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The Ilizarov Method The Ilizarov Method
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Stuart A. Green, M.D.
In 1951, Gavriil A. Ilizarov, a surgeon working in Kurgan, Siberia, developed a circular external skeletal xator that attached to bone segments with tensioned transxion wires.18 His device was a modication of other external xators, popular at the time in the then Soviet Union, that followed the principle of connecting Kirschner wire (K-wire) bows together with threaded rods. By encircling the limb with solid rings, Ilizarov could attach two or more tensioned wires to limb segments for enhanced xation. Moreover, his frame proved springy enough to permit axial micromotion, yet stable enough to limit translational movement. Initially, the device was used for fracture management. By adding hinges to the threaded connector rods, Ilizarov could gradually correct deformities in any plane. When Ilizarov began using his xator for limb lengthening, he performed the standard Z osteotomy, followed by gradual distraction and bone grafting of the resultant osseous defect. During the course of a lower extremity stump lengthening, Ilizarov observed new bone formation within the distraction gap of an individual who slowly distracted his own frame. Pursuing and extending his observations, Ilizarov developed an entire system of reconstructive orthopaedics and traumatology based on a bones capacity to form new osseous tissue within a surgically created gap under appropriate conditions of osteotomy, soft tissue preservation, external xation, and distraction.23
they have developed therapeutic strategies that allow a surgeon to achieve the following: Percutaneous treatment of all closed metaphyseal and diaphyseal fractures, as well as many epiphyseal fractures Repair of extensive defects of bone, nerve, vessel, and soft tissues without the need for graftingand in one operative stage Bone thickening for cosmetic and functional reasons Percutaneous one-stage treatment of congenital or traumatic pseudarthroses Limb lengthening or growth retardation by distraction epiphysiolysis or other methods Correction of long bone and joint deformities, including resistant and relapsed clubfeet Percutaneous elimination of joint contractures Treatment of various arthroses by osteotomy and repositioning of the articular surfaces Percutaneous joint arthrodesis Elongating arthrodesis, a method of fusing major joints without concomitant limb shortening Filling in of solitary bone cysts and other such lesions Treatment of septic nonunion by the favorable effect on infected bone of stimulating bone healing Filling of osteomyelitic cavities by the gradual collapsing of one cavity wall Lengthening of amputation stumps Management of hypoplasia of the mandible and similar conditions Ability to overcome certain occlusive vascular diseases without bypass grafting Correction of achondroplastic and other forms of dwarsm
GENERAL INDICATIONS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz With the Ilizarov method, osseous xation is achieved with tensioned smooth Kirschner transxion wires attached to an external xator frame. The apparatus consists of a small number of components that can be assembled into an unlimited number of different congurations. Ilizarov and his group never use plates and screws, intramedullary nails, or even threaded external xation pins; nevertheless,
FRACTURE MANAGEMENT
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Ilizarovs xator is rst and foremost a system for acute fracture management; most patients treated with the apparatus in Russia have worn the frame for the reduction
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Copyright 2003 Elsevier Science (USA). All rights reserved.
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SECTION I General Principles
and xation of displaced long bone fractures. When used for acute limb trauma, the Ilizarov apparatus allows anatomic repositioning of fracture fragments in a circular external skeletal xator that is axially dynamic yet minimally invasive. A frame applied to a short, oblique, unstable tibial fracture, for example, might require only eight K-wires for reduction, approximation, and stabilization. Stiffness is imparted to the bone-xator conguration by tensioning the wires to about 100 to 130 kg at the time the frame is applied.1 Acute fracture fragments are reduced by a number of strategies, the details of which are beyond the scope of this chapter. In principle, one or two rings are attached perpendicular to each major bone fragment (each with at least one pair of crossed wires). The fracture is reduced and compressed by adjusting the position of the rings with respect to one another. Ilizarovs method was ideally suited for both the Soviet style of medical care under the Communist regime and the labor-intensive medical care system that, as of this writing, has replaced it, for the following reasons: 1. Implants for internal xation of unstable fractures are sometimes made of low-quality metals or have limited availability. 2. Periodic shortages of antibioticsespecially the second- and third-generation cephalosporins commonly used for surgical prophylaxis in the Western worldrequire that such medications be reserved for open fractures and established cases of sepsis, rather than as prophylactic coverage for clean implant surgery. 3. Despite a high initial cost for the apparatus, all parts except the K-wires are reusable, resulting in substantial long-term savings. 4. The labor-intensive application of circular transxion wire external xation constitutes no particular problem in a nation with a federalized health care system. Likewise, the high physician-to-population ratio in many areas of Russia permits a team of three surgeons to be available for frame application, a measure that greatly speeds up the operation. 5. Russian physicians and surgeons are well trained in topographic anatomy, which reduces the likelihood of complications from inadvertent impalement of neurovascular structures. 6. Full disability insurance, equal to a workers wages, permits protracted time off work without concern for loss of job or other such problems and allows a more leisurely approach to post-traumatic therapeutics. Also, in a socialized medical system, frequent clinic visits and a prompt return to the operating room for a wire exchange incur no added expense. 7. Image intensication uoroscopy is not available in general hospitals in Russia, making closed intramedullary nailingthe standard of care for many fractures in Western countriesall but impossible. For orthopaedic traumatology as practiced in Western countries, the rather time-consuming application of circular transxion wire external xation will probably never supplant the simpler half-pin frames used to stabilize the types of injuries commonly thought to require external xation, such as type II and type III open fractures. Ilizarovs methods of fracture treatment will nd a place
in the care of displaced articular fractures requiring reduction and stabilization, especially in locations in which extensive internal xation has proved risky, such as at the lower end of either the tibia or the humerus. After all, the usual method of managing such injuries includes reduction and stabilization with K-wires, followed by the application of more extensive internal xation components. With the Ilizarov method, the K-wires used for reduction are left in place and attached to an external skeletal xator, which is secured to intact bone elsewhere on the limb, minimizing the amount of hardware at the site of injury. Closed diaphyseal fractures are treated in circular xators only if well-controlled studies demonstrate that the Ilizarov apparatus is clearly superior to other methods of care. Ilizarovs techniques will nd their greatest applications in the eld of traumatology for post-trauma reconstruction dealing with nonunions, malunions, post-traumatic osteomyelitis, and residual limb shortening. To understand how the Ilizarov techniques work, it is important to understand the features of his method that encourage bone formation within the distraction gap of a cortical osteotomy.21, 22, 30 The biologic principles that are required for optimizing neoosteogenesis include the following: c Maximal preservation of marrow blood supply with a percutaneous corticotomy-osteoclasis instead of an open transverse osteotomy. c External skeletal xation stable enough to eliminate shear at an osteotomy or fracture site, yet springy enough to allow micromotion in the bones mechanical axis. c A delay (latency) after surgery of about 1 week (although this could be more or less, under certain circumstances) before commencement of distraction for limb lengthening or opening a wedge. c A distraction rate of 1.0 mm/day, modied, if necessary, by the characteristics of regenerate bone formation in the distraction gap. c Distraction in frequent small stepsat least four times daily (0.25 mm every 6 hours)instead of in a single step. c Physiologic use of an elongating limba measure that promotes rapid ossication of the newly formed bone. (Obviously, the xator must be comfortable for the patient and permit an adequate range of joint motion.) c A period of neutral xation after distraction to permit the regenerate bone to strengthen, with this period lasting at least as long as the time needed for limb lengthening or correction of a deformity, and possibly longer.
EXPERIMENTAL BACKGROUND
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz To conrm the importance of these measures, Ilizarov and co-workers performed a series of experiments utilizing a canine tibia model and the Ilizarov transxion wirecircular external skeletal xator.21, 22
CHAPTER 21 The Ilizarov Method
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FIGURE 211. An experimental design to study the effect of xator stability on new bone formation during distraction. Open transverse osteotomies were performed in the tibias of dogs that were in external xators of differing stabilities. The conguration for the rst group consisted of two rings loosely afxed to bone with wires. The second group wore more stable xators of two rings secured to the bone with tensioned wires. The third group of animals were stable in a four-ring frame, each ring of which was afxed to bone with a pair of tension wires. (From Ilizarov, G.A. Clin Orthop 238:250, 1989.)
In the rst group of experiments, an open transverse osteotomy of the midtibia was performed, followed by application of a circular external xator in three congurations of progressively increasing stability. In the rst conguration, a two-ring frame was applied with a pair of loosely attached wires at each ring level. In the second conguration, a two-ring frame was also used, but a pair of crossed wires was xed with tension to each ring. The third (most stable) xation consisted of a four-ring frame, with each ring afxed to bone with a pair of tensioned crossed wires (Fig. 211). Following a 5-day delay after xator application, the osteotomy sites were distracted at a rate of 0.125 mm every 6 hours. Ilizarov and co-workers21 observed that the unstable frame with loosely attached wires led to a brous nonunion with, in some cases, full-shaft width displacement at the osteotomy site (Fig. 212). The more stable two-ring conguration with tensioned wires led to patchy areas of bone and cartilage formation but ultimately resulted in a pseudarthrosis in most cases (Fig. 213). The most stable conguration (four rings) led to direct osteogenesis without intervening cartilage formation (Fig. 214). As part of that study, Ilizarov and co-workers21 used the same rate of distraction and the four-ring xator conguration to study a second variable: preservation of blood supply (Fig. 215). Three types of osteotomy were performed in this series: 1. Open transverse osteotomy with transection of the bone marrow and nutrient vessels 2. Open transverse osteotomy with transection of only one third of the bone marrow 3. Closed osteoclasis using the apparatus and a curved wire to crack the bone, using the mechanical advantage gained by the apparatus
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FIGURE 212. The animals maintained in unstable two-ring xators developed brous nonunions with focal areas of hemorrhage and brous tissue formation in the distraction gap. (From Ilizarov, G.A. Clin Orthop 238:257, 1989.)
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FIGURE 213. The animals with two-ring congurations secured to bone with tension wires demonstrated the formation of cones of bone attached to the endosteal canal and areas of cartilage formation in the distraction gap. (From Ilizarov, G.A. Clin Orthop 238:257, 1989.)
FIGURE 214. The most stable conguration (four rings) led to direct osteogenesis in the distraction gap without intervening cartilage formation. (From Ilizarov, G.A. Clin Orthop 238:258, 1989.)
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FIGURE 215. A study to dene the effect of preservation of blood supply. The canine tibia was used in a stable four-ring conguration (each ring was afxed to bone with crossed tension wires). In the rst group of dogs, the osteotomy was performed with open technique, transecting the marrow and nutrient artery. In the second group of dogs, an open osteotomy-corticotomy was performed, but only one third of the marrow was transected by the osteotome. In the third group of dogs, the osteotomy was performed by a closed osteoclasis technique using tension developed by the apparatus. The study demonstrated that the best quality of bone formation was associated with the maximal preservation of blood supply. (From Ilizarov, G.A. Clin Orthop 238:250, 1989.)
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FIGURE 216. Ilizarovs experiments to evaluate the inuence of marrow preservation on bone formation during lateral distraction of a cortical fragment. In the dogs in group 1, a segment of cortex was separated from the tibia using a rotary cutter that limited penetration of the bone, whereas the dogs in group 2 underwent the identical cortex-splitting procedure, but the marrow was traversed by an osteotome. The best osteogenesis occurred in animals with maximal preservation of the marrow. (From Ilizarov, G.A. Clin Orthop 238:252, 1989.)
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The researchers observed that the greater the preservation of bone marrow, the better the quality of new bone formation within the distraction gap. In the second series of experiments, Ilizarovs group widened canine tibias instead of lengthening them (Fig. 216). A split-off segment of tibia, constituting approximately 40% of the bones length and 30% of the cortical circumference, was moved laterally (after a 3-day delay following osteotomy) by an Ilizarov apparatus modied for lateral traction. In half the animals, the bone was cut with a rotary cutter that limited damage to the marrow, whereas in the other half, the marrow was transected with an osteotome. The new bone that formed was parallel to the lateral distraction vector (i.e., perpendicular to the bones mechanical axis) (Fig. 217).21 As with longitudinal lengthening, damage to the marrow decreases new bone formation. In the third experiment, also using the canine tibia, bone was lengthened, after either open osteotomy or closed osteoclasis, at three different rates of distraction (0.5 mm, 1.0 mm, and 2.0 mm) in combination with a second variable: the frequency of distraction (1 step/day, 4 steps/day, or 60 steps/day in an autodistractor). It was learned that a rate of distraction of 0.5 mm/day often led to premature osseous consolidation (Fig. 218),22 whereas a distraction rate of 2.0 mm/day resulted in damage of periosseous soft tissue and suboptimal new bone formation. The best results were achieved with a distraction of 1.0 mm/day. Ilizarov and co-workers20 also observed that the more highly fractionated the distraction frequency, the better the outcome. Thus, distraction at 60 steps/day resulted in a better quality of bone formation than 4 steps/day which, in turn, produced better neoosteogenesis than distraction at 1 step/day (Fig. 219).22 Likewise, the periosseous soft tissuesincluding the nerves, fascia, blood vessels, muscles, and skinresponded more favorably to a highly fractionated distraction, which mimicked
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FIGURE 217. Neovascularization takes place during lateral distraction of a split-off cortical bone fragment. (From Ilizarov, G.A. Clin Orthop 238:266, 1989.)
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FIGURE 218. A canine experiment to evaluate the effect of the rate of distraction. In this animal, distraction at a rate of 0.5 mm/day in four divided steps led to premature consolidation of the bone in the distraction gap. A secondary fracture occurred at the lower end of the distraction gap between the newly formed bone and the original distal shaft fragment. (From Ilizarov, G.A. Clin Orthop 239:268, 1989.)
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FIGURE 219. A, Distraction at 1.0 mm/day in 60 steps with an autodistractor results in excellent bone formation in the widening distraction gap. The growth zone of the distraction regeneration is a dark band that zigzags across the center of the newly formed bone. B, Distraction at a rate of 1.0 mm/day in 4 steps results in satisfactory bone formation. C, Distraction at a rate of 1.0 mm in 1 step (following open osteotomy) results in poor quality of the newly formed bone. (AC, From Ilizarov, G.A. Clin Orthop 239:268, 1989.)
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anatomic considerations limit the surgeons ability to insert wires crossing at 90 within the bone. For this reason, transxion wires usually end up crossing each other at a more acute angle, thereby diminishing xator stability. To overcome this problem, the surgeon must either use more than two wires at each plane of xation or insert additional wires away fromor oblique tothe rings plane of xation. For added stability, Ilizarovs xation system also utilizes beaded wires to prevent the bone from sliding along the wire.
INSERTING TRANSFIXION WIRES

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zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz When inserting wires, an important technical principle is to avoid necrosis of tissues at the time of insertion. Necrosis of the soft tissues can be caused by either wrapping up of tissues, excessive tension, or thermal injury from heat build-up during drilling.8, 9, 11, 17 With transxion wires, a spinning bayonet point may wrap up soft tissues, causing necrosis (Fig. 2114). Therefore, the surgeon should push transxion wires straight through the tissue to the bone before turning on the drill. If the wire misses the bone, the surgeon should withdraw it completely and reinsert it rather than redirecting it within the limbs tissues. At times, when inserting a transxion wire with a motorized chuck, wire exibility may cause the wire to bend, reducing accuracy of placement. For this reason, whenever inserting a wire, manually grasp the wire close to its tip to stabilize it. Because a spinning wire can wrap up surgical gloves, hold the wire with a wet 2 2-inch gauze pad (Fig. 2115). When inserting transxion wires into bone with a power drill, the dense cortical bone, by offering substantial resistance to the wire points progress, may cause heat build-up, which hardens the bone even more, resisting additional progress of the wire point. For this reason, the drill should be stopped every few seconds, using a stop-start action to advance the wire slowly through hard osseous tissue. Furthermore, complete intracortical insertion of a wirenot accompanied by the feel of crossing the marrow to encounter a second cortexis especially prone to excessive heat build-up, thermal damage, and the possibility of wire hole osteomyelitis. As soon as a transxion wires point penetrates a bones far cortex, the surgeon should not continue drilling, because the spinning wire tip might damage tissues on the limbs opposite side. Instead, the surgeon should grasp the wire with pliers and hit the pliers with a mallet to drive the wire through (Fig. 2116). A most important principle when using any transxion implant: if the tip of a wire (or pin) emerges from the opposite side of a limb either smoking or too hot to be comfortably held between the surgeons ngertips, then the wire should be withdrawn, cooled, and reinserted elsewhere. With transxion wires, it is necessary to check the range of motion to make sure that no undue tension occurs during the anticipated range required while the xator is on the limb. If necessary, a wire should be reinserted if movement of an adjacent joint causes skin tension around a wire.
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FIGURE 2110. Under optimal conditions of distraction and stabilization, osteoblasts possess elongated organelles, with stretched-out endoplasmic reticulum forming parallel rows (upper arrow) and elongated mitochondria (lower arrow). (From Ilizarov, G.A. Clin Orthop 238:270, 1989.)
the natural process of growth (Figs. 2110 and 2111).22 Moreover, with a 60 step/day autodistractor (85 m every 24 minutes), changes within the elongating tissues took on histologic and electron microscopic features characteristic of cellular growth during embryonic, fetal, and neonatal life (Fig. 2112).22 Clearly, Ilizarov discovered a previously hidden biologic plasticity of osseous tissue. With his techniques, a surgeon can create a sort of growth plate anywhere in bone that ossies in both the proximal and the distal directions from a central growth zone during distraction (Fig. 2113).22 Consolidation of the entire regenerate region takes place during the neutral xation period that follows distraction.
TRANSFIXION WIRES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Transxion wire external xators use smooth K-wires for attachment to bone; therefore, xation is not secure unless two or more wires are used at each level of xation. For maximal stability, the two wires should cross each other at a right angle at each plane of xation.1 Unfortunately,
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FIGURE 2111. A, Resting fascia has a wavy shape under light microscopy. B, Distraction of fascia at a rate of 1.0 mm in one step produces pulled-out collagen bers and areas of focal homogenization (arrows). C, Distraction at a rate of 1.0 mm/day in four steps results in retention of the wavy shape of collagen bers but with a few patches of focal homogenization. Numerous broblasts are seen in the lower portion of the eld. (AC, From Ilizarov, G.A. Clin Orthop 239:272, 1989.)
Certain important techniques of transxion wire insertion ensure maximal functional limb use and joint mobility: c Avoid impalement of tendons. c Avoid (whenever possible) transxing synovium. c Penetrate muscles at their maximal functional length. This last rulecritically important for a successful long-term applicationmeans that the position of a nearby joint must change as a wire passes through the
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FIGURE 2112. During elongation of a limb, the nerves and Schwann cells take on the histologic characteristics seen during fetal and embryonic growth. A Schwann cell (arrows) is seen in the two developing axons (A). (From Ilizarov, G.A. Clin Orthop 238:272, 1989.)
exor and extensor muscle groups. For example, when the surgeon is inserting a wire from anterolateral to posteromedial in the distal femoral metaphysis, the knee should be exed to 90 before the wire is inserted through the quadriceps; the wire is then pushed straight down to the femur before drilling. The wire is driven through the bone with a power drill. As soon as the wire point emerges through the far cortex, the surgeon should stop drilling, extend the knee, and hammer the wire through the limbs opposite side. When inserting a wire into the lower leg, the surgeon should plantar ex the foot when transxing the anterior compartment, invert the foot when inserting wires into the peroneal muscles, and dorsiex the foot during triceps surae impalement. When a wire is being inserted near a tendon, a simple technique helps the surgeon avoid tendon transxion. First, palpate the worrisome tendon to determine its exact course and location. Next, holding the transxion wire in one hand (do not attach the wire to a drill), palpate the position of the tendon with the other hand, and poke the wire through the skin down to, but not quite touching, the bone. Then, wiggle the structure ordinarily moved by the tendon in question. For example, dorsiex and plantar ex the ankle when a wire is inserted near the tibialis anterior tendon. If the wire tip has impaled the tendon, the wire will move as the involved part is put through a range of motion. If this occurs, withdraw the wire and reinsert it in a slightly different position. Once wires are in place, after the nal frame congu-
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FIGURE 2113. A, Electron micrograph of the central (growth) zone of the distraction regenerated bone. Fibroblast-like cells appear in a relatively avascular central zone, forming collagen bers that are oriented parallel to the tension-stress vector of elongation. Osteoblasts appear in the vascularized spaces between the collagen bers and form bone directly on the collagen molecules. The newly formed bone condenses into trabeculae proximally and distally. B, Anteroposterior and lateral projection radiographs of a 32-year-old woman with 4 cm of tibial shortening following an injury incurred while skiing. C, A distal tibial and bular corticotomy was performed using the Ilizarov technique. Distraction started on postoperative day 7. The rate was 0.25 mm every 6 hours. D, Progressive ossication of the distraction gap occurred during the neutral xation period that followed elongation. (AD, From Ilizarov, G.A. Clin Orthop 238:262, 1989.)
ration is established, it is important to put the adjacent joints through a range of motion to be sure that the wires do not interfere with joint motion by causing excessive soft tissue tension at the end of either exion or extension. When transxion wires are used, bending the wire for ring attachment may cause excessive soft tissue damage, as the wire, being very narrow, concentrates pressures over a small area. For this reason, transxion wire xator systems use special strategies to ensure that a wire is not bent during frame attachment. The original Ilizarov equipment uses washers, posts, and other hardware to achieve this goal. Other circular xators use other techniques. In any case, the principle of not bending a wire when attaching it to a frame is a critical element to successful tensioned wire external xation (Fig. 2117).
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FIGURE 2114. The bayonet point of an Ilizarov wire can wrap up soft tissues, a possible source of deep sepsis. When inserting a wire, push the implant straight through the tissues down to bone before the wire starts to spin.
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FIGURE 2115. To stabilize a wire, grasp it with a moistened 2 2-inch gauze sponge.
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PIN TECHNIQUES
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Many circular xator systems permit supplementary xation with threaded pins. This technique is especially helpful for proximal femur mountings, because transxion wires in this region must exit through the buttocksa situation requiring special beds and chairs for the patient. Also, a high rate of wire sepsis occurs in this region. For these reasons, the Ilizarov method has been modied for the proximal femoral mounting to include half pins for xation. At Rancho Los Amigos Medical Center, we have had excellent success with congurations that use half pins in many different locations,9, 10, 12, 15 based on the observation of DeBastiani and associates5 that good regenerate bone forms in a distraction gap if one follows Ilizarovs biologic principles of marrow preservation, stability, latency, and distraction. These observations suggest that half pins may be substituted for transxion wires at one or both ends of an
FIGURE 2117. A, When, following insertion, a wire is off the plane of a ring, do not bend the wire to the ring. (This creates undue soft tissue tension.) B, Instead, build up hardware to secure the wire where it lies.
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FIGURE 2116. After the bone is penetrated with a wire, drive the point of the wire through the skin on the opposite side of the limb with pliers and a mallet.
external xator conguration when the frame is used for many, if not all, Ilizarov-type applications. Numerous experienced surgeons have started using half pins in place of wires in many Ilizarov-type xator congurations (Fig. 2118). The use of pins made from a titanium alloy rather than stainless steel has led to a reduction in implant site sepsis at Rancho Los Amigos Medical Center.10, 15 This observation has been made with respect to other orthopaedic implant systems as well, including total joint implants and intramedullary nails. To elucidate the mechanism of titanium tissue tolerance, Pascual and co-workers added powdered stainless steel, pure titanium, titanium alloy, and cobalt chromium to mixtures of bacteria and viable human polymorphonuclear leukocytes.29 The investigators then measured respiratory burst activity (a measure of intracellular bacterial killing by white blood cells [WBCs]) at various times after the beginning of incubation. They found that titanium and, to a lesser extent, cobalt chromium, resulted in only a slight inhibition of normal respiratory burst activity when compared with the inoculum that did not contain any metallic powder. Stainless steel, on the other hand, caused a marked reduction in respiratory burst activity, suggesting interference with a critical step in the bactericidal activity of human WBCs.
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This inhibition of a vital cellular function probably has the effect of reducing host resistance to implant site sepsis. The toxic effect of steel on cellular function may be related to the elution of certain metallic ionsperhaps nickel or chromiumfrom the implants surface. The use of titanium pins does not completely eliminate pin site sepsis; the effect is to reduce the incidence of pin tract infections by about 50%.15 Moreover, I have noted that when implant site infections do occur around titanium pins, the problem stays localized to the immediate environment around the implant. Extensive cellulitis that extends for many centimeters around the pin hole (a common phenomenon when stainless steel pins are used) occurs rarely, if at all, with titanium alloy implants. Despite a substantial reduction in the rate of implant site sepsis during the past two decades, pin and wire site infections remain the principal drawback to the use of external skeletal xation. Moreover, many additional problems commonly associated with external xation, such as undue pain and decreased limb usage while in the frame are often secondary consequences of implant-skin interface sepsis. Two strategies designed to further reduce implant site sepsis have been developed; both involve coating the implants. Because pin site infections are often associated with implant loosening, any technology that reduces the
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FIGURE 2119. Irrigate the drill bit with cooled irrigating solution.
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FIGURE 2118. A, Ring-gripping clamps, called Rancho Cubes, are used to secure pins to Ilizarov rings. B, A Rancho swivel assembly is used to secure a nonperpendicular pin to a ring.
possibility of loosening should also decrease the incidence of pin infections. Based on this logic, hydroxyapatite (HA)-coated pins have been developed that reproduce the osseous integration that occurs with HA-coated total joint implants.3 Clinical studies have conrmed the lower rate of pin site sepsis associated with HA-coated implants.28 A comparable reduction in pin site sepsis may be associated with the use of titanium pins and wires, rather than those made of stainless steel. The second technique designed to reduce pin or wire site sepsis involved coating the implants with an antimicrobial substance. So far, silver is the only such substance that has been extensively tested. Proponents of silvercoated pins claim a reduced pin site infection when such implants are used.31 A threaded pinespecially a modern one with selfcutting utes at the tipcan wrap up soft tissues in the threads grooves. For this reason, surgeons should always use a trochar and sleeve to insert threaded pins into bone. Surgeons should not use a power drill to insert a threaded pin directly into bone, because heat build-up at the pins point could cause a thermal injury to the bone. Instead, the bone hole should be predrilled with a sharp uted drill bit and a drill sleeve and the pin inserted by hand. When drilling, the surgeon should stop the drill every few seconds to allow the cutting tip to cool down. The heat generated by drilling not only damages the bone but also work hardens osseous tissue, which then resists further advancement. A worthwhile practice is to irrigate the exposed portion of the drill bit to cool it and conduct heat away from the tip (Fig. 2119). If much resistance is encountered during drilling, check the drill bit tip between the ngertips for excessive temperature. If the tip cannot be comfortably held for 15 or 20 seconds, the implant should not be left in the bone
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until it passes through the skin in an improved position (Fig. 2121). If the interface tension exists on the insertion side of a limb, snap off the wires blunt end obliquely to create a point, and advance the wire to just below the skin surface by the pliers-mallet method on the limbs far side. Tap the wire back through the skin after making a position adjustment.
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MOUNTING STRATEGIES
FIGURE 2120. The bone in the utes of a drill bit should be white, never black or brown (a sign of thermal injury to bone).
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Juxta-articular Mountings
One might wonder why we should be concerned with the composition of the wire available when the preceding section recommended the use of half pins for external xation. I have come to the conclusion that in certain anatomic locations, wire mounts are actually superior to pin mountings, regardless of the material from which the implant has been fabricated. In general, wires provide better xation in the juxta-articular regions of a long bone, whereas half pins are generally superior for diaphyseal locations. Threaded pins are less than ideal for xation of cancellous bone near a joint surface for several reasons. First, threads do not hold well in spongiosa, especially if any degree of osteopenia is present. Second, even when a threaded pin achieves initial stability in a juxta-articular fragment, the passage of time frequently leads to loosening, because the loss of a very small volume of bone around the implant diminishes xation more rapidly than a comparable loss of bone volume around a threaded implant secured in cortical bone. Third, once the xation of a half pin in a cancellous bone has been decreased by resorption of osseous tissue from around the implant, a substantial hole has been created in the bone fragment that limits the anatomic options for additional or subsequent xation. On the other hand, when a wire is used to secure juxta-articular fragments, the bone hole is tiny, and the
hole, as there will be necrotic (thermally injured) bone in communication with the pins bacteriologic environmenta setup for chronic osteomyelitis. Instead, the pin (wire) should be inserted elsewhere. Likewise, the bone in the drill bits utes should be white, never black or brown, which is a sign of burned bone (Fig. 2120).
THE IMPLANT-SKIN INTERFACE
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz After inserting a wire or pin but before attaching it to the frame, check the skin interface for evidence of tissue tension while the limb is in its most functional position that is, with the knee extended and the ankle at neutral. Interface tension creates a ridge of skin on one side of a wire or pin. Incise the ridge to enlarge the skin hole around either a transosseous pin or an olive wire. Close the enlarged hole with a nylon suture on the side of the wire opposite the released ridge. When the ridge of skin is adjacent to a smooth wire, slowly withdraw the wire (with pliers and a mallet) until its tip drops below the skin surface. Allow the skin to shift to a more neutral location, and advance the wire again
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FIGURE 2121. The wire-skin interface. A, Tension on the skin is caused by a transxion wire. To correct the situation, withdraw the wire to below skin level, allow the skin to shift to a neutral position, and (B) drive the wire forward. The arrow points to the original wire hole.
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loosening that does occur becomes established without creating a very large hole. Furthermore, multiple cross wires can be placed in a fairly small fragment, thereby creating a trampoline effect that supports the bone. Also, in most locations, there are no muscle bellies surrounding juxta-articular bone. For the most part, such fragments are adjacent to either tendons or neurovascular structures that can, with care, be avoided during wire placement. Moreover, most of these neurovascular structures are either anterior or posterior to the articular bone fragments, leaving the mediolateral corridor for safe wire insertion. The clinical techniques of fracture reduction and deformity correction with circular external xation by Ilizarovs methods require that the surgeon understand the relationship between the moving bone fragments initial position and its nal position with respect to the stationary bone fragment that serves as the frame of reference for the reduction maneuver. There are four ways that the moving fragment can change position to effect a reduction: angulation, translation, rotation, and axial shortening or lengthening. With the classic Ilizarov xator conguration, separate assemblies are used to achieve each one of these displacements, although angulation and shortening can often be combined in one maneuver by placing the hinge axis at a distance from the edge of the bone along the line that divides the deformity angle in half, the bisector line. In some cases, translation can also be corrected with the same mechanism that realigns angulation and shortening, but only in situations in which the translational offset is in the same plane as the angulation and shortening. In all other cases, separate assemblies must be constructed to eliminate the different deformities. Taylor realized that regardless of the number of assemblies needed to reduce or align bone fragments, the moving bone makes a single pathway from its displaced position to its reduced position. In some situations, the pathway may be a straight line, and in other cases, the pathway may be spiral or otherwise curved, but the nature of that path can be determined in advance by noting the three-dimensional location of the starting position of the fragment with respect to a frame of reference, and mathematically comparing that position with the nal position. Indeed, it is not necessary to consider the entire moving fragment to dene the pathway. Instead, a single point on the moving fragment may be used as a substitute for the whole fragment as long as the relationship of the point to the rest of the fragment remains unchanged as the fragment moves through space from its starting position to its nal position. Likewise, if the moving fragment is secured to a ring (or block of rings) and the stationary fragment is secured to another ring or block of rings, then the rings can be considered as part of their respective fragments. Therefore, correction of the deformity or displacement via the rings will correct the osseous deformity as well. Indeed, this is a basic Ilizarov concept. The unique feature of the method that considers the pathway that the moving bone fragment must take as the route to alignment of the fragments is the application of engineering principles to the problem of deformity correction and fracture fragment reduction. Connecting the ring surrounding the moving fragment to the ring of the stationary fragment with six struts allows for
complete repositioning of the moving ring by adjusting the lengths of the struts. In this manner, the gradual reduction of a displaced fracture, or the correction of a deformity, or limb elongation or compression in its own axis can be accomplished with ease, provided the exact relationship between the rings and their respective bone fragments are known, as well as the precise position of the rings with respect to each other. The reduction-repositioning system must be used with a computer program that details the precise amount of lengthening or shortening of each strut required to gradually move a bone fragment into position. With such a program, it is also possible to designate a particular neurovascular bundle as being at risk of stretch injury if the bone fragment is moving too rapidly from its initial to nal position. With this information, combined with a parameter that denes the maximum tolerable stretch of the structure at risk, the computer program can tell the clinician how fast the struts can be lengthened without causing injury to that structure. To use the spatial frame successfully, several parameters must be entered into the computer, including a numerical description of the exact relationship of the fragments to their respective rings in all planes, as well as precise measurements dening both the initial and nal position of the moving fragment with respect to the stationary fragment. This particular feature of the system has proved to be most troublesome to surgeons comfortable with the classic Ilizarov reduction techniques, in which errors in measurement are correctable without much difculty by using the proper correction assemblies, even when they are added to the xator long after it was applied to the patient. Nevertheless, the system is popular with surgeons who have become familiar with its features.
Hybrid Mountings
For more substantial fragments that include not only the articular end of the bone but also the metaphyseal region, various combinations of pins and wires have proved successful for mount external xation. The stability of these mounting strategies has been studied by Calhoun and associates.3 They analyzed a number of different pin and wire combinations to determine the amount of stability available as one converts from an all-wire mounting technique to one that uses only half pins. Using two crossed tension wires as the standard, Calhoun and associates learned that the popular T conguration (consisting of a transxion wire and perpendicular half pin) is not as stable as two tension wires crossed at 90. Indeed, Calhoun and associates3 learned that whenever a wire is removed from a circular xator mounting plan, it should be replaced by two half pins. Thus, stability comparable with that produced by two tensioned wires at 90 to each other requires one wire and two half pins in a reasonable geometric conguration. At Rancho Los Amigos Medical Center, we are fond of using certain congurations in the periarticular and epiphyseal-metaphyseal regions of bones that, in our clinical experience, have proved to be stable. The rst of
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FIGURE 2122. The H mounting. A, With parallel counterpulling beaded wires. B, With crossed counterpulling beaded wires.
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these mountings is what we call the H mounting, consisting of two counterpulling olive wires at about the same level and a single half pin, which is either perpendicular to the two wires or at some angle between 60 and 120 to the wires (Fig. 2122A). Alternatively, the wires can be crossed with respect to each other (see Fig. 2122B). Usually, the wires are placed in the coronal
plane, so the crossing angle between them cannot be too great. This conguration is especially valuable in the distal radius, calcaneus, and scapula (Fig. 2123). The T mounting, consisting of a single wire and a perpendicular half pin (Fig. 2124), is not particularly stable, as noted by Calhoun and associates.3 The T mount, however, can be considered stable if the wire also passes
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FIGURE 2123. The H mounting of wrist (A), calcaneus (B), and scapula (C).
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FIGURE 2124. The T mounting.
FIGURE 2126. The A mounting.
through an intact bone. For example, transxing the distal radius and ulna with a single wire would then require only a single half pin to complete the mounting of the distal radius fragment. Of course, the radius cannot be lengthened when it is xed to the ulna, but such a conguration is useful in bone transport cases and similar mounting needs (Fig. 2125). Another strategy we often use is the A mounting, in which two half pins are inserted at the same or nearly the same transverse level in the bone, with the angle between them measuring from 60 to 120. A single wire (preferably an olive wire) is then inserted perpendicular to the line bisecting the angle between the half pins (Fig. 2126). (The crossed implants make up the letter A within the bone.) This mounting is useful for a proximal tibial xation (Fig. 2127).
It is often possible to use titanium half pins in juxta-articular regions, especially if the bone is of good quality. In relatively stable situations, two half pins at right angles will sufcea V conguration (Fig. 2128). In other cases, more stability can be achieved by employing three half pins in a W conguration (Fig. 2129). We have developed a mounting conguration for the distal femur that secures the condyles without synovial penetration. We rst insert K-wires in the coronal plane from distal to proximal, crossing each other 6 mm apart. We next employ a cannulated drill bit to enlarge the K-wire tracts, drilling from proximal to distal. The 6-mm threaded half pins are inserted into the drilled holes from the proximal to the distal direction. A supplementary half pin is added for additional xation (Fig. 2130).
TECHNIQUES Corticotomy
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FIGURE 2125. The T mounting in the ulna for bone transport.
To preserve both the periosseous and the intraosseous soft tissues at the time of osteotomy, Ilizarov developed techniques for percutaneous osteotomy of a bone without transecting the marrows nutrient vessels. The procedure is called a corticotomy if performed in the metaphyseal region of a bone and a compactotomy if accomplished in the diaphysis.26 Through an incision no wider than a narrow osteotome, a small periosteal elevator (or joker) is used to elevate the periosteum as far around the bone in both directions as possible. Next, a starting notch is made in the bones near cortex, followed by progressive intracortical advancement of the osteotome, rst on one side of the bone and then on the other. Because the osteotome tends to jam as it advances, the surgeon must twist or wiggle the blade within the bones cortex to make room for further advancement. One should not be overly concerned if the osteotomy crosses the marrow on occasion. Instead, distraction can be delayed 2 to 3 days beyond the planned latency interval. The opposite cortex is cracked by rotating the os-
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FIGURE 2127. A mountings in the proximal and distal tibia. A, Photograph of the conguration. B, Radiograph of the conguration.
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teotome 90 within the cortical cuts on both sides of the bone or, alternatively, by performing a closed osteoclasis in torsion by counterrotation of the rings attached to each bone segment. (The distal fragment should always be rotated externally, as internal rotation might unduly stretch the peroneal nerve in the leg or the radial nerve in the arm.) Because the object of a corticotomy is to create a nondisplaced fracture, it is important to restore the bone to its precorticotomy alignment immediately after completing the procedure. To accomplish this, the external xator must already be secured to the limb before the bone is osteotomized. Obviously, an intact external xator would prevent torsional osteoclasis of a bones far cortex. Therefore, the surgeon must disconnect from the rings all longitudinal rods traversing the corticotomy level. After
corticotomy, the rods must be reattached to their original positionand at their original lengththereby reestablishing the precorticotomy alignment of the bone. To ensure correct alignment, the surgeon should count the holes in the rings, making note of the position of each connecting rod before removing it. Short, threaded sockets can be used between a ring and the threaded rods connected to it, or one-hole posts can serve the same function. The sockets or post can be detached from one ring before corticotomy and reassembled afterward.
Latency
There is a latency (delay) before distraction commences, the purpose of which is to allow the rst stage of fracture
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FIGURE 2128. The V mounting.
FIGURE 2129. The W mounting.
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FIGURE 2130. The W mounting for the distal femur avoids transsynovial pins or wires. A, Radiograph of the mounting. B, Photograph of the pin conguration.
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healing to begin. During distraction, corticotomy site fracture healing tries to catch up with the distracting bone ends but under most circumstances does not consolidate the regenerate bone within the distraction gap until the neutral xation period after elongation. Generally speaking, the delay is 5 to 7 days, but this can be lengthened or shortened under certain circumstances. When the corticotomy is oblique, the latency should be shortened by 1 to 2 days because oblique corticotomies heal more rapidly than transverse ones. Latency should be prolonged if (1) the osteotome seems to have crossed the marrow canal during corticotomy, (2) there has been considerable comminution at the site of corticotomy (delay should be 3 or 4 days), (3) there has been substantial displacement of the major fragments during corticotomy, and (4) fragments were counterrotated (during torsional osteoclasis of the posterior cortex) more than 30. If the bone is of poor qualityeither extremely dense or osteopenicthe latency interval should be increased up to 14 days, especially if the soft tissues surrounding the bone are also of suboptimal quality.
Distraction
After latency, the corticotomy gap is usually distracted 0.25 mm every 6 hours. This rate and frequency may be altered, depending on the clinical circumstances. For an adult with dense bone and suboptimal surrounding tissues, a more appropriate rate and frequency would be 0.25 mm every 8 to 12 hours.
transport wires. Usually two crossed wires are used for this purpose; if only one wire is used, the transported segment may twist on that wires axis. As the transport ring is gradually moved along the xator frame, the transport wires cut through soft tissues by causing necrosis ahead of the wires; the skin and tissues heal behind the wires. In this manner, transport wires cut through soft tissues as a hot wire cuts through ice. Because the transport wires movements are gradual, there is little pain associated with the transport process; nevertheless, the area of focal necrosis at the wires leading surface often becomes infected, as one might expect with any wire causing soft tissue damage by compression. The inammation surrounding the necrotic area causes patient discomfort. A serous or purulent discharge often accompanies the process. Usually the inammation stops once bone transport has been completed; nevertheless, I maintain patients on oral antistaphylococcal antibiotics as soon as soft tissue inammation appears during the course of bone fragment transportation. When planning to move a bone segment through a limb by way of transport wires, the surgeon must consider both the initial and the nal positions of the transport wires, as well as the path the wires will cut through soft tissues. With longitudinal bone segment movement, the transport wires generally move parallel to neurovascular structures and tendons; thus, little likelihood for transection of such structures exists. However, one should recognize the danger of a proximally moving transport wire entering the bifurcation of a nerve or vessel.
Transport Wires
Wires that move a major bone segment through tissues by rmly securing the segment to a movable ring are called
Directional Wires
One or more directional wires may be used to pull a bone segment through soft tissues. For this purpose, olive wires, kinked wires, or twisted wires can be used. The technique
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involves the following: One or two wires are driven obliquely through bone, exiting the soft tissues on the limbs opposite side. The tips of the wires are curved with pliers; by grasping the proximal end of the wire with pliers and striking the pliers with a hammer, the surgeon can back out the wire until the tip is under the skin. Once the tip is within the soft tissues, the wire is slowly wiggled and advanced (with pliers and a hammer) until the tip moves up the limb. Usually the wire point emerges somewhere in the region of the skeletal defect. Thereafter, the surgeon may have to bend the wire in another direction, withdrawing the wire below the skin line, and advance the wire through the skin farther along the limb. The process of tip protrusion, wire bending, retraction, and advancement may have to be repeated to achieve the optimal nal wire position. It may be helpful to rotate the wire 180 so that the curve points away from the limb. The wires curved end readily passes through the skin without the points scratching intact skin near the exit hole. As a trick to help determine the direction of the wires curve, one can bend the proximal end to a right angle, pointing in the same direction as the tips curve. In most instances the longitudinal directional wires used for compression-distraction osteosynthesis emerge through the skin adjacent to the target segment. The wires are then secured with nuts into the groove of threaded rods for progressive traction (after the usual latency interval). Unfortunately, longitudinal directional wires end up at a rather oblique angle to the bones mechanical axis as the transport process nears completion. For this reason, the directional wires may become progressively less effective in achieving the nal stages of interfragmentary compression. When this occurs, the patient must return to the operating room for removal of the directional wires and application of an additional ring and transverse wires as the defect closes. Problems with treating nonunions and pseudarthroses seem to arise more frequently at the site of original pathology than at the region of elongation. Atrophic nonunions do not magically unite because a transxion wire external xator has been applied to a limb. For this reason, Ilizarovs group in Kurgan has developed numerous strategies to encourage bone healing at a site of a likely delayed union, whether due to limited bone contact, atrophic bone ends, or related difculties.19, 20, 27
outlined later can be put into effect. In some cases it may be sufcient to introduce a curette into a false synovial cavity through a stab incision to debride the bone ends. Ilizarov claims that compression of a synovial pseudarthrosis for 2 weeksenough time to cause necrosis of brocartilage and an inammatory reactionmay be sufcient to stimulate healing. If the radiographs demonstrate a pencilin-cup appearance of the pseudarthrosis, in which only one side of the nonunion is showing proliferative changes while the other fragment appears to have the same contour that was present immediately after the injury, the side of the nonunion demonstrating no progress toward healing may be nonviable. In some cases a bone scan will clarify the issue, demonstrating lack of circulation in osseous tissue of questionable viability. If bone scans are to be used in this manner, it is important to obtain a three-phase study, with an initial scan taken shortly after injection of the radionuclide so that the nonviable bone end can be more readily distinguished from any surrounding periosteal tissue reaction. If substantial doubt remains about the viability of the osseous tissue in question, the surgeon should explore the wound. Likewise, if there is persistent or recurrent drainage from the site of the nonunion, debridement of nonviable and marginally viable osseous tissue is necessary, in accordance with the principle described earlier in this chapter. Thereafter, the skeletal defect must be closed by the technique of bone transport. In the absence of nonviable tissue, several strategies can be applied to nonunions. These are discussed in the sections that follow.
Transverse Nonunion without Shortening

Hypertrophic nonunions without shortening and in good axial alignment have long been treated with external skeletal xation, as well as a variety of other methods. In many cases a percutaneous or open bular osteotomy or a slice bular ostectomy may be necessary to promote union. In these situations, the strategy of axial compression usually ensures union, especially if the nonunion is hypertrophic (Fig. 2131). A two-ring, three-ring, or four-ring conguration can be applied, depending on the intrinsic stiffness of the fracture conguration. (The more stable the nonunion, the fewer the rings.) If the limb shortening is less than 1.5 cm, no lengthening will be necessary.
MANAGEMENT OF NONUNIONS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Although individual nonunion patterns require treatment strategies tailored to the patient, certain general therapeutic strategies can be applied to common nonunion congurations. As a rule, the principles described later apply to cases in which both bone ends are viablethat is, both sides of the nonunion demonstrate proliferative changes on roentgenographic evaluation. If the nonunion has characteristics of a true synovial pseudarthrosis (i.e., formation of a false joint cavity lined with synovium and lled with synovial uid), then the cavity must be entered surgically and the brocartilaginous ends of the bone scraped down to osseous tissue before the treatment plans
Transverse Nonunion with Shortening

In some situations a transverse nonunion with a satisfactory mechanical alignment of the bone may be accompanied by shortening because of traumatic bone loss or a healed fracture elsewhere in the bone. In these situations the surgeon might be inclined to compress the nonunion while performing a lengthening corticotomy elsewhere on the limb. Such a treatment plan is not necessary; instead, the principle of monolocal consecutive compression-distraction osteosynthesis can be applied. By this technique, a nonunion site is rst compressed for 2
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FIGURE 2131. A, A transverse nonunion of the tibia without shortening or angulation. B, Compression of a transverse nonunion of the tibia with a stable four-ring conguration.
FIGURE 2133. A, An oblique hypertrophic nonunion of the diaphysis without shortening or angulation. B, Treatment with olive wires that provide interfragmentary compression while the xator acts as a compressor.
weeks and then gradually distracted (Fig. 2132). The compression stimulates neoosteogenesis, and the distraction stimulates the formation of regenerate bone in the elongating gap. The standard frequency of distraction (0.25 mm every 6 to 12 hours) is used. Bone will ll the distraction gap. If necessary, the hypertrophic nonunion may have to be realigned gradually so that the mechanical axes of both the proximal and the distal fragments are collinear.
longitudinal compression causes the bone fragments to slide past each other, leading to limb shortening. When there is an oblique nonunion line, it is necessary to achieve side-to-side (transverse) compression combined with compression in the bones mechanical axis (Figs. 2133 and 2134). Such side-to-side compression can be achieved in a number of ways: 1. Olive wires traversing the fracture site from opposite directions, applying interfragmentary compression by way of the apparatus. 2. Rings applied close to the fracture site, achieving transverse compression toward and away from longitudinal plates in the conguration.
Oblique Nonunion without Shortening

In situations in which the fracture line is oblique rather than perpendicular to the bones mechanical axis, simple
FIGURE 2132. A, A transverse hypertrophic nonunion of the tibial shaft and the concomitant shortening elsewhere in the bone (arrow). B, Management was by compression of the hypertrophic nonunion for 2 weeks, followed by distraction to overcome shortening. C, Distraction of a hypertrophic nonunion results in new bone formation if the osteogenic process has been stimulated.
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3. Arched wires, a technique frequently used for fracture reduction whereby transxion wires are passed through a bone segment and slightly curved in the direction the surgeon wishes to translate the bone segments. The wires are then tightened to straighten them, thereby moving the bone segment toward the concavity of the curve of the wires. Side-to-side interfragmentary compression must be combined with axial compression in the bones mechanical axis.
Oblique Nonunion with Shortening

This common pattern of nonunion can occur anywhere along the length of the bone. Although the surgeons inclination might be to attempt side-to-side compression with the bone as it lies, a far more acceptable strategy is to distract the limb to overcome shortening, while at the same time using the rings of the apparatus to simulta-
neously restore the bones mechanical axis and achieve side-to-side compression (Fig. 2135). To achieve this goal, it is necessary to construct the frame with the rings closest to the nonunion site sliding along the apparatus during distraction, while at the same time applying transverse traction to the bone ends. To accomplish this, the sliding mechanism that connects the innermost rings to the apparatus can be made with either a buckle (which slides along the plate) (Fig. 2136) or, alternatively, a bushing that has a nut on either side of it; the bushing will slide along any threaded rod (Fig. 2137). Because the bushing has a tapped hole in its side, it can be used to connect a ring to the rod while allowing a translation movement in the ring. Once the distraction has been completed, nal adjustment in the ring position should be made to allow restoration of the bones mechanical axis. Finally, axial compression combined with side-to-side compression should achieve union.
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FIGURE 2134. A, A 45-year-old woman with an oblique nonunion of the distal tibia. There had been a previously attempted plating followed by serious infection, with a skin slough. The wound is now closed as a result of skin grafting. B, A lateral projection radiograph of the reduction with counterpulling olive wires. C, The apparatus seen from the frontal plane. The counterpulling olive wires are attached to the three-hole post, projecting downward from the middle ring. D, The nal result shows consolidation.
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FIGURE 2135. A, Oblique nonunion with shortening. B, Straight longitudinal distraction will increase the gap. C, If the distraction is combined with simultaneous transverse compression, the fracture site will be reduced. Transverse and axial compression are continued until union.
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Angulated Nonunion without Shortening

When a nonunion is angulated, the surgeon should restore the bones mechanical alignment as nearly perfectly as possible before compression. The technique employed follows the principles of deformity correction. A hinge (or pair of hinges) is placed in the xator conguration with the axis of the hinge located over the apex of the deformity (Fig. 2138). (In most cases two hinges are used, with the axis of the hinges forming an imaginary line that passes through the deformitys apex.) Frequently the apex of the deformity is somewhat difcult to ascertain. Standard radiographs in the anteroposterior and lateral projections often demonstrate a deformity in two planesfor example, with the apex posterior on the lateral projection and lateral on the anteroposterior projection. A thoughtful analysis of such a deformity, however, reveals that the deformity, or any deformity for that matter, can exist in only one plane, with the apex posterolateral. To best determine the plane of the deformity, it may be necessary to obtain radiographs of the limb at several oblique projections, with the projection demonstrating the maximal angular deformity being the one that most truly represents the deformitys plane; moreover, the plane of the deformity is perpendicular to the radiographic projection that shows the bone to be straight. Obviously, rotation, translation, or other axial deviations can be included with an angular deformity, but the angular deformity itself can exist in only one plane. When there is good bone contact and hypertrophic changes on both sides of the nonunion line, the xator is applied with a pair of rings on the proximal fragment and a pair of rings on the distal fragment; each fragments rings are perpendicular to that fragments mechanical axis. Hinges are placed between the proximal and the distal ring clusters, and the nonunion site is compressed for 2 weeks, thereby increasing the deformity slightly. After the preliminary compression, the deformity is gradually corrected, utilizing a threaded distractor on the concave side. Usually, twisted plate and post assemblies are used to accomplish the distraction. If the nonunion is stiff, a push congura-
tion can be used, using a plate on the deformitys convex side stabilized to the proximal and distal rings with twisted plates and effecting a pushing action on the rings adjacent to the site of nonunion. With either conguration, it is necessary to calculate the rate of correction at the point
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FIGURE 2136. The apparatus used for simultaneous elongation and side-to-side compression when treating an oblique hypertrophic nonunion with shortening. The 17-hole plates allow sliding of buckle assemblies that push or pull the middle two rings.
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FIGURE 2137. A, Another conguration to provide simultaneous elongation and transverse compression. In this case, bushings slide along threaded rods during lengthening and simultaneously provide a xation point for transverse compression of the third and fourth rings in the conguration. B, Pretreatment and post-treatment radiographs of the same patient (a hypertrophic nonunion of the distal tibia 8 months after an open fracture).
of either distraction or push to correspond to an opening of the base of the deformity at a rate of 1.0 mm/day in divided segments. When the deformity is fully corrected, the nonunion site will have a wedge conguration with triangular regenerate bone lling the gap (see Fig. 2138B).
Angulated Nonunion with Shortening

In many nonunions, shortening without translation may accompany the angulation. In this situation the deformity can be corrected while limb length is simultaneously restored by using a distraction wedge technique. The
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FIGURE 2138. A, Angulated nonunion without shortening. B, The treatment of an angulated hypertrophic nonunion without shortening involves the placement of a hinge (black dot) at the apex of the deformity. The rings of the apparatus are applied perpendicular to the mechanical axis of their associated segments. Gradual distraction (after initial compression) should result in a triangle of regenerated bone in the widening gap.
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regenerate bone within the distraction gap will become trapezoidal, with its length corresponding to the amount of limb elongation (Figs. 2139 and 2140). To achieve this goal, the apex of the hinges for deformity correction is placed at a distance away from the bone, which can be determined by making acetate cutouts and rotating the fragments around a thumbtack hinge.
Nonunion with Rotational Malalignment

If there is a rotational deformity combined with angulation, displacement, or shortening, the rotation should be corrected last. A gradual twist distributed over the entire length of the regenerate is more satisfactory than rotation through the corticotomy site that tears at the healing tissue (Fig. 2143). Another important point: Whenever a rotational correction must be made, it is easier to correct the rotary deformity once the mechanical axis of the bone has been restored to normal, as the surgeon will be dealing with a problem in only one plane. When correcting a rotational malalignment, be sure that the bone segments in question are in the center of the conguration rather than in the more customary eccentric location. If this step is not taken, the bone fragments will rotate around an imaginary axis in the center of the conguration, thereby becoming displaced with respect to each other when the rotation is completed. This principle must be considered whenever a xator is initially applied to correct the deformity. Obviously, a derotation assembly should be included in the conguration.
Angulation Nonunion with Translation without Shortening

Many angulated nonunions display some element of translation; if the angular deformity is corrected, the axes of the proximal and distal fragments will not be collinear. Such a residual displacement can often be corrected in a single maneuver based on Ilizarovs concept of a translational hinge. The apex of the hinge must be located at the intersection point of two lines that follow the edge of the bone fragments on the deformitys convex side. A simpler method is to make cutouts of the fracture, placing each cutout on a separate sheet of clear acetate or x-ray lm, and to perform the rotation through a thumbtack hinge. It is usually necessary to correct the angulation before correcting the displacement (Fig. 2141).
Segmental Defects
SEGMENTAL DEFECTS WITHOUT SHORTENING When a segmental defect is present, angulation, translation, and rotation can be easily corrected at the time the xator is in place, as the soft tissues in the defect will be sufciently pliable to allow restoration of the bones mechanical axis.13 Thus, the frame conguration for segmental defect management is actually quite a bit simpler than one applied to correct a deformity, because all the rings can be in a straight line. If, after the xator is applied, an axial displacement, angulation, or rotation is noted, the correction should be done on the operating table while the patient is still anesthetized. Because the
Angulated Nonunion with Translation and Shortening

When there is angulation, translation, and shortening, alignment of the bone fragments can be restored utilizing a translational hinge, but the apex of the hinge must be displaced from the convex edge of the deformity by a distance that corresponds to the amount of shortening present. One can use Ilizarovs formula or cutouts for this correction. The shortening must be corrected before the translation, lest one bone fragment block repositioning of the other (Fig. 2142).
FIGURE 2139. A, Angulated hypertrophic nonunion with shortening. B, Correction of the problem with a hinge (black dot) in the conguration located at some distance from the apex of the deformity. The rings of the apparatus are applied perpendicular to the mechanical axis of their associated segments. Gradual distraction leads to the formation of a trapezoidal regeneration that simultaneously achieves deformity correction and lengthening.
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FIGURE 2140. A, A clinical photograph of a patient with a failed ankle arthrodesis. B, Radiographic appearance of the patient. Note the valgus angulation of the failed tibiotalar arthrodesis site. C, The apparatus used for correction of the deformity. The distal rings are perpendicular to the hindfoot axis, and the proximal rings are perpendicular to the tibial axis. A lateral distraction assembly is effecting a slow correction. D, A gradual realignment of the talus under the tibia has occurred. E, A clinical photograph of the patient 1 month after removal of the xator.
strategy for defect treatment usually involves corticotomy and bone transport, the intercalary transported segment must be in perfect alignment with the target fragment before the corticotomy is performed or the fragments will not be aligned at the completion of bone transport. When planning the solution to the problem of a segmental defect, the nal contact point between the intercalary and the target fragments must be considered before the two bone ends meet. The most stable conguration occurs when one fragment invaginates into the other until rm contact between the exterior surface of the inner
fragment makes circumferential contact with the endosteal surface of the receptacle fragment. As it turns out, however, this process of invagination is at odds with the principle of collinearity between the fragments, because a point carved in the cortex of the intercalary fragment would probably become displaced as it penetrated into the target fragment. Nevertheless, it is surprising how often jagged fragment ends are left after a post-traumatic skeletal deciency, whether because of an absolute loss of bone at the time of initial injury or as a consequence of debridement.
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When the skeletal defect follows a segmental resection of infected osseous tissue, it is advisable to square off the bone ends to create a transverse point of contact (Fig. 2144). Bear in mind, however, that there is a signicant incidence of long delays in bone healing when two seemingly parallel bone surfaces come together. For one thing, the bone carpentry work is seldom perfect, so contact is usually made at a high point on one or the other of the cut bone surfaces. Also, it is likely that cutting the bone with an oscillating saw may damage viable bone several cell layers into the tissue. For this reason, it is safer to use an osteotome (or chisel), followed by careful rasping of the cut surfaces and then by roughing up the smooth surface of the cut bone ends with a curette or rongeur after squaring off bone fragments. In any event, if there is delayed union at the point of contact between the intercalary and the target segments, a small cancellous bone graft can be packed around the region to promote healing. In some situations a surgeon might be tempted to resect abnormal bone, immediately compress the site of pathology, and compensate for the resultant shortening by limb elongation through healthy tissues. Although this proposal
is appealing, I have found that immediate compression of a segmental defect larger than 2.5 cm distorts the surrounding soft tissues, making wound closure difcult and leading to edema distal to the area of compression, possibly because of distortion and kinking of lymphatic vessels. For this reason, it is wiser to leave a segmental defect and the surrounding soft tissues at full length and close the defect by the technique of bone transport. When extensive segmental debridement of nonviable bone is required, one end of the residual osseous tissue can be fashioned into a point while the other side is made trough shaped. After transport of an intercalary bone segment, the point is impaled into the trough, ensuring good bone contact and stability (Figs. 2145 and 2146). PARTIAL SEGMENTAL DEFECT WITHOUT SHORTENING A method of dealing with a partial segmental defect (i.e., when one cortex is long enough to achieve contact, but there is substantial deciency of the remaining cortical bone) is to use the method of splinter fragment transport. With this technique, a lengthwise split is created in the
FIGURE 2141. A, Nonunion associated with angulation and translation. B, In some cases, the deformity can be corrected with a distractional hinge (black dot). The center of rotation is placed along a line at the intersection of the cortices, along the convex side of the deformity. Gradual correction results in simultaneous correction of the deformity and elimination of the translation. C, An alternative strategy for dealing with angulated displaced nonunions. Sequential elimination of, rst, the angulation and, second, the translation results in elimination of the deformity.
B
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FIGURE 2142. A, A nonunion associated with angulation, translation, and shortening. B, In some cases, a translation hinge (black dot) placed with its axis at a distance from the point of intersection of the convex edge of the fracture fragments results in correction of angulation, shortening, and translation. C, An alternative strategy is sequential correction of the deformity, with angulation corrected rst, followed by correction of shortening, and, as the last step, correction of translation (D).
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FIGURE 2143. A, Nonunions that combine rotation, angulation, and displacement, with and without shortening. B, In both cases, rotation is corrected last; moreover, the axes of the bone fragments must be collinear and in the center of the conguration before malrotation is corrected, lest gradual counterrotation of the fragments result in axial displacement of one with respect to the other.
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B
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C
FIGURE 2144. A, A partial skeletal defect can be converted to a complete transverse skeletal defect for reconstruction by the bone transport method. B, With a complete transverse defect, a corticotomy through healthy bone is followed by gradual transport of the intercalary segment toward the target segment. New bone forms in the distraction gap. C, Crossed directional wires can be used in place of a transport ring to move an intercalary bone segment through a limb.
cortex involving approximately half of the cortical circumference. The split fragment is then drawn longitudinally across the defect, after an appropriate delay, until it makes contact with the target bone on the other side of the gap (Fig. 2147). SEGMENTAL DEFECT WITH SHORTENING When a segmental defect is accompanied by shortening, the problem can be overcome by performing a bone transport procedure identical to the one described in the preceding section. However, after contact and compression between the intercalary and the target fragments, the limb
is lengthened through the corticotomy site, moving the intercalary and target fragments together as a unit away from the corticotomy gap (Figs. 2148 and 2149). In situations requiring lengthening in limb segments with paired bones, both bones will be short (Fig. 2150A). In the lower leg, after completing the bone transport to eliminate a tibial defect, it will be necessary to osteotomize the bula to restore limb length. If the surgeon performs the bone transport before limb elongation, an osteotomy of the shortened bula will have already healed before elongation commences (see Fig. 2150B), necessitating a return trip to the operating room for a repeat bular osteotomy. A wiser strategy is to lengthen the limb,
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FIGURE 2145. A, Pretreatment and post-treatment radiographs of a 5-cm skeletal defect. There is also a cavitary osteomyelitis around the lower pin in the upper segment (on the left). The radiograph on the right shows the tibia after the xator has been removed. B, A corticotomy performed through the area of cavitary osteomyelitis (which was not draining at the time). C, Appearance at the beginning of distraction. D, Appearance at approximately 1.5 cm of bone transport. Note the new bone forming in the corticotomy gap. E, Appearance at 3.0 cm of bone transport. F, Appearance at the completion of bone transport. Note the elimination of the cavity. G, Further maturation of the bone in the distraction gap at the end of treatment. H, Appearance of the patient at the completion of treatment.
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FIGURE 2146. A, With a substantial skeletal defect, it is possible to create two corticotomies in bone, transporting the rst intercalary segment at a rate of 2.0 mm/day and the second at a rate of 1.0 mm/day. Each corticotomy gap widens at a rate of 1.0 mm/day with this strategy. B, Another strategy for dealing with a large skeletal defect. Proximal and distal corticotomies are performed, and the two intercalary segments are moved toward each other. The defect closes at the rate of 2.0 mm/day, but each corticotomy site opens at the rate of only 1.0 mm/day.
through a tibial corticotomy and bular osteotomy, before bone transport to prevent premature union of the bular osteotomy. Thereafter, the bone transport of the tibia should be continued until the gap is closed (see Fig. 2150C). Obviously, when paired bones are lengthened, both ends of both bones must be secured to the frame, or one or the other end will subluxate or dislocate from its anatomic position.
Septic Nonunions
External skeletal xation has long been a weapon in the surgical assault on septic nonunions. The xator, by virtue of its rigidity, permits control of limb length and alignment without the need for hardware traversing the site of sepsis. A stable biomechanical environment promotes both osseous healing and immune function simultaneously.
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FIGURE 2147. A method of eliminating a partial skeletal defect using slivers. A cortical fragment (curved arrow) is separated from one bone segment and is gradually drawn across the wound (straight arrows).
FIGURE 2148. A segmental defect accompanied by shortening.
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FIGURE 2149. A, Roentgenogram of the leg of a 21-year-old man with a 7.5-cm tibial defect and 2.5-cm of limb shortening (note bular overlap), resulting in a true tibial defect of 10 cm. B, Roentgenographic appearance during bone transport. Note the corticotomy site (C) and the transported intercalary segment. The shortening has not yet been overcome (note bular overlap). C, Appearance at the completion of bone transport and restoration of limb length. Note that the bular overlap has been eliminated. New bone is forming in the distraction gap. D, Appearance toward the end of xation. A small cancellous bone graft has been placed between the distal tibia and the distal bula because of the atrophy of the bone ends in this region. E, Final radiographic appearance. Note the 10 cm of regenerated bone in the proximal tibia and the small bone graft in the distal interosseous space. F, The clinical appearance of the skin during bone transport. The wires cut through the skin, with necrosis ahead of the wire and healing behind.
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DEBRIDEMENT Debridement of nonviable tissues remains the hallmark of osteomyelitis surgery. An equally important principle, and one that is often overlooked, is the need for elimination of residual cavities (actually, hard wall abscesses) within infected bone. In certain septic nonunions, infection may persist in the absence of nonviable bone. In these cases false movement at the septic focus leads to persistent drainage. An infection in which drainage is motion related rather than necrosis related is often called a stulous pseudarthrosis to distinguish it from post-traumatic osteomyelitis, in which nonviable bone, usually in the form of sequestered fragments, is present. If osseous healing in such motionassociated infections leads to bone union, the sepsis is usually eradicated. If, however, immobilization of the focus of infection is only temporarythe result of stable external xationand not accompanied by osseous union, drainage may reappear shortly after the xator is removed and false motion starts again. Therefore, as a general
principle, an external xator should not be removed from a patient with an infected nonunion until the fracture is united.24 In another common pattern of post-traumatic sepsis, there may be nonviable bone within and surrounded by living osseous tissues. Such a sequestra incontinuity is fairly common in patients with septic nonunions treated at the Problem Fracture Service at Rancho Los Amigos Medical Center. For this reason, I explore every septic nonunion with wound drainage, often to nd a sequestra in continuity requiring debridement, even if radiographs fail to demonstrate areas of nonviable bone. Sequestra in continuity is the most difcult to diagnose with standard radiographic, tomographic, scintigraphic, and other noninvasive studies. At times, the lack of callus from one or another side of a fracture siteespecially where an experienced eye would ordinarily expect to see callus may be a tipoff to the presence of sequestra in continuity. Equally often, however, radiographs do not provide this type of information. Unfortunately, wound exploration may potentially devitalize additional bone as the perios-
FIGURE 2150. A, A skeletal defect with shortening accompanied by union of the bula. B, Simultaneous corticotomy of the tibia and bula, followed by bone transport to close the tibial defect, results in premature union of the bula before length is restored, necessitating a second bular corticotomy. C, A more appropriate strategy is to perform simultaneous corticotomies of the tibia and bula but lengthen the limb before transporting the intercalary segment. In this manner, bular shortening will be overcome during the initial portion of tibial corticotomy gap distraction. Completion of the bone transport eliminates the residual tibial defect.
B
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teum is elevated during the course of exposure. For this reason, the surgeon should carefully limit subperiosteal dissection, choosing instead the extraperiosteal route to the bone in question. An infected nonunion draining to the surface points to a septic focus through an open sinus. Enlarging the sinus opening usually leads to an obvious sequestrum. During debridement, I do not excise the sinus tract, because its epithelialized granulation tissue is a natural response to the infection rather than a source of sepsis. Likewise, healthy granulation tissue, noted for its beefy red color and friability, should be left in place. Grayish-brown granulation, on the other hand, probably represents reactive tissue overwhelmed by microorganisms and calls for debride ment. Densely collagenized brous tissue surrounding bone fragments probably has little potential for new bone formation once the limb has been stabilized; indeed, such avascular tissue may inhibit host defenses. For this reason, I resect dense avascular or hypovascular collagenized brous tissue. It is often difcult to determine where this reactive tissue ends and normal periosteum, nerves, tendons, or fascia begin. As an aid to the resection, consider the following: First, the dense brous tissue represents the end-stage of biologic material that started as granulation tissue. Thus, the pathologic process leading to avascular brous tissue formation must be at least several months old. Second, the dense brous tissue requiring debridement is usually located within the original perios teal sleeve. Hence, it is often necessary to dene the location and extent of the preinjury periosteal envelope before debridement. With this objective in mind, one can nd the periosteum where it is adherent to normal bone (i.e., beyond the extent of distorted anatomy) and trace this periosteum toward the center of the infected region. A large curette aids in the separation of periosteum from proliferative tissues lining its inner surface. Once bone and soft tissue debridement is complete, the surgeon may be left with a sizable segmental defect requiring osseous and soft tissue reconstruction. Since the mid-1980s, numerous strategies have evolved to deal with such post-traumatic tissue deciencies. These have always included one or another method of bone grafting to compensate for the loss of osseous tissue. Likewise, skin defects are usually eliminated by a cutaneous graft, transposition or musculocutaneous free aps, or gradual closure by secondary intention. Osseous defects longer than 10 cm seem beyond the limit of cancellous bone grafting; for this reason, microvascular free osseous transfers have gained popularity. For some bones, especially the weight-bearing tubular bones of the lower limb, the transplanted osseous tissue (usually the bula or iliac crest) may fail to incorporate or may refracture when subjected to unprotected weight bearing.7 The techniques already described for reconstructive surgery of uninfected nonunions developed by Ilizarov are ideally suited for eliminating skeletal defects after debride ment of infected or nonviable osseous tissues, without the need for bone grafting or free microvascular transfers.14, 32 After debridement, the mechanical axes of the bone fragments are aligned collinearly, and a corticotomy is performed through healthy tissue after the frame is
applied. The defect is closed by bone transport, incorporating the principles outlined previously in the sections dealing with bone transport with and without shortening. PROBLEMS WITH THE REGENERATE BONE Ilizarovs method includes the creation of regenerate new bone during elongation of the osteotomized segments. Dealing with the regenerate bone is a new experience for most orthopaedic surgeons. The regenerate bone in a distraction gap can ossify too rapidly, limiting distraction, or more commonly, it may mature too slowly, prolonging the period of xator application. Ordinarily the distraction gap shows small hazy patches of calcication, often within the rst 2 weeks after cortical osteotomy of a long bone. One should not be concerned if no calcication appears within the gap, which is slightly less than 1.0 cm wide by the end of the second postoperative week (5 days predistraction xation, followed by 9 days of distraction at a rate of 1.0 mm/day). Distraction should continue at a slightly slower rate for 2 more weeks. By the fourth week after surgery, some calcication should be visible within the distraction gap. If not, one should reverse the distraction and begin compressing the gap over 2 to 3 days. Then, after a brief rest of 3 or 4 days, distraction should be commenced once again. Usually bone will form during the second distraction interval. At any point during elongation, when the quality of neoosteogenesis within the distraction gap causes concern, the distraction can be stopped or reversed briey in what has been called an accordion procedure. Ideally, the regenerate bone should appear on radiographs as longitudinal striations attached to both cortical fragments with a clear growth zone in the center. Once elongation or correction has been completed, the xator is left in place for at least as long as the time spent during elongation or deformity correction. This period of neutral xation after correction often taxes the patientsand the surgeonstolerance. Ilizarov recommends training the regenerate by compressing the frame slightly (0.25 mm twice a week) toward the end of the neutral xation period. This maneuver is used both for the regenerate bone in a distraction gap and for any areas of tardy bone healing at a fracture or nonunion site. The xator can be removed if the site of nonunion is united and the regenerate is mature and demonstrates the following: 1. No defects or shark bites along the regenerate bones edge on three sides of the distraction zone 2. Complete ossication of the radiolucent central growth zone of the regenerate bone 3. Uniform radiographic density of the regenerate bone (in both projections) that appears, to the surgeons eye, to be halfway between the density of the adjacent normal bones cortex and that of its marrow canal Before removal of either a pin or a wire xator, one should loosen the frame 1 to 2 mm every 1 to 2 days, reversing distraction, and allow it to oat on the limb to test osseous stability. When a transxion wire xator has been used for limb elongation, the wires are usually bent
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toward the center of the limb segment. If the threaded connecting rods are loosened, the rings above and below the distraction region may not be secure enough for patient comfort. Also, if the frame must be restabilized because the limb is not ready for xator removal, the wires will be loose. For these reasons, it is often necessary to reapply tension to the wires if ring positions are altered at the end of the neutral xation period.
COMPLICATIONS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Researchers at Ilizarovs institute summarized the complications associated with 3669 xator applications during the period from 1970 to 1975.6 Analyzing wire tract infections, they found an 8.3% rate of purulent soft tissue sepsis and osteolysis. Limb transxion, whether by smooth wire or threaded pin, violates the bodys principal barrier to bacterial invasion: the intact skin. An important principle designed to prevent pin or wire sepsis is to prohibit tissue motion along the implant. A bulky wrap of gauze lling the space between the skin and the xator is important for proper xator management to reduce the incidence of implant sepsis, especially in the rst month or so after the frame is applied.8 Special slotted sponges are available for use with the transxion wire xators to accomplish this.28 In Russia and Italy, medicine bottle stoppers are placed over each transxion wire to hold gauze sponges against the skin, thereby achieving skin-wire interface stability. Various pin and wire care protocols have been suggested over the years, but no single technique seems superior. For this reason, I prefer to leave pin or wire sites alone, wrapped up completely in a bulky wrap, not to be touched while the frame is on the patient, unless a problem develops at the site. The patient can shower with the frame on but should rewrap the pin sites afterward with a bulky wrap as described previously. When pin or wire sepsis does occur, oral antistaphylococcal antibiotics should be started as soon as soft tissue inammation develops, and the patients activities should be curtailed. If these measures do not relieve the problem within 48 to 72 hours, the patient may have to be admitted to the hospital for parenteral antibiotic therapy. If necessary, an implant may have to be removed and another inserted elsewhere to control sepsis. When removing an infected pin or wire, the surgeon should curette the bone hole if there is radiographic evidence of osteolysis or sequestrum formation. Chronic pin site or wire site osteomyelitis should be treated with a parenteral course of antibiotics, curettage, and perhaps bone grafting or some other technique used to deal with chronic osteomyelitis.16
element of the frame to impede movement of the limb segments. If adjustments are necessary, the xator should be stabilized with a temporary strut before any important structural elements of the frame are moved. Pin or wire tips can catch on clothing and bedding, even when they are properly covered or curled into the frame. To avoid this, one can cover the external xator with a double-thickness stockinette. The expanded indications for external xation currently coming from Russia will present remarkable therapeutic opportunities and an entirely new constellation of difculties as surgeons attempt reconstructions to a degree never before thought possible. With time, surgeons in Western nations will learn of the best use for circular wire external xators in restorative traumatology.
REFERENCES 1. Aronson, J.; Harp, J.H. Mechanical considerations in using tensioned wires in a transosseous external xation system. Clin Orthop 280:2330, 1992. 2. Caja, V.L.; Moroni, A. Hydroxyapatite coated external xation pins: An experimental study. Clin Orthop 325:269275, 1996. 3. Calhoun, J.H.; Li, F Bauford, W.L.; et al. Rigidity of halfpins for the .; Ilizarov external xator. Bull Hosp Jt Dis 52:2126, 1992. 4. Collinge, C.A.; Goll, G.; Seligson, D.; Easley, K.J. Pin tract infections: Silver vs uncoated pins. Orthopedics 17:445448, 1994. 5. DeBastiani, G.; Aldegheri, R.; Renzi-Brivio, L.; Trivelli, G. Limb lengthening by callus distraction (callotasis). J Pediatr Orthop 7:129134, 1987. 6. Devyatov, A.; Kaplunov, A.A. Complications of use of the Ilizarov apparatus. In: Ilizarov, G.A., ed. Applications of CompressionDistraction Osteosynthesis in Traumatology and Orthopaedics. Kurgan, USSR, 1978. 7. Gordon, L.; Chiu, E.J. Treatment of infected nonunions and segmental defects of the tibia with staged microvascular muscle transplantation and bone grafting. J Bone Joint Surg Am 70:377385, 1988. 8. Green, S.A. Complications of External Skeletal Fixation. Springeld, IL, Charles C Thomas, 1981. 9. Green, S.A. The use of wires and pins. Tech Orthop 5:1925, 1990. 10. Green, S.A. The Ilizarov method: Rancho technique. Orthop Clin North Am 22:677688, 1991. 11. Green, S.A. Techniques for transxion wire xators. In: Chapman, M., ed. Operative Orthopaedics. Philadelphia, J.B. Lippincott, 1991. 12. Green, S.A. The Rancho mounting technique for circular external xation. Adv Orthop Surg 16:191200, 1992. 13. Green, S.A. Segmental defects. A comparison of bone grafting and bone transport for segmental skeletal defects. Clin Orthop 300:111 117, 1994. 14. Green, S.A.; Diabal, T. The open bone graft for septic nonunion. Clin Orthop 180:109, 1983. 15. Green, S.A.; Harris, N.L.; Wall, D.M.; et al. The Rancho mounting technique for the Ilizarov method: A preliminary report. Clin Orthop 280:104116, 1992. 16. Green, S.A.; Ripley, M. Chronic osteomyelitis of pin tracks. J Bone Joint Surg Am 66:1092, 1984. 17. Green, S.A.; Wall, D.M. Ilizarov external xationTransxion wire technique. Mediguide Orthop, January 1989, pp. 18. 18. Ilizarov, G.A. A method of uniting bones in fractures and an apparatus to implement this method. USSR Authorship Certicate 98471, 1952. 19. Ilizarov, G.A. Angular deformities with shortening. In: Coombs, R.; Green, S.; Sarmiento, A., eds. External Fixation and Functional Bracing. Frederick, MD, Aspen, 1989. 20. Ilizarov, G.A. Fractures and nonunions. In: Coombs, R.; Green, S.; Sarmiento, A., eds. External Fixation and Functional Bracing. Frederick, MD, Aspen, 1989. 21. Ilizarov, G.A. The tension-stress effect on the genesis and growth of tissues: Part I. The inuence of stability of xation and soft tissue preservation. Clin Orthop 238:249, 1989.
Fixator Problems
A xator itself may cause problems for the patient, especially if the surgeon has not allowed enough room for limb swelling, as tissues may press up against frame components. Likewise, it is possible for one or another
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SECTION I General Principles 28. Paley, D.; Jackson, R.W. Surgical scrub sponges as part of the traction apparatus: An alternative to pin site care to reduce pin track infections. Injury 16:605606, 1985. 29. Pascual, A.; Tsukayama, D.T.; Wicklund, B.H.; et al. The effect of stainless steel, cobalt chromium, titanium alloy, and titanium on the respiratory burst activity of human polymorphonuclear leukocytes. Clin Orthop 280:281288, 1992. 30. Tajana, G.F Morandi, M.; Zembo, M.M. The structure and .; development of osteogenic repair tissue according to Ilizarov technique in man. Orthopedics 12:515523, 1989. 31. Wassall, M.A.; Santin, M.; Isalberti, C.; et al. Adhesion of bacteria to stainless steel and silver-coated orthopedic external xation pins. J Biomed Mater Res 36:325330, 1997. 32. Weiland, A.J.; Moore, J.R.; Daniel, R.K. Vascularized autografts: Experience with 41 cases. Clin Orthop 174:87, 1983.
22. Ilizarov, G.A. The tension-stress effect on the genesis and growth of tissues: Part II. The inuence of the rate and frequency of distraction. Clin Orthop 239:263, 1989. 23. Ilizarov, G.A. Transosseous Osteosynthesis. Heidelberg, SpringerVerlag, 1991. 24. Morandi, M.; Zembo, M.; Ciotti, M. Infected tibial pseudarthroses: A two year follow up in patients treated by the Ilizarov technique. Orthopedics 12:497514, 1989. 25. Moroni, A.; Aspenberg, P.; Toksvig-Larsen, S.; et al. Enhanced xation with hydroxyapatite coated pins. Clin Orthop 346:171177, 1998. 26. Paley, D. The Ilizarov corticotomy. Tech Orthop 5:4153, 1990. 27. Paley, D.; Chaudray, M.; Pirone, A.M.; et al. Treatment of malunions and malnonunions of the femur by detailed preoperative planning and the Ilizarov technique. Orthop Clin North Am 21:667693, 1990.

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SECTION I General Principles

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CHAPTER 21 The Ilizarov Method

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SECTION I General Principles

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CHAPTER 21 The Ilizarov Method

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SECTION I General Principles

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CHAPTER 21 The Ilizarov Method

INSERTING TRANSFIXION WIRES

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SECTION I General Principles

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CHAPTER 21 The Ilizarov Method

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SECTION I General Principles

Presentation Print Graphic

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CHAPTER 21 The Ilizarov Method

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SECTION I General Principles

THE IMPLANT-SKIN INTERFACE

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CHAPTER 21 The Ilizarov Method

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SECTION I General Principles

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CHAPTER 21 The Ilizarov Method

FIGURE 2124. The T mounting.

FIGURE 2126. The A mounting.

FIGURE 2125. The T mounting in the ulna for bone transport.

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SECTION I General Principles

FIGURE 2128. The V mounting.

FIGURE 2129. The W mounting.

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CHAPTER 21 The Ilizarov Method

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SECTION I General Principles

Transverse Nonunion without Shortening

Transverse Nonunion with Shortening

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CHAPTER 21 The Ilizarov Method

Oblique Nonunion without Shortening

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SECTION I General Principles

Oblique Nonunion with Shortening

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CHAPTER 21 The Ilizarov Method

Angulated Nonunion without Shortening

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SECTION I General Principles

Angulated Nonunion with Shortening

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CHAPTER 21 The Ilizarov Method

Nonunion with Rotational Malalignment

Angulation Nonunion with Translation without Shortening