently as possible within the safe soft
tissue pathways. The wires should also be placed to
fixate the fracture pattern of the plateau and not placed in
a “standard pattern.”
The posterior lateral boundary is the fibular head.
Wires can be placed through the fibula to stabilize
posterior lateral comminution of the lateral plateau and

5
6 J.J HUTSON JR
FIG. 2.1. Proximal tibia 1 to 2 cm distal to knee joint. The patella
tendon anteriorly, the pes anserinus tendon group posterior medially,
and the peroneal nerve posterior laterally define the safe zone for wire
and pin placement in the proximal tibia. Fixation of tibia plateau
fractures and fixation of proximal tibia ring blocks will occur at this
level of the tibia. The distal extension of the knee joint capsule
demarcates the proximal placement of horizontal reference wires. The
safe wire zone forms an arc of approximately 60° in the medial lateral
plane.
to tether the fibula during lengthening of the tibia.
Posterior and adjacent to the fibula head is the peroneal
nerve. The peroneal nerve is at risk when placing a
fibular head wire.4 The wire should always be placed
through the expanded cancellous head and never through
the neck of the fibula. The wire is started at the midsec-
tion, avoiding the posterior half of the fibula (Fig. 2.2).
Flexing the knee during insertion will relax the peroneal
nerve and may prevent nerve injury. A smooth bayonet
wire is used to secure the fibula. Occasionally, an olive
wire is inserted if the wire will be used to drag the
posterior lateral corner of a plateau fracture into reduc-
tion. If the postoperative examination reveals peroneal
motor and sensory loss, the fibula head wire is removed.
The pes anserinus tendons (SGT) and medial head of
the gastrocnemius muscle limit the posterior medial
angulation of the wire pathway. Posterior placement of
wires medially will tether these structures causing pain
and loss of knee motion. The posterior medial border of
the tibia can be palpated with the wire point. Swelling
from the fracture usually prevents manual definition of
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 2.2. An olive wire should pass through the midportion of the
fibular head. A wire placed posterior to the head can injure the peroneal
nerve. If the olive on the wire is overshadowed by the fibular head
image (black arrow), the wire should be repositioned to the midportion
of the fibular head. The peroneal nerve crosses the fibular neck. A
tensioned wire should not be placed in the neck of the fibula.
the posterior medial corner. When placing the wire, the
point will contact bone quickly. If the wire plunges
several centimeters, the wire is posterior to the plateau
and must be withdrawn. After the olive wire is seated on
the cortex, examine its position with fluoroscopy. If the
medial cortex overshadows the olive on the wire, the
wire is around the corner posteriorly and is positioned in
a more anterior corrected position (Figs. 2.3).
The popliteal artery and posterior tibial nerve are not
at risk from transfixion wires, but from anterior-posterior
(AP) half pins placed into the proximal fixation block of
Type A tibial plateau fractures, proximal shaft fractures,
and the 5/8 to full ring fixation block used for proximal
bone transport. The artery is directly posterior to the
pathway of the half pin. The artery, vein, and nerve can
be injured by “plunging” with the drill bit. Drilling the
posterior cortex requires skill and patience. The drilling
is done at low speed revolutions and the tool controlled
so that the drill tip just clears the cortex. When using a
conical point drill, a slight give will be felt as the point
exits the posterior cortex. Relaxing the pressure on the
drill at this point will limit plunging. “A dull tool is a
FIG. 2.3. Placement of the posterior medial to anterior lateral olive
wire must avoid impaling the medial gastrocnemius muscle and pes
anserinus tendon group. The wire point should contact the cortex
without passing along the posterior cortex for several centimeters. If the
fluoroscopic view shows the olive overshadowed by the cortex (black
arrow), the wire is removed and repositioned more anteriorly.
 CHAPTER 2 7

FIG. 2.4. Proximal third tibia. (A) The anterior

tibial and posterior tibial nerve and arteries de-
fine the safe wire and pin pathways in the prox-
imal tibia. The gastrocnemius soleus muscle unit
is massive at this level and requires anterior
eccentric ring placement to avoid soft tissue
impingement. (B) The medial face of the tibia is
available for pin and wire fixation. The anterior
tibial artery parallels the posterior cortex of the
tibia. Horizontal transfixation wires must be
placed anteriorly in the shaft to avoid injury to
the anterior tibial artery and nerve. The medial
face wire parallels the medial cortex of the tibia
and traverses the medullary canal. This wire can
be placed in the proximal and mid-third tibia.
Distally it can penetrate the anterior tibial tendon
and should not be placed. (C) Half pins are
placed medial to the crest in the AP plane and in
the medial lateral plane. (D) Overdrilling or
“plunging,” can injure the anterior and posterior
neurovascular bundles as well as backside ex-
tension of the half pin. The neurovascular bun-
dles should never be placed in jeopardy by a pin
or wire.

dangerous tool,” a lesson learned in eighth grade shop.
Use sharp drill bits, discard dull bits.
The bone in the plateau metaphysis is not dense. The
posterior cortex is thicker than anteriorly. Aggressive
screwing of the half pin can drag the shank through the
anterior cortex, twisting several centimeters of the
threads into the popliteal fossa, damaging the vessels and
nerve. When placing a half pin, always consider the bone
anatomy. The plateau is 35 mm to 40mm in the AP plane
and the shaft is 20 mm to 30mm. If the pin has been
twisted in greater than these depths, examine the pin
position with the fluoro before continuing.
The tibial shaft is dense cortical bone, which provides
excellent purchase for half pins (Figs. 2.4 A,B, C, 2.5,
and 2.6A). The anterior crest and medial face of the tibia
shaft are subcutaneous and half pins are placed into the
bone without penetrating muscles. The biomechanics of
half pins are different from tensioned wires. The half
pins displace under load as a cantilever compared with
wires, which have symmetric axial deformation under
load. Using half pins has not caused decreased union
rates of fractures compared with frames with only ten-
sioned wires. The advantage of half pins over wires is
muscle penetration is not needed to stabilize the tibial
shaft and the half pins can be placed in the AP plane. The
AP plane has the greatest deforming forces when walk-
ing on a tibia, and pins placed in this plane produce
greater frame stiffness than pins in the medial plane.1
Tensioned wires cannot be placed in the AP plane be-
cause the posterior tibial nerve, artery, and muscle would
be injured. Placement of half pins in the tibial shaft has
greater risk than wire placement. The AP half pin re-
quires drilling directly toward the posterior tibial nerve
and artery. Overdrilling or twisting of the half pin be-
yond the posterior cortex can damage the nerve and
artery (Figs. 2.4 D, 2.6 B). The medial placement of half
pins carries the same risk for the anterior tibial nerve and
artery when adding a divergent plane to a fixator block
on the tibial shaft. The disadvantages to half pins are the
inherent risk of placement described above, the tendency
for the pin to break at the shaft-thread junction, the
reduced stiffness compared with tensioned wires and the
large track cut through the skin when transporting with
half pins on the transport ring block. The safe zone for
half pins is 10° to 15° off the anterior crest to 90°
medially. The half pin is always placed through the

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

8 J.J HUTSON JR
FIG. 2.5. Midshaft tibia. The posterior tibial and flexor hallucis
longus muscles form the floor of the tibial shaft and are exposed with
midshaft bone loss in high-energy tibial fractures. These muscles can
have tissue loss in trauma and the posterior tibial nerve and artery can
have little protection or be exposed directly in the zone of injury.
Careful dissection is necessary when debriding open fractures with
bone loss in the midshaft tibia. The pin and wire pathways are similar
to the proximal tibial shaft. The anterior tibial nerve and artery are still
located posteriorly along the shaft. Below this level, the anterior tibial
artery begins its ascent to cross over the ankle joint anteriorly. Trans-
fixation olive wires placed in the distal third tibia may penetrate the
artery. The posterior tibial artery and nerve are located between the
soleus and the three muscles of the posterior medial hindfoot.
intramedullary canal and is never accepted in a periph-
eral unicortical position. A half pin should not be placed
directly through the tibial crest. This places a stress riser
in the tension band of the tibia, which may cause sec-
ondary fracture. The tibial shaft from the plateau to
plafond metaphysis is available for half pin placement.
Tensioned wires are used on the tibial shaft for spe-
cific reduction techniques and fixation of smaller frag-
ments (Fig. 2.4 B). Tensioned wires placed in the medial-
lateral plane are excellent reduction tools to correct varus
and valgus angulation and compress butterfly fragments
using a drag wire technique. Anterior posterior malalign-
ment can be corrected with arch wires. Tensioned wires
are also used on small bone blocks for bone transport.
The controlling factor for placement of tensioned wires
in the tibia shaft is the location of the anterior tibial artery
and nerve. Wires are not placed in the AP plane to avoid
injury to the posterior tibial nerve. The anterior tibial
artery emerges from the popliteal fossa over the in-
terosseous membrane parallel to the posterior cortex of
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 2.6. Distal third tibia. (A) The anterior tibial artery and nerve
are crossing the midshaft tibia and can be injured with transfixation
wires. The original Hoffman fixator application technique described
multiple pins placed in this plane. At this level, nerve injury would
result in loss of deep peroneal sensation between the great and second
toe. The artery loss would be more severe and could compromise the
viability of the foot if the posterior tibial artery was damaged. The wire
pathway through the fibula and tibia paralleling the interosseous
membrane may also injure the anterior tibial artery. (B) The posterior
tibial artery and nerve are migrating posterior medially, but are vul-
nerable to injury by plunging of the drill bit or backside penetration of
the half pin. The saphenous vein parallels the medial posterior shaft and
should be avoided if possible. A medial face wire at this level would
penetrate and bind the tibialis anterior tendon.
the tibial shaft. The artery and nerve continue in a
posterior alignment as it descends to the ankle. At the
junction of the middle and distal third tibia, the artery
and nerve gradually migrate anteriorly until it crosses the
ankle in the midanterior plafond. Wires placed through
the proximal and middle third tibia should avoid poste-
rior location and tend to pass through the anterior portion
of the tibial shaft intramedullary canal. Medial face wires
provide a safe pathway for tensioned wires along the
proximal and medial shaft. The wire is placed through
the posterior medial edge of the tibia, through the canal
just under the medial face of the tibia and out the anterior
lateral cortex of the tibia (Fig. 2.4 B).
The position of the anterior tibial artery is variable and
it can be injured when placing medial-lateral tensioned
wires. The wire is placed through the soft tissue by direct
penetration and not twisted through on the drill. The
patient is not paralyzed. If a wire contacts the nerve,
contractions will be observed in the musculature indicat-
ing repositioning of the wire in a different pathway. After
drilling through the bone, the wire is hammered through
the anterior lateral muscle compartment. A wire can pass
 CHAPTER 2
FIG. 2.7. Distal tibia metaphysis. The anterior tibial artery has
migrated anteriorly. The posterior tibial neurovascular bundle is mi-
grating to a location behind the posterior tibial and flexor digitorum
communis tendons. The nerve and artery are vulnerable to injury from
a poorly placed wire behind the posterior tibia.
by the artery only to have the olive on the wire injure the
vessel when passing the wire from lateral to medial. If
the artery is damaged, a pulsatile stream of blood will
emerge from the pinhole. Remove the wire and place
pressure on the leg and the bleeding will stop in several
minutes. Check the leg for compartment syndrome at the
end of the procedure and during the postoperative period.
If the pulse in the foot is absent, the leg may have injury
to the posterior tibial artery. An arteriogram is obtained
to determine if a vessel repair is needed. The arterial
blood flow in the leg with high-energy trauma must be
known before placing a distal third medial lateral olive
wire, which can injure the anterior tibial artery. If the
patency of the arteries is not known, avoid transfixation
wires, which place the anterior tibial artery at risk.
When placing medial-lateral tensioned wires, a cross
sectional anatomy chart or book should be observed
before placing the wire. This is essential in the distal
third of the leg where the artery pathway is rapidly
changing from posterior to midanterior at the ankle joint.
By combining the safe pathways of tensioned wires and
half pins, the various fragments and bone blocks of the
tibia can be fixated without injury to the vital structures
of the lower leg.
Tensioned wires are predominantly used for fixation
9
FIG. 2.8. Distal tibia 1 cm above ankle joint. Safe wire placement is
determined by the proximal extent of the ankle joint capsule and the
nerves, arteries, and tendons traversing the ankle joint. The safe wire
arc of approximately 60° is defined by the anterior tibial tendon
anterior medially, extensor digitorum communis anteriorly lateral, the
peroneal tendons posterior laterally, and the posterior tibial tendon
posterior medially. A wire pathway is available between the peroneal
tendons and Achilles tendon posterior lateral and exiting the tibia
medial to the anterior tibial tendon. The wire may injure the sural
nerve. The wire is used to secure the posterior malleolar fragment in a
pilon fracture variant. The wire skewers the flexor hallucis longus
hindering ankle motion and is in the plane of motion. Usually it is used
for 6 to 8 weeks and then removed in the clinic to improve ankle
motion. The joint capsule extends approximately 8 mm superior to the
joint and wires should not be placed below this when fixating pilon
fractures.
of the distal metaphysis in distal tibia and pilon fractures
(Figs. 2.7, 2.8). The wire pathways are defined by the
proximal extent of the joint capsule and the nerves,
tendons, and arteries. The joint capsule extends approx-
imately 8 mm superior to the joint and the wires are
placed at or above this level. The posterior tibial tendon
and the anterior tibial tendon bracket the safe wire
pathways medially and the peroneal tendons and the
extensor digitorum tendons define the lateral pathways.
The safe wire pathways form an approximate 60° arc
on the medial and lateral sides of the ankle. The posterior
medial location of the posterior tibial nerve and artery at
the distal metaphysis is the most vulnerable position of
the neurovascular bundle when shooting tensioned wires
using Ilizarov fixators on distal tibia fractures. The pos-
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
10 J.J HUTSON JR

offset by the penetration of these less critical structures.

If there is an anterior lateral fragment that necessitates
wire fixation in the anterior lateral quadrant, then a wire
can be placed that encroaches on these tendons. This
compromise does not exist for the tibialis anterior, ex-
tensor hallucis longus, and anterior tibial neurovascular
bundle; a wire cannot pass through these structures. The
superficial peroneal nerve’s location is variable. Anterior
lateral wires can injure the nerve. A postoperative wire
FIG. 2.9. Posterior placement of an olive wire on the posterior medial
distal metaphysis will impale the posterior tibial and or flexor digito- revision may be needed if there is loss of sensation or
rum communis tendons. If the olive on the wire is overshadowed by the paresthesia. The lateral quadrant is fixated with wires
cortex (black arrow), the wire is repositioned anteriorly. Gross poste- placed through the fibula. The peroneal tendons are
rior misplacement of the wire can injure the posterior tibial artery and
nerve. located in sheathes on the posterior surface of the lateral
malleolus. A wire placed posteriorly will penetrate the
sheath and tendon (Fig. 2.10). Peroneal tendon penetra-
terior tibial nerve and artery are the critical structures in
tion will cause painful ankle motion and “weeping” of
the distal leg and must not be injured by errant wire
the wire during the course of treatment.
placement. The neurovascular bundle is located posterior
Fixation of posterior malleolar fragments when treat-
lateral to the posterior tendon tunnels (TDH) and will not
ing pilon fractures is not possible in the 60° safe pathway
be penetrated if the tensioned wires are placed anterior to
arch. These fragments can be fixated with an olive wire
the posterior tibial tendon and sheath. The posterior edge
placed posteriorly between the peroneal and Achilles
of the medial malleolus is palpated and the tendon
tendons emerging anteriorly medial to the tibialis ante-
adjacent to it. The wire is placed just anterior to the
rior tendon (Fig. 2.8). The wire is in the plane of ankle
tendon. The point of the wire should contact bone
motion and retards motion and binds the flexor hallucis
quickly when placing the posterior medial wire. If the
longus muscle. This wire is placed as a “fourth wire” on
wire traverses several centimeters of soft tissue before
the fracture ring when using a distraction footplate across
bone contact, the wire is too posterior and is relocated
anteriorly. If the olive on the wire is overshadowed by
the malleolar cortex, the wire is around the posterior
medial corner and is repositioned (Fig. 2.9). The wire is
drilled from posterior medial to anterior lateral to reduce
the chance of neurovascular bundle injury. A wire placed
in the posterior tibial tendon will retard ankle motion and
will “weep” serous fluid during the treatment course.
The anterior tibial tendon is palpated and should not
be skewered by the tensioned wire. The anterior ankle is
a no wire zone. The extensor digitorum longus has four
tendons and is spread over the anterior lateral plafond.
To increase divergence of the wire pathways, this tendon
group is often violated with wires. The gain in fixation is

FIG. 2.10. A wire placed posterior to the lateral malleolus will impale
the peroneal tendons. If the olive on the wire is overshadowed by the fibula
cortex (black arrow), it should be repositioned anteriorly.
FIG. 2.11. The hindfoot and midfoot. The posterior tibial nerve and
artery must be avoided when placing wires in the calcaneus. The
posterior tubercle is available for placement of horizontal reference
wires and an opposed divergent olive wire. The talar neck is centered
on the fluoroscopic view and the olive examined for position. The
midfoot wires should be placed to avoid the navicular cuneiform joint
and the joint between the first metatarsal and medial cuneiform. Wires
at the base of the metatarsals are directed obliquely as illustrated. A
wire passing through the first and fifth metatarsal will injure soft tissues
in the plantar foot and should be avoided.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 2
the ankle, and is removed at 6 weeks when the foot frame
is removed in the clinic to start ankle motion. An AP half
pin may be added to a distal ring fixation block if the
metaphysis is intact in distal tibia fractures. The pathway
of the drill and half pin can directly injure the posterior
tibial nerve and artery if the drill is plunged through the
posterior cortex, or the half pin over twisted into the
posterior leg.
Fixation of the foot is always by wires in the medial
lateral plane (Fig. 2.11). The posterior tibial nerve and
artery are the critical structures in the foot, and no wire
or pin should encroach on the soft tissues adjacent to the
nerve. The body of the calcaneus is used for placement of
horizontal reference wires when using distraction frames
for pilon fractures. Opposed olive wires are placed to
control translation and prevent equinus of the hind foot.
Calcaneal wires can be placed in multiple planes, the
only requirement is avoiding the posterior tibial nerve on
the medial wall as the nerve branches and continues to
the midfoot.
Wires can be placed in the talar neck to improve
fixation of the hind foot in the medial lateral plane. A
true lateral view of the ankle joint is used to locate the
pathway. After “shooting” the olive wire, the olive’s
position on the talar neck will identify the actual pathway
of the wire through the talus. It is difficult to determine
11
the position of the talar neck by palpation. Using fluo-
roscopy prevents wire placement in the ankle or talona-
vicular joint. Additional wires can be placed in the
midtarsal zone or base of the metatarsals. These wires are
rarely indicated when treating tibial fractures with Il-
izarov fixators, and are used for reconstruction of com-
plex foot deformities and malunions.
REFERENCES
1. Behrens F, Johnson W, Koch T, Kovcevic N. Bending stiffness of
unilateral and bilateral fixator frames. Clin Orthop 1983;178:103–
108.
2. De Coster TA, Crawford MK, Krant MAS. Tibial transfixation pins.
J Orthop Trauma 1999;13:236 –240.
3. DeCoster TA, Stevens MS, Robinson B. Safe Extra-capsular Place-
ment of. Proximal and Distal Tibial External Fixation Pins. Ortho-
pedic Trauma Association Annual Meeting, 1997; Louisville, Ky.
Abstract.
4. El-Shazly M, Saleh M. Displacement of the common peroneal nerve
associated with upper tibial fracture: implications of fine wire
fixation. J Orthop Trauma 2002;16:204 –207.
5. Faure C, Merloz P. Transfixation Atlas of Anatomical. Sections for
the External Fixation of Limbs. Berlin, New York: Springer Verlag;
1987.
6. Hutson J. The centered lateral flouroscopic image of the knee: the
key to safe tensioned wire placement in periarticular fractures of the
proximal tibia. J Orthop Trauma 2002;16:196 –200.
7. Reid JS, Van Slyke MA, Moutton MJ, et al. Safe placement of
proximal tibial transfixation wires with respect to capsular penetra-
tion. J Orthop Trauma 2001;15:10 –17.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
Techniques in Orthopaedics®
17(1):12–14 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia
Appendix 1: True Lateral Centered View
James J. Hutson, Jr.,
The true centered lateral view is a technique that
prevents intra-articular wire penetration of the joint. The
technique uses the same principles used in placing in-
tramedullary nail locking screws freehand.
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
12
M.D.
On the anterior-posterior view, the horizontal refer-
ence wire is placed 1 cm below the tibial plateau, or 8
mm above the tibial plafond in the midshaft plane. The
joint is aligned on the lateral fluoroscopic view so that
the condyles of the femur or the dome of the talus are
aligned with overlapping cortical images and the joint
line is centered on the fluoroscope image. The olive wire
will be observed on end and the olive on the wire will
mark the true location of the wire in relation to the tibial
plateau or plafond. This technique will prevent joint
penetration and septic arthritis (Figs. 1–5).
APPENDIX 1, FIG. 1. (A) The horizon-
tal reference wire is placed 1 cm inferior to
the tibial plateau or 8 mm superior to the
tibial plafond. The wire is placed parallel to
the joint in tibial plateau fractures and pilon
fractures. In tibial shaft fractures and prox-
imal distraction osteogenesis, the proximal
tibia wire is placed in 3° varus (see Fig. 6.3).
The distal tibia horizontal reference wire is
always placed parallel to the plafond. (B)
The horizontal reference wire is placed to
avoid penetration of the joint capsule of the
knee (dark gray area) which extends distal
to the knee joint 1 cm in the mid tibia. The
horizontal reference wire is placed 8 mm
proximal to the ankle joint to avoid penetra-
tion of the joint capsule.
 APPENDIX 1 13

APPENDIX 1, FIG. 3. The posterior capsule of the knee joint

descends inferiorly medially and laterally. (A) The horizontal reference
wire is placed one centimeter below the joint on the true lateral
centered view. To avoid penetrating the joint when placing wires (B)
and (C), place the wires on the inferior surface of the carbon fiber
fracture ring, which clears the wire pathways from the posterior
capsule.

APPENDIX 1, FIG. 2. (A) The true lateral centered view will have
the joint line centered on the fluoroscopic image and the condyles of
the femur juxtaposed or the dome of the talus in profile. (B) The wire
olive will mark the position of the wire on the cortex and its position
in relation to the joint surface. If the joint is not centered and the
condyles are not aligned, the wire position cannot be evaluated accu-
rately, and the wire may be in the joint (middle image). The true lateral
centered view of the ankle will have the ankle joint centered on the
fluoroscopic image and the dome of the talus in profile. The olive is
placed 8 mm above the joint.

APPENDIX 1, FIG. 4. When using hybrid fixator systems, the

wires are all placed superior to the ring. The posterior medial and
lateral wires must be placed at least 4 mm to 5 mm below the horizontal
reference wire to avoid the capsule of the posterior knee. (A) The
horizontal reference wire is placed using the true centered view image.
(B) The posterior capsule can be penetrated by wire (C) if it is not
placed at least 5 mm below the horizontal reference wire. (D) All of the
wires on a large ring hybrid fixator are placed between the horizontal
reference wire and the superior surface of the ring.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

14 J.J. HUTSON JR

APPENDIX 1, FIG. 5. Posterior wire clearance on hybrid fixators

with universal hinge mechanisms can be facilitated by rotating the
fixation ring around the horizontal reference wire to parallel the tibial
plateau; effectively clearing the posterior capsule. (A) Horizontal
reference wire. (B) Wire fixation zone between reference wire and
superior surface of ring. (C) The second and third wires should still be
placed 5 mm below the reference wire. The tilting of the fixation ring
to parallel the posterior slope of the plateau increases the safety factor
when placing posterior medial and lateral wires.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

Techniques in Orthopaedics®
17(1):15–25 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 3: Practical Biomechanics for the Application of

Ilizarov Fixators to Fractures of the Tibia

James J. Hutson, Jr., M.D.

Summary: The biomechanics of tensioned wires and half pins are described. The
effects of wire position, number, and configuration on constructing a stiff periarticular
fixation block are illustrated. Half pin application to the shaft and construction of a
stable base for fixation of periarticular fractures are illustrated. The selection of
appropriate ring diameter is based on soft tissue clearance and frame stiffness. Key
Words: Ilizarov fixator—Biomechanics—Ring sizing.

The Ilizarov system is designed to allow the surgeon
the ability to construct a unique external fixator for each
fracture to be treated. The diameter and number of rings
used, the connecting rods and working length mecha-
nisms, and the configuration of the tensioned wires and
half pins are factors that can be designed by the surgeon
to reduce and stabilize the fracture.8 A well-designed
fixator will lead to fracture healing. A poorly designed
fixator will cause instability, poor reduction, and non-
union of the fracture. The application of biomechanical
principles to fixator construction learned over the past
years is the key to building a well-designed frame which
will function as a “machine for healing.”
The biomechanics for external fixation of tibial shaft
fractures have been studied by several investigators, and
their findings can be extrapolated to the treatment of
periarticular fractures of the tibia. Most of the studies
have been based on bone models consisting of 1-inch
diameter PVC pipe. This is a reasonable comparison to
shaft fractures, but not for periarticular fractures. Tibial
plateau and pilon fractures occur in the expanded me-
taphyseal bone adjacent to joints. The cortical thickness
is decreased, the cancellous bone less rigid, and the bone
block undergoing fixation has one to multiple fractures
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
The author has been conducting a reading tour of modern architec-
ture and the concept of the “machine for living” by Le Corbusier has
been borrowed.
further compromising the stiffness of the periarticular
bone block. In comparison, the tibia shaft adjacent to the
fracture has dense bicortical bone, which provides excel-
lent purchase for tensioned wires and half pins. Three or
four fixation points in the cortical shaft will produce
excellent stiffness of fixation, which will be more than
adequate for fixation of the fracture.15 One of the most
common mistakes I have observed in the early fracture
frames of surgeons, is the overbuilding of the fixation
block on the tibial shaft, vastly out of proportion to the
fixation stiffness which can be constructed in the metaph-
yseal bone block. Frame stiffness is not based solely on the
number of wires and half pins used, but on the configuration
of the pins and wires. I have observed Ilizarov frames with
six or seven fixation points in the tibial shaft and two
smooth wires, almost parallel in alignment attempting to
control the metaphyseal bone block. The shaft is rigidly
fixed and the metaphysis is sliding and wobbling on the
smooth wires. This causes instability at the fracture site and
functional rehabilitation is hampered by pain. The fracture
does not heal, and a failure of treatment occurs. There is no
reason to build the tibial shaft side of the frame vastly stiffer
than the opposing metaphyseal bone block. An effort
should be made to balance the fixation; the fixation of the
shaft needs only to be stiff enough to support the fixation of
the metaphysis.
In fractures with metaphyseal comminution, the fixa-
tion at the joint level cannot approach that of the shaft.15
The frame may require bridging the joint, using ligamen-
totaxis to provide further support and prevent collapse of
the comminuted joint surface through the tensioned
wires on the metaphyseal carbon fiber fracture ring. The

15
16 J.J. HUTSON JR

FIG. 3.1. Increasing the number of tensioned wires across a ring

increases the axial and rotation stiffness. Stiffness to bending is
increased by diverging the wire angulation equally around the ring. The
PVC pipe model indicates when fixating periarticular fractures, as
many wires as possible should be placed across the fracture with as
divergent as possible angulation between the wires.

length of bone available for fixation in the metaphysis

may be no more than 1 to 2 cm in C3 plateau and pilon
fractures; this presents further problems of fixation at the
joint. It becomes clear that the key to successful fracture
fixation is the fixation at the level of the joint (metaph-
FIG. 3.2. (A) The ideal biomechanical placement of tensioned wires
yseal fixation block). The surgeon should use all meth- through the tibial plateau would be a 90° crossing angle. (B) Juxtapo-
ods possible to stabilize the metaphysis to gain fracture sition of the soft tissues on the plateau clearly illustrates why this is not
stability and healing. Because of the small length of the possible. The biomechanics of the system are always subordinated to
safe wire pathways. (C) The safe wire pathways through the plateau
metaphyseal fragment, usually only one ring will be form an arc of 60°. This produces a configuration that is stiff in medial
available for fixation of the metaphyseal bone block. A lateral bending, but not stiff in the AP bending plane, where the greatest
review of the biomechanical research applying to fixa- bending forces are observed in tibial biomechanics.
tion with a single ring is indicated.
Orbay, Frankel, and Kummer demonstrated several prin- ysis adjacent to the joint surface, a similar biomechanical
ciples of single ring fixation with tensioned wires:11,13 function of a drop wire is produced by using an anterior-
posterior (AP) half pin extended from the ring on a
1) Increasing the number of wires crossing a ring
Rancho universal cube (Fig. 3.7). This configuration has
equally spaced increased the axial stiffness (Fig. 3.1).
greater stiffness to bending in the AP plane compared
2) Increasing the number of crossing wires increased
with a drop wire in the medial lateral plane. This appli-
torsional stiffness (Fig. 3.2).
cation is only used when there is no comminution at the
3) Increasing the angular divergence between the
level of the metaphysis.
wires to 90° increased shear stiffness (Fig. 3.3).
In summary, the widest possible crossing angle al-
4) Using olive wires compared with smooth wires
lowed by safe wire pathways should be used. Olive wires
increased shear stiffness (Fig. 3.4).
should be spread above and below the ring as far as
5) Increasing the angular divergence between the
possible in the available bone by drop wires and angular
wires to 90° increased bending stiffness (Fig. 3.5).
wires (a wire passing from one side of the ring to the
6) A drop wire 4 cm from the ring increased bending
opposite side). This configuration will provide the best
stiffness (Fig. 3.6).
fixation of the metaphysis.
If there are not fracture extension lines in the metaph- Podolsky and Chao tested tensioned wires and found

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 3
FIG. 3.3. Translation is the sliding of the bone or PVC pipe model
across the plane of the ring fixator. (A) Translation increases as the
crossing angle of the wires approaches parallel. (B) Translation is
minimized by increasing the wire angulation to 90°. Increasing the
number of wires on the ring and increasing the angular divergence
between the wires decreases translation. (C) A translation force applied
90° to the acute angular divergence causes minimal translation. (D) The
addition of olives or stoppers on the wire reduces translation compa-
rable to 90° angular divergence of wires on a ring. The model indicates
that olive wires should be used on periarticular fractures to increase
translation stiffness in the medial lateral plane.
1.8 mm tensioned wires increased axial stiffness com-
pared with 1.5 mm wires.14 Decreasing the distance
across the ring and the distance between the bone and the
ring increased rigidity. With increasing axial forces, the
Ilizarov device was stiffest under axial compression and
torque. The data indicates using 1.8 mm wires and using
a ring diameter that clears the soft tissue envelope. Using
overly large rings unnecessarily reduces the axial and
torsional stiffness of the fixator.
Aronson defined the self-stiffening effects of ten-
sioned wires.1 As an axial load is applied, the wires
become more rigid as the load increases. In the cortical
fractures models with two-rings on either side of the
fracture, compressing the fracture ends greatly increased
rigidity of the system. Of importance is the fixation of
the wires to the ring. Slotted bolts have the strongest
fixation and should be torqued to 44 inch-pounds, for
maximum fixation. Turning the wrenches beyond this
will lead to bolt failure. The slotted fixation bolts are also
easier to use than cannulated fixation bolts. To place a
cannulated bolt, the wire has to be threaded through the
hole, which places the surgeon’s fingers at further risk. The
wire has to be lifted off the ring to place the bolt in the ring
hole and when the wire is tensioned, a kink is formed in the
17
FIG. 3.4. (A) If a smooth tensioned wire is used as a horizontal
reference wire, the periarticular fragment can slide along the wire. This
has been used as a reduction maneuver in some techniques. The
drawback is that translation is not controlled by this wire in the medial
lateral plane and can cause translation instability. (B and C) Using an
olive wire increases translation stiffness especially if opposed by a
second wire. The drawback to using an olive wire is that the wire will
have to be loosened to change the alignment in the medial lateral plane
during a reduction if an improvement in position is needed.
wire. If the wire position needs to be revised, the kink may
obstruct the adjustment and a new expensive wire is
needed. The slotted bolt is placed over the wire without the
need to move the wire and clamps the wire with a three-
point chuck, which does not deform the wire (Fig. 3.8).
Swirsky has tested tensioned wires and demonstrated
that wires placed on one side of the ring and tensioned
sequentially will sequentially offload the tension on the
previously tensioned wire.16 The further the wire is
tensioned away from the ring, the greater the offloading
effect (Fig. 3.9). This effect illustrates the need to place
the tensioned wires on the opposite side of the ring. A
horizontal reference wire will be placed below the joint
and the second and third wires placed on the opposite
side of the ring or as crossing wires. The exception to the
rule are fractures with severe comminution that have
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
18 J.J. HUTSON JR
FIG. 3.5. Bending plane stiffness is increased by diverging the angle
of the wires to 90° and increasing the number of wires on the ring. (A)
Bending stiffness is minimal when the force is applied 90° to the acute
angular axis of the ring. This is a model of periarticular bone fixation.
This ring is weak to bending stiffness in the AP plane. (B) Increasing
the wire divergence increases the bending stiffness. A 90° crossing
angle is not possible in proximal and distal periarticular fractures (Figs.
2.1 and 2.6). (C) A bending force applied parallel to the acute angular
axis causes minimal deformation. The model indicates that the widest
possible crossing angles of the tensioned wires should be used on the
periarticular fixation blocks of fractures.
only a small section of metaphyseal bone available for
fixation; all the wires will be placed on one side of the
ring (usually observed in pilon fractures).
There are no studies dealing with bone models that have
fractures at the level of ring fixation, but I have observed
that building a single unit from several fragments will
enhance fixation of the wires. This is applicable to periar-
ticular fractures, which have limited displacement and little
crushing and comminution. This can often be accomplished
with percutaneous cannulated screws. I have also used 3.5
mm pelvic screws, which are long enough to cross the
metaphysis, but have the smallest profile to interfere with
the passage of tensioned olive wires.
The fibula head provides support to the posterior
lateral plateau. The bone quality is usually good and
passage of one wire through the fibula will increase
strength of system, in a similar fashion, the lateral mal-
leolus can help in fixation of pilon fractures.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
Fixation of the metaphysis must be supported by a
stable ring system secured to the cortical shaft. Calhoun
has demonstrated that there is equivalent rigidity of a
ring system in bending between two tensioned wires and
two 5 mm pins, and slight increase in axial rigidity of the
tensioned wires compared with the cantilever 5 mm half
pins.5,6 This allows consideration for hybrid frames. Half
pins only penetrate one soft tissue compartment and
avoid the transfixation of muscles and possible injury to
nerves and vessels observed with transfixation-tensioned
wires. They are an excellent fixation device in the soft
tissue zones of the midtibia and femur. Using the me-
chanical models of Calhoun and Flemming, the stable
ring unit on one side of the tibial shaft model consists of
two rings, separated approximately 150 mm with two
wires on each ring. This can be changed to two rings with
two half pins at divergent angles. The lessons of half pin
frames still apply; rigidity is gained by increasing the
number of pins, pin spread, and multiple planes of fixation.
I have labeled this unit as the “stable base” on which the
metaphyseal fixation is supported. Working length is de-
fined as the length between two points of fixation. The
stresses in the system are directly proportional to the square
(L2) of the length (Fig. 3.10). Therefore, the distance be-
tween the metaphyseal system and the stable base should be
constructed with as short of threaded rods as possible. Most
frames will have a working length of 150 mm to 250 mm
rods. I have constructed a few frames with extensive shaft
comminution with 300 mm rods.
At least four rods are needed between ring systems. In
some 180 mm and 200 mm ring constructs, five or six
rods to resist torquing and bending are needed, especially
if the working length is long.
Carbon rings have the advantage of radiolucency and
should be used at the metaphyseal fracture zone. They
weigh 45% of the weight of corresponding steel rings.
They resist plastic deformation better than steel rings, but
this is only at extreme loads, which are not reproducible
in clinical situations. They are thicker (8 mm versus
5mm) and tend to score with heavy wire compression.12
My preference is to use carbon fiber rings at the fracture
zone and steel rings for the stable base unit.
Lastly, how rigid should a frame be? Severe rigidity
and excess motion hamper fracture healing.7,10,17 We
have all had experience with fracture bracing and ob-
served the gradual decline in motion as the fracture heals.
The axial motion of the Ilizarov tensioned wire system is
probably conductive to healing. In reality, with comminuted
periarticular fractures, you will not ever be able to produce
too rigid of fixation in the metaphysis, and in many in-
stances, will have problems with lack of stability.
 CHAPTER 3 19

FIG. 3.6. (A) To increase stiffness in the AP plane, a drop wire on a second ring, or on a two-hole post or long male hinge can be added to the
fixation block. Increasing the distance of the drop wire increases the stiffness to bending in the plane 90° to the acute angular axis of the ring system.
The model indicates using the available length of bone in a fracture segment to increase the distance between the wires during fracture fixation. The greater
the wire spread, the greater the stiffness of the fixator. (B) The metaphyseal bone available for the fixation of periarticular fractures may be limited by
comminution of the metaphysis. The wires on the carbon fiber ring can be “dropped” off the ring using washers, hinges, and posts to increase the span of
fixation, increasing stiffness. A second ring of fixation is added if there are 3 cm or more of available bone for fixation rather than using a three-hole post,
which can deform the ring when tensioned (see Fig. 3.9). Wire elevation can be adjusted above the ring with precision using the components of the Ilizarov
system. The sequence is: one washer, two washers, three washers, bottom hole two-hole post, long male hinge, top hole two-hole post, three-hole post. Rather
than using a three-hole post, a second ring can be added that is biomechanically stiffer than the three-hole post.

A summary of the above studies will provide a guide
for constructing the periarticular fixation block in tibial
plateau and pilon fractures:
1) Use 1.8 mm olive wires.
2) Tension wires to a maximum, without distorting
the frame. Usually, 110 kg of tension across the
ring, and 50 kg to 90 kg of tension when the wires
are elevated away from the ring on long male
hinges or two and three hole posts (Fig. 3.9).
3) Use as many wires as possible in the metaphyseal
fixation block. Three wires are a minimum, and
four wires if space on the ring is available.
4) Place wires with maximum divergent angulation
as permitted by soft tissue safe zones.
5) Spread wires over the greatest length available in
the fracture zone. This will encompass an area
from 1 cm below the joint surface extending to
the metaphyseal shaft junction of the fracture.
6) Place wires on opposite sides of the ring to reduce
the unloading effects of sequential wire tensioning.
7) Use slotted fixation bolts with approximately 40
inch-pounds of torque.
8) Reassemble metaphyseal fractures with low pro-
file 3.5 and 4.5 cannulated screws and 3.5 mm
pelvic screws.
9) Use the smallest rings that provide adequate soft
tissue clearance.
10) Secure the fibula in the metaphyseal construct.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

20 J.J. HUTSON JR
FIG. 3.7. The use of half pins with Ilizarov fixators allows placement
of fixation pathways that are not available when using only tensioned
wires. A half pin can be placed in the AP plane to increase the bending
stiffness of the ring. This configuration is only possible in larger fracture
fragments without comminution. A half pin placed through fracture planes
will displace the fragments and provide little increase in stiffness.
11) Reduce working length of threaded rods between
fixation blocks to a minimum.
12) Use four rods between rings.
13) Use carbon fiber ring over the metaphysis.
BIOMECHANICS OF HYBRID ILIZAROV
FRAMES: BUILDING A STABLE BASE
Reconstruction of periarticular fractures combines a
metaphyseal operative ring with a supporting diaphyseal
stable base. The soft tissues adjacent to the tibial shaft
FIG. 3.8. The slotted fixation bolt fixates the wire with a three-point
chuck. The cannulated bolt pulls the wire into the ring hole and kinks the
wire, preventing secondary wire manipulation. The slotted bolt can be
placed over wire without moving it from the ring, whereas the cannulated
bolt requires deforming the wire to place the bolt in the ring hole. The
cannulated bolt has no use in fracture reduction with Ilizarov fixators.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 3.9. Wires placed directly on rings can be tensioned to 110 kg
of force. The wires should be placed on opposite sides of the ring to
reduce ring distortion and primary wire relaxation. Wires tensioned on
long male hinges and posts have mechanical advantage from the lever
arm effect and cannot be tensioned as forcefully. Tension across two
hinges is usually 90 kg or less, and across a two-hole post is 50 to 70 kg
or less. The posts are observed during tensioning. Once they start to bend
over and distort the ring, the tensioning is stopped. Further tensioning will
severely distort the ring. Three-hole posts should not be used to increase
wire spread on a fixation block. A second ring should be added to the
periarticular fixation block if 3 cm of bone is available for fixation.
allow access to the tubular bone in a 90° zone on the
anterior medial surface of the tibia. Early Ilizarov frac-
ture models used tensioned wires in this zone, resulting
in painful muscle penetration. The development of the
Rancho cube half-pin fixation system by Green allowed
the use of half pins on the Ilizarov ring system. The
combination of diaphyseal half pins and metaphyseal
tensioned wires produced the “hybrid frame.” The bio-
mechanics of the half-pin system have been studied by
FIG. 3.10. Working length is the distance between two fixation points
on which a force is applied. The stiffness is inversely proportional to the
working length squared. The distance between the fixation blocks when
treating fractures should be reduced to as small as possible to increase
stiffness of the frame. Unnecessary separation of the ring blocks affects
fracture stiffness and healing.
 CHAPTER 3 21

FIG. 3.11. The stiffness to bending in the plane of fixation is increased

by increasing the distance between the half pins. Reducing the distance
between the fixator and the bone increases bending and axial stiffness of
the fixator. The model indicates the ring diameters should be reduced as
small as possible with adequate soft tissue clearance and the half pins
should be spread over the available fragment length to increase stiffness.

several researchers and their concepts can be applied to

the diaphyseal bone construct.
Bending moments in the AP plane are two to five FIG. 3.12. (A) Two half pins in the AP plane have little bending
times greater than in the horizontal plane. To resist this stiffness in the medial lateral plane. (B) Adding a divergent medial face
bending force, half pins should be placed primarily in the half pin increases the AP plane bending stiffness and greatly increases
medial lateral plane stiffness. (C) Addition of a second medial plane half
AP plane with additional pins in a divergent plane to pin will further increase the bending stiffness of the fixation block.
increase stability. Behrens demonstrated with AO tubular
fixators mechanical stiffness was increased by:2,3,4
1) increasing the diameter of the half pin (most ex-
2) Reduction in frame to bone distance increased
ternal half pin systems use 5 mm pins)
compressive and bending stiffness (Fig. 3.11).
2) applying the half pins in the AP plane
3) Diverging the pin angles from 0° to 90° on the ring
3) increasing the distance between the half pins
increased AP bending strength 67% and the trans-
4) decreasing the frame to bone distance
verse bending strength 123% (Fig. 3.12).
5) adding a second plane of fixation divergent to the
4) Increasing pin number from two to four per seg-
AP plane
ment increased compressive and bending stiffness
The above concepts were explored by Johnson and (Fig. 3.12).
Fischer using an open ring system with half pins in a
Minimal pin frames with only two pins per side have
tubular bone model.9 The biomechanical testing demon-
greater interface problems (loosening, infection) than
strated:
three pins per side frames.17
1) Increasing pin spread from 5 cm to 11 cm in- A summary of the above mechanics applied to a
creased bending strength by approximately 100% hybrid circular frame section used as a “stable base”
(Fig. 3.11). would result in construction of the following:

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

22 J.J. HUTSON JR
1) Circular rings fitted to provide adequate soft tissue
clearance.
2) Use the smallest ring possible with adequate soft
tissue clearance (1 cm to 2 cm).
3) The rings are separated by 150 mm threaded rods
to give an inside separation of 13 cm. Occasion-
ally, on a petite patient, 120 mm or 100 mm rods
may be used.
4) The half pins will be in the anterior medial quad-
rant.
5) Place the threaded rods in the AP plane on the
anterior lateral and posterior medial holes of the
ring.
6) Use two pins in the AP plane, one on each ring, and
at a minimum, a third pin as divergent as possible
in the medial-lateral plane. On small patients, three
pins will suffice. On large patients, four divergent
pins are needed.
7) Patients with extensive shaft extension may require
hybridization of the stable base, use half pins on
the midring shaft, and tensioned wires on the me-
taphysis opposite the periarticular fracture.
The stable base on some fractures is constructed first
with fracture reduction based off the frame (pilon frac-
tures). On other fracture patterns, a single AP half pin on
a universal mounting on the distal ring is combined with
a metaphyseal horizontal reference wire for reduction.
Mid-frame reduction techniques are used followed by the
addition of further half pins once the fracture is reduced.
In summary, a hybrid stable base will be constructed
with:
1) Two rings separated by 150 mm rods (use four
threaded rods).
2) Three to four divergent half pins with at least two
pins in the AP plane.
The Biomechanics of Universal Clamps
The Ilizarov frame in one technique of reduction is a
dynamic scaffold that surrounds the fracture. Application
of reduction techniques allows specific corrections in
one plane of deformity without loosening all axis of
stability. Universal clamps and connecting rods are also
used in fracture reduction. This method allows universal
motion at the clamp with freedom of motion in all three
axis of deformity. This technique appears deceptively
simple. “Fire some pins into the bone and correct the
fracture alignment.” The soft tissue forces deforming a
fracture can be very difficult to overcome. The universal
clamp requires “all or nothing” fixation.2 This may be
effective for simpler fracture patterns, but can lead to
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
failure of reduction in complex unstable fractures. The
disadvantages to universal clamps are:
1) Size and shape of clamps dictate pin placement and
spread.
2) Pin exchange may require clamp release.
3) Frame build down through sequential loosening is
not possible.
4) Midframe manipulation of the fracture is not
possible.
RING SIZING FOR ILIZAROV EXTERNAL
FIXATORS
The Ilizarov fixator system has a large assortment of
sequentially sized half rings, which are constructed into
full rings with nuts and bolts. Early in the introduction of
the Ilizarov system in America, full rings were manufac-
tured, but these are no longer available. The rings come
in sizes from 80 mm to 240 mm inside ring diameter. The
smaller ring sizes from 80 mm to 130 mm are usually
used on forearm fractures, pediatric applications, or vet-
erinary applications. Most adult acute fracture and post-
trauma reconstructions are accomplished with ring sizes
from 140 mm to 240 mm. For Ilizarov treatment of spine
deformities, a truly esoteric discipline, larger rings have
been manufactured up to 300 mm. The rings are manu-
factured in two different materials, one is stainless steel
and other is carbon fiber. The stainless steel rings are 5
mm in thickness and the carbon fiber rings are 8 mm in
thickness. The strength and stiffness of the carbon fiber
rings are greater than the stainless steel rings.12 The
advantages of the stainless steel rings are the thinner
profile and the mechanical property that nuts and bolts
tighten down onto the ring, come to a firm stop and there
is no surface shredding which is seen in carbon fiber
rings when nuts are tightened down with high torque.
The advantages of the carbon fiber rings are they weigh
less, and are stiffer and stronger. The most important
advantage is that they are partially radiolucent on x-ray.
The fixation of tensioned wires to a carbon fiber ring is
not as secure when compared with the stainless steel
ring. Initially, washers were used, but over time it was
observed that there was enough compression between the
wire and the carbon fiber of the ring that the wires could
be placed directly on the carbon fiber and tensioned.
The selection of a ring size is determined by the size
of the patient’s extremity and the condition of the soft
tissues of the extremity (Figs. 3.13A to 3.13D ). A
patient undergoing an elective procedure with low en-
ergy osteotomies and limited incisions, will not be ex-
pected to have severe swelling after the procedure and
 CHAPTER 3
FIG. 3.13. Rings are chosen that provide adequate soft tissue clear-
ance. The stiffness of a tensioned wire is decreased by increasing the
ring diameter. (A) Overly large rings decrease fixator stiffness. (B) The
ring size chosen should be the smallest diameter ring which provides
adequate soft tissue clearance. (C) Selection of a ring with poor soft
tissue clearance causes soft tissue impingement and pain leading to
wire infections and poor functional use. (D) Poor positioning of the
bone block in the ring causes soft tissue impingement. A poor initial
alignment of a horizontal reference wire is the cause of soft tissue
impingement when reducing fractures with Ilizarov fixators.
ring sizes can be chosen which reduce the diameter of the
frame. Patients with traumatic injuries and multiple
trauma may have severe swelling of the their injuries,
and greater room between the ring and the soft tissues
will need to be used in the frame to prevent soft tissue
impingement following the frame application. There are
multiple advantages of using a smaller ring in frame
construction (Fig. 3.13B). One is that the stiffness of the
tensioned wire is greater on a smaller ring compared with
a ring of the larger diameter when the wires are tensioned
equally.14 A wire tensioned to 110 kg on a 150 mm ring
will have greater stiffness than a wire tensioned to 110 kg
on a 200 mm ring. Reducing the working length of a wire
from the ring to the bone also will increase the stiffness.
A bone stabilized eccentrically in a ring, such as a
proximal tibia shaft fracture where metaphysis and shaft
are placed closer to the anterior inside diameter of the
ring compared with the posterior diameter, will increase
the stiffness of the fixation. The patient’s day-to-day
existence with the external fixator will be made easier
with smaller rings. The smaller the frame, the easier it is
for them to slide their clothes over the ring. With some
smaller ring constructions, regular pants and shorts will
fit over the ring avoiding the need to have custom clothes
23
manufactured or purchased. When patients have bilateral
fixators in place on the lower extremity, it is important to
try and use the smallest ring possible so their legs are not
forced apart by massive ring systems, which are unnec-
essarily large. The advantages of using larger rings are
that greater space is placed between the inside diameter
of the rings and the patient’s soft tissues (Fig. 3.13A).
This enables the patient to perform maintenance on the
half pins and wires with greater facility making pin care
much easier. Using larger rings also makes the surgeon’s
technical effort less difficult. With a large ring, a surgeon
may misjudge the overall final alignment and still have
room within the rings to have adequate soft tissue clear-
ance. With smaller ring diameters comparable to the size
of the extremity, the initial reduction choices have to be
more accurate. The larger rings also have a larger number of
fixation holes, which, on a complex external fixator, may
make it easier to place hinges and complex drive mecha-
nisms. This also facilitates adding additional fixation points
in periarticular fractures, adding a fourth tensioned wire
through the metaphyseal zone. Excessive space between the
ring and the soft tissues when using large rings does make
the fixator bulkier. When rings 180 mm and larger are used,
a fifth threaded rod may need to be used between the rings
to obtain equal stiffness to frames built with smaller rings
and four threaded rods.
The external fixator construct for different fractures
and reconstructions will mandate larger and smaller
rings. A construct that will be on the proximal two-thirds
of the tibia will be placed several centimeters above the
tibial shaft with the tibia in an anterior eccentric position
to increase the stiffness of the construct and provide
clearance for the gastrocnemius and soleus muscles pos-
teriorly. A fixator assembly placed on the distal ankle,
which would be used for nonunion/malunion reconstruc-
tion, ankle arthrodesis, and pilon fractures would have a
different configuration. The tibial shaft would be placed
in a centered position, to allow for soft tissue clearance
on the anterior aspect of the ankle. An Ilizarov fixator
that was placed for an extensive tibial shaft fracture or
for a combination tibial plateau/pilon fracture or recon-
struction of the tibia with transport proximally and dis-
tally, would need to be placed so that the soft tissues of
the anterior ankle have adequate clearance. If a frame is
placed orthogonally, on the distal tibia, its position prox-
imally over the tibia tubercle will be anterior to what one
would place for a tibial plateau fracture. Because of the
bulk of the gastrocnemius and soleus musculature
posteriorly, a larger ring may need to be used for a
full-length tibial frame compared with what could be
used for a distal tibial frame (Fig. 3.14). A patient who
had a pilon fracture or tibial plateau fracture might
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
24 J.J. HUTSON JR
FIG. 3.14. Ring diameter will have to be increased depending on the
expanse of fixation. A three-ring fracture frame for a plateau or pilon
fracture will need to have larger rings if the frame spans the entire
length of the tibia. The anterior clearance for a proximal tibia fracture
is inadequate for the soft tissues anterior to the ankle. (A) Anterior
clearance is adequate for a proximal tibia fracture. (B) Extension of the
fixator to the ankle causes painful impingement (arrow). The frame
cannot be adjusted forward because the proximal musculature would be
against the ring. (C) Increasing the ring diameter allows soft tissue
clearance at the ankle and proximal calf musculature.
easily be treated with 160 mm ring, but if they had a
combination of pilon/tibial plateau fracture or commi-
nuted tibial shaft fracture, which was to be treated
with superior and inferior horizontal reference wires,
would need a 180 mm ring. In over 270 periarticular
fractures of the tibia, which I have done over the past
nine years, the 160 mm ring size has been the most
common. On some smaller patients, I have used 150
mm rings. On larger patients, 180 mm to 240 mm rings
have been necessary. The 240 mm rings have been
used on morbidly obese patients that are in the 300 to
400 pound range. Fortunately for these patients, there
is a conical section to the leg and a smaller ring than
expected can often be used for tibial pilon fractures.
The goal of the surgeon placing an Ilizarov fixator is
to place the most compact frame possible, which in-
creases the stiffness of the system, makes day-to-day use
of the frame easier on the patient but has adequate soft
tissue clearance to allow pin maintenance and prevent
impingement of the frame on the soft tissues. Adequate
skin and soft tissue clearance is approximately 2 to 3 cm.
This will usually allow for postoperative edema in the
frame. Lesser soft tissue clearances of 1 cm can be
accepted, but will require extra attention from the patient
for pin maintenance. Usually this occurs after a complex
fracture reduction in which swelling greater than antici-
pated has occurred. I have observed patients who have
had a frame placed, but due to the effects of multiple
trauma and organ failure have had massive edema with
the edematous skin pressing up against the rings. If this
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
occurs, the frame does not need to be removed but the
rings can be padded with pieces of sponge or cardboard.
An exception to the rule is the placement of a free flap
underneath a frame. Free flaps do not tolerate pressure
from a peripheral ring. If you are going to place an
Ilizarov fixator on an extremity that has had a recent free
flap, then adequate clearance tending toward a choice of
larger rings should be considered. If this complication
does occur, bypass the flap zone using plates and a larger
ring. The offending ring can be removed, without losing
alignment. This will probably take about 1 hour, but is
certainly demanded whenever a flap is at risk from
peripheral pressure of a circular fixator ring. More than 2
to 3 cm of clearance is excessive. The patient will need
to deal with a larger frame than is necessary, and the
stiffness of the frame will be compromised which may
be detrimental to the quality of a bone transport or the
healing of the fracture. The location of the extremity
in relation to the ring also will determine the ring size.
A ring with limited clearance of 1 centimeter anteri-
orly over the tibial metaphysis or tibial pilon will
probably be tolerated as the patient swells, there will
tend to be a gravitational effect on the soft tissues
reducing anterior soft tissue expansion. A ring which
is already touching the calf on a complex reconstruc-
tion or high energy fracture, will lead to significant
problems as swelling occurs over the next 24 to 48
hours. If this does occur, the placement of smooth
cardboard between the ring and the skin will provide a
large surface on which the soft tissues will rest pre-
venting circular impingement and blockage of lym-
phatic and venous flows. Elevation of the extremity
can be very helpful in these situations.
The Ilizarov rings are also constructed so they can be
used as inside and outside rings. The 150 mm ring fits
inside the diameter of the 180 mm ring. The 160 mm ring
fits into the 200 mm ring, the 180 mm ring fits into the 220
mm ring, and the 200 mm ring fits inside the 240 mm ring.
For certain constructs, this will be useful. The rings can be
connected to each other with two-hole plates and remain
concentric.
Ring stiffness can be augmented by bolting two rings
together. Another option is to use a custom manufactured
double thickness ring, which is available. These rings
may be useful on transport rings. The use of these heavy
rings with stainless steel half pins may improve the
stability of bone transport.
In my observation of external fixators systems, espe-
cially hybrid fixators, I have noticed a tendency to use
rings that are much larger than needed. Many biome-
chanical studies on hybrid fixation have used 200 mm
rings as the base ring in their experimental system. I have
 CHAPTER 3
found that the need for a 200 mm ring is less than 5% in
the patients that I have taken care of with periarticular
fractures of the tibia. The most common ring size is 160
mm, which usually provides clearance on most patients
with some patients requiring a 180 mm ring. In your
reconstructions, try and select the ring size which gives
adequate soft tissue clearance but does not produce
excessive space between the soft tissues and the inside
diameter. Pay close attention to the soft tissues during the
postoperative period. If excessive swelling does occur,
use soft tissue supports to prevent damage to the soft
tissue, elevate the extremity, and manage the patient’s
physiologic status such as improving nutrition and man-
aging of fluid intake and output to reduce the problem.
Remember to use slightly larger rings than expected
when a free flap will be part of your reconstruction. If
excessive swelling does occur and you are alarmed by
the situation, plates, rods, and an expanded ring size can
be used to bypass the flap zone allowing removal of the
offending ring. The ring can be removed and time can be
allowed to pass allowing resuscitation of the extremity.
The ring can be replaced, or if necessary, a new frame
can be placed.
One aspect of ring selection that has not been covered
in this section is the timing of surgery. A patient is not a
candidate for stabilization and reconstruction of extrem-
ity until the patient and his or her extremity has been
resuscitated. The use of medial foot and ankle frames,
anterior bridge frames, and lateral femoral frames have
been well described in the literature. Skeletal traction as
well as traveling frames can also be used. Resuscitating
the extremity before reconstruction will greatly reduce
the need to use massive rings and will reduce the
complications of skin sloughing and infection, which
are seen with reconstruction done before appropriate
resuscitation of the extremity. Another principle that
one needs to remember is that it is not uncommon to
start off on a reconstruction with a ring size that you
thought was appropriate only to find out that the next
size up would have been better. Even though I have
had great experience with periarticular fractures, I still
have days where I underestimate the tibia curvature or
25
swelling of the soft tissues about the ankle, which lead
to impingement by the ring system on the soft tissues.
The best thing to do in this situation is admit that you
made a wrong choice in ring size and disassemble the
frame and build it with the next ring size up. If this
never occurs in your practice, you are probably using
rings that are too large.
REFERENCES
1. Aronson J, Harp J. Mechanical considerations in using tensioned
wires in a transosseous external fixation system. Clin Orthop
1992;280:23–29.
2. Behrens F. A primer of fixation. Devices and configurations. Clin
Orthop 1989;241:5.
3. Behrens F, Johnson W, Koch T, Kovacevic N. Bending stiffness of
unilateral and bilateral fixator frames. Clin Orthop 1983;178:103.
4. Behrens F, Johnson W. Unilateral external fixation. Clin Orthop
1989;241:48 –56.
5. Calhoun J, Li F, Ledbetter B. Biomechanics of the ilizarov fixator
for fracture fixation. Clin Orthop 1992;280:15–22.
6. Calhoun JH, Buford WL, Ledbetter BR. Rigidity of half pins for
the Ilizarov external fixator. Presented at: Advanced Applications
of the Ilizarov Technique Meeting, Smith Nephew Richards; June
1992; Naples, Fl.
7. Chao Ey, Aro H, Lewallen DG. The effect of rigidity on fracture
healing in external fixation. Clin Orthop 1988;241:24 –35.
8. Fleming B, Paley D, Kristiansen T, Pope M. A biomechanical
analysis of the Ilizarov external fixator. Clin Orthop 1989;241:
95–105.
9. Johnson W, Fischer D. Skeletal stabilization with a multiplane
external fixation device. Clin Orthop 1983;180:34.
10. Kenright J, Goodship AE. Controlled mechanical stimulation in
the treatment of tibial fractures. Clin Orthop 1989;241:36 – 47.
11. Kummer F. Biomechanics of the Ilizarov external fixator. Clin
Orthop 1992;280:11–14.
12. Nele U, Mafulli N, Pintore E. Biomechanics of radiotransparent
circular external fixators. Clin Orthop 1994;308:68 –72.
13. Orbay G, Frankel V, Kummer F. The effect of wire configuration
on the stability of the Ilizarov external fixator. Clin Orthop 1991;
270:299 –302.
14. Podolsky A, Chao E. Mechanical performance of Ilizarov circular
external fixators in comparison with other external fixators. Clin
Orthop 1993;293:61–70.
15. Pugh KJ, Wolinsky PR, Danson JM, Stahlman GC. The biomechan-
ics of hybrid external fixation. J Ortho Trauma 1999;13:20–26.
16. Swirsky S, Milne E, Zych G, Hutson JJ, Latta L. Tension changes
on the first wire on tightening the second wire on open and closed
external fixator rings. Presented at: Orthopedic Research Society,
Dallas 2002. Abstract.
17. Wu J, Shyr H, Chao E, Kelly P. Comparison of osteotomy. Healing
and external fixation devices with different stiffness characteris-
tics. JBJS 1984;66A:1258.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
Techniques in Orthopaedics®
17(1):26–33 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 4: Basic Frame Construction: Building Fixation Blocks

and Designing Working Length Mechanization

James J. Hutson, Jr., M.D.

Summary The fixation blocks used in Ilizarov fixators are illustrated: single ring, ring
and 5/8 ring, periarticular double ring block, shaft double ring block, transport ring,
and foot frame. Working length mechanisms are illustrated: distraction, compression,
rotation, angular correction, translation, and neutralization. Working length rod selec-
tion used in fracture treatment is illustrated. Universal hinge mechanisms are dis-
cussed. Keywords: Ilizarov fixation blocks—Working length mechanisms.

The treatment of skeletal deformities, fractures, post-
traumatic nonunion, and malunions with Ilizarov fixators
requires the manipulation of one area of the skeleton and
adjacent soft tissues against a second area of fixation of
bone and soft tissue. The mechanization of the adjacent
fixation blocks can achieve distraction, rotation, transla-
tion, angular correction, compression, or combinations of
these mechanical processes. The fixation of the skeleton
and soft tissues can be considered as fixation blocks.
These blocks of fixation incorporate the biomechanical
principles of external fixation with cantilever half pins
and tensioned wires. The fixation blocks may consist of
a single ring and increase to multiple rings with special-
ized foot plates and 5/8-full ring. The construction of
these fixation blocks will be described below. Ilizarov
fixators can be constructed using threaded rods, which
traverse the entire frame. The fixation blocks are not
constructed as separate units of fixation, but the rings are
moved up and down the long threaded rods to manipulate
the fracture. This construct can function well, but frame
modifications are quite time consuming. Every nut must
be loosened and modified to change the configuration of
the frame and changes in position of the rod require
complete removal by laborious turning of the rod and
nuts for removal and replacement. Using interconnecting
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
rods and hinges between the fixation blocks allows rapid
changes in configuration of the frame, greater adaptabil-
ity, and use of the uniqueness of the Ilizarov system to be
constructed as a “custom” fixator for each patient’s
injury or deformity.
SINGLE RING FIXATION BLOCK
A minimum of two opposed olive wires are placed
with the greatest divergent angulation between the wires
(Fig. 4.1). A 90° crossing pattern produces the stiffest
construct, but anatomic structures limit the angulation to
60° on the distal femur, tibial plateau, and distal tibia.
The addition of a third and fourth wire increases stiff-
ness. These wires are dropped off of the ring with male
support post and long hinges to improve bending stiff-
ness. The wires should be placed above and below the
ring to balance the tension to reduce ring deformation.
When reducing periarticular fractures of the tibial pla-
teau and pilon, the wires may be on the same side of the
ring when the available bone fragments for fixation are
only 1 to 2 cm in height. Half pins are added to the single
ring if the bone available for fixation is 4 centimeters or
longer (Fig. 4.2).
RING AND 5/8 RING FIXATION BLOCK
The 5/8 ring is designed to be used on proximal
fixation of the tibia in reconstructive procedures and
fractures of the shaft. The 5/8 ring is an open section. If
tensioned wires are placed on the ring, severe deforma-

26
 CHAPTER 4
FIG. 4.1. The single ring fixation block is used on proximal and
distal periarticular fractures. The length of the bone block has 1 to 3 cm
of bone available for fixation and a closed single ring is indicated. The
wires are divergent in the safe zone, opposed olive wires are used and
wire spread is increased with drop wires when possible. A minimum of
three wires is used to fixate the metaphysis. Four wires will improve
fixation. The metaphyseal block is stabilized in the horizontal plane.
tion will occur unless the 5/8 ring is supported by a full
ring below it. Three hexagonal sockets are used to
connect the 5/8 ring, 3 or 4 cm in length. The 4-cm
sockets allow the 90° wrenches to be used inside the
frame. This configuration crowds the preferred proximal
location of corticotomies and 3-cm sockets are used for
lengthening. When lengthening, the wire pathways are
FIG. 4.2. If the proximal or distal metaphyseal fragment is not
comminuted and has 4 to 5 cm of bone available for fixation, an
anterior half pin can be used to increase stiffness in the AP plane. This
fixation block is used for Type A proximal and distal tibia fractures.
27
FIG. 4.3. The 5/8-full ring fixation block is used for Type A proximal
tibia fractures and as the proximal fixation block for distraction osteo-
genesis. The 5/8 ring must be supported by the second full ring
connected by a 3- to 4-cm hexagonal post. The fixation block is
composed of a horizontal reference wire, fibula head wire, anterior
medial half pin, and a medial face wire on the full ring. The half pin is
not placed until the corticotomy has been completed to prevent crack
extension to the half pin. The fibula head needs to be fixated during
lengthening to prevent the fibula from being dragged inferiorly during
the lengthening.
horizontal reference wire, medial face wire, fibular fix-
ation wire, and anterior-posterior (AP) half pin (Fig. 4.3).
DOUBLE-RING FIXATION BLOCKS
When the bone available for fixation is greater than 4
cm, a double ring block is indicated. Stiffness is directly
proportional to the distance between pins in the plane of
fixation. Anterior-posterior bending stiffness is increased
by 100% when increasing the pin spread from 5 to 11
cm. The double ring blocks should always expand to use
the entire length of bone available to increase stiffness of
the frame. When the rings are separated by 150 mm
threaded rods, the fixation wires and pins are spread 12
to 15 centimeters. This pin/wire spread produces frame
stiffness that is adequate for all applications of the
Ilizarov fixator. Midshaft ring blocks (stable bases)
should have at least two AP pins and one medial pin
angulated at 90° (Fig. 4.4). Olive wires can also be used.
An olive wire will be used as a draw wire to reduce and
compress fracture fragments (Fig. 4.5). Double ring
blocks adjacent to the joint will combine opposed olive
wires with divergent angulation at the level of the me-
taphysis and AP and medial face half pins on the central
ring of the ring block (Figs. 4.6A, 4.6B). Additional half
pins and wires may be used to reduce fracture fragments
or stabilize corrections of malunion and congenital de-
formities, which must overcome strong soft tissue resis-
tance for correction.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
28 J.J. HUTSON JR

FIG. 4.4. A double ring block with two AP half pins on Rancho
universal cubes. A medial half pin can be used as a stable base for
proximal and distal periarticular fractures. The rings are separated by
120 to 150 mm rods.

FIG. 4.6. Proximal (A) and distal (B) periarticular fracture blocks have
length allowing a two ring fixation block to be constructed. Divergent olive
wires are used at the metaphyseal level. The initial wire is usually placed
as a horizontal reference wire. The shaft fixation can be divergent medial
half pins or tensioned wires. The fibula head or lateral malleolus is not
fixated with a wire unless there is a specific need to control the fibula or
posterior lateral quadrant of the metaphysis.
FIG. 4.5. The midtibial double ring fixation block can also have
tensioned wires included in the fixation. These wires are used as arch
or draw wires in the medial lateral plane. The medial plane half pin is
always added secondarily after the fracture is reduced to increase frame
stiffness.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 4
FIG. 4.7. The foot fixation block is used for bridging frame distrac-
tion reduction of pilon fractures and for arthrodesis salvage of severe
pilon fractures. For reduction of pilon fractures, only the calcaneus is
fixated by a horizontal reference wire and medial oblique wire. The
talar neck and midfoot wires are used for arthrodesis and forefoot cavus
problems.
THE FOOT FRAME
The “U” shaped foot ring with extended sides has
replaced foot plates constructed of half rings and plates.
Foot plates are available in 140 mm, 160 mm, and 180
mm sizes (Fig. 4.7). The foot plate is an open section and
must be closed with a matching half ring. The ring can be
placed in the same plane attached by hexagonal sockets
extended past the toes, or placed at 90° to the foot plate
arching over the foot. For frame stiffness, four threaded
rods are required between the tibial construct and the
foot plate; two rods are placed posteriorly and orthogonal
with the tibial rings and two rods anteriorly extended to
the foot plate by plates attached to the tibial metaphyseal
ring. Two opposed angulated wires stabilize the calca-
neus. A medial to lateral talar neck wire, mid cuneiform
wires, or metatarsal base wires are used to secure the
foot.
TRANSPORT RINGS
Distraction osteogenesis can be accomplished exter-
nally by a transport ring. When only small lengths of
bone are available, a medial face wire and 90° medial
face half pins will control the transport. Longer transport
segments have the tendency to waggle during transport.
This is caused by nonsymmetric soft tissue origins and
attachments to the transport segment. Waggle can be
29
FIG. 4.8. A single ring with three divergent half pins can be used for
intercalary bone transport. The trailing oblique pin reduces the axial
deformation of the transport block during lengthening. Fractures with
extensive bone loss and short transport segments will only have length
for tensioned wires and a wire and a half pin on the bone block. The
bolts and nuts used to secure half pins during transport must be
tightened securely, or the half pin will rotate rather than lengthen.
limited by spreading half pins widely on the transport
ring (Fig. 4.8). An AP pin placed 3 cm from the docking
end of the transport, a medial face half pin, and a trailing
oblique AP half pin within 3 cm of the corticotomy will
reduce angulation of the transport. An alternative is to
use a medial face wire, medial half pin, or trailing
oblique pin. Wires traversing the anterior lateral com-
partments are extremely painful and should be avoided
during transports.
DUMMY RINGS
Dummy rings can be placed in a frame to stabilize
long working length of rods. They are also placed if a
future fixation is planned, but not needed acutely. In
fracture work, the ring is placed in the working length of
the zone of injury if a large fragment may require a
separate olive wire to improve reduction (working length
ring). Consolidation can be improved by adding fixation
to the corticotomy end of a transport on a dummy ring
after completion and docking of the transport. This
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
30 J.J. HUTSON JR
FIG. 4.9. The wire and half pin fixation should be placed 2 to 3 cm
from the fracture zone. The threaded rods connecting the fixation
blocks should equal the working length plus 50 mm. The additional
length is needed for distraction of the fracture and to allow adjustment
of the ring positions during the early stages of the reduction. The
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
reduces shear at the shaft regenerate junction, improving
maturation.
WORKING LENGTH MECHANIZATION OF
ILIZAROV FRAMES
The Ilizarov method can be used for a myriad number
of mechanizations: angular correction, rotation, transla-
tion, distraction, compression, and neutralization of the
axial skeleton and joints. These functions may be done
one at a time, in conjunction, or sequentially. Blocks of
fixation must be placed on the skeleton on both sides of
the joint, deformity, or fracture to apply a corrective
force. These blocks will be a combination of the fixation
blocks described earlier. The working length is the dis-
tance between the fixation blocks. Stiffness of the frame
is inversely proportional to the square of the working
length (Fig. 3.10). The working length should be reduced
to the smallest span possible that allows for safe soft
tissue clearance and placement of the rods, hinges, and
drive mechanism of the Ilizarov system. It is impractical
to have the fixation blocks closer than 3 cm to the
fracture or deformity. On transports, rings crowding the
construct can block docking and obscure the bone ends
for freshening of the cortical surfaces and bone graft. The
working length is the least distance between the blocks
of fixation that affords space for manipulating the defor-
mity or fracture (Figs. 4.9A, 4.9B, 4.9C, 4.9D, 4.9E,
4.9F, 4.9G, 4.9H, 4.0B).
ANGULAR CORRECTION
Angular corrections are constructed with hinges be-
tween two fixation blocks (Fig. 4.10). The axis of the
hinges must be aligned. The axis is aligned 90° to the
true plane of deformity and centered over the shaft or
aligned outboard of the apex to distract during angular
correction. A distraction “clicker” is placed opposite the
hinges on the concave side of the deformity. Twisted
plates are mounted to the fixation blocks and a long male
working length rods are from 150 to 300 mm with extensive shaft
fracturing. A working length ring is placed to reduce and fixate a large
fragment, which extends into the shaft. The working length rods can
extend across the knee and ankle joint to use ligamentotaxis in the
reduction of periarticular fractures. (A and E) Proximal and distal
periarticular fractures without shaft extension have short working
lengths (large arrow) increasing the stiffness of fixation. (B and F)
Extension of the fracture into the adjacent shaft will increase the
working length and decrease frame stiffness. (D and H) Fracture
fixation and stiffness can be increased by placing working length rings
over shaft extension fragments. Olive wires are used to secure and
reduce the fragment. (C and G) Joint bridging rings should have the
working length reduced to increase stiffness.
 CHAPTER 4 31

FIG. 4.11. Compression between fixation blocks is used to stabilize

fractures to promote healing. It is also used for arthrodesis of the ankle
in the salvage of severe pilon fractures. For compression to be effec-
FIG. 4.10. Angular correction can be done between fixation blocks. tive, the fixation blocks must have stable fixation of the fractured bone
It is used to correct malunions. Angular correction is used by some segment and the working length reduced to a minimum to prevent
surgeons during acute reductions of fractures or as an early postoper- instability.
ative maneuver to correct misaligned fractures not apparent on the
fluoroscope. If during surgery there is confusion about the alignment of
a fracture reduction, obtain a 17-inch x-ray. The alignment will be the patient to turn square nuts or distraction clickers.
clearly elucidated by the x-ray, and correction can be carried out if
necessary. Compression is confirmed with x-ray images of the
fracture site. Tensioned wires will be arched with the
concave arch toward the docking site. Cantilever half
hinge secured to the plates with a nylon lock washer to pins will be angled away from the compressed surfaces.
allow rotation as the angular correction proceeds. Only Compression can be adjusted during each office visit 1 or
one clicker is used. Two drive mechanisms may be 2 mm to maintain stability. The fixation of the Ilizarov
needed for contracture correction of the joints, but will
need constant adjustment to maintain balance of forces.
If one clicker is not exactly parallel to the adjacent
clicker and not equidistant from the center of angular
correction, different rates of distraction will be needed.
Once the angular correction has been completed, the
clicker is usually removed and two additional threaded
rods are placed on the frame. These rods may need to be
placed with conical washers if the frame is not straight,
but the bone shafts are aligned. The hinges are tightened.
The fixation blocks can also be compressed to improve
stiffness or distracted to regain further length by adding
threaded rods and square nuts or placing clickers be-
tween the frame blocks and removing the hinges and
threaded rods.

Compression–Distraction
The minimum number of threaded rod supports or
distraction “clickers” that can be used in the working
length is four (Figs. 4.11, 4.12). The ideal location for the
rods is an equal 90° spread around the rings. The location
FIG. 4.12. Distraction is the essential maneuver of fracture reduction.
of wires, pins, hinges, and other fixation hardware alters Without distraction to length, or over distraction, the displaced fracture
the placement of the rods and placement is modified to fragments cannot be reduced. Distraction is also used to generate new
provide the greatest separation of the rods around the bone for reconstruction of bone loss. Distraction can be done by manual
traction, turning nuts on the threaded rods, or using distraction clickers.
ring. If the frame will be distracted or compressed, the Lengthening is usually done with distraction clickers and intercalary
rods or clickers should be placed to allow easy access for transport with square nuts.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

32 J.J. HUTSON JR

on the threaded rod 4 times a day to regain length

followed by secondary reduction. Distraction is used for
distraction osteogenesis to reconstruct bone loss.

ROTATION
Rotational deformities are best treated by acute rota-
tional corrections during frame application (Fig. 4.13).
Rotational corrections with the frame in place are
difficult. Complex drive mechanisms to rotate the
rings can be constructed. If the tibia is not centered in
the frame, translation will occur and will need to be
corrected after rotation. At the beginning of a defor-
mity correction or fracture reduction, expend the effort
to align the extremity in correct rotation. Examine the
opposite extremity preoperatively and visualize the
correct alignment sight picture. Adherence to this
technique will eliminate the need for constructing
rotational correction mechanism.

FIG. 4.13. (A) The distal tibia at the start of the reduction will be
rotated to correctly align with the proximal tibia. The second toe of the
neutral flexed foot is aligned with the tibial tubercle and patella. This
must be done with accuracy. (B) The rotation to correction must be
centered on the axis of the proximal tibia as seen in the midrow of
figures. (C) If the distal tibia is not aligned axially, the rotation will be
correct, but the axial alignment will be displaced, which will need
correction before proceeding with the reduction. Late rotational cor-
rections are possible, but require complex fixator constructions. This
technique is rarely applied when treating rotational malunions. It is
essential that correct rotation be established early in the reduction of
tibia fractures.
TRANSLATION
Translation can be corrected with parallel drive mech-
anisms between the ring blocks (Fig. 4.14). An outrigger
plate and drawing olive wires can also be used to trans-
late bone segments. Translation in many reconstructions
and fracture reductions is corrected acutely by manipu-
lating the skeleton with the frame. The axial skeleton
should be aligned acutely, avoiding the need for mechan-
ical translation correction by moving the ring blocks.

system is not rigid enough to counteract the obliquities

of angular surfaces at the docking site. If osteotomies
or fracture surfaces are not square, or if a spike of
bone cannot be compressed into a fracture defect that
is square, the axial alignment will deform with com-
pression until stability is established. This may result
in angular deformities of an unacceptable degree. The
skilled technician will create square osteotomies and
use judicious acute shortening to create surfaces which
when compressed, will align the fracture or angular
deformity.
Distraction of the fracture is essential to achieve ana-
tomic reduction of the fracture. Distraction is applied
between the fixation blocks that have been aligned or- FIG. 4.14. Translation correction is used for the treatment of non-
unions. It can be used for delayed unions of oblique metaphyseal, shaft
thogonally on the fracture. Distraction can be applied fractures. Initial anatomic reduction of fractures and application of
acutely, or for late reductions, applied 1/4 turn of the nuts biomechanical principles obviates the need for this technique.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 4
FIG. 4.15. Rarely, a low energy spiral distal tibia fracture will be
observed that can be reduced anatomically with percutaneous screws.
The Ilizarov fixator is placed as a neutralization frame. This frame is
indicated in burn patients with a poor soft tissue envelope who could
not be casted. Neutralization is also used after bone transport to
increase the stress on the regenerate bone to stimulate further matura-
tion of the immature bone.
NEUTRALIZATION
The Ilizarov fixator is used as a neutralization device
(Fig. 4.15). The application is used to axially offload
fractures treated with limited internal fixation or low
energy oblique spiral fractures that need support to pre-
vent further displacement. These frames are used in burn
patients, elderly patients with ischemic vascular disease,
and in clinical situations where skeletal support is
needed, but skin condition does not allow casting or
splinting.
33
Neutralization is also used to increase bone transport
after distraction osteogenesis. The distraction applied to
the tibia to lengthen the leg is removed by loosening the
nuts on the distraction rods. The ring blocks settle into a
neutral position and the nuts are retightened. Some wires
may become loose after this maneuver and need to be
retightened. ‘Neutralization’ of the transport is indicated
when there is at least a posterior, medial, and lateral
neocortex on the bone transport in the distraction gap. If
neutralization is done prematurely, the transport will
collapse.
UNIVERSAL HINGE MECHANISMS
Universal hinge connecting rods (Quick Connect
Smith Nephew, Orthofix, ACE, EBI) and multiplanar
linkage systems (Spacial Frame Smith Nephew) can be
used in the working length of frames. These systems
allow universal mechanization of the axial skeleton, and
can be used to reduce and align bone segments. They are
appealing to many surgeons because the fixation blocks
can be manipulated grossly into alignment without un-
derstanding the principles of placing levers and pivot
points to manipulate the bone segments in deformity
correction and fracture reduction. These systems can be
used successfully to align fractures and malunions, but
are unable to apply opposed reduction techniques for
reducing and stabilizing fractures and nonunions. The
weakness of these universal linkages is the need to
loosen all axis of motion to correct one plane of motion
and the difficulty of adding wires and pins in the working
zone of the fracture or reconstruction. The universal
linkages also are expensive and can double the cost of a
frame.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
Techniques in Orthopaedics®
17(1):34–45 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 5: Reduction Techniques Used for Ilizarov Treatment of

Tibial Fractures

James J. Hutson, Jr., M.D.

Summary: Reduction techniques used to reduce tibia fractures with Ilizarov fixators
are illustrated. Techniques include: wire positioning and angular correction, horizontal
wire positioning on rings, draw and arch wire techniques, half pin reduction tech-
niques, laminar spreader techniques, limited internal fixation with pins, screws and
plates, universal hinge mechanisms, and universal Rancho cube reduction techniques.
Key Words: Ilizarov fixator tibia fracture reduction techniques.

During the treatment of tibial fractures with Ilizarov
fixators, multiple reduction techniques will be combined
to reduce the fracture. The sequence of applying these
techniques will vary with each fracture pattern. There
may be several paths to reduction that result in anatomic
alignment of the fracture. An overview of reduction
techniques will be illustrated and their application will be
further defined during the discussion of tibial plateau,
shaft, and plafond fractures.
The most basic reduction technique is manual traction
and correction of rotation of the fractured tibia. The
application of any external fixator system should be
preceded by manual reduction, and placement of the
fixator while the extremity is maintained in alignment.
Additional local support with folded towels under the
popliteal fossa and distal tibia superior to the ankle will
improve alignment. Traction can be maintained with a
sterile traction pin and bow through the calcaneus with a
weight suspended from a pulley at the foot of the oper-
ating room table while the frame is applied. This tech-
nique will require preplacement of the assembled frame,
or construction of the rings around the tibia. “Traveling
traction,” a simple device with proximal and distal Stein-
man pins connected by Roger Anderson type clamps to
connecting rods bridging the fracture may be left in place
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
and scrubbed and prepared into the field, maintaining
distraction during the early phase of the reduction (Fig.
5.1). The strategy of these techniques is applying traction
before frame application. Once the Ilizarov fixator is
applied, the simple distraction system is removed.
Distraction can also be applied with precise control by
incorporating distraction into the reduction sequence
with the Ilizarov fixator. The placement of horizontal
reference wires and orthogonal fixation blocks allows
distraction to be placed across the fracture, providing the
same effect as extrinsic distraction methods described
above. This method requires preoperative planning. In-
trinsic traction produces excellent axial alignment of the
fracture, avoiding the need for universal hinge mecha-
nisms and complex fixation block manipulations. Axial
traction with correct rotation of the fracture and reestab-
lishment of length or slight overlengthening is essential,
before proceeding with the sequence of reduction. When
applying resuscitation bridge frames, this principle
should be followed. Realign the extremity axially (align
anterior-posterior (AP) and lateral view), correct rotation
of the extremity, and regain length or overdistract. A
fracture stabilized in this manner can be reconstructed 3
to 6 weeks post injury if multiple trauma prevents a
return to surgery. The poorly aligned and shortened
fracture will require a difficult reduction with stripping
of callus and fibrous contracted soft tissues that will
compromise function, or require incremental distraction
through the Ilizarov frame and a delayed reduction.
The importance of axial alignment and distraction is
illustrated by the reduction sequence which posterior

34
 CHAPTER 5 35

FIG. 5.2. The nuts and bolts to assemble the rings are used as
alignment guides for axial alignment of the tibia in the AP plane. The
tibial shaft should be centered under the nuts and bolts and aligned
axially.

reducing the iatrogenic damage of a wider approach to

obtain reduction.
Wire position on the ring is manipulated to improve
the alignment of the fracture. The anterior and posterior
bolts and nuts used to assemble the rings are excellent
FIG. 5.1. Early distraction of distal tibia fractures facilitates second-
ary reduction 1 to 2 weeks after the injury. Traveling traction is applied
landmarks to align the fracture. The bolts should be
by placing a proximal tibia and distal calcaneal pin, and maintaining placed in the AP plane and centered over the midtibia
distraction with medial and lateral rods and clamps. The device is (Fig. 5.2). Their alignment along the Ilizarov fixator is
applied with local anesthesia. The distraction frame does not control
displacement in the AP plane similar to calcaneal pin traction on a
used for a reference to align the tibial shaft. If the shaft
Bohler frame. The frame can be left in place during surgery to distract is aligned with the bolts, the soft tissues of the leg will
the ankle to facilitate joint reduction. The distal transfixation pin can be have the best clearance from the rings. A threaded rod
suspended from the overhead bed frame by ropes to improve the
alignment when the patient is in bed. To prevent posterior displace-
without nuts is passed through the holes laterally or
ment, a half pin can be placed on the medial side of the frame at medially of the Ilizarov fixator, and used as a guide for
midshaft level. aligning the posterior cortex of the tibia parallel with the
frame, while imaging with the fluoroscope (Fig. 5.3). To
align the tibia with the Ilizarov frame, the olive wires
malleolar fragments of pilon fractures are reduced. The
fragment cannot be reduced until the dome of the talus is
reduced axially with the shaft, the talus rotationally
aligned, and the ankle out to length. If the talus is aligned
posteriorly, it will be difficult to reduce the posterior
fragment to the anterior metaphyseal fragments. If the
talar dome is in a shortened position, it will be difficult
to reduce the plafond fragments because the dome of the
talus will be occupying the volume where the metaphy-
seal joint fragments would be in a reduced position.
Having the dome of the talus aligned axially and out to FIG. 5.3. A threaded rod is placed through the lateral holes of the
length allows the plafond fragments to be reduced. Often rings without nuts and is used to align the posterior cortex of the tibia
during reduction (white arrow). Once the alignment is anatomic, the
the fragments will be reduced by ligamentotaxis. Percu- rod is removed for placement of additional wires and half pins to
taneous fixation or a limited open reduction is possible, increase fixation of the fracture.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

36 J.J. HUTSON JR

FIG. 5.5. The plateau is aligned in approximately 3° of varus in

relation to the shaft. The plafond forms a right angle with the shaft. The
horizontal reference wire in the proximal metaphysis is aligned 90° to
the anatomic axis of the shaft when reducing tibial shaft fractures. The
proximal wire will have a slight angulation toward the medial plateau
as illustrated. The distal wire will parallel the joint surface.

will need to be manipulated on the rings (Fig. 5.4). The

tibia wire is manipulated to correct rotation, AP align-
ment, and medial lateral alignment. If a horizontal ref-
erence wire is placed adjacent to the joint, the wire will
form an angle of approximately 87° with the AP plane
through the ring bolts (Fig. 5.5). The angle with the
frame may vary several degrees, if the reference wire is
not exactly 90° to the anatomic axis of the tibia Figure
5.6). This is easily compensated for by bolting the wire
to the ring at the angle that gives correct angular align-

FIG. 5.4 Alignment of proximal and distal horizontal reference

wires. The horizontal reference wire is aligned on the ring with the
anterior ring bolts used as an axial alignment guide. The proximal and
distal metaphyseal bone blocks are aligned correcting axial alignment
and rotation. (A) The tibial plateau is usually aligned as the first
reduction maneuver. (B) The tibial plafond is aligned on the distal
carbon fiber fracture ring after placing a two ring stable base on the
midshaft tibia. The horizontal reference wire is manipulated on the ring
to center the metaphysis on the axis of the tibial shaft and correct FIG. 5.6. (A) Correct alignment of the horizontal reference wire will
rotation and translation. Varus and valgus alignment can be manipu- result in axial alignment of the tibia in the fixator. (B) A wire parallel
lated by angular adjustments of the wire on the ring (Fig. 5.7). to the joint will cause medial angulation in the frame. (C) Angular
adjustments can be used on the proximal ring to align the fixator with
the anatomic shaft. The initial alignment of the horizontal reference
wire should be precise, as the entire reduction sequence will be affected
by the wire’s position.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 5
FIG. 5.7. Angular adjustments to the path of the tensioned wire can
be adjusted precisely. These adjustments are used to align the tibia
axially in the fixator so that the shaft will be centered on the anterior
nuts and bolts of the frame. The angular wires are also used to fixate
pilon fractures in the coronal plane. The sequence of elevation is: one
washer, two washers, three washers, bottom hole two hole post, long
male hinge, top hole two hole post, and three hole post. Wires can be
placed across the plane of the ring. The angular pathways are useful in
stabilizing metaphyseal fracture fragments.
ment to the bone block being secured to the frame (Fig.
5.7). This wire is moved anterior and posterior until the
fragment is aligned with appropriate soft tissue clearance
and the adjacent fragment in the fixation block across the
working length of the fracture. If the fragments cannot be
aligned without soft tissue impingement on the rings, a
larger diameter ring will need to be used.
Medial and lateral translation is controlled by sliding
the olive wire through the loosened slotted fixation bolts
aligning the bone block in anatomic alignment with the
frame or opposing bone block (Figs. 5.4A, 5.4B). The
olive wire is then tensioned. A smooth wire can be used
37
and the bone slid along the tensioned wire. This allows
easier translation, but unstable fixation (Figs. 3.4A, 3.4B,
3.4C). The bone can easily slide on the wire during the
reduction but cannot serve as a pivot point for reducing
the fracture. Control of translation will require a second
wire placed at a divergent angle if a smooth wire is used.
The drawback to using the olive wire is that a retension-
ing sequence will be needed to move an olive wire. This
may be needed two or three times as the sequence of
reduction proceeds. This technique is more demanding,
but gives more precise alignment of the bone block.
The angular alignment in the coronal plane is easily
adjusted by elevating the wire off the ring with washers
and posts (Fig. 5.7). Precise angular corrections are made
with increasing angulation from: one washer, two wash-
ers, three washers, bottom hole two-hole post, long male
hinge, and second hole of a two-hole post.
This technique is useful to “tweak” the alignment of
the bone block in the coronal plane of the frame. If a
horizontal reference wire is tensioned to the ring and the
resulting alignment of the bone block is in varus or
valgus, the appropriate angular correction is made by
loosening the reference wire and elevating the wire off
FIG. 5.8. (A) Acceptance of a poorly placed wire causes distal ring
soft tissue encroachment and axial malalignment. (B) The inexperi-
enced surgeon will align the distal metaphysis in the middle of the ring
causing a valgus deformity of the shaft. Revision of the proximal
horizontal reference wire will correct the malalignment. (C) An ad-
vantage of universal connecting rods is the ability to align the frac-
ture in spite of poor alignment of the fixation blocks with the axis of
the tibia.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
38 J.J. HUTSON JR
FIG. 5.9. The draw wire is used to reduce the fracture in the medial
lateral plane. The fracture must be distracted before using the tech-
nique. An olive wire is placed in the medial lateral plane. The fixation
bolts are brought down on the ring but not tightened. The tensioner is
used to draw the wire through the fixation bolts and reduce the fracture.
Once reduced, the olive side of the wire is tightened and the tensioner
completely removed from the wire. The wire is tensioned to 110 to 130
kg of force. The fracture fragment must pivot around a fixation point.
In the illustration, the pivot point is the distal half pin on a universal
Rancho cube. The midtibia universal Rancho cube is loosened after
being used for distraction to allow the fragment to move in the medial
lateral plane. On the proximal fixation block, an olive drop wire has
been placed to oppose the reduction force.
the ring and retensioning the wire (Fig. 5.6). The bone
block should axially align with the bolts and threaded
rods of the frame. This technique reduces the need for
reshooting the olive wire in a corrected position. The
horizontal reference wire needs to be placed as accu-
rately as possible. Precision placing these wires facili-
tates axial alignment of the bone block. In patients with
tibia vara, tensioning the wire to the frame will reveal the
magnitude of the angular variation from normal and a
new reference wire will need to be placed to accommo-
date the abnormal alignment of the tibia. The initial
alignment of the bone block is critical to the sequence of
the reduction; if the alignment is accurate the reduction
will be centered in the ring system. If the bone block is
in varus or valgus, the anatomic reduction of the tibia
will encroach on the rings at the opposing bone block of
the fracture (Fig. 5.8). This malalignment can be ad-
dressed by “backtracking” and realigning the reference
wire bone block, using bigger rings, which accommodate
sloppy alignments, or using universal hinge mechanisms
between the fixation blocks. Esthetically, having the
reduced tibia centered in the rings is the preferred align-
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
ment. Sloppy alignment presents an image of a reduced
tibia angled across a large diameter ring system and
universal connections have a reduced tibia with offset
ring blocks (Fig. 5.8C). If the tibia is reduced, the
appearance of the frame is incidental, but poor initial
alignment can cause difficulty obtaining anatomic align-
ment or having adequate soft tissue clearance.
Arch wire technique and draw wire technique are
active reduction methods that allow bone blocks and
bone fragments to be manipulated by the Ilizarov system.
These techniques are powerful tools to reduce and sta-
bilize fractures. The draw wire technique is done by
placing an olive wire through the bone fragment or bone
block in alignment with the direction of movement that
will align or translate the bone into anatomic alignment
(Fig. 5.9). The wire is connected to the ring, or offset
hinges or post with loosened slotted fixation bolts. The
frame is built out to the wire. The olive wire is placed
against the fragment that is to be manipulated. The
tensioning tool is placed on the wire and the handle
rotated. The teeth in the tensioner grab the wire and pull
it into the tool moving the olive wire toward the ten-
sioner. The fragment or bone block is powerfully pulled
into reduction. This maneuver should be done slowly
under fluoroscopic observation. The fracture can be split
FIG. 5.10. The arch wire technique is used in the medial lateral
plane. The fracture must be distracted before using the technique. The
olive wire is placed through the tibial shaft and arched up one or two
holes on the ring. The wire on the olive side is tightened. The wire is
tensioned to 110 to 130 kg of force. The arch will flatten and the
fragment moved anteriorly to reduce or compress an oblique shaft
metaphyseal fracture. To be effective, the fragment must rotate around
a pivot point, which is aligned axially with the tibia. In the illustration,
the pivot point is the distal tibia reference wire. The reduction force of
the fragment must be opposed by the opposite fragment, which has
been fixated stiffly to prevent displacement.
 CHAPTER 5
FIG. 5.11. Posterior angular displacement is reduced by pushing up
manually or pulling up with a towel under the leg. The towel is pulled
over the anterior rods and clamped to hold the reduced position. The
aligned fracture is fixated with wires or pins once in the reduced position.
Temporary rods can be placed through unused ring holes anteriorly to
widen the width of the towel as it is pulled over the rods.
with excessive force or the fracture over corrected. The
fragment or bone block must have an opposed fixation
point to prevent deformation. If a fragment is being
reduced to a larger shaft/metaphyseal bone block, the
bone block must be stabilized with an opposed olive wire
or half pin, if not the reduction maneuver will not reduce
the fragment, but displace the bone block into malalign-
ment. If the reference wire is smooth, a draw wire will
not angulate the fragment, but translate it on the wire.
Once the desired correction is obtained, the fixation bolt
on the olive wire is tightened, the tensioner is completely
loosened and removed from the wire and the wire ten-
sioned to the appropriate tension for the configuration. A
3.5 mm washer from the small fragment set may be
placed on the olive wire to increase the surface area of
contact on metaphyseal fragments and cortical fragments
with nondisplaced fractures. The draw wire effect should
be remembered when tensioning any olive wire. If the
olive side fixation bolt is not tightened, or loosely tight-
ened, the olive will become a draw wire. Tensioning will
cause the olive wire to move through the fracture and can
explode a carefully reduced fracture.
The direction of reduction of a draw wire is along the
axis of the olive wire and tensioner. A corrective force
can be applied 90° to the olive wire using the arch wire
technique (Fig. 5.10). This maneuver is usually used to
move a posterior fragment or bone block in an anterior
direction to reduce or compress a fracture. Oblique
periarticular fractures in the coronal plane are com-
pressed to a shaft fragment that has been stabilized with
AP half pins. A bone block that has been aligned with a
horizontal reference wire in the AP plane may have
posterior angulation with the bone block rotating on the
39
axis of the reference wire. An arch wire is one method to
rotate the bone block into axial alignment in the frame.
The arch wire technique provides a method to move
fragments or bone blocks when the direct AP approach is
blocked by overlying fragments. It allows an AP correc-
tion with the wire placed in a medial-lateral plane.
The olive wire is placed in the medial lateral plane
through the fragment that is to be manipulated. The olive
is positioned on the side of the fracture to prevent varus
or valgus displacement during the technique. If the frac-
ture was in valgus before placing the horizontal reference
wire, the olive would be on the lateral side of the fracture,
if varus, on the medial side of the fracture. The medial
lateral pathway has to be chosen to avoid the anterior
tibial artery and nerve (Fig. 2.4 B). Before “shooting”
this wire, an anatomic cross-section should be studied to
avoid impaling these structures. The wire pathway will
need to be altered by moving it anteriorly or angulating
the wire offplane from posterior medial to anterior lateral
(a flattened medial face wire). The wire position is
observed on the ring, or ring extensions (long male hinge
or two-hole post). The nondeformed straight wire hole
position is marked and the wire fixation bolt moved
anteriorly one or two holes, and the wire is secured to the
ring. Displacing the wire more than two holes exceeds
the capacity of the tensioner to tighten the wire. If the
correction requires more than two holes of displacement,
then manual pressure, towels placed between the ring
and posterior surface of the leg, or looping a towel
posterior to the leg and over the anterior threaded rods
(towel technique) needs to be done first to grossly im-
prove the alignment (Fig. 5.11). The wire will form an
FIG. 5.12. The Rancho universal cube is assembled with an 8-mm
bolt, long male hinge, star washer, and one hole Rancho cube. The
assembly can rotate through the long male hinge and axis of the 8-mm
bolt. The 5-mm half pin slides through the Rancho cube.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
40
FIG. 5.13. (A) The universal Rancho cube half pin can be moved on
the ring holes to translate the fixation point. (B) The universal Rancho
cube can be rotated medial or lateral on the axis of the long male hinge
for small medial lateral position corrections of the shaft. Because this
correction occurs by rotation, it is only used for small changes to
“tweak” the alignment of the fracture.
arch with the convex side posterior. The olive wire side
fixation bolt is tightened and the tensioner is tightened on
the wire opposite the olive. As the wire is drawn into the
tool, the arch will flatten and the fragment or bone block
be moved anteriorly. The fragment or bone block oppos-
ing the arch wire fragment has to be stabilized in the AP
plane to oppose the deforming force of the arch wire. If
this is not done, the overlying fracture fragment will be
displaced. There will be a persistent arch in the wire
indicating the Ilizarov system is actively forcing the arch
wire fragment into the opposed bone; this is a desirable
configuration. The arch wire technique applies consider-
able force on the Ilizarov frame. More force can be
applied to an arch wire directly on a ring, and this
configuration of the Ilizarov fixator should be assembled
if possible. Using the arch wire offset on long male
hinges and post reduces the tension that can be applied to
the wire. The frame must have at least four threaded rods
supporting the rings before using the arch or draw wire
technique or frame deformation will occur. The skin will
become tented over the wire after large arch wire reduc-
tions. The skin is released by sharp excision and repaired
with a 5.0 nylon suture. Another technique is to use the
arch wire as a reduction tool. Once the fracture is
reduced, place a new wire or pin to maintain the reduc-
tion, reducing the painful tenting of the skin.
The arch and draw wire techniques may be combined.
The wire is placed and the arch is formed in the wire on
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
J.J. HUTSON JR
the ring to reduce the fragment in the AP plane. The olive
side is not tightened and the tensioner is used to draw the
olive in the medial lateral plane to correct varus/valgus
angulation. Once the alignment is corrected, the fixation
bolt on the olive wire side is tightened, and the arch wire
is retensioned moving the fragment in the AP plane,
aligning or compressing the fragment. Ideally, the draw
wire would be placed in the plane of deformity, but soft
tissue structures in unsafe pathways must be avoided.
This is done by combining the arch and draw wire
techniques. The blood supply is the most important
factor in healing fractures, and great effort should be
exerted to preserving it during the reduction of the
fracture.
Half pins and Steinman pins are used to improve the
reduction of tibial fractures. Half pins should be placed
initially during the reduction on universal mountings,
which allow the fracture to be manipulated during the
course of the reduction (Fig. 5.12). If half pins are
mounted on Rancho cubes bolted directly to the frame,
the pins cannot be manipulated, and if the fracture
requires further manipulation, the Rancho cube will have
to be unbolted, the fracture moved, and the half pin
chased with washers and offset hinges to reconnect it to
the frame.
The initial half pins should be connected to the rings
with a Rancho universal cube assembly. The Rancho
universal cube consists of a one-hole cube connected to
a long male hinge with a star washer between the cube
FIG. 5.14. (A) The Rancho cube can be rotated through the 8-mm
bolt for angular corrections in the AP plane. (B) The half pin can be
adjusted in the AP plane to align the fracture fragments in the lateral
fluoroscopic image.
 CHAPTER 5
FIG. 5.15. Anterior-posterior plane corrections can be done with
force using a laminar spreader. A second Rancho cube is bolted to the
half pin above the ring universal cube. The half pin cube is loosened
and the laminar spreader opened powerfully, reducing the fracture. The
opposing fragment must be fixated stiffly to prevent migration with
reduction. The universal cube is tightened once the reduction is ob-
tained. The fragment must rotate around a pivot point, in the illustra-
tion, the distal horizontal reference wire. Distraction of the fracture is
essential before using the technique.
and hinge, and an 8-mm bolt (or 10-mm bolt with 2 mm
washer). There is a commercially produced universal
cube that can be used, but does not work as well. The half
pin position can be manipulated in several ways (Figs.
5.13A. 5.13B, 5.14A, 5.14B). The male hinge is posi-
tioned on the ring, and moved on the ring by placing it in
adjacent holes. This allows correction of alignment in the
frontal plane and is done to move the tibia shaft medial
or lateral to improve alignment. The cube can rotate on
the axis of the threaded shaft of the long male hinge,
producing small medial lateral corrections of 5 mm. This
correction is limited, if more displacement is needed, the
rotation becomes too great to accept. This correction is
used to “tweak” the reduction 5 mm in the medial lateral
plane. The Rancho cube can rotate on the 8-mm bolt
securing it to the long male hinge, allowing angular align-
ment change in the sagittal plane. This plane of correction
is used when correcting posterior displacement (recurva-
tum) in shaft fractures or periarticular fractures.
The last reduction available using a universal Rancho
cube, is the half pin sliding through the cube allowing
41
change in position of the tibia distance between the
ring and tibia. If the universal Rancho cube is in the
sagittal plane, the tibia can be manipulated anterior-
posterior. If the universal Rancho cube is in any other
plane, the tibia will be moved along the axis of the pin.
This is used as a powerful reduction technique when
aligning fractures.
The laminar spreader technique allows precise manip-
ulation of fracture alignment using half pins and univer-
sal Rancho cubes (Fig. 5.15). A second one-hole cube is
bolted to the half pin 1 cm peripheral (above) the uni-
versal Rancho cube. A laminar spreader is placed be-
tween the cubes. The bolt securing the half pin to the
universal cube is loosened. The laminar spreader is
clicked open and the tibial fragment is moved toward the
ring with precise control until it is reduced. This tech-
nique is extremely effective in the AP plane during
fracture reduction. A fragment displaced posteriorly, can
FIG. 5.16. (A) A free wire is used to fixate small fragments of
subchondral bone. The wires are drilled through the fragments percu-
taneously or through an open approach. The wire can be passed out of
the skin on the opposite side of entry to remove it out of the open
approach. The wire must be placed in a safe wire pathway. The wire is
only used when a distraction-bridging frame is stabilizing the joint. It
is removed in clinic when the femoral distraction ring or footplate is
removed. (B) A brad wire is an internal fixation device to fixate small
osteochondral fragments. The wire is bent over 180° and tamped into
the soft bone of the metaphysis. This prevents wire migration. The wire
is drilled to length just emerging from the opposite cortex. The wire is
backed up 7 or 8 mm, bent over, and cut. It is then tamped into the
bone. This technique prevents the point from extending deeply into the
soft tissues. A brad wire is used in the AP plane when a free wire would
be in an unsafe wire pathway.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
42 J.J. HUTSON JR
FIG. 5.17. Percutaneous reduction or limited open reduction is used
to reduce the metaphysis and joint before placing tensioned wires. (A)
With large fragments, a screw can be placed below the horizontal
reference wire pathway. (B) In most periarticular fractures, the limited
space available prevents screw placement in the metaphysis below the
wires. A 4.5 mm cannulated screw is better placed in a subchondral
position avoiding the wire pathways. (C) Massive 7.3 mm cannulated
screws with washers block the wire pathways and fragment commi-
nuted fractures. Wires in contact with these large screws may cause
deep infections. (D) Large diameter screws can displace fissures and
nondisplaced fractures in the metaphysis. Because the opposed olive
wires will stabilize the metaphysis, smaller diameter screws are used
for the “limited” internal fixation.
be drawn anteriorly into reduction with leverage and
precision. It is used to compress oblique plane fractures
of the shaft to improve stiffness and prevent nonunions at
the junction of the distal tibia and metaphysis. The tech-
nique is used on the medial face of the tibia to move a
fragment medially, but not laterally. The AP plane cor-
rection of the laminar spreader technique is duplicated by
using an arch wire. The two techniques compliment each
other. The half pin laminar spreader technique is used on
larger shaft fragments and the arch wire technique on
smaller oblique fractures, especially the posterior frag-
ment of an oblique coronal plane fracture.
The insertion handle can be applied to a half pin and
used to push a fragment away from the ring. This
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
technique is used to improve reduction or correct over-
corrections using the laminar spreader technique.
Steinman pins and screws are used to improve reduc-
tions of fractures. Steinman pins are used as small
fragment “nails” to secure fragments that are too small to
fixate with screws (Fig. 5.16). A fragment has to be three
times the diameter of a screw to not fail during fixation.
Fragments 1 cm or greater in size can be fixated with 3.5
mm cortical screws or cannulated screws. As the frag-
ments become smaller than 1 cm, 0.045 Steinman pins
FIG. 5.18. (A) Segmental shaft fractures and shaft extension from
periarticular fractures can have coronal fractures. If these fractures are
not identified before fixation, half pins can split them apart. Anterior-
posterior percutaneous cannulated lag screws are used to reduce and
fixate the fragments. Olive wires are used for fixation rather than half
pins. (B) Moderate shaft extension in distal tibia fractures is reduced
with two AP cannulated lag screws. This is reasonable in fractures with
limited displacement and soft tissues that are not shredded adjacent to
the fracture. Two screws are placed and sequentially tightened to close
the fracture gap. If one screw is used to reduce the fracture, the
fragment may be split and the fixation lost. (C) High energy pilon
fractures are associated with posterior proximal extension with wide
displacement and soft tissue disruption. A lag screw is indicated if the
fragment is reduced near anatomically. If it is not possible to achieve
a good reduction, placing a screw across a wide displacement gap will
have little effect on healing. An arch wire may be placed in this
fragment on a working length ring or the fracture compressed to
stimulate healing. Usually this fracture heals with a large posterior
callus which bridges from the shaft to the posterior fragment with scant
new bone in the widened fracture gap.
 CHAPTER 5 43

are used as nails or subchondral “rebar” to align the

fragments. The Steinman pins are placed beneath the soft
tissue as permanent fixation, or used as free wires, which
are placed internally, but exit through the skin allowing
them to be removed as the fracture heals (Fig. 5.16A).
Steinman pins, which are used internally, need to have
one end bent over 180° and impacted into the bone to
prevent migration (Fig. 5.16B). They should never be cut
as straight wires, which can migrate and cause problems.
The use of Steinman pins is confined to aligning the
joint surface and epiphyseal fracture fragments of the
plateau and plafond. Because the Ilizarov technique uses
indirect reduction principles, the fragmentation of the
metaphysis does not require anatomic alignment, but
only axial alignment. The joint surface demands accurate
reduction, and this is the indication for Steinman pin
application.
Larger Steinman pins are used as temporary pushing
pins to gain control of a fracture fragment in the early
phase of fracture healing. These pins are connected to the
frame with Rancho cubes or buckle clamps. The pins are
removed after 6 weeks when early callus has stabilized
the fracture. Olive wires are used as small fragment push
pins by cutting the wire several millimeters beyond the
olive and connecting it to one side of the ring.
Interfragmentary screws are used to align joint surface
fractures (Figs. 5.17A, 5.17B, 5.17C, 5.17D). Proximal
periarticular fractures with lesser comminution (C1, C2,
and nondisplaced A fractures) are converted into a uni-
fied metaphyseal block with lag screws. The sagittal
fracture of the C1 and C2 fractures are manipulated with
large pelvic reduction clamps, percutaneous threaded
Steinman pins (joy sticks) or limited open reduction, and
stabilized with a small diameter screw. A 4.5 mm can-
nulated screw is placed just below the joint in a subchon-
dral position to stabilize the fracture (Fig. 5.17B). If the
metaphyseal fragments are larger, the screws can be
placed several centimeters below the joint surface (Fig.
5.17A). The longest 4.5 mm cannulated screw available FIG. 5.19. Limited small plate fixation can be used to fixate anterior
and posterior medial fracture fragments that are difficult to control with
is 72 mm. This is not long enough to gain cortex-to- tensioned wires. The plates are located away from the wire pathways
cortex fixation, but provides enough stability until the avoiding bacterial contamination from the pintrack. Plating in the
olive wire cluster is placed in the metaphysis. Long 3.5 medial and lateral corridors in contact with the wires will lead to deep
infection. (A) The anterior tubercle plate can fixate patella tendon
mm pelvic cortical screws are available, which are used avulsions. (B) The posterior medial plate is placed through a limited
to stabilize the plateau. The screws are positioned just posterior medial approach and is slid under the pes anserinus tendon
below the subchondral surface of the joint. Large diam- group. The posterior medial corner is reduced and the coronal split
associated with the C3.3 fracture pattern is fixed with an AP 4.5 mm
eter cannulated screws (6.5 mm and 7.3 mm) can be used cannulated screw. The plates are used as buttress or spring plates and
in larger fragment fixation, but tend to block the path- may not have screw purchase in the metaphysis. (C) Unstable oblique
ways for the olive wires (Figs. 5.17C, 5.17D). The use of fragments located anteriorly in pilon fractures can be unstable. Align-
ing the fragment with the proximal shaft will facilitate reduction of the
large washers on the screws obscures the pathways for anterior plafond. A spring plate placed anteriorly will control this
the tensioned wire leading to poor stabilization of the unstable fragment. The spring plate is placed away from the tensioned
metaphyseal block and nonunion of the fracture. Large wire pathways.
6.5 mm screws combined with two smooth tensioned

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

44 J.J. HUTSON JR
FIG. 5.20. Working length rings are placed on the fixator to control
shaft extension of the fracture. The metaphysis is aligned using a
horizontal reference wire and further fixated with divergent opposed
olive wires. Once axial alignment is achieved, the shaft extension
fragment can be reduced with an olive wire using an arch or draw wire
technique. The working length ring is moved superior or inferior on the
fixator until it is in the best position to fixate the fragment. Once in
place it combines with the metaphyseal ring as a double ring block. The
draw wire reduction of the shaft fragment is opposed by the olive wire
on the fracture reduction ring and the AP half pin on the mid tibial ring.
(A) On the distal tibia illustration, the olive wire of the working ring
becomes part of the distal fixation block. The frame would be com-
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
wires with marginal angular divergence on a hybrid
frame have been associated with an unacceptable rate of
nonunion. The interfragmentary screws are needed only
to align the joint surface; the Ilizarov fixator tensioned
wires stabilize the fixation blocks and maintain axial
alignment. This is the essence of using these systems.
In C3.2 and C3.3 tibial plateau fractures, there is a
coronal split of the medial plateau. This is reduced
percutaneously or with a limited open reduction and
stabilized with an anterior-posterior 4.5 mm cannulated
screw, 3.5 mm cortical screw, or 4.0 mm cancellous
screw. These screws are placed subchondrally, to avoid
blocking the tensioned wire pathway (Fig. 7.19).
Distally, in the tibial plafond, small diameter screws
are used to secure joint surface fragments. The most
common application is a cannulated anterior to posterior
screw for the coronal plane fracture involving the poste-
rior malleolus (Fig. 8.33). This screw should be placed in
a subchondral position to clear the pathway for the
tensioned wire cluster.
Interfragmentary screws are also applicable to shaft
fractures which have obtuse fracture patterns greater than
60°, which are difficult to compress and stabilize with
tensioned wire fixators. Two patterns will be observed.
One is a shaft fragment, which has a coronal split parallel
to the shaft that can be stabilized with AP lag screws
followed by tensioned wire fixation (Fig. 5.18A). These
fragments will further displace if a half pin is used. The
other fracture is the long oblique fracture in the coronal
plane, associated with distal tibial plafond fractures with
proximal extension (Fig. 5.18B). The Ilizarov fixator is
used to distract the fracture and multiple lag screws are
placed. This is done percutaneously. The Ilizarov fixator
will function as a neutralization frame in this configura-
tion and healing is facilitated by an anatomic reduction.
If the fracture was caused by a high-energy mechanism,
and excellent reduction cannot be obtained, then com-
pression and late bone grafting, or the use of squaring
osteotomies and compression may be indicated (Fig.
5.18C).
Limited internal plating is used to fixate fragments in
the anterior and posterior quadrants of periarticular frac-
tures. Anterior tibial tubercle fragments and posterior me-
dial tibial osteochondral fragments are the most common
pressed between the distal fixation block and the stable base. (B) On the
proximal tibia model, the working length olive wire is compressing the
fragment to the shaft and stable base fragment. This alignment changes
the biomechanics of the system. Compression of the fracture would be
done by compressing the fracture metaphyseal ring to the reconstructed
shaft using the nuts on the carbon fracture ring. Fixation wires and pins
should not be placed across the fracture, but kept isolated to individual
fixation blocks to allow compression of the fracture.
 CHAPTER 5
FIG. 5.21. A hinge can be placed on Type A and Type C fractures
at the level of the fracture. This is used as a reduction technique or a
postsurgery frame manipulation to correct valgus or varus alignment
that was not corrected at surgery. This technique is used by Roger
Atkins, (Bristol, United Kingdom).
usage of this technique (Figs. 5.19A, 5.19B). These plates
function as spring plates and have the proximal hole mod-
ified by cutting spikes on the end to impinge the bone. The
plates are placed in soft tissue zones where olive wires
cannot be placed. Plates are not placed medially or laterally
adjacent to the wires, to avoid infection. Plates are also used
for pilon fractures to provide an anterior buttress plate for
unstable comminution (Fig. 5.19C).
Working length rings are important reduction tech-
niques to stabilize shaft extension associated with peri-
articular fractures. The rings are placed between the
stable base and fracture reduction ring. Their position is
aligned to fixate large oblique shaft extension fragments
(Figs. 5.20A, 5.20B).
FIG. 5.22. The biomechanics of the hybrid fixator can be improved by
using the shortest connecting rods possible and expanding the fixation
block to two rings. This increases the stiffness of the system. Some
systems also have connecting rod add-on pin clamps, which allow a half
pin to be placed closer to the fracture site to increase stability.
45
FIG. 5.23. The most common reduction technique using hybrid fix-
ators is manipulation manually of two fixation blocks connected by
universal connecting rods. This technique is duplicated in the ”American”
Ilizarov system by Quick Connect Rods (Smith, Nephew, Richards). The
configuration is equivalent to other hybrid fixators and suffers from the
same weaknesses. The technique is effective for moderate fracture patterns
treated early. Powerful reduction forces cannot be applied using the
technique and it has been associated with nonunions of pilon fractures. The
fixators have excessive working lengths, single clamp or ring fixation
blocks on the shaft, and overly large rings. The universal hinge mecha-
nisms are massive, obscure x-rays, and are expensive.
Hinges are placed between the fixation ring and stable
base to correct varus and valgus alignment. This tech-
nique is used to correct postoperative residual varus and
valgus if needed. Some surgeons use it as an active
reduction method during surgery (Fig. 5.21).
Universal hinges are used to reduce fractures and repre-
sent a different strategy of reduction (Fig. 5.22). Ilizarov
rings fixated with wires and half pins are applied proximal
and distal to the fracture. The rings should be placed
orthogonally. The fixation blocks are grasped manually
with the hinges loosened. The fracture is reduced and the
universal joints are tightened. Using Ilizarov rings con-
nected by these universal rods duplicates hybrid fixators
using a massive universal connecting rod and secondary
support post (Fig. 5.23). The Ilizarov ring has advantages
over the massive 5/8 open rings used in these systems. The
ring is lighter, less radio-opaque, and comes in smaller
diameters. Placing a biomechanically stiff fixation block on
the metaphysis is facilitated by the low profile of the ring
and the ability to place three to four opposed divergent olive
wires on the ring using the biomechanical principles illus-
trated in Chapter 3. The universal hinge reduction technique
is applicable to periarticular fractures with moderate com-
minution that are treated early or have been maintained in
distraction to length.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
Techniques in Orthopaedics®
17(1):46–57 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 6: The Treatment of Tibial Shaft Fractures with

Ilizarov Fixators

James J. Hutson, Jr., M.D.

Summary: The strategy of reduction of tibial shaft fractures and segmented tibia
fractures is discussed. The technical sequence of reduction is illustrated. Initial
alignment of the horizontal reference wire and techniques to gain initial anatomic
alignment is illustrated. Key Words: Ilizarov fixator tibia shaft segmental fracture.

The reduction of tibial shaft fractures using tensioned
wire fixators employs two strategies of reduction. The
simplest and most common technique is placing an
orthogonal bone fixation block on the proximal and
distal fragment of the shaft, and connecting them with
universal connecting rods1 (Figs. 5.22, 5.23). If the
fixation rings are not placed anatomically, the universal
hinges will allow reduction, but the rings will not be
axially aligned preventing axial compression and distrac-
tion; valuable maneuvers during reduction and fracture
healing. These fixator systems require manual grasping
of the ring blocks, reduction of the fracture, and a
tightening of the universal mechanism to stabilize the
fracture. Exposure of the surgeon’s hands to fluoroscopic
radiation is a common occurrence. The universal hinges
also have an “all or none” freedom of motion. To correct
a deformity in one plane, all axis of motion have to be
loosened, which can cause further loss of reduction. The
universal hinges have long working lengths to accom-
modate the complex hinge mechanisms causing loss of
stiffness in the frames. These frames are applicable to
simpler fracture patterns treated early. They are difficult
to use in late fracture reduction in which soft tissue
shortening will require forceful distraction to obtain
reduction or in fractures with high-energy comminution
or segmental fracture patterns. The universal hinge strat-
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
egy is effective for simpler fractures and allows novice
external fixator surgeons to stabilize complex fractures.
The second strategy of reduction using circular fix-
ators uses the fixator as an intrinsic distraction frame,
which provides an orthogonal scaffold to manipulate the
fracture.2 Controlled distraction is used to gain axial
alignment. Distraction creates ligamentotaxis, which re-
duces periarticular fractures. The mechanical advantage
of the screw is used to distract the fracture, which is
superior to manual distraction used in the universal hinge
techniques. This technique is similar to using a femoral
distractor when plating a distal femur fracture. Distrac-
tion is applied through horizontal reference wires placed
through the bone rather than the surgeons attempting to
“pull the leg” during the procedure.
TIBIAL SHAFT FRACTURES REDUCTION
TECHNIQUE
The tibial shaft is reduced by distracting between two
horizontal reference wires, a plateau wire and a plafond
wire (Figs. 6.1— 6.12). The plateau wire is placed 1 cm
below the joint through the midtibia. The wire is not
parallel to the joint, but approximately 3° varus to be 90°
to the axis of the shaft (Fig. 6.3). A four-ring frame, a
proximal and distal double ring block connected by
separate working rods is placed over the tibia. The
proximal tibia is aligned in the frame using the anterior-
posterior (AP) nuts and bolts as an alignment guide (Fig.
6.4). The nuts and bolts that are used to assemble the half
rings are always placed in the AP plane. The ring block
should have fixation over the available bone of the

46
 CHAPTER 6 47

FIG. 6.1. Reduction of a tibial shaft fracture requires distraction to

FIG. 6.3. The plateau is aligned in approximately 3° of varus in
length, correction of rotation, and axial alignment of the fracture
relation to the shaft. The plafond forms a right angle with the shaft. The
segments.
horizontal reference wire in the proximal metaphysis is aligned 90° to
the anatomic axis of the shaft when reducing tibial shaft fractures. The
proximal wire will have a slight angulation toward the medial plateau
fragment, spacing the pins and wires to increase the as illustrated. The distal wire will parallel the joint surface.
stiffness of the frame. Single ring fixation blocks are less
stiff than appropriately spaced double ring fixation
expose the distal tibia. A horizontal reference wire is
blocks.
placed 1 cm above the plafond. The frame is lengthened
The proximal tibia horizontal reference wire is aligned
to the level of the horizontal reference wire, and the
on the proximal ring with the shaft aligned with the AP
distal fragment is aligned on the ring axially with the AP
nuts and bolts on the ring system (Figs. 6.5A. 6.5B,
bolts and nuts and laterally with the midshaft of the
6.5C). Manual traction is placed on the leg, and the foot
proximal metaphyseal bone block. The wire is tensioned
is rotated so that the second toe aligns with the tibial
to 110 kg and the fracture is distracted between the
tubercle. It is essential to establish correct rotational
proximal and distal horizontal reference wires (Fig.
alignment at this stage of the reduction. The frame is
6.6A). The overall alignment is examined. If the axial
temporarily shortened through the working length rods to

FIG. 6.2. Horizontal reference wires are placed in the proximal and FIG. 6.4. The nuts and bolts used to assemble the half rings are
distal metaphysis. The fracture will be distracted and aligned by aligned in the AP plane and are used as alignment guides for axial
manipulation of the wires. alignment of the tibia.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

48 J.J. HUTSON JR

FIG. 6.5. (A) Correct alignment of the horizontal reference wire will
result in axial alignment of the tibia in the fixator. (B) A wire parallel
to the joint will cause medial angulation in the frame. (C) Angular
adjustments can be used on the proximal ring to align the fixator with
the anatomic shaft. The initial alignment of the horizontal reference
wire should be precise, as the entire reduction sequence will be affected
by the wire’s position.

alignment is good, secondary reduction techniques will

be used to align and stabilize the fracture. If the align-
ment is unsatisfactory, the wire position will be revised
on the rings correcting rotation, translation, and angula-
tion as needed. The surgeon should not proceed to
secondary reduction until the alignment with the two

FIG. 6.7. (A) Acceptance of a poorly placed wire causes distal ring
soft tissue encroachment and axial malalignment. (B) The inexperi-
enced surgeon will align the distal metaphysis in the middle of the ring
causing a valgus deformity of the shaft. Revision of the proximal
horizontal reference wire will correct the malalignment. (C) An advan-
tage of universal connecting rods is the ability to align the fracture in
spite of poor alignment of the fixation blocks with the axis of the tibia.

horizontal reference wires is acceptable (Figs. 6.7A,

FIG. 6.6. (A) The tibial shaft is manually distracted. A horizontal
reference wire is placed in the distal tibia and the metaphysis is aligned
axially with the proximal fragment. The fracture is distracted out to
length or slightly overdistracted. Distraction is the key to reduction. (B)
There will usually be a posterior sag. (C) The posterior angulation is
reduced with towels placed under the leg or by using a towel to pull up
the fracture and clamping the towel over the threaded rods of the frame.
(D) A long threaded rod can be placed through the rings without nuts
to provide an alignment guide for the posterior cortex of the tibia (white
arrow).
6.7B, 6.7C). To evaluate lateral view alignment, a
threaded rod is placed laterally through the rings without
nuts attaching the rod. The posterior cortex of the tibia
should be parallel with the rod (Fig. 6.6B).
The lateral fluoroscopic view will usually reveal pos-
terior angulation of the fracture. The horizontal reference
wire forms an axis, which the bone block rotates on in
the sagittal plane. The fracture can be reduced by several
methods. The simplest is forcing folded towels between
the ring and the posterior leg, elevating the leg and
reducing the fracture. Once aligned, the bone block can
have secondary tensioned wires or half pins placed on
the fixation block to stabilize the fracture. A towel can be
placed under the calf as a sling, pulled up anteriorly over
the threaded rods, and clamped with a towel clip (Fig.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 6 49

6.6C). The position of the bone block is adjusted by

pulling up on the towel with more force. Once the tibia
is aligned, secondary pins and wires are placed in the
fragment. Half pins should be mounted on universal
Rancho cubes to allow manipulation. The posterior dis-
placement is corrected by using the arch wire technique
or the laminar spreader half pin technique (Figs. 5.9,
5.10). The lateral alignment is reevaluated by placing a
threaded rod through the rings without nuts and using it
as a guide, the posterior cortex should align with the rod.
The anterior cortex is bowed anterior and not a reliable
guide to alignment.
The AP alignment will need secondary reduction. The
AP half pins help to control the medial-lateral alignment.
The pins can be rotated slightly to improve the reduction
(Fig. 5.13B). Half pins can be pushed or pulled through
medial universal Rancho cubes to align the fracture, or
olive wires using the draw wire technique can be placed
to align the fracture. The periarticular bone block is
aligned in the proximal ring block orthogonally, and the
larger shaft fragment aligned with half pin reduction

FIG. 6.9. With the tibia reduced, additional fixation is added to the
fixator to increase stiffness. The fracture is compressed across the
working length.

techniques or draw wire techniques (Fig. 6.8). Basically,

one bone block is aligned orthogonally, and the second is
reduced to the first bone block with varying reduction
techniques. Once the fracture is aligned, additional pins
and wires are added to the frame to increase stiffness and
the fracture site is compressed (Fig. 6.9). Compression of
the fracture site before secondary stiffening of the frame
and fracture fixation will cause deformation rather than
compression.
In summary, the basic reduction technique for tibial
shaft fractures is:
1) Place tibial plateau horizontal reference wire.
2) Align proximal bone block in frame and tension wire.
3) Place tibial plafond horizontal reference wire.
4) Align distal bone block axially with proximal bone
FIG. 6.8. The proximal fragment is aligned orthogonally in the block and distract the fracture.
fixator and stabilized with a half pin or wire. The distal fragment is
reduced to the proximal fragment by the reduction techniques described 5) Correct posterior angulation of bone blocks and
earlier. In this illustration, an arch wire has been used. The distal stabilize secondarily.
horizontal reference wire is the pivot axis for the arch wire reduction at 6) Add secondary stabilization to proximal bone block.
the midshaft. The reduction is opposed by an AP plane half pin on a
universal Rancho cube, which was used to align the proximal fixation 7) Use reduction techniques to reduce distal fragment
block orthogonally. to proximal bone block.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

50 J.J. HUTSON JR

FIG. 6.10. The safe wire pathways of the proximal tibia are in the
medial lateral plane. The gray arc sections indicate the sections of the
ring where threaded rods can be placed without interfering with wire
and pin fixation. The anterior lateral one to three holes are not blocked
by fixation wires and pins. During fixator construction, threaded rods in
the working length are placed in the anterior lateral and posterior
medial three hole, as these ring holes are seldom blocked by fixation
wires. The posterior lateral rod is easily placed. The anterior medial
threaded rod must be placed avoiding the tensioned wires and half pins.
Wire position always has precedence over threaded rod position. The
threaded rods are always placed in the posterior medial and anterior
lateral three holes in the working length of the fixator to avoid
overlying the fracture image on fluoroscopy (dark gray nuts).
8) Add secondary stabilizing half pins and wires.
9) Compress the fracture across the working length rods.
FIG. 6.11. The gray arcs define the safe threaded rod section on the
ring at the midtibia. The threaded rods used to construct the stable base
on periarticular fractures are placed initially in the anterior lateral one
hole and posterior medial one hole leaving a one-hole separation
between the working length rod and stable base rod (dark gray nuts).
Positioning the rods in the AP plane also increases the frame stiffness
to bending in the AP plane.
and tensioned wires can be placed through the tibia in the
medial lateral plane carefully altering the wire path to
avoid the anterior tibial artery.
The “unsafe” zones for pins and wires are the anterior
lateral and posterior medial five to six hole segments of
the rings. Threaded rods can always be placed through
these holes on the rings when constructing a fixator. Four

THE PLACEMENT OF THREADED RODS

ACROSS FIXATION BLOCKS DURING THE
TREATMENT OF TIBIAL FRACTURES WITH
ILIZAROV FIXATORS
The placement of threaded rods to assemble the fixa-
tion blocks and span the working length of the frame
must allow placement of tensioned wires and half pins on
the Ilizarov fixator, to gain control of the fracture. The
threaded rods should also be placed to provide the
clearest image of the fracture reduction. Rods connecting
fixation blocks also are used as alignment guides to
assess the orthogonal position of the tibia in the frame. If
the threaded rods parallel the tibia on the fluoroscopic
image, then the fracture is well aligned. The anatomy of
the soft tissues of the lower leg dictate safe wire and pin
corridors for fixation of tibia fractures. The proximal and
distal metaphysis have approximately a 60° arc in the
FIG. 6.12. The gray arcs define the threaded rod positions on the
safe zone on the medial and lateral side. The medial tibia distal tibia ring. The working length rods are placed in the anterior
is available to half pins from approximately 10° to 90° lateral and posterior medial three hole (dark gray nuts).

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 6
FIG. 6.13. The tibia can have several patterns of segmental fractures.
Proximal and distal periarticular fractures are combined with segmental
shaft fractures. Proximal and distal periarticular fractures are com-
bined. Complex multisegmental patterns occur. Segmental shaft frac-
tures with soft tissue compromise are also indications for Ilizarov
fixators.
rods are needed to provide adequate stiffness for Ilizarov
fixators. The fixator can be assembled with two rods for
initial alignment, then the medial and lateral rods can be
placed once the pathways of the half pins and wires are
known. Fixation blocks are pre-assembled with the
threaded rods in the anterior lateral one hole, and poste-
rior medial one hole. This will place the rods adjacent to
the shaft to use as an alignment guide. This also places
the threaded rods in the AP plane of the tibia, which
FIG. 6.14. Intramedullary nailing is the preferred treatment for
segmental shaft fractures. Ilizarov fracture fixation is indicated if there
is local infection, severe ischemic vascular disease, compromised soft
tissue envelope, or early callus with shortening that would prevent
reduction by intramedullary nailing. Fracturing extending into the
metaphysis and joint surface is an indication for Ilizarov fixators when
treating segmental tibia fractures.
51
FIG. 6.15. The reduction strategy for segmental tibia shaft fractures
is: distraction between horizontal reference wires, alignment of proxi-
mal and distal metaphysis, alignment of segmental shaft fragment,
stabilization, and compression of fracture.
increases the frame stiffness to AP bending. The working
length rods connecting the fixation blocks are placed in
the anterior lateral and posterior medial three holes. This
separates the rods over the zone of injury for clear x-ray
FIG. 6.16. The fixator is designed with three fixation blocks and two
working length sections. Horizontal reference wires are placed and the
proximal and distal metaphysis is aligned axially. The proximal me-
taphysis is carefully aligned on the proximal fracture ring. Because this
essentially will be a shaft reduction technique, the wire should be
placed 90° to the axis of the shaft and not parallel to the joint (Figs. 6.3,
6.5). The distal metaphysis is aligned using the AP nuts and bolts of the
frame centering on the axis of the proximal fragment. In a similar
technique, the proximal and distal metaphysis are aligned in the lateral
plane. The fracture is distracted. Axial distraction out to length or
overdistraction is essential to reduce the fragments. If the fragments are
overriding, reduction will be difficult. The distal and proximal frag-
ments are aligned orthogonally using olive wires or half pins mounted
on universal cubes. In the lateral fluoroview, the metaphyseal frag-
ments are rotated on the horizontal reference wire with reduction
techniques and stabilized with half pins or wires.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
52 J.J. HUTSON JR
FIG. 6.17. The technique of opposed olive wires is used to reduce
the segmental fragment. The olive wires are placed square to the axis
of the fragment. The olive wire proximally and the half pin distally
(gray arrows), will oppose the reduction force that will be applied to the
olive wires on the segmental fragment.
imaging and provides clearance from the nuts on the
fixation block threaded rods on the one hole of the ring.
The Ilizarov fracture frame can be rapidly assembled
with two rods across each fixation block and working
length, the tibia aligned using the horizontal reference
FIG. 6.18. For smaller segmental fragments, the fixator configura-
tion is modified to have a single ring control the segmental fragment.
The proximal and distal fixation blocks are connected by long working
length rods.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 6.19. A combination of opposed arch and draw wire techniques
is used to reduce the fracture. Olive wires and half pins on the
metaphyseal segments oppose the reduction force of the segmental
fragment reduction (gray arrows). Observe that the posterior angulation
of the distal end of the segmental fracture was reduced by an olive wire,
combining an arch and draw wire technique.
wires, and further rods added once the surgeon evaluates
where the fixation wires and pins will be placed on the
frame.
The anterior lateral and posterior medial rods will usually
not ever be moved to place wires and pins because they are
in the ring quadrants where there is no safe wire or pin
pathway, and thus will not have to be moved to allow
fixation of wires or pins. The early frame with two rods is
not stiff enough to apply forceful traction or reduction
maneuvers. The frame construction will need to have at
least four rods between the fixation blocks to distract. Four
rods will provide adequate frame stiffness for most distrac-
tion and fracture reduction techniques. The basic concept:
early assembly with two rods in the anterior lateral and
posterior medial ring segments can be done to establish
working length distances and fixation block sizing, fol-
lowed by build up of the frame as further half pins and
wires are added as the reduction progresses. There is no
formula for a fracture frame. The early frame is aligned and
 CHAPTER 6
FIG. 6.20. Additional pins and wires are added to the frame to
increase stiffness and the fracture is compressed.
fitted, followed by further reduction techniques, and final
stabilization of the fixator.
The fixator for fracture treatment is not preconstructed
the day prior to surgery. It is difficult to choose the
FIG. 6.21. Tibial plateau with midshaft segmental fracture. A
limited open reduction or percutaneous reduction is done to align the
plateau joint surface. The fixator consists of a single ring fixation block
proximal and a periarticular fixation block distal, connected with
working length rods with two midtibial rings. The fracture is distracted.
The distal segment is reduced using a laminar spreader technique.
53
FIG. 6.22. The proximal metaphysis is stabilized orthogonally with
horizontal plane wires. A universal Rancho cube half pin is placed
proximally in the segmental segment and a draw wire technique is used
to reduce the distal fracture. The pivot point for the draw wire is the
proximal half pin.
appropriate ring diameter without the patient’s extremity
exposed on the operating room table. The spacing mea-
sured on x-rays is not accurate. The fracture is studied
before surgery, and a preoperative plan is designed, the
strategy of reduction.
SEGMENTAL TIBIA FRACTURES
Segmental tibia fractures occur in several patterns
(Fig. 6.13). The most common is the proximal periartic-
ular fracture combined with a midshaft fracture. A sim-
ilar fracture pattern is observed with distal tibia periar-
ticular fractures. Combinations of proximal and distal
periarticular fractures occur. Segmental tibial shafts frac-
tures are usually treated with intramedullary nailing.
Indications for using an Ilizarov fixator on segmental
tibial shaft fractures are severe soft tissue contamination,
compromised soft tissue from ischemic vascular disease,
compromised immune system, and bone loss requiring
reconstruction (Fig. 6.14). The Ilizarov method has the
lowest iatrogenic soft tissue damage associated with its
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
54 J.J. HUTSON JR

FIG. 6.24. Pilon shaft segmental fracture. The joint surface of the
pilon fracture is reduced by percutaneous or limited open reduction.
The fixation is placed subchondral to avoid the wire pathways. Hori-
zontal reference wires are placed proximally and distally, the metaph-
yseal bone blocks are aligned and the fracture is distracted. The
proximal segment is aligned orthogonally using a half pin reduction
technique.

niques section on segmental fractures that have a plateau

or pilon component]. A bridging femoral ring or foot
plate can be incorporated into the reduction sequence of
FIG. 6.23. Additional pins and wires are added to the fixator to
increase stiffness and the fracture is compressed. the segmental tibia fracture. This is a complex frame, but

application. Intramedullary nailing damages the intramed-

ullary blood supply and places a large metallic surface in
the zone of injury. The soft tissue injury from the half pins
and wires is moderate, and the fixation of the fracture
requires no implant in the zone of injury. The intramedul-
lary nail is indicated if the soft tissue envelope can protect
the nailing, if not, a tensioned wire fixator can be used to
treat the fracture. Grade IIIB segmental shaft fractures may
be nailed if the patient is a candidate for a local or free flap.
If the patient is not physiologically able to have a flap, then
a circular fixator is indicated.
Type A periarticular fractures have a unified metaphy-
seal bone block (Fig. 1.1). Type C fracture can be divided
into two fracture patterns. Fractures with lesser comminu-
tion can be reduced with percutaneous or open reductions
and stabilized with limited internal fixation (Fig. 5.17A,
5.17B). This converts an unstable metaphyseal block into a
stable block comparable with a Type A fracture. This
allows the segmental fracture to be reduced without span-
ning the joint, decreasing the difficulty of reduction.
Fracture patterns with severe joint comminution, C3
tibial plateau and pilon fractures may require distraction
across the joint to support the fracture for 6 weeks until
early healing can stabilize the metaphyseal block [Note:
Segmental tibia fractures which have a plateau or pilon FIG. 6.25. The segmental fragment is reduced using a combination
component, require reduction of the periarticular fracture of olive wire and half pin reduction techniques. Usually one end of the
segmental fragment will be close to axial alignment and is fixated first
and the segmental shaft fracture. It is suggested that (the half pin on an universal cube). The displaced end is reduced by a
Chapters 7 and 8 are read before completing the tech- draw/arch wire combined technique.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 6 55

FIG. 6.26. An olive wire can be used to stabilize the fragment and
a half pin reduction can be used if the displacement is primarily in the
AP plane. Small medial lateral plane corrections can be done by
rotating the half pin. The half pin reduction pivots around the tensioned
olive wire.
FIG. 6.27. The distal metaphysis is stabilized with a horizontal
works well. Preconstruction of the metaphyseal block cluster of wires. Additional pins and wires are added to the fixator to
increase stiffness and the fracture is compressed.
negates the need for joint spanning frames and should be
accomplished, if possible.
Ilizarov reduction of segmental tibia fractures uses the bolts on the rings, the proximal metaphysis is aligned
technique of proximal and distal horizontal reference with the distal metaphysis; the tibial tubercle should
wires (Fig. 6.15). This technique was described by Harry align with the center of the tibial plafond. Angular
Tucker on 52 fractures of the tibial shaft, and can be corrections on the plateau wire may need to be added to
extrapolated to segmental tibia fractures.2 This technique
requires that the metaphyseal blocks be intact (Type A)
or reconstructed (Type C). A horizontal reference wire is
placed 1 cm below the joint line of the plateau and 8 mm
above the tibial plafond (Fig. 6.16). The horizontal ref-
erence plateau wire is placed, followed by the Ilizarov
frame consisting of a proximal ring block, midtibial ring
block, and distal tibia ring block. Depending on the size
of the fracture segments, the ring block may be one or
two rings. A 5/8-full ring block may be used on segmen-
tal fractures where the proximal segment is larger than 4
to 5 cm. The ring blocks are connected by working
length threaded rods allowing independent adjustment of
the ring blocks across the two working lengths of the
fracture (Fig. 6.17). The segmental mid tibia block can
sometimes be constructed as a working length ring be-
tween proximal and distal ring blocks if the segmental FIG. 6.28. Segmental periarticular tibia fractures. Both the proximal
and distal periarticular fracture will be reduced to the shaft segment
fragment is small (Fig. 6.18). The horizontal reference double ring fixation block. The stable base is applied during the
wire is placed in the distal tibia. Using the AP nuts and reduction of the tibial plateau (see Chapter 7).

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

56 J.J. HUTSON JR
FIG. 6.29. The tibial plateau fracture is reduced first. The joint is
reduced with limited internal fixation and a horizontal reference wire
placed. The plateau bone block is aligned on the ring. The shaft is
aligned orthogonally with two AP half pins on Rancho cubes and the
fracture distracted. Reduction techniques are used to improve the
alignment. The proximal metaphysis is stabilized with a divergent
cluster of wires.
align the proximal tibia shaft with the axis of the frame
(Figs. 6.5A, 6.5B, 6.5C). (Remember, the plateau is in
approximately 3° varus. This can be accounted for by
placing the reference wire at a 3° angle or using washers
under the wire on the lateral side of the frame.) A
threaded rod without nuts can be placed through the rings
medially or laterally. This is used to line up the posterior
cortex of the ring blocks. Towels can be placed under the
leg and over the frame to improve the alignment of the
posterior cortex. The overall alignment of the proximal
and distal ring blocks should be established at this point.
The ring blocks are distracted forcefully through the
working length rods. The reduction of the segmental
fragment will improve with distraction, and sometimes
FIG. 6.30. Distraction is placed across the pilon fracture with a
horizontal reference wire in the calcaneus. The dome of the talus is
aligned axially with the tibial shaft.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 6.31. The joint surface is reduced with limited internal fixation.
align anatomically. The system is basically aligning the
fracture by pulling through two horizontal wires, a very
basic reduction maneuver. Sometimes after applying
traction, misalignment will become apparent, and the
metaphyseal blocks will need to be adjusted, correcting
rotation, translation, or angulation. These adjustments
are made and the fixator distracted. The secondary re-
duction should not be done until the initial axial align-
ment is acceptable.
The proximal and distal fixation blocks are evaluated
on the lateral fluoroscopic view. The horizontal reference
wire forms an axis of rotation. The bone block rotates
around the reference wire. Usually, the fragments are
rotated (sagged) posteriorly. The fragment is rotated into
axial alignment. This can be done with folded towels
between the leg and rings, towels placed under the calf
and over the anterior rods of the frame pulled up to
reduce the fracture and clamped, manual pressure, or
using arch wire or laminar spreader reduction techniques.
To fix the position of the proximal and distal bone blocks
on the lateral view once the alignment is axial, secondary
FIG. 6.32. The fracture fixation ring is aligned over the metaphysis
and the pilon fracture fixated with three or four opposed divergent olive
wires. Additional threaded rods are added to the fixator to increase
stiffness.
 CHAPTER 6
wire and half pin fixation is placed into the bone block to
stabilize the fragment. The proximal and distal bone blocks
are now aligned and stabilized. The segmental bone block is
manipulated with draw and arch wires, half pins, and
manual reduction (Fig. 6.19). The fragment can be angled
and requires opposed proximal and distal reduction maneu-
vers to reduce the segmental fragment. Well-placed op-
posed draw-arch wires can reduce these fragments with
excellent control (Figs. 6.17, 6.18). Carefully examine the
segmental fragments; sometimes there are nondisplaced
coronal fractures that can be stabilized with AP percutane-
ous 4.5 cannulated screws (Fig. 5.18A). If these fractures
are not recognized and fixed, the fragment can disassemble,
compromising the reduction. Once the fracture is aligned,
the independent working length threaded rods should be
compressed to increase stability of the fracture (Fig. 6.20).
Tibial plateau, midshaft segmental tibia fractures are
approached by examining the plateau fracturing. If there
is moderate comminution, the plateau is reconstructed
with a limited internal fixation to form a unified bone
block (Figs. 6.21, 6.22, 6.23). Tibial shaft, pilon segmen-
tal fractures are approached with a similar technique
(Figs. 6.24, 6.25, 6.26, 6.27). Segmental plateau, pilon
fractures are treated by reducing the plateau first, fol-
lowed by reduction of the pilon. Both the plateau and
pilon will be based on a mid tibial orthogonal stable base
(Fig. 6.28). A horizontal reference wire is placed in the
reconstructed plateau (Fig. 6.29). The leg is distracted
and two AP half pins on universal Rancho cubes are
placed on the stable base. [Note: This technique is
57
described in detail in Chapter 7]. Once the plateau is
stabilized, the pilon fracture is reduced using a distrac-
tion bridging frame technique (Figs. 6.30, 6.31, 6.32).
[Note: This technique is described in detail in Chapter 8].
A rare patient will have high-energy comminution of
the plateau and plafond. An Ilizarov fixator is con-
structed using proximal femoral bridging and distal cal-
caneal bridging. We have used this frame once in the past
10 years.
The basic reduction technique for segmental tibia shaft
fractures is:
1) Place horizontal reference wire proximal metaphysis.
2) Construct frame with proximal, midtibial, and dis-
tal tibial fixation blocks connected by proximal and
distal sets of working length rods.
3) Align proximal and distal bone blocks and distract
fracture.
4) Align proximal and distal bone blocks orthogo-
nally in frame with wire and half pin techniques.
5) Reduce segmental fragment with opposed olive
wires, or wires and universal Rancho cube.
6) Place additional half pins and wires to increase
stiffness of fixator.
7) Compress proximal and distal fracture sites.
REFERENCES
1. Mikulak SA, Gold SM, Zinar DM. Small wire external fixation of
high energy tibial plateau fractures. Clin Orthop 1998;356:230–238.
2. Tucker H. Management of unstable open and closed tibial fractures
using the Ilizarov method. Clin Orthop 1992;280:125–135.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
Techniques in Orthopaedics®
17(1):58–70 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 7: The Treatment of Proximal Periarticular Tibial

Fractures with Ilizarov Fixators

James J. Hutson, Jr., M.D.

Summary: The techniques to reduce and fixate OTA Type A, C1, C2, and C3 fractures
are illustrated. Fractures with an intact or reconstructible metaphysis are fixated with
nonbridging frames (Type A, C1, C2). C3 fractures with joint comminution are treated
with bridging extension across the knee joint. Techniques to reduce the joint surface
are illustrated. Early resuscitation of the injured patient with emphasis on compartment
syndrome and vascular injury is described. The technique for applying half pin anterior
resuscitation fixators is illustrated. Key Words: Ilizarov fixator—Tibial plateau
fracture.

Proximal tibial periarticular fractures with shaft disso-
ciation are indications for using Ilizarov external fixators.
These fractures are described as Schatzker Type V and VI,
or Orthopedic Trauma Association (OTA) Fracture and
Dislocation Compendium Type A and C fractures.2,6
Unicondylar lateral and medial plateau fractures (OTA
Type B) can be reconstructed with open reduction and
internal fixation using the intact condylar column of
bone as fixation for a buttress plate. Severe comminution
may require a joint spanning external fixator to supple-
ment the fixation when buttress plating Type B frac-
tures.9 A compromised soft tissue envelope associated
with a Type B fracture can also be an indication for using
an Ilizarov fixator.11
OTA Type A and C fractures have dissociation of the
metaphyses from the shaft. Type C fractures have frac-
turing of the joint surface, which is sagittal plane dis-
placement in C2 fractures and bicondylar comminution
in C3.3 fractures. Low-energy fractures can be treated
with internal fixation. Increasing severity of bone frag-
mentation and soft tissue injury are indications for using
Ilizarov fixators in proximal tibial periarticular fractures.
Proximal tibial periarticular fractures with ipsilateral
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
distal femur fractures can be treated with circular ten-
sioned wire on the tibia and internal fixation on the
femur. The femur should be fixated primarily using a
retrograde nail or plating using a blade plate, condylar
plate, or less invasive plate. Applying an Ilizarov fixator
to the femur and tibia will prevent flexion of knee from
frame impingement and only is indicated in grossly
contaminated high-energy fractures.
INITIAL MANAGEMENT
Proximal periarticular fractures are the result of high-
energy trauma. Type C fractures are usually caused by
auto crashes and falls from height, and Type A fractures
are caused by pedestrians hit by a car.4 Type A fractures
have a higher incidence of open wounds associated with
the injury. Patients with bicondylar tibial plateau frac-
tures frequently will have multiple trauma and require
resuscitation before reconstruction of the fracture. Arte-
rial injury and compartment syndrome are frequently
associated injuries observed in proximal tibia fractures.
In our series of 200 proximal tibial fractures, there has
been a 15% (1 in 6) incidence of compartment syndrome.
A careful neurologic and vascular examination is neces-
sary in all patients with proximal tibial fractures. Open
fractures should be examined with sterile gloves and
rapidly covered with loose sterile dressings. The extrem-
ity should be splinted with a well-padded medial and

58
 CHAPTER 7
FIG. 7.1. A half pin bridging frame is placed at the time of injury to
stabilize the extremity. The fracture should be distracted to length.
Place the rod-to-rod clamps over the femoral condyles to avoid inter-
fering with the CT scan of the tibial plateau (black arrow). Avoid
placing the distal half pin in the supra patellar pouch (white arrow).
lateral splint. Applying an ill fitting off the shelf brace
without padding should be avoided.
Open fractures and fractures with compartment syn-
dromes require emergent surgical treatment. After me-
ticulous debridement and medial and lateral compart-
ment releases, the fracture should be stabilized. If the
patient is stable physiologically, an acute reduction with
an Ilizarov fixator can be done, but in most fractures, an
anterior half pin bridge frame is rapidly placed stabiliz-
ing the fracture and maintaining length and axial align-
ment (Fig. 7.1). When constructing the bridge frame, do
not place the rod-to-rod clamps directly over the fracture.
Place them superior, over the femur to avoid obscuration
of the radiographic imaging of the fracture. Closed frac-
tures are stabilized with bridge frames to resuscitate a
multiple trauma patient or gain control of a comminuted
fracture. Splints can be used on patients with lower
energy trauma, but require frequent examination. We
have observed severe swelling and fracture blisters in
patients with “simpler” fractures that have required
placement of a bridge frame to resuscitate the extremity.
An alternative to using a bridge frame is placing a distal
tibial traction pin, but this is rarely used.
59
Once the fracture has been stabilized, further x-ray and
computed tomography (CT) evaluations of the fracture
are completed. C2 and C3 fracture patterns are mapped
using CT, identifying the location of depressed frag-
ments and indicating surgical approaches. After the ex-
tremity and patient are resuscitated, 7 to 14 days postin-
jury, the reconstruction of the fracture can proceed. If the
patient had a compartment syndrome, the medial wound
should be closed primarily before placing the Ilizarov
fixator. The lateral wound functions as a relaxing inci-
sion and is split thickness skin grafted with meshed graft
after the frame has been applied. It is not difficult to skin
graft through a fixator. Rarely, the swelling from a
compartment syndrome will prevent medial closing and
skin grafting will be needed medially and laterally.
The goal of treatment of periarticular proximal tibial
fractures is to reestablish axial length and alignment,
reduce the joint surface in Type C fractures, and recon-
struct bone loss. Stable fixation will facilitate functional
rehabilitation improving the final outcome. Reconstruc-
tion of the metaphysis will use four fracture reduction
methods (Fig. 7.2). OTA Type A fractures have an intact
metaphysis or nondisplaced fracture lines. Axial align-
ment, translation, rotation, and length are aligned at the
fracture zone and the fracture fixated by the Ilizarov
fixator. C2 Fractures are reduced percutaneously or with
a limited open reduction reconstructing the metaphysis
into a unified block. C3 fractures with moderate commi-
nution (big pieces) are reduced percutaneously or with
FIG. 7.2. Reduction methods. Type 1 reduction requires no reduc-
tion of the joint surface. Type 2 fractures can be reduced with percu-
taneous techniques. Type 3 fractures can be reduced percutaneously or
by limited open reduction. Type 4 fractures are reduced with open
reduction.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
60 J.J. HUTSON JR
limited open reductions. The metaphysis is reduced be-
fore placing the Ilizarov fixator or a bridging frame is
used to distract the joint and reduce the fragments after
ligamentotaxis has regained length. C3 fractures with
severe comminution require open reduction of the joint
surface. Bridging distraction is used to facilitate reduc-
tion of these complex fractures. The strategy of reduction
is to place horizontal reference wires and orthogonal
fixation blocks. The fixation blocks are distracted axially
correcting alignment and rotation. The joint surface re-
duction may be accomplished before placing the Ilizarov
fixator or after placing the Ilizarov fixator, when the
frame is used as an intrinsic distractor in the bridging
frame configuration.
TECHNIQUE OF REDUCTION WITH INTACT
OR RECONSTRUCTED METAPHYSEAL
BLOCK: OTA TYPE A, C1 AND C2 FRACTURES
WITH MODERATE COMMINUTION
The patient is placed supine on a fluoroscopic operat-
ing table. A padded sand bag or gel bag is placed under
the trochanter to rotate the patella into the AP plane. A
tourniquet is placed on the thigh, but not inflated. The leg
is prepared and draped exposing the distal femur and leg.
Type A and reconstructed Type C fractures require
correction of rotation, axial alignment and distraction to
length to reduce the fracture (Fig. 7.3). A horizontal
reference olive wire is placed 1 cm below the tibial
plateau joint surface using the centered lateral view to
confirm the position of the wire (Appendix 1).3 The
Ilizarov frame is passed over the foot and leg and aligned
on the horizontal reference wire. The metaphysis is
aligned on the carbon fiber ring with the anterior tibia
clearing the ring by 2 to 3 cm and the posterior ring
clearing the calf musculature. The bolts and nuts used to
assemble the rings should be in the anterior-posterior
(AP) plane centered on the tibia (Fig. 5.2).
Two strategies of reduction can be used to reduce the
fracture. The first is to complete the fixation block on the
metaphysis with at least three to four opposed divergent
olive wires. The proximal metaphyseal block is aligned
orthogonally with the ring on AP and lateral fluoroscopic
view. The joint surface on the lateral view is not parallel
to the ring, but tilted inferiorly 7° to 9° (Appendix 1, Fig.
3). The tibia is distracted manually and a second fixation
block is placed orthogonally on the tibia shaft connected
to the proximal fixation block with universal connecting
rods. The distal fixation block is fixated to the tibia with
half pins and olive wires with at least three to four
fixation points, while manually distracting and aligning
the tibia. After the fixation blocks are placed, the uni-
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 7.3. Type A proximal tibia fractures are reduced by aligning the
metaphysis with the shaft. Rotation, shortening, and displacement are
corrected to align the fracture. The force vector arrows indicate the
fracture displacements, which will be corrected by the reduction.
versal connecting rods are loosened and the alignment is
improved by manual reduction (Figs. 5.22, 5.23).5 A
variation of this technique is using a multilinkage system
(Spatial Frame Smith Nephew Richards) that uses a
computer program to determine the corrections to be
applied to each linkage. The advantage of this technique
is the ease of application. Fixation blocks are applied on
the metaphysis and shaft and manual reduction is ap-
plied. This technique is also the basis of reduction for
Hoffman II (Howmedica), Synthes, Ortho Fix, Biomet,
and ACE hybrid fixators. The disadvantages of this
technique are that the frame usually ends up nonorthogo-
nal to the axis of the fracture and the universal connect-
ing rods are not parallel, negating the technique of axial
distraction and compression to treat the fracture (Fig.
6.7C). The universal connecting rods require increased
working length, decreasing the stiffness of the fracture,
and are expensive. The universal connecting rods cannot
be loosened in single planes and require all or nothing
corrections of alignment; all axis of motion must be
loosened to adjust any plane of deformity. The universal
connecting rods prevent the use of working length rings
to increase fixation of fractures with shaft extension. The
technique has wide usage and has had high success, but
has been identified as the source of nonunions, especially
in pilon fractures.10
The second strategy of reduction is to use a modified
horizontal reference wire technique described by Tucker
for treatment of tibial shaft fractures.8 Horizontal refer-
ence wires can be placed in the plateau and plafond, and
the fracture distracted followed by reduction similar to
 CHAPTER 7 61

tibial shaft fractures. In the tibial plateau fractures, the

fracture is in the proximal third and the distal shaft is
available for fixation, negating the need to place a distal
metaphyseal wire, which is more painful than half pins in
the tibial shaft. The technique is modified by distracting
between a horizontal reference wire in the plateau and an
orthogonal fixation block with two AP half pins mounted
on universal Rancho cubes secured to the distal shaft.
After distraction, the posterior angulation on the lateral
view is corrected with manual pressure, towel technique,
arch wire, or laminar spreader technique. The AP align-
ment is reduced with a drag wire or half pin reduction
techniques.

TECHNIQUE OF REDUCTION
The patella is aligned in the AP plane with a padded
sandbag under the trochanter. A horizontal reference
wire is placed 1 cm below the joint using the true lateral
centered view (Appendix 1, Figs. 1, 2). The Ilizarov
fixator consisting of a proximal carbon fiber plateau
fracture ring, working length rods placed in the anterior
lateral and posterior medial three hole connected to a
two-ring stable base (two rings separated by 150 mm
rods in the anterior lateral and posterior medial one hole)
(Figs. 6.10, 6.11). The working length rods are the
distance from the plateau ring to 2 to 3 cm inferior to the
fracture site plus 50 mm (Figs. 4.9A, 4.9B, 4.9D). The
early alignment of the fracture can be done with two
rods, adding the medial and lateral rods as the reduction
proceeds. The tibial plateau is aligned in the proximal
ring centering the AP nuts and bolts on the tibial tubercle
(Fig. 7.4). Adequate soft tissue clearance of 2 to 3 cm
should be observed. If the rings are crowding the soft
tissues, rebuild the frame with the next larger rings. The
horizontal reference wire is tensioned to 110 kg.
The ankle is grasped and the second toe aligned with
the tibial tubercle to correct rotation. The fracture is
distracted manually. The reduction is observed on fluo-
roscopy and when the best alignment is obtained, an AP
half pin mounted on a universal Rancho cube is placed
on the distal ring of the stable base in the anterior medial
one or two hole (Fig. 7.4). A second half pin is placed
with a universal Rancho cube on the mid tibial ring in the
AP plane (Fig. 7.5). The overall alignment should be
improved, but will need “tweaking” at this stage. This
step may reveal a poor initial placement of the horizontal
reference wire, which can be improved with small angu-
lar corrections or reinsertion of the wire (Figs. 5.6A,
5.6B, 5.6C). Precision in placing the horizontal reference
wires facilitates subsequent reduction of the fracture.
The AP half pins are tightened and additional threaded
FIG. 7.4. A horizontal reference wire is placed through the metaph-
ysis. The fixator has a single ring fixation block and a double ring
stable base. The proximal tibia is aligned in the rings and the shaft
connected to the distal ring with a universal Rancho cube. Manual
distraction is placed on the tibia to align the shaft anatomically before
placing the distal half pin into the tibia on a universal Rancho cube. The
tibia usually will not align completely and will need midfracture
manipulation on the middle ring. The foot and second toe is aligned
with the patella and tibial tubercule to correct rotation. The distal tibia
is aligned so that the anatomic axis of the plateau metaphysis centers on
the tibia at the level of the distal ring.
rods are placed medially and laterally to stiffen the
frame. The fracture is distracted. If the fracture is less
than 1 week old, length will be regained easily. If the
fracture has shortened in a splint and several weeks have
passed, strong reduction traction will be needed to regain
length. In fractures 4 to 6 weeks old that have shortened,
acute correction of length may not be possible, and a
lengthening sequence may be needed, a 1/4 to 1/2 turn 4
times a day for several weeks to regain length. If traction
is applied, and no lengthening is observed, the Rancho
cube bolt connecting the cube to the long male hinge was
not tightened sufficiently, and the pin is rotating on this
axis, repeat the maneuver with the nut tight. The other
cause may be failure to tension the horizontal reference
wire or “cut out” of the wire in the soft metaphyseal
bone. Distraction is the key to reduction. This principle
pertains to plating and intramedullary nailing as well.
Without distraction, overriding fragments of bone cannot

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

62 J.J. HUTSON JR

The fracture is viewed on the AP image and the shaft

manipulated medially or laterally. This is done by rotat-
ing the Rancho cube for small corrections (5 mm or less),
using a medial half pin to push or pull the shaft fragment,
or using a draw wire technique to reduce the fracture
(Fig. 7.7). The nut holding the long male hinge to the
frame needs to be loosened, as well as the half pin bolt to
use a draw wire technique for a larger correction.
Once the fracture is reduced, additional tensioned
wires and half pins are added to the fixator in divergent
planes to increase stiffness. The fracture is compressed
with the frame to increase stability (Fig. 7.8). A working
length ring may need to be placed on Ilizarov fixators if
preoperative planning identifies fracture extension,
which can be controlled with an olive wire (Fig. 5.20B).
A draw wire is used to compress the fragment against the
metaphysis. Only larger fragments should be treated with
working length wires. Avoid placing wires into zones of
comminution. The wire provides no fixation, but does
form a highway for bacteria to enter the fracture site. If
the need for a working length wire is realized after a

FIG. 7.5. A midring half pin is placed on a Rancho cube and the
fracture is distracted between the fixation blocks. The half pins are
manipulated to align the posterior angulation of the fracture. Strong
traction will be needed for fractures that are 2 weeks or older.

be reduced, and alignment and translation cannot be

corrected.
With the fracture distracted, the residual posterior
angulation of the fracture is corrected. The tibial plateau
metaphyseal block is rotated on the horizontal reference
wire into an orthogonal position and fixated with an
additional two to three opposed divergent olive wires
(Fig. 7.6). The metaphysis is reduced by manual pressure
under the gastroc, placing towels between the ring and
fracture site, draping a towel under the calf and over the
AP rods and pulling up followed by clamping the towel
(the towel technique) or, in rare cases, using an arch
wire. The towel technique usually aligns the posterior
metaphysis. The midring Rancho cube will need to be
loosened to allow the half pin to slide anteriorly through
the cube. The shaft fragment can also be manipulated
using a laminar spreader technique to reduce axially the
shaft on the lateral view (Figs. 5.15, 7.6). The posterior FIG. 7.6. A laminar spreader technique can be used to align the
angulation is usually reduced first, allowing the metaph- posterior cortex. Usually the metaphyseal alignment will be corrected
by this technique. The metaphysis is fixated with divergent olive wires.
ysis to be fixated in an orthogonal position. The tibial The shaft pivots around the distal Rancho half pin. A threaded rod is
shaft is then reduced to the metaphysis. This principle is placed on the medial or lateral side of the frame without nuts and used
used in most reduction sequences. The proximal side of as a guide to align the posterior cortex. If the metaphysis does not rotate
into anatomic alignment, manual pressure, towel techniques, or an arch
the fracture is aligned orthogonally first, followed by the wire technique can be used to align the fragment bone block, followed
distal segment of the fracture. by fixation with additional olive wires.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 7 63

FIG. 7.7. The shaft is reduced in the medial lateral plane using a
draw wire technique. The Rancho cube on the middle ring is loosened
to allow the shaft to reduce. FIG. 7.8. A medial half pin is added to the fixator to increase
stiffness and the fracture is compressed.

three-ring frame is in place, plates can be added across

the working length attached to post on the rings, and the cluster placed in the metaphysis will be insufficient to
draw wire tensioned on the plates. maintain fixation and the joint will collapse through the
The above techniques are used for C fractures by wires leading to poor result. This phenomenon is ob-
reconstructing the joint surface percutaneously or by served when using plates and a subchondral raft of
open reduction (Figs. 7.9, 7.10, 7.11). C1 and C2 frac- screws. If the plateau is crushed, the surface will settle
tures are reduced with pelvic reduction clamps or Stein- through the screws and the plate edge will ‘migrate’
man pin “joy sticks” and lagged together with cannulated
screws. C3 fractures with moderate comminution will
require an open reduction and limited internal fixation.
Bone graft can be used to support the joint surface. The
meniscus is often torn and incarcerated in the fracture
preventing reduction.4 The fixation screws are placed
just below the joint surface to clear the metaphysis 1 cm
below the joint for the tensioned wire pathways. With the
metaphyseal block reconstructed, a Type A reduction
sequence is used to reduce the fracture.

TECHNIQUE OF BRIDGING FRAME

DISTRACTION FOR COMMINUTED C3 TIBIAL
PLATEAU FRACTURES
Tibial plateau fractures will be observed which have
severe comminution and soft tissue injury that compro-
FIG. 7.9. The C1 and C2 tibial plateau fracture has a sagittal fracture
mise extensive open reduction and stable reconstruction of the joint surface, which can be reduced by percutaneous or limited
of the metaphyseal bone block (Fig. 7.12). The wire open methods.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

64 J.J. HUTSON JR
FIG. 7.10. (A) On larger fragments, the screw can be placed below
the reference wire. (B) The screw is placed just below the joint surface
in C2 fractures to avoid interference with the limited wire pathways.
above the joint. Distraction between horizontal reference
wires is applied to this difficult fracture by repositioning
the horizontal reference wire at the base of the femoral
condyles parallel to the joint surface and distracting
across the joint and reducing the metaphysis by bridging
ligamentotaxis (Figs. 7.13A, 7.13B). This strategy is also
used in plating proximal tibial fractures. A distractor is
placed across the joint to reduce the fracture before
plating and with severe comminution will be left in place
for 6 weeks. This technique using Ilizarov fixators facil-
itates the reduction and salvage of severely comminuted
C3 plateau fractures, and can also be applied to less
comminuted patterns to use percutaneous reductions
avoiding large extensile approaches.
The concept of bridging fixation is not a repudiation of
early motion in fracture treatment. Stable fixation is
required to start early motion. An attempt to mobilize a
periarticular fracture with unstable internal fixation
causes acute pain and disassembly of the fracture result-
ing in malunion or nonunion. The unstable fixated frac-
ture is splinted leading to periarticular fibrosis that is
aggravated by the iatrogenic injury of the surgical ap-
proach. When this scenario occurs, the fracture and joint
is exposed to the negative aspects of internal fixation
without the benefit of stable fixation and early motion.
Bridging fixation is a compromise. The joint is main-
tained in distraction until early callus develops stabiliz-
ing the condylar block. The fracture through osteogenic
bone healing is converted from an unstable assembly of
fragmented shards, to a unified bone block. Delayed
motion is started after removal of the bridging compo-
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
nent of the frame. Distraction and ligamentotaxis across
the joint facilitates reduction of the fracture and limited
open reduction and percutaneous reductions are applica-
ble to joint surface reduction. The iatrogenic soft tissue
injury from extensile approaches is lessened by using
distraction frames. The disadvantage to distraction is the
fibrosis and adhesions, which occur in a joint that is not
moving through an arch of motion.1 Manipulation of the
knee will be needed in patients who are not able to
progress to 90° of flexion within weeks of removal of the
distraction ring.
The indications for the use of distraction frames are
comminution of the plateau, which cannot be recon-
structed into a stable bone block, and less comminuted
C3 fractures, which can be reduced percutaneously using
ligamentotaxis and percutaneous reduction techniques.
Fractures with larger fragments may need less than 6
weeks of distraction to become stable allowing ring
removal at 3 to 4 weeks.
TECHNIQUE DISTRACTION FRAMES TIBIAL
PLATEAU
Many patients with C3 tibial plateau fractures will
have had a bridge frame placed during resuscitation of
the injury (Fig. 7.1). The bridge frame should be re-
moved completely; it is difficult to chase the half pins in
the tibia and the pins may have been placed with poor
technique. A padded sand bag is placed under the tro-
chanter to rotate the patella into the AP plane. A tourni-
quet is placed on the superior thigh.
The tibial plateau bridging frame is assembled with a
two-ring stable base separated by 150 mm rods that will
be secured to the distal tibia with two AP half pins
mounted on Rancho universal cubes. The distraction
FIG. 7.11. The fracture is reduced by the same technique as the Type
A fractures once the metaphyseal bone block has been reconstructed.
 CHAPTER 7 65

frame will be constructed with independent distraction

across the femoral condyles to the stable base and a
separate carbon fiber tibial plateau fracture ring. The
strategy of reduction is to distract between the femoral
condyles and the stable base/distal tibia aligning axially
the shaft with the knee joint, regaining length and using
ligamentotaxis to reduce the tibial plateau fracture. After
the fracture is distracted and aligned, the joint surface
will be reduced by percutaneous or limited internal
fixation. The independent carbon fiber fracture ring will
then be used to stabilize the plateau with three to four
opposed divergent olive wires. The independent mount-
ing of the distracting ring allows axial distraction and
alignment to be isolated from fixation of the plateau. The
distraction ring distracts the femoral condyles, pulling
them away from the space needed to elevate and reduce
the tibial plateau joint surface. It is impossible to reduce
a comminuted plateau to anatomic height if the femoral
condyles are shortened, occupying the space that the
tibial plateau anatomically should be reduced. This con-
dylar “crush down” is always corrected by distraction
before attempting the joint surface reduction. This con-
cept is applicable to plating of tibial plateau fractures. A
bridging femoral external fixator is used to regain length
when plating.
The threaded rod length for the femoral distraction
ring is the distance from the proximal femoral condyle to
the tibial shaft 2 to 3 cm inferior to the fracture, plus 50
mm (usually 250 to 300 mm rods) (Fig. 4.9C). The
working length rod for the carbon fiber fracture ring is
the distance from 1 cm below the joint to 2 to 3 cm below

FIG. 7.12. The C3.1 tibial plateau fracture has lateral condyle
comminution and metaphyseal shaft dissociation
FIG. 7.13. (A) The femoral condyle in C3.1 tibial plateau fractures
crushes down the lateral joint surface. The plateau cannot be reduced until
the offending condyle is distracted out to length. Axial ligamentotaxis
improves the reduction of the plateau. The medial plateau can be reduced
percutaneously. The lateral plateau will require an open reduction. The
distraction does not incorporate a hinge because flexion of the knee would
relax ligamentotaxis on the posterior capsule and loss of alignment of the
posterior fragments would occur. The lateral meniscus can be torn and
incarcerated in the fracture site (white arrow). If the fracture does not
reduce with distraction, and there is a large gap in the plateau, the meniscus
is torn. (B) The C3.1 fracture is distracted through the knee joint by placing
a horizontal reference wire above the femoral condyles and distracting
through outrigger rods on two hole plates connected to a double ring stable
base with two AP half pins. The tibial shaft is manipulated on the midtibial
ring to axially align the fracture. The carbon fiber fracture ring is recessed
into the stable base by spinning down the nuts on the threaded rods. This
gives an unobstructed fluoroscopic image and allows operative approaches
to be made on the medial and lateral plateau with the frame in place
providing intrinsic traction

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

66 J.J. HUTSON JR

the fracture plus 50 mm (usually 150 to 200 mm rods)

(Figs. 4.9A, 4.9B). The tibia is evaluated for diameter
and the fracture reduction rings and stable base rings are
chosen with adequate soft tissue clearance (usually 160
to 180 mm). The femoral distraction ring is the ring that
will fit around the tibial rings (180/150, 200/160, 220/
180, and 240/200) (Fig. 7.14B). The 240 mm ring around
the 200 mm ring can accommodate fractures in patients
with morbid obesity.
The femoral distractor ring is connected to the proxi-
mal ring of the stable base with three, two-hole plates,
forming a triangle of distraction (Fig. 7.14A). Four rods
can be used, but you begin to run out of space. The C3.1
fracture pattern is the most common. The plates are
placed on the rings to allow the lateral approach to be
used to elevate the depressed joint surface.
The fracture ring threaded working length rods are
placed in the anterior lateral and posterior medial three
holes. The nuts are spun down on the fracture ring and it
is slid down into the stable base to clear the image of the
tibial plateau during the initial distraction and reduction
of the fracture (Fig. 7.13B).
A horizontal reference wire is placed just above the
femoral condyles from lateral to medial. Some patients
can have extensive suprapatellar pouches draping over
the condyles. If a wire is placed and there is egress of
fatty blood, the pouch has been violated and the wire
should be repositioned posterior or superior of the of-
fending wire. The frame is slid over the leg and the
femoral wire aligned on the ring to center the tibia and
knee in the ring system. The wire is tensioned. Minor
angular corrections can be made with washer elevation
off the wire on the ring. The fracture ring is slid up to the
joint and the soft tissue clearance evaluated. The frame is
rebuilt with larger rings if the soft tissue clearance is
inadequate.
Distraction is placed on the leg. The foot is rotated to
align with the patella. The stable base is adjusted so that
the midtibial ring will be 2 to 3 cm below the distal
extent of the fracture. With the leg manually distracted
and the alignment of the tibia with the condyles reduced,
an AP half pin is placed through the distal ring universal
Rancho cube followed by a half pin through a universal FIG. 7.14. The femoral distraction ring is connected independently to
the stable base by three two-hole plates. This allows the metaphyseal
Rancho cube on the midtibial ring (Fig. 7.13B). The carbon fiber fracture ring to be manipulated as needed to reduce the
midtibial half pin can be manipulated to improve the fracture. The femoral distraction ring is easily removed once the commi-
alignment of the fracture or a draw/arch wire can be nuted metaphysis has healed with early callus at 6 weeks. (A) Three,
two-hole plates are aligned on the midtibial ring of the stable base.
placed to improve the reduction of the shaft alignment. Threaded rods are connected to the femoral distraction ring. The rods
A medial to lateral olive wire is placed on the femoral range from 250 to 300 mm in length. (B) The carbon fiber fracture ring has
distraction ring avoiding the supra patellar pouch. The no connection to the femoral ring. It is mounted on independent working
length rods to the stable base in the anterior lateral three hole and posterior
fracture is distracted forcefully between the condyles and lateral three hole. (C) Opposed olive wires are placed parallel to the
the stable base. On fluoroscopy, the condyles will dis- femoral joint surface above the condyles of the knee.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 7 67

FIG. 7.16. The femoral distraction ring can be made more stable on
larger patients by extending the fixation proximal on the femur.

without elevating flaps. The collateral ligament is usually

FIG. 7.15. Distraction across the joint will elevate the plateau to its
anatomic position. The joint surface will need to be reduced. The
medial condyle is reduced percutaneously. The lateral condyle is
reduced through a lateral approach. Manipulation of the midtibial half
pin has been used to correct the shaft alignment.
torn away from the anterior fragment. This approach can
also be used to place a posterior medial buttress plate.
The fracture can be exposed through a total knee ap-

tract away from the plateau and a space will be observed

that will be occupied by the reduced tibial plateau (Figs.
7.15). The femoral distraction ring can be made more
stable by using half pin fixation in the distal shaft on
larger patients (Fig. 7.16). Rather than using a second
ring, a Hoffman II (Stryker) extension is used, connected
by a Miami post.
The fracture is evaluated. The medial plateau will
usually be reduced by ligamentotaxis. If it is still de-
pressed, it is elevated with percutaneous elevators or
Steinman pins through small access incisions (Fig. 7.17).
Joker and Cobb elevators with small heads are effective
tools. Be careful not to penetrate the posterior capsule
and injure the popliteal artery and posterior tibial nerve.
C3.3 and C3.2 fractures will have a coronal split of the
mid medial plateau. This can be reduced percutaneous
with threaded Steinman pin joysticks (Figs. 7.18, 7.19A,
7.19B, 7.19C, 7.19D). The fracture is reduced and mul-
tiple smooth Steinman pins are placed across the frac-
ture. An AP 4.5 mm cannulated screw is placed in a
FIG. 7.17. The medial condyle is reduced using “joysticks” or
subchondral position to secure the reduction. The frac- placing elevators under the fragment to manipulate its position. Liga-
ture is reduced through a medial mid line approach mentotaxis will keep the fragment reduced once elevated.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

68 J.J. HUTSON JR
FIG. 7.18. C3.3 tibial plateau fractures have coronal fracturing of the
medial condyle that are depressed and rotated. Distraction across the
fracture is necessary to reduce fragments.
FIG. 7.19. After the plateau has been distracted, the medial condyle
fragments can be reduced. (A) This can be done percutaneously with
“joysticks” or through a posterior medial approach. The fragments are
rotated and elevated until the joint surface is level. (B) A Steinman pin
is placed to hold the reduction and a 4.5 mm cannulated screw placed
subchondral to fixate the medial condyle. (C) A small plate can be
applied posteriorly to buttress the posterior medial fragment. (D) The
olive wire pattern on the ring should have a posterior medial to anterior
lateral wire to support the posterior medial fragment.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
proach, but this requires elevation of a large flap and
does not expose the posterior medial corner. The large
flap can become necrotic if there have been high-energy
contusions of the knee or open wounds. A direct sharp
dissection approach with minimal elevation of flaps is
the safest and least damaging of exposures.
The lateral plateau will need percutaneous or open re-
duction in C3.1 and C3.3 tibial plateau fractures (Figs.
7.20A—7.20E, 7.21). The impaction and displacement of
the joint fracture can be several centimeters. The lateral
meniscus will be torn and displaced in many fractures. After
distraction, if the joint appears reduced with no large frac-
FIG. 7.20. The crushed lateral condyle is reduced through a lateral
approach. The lateral meniscus is often torn and incarcerated in the
joint. The joint surface is elevated and held in place with 0.045
Steinman pins. The pins can be left in place as “free pins” and driven
out through the medial skin. The pins are left in place until the femoral
ring is removed. The fragments are fixated with 3.5 and 4.5 mm screws
if large enough, or with additional Steinman pins if comminuted. The
joint is augmented with cancellous allograft or autograft. The meniscus
is repaired to the capsule. (A) The depressed osteochondral joint fragments
are elevated. A small osteotome is used to cut a plane 10 to 15 mm below
the fragment if the fragment is impacted before elevation. (B) A 0.045
Steinman pin is placed just below the subchondral bone to hold the joint
surface reduced. The pin is driven out the medial side of the leg so that it
does not interfere with the lateral operative field. The pin can be left as a
free wire or removed if subsequent fixation stabilizes the joint surface
fracture fragments. (C and D) Both 3.5 and 4.5 mm pelvic and cannulated
screws are used to stabilize and compress the joint when fragmentation is
moderate. (E) Cancellous allograft and autograft is used to augment the
joint surface when crushing creates relative bone loss.
 CHAPTER 7 69

medial plateau and through the skin as free wires. Using

FIG. 7.21. The reduced plateau is protected from femoral crush-
down by the bridging femoral ring. The lateral femoral condyle is used
as a mold to align the lateral plateau fragments. These fragments in
severe fractures will have crushed “mushy” bone, which is supported
by grafting and subchondral 0.045 wires. There will be no space
between the plateau and condyle if the joint is reduced to anatomic
height. The repaired meniscus will have a tight fit between the condyle
and plateau.
multiple 0.045 Steinman pins is effective in salvaging a
reasonable joint surface in the face of severe comminu-
tion. The long-term result is greatly dependent on the
joint reduction. Avoid the attitude that you are only creating
bone stock for the total joint surgeon. With the condyle
reconstructed, repair the meniscus to the joint capsule.
Avoid suturing the meniscus to the iliotibial band.
Small fragment plates are used to control two specific
fracture patterns (Figs. 5.17A, 5.17B). One is an avulsion
of the tibial tubercle, which is controlled with a 1/3
tubular spring plate. The other is a posterior medial
corner fragment, which can be plated in C3.3 and C3.2
fractures to elevate the posterior lip of the joint.9 Plating
should be avoided in the medial lateral plane of the
tensioned wires as it is associated with deep infection.7
Auxiliary plates are located either anteriorly or posteri-
orly to avoid contact with the wires.
The iliotibial band and incision are repaired. A hori-
zontal reference wire is placed and the carbon fiber
fracture ring is elevated to the wire (Fig. 7.22). The wire
is tensioned. A minimum of three divergent olive wires
are placed, directing the wires in pathways that will
stabilize and secure the key fracture fragments in the
plateau. The stable base is stiffened with a medial half

ture gaps, the meniscus is probably not incarcerated. If there

are persistent gaps and depressed fragments, then an open
approach is indicated. Less severe fractures are percutane-
ously manipulated (C2 and lesser C3.1). Subchondral 4.5
mm cannulated screws are placed to align the plateau
followed by fixation with tensioned wires.
The joint is exposed through an anterior lateral ap-
proach. The incision is done with sharp dissection and no
flaps are elevated. Operating with the ring system in
place is not difficult. After several procedures you be-
come adept at the technique. The iliotibial band is split
vertically and the joint exposed by incising the capsule
and synovium. The meniscus is elevated from the rim if
still intact. Often the meniscus is displaced and incarcer-
ated in the fracture. A heavy single prong skin hook is an
excellent tool to pull the meniscus out of the fracture gap.
Several traction sutures are placed in the meniscus and it
is elevated to observe the joint. The lateral femoral
condyle distracted out to length serves as a mold to
reduce the plateau. There should be no space after the
reduction between the plateau and the condyle. The
fragments are elevated to realign the joint. Cancellous FIG. 7.22. The carbon fiber fracture ring is elevated on independent
allograft or autograft is used to support depressed frag- working length rods from the stable base. The metaphysis is fixated
with a divergent cluster of opposed olive metaphysis wires. Three or
ments. Small osteocartilaginous fragments can be pinned four wires are placed. A medial half pin is placed on the stable base to
with subchondral free wires, which are driven across the increase frame stiffness.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

70 J.J. HUTSON JR
pin. There should be at least four threaded rods in the
stable base and working length of the frame.
Rarely, a C3 fracture will be observed with distal shaft
extension. Preoperative planning will identify these com-
plex fractures. The fracture will have displacement of the
joint, metaphysis, and fracture extension into the shaft.
The shaft extension usually will not be comminuted in
C3 fractures because the fracture is the result of axial
loading. After distraction of the fracture by the bridging
fixator, the oblique fracture lines in the shaft will often
align anatomically. Percutaneous 4.5 mm screws can be
placed to lag these fragments together. Half pin fixation
is contraindicated as the threads of the pin twisting
through the far cortex can displace the fracture. One or
two olive wires on a working length fracture ring, placed
to compress the larger fragments, are used to increase the
stability of the fracture.
When a C3 fracture with shaft extension is observed
during preoperative planning, the working length ring is
added to the threaded rods supporting the carbon fiber
fracture ring. A working length ring should be carbon
fiber so as not to obscure the tibial shaft component of
the fracture.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
REFERENCES
1. Akeson WH. Effects of immobilization on joints. Clin Orthop
1987;219:28.
2. Fracture and dislocation compendium. Orthopedic Trauma Asso-
ciation Committee for Coding and Classification. J Orthop Trauma
1996;10(suppl 1):v–ix, 1–154.
3. Hutson JJ. The centered lateral flouroscopic image of the knee: the
key to safe tensioned wire placement in periarticular fractures of
the proximal tibia. J Orthop Trauma 2002;16:196 –200.
4. Hutson JJ. The treatment of complex proximal tibial fractures
(OTA Type C) with bridging hybrid fixation. Presented at: Annual
Meeting Orthopedic Trauma Association; October 8 –10, 1998;
Vancouver, British Columbia, Canada.
5. Mikulak SA, Gold SM, Zinar DM. Small wire external fixation of
high energy tibial plateau fractures. Clin Orthop 1998;356:230–238.
6. Schatzker J, Tile M. The Rationale of Operative Fracture Care.
Heidelberg, Germany: Springer Verlag; 1987.
7. Stamer DT, Schenk R, Staggers B, et al. Bicondylar tibial plateau
fractures treated with a hybrid external fixator. J Ortho Trauma
1994;8:455– 461.
8. Tucker H. Management of unstable open and closed tibial fractures
with the Ilizarov method. Clin Orthop 1992; 280:125–135.
9. Watson JT, Coufal C. Treatment of complex lateral plateau frac-
tures using Ilizarov techniques. Clin Orthop 1998;353:97–106.
10. Watson JT, Karges DE, Cramer KE, Moed BR. Analysis of failure of
hybrid external fixation. In: Techniques for the treatment of distal tibia
pilon fractures. 16th Annual Meeting, Orthopedic Trauma Associa-
tion. October 12–14, 2000; San Antonio, Tx. Abstract.
11. Watson JT, Moed BR, Karges DE, Cramer KE. Pilon fractures.
Treatment protocol based on severity of soft tissue injury. Clin
Orthop 2000;375:778 –790.
Techniques in Orthopaedics®
17(1):71–92 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 8: The Treatment of Distal Tibia Periarticular Fractures

with Ilizarov Fixators

James J. Hutson, Jr., M.D.

Summary: The early treatment of pilon fractures using joint spanning devices for
resuscitation is discussed. Compartment syndromes, vascular injury, and injuries that
may need amputation are discussed. Reduction technique for Type A and C1 and C2
pilon fractures using tibial frames is illustrated. Treatment for C3 pilon fractures with
bridging frames is also illustrated. Management of fibular fracture patterns and joint
comminution are illustrated. Reconstruction techniques of bone grafting, acute short-
ening, intercalary bone transport, and lengthening are illustrated. Key Words:
Ilizarov fixator pilon fractures treatment.

INDICATIONS FOR ILIZAROV FIXATORS another method of treatment. Low-energy fractures with
moderate displacement and soft tissue injury can be
Distal periarticular tibia fractures can be treated with
treated with small plate internal fixation. This fixation
Ilizarov fixators with excellent results. Orthopaedic
may need to be augmented with joint spanning external
Trauma Association (OTA) Type A and Type C fractures
fixation. Low energy distal tibia Type A fractures may
are indications for the use of Ilizarov fixators. Type B
also be treated with intramedullary nails. Increasing
fractures have an intact column of bone extending to the
severity of comminution, proximal extension of the frac-
plafond, which maintains length and can be used as
ture, and injury to the soft tissue envelope are indications
fixation for buttress plates and screws. A joint bridging
for using Ilizarov fixators for the treatment of pilon
frame is necessary in Type B fractures with severe
fractures.13 Dehiscence of the operative wound is the
comminution with greater than 50% of the joint surface
reason most free flaps are required in pilon fracture
crushed. Ilizarov fixators may be used for Type B frac-
treatment.11 This complication can be avoided by using
tures, if there is compromise of the soft tissue envelope
Ilizarov fixators.6 The soft tissue damage from tensioned
and placement of plates in the zone of injury would
wires is less severe than internal plating, and the surface
increase the risk of wound slough and infection.
area of the fixation device is minimal compared with
Type A fractures have intact plafond metaphyseal
plates.
bone blocks (or have nondisplaced fractures entering the
The fracture pattern of the fibula must also be evalu-
joint surface) with dissociation of the shaft from the
ated. The fibula will have three patterns of injury: intact,
metaphysis. Type C fractures have displaced fracturing
simple oblique/transverse fracture, and comminution. In-
of the joint surface with dissociation of the shaft from the
creasing levels of fibula fracturing is an indication for the
metaphyseal bone. The severity of the comminution and
use of Ilizarov fixators for pilon fractures.
the physiologic status of the soft tissue envelope are
Segmental bone loss at the shaft/metaphyseal junction
evaluated to decide if an Ilizarov fixator will be used, or
will require reconstruction. Autogenous bone grafting
may be used to reconstruct the defect, but should not be
From the Division of Trauma and General Orthopaedics, Department used acutely in the zone of injury. The bone graft is
of Orthopaedics and Rehabilitation, University of Miami, Ryder nonviable material, which the acute soft tissue envelope
Trauma Center, Miami, Florida. will have to incorporate, and may further compromise
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box the wound. Delayed bone grafting after resuscitation of
016960, Miami, FL 33101. the extremity is indicated, usually 6 to 24 weeks postin-

71
72 J.J. HUTSON JR

jury. The Ilizarov method allows bone loss reconstruc-

tion with segmental transport, acute shortening, and
proximal corticotomy and lengthening. These techniques
bring living bone into the zone of injury and can tolerate
compromised soft tissue viability.
Severe hind foot injuries combined with pilon frac-
tures can also be treated with Ilizarov fixators. The hind
foot is reduced and stabilized with minimal internal
fixation and the axial alignment maintained by the Il-
izarov fixator.5
In summary, the indications for treatment of distal
tibial periarticular fractures with Ilizarov fixators are:
1) Compromised soft tissue envelope.
2) Moderate to severe fracturing of the joint and
metaphysis.
3) Proximal extension of the fracture to the midshaft.
4) Comminution of the fibula/lateral malleolus.
5) Metaphyseal shaft junction bone loss.
6) Type B plafond fractures with greater than 50%
joint comminution.
7) Complex pilon fracture— hind foot fracture injuries.

INITIAL MANAGEMENT AND
PREOPERATIVE PLANNING
Initial examination of the distal tibia/pilon fracture
should precisely evaluate the vascular and neurologic
status of the foot and lower leg. Pilon fractures can be
complicated by injury to the posterior tibial nerve and
artery. In severe injuries, laceration or stretch injuries of
the posterior tibial nerve and artery are associated with
pilon fractures. Massive injury may not be salvageable
and amputation may need to be considered.
Compartment syndrome may occur in the foot and
lower leg requiring fasciotomies. Open wounds should
be examined with sterile gloves and covered quickly
with sterile gauze. Dressings should be applied loosely.
Deformity of the extremity should be reduced with gen-
tle traction and splinted. Soft tissue injury is resuscitated
by reducing the extremity into anatomic alignment. In-
travenous antibiotics are given early. Patzakis stated,
“The single most important factor in reducing infection
rate (in open fractures) was early administration of anti-
biotics that provide antibacterial activity against both
gram-positive and gram-negative microorganisms.”8 An-
kle and tibial radiographs are completed after initial
resuscitation and evaluation.
Pilon fractures with open wounds, severe comminu-
tion, and compartment syndromes will require emergent
surgical intervention. Debridement of open wounds
should be meticulous with careful dissection and exci-
FIG. 8.1. A half pin fixator with a calcaneal transfixation pin
provides excellent alignment of distal tibia fractures and is stable. The
forefoot position can be controlled with a first metatarsal base pin. The
fixator can be used as a distraction frame for limited internal fixation of
pilon fractures. This resuscitation frame is an excellent device, but
increases the cost of treatment. Reuse of the components can reduce
cost.
sion of compromised tissue and contamination. Adson
forceps and tenotomy scissors should be used to care-
fully inspect and remove compromised tissue. Perios-
teum should not be stripped from bone. The interval
between the tibia and fibula in pilon fractures with
syndesmosis injuries requires careful exploration. For-
eign debris can be sequestered in this area. Severe
contamination will require a separate anterior lateral
approach. After the surgical debridement is complete,
copious irrigation with low-pressure pulse lavage is used
to wash away small detritus. As the lavage impacts the
tissue, devitalized pedicles and strands of tissue will
become evident and should be trimmed away.
Compartment syndrome is evaluated, and appropriate
fasciotomies are opened. Resuscitation of the extremity
will be facilitated by temporary bridging of the distal
tibia and ankle. Simple half pin fixators can be placed
with a fixation block of two pins in the midtibial shaft
and foot fixation with a calcaneal pin and a talar neck or
first metatarsal pin (Fig. 8.1). The extremity should be
axially aligned with the talar dome centered on the tibial

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 8 73

and radiographic studies evaluated. If the posterior tibial

nerve sensory is absent, surgery on the pilon fracture is
indicated earlier if there is a displaced posterior frag-
ment, which is usually rotated 90° and pressing against
the posterior tibial nerve and artery (Fig. 8.2). Computed
tomographic (CT) scanning is recommended after initial
stabilization. The x-rays and CT scan are evaluated. The
fracture pattern may be amendable to percutaneous reduc-
tion techniques if there is simple fracturing of the plafond.
The CT scan will reveal the appropriate pathways of per-
cutaneous screws to compress the fragments and reduce the
fracture. Comminuted fractures will require open reduction.
FIG. 8.2. The posterior fragment in high-energy pilon fractures can The fracture pattern will indicate the surgical approach
impinge on the posterior tibial nerve and artery. The fragment is
displaced posteriorly and rotated 90°. If the patient has acute loss of (Figs. 8.3A, 8.3B, 8.3C, 8.3D). The anterior medial ap-
plantar sensory function and the displacement persists after placing the proach is the most common (Fig. 8.3B). Fractures with
extremity in a distraction frame, an early reduction of the posterior lateral comminution are reduced through the anterior lateral
fragment is done.
interval (Fig. 8.3A). Anterior posterior screws can be placed
through limited anterior incisions (Fig. 8.3D). The tendons,
shaft, the extremity out to length, the second toe aligned artery, and nerve require exploration and retraction to ex-
with the tibial tubercle, and the foot in neutral plantar pose the tibial surface to prevent injuries to these structures.
position. Failure to establish good position will compli- Rarely, a posterior medial approach will be needed to
cate later reconstruction. Regaining length and preven- realign a posterior medial fragment (Fig. 8.3C).
tion of equinus are essential. The initial phase of treat-
ment should be thought of as resuscitation. The goal of
REDUCTION TECHNIQUE FOR TYPE A
treatment is meticulous debridement of the tissues to
DISTAL TIBIA FRACTURES
decrease the incidence of infection, decompression of
compartment syndrome, reestablishment of axial length Distal tibia and pilon fractures occur at the terminal
and alignment, and prevention of equinus. Reconstruc- end of the extremity and the unsupported mass of the
tion is not attempted until the extremity and patient are
physiologically resuscitated. Further debridement may
be indicated. If there is severe mutilation of the extrem-
ity, the initial resuscitation will allow an interval period
of observation. Twenty-four to seventy-two hours of
observation usually will determine if salvage of the
injury is indicated. If the leg is not viable, the patient and
family can observe the leg in a quiet environment and
understand the need for amputation.
Closed pilon fractures with comminution also are
stabilized with bridge frames to regain length and resus-
citate the soft tissues. Less expensive calcaneal pin
traction with the leg supported on a Bohler frame can
maintain length, but provides poor control of rotation and
axial alignment. The patient is bound to the bed. Simple
traveling traction can be applied with a proximal tibial
metaphyseal Steinman pin and a calcaneal pin with
medial and lateral connecting rods using Synthes or
Hoffman II external fixators12 (Fig. 5.1). Closed lower- FIG. 8.3. The pattern of the fracture determines the surgical ap-
proach for open reduction. (A) If the comminution is lateral, an anterior
energy pilon fractures can be stabilized in well-padded lateral approach is used. (B) If medial, an anterior medial approach. (C)
medial and lateral splints. The posterior medial approach is used for open reduction of the
The extremity and patient will be resuscitated by 1 to posterior malleolus. (D) Anterior-posterior lag screws are placed
through a formal anterior approach. The dorsalis pedis artery and deep
3 weeks after injury. During the first week, the soft peroneal nerve can be injured if a safe pathway is not dissected down
tissues are examined, the neurologic status evaluated, to bone.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

74 J.J. HUTSON JR

ankle and foot is easily manipulated to realign the frac-

ture (Fig. 8.4). This allows modification of the reduction
strategy, which avoids using a horizontal reference wire
in the proximal tibia. The distraction to reduce the
fracture is between an orthogonal two-ring stable base
with two AP half pins mounted on universal Rancho
cubes and a horizontal reference wire placed 8 mm above
the tibial plafond or horizontal reference wire in the
calcaneus, if a bridging frame strategy is needed to treat
comminution of the plafond. The distal metaphysis is
manipulated on the distal ring to align the fracture in
Type A and reconstructed Type C fractures.

Technique
A padded sand bag is placed under the hip to rotate the
patella into the AP plane. A tourniquet is placed on the
thigh and the leg prepared and draped above the knee.
The fracture is evaluated with fluoroscopy marking the
proximal extent of the fracture and horizontal reference
position wire 8 mm above the plafond. The working
length of the fracture is determined by choosing a rod 50
mm longer than the working length. The working length
is the distance from the horizontal reference wire to the
half pin, or wire placed 2 to 3 cm superior to the
proximal extent of the fracture on the stable base (Figs.
4.9E, 4.9F). The distal bone block is evaluated to deter-
mine the length of bone that is available for fracture ring
fixation. Usually only one ring will be needed to fixate
the distal metaphysis. If preoperative planning identifies
proximal extension of the fracture and the need for a
FIG. 8.4. The Type A distal tibial fracture has an intact joint surface
and metaphyseal shaft dissociation. The reduction strategy is to distract
the fracture with a horizontal reference wire and align the fracture
axially.
FIG. 8.5. The reduction of distal tibia fractures has a different
strategy of reduction compared with tibial plateau fractures. An orthog-
onal stable base with two AP half pins on universal Rancho cubes is
placed on the tibial shaft 2 to 3 cm superior to the fracture. The initial
two rods are placed in the anterior lateral and posterior medial one hole.
working length ring, then it will be added to the fracture
frame (Fig. 4.9 H).
A two-ring stable base separated by 150 mm rods is
aligned on the tibia (smaller rods are indicated on shorter
tibias) (Fig. 8.5). Two anterior-posterior (AP) half pins
mounted on universal Rancho cubes are placed through
the anterior medial face of the tibial shaft. The distal half
pin should be positioned 2 to 3 cm proximal to the
fracture. The stable base is manipulated until it is orthog-
onal to the tibia on AP and lateral fluoroscopic view. The
ring clearance for pilon fractures needs to be more
anterior than tibial plateau fracture frames to provide
adequate clearance for soft tissues, (the ankle requires
more anterior clearance than the tibial plateau) (Figs.
3.14B, 3.14C). The frame will clear the gastroc posteri-
orly and provide adequate clearance anteriorly at the
ankle. The most common ring size is 160mm. The stable
base functions as a horizontal reference wire for aligning
the fracture. If the stable base is orthogonal, then a
horizontal reference wire through the plafond centered
on the shaft will enforce axial alignment in the coronal
plane (varus/valgus). A horizontal reference wire is

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 8 75

FIG. 8.6. A horizontal reference wire is placed 8 mm above the

plafond while the foot is manually distracted and aligned with the shaft.

placed in the plafond (Fig. 8.6). The distal metaphysis is

aligned on the fracture ring (Figs. 8.7A— 8.7E). The
plafond should be aligned axially on the AP and lateral
fluoroscopic views so that a centering line on the shaft
centers on the metaphysis. Rotation is evaluated and the
foot rotated to align the tibial tubercle with the second
toe. Small varus valgus corrections can be applied by
elevating the reference wire off of the ring with washers
and long male hinges (Fig. 5.7). The AP half pins are
tightened in the Rancho cube and the reference wire is
tensioned to 110 kg. The working length rods in the
anterior lateral and posterior medial three holes, and the
medial lateral rods are distracted reducing the fracture
out to length or slightly overlengthening the fracture. The
fracture alignment is evaluated. The reference wire po-
sition on the ring may need repositioning to improve the
alignment of the fracture.
The reference wire is now an axis the metaphysis can FIG. 8.7. The distal fragment is manipulated on the carbon fiber
fracture ring until the fragment is aligned axially with the shaft, and the
rotate on to reduce the fracture in the sagittal plane (Fig. rotation is correct. (A) Translation is corrected by moving bone block
8.8). Manipulation of the foot can align the fracture. with olive wire through loosened fixation bolts. (B) Rotation is cor-
Arch and draw wires are used to align the fracture and rected by aligning second toe with tubercle. (C) Anterior-posterior
position is corrected by moving horizontal reference wire on ring holes.
compress oblique fractures (Figs. 8.9, 8.10, 8.11). Prox- (D) All corrections are combined during this stage of reduction until the
imal shaft extension is stabilized with wires or pins on a metaphysis is rotated anatomically and centered on the tibial shaft. (E)
working length ring (Fig. 5.20A). Long oblique fractures With the carbon fiber fracture ring connected to the orthogonal stable
base, there will be close to anatomic alignment. The fracture ring is
in the coronal plane may be reduced with AP lag screws distracted until the fracture is out to length before proceeding with local
after distraction (Fig. 5.18). Two screws are placed reduction techniques.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

76 J.J. HUTSON JR

the fracture (Figs. 8.17 A, 8.17B). The Spatial Frame

uses this strategy by incorporating a computer directed
alignment of the independent linkages. The advantage to
these systems is the ease of application, allowing novice
Ilizarov surgeons to obtain good alignments of fractures.
The systems prevent the use of working length rings and
the local applications of arch wire, draw wire, and
laminar spreader technique to compress oblique frac-
tures. The universal hinges must be loosened to correct
any plane of fixation and depend on the grasping of
fixation blocks with manual reduction.

TECHNIQUE FOR TREATING C3

FIG. 8.8. After placing the horizontal reference wire and distracting,
the distal metaphysis can be reduced by rotating the foot around the
reference wire. This is a simple but effective reduction maneuver.
PILON FRACTURES
Increased comminution of the joint surface with me-
taphyseal fragmentation (OTA C2 and C3 fractures)
requires complex reduction strategies to reduce fractures

together and tightened several turns back and forth to

reduce the fractures. In larger fragments, attempts to
reduce the fracture with one screw and high torque can
comminute the fragment.
Varus/valgus is improved by using a draw wire in the
distal fragment in the medial-lateral plane. Once the
fracture is aligned, a divergent cluster of opposed olive
wires is placed on the fracture ring spreading the wires
over the longest distance possible (Fig. 8.12). The tibial
shaft position may be improved by adjusting the half pin
in the midtibial ring Rancho cube. A medial face pin on
a Rancho cube (do not use a universal cube) is placed on
the stable base to stiffen the fixation. A second medial
pin is used in larger patients. The fracture site is com-
pressed. Fixation should be isolated to each fixation
block to allow compression. Fixation crossing the frac-
ture from one fixation block to the opposite prevents
compression of the fracture. Apply a footplate with
elastic straps to the Ilizarov fixator to control equinus.
Type C fractures with moderate or simple fracturing
are converted to Type A reductions by reconstructing the
plafond with percutaneous screws or limited open reduc-
tion. The assembled metaphysis is reduced with a hori-
zontal reference wire as described above (Figs. 8.13,
8.14, 8.15, 8.16). FIG. 8.9. Type A fractures typically have an oblique fracture pattern,
The alternative method to reducing Type A fractures is which must be stabilized and compressed to avoid nonunion. A hori-
to place a stable base on the tibial shaft and fixate a ring zontal reference wire is placed and the fracture is distracted. If the
oblique fracture is in the sagittal plane, the fracture is forcefully
to the distal metaphysis with an opposed cluster of olive reduced with a draw wire technique against the shaft fragment stabi-
wires. The fracture reduction ring should be placed lized by the AP half pins. A medial half pin could be added to the stable
orthogonal to the plafond and metaphysis. The two base to directly oppose the olive wire below the middle ring. The olive
wire on the medial side of the metaphysis has to be aligned anatomi-
fixation blocks are connected by universal connecting cally. The draw wire will compress the oblique fragment and the
rods. The two fixation blocks are manipulated to reduce metaphysis will not be over-reduced medially (white arrow).

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 8 77

FIG. 8.11. If the oblique fracture is located superior to the metaph-

yseal shaft junction, a laminar spreader technique is used to forcefully
reduce the oblique fracture. These fractures are stabilized by secondary
compression. Placing lag screws across the fracture does not improve
fixation. Lag screws are only used for vertical splits and spiral fractures
that can be reduced anatomically. The distal fragment rotates around
the horizontal reference wire pivot point and the reduction is opposed
by the AP half pin on the mid ring.

secondary fixation after open reduction. A horizontal

reference wire is placed in the fixation cluster and the
FIG. 8.10. If the oblique fracture is in the coronal plane, an arch wire ring is aligned with the wire. The remaining wires are
technique is used to forcefully rotate the metaphysis around the hori-
zontal reference wire and reduce the fracture. This maneuver applies
chased with fixation components. Once a second wire is
strong forces to the fixator and a working length ring is needed. added to the fixation cluster, the metaphysis position is
fixed in relation to the ring. This technique may result in
of the tibial plafond (Fig. 8.18). Percutaneous reduction
is possible with C2 fractures, but most C3 fractures will
require a limited open reduction. Axial distraction is
essential to reduce these complex fractures. Comminu-
tion will prevent an initial stable reconstruction of the
plafond, and bridging distraction to the calcaneus is used
to protect the fragile metaphyseal block for 6 weeks until
early callus has stabilized the fracture.
There are two strategies to reduce these fractures. One
is to apply extrinsic traction by calcaneal pin traction,
proceed with an open reduction aligning the shaft and
metaphysis and applying the Ilizarov fixator as a neu-
tralization frame around the reduction, and secondarily
adding a calcaneal ring or footplate to the frame. This
technique is an extension of the Type A fracture reduc-
tion where the metaphyseal bone block is reduced before
applying the Ilizarov fixator. Watson recommends plac-
ing the olive wires through the plafond reconstruction
during the open reduction, followed by closing and
assembly of the ring around the metaphyses.12 The wires
are “chased” by the fixation bolts with washers, long
male hinges, and posts to prevent deformation of the wire FIG. 8.12. Additional divergent olive wires are added to the carbon
fiber fracture ring to fixate the metaphysis. A medial plane half pin is
pathway. The reference wire is tensioned first. The ten- added to the stable base to increase stiffness and the fracture is
sioned wires are not used as active reduction tools, but as compressed.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

78 J.J. HUTSON JR
FIG. 8.13. C2 pilon fractures are converted to a unified bone block
with limited internal fixation. The fixation is placed subchondral to
clear the wire pathways.
the fracture ring not aligning with the orthogonal stable
base because the ring would have to be “clammed
shelled” in the exact anatomic position to match the
stable base. If the stable base is applied with half pins on
universal cubes, its position can be modified to align the
rings. If the stable base was not mounted on universal
cubes, the threaded rods over the working length would
require conical washers so that the angular difference
between the rings can be compensated for by the limited
FIG. 8.14. Once the metaphysis is reassembled, a stable orthogonal
base is placed.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
universal motion of the threaded rods in the conical
washers. Using conical washers on threaded rods is
another reduction technique that allows minor correc-
tions of fracture alignment between fixation blocks.
The second method is to incorporate intrinsic distrac-
tion into the reduction sequence (Figs. 8.19 – 8.23). Us-
ing the Ilizarov fixator as an intrinsic distraction frame
allows precise alignment of the talus with the tibial shaft
and plafond. The dome of the talus becomes an anatomic
form to reconstruct the fragmented plafond. The commi-
nuted fragments are reduced onto the plafond, which is
distracted out to length and aligned rotationally using the
second toe in alignment with the tibial tubercle. Once the
fracture is distracted anatomically, the fracture is evalu-
ated for joint surface alignment. C2 fractures with large
fragments and no crushing of the joint surface are re-
duced with percutaneous methods using pelvic reduction
clamps, joysticks, cannulated screws, and Steinman pins.
The fragments can be reduced using olive wire reduction
techniques, arch, and draw wires. The carbon fiber frac-
ture ring is slid distal over the threaded rods and a
horizontal reference wire is placed. The wire is tensioned
on the ring, and two or three additional wires are placed
FIG. 8.15. A horizontal reference wire is placed 8 mm above the
joint and the metaphysis aligned axially on the ring. The working
length rods are placed in the anterior lateral and posterior medial three
holes to clear the fluoroscope image (black arrows). The working
length rods are placed in the anterior lateral and posterior medial three
holes to clear the fluoroscope image (black arrows).
 CHAPTER 8 79

tibia should be closed. When large plates were used, this

was impossible and wounds often were closed with
sutures only in the dermal layer under high tension. This
leads to skin slough, plate exposure, and the agonizing
path to infected nonunion. In the 100 pilon fractures
treated at our institution with Ilizarov fixators, there has
been no wound slough or dehiscence.6 This is the advan-
tage of allowing the soft tissues to resuscitate and avoid-
ing extensive interval fixation of pilon fractures.

FIG. 8.16. The metaphysis is reduced axially and three to four di-
vergent opposed olive wires fixate the fracture. Posterior fragments split
from the metaphyseal bone block can be lagged to the shaft. This screw
does not prevent compression across the fracture site. The working
length rods are located in the anterior lateral and posterior medial three
hole of the ring. The medial and lateral rods are located between the
tensioned wires where ring holes are available (black arrows).

with divergent angulation determined by the pattern of

the fracture.
C3 plafond fractures will have crushing of the joint
surface that will require open reduction to achieve ac-
ceptable reduction. The critical factor in the outcome of
pilon fractures is the reconstruction of the joint surface.
Malunion and nonunion of the metaphysis and shaft can
be reconstructed secondarily with good result. Malunion
of the joint surface is very difficult to correct second-
arily, and will rapidly lead to a painful ankle. The high
rate of infection in open reduction and plating of pilon
fractures was not a direct result of the open reduction; it
FIG. 8.17. (A) An alternative reduction technique is to apply fixation
was a complication of the massive internal fixation and blocks to the tibial shaft and distal metaphysis, and connect the blocks
the failure of the soft tissue envelope to survive over the with universal connecting rods. The fracture is manually reduced. This
hardware. The threshold to perform an open reduction technique is simple, but the ability to compress oblique fractures of the
distal tibia is poor and nonunions are common. The ability to use
has been lowered as we have observed the outcomes of opposed olive wires to forcefully compress the oblique fracture is not
pilon fracture treatment. If the percutaneous reduction is possible with this technique. Compression occurs through the long
not good, proceed with an open reduction. There is no working distance of the universal hinge mechanisms. (B) If a distal
tibia is not maintained in traction until definitive external fixation, the
advantage to operate through small incisions. The retrac- distal fragment will shorten and early fracture healing will bind the frag-
tion on the skin edges is more damaging than extending ment. A late reduction attempt using universal connecting rods will not
the incision several more centimeters. The incision be able to reduce the fracture because strong axial traction was not
placed across the fracture prior to the translation reduction maneuver.
should be a sharp dissection without undermining the The long working length of the connecting rods rotating through the
flaps. After the open reduction, the fascia layer over the proximal hinge cannot apply direct local forces to reduce the fracture.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

80 J.J. HUTSON JR
FIG. 8.18. The C3.2 pilon fracture has comminution of the plafond
and extension into the metaphysis.
The surgical approach to the fracture will be deter-
mined by the fracture pattern (Figs. 8.3A— 8.3D). An-
terior medial and lateral are the most common ap-
proaches. The fracture interval is exposed. Small
Penfield elevators are excellent tools for exploring a
fracture. The thin profile allows gentle probing and
prying of the impacted fractures, and the dull edge
prevents soft tissue injury if inadvertent plunging occurs
posteriorly. The orientation of the fragments is usually
anatomic, in spite of proximal impaction. If a fragment is
loose, mark the anterior edge. If it becomes dislodged,
rotational alignment can be difficult if the alignment was
FIG. 8.19. A stable base is aligned orthogonally on the tibia shaft 2
to 3 cm superior to the fracture. A horizontal reference wire is placed
in the calcaneus and the pilon fracture is distracted. A fracture reduc-
tion ring is positioned on the working rods, superior to the fracture. The
carbon fiber ring will be repositioned over the metaphysis when the
joint is reduced. This limited frame construction can be used as a
resuscitation frame and 1 to 2 weeks later be completed with reduction
of the pilon fracture.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 8.20. The working length rods span the distance from the stable
base to the foot plate. The posterior rods are placed five to six holes
medial and lateral of center (black arrows). Depending on the approach
to the pilon fracture, an anterior rod is placed on a plate extension from
the stable base to control the foot plate (white arrows). If the approach
is medial, the rod is placed lateral. The posterior working length rods
are usually 200 to 250 mm in length. The working length rods should
always have 50 mm additional length to allow for distraction of the
fracture and modification of the fixator during the early stages of
reduction. The unused rod length is always “buried” in the space
between the rings of the stable base.
not established earlier. Small crushed cortical fragments
should be removed, their location noted so a gap in the
reduction will be expected.
Crushing deformation of the joint can cause joint step
off in spite of anatomic alignment of the metaphysis (Fig.
8.24). The crushing causes the angle between the metaph-
yseal cortex and plafond surface to be reduced. Reduction
of the metaphyseal cortex does not align the joint. An
elevator or osteotome will need to be worked above the
joint surface and the crushing displacement reduced leaving
a defect, which is filled with autogenous or allogenic
cancellous bone graft. The talar dome is used as a form to
align the fragment. This cannot be observed directly, but
assessed on the true centered lateral view of the ankle on
fluoroscopy. Small 0.045 Steinman pins are used to control
these delicate fragments.
The other difficult fragment to align is the posterior
malleolus fragment that is displaced posteriorly. A direct
posterior medial approach can be used to reduce this
fragment, but this is awkward and encroaches on the
posterior tibial artery and nerve. The fragment is ob-
served through an anterior approach. If the talus is
distracted and axially aligned, the fragment is pulled over
the top of the dome into its anatomic position (Figs.
8.25A— 8.25D). A small threaded Steinman pin is
drilled into the fragment under fluoroscopic control.
(Avoid over drilling and impaling the artery and nerve.)
Traction is placed on the fragment reducing it onto the
 CHAPTER 8 81

the fragment. The pin should be placed with caution to

avoid injury to the posterior tibial nerve and artery. The
entire width of the fragment needs to be crossed by the
pin. The talar dome should be aligned axially and out to
length before manipulating the fragment. The posterior
fragment is reduced and pinned in place either with an
anterior lateral Steinman pin or an inferior pin emerging
through the posterior talar dome.
The posterior fragment is difficult to fixate in the 60°
medial lateral safe wire zone at the ankle unless it is a
large fragment. A posterior lateral to anterior medial
pathway is available (Fig. 8.27B). The wire is only used

FIG. 8.21. The foot is rotated on the foot plate to align the second
toe with the tibial tubercle and patella.

plafond. The reduction is usually unstable and wants to

displace. A smooth Steinman pin is drilled through the
calcaneus and talus located posteriorly and across the
ankle joint securing the posterior fragment in a reduced
position. The pin can be further drilled into the shaft
increasing the fixation of the fragment. This technique is
possible only when the talus is distracted and anatomi-
cally aligned. It is essential to have the talus distracted to
reduce the posterior fragment, regardless of the method
of fixation being used to treat the pilon fracture. With
bridging distraction, the pin can be left in place until the
foot frame is removed 6 weeks later. If the anterior
fragments are large, a 4.5 mm cannulated screw is placed
after reducing the anterior to the posterior fragment
(Figs. 8.3D, 8.26). If there is good purchase, the inferior
pin is removed. If there is comminution, the inferior pin
should be left in place until the foot frame is removed.
The posterior fragment can also be manipulated pos-
teriorly by placing a Steinman pin into the fragment (Fig.
8.25 D). The pin is placed through the medial soft tissue
FIG. 8.22. The hindfoot is aligned on the foot plate to center the
sliding along the tibial cortex. The Steinman pin needs to dome of the talus on the AP and lateral fluoroscopic image with the
be of a larger diameter to be stiff enough to manipulate anatomic axis of the tibia.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

82 J.J. HUTSON JR
FIG. 8.23. The varus valgus alignment of the talar dome is corrected
with angular adjustments as needed.
when the ankle is bridged with a calcaneus distraction
wire. When the foot frame is removed at 6 weeks, the
wire is also removed. The other marginal wire is the
anterior lateral to posterior medial olive wire that en-
croaches on the extensor digitorum communis tendons to
fixate an unstable fragment. This wire is placed if the
anterior lateral plafond is unstable (Fig. 8.27A).
Where possible, interfragmentary small Steinman pins
and small fragment screws should be used to reduce the
joint surface. Steinman pins are drilled through small
fragments and out through the skin on the opposite side
through safe wire corridors (Figs. 5.16A, 5.16B). The
FIG. 8.24. Impaction of the joint can cause reduction puzzles. If the
metaphyseal cortices are aligned anatomically, but a step off in the joint
is observed, there is impaction of the cancellous bone. The joint
fragment will have to be pried free of the fragment and reduced onto
the dome of the talus. The fragment can be fixated with a brad wire and
supported by bone graft. The talus must be distracted to reduce this
fragment.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 8.25. Distraction of the hind foot removes the talus from the
space in which the plafond fragments are aligned in anatomic align-
ment. The posterior malleolar fragment can be reduced onto the surface
of the dome of the talus. The fragment can be reduced through a
posterior medial approach, which is difficult and exposes the tibial
nerve and artery to injury. The fragment can be reduced with a
“joystick” and held in place with a Steinman pin placed through the
calcaneus and talus. A third method is to place a threaded Steinman pin
into the fragment through an open anterior approach and pull the
fragment over the dome of the talus. The fragment is pinned in place
with a calcaneal talar Steinman pin. The posterior malleolar pins are
removed after 6 weeks when the foot plate is removed. (A and B) The
dome of the talus without distraction occupies the space where the joint
fragments must be positioned to reduce the fracture. (C) Anatomic
distraction clears the space for the joint fragments to be reduced. The
dome of the talus becomes a template. (D) A “joystick” can be placed
in the posterior fragment through an open approach or percutaneously
through the skin to reduce the fragment. The posterior fragment is
pinned in place by a 0.062 Steinman pin passed through the calcaneus
and talus.
wires are cut and bent over as “free wires,” which are left
in place until the foot frame is removed. The small
screws and wires are placed subchondrally to clear the
pathway for the tensioned olive wires. On larger frag-
ments, screws and wires are placed in the metaphysis to
improve reduction.
The purpose of the “limited” internal fixation is to
align the joint and metaphysis. The Ilizarov fixator will
 CHAPTER 8
FIG. 8.26. The level of comminution of the anterior plafond will
determine the fixation. If the anterior fragments are not crushed, a 3.5
or 4.5 mm cannulated screw is placed. If the anterior plafond is
crushed, a subchondral 0.045 Steinman pin is used to align the joint and
is also used as a brad wire (Fig. 5.15). Both configurations are
augmented with cancellous allograft or autograft. The posterior frag-
ment has been pulled over the dome of the talus and fixated with a
calcaneal talar 0.062 pin. With secure fixation to the anterior fragment
with a subchondral screw, the calcaneal talar pin may be removed. If
the joint is fragmented, the calcaneal talar pin is left in place for 6
weeks until the distraction foot frame is removed in clinic.
maintain axial alignment and stiffness, and the olive
wires at the fracture ring will reinforce the joint fixation.
Therefore, internal fixation is limited to what is needed
to align the joint and metaphysis.
FIG. 8.27. (A) Anterior lateral fragments may require an olive wire
that encroaches on the extensor digitorum tendons. If this wire is
needed to improve the reduction, it has little morbidity. (B) The
posterior malleolar wire is indicated to fixate unstable posterior mal-
leolar fragments. The wire is usually removed when the foot plate is
removed 6 weeks after reduction.
83
FIG. 8.28. After the joint is reduced, the carbon fiber fracture ring is
repositioned over the fracture and three to four olive wires are placed.
Coronal plane angular wires are effective fixation at the medial mal-
leolus. A medial half pin is added to the stable base to increase
stiffness. The carbon fiber fracture ring is supported anteriorly by two
threaded rods from the inferior ring of the stable base. These rods are
usually 100 to 150 mm in length. Six weeks after fixation, the foot plate
is removed in clinic to start ankle motion. The posterior working rods
are spun up into the stable base and retightened one at a time. An
opposed divergent medial olive wire is placed through the calcaneus to
prevent translation on the horizontal reference wire.
Cancellous allograft and autograft are used to support
crushed fragments. Use only enough to maintain the
reduction. Excess graft increases the “dead bone load” at
the fracture site and may lead to infection.
With the metaphysis reconstructed, a horizontal refer-
ence wire is placed through the plafond 8 mm above the
joint surface (Fig. 8.28). The wire is placed laterally or
medially based on the fracture pattern. The olive wire is
positioned to control a fragment and not at the edge of a
fracture. Two or three olive wires are placed with diver-
gent angulation and wire spread on the ring to fixate the
metaphyseal block. Tensioned wires can be placed in the
coronal plane. This wire pathway is effective to fixate
medial malleolar fragments.9,12 If the fracture extends
proximally into the shaft, a working length ring is added
to the frame to control the proximal fragments. Half pins
are not used in the metaphysis of pilon fractures. The
comminution inherent to Type C fractures is a contrain-
dication to the use of half pins.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
84 J.J. HUTSON JR
TECHNICAL SEQUENCE OF PILON BRIDGING
FRAME ILIZAROV FIXATOR
1) Two ring stable base separated by 150 mm
threaded rods. Measure distance from calcaneus
to stable base and add 50 mm to select working
length rod. Place rods in posterior medial and
lateral 5 or 6 hole on the foot plate. Place one or
two carbon fiber rings on the working length rods
aligned with the AP bolts and the foot plate in AP
alignment. Use two rings when preoperative plan-
ning dictates the need for a working length ring.
2) Align the stable base 2 to 3 cm superior to the
fracture with two AP half pins mounted through
universal Rancho cubes. The stable base is
aligned orthogonally.
3) Place a horizontal reference wire through the calca-
neus. Align the hindfoot by positioning the olive
wire on the foot plate. Align the second toe with the
tibial tubercle to correct rotation.
4) Close the foot plate with a carbon fiber ring
allowing clearance for the forefoot and toes.
5) Connect the foot plate to the stable base anteriorly
with a threaded rod connected by an outrigger
plate. The anterior rod should be placed on the
side of the frame opposite the surgical approach.
6) Tension the calcaneal wire. Observe the align-
ment with the tibia shaft and reposition until the
talus is anatomically aligned with the tibia.
7) Tighten the universal cubes on the AP half pins
and distract the fracture 1 to 2 cm by pulling the
working length rods equally through the stable
base tightening the nuts. A long male hinge can be
placed between the ring and nut to measure equal
distraction lengths.
8) Evaluate the fracture. Use percutaneous or open
reduction techniques to align the joint surface.
Close the surgical approach after reduction.
9) Place a horizontal reference wire in the metaph-
ysis. Slide the carbon fiber fracture ring down the
threaded rods adjacent to the reference wire. Build
up fixation to the wire and tension the wire. Two
threaded rods are placed from the stable base to
the fracture ring in the anterior lateral and medial
quadrant.
10) Use arch wire, draw wire, and working length ring
olive wires to improve the reduction.
11) Add additional olive wires to the fracture fixation
ring with divergent angulation. Use at least three
wires. Add medial fixation to the stable base.
12) Compress the foot and fracture reduction ring into
the stable base 5 mm.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
AVOIDING SHAFT METAPHYSEAL
NONUNIONS IN TREATING
PILON FRACTURES
Hybrid fixation has been associated with a high inci-
dence of nonunion at the shaft metaphyseal junction.1,14
The nonunions are the result of unstable fixation of pilon
fractures with hybrid fixators. Ilizarov fixation allows
aggressive reduction and stabilization of the shaft me-
taphyseal junction. The following principles will reduce
the incidence of nonunion. We have observed 4 non-
unions in 125 distal tibia fractures treated with Ilizarov
fixators (2.4%).
1) Fixate the metaphyseal bone block with at least
three divergent, opposed olive wires spread over
the largest length possible.
2) Use appropriate size rings. Avoid using 200 mm
rings on ankles less than 100 mm in diameter.
3) Reduce the working length between fixation blocks.
The distal fixation wire or pin should be 2 to 3 cm
above the fracture.
4) Secure the stable base to the tibia with at least three
half pins using biomechanical principles. (Avoid
using double pin blocks with the half pins spread
less than 5 cm.)
5) Use draw wires and arch wires and laminar
spreader pin techniques to compress the shaft frag-
ment to the metaphyseal bone block.
6) Use acute shortening to create stable fractures with
bone compression between fixation blocks.
7) Prevent equinus with foot plates, toe slings and
early weight bearing.
8) Bone graft the shaft metaphyseal junction at 12 weeks
if callus has not started to bridge the fracture gap.
FIXATION OF THE LATERAL MALLEOLUS
AND DISTAL FIBULA IN PILON FRACTURES
Distal tibia and pilon fractures combine injuries to the
tibia and fibula. The fibula may be intact, have sample
oblique or transverse fracture, or have comminution (Fig.
8.29). The fibula can have associated injury of the
tibial-fibular syndesmosis, usually seen in pilon fractures
with intact fibula or distal third fibular oblique fractures
(Fig. 8.30). The lateral malleolus has anterior and pos-
terior ligaments to the tibial plafond, which help align the
posterior and anterior lateral joint fragments during re-
duction of pilon fractures.
Fixation of the lateral malleolus/fibula was the first
step in reducing pilon fractures in Reudi and Allogow-
er’s treatment protocol. Fixation of the fibula established
the length of the lateral column and reduced the anterior
 CHAPTER 8
FIG. 8.29. Five configurations of the fibula will be observed when
treating pilon fractures. Ten percent of distal tibial fractures will have
an intact fibula. Simple oblique fractures of the lateral malleolus will be
treated in three configurations: no fixation, plate fixation, or intramed-
ullary fixation. The last pattern is comminution, which is usually not
fixated. If the tibial column has moderate comminution, the fragments
are reconstructed to anatomic length. Fixation of the lateral column
facilitates reduction of the pilon fracture.
lateral and posterior fragments of the plafond joint sur-
face. The joint surface was reduced and the metaphysis
augmented with bone graft to reconstruct bone loss. The
medial column was stabilized with plating. The protocol
was based on regaining length by fibula fixation. Resto-
ration of fibular length necessitated restoration of tibial
length. In low to moderate energy fractures, reconstruc-
tion of the tibial plafond to length was possible with
internal fixation and bone graft (Fig. 8.29). In high-
energy pilon fractures with metaphyseal shaft comminu-
tion, reconstruction of the medial column was difficult,
requiring long plates and extensive grafting (Fig. 8.31).
This resulted in a tibial column collapse with varus defor-
mation (Fig. 8.32). Varus deformation also occurs in low
energy pilon fractures treated by isolated fibular plating. An
FIG. 8.30. If the fibula is constructed to length and the lateral
ligaments and syndesmosis are torn, the tibial column will migrate
superiorly causing lateral column impingement on the calcaneus and
increasing the malleolar angle. An unusual pilon fracture variant will
have an intact fibula with comminution of the plafond. The plafond is
literally driven past the fibula avulsing the tibia fibular ligaments
85
FIG. 8.31. Pilon fractures without metaphyseal comminution are
reconstructed to length (Fig. 8.29). C3 pilon fractures have comminu-
tion of the joint and metaphysis and reconstructing the fibula is
optional. The AO method used the lateral malleolus and fibula as an
internal distractor to regain length. Regaining length using the Ilizarov
system is accomplished by distraction between orthogonal fixation
blocks. The fibula is fixated only if it improves the reduction. The C3
fracture can have an intact fibula, simple oblique fracture, or commi-
nuted fibula.
intact fibula or fixation of the fibula by plating or intramed-
ullary nailing results in anatomic length of the lateral
column in pilon fractures. This anatomic length dictates that
the reconstruction of the tibia plafond and metaphysis will
also require reconstruction to anatomic length to produce a
stable pilon fracture, which will proceed to healing without
deformation into varus.
Ilizarov treatment of pilon fractures differs fundamen-
tally from classic open reduction internal fixation (ORIF)
in the strategy of reduction. Axial length and alignment
are not gained by fibular reconstruction, but by axial
distraction between a proximal orthogonal stable base
and a horizontal reference wire in the calcaneus. The
FIG. 8.32. If the fibula is plated to length and the anterior and pos-
terior tibial fibular ligaments are intact, the tibial column will collapse
into varus unless the metaphyseal comminution is reconstructed.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
86 J.J. HUTSON JR
FIG. 8.33. The tibial column can be distracted to length and bone
graft placed to reconstruct the metaphyseal comminution. (A) Plating
of the fibula reconstructs the fibula to anatomic length. (B) Reduction
of the joint if the anterior and posterior ligaments are avulsed does not
reduce the plafond to anatomic length when there is metaphyseal
comminution. (C) Bridging distraction reduces the plafond and medial
column to length (if there is an occult subtalar dislocation, bridging
distraction will not pull down the talus. A screw or pin is placed across
the subtalar joint if this is observed). (D) Autograft is used to recon-
struct the metaphyseal defect.
dome of the talus is distracted and aligned with the shaft
using the external fixator without fixation of the fibula.
Fixation of the fibula becomes elective. The fibula/lateral
malleolus is only fixated when it will improve the final
reduction, and is used in fracture patterns that allow the
medial column to be reconstructed to anatomic length.
Pilon fractures with intact fibulas are associated with
syndesmoses tears. The plafond is impacted superior and
lateral. The plafond impaction may have a valgus slope
from the talar dome being forced up into the joint surface
as the syndesmoses tears. A similar pattern will occur
with a distal fibula shaft oblique fracture. Plating the
fibula will reestablish fibular length. If the tibia plafond
has moderate fragmentation, the tibial column should be
reconstructed to anatomic length. An olive wire is placed
through the fibula to reduce the lateral malleolus to the
distal tibial metaphysis. Comminution of the metaphysis
compromises the reconstruction of the tibia. Moderate
shortening of the tibia will encourage healing of the
fracture. This situation produces a fibula plus ankle
mortise (Fig. 8.30). The lateral malleolus impinges on
the calcaneus and the malleolar angle is greater than
10°. With severe comminution, the intact fibula extends
inferiorly 1 to 2 cm producing a painful ankle. This
malalignment is treated by fixating the tibial joint surface
at the anatomic position and reconstructing the metaph-
ysis with bone graft or bone transport (Figs. 8.33
A— 8.33D, 8.34). An alternative method is doing an
oblique distal fibula resection, 6 to 7 cm superior to the
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 8.34. Extensive grafting of the metaphysis places a great
demand on the local fracture physiology and may compromise a
precarious soft tissue envelope. Living bone can be transported into the
metaphysis by distraction osteogenesis. New bone formation occurs
proximal to the zone of injury. The transport also recruits local soft
tissue to heal open wounds.
joint, of 1 to 2 cm to allow the fibula to shorten to the
level of the tibial plafond. Always cut less than mea-
sured, test the alignment, and resect more if indicated. If
the fibula has an oblique or transverse fracture, the end of
the fracture is allowed to slide by each other (Fig. 8.35).
If the fracture is within 6 cm of the plafond, this may
cause the fibula to angulate into a poor position compro-
mising the ankle mortise (Fig. 8.36). If this occurs, the
fracture is fixated to length with reconstruction of the
mortise and tibial metaphysis to length or the mortise can
be shortened anatomically by resecting a segment of
fibula. Failure to fixate the fibula in low to moderate
energy valgus impaction injuries will cause persistent
valgus and malreduction of the anterior lateral and pos-
terior tibial plafond fragments. This pilon fracture pattern
has intact medial cortex with progression of comminu-
tion toward the lateral side of the joint.
FIG. 8.35. If the fibula fracture is not fixated to length, the medial
and lateral columns can shorten to promote healing of the metaphysis.
If shortening is greater than 2 cm, a proximal lengthening can be done
to equalize the leg length in suitable candidates.
 CHAPTER 8
FIG. 8.36. Shortening of the medial and lateral column may cause
malalignment of the lateral malleolus if there is an oblique fracture.
This usually will not occur in comminuted fibula fractures. A small
resection of the fibula shaft, to allow correct alignment, may be needed
to restore the mortise alignment.
Comminution of the lateral malleolus is a contraindica-
tion to fixating the fibula. The lateral malleolus will be
reduced indirectly by the anterior and posterior tibial fibula
ligaments. Occasionally, the lateral malleolus will be dis-
placed superior to the plafond. A sharp skin hook or
Steinman pin can be used to distract the fibula and its
position can be fixed with an olive wire on the fracture ring.
In summary, fixation of the fibula requires reduction
of the tibial plafond at anatomic length. This is indicated
in low to moderate energy pilon fractures without com-
minution of the metaphysis. Comminution of the tibial
metaphysis requires reconstruction if fibula length is
established. If shortening of the metaphysis is planned as
part of the reconstruction, then the fibula should not be
fixated or in an intact fibula, an oblique resection of the
fibula should be considered.
Type A distal tibia fractures are approached with the
same strategy. If the distal metaphysis has moderate
fragmentation, plating or intramedullary nailing of the
fibula is indicated to reconstruct the lateral column to
length. If the metaphysis is comminuted, and shortening
will be accepted, then the fibula should not be fixated,
but be allowed to shorten.
THE USE OF BYPASS JOINT SPANNING
ILIZAROV FIXATORS IN PILON FRACTURES
Joint spanning bypass circular external fixators are
used to treat pilon fractures that have moderate fracturing
and pilon fractures with severe comminution and mar-
ginally reconstructible joint surfaces. These fractures are
at opposite ends of the spectrum of pilon fractures.
The concept of limited internal fixation with axial
external fixation has been used extensively the past 10
87
years to treat pilon fractures. Joint spanning half pin
frames (Orthofix, Biomet, Hoffman II, Synthes) have
been used to distract the pilon fracture followed by
limited internal fixation. These systems use cantilever
half pins in the calcaneus, talar neck, and first metatarsal
base. The placement of half pins in the calcaneus pre-
vents early weight bearing in the frame, and early loos-
ening and infection are associated with half pin fixation
of the calcaneus and first metatarsal. Attempts have been
made to use hinged ankle joints, which have been un-
successful. The strategy of using joint spanning frames is
that limited fixation of the pilon can be used to align the
fracture with the axial alignment and stiffness controlled
by the external fixator. Because there is no “limited”
fixation at the metaphyseal level of the distal tibia, the
frames are maintained until healing occurs, and no ankle
or hind foot motion is possible until frame removal. Pilon
fractures require 12 to 24 weeks or longer for healing.6
This process necessitates at least a 3-month interval of
joint spanning fixation, which may extend to 6 months or
more if union of the pilon fracture does not occur
promptly. The alternative is to remove the external fix-
ator before healing, and use a fracture brace often result-
ing in late varus collapse of the fracture. Prolonged half
pin spanning of the joint when using a talar neck pin can
lead to varus and cavus of the foot, which is difficult to
treat. These systems are easy to use, but are only indi-
cated in fractures that are expected to heal by 12 weeks.
Fractures with proximal shaft extension, bone loss, or
comminution usually will require 4 to 6 months of axial
support until healing. C2.3 and C3.3 pilon fractures have
comminution and shaft extension, and probably should
not be treated by joint spanning frames.
Ilizarov fixators can also be used as joint spanning
frames for low-energy pilon fractures treated with lim-
ited internal fixation. The frame consisted of an orthog-
onal stable base 2 to 3 centimeters proximal to the
fracture and a foot plate connected by four thread rods to
the stable base. The two anterior rods are connected to
the stable base by outrigger plates. The stable base has
two AP half pins mounted through universal Rancho
cubes and a medial half pin. A horizontal reference wire
is placed in the calcaneus and the wire is positioned on
the foot plate aligning the dome of the talus with the tibia
shaft in the AP and lateral flouroimage. Foot rotation is
aligned with the tibial tubercle. The foot is secured by an
opposed divergent olive wire in the calcaneus. Toe traps,
suspended by rubber bands on an arch, applied by phys-
ical or occupational therapists are used to control the
forefoot preventing cavus and varus.
A talar neck wire is added to the foot frame to increase
stiffness. Rarely, metatarsal wires are placed for patients
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
88 J.J. HUTSON JR
FIG. 8.37. C3 fractures with severe comminution will have frag-
ments that are too small for tensioned wires to improve the reduction.
unable to use the toe traps (usually because of post-
traumatic brain injury) to prevent forefoot varus and
cavus. The patient can place partial weight on their foot
with the Ilizarov frame in place, compared with no
weight with half pins in the calcaneus. The longevity of
tensioned wires in the foot is greater than half pins. The
Ilizarov fixator in this simple configuration is less ex-
pensive than the half pin frames. The joint bypass frame
is indicated to axially align and support pilon fractures
with moderate fracturing treated with limited internal
fixation and crushing injuries of the foot and ankle with
soft tissue loss during reconstruction.
The frame maintains neutral plantar foot position pre-
venting equinus during treatment, and also protects free
flaps from pressure by elevating the foot away from the
bed. The bypass frame not only duplicates the joints
spanning of half pins frames, but allows superior foot
fixation and infinite modification to deal with distal tibia
and hind foot injuries. An extended stable base is used in
patients with an intramedullary nail in the tibia. Tensioned
wires are placed in the proximal and distal tibial metaphysis
avoiding the pathway of the nail and connected by long
rods. Usually to improve stiffness, a dummy ring is placed
at midshaft. The elongated stable base is used to secure a
foot plate with tensioned wires in the foot, to prevent
equinovarus during treatment of complex foot injuries as-
sociated with tibial shaft fractures.
Pilon fractures with unreconstructable comminution
are treated with bypass Ilizarov frames (Figs. 8.37, 8.38).
Pilon fractures will be observed with severe crushing
with fragmentation of the joint surface. Most fragments
will be less than 1 cm2 in size and fixation with plates
and screws will be impossible. There will be marginal
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
fixation pathways for tensioned wires in the carbon fiber
fracture reduction ring. Placing tensioned wires through
the metaphysis will not increase fixation and could
provide a bacterial ingress along the wire causing a deep
infection, septic arthritis, or both.
Thirteen pilon fractures were treated by Guadinez
without fixation at the metaphysis of the tibia with
reasonable result; healed fractures and axial alignment of
the tibia.4 This concept accepts the inevitability of ankle
joint post-traumatic arthritis, but reestablishes axial
length and alignment of the tibia. These severe pilon
fractures should not be acutely bone grafted. Grafting
increases the dead bone load at the zone of injury. The
joint surface fragmentation may be reconstructible with
0.045 Steinman pins. A limited approach is made to the
fracture. The joint fragments are aligned with subchon-
dral wires, similar to rebar in a concrete sidewalk. The
Steinman pins are bent over 180° and used as brad wires,
or placed through the skin as free wires in safe pathways
to be removed after healing of the fracture. Often the
central plafond will be morselized and fixation possible
only in the peripheral fragments of the plafond fracture.
The goal is to reconstruct a reasonable talus plafond
junction that will transfer weight successfully. These
junctions probably are filled with fibrocartilage after
healing of the fracture allowing slight motion of the joint.
Fractures will be observed where crushing prevents
even small wire fixation. These should be aligned axially
with the by-pass frame and allowed to heal. A talar neck
wire is used to secure the talus in these high-energy
FIG. 8.38. The Ilizarov fixator is used as a joint spanning frame;
0.045 Steinman pins are used to reconstruct portions of the joint. A
talar neck wire is added to the foot plate to stabilize the hind foot (white
arrow). The calcaneus is always fixated with medial and lateral diver-
gent opposed olive wires. The wires must avoid the posterior tibial
nerve and artery.
 CHAPTER 8 89

of the distal tibia and metaphysis. The distal tibia can be

stripped of soft tissue proximally compromising the
blood supply to the bone causing subsequent necrosis.
Large defects occur, sometimes greater than 10 cm. Pilon
fractures can have bone loss of the plafond or necrosis
with contamination, which require debridement of the
plafond. The Ilizarov method is used to reconstruct the
bone loss observed in pilon fractures with good results.
Acute shortening is used to reconstruct bone loss
(Figs. 8.41, 8.42). The shaft fragments are compressed
into the plafond bone block creating a stable construct,
which allows early weight bearing. The fracture surfaces
may have oblique orientation and compression will cause
the thin edge of one fragment to deform the opposite
bone block and be unstable. An osteotomy of the oblique
fracture surface in the horizontal plane to create approx-
imately 50% surface area of the shaft or metaphysis is
done converting an unstable oblique compression into a
stable horizontal compression. The plafond bone block is
trabecular bone and has excellent blood supply from the
surrounding soft tissue. The opposing shaft fragment has
compromised blood supply; there may be several milli-
meters to several centimeters of dead bone. Acute short-
ening is not done emergently at the time of admission,
FIG. 8.39. (A) Open pilon fractures can have severe crushing of the
joint with contamination. The joint surface may be lost or become
necrotic and infected. (B) A squaring osteotomy of the viable distal
tibia and dome of the talus is done after excision of the destroyed joint
fragments. The ankle is arthrodesed using an Ilizarov fixator by acutely
shortening and compressing the squared surfaces. (C) A proximal
lengthening is done if the patient is a candidate for lengthening.

fractures. The alternative treatment in these fractures,

especially if there is a contaminated open soft tissue
envelope, is to excise the destroyed plafond, and recon-
struct the ankle with acute shortening to arthrodesis with
proximal lengthening (Fig. 8.39A— 8.39C), or interca-
lary bone transport to arthrodesis for pilon fractures with
greater than 3 to 4 cm of bone loss (Fig. 8.40).
The bypass frames for pilon fractures with severe com-
minution are maintained until the fracture is healed. Re-
moval before healing will lead to deformation and non-
union. The goal of treatment is to reconstruct axially length
and alignment with expectation of secondary ankle arthro-
desis after healing of the fracture. Combining ankle arthro-
desis with acute fracture treatment is not recommended.

RECONSTRUCTION OF BONE LOSS IN

PILON FRACTURES
Pilon fractures can have crushing of the metaphysis
with relative bone loss; anatomic bone loss associated
with open fractures and delayed bone loss from necrosis
FIG. 8.40. Pilon fractures can cause complete loss of the plafond.
This severe injury is salvaged by transport to arthrodesis. Docking site
revision and bone grafting is usually needed to complete the arthrodesis.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

90
FIG. 8.41. Acute shortening of the distal tibia. Local osteotomies of
the tibia and fibula are done to allow the fracture to shorten into a stable
position.
but after resuscitation of the fracture 10 to 21 days after
the injury. The shaft fragment is examined with the
tourniquet down. Viable bone will have punctate bleed-
ing points and a slight pinkish hue. Necrotic bone will
have no bleeding and have a dense white color. A small
osteotome (a sharp edge is essential) is used to shave
away thin fragments helping to identify the transition
from dead to living bone. A high-speed burr can be used,
but must be cooled with iced saline to prevent thermal
necrosis. Ronguers and Kerrison punches can also be
used to explore the bone. The proximal fragment is care-
fully chipped away from distal to proximal until the tran-
sition zone to viable bone is observed. The removal of
necrotic bone may be extensive. A horizontal osteotomy
is done at this level, creating approximately 50% cross
sectional area for compression. Proximal placement of the
osteotomy to gain a full cross section would produce a
more stable construct, but at the expense of leg length
adding multiple centimeters to the reconstruction. The os-
teotomy is done with a Ronguers, burr, or microoscillat-
ing saw, protecting the soft tissue with minimal stripping.
Iced saline must be used to prevent thermal necrosis.
The acute shortening should be 2 to 3 centimeters in
length. The carbon fiber fracture ring on the plafond is
compressed against the stable base on the tibia shaft.
Because the base ends have surfaces 90° to the shaft,
compression will align the fracture and the axial align-
ment is easily obtained. A posterior tibial pulse must be
palpable after the acute shortening.
The debridement may have resulted in a bone loss gap
greater than 2 to 3 cm. Two strategies are used to treat
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
J.J. HUTSON JR
this magnitude of bone loss. An acute shortening can be
done and further delayed shortening carried out over
several days at a rate of 1 mm four times a day, using
square nuts on the working length rods connecting the
plafond and stable base. This allows several more cen-
timeters to be closed. The advantages of acute shortening
is viable bone is compressed increasing stability, align-
ment is obtained acutely, and the Ilizarov fixator frame is
simple to construct. Because viable bone is being com-
pressed into the zone of injury, soft tissue closure is not
required and pilon fractures with extensive soft tissue
injury can be treated without free flap coverage.
The disadvantage to acute shortening is the risk of
vascular compromise by kinking the blood vessels (Figs.
8.43A, 8.43B). A pulse must be present after acute
shortening. If not, relengthen the frame to anatomic
length, which should reestablish the blood flow to the
foot. A delayed shortening can be done or an intercalary
transport to docking of the fracture site can be con-
structed to close the bone loss gap. Acute shortening
cannot be done without fibular resection if there is not
comminution of the fibula. Usually, moderate shortening
of 2 to 3 cm is accommodated by compression of the
fibular fragments; longer shortening will require fibular
resection. The contour of the leg is distorted. Shortening
causes circumferential bulging of the distal leg, which
does not resolve over time. Surgical incisions are closed
before shortening.
Acute shortening is combined with proximal corti-
cotomy and lengthening using a bifocal frame (Fig.
8.42).10 A 5/8-full ring fixation block is placed on the
proximal tibia and length is regained through a corti-
FIG. 8.42. The acute shortening can be combined with proximal
lengthening to equalize leg length.
 CHAPTER 8 91

port, the frame is converted to a bifocal frame to regain

equal leg length (see Chapter 12).
Pilon fractures with complete loss of the plafond from
contamination, crushing, and necrosis are salvaged with
arthrodesis. Acute shortening of the talus to the shaft
fragment is combined with proximal corticotomy to
regain leg length. Larger defects may require intercalary
bone transport to arthrodesis.
The Ilizarov technique allows living bone to be trans-
ported into the zone of injury in pilon fractures. Living
bone has resistance to infection and tolerates compro-
mised overlying soft tissue. Stable axial alignment is
created which promotes fracture healing.
Using massive iliac crest graft to reconstruct bone loss
is less effective compared with bone transport.2,3,7 Large
FIG. 8.43. (A) The muscles and tendons, nerves, arteries, and veins defects require multiple harvest sites for bone graft. The
are anatomically out to length when a fractured tibia is reduced without
shortening. (B) Acute shortening causes the soft tissue structures
bone graft is not living bone, and has to be placed in a
passing the fracture zone to expand peripherally. The skin diameter soft tissue bed, which has been resuscitated and can
increases and places tension on wound closures. The shortening does support the effects of dead bone load. New bone forma-
not create loose skin. The muscle tendon units lose mechanical effi-
ciency. The arteries and veins are deformed and may have reduction of
tion occurs posteriorly. Iliac crest graft should be used to
blood flow or obstruction causing ischemia. Careful monitoring of the enhance healing of adjacent viable bone blocks and not
extremity is necessary after acute shortening. as a reconstruction for segmental bone loss.
Acute shortening and bone transport are excellent
techniques to reconstruct bone loss in pilon fractures.
cotomy by distraction histogenesis. The bifocal frame New bone formation is accomplished at the proximal
combines distraction proximally and compression dis- tibia outside of the zone of injury. Living bone and soft
tally. Lengthening is elective. Patients with contraindi- tissue is transported to the zone of injury improving the
cation to bone transport (psychosis, tobacco abuse, isch- fracture environment
emic vascular disease, end stage immunodeficiency
disease) are treated without lengthening, and full sole
TECHNICAL SEQUENCE FOR BIFOCAL AND
elevations are used in their shoes to equalize leg length.
INTERCALARY TRANSPORT ILIZAROV
Intercalary bone transport is an alternative to acute
FIXATOR FOR PILON FRACTURES WITH
shortening (Fig. 8.44). The plafond bone block is main-
BONE LOSS
tained by the Ilizarov fixator at anatomic length. Fibula
length is maintained. The plafond fixation block is con- Bifocal Fixator
nected to a 5/8-full ring proximal tibial bone block with
1) Assemble frame with: 5/8-full ring fixation block
a transport ring-bone block at the midtibial level. A
proximal tibia; 4 cm distraction clickers proximal
corticotomy is done, and the shaft is transported distally
until docking with the plafond bone block. This Ilizarov
frame is more complex than the bifocal acute shortening
frame, but allows massive bone loss to be reconstructed.
Our longest salvage has been 17 cm. Bone grafting and
revision of the docking site is needed in greater than 50%
of fractures. Docking can be improved by revision of the
plafond bone block and tibial transport segment, excising
the fibrous cap, squaring the bone ends to bleeding bone,
and acutely shortening to compress the docking site. The
Ilizarov frame is converted to a bifocal frame to com-
plete leg lengthening (see Chapter 12).
In pilon fractures with large bone defects, the plafond
block can be shortened 5 cm to reduce the intercalary FIG. 8.44. Distal tibia bone loss associated with pilon fractures can
bone transport distance, and after docking of the trans- be reconstructed with intercalary bone transport.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

92 J.J. HUTSON JR
working length; midtibial stable base with 120 to
100 mm rod length; working length rods distal
tibia; and carbon fiber fracture fixation block or
bridging foot frame with carbon fiber fixation ring.
2) Corticotomy is done with a giggly saw before
frame application, or with osteotomes after frame
application.
3) Place horizontal reference wire proximal tibia and
align proximal and midtibia fixation blocks on
extremity in orthogonal position.
4) Align the plafond and foot fixation block anatom-
ically with the proximal shaft. The acute shortening
osteotomy and fibula osteotomy is completed be-
fore frame application, if needed.
5) Add wires and pins to increase the stiffness of
fixation in all fixation blocks.
6) Compress the distal metaphyseal bone block to the
midtibial stable base using acute or delayed short-
ening.
7) Begin distraction osteogenesis with distraction
clickers.
Intercalary Transport Fixator
1) Assemble frame with: 5/8-full ring proximal tibial
fixation block; long working length rods which
will span the distance from the proximal tibial
fixation block to the distal carbon fiber fracture
fixation block and foot frame; midtibial transport
ring with AP pin, trailing AP pin, and medial pin
(Fig. 4.8). Square nuts are used on the superior side
of the midtibial distraction ring.
2) Align the fixator using a horizontal reference wire
proximally and a half pin in a universal Rancho
cube on the midtibial distraction ring. Align the
distal tibial metaphyseal bone block and foot plate
axially with the tibial shaft. Leave the foot plate in
place until completion of bone transport. Add wires
and half pins to increase stiffness of the fixation
blocks. Start distraction histogenesis and continue
transport until docking. Revision of the docking
site, acute shortening, and bone grafting may be
needed after long bone transports.
Intercalary transport frames that are placed on a short-
ened tibia need to be converted to lengthening frames
after docking at the fracture site. The frame is modified
by removing the long working length rods one at a time.
New working length rods are placed between the tibial
transport ring and distal metaphyseal fracture ring. The
mid and distal fixation blocks are compressed. Distrac-
tion clickers or threaded rods with square nuts are placed
between the proximal 5/8-full ring block and the
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
midtibial transport ring and distraction is continued until
equal leg length is obtained (see Chapter 12).
TECHNIQUE FOR REMOVING THE FOOT
PLACE TO START ROM OF ANKLE 6 WEEKS
POSTOPERATIVELY
1) Scrub the olive wire skin pin interface with beta-
dine.
2) Inject the olive side of the skin with 2% lidocaine.
Wait 15 to 20 minutes.
3) Cut the wires from the foot plate and remove the
foot plate and outrigger rod from the frame.
4) Cut the wire on the opposite side of the olive at the
skin level with sterile wire cutters and remove the
olive wire.
5) Sequentially, move the posterior threaded rods su-
periorly so that the excess rod length is buried in
the stable base between the rings. Start range of
motion exercise for ankle and hind foot. Continue
partial weight bearing.
REFERENCES
1. Anglen JO. Early outcome of hybrid external fixation for fractures
of the distal tibia. J Orthop Trauma 1999;13:92–97.
2. Cierny III G, Zorn KE. Segmental tibia defects comparing con-
ventional and Ilizarov methodologies. Clin Orthop 1994;301:118 –
123.
3. Green SA. Skeletal defects. A comparison of bone grafting and
bone transport for segmental skeletal defects. Clin Orthop 1994;
301:111–117.
4. Guadinez RF, Malik AR, Szporn M. Hybrid external fixation in
tibial plafond fractures. Clin Orthop 1996;329:223–232.
5. Hutson JJ. Ilizarov treatment of severely comminuted calcaneus
fractures and crush injuries of the foot. Tech Orthop 1996;11:150 –
159.
6. Hutson JJ, Zych GA. The treatment of 100 tibia/fibula, distal
segment (43) fractures with circular tensioned wire fixators. Pre-
sented at: Annual Meeting Orthopedic Trauma Association; Octo-
ber 12–14, 2000; San Antonio, Tx.
7. Marsh JL, Prokuski L, Bierman JS. Chronic infected tibial non-
unions with bone loss conventional techniques versus bone trans-
port. Clin Orthop 1994;301:139 –146.
8. Patzakis MJ, Wilkins J. Factors influencing infection rate in open
fracture wounds. Clin Orthop 1989;243:36 – 40.
9. Pavolini B. Crossing wires in the distal tibia. Tech Orthop 1996;
11(2):208 –209.
10. Saleh M, Rees A. Bifocal surgery for deformity and bone loss after
lower limb fractures. J Bone Joint Surg Br 1995;77:429 – 434.
11. Sirkin M, Sanders R, Di Pasquale T, Herscovici D. A staged
protocol for soft tissue management in the treatment of complex
pilon fractures. J Orthop Trauma 1999;13:78 – 84.
12. Watson JT. Tibial pilon fractures. Tech Orthop 1996;11:150 –159.
13. Watson JT, Moed BR, Karges DE, Cramer KE. Pilon fractures
treatment protocol based on severity of soft tissue injury. Clin
Orthop 2000;375:78 –90.
14. Wyrsch B, McFerran M, McAndrews M, et al. Operative treatment
of fractures of the tibial plafond. J Bone Joint Surg Am 1996;78:
1646 –1657.
Techniques in Orthopaedics®
17(1):93–96 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia
Chapter 9: Management of the Tibia Fracture to Union
James J. Hutson, Jr.,
Summary: Pain management, physical therapy, evaluation of healing and frame
removal are discussed. Time to union for tibial plateau, shaft, and pilon fractures is also
discussed. Key Words: Ilizarov fixator tibia fracture frame removal.
Functional weight bearing, joint range of motion, and
strengthening of the injured extremity are the essential
elements stimulating fracture healing when using
Ilizarov fixators. The axial compression of the wires with
weight bearing stimulates bone healing, decreasing the
frame time of the fixator. Patients who participate in
early functional use of the extremity have less swelling,
rapid bone healing, and improved range of motion of the
adjacent joints. The salubrious effects of functional use
observed in fracture bracing parallels the fracture healing
observed using Ilizarov fixators.
In the acute postoperative recovery, the extremity
should be elevated. Pillows should not be placed under
the knee, which causes flexion contractures. The leg
should be elevated with the knee in extension. The
patient should be educated that early weight bearing is
beneficial and possible. Most patients are anxious that
movement of the leg will displace the fracture. They
need encouragement to use the extremity and assurance
that the frame will not fall apart. Physical therapy is
started once the acute operative pain has subsided.
Fracture surgery is very painful and effective pain
management is essential in the perioperative period.
Application of Ilizarov fixators in trauma is not painless,
and adequate opiate pain management is indicated. It has
been my observation that patients do have pain associ-
ated with having an Ilizarov fixator on their extremity
and that most patients need variable levels of pain con-
trol. A small subset of patients will use minimal pain
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
93
M.D.
medication and a difficult group will demand massive
amounts of medication. These patients have had a prior
history of substance abuse, or are addicted at the time of
their injury. It is not practical to detoxify a patient
following a traumatic injury while they are healing with
an Ilizarov fixator on their leg. The patients are placed on
a maintenance level of medication, usually 4 times a day,
and carried until the fracture has healed and the Ilizarov
fixator removed. The opiate medication is tapered after
frame removal or they are referred to a pain management
specialist. Reasonable patients will use Tylenol during
the day and use opiate medication at night, when the
extremity is more painful after a day of activity. The
need for pain medication will subside as the fracture
heals. When the fracture has united, many patients will
walk full weight on the leg with minimal pain. This
indicates the fracture has united and frame removal is
indicated.
The location and severity of the fracture will affect the
function of the extremity. Proximal tibial fractures will
have a metaphyseal fracture ring which blocks flexion
past 90°. The patient is encouraged and assisted to flex
the knee until the ring pushes against the posterior thigh.
This range of motion will improve after frame removal
with continued therapy. Assisted motion to maintain full
extension is essential during healing. Strengthening of
the upper and lower leg musculature continues during
fracture healing and weight bearing is increased as tol-
erated until frame removal. Patients will use crutches or
walkers during fracture healing, and some will advance
to cane-assisted gait.
Patients treated with bridging frames will be able to
walk partial weight with their leg extended until the
femoral distraction ring is removed in clinic. Range of
motion exercises of the knee are started after femoral
94 J.J. HUTSON JR
ring removal in clinic 6 weeks after surgery. If motion
does not increase to 90° by 4 weeks after bridging ring
removal, the knee is manipulated under anesthesia and
continuous passive motion machines are used at home.
Approximately 15% to 20% of patients with a bridging
knee frame will need to have manipulation of their knee.
Physical therapy continues after frame removal and pa-
tients that are fortunate enough to have comprehensive
insurance will benefit from therapy up to 1 year after
their injuries. Recovery from high-energy tibial plateau
fractures requires 2 years. The patients are active during
this period and are slowly getting better. Strength and
motion will improve, swelling will subside, and they will
reach a functional plateau. The long-term outcome is
directly related to the severity of crushing of the joint
surface. The rate of degeneration of the cartilage deter-
mines the long-term function of the joint.
Postoperative management of pilon fractures will fo-
cus on rehabilitation of the ankle joint. Stable fracture
configurations, distal tibia Type A and C1, C2 fractures
can be fixated with tensioned wires at the level of the
metaphysis and a midtibial stable base fixation block.
The ankle joint is not bridged and ankle motion therapy
is started in the postoperative period. The patient will
have postoperative pain. Early movement of the ankle
may be resisted. An equinus contracture can develop
rapidly. Plantar flexion of the foot in a resting position
cannot be tolerated in pilon fractures. If the patient
cannot maintain active ankle motion or neutral planter
position of the ankle, a foot plate with elastic straps is
attached to the fixator. The foot plate is removed several
times a day for ankle motion therapy. Patients with
altered mental status, neuropathy, or plantar nerve injury
can develop full thickness pressure ulcers using foot
plates with elastic straps. The foot plate must be removed
for 30 minutes every 2 hours in these patients. If this is
not possible, a foot plate can be added to the frame to
control equinus. The treatment for equinus is to prevent
it from occurring.
Early touch down weight bearing is started in the post-
operative period and the weight advanced as tolerated until
full weight ambulation in the fixator is obtained. Constant
therapy to maintain dorsiflexion is essential during rehabil-
itation. Most patients lose dorsiflexion when treated with
tensioned wires fixators.
Comminuted pilon fractures often are treated with
joint spanning fixators. The hindfoot is distracted and
aligned with the tibial shaft and foot position is main-
tained in neutral plantar flexion. The foot is removed
from the fixator 6 weeks after surgery to start ankle
motion therapy. The opposed olive wires in the calcaneus
are removed in clinic with local anesthesia. Free wires
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
used to fixate small joint fragments are removed when
the foot plate is removed. Rehabilitation continues as
described for Type A, and C1, C2 fractures. The forefoot
position can be aligned in neutral plantar flexion with a
metatarsal base tensioned wire. This wire tends to be
painful. A better method to control the forefoot is to have
the occupational therapist add elastic toe slings sus-
pended on malleable wire supports connected to the
frame. This prevents flexion contracture of the toes and
cavus position of the forefoot. After the foot frame is
removed, functional weight bearing and ankle-hindfoot
motion is continued to prevent equinus. Placing the foot
flat on the floor with every step is the most effective
therapy to prevent equinus. A sandal with straps over the
forefoot can be used when walking to protect the plantar
surface.
The time to fracture union is directly related to the
severity of the fracture, soft tissue injury, location of the
fracture, and traumatic bone loss. Secondary factors also
affect the time to union and Ilizarov frame removal.
Smoking, drug use, ischemic vascular disease, and dia-
betes can increase the time to union. Patient noncompli-
ance with physical therapy, reluctance to place weight on
the extremity, and the use of wheelchairs, in spite of
education on the need to walk with a walker or crutches,
can increase the “frame time” for fracture union. Patients
with bilateral lower extremity fractures that cannot stand
for several months have delayed fracture healing. High-
energy tibial fractures may be bilateral, or there can be
contralateral complex fractures, which prevent early
functional rehabilitation. Pool therapy is beneficial to
these patients. Using floats, they are able to walk partial
weight on both lower extremities during the early phases
of rehabilitation.
The Ilizarov fixator should not be removed until the
fracture has united. The blood supply of the tibia and
adjacent musculature are located posterior and lateral and
early healing occurs in this quadrant of the zone of injury.
Radiographic examination will reveal callus developing
posteriorly and laterally, which will increase in volume and
density as the fracture heals. Fractures stabilized with well
designed fixators will not produce massive peripheral cal-
lus, but will heal with interfragmentary new bone and
moderate peripheral callus. Extensive peripheral new bone
formation can be an indication of fracture instability from
poor fixator biomechanics or occult deep fracture infection.
Removal of the fixator is indicated when callus is
observed traversing the fracture lines and has early mat-
uration with defined neocortical margins. The Ilizarov
fixator should be maintained on the fracture until there is
radiographic evidence of healing and the patient is walk-
ing full weight bearing in the frame, or at least 50% with
 CHAPTER 9
FIG. 9.1. The graph shows that the majority of proximal tibial
periarticular fractures have clinical union from 12 to 28 weeks. The
frame time is affected by many variables. There is no “cookbook” time
to remove the fixator. The Ilizarov fixator is removed when the fracture
has united with callus. The fixator is removed in clinic or under
anesthesia. The 144-week frame time occurred in a “street person” who
refused frame removal because the external fixator on his leg increased
the money he collected on the street.
a walker or crutches. Removal of the fixator before
maturation of the callus will require the use of fracture
braces, cast and assisted weight bearing. If the frame is
removed before fracture stability, a malunion or non-
union can occur which will require secondary treatment
to salvage a good result for the patient. It is better to
maintain the fixator for an additional 1 or 2 months when
fracture healing is not clearly evident than to remove the
fixator early. This concept is especially applicable to
patients who are unreliable and have marginal support.
With the Ilizarov frame in place, they can be active and
walking full weight on their extremity. With advanced
healing in the fixator, they can literally walk out of the
clinic after frame removal without the need for progres-
sive return to full weight ambulation.
The time to union will vary from 12 weeks to 26
weeks for periarticular fractures of the tibia treated with
Ilizarov fixators. Fractures with shaft involvement will
usually require at least 6 months of frame time.1 Tibial
plateau fractures without shaft extension heal rapidly and
most fixators can be removed between 12 and 16 weeks
(Fig. 9.1). Fractures with shaft extension will require
extended frame times up to 6 months. After frame
removal, a hinged knee orthosis should be used for 4 to
8 weeks and the patient will use crutches or a cane until
they are comfortable walking independently. Rehabilita-
tion will continue for up to 1 year if funding is available.
Pilon fractures take longer to heal than tibial plateau
fractures. Pilon fractures with moderate metaphyseal
fracturing may be ready for frame removal at 12 weeks,
but most pilon fractures require 16 weeks to 26 weeks for
union of the fracture (Fig. 9.2). Premature frame removal
in pilon fractures usually leads to angular deformation
and nonunion.2 When joint spanning frames are used for
pilon fractures without tensioned wire fixation at the
95
level of the fracture, the ankle and hindfoot are fixed and
ankle motion cannot be started until the frame is re-
moved. If there is a delay in healing at the metaphysis
shaft junction, the patient cannot mobilize the ankle and
hindfoot, creating a dilemma. If the frame is removed to
start ankle motion before union, angulation and malunion
will occur. If the frame is left in place for bone grafting
or until fracture healing, the ankle and hindfoot will have
further arthrofibrosis and forefoot cavus, which will
require extensive therapy to resolve. Because of this
dilemma, joint spanning frames without tensioned wire
fixation at the fracture zone of the metaphysis should
only be used for pilon fractures that are expected to heal
by 12 to 16 weeks.
Pilon fractures heal with callus posteriorly as the
initial response. Once the fracture is stabilized by callus,
additional healing will proceed throughout the fracture.
The fracture does not heal circumferentially, but by
columns of new bone maturing across opposed frag-
ments. If a computed tomography (CT) scan is done on
a pilon fracture after healing, dense columns of new bone
will be observed traversing the fracture site. The shock
absorbing function of the trabecular bone is lost, and may
be one of the factors leading to post-traumatic arthritis.
Fixator removal is indicated when callus can be observed
bridging the fracture zone with a neocortical margin. The
lateral x-ray view will show the dense callus posteriorly.
Usually, the fixator can be removed with posterior heal-
ing and fibula union. Fractures with shaft extension will
require 6 months or more of frame time. The fracture will
continue to heal for several years after frame removal.
Most manual workers will not be able to do medium to
heavy lifting, pushing, or pulling for 2 years after a distal
tibia fracture.
After frame removal, the patient is casted for 2 weeks
FIG. 9.2. The frame time for distal tibial periarticular fractures
shows that the majority of fractures are clinically united between 12
and 28 weeks. The fractures with shaft extension tend to require 6
months of fixation time. Fractures in the metaphysis heal quickly and
the frame is removed from 12 to 16 weeks. Type A fractures with distal
tibial shaft bone loss required prolonged frame times to regenerate new
bone by distraction osteogenesis.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
96 J.J. HUTSON JR
and encouraged to walk full weight bearing. The pin sites
heal during this period and 2 weeks later in clinic, a hinged
fracture brace can be fitted. Occasionally, if the post frame
removal x-ray shows marginal callus, a short leg walking
cast will be used for an additional 4 weeks. The x-ray taken
after frame removal will show detail of fracture healing
obscured by the frame components. Subtle maturation in
the callus or marginal healing will be evident. This initial
post frame removal x-ray will indicate the level of function
and therapy the patient will continue.
Tibial shaft fractures will require 6 months of external
fixation to heal the fracture. Fractures associated with
high-energy soft tissue injuries may require extended
external fixation before healing. Functional use is essen-
tial for the fracture to heal. Tibial shaft fractures will not
heal if the patient continues to use crutches or a wheel-
chair. The fracture fragments will have scant callus
develop across the fracture site. A well-applied fixator
will produce stiffness at the fracture site with com-
pressed fragments. The axial loading of the fracture in
this configuration produces interfragmentary callus with
moderate peripheral expansion of the callus. Expansive
immature callus is evidence of an unstable fixation of the
fracture. Prior to fixator removal, the patient should be
able to walk full weight bearing on the leg. The callus on
x-ray will have a clear neocortex with new bone travers-
ing the fracture site. The Ilizarov fixator is destabilized
by loosening and taping over the working length rod
fixation nuts, and having the patient continue full weight
gait for 2 weeks. If the fracture remains stable and there
is no increase of pain at the fracture site, the fracture is
ready for fixator removal. The working length rods can
be removed from the leg and the fracture manually
stressed. There should be no motion. If there is doubt of
clinical union, the fixator rods should be reassembled
and further treatment time in the fixator continued, or
bone grafting or other measures to stimulate union
should be scheduled.
Frame removal can be done in clinic or with outpatient
anesthesia. Frame removal in clinic is applicable to
patients who can tolerate pain during the removal of the
pins and wires. Twisting out half pins and removing
wires can be very painful. The patient’s personality has
to be evaluated. If they have significant anxiety, have
had a difficult time during their fixation course, had
multiple trauma with months of painful recovery, or
request anesthesia, the Ilizarov fixator should be re-
moved with outpatient anesthesia. The number of pins
and wires must be considered. Most patients will tolerate
the removal of six, seven, or eight wires and pins. More
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
complex Ilizarov fixators with 10 or more pins and wires
need to be removed with outpatient anesthesia.
The soft tissues adjacent to the half pins and olive wire
side of tensioned wires are prepared with alcohol or
betadine. Lidocaine is injected locally around each wire
and pin to be removed. If the patient has an exaggerated
response to the lidocaine injections, abandon the frame
removal in clinic, and schedule them for outpatient
anesthesia. The frame is disassembled and removed from
the extremity. The olive wires are cut away from the
frame rather than unbolting the slotted fixation bolts.
Sterile wire cutters should be used to cut the olive wires
at the level of the skin on the side opposite the olive.
Smooth wires are removed from either side and do not
require local anesthesia. After the lidocaine has produced
local anesthesia, the half pins are slowly twisted out. A
three-hole Rancho cube is used to twist out the pin, and
kept as a tool on the removal tray. The most painful time
of half pin removal is the initial loosening. The threaded
tip is in the soft tissues and periosteum of the opposite
cortex of the bone. The first turns of the half pin will be
the worse, and the patient should be warned to expect
pain. The first turns of the half pin can lead to severe
screaming and crying by the patient indicating they are
not going to tolerate frame removal in the clinic. If there
is doubt that a patient will not tolerate frame removal in
the clinic, a trial twisting of the half pin is conducted
before frame removal. If they cannot tolerate the pin
twisting, then they are scheduled for outpatient anesthe-
sia. Once the half pin is twisted into the bone, the pain
subsides and removal is tolerated. The patient needs a lot
of support during the process and “ time outs” to prepare
for the next pin. The half pins cause more pain than the
olive wires and should be removed first. After the pins
and wires have been removed, sterile dressings are
placed and are kept in place for 2 days to absorb the
bloody drainage.
The fracture is splinted with a cast or fracture brace
and crutches are used at 50% weight until the patient is
seen in clinic several weeks later. A post fixator x-ray is
evaluated for maturity of healing. The fracture is “pro-
tected” with a fracture brace until mature callus is evi-
dent. The callus will continue to mature for several years
after treatment with the anterior cortex the last quadrant
of the fracture to develop dense neocortex.
REFERENCES
1. Tucker H. Management of unstable open and closed tibial fractures
with the Ilizarov method. Clin Orthop 1992;280:125–135.
2. Wyrsch B, McFerran M, McAndrews M, et al. Operative treatment
of fractures of the tibial plafond. J Bone Joint Surg Am 1996;78:
1646 –1657.
Techniques in Orthopaedics®
17(1):97–99 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 10: Managing Delayed Union and Non Union of Tibial

Fractures Treated with Ilizarov Fixators

James J. Hutson, Jr., M.D.

Summary: Delayed union is the result of lack of compliance in therapy, poor

reduction of the fracture, tobacco and drug abuse, physiologic factors, and necrotic
bone and infection at the fracture site. Treatment consists of compliance with therapy,
improvement of fracture stability, cessation of smoking and drug use, bone grafting,
and delayed exploration of necrotic fragments at the fracture site. Key Words:
Ilizarov fixator tibia fracture delayed union.

Fractures will be observed that are not progressing to
union and callus is not bridging the fracture site. The
patients’ compliance with physical therapy and func-
tional weight bearing should be assessed. If there has
been noncompliance and minimal functional rehabilita-
tion, an intensive effort should be expended to increase
the functional use of the extremity. Fracture callus will
usually develop in response to functional loading and
healing will occur. Wires and pins, which are painful to
the patient, are evaluated for infection, skin tenting, and
loosening, and treated. If possible, take away the pa-
tient’s wheelchair or reduce the wheelchair usage to a
minimum.
If the patient is complying with functional rehabilita-
tion without healing of the fracture, then the zone of
injury, fracture fixation, and systemic factors needs to be
assessed. Cessation of tobacco and drug use, improve-
ment in nutrition, and elimination of antiinflammatory
medications will improve fracture healing. In urban
trauma centers, many patients will continue to smoke and
abuse drugs, which will retard fracture healing. The time
to union will be prolonged, but most of these patients
will heal their fracture.
Instability of fixation is the most common cause for
fracture nonunion. Hybrid fixators with two smooth
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
wires through the metaphysis and excessive working
lengths across the fracture are nonunion machines.5 The
universality of Ilizarov fixators will eliminate this inad-
equate level of fixation in the treatment of tibia fractures.
The fixator should be evaluated. Is there adequate fixa-
tion of the fixation blocks? Additional half pins and
tensioned wires are placed in the tibia to increase stabil-
ity. If the fracture is distracted without compression of
the fragments, callus formation will be retarded. The
fracture can be compressed acutely several millimeters
by turning the nuts on the working length rods. The
frame is compressed on subsequent office visits to main-
tain stability. A compressed fracture will show arching of
the tensioned wires away from the fracture site. This
technique is effective on oblique fractures at the meta-
physeal shaft junction. If the fixation is unstable, com-
pression will slide the fragments past each other in the
oblique plane of the fracture. If there is gross instability,
additional fixation of the opposed fragments will be
needed. A draw olive wire, compressing an oblique
fragment, is an effective technique to increase stability of
an unstable fragment.
The reduction of the fracture needs to be evaluated.
There may be axial alignment on one x-ray view, but the
fracture is displaced on the 90° view, and if an oblique
plane x-ray is obtained, a large gap will exist between the
fracture surfaces. This gap is compressed if it is small. A
larger malreduction will require manipulation of the
frame with a translation mechanism or a return to surgery
for a revision of the fixation. Adequate reduction is
essential for fracture healing.

97
98 J.J. HUTSON JR

cause nonunion. Observation of the x-ray will reveal

necrotic fracture fragments which are radio dense com-
pared with the adjacent osteopenic vascularized bone.
The fracture site will be atrophic or there may be periph-
eral serpentine bone attempting to bridge the fracture
(involucrum). The necrotic bone may be the result of
reluctant debridement in open fractures or the progres-
sion of necrosis in high-energy wounds. High-energy
gunshot wounds are a common cause of nonunion. The
mass of bone shards is devitalized. The fracture is
aligned in the fixator and callus often does not develop.
A secondary late debridement of the necrotic bone cre-
ates a large segmental defect, which requires bone trans-
port or acute shortening to salvage. The decision to
widely debride a gunshot injury is complex. Lower-
energy fractures will readily heal without debridement.
In high-energy gunshot wounds, the dense cortical frag-
FIG. 10.1. The metaphyseal shaft junction proximally and distally is
bone grafted for delayed union if it has not healed by 3 to 6 months. An ments with no soft tissue attachments should be re-
osteotomy of the fibula midshaft or distal is also done (white arrow). moved, and the reconstruction based on the remaining
The fixator is modified to increase stability and the nonunion site viable bone.
compressed.
Exploration of the nonunion site prior to bone grafting
may reveal necrotic bone. The necrotic bone must be
The fracture can be stable, reduced, and compressed
and still have delayed healing. If progress toward union
is not observed by 3 to 4 months, iliac bone grafting is
indicated to stimulate fracture healing (Fig. 10.1). The
junction of the shaft and metaphysis in proximal and
distal periarticular fractures and midshaft fractures is the
location where bone grafting is indicated. A direct ante-
rior lateral approach to the posterior lateral quadrant of
the fracture is used to bone graft the fracture site (Fig.
10.2A). The interosseous membrane is elevated from the
shaft and the fracture site debrided of dense fibrous
tissue. The cortical surfaces are scaled with a sharp
osteotome until punctate bleeding is observed and the
bone graft placed. The graft should extend 2 to 3 cm
proximal and distal from the fracture site. The posterior
lateral approach is not used for bone grafting because it
was described to treat patients with infected nonunions
with draining anterior wounds (Fig. 10.2B).2 The ap-
proach is difficult and can jeopardize the posterior tibial
nerve and artery if the dissection deviates posteriorly
from the surgical plane (Fig. 10.2C). Soft tissue injury
can distort the anatomy, and disorientation during the
approach is possible.
A minimum of 3 months in the fixator is needed for
the fracture to heal after autologous bone grafting. The FIG. 10.2. (A) The cancellous autograft is placed on the posterior
lateral surface of the nonunion through an anterior approach. (B) The
patient is encouraged to function in their frame to stim- posterior lateral approach is not used because it places the posterior
ulate union after bone grafting. The graft will create a tibial artery and nerve at risk. The tissue planes are difficult to dissect
lateral bridge of bone with neocortical margins bridging in the zone of injury at the nonunion site. The peroneal vein and artery
are injured when passing the fibula. (C) If the posterior tibial muscle is
the fracture site. not dissected from the damaged interosseous membrane, the approach
Necrotic bone or infection at the fracture site will can lead directly to the posterior tibial artery and nerve.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

 CHAPTER 10
excised. The fracture site is always cultured. If there are
viable opposed bone fragments, the nonunion site is
grafted with autologous cancellous bone graft. If there is
a segmental loss of bone, the treatment method will be
changed and acute shortening or intercalary transport
used to reconstruct the defect. Segmental defects less
than 5 cm can be treated with massive autologous grafts.
It is our experience that bone transport is the superior
method to reconstruct bone loss.3,4
There will be a small subset of patients with oblique
fractures at the metaphyseal shaft junction who will not
heal in an Ilizarov fixator. Months of walking on the
frame, bone stimulation, and bone grafting will not result
in union of the fracture. These fractures can be treated by
several methods. One is to create square osteotomies of
the oblique fracture surfaces to form a stable compress-
ible construct and acutely shorten the extremity for 1 or
2 cm. A second Ilizarov frame is needed which some
patients will object to. If the patient has a viable soft
tissue envelope, fixation with a blade plate and bone
graft will unite the fracture.1 The pin sites are allowed to
heal for several months and at the time of surgery, the
99
white blood cell count and the sedation rate should be
normal. We have used this method on 3 of 200 proximal
tibia fractures. The risk of this technique is a deep
infection. The last method is to have the patient use a
fracture brace. The fracture will angulate into varus,
increasing the stability of the fracture site and lead to
union. The last method is applicable to patients who are
poor physiologic candidates for revision surgery.
REFERENCES
1. Carpenter CA, Jupiter JB. Blade plate reconstruction of metaphyseal
nonunion of the tibia. Clin Orthop 1996;332:23–28.
2. Connolly JF. Tibial Nonunion Diagnosis and Treatment. American
Academy of Orthopedic Surgeons Monograph Series; 1991.
3. Green, SA Skeletal defects: a comparison of bone grafting and bone
transport for segmental skeletal defects. Clin Orthop 1994;301:111–
117.
4. Marsh JL, Prokuski L, Bierman JS. Chronic infected tibial non-
unions with bone loss: conventional techniques versus bone trans-
port. Clin Orthop 1994;301:139 –146.
5. Watson JT, Karges DE, Cramer KE, Moed BR. Analysis of failure
of hybrid external fixation. Techniques for the treatment of distal
tibia pilon fractures. 16th Annual Meeting, Orthopedic Trauma
Association. October 12–14, 2000; San Antonio, Tx. Abstract.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
Techniques in Orthopaedics®
17(1):100–102 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 11: Managing Infectious Complications of

Ilizarov Fixators

James J. Hutson, Jr., M.D.

Summary: Pin and wire insertion techniques are discussed. Postoperative gauze or
sponges are used for the first 2 to 3 weeks. Pin maintenance is discussed. Pins adjacent
to tendons may have clear drainage. Loose wires or pins cause inflammation. Deep
wire infections are treated with intravenous antibiotics and possible removal. Septic
arthritis is treated by wire removal and arthrotomy. Deep fracture infection is treated
by debridement. Key Words: Ilizarov wire infection—Septic arthritis.

Infection of the wires and pins is the most common
complication of using Ilizarov fixators for the treatment
of tibial fractures. All patients will have wires and pins
that develop local edema, redness, and have serous drain-
age during the course of their treatment. Maintenance of
the wire and pin interface with the soft tissues is critical
to reduce the incidence of infection.
Wire and pin insertion technique is the initial phase of
management. The skin should be cut sharply where half
pins are placed into the tibia. Vigorous spreading with
hemostats damages the skin. The incision should be long
enough to prevent the drill guide from crushing the
tissues. If the incision is gaping open after pin placement,
the wound is closed with 5.0 nylon suture around the pin.
The skin should not tent over a pin or wire. After
reducing a fracture that has shortened in a splint, the skin
will have been stretched over a wire. A relaxing incision
will allow the skin to move over the pin or wire relieving
painful pressure. The relaxing incision is closed with 5.0
nylon.
The drill bits should have sharp edges. A dull bit will
generate local heat and burn a 2 or 3 mm cylinder of dead
bone around a half pin. This will lead to a ring seques-
trum and deep pin track infection, which will require
operative debridement. Only bayonet tensioned wires
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
should be used. The sharp edges of the point and the
minimally larger cross section of the tip, compared with
the pin diameter, will cut through cortical bone with less
heat than a trocar tip. The wire is drilled with low speed
revolutions and stopped several seconds intermittently
during drilling. Examine the bayonet point after it
emerges from the tibia. The bone dust should be moist,
white, and soft. If it is brown or black, or burnt bone odor
permeates the surgical suite, the cortical bone was dam-
aged by heat and the wire should be replaced to another
location. Once a wire is used to cut through cortical
bone, but removed to improve position, it should be
discarded or used in the metaphysis.
Postoperatively, foam sponges are placed over the pin
and wire sites and a bulky compressive dressing placed
under the rings and rods of the frame. The sponges are
removed several days to several weeks later. If there is
postoperative hemorrhage that saturates the compressive
dressing and sponges, the sponges are changed at bedside
before discharge. The dressings are removed in clinic
and pin and wire management is started.
The goal of wire care is to maintain the wire skin
interface during the course of treatment. On a daily basis,
the pins and wires are cleaned to remove dried blood and
secretions. Washing the leg and fixator in the shower and
cleaning the pins with clean 4 x 4’s is most effective. A
mixture of 50% saline and 50% peroxide (3% peroxide
solution) is used to remove hardened crust. Peroxide can
irritate the skin, and is discontinued if redness and dry
skin is observed around the wires. Applicator sticks are
used to clean the pin sites. If a pin site is clean, the skin

100
 CHAPTER 11
should not be manipulated unnecessarily. A light coating
of Bactriban ointment may be used to reduce local
inflammation around the pins.
Patients will fall into one of three groups during the
course of treatment. A group will tolerate the pins and
wires well, and have occasional wire inflammation,
which will rapidly respond to a short course of oral
cephalosporin treatment. The second group will have
intermittent wire and pin inflammation and require mul-
tiple courses of oral antibiotics and possibly need chronic
oral cephalosporin medication or quinolone therapy. The
last group of patients will have early and constant wire
inflammation. One cause, is poor pin maintenance. An-
other group will be patients that physiologically do not
tolerate the pins and wires and have chronic edema,
redness, and drainage. These patients develop pan pin
cellulitis, which necessitates admission to the hospital for
pin care, intravenous vancomycin antibiotic therapy, and
whirlpool treatment to clean their extremity. The antibi-
otics are given for 7 days. Methicillin resistant Staphy-
lococcus Aureus is the most common infecting organism.
This group of patients requires chronic oral antibiotic
suppression until frame removal.
Isolated wires and pins can develop drainage and
edema. The pin/wire location should be evaluated for
adjacent tendons. If the wire has penetrated the sheath or
tendon, there will be constant clear yellow drainage,
which forms a crust. The pin or wire should be removed
and replaced in safe zone position if necessary.
The wire may have a loose fixation bolt and need to be
retensioned in clinic, or the wire or pin may have a
fatigue failure and need to be removed. The incidence of
wire breakage is minimal in treating tibial fractures with
Ilizarov fixators. Prolonged frame times are associated
with wire failure and deep wire infections. A wire can be
retensioned in clinic by rotating the slotted fixation bolt
on the frame. This method was initially used by Russian
surgeons before tensioning tools were available.
Infection of the wire/pin can be the cause of the
inflammation. The patient will have increasing pain with
activity as the first symptom, followed by worsening
edema, redness, and drainage. If the inflammation does
not respond to pin care and oral antibiotics, a deep pin
track infection has occurred. Radiographic evaluation of
the pin bone interface will reveal lysis of the cortex and
peripheral bone loss around the pin. A “halo” of osteol-
ysis will be observed where the olive is in contact with
the bone. If the infection is observed early, a 1-week
course of intravenous antibiotics can resolve the infec-
tion. If the bone loss is substantial, the pin is discon-
nected from the frame. If it is loose, or twists out easily,
it is no longer providing fixation and is removed. A new
101
pin/wire may need to be placed if the fracture has not
healed and the frame becomes unstable with loss of the
fixation point. The pintrack infection usually resolves
with removal of the pin/wire. If persistent local edema
and drainage is observed 2 to 4 weeks after pin/wire
removal, x-ray will show further lysis of bone at the
pintrack. The pintrack infection will require operative
debridement, culture of the pintrack, and a formal course
of intravenous antibiotics. The pintrack infection, at this
stage, is an osteomyelitis and not a bacterial contamina-
tion of an implant. Pintrack infections may not become
apparent for months to years after frame removal. We
have observed several infections that became apparent 3
to 6 months after frame removal, and one wire infection
18 months after frame removal.
Septic arthritis is a rare complication of treatment with
Ilizarov fixators. The cause of infection is always a
poorly placed periarticular wire that has violated the joint
capsule. The complication is preventable by using care-
ful technique when placing periarticular wires. The true
lateral centered view should be used to evaluate all wires
during construction of the frame (Appendix 1).
The first symptom of septic arthritis will be increasing
knee pain, which can become quite painful. The patient
will splint the knee and have loss of motion. The knee
will have increasing swelling and redness. A lateral
x-ray, centered on the joint, will identify the offending
wire and it should be removed. The knee joint should be
debrided with a limited open arthrotomy or arthroscopi-
cally. Serial aspiration is inadequate treatment. Obtain
cultures before starting intravenous antibiotics. A 3-week
or longer period of antibiotics is indicated. Loss of
motion can persist and a manipulation of the knee under
anesthesia is required several weeks after the infection.
Deep fracture site infections are the most severe com-
plication when treating tibial fractures with Ilizarov fix-
ators. Deep fracture infections are the result of high-
energy trauma, with comminution of the tibia and
crushing injuries of the soft tissues. The infection can
occur early in the postoperative period in the soft tissues
and hematoma of the fracture. Fractures with crushing
and comminution require longer periods of intravenous
antibiotic coverage than the recommended 72-hour pe-
riod. If there has been extensive crushing and marginal
wounds, the patients will be treated for 1 to 2 weeks,
have serial debridements, and be treated with hyperbaric
oxygen therapy. This therapy is continued until the
wound becomes resuscitated with vigorous viable tissue.
The late deep infection will cause increasing pain at
the fracture site, edema, and redness. The function of the
extremity will deteriorate. Purulent drainage will occur
from the surgical wounds and through sinus tracks. The
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
102 J.J. HUTSON JR
late infection is always associated with a necrotic frag-
ment or fragments of bone. Inspection of the x-ray will
identify the infected fragment, which has relative radio-
density to the osteopenic viable bone at the fracture site.
The fracture can have serpentine, hypertrophic callus on
the periphery of the comminuted bone fragments, which
is an involucrum. Often, the fracture will not heal and
there is instability at the fracture site. A culture is taken
before starting intravenous antibiotics. The fracture site
is debrided and necrotic bone removed, regardless of the
length of resection. Antibiotic beads are placed in the
wound. Repeat debridements are indicated until the frac-
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
ture site has viable tissue throughout the wound. After
the infection has been contained, reconstruction of bone
loss is considered. Acute shortening and intercalary
transport are used to close the defect. This technique is
preferable to autologous bone grafting, which places
great demands on the zone of injury to incorporate the
bone graft. If the infected necrotic bone encompasses the
joint surface, the salvage of the infection is arthrodesis of
the knee or ankle combined with leg lengthening to
equalize leg lengths. The key to successful management
of deep infection is debridement of the necrotic frag-
ments of bone.
Techniques in Orthopaedics®
17(1):103–109 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia

Chapter 12: Reconstruction of Bone and Soft Tissue Loss In

Fractures of the Tibia

James J. Hutson, Jr., M.D.

Summary: Debridement of necrotic bone is critical to unite tibial fractures. Free flap
reconstruction is done using half pin frames followed by delayed Ilizarov reconstruc-
tion after flap maturation. Antibiotic beads are used to resuscitate the wound.
Antibiotic spacers are used to maintain a soft tissue tunnel for reconstruction. Bone
loss can be reconstructed by acute shortening, lengthening, intercalary transport, or a
combination of these techniques. Key Words: Ilizarov reconstruction bone tibia
fractures.

High-energy tibial fractures can have direct bone loss,
secondary bone loss from contamination and ischemia,
and relative bone loss from severe comminution. Recon-
struction of the bone loss is essential to obtain union of
the fracture and maintenance of axial length. The Ilizarov
method provides efficient and reliable reconstruction
techniques to reconstruct bone loss associated with tibial
fractures. Distraction histogenesis is used to create new
bone, which can reconstruct massive defects in the tibia.
Local reconstruction can be facilitated with the technique
of acute shortening. Combining acute shortening with
distraction histogenesis can solve bone loss and soft
tissue dilemmas associated with tibial fractures.10 The
need for bone grafting can almost be eliminated in pilon
and tibial plateau fractures except for reconstruction of
the joint surface. In 115 pilon fractures treated at our
trauma center over the past 10 years, one fracture has
required metaphyseal shaft bone grafting to obtain union.
The bone grafting incidence has approached 50% in
series not using Ilizarov fixators for pilon fractures.1,13
The methods used to reconstruct bone loss are described
below.
Union of fractures is facilitated by stable fixation and
functional loading of the injured extremity. Tibial frac-
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
tures with bone loss or devitalized bone will not unite if
necrotic bone is opposed at the fracture site. Necrotic
bone is tolerated in noncontaminated well-vascularized
fractures, but will compromise healing in traumatized
soft tissue envelopes. Debridement of the fracture is the
critical event in the treatment of high-energy tibial frac-
tures. Meticulous debridement of damaged soft tissue
and excision of devitalized bone is essential for success-
ful outcome. The zone of injury must be resuscitated
before commencing reconstruction. Bridging frames are
used to stabilize the extremity at the time of the debride-
ment.12 Multiple surgical debridements are often neces-
sary to debride the fracture. The bone is evaluated for
bleeding. A sharp osteotome or burr irrigated with cold
saline is used to remove thin layers of bone to observe if
there is punctate bleeding. High-speed burrs and oscil-
lating saws rapidly burn the bone from friction. Iced
saline is used to prevent local bone necrosis from heat
injury. Necrotic cortical bone must be excised.11 Dense
cortical fragments will not revascularize acutely, but
require years of creeping substitution to become viable.4
Trabecular bone adjacent to the joint should be debrided,
irrigated, and maintained. There is usually rapid vascular
invasion of the trabecular bone structure and reconstruc-
tion of the joint surface is crucial to maintain function.
After the fracture has been debrided, the soft tissue
envelope and fracture are assessed for reconstruction. In
most fractures, the fracture can be reduced and stabilized
and not require bone or soft tissue reconstruction. Frac-

103
104 J.J. HUTSON JR
FIG. 12.1. Open fractures with extensive bone and soft tissue loss
should have an antibiotic spacer block placed into the bone bed after
the initial debridement. This creates a soft tissue tunnel for later
reconstruction. If a free flap is placed on the wound bed without the
spacer, the graft becomes adherent to the posterior musculature.
tures with bone and soft tissue loss will require recon-
struction.
Soft tissue reconstruction is technically demanding
compared with bone transport with an Ilizarov fixator. If
the wound requires a local rotation or free flap, plastic
surgery consultation is obtained. An arteriogram is ob-
tained to evaluate the arterial survival. Free flap recon-
struction has been combined with acute Ilizarov applica-
tion, but this requires palpating the pedicle and placing
tensioned wires acutely through the flap.6 A more con-
servative approach is to maintain the tibia in alignment
with a simple half pin fixator during the free flap surgery
and postoperative recovery period for 6 to 8 weeks
followed by delayed Ilizarov fixator reconstruction.6,12 If
a free flap fails with an Ilizarov fixator in place, the
salvage may require removal of the Ilizarov fixator.
Because of the technical difficulty of placing a free flap
in a traumatized extremity, this phase of the reconstruc-
tion should be accomplished and stabilized physiologi-
cally before proceeding to skeletal reconstruction.
The soft tissue bed adjacent to the tibial shaft can be
exposed for many centimeters with bone loss. The pos-
terior tibial nerve and artery are minimally protected by
the posterior tibial and flexor hallucis muscle. The mus-
cles can have extensive damage, affording little separa-
tion between the nerves and exposed periosteal bed of
the tibia. If there is a large segmental defect, a free flap
placed over the wound anteriorly will collapse into the
posterior musculature and rapidly become adherent oblit-
erating the transport track for the reconstruction (Fig.
12.1). After several weeks, the plane between the flap
and posterior musculature will be impossible to detect. A
late dissection to form a soft tissue tunnel is very difficult
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
FIG. 12.2. Transporting into antibiotic beads forces the beads into
the posterior compartment. Antibiotic beads are used during the initial
debridement of open fractures. Once the wound is clean, antibiotic
spacer cylinders are used to maintain the soft tissue anatomy.
because the location of the posterior tibial nerve is
unknown.
Another phenomena is also observed with GIIIB
wounds of the tibia. The anterior lateral musculature will
be stripped off the lateral cortex of the tibia. The anterior
muscles of the leg will fall away from the shaft forming
a “pancake” muscle which exposes the shaft 270° with
the entire musculature located posterior to the shaft. If a
free graft is placed on this soft tissue deformity, no
tunnel for bone reconstruction will be created complicat-
ing bone reconstruction secondarily. This phenomena
can be prevented by using towel slings under the mus-
culature to elevate and form the musculature. Green
surgical towels are placed under the calf and over the
anterior bars of the external fixator and held in place with
Kocher clamps. The towels are replaced with each dress-
ing change and maintained until soft tissue healing.
Antibiotic beads have been used to maintain the tibial
shaft space.12 The beads are excellent treatment devices
during the early debridement of the fracture.9 The beads
rapidly become entrenched in the soft tissues and sur-
rounded by fibrous tissue (Fig. 12.2). Removal of the beads
can be difficult. If there has been damage to the posterior
tibial muscle, the beads can lodge against the nerve and
artery. After removal of the beads, a multiloculated cavity
will remain which is not ideal for tibial reconstruction,
whether using massive cancellous autograft, mesh cages, or
Ilizarov bone transport.
 CHAPTER 12 105

An antibiotic methyl-methacrylate spacer can be used

to prevent the problem of beads left long-term in the
tibial shaft space (Fig. 12.1). A 2.5 cm antibiotic methyl-
methacrylate cylinder is molded over a 2 mm stainless
steel pin. The cylinder is cut to length before the cement
sets. Antibiotic powder is mixed with the cement to
provide local bacterial control and weaken the cement so
it will split easily when struck by an osteotome at the
time of removal. Then, 3.6 g of powdered tobramycin or
2.0 g of vancomycin is mixed with 20 g of methyl-
methacrylate cement. The vancomycin has to be ground
into a powder with the smooth end of a curette before
mixing. The antibiotics and cement are thoroughly mixed
dry before adding the monomer liquid to the mixture.
The cylinder pin is placed into the proximal and distal
fracture end of the tibia. The anterior and posterior
musculature will mold around the cylinder creating an
anatomic space for reconstruction of the tibia. After
several days, the soft tissues will have formed a cylinder
around the spacer. The cylinder is removed by elevating
the distal end of the free flap when the Ilizarov fixator is
placed or bone graft placed in the defect. Long nose wire
cutters are used to cut the pin, or the bone cement can be
split and fragmented with an osteotome to remove the
spacer. Two months after placement of the free graft, a
cylinder tunnel from the proximal to the distal fracture
will be created with a pseudo periosteal membrane. If
there is a large bone defect, a smaller spacer can be
placed, and the bone transported half way over the
Steinman pin and the second spacer removed to complete
the defect (Figs. 12.3A—12.3D).
Another method for preventing skin collapse onto the
FIG. 12.3. Antibiotic impregnated spacer blocks can prevent soft
posterior musculature of the bone tunnel is to place a tissue collapse during long transports. The spacer is removed to
stainless steel pin connected to the frame to support the complete the docking. (A) The soft tissues over large intercalary
soft tissues. The pin is placed parallel to the bone tunnel defects will sag into the wound and become adherent to the posterior
wall of the muscles. An antibiotic spacer block on a Steinman pin half
and bent to come through the skin at both ends. The pin the length of the defect is placed in the wound bed to prevent collapse.
is connected to the Ilizarov fixator during the transport (B) The transport proceeds until the spacer block fills the remaining
and removed as the transported tibia fills the soft tissue defect. (C) The spacer block is removed in surgery. If a high concen-
tration of antibiotic powder was mixed with the cement, the block will
tunnel (Figs. 12.4). fracture easily with a few cuts from an osteotome and will be removed
After the soft tissue reconstruction has been stabilized, in pieces. (D) The transport is completed to docking. Local revision of
the technique for reconstruction of the tibia will be the docking site with removal of the fibrous cap, freshening to the
docking sites to bleeding bone and autografting may be needed to heal
determined. If the bone gap is less than 3 to 4 cm, several the docking site.
methods can be considered. One is to use a massive
autograft to fill the defect. This avoids the complexity of
bone transport, but has the morbidity of the donor site formation in the worst possible location in the leg for
and requires the zone of injury to incorporate the bone regeneration of bone.5,8
graft and heal the fracture. The bone graft is necrotic Bone transport allows new bone formation to occur at
bone and the local physiology at the fracture site must be a location in the tibia outside of the zone of injury. New
competent to revascularize the bone graft and resist bone is created in the least damaged section of the leg.
infection. This technique places the greatest demand on The Ilizarov method transports living bone into the zone
the zone of injury, the technique demands local bone of injury bringing its own blood supply and recruiting

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

106 J.J. HUTSON JR
FIG. 12.4. Proximal tibial shaft bone loss is reconstructed with a
distal corticotomy and intercalary bone transport. The distal corti-
cotomy does not function as well as the proximal tibial corticotomy
when generating new bone by distraction osteogenesis. The distal
corticotomy is used when there has been proximal tibial shaft bone loss.
For large midshaft defects, a proximal and distal transport can be
combined to reduce the reconstruction time. The preferred site for
distraction osteogenesis is the proximal tibia inferior to the tibial
tubercle. Midshaft corticotomies produce poor new bone formation and
are not used. If the transport segment has a spiked configuration, a
squaring osteotomy to have 50% of the shaft leveled is done (white
arrow).
soft tissues to close open wounds.3 Because there are no
metal implants in the zone of injury, early free flap
coverage is not necessary in GIIIB wounds with moder-
ate soft tissue separation or loss. As the bone is trans-
ported into the fracture site, local soft tissues are re-
cruited and wound closure occurs secondarily.
Living bone is transported into the zone of injury by
two techniques. Acute shortening closes the defect
acutely (Figs. 8.41, 8.42, 8.43). This technique can be
used in comminuted fractures. The proximal fracture
segment is compressed into the opposite segment until
stable contact is established. Oblique fracture patterns
can cause angular malalignment when compressed. Lim-
ited transverse osteotomies of the bone spikes are cut
with a micro-oscillating saw, Ronguers, or a Keristan
punch to create square compressible surfaces. Usually
50% of the shaft cross section is needed to produce
stability. In traumatic leg injuries, 2 to 3 cm of shorten-
ing can be done.7 The pulse must be detectable after
shortening the tibia. If the fibula is intact, or has a simple
fracture pattern, a small segment is resected to allow
shortening. Remove half of what is needed with an
oblique resection, evaluate the alignment, and remove
further bone if the fibula is still interfering with docking
at the tibia fracture site. Shortening can be greater than 3
cm if a delayed rate is used. After acutely shortening 3
cm, the fracture is compressed 1 mm 4 times a day until
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
the fracture surfaces are compressed. This technique is
used for further shortening to 5 or 6 cm. This technique
is indicated when patients have large GIIIB wounds, and
are not candidates for free flaps or have had failure of a
free flap.
The disadvantages to acute shortening are the risk to
kinking the vasculature, removing part of the fibula,
which often does not regenerate with secondary length-
ening, and the bulbous expansion of the soft tissues,
which distorts the contour of the leg and can place
tension stress on suture closures causing dehiscence of
the wound.7 The wounds and surgical extension should
be closed with nylon sutures prior to shortening the
extremity to prevent gaping wounds at the fracture site.
Acute shortening also directly causes a leg length dis-
crepancy that may need secondary lengthening.
The advantages of acute shortening are local viable
bone is transported acutely into the fracture site, acute
alignment of the fracture is established with compressed
bone surfaces, which promotes healing, and soft tissues
are recruited into the zone of injury.
The second method of bone transport is intercalary
transport (Figs. 8.40, 8.44, 12.4). The fracture is aligned
and fixated with the Ilizarov fixator maintaining length.
A corticotomy is done proximally or distally and the
transport segment is distracted 1/4mm 2 times a day. The
distraction continues until the fracture ends dock and are
compressed. The living bone of the transport segment is
transported into the zone of injury, again bringing blood
supply and soft tissues to the fracture site to promote
healing.3
The distraction rate in adult trauma patients is less
than the rate of 1/4 turn 4 times a day used to lengthen
children and adolescents. Adult trauma patients are dis-
tracting bone in a traumatized extremity, have decreased
ability to generate new bone as they age, may have
ischemic vascular disease, and may be using steroids as
well as abusing drugs and tobacco. All of these factors
affect the ability to generate new bone. The distraction
rate is usually started at 1/4 turn twice a day and the
regenerated bone observed. If there is active bone for-
mation, usually observed in patients in their twenties, the
rate may be increased to 3 times a day. If the bone
formation is less vigorous, then the rate is continued at
twice a day. The rate may be decreased to one 1/4 turn a
day in tobacco abusers and patients with preexisting
diseases. Some of these patients may need a “distraction
holiday” for several weeks if no bone formation is
observed. Delayed shortening to salvage a limb with
bone loss should be considered for patients who are not
candidates for distraction histogenesis, the leg length
discrepancy is equalized with a prosthetic shoe.
 CHAPTER 12
FIG. 12.5. Comminution of the metaphyseal shaft junction can be
compressed with an intercalary transport. This technique is used for
gunshot injuries.
Comminution of the metaphyseal shaft junction may
require bone grafting to unite. Intercalary bone transport
can be used to compress the zone of comminution to
promote healing of the fracture avoiding a bone graft.
The technique is applicable to gunshot injuries with
extensive comminution. The shaft is transported to com-
press the fracture zone (Fig. 12.5). The shaft will com-
press against the metaphysis increasing stability at the
fracture site. The metaphyseal fragment may rotate in the
AP plane using this technique, even though it is fixated
with three or four tensioned wires (Fig. 12.6). The 60°
arc of fixation of the wires is less stiff to AP plane
bending. Squaring osteotomies are cut on the shaft and
metaphyseal bone blocks to correct the rotation (Fig.
FIG. 12.6. Bone transport to compress comminution can cause the
metaphysis to rotate because a spike of bone exerts a force on the
metaphysis, deforming its position. The olive wire cluster does not
rigidly hold the position of the fragment when it is affected by an
eccentric force vector.
107
FIG. 12.7. Squaring osteotomies will allow axial compression with-
out deformation. For small lengthenings, acute shortening, and length-
ening can also be used.
12.7). When bone segments are compressed, angular
deformation occurs at the docking site if the docking
surfaces are not square. A well-aligned fracture can be
malaligned by this technical complication. Management
of the docking site is essential to maintain axial align-
ment of reconstructions.
Intercalary transport can be used to reconstruct mas-
sive tibial defects.6 The frame time is approximately 1.5
to 2 months per centimeter for long transports. During
prolonged transports, the end of the bone pushing
through the tissues will develop a cortical rim and have
a fibrous cap that inhibits healing at the docking site (Fig.
FIG. 12.8. (A) During long transport to reconstruct tibial bone loss,
the skin becomes bound to the posterior tissues with scar tissue. (B) As
the transport nears docking, a deep invaginated skin cleft will develop
that will impede docking. The bone ends opposing the docking site
have developed a rounded neocortex that has a dense fibrous cap.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
108 J.J. HUTSON JR
FIG. 12.9. (A) The fibrous end caps and invaginated skin require
sharp excision to expose the bone ends (gray arrow). The ends of the
bone are “freshened” with osteotomes or a burr. A cancellous auto-
graph is considered. The intercalary transport continues until the bone
ends are compressed. The ends are compressed without docking site
preparation in classic Ilizarov method. This is successful less than 50%
of the time. (B) An alternative docking management is to cut squaring
osteotomies removing small slices of bone to create compressible
bleeding surfaces (gray arrows). The gap is acutely shortened and
compressed. If the fibula is intact, an oblique osteotomy is done. The
long working length rods between the proximal and distal fixation
blocks are removed one at a time. The long rods are replaced with a rod
between the transport ring and distal ring and used to compress the
docking site. An independent distraction clicker or rod with square nuts
is placed between the proximal and transport ring blocks. The leg is
lengthened to equal leg lengths. This technique converts the frame from
an intercalary transport system to a bifocal frame.
12.8). Prior to docking, the fibrous cap should be re-
moved and the opposing fracture surfaces denuded of the
cortical cap until bleeding bone is exposed. A bone graft
is placed at the docking site, but a more effective method
is to perform an acute shortening to compress the dock-
ing site and convert the fixator to a lengthening frame to
regain the remaining centimeters of length (Fig. 12.9).
The transport ring block on long transports on extrem-
ities that have had free flaps need to have the fixation
pins and wires placed in a position that avoids the pedicle
during the entire distraction.
Acute shortening, intercalary transport, and lengthen-
ing can be used sequentially and in combination to
reconstruct tibias with massive bone loss. Lengthening is
combined with acute shortening in a bifocal frame to
regain equal leg lengths10 (Fig. 8.41). This bifocal ap-
proach allows acute reduction and alignment of the
fracture, producing early stability. Lengthening is tech-
nically easier than intercalary transport. During the trans-
ports, shoes or sandals are modified with sole elevations.
As the transport lengthens the extremity, the sole is cut
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002
down to maintain relative equal length. On extremities
with massive bone loss, the extremity can be shortened
during the debridement stage using the half pin fixator,
approximately 5 cm, the fracture gap reduced, and the
bone loss reconstructed with an intercalary transport. A
17 cm deficit could be reduced to 12, which would
reduce the intercalary transport time to a reasonable
period. With docking, the reconstruction will gain stiff-
ness. The patient and fracture would be evaluated. If the
frame is in good repair, and the patient psychologically
willing, an additional 5 cm of length could be generated
by converting the frame to a lengthening configuration
(Fig. 12.9B). If the patient were tolerating the reconstruc-
tion poorly, then no further lengthening to regain equal
length would be offered. The patient could start the
maturation phase of the reconstruction and use a shoe
prosthetic. After the extremity has developed mature
bone and the soft tissues are rehabilitated, a second stage
lengthening will equalize the leg lengths. This staged
reconstruction is similar to pediatric reconstruction. The
patient must have appropriate mental and physiologic
health for a second lengthening to be offered.
Hyperbaric oxygen therapy is used to reduce the need
for tissue transfers, especially GIIIB open wounds on the
medial ankle when treating pilon fractures. An advantage
of the Ilizarov method is fixation of the fracture without
plates in the fracture zone. Compromised medial wounds
which would need free flap for coverage when using
plate fixation, are treated with local wound care and
hyperbaric oxygen therapy. The wound will usually de-
velop a vascularized tissue base and close by secondary
intention or accept a split thickness skin graft. Patients
who have crush injuries with compromised flaps are
treated twice a day for a week. and may have further
treatments if the therapy is improving the wound.2
REFERENCES
1. Anglen JO. Early outcome of hybrid external fixation for fractures
of the distal tibia. J Orthop Trauma 1999;13:92–97.
2. Bouachour G, Cronier P, Gouello JP, et al. Hyperbaric oxygen
therapy in the management of crush injuries: a randomized double
blind placebo controlled trial. J Trauma 1996;41:333–339.
3. Cierny III G, Zorn KE. Segmental tibia defects comparing con-
ventional and Ilizarov methodologies. Clin Orthop 1994;301:118 –
123.
4. Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone
grafts in the reconstruction of segmental skeletal defects. J Bone
Joint Surg Am 1980;62:1039 –1057.
5. Green SA. Skeletal defects a comparison of bone grafting and bone
transport for segmental skeletal defects. Clin Orthop 1994;301:
111–117.
6. Lowenburg DW, Feibel RJ, Louie KW, Eshima I. Combined
muscle flap and Ilizarov reconstruction for bone and soft tissue
defects. Clin Orthop 1996;332:37–51.
7. Lowenberg DW, Van der Reis W. Acute shortening for tibia
defects: when and where. Tech Orthop 1996;11:210 –215.
 CHAPTER 12 109

8. Marsh JL, Prokuski L, Bierman JS. Chronic infected tibial non-
unions with bone loss: conventional techniques versus bone trans-
port. Clin Orthop 1994;301:139 –146.
9. Ostermann PA, Henry SL, Seligson D. Timing of wound closure in
severe compound fractures. Orthopedics 1994;17:397–399.
10. Saleh M, Rees A. Biofocal surgery for deformity and bone loss
after lower limb fractures. J Bone Joint Surg Br 1995;77:429 – 434.
11. Swiontkowski MF. Criteria for bone debridement in massive lower
extremity trauma. Clin Orthop 1987;243:41– 47.
12. Watson JT. Treatment of tibial fractures with bone loss. Tech
Orthop 1996;11:132–143.
13. Wyrsch B, McFerran M, McAndrews M, et al. Operative treatment
of fractures of the tibial plafond. J Bone Joint Surg Am 1996;78:
1646 –1657.

Techniques in Orthopaedics®, Vol. 17, No. 1, 2002

Techniques in Orthopaedics®
17(1):110–111 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia
Appendix 2: Acute Shortening to Reconstruct Fractures and
Post-Traumatic Deformities with Ilizarov Fixators
James J. Hutson, Jr.,
Resection of bone at the fracture zone of injury, zone
of deformity in posttraumatic deformity, and nonunion
can facilitate reconstruction. In the management of acute
fractures, indications for acute shortening are:
1) Oblique fracture patterns with bone loss. Fracture
surfaces are constructed that can be compressed to
stabilize the fracture.
2) Necrotic contaminated fracture surfaces.
3) Soft tissue injuries with loss of tissue not amenable to
local or free grafts.
The length of shortening that can be tolerated acutely
has not been clearly demonstrated by experimental stud-
ies. Two to three centimeters is generally accepted as the
limit for acute shortening. Greater lengths can be excised
and shortened, but this is done gradually at a rate of 4 to
8 mm per day after the initial 2 to 3 cm acute shortening.
The fracture surfaces are compressed to promote stability
and union of the fracture. Proximally or distally, a
corticotomy is completed and the frame functions to
increase leg length by distraction histogenesis using
“clickers” in four quadrants.
Removal of bone at the fracture site is done carefully.
Elevate minimally the perosseous tissues to expose the
bone. Use small metacarpal retractors to protect the soft
tissues. Use a micro-oscillating saw and cut slowly
through the layers of the bone. Remove sections of bone
with osteotomes and cut deeper into the cortex with the
saw until the posterior cortex is reached. Do not strip the
tissues widely and cut completely through the diameter
of the cortex. The posterior cortex cut should be com-
pleted with the osteotome. The posterior edge is drilled
with multiple small holes in the plane of the osteotomy.
Use a sharp drill and irrigate with iced saline. The
fragment is broken away with an osteotome or twisted
From the Division of Trauma and General Orthopaedics, Department
of Orthopaedics and Rehabilitation, University of Miami, Ryder
Trauma Center, Miami, Florida.
Address correspondence and reprint requests to James J. Hutson, Jr.,
MD, Department of Orthopaedics and Rehabilitation (D27), P.O. Box
016960, Miami, FL 33101.
110
M.D.
off with a Ronguer. Small edges protruding from the
osteotomy are removed with Keristan punches until the
osteotomy is flat. Cutting completely through the bone
can cause iatrogenic laceration of the posterior tibial
nerve and artery. The saw blade can become hot, and
burn the living bone tissue. Irrigate the field copiously
with frozen normal saline slush to cool the oscillating
saw blade. Protecting the bone from heat injury will
produce medullary and cortical bleeding immediately
following bone resection, which indicates the level of
osteotomy in available bone. If the bone end appears
necrotic, consider further bone excision until viable bone
is exposed. Through a lateral approach, cut the fibula
obliquely and remove a segment long enough to allow
compression of the tibial fragments. Remove half of the
fibular resection, evaluate the shortening, and remove
more of the fibula if needed. Excessive fibular resection
will prevent bone-to-bone contact, compromising the
construct. The fibula can be removed at a level above,
below, or adjacent to the zone of injury, depending on
the fracture pattern.
With the osteotomies completed, a trial shortening is
done manually. Observe the soft tissue tension and bulg-
ing. Check the pulse. Make sure the tourniquet is de-
flated. If the pulse diminishes or is not palpable, slowly
lengthen the leg and observe for return of the pulse. The
extremity will need close postoperative monitoring for
48 to 72 hours. This level will be the maximum acute
shortening possible. If the osteotomy surfaces are not in
contact, gradual shortening over several days can be used
to compress the bone ends.
With viable bone in the depth of the wound, and no
hardware in the zone of injury, large wounds can be
treated with normal saline dressing changes and allowed
to heal by secondary intention. Once granulation tissue
covers all surfaces, a split thickness skin graft will close
the soft tissue envelope. Hyperbaric oxygen should be
considered for marginal wounds to improve the soft
tissue viability.
Shortening of the extremity is the obvious disadvan-
tage of this technique. Most patients will need a length-
 APPENDIX 2
ening procedure in the normal tissue zone of the leg to
reconstruct the extremity. Shortening distorts the contour
of the leg, adding circumference to the soft tissues from
compression at the fracture site. Weakness of the motor
units will occur from alteration of the structure of the leg.
ACUTE SHORTENING IN RECONSTRUCTION
Malunions, nonunion, infections, and combinations of
these problems can be treated by segmental excision of
the zone of injury. Osteotomies of the tibial shaft square
to the axis of the tibia when compressed will realign the
tibia anatomically. Acute correction of rotation is accom-
plished concomitantly. Excision of the “bad bone” at the
zone of injury can eliminate a focus of infection, remove
fibrous avascular nonunion tissue, and produce viable
111
bleeding bone ends in relatively normal bone to com-
press and correct the malunion/nonunion.
Application of the Ilizarov fixator will acutely align
the fracture deformity, avoiding complex angular and
rotation frame constructs to correct the deformity
through the zone of injury. Simple lengthening will
restore length. Motor unit function will be affected by the
dual focus frame to a much greater degree than local
angular correction. Post-traumatic ankle malunions are
reconstructions in which acute shortening is a valuable
strategy. The distal tibial metaphysis can be squared to
compress on the talus and length regained proximally. If
the bone at the deformity site is vascular and of good
quality, an angular rotational correction at the level of
injury is indicated. If the bone is infected or of poor
quality, resection, shortening, or lengthening are indi-
cated.
Techniques in Orthopaedics®, Vol. 17, No. 1, 2002